Mark A. Ward

Immunogenicity and safety of Haemophilus influenzae type b-tetanus protein conjugate vaccine alone or mixed with diphtheria-tetanus-pertussis vaccine in infants☆☆☆★

Haemophilus capsular polysaccharide-tetanus toxoid conjugate (PRP-T) and diphtheria-tetanus-pertussis (DTP) vaccines were administered in a single syringe (group 1) or separate syringes (group 2) to 284 infants at 2, 4, and 6 months of age. Group 1 infants had a slightly greater incidence of local reactions. Systemic reactions were similar. The geometric mean titers of polyribosylribitol phosphate (PRP) serum antibody concentrations after the third dose of PRP-T vaccine were 4.8 and 4.3 micrograms/ml for groups 1 and 2, respectively. Antibody responses to DTP antigens were also similar. The immunogenicity and safety of the PRP-T and DTP vaccines are equivalent when the vaccines are administered in separate syringes or the same syringe to infants.

Etomidate versus pentobarbital for sedation of children for head and neck CT imaging

Objectives: We compare etomidate to pentobarbital for sedation of children for head and neck computed tomography imaging. Methods: We performed a prospective, randomized, double-blinded trial of patients aged 6 months to 6 years enrolled from the emergency department or radiology department at a large urban childrens hospital. The primary outcome measure was sedation success rate. Results: A total of 61 patients were enrolled in the study (27 etomidate group, 34 pentobarbital group) at 2 different dosing regimens for etomidate. The final analysis group included 17 etomidate patients and 33 pentobarbital patients. The success rate for the etomidate group was 57% at total doses of up to 0.3 mg/kg (n = 7) and 76% at total doses of up to 0.4 mg/kg (n = 17), in contrast to a success rate of 97% for pentobarbital at a total dose of up to 5 mg/kg (n = 33). The success rate for pentobarbital was significantly greater than the final etomidate group (P = 0.04; difference in proportions 20.5%, 95% CI 1.9% to 44.4%). Patients receiving etomidate had significantly shorter induction times (P = 0.02; difference of means 2.1 minutes, 95% CI 0.35 to 3.86), sedation times (P < 0.001; difference of means 31.3 minutes, 95% CI 24.0 to 38.5), and total examination times (P < 0.001; difference of means 53.1 minutes, 95% CI 40.8 to 65.3). Significantly more parents in the etomidate group perceived their child to be back to baseline by discharge from the hospital (P < 0.001; difference of proportions 60.7, 95% CI 29.1 to 92.4) and expressed fewer concerns about their childs behavior after discharge (P = 0.024; difference of proportions 28.6, 95% CI 6.5 to 50.7). Conclusions: At the dosing used in this study, pentobarbital is superior to etomidate when comparing success rates for sedation. However, among the successful sedations, the duration of sedation was shorter in the etomidate group than in the pentobarbital group. Pentobarbital is associated with more frequent side effects and parental concerns compared to etomidate.

What is a clinical pearl and what is its role in medical education

Background: Despite the advent of evidence-based medicine, clinical pearls, verbal and published, remain a popular and important part of medical education. Aims: The purpose of this study was to establish a definition of a clinical pearl and to determine criteria for an educationally sound clinical pearl. Methods: The authors searched the Medline database for material dealing with clinical pearls, examined and discussed the information found, and formulated a consensus opinion regarding the definition and criteria. Results: Clinical pearls are best defined as small bits of free standing, clinically relevant information based on experience or observation. They are part of the vast domain of experience-based medicine, and can be helpful in dealing with clinical problems for which controlled data do not exist. Conclusions: While there are no universally accepted criteria for preparing or evaluating a clinical pearl, we propose some rational guidelines for both.

Shigella vulvovaginitis in a prepubertal child.

A 5-year-old Hispanic girl presented to the Texas Children’s Hospital emergency department with an 8-month history of vaginal discharge. The discharge was yellow and associated with a foul odor; no blood was noted. The discharge was initially minimal but increased in quantity until it began to cause extensive staining of the patient’s underwear. There was associated dysuria but without urinary frequency or urgency. There was no history of diarrheal illness in the patient. A physician had seen the patient in Mexico 8 months earlier and prescribed an unknown oral medication. There was no improvement after this treatment. Because of continued discharge, the patient had also been evaluated and treated with an unknown antibiotic by a physician in the United States 7 months before her visit to our emergency department; again, there was no change in the discharge. There was no vomiting, diarrhea, or fever. The patient’s general health was good, with no history of serious illness or hospitalization. Immunizations were current; she had no allergies and was taking no medications. She lived at home with her mother, father, uncle, 2 cousins, and a family friend. None of the other household members had been ill during our patient’s illness. The general physical examination result was normal. The genital examination was performed under sedation because of the patient’s extreme anxiety. A moderate amount of yellowish discharge was present in the vaginal vestibule. Cultures of the discharge were obtained. Direct visualization and irrigation of the vagina with saline revealed no evidence of a foreign body. A presumptive diagnosis of nonspecific vaginitis was made, and sitz baths were prescribed. In addition, instructions for improved hygiene were provided, and outpatient follow-up was arranged. The vaginal cultures subsequently grew S. flexneri, susceptible to third-generation cephalosporins and resistant to ampicillin and trimethoprim/sulfamethoxazole. The family was contacted, given a prescription for cefixime, and told to come back to the emergency department if the discharge does not resolve. DISCUSSION Vaginal discharge is a common gynecologic complaint of premenarchal children evaluated in the emergency department. Therefore, emergency medicine practitioners need to be able to differentiate the various etiologies and prescribe appropriate therapy. A regular vaginal culture should be obtained in any child with persistent vaginal discharge or in any child with discharge that is suggestive of a bacterial cause before being treated with an antibiotic. Not all vaginal discharges in premenarchal girls are abnormal. Physiological leukorrhea is a normal phenomenon resulting from the effects of estrogen on the vaginal mucosa. The discharge is clear or white and is odorless. There is no associated irritation or pruritis. This entity occurs most commonly in the neonatal period because of placental and maternal hormones. It also occurs in girls nearing menarche because of the estrogen surge that is occurring. Vaginal foreign bodies are another common cause of vaginal discharge, accounting for about 4% of cases in premenarchal girls. The discharge may be profuse and most commonly presents as vaginal bleeding. A vaginal foreign body should be suspected in girls with persistent, recurrent, or severe discharge or premature vaginal bleeding. Direct visualization with or without vaginal irrigation is necessary to make the diagnosis. As in our case, because of the patient’s extreme anxiety and agitation with the physical examination, sedation was necessary to allow for an adequate examination. The need for sedation is rare, and most of patients requiring gynecologic examinations are cooperative if the practitioner approaches the child with patience and understanding. The most common cause of vaginal discharge in prepubertal girls presenting to the emergency department is nonspecific vaginitis, accounting for up to 75% of cases in this age group. Several factors predispose the prepubertal girl to vaginitis. These include the relatively alkaline vaginal pH, the lack of the protective effects of estrogen, the thin vaginal epithelium because of lower estrogen levels, the relative lack of lactobacilli, the immature antibody response, and the variations in the configuration and location of the hymen. In addition, poor hygiene is thought to contribute to the problem by resulting in vulvar and vaginal fecal contamination. This is supported by the frequent isolation of Escherichia coli and other coliform organisms from the discharge in these cases. Some specific organisms that may cause vaginitis and discharge in prepubertal girls include Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. These are rare causes of vaginal discharge in prepubertal girls. Identification of any organism potentially transmitted by sexual contact should raise the possibility of sexual abuse and result in an appropriate evaluation. Illustrative Case

Balancing Service and Education in Residency Training: A Logical Fallacy.

The system of residency training in the United States has at its core a perpetual tension between service and education. Graduate medical education (GME) is financed through prospective payments to teaching hospitals, where house officers compose a significant portion of the health care workforce. Numerous changes have occurred during the past 20 years that have put increasing pressure on this delicate balance. Radical transformation in the structure and process of GME training, most notably duty hour limitations, has led to compression of work, coupled with increasing emphasis on patient safety and quality. Hospitals have simultaneously undergone equally radical changes resulting from economic forces that have intensified pressure on faculty to increase clinical productivity to generate revenue. As a result, less time is available for faculty to teach and for trainees to learn.

Transforming teaching into scholarship

Background:  Traditionally, scholarship has been defined very narrowly as the number of one’s publications and grant awards. Recently this definition has broadened to include dissemination of knowledge, experience or a tangible product shared with the educational community.

Value Placed on Formal Training in Education by Pediatric Department Chairs and Residency Program Directors

BACKGROUND While much is known about how educational leaders at the medical school level (eg, deans) view the importance of formal training in education for medical school teachers, little is known about how leaders at the clinical level (eg, department chairs) view such training. We sought to determine how pediatric department chairs and residency program directors view the value of formal training in education, such as that at a Master of Education (MEd) level, and to estimate the number of clinical pediatric faculty with or pursuing such training. METHODS A survey designed to assess the value placed on formal training in education and to estimate the number of clinical faculty with or pursuing such training was mailed to pediatric department chair persons and residency program directors at all 131 allopathic medical schools in the United States and Puerto Rico. RESULTS Eighty department chairs (61%) responded, and most indicated that when hiring new faculty, they view an applicant with an MEd as having an advantage. Both chairs and residency directors considered an MEd to be advantageous for a residency director by a ranking of 4.5 and 4.2, respectively, on a scale of 1 to 5 (P  =  .008). Of the 80 chairs who responded, 58.8% of respondents reported one or more faculty in their department had or was pursuing an MEd. Of the 72 responding residency directors (55%), 11 respondents (15.3%) indicated that they had an MEd. CONCLUSION More than half the medical school pediatric chairs responding to the survey had one or more clinical faculty with or pursuing an MEd in their departments. Survey results indicated that such training is valued by both department chairs and residency directors. Given the time and expense involved in obtaining an MEd, awareness of these data 5 be helpful to those considering pursuing, offering, or requiring such training.

Third place winner: Three-year-old female with intermittent ovarian torsion

We report an atypical case of ovarian torsion, an uncommon cause of abdominal pain in a very young girl. She presented with intermittent episodes of groin and thigh pain over a 10-week period. The child had minimal objective findings at the time of each evaluation. Despite the delay in diagnosis, the ovary was preserved. Despite its rarity, ovarian torsion must be considered in the differential diagnosis of abdominal pain in young girls.

Automated External Defibrillators and Simulated In-Hospital Cardiac Arrests

OBJECTIVE To test the hypothesis that pediatric residents would have shorter time to attempted defibrillation using automated external defibrillators (AEDs) compared with manual defibrillators (MDs). STUDY DESIGN A prospective, randomized, controlled trial of AEDs versus MDs was performed. Pediatric residents responded to a simulated in-hospital ventricular fibrillation cardiac arrest and were randomized to using either an AED or MD. The primary end point was time to attempted defibrillation. RESULTS Sixty residents, 21 (35%) interns, were randomized to 2 groups (AED = 30, MD = 30). Residents randomized to the AED group had a significantly shorter time to attempted defibrillation [median, 60 seconds (interquartile range, 53 to 71 seconds)] compared with those randomized to the MD group [median, 103 seconds (interquartile range, 68 to 288 seconds)] (P < .001). All residents in the AED group attempted defibrillation at <5 minutes compared with 23 (77%) in the MD group (P = .01). CONCLUSIONS AEDs improve the time to attempted defibrillation by pediatric residents in simulated cardiac arrests. Further studies are needed to help determine the role of AEDs in pediatric in-hospital cardiac arrests.

Strengthening the Pipeline for Clinician-Scientists: The Pediatrician-Scientist Training and Development Program at Texas Children's Hospital

n 1979, Wyngaarden proclaimed the clinician-scientist an “endangered species.” Decades later, despite strong national efforts, it remains challenging to secure durable futures for clinician-scientists. Only 39% of self-identified physician-scientists attain K-series grants and only 25% garner R-level funding. The average age at R01 funding has increased from the mid-30s to the mid-40s, and fewer physicians report research as their primary activity. Physician-scientist challenges have particularly impacted pediatrics; in 2005, pediatric departments captured only 11.3% of National Institutes of Health (NIH) funding, 25% less than 10 years prior.