Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup).

Aerosolized racemic epinephrine, but not L-epinephrine, is commonly used in treating croup. The efficacy and adverse effects of nebulized racemic and L-epinephrine in the treatment of laryngotracheitis were compared. Children 6 months to 6 years of age with a croup score of 6 or above were assigned in a randomized double-blind fashion to receive either racemic (n = 16) or L-epinephrine (n = 15) aerosols. Croup score, heart rate, blood pressure, respiratory rate, fraction of inspired oxygen, and oxygen saturation were recorded before treatment and at 5, 15, 30, 60, 90, and 120 minutes after the aerosol. Patients in both groups showed significant transient reduction of the croup score and respiratory rate following the aerosol (P less than .001), but there were no differences between treatment groups when croup score, heart rate, blood pressure, and respiratory rate were assessed over time. It is concluded that L-epinephrine is at least as effective as racemic epinephrine in the treatment of laryngotracheitis and does not carry the risk of additional adverse effects. L-Epinephrine is also more readily available worldwide, is less expensive, and can be recommended for this purpose.

Acute hemorrhage in dogs: construction and validation of models to quantify blood loss.

We examined the ability of commonly used clinical parameters to quantify acute hemorrhage in dogs. Eight animals were bled 40 ml/kg body wt over 100 min. Ten hemodynamic and 20 blood laboratory parameters were obtained every 10 min to construct, with use of linear regression analysis, models that quantify blood loss. During model construction, the best indicator of quantity of hemorrhage was arterial base deficit [ABD; coefficient of variation (CV) 35%]. This model was more accurate (P < 0.05) than 27 others (CV range 43 to 63%) and similar to systolic (CV 40%) and mean (CV 40%) arterial pressures. In validation studies in 10 additional animals, our best models based on ABD and systolic and mean arterial pressures each unexpectedly showed a significant (P < 0.05) decrease in accuracy (CV 86, 57, and 60%, respectively) attributable to large baseline (before hemorrhage) variability among animals. To eliminate this variability, models based on changes from baseline measurements were investigated. The best predictor of change in blood volume was change in ABD (CV 27%). This model was significantly (P < 0.05) more accurate than any of 27 others (CV range 36 to 65%) and similar to change in venous base deficit and venous pH (each CV 31%). When validated, acid-base models such as ABD, venous pH, and arterial bicarbonate were the best predictors of volume change (CV range 28 to 40%). With the use of multivariate analysis, pairwise combinations of single parameter models (n = 465) improved prediction errors only minimally. In summary, most commonly used hemodynamic and blood indexes could not be validated as accurate measurements in quantifying hemorrhage. In contrast, changes in acid-base parameters were validated as moderately accurate predictors of blood volume changes and therefore may have utility in the assessment of patients with ongoing hemorrhage.

Leukocyte CD18 monoclonal antibody worsens endotoxemia and cardiovascular injury in canines with septic shock.

We investigated the effects of a murine monoclonal antibody directed against the canine leukocyte CD11/18 adhesion complex (MAb R15.7) in a canine model of septic shock. Awake 2-yr-old purpose-bred beagles were studied 7 days before and 1, 2, 4, and 10 days after intraperitoneal placement of an Escherichia coli-infected fibrin clot. Starting 12 h before clot placement, animals received 0.5-1 mg/kg iv every 12 h (4 doses total) of either MAb R15.7 (MAb group, n = 8) or, as controls, murine serum protein (n = 8). After infected clot placement, all animals received antibiotic (ceftriaxne, 100 mg.kg-1.day-1 for 4 days). Two of eight control animals and four of eight MAb animals died (P = 0.4). During the first 8 h after clot placement, MAb animals, compared with control animals, had greater (P < 0.06) increases in serum endotoxin levels and higher (P < 0.05) neutrophil counts. Day 1 after clot placement, MAb animals, compared with control animals, had decreased (P < 0.05) central venous pressure and arterial pH and increased (P < 0.05) arterial lactate. Day 2 after clot placement, MAb animals, compared with control animals, had decreased (P < 0.05) cardiac index and mean arterial pressure. In summary, MAb R15.7, although associated with increased neutrophil counts, worsened serum endotoxemia, acidosis, and cardiovascular function in this canine model of septic shock. These data suggest that in septic shock, antibody directed against this leukocyte membrane protein complex may be harmful, possibly via impairment of normal leukocyte function.

Cardiopulmonary effects of granulocyte colony-stimulating factor in a canine model of bacterial sepsis.

We investigated the effects of recombinant granulocyte colony-stimulating factor (G-CSF) in a canine model of septic shock. Awake 2-yr-old beagles were studied before and after intraperitoneal placement of an Escherichia coli-infected clot. Nine days before and until 3 days after clot placement, animals received daily high-dose (G-CSF (5 microgram/kg body wt; n = 17), low-dose G-CSF (0.1 microgram/kg body wt; n = 17), or a control protein (5 micrograms/kg body wt; n = 20). Survival rate was greater (P < 0.04, Wilcoxon test) in the high-dose G-CSF group (14/17) than in the low-dose G-CSF (10/17) and control (12/20) groups. High-dose G-CSF improved cardiovascular function, as evidenced by increased left ventricular ejection fraction (day 1 after clot; P < 0.001) and mean arterial pressure (day 2; P < 0.02) compared with low-dose G-CSF and control groups. High-dose G-CSF increased (P < 0.001) mean peripheral neutrophils before (-3 days) and after (2 h to 4 days) clot and produced a more rapid (P < 0.001) rise (day 2) and fall (day 4) in mean alveolar neutrophil numbers compared with the low-dose G-CSF and control groups. High-dose G-CSF decreased mean serum endotoxin (2-8 h; P < 0.002) and tumor necrosis factor (2 h; P < 0.02) levels and lowered blood bacteria counts (2-6 h; P < 0.04) compared with the low-dose G-CSF and control groups. Thus, in this canine model, G-CSF sufficient to increase peripheral neutrophils before and during peritonitis and septic shock enhances host defense, reduces cytokine (tumor necrosis factor) levels, and improves cardiovascular function and survival.

Modulation by opiates of small intestinal prostaglandin E2 and 3',5'cyclic adenosine monophosphate levels and of indomethacin-induced ulceration in the rat.

We studied the effect of parenteral morphine and naloxone administration on intestinal mucosal Prostaglandin E2 (PGE2) and 3',5' cyclic adenosine monophosphate (cAMP) levels and on indomethacin-induced intestinal ulceration in the rat. Compared to the control group, morphine significantly decreased whereas naloxone markedly increased both PGE2 and cAMP mucosal levels, respectively. Morphine or naloxone alone did not cause mucosal injury. However, when given with indomethacin, morphine significantly potentiated the ulcerogenic effect of indomethacin while naloxone exerted a protective effect. These results suggest that opioid peptides may play a role in modulation of intestinal mucosal PGE2 and cAMP levels. In addition, enhancement of indomethacin-induced ulcer formation by morphine and amelioration by naloxone might be in part mediated through their effect on mucosal PGE2 and cAMP levels.

Gerstmann tetrad in leopard syndrome.

We report a 12-year-old boy with multiple lentigines (Leopard) syndrome who was evaluated for learning difficulties and Gerstmann tetrad syndrome (i.e., dyscalculia, left-right disorientation, finger agnosia, and dysgraphia). Cranial computed tomography revealed left ventriculomegaly, more pronounced in the occipital horn suggesting mild atrophy of the left parietal lobe. This is the first report of an association between the Leopard and Gerstmann syndromes and one of the few to demonstrate a computed tomographic abnormality in the latter.

Comparison of a tympanic thermometer to rectal and oral thermometers in a pediatric emergency department.

We performed a clinical trial of a new tympanic thermometer to test its accuracy in a pediatric emergency department. Tympanic temperature was compared to oral or rectal glass and electronic temperature, depending on the developmental age of the child. Results were controlled for age of the child, cooperation, quantity of cerumen, and the presence or absence of otitis media. Our results suggest good correlation of tympanic with oral and rectal glass thermometry except in infants less than three months of age. Sensitivity and specificity, respectively, were 80% and 93% for detecting fever of 38 degrees C and 80% and 95% for detecting fever of 38.5 degrees C.

Single-dose ceftriaxone versus 10 days of cefaclor for otitis media.

We conducted a controlled clinical trial to determine the efficacy of single-dose intramuscular ceftriaxone for the treatment of acute otitis media. Fifty-four children aged 18 months to 6 years with clinical and tympanometric evidence of otitis media were randomized to receive either 50 mg/kg ceftriaxone or 10 days of oral cefaclor 40 mg/kg/day. Resolution of symptoms and clinical and tympanometric appearance of the tympanic membrane at follow-up visits were used to determine outcome. Thirty-one children received ceftriaxone and 23 received oral cefaclor. There were no treatment failures. There were no significant differences between groups in persistence of effusion or recurrence of acute otitis media. We conclude that a single intramuscular dose of ceftriaxone compares favorably with 10 days of oral cefaclor for the treatment of acute otitis media.

Development of the specialty of emergency medicine in Israel: comparison with the UK and US models.

OBJECTIVES: To describe the development of emergency medicine (EM) in Israel and review the specific problems faced by the discipline and describe the solutions that were found. METHODS: A comprehensive literature search was conducted for data on development of EM in the UK and in North America, and the personal knowledge of two of the authors (PH and YW) was used in preparing the article. RESULTS: There are differences in development of EM between Israel and the UK/US models. In Israel the specialty developed within the context of established high quality clinical practice and consequently it met resistance from the system, which did not wish to invest in what it felt might be marginal improvements in patient care. The economics of Israeli medicine also dictated that EM be made into a super-specialty rather than a primary specialty. Certified specialists from family medicine, paediatrics, internal medicine, general surgery, anaesthesia, and orthopaedic surgery can access training positions in EM. Currently there are seven active EM programmes of 2.5 years duration and 16 residents. The curriculum is flexible and a national certification examination is being developed. CONCLUSIONS: Development of EM can and should take different paths according to the specific local needs and realities. There is no single ideal model suitable for all circumstances. The practice of clinical EM in Israel is comparable with that of any developed country and daily progress is being made in the academic areas of teaching and research. There are worldwide similarities in the process of developing EM as a distinct discipline.

Poison exposure in children before Passover.

BACKGROUND: Extensive cleaning of homes in Israel before Passover may result in increased exposure of children to cleaning substances. OBJECTIVES: To evaluate the potential danger of Passover cleaning to children, and to study the risk factors in order to identify areas for prevention. METHODS: All cases of poison exposure in Jewish and Arab children under the age of 15 years reported to the Israel Poison Information Center during 1990-95 (n = 5,583) were analyzed for the 6 weeks before and 6 weeks after Passover. Poison exposures in Jewish children < 15 years old were studied in seven pediatric emergency rooms for the 2 weeks before and 6 weeks after Passover (n = 123). RESULTS: The IPIC data showed a highly significant 38% increase in the average weekly poison exposure rate for the 2 weeks before Passover compared with the remaining 10 weeks. Data recorded by the pediatric emergency rooms showed a twofold increase in cleaning substance poisoning during the 2 weeks before Passover compared with the following 6 weeks. The rise in exposures to cleaning substances was observed among children from secular, religious and ultra-orthodox families. In these exposures, the substance was found in open containers in 70% of cases. CONCLUSIONS: The extensive cleaning of homes among Jewish families in preparation for Passover poses the danger to young children of cleaning substance poisoning. Increasing public awareness, closer observation of children, and keeping these substances in closed containers should increase children's safety during this annual cleaning.

Emergency medicine in Israel: state of the art.

Emergency medicine is in its infancy in Israel but is developing rapidly. Medical and government authorities such as the Israeli Medical Association and the Israeli Ministry of Health have already recognized the need for this field in Israel, although it remains for emergency medicine to be recognized as an independent medical specialty. Those involved in the intense process of obtaining formal recognition believe this will occur in the next year.

Pediatric telephone advice: a new medical service in Israel.

Although controversy still exists about dispensing medical advice over the telephone, such services are widely offered by pediatricians in the USA. In Israel, however, such services have not yet been developed. In a joint project of the Moked Keshev (a private medical help line) at Magen David Adom (national ambulance service) and the Children's Medical Center of Israel, the first pediatric telephone advice service in Israel was established. In this study we analyzed 512 consecutive incoming calls received during the first 11 months of service operation. Of these, 42% of calls concerned children in the 1 month to 1 year age group. Unexpectedly, calls were almost evenly distributed throughout the week with a slight decrease on Fridays and Saturdays (sabbath), and 45.7% of the calls were received during the morning shift. The three most common reasons for contact were: of a general nature such as fever (23%), gastrointestinal problems (19%), and medical questions (18%). In only 20.7% of the cases were the patients advised to go to the nearest hospital emergency department, emphasizing the non-emergent nature of the calls. At the time of follow-up (within 24 h), patient status was assessed as: improved (73.7%), same (22.6%), and worse (3.8%). Of those who became worse, none required an emergency department evaluation. The present study demonstrates that a Pediatric Telephone Advice Service in Israel is technically functional, medically safe, and contributes to the health management of children.

Stress fractures: a diagnostic problem.

Three cases of stress fracture, in which diagnosis was aided by sequential radiographs and radionuclide scanning are presented; and a procedure for their management, which attempts to eliminate the need for invasive investigations, is suggested.

The validity of the uriscreen test for early detection of urinary tract infection in children.

OBJECTIVE: To determine the validity of the Uriscreen, a rapid diagnostic test based on the detection of urine catalase for the early detection of urinary tract infection (UTI) in children, compared with standard urinalysis and dipstick tests. STUDY DESIGN. Cross-sectional study. STUDY POPULATION: Children 1 month to 17 years of age who presented to the emergency department of a pediatric tertiary care center between March and November of 1996 with symptoms suggestive of UTI. METHODS: Urine specimens obtained from a random sample of 121 patients were evaluated simultaneously for possible UTI by Uriscreen (catalase test), urinalysis (microscopic pyuria), dipstick (leukocyte esterase and nitrite), and quantitative urine culture. All specimens were collected by one of three sterile techniques (midstream void technique, bladder catheterization, or suprapubic aspiration), as appropriate for age, and tested immediately. Using the quantitative urine culture as the gold standard (reference test), the sensitivity, specificity, and positive and negative predictive values of all the screening tests were determined and compared. Age, sex, temperature, presenting symptoms, and method of urine collection were recorded for each participant. RESULTS: Of the 121 patients, 35 (28.9%) had positive culture results: 30 girls (85.7%) and 5 boys (14.3%). Compared with urinalysis and dipstick tests, Uriscreen had the highest sensitivity (100% vs 88.6% and 97.1%, respectively) and the highest negative predictive value (100% vs 95% and 98.6%, respectively), but the poorest specificity (68.6% vs 88.4% and 82.5%, respectively) and positive predictive value (56.4% vs 75.6% and 69.4%, respectively). CONCLUSIONS: The clinical use of Uriscreen for the presumptive diagnosis of UTI in children is limited and not significantly superior to urinalysis or the dipstick test. However, because of its 100% sensitivity and negative predictive value and its ease of use, rapidity, and low cost, it is recommended highly for ruling out the diagnosis of UTI. In laboratories, a negative Uriscreen result may prevent the need for performing expensive urine cultures.

Sucralfate is protective against indomethacin-induced intestinal ulceration in the rat.

The therapeutic effects of sucralfate on ulcerated gastric and duodenal mucosa is well known. There is, however, very little information about its effect on the mucosa of the small intestine. We studied the possible protective effect of sucralfate against indomethacin-induced intestinal ulceration in the rat. Sucralfate was found to possess a marked protective effect on the intestinal mucosa (ulcer index 23.16 +/- 6.58 vs. 225 +/- 36.37; p less than 0.001). Sucralfate elevated basal mucosal prostaglandin E2 generation (p less than 0.001), and partially overcame the inhibition of prostaglandin E2 synthesis caused by indomethacin (p less than 0.03), but had no effect on mucosal cAMP level. The effect of sucralfate on prostaglandin E2 content might partially explain its protective effect on the intestinal mucosa.

Naloxone is protective against indomethacin-induced intestinal ulceration in the rat.

Naloxone, an opiate antagonist, was reported to protect against stress ulcers in dogs and rats. We studied its possible protective effect against indomethacin-induced intestinal ulceration in the rat. Naloxone was indeed found to possess a marked protective effect on the intestinal mucosa (ulcer index 73.3 +/- 13.6 vs. 273.8 +/- 21.8, p less than 0.001). Naloxone was found to elevate basal intestinal mucosal prostaglandin E2 (p less than 0.001) and cyclic adenosine monophosphate levels (p less than 0.005) but was unable to overcome the inhibition of prostaglandin E2 caused by indomethacin. An increase of cyclic adenosine monophosphate levels was seen, however, even in the presence of indomethacin, suggesting that cyclic adenosine monophosphate, but not prostaglandins, may play a role in the protective effect of naloxone.