Identification of the novel HLA-C*07:315 allele.

The HLA-C*07:315 allele is mostly identical to HLA-C*07:09 but has a non-synonymous substitution of C to G in exon 2.

Internet use in patients with cardiovascular diseases: Bad Berka Cross-Sectional Study (BABSY).

BACKGROUND: Internet has become a significant resource for dissemination of medical information. We sought to investigate prevalence and usage patterns of Internet access among consecutive patients with cardiovascular diseases. METHODS: A cross-sectional study was performed using a questionnaire as study tool. Among patients with Internet access, the type of health information sought and the impact of these on daily life were assessed. RESULTS: Of 1063 patients invited to the study, 1000 patients [68% male gender, mean age 66 ± 11 years (range 27-83 years)] agreed to complete the questionnaire. 216/1000 (21.6%) used Internet to obtain information related to their disease. The patient education was graded as: low (15%), medium (66%) and high (19%). Reasons for Internet use were as follows: 24-h availability 142/216 (65.7%); free of charge 58/216 (26.9%); and anonymity 50/216 (23.2%). Younger (≤ 66 years) age (35.2% vs. 15.3%; p = 0.0001), male gender (24.6% vs. 15.4%; p = 0.001) and higher education level (49.4% vs. 16.1%; p = 0.001) were significantly associated with Internet use. 30.6% (66/216) of Internet users changed their individual health behaviour attributable to information found on the Internet. However, this was not related to age, gender or level of education (p = 0.5, p = 0.6 and p = 0.4, respectively). Patients without Internet use obtain health information mainly from the pharmacist (62%) or from their treating physician (58%). CONCLUSIONS: A relevant number of patients with cardiovascular disease access the Internet for health information. The impact of such information on health-related behaviour in daily life was low.

Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance.

BACKGROUND: Recovery of myocardial function after revascularization of acutely occluded coronary arteries may require several days. During this critical time, patients in cardiogenic shock may have low output. A newly developed percutaneous left ventricular assist device (VAD) may offer effective treatment for these patients by providing active circulatory support. METHODS AND RESULTS: Between May 2000 and May 2001, VADs were implanted in 18 consecutive patients who had cardiogenic shock after myocardial infarction. The device was connected to the patient's circulation by insertion of a 21F venous cannula into the left atrium by transseptal puncture; blood was returned to the iliac artery through an arterial cannula. Mean duration of cardiac assistance was 4+/-3 days. Mean flow of the VAD was 3.2+/-0.6 L/min. Before support, cardiac index was 1.7+/-0.3 L/min per m(2) and improved to 2.4+/-0.6 L/min per m(2) (P<0.001). Mean blood pressure increased from 63+/-8 mm Hg to 80+/-9 mm Hg (P<0.001). Pulmonary capillary wedge pressure, central venous pressure, and pulmonary artery pressure were reduced from 21+/-4, 13+/-4, and 31+/-8 mm Hg to 14+/-4, 9+/-3, and 23+/-6 mm Hg (all P<0.001), respectively. Overall 30-day mortality rate was 44%. CONCLUSIONS: A newly developed VAD can be rapidly deployed in the catheterization laboratory setting. This device provides up to 4.0 L/min of assisted cardiac output, which may aid to revert cardiogenic shock. The left ventricle is unloaded by diverting blood from the left atrium to the systemic circulation, making recovery more likely after an ischemic event. The influence of this device on long-term prognosis warrants further investigation.

Autoantibodies against human ventricular myosin in sera of patients with acute and chronic myocarditis.

OBJECTIVES: The present study investigated the presence of antimyosin autoantibodies in sera of patients with myocarditis and in three control groups: healthy blood donors, patients with alcoholic cardiomyopathy and patients with other cardiac diseases. BACKGROUND: An increasing body of evidence indicates that in the course of myocarditis, autoimmunologic mechanisms may play a pathogenetic role. Animal studies with Coxsackie B3 virus-induced murine myocarditis could demonstrate the appearance of circulating autoantibodies against cardiac myosin. METHODS: Sera were analyzed by enzyme-linked immunosorbent assay (ELISA) and Western blot with human left ventricular myosin as antigen. RESULTS: Seventeen (42%) of 40 serum samples from patients with myocarditis showed antibody-binding against myosin, whereas only 1 (2.5%) of 39 samples from healthy blood donors and 9 (21%) of 43 samples from patients with other cardiac diseases showed autoantibodies against myosin (p < 0.05 vs. myocarditis). In sera from patients with alcoholic cardiomyopathy (n = 12), no antibodies against human ventricular myosin could be detected. In Western blots, the antimyosin antibodies in patients with myocarditis bound to the myosin heavy chain. Using protein-A sepharose chromatography, it could be shown that the antimyosin autoantibodies are of the immunoglobulin G (IgG) type. In ELISA, the antimyosin autoantibodies bind equally to myosin prepared from either cardiac or skeletal muscle, respectively. CONCLUSIONS: These results demonstrate the presence of autoantibodies against human ventricular myosin in patients with myocarditis. The prevalence of these autoantibodies is significantly higher in patients with myocarditis than in patients with other cardiac diseases. No organ specificity of the autoantibodies could be detected.

Antimyosin scintigraphy and immunohistologic analysis of endomyocardial biopsy in patients with clinically suspected myocarditis--evidence of myocardial cell damage and inflammation in the absence of histologic signs of myocarditis.

OBJECTIVES: This study compares the results of antimyosin scintigraphy in patients with clinically suspected myocarditis with histologic and immunohistologic findings in the endomyocardial biopsy. BACKGROUND: In patients with clinically suspected myocarditis, antimyosin scintigraphy often demonstrates myocardial cell damage but histologic evaluation of the endomyocardial biopsy often fails to show evidence of myocarditis. Recently developed immunohistologic techniques appear to be more sensitive for the detection of myocardial inflammation than histologic analysis alone. Studies comparing antimyosin scintigraphy and immunohistologic analysis of the endomyocardial biopsy in patients with clinically suspected myocarditis are not yet available. METHODS: Sixty-five patients with clinically suspected myocarditis underwent antimyosin scintigraphy. Antimyosin antibody uptake was correlated with histologic and immunohistologic findings in the endomyocardial biopsy. RESULTS: Antimyosin scintigraphy showed evidence of myocardial cell damage in 36 (55%) of the 65 patients and was negative in 29 (45%) patients. Histologic analysis of the endomyocardial biopsy revealed myocarditis in nine patients: six had a positive and three had a negative antimyosin scan, respectively. Thirty (83%) of 36 patients with evidence of myocardial cell damage on antimyosin scintigraphy were histologically negative for myocarditis. Immunohistologic analysis showed evidence of myocarditis in 31 (86%) of 36 patients with a positive antimyosin scan and also in 17 (59%) of 29 patients with a normal scan (p < 0.047). CONCLUSIONS: Antimyosin scintigraphy often shows myocyte injury in patients with clinically suspected myocarditis. Histologic analysis of the endomyocardial biopsy alone is often negative, but additional immunohistologic analysis of the endomyocardial biopsy frequently provides evidence of myocardial inflammation in these patients. With immunohistologic analysis as the reference method, antimyosin scintigraphy has a high specificity but a lower sensitivity for the detection of myocarditis.

Antimyosin autoantibodies are associated with deterioration of systolic and diastolic left ventricular function in patients with chronic myocarditis.

OBJECTIVES: The study evaluates the clinical course and the development of systolic and diastolic left ventricular function in patients with chronic myocarditis with or without autoantibodies against cardiac myosin. BACKGROUND: Patients with myocarditis often show autoantibodies against cardiac myosin. The clinical and pathophysiologic significance of these antimyosin autoantibodies (AMAAB) is yet unknown. The results from studies comparing the clinical course and the development of left ventricular function in patients with chronic myocarditis with or without AMAAB are not yet available. METHODS: Thirty-three patients with biopsy proven chronic myocarditis underwent analysis of AMAAB, right and left heart catheterization and left ventriculography at baseline and after six months. Left ventricular volumes and ejection fraction as well as the time constant of left ventricular relaxation "tau" and the constant of myocardial stiffness "b" were determined at baseline and at follow-up. RESULTS: In 17 (52%) patients, AMAAB could be detected at baseline. After six months, AMAAB were still found in 13 (76%) initially antibody-positive patients. No initially antibody-negative (n = 16) patient developed AMAAB during follow-up. Clinical symptoms improved slightly in antibody-negative patients and remained stable in antibody-positive patients. Left ventricular ejection fraction developed significantly better in antibody-negative patients (+8.9 +/- 10.1%) compared with antibody-positive patients (-0.1 +/- 9.4%) (p < 0.012). Stroke volume (SV) and stroke volume index (SVI) also improved in antibody-negative patients (SV: +20 +/- 31 ml; SVI: +10 +/- 17 ml) compared with antibody-positive patients (SV: -14 +/- 43 ml; SVI: -8 +/- 22 ml) (SV: p < 0.015; SVI: p < 0.016). Left ventricular end-diastolic and end-systolic volumes and the time constant of left ventricular relaxation "tau" did not change significantly different in antibody-positive and antibody-negative patients. The constant of myocardial stiffness "b" improved significantly in antibody-negative patients (-6.1 +/- 10.8) compared with antibody-positive patients (+7.3 +/- 22.6) (p < 0.040). Analyzing only the persistently antibody-positive patients yielded essentially the same results. CONCLUSIONS: Antimyosin autoantibodies are associated with worse development of left ventricular systolic function and diastolic stiffness in patients with chronic myocarditis.

Cardiac troponin T in patients with clinically suspected myocarditis.

OBJECTIVES: The present study investigated whether myocyte injury can be assessed sensitively by measurement of serum levels of cardiac troponin T (cTnT) in patients with clinically suspected myocarditis and whether cTnT levels may predict the results of histologic and immunohistologic analysis of endomyocardial biopsy specimens. BACKGROUND: Conventionally used laboratory variables often fail to show myocyte injury in patients with clinically suspected myocarditis, possibly because of a low extent of myocardial injury in these patients. Sensitive variables for myocyte injury have not yet been investigated. METHODS: Eighty patients with clinically suspected myocarditis were screened for creatine kinase (CK) activity, MB isoform of CK (CK-MB) activity and cTnT. Endomyocardial biopsy specimens were examined histologically and immunohistologically. RESULTS: cTnT was elevated in 28 of 80 patients with clinically suspected myocarditis, CK in 4 and CK-MB in 1. Histologic analysis alone of the endomyocardial biopsy specimen revealed evidence of myocarditis in only five patients, all with elevated cTnT levels. Twenty-three of 28 patients with elevated cTnT levels had histologically negative findings for myocarditis. Additional immunohistologic analysis revealed evidence of myocarditis in 26 (93%) of 28 patients with elevated cTnT levels and in 23 (44%) of 52 patients with normal cTnT levels. Mean cTnT levels were higher in patients with myocarditis proved histologically or immunohistologically, or both, than in patients without myocarditis (0.59 +/- 1.68 vs. 0.04 +/- 0.05, p < 0.001). CONCLUSIONS: Measurement of serum levels of cTnT provides evidence of myocyte injury in patients with clinically suspected myocarditis more sensitively than does conventional determination of cardiac enzyme levels. Myocardial cell damage may be present even in the absence of histologic signs of myocarditis. Additional immunohistologic analysis often shows lymphocytic infiltrates in these patients. Elevated levels of cTnT are highly predictive for myocarditis in this group.

Catheter-based percutaneous myocardial laser revascularization in patients with end-stage coronary artery disease.

OBJECTIVES: This study evaluates the feasibility and safety of a catheter-based laser system for percutaneous myocardial revascularization and analyses the first clinical acute and long-term results in patients with end-stage coronary artery disease (CAD) and severe angina pectoris. BACKGROUND: In patients with CAD and intractable angina who are not candidates for either coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA), transmyocardial laser revascularization (TMR) has been developed as a new treatment that results in reduced angina pectoris and increased exercise capacity. However, surgical thoracotomy is required for TMR with considerable morbidity and mortality. METHODS: A catheter-based system has been developed that allows creation of laser channels in the myocardium from within the left ventricular cavity. Laser energy generated by a Holmium: YAG (Cardiogenesis Corporation, Sunnyvale, California) laser was transmitted to the myocardium via a flexible optical fiber capped by an optic lens. The optical fiber was maneuvered to the target area under biplane fluoroscopy through a coaxial catheter system permitting movement in three dimensions. RESULTS: Thirty-four patients with severe CAD not amenable to either CABG or PTCA and refractory angina pectoris (Canadian Cardiologic Society [CCS] Angina Scale Class III-IV) were included in the study. Ischemic regions were identified by coronary angiography and confirmed by thallium scintigraphy. The percutaneous myocardial revascularization (PMR) procedure was successfully completed in all patients. In 29 patients, one vascular territory of the left ventricle and in 5 patients, two vascular territories were treated. Eight to fifteen channels were created in each ischemic region. Major periprocedural complications were limited to an episode of arterial bleeding requiring surgical repair. There was one death early after PMR, due to a myocardial infarction (MI) in a nontreated region. Clinical follow-up at 6 months (17 patients) demonstrated significant improvement of angina pectoris (CCS class before PMR: 3.0+/-0.0, six months after PMR: 1.3+/-0.8, p<0.0001) and increased exercise capacity (exercise time on standard bicycle ergometry before PMR: 384+/-141 s, six months after PMR: 514+/-158 s, p<0.05), but thallium scintigraphy failed to show improved perfusion of the laser treated regions. CONCLUSIONS: Percutaneous myocardial revascularization is a new safe and feasible therapeutic option in patients with CAD and severe angina pectoris not amenable to either CABG or PTCA. Initial results show immediate and significant improvement of symptoms and exercise capacity but evidence of improved myocardial perfusion is still lacking.

Single-dose amoxicillin therapy with follow-up urine culture. Effective initial management for acute uncomplicated urinary tract infections.

To learn whether a single dose of amoxicillin is safe, effective therapy for acute uncomplicated urinary tract infections, 388 symptomatic nonpregnant women were randomly grouped to receive oral amoxicillin, either as a single 3 g dose of 250 mg three times a day for two weeks. Patients had quantitative as well as dip-slide cultures of urine and tests for antibody-coated bacteria in urine. Follow-up urine cultures were obtained one week after completion of treatment. Results of antimicrobial susceptibility and antibody-coated bacterial tests did not alter the randomized therapy. Among 162 patients with bacteriologically confirmed infections, cure rates were 60.6 percent (43 of 71) for single-dose versus 73.6 percent (67 of 91) for two-week treatment (p = 0.07). Although more antibody-coated bacteria-negative patients (89.6 percent; 26 of 29) were cured overall, a substantial proportion of antibody-coated bacteria-positive patients were also cured by both single-dose (59.3 percent; 32 of 54) and 14-day therapy (64.6 percent; 42 of 65). There were fewer adverse effects in the single-dose treatment group. We conclude that a single 3 g dose of amoxicillin, with follow-up urine culture, provides safe and effective management for acute uncomplicated urinary tract infections in nonpregnant women.

Ventriculoperitoneal shunt-associated infection due to Haemophilus influenzae.

We report two children with ventriculoperitoneal shunt infections due to Haemophilus influenzae, type b. One child was cured with systemic and intraventricular antimicrobial therapy alone. The other child had persistently positive ventricular fluid cultures, ultimately required shunt removal in addition to antimicrobial therapy, and still had a relapse, which responded to antimicrobial therapy alone. In treating children with this problem we recommend removal of the shunt apparatus unless there is prompt sterilization of ventricular fluid and clinical improvement. Systemic antimicrobial therapy should be continued for two to four weeks.

Respiratory syncytial virus infection in children with bronchopulmonary dysplasia.

Little is known about the risk of severe illness from respiratory syncytial virus infection in children with bronchopulmonary dysplasia. A prospective study was done of the natural history of respiratory syncytial virus infection in 30 children less than 2 years of age with bronchopulmonary dysplasia who were in a home oxygen program. Surveillance to identify children with acute respiratory symptoms was done by weekly telephone interview. Symptomatic children were examined, oxygen saturation was determined by oximetry, and nasopharyngeal lavage fluid was collected for virus cultures and rapid respiratory syncytial virus antigen tests. During the 4-month study period (December to April), 27 children had one or more acute respiratory illnesses, and respiratory syncytial virus developed in 16/27 (59%). Passive smoking and greater than or equal to four members in the home increased the risk of symptomatic respiratory syncytial virus (P less than .01 and P less than .03, respectively). Of 16 children, 11 (69%) required hospitalization. Of the 11 hospitalized children with respiratory syncytial virus, nine were either still receiving oxygen at home or required oxygen therapy within the previous 3 months v none of five nonhospitalized children (P less than .005). Five of the hospitalized children were greater than 12 months of age and five had respiratory syncytial virus infection previously that had been confirmed by culture results. Hospitalizations were prolonged and complicated. Seven of 11 children were hospitalized for greater than 1 week; four were admitted to the intensive care unit; four were treated with ribavirin aerosol, and two needed mechanical ventilation. There were no deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunization of high-risk infants younger than 18 months of age with split-product influenza vaccine.

Influenza is an important cause of serious illness in very young children with cardiopulmonary disease. A 4-year study was conducted at two centers to assess immunogenicity and safety of influenza split-product vaccine in children aged 3 to 18 months with bronchopulmonary dysplasia and congenital heart disease. A total of 113 children were studied: 62 children 3 to 5 months of age and 51 children 6 to 18 months of age. Sera were drawn prior to first and second immunization and 3 weeks after second immunization and were tested by hemagglutination inhibition; protection was defined as greater than 1:32. Ninety-five children were surveyed for adverse reactions. Seroresponses were age and antigen specific. Best responses for all ages were to A/Mississippi (H3N2) (97%). Children older than 6 months of age had better seroresponses to A/Leningrad (H3N2) (73%, P less than .03) and B/Victoria (62%, P less than .02) than did children younger than 6 months of age. Seroconversion rates to the remaining antigens were low. Only 9% of children experienced adverse reactions; all but one were mild. The immunologic mechanisms responsible for preventing serious influenzal disease and more effective immunization strategies need to be defined for very young high-risk children.

Serum antibody response to pneumococcal vaccine in children with nephrotic syndrome.

Children with nephrotic syndrome are susceptible to serious pneumococcal disease and may be immunodeficient on the basis of abnormal humoral immune responses to natural antigens or immunoglobulin loss during relapse. As part of an ongoing study to evaluate pneumococcal anticapsular antibody concentration and immunologic competence, 27 steroid-responsive and six steroid-resistant patients with nephrotic syndrome, and 12 age-matched control subjects, were vaccinated with polyvalent pneumococcal vaccine. Antibody responders were defined as patients with at least a twofold increase in antibody after vaccination as well as an antibody concentration greater than 200 ng of anticapsular antibody nitrogen per milliliter (ngN/ml) after vaccination. Pneumococcal antibody concentrations before and after vaccination were significantly depressed in steroid-resistant patients when compared with control subjects (P less than .002) and with the steroid-responsive nephrotic syndrome group (P less then .001). Steroid-responsive nephrotic children who were not receiving corticosteroid therapy at the time of vaccination had significantly higher antibody concentrations to five pneumococcal types before vaccination and to seven types after vaccination compared with control subjects (P less than .05). Fewer steroid-responsive patients receiving corticosteroids achieved antibody concentrations greater than or equal to 200 ngN/ml against type 19F compared with patients not receiving steroids or with control subjects (P less than .05). These results suggest that pneumococcal vaccine is immunogenic in children with steroid-responsive nephrotic syndrome and may protect these patients from disease due to pneumococcal types contained in the vaccine.

Probable graft-vs-graft reaction in an infant after exchange transfusion and marrow transplantation.

A newborn with graft-vs-host (GVH) disease following an exchange transfusion was treated by attempting to eradicate the incompatible graft and to reconstitute the child hematologically and immunologically with a bone marrow transplant. The patient was a female term infant (blood group B, Rh+ Coombs test positive) who received a one-unit group O, Rh- exchange transfusion from an unrelated female donor for hyperbilirubinemia due to ABO incompatibility on day 2. Signs of acute GVH disease began on day 8 and the clinical diagnosis was supported by skin biopsy. With antithymocyte globulin and high dose dexamethasone, the GVH reaction improved somewhat. Cyclophosphamide, 200 mg/kg total dose, was given over four days followed by a marrow graft from a brother who was HLA-A, B identical, and probably also D locus compatible in mixed lymphocyte culture. All signs of GVH resolved with cyclophosphamide treatment and hematologic reconstitution was evident by 14 days after transplant. Two weeks later the GVH reaction and aplastic anemia recurred and Y chromatin was detected in only 6% of marrow cells. The infant died on day 80. Autopsy showed disseminated candidiasis, disseminated cytomegalovirus infection, thymic dysplasia, hypoplastic marrow, and other histopathologic changes consistent with GVH disease. The persistence of female cells in blood and bone marrow and the destruction of the reconstituted marrow suggest that the original incompatible transfusion-derived graft was not eliminated and that it ultimately rejected the histocompatible marrow graft.

Initial results of laser-based percutaneous myocardial revascularization for angina pectoris.

Results of a 30-patient pilot study of a recently developed percutaneous myocardial revascularization approach are described. The feasibility and positive safety profile of percutaneous myocardial revascularization are clearly demonstrated, with no mortality associated with the treatment or in the immediate post-treatment period and an incidence of only 1 major complication.

Syringe preparation technique and minor adverse reactions to diphtheria-tetanus-pertussis immunization.

Minor local reactions and subcutaneous abscesses following diphtheria, tetanus and pertussis immunization have been attributed to vaccine left in the subcutaneous needle path from vaccine coating the needle. Various syringe preparation techniques have therefore been advocated to prevent reactions. To evaluate these recommendations we compared rates of minor reactions in 200 children randomly assigned to one of three groups that differed only in the handling of the filled syringe: in Group 1 the needle was changed before injection; in Group 2 the needle was wiped with sterile gauze before injection; in Group 3 the same needle was used to draw up and to inject the dose and was not wiped. Overall 27% of children had febrile (greater than 38 degrees C) reactions, 62% became fussy and 79% had a local reaction. Rates of reactions were nearly identical in the three groups, except that children in group 2 receiving their second dose or more of diphtheria-tetanus toxoid-pertussis vaccine were more likely to become febrile at greater than 38 degrees C (32%) or fussy (78%) (P less than 0.05 and P less than 0.02, respectively). We conclude that changing needles does not reduce the rate of minor local and systemic reactions. Wiping needles may increase the rate of reactions.

Serum IgG subclass antibody responses in children vaccinated with influenza virus antigens by live attenuated or inactivated vaccines.

To ascertain whether live attenuated or inactivated vaccines can be considered equivalent, we examined the primary antibody response of children following vaccination with influenza virus antigens in three different formulations. Nine children received cold recombinant vaccine (CRV) containing A/Korea/82 (H3N2) and A/Dunedin/83 (H1N1) variants. Eight of these children responded to HA of the H3N2 subtype and the major portion of the elicited antibody was in the IgG1 subclass. Antibody of low titer in the IgG2 and IgG3 subclasses was detected in two and six serum specimens, respectively. Six of the nine children administered with CRV responded to the H1 antigen and only IgG1 antibody was detected. Serum specimens from eight children less than one year of age (5 less than 6 months of age) who had developed an antibody response to trivalent inactivated vaccine (TIV) vaccination were examined. High levels of IgG1 antibody to purified H3 were detected in all eight children. Low titers of antibody in IgG2 and IgG3 subclasses were detected in two and five children, respectively. Antibody responses to purified H1 showed a similar subclass distribution. In order to examine secondary response, eight children primed by immunization with TIV vaccine were subsequently given a single booster dose of purified hemagglutinin (HA) conjugated to diphtheria toxoid (HA-D). In 6/8 specimens antibody rises were detected to purified H3 and H1 antigens. Prior to the HA-D immunization, low levels of HA specific IgG1 antibody were detected in all serum specimens and vaccine induced responses were primarily of the IgG1 subclass.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of nasopharyngeal washings and swab specimens for diagnosis of respiratory syncytial virus by EIA, FAT, and cell culture.

Respiratory secretions for viral diagnosis are often collected with nasopharyngeal (NP) swabs, although many laboratories recommend NP aspirates or washings. We compared results using NP washings and NP swabs in three diagnostic RSV tests, a rapid RSV EIA antigen test (Abbott Laboratories), an indirect fluorescent antibody test (FAT) with rabbit antiserum, and virus culture (HEp-2 cells). Paired samples were collected from 121 children with suspected RSV bronchiolitis or pneumonia. A minitip swap was passed into the nasopharynx for 10 sec, rotated and withdrawn. The opposite nares was irrigated with approximately 1 ml of saline and aspirated using a syringe and plastic feeding tube. Fifty-one children (42%) grew RSV in culture, 49 from NP washings versus 27 from NP swabs (p less than 0.001). Fifty-three (44%) were positive by FAT, 52 from NP washings versus 12 from NP swabs (p less than 0.001). Fifty-eight children (48%) had positive RSV EIA tests, 57 from NP washings versus 35 from NP swabs (p less than 0.001). Detection by EIA was more sensitive than culture regardless of the method of specimen collection. We conclude that NP washings are superior to NP swabs for RSV culture and rapid diagnosis by EIA or FAT.

Pediatric blood cultures.

The clinical and laboratory issues important in pediatric blood cultures are similar to those in adult blood cultures with a few noteworthy exceptions. The collection of an uncontaminated specimen and an ample volume of blood is more difficult, especially in neonates. In addition, children often have previously received oral antibiotics or a broad-spectrum parenteral antibiotic. The relative frequencies of the pathogens causing bacteremia in children are different in important ways from in adults. Haemophilus influenzae b, although much less common than in the past, is still an important pediatric pathogen. Meningococcemia is relatively more common in children than in adults, and enterobacteriaceae and anaerobes are relatively less common. Group B streptococci, E. coli, coagulase-negative staphylococci, and Candida sp. are the principal pathogens in neonates. More changes in the distribution of blood-borne pathogens can be expected in the future with the introduction of new or more effective vaccines against the pneumococcus, meningococcus, and, possibly, group B streptococcus. In suspected community-acquired bacteremia in otherwise normal children, a single aerobic blood culture of adequate volume is sufficient. Sick neonates, hospitalized children with indwelling intravascular devices, and immunocompromised children may need multiple blood cultures, paired cultures from an indwelling vascular catheter and a peripheral vein, or use of special media. There is no single optimal system for pediatric blood cultures. The BACTEC systems have been adopted as a single system in many hospitals serving both children and adults because of the favorable results reported in children and the preference of using a single automated system. To maximize the detection of bacteremia and fungemia, some laboratories may wish to combine a BACTEC system with a second complementary system, such as the Isolator. Anaerobic, mycobacterial, and other special blood culture media should be reserved for selected patients.

Diagnostic value of intraoperative swabs of heart valves in infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: Intraoperative swabs of heart valves are obtained regularly from patients undergoing heart valve surgery for infective endocarditis (IE) in order to confirm the preoperative diagnosis and to adjust the antibiotic regimen. The study aim was to assess the diagnostic value of intraoperative swabs of heart valves in IE. METHODS: A total of 83 patients was referred for surgical treatment of active IE between October 1994 and May 1999. Preoperatively, microorganisms were isolated using a minimum of two positive blood cultures; results were compared with those obtained from intraoperative heart valve swab cultures. RESULTS: Preoperatively, 73 patients (88%) had a positive blood culture, and 10 (12%) had culture-negative endocarditis. The intraoperative swab confirmed the preoperative diagnosis in 31 cases (37%). Bacteria were isolated in three of the ten patients with preoperative culture-negative IE. Despite positive histopathological findings in seven patients, no microorganisms were cultured either pre- or intraoperatively. Among the remaining 42 patients (51%) with active IE, 25 valve cultures were sterile and 17 valve swabs were presumed to be contaminated. CONCLUSION: In patients with active IE in whom the causative agent could be isolated and identified before surgery, intraoperative valve swabs did not contribute further to patient management. In isolating contaminants, the risk of inappropriate modification of the antibiotic regimen is imminent. The diagnostic validity in culture-negative IE appears negligible.