Visual biofeedback using transperineal ultrasound in second stage of labor.

OBJECTIVE: To assess the obstetric and psychological effects of visual biofeedback by transperineal ultrasound (TPU) during the second stage of labor. METHODS: This was a prospective, single-center observational study of low-risk nulliparous women with epidural analgesia undergoing vaginal delivery. Visual biofeedback using TPU was provided to 26 women during the second stage of labor. Pushing efficacy was assessed by the change in the angle of progression (AoP) at rest and during pushing efforts, before and after biofeedback. Obstetric outcomes included incidence of perineal tearing, mode of delivery and length of second stage of labor. Psychological outcomes were assessed by self-reported measures obtained during the postnatal hospital stay and included measures of perceived control and maternal satisfaction with childbirth, as well as level of maternal feelings of connectedness with the newborn. Obstetric and psychological results were compared with those of a control group of 69 women who received standard obstetric coaching from midwives. RESULTS: Pushing efficacy increased significantly following visual biofeedback by TPU (P = 0.01), as indicated by a significantly lower delta AoP before (mean, 22.2° (95% CI, 13.9-31.7°)) compared with after (mean, 35.2° (95% CI, 25.9-45.3°)) biofeedback. A significant association was found between visual biofeedback and an intact perineum following delivery (P = 0.03). No significant differences were found between the two groups with regard to mode of delivery or length of the second stage. Feelings of maternal connectedness with the newborn were significantly stronger (P = 0.003) in women who received visual biofeedback than in those who did not. However, perceived control during childbirth and maternal satisfaction with childbirth did not differ significantly between the biofeedback and control groups. CONCLUSIONS: This pilot study suggests that biofeedback using TPU may serve as a complementary tool to coached maternal pushing during the second stage of labor, with obstetric as well as psychological benefits. Further studies are required to confirm our findings and define the optimal duration of the intervention. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Impact of PCV7/PCV13 introduction on invasive pneumococcal disease (IPD) in young children: Comparison between meningitis and non-meningitis IPD.

BACKGROUND: The worldwide introduction of pneumococcal conjugate vaccines (PCV) into National Immunization Programs resulted in rapid and substantial reduction of invasive pneumococcal disease (IPD) rates in children. However, the reduction of meningitis vs. non-meningitis IPD (nm-IPD) was not yet fully elucidated. We compared 7-valent and 13-valent PCV (PCV7 and PCV13) impact on pneumococcal-meningitis vs. nm-IPD in Israeli children <5years. METHODS: We conducted an ongoing nationwide, prospective, population-based, active surveillance. PCV7 and PCV13 were implemented in Israel in July 2009 and November 2010, respectively. All pneumococcal isolates (blood and/or CSF) from IPD episodes in children <5years from July 2000 through June 2015 were included. Extrapolation for missing serotypes (34.7% of all isolates) was conducted. RESULTS: 4163 IPD cases were identified; 3739nm-IPD (89.8%) and 424 meningitis (10.2%). During the pre-PCV period (2000-2008), children <12months constituted 52.1% and 33.7% of meningitis and nm-IPD, respectively (p<0.001). The respective proportions of non-PCV13 serotypes (non-VT) were 18.2% vs. 10.1%, (p<0.001). Comparing the last study year (2014-2015) to the mean of pre-PCV period, meningitis incidence in children <5years decreased non-significantly by 27%, while nm-IPD decreased significantly by 69%. Dynamic rates of meningitis and nm-IPD caused by PCV13 serotypes were similar, with 93% and 95% overall reductions, respectively. However, non-VT increased in meningitis relatively to nm-IPD, mainly in children <24months. Serotype 12F rose sharply and significantly since 2009-2010 through 2014-2015 (28.6% of all non-VT meningitis in children <24m). CONCLUSIONS: The overall impact of PCV7/PCV13 in children <5years in Israel was less prominent in meningitis than in nm-IPD. This could be attributed to the younger age of children with meningitis and differences in causative serotypes between the two groups, as the decline of the incidence of meningitis and nm-IPD caused by vaccine-serotypes is similar. Continuous monitoring of meningitis and nm-IPD is warranted.

Carriage rate of carbapenem-resistant Klebsiella pneumoniae in hospitalised patients during a national outbreak.

During a national outbreak of carbapenem-resistant Klebsiella pneumoniae (CRKP) in Israel, we conducted a point prevalence survey to determine the extent of asymptomatic carriage. Subsequently, a retrospective case-control study was done, comparing carriers of CRKP with non-carriers, in order to detect risk factors for carriage. Oral, perianal and rectal swabs were obtained from all hospitalised eligible and consenting patients. Selective media for carbapenem-resistant Gram-negative bacteria were used and pulsed-field gel electrophoresis (PFGE) helped to determine clonal source. Culture was obtained from 298 patients. Sixteen (5.4%) were carriers of CRKP, with a higher carriage rate in medical and surgical wards. Only 18% of carriers were treated with any carbapenem prior to the survey. Five of the 16 carriers had a positive clinical specimen for CRKP, hence a clinical infection versus asymptomatic carriage ratio of 1:3. The rectum was the most sensitive site sampled, detecting 15/16 carriers, and the overall sensitivity of the method was 94% with a negative predictive value of 99.6%. In a multivariate analysis of risk factors for CRKP carriage, three variables were significantly related to carriage state: diaper use, longer duration of hospital stay and vancomycin use. PFGE demonstrated that all 16 isolates were identical, confirming clonal origin. A point prevalence survey performed at a single medical centre during an outbreak of CRKP demonstrated a carriage rate of 5.4%. The clonal origin of these isolates suggests that strict adherence to isolation procedure may contain this outbreak.

Q fever endocarditis; not always expected.

Q fever endocarditis is a chronic disease with protean manifestations. The clinical and serological manifestations of nine patients diagnosed as having Q fever endocarditis during a 19-year period are reviewed. Four patients (44%) required valve replacement due to congestive heart failure. Three of these four patients were diagnosed as having Q fever endocarditis only after elective valve surgery, by histopathological examination of the valve and subsequent serological tests. Prior to surgery they were afebrile and had no other symptom or sign indicative of endocarditis. The antibiotic treatment and the decreasing titres of Q fever antibodies of all nine patients during several years of follow-up are summarized. Careful assessment of heart valves for histopathological evidence of inflammation is suggested, even after elective replacement. If found, clinical and laboratory evaluation should include determination of anti-Coxiella burnetti antibodies.

A week-by-week analysis of the low-risk criteria for serious bacterial infection in febrile neonates.

OBJECTIVE: To examine the reliability of "low-risk" criteria (LRC) to exclude serious bacterial infection (SBI) in febrile neonates (< or =28 days), according to age in weeks. DESIGN: Epidemiological and clinical data and final diagnosis of all febrile neonates presenting to the emergency room from June 1997 to May 2006 were reviewed. Neonates who fulfilled specific LRC for the presence of SBI were classified as LRC+. The prevalence of SBI and the percentage of LRC+ neonates who had SBI were calculated for each of the first 4 weeks of life. RESULTS: A total of 449 neonates were evaluated. Eighty-seven (19.4%) neonates had an SBI. The prevalence of SBI among infants 3-7, 8-14, 15-21 and 22-28 days of age was 21.6%, 26.1%, 17.9% and 12.1%, respectively (p = 0.007 for linear trend after second week of life). Of the 226 LRC+ neonates, 14 (6.2%) had an SBI, including one case of bacteraemia and meningitis and 13 cases of urinary tract infection (UTI). The negative predictive value (NPV) of the LRC for SBI was 93.8% (95% CI 90.1% to 96.4%). The prevalence of SBI among LRC+ infants 3-7, 8-14, 15-21 and 22-28 days of age was similar, with rates of 15%, 6.3%, 3.0% and 6.7%, respectively. CONCLUSION: LRC are not sufficiently reliable to exclude the presence of SBI, including bacteraemia and meningitis in febrile neonates of all ages. All febrile neonates should therefore be hospitalised, undergo a full "sepsis evaluation" and receive empirical intravenous antibiotic therapy.

Cytomegalovirus-associated protein-losing gastropathy in childhood.

Menetrier's disease is an uncommon disease in childhood, characterized by gastric hypertrophy and hypoalbuminemia secondary to protein loss through the gastric mucosa. This paper describes a series report of protein-losing gastropathy associated with cytomegalovirus (CMV) infection in children and reviews the literature. We reviewed the medical records of eight children with diagnosis of Menetrier's disease or protein-losing gastropathy with evidence of acute CMV infection. During a five-year period there were eight children that were diagnosed with CMV-associated protein-losing gastropathy, all in one medium-sized pediatric ward in a general hospital. The mean age was 32 months and there was no gender predominance. The most common presenting symptoms were vomiting and edema. Average symptoms' duration prior to admission was 3.2 weeks and mean albumin at presentation was 1.8 g/dl (range, 1.5-2.5 g/dl; normal values, 3.5-5 g/dl). All eight children fully recovered. In conclusion, CMV infection should be suspected in every child who presents with protein-losing gastropathy. The availability of newer, rapid diagnostic techniques such as polymerase chain reaction (PCR) may facilitate diagnosis, as serology studies may be misleading. Usually, only supportive care is required, but treatment with ganciclovir may be considered for severe or prolonged cases.

Targeted delivery of a suicide gene to human colorectal tumors by a conditionally replicating vaccinia virus.

We have generated a thymidine kinase gene-deleted vaccinia virus (VV) (Copenhagen strain) that expressed the fusion suicide gene FCU1 derived from the yeast cytosine deaminase and uracil phosphoribosyltransferase genes. Intratumoral inoculation of this thymidine kinase gene-deleted VV encoding FCU1 (VV-FCU1) in the presence of systemically administered prodrug 5-fluorocytosine (5-FC) produced statistically significant reductions in the growth of subcutaneous human colon cancer in nude mice compared with thymidine kinase gene-deleted VV treatments or with control 5-fluorouracil alone. A limitation of prodrug therapies has often been the requirement for the direct injection of the virus into relatively large, accessible tumors. Here we demonstrate vector targeting of tumors growing subcutaneously following systemic administration of VV-FCU1. More importantly we also demonstrate that the systemic injection of VV-FCU1 in nude mice bearing orthotopic liver metastasis of a human colon cancer, with concomitant administration of 5-FC, leads to substantial tumor growth retardation. In conclusion, the insertion of the fusion FCU1 suicide gene potentiates the oncolytic efficiency of the thymidine kinase gene-deleted VV and represents a potentially efficient means for gene therapy of distant metastasis from colon and other cancers.

Pyroelectric effect induced by the built-in field of the p-n junction in the quantum paraelectric PbTe: experimental study.

We report here the first observation of a pyroelectric effect in a nonpolar semiconductor. This effect originates in the temperature-dependent electric dipole of the PbTe p-n junction. The junction was illuminated by a chopped CO(2) laser beam, and periodic and single-pulse pyroelectric signals were observed and measured as a function of temperature, reverse bias voltage, and chopper frequency. The measured pyroelectric coefficient is approximately 10(-3) microC/cm(2) K in the region of 40-80 K. The theoretical model describes quantitatively all experimental features. The time evolution of the temperature inside the junction region was reconstructed.

Prevalence and predictive features of bacteremic urinary tract infection in emergency department patients.

The aim of this study was to determine the prevalence and predictive features of bacteremia among patients evaluated in the emergency department for urinary tract infection. Of the 350 patients with symptomatic urinary tract infection included in this retrospective study, 53 (15%; 95%CI 11.6-19.4%) were bacteremic. Five variables were independently associated with bacteremia: residence at home rather than in an institution (OR 4; 95%CI 1.5-10.7), presence of an indwelling urinary catheter (OR 3.3; 95%CI 1.3-8.8), presence of band forms in the blood count (OR 3.3; 95%CI 1.5-7.2), shaking chills (OR 2.3; 95%CI 1.1-4.8), and neutrophilia (OR 1.1; 95%CI 1.04-1.15). These easily assessable parameters may assist in the diagnosis of bacteremic urinary tract infection and the selection of empiric antibiotic treatment, thus potentially improving a patient's prognosis.

Prospective drug utilization evaluation of three broad-spectrum antimicrobials: cefepime, piperacillin-tazobactam and meropenem.

BACKGROUND: Cefepime, piperacillin-tazobactam and meropenem are among the broadest-spectrum and most expensive antimicrobials. AIM: To evaluate guidelines for appropriate use of these drugs. METHODS: We developed guidelines for use of these antibiotics, and conducted a two-phase drug utilization evaluation. We included all patients who received one of the study drugs during two 3-month periods, with an educational intervention in the intervening period. Appropriateness was determined for initiation of treatment, and for adaptation or continuation of established treatment. RESULTS: Overall, 205 patients received 271 courses with one of these antibiotics, for a total of 709 defined daily doses (DDD) of cefepime, 543 of piperacillin-tazobactam, and 680 of meropenem (8.3, 6.3 and 7.9 DDD/1000 admission days, respectively). Of these 271 courses, 234 were appropriate (86%). Treatment was continued for > or =5 days in 60%, of which 88% were appropriate (NS). Of the 271 courses, 210 (77%) were empirical (83% appropriate), while 61 (23%) were based on a relevant culture result (97% appropriate) (p < 0.001). Appropriateness differed significantly between departments (p < 0.001), and between the two phases (p < 0.001). The major difference between the two surveys was a decrease in meropenem usage (p < 0.05). DISCUSSION: The vast majority of courses with cefepime, piperacillin-tazobactam and meropenem are empirically selected and continued, underlying the importance of an optimal initial choice. Antibiotic guidelines, in conjunction with formal infectious disease consultation, can contribute to more appropriate use of these drugs.

Assessment of the clinical significance of production of extended-spectrum beta-lactamases (ESBL) by Enterobacteriaceae.

BACKGROUND: We conducted a retrospective, cohort-controlled study to evaluate the effect of extended-spectrum beta-lactamase (ESBL) production by Enterobacteriaceae isolated from blood cultures, and of third or fourth generation cephalosporin treatment, on outcome. METHODS: Four hundred and fifty patient-unique Enterobacteriaceae, isolated from blood cultures during 2000 (before routine ESBL testing was introduced), were tested for ESBL by double-disk method and by E-test, assessing cefotaxime, ceftazidime and cefpodoxime, with and without clavulanate. Cases consisted of ESBL-positive (+) samples, originally reported as ceftazidime-susceptible; controls were ESBL-negative (-). Patient records were extensively reviewed. RESULTS: We identified 68 Enterobacteriaceae that were ESBL(+); they were compared with 186 ESBL(-) control organisms. Patients with sepsis due to an ESBL(+) organism more often had nosocomial infection, resided in nursing homes, were functionally dependent, had an indwelling catheter, had Klebsiella, and had a lower serum albumin level (all p < 0.001). Survival of patients with ESBL(+) and ESBL(-) sepsis was, respectively, 71% and 84% (p < 0.05). Multivariate analysis revealed that the only independent risk factor for death was a low serum albumin. Neither empiric nor definite treatment with cephalosporins was found to be an independent risk factor for death. Subset analysis was conducted on 15 patients with ESBL(+) sepsis and 21 controls with ESBL(-) sepsis, who had been treated with ceftazidime or cefepime only. In this subset, ESBL(+) patients more often resided in nursing homes (< 0.05), they had a significantly lower APACHE-II score (< 0.01) and the infection was more often nosocomial (< 0.005). Survival of ESBL(+) and ESBL(-) patients was 67% and 71%, respectively (NS). Time till defervescence did not differ between cases and controls. CONCLUSION: Mortality of patients with ESBL(+) sepsis was higher than that of patients with ESBL(-) sepsis. The reason appears to be related to other factors rather than to empiric treatment with cephalosporins or the nature or resistance pattern of the organism. This, at least, appears to be the case for patients with urosepsis, who constituted the majority of patients in this study.

Procalcitonin in preterm infants during the first few days of life: introducing an age related nomogram.

OBJECTIVE: To determine normal concentrations of procalcitonin in preterm infants shortly after birth and to assess its accuracy in detecting bacterial infection. METHODS: Blood samples of 100 preterm infants were prospectively drawn during the first 4 days of life for determination of procalcitonin concentration. Infants were classified into four groups according to their sepsis status. RESULTS: Mean (SD) gestational age and birth weight were 32 (2.9) weeks and 1682 (500) g respectively. A total of 283 procalcitonin concentrations from healthy infants were plotted to construct nomograms of physiologically raised procalcitonin concentration after birth, stratified by two groups to 24-30 and 31-36 weeks gestation. The peak 95th centile procalcitonin concentration was plotted at 28 hours of age; values return to normal after 4 days of life. Only 12 infants were infected, and 13 of their 16 procalcitonin concentrations after birth were higher than the 95th centile, whereas samples taken at birth were lower. In a multivariable analysis, gestational age, premature rupture of membrane, and sepsis status influenced procalcitonin concentration independently, but maternal infection status did not. CONCLUSIONS: The suggested neonatal nomograms of preterm infants are different from those of term infants. Procalcitonin concentrations exceeding the 95th centile may be helpful in detecting congenital infection, but not at birth.

Group A streptococcus bacteraemia: comparison of adults and children in a single medical centre.

Group A streptococcus (GAS) bacteraemia is often associated with soft-tissue infection, with significant morbidity and mortality. Little is known concerning the differences between adults and children with GAS bacteraemia. Records for 98 of 116 cases of GAS bacteraemia (60 adults and 38 children, aged 7 days to 96 years) occurring during a 10-year period (1993-2002) were located and reviewed. GAS bacteraemia comprised 0.6% of all bacteraemias in adults, compared to 3.3% in children (p < 0.001). The rate of adult GAS bacteraemia was two cases/1000 hospitalisations, compared to 13/1000 in children (p < 0.001). Seventy-six (78%) patients had concomitant tissue involvement, with skin or soft-tissue infection being the most common (62%). Fifty-three (88%) of 60 adults and five (13%) of 38 children had underlying conditions (p < 0.001). Twelve patients died, only one of whom was a child. Parameters associated with mortality were older age, lower temperature, hypotension, a need for surgical intervention, toxic shock syndrome, disseminated intravascular coagulation, thrombocytopenia, lymphopenia, hypocalcaemia, renal failure and acidosis (p < 0.05).

Prospective hospital-wide studies of 505 patients with nosocomial bacteraemia in 1997 and 2002.

We conducted surveys in 1997 and 2002 to determine the rate, underlying sources and outcome of nosocomial bacteraemia. Blood culture results were reviewed daily. All patients with positive cultures drawn >or=48 h after hospitalization were included in the study and their charts were reviewed. The underlying source of infection was determined by pre-defined clinical and/or microbiological criteria. Patients were followed until discharge or death. In 1997 and 2002, 851 and 857 patient-unique cases of bacteraemia were diagnosed, respectively, excluding contaminants; of these, 228 (27%) and 277 (32%) cases, respectively, were hospital acquired (P<0.05). The overall rate decreased from 7.5 to 7.0 per 1,000 admissions (P<0.001). The sources of bacteraemia in 1997 and 2002, respectively, were: intravascular catheters (36% and 27%, P<0.05), urinary tract (8% and 15%, P<0.05), respiratory tract (5% and 13%, P<0.01) and surgical sites (14% and 4%, P<0.001). In one-third of patients, the source of bacteraemia could not be determined. Only 52% and 54%, respectively, of these patients were discharged alive (difference was not significant). In 1997, Staphylococcus aureus was the most frequent isolate (26%), followed by coagulase-negative Staphylococcus (13%) and Klebsiella pneumoniae (11%). By 2002, the incidence of S. aureus had fallen to 11% (P<0.001), acinetobacter was the single most frequently isolated organism (increased from 6% to 17%) (P<0.001). In-hospital mortality associated with acinetobacter bacteraemia (57%) was significantly higher than that for other organisms (31-43%) (P<0.05). In conclusion, prospective surveys of nosocomial bacteraemias provide valuable information, facilitating the pursuit of successful interventions.

Non-Typhi Salmonella gastroenteritis in children presenting to the emergency department: characteristics of patients with associated bacteraemia.

The records of children with Salmonella gastroenteritis only (n = 97), and those with associated bacteraemia (n = 64), seen in one medical centre during a 12-year period, were analysed retrospectively. Mean patient age was 2.24 +/- 2.8 years (range, 0.05-16 years), and 49% were male. Children with bacteraemia presented after a longer duration of symptoms (7.0 +/- 6.9 vs. 3.9 +/- 4.6 days, p 0.0002), and had higher erythrocyte sedimentation rates (45 +/- 22 vs. 33 +/- 22 mm/h, p < 0.02) and lactate dehydrogenase values (924 +/- 113 vs. 685 +/- 165 IU/L, p 0.001). There was a trend in bacteraemic children towards immunosuppression (6.3% vs. 1.0%, p 0.08) and a lower number of siblings (2.9 +/- 1.9 vs. 3.8 +/- 2.7, p 0.063). Non-bacteraemic children had a more severe clinical appearance, and a higher percentage had a moderate to bad general appearance (51.5 vs. 29.7%, p < 0.01), with dehydration (37.1 vs. 18.8%, p 0.02) and vomiting (58.8 vs. 39.0%, p 0.02). Laboratory dehydration indicators were also markedly worse in non-bacteraemic children, with urine specific gravity of 1020 +/- 9.4 vs. 1013 +/- 9.0 (p 0.0002), base excess of - 4.2 +/- 3.0 vs. - 2.5 +/- 3.4 mEq/L (p 0.01), and blood urea nitrogen of 10.1 +/- 7.0 vs. 7.4 +/- 4.5 mg% (p 0.002). Thus, the clinical presentation of bacteraemic children was more gradual, and associated gastroenteritis and dehydration was less pronounced. These findings may contribute in part to the inadvertent discharge of bacteraemic children from the emergency department.

Susceptibility trends in bacteraemias: analyses of 7544 patient-unique bacteraemic episodes spanning 11 years (1990-2000).

The aim of the present study was to design more accurate tools for the selection of appropriate antimicrobial therapy for hospitalized patients with suspected sepsis. We created a large database comprising data on all patient-unique blood cultures obtained over an 11 year period (1 January, 1990 through 31 December, 2000). Improved statistical tools were applied to assess the trends in in vitro activity of individual antibiotic agents against various bacteria over time, and to calculate susceptibility rates of subsets of organisms. During the 11 year study period, 173571 blood cultures were obtained, of which 17703 (10.2%) were positive, with 7544 patient-unique blood cultures (4.3%). The mean annual number of positive, patient-unique cultures was 686 (standard deviation=79). The 10 most frequently isolated organisms were: Escherichia coli (1494), Staphylococcus aureus (1240), Klebsiella pneumoniae (779), Enterococcus spp. (631), Pseudomonas aeruginosa (488), Streptococcus pneumoniae (447), Enterobacter spp. (338), Acinetobacter spp. (298), Proteus mirabilis (260) and Candida spp. (254). No significant change was detected in the annual rates (means, standard deviations) per 1000 admissions of these organisms: the highest was E. coli (5.5, 1), the lowest was Candida (1, 0.3). Forty percent of organisms (N=2943) were obtained from patients in the emergency department (ED), 23% (1744) in medical departments, 15% (1134) in paediatric units, 13% (998) on surgical wards and 9% (709) in intensive care units (ICUs). Trend statistical analysis revealed a significant decrease in susceptibility in ED Enterobacteriaceae to eight of 15 (53%) tested antimicrobials, with a mean annual decrease of 1.6%+/-0.6%, in the ICU isolates, a significant decrease was detected in only five (33%) of the tested antimicrobials, with a mean annual decrease of 2.5%+/-1.3%. The difference in susceptibility between ED and ICU isolates was significant for all antimicrobials (P<0.001). A significant decrease in the susceptibility of E coli to nine of 15 drugs (60%) was detected, ranging from 0.7% to 2.7% annually. In K. pneumoniae a significant decrease in susceptibility of K. pneumoniae was detected with only two agents. Pseudomonas spp. isolates remained highly sensitive to all traditional anti-pseudomonal agents, without significant decay in sensitivity rates over time. Susceptibility of S. aureus to methicillin decreased significantly for several subsets of patients (P<0.001). Marked differences in susceptibility rates between the departments were detected. Trend statistical analyses, when appropriately applied to multi-year databases of microbial susceptibilities, may yield susceptibility tables that are significantly more accurate than traditional semi-annual or annual tables.

Urine polymerase chain reaction as a screening tool for the detection of congenital cytomegalovirus infection.

OBJECTIVES: To define the incidence of congenital cytomegalovirus (CMV) infection in a defined population in Israel as diagnosed by urine polymerase chain reaction (PCR), and to assess the utility of this method for screening for congenital CMV infection. DESIGN: A convenient sample of urine specimens from asymptomatic newborns were subjected to CMV PCR. Positive results were validated by urine tube culture and by determination of serum CMV IgM antibodies. Maternal CMV IgG was determined in a representative sample of mothers. Newborns with positive urine specimens underwent full clinical evaluation. Epidemiological characteristics of the mothers were extracted from the medical records. SETTINGS: Two medical centres in Israel with different population characteristics. PATIENTS: A total of 2000 newborns (1000 in each medical centre). MAIN OUTCOME MEASURE: Presence of CMV DNA in the urine. RESULTS: Despite significant epidemiological differences between the populations in the two hospitals, the CMV seroprevalence was similar, 80.5% and 85%. Fourteen of the 2000 newborns screened (0.7%) were PCR positive. Urine culture was positive in nine of 10 specimens; IgM was positive in only two of 13 newborns with positive PCR. Eleven newborns underwent full or partial evaluation, and only one (9%) was symptomatic. CONCLUSIONS: The incidence of congenital CMV infection in the study population was 0.7%; over 90% were asymptomatic. Urinary CMV PCR is a reliable, rapid, and convenient method, and thus may serve as a screening tool for the detection of congenital CMV infection.

Changing epidemiology of infective endocarditis: a retrospective survey of 108 cases, 1990-1999.

The aim of this study was to report the experience with infective endocarditis over the past decade, describe the changing clinical and epidemiological features of the disease, and attempt to determine the optimal number of blood culture sets required for diagnosis. All cases diagnosed during a 10-year period were reviewed clinically and microbiologically. In addition, a retrospective assessment of blood culture data was performed. From the period 1990-1999, 108 cases that met the von Reyn or Duke's criteria were recorded. The major underlying cardiac condition was the presence of a prosthetic valve ( n=33 patients, 31%). Among patients with native valves, nonrheumatic valvular heart disease of the elderly was the most common underlying factor ( n=19 patients, 25%). Overall, 13 patients (11%) died. Predictors on admission for increased mortality were shortness of breath, age >60 years, time to defervescence, erythrocyturia, hemoglobin level <10 g/dl, and leukocytosis >15,000 (all P<0.05). Analysis of blood culture data showed that the diagnostic yield among groups from whom either only one or more than six blood culture sets were drawn was reduced compared with that among groups from whom between two and five culture sets had been taken. The outcome of endocarditis in this series from a community hospital was much more favorable compared with that reported in surveys from large tertiary centers. Moreover, obtaining more than two or three blood cultures is neither helpful nor cost-effective in the initial assessment of patients with suspected endocarditis.