Acoustic reflectometry in the detection of middle ear effusion.

Acoustic reflectometry, a new technique for detecting middle ear effusion, was compared with results from tympanocentesis or myringotomy in 75 patients (141 ears). There was a highly significant association (P less than .0001) for ears having middle ear effusion with high reflectivity (5 through 9 units) and for ears having no middle ear effusion with low reflectivity (0 through 4 units). In a pediatric population with middle ear effusion present in 98 of 141 ears and using reflectivity readings greater than 4 to indicate middle ear effusion, the sensitivity of this technique was 86.7% and the specificity was 69.8%. False-positive errors usually occurred in ears with thick tympanic membranes, or in ears in which reflectivity was determined prior to the induction of anesthesia. False-negative errors usually occurred in ears with both air and fluid. This technique was validated by direct comparison with tympanocentesis or myringotomy and can be used with pneumatic otoscopy and impedance tympanometry to follow children with middle ear effusion.

Jimson "loco" weed abuse in adolescents.

Over a three-year period, 29 adolescent patients were hospitalized because of intentional Jimson weed ingestion. Their records were reviewed for the presence of signs and symptoms of atropine/scopolamine toxicity clinical course, treatment, and outcome. Twenty-two were male and seven were female. All had mydriasis, hallucinations, and were disoriented. Tachycardia (heart rate greater than 95), dry mucous membranes, and flushed facies were often present. Urinary retention requiring catheterization was present in five patients. Sixty-five percent (17/26) had detectable atropine or scopolamine in their urine. The average length of hospitalization was 1.8 days. No serious complications were encountered during hospitalization and full recovery were noted in all patients. Gastric lavage and hospital admission for close monitoring and medical support are essential phases of management. Physicians who care for adolescents should be aware of this relatively new form of drug abuse and its management.

Serological response to measles revaccination in a highly immunized military dependent adolescent population.

In the spring of 1986, there was a measles outbreak in the city of El Paso, Texas, with 92 cases reported to the City-County Health Department. Of those 92 cases, 31 (32%) occurred within a public high school's student population of 2524. A mass measles vaccination program was undertaken at that high school in order to limit the outbreak. The student enrollment included a military dependent population of 368 students. Despite documented histories of prior measles immunizations in this military dependent subgroup, three individuals contracted the disease. Since this subgroup of students represented a highly immunized adolescent population, it was of interest to serologically determine their immune status prior to and following reimmunization with the expectation that such a study would provide information relating to the level of "protective" immunity. Prevaccination and postvaccination sera were obtained from 95 students. Results of measuring anti-measles antibody activity by ELISA indicate that 13 (14%) students responded to revaccination and experienced a fourfold or greater rise in IgG antibody levels. There were no detectable IgM responses. All of the students who responded to revaccination produced an anamnestic response (IgG boost only). Since most of these individuals had received first immunizations at 15 months of age or older, these findings suggest that secondary vaccine failure (waning immunity) was responsible for the putative "lowered" immunity in these individuals, instead of primary vaccine failure (maternal antibody suppression). These findings support current recommendations for measles booster revaccination of school-age children and adolescents.

Erythromycin prophylaxis for recurrent otitis media.

Patients with recurrent otitis media without persistent middle ear effusion were studied for antibiotic prophylaxis efficacy. In the first phase, erythromycin ethylsuccinate was used as prophylaxis for otitis media in 45 patients in a dose of 10 mg/kg twice daily. Acute otitis media occurred in eight of 45 (18%) while receiving erythromycin, and in 22 of 41 (54%) following prophylaxis termination. The attack rate (episodes of otitis media per 2-month period) was 0.86 before prophylaxis, 0.20 during prophylaxis, and 0.79 following prophylaxis. In a second phase of the study, erythromycin was compared with sulfisoxazole for otitis media prophylaxis in a group of 42 children. Sulfisoxazole (500 mg per dose) was administered twice daily. Acute otitis media occurred in five of 28 (18%) children while receiving erythromycin and in nine of 21 (43%) children while receiving no prophylaxis. The attack rate (episodes of otitis media per 2-month period) was 0.81 before erythromycin prophylaxis, 0.18 while receiving erythromycin, and 0.50 after erythromycin prophylaxis. Acute otitis media occurred in eight of 14 (51%) children while receiving sulfisoxazole, and in two of five (40%) children while receiving no prophylaxis. The attack rate (episodes of otitis media per 2-month period) was 0.78 before sulfisoxazole, 0.72 while receiving sulfisoxazole, and 0.56 after sulfisoxazole prophylaxis. Erythromycin antimicrobial prophylaxis for children with recurrent otitis media was superior to no prophylaxis and to sulfisoxazole prophylaxis in this study of patients with recurrent otitis media without persistent middle ear effusion.

"Latchkey". Three voices with one message.

Two to five million children, 6 through 13 years old, are unsupervised at home after school. This practice, called "latchkey," involves issues of children without adult supervision for periods of time and questions of safety and social isolation. There are no published age guidelines for "latchkey" or data on actual practice. To investigate age guideline opinions and the factors that influence them, a survey of pediatricians (the professional voice), military police (the legal voice), and parents (the popular voice) was undertaken. Solicited opinions concerned ages at which children can be left alone for brief or extended periods and can be allowed to babysit younger children. The three "voices" expressed similar mean ages and distributions for each of the "latchkey" questions. For less than 15 minutes without supervision, the means approximated 9 years; for periods of 1 hour or longer, 12 years; and for babysitting, 14 years. The data presented do not address actual or appropriate practice, but instead provide a basis to begin investigation.

Assessing middle ear disease: beyond visual otoscopy.

Visual otoscopy, the first step in the diagnosis of middle ear conditions, permits an assessment based on the color and appearance of the tympanic membrane. With pneumatic otoscopy, the mobility of the tympanic membrane can be evaluated. Several other techniques can be used to augment visual and pneumatic otoscopy. Impedance tympanometry provides an objective record of tympanic membrane movement. The acoustic otoscope evaluates middle ear contents by the reflectivity of sound from the tympanic membrane.

Urinary tract infections in children.

A five-year review of pediatric patients with urinary tract infections shows that absolute colony counts are not satisfactory as the sole criterion for urinary tract infection. Prior to culture results, patients can be treated empirically if the urine is nitrite-positive or if there is more than an occasional organism per high power field on unspun urine. In this series, no diagnostic or therapeutic benefit resulted from localizing studies. Patients with enuresis and infection should undergo radiologic evaluation for an anatomic abnormality.

Uvulitis and Hemophilus influenzae b bacteremia.

Uvulitis and Hemophilus influenzae b (HIb) bacteremia occurred in two infants. Uvulitis may be associated with HIb bacteremia, with or without epiglottitis. An acutely inflamed uvula in a febrile infant should alert the physician to the possibility of HIb bacteremia and potentially serious sequelae. Hospitalization and parenteral antibiotic therapy are recommended.

Peritonsillitis: abscess or cellulitis?

Peritonsillitis encompasses both cellulitis and abscess. To determine the distinguishing factors for cellulitis and abscess, we reviewed 29 patients, 15 with cellulitis and 14 with abscess. Common presenting complaints included dysphagia, trismus, drooling, voice change and fever. Unilateral tonsillar enlargement was usually present, and uvular deviation was noted in 10 of 29 patients. The mean ages of patients with abscess was 15.0 years, and that of patients with cellulitis was 10.8 years. The two groups differed significantly by age (P = 0.02), and discriminant analysis showed age, dysphagia and drooling to be discriminators for abscess patients, while bilaterality or fever were not. Trismus was a discriminator for cellulitis patients. Etiology for abscess included Group A and non-Group A beta-hemolytic streptococci, Group D streptococcus, alpha-streptococcus, anaerobic diphtheroids and coagulase-negative staphylococci. The etiology of the cellulitis was Group A and non-Group A beta-hemolytic streptococci and Streptococcus pneumoniae. Peritonsillitis appeared to increase in frequency. On presentation patients with cellulitis are similar to patients with abscess. Abscess is more likely in adolescents. Recommended therapy is intravenous penicillin and prompt drainage for patients failing to respond.

Detection of bacterial antigen in pleural fluid by counterimmunoelectrophoresis.

Pleural fluid specimens from 87 patients were studied using counterimmunoelectrophoresis with pneumococcal, staphylococcal, and Hemophilus influenza b antisera. This method compared favorably with traditional bacteriologic methods and in addition provided a presumptive etiologic diagnosis in more than half of the specimens with negative bacterial cultures. One cross-reaction between H. influenza b antiserum and a pleural fluid specimen with an Escherichia coli isolate was observed.