Cynthia Christy

Intrauterine herpes simplex virus infections

Neonatal herpes simplex virus (HSV) infection is usually acquired at birth, although a few infants have had findings suggestive of intrauterine infection. We describe 13 babies who had clinical manifestations of intrauterine HSV infection, including skin lesions and scars at birth (12), chorioretinitis (eight), microcephaly (seven), hydranencephaly (five), and microphthalmia (two). All infants had combinations of these defects. Infection was proved by viral isolation in each case; all isolates were HSV-2. Two infants died during the first week of life; 10 of the surviving infants had severe neurologic sequelae, and one infant was blind. Four mothers experienced an apparent primary genital HSV infection, and one had recurrent infection, at varying times during gestation. The remaining women denied a history of symptoms of genital HSV infection. These findings indicate that intrauterine HSV infection can occur as a consequence of either primary or recurrent maternal infection and has severe consequences for the fetus.

Intramuscular versus oral antibiotic therapy for the prevention of meningitis and other bacterial sequelae in young, febrile children at risk for occult bacteremia

Because studies of the treatment of children with occult bacteremia have yielded conflicting results, we compared ceftriaxone with amoxicillin for therapy. Inclusion criteria were age 3 to 36 months, temperature > or = 39 degrees C, an acute febrile illness with no focal findings or with otitis media (6/10 centers), and culture of blood. Subjects were randomly assigned to receive either ceftriaxone, 50 mg/kg intramuscularly, or amoxicillin, 20 mg/kg/dose orally for six doses. Of 6733 patients enrolled, 195 had bacteremia and 192 were evaluable: 164 Streptococcus pneumoniae, 9 Haemophilus influenzae type b, 7 Salmonella, 2 Neisseria meningitidis, and 10 other. After treatment, three patients receiving amoxicillin had the same organism isolated from their blood (two H. influenzae type b, one Salmonella) and two from the spinal fluid (two H. influenzae type b), compared with none given ceftriaxone. Probable or definite infections occurred in three children treated with ceftriaxone and six given amoxicillin (adjusted odds ratio 0.43, 95% confidence interval 0.08 to 1.82, p = 0.31). The five children with definite bacterial infections (three meningitis, one pneumonia, one sepsis) received amoxicillin (adjusted odds ratio 0.00, 95% confidence interval 0.00 to 0.52, p = 0.02). Fever persisted less often with ceftriaxone (adjusted odds ratio 0.52, 95% confidence interval 0.28 to 0.94, p = 0.04). Although the difference in total infections was not significant, ceftriaxone eradicated bacteremia, prevented significantly more definite focal bacterial complications, and was associated with less persistent fever.

Field trial of rhesus rotavirus vaccine in infants.

Orally administered rhesus rotavirus vaccine (RRV) was evaluated in a placebo-controlled study in 176 infants (ages 2 to 4 months). Eighty-eight infants received a dose of 10(4) plaque-forming units of the vaccine, and 88 received the placebo. RRV was well-tolerated but mildly reactogenic in the 10 days after vaccination. There were mild febrile reactions (greater than or equal to 38 degrees C rectally) in 40% of the vaccinees and in 16% of the placebo recipients (P = 0.001). More of the vaccinees had loose stools than did the placebo recipients (P less than 0.05). RRV was immunogenic and induced a 4-fold or greater rise in serum neutralizing antibody responses in 67% of the vaccinees; however, breast-fed infants were less likely to develop a seroresponse than infants who were not breast-fed. Despite the good immunogenicity of RRV the overall incidence of rotavirus-associated illnesses was similar between the vaccine and placebo recipients. The failure of RRV in Rochester may be related to the fact that the circulating rotaviruses were predominantly serotype 1 and RRV is a serotype 3 rotavirus. Because the serotypes of rotavirus that predominate may vary from year to year, a polyvalent preparation may be necessary to provide effective vaccination against rotaviruses.

Teaching Patient Communication Skills to Medical Students A Review of Randomized Controlled Trials

Tools to examine the effects of teaching interventions across a variety of studies are needed. The authors perform a meta-analysis of 24 randomized controlled trials evaluating the effects of teaching on medical students’ patient communication skills. Study quality is rated using a modified Jadad score, and standardized mean difference effect size (d) measures are calculated. Fifteen of 24 studies have sufficient data for analysis. Students’ ability to establish rapport improves after teaching. The effects are large when the teaching intervention was small group discussion (n = 5) or giving structured feedback on a student-patient interview (n = 6). A similar effect of teaching is seen on student data gathering skills (n = 5). Teaching medical students patient communication skills using small group discussion or providing feedback on a student-patient interview results in improvement in student performance.

Evaluation of the protective efficacy of a serotype 1 bovine-human rotavirus reassortant vaccine in infants

The objective of this study was to evaluate the efficacy of a live, attenuated bovine (strain WC3) x human (strain WI79, serotype G1) rotavirus reassortant (WI79-9) virus vaccine for prevention of symptomatic rotavirus gastroenteritis in infants. The study was a prospective, randomized, double-blind, placebo-controlled trial, conducted over a single rotavirus season in 325 infants who were 2 to 8 months old at enrollment. Subjects were randomized to receive either placebo or WI79-9 virus vaccine at 10(7.3) plaque-forming units in three oral doses each separated by 2 months. Subjects were followed for 7 days after each dose for occurrence of adverse events and during the subsequent winter for development of rotavirus gastroenteritis. Administration of WI79-9 virus vaccine was well-tolerated, and the rates of low grade fever after each dose were no higher in vaccine recipients (8 to 21%) than in placebo recipients (14 to 19%). The protective efficacy of the WI79-9 vaccine during a subsequent epidemic of predominantly serotype G1 rotavirus was 87.0% (95% confidence limits, 62.6 to 95.5%) against relatively severe rotavirus gastroenteritis (rotavirus gastroenteritis with a clinical severity score of > 8) and was 64.1% (95% confidence limits 35.9 to 79.9%) against all symptomatic rotavirus episodes. The WI79-9 vaccine was safe and effective in prevention of homotypic human rotavirus infection in infants. Further studies of reassortant vaccines based on the bovine WC3 rotavirus should be performed.

Neonatal Trichosporon beigelii infection: report of a cluster of cases in a neonatal intensive care unit.

Trichosporon beigelii, a ubiquitous yeast found in soil, causes superficial dermatologic infections in normal hosts and rare cases of disseminated disease among immunocompromised patients. Neonatal cases are exceptionally rare. We report a cluster of cases of T. beigelii infections in a tertiary care hospital in Rochester, NY, during May to July, 1991. Three cases occurred in very low birth weight premature infants (23 to 25 weeks of gestation), two of whom died. The organism was isolated from urine alone in one case, skin and blood in one case and blood, tracheal aspirate and central venous catheter tip in one case. In a fourth, full term infant with respiratory distress syndrome T. beigelii was grown only from a femoral central venous catheter tip with no clinical evidence of infection. An epidemiologic investigation was performed and the mode of transmission in this outbreak was not identified, although cross-infection was suspected in the initial two cases. Our isolates were inhibited but not killed by usually achievable concentrations of amphotericin B. T. beigelii may cause outbreaks of serious infection in neonatal intensive care units, especially among premature infants.

Professionalism in Practice: Strategies for Assessment, Remediation, and Promotion

The Council on Medical Student Education in Pediatrics continues its series on great clinical teachers, focusing on professionalism in practice. The Council on Medical Student Education in Pediatrics is in agreement with the Liaison Committee on Medical Education, Accreditation Council on Graduate Medical Education, and the CanMEDS Physician Competency Framework, that professionalism is essential to the practice of medicine, regardless of the level of training. Clinical teachers are in an excellent position to promote and assess professional behaviors in students but are often hesitant to address lapses in professionalism; however, addressing professionalism early is critical, as professional misbehavior in medical school is a major risk factor for subsequent censure by state medical boards.1 This article discusses tools and strategies for the assessment, remediation, and promotion of professionalism in medical students. Many practitioners say, “I know it when I see it,” but defining professionalism can be challenging. Professionalism is built on the principles of excellence, humanism, accountability, and altruism and is demonstrated through clinical competence, communication, and ethical understanding.2 Humanism and altruism encompass beneficence, respect, truthfulness, and placing the needs of the patient above ones own. Excellence and accountability include striving for high-quality patient care, making a commitment to lifelong learning, and exhibiting responsibility to duty. Professional maturity requires the development of these behaviors through deliberate practice so that they become the habits that define a good physician. Evaluating professionalism is the responsibility of every clinical teacher. Assessable components include adherence to ethical practice principles, effective interactions with patients and the people who are important to these patients, effective interactions with individuals within the health care system, reliability and accountability, and commitment to improvement.3 The development of professionalism in medical … Address correspondence to April O. Buchanan, MD, Department of Pediatrics, University of South Carolina School of Medicine, Greenville Hospital System University Medical Center, 701 Grove Rd, 4th Floor Balcony Suites, Greenville, SC 29605. E-mail: abuchanan{at}ghs.org

Recruiting and Retaining Community-Based Preceptors: A Multicenter Qualitative Action Study of Pediatric Preceptors

Purpose The recruitment and retention of community preceptors to teach medical students is difficult. The authors sought to characterize the underlying motivational factors for becoming a preceptor and to identify strategies for recruiting and retaining community-based pediatric preceptors. Method This multicenter qualitative action study included semistructured interviews with community-based pediatric preceptors affiliated with 12 institutions from August to December 2015. Only active preceptors were included, and participating institutions were diverse with respect to geographic location and class size. Interviews were conducted over the telephone and transcribed verbatim. Six investigators used deidentified transcripts to develop a codebook. Through a constant comparative method, codes were revised as data were analyzed and disagreements were resolved through discussion. All investigators organized the themes into dimensions. Results Fifty-one preceptors were interviewed. Forty-one themes coalesced into four dimensions: (1) least liked aspects of teaching, (2) preparation to teach, (3) inspiration to teach, and (4) ways to improve recruitment and retention. Time constraints and patient care demands were the most commonly cited deterrents to teaching. Successful preceptors balanced their clinical demands with their desire to teach using creative scheduling. External rewards (e.g., recognition, continuing medical education credit) served as incentives. Internal motivation inspired participants to share their enthusiasm for pediatrics and to develop longitudinal relationships with their learners. Conclusions Changes in health care delivery have imposed more time constraints on community-based preceptors. However, this study identified underlying factors motivating physicians to volunteer as preceptors. Strategies to recruit new and retain current preceptors must be collaborative.

1074 SAFETY AND IMMUNOGENICITY OF A LIVE ATTENUATED RHESUS MONKEY ROTAVIRUS VACCINE

Rotavirus is a major worldwide cause of acute gastroenteritis in children. We recently evaluated a rhesus monkey rotavirus (RRV-1) which shares neutralization specificity with human sero-type 3, as a potential vaccine candidate. We administered RRV-1 (106 TCID50) or placebo orally to 40 adult volunteers who had low or undetectable levels of serum neutralizing antibody under double-blind conditions. Volunteers were evaluated daily for signs and symptoms of gastroenteritis, and stools were examined for RRV-1 by ELISA and tissue culture. Administration of RRV-1 did not induce illness. RRV-1 was shed in the stools of 11/21 (53%) vaccinees for 1 to 6 days without transmission of RRV-1 to other subjects, although one placebo recipient shed wild-type rotavirus from a community-acquired infection. Fourfold or greater serum neutralizing antibody rises to RRV-1 were noted in all vaccinees (21/21) and in 1/18 placebo recipients. Serum antibody rises were also demonstrated by immune adherence hemagglutination in 20/21 volunteers who received RRV-1 and in 1/18 who received placebo, and by complement fixation in 17/21 who received RRV-1 and 0/17 who received placebo. Transient asymptomatic serum ALT and AST rises were seen with similar frequencies in RRV-1 (3/21) and placebo (5/19) recipients. Thus, RRV-1 appears to be attenuated and highly immunogenic in young adults, and warrants additional study in children.