Lancet, 1993 Aug 21, 342(8869), 457 - 61 Dexamethasone therapy for bacterial meningitis in children . Swiss Meningitis Study Group; Schaad UB et al.; Routine use of steroids as adjunctive treatment of bacterial meningitis remains controversial . We have carried out a prospective, placebo-controlled, double-blind study of dexamethasone in 115 children with acute bacterial meningitis in Switzerland . The patients were randomly assigned to receive either placebo (n = 55) or dexamethasone (n = 60) in addition to optimum antibiotic treatment (100 mg/kg daily ceftriaxone) . Dexamethasone therapy (0.4 mg/kg) was started 10 min before the first dose of ceftriaxone and given every 12 h for 2 days . Baseline demographic, clinical, and laboratory features of the two groups were similar . After 24 h treatment meningeal inflammation as shown by cerebrospinal fluid (CSF) glucose concentration was significantly less with dexamethasone than with placebo (mean increase in glucose 63 {76} vs 40 {75}%, p = 0.008) . However, other indices of inflammation showed similar changes in both groups . Addition of dexamethasone did not affect the rate at which CSF became sterile . Both groups showed prompt clinical responses and similar frequencies of complications (15 vs 12%) . Monitoring for possible adverse effects of dexamethasone revealed no abnormalities . At follow-up examinations 3, 9, and 15 months after hospital discharge, 9 (16%) of 55 placebo recipients and 3 (5%) of 60 dexamethasone recipients had one or more neurological or audiological sequelae (p = 0.066); the relative risk of sequelae was 3.27 (95% CI 0.93-11.47) . Our results and those of similarly designed studies lead us to believe that adjunctive dexamethasone therapy improves outcome from bacterial meningitis in infants and children . We recommend its use, preferably in the dose regimen used in this study. Clin Infect Dis, 1993 Aug, 17 Suppl 1, S37 - 46 Infections caused by Mycoplasma pneumoniae and possible carrier state in different populations of patients; Foy HM; Mycoplasma pneumoniae causes not only pneumonia but also other respiratory syndromes such as bronchitis, bronchiolitis, pharyngitis, and croup . These infections mimic viral respiratory syndromes . Most cases are treated on an outpatient basis . Epidemics take place at intervals of 4-7 years . The incidence rate is highest among school children and second highest among children < 5 years of age . Among persons who have had M . pneumoniae pneumonia, rates of subsequent infection with this organism are low, and immunity appears to increase with age . The carrier state may last for several months . Patients with humoral immunodeficiency often develop severe infections due to M . pneumoniae, with involvement of the joints; in these individuals the carrier state may persist . M . pneumoniae has been isolated from bronchial washings from children with AIDS . These children have recovered from mycoplasmal infection with appropriate antibiotic treatment . Dermatologic, neurological, cardiac, renal, and pulmonary complications occur, although data on their frequency are lacking. Chest, 1993 Aug, 104(2), 366 - 70 Thoracic actinomycosis; Hsieh MJ et al.; Actinomycotic infection is uncommon and primary actinomycosis of the lung and chest wall has been less frequently reported . This disease may present as chronic debilitating illness with radiographic manifestation simulating lung tumor, pulmonary infiltrating lesion, or chronic suppuration . From 1984 to 1990, we experienced 17 cases of thoracic actinomycosis . There were nine patients who presented with a clinical picture of a suppurative lesions and the remaining eight were suspected of having primary lung tumor initially . In no case was an accurate diagnosis made at the time of hospital admission . Final diagnosis was based on aspiration (n = 3), anaerobic sputum culture (n = 1), bronchoscopic biopsy specimens (n = 4), and histologic examination of the resected tissue in the remaining 9 patients who received surgical excision . Among the 17 patients, 8 were treated medically and the other 9 received surgical intervention followed by antibiotic treatment . Regarding the surgically treated patients, suspected malignancy is the most common indication for operation (seven of nine) . However, both medically and surgically treated patients achieved good clinical results, and the postoperative courses were uneventful . We would like to remind physicians of this unusual entity and review our own experience with particular emphasis on the clinical diagnosis and management of this unique disease. Intern Med, 1993 Aug, 32(8), 659 - 62 Serial bronchoalveolar lavage studies in a patient with intra-alveolar fibrosis following Legionnaires' disease; Nishi E et al.; A 48-year-old male developed acute respiratory failure owing to Legionnaires' disease (LD) . Antibiotic treatment including erythromycin and rifampicin was not effective, thus transbronchial lung biopsy was performed . The histological examination of the lung showed intra-alveolar fibrosis . Corticosteroid therapy was begun and he responded well with definite clinical improvement . Bronchoalveolar lavage (BAL) was performed three times in the following year . The first BAL showed an increase of lymphocytes which then decreased significantly in the following studies . This case report thus demonstrates the importance of lung biopsy of protracted LD and the usefulness of BAL in the assessment of corticosteroid therapy. J Belge Radiol, 1993 Aug, 76(4), 234 - 6 Xanthogranulomatous pyelonephritis in a child; de Foer B et al.; Xanthogranulomatous pyelonephritis is an uncommon form of chronic aggressive infection of the kidney and surrounding tissues usually affecting middle aged women . It is rarely seen in childhood . We report the case of a female child with a history of fatigue, progressive anorexia, and fever in whom a diagnosis of pyelonephritis on a predisposing factor of lithiasis was suggested . After initial antibiotic treatment, nephrectomy was needed for an acute general deterioration . Pathology demonstrated xanthogranulomatous pyelonephritis. Surg Gynecol Obstet, 1993 Aug, 177(2), 126 - 30 Infection in inguinal hernia repair considering biomaterials and antibiotics; Gilbert AI et al.; Synthetic biomaterials have been incriminated for promoting wound infection . Perioperative antibiotics have received praise for reducing the rate of infection after certain operations . These claims were tested in a cooperative multicenter prospective study of 2,493 inguinal hernia repairs . This study was done to examine the effect of prophylactic antibiotics in primary and recurrent inguinal hernia repaired with synthetic biomaterials . Clinical signs and symptoms of wound infection and the results of each infected repair are reported . The rate of infection was about 1 percent, whether or not biomaterials or antibiotics were used . More than 70 percent of wound infections occurred in patients 60 years of age or older . Removal of biomaterials from the infected wounds was not necessary and generally is not recommended . Recurrence has not occurred in any of the infected repairs . With or without prosthetic repair, the treatment of infected inguinal hernia wounds was relatively simple, of reasonable cost and concluded with a good result . The expense incurred for routine prophylactic antibiotic treatment in inguinal hernia operation could not be reconciled by any benefits obtained. Jpn J Antibiot, 1993 Aug, 46(8), 697 - 705 {Effect of combination therapy with sulbactam/cefoperazone and amikacin in the treatment of infectious diseases accompanied by hematological disorders}; Matsushima T et al.; We studied the efficacy and safety of a combination therapy with sulbactam/cefoperazone (SBT/CPZ) and amikacin (AMK) on severe infections in the patients with hematological disorders . We administered SBT/CPZ and AMK to 65 patients and analyzed the result of 57 patients, except for 8 drop outs, for evaluation . The overall clinical efficacy of this combination therapy was 64.9% (excellent in 15 patients, good in 22 patients) . Thirty seven patients had sepsis and suspected sepsis . The efficacy was 67.6% in these patients . The rate of improvement in the cases (18 patients) with neutrophil counts under 500/mm3 during the administration among 28 patients who had not responded to prior antibiotic treatment was 67.9% . Diarrhea was found in 1 patient as an apparent side effect likely related to this drug regimen . It appears that combination therapy of SBT/CPZ and AMK was a useful regimen in the treatment of infectious diseases complicated with hematological disorders. Gut, 1993 Aug, 34(8), 1145 - 7 Lithotripsy of an impacted calcified stone in the cystic duct accompanied by cholecystitis in severe Crohn's disease; Stolzel U et al.; A 35 year old women patient with Crohn's disease and previous multiple abdominal operations presented with a calcified stone of 12 mm diameter in the cystic duct giving rise to cholecystitis . The surgeons declined to operate because of extensive intra-abdominal adhesions caused by multiple intestinal resections and chronic enterocutaneous fistulas . It was possible to fragment the stone in three lithotripsy sessions . The fragments were excreted spontaneously through the ductus choledochus and the cholecystitis was cured by antibiotic treatment . The patient remained symptom free after 12 months. Clin Infect Dis, 1993 Aug, 17(2), 218 - 23 High levels of tumor necrosis factor-alpha and interleukin-6 in the ascitic fluid of cirrhotic patients with spontaneous bacterial peritonitis; Zeni F et al.; We prospectively measured the concentrations of immunoreactive tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1), and interleukin-6 (IL-6) in the serum and ascitic fluid of 14 alcoholic cirrhotic patients with spontaneous bacterial peritonitis (SBP) and 16 alcoholic cirrhotic patients with sterile ascitic fluid . TNF-alpha levels in ascitic fluid were significantly higher for the patients with SBP: 399.57 +/- 129.23 pg/mL vs . 35.76 +/- 5.57 pg/mL (P < .001) . IL-6 levels in ascitic fluid were also significantly higher for the patients with SBP: 170,713 +/- 57,109 ng/mL vs . 5,414 +/- 973 ng/mL (P < .001) . By contrast, serum levels of TNF-alpha and IL-6 were just slightly more elevated than normal values . The concentration of IL-1 in the ascitic fluid of all patients was elevated, but there was no difference between patients with SBP or sterile ascites in this respect . In the patients with SBP, levels of TNF-alpha and IL-6 in ascitic fluid decreased during the first 48 hours of antibiotic treatment . Our results suggest that measurements of TNF-alpha and IL-6 in ascitic fluid may become useful markers both for the diagnosis of SBP and for monitoring the treatment of cirrhotic patients. Dtsch Med Wochenschr, 1993 Jul 2, 118(26), 975 - 8 {Pulmonary valve endocarditis and atrial fibrillation}; Harder D et al.; A 61-year-old man became ill with a fever of 39.4 degrees C, decreased exercise tolerance and headache as well as chest pain . Physical examination 3 weeks after the onset of symptoms merely revealed irregular heart rate at 100 beats/min . Erythrocyte sedimentation rate was increased (30/61 mm), as were serum bilirubin, lactate dehydrogenase, alkaline phosphatase, gamma-GT and C-reactive protein . The ECG showed atrial fibrillation with a rapid and irregular ventricular rate, as well as ventricular extrasystoles (Lown type IIIA), there were no abnormal findings on either the chest radiography or transthoracic echocardiography . Antiarrhythmic treatment brought about atrial flutter with 4:1 a-v conduction . Transoesophageal echocardiography now revealed vegetation on the pulmonary valve and microthrombi in the left atrial appendage . Ten days after starting intravenous penicillin G (10 mega units four times daily), gentamycin (60 mg three times daily) and heparin (30,000 units over 24 h) sinus rhythm was restored, the vegetation had got smaller and no thrombi were demonstrated . After 27 days antibiotic treatment was changed to oral penicillin V . After 4 weeks the patient was discharged symptom-free. Monatsschr Kinderheilkd, 1993 Jul, 141(7), 602 - 6 {Necrotizing enterocolitis in the newborn infant . Pathogenetic risk factors in a 3 year analysis}; Bosse U et al.; In a clinical study possible risk factors causing necrotizing enterocolitis (NEC) were studied in 17 preterm infants with NEC and compared with a control group of 17 healthy preterm infants . We found a more frequent rate of blood exchange transfusions and a lower rate of breast milk feeding in patients who later developed NEC than in the control group . But there were no differences between both groups concerning factors promoting hypoxia of the gut, the number of infections, antibiotic treatment, or hyperosmolar enteral feeding . The preterm infants with NEC did not show any characteristics in history, physical examination and clinical course . These children could not be distinguished as a risk group for this illness from the newborn infant control group . Therefore, with the exception of breast milk feeding, no special prevention of the necrotizing enterocolitis can be recommended. Am J Hosp Pharm, 1993 Jul, 50(7), 1424 - 6 Diagnoses and prescribing for pediatric patients at two hospitals in Harare, Zimbabwe; Kasilo OM et al.; PIP: During March-August 1990 in Zimbabwe, researchers reviewed the medical records of 500 consecutive patients, 0-12 years old, at Harare Hospital and Parirenyatwa Hospital to lean what the most frequent pediatric diagnoses were and to compare prescribing patterns . These hospitals were of comparable size but served different populations . Patients at Harare Hospital tended to have a lower income and be children than those at Parirenyatwa Hospital . Parirenyatwa Hospital specialized in cardiovascular, hematology, medicine, and oncology services . Clinicians identified 737 diagnoses . The most common diagnoses included respiratory infections (39.4% of patients), gastroenteritis (16.8%), malnutrition (10.4%), sepsis (9.6%), and AIDS (8.6%) . 97.8% of the children received at least 1 medication (1725 prescriptions) . The mean drugs prescribed per patient stood at 3.45 (range, 0-18) . Patients with AIDS accounted for the high end of the range . The most frequently prescribed drug type was antibiotics (about 35%), especially penicillin . The recommended duration of antibiotic treatment is 7-14 days, but the mean duration among these children was only 5.1 days . Harare Hospital had more patients admitted for infections and neurologic conditions than did Parirenyatwa Hospital (47.1% vs . 35.% and 4.5% vs . 2%, respectively), which accounted for the higher prescription rate for anti-infective drugs and central nervous system drugs at Harare Hospital (55.4% vs . 47.3%, and 3.5% vs . 2.6%, respectively) . Parirenyatwa Hospital had more surgical procedures and febrile convulsions than Harare Hospital, which explained why it had higher prescription rate for analgesics (12.5% vs . 8.7%) . It also had more children diagnoses with respiratory infections . Harare Hospital had more malnutrition, sepsis, and AIDS pediatric cases . Since the two hospitals served different socioeconomic populations, it was not surprising to find differences in prescription patterns, which were appropriate and tended to abide by the Essential Drugs List recommendations . J Clin Psychiatry, 1993 Jul, 54(7), 263 - 8 Psychiatric manifestations of Lyme borreliosis; Fallon BA et al.; BACKGROUND: Lyme borreliosis (Lyme disease), a tick-borne spirochetal illness, has later manifestations that may include arthritic, neurologic, ophthalmologic, and cardiac symptoms . Recent reports suggest psychiatric symptoms may also be part of the clinical picture . METHOD: Using a structured interview (SCID), we interviewed three patients who had developed a psychiatric disorder for the first time after infection with Borrelia burgdorferi . RESULTS: During Lyme borreliosis, one patient had major depression and panic disorder, one patient had an organic mood syndrome with both depression and mania, and the third patient had panic disorder . These disorders remitted after adequate antibiotic treatment . CONCLUSION: While depression has been previously linked to neuroborreliosis, this is the first report to link panic disorder and mania with borrelial infection . Because of the rapid rise of Lyme borreliosis nationwide and the need for antibiotic treatment to prevent severe neurologic damage, mental health professionals need to be aware of its possible psychiatric presentations. Rofo, 1993 Jul, 159(1), 28 - 32 {The percutaneous aspiration and drainage of infected fluid retention after organ transplantation}; Schimmerl S et al.; Local postoperative infections in immunosuppressed patients carry a high mortality rate . In this group of patients interventional radiological procedures are particularly valuable in diagnosis and treatment . We report on the results of radiologically controlled aspirations (11 cases) and drainage (37 cases) of infected fluid collections in 47 patients following transplantation of various organs . By percutaneous aspiration or drainage, 91.7% of infected fluid collections were successfully treated or the clinical condition of the patient improved so that surgical intervention could be avoided . The causative organism was identified and antibiotic treatment carried out in 72.9% (35 cases) . Surgical intervention was necessary in only 4.3% (2/48) . Needle aspiration or drainage of percutaneously accessible fluid collections thought to be infected appears to be particularly useful for transplant patients at increased risk and is a good alternative to surgical treatment. Surg Gynecol Obstet, 1993 Jul, 177(1), 49 - 53 Placement of central venous catheters by cut-down with electrocardiogram positioning; Redo SF et al.; A technique of placement of central venous catheters for hyperalimentation, long term antibiotic treatment or chemotherapy by cut-down and positioning of the catheter tip with intravascular electrocardiography is described . The method was used in 384 patients during a period of four years . The patients varied from premature newborns to adolescents . The external jugular vein was used in 218 patients, the internal jugular vein in 150, the cephalic vein in 11 and the axillary vein in five . Catheters were successfully positioned by electrocardiogram (ECG) control in 95 percent of the patients . In only 5 percent of the patients, the ECG was difficult to interpret because of interference, poor electrode contact or unsatisfactory ECG image or tracing . Roentgenograms to check catheter location did not have to be done in the operating room . Confirmation of catheter position was done in the recovery room or on return to the neonatal intensive care unit . Using the cut-down procedure described, there were no complications, such as bleeding or chest wall infections, along the course of the catheter. Postgrad Med, 1993 Jul, 94(1), 133 - 4, 137-42 Erythema migrans . Rash as key to early diagnosis of Lyme disease; Masters EJ; The presence of erythema migrans offers physicians the best opportunity for diagnosis and treatment of Lyme disease . Serologic testing has poor sensitivity in patients with early disease . Therefore, aggressive antibiotic treatment initiated solely on the basis of clinical findings is appropriate . A number of recently studied regimens have shown success against the infection. Ophthalmology, 1993 Jul, 100(7), 998 - 1002 Primary T-cell immunoblastic lymphoma of the orbit in a pediatric patient; Leidenix MJ et al.; BACKGROUND: The authors report a case of an 8-year-old pediatric patient with a 2-week history of painless periorbital swelling unresponsive to antibiotic treatment . METHODS: Computed tomography (CT) showed a large, lateral, anterior left orbital soft tissue mass with bony erosion into the anterior cranial fossa through the roof of the orbit laterally . Surgical exploration showed a hard white mass that had eroded through the roof of the left orbit and into the anterior cranial fossa, with herniation of the brain and associated dura through the defect . Results of a complete evaluation of the child for systemic lymphoma, including a lumbar puncture, chest x-ray, bone scan, bone marrow aspirate, and chest/abdomen CT, were negative . RESULTS: Results of histopathologic and immuno-histochemical evaluation showed a primary orbital T-cell immunoblastic lymphoma . The patient was treated with intrathecal ara-C (Cytosar-U) and methotrexate, 16.2 Gy of whole brain irradiation, and a chemotherapeutic protocol consisting of cyclophosphamide (Cytoxin), vincristine (Oncovin), methotrexate, daunomycin, and prednisone . The patient remains free of lymphoma 33 months after diagnosis, with 20/20 visual acuity in both eyes . CONCLUSION: The authors believe that this is the youngest documented case of a primary T-cell immunoblastic lymphoma of the orbit. Klin Padiatr, 1993 Jul-Aug, 205(4), 264 - 71 {Long-term treatment with recombinant human granulocyte colony stimulating factor in patients with severe congenital neutropenia}; Zeidler C et al.; Severe congenital neutropenia is a disorder of myelopoiesis characterized by severe neutropenia secondary to either a maturational arrest of myelopoiesis at the level of promyelocytes (Kostmann-Syndrome; SCN) or regular cyclic fluctuations in the number of blood neutrophils with a median ANC below 500/microliter (cyclic neutropenia) . We have treated 32 patients with SCN and 4 patients with cyclic neutropenia . Thirty of 32 patients with SCN and all 4 patients with SCN responded to r-met HuG-CSF treatment with an increase of the median ANC to above 1000/microliter . The doses needed to achieve and maintain the response varied between 0.8 and 120 micrograms/kg/d . Long-term treatment did not exhaust the myelopoiesis: The mean ANC remained stable up to 5 years of treatment . The increase in ANC was associated with dramatic clinical responses: significant reduction of severe bacterial infections, reduction of intravenous antibiotic treatment episodes, and reduction of hospitalizations . No severe bacterial infections occurred in any of the r-met HuG-CSF responders during long-term treatment . Severe adverse event, most likely associated with the underlying disease, included the development of MDS/Leukemia in two patients, and osteopenia/osteoporosis in 12 patients . These results demonstrate the beneficial effects of r-met HuG-CSF treatment in severe congenital neutropenia patients. Cas Lek Cesk, 1993 Jun 28, 132(13), 393 - 6 {Candida sepsis . I . Risk factors, pathogenesis and the clinical picture}; Dlouhy P et al.; Candida sepsis is a serious and ever increasing complication in patients with a reduced defense capacity . At the intensive care unit of the infectious department in 1978-1990 from a total of 430 patients with the diagnosis of sepsis 20 (4.7%) had a Candida aetiology . Candida sepsis is suspected in particular in leukaemic patients with neutropenia, in organ transplantations and in patients given intensive care on account of a serious primary disease, bacterial infection or after surgery . The risk of deep candidosis is increased by venous catheters, hyperalimentation, antibiotic treatment, invasive operations . Diagnosis is supported by endophthalmitis and skin lesions; signs of affection of the liver, lungs, kidneys and cardiac valves are sought . Analysis of risk factors, pathogenesis and the clinical picture of invasive Candida infections is based on ample data in the literature. Arch Intern Med, 1993 Jun 14, 153(11), 1380 - 3 Complement factor I deficiency with recurrent aseptic meningitis; Bonnin AJ et al.; Patients with deficiency of the complement regulatory protein factor I typically present with systemic pyogenic bacterial infections, including meningitis . We report a novel case with total deficiency of factor I in serum and plasma; the patient experienced nine consecutive episodes of aseptic meningitis within a 2-year period . There was no history of previous bacterial sepsis . Aseptic meningitis recurred despite attempted penicillin prophylaxis . Each episode resolved rapidly without sequelae, with or without antibiotic treatment . Serum complement profiles showed persistently low levels of C3, factor B, and factor H and undetectable factor I protein . Family complement studies could not be performed . Except for a minimally increased titer of antinuclear antibody, no other immunologic abnormality was detected . Results of an oral ibuprofen challenge were negative . We conclude that deficiency of factor I may predispose to aseptic, as well as pyogenic bacterial, meningitis. Dtsch Med Wochenschr, 1993 Jun 4, 118(22), 814 - 9 {Disseminated toxoplasmosis in AIDS}; Holch A et al.; Within one year a 46-year-old HIV-positive man developed Pneumocystis carinii pneumonia, candida oesophagitis and recurrent mucocutaneous herpes simplex infections . He finally developed a constant fever without any infection-localizing features . There was pancytopenia, increased activities of the transaminases, lactate dehydrogenase, amylase and lipase, as well as diffuse ST-segment changes in the ECG and discrete pulmonary infiltrates . The anti-toxoplasmosis titre was 8 IU/ml . Despite extensive diagnostic tests no firm diagnosis could be established . The pulmonary infiltrate and the fever regressed under antibiotic treatment with co-trimoxazole . Two months later his general condition deteriorated again with some disorientation and subfebrile temperature, epididymitis and renewed rise in abnormal laboratory values . For the first time computed tomography showed some punctate contrast-medium concentrations in the subcortical area and the medulla . The patient died on the same day . Histological material obtained at the time of autopsy revealed pseudocysts with Toxoplasma gondii and necrotizing inflammation in the brain, myocardium and lungs, as well as the entire gastrointestinal and urogenital tracts . In addition, cytomegalovirus infection of the lung and adrenals was demonstrated . Anti-toxoplasmosis IgG titre, determined postmortem, again registered a marked rise to 251 IU/ml . This suggests that there was reactivation of the toxoplasmosis as part of the immunosuppression process. Arch Ophthalmol, 1993 Jun, 111(6), 837 - 40 Chronic Nocardia asteroides endophthalmitis after extracapsular cataract extraction; Zimmerman PL et al.; A 65-year-old man underwent an uncomplicated extracapsular cataract extraction with placement of a posterior chamber intraocular lens . The patient developed delayed-onset chronic endophthalmitis caused by Nocardia asteroides . This was confirmed on multiple intraocular cultures, as well as histopathologic examination of the lens capsular bag . The patient was treated with periocular, intravitreal, and systemic antibiotic treatment, combined with intraocular lens removal, total capsulectomy, and three vitrectomies in an attempt to eradicate the organism and calm the eye . The patient went on to develop widespread endophthalmitis that required enucleation of the infected globe . To our knowledge, this is the first case of delayed-onset chronic endophthalmitis caused by N asteroides after extracapsular cataract extraction with a posterior chamber intraocular lens. Curr Opin Neurol Neurosurg, 1993 Jun, 6(3), 403 - 9 Bacterial meningitis and Lyme neuroborreliosis in childhood; Christen HJ; Neurologic infections represent a major problem in child neurology . Recent research on this issue has had important implications for diagnosis and pathophysiology of infectious diseases of the child's brain, resulting in new therapeutic approaches . A better understanding of the molecular pathophysiology of bacterial meningitis has developed, and therapeutic interventions focus on the host's inflammatory response . Therapeutic trials with dexamethasone in addition to antibiotic treatment have yielded promising results in reducing morbidity and long-term neurologic sequelae in bacterial meningitis . The detection of Lyme borreliosis in 1977 substantially influenced the differential diagnosis of inflammatory central nervous system diseases . Lyme neuroborreliosis proved a main cause of acute peripheral facial palsy and aseptic meningitis in children . An effective antibiotic treatment has become available for a large number of patients with these illnesses. Chest, 1993 Jun, 103(6), 1897 - 9 Melioidosis pneumonia and blast injury; Wang CY et al.; We present the case of a 24-year-old woman with acute septicemic melioidosis resulting from inhaled infective dust during a blast injury . With appropriate antibiotic treatment and supportive therapy in the ICU, the patient made an uneventful recovery. Chest, 1993 Jun, 103(6), 1819 - 25 Resting energy expenditure . Evolution during antibiotic treatment for pulmonary exacerbation in cystic fibrosis; Naon H et al.; STUDY OBJECTIVES: To compare the changes in resting energy expenditure (REE) to concomitant changes in clinical status and pulmonary function in cystic fibrosis (CF) patients during treatment for acute pulmonary exacerbation . To determine if weight loss during exacerbation in CF is related to decreased calorie intake or increased energy needs . DESIGN: Measurements of REE, pulmonary function tests, oxygen saturation, respiratory rate, maximal inspiratory pressure (MIP), white blood cell count, chest x-ray films and attribution of clinical score (ACS) on admission, mid-hospitalization, and discharge . Anthropometric measurements on admission, assessment of dietary intake and nitrogen balance upon admission and prior to discharge . SUBJECTS: Thirteen CF patients admitted for treatment of acute pulmonary exacerbation with a mean age of 11.0 +/- 7.9 (SD) years . RESULTS: From admission to discharge, REE decreased from 44.5 +/- 9.0 to 33.8 +/- 8.5 kilocalorie (kcal)/kg/d (p < 0.003) . Similarly, the ACS improved from 7.5 +/- 2.0 to 4.0 +/- 2.2 (p < 0.0001); the absolute neutrophil count decreased from 10,685 +/- 6,226/microliters to 6,363 +/- 168/microliters (p < 0.005); respiratory rate decreased from 32.6 +/- 6.2 to 25.0 +/- 3.7 breaths per minute (p < 0.01); and MIP increased from 77.5 +/- 20.0 to 90.0 +/- 20.4 cm H2O (p < 0.01) . In parallel, less significant improvements occurred in pulmonary function tests, oxygen saturation and chest x-ray film scores . Calorie intake was 1,893 +/- 635 and 2,054 +/- 707 kcal/d on admission and discharge, respectively (p = NS); during hospitalization, weight increased from 23.6 +/- 10.1 to 25.7 +/- 10.1 kg (p < 0.005) . While carbohydrate and fat content of the diet remained essentially unchanged, a significant increase in protein intake (3.15 +/- 0.92 to 3.5 +/- 0.81 g/kg/d {p < 0.05}) and in nitrogen balance (1.8 +/- 2.5 to 5.6 +/- 2.9 g of nitrogen per day {p < 0.05}) were observed . CONCLUSIONS: In acute CF, pulmonary exacerbation, changes in REE parallel those of clinical improvements and are more sensitive than pulmonary function tests and chest x-ray films as an objective clinical correlate . Increased metabolic requirements but not decreased dietary intake are the cause of weight loss in CF patients. Clin Otolaryngol, 1993 Jun, 18(3), 178 - 80 Parental cigarette smoking and tonsillectomy in children; Hinton AE et al.; The deleterious effects of parental smoking on the upper respiratory tracts of children are becoming increasingly recognized . This study examines the effect of parental smoking on the frequency of tonsillitis and incidence of tonsillectomy in children . A group of children being admitted for tonsillectomy and a control group of children from an orthoptic clinic were studied . Details recorded about the children included a history of tonsillectomy and the number of courses of antibiotics taken for sore throats in the previous 12 months . Parents were questioned about their smoking habits . A marked and statistically significant association has been found between the incidence of tonsillectomy in children and parental smoking in the home environment . There was a higher frequency of attacks of tonsillitis requiring antibiotic treatment in those children whose parents smoked . This effect may be mediated by altered oropharyngeal flora, mucociliary dysfunction, increased cross infection or a combination of these . If parents are encouraged to stop smoking there will be a reduction in tobacco smoke levels in the home environment and this should lead to a fall in both the incidence of tonsillitis and the need for tonsillectomy in their children. Ann Cardiol Angeiol (Paris), 1993 Jun, 42(6), 331 - 8 {Infectious endocarditis on permanent endocavitary pacemakers: value of echocardiography and review of the literature}; Kugener H et al.; Infectious endocarditis around indwelling pacemakers is rare (0.15% of all implantations) . They have a gloomy prognosis with a global mortality rate of nearly 34% as emerges from this review of the literature concerning 58 cases of infectious endocarditis published within the past 16 years . On the basis of the 6 cases which the authors report, they stress the importance and sometimes difficulty of using ultrasound in a positive diagnosis . Cardiographic ultrasound, which can determine the size and emboligenic nature of vegetations is capital in choosing how to remove the pacemakers . Percutaneous ablation by simply pulling or by catheterization currently gives the best results, but it may be necessary to resort to surgery involving right atriotomy if emboligenic vegetations are present . By combining antibiotic treatment and ablation of the intracavitary material, a cure is obtained in 92% of cases . These figures should be compared with the lack of success of using antibiotic treatment alone which results in a high level of mortality (84%). Infect Dis Clin North Am, 1993 Jun, 7(2), 295 - 329 Diagnosis of ventilator-associated pneumonia; Meduri GU; Ventilator-associated pneumonia is a frequent complication of mechanical ventilation, and it carries a significant added mortality . Proper recognition and treatment of pneumonia are associated with improved outcome . Clinical manifestations of pneumonia, chest radiograph findings, and routine analysis of the tracheal aspirate are inadequate, alone or in combination, in diagnosing pneumonia . This article discusses the methodologies that are presently available for diagnosing pneumonia in ventilated patients . Correct use of these techniques helps the clinician to establish a diagnosis with a high degree of reliability and facilitates the rational use of antibiotic treatment. Dtsch Med Wochenschr, 1993 May 14, 118(19), 701 - 4 {Extrathoracic prolapse of the pulmonary parenchyma after a bout of coughing with spontaneous serial rib fractures}; Rob PM et al.; A 54-year-old man with an feverish infection of the lower respiratory tract developed severe pain in the lateral and basal part of the left thorax after a severe coughing bout . A haematoma occurred at the site and it looked as though tissue evaginated at that spot on coughing and pressing . The clinical diagnosis was pneumonia and abnormal mobility of the eighth to tenth rib on the left with crepitations . The chest radiograph demonstrated fractures of these ribs and extrathoracic sickle-shaped collection of air in the left laterobasal area . Computed tomography additionally showed prolapse of pulmonary tissue on pressing . This was thus a case of "cough fracture", complicated by herniation of lung tissue . There was no evidence of incarceration of lung tissue and, as the patient was very obese, surgery was not indicated . Symptoms and signs of infection regressed on symptomatic and antibiotic treatment . The rib fractures healed as pseudoarthroses . Lung tissue prolapse on pressing was still present 3 months later. Rev Clin Esp, 1993 May, 192(9), 437 - 40 {Thoracic actinomycosis . Presentation of 3 cases}; Roger N et al.; We have had the chance to follow three patients with thoracic actinomycosis in a relatively short period of time (18 months) . They were three male patients, with chronic dental infections . The illness appeared as toxic syndrome and fever . In all three cases diagnosis was made through samples obtained through fibropticbronchoscopy . At the same time all of them evolved favorably to the antibiotic treatment (penicillin and/or tetracyclines) prescribed . We conclude that the diagnosis of thoracic actinomycosis should be suspected in those patients with a compatible clinical and radiological condition, and who has suffered previous weakening diseases and periodontal lesions. Arch Androl, 1993 May-Jun, 30(3), 183 - 91 Effect of early antibiotic treatment on the formation of sperm antibodies in experimentally induced epididymitis; Greskovich F et al.; This investigation was conducted to evaluate whether or not experimentally produced epididymitis could induce the development of cytotoxic sperm antibodies and if effective antibiotic therapy could reverse the development of immunity to sperm . Escherichia coli was injected into the tail of the epididymis in adult Lewis rats to induce epididymitis and was allowed to incubate for 24 h, 72 h, 8 days, or 15 days . Serum titers of cytotoxic sperm antibodies at these time intervals were determined . Sperm antibody titers began to rise 3 days after inoculation, peaked, and plateaued at 8 days . The titers were negligible in the control rats . Two other groups of rats were inoculated with E . coli in a similar manner and were treated with tetracycline 25 mg/kg/day starting at either 24 h or 8 days after inoculation, for 7 days . The antibody titers became negligible in these two treated groups, the results being statistically significant when contrasted with the infected but untreated groups (p < .001 and < .05, respectively, for the 24-h and 8-day groups) . However, histological examination of the antibiotic-treated and untreated specimens revealed significant inflammation and infection of the epididymis in both treated groups . Testicular alterations were consistent in both groups . It is concluded that epididymitis consequent to infection with E . coli can induce cytotoxic antibody formation in Lewis rats . Treatment with appropriate antibiotics may suppress the antibody response either through a direct immunosuppressive effect of the antibiotic or through a decrease in the antigenic load of killed sperm secondary to eradication of the infection. Radiol Clin North Am, 1993 May, 31(3), 667 - 76 The newborn chest; Wood BP; Newer therapeutic techniques in the respiratory management of preterm and full-term neonates have resulted in improved survival, particularly in those infants who have respiratory distress syndrome, severe pneumonia, and surgical lesions of the chest . Although respiratory distress syndrome is being seen less frequently because of improved ventilatory management and the use of surfactant replacement therapy, the increased survival of preterm infants has resulted in an increased incidence of bronchopulmonary dysplasia, still a frequently seen pulmonary abnormality . Children who have severe pulmonary disease related to diaphragmatic hernia, meconium aspiration pneumonia, and infectious pneumonia are treated with extracorporeal membrane oxygenation, resulting in a higher survival rate and better outcome . Other abnormalities of the lung, including pneumonia, are seen in both preterm and full-term infants, have characteristic radiographic appearances, and require prompt antibiotic treatment. Arch Pathol Lab Med, 1993 May, 117(5), 540 - 1 Anergic disseminated toxoplasmosis in a patient with the acquired immunodeficiency syndrome; Artigas J et al.; Cerebral toxoplasmosis is the most common cause of focal brain disease in patients with the acquired immunodeficiency syndrome . A 24-year-old human immunodeficiency virus-infected woman with two previous episodes of Pneumocystis carinii pneumonia presented with diarrhea and fever . Despite antibiotic treatment, septic shock developed, and she died 3 weeks after the symptoms began . Histologic and histochemical studies revealed an anergic toxoplasmosis with dissemination in all examined organs . There were multiple foci of toxoplasmic cysts and free tachyzoites, sometimes with minute areas of necrosis, but no inflammatory reaction at all . Since effective treatment of toxoplasmosis is available, the occurrence of this rare form of toxoplasmosis should be kept in mind. J Infect Dis, 1993 May, 167(5), 1074 - 81 Invasion of human skin fibroblasts by the Lyme disease spirochete, Borrelia burgdorferi; Klempner MS et al.; The ability of Borrelia burgdorferi to attach to and invade human fibroblasts was investigated by scanning electron and confocal microscopy . By scanning electron microscopy, B . burgdorferi were tightly adherent to fibroblast monolayers after 24-48 h but were eliminated from the cell surface by treatment with ceftriaxone (1 microgram/mL) for 5 days . Despite the absence of visible spirochetes on the cell surface after antibiotic treatment, viable B . burgdorferi were isolated from lysates of the fibroblast monolayers . B . burgdorferi were observed in the perinuclear region within human fibroblasts by laser scanning confocal microscopy . Intracellular spirochetes specifically labeled with monoclonal anti-flagellin antibody were also identified by fluorescent laser scanning confocal microscopy . These observations suggest that B . burgdorferi can adhere to, penetrate, and invade human fibroblasts in organisms that remain viable. Arch Otolaryngol Head Neck Surg, 1993 May, 119(5), 561 - 2 Actinomycosis otomastoiditis; Tarabichi M et al.; We reviewed the reported experience with actinomycosis otomastoiditis in the international literature, along with a recent case from our experience . All recently reported cases presented with persistent drainage and partial response to multiple courses of antibiotics . Diagnosis was uniformly made postoperatively, and the outcome was excellent following a prolonged course of antibiotic treatment. Am J Otolaryngol, 1993 May-Jun, 14(3), 179 - 86 Acute "idiopathic" peripheral facial palsy: clinical, serological, and cerebrospinal fluid findings and effects of corticosteroids; Hyden D et al.; INTRODUCTION: The causes for peripheral facial palsy remain obscure in many patients . Evidence exists suggesting viruses, especially those belonging to the herpesvirus group, may be causative . This study was developed to evaluate this theory . METHODS: One hundred forty-seven patients with acute peripheral facial palsy of primarily unknown origin were studied . All were examined within 1 week of onset . Subsequent follow-up was undertaken until the palsy had recovered or become static . Paried cerebral spinal fluid and serum samples were obtained for serological evaluation to detect herpes simplex, varicella zoster, cytomegalovirus, measles, mumps, rubella, tick-borne encephalitis, adenovirus, Epstein-Barr virus, and human immunodeficiency virus, as well as the antibodies to Borrelia burgdorferi . RESULTS: Elevated antibiotic titers to Borrelia burgdorferi were observed in 11% of patients, whereas 9% of patients demonstrated elevated viral titers . Antibody pattern consistent with Epstein-Barr virus reactivation was present in 13% . A total of 67% were classified as idiopathic . CONCLUSION: Patients with reactivated Epstein-Barr virus were characterized by having a higher incidence of auricular pain and displayed diabetes mellitus in a higher frequency than in other groups . In the Borrelia group, neck/back pain was more common . Healing was less favorable in the Borrelia group despite an equal rate of palsy at onset and adequate antibiotic treatment . Corticosteroid treatment used in 44% of the patients did not significantly improve the functional outcome. Mycopathologia, 1993 May, 122(2), 115 - 22 Disseminated trichosporonosis in a neutropenic murine model; Hospenthal D et al.; Life-threatening disseminated infection with Trichosporon beigelii (trichosporonosis) is a rare mycosis most commonly seen in patients with hematologic malignancies made neutropenic by cytotoxic therapy . This infection is usually resistant to conventional antifungal therapies . Poor correlation between therapeutic outcome of trichosporonosis and in vitro susceptibility of clinical isolates of T . beigelii to antifungal agents is often reported . To obtain a better understanding of its pathogenesis, and to aid in the future study of the therapy of this disease, a murine model of trichosporonosis was developed . The in vitro growth of clinical isolates of T . beigelii was first studied . Subsequently, mice made neutropenic with cyclophosphamide were inoculated intravenously with the fungus to produce the disease model . Inoculum size which produced 100% mortality, yet allowed an apparent therapeutic window (6 x 10(6)) was determined . Tissue distribution and burden of organism during the course of infection was examined by viability and histopathologic studies . T . beigelii disseminated rapidly in this model, involving numerous organs including the heart, brain, kidneys, lungs, and liver . The heart and kidneys of the infected animals showed evidence of infection as early as 6 hours following inoculation . Further understanding of the pathogenesis of trichosporonosis in the neutropenic host was imparted by this study . This will aid in the future study of antibiotic treatment of this disease and its untreated progression. Jpn J Antibiot, 1993 May, 46(5), 388 - 96 {A multi-institutional study on the efficacy and toxicity of imipenem/cilastatin sodium in severe infections complicating hematological diseases and cancers in children . Study Group of Infectious Diseases in Pediatric Hematology/Oncology in Hokkaido}; Takeda T et al.; A multi-institutional study was conducted between September 1990 and April 1992 to evaluate the efficacy and toxicity of imipenem/cilastatin sodium (IPM/CS) in severe infections in cases of granulocytopenia in children with hematological diseases and cancers . A total of 60 episodes of infection were treated with the drug, and an overall efficacy rate of 80% (48/60) was obtained . The efficacy rate in patients who were positive for Endospecy test was 90.0% . A group of patients who had previously received other antibiotics showed an efficacy rate of 79.2%, while the patients who had not received previous antibiotic treatment showed an efficacy rate of 80.6% . The difference between the 2 groups was statistically insignificant, however . Granulocyte counts appeared to have influence on the efficacy of the drug, but the influence was not strong . Three patients had nausea, vomiting and/or diarrhea, and 2 other patients showed abnormal liver function test parameters though they recovered soon after the cessation of the drug treatment . From these results, we have concluded that IPM/CS is an effective antibiotic for treatment of severe infections with hematological diseases and cancers in children. J Neurol, 1993 May, 240(5), 278 - 83 Borrelia burgdorferi myositis: report of eight patients; Reimers CD et al.; Myositis is a rare manifestation of Lyme disease of unknown pathogenesis . This study describes the course of disease in eight patients with Lyme disease, aged 37-70 years, all of whom were suffering from histologically proven myositis . The clinical, electrophysiological, and myopathological findings are reported . One patient showed signs and symptoms of myositis of all limbs . In six patients myositis was localized in the vicinity of skin lesions, arthritis or neuropathy caused by Borrelia burgdorferi . In another patient suffering from pronounced muscle weakness of the legs and cardiac arrest, inflammation of the myocardium, the conducting system and skeletal muscles was revealed at autopsy . Muscle biopsy revealed lymphoplasmocellular infiltrates combined with few fibre degenerations in three patients . The lymphoplasmocellular infiltrates were found predominantly in the vicinity of small vessels . Several spirochetes were stained in six of seven muscle biopsy samples by means of the immunogold-silver technique . Culturing of B . Burgdorferi from the muscle biopsy samples was, however, unsuccessful . Antibiotic treatment succeeded in curing the myositis in four of six patients . In one patients signs and symptoms improved . One patient died from cardiac arrest caused by myocarditis and Guillain-Barre syndrome . The outcome is unknown in one patient . Clinical and myopathological findings indicate that Lyme myositis can be caused either by local spreading of B . burgdorferi or an unknown antigen or toxin from adjacent tissues or haematogenously. Ugeskr Laeger, 1993 Apr 26, 155(17), 1265 - 9 {Neurological complications of Mycoplasma pneumoniae infections}; Hagelskjaer LH et al.; Mycoplasma pneumoniae (Mp) infections are well known for the classical clinical picture of primary atypical pneumonia . The infection shows a predilection for young age groups . Every fourth-fifth year Mp epidemics are seen, lasting several months particularly in autumn/wintertime . The last Mp epidemic in Denmark was seen autumn/winter 1991-1992 . The central nervous system (CNS) is involved in less than 0.1% of all Mp infections, but among patients treated in hospital, CNS involvement occurs in up to 7% . Among patients with acute, febrile, nonbacterial CNS affection the incidence of Mp infections is shown to be 5%, with a maximum of 10% during Mp epidemics . In up to 20% the CNS complications are seen without preceding pulmonary symptoms . The pathogenesis is unknown, but probably involves several mechanisms . The spectrum of clinical findings is wide, ranging from mild meningeal signs to severe neurological symptoms and a poor outcome . Mp encephalitis has a particularly high morbidity and mortality . The effect of antibiotic treatment is doubtful, but the treatment is often instituted late . It may be debated, whether early antibiotic treatment can reduce the frequency of the CNS complications and their sequelae . Mp infection should be remembered as a differential diagnosis in any patient with fever and neurological symptoms . It can be recommended to add Mp diagnostic measures to the screening investigations, especially in patients with recent respiratory symptoms and during Mp epidemics . It is important to attempt to detect Mp by culture or polymerase chain reaction (PCR) from throat, respiratory tract and cerebrospinal fluid (CSF) . Mp serology from blood and CSF should be performed early in cases where Mp infection is suspected. Neurologia, 1993 Apr, 8(4), 152 - 5 {Spinal epidural abscesses . Conservative treatment . Three cases}; Guridi J et al.; Spinal epidural abscesses (SEA) are an infrequent disease which should be suspected in patients with spinal and/or radicular pain, neurologic deficits and fever . We present 3 patients with SEA (two lumbar and one dorsal) who recovered following exclusively antibiotic treatment . The complete disappearance of the abscess was proven by magnetic resonance . Patients with SEA and discrete, stable deficits and with known germs, are susceptible to medical and not surgical treatment. Clin Otolaryngol, 1993 Apr, 18(2), 115 - 7 An audit of the complications of paediatric tonsillectomy, adenoidectomy and adenotonsillectomy; Kendrick D et al.; Tonsillectomy, adenoidectomy and adenotonsillectomy are among the commonest surgical procedures undertaken in children . The notes of 413 consecutive children having tonsillectomy, adenoidectomy or adenotonsillectomy were analysed retrospectively to determine complication rates . Of the total number of children, 5.6% had at least one complication, the most common of which was haemorrhage occurring as a first complication in 3.9% (16 children) . Three children with bleeding required active treatment (0.7%), one requiring transfusion and two requiring a return to theatre, all within 3 1/2 hours of operation . The incidence of reactionary bleeding was not associated with the grade or seniority of the surgeon . Six children (1.5%) developed a fever post-operatively, of which one required antibiotic treatment . On the basis of these results it is feasible for such procedures to be carried out on a day-care basis. Br J Urol, 1993 Apr, 71(4), 457 - 9 Transrectal ultrasound examination of the prostate: complications and acceptance by patients; Aus G et al.; Transrectal ultrasound scan (TRUS) of the prostate was performed on 511 patients, 391 of whom also underwent between 1 and 5 transrectal 1.2 mm core biopsies . The infection rate in the whole group was 4.1%; 32% of the patients were given antibiotic prophylaxis with norfloxacin 400 mg twice daily for 1 week and in this group the infection rate was 0.8% . In the remaining patients, who received 400 mg norfloxacin at the time of biopsy and another 400 mg the same evening, the infection rate was 5.6% . The only risk factor identified for post-biopsy infection was steroid medication . Only minor discomfort (or none at all) was reported by 95% of patients during the examination procedure . If TRUS was combined with core biopsy 92% reported either minor or no discomfort . Of 78 patients who experienced both finger-guided fine needle aspiration biopsy and TRUS-guided core biopsy 82% preferred the latter procedure . TRUS and core biopsy proved acceptable to most patients . Antibiotic treatment with 2 tablets of norfloxacin failed to prevent infection. Am J Obstet Gynecol, 1993 Apr, 168(4), 1223 - 30 Preterm birth prevention: where are we? Creasy RK. OBJECTIVE: The purpose of this study was to review the current approaches to preventing preterm delivery . STUDY DESIGN: The problem of preterm birth was assessed by reviewing the different components that play a role in preterm birth prevention, excluding infection, antibiotic treatment, and tocolytic treatment . RESULTS: Prevention of preterm labor must initially discriminate those at risk . Positive predictive values of various approaches are currently not adequate enough to warrant intervention . Prevention modalities, in part because of poor prediction, are mostly unproved . Accurate diagnoses of preterm labor remains difficult and confuses analyses of tocolytic agents . Cervicovaginal fetal fibronectin, perhaps in combination with cervical evaluation, shows promise . Early detection programs remain controversial, but most reviews indicate that daily patient contact with high-risk patients gives cause for some optimism . Antenatal maternal glucocorticoid treatment at specific gestational ages improves neonatal outcome . CONCLUSION: The incidence of preterm birth is rising in the country . However, improved definition of the various components of the problem has provided an improved understanding of the problem . There is a new continuing effort and a search for new and innovative ways to address this vexing national problem. Surg Clin North Am, 1993 Apr, 73(2), 291 - 306 Empiric antibiotic therapy of abdominal sepsis and serious perioperative infections; Shands JW Jr; This article discusses empiric therapy for several serious infections in surgical patients . The accepted antibiotic treatment for purulent peritonitis, the empiric treatment of postsurgical wound infection, and the empiric treatment of postsurgical pneumonia are discussed . The cost of the various regimens is listed . Recommendation of the various regimens is based on the seriousness of the infection, peculiarities of the hospital flora, effectiveness of the regimens, and cost. Singapore Med J, 1993 Apr, 34(2), 172 - 4 Left ventricular outflow tract (LVOT) vegetations and spontaneous obliteration of a large ruptured intracranial mycotic aneurysm in a case of infective endocarditis; Quah BS et al.; A 10-year-old girl with mild aortic regurgitation presented with cerebral infarction . Two-dimensional echocardiography showed vegetations on the septal wall of the left ventricular outflow tract without involvement of the aortic valve itself . After successful antibiotic treatment the patient developed an intra-cranial haemorrhage due to rupture of a large intracranial mycotic aneurysm . Consent for surgical treatment of the mycotic aneurysm was not obtained . Twelve months later repeat angiography showed that the aneurysm had undergone spontaneous obliteration. Aktuelle Traumatol, 1993 Apr, 23(2), 72 - 6 {Treatment of infected intramedullary osteosynthesis . A comparison of various therapeutic procedures}; Kruger-Franke M et al.; A retrospective study was undertaken of the results of three different treatment regimens in 24 patients with postoperative infection subsequent to intramedullary nailing treated in our hospital between 1980 and 1989 . In all cases, the nail was first removed . There- after, 9 patients were treated with continuous sump drainage (A), 9 patients received gentamicin PMMA chains and secondary cancellous bone grafts (B), and 6 patients were treated with local myoplasty (C) . The results of a follow-up examination performed 27 months after the end of treatment showed 5 patients in group A with signs of residual infection . In groups B and C, no patient had clinical or radiological signs of residual infection at follow-up . These results confirm the positive effects of local antibiotic treatment and local myoplasty in posttraumatic bone infection. Aktuelle Traumatol, 1993 Apr, 23(2), 68 - 71 {Local preventive antibiotic treatment in intramedullary nailing with gentamycin impregnated biomaterials}; Hettfleisch J et al.; The benefit of antibiotics applied intravenously to avoid postoperative infection after intramedullary nailing has not yet been proven . Local antibiotic-releasing systems might be more effective because of the high concentration available in the compartments of interest . We report on the pharmacokinetic results of ten patients with intramedullary nailing of the tibia, respectively 15 patients undergoing the same procedure at the femur, in whom we used gentamicin-impregnated biomaterials for perioperative prophylaxis . The elution of gentamicin from a collagen sponge was complete and pharmacokinetic data suggest this drug releasing system is superior to PMMA beads in respect of the studied indication. Bildgebung, 1993 Mar, 60(1), 23 - 6 {Ultrasound-controlled percutaneous drainage of subhepatic liver abscess after conventional cholecystectomy}; Weiler H et al.; From February 1984 to August 1991 subhepatic abscesses were detected by ultrasound in 7 patients with fever following conventional cholecystectomy . Cholecystectomy had been performed in all these patients 6 to 27 days previously . All patients had received antibiotic prophylaxis at the time of cholecystectomy . Three of the 7 patients were at first afebrile, later on again febrile . In the remaining 4 of the 7 patients antibiotic treatment was continued in the face of persistent fever . Percutaneous catheter drainage was performed in all patients . In all of the 7 cases the subhepatic abscesses resolved completely within 10 days to 7 weeks. Ann Rheum Dis, 1993 Mar, 52(3), 206 - 10 Rational diagnosis and treatment in unclassified arthritis: how clinical data may guide requests for Lyme serology and antibiotic treatment; Blaauw I et al.; To improve the appropriateness and efficiency of diagnostic serological tests and subsequent antibiotic treatment, clinical data from 102 patients with unclassified arthritis were analysed to investigate whether the presence of positive IgG antibodies to Borrelia burgdorferi could be predicted . The clinical data were blindly ranked from 1 to 4 (1, Lyme arthritis unlikely; 4, Lyme arthritis very likely) . Antibodies to B burgdorferi were positive in nine of 102 patients (9%) . Six of 15 (40%) patients with rank numbers 3 and 4 were positive for antibodies to B burgdorferi, in contrast with only three of 87 (3%) patients with rank numbers 1 and 2 . The likelihood ratio of positive Lyme serology for patients ranked 3 and 4 was 12.0, for patients ranked 2 to 4, 4.5, and for patients with arthritis of the knee, 3.0 . These likelihood ratios were associated with a post-test probability of 55, 30, and 20% respectively . The clinical history in patients with unclassified arthritis can largely predict the presence of antibodies to B burgdorferi . The absolute value of a likelihood ratio can be a contributing factor in deciding to request tests for antibodies to B burgdorferi in patients with unclassified arthritis. Br J Urol, 1993 Mar, 71(3), 346 - 9 Treatment of vesicoureteric reflux . Results of a prospective study; Scholtmeijer RJ; Between 1982 and 1986, 96 children with non-obstructive vesicoureteric reflux were included in a prospective study . Three patients withdrew from the study and results are therefore presented on 93 children with 135 refluxing ureters who were followed up for at least 5 years . Initially, all children with reflux grade III or less received antibiotic treatment only . Those with reflux grade IV were randomised to antibiotic treatment alone versus surgery plus antibiotic treatment; the primary treatment of reflux grade V was reimplantation . In 85 ureters treated by antibiotics only, reflux disappeared in 64 cases and was reduced in 12 . In 50 ureters treated by reimplantation, reflux was cured in 46 cases and no severe ureteric obstruction was seen . Conservative management of reflux grade IV was less successful than surgery . The results of conservative, non-surgical treatment of reflux grades I-III were satisfactory, but for grades IV and V surgery should be the treatment of choice if detrusor instability has been excluded. J Heart Lung Transplant, 1993 Mar-Apr, 12(2), 308 - 24 The role of transbronchial biopsies in the management of lung transplant recipients; Sibley RK et al.; We examined the utility of the transbronchial biopsy in the management of 53 lung transplant patients . One hundred thirty-three protocol biopsies were performed to ascertain the frequency and nature of abnormalities in clinically stable or asymptomatic patients; 128 diagnostic biopsies were performed in clinically ill patients to assess the morphologic abnormalities before the institution of therapy, and 105 biopsies were performed to assess the response to therapy . Histologic evidence of acute rejection was found in 24% of the protocol biopsies, and infection was found in 17% . Twenty-five patients with grade 1 or grade 2 perivascular infiltrates in protocol biopsies did not receive antirejection therapy . Follow-up biopsy in these patients showed spontaneous resolution of the infiltrates in 19% and increased infiltrates in 6 . Only two of these patients became clinically ill, representing "progression" to clinical rejection in only 8% of the nontreated patients . Forty percent of the biopsies performed to rule out acute rejection or infection had histologic features of acute rejection, and another 23% had features of infection . Treatment of patients with clinical and histologic evidence of rejection was associated with rapid resolution of clinical symptoms in nearly 90% of the patients, but follow-up biopsies showed residual infiltrates compatible with ongoing or resolving rejection in 52% . Despite repeat antirejection therapy in some patients, these infiltrates persisted for an average of 30 days after the diagnostic biopsy . Follow-up biopsies also showed asymptomatic infection, usually cytomegalovirus pneumonitis, which often persisted for weeks despite the lack of symptoms . Perivascular infiltrates compatible with acute rejection were also found in 38% of biopsy specimens with evidence of infection . These perivascular infiltrates resolved with antibiotic treatment alone in nearly 50% of the patients with these features . Although perivascular mononuclear cell infiltrates are the cardinal histologic feature of acute rejection, similar infiltrates occur in patients who apparently have infection alone and other patients who have both infection and rejection; infiltrates compatible with minimal, mild, and moderate acute rejection also occur in clinically asymptomatic patients . These histologic findings are a challenge to both the pathologists' and the clinicians' skills in the management of the lung transplant patient. Dan Med Bull, 1993 Mar, 40(1), 125 - 7 Do specialists give special antibiotic treatment? Friis H, Vejlsgaard R. The use of antibiotics is increasing with increasing ecological and economic problems as a consequence . In Denmark, antibiotics are prescribed by doctors and in order to intervene, it is important to know details about prescription habits . Danish patients are referred to specialists by their general practitioner when further investigation or treatment is needed . In one week in 1988, 180 specialists (60%) participated in a study registering all prescriptions made by these specialists . Only 3.2 patients per specialist were treated with antibiotics . The infections were mainly of the upper respiratory tract, the skin, or gynecological . The prescribed daily dosages (PDD) did not differ from those given by the general practitioners, but the specialists used significantly less penicillin and significantly more erythromycin, tetracycline or local antibiotics . Compared with the general practitioners the specialists in Denmark only prescribed approximately 10% of the total amount of antibiotics used outside the hospitals . Their contribution to the potential ecological and economic problems caused by antibiotics in Denmark is limited. Dev Med Child Neurol, 1993 Mar, 35(3), 267 - 74 Seizure exacerbation related to beta-lactam antibiotics in a child with cerebral dysgenesis; Keskin S et al.; A three-year-old boy with right hemimegalencephaly, developmental delay and left hemiparesis had well-controlled left focal seizures . Occasionally he had generalized seizures if he was given beta-lactam antibiotics . An EEG with simultaneous penicillin injection was performed to examine this apparent association: a secondarily generalized seizure was documented within two minutes of intravenous administration of the penicillin . This procedure confirmed the suspicion of a causal link between antibiotic treatment and seizures . The factors increasing susceptibility to beta-lactam antibiotic-induced seizures are reviewed. An Esp Pediatr, 1993 Mar, 38(3), 229 - 31 {Thyroid cancer in childhood: review of 7 cases}; Martinez Ibanez V et al.; Thyroid carcinoma in childhood is a rare, but nevertheless malignant disease, with a high incidence of nodal metastasis . Seven children, 6 boys and 1 girl, aged 4 to 9 years with thyroid carcinoma were treated at the Hospital Infantil Valle de Hebron of Barcelona between 1965 and 1990 . The diagnosis was established by cervical nodal biopsy in all cases except one . Papillary carcinoma was found in 4 cases, follicular type in 2 cases and one case of mixed carcinoma was diagnosed . Surgical treatment consisted in lobectomy on the affected side, followed by total thyroidectomy on the opposite side and bilateral resection of involved nodes one or more times . In two patients, treatment with sodium-iodine I131 showed active tissue in the thorax and wound . Both were treated effectively . All patients are alive without recurrences during a follow-up period of 1 to 23 years . Main complications were: temporary recurrence of the nerve injury in two patients and a controlled hypoparathyroidism in another two cases . In all cases, treatment with L-thyroxine was required . Thyroid carcinoma in children carries a considerably better prognosis than in adult patients . We must suspect thyroid carcinoma and indicate biopsy in all cases of cervical nodes resistant to antibiotic treatment . Early diagnosis, total thyroidectomy, radioiodine treatment and hormone administration permit radical cure even in the case of metastatic disease. Chemotherapy, 1993 Mar-Apr, 39(2), 147 - 52 Ceftriaxone plus conventional or single-daily dose amikacin versus ceftazidime/amikacin as empiric therapy in febrile neutropenic patients; Leoni F et al.; Results of antibiotic treatment in 144 febrile episodes during drug-induced granulocytopenia are reported . 63 episodes were treated with ceftazidime plus amikacin and 81 with ceftriaxone (CFX) using single daily doses combined with amikacin either divided in three doses (CFX-1 group) or administered as single doses (CFX-2 group) . The response rates were 51, 80, and 57% respectively . In this study CFX was more effective than ceftazidime and amikacin provided better results when administered using the standard 8-hour scheduling. Pediatr Infect Dis J, 1993 Mar, 12(3), 179 - 83 Febrile children with no focus of infection: a survey of their management by primary care physicians; Jones RG et al.; We mailed a checklist survey to 1600 randomly selected pediatricians, family practice physicians (FPPs) and emergency medicine physicians (EMPs) in the United States regarding their management of children with high fever and no focus of infection at various ages: 3 weeks; 7 weeks; 4 months; and 16 months . Completed questionnaires were returned by 211 of 600 (35.2%) pediatricians, 145 of 500 (29%) FPPs and 141 of 500 (28.2%) EMPs . Most pediatricians, FPPs and EMPs would hospitalize a 3- or 7-week-old infant with fever and most pediatricians and FPPs would treat infants of this age group empirically with antibiotics . Most pediatricians, FPPs and EMPs would not hospitalize a 4-month-old or a 16-month-old with high fever with no focus of infection but 44 and 25% of pediatricians, 38 and 24% of FPPs and 41 and 34% of EMPs, respectively, would treat a 4- and 16-month-old child with high fever and no focus of infection with antibiotics . The preferred antibiotic treatment for hospitalized 3- and 7-week-old infants was ampicillin plus gentamicin or ampicillin plus cefotaxime; for older outpatients preferred treatment was amoxicillin or ceftriaxone . We conclude that hospitalization and empiric antibiotic treatment of very young infants (< 2 months of age) with high fever and no focus of infection are preferred by most of the pediatricians, FPPs and EMPs surveyed . Nearly one-half of these physicians would treat 4-month-olds and a fourth would treat 16-month-olds with high fever and no focus of infection with antibiotics as outpatients. BMJ, 1993 Feb 27, 306(6877), 556 - 7 Knowledge and use of secondary contraception among patients requesting termination of pregnancy; Bromham DR et al.; PIP: The results of a survey of 769 patients attending the St . James's University Fertility Control Clinic, England, for abortion services showed that patients seeing general practitioners were less knowledgeable than those attending specialist clinics . There was a demonstrated need for counseling on pill and condom use and protection against sexually transmitted diseases . Knowledge of postcoital methods was also found to be lacking . The survey was conducted between April 1, 1991, and January 31, 1992 . Respondents included minorities such as Afro-Caribbean (8%) and Asian (9%) . 307 of the cases were using a less effective form of contraception at the time of conception, usually a change from the pill to condoms . Of the 171 people reporting failure of contraception, 93 noted a split or leaking condom; 13, a condom falling off during intercourse; 32, inconsistent use of condoms;l 32, forgetting to take contraceptive pills or using antibiotics with the pill; and 1, a late injection of medroxyprogesterone acetate . 45 of the 309 people who had conceived while using condoms recognized a potential condom failure, and only 20 attempted any emergency contraceptive method such as the postcoital pill . Only 30% of the 171 patients with recognized condom failure and 12% of the 210 who had not used any contraception had adequate knowledge of the existence, timing, and source of postcoital pills; i.e., 20% of 381 . Only 2% of the 171 nd 2% of the 381 patients, had knowledge of postcoital insertion of an intrauterine contraceptive device . Given the choice between and unplanned pregnancy and postcoital contraceptive, most (718 out of 769) preferred using postcoital contraception . Contraceptive information was given to 501 by a general practitioner, to 102 by a community family planning clinic, and 163 had no medical advice . There was a range of knowledge of postcoital contraceptive methods . Knowledge of how to deal with forgotten pills, severe vomiting, severe diarrhea, and concurrent antibiotic treatment among the 422 patients who had ever used the combined pill also was variable . 19% of the 372 patients treated by general practitioners knew 4 correct answers, but 50% of the 50 patients in community family planning clinics answered correctly 4 times . Differences could not be explained by other demographic characteristics . J Neurooncol, 1993 Feb, 15(2), 133 - 9 Recurrent brainstem gliomas treated with oral VP-16; Chamberlain MC; 12 patients: (7 males and 5 females) with recurrent brainstem gliomas were treated with the oral topoisomerase inhibitor VP-16 (Etoposide) . Patients ranged in age from 3 to 49 years with a median age of 7 years . All patients had been previously treated with radiation therapy (conventional fractionation: 4; hyperfractionation: 8) and 5 had received prior nitrosourea-based chemotherapy at time of tumor recurrence . Tumor recurrence was documented by radiographic tumor enlargement utilizing brain MRI with gadolinium enhancement (12) and clinical neurologic deterioration (9) . Two patients underwent biopsy pathologically documenting tumor recurrence . Each cycle of therapy consisted of 21 days of VP-16 (50 mg/m2/day) followed by a 14 day rest followed by an additional 21 days of VP-16 (50 mg/m2 day) . Complete blood counts were followed bi-weekly and a neurologic examination and brain MRI scan with contrast were performed prior to initiation of each cycle of therapy . Treatment related complications included: partial alopecia (5); diarrhea (5); weight loss (4); neutropenia (2); and thrombocytopenia (4) . No patient required transfusion or antibiotic treatment of neutropenic fever . There were no treatment related deaths . 12 patients were evaluable of whom 6 demonstrated a radiographic response (1 complete; 3 partial; 2 stable disease) with a median duration of response of 8 months . In summary; oral VP-16 is a well tolerated and relatively non-toxic chemotherapeutic agent with apparent activity in this small cohort of patients with recurrent brainstem gliomas. Int J Androl, 1993 Feb, 16(1), 1 - 13 Infection in the male reproductive tract . Impact, diagnosis and treatment in relation to male infertility; Purvis K et al.; The following are the conclusions that can be derived from a review of the literature regarding the role of infection in the aetiology of male infertility . (i) Temporary inflammatory episodes in the male reproductive tract which are self-limiting are probably common . (ii) Caution should be exercised in the use of leukospermia or bacteriospermia as parameters for glandular infection . (iii) There is a need for alternative techniques for detecting non-symptomatic deep pelvic infections in the male; one technique of great promise is rectal ultrasound . (iv) Rectal ultrasound indicates that a large number of men with poor sperm quality have a non-symptomatic, chronic prostatovesiculitis . (v) Increasing evidence implicates Chlamydia trachomatis as being a major cause of chronic non-bacterial prostatitis . (vi) An important aspect of chlamydial infections in men may be that the male accessory sex glands may function as reservoirs for the organism, increasing the probability of infection in the female . (vii) Ureaplasma urealyticum may also play an important aetiological role in male infertility but its significance is confounded by its acknowledged function as a commensal in the reproductive tract . (viii) One of the manifestations of male reproductive tract infection is the induction of sperm autoantibodies . (ix) There is a need for more systematic controlled studies of the effects of antibiotic treatment on sperm quality with different preparations for extended periods using patient groups in which a glandular infection has been verified, e.g . by rectal ultrasonography. Ophthalmologe, 1993 Feb, 90(1), 35 - 9 {Excimer laser sclerostomy of secondary glaucoma}; Kampmeier J et al.; Initial results after nine ab externo sclerotomies on seven patients awaiting enucleation because of intensive pain caused by secondary glaucoma have encouraged us to present the methods used for this technique of fistula construction and the course in these patients . A special applicator permits precise manual positioning of the excimer laser beam (lambda = 308 nm) subconjunctivally at the limbus using a quartz-quartz fiber (diameter: 0.32 mm) . The energy applied at the fibertip is 4 mJ per pulse, with a repetition rate of 80 Hz . All patients undergoing the operation, which lasted only a few minutes, were treated as out-patients without a retrobulbar anaesthesia . Because of the minimal irritation of the anterior chamber, only antibiotic treatment was required after the operation . The intraocular pressure immediately decreased to normal levels after the operation without any further glaucoma treatment in five cases . In the other two cases reduced, but still minimally elevated, pressure was recorded . In the case of one heavily inflamed eye, which had been subjected to two operations, pain felt by the patient was relieved when the pressure was reduced . The maximum period of post-operative follow-up so far is over 10 months and the decrease of intraocular pressure has remained adequate without any additional antiglaucoma therapy . In all cases enucleation was avoided. Ann Pharmacother, 1993 Feb, 27(2), 155 - 61 Pharmacy-enforced outpatient drug treatment protocols: a case study of Medi-Cal restrictions for cefaclor; McCombs JS et al.; OBJECTIVE: To evaluate whether a pharmacy-enforced treatment protocol successfully limited the use of a high-cost medication to high-risk patients . DESIGN: A case study cost-effectiveness analysis was conducted to evaluate a treatment protocol for cefaclor . Episodes of care were defined, healthcare expenditures for all services were aggregated, and demographic data were retrieved from a five percent random sample of California Medicaid (Medi-Cal) recipients . Data were available for episodes occurring before cefaclor was made available under Medi-Cal . SETTING: Medi-Cal added cefaclor to its formulary, limiting its use to patients over 50 years of age with lower respiratory tract infections (LRTIs) . The unit of analysis was an episode of outpatient antibiotic treatment . PATIENTS: Confirmed LRTI episodes and unconfirmed LRTI cefaclor episodes were analyzed, including multiple episodes of treatment for individual patients . A total of 7855 non-cefaclor LRTI episodes and 2556 cefaclor episodes were analyzed . MAIN OUTCOME MEASURES: The primary outcome measures were healthcare expenditures three months after the initiation of antibiotic therapy, differentiated by type of service . RESULTS: Physicians directed cefaclor toward higher-risk patients over age 50 years, even in unconfirmed LRTI episodes . Cefaclor use was estimated to reduce posttreatment costs by $388 per patient (p < 0.001), primarily because of reduced hospital expenditures of $366 (p < 0.001) . CONCLUSIONS: Pharmacy-enforced outpatient drug treatment protocols may be a viable alternative to restrictive formularies and prior authorization . In the case of cefaclor, the Medi-Cal treatment protocol appeared to allow high-risk patients better access to a high-cost medication while reducing total posttreatment costs. Am J Surg, 1993 Feb, 165(2A Suppl), 14S - 19S Prevention of infections following penetrating abdominal trauma; Fabian TC; A major problem for patients who survive a traumatic injury is morbidity due to infectious complications; this risk increases when there is injury to the liver, pancreas, or colon, the abdominal trauma index is > 25, and/or surgery is prolonged . For major injuries of either the liver or pancreas, the use of closed suction drainage decreases the risk of infection; sump drainage should be avoided . Most penetrating colon injuries can be managed with primary repair or resection and anastomosis, unless there is an underlying medical condition or a need for massive transfusions . For gunshot wounds penetrating the colon, removal of retained missiles should be attempted because these increase the risk of abscess . A brief course of appropriate antibiotic treatment should be initiated as soon as possible after wounding and should be continued for 24 hours . Prolonged courses of antibiotic provide no added benefits. J Am Acad Dermatol, 1993 Feb, 28(2 Pt 2), 312 - 4 Recurrent erythema migrans despite extended antibiotic treatment with minocycline in a patient with persisting Borrelia burgdorferi infection; Liegner KB et al.; Erythema migrans recurred in a patient 6 months after a course of treatment with minocycline for Lyme disease . Polymerase chain reaction on heparinized peripheral blood at that time demonstrated the presence of Borrelia burgdorferi-specific DNA . The patient was seronegative by Lyme enzyme-linked immunosorbent assay but showed suspicious bands on Western blot . Findings of a Warthin-Starry stain of a skin biopsy specimen of the eruption revealed a Borrelia-compatible structure . Reinfection was not believed to have occurred . Further treatment with minocycline led to resolution of the erythema migrans. Chest, 1993 Feb, 103(2), 639 - 41 Cardiac abscess following percutaneous transluminal coronary angioplasty; Timsit JF et al.; We report the first case of myocardial abscess directly related to percutaneous transluminal angioplasty (PTCA) . Infectious complications of PTCA are very rare and limited to a few cases of groin infection and septic endarteritis most often after repeated procedures . In our patient, a problematic and repeated procedure probably led to a direct colonization and subsequent infection of an intimal dissection of the right coronary artery . Standard aseptic techniques can be inadequate in the case of early repuncture or if there is an indwelling line . Prophylactic antibiotic treatment should be considered in this case, although its usefulness has not been yet formally demonstrated. J Invest Dermatol, 1993 Feb, 100(2), 103 - 9 Effects of adequate versus inadequate treatment of cutaneous manifestations of Lyme borreliosis on the incidence of late complications and late serologic status; Plorer A et al.; Eighty-two patients who were treated at the Department of Dermatology, Innsbruck, Austria, from 1980 to 1987 for cutaneous manifestations of Lyme disease were subjected to a clinical follow-up investigation aimed at detecting dermatologic, neurologic, and internal late complications of borreliosis . Only 54 of these patients had received adequate antibiotic treatment according to current standards . Also, their sera were investigated for the presence of immunoglobulin G (IgG) and IgM Borrelia burgdorferi antibodies by an indirect immunofluorescence assay, three different enzyme-linked immunosorbent assays, and immunoblotting . As a control, the sera of 126 healthy blood donors were investigated with the same assays . Results showed no unambiguous clinical late complications of Lyme borreliosis, even in inadequately treated or untreated patients . Seropositivity varied considerably according to the assay used; the indirect immunofluorescence assay yielded the highest scores . The proportion of seropositive results (immunofluorescence assay) was 59% in patients with erythema chronicum migrans, 69% in those with lymphocytoma cutis, and 100% in those with acrodermatitis chronica atrophicans (overall 63%); in contrast, only 31% of the blood donor control group were found to be seropositive . Seropositivity did not correlate with adequacy of treatment, interval between onset of symptoms and treatment, time span since treatment, age of patients, and presence of antinuclear antibodies . Immunoblot pattern showed high incidence of antibodies against the 29/31-kD (outer surface proteins OspA and OspB) and 55/58-kD antigens in general and against the 41-kD protein (flagellin) in patients with acrodermatitis chronica atrophicans only. Arch Otolaryngol Head Neck Surg, 1993 Feb, 119(2), 169 - 72 Needle aspiration of peritonsillar abscess in children; Weinberg E et al.; Needle aspiration for the treatment of peritonsillar abscess was assessed in 43 consecutive children aged 7 to 18 years (mean age, 13.9 +/- 2.5 years) during the 3-year period from 1988 through 1991 . A positive aspirate was obtained in 31 (76%) of the 41 patients who cooperated for needle aspiration; a mean of 2.9 +/- 1.9 mL of pus was withdrawn . Of the 31 children with a positive aspirate, in 27 (87%) the abscess resolved, two (6%) required a second aspiration for resolution, and two (6%) underwent immediate tonsillectomy for persistent abscess . Of the 10 children (24%) with negative aspirations, in six (60%) the abscess resolved with antibiotic treatment alone, three (30%) underwent immediate (quinsy) tonsillectomy, and in one (10%) the abscess spontaneously drained . No bleeding, airway obstruction, or anesthetic complications occurred . Needle aspiration of peritonsillar abscess in children, with tonsillectomy reserved for nonresponders, appears to be an efficacious and safe method of treatment. Pediatr Infect Dis J, 1993 Feb, 12(2), 115 - 20 Potential interventions for preventing pneumonia among young children: lack of effect of antibiotic treatment for upper respiratory infections; Gadomski AM; Upper respiratory infections (URI) are a source of significant morbidity in childhood and have been associated with the development of certain bacterial infections . However, the high incidence of URI contrasted with the low incidence of lower respiratory infection (LRI) suggests a low rate of development of viral or bacterial LRI after URI . Because the etiology of URI is primarily viral, antibiotics do not have any significant effect on the URI episode itself but have been used to treat URI in hopes of preventing bacterial complications after URI . Meta-analysis of studies in developed and developing settings suggests that antibiotic treatment of children with URI does not shorten the course of URI and does not prevent the development of pneumonia . Several studies reporting both positive and negative results could not be included in the meta-analysis because they were not randomized trials or did not detail LRI outcomes in children sufficiently . Because of limitations in study design and definition of LRI, research in this area cannot be considered definitive . However, the weight of theoretical and experimental evidence is against antibiotic treatment of URI as a means of preventing the development of pneumonia after URI. Ital J Orthop Traumatol, 1993, 19(1), 57 - 69 Post-operative intervertebral discitis . Evaluation of 12 cases and study of ESR in the normal postoperative period; Postacchini F et al.; Twelve cases of intervertebral discitis following lumbar discectomy were evaluated and ESR was assessed in 70 patients operated on and without evidence of postoperative infection . Six of the intervertebral discitis patients were studied retrospectively and 6 prospectively . In the retrospective group, patients reported that symptoms appeared on average 15 days after the operation . Antibiotic treatment generally began 31 days after the operation and lasted 62 days; symptoms regressed after 3.9 months . All patients showed long-term radiographic vertebral changes and osteolysis in the cases treated later . In the prospective group, the first symptoms appeared on average 5 days after the operation, treatment started after 8 days and lasted 41 days . Symptoms regressed after 1.8 months . There were only 3 cases of vertebral radiographic changes . In both groups, ESR was always more than 70 . The most useful diagnostic imaging tests were conventional tomography and MRI . Needle biopsy had no effect on the length of treatment . In 14% of patients without infective complications, ESR increased noticeably a week after the operation but, in contrast to the intervertebral discitis patients, it did not then continue to increase . Close post-operative observation permitted early detection of intervertebral discitis . Early and high-dose antibiotic treatment, even if unspecific, can resolve this infection in a few weeks. Zentralbl Gynakol, 1993, 115(5), 202 - 4 {Reconstruction of the breast with the m . latissimus dorsi flap after previous mastectomy}; Torsten U et al.; The application of this method over 11 years has shown that careful preoperative planning is crucial for the achievement of good results . There is, however, no restitutio ad integrum . The reconstructed breast will always have a rather firm structure and tend to be scarred . However, the risk of necrosis is reduced by the good vascular and nervous supply which also provides optimal conditions for mamilla reconstruction . Intra- and postoperative antibiotic treatment lowers the risk of infection. Scand J Infect Dis, 1993, 25(2), 185 - 91 Helicobacter pylori in 205 consecutive endoscopy patients; Befrits R et al.; The presence of Helicobacter pylori in the gastric, antral mucosa of 205 consecutive, unselected gastroscopy patients was investigated by 1-3 biopsies for urea broth test and culture, 1 biopsy for histological examination and 1 blood sample for serology by ELISA . Overall, 41% were positive for H . pylori by culture, 32% by urea broth test, 24% by histological staining and 67%, 56% and 49% for the 3 cut-off limits applied to serology . Culture and serology indicated the presence of H . pylori in 79-92% of the 14 cases with duodenal ulcer, in 59-82% of the 28 cases with gastric ulcers, in 45-71% of the 51 cases with endoscopic gastritis and in 33-69% of 13 cases with oesophagitis . In patients with histological antritis, H . pylori was identified by culture in 71% (60/84), by serology in 95%, 88% and 81% with the different cut-off limits . The sensitivity of serology ranged from 99-78% depending on the cut-off limits and the specificity from 78-100% against all parameters combined . These results suggest that serology is a useful screening method for the presence of H . pylori . Future antibiotic treatment studies are required to evaluate the clinical relevance of H . pylori in gastrointestinal disease and to investigate the possibility to monitor eradication by serology. Neurol Neurochir Pol, 1993 Jan-Feb, 27(1), 55 - 61 { Ceftriaxone (Rocephin "Roche") in short-term program of perioperational prophylaxis in neurosurgery}; Bidzinski J et al.; Own experience is presented in the administration of prophylactic antibiotic treatment in clean neurosurgical operations . The clinical material comprised 131 patients subjected to 138 operations . For prophylaxis ceftriaxone (Rocephin "Roche") was given by the so called short term programme in which 2 g of the drug was given intravenously before the operation, and 1 g after 24 hours . The frequency of postoperative infections was 0.7% in the group . The effectiveness is stressed of the short-term programme of prophylactic antibiotic treatment in the prevention of postoperative infections in neurosurgery emphasizing that operations in emergency cases, perioperative steroid therapy, tumours, craniotomy with free bone flap do not reduce the effectiveness of the method. Eur J Appl Physiol Occup Physiol, 1993, 66(4), 372 - 5 The relationship between short-term antibiotic treatments and fatigue in healthy individuals; Burstein R et al.; Antibiotic treatment tends sometimes to result in sensations of fatigue and decreased physical performance . The effects of antibiotics were therefore studied in 50 healthy, male trainees, aged 18-25 years, assigned in a random, double-blind fashion to one of the following treatments: tetracycline, ampicillin, trimethoprim/sulphamethoxazole, placebo I and placebo II . Duration of treatment was five times the half-life of each agent and the placebo was matched accordingly . Muscle enzyme activity (serum glutamine oxaloacetate transaminase, lactate dehydrogenase, creatine phosphokinase), maximal aerobic capacity (VO2max), muscle strength (MS), and rating of subjective sensation of fatigue were assessed prior to and upon conclusion of treatment . Compared to pretreatment values, plasma enzymes activity was elevated in all five groups (P < 0.005) . No differences in VO2max or in MS were found among the subjects treated with either one of the antibiotics or those given a placebo . A significant difference in VO2max was found between the groups treated for 1 day (antibiotic and placebo) and the groups treated for 3 days (antibiotic and placebo) (P < 0.0001) . The rating of subjective sensation was not affected by any of the agents . We concluded that in healthy individuals, a short-term antibiotic treatment had no deleterious effect on aerobic capacity or on muscle strength and was not associated with subjective side effects . The time interval between the two maximal tests could, however, have affected the aerobic capacity . Physiological disturbances associated with a sensation of fatigue following a longer period of antibiotics cannot be excluded. Respiration, 1993, 60 Suppl 1, 38 - 44 Antibiotic treatment of pediatric community-acquired lower respiratory tract infections: challenges and possible solutions; Dagan R; Bacterial pneumonia presents a real challenge in childhood, since its morbidity is impressive, its diagnosis is elusive and the treatment options are not always clear . Despite these difficulties, appropriate management based on an individual approach, good clinical skills and available antibiotics provides a rapid cure to most cases . The problems in diagnosis and treatment as well as the therapeutic approach to childhood bacterial pneumonia are discussed. Cesk Pediatr, 1993 Jan, 48(1), 49 - 51 {Personal experience with the use of Rulid (roxithromycin) in children less than 1 year of age}; Jakubicka J et al.; The authors give an account of the use of Roxithromycin (preparation Rulide) in children of the youngest age group, i.e . in infants . From January 1989 to April 1992 they treated 24 children under 5 weeks to 12 months of age with Roxithromycin . Roxithromycin was administered in amounts from 5 to 10 mg/kg after 12-hour intervals in the course of 4 to 12 days . In 22 children a favourable clinical effect was observed, in two children antibiotic treatment had to be changes because there was no clinical response . Undesirable effects, i.e . vomiting, during Roxithromycin were observed only in two children . In no instance was it necessary to discontinue treatment. Eur Arch Otorhinolaryngol, 1993, 250 Suppl 1, S23 - 5 Antibiotic treatment of sinusitis in general practice . A double-blind study comparing ofloxacin and erythromycin; Husfeldt P et al.; The present study compared ofloxacin and erythromycin in a double-blind study with parallel groups for clinical efficacy and the number and severity of adverse reactions in patients treated in general practice for acute or chronic sinusitis . All patients lived in medium-sized to large towns and rural districts in the northern and western parts of Sealand, Funen and eastern Jutland, Denmark . Three hundred and nineteen patients were enrolled in the study, of whom 280 were clinically evaluable . From this total number, 136 patients were treated with ofloxacin (31 males and 105 females) and 144 patients were treated with erythromycin (40 males and 104 females) . Following administration of either ofloxacin 400 mg once daily or erythromycin 500 mg twice daily for 7-14 days, 94.9% of the ofloxacin-treated group and 94.4% of the erythromycin-treated group were cured of their infections . There was no difference in clinical efficacy . Complications occurred in 18 of 155 patients in the ofloxacin-treated group and 32 of 164 in the erythromycin-treated group (P < 0.05), corresponding to 27 and 45 symptoms respectively (P < 0.01) . This difference in adverse reactions principally involved gastrointestinal symptoms, i.e . 19 in the ofloxacin-treated group and 41 in the erythromycin-treated group (P < 0.01) . Present findings show that the two antibiotics are comparable as to clinical efficacy, but the frequency of adverse reactions is significantly higher in the erythromycin-treated group due to the greater incidence of gastrointestinal adverse reactions. Infection, 1993 Jan-Feb, 21(1), 57 - 60 Meningitis due to Fusobacterium necrophorum subspecies necrophorum . Case report and review of the literature; Jacobs JA et al.; This paper reports a case of fatal meningitis caused by Fusobacterium necrophorum subsp . necrophorum in a previously healthy five-year-old child . The organism was isolated in pure culture from the cerebrospinal fluid and from intracranial pus obtained at autopsy . The role of F . necrophorum in the development of meningitis is reaffirmed and its isolation and identification are discussed . The clinical presentation of the present case resembles the previously published reports and highlights the poor prognosis in spite of appropriate antibiotic treatment. J Gastroenterol Hepatol, 1993 Jan-Feb, 8(1), 35 - 8 Emergency endoscopic nasobiliary drainage for acute calculous suppurative cholangitis and its potential use in chemical dissolution; Lin XZ et al.; Acute suppurative cholangitis is one of the common causes of acute abdomen in Taiwan . Emergency decompression is a life-saving procedure if patients fail to respond to antibiotic treatment . From July 1988 to June 1991, 224 patients were encountered with concomitant bile duct stones and cholangitis; 40 were brought to the emergency service with shock or mental confusion or responded poorly to antibiotic treatment . The patients consisted of 20 males and 20 females aged 21-81 years (mean age 64 years); 55% had intrahepatic duct stones, 50% had positive blood culture, 38% had undergone previous biliary surgery, 25% had concomitant medical illnesses and 20% presented with mental confusion . Emergent endoscopic nasobiliary drainage (ENBD) was performed within 48 h of each patient's arrival in the emergency room . In 3 days all the patients exhibited significant improvement as defined by body temperature, vital signs, white blood cell count, serum bilirubin and alkaline phosphates levels . When their condition had stabilized, 21 patients underwent elective surgery . Six patients received ethylenediaminetetraacetic acid infusion through an ENBD tube . Two of the patients' stones dissolved completely . Six patients received papillotomy with stone removal . The remaining patients refused further treatment . There was no hospital mortality . It is therefore concluded that ENBD offers an effective treatment for acute calculus suppurative cholangitis and it is a potential route of administration for the chemical dissolution of bile duct stones. Ann Oncol, 1993 Jan, 4(1), 81 - 2 Combination chemotherapy with tauromustine (TCNU), 5-fluorouracil and leucovorin in advanced colorectal carcinoma: a dose-finding study; Taal BG et al.; BACKGROUND: In preparation for a phase II trial we performed a dose-finding study involving tauromustine (TCNU), fluorouracil (5-FU) and leucovorin (LV), applied in patients with colon cancer . To prevent TCNU/5-FU antagonism, a phenomenon recently demonstrated in vitro, special attention was paid to the sequencing of these agents . PATIENTS AND METHODS: In 25 patients with advanced colorectal carcinoma (13 M, 12 F, median age 51 yrs), four dose levels of TCNU (25, 30, 35 or 40 mg/m2) were investigated . The agent was administered orally once per week in weeks 1 through 4, in combination with fixed i.v . doses of 400 mg/m2 5-FU and 80 mg/m2 LV, once a week, weeks 1 through 8 . Unless progression occurred, two 8-week cycles were applied . TCNU was administered at least 24 hours prior to 5-FU, because recent in vitro studies suggested that such an interval is required to obtain additive cytotoxicity . RESULTS: All 25 patients were evaluable for toxicity; 23 patients received at least one full 8-week course, and 13 were eligible for second cycles . Significant haematologic toxicity, predominantly thrombocytopenia WHO grade 3 or 4, was mainly encountered at the 35 and 40 mg/m2 dose levels . Although occasionally severe, myelosuppression did not result in toxic deaths; spontaneous haemorrhage was never observed, and platelet transfusions were not required . Additional toxicity, also related to the two higher dose levels, consisted of diarrhea (WHO grade 3) and the 'hand and foot syndrome', both occurring in a single patient; two patients developed fever of undetermined origin, but only one of them required hospitalization and antibiotic treatment . The overall response rate was 20% (7 partial responses in 25 evaluable patients) . CONCLUSIONS: For phase II studies, we recommend a weekly oral dose of 40 mg/m2 TCNU, weeks 1 through 4, in combination with 400 mg/m2 5-FU and 80 mg/m2 LV (IV), once a week, weeks 1 through 8. J Periodontol, 1993 Jan, 64(1), 60 - 2 Periodontal infection leading to periostitis ossificans ("Garrè's osteomyelitis") of the mandible . Report of a case; Van den Bossche LH et al.; Periostitis ossifications ("Garre's osteomyelitis") of the mandible is a rather rare pathology that occurs as a hard swelling at the mandibular angle, persists for a long period, and is mostly painful on palpation . Clinical signs of infection are rarely noted . The etiological factor is generally a carious first permanent molar with a periapical infection or a fracture of the jaw . In this case, a 10 year-old girl showed a fixed painful swelling of the right mandibular angle . This revealed to be periostitis ossificans, although none of the classical causes were present . The symptoms were evoked by a periodontal infection: there was an osseous crater and a probing pocket depth of more than 10 mm disto-lingually of the first right permanent molar of the mandible . This was likely the etiological factor . Extraction of the first and second permanent right molar, curettage of the corresponding alveoli, and antibiotic treatment resulted in complete healing, clinically and radiologically, after 9 months. Neurology, 1993 Jan, 43(1), 169 - 75 Borrelia burgdorferi-specific intrathecal antibody production in neuroborreliosis: a follow-up study; Hammers-Berggren S et al.; We used a capture ELISA with biotinylated Borrelia burgdorferi flagella as antigen to analyze the kinetics of intrathecal antibody production against B burgdorferi in 27 patients with neuroborreliosis . All patients had lymphocytic pleocytosis, 13/27 had intrathecal specific IgM production, and 26/27 had intrathecal IgG synthesis against B burgdorferi before therapy . All patients improved after antibiotic treatment . At follow-up, 11 months to 8 years later (median, 1 1/2 years), 20 patients had had a complete clinical recovery, and seven suffered from sequelae . One patient without sequelae had persistent specific intrathecal IgM synthesis . Ten of 20 patients without sequelae and five of seven patients with sequelae had persistent intrathecal IgG production against B burgdorferi . None of the 16 patients with persistent specific intrathecal antibody synthesis had pleocytosis at follow-up . Therefore, intrathecal immunoglobulin production against B burgdorferi, especially IgG, may persist for years after treatment of neuroborreliosis without clinical signs of active disease. Epilepsia, 1993 Jan-Feb, 34(1), 161 - 2 Clarithromycin-carbamazepine interaction: a case report; Albani F et al.; We report a clinically relevant interaction between a new macrolide antibiotic, clarithromycin, and carbamazepine (CBZ) . In a patient receiving CBZ monotherapy, 10-day antibiotic treatment increased CBZ concentration despite concomitant CBZ dose reduction and doubled the CBZ concentration/dose ratio . Concentration of the CBZ epoxide (CBZ-E) metabolite was reduced, suggesting that the interaction occurs at a metabolic level. Pediatr Infect Dis J, 1993 Jan, 12(1), 20 - 4 Factors influencing outcome in children treated with antibiotics for acute otitis media; Berman S et al.; Factors affecting outcome were analyzed from 3 antibiotic clinical trials that had identical case definition and outcome criteria . Overall 102 subjects with acute otitis media had an initial tympanocentesis, were enrolled in one of the clinical trials, were randomized to receive 10 days of oral treatment and had a posttherapy visit . The antibiotics used were cefixime (38), cefaclor (25), loracarbef (14), amoxicillin plus clavulanate (16) or amoxicillin (9) . Fifty-five of the 102 (54%) study subjects were classified as cured or improved at the 21- to 28-day posttherapy visit . Factors analyzed in relation to outcome included antibiotic administered, isolation of a pathogen from the middle ear aspirate, study subject age and sex, history of recurrent otitis media, unilateral vs . bilateral involvement, season of enrollment and history of antibiotic administration in the month before enrollment . Univariate analysis identified the following four factors associated with higher posttherapy visit failure rates: a history of recurrent otitis media; enrollment during winter respiratory season (December through March); a history of being treated with an antibiotic during the month before enrollment; and administration of cefaclor compared with other antibiotics . However, only a history of recurrent otitis media and enrollment during the winter respiratory season met the 0.05 significance level for entry into a model derived from logistic regression to assess interactions among factors . Clinical guidelines for the management of otitis media should take into consideration that children with a prior history or recurrent otitis media and infection during the winter season more often fail to respond to antibiotic treatment and have a higher risk of developing a persistent middle ear effusion. Eur J Cancer, 1993, 29A Suppl 3, S2 - 6 GM-CSF in marrow transplantation; Antman KH; Bone marrow transplantation (BMT) is being increasingly used in a wide variety of diseases . During the period of re-engraftment the patient is particularly susceptible to a number of opportunistic infections which can radically affect acute morbidity and mortality . Recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) has been shown to mobilise haemopoietic progenitor cells for use after high-dose therapy, to enhance myeloid engraftment and stimulate mature monocytes/macrophages and neutrophils . Evidence is emerging that GM-CSF may be useful in BMT . A review of clinical trials in patients receiving BMT has revealed that the administration of rhGM-CSF significantly reduces the duration to re-engraftment, number of antibiotic treatment days, and the period of hospitalisation . Thus, rhGM-CSF appears to be a useful adjunct to BMT. Microbiol Immunol, 1993, 37(4), 325 - 9 Neurologic abnormalities in two dogs suspected Lyme disease; Azuma Y et al.; A 2-year-old mongrel dog developed neurological signs following tick bite . These included astasia, persistent tonic convulsions and hyper-reflexia . Both serum IgG and IgM antibody titers against Borrelia burgdorferi were positive in enzyme-linked immunosorbent assay (ELISA) . The neurological signs subsided after high-dose penicillin and streptomycin treatment . A strain of spirochetes (P427a) was isolated from the midgut of Ixodes persulcatus feeding on the dog . Morphological characteristic, immunological property and protein profile revealed that the isolate was B . burgdorferi . Similarly, a 2-year-old Labrador retriever dog developed neurological signs after tick bite and showed a positive IgG antibody titer against B . burgdorferi . Antibiotic treatment was effective also in this case . These findings suggest that neurological symptoms shown in both dogs were caused by infection with B . burgdorferi. Clin Exp Obstet Gynecol, 1993, 20(2), 108 - 10 Cesarean section: an economic appraisal of infectious complications; Franchi M et al.; From March 1991 to April 1992, in the Dept . of Obstetrics and Gynecology, University of Pavia-Varese, 107 out of 115 consecutive patients submitted to cesarean section were evaluated for the clinical and economic evaluation of infectious complications . On the grounds of our previous experience we distinguished two groups: a high infection risk group (50 pts), because of labor and/or rupture of membranes, HIV+, diabetes; and a low infection risk group (57 pts) . Our findings support the choice of these selective criteria both for the infectious event or for the use, and thence for the costs, of antibiotic treatment . In fact, based on this experience we believe that in cesarean sections with high infection risk AP is always recommended whereas in the low risk ones AP should not exceed L . 10.095 to be cost-effective. Caries Res, 1993, 27(2), 154 - 60 The Finnish Family Competence Study: the relationship between caries, dental health habits and general health in 3-year-old Finnish children; Paunio P et al.; The aim of this study was to examine how dental health related habits, infectious diseases and long-term illness are associated with dental health at the age of 3 in first-born children resident in a Finnish province . The study was designed as a survey using stratified randomised cluster sampling, confidential questionnaires and clinical dental examinations . The results were analysed using polytomous logistic models . In the stepwise analysis the only statistically significant explanatory factors were the use of juice at night and dental cleanliness . Antibiotic treatment or long-term illness was not significantly associated with dental health. Infection, 1993, 21 Suppl 1, S21 - 7 {Possibilities for the use of the basic cephalosporin cefuroxime in bone surgery . Tissue levels, effectiveness and tolerance}; Ketterl R et al.; In a prospective study with 725 patients we demonstrated the effectiveness and tolerability of cefuroxime as antibiotic prophylaxis in trauma surgery . The infection rates were 0.5 to 1.2% in the different treatment groups . Only in patients with third degree open fractures infection occurred in 8.3% . In addition, the serum drug levels (112 mg/l) and tissue concentrations in bone cortex (15 mg/kg), spongiosa (28 mg/kg), joint cartilage (44 mg/kg) and capsule (57 mg/kg) were measured 1 h following infusion of 1.5 g cefuroxime in 14 patients using HPLC . In a further clinical study with 68 patients suffering from chronic posttraumatic osteomyelitis of the tibia, we could show the value of the surgical treatment with unroofing of the tibia and performing muscleflaps in combination with antibiotic treatment using cefuroxime . Only 4.6% of the patients showed a persistent infection and the reinfection rate was 7.4%. Pediatr Radiol, 1993, 23(7), 563 - 4 Sonographic diagnosis of a huge necrotizing thymic cyst; Deeg KH et al.; We report on a 10-year-old boy with a huge right-sided thoracic mass . The chest radiograph, ultrasonography CT and laboratory data were suspicious of an abscess-forming pneumonia . Following unsuccessful antibiotic treatment the mass was surgically removed . Histological examination revealed a huge necrotizing thymic cyst. Pediatr Radiol . 1993;23(7):556. Gradenigo syndrome: a case report; Tutuncuoglu S et al.; The case is presented of a 13-year-old boy with recurrent episodes of otitis media who developed Gradenigo syndrome . Mastoid and petrous bone involvement were demonstrated by CT . Symptoms resolved with antibiotic treatment. Surg Gynecol Obstet, 1993, 177 Suppl, 30 - 4; discussion 35-40 Cefepime for infections of the biliary tract; Thompson JE Jr et al.; Antibiotic treatment of biliary tract infections is widely accepted . An open, prospective, randomized, multicenter trial comparing cefepime (2 grams every 12 hours) with gentamicin (1.5 milligrams per kilograms every eight hours) plus mezlocillin (3 grams every four hours) for a minimum of five days was undertaken . Of the 149 pa