Digitizing pediatric chest radiographs: comparison of low-cost, commercial off-the-shelf technologies.

OBJECTIVE: To compare low-cost, off-the-shelf technology for digitizing pediatric chest radiographs. MATERIALS AND METHODS: Forty pediatric chest radiographs (hard copy), each with a single abnormality, were digitized using a commercial film digitizer and two low-cost METHODS: a digital camera and a flatbed scanner. A stratified, randomized, block design was used where 20 readers evaluated 40 different images to determine the ability to accurately detect the abnormality. Readers then rated all 160 images (40 images x 4 methods) for conspicuity of the abnormality and overall image quality. RESULTS: Abnormalities were correctly identified on 82.3 % of hard copy images, 82.9 % of flatbed scanner images, 74.3 % of film digitizer images, and 69.7 % of digital camera images (p < 0.05) when compared to hard copy or flatbed scanner images. Lesion conspicuity was rated higher on hard copy (p < 0.05) than all digitized images. Conspicuity ratings were similar for flatbed scanner and film digitizer images, but lower in digital camera images (p < 0.05). For overall image quality, all were rated significantly different from each other (p < 0.05), with hard copy > flatbed scanner > film digitizer > digital camera images. CONCLUSION: A low-cost flatbed scanner yielded digital pediatric chest images which were significantly superior to digital camera images While flatbed scanner images were interpreted with the equivalent diagnostic accuracy of hard copy images, they were rated lower for image quality and lesion conspicuity.

Scleroderma in childhood: a 35-year history of cases and review of the literature.

Scleroderma is a connective tissue disease with a variety of clinical presentations. The purpose of our study was to review representative cases of scleroderma in childhood to determine the initial presentation, course of the disease, orthopaedic manifestations, and the necessity and success of surgical intervention. Records from the four medical centers were retrospectively reviewed to identify the patients who were diagnosed with scleroderma over the past 35 years. Data on disease presentation, course, treatment, and response were collected. Seventeen cases representing the variety of clinical presentations are presented. Scleroderma characteristically presents with asymmetric lesions involving the extremities and remains a diagnostic and therapeutic challenge. Treatment must be individualized to the patient and his or her specific limitations brought about by the disease. Early diagnosis, supportive care, and physical therapy combined with early orthopaedic surgical intervention to release joint contractures are among the most efficacious treatments.

Lavage administration of dilute recombinant surfactant in acute lung injury in piglets.

In an acute lung injury model, we previously observed reversal of pulmonary dysfunction with natural surfactant administered by lavage (dose = 18 mg/kg phospholipid). The present study questioned whether a lower dose of phospholipid would be effective if a recombinant preparation rather than natural surfactant were used. Acute lung injury was induced by repeated saline lung lavage in ventilated, sedated, and paralyzed piglets. Three concentrations of recombinant surfactant were studied (low phospholipid, 1 mg/mL; medium phospholipid, 4 mg/mL; high phospholipid, 13.5 mg/mL). Control piglets received no surfactant. Thirty-five milliliters per kilogram of surfactant was administered by gravity, followed by passive drainage of excess fluid. All treatment groups retained similar volumes (4.7+/-0.3 mL/ kg), corresponding to phospholipid doses of 4+/-0.4, 22+/-3, and 67+/-4 mg/kg in low, medium, and high-dose groups, respectively. Treatment groups showed significant improvement in Pao2 compared with controls. Other parameters different from controls were found in only the medium and high-dose groups. All surfactant-treated groups showed improvement over time in Pao2, Paco2, lung resistance mean airway pressure, functional residual capacity, and dynamic compliance. These data support the statement that whereas there is a dose response to exogenous surfactant, the effective dose of recombinant surfactant in acute lung injury may be as low as 4 mg/kg phospholipid when administered by lavage.

Pacific Island Health Care Project: early experiences with a Web-based consultation and referral network.

The Pacific Island Health Care Project (PIHCP) has in the past provided definitive care at the Tripler Army Medical Center (TAMC) for nearly 3000 patients. To contain costs, increase access, and provide consultative and referral services to physicians in the Pacific Basin, a web-based network was established in 1997. Four sites in the Western Pacific were provided with a desktop computer, digital still and video cameras, flatbed scanners, and printers. Consultations with supporting imagery are submitted to TAMC where the consults are data-based and dynamically posted on a secure web server. TAMC consultants triage and comment on the cases and the educational significance. Unnecessary or inappropriate referrals are returned with instructions for local care. Cases are formatted to allow rapid response, image review, consultant/provider interaction, and peer review. More than 180 consults have been submitted from the island nations electronically (30 September 1998) and initial experience indicates that the Internet can be easily used as an inexpensive store and forward consultation format. There has been an overwhelming enthusiasm for this project by all participants and for the first time since the inception of the PIHCP, funding was available during the entire fiscal year, with tens of thousands of dollars saved.

Unilateral leptospiral pneumonia and cold agglutinin disease.

Pneumonia that is unresponsive to appropriate antibiotic therapy suggests an infection due to more unusual or resistant organisms. In this report, a child with unilateral pneumonia, pleural effusion, and anti-I cold hemagglutinin antibodies is presented. The usual causes of this clinical picture were suspected and treated, but the child did not improve. Features of her history suggested a more unusual etiology, and a diagnosis of leptospirosis was made. A brief discussion of leptospiral disease in children is provided.

Prospective randomized double blind placebo-controlled evaluation of azithromycin for treatment of cat-scratch disease.

OBJECTIVE: To determine the efficacy of azithromycin in the treatment of patients with typical cat-scratch disease. DESIGN: Prospective, randomized, double blind, placebo-controlled clinical trial. SETTING: Large military medical center and its referring clinics. PATIENTS: Active duty military members and their dependents with laboratory-confirmed, clinically typical cat-scratch disease. INTERVENTION: Study participants assigned by randomization to treatment with oral azithromycin or placebo for 5 days. OUTCOME MEASURES: Lymph node volume was calculated using three dimensional ultrasonography at entry and at weekly intervals. The ultrasonographer was blinded to the treatment groups. Endpoint evaluations were predetermined as time in days to 80% resolution of the initial total lymph node volume. RESULTS: Demographic and clinical data showed that the azithromycin and placebo treatment groups were comparable at entry although the placebo group tended to be older. Eighty percent decrease of initial lymph node volume was documented in 7 of 14 azithromycin-treated patients compared with 1 of 15 placebo-treated controls during the first 30 days of observation (P = 0.026). After 30 days there was no significant difference in rate or degree of resolution between the two groups. CONCLUSIONS: Treatment of patients with typical cat-scratch disease with oral azithromycin for five days affords significant clinical benefit as measured by total decrease in lymph node volume within the first month of treatment.

Cerebral vasculitis in an adolescent with juvenile rheumatoid arthritis.

A 16-year-old girl with longstanding polyarticular juvenile rheumatoid arthritis was referred from Chuuk State, Federated States of Micronesia, for evaluation and management of weakness and joint pains. She had a right hemiparesis with central facial weakness, polyarticular arthritis, and a dense cataract of the left eye with phthisis bulbi. Extensive evaluation using magnetic resonance angiography revealed vasculitis of the anterior and middle cerebral arteries. She was treated with "pulse" doses of methylprednisolone intravenously and she improved remarkably. Repeat angiography demonstrated dramatic improvement of the vasculitis. There is a paucity of literature regarding cerebral vasculitis in juvenile rheumatoid arthritis. That literature is reviewed, and our patient is discussed with regard to the few published reports.

The expanding spectrum of Bartonella infections: II. Cat-scratch disease.

Recent advancements and developments in molecular biotechnology have allowed more precise reclassification of many microorganisms. With the use of these new taxonomy tools, several organisms previously thought to belong to other genera have been recently described as bartonellae. Of the 11 organisms now described as Bartonella spp., only four have been shown to be pathogenic for humans. Table 1 lists the four Bartonella human pathogens along with the their known epidemiology and the scope and range of disease associated with each. All are now considered to be bacteria and can be grown on blood-enriched agar although primary isolation in some may best be achieved in cell tissue culture. B. bacilliformis infection is limited to certain geographic regions in South America where the only human reservoir and the sandfly vector(s) that spreads the disease reside together. Specific antibiotic treatment is dramatically effective in treating the highly fatal, acute intraerythrocytic hemolytic form of the disease, but their effectiveness in treating the vascular proliferative forms (verruga peruana) or the chronic asymptomatic, bacteremic, carrier state of the disease has not been effective. This disease should remain confined to its present endemic geographic areas in South American unless asymptomatic bacteremic persons from these areas migrate to areas where sandflies and humans exist that are capable of establishing this infection in new endemic areas. B. quintana and B. henselae cause a wide range of clinical diseases in humans, the type and extent of which varies significantly with the immune status of the host. In immunocompetent hosts the pathologic response is granulomatous, suppurative, extracellular and intracellular, generally self-limited and usually unresponsive to antibiotic treatment, even to those drugs to which the organism is shown to be sensitive in vitro. In contrast, in immunocompromised hosts the pathologic response is vasculoproliferative, organisms may be seen intracellularly but they are often seen in abundance in extracellular clumps and infection is usually progressive and fatal unless treated. In these patients clinical response to treatment with drugs that are effective in vitro against these organisms has usually been dramatic. Of these agents those that penetrate cells and are found in high concentrations intracellularly, such as erythromycin, clarithromycin, azithromycin, rifampin, doxycycline and gentamicin, appear to be most effective. These agents not only appear to provide the most dramatic treatment response in patients with BA, BP and PRFB and other manifestations of B. henselae (and B. quintana as well) in immunocompromised persons, they appear to be the most promising agents for treatment of persons with both typical and atypical CSD. Further studies will be necessary to more clearly elucidated the mechanisms responsible for the diverse clinical presentations of infection with these organisms in human hosts relative to their immune status. In addition clarification of the epidemiology of B. elizabethae infections in humans may be helpful in understanding the nature of infection with Bartonella organisms.

Acne fulminans treated with isotretinoin and "pulse" corticosteroids.

Acne fulminans (AF) is a rare and severe form of acne that occurs almost exclusively in white adolescent boys. We report AF in a 16-year-old white boy developing 14 months after the onset of uncomplicated acne vulgaris. The symptomatology, etiology, treatment, and prognosis of AF are discussed.

Wine as a digestive aid: comparative antimicrobial effects of bismuth salicylate and red and white wine.

OBJECTIVE: To test whether red and white wines are as potent as bismuth salicylate against the bacteria responsible for traveller's diarrhoea to try to explain wine's legendary reputation as a digestive aid. DESIGN: Red and white wine, bismuth salicylate, two solutions containing ethanol (diluted absolute ethanol and tequila), and sterilised water were tested against suspensions of salmonella, shigella, and Escherichia coli to determine relative antibacterial activity. Suspensions of 10(7) colony forming units of shigella, salmonella, and E coli were added to the test solutions and plated on standard nutrient agar at 0, 10, 20, 30, 60, and 120 minutes and 24 hours. Dilutions of wine and bismuth salicylate were then tested with E coli as the test bacterium, and the experiment repeated. MAIN OUTCOME MEASURES: Exposure times necessary for eradication of organisms for the different solutions; decreases in colony counts at the different exposure times for dilutions of wine and bismuth salicylates. RESULTS: Undiluted wine and bismuth salicylate were both effective in reducing the number of viable organisms (by 10(5)-10(6) colony forming units) after 20-30 minutes. Dilutions of wine were much more effective in decreasing colony counts than were similar dilutions of bismuth salicylate. CONCLUSION: The antibacterial property of wine is largely responsible for wine's reputation as a digestive aid.

Pyoderma gangrenosum and cranial osteolysis: case report and review of the paediatric literature.

Pyoderma gangrenosum is a poorly understood, ulcerating cutaneous disorder which is rarely seen in the paediatric age-group. We report a 3-year-old boy who developed an ulcer over the left frontoparietal scalp at the age of 1 year. A 9-cm area of underlying cranial bone was destroyed. The appearance on radiographs and CT scan was suggestive of eosinophilic granuloma, osteomyelitis, or other destructive processes. Biopsies of the scalp lesion and calvaria showed granulation tissue and degenerating bone. After the biopsies the scalp lesion increased in size, and wound dehiscence occurred. Ulceration developed at the site of a PPD skin test, which on biopsy was consistent with the diagnosis of pyoderma gangrenosum. Pyoderma gangrenosum should be added to the differential diagnosis of cutaneous disorders which can result in osteolytic/osteonecrotic defects.

Cat-scratch disease in Hawaii: etiology and seroepidemiology.

OBJECTIVE: To study the etiology and seroepidemiology of cat-scratch disease (CSD) in Hawaii. METHODS: Blood and fine-needle aspirate (FNA) from the lymph nodes of 39 consecutive patients with clinical CSD were cultured for Bartonella henselae, and blood samples from index cats, stray cats, and dogs were cultured and their sera were tested by indirect fluorescence antibody test for antibodies to B. henselae and Afipia felis. Sera from age- and sex-matched human subjects without cat exposure served as controls. RESULTS: Warthin-Starry staining showed positive results in only 4 of 32 FNAs, and B. henselae was isolated from only one FNA specimen. All of 38 patients who had two or more sera tested had elevated titers of antibody to B. henselae. Only 1 of 48 human control sera had antibody to B. henselae. Of 31 kittens, 21 had positive blood culture results and elevated antibody titers to B. henselae. Of three adult cats, all had negative blood culture results, but they had serologic evidence of past infection. Of 23 adult stray cats, 18 had elevated titers of antibody to B. henselae, but in only one was the blood culture result positive. Results of IFA tests were marginally positive for A. felis in 1 of 29 patients with CSD and in one adult stray cat and one dog. CONCLUSIONS: This study shows that the B. henselae IFA test is both highly sensitive and specific for the detection of infection caused by B. henselae and for the laboratory diagnosis of CSD, and that FNA is seldom helpful in confirming the diagnosis. We further demonstrated that CSD in Hawaii is due to B. henselae and that infection is directly linked to the scratch or bite of a kitten. Older cats seldom have bacteremia but often have serologic evidence of past infection. Our study fails to implicate dogs in the epidemiology of CSD in Hawaii, and A. felis was not etiologically implicated in CSD in the human subjects and animals we studied.