Management of clinically diagnosed subacute rhinosinusitis in children under the age of two years: a randomized, controlled study.

BACKGROUND: In children, a diagnosis of rhinosinusitis is usually made on clinical grounds. Subacute rhinosinusitis (SRS) may be the cause of persistent cough, low-grade fever, snoring, ear problems and difficult feeding in children under the age of two years. OBJECTIVE: To compare the efficacy of culture-based antibiotics and empiric amoxicillin-clavulanate (40 mg/kg/day) in treating SRS in children under the age of two years. STUDY DESIGN: Randomized, controlled study. POPULATION: Sixty children with persistent nasal discharge and nasal obstruction (and other related symptoms) for 30-90 days. METHODS: Group one (n = 30) received culture-based antibiotics and group two (n = 30) were treated empirically with 40 mg/kg/day of amoxicillin-clavulanate. Treatment was continued for two weeks. RESULTS: At the end of the three-week follow-up period, statistically significant greater improvements in nasal obstruction (p = 0.037) and nasal discharge (p = 0.003) were seen in group one compared with group two. CONCLUSION: culture-based antibiotics were more efficacious than empiric amoxicillin-clavulanate (40 mg/kg/day) in treating SRS in children under the age of two years.

Quality of care of children with chronic diseases in Alexandria, Egypt: the models of asthma, type I diabetes, epilepsy, and rheumatic heart disease. Egyptian-Italian Collaborative Group on Pediatric Chronic Diseases.

OBJECTIVES: To evaluate the quality of care delivered to children suffering from index chronic diseases using specific indicators of health care delivery and to study the predictors of suboptimal quality of care (SQC) and its outcome on children. DESIGN: Over a 9-month period, guidelines for optimal care were formulated. A specific questionnaire for every studied chronic disease was prepared in collaboration with the clinicians in charge of the diseased children (66% pediatricians and pediatric specialists and 34% adult specialists). The clinicians were asked to write the details of daily practice, ie, how these children were managed on a routine basis as well as in an emergency situation. A cross-sectional study was conducted over a 4-month period and included 953 children suffering from bronchial asthma (BA), childhood epilepsy (CE), type I diabetes mellitus (IDDM), and rheumatic heart disease (RHD). A systematic random sample of children was selected from children visiting the ambulatory settings of all children's hospitals. Every fourth child was selected on 2 randomly chosen days each week, while all diseased children admitted in the hospital settings of the children's hospitals during the study were included. A general form describing the impact of the diseases on the child was prepared. A network of clinicians was created in all children's hospitals; seminars were held during which the content validity of the questionnaire was tested. Items were evaluated for their internal consistency using the Cronbach alpha. According to the degree of adherence to the recent therapeutic guidelines concerning selected indicators of the quality of care specific to every disease, children were categorized as receiving optimal quality of care or SQC. These indicators were: the use of inhaled bronchodilators in acute asthmatic attacks in mild asthma and the use of the prophylactic drugs (inhaled sodium cromoglycate or inhaled beclomethasone) in moderate to severe chronic BA in between acute asthmatic attacks; compliance with antiepileptic drugs in epileptic children; regular performance of self-monitoring of blood glucose and/or urine testing in diabetic children; and compliance with prophylactic antibiotics in children suffering from RHD. The records of the outpatient clinics for ambulatory and hospitalized cases were reviewed to assess the degree of compliance with the prescribed management before the index visit. Sociodemographic characteristics and health care system-related predictors of SQC were analyzed via stepwise logistic regression analysis. The impact of illness on the child was assessed by 7 items which were: dependence on parents in domestic activities, level of activity compared with peers, mood compared with peers, level of socializing, degree of discomfort attributable to illness, level of physical disadvantage, and urinary incontinence. Factor analysis with Varimax rotation was performed on items related to the impact of illness. Parental satisfaction with care was rated as excellent, very good, fair, or poor. Information on school outcome was obtained by asking the caretakers whether the child was able to attend school regularly despite his sickness. Scholastic achievement was also rated as excellent, very good, good, and acceptable. Parents were asked whether the child had ever repeated a grade because of his sickness. SETTING: Ambulatory and hospital settings of all children's hospitals in Alexandria, Egypt. RESULTS: Only 52% of mild asthmatics were given inhaled bronchodilators during acute attacks and 6.84% of moderate to severe asthmatics were taking prophylactic drugs (inhaled sodium cromoglycate and/or inhaled beclomethasone) between acute attacks. Similarly, only 53 of 134 (39.6%) of diabetic children were regularly performing self-monitoring of blood glucose and/or urine testing. In contrast, in epileptic children, 121 of 173 (69.9%) were judged as being compliant by their managing clinicians and more than two

Risk factors for congenital heart diseases in Alexandria, Egypt.

A matched case control study has been conducted in the children's hospitals in Alexandria, Egypt, during 2 years-period, aiming at investigating the risk factors for the occurrence of congenital heart diseases. Our results showed that the significant risk factors for developing any type of congenital heart disease and ventricular septal defects were: older paternal age at birth, positive consanguinity, positive family history, female sex hormones, irradiation, hazardous maternal occupation, diabetes mellitus and suburban or rural residence. However, some environmental/teratogenic factors were not implicated in the etiology of atrial septal defects or pulmonary stenosis. These findings strongly suggest that environmental factors vary according to the specific type of congenital heart disease. This study emphasizes on the need to instruct the public about the importance of pre-marital counseling and the deleterious effects of various teratogens in the environment.

Congenital heart disease among school children in Alexandria, Egypt: an overview on prevalence and relative frequencies.

A study was undertaken to determine the prevalence and relative frequencies of congenital heart diseases diagnosed by echocardiography among school children in Alexandria, Egypt. The study was conducted during a 1-year period (1 May 1995-1 May 1996) at the Students' Health Insurance Hospital, which is a referral center for all health insurance units, providing an echocardiography service. The prevalence of congenital heart diseases (CHD) among school children accounted for 1.01/1,000. There was a male predominance in cases of pulmonary stenosis and single ventricle, while in cases of patent ductus arteriosus, mitral valve prolapse, and partial atrioventricular canal there was a female predominance. The commonest cardiac defects were ventricular septal defects, pulmonary stenosis, and atrial septal defects. Pulmonary stenosis ranked the second commonest defect and is a peculiar finding in our Egyptian population. The mere presence of these cardiac defects in school children is an indicator of the poor quality of care provided to this growing childhood population.

Profile of secondary prophylaxis among children with rheumatic heart disease in Alexandria, Egypt.

A cross-sectional study was conducted in specialist children's hospitals in Alexandria, which aimed to evaluate the current regimen of secondary prophylaxis for children suffering from rheumatic heart disease. Two-thirds of the patients had complied with their prophylactic regimen. Prophylactic failure occurred in one-third of the patients, raising doubts about the efficacy of the brands of penicillin prescribed. Recurrence of rheumatic fever was recorded in 37.3% of the patients, with semiruban or rural residence and non-compliance with secondary prophylaxis the significant risk factors. These unsatisfactory findings suggest the need for a more effective strategy of primary and secondary prophylaxis for controlling rheumatic fever in our community.

Balloon dilation of the right ventricular outflow tract in tetralogy of Fallot: a palliative procedure.

Fifteen patients requiring palliation for tetralogy of Fallot were treated by balloon dilation because of hypercyanotic spells. The mean age at dilation was 1.9 +/- 0.7 years (range 0.5-3), and the mean weight 9.8 +/- 2.1 kg (range 6.0-13.5). Dilation of the outflow tract was combined with dilation of the left and/or right pulmonary arteries in 5 patients. Successful dilation was achieved in 12 patients (80%), but failed in 3 patients with hypoplastic pulmonary arteries. In one patient, the stenosis of the right pulmonary artery could not be dilated because of a very sharp angle at the site of the stenosis. Two of the 3 patients in whom the procedure failed died of severe cyanotic spells within 24 hours of the unsuccessful procedure. No major complications occurred during or after the procedure in the cases undergoing successful dilation. The arterial oxygen saturation increased significantly, from 71 +/- 5.7% to 89 +/- 3.9%, immediately after the procedure (p < 0.005). During a period of follow up of 6 +/- 3.7 months (range 1-13), the procedure was repeated on 3 occasions, and successfully accomplished in 2 of these. In conclusion, balloon dilation is a satisfactory palliative procedure for tetralogy of Fallot in those units in which total correction is not performed under 2 to 3 years of age.

Prevalence of rheumatic heart disease among school children in Alexandria, Egypt: a prospective epidemiological study.

The aim of this work was to study the epidemiologic features of Rheumatic Heart Disease (RHD) among basic education students in Alexandria, including the demographic and clinical profiles as well as risk factors for RHD development. A stratified random sampling technique was used to allocate 5465 school children in the six educational zones of Alexandria. Clinical RHD cases were confirmed by using chest X-ray, ECG and echocardiography. Factors related to occurrence of RHD were studied using a case control design. Thirty four RHD cases (with an estimated prevalence of 6.2/1000 students) were diagnosed. Low socioeconomic status, chronic tonsillitis, positive family history of acute rheumatic fever/RHD and paternal consanguinity were significantly associated with the occurrence of RHD. Almost all previously diagnosed cases were enrolled in a prophylaxis program, with a defaulter rate of 31%. More than half of the identified cases had moderately severe valvular lesions. We recommend the implementation of an educational program targeted to both parents and teachers; the training of upgrading of school health physicians, and the standardization of secondary prophylaxis programs nationwide, with emphasis on assurance of compliance.

Rheumatic fever prophylaxis using benzathine penicillin G (BPG): two- week versus four-week regimens: comparison of two brands of BPG.

OBJECTIVE: This prospective study was aimed at answering two important questions: 1) Is a biweekly schedule of 1.2 million U intramuscular benzathine penicillin G (BPG) superior to a 4-week one in the prevention of upper respiratory Group A beta-hemolytic streptococcal (GABHS) infections and rheumatic fever (RF) recurrences? 2) Is there a difference in the bioavailability of BPG obtained from different manufacturers? METHODOLOGY: Three hundred sixty rheumatic patients aged 4 to 20 years were randomly assigned to either a biweekly (190 patients) or 4-week (160 patients) BPG prophylactic schedule and were followed-up monthly for 2 years by clinical examination, throat swab culture for GABHS and measurement of antistreptolysin O titer to detect GABHS infection and/or recurrences of RF (according to revised Jones' Criteria). Thereafter, 34 rheumatic subjects, aged 8 to 16 years were randomly assigned to receive a 4-week injection of 1.2 million U of either a locally manufactured BPG brand (22 patients) or an imported one (12 patients). Sera of all patients were tested for penicillin level by plate diffusion method on days 1, 2, 3, 4, 5, 6, 7, 14, 21, and 28 after the intramuscular injection of BPG. RESULTS: The GABHS infection rate was found to be 0.2% and 0.3% for patients on the biweekly and 4-week BPG schedules, respectively, with no significant differences between them. However, the RF recurrence rate/patient/year for the 4-week schedule patients (0.12) was double that for the biweekly schedule ones (0.06). Estimation of the bioavailability of the two different brands of BPG demonstrated a difference in their pharmacokinetics and a decrease in the serum penicillin concentration below the minimum inhibitory concentration 3 weeks after the injection of either brand. CONCLUSION: Although a biweekly schedule may not be superior in preventing upper respiratory GABHS infection, it may play a role in preventing the sequelae of such infections. The short duration of penicillinemia explains the superiority of the 2-week schedule in RF prophylais. The difference in the pharmacokinetics of penicillin brands might contribute to the high recurrence rate of RF reported in Egypt.

Reversibility of mitral regurgitation following rheumatic fever: clinical profile and echocardiographic evaluation.

The clinical disappearance of the murmur of rheumatic mitral regurgitation after period of time has been documented by many researchers. However no studies have related the disappearance of the murmur with the functional or anatomical state of the mitral valve. This study was done to elucidate the mitral valve status using doppler and color coded echocardiography among those children who have lost their apical pansystolic murmur on auscultation following a documented attack of rheumatic fever. The study sample consisted of 51 patients including 31 patients in whom the murmur has disappeared (group I), and 20 patients with persistent isolated mitral regurgitation (group II). Patients of group I had significantly lower grades of murmur intensity, lower incidence of cardiomegaly, and had no heart failure in the initial attack. They were more compliant with prophylaxis and had less recurrences than patients of group II. The murmur disappeared in patients of group I from 1/2 to 14 years after the initial attack. Echocardiography revealed that such patients had a normal mitral valve apparatus, and a normal heart size and function. Only 5 patients of this group had a significant regurgitant jet demonstrated by colour doppler. We concluded that recovery of the mitral valve and return of cardiac functions to normal is possible in patients who had mitral regurgitation following rheumatic fever. Some of them may still have an inaudible mild regurgitation. Patients who have lost their murmur may be allowed to exercise freely, yet penicillin prophylaxis should not be discontinued.

Coxsackie virus infections in rheumatic fever.

The close relationship between Group A beta Hemolytic Streptococci (GABS) and rheumatic fever is a well established one. However, the concept of the streptococcus as the sole etiologic agent of the rheumatic heart disease (RHD) has been challenged over the past years. Since coxsackievirus group B (CVB) has long been proposed as a cause of acquired valvular disease simulating rheumatic fever, we attempted in this study to document infections with this group of viruses in patients with rheumatic fever. We obtained blood samples from 106 patients with old (quiescent) rheumatic fever/rheumatic heart disease [group I], 94 patients with acute rheumatic fever (ARF) [group II], and 74 normal matched controls. We tested for the presence of neutralizing antibodies to the 6 serotypes of CVB by a micro neutralization test. We have found that infection with CVB, especially types B2 and B4, was common in the studied population. Forty-two percent of normal individuals had evidence of infection with any of the 6 serotypes of CVB. Patients of group I had significantly more frequent infections with CVB 2. Patients in group II had significantly more frequent infections with CVB 2 and CVB 6. There was no clear correlation between such infections and the clinical course of rheumatic fever. There was no difference in the incidence of CVB infections between patients with definite ARF, and patients with suspected ARF. We set a low order association between rheumatic fever and infection with CVB types B2 and B6. We emphasize the importance of pursuing the investigation of the role of CVB in relation to RHD.

An international comparison of the prevalence of streptococcal infections and rheumatic fever in children.

Differences in the socioeconomic standards of living remain an important and feasible partial explanation for the difference in incidence of rheumatic fever following GABHS infection in Egyptian compared with American children. However, past and ongoing studies of the epidemiology, diagnosis, and treatment of GABHS infections in Egypt, the United States, and elsewhere suggest other significant factors are relevant. Additional knowledge about the rheumatogenic GABHS serotypes that are most prevalent in all countries is an important area where additional research is needed. Streptococcal research will help not only in improving the quality of primary prevention of rheumatic fever, but also in developing streptococcal vaccines.

Benzathine penicillin G for rheumatic fever prophylaxis: 2-weekly versus 4-weekly regimens.

Rheumatic fever is still one of the major public health problems in Egypt and the developing countries. It is characterized by a high tendency to recur following streptococcal infections. The use of long acting penicillin for prophylaxis against strep infections was a good achievement in this field, yet, recurrences have been reported in patients following monthly prophylactic programs. Clinical experience in Alexandria have shown for a long time that giving penicillin every 2 weeks is followed by less recurrences of rheumatic fever. Recently, reports came showing that effective penicillin levels are not maintained except for 2 to 3 weeks after the injection. In the present study, we compared two regimens of prophylaxis with 190 patients in the 2-weekly regimen, and 170 patients in the 4-weekly regimen being followed up for 2 consecutive years. Two hundred and sixty nine streptococcal infections occurred during this period. Although the streptococcal infection rate was equal in both groups, the rheumatic fever recurrence rate and the RF attack rate were significantly higher in the group of patients on the 4-weekly schedule. The results of this study have shown the superiority of the 2-weekly schedule in the adequate control of RF recurrences. We suggest that this schedule should be implemented for secondary prophylaxis of rheumatic fever in Egypt and other areas with severe RF.