Patricia A. Treadwell

Developing an OSTE to address lapses in learners' professional behavior and an instrument to code educators' responses

Purpose. To develop an instrument for measuring medical educators’ responses to learners’ lapses in professional behavior. Method. In 1999, at the Indiana University School of Medicine, a 22-item checklist of behaviors was developed to describe common responses used by educators responding to learners’ lapses in professional behavior. Four medical students were trained to portray lapses in professional behaviors. These students and seven clinical observers trained to categorize behaviors as present or absent. Interrater reliability was assessed during 18 objective structured teaching evaluations (OSTEs). Videotaped OSTEs were coded twice at a one-month interval for test–retest reliability. Items were classified as low, moderate, or high inference behaviors. Script realism and educator effectiveness were assessed. Results. Educators rated OSTE scripts as realistic. Raters observed an average of 6 ± 2 educator behaviors in reaction to learners’ lapses in professional behavior. Educators’ responses were rated as moderately effective. More experienced educators attempted more interventions and were more effective. Agreement was high among raters (86% ± 7%), while intraclass correlation coefficients decreased with increasing inference level. From videotaped OSTEs, raters scored each behavior identically 86% of the time. Conclusions. Accurate feedback on educators’ interactions in addressing learners’ professionalism is essential for faculty development. Traditionally, educators have felt that facultys responses to learners’ lapses in professional behavior were difficult to observe and categorize. These data suggest that educators’ responses to learners’ lapses in professional behavior can be defined and reliably coded. This work will help provide objective feedback to faculty when engaging learners about lapses in professional behavior.

Cutaneous Histoplasma capsulatum in a nonimmunocompromised patient with previously treated cutaneous Mycobacterium kansasii

This report describes a black woman with a history of cutaneous Mycobacterium kansasii responsive to antituberculous drugs. A culture several years later of cutaneous lesions was also positive for Histoplasma capsulatum. Both cutaneous diseases are rare and most often occur in immunocompromised hosts. There is no known association between these two diseases. This patient may have an as-yet unidentified immunodeficiency that predisposes her to these rare infections. Her case emphasizes the importance of repeat biopsy for atypical skin lesions.

ELEMENTAL MERCURY FOREIGN BODY GRANULOMAS

A 21-year-old white man presented to the local county hospital emergency room (ER) stating that he had injected his left hand and both arms with approximately 50 mm of elemental mercury from a blood pressure column. He had a recent psychiatric history of numerous suicide attempts and left the ER without being seen by a physician. The patient returned 4 days later complaining of swelling and redness of his left hand and arm. On examination his left hand was minimally swollen, erythematous, and very tender. Symptomatic treatment was recommended by poison control, as the patient was without any systemic symptoms after more than 24 hours, and the amount of mercury was thought to be small. The patient was instructed to keep his left arm elevated and to apply ice packs. Five days later the patient was admitted for a self-inflicted gunshot wound to his chest resulting in pulmonary contusions. Chest x-ray revealed numerous small globular opacities in both lung fields. X-rays of the left hand (Fig, 1) and both forearms also showed metallic densities in soft tissues. An abscess on the left hand was incised and drained of pus and globular metallic material. The patient was seen in consultation with psychiatry and was discharged after 3 days. One week after discharge the patient was again seen in the ER for two left hand abscesses, which were incised and drained of pus and metallic material. He was then temporarily lost to follow-up. Ten months later, the patient presented to the Dermatology Department of Indiana University complaining of tenderness and erythema of both arms, and slight weakness of his left hand. Examination revealed geometrically shaped raised erythematous lesions on his left hand (Fig, 2) and left arm. His right arm showed a firm raised area measuring 8 x 10 x 2 cm with normal overlying skin, A punch biopsy was obtained from the patients left hand (Fig, 3). The biopsy showed a diffuse fibrotic reaction in the mid to deep dermis. It also revealed scattered lymphocytes and numerous histiocytes filled with what appeared to be hemosiderin. In addition, there were focal areas containing necrotic debris and polymorphonuclear leukocytes sugges-

Extranodal spread of anaplastic large cell (CD30+) lymphoma presenting as a cutaneous perivascular infiltrate

Cutaneous lesions of anaplastic large cell (CD30+) lymphoma (ALCL) typically present as solitary or multiple ulcerated nodules. This tumor is histologically characterized by a diffuse dermal and sometimes subcutaneous infiltrate composed of bizarre, pleomorphic, neoplastic cells that may be occasionally multinucleated. We report a case of extranodal spread of ALCL to the skin in a 21/2‐year‐old boy presenting as a widespread papular eruption that on biopsy showed lymphoma restricted to the perivascular and periadnexal dermis.

Systemic conditions in children associated with pigmentary changes

Systemic conditions may have pigmentary associations. Prompt recognition of these associations allows the practitioner to initiate the appropriate workup and therapy when indicated. This contribution highlights some of the clinical features of neurofibromatosis 1, LEOPARD syndrome, acanthosis nigricans, hypomelanosis of Ito, incontinentia pigmenti, CHILD syndrome, and piebaldism to assist the dermatologist in making the proper diagnosis.

Cutaneous Tumor and Tumor Syndromes

Cutaneous tumors may be benign or can be associated with more serious medical issues. In some cases reassurance may be appropriate, in other cases further workup may be indicated in order to address possible complications.

The Management of Persistent Pediatric Skin Problems

Skin disease poses an additional problem not usually found in diseases of other systems because the skin is visible, making support and counseling of the parents important. This article deals specifically with management of disorders such as fungus infections of the scalp, acne, urticaria, staphylococcal infection, among others.