Group D enterococcal meningitis. Clinical and therapeutic considerations with report of three cases and review of the literature.

Three patients with meningitis due to the Lancefield group D enterococci are described and the pertinent literature is reviewed. Anatomic central nervous system (CNS) defects, prior neurologic or neurosurgical interventions, group D enterococcal endocarditis, and urinary tract infection appear to be important predisposing factors. Of note is the frequent lack of cellular response in the spinal fluid to enterococci. The mortality of this infection is high (33%) and is probably dictated as much by the underlying disorder as the infection itself. The therapeutic importance of careful separation of group D streptococcal isolates into enterococci and nonenterococci, especially in instances of CNS infections, is emphasized. We discuss the appropriate antimicrobial therapy for enterococcal meningitis.

Candida meningitis. Report of seven cases and review of the english literature.

Seven patients with Candida meningitis are reported. These 7, plus 21 previously cited cases, were reviewed. This infection arose by two distinct mechanisms: hematogenous dissemination and direct inoculation. Recent antibiotic therapy, corticosteroid administration and severe underlying diseases were important predisposing factors. Fever, meningismus, elevated CSF pressures and localizing neurologic signs were commonly noted. Organisms were seen on gram-stain of CSF in only 43% of cases. Mortality rate in patients receiving inadequate or no antifungal therapy was high (greater than 90%), while those patients given appropriate antifungal drugs, especially intravenous amphotericin B, had a significantly lower mortality rate (38%). Several factors associated with poor prognosis were delineated in this study: diagnostic interval after symptomatic onset longer than two weeks, CSF glucose levels below 35 mg/100 ml and presence of intracranial hypertension and focal neurologic deficits.

Emergency medical services and the pediatric patient: are the needs being met? II. Training and equipping emergency medical services providers for pediatric emergencies.

Emergency medical services have been organized to meet the needs of adult patients. A study was undertaken to determine the training in pediatrics offered to paramedics and emergency medical technicians throughout the United States and the equipment carried by prehospital care provider agencies. Most training (50%) takes place at colleges and universities and the remainder at hospitals and emergency medical services agencies. Many programs (40%) have less than ten hours of didactic training in pediatrics and 41% offer ten hours or less of clinical experience. Some programs offer no training in pediatric emergency medicine. The most common deficiencies in pediatric equipment included backboards, pediatric drugs, resuscitation masks, and small intravenous catheters. More attention to training and equipping prehospital personnel for pediatric emergencies may help to improve outcomes of out-of-hospital resuscitations of infants and children.

Emergency medical services and the pediatric patient. III: Resources of ambulatory care centers.

Ambulatory care centers have emerged as a new health care resource in many communities. Little information is available about the services that these centers offer to pediatric patients. A national survey of 254 ambulatory care centers was undertaken to determine their characteristics, including the number of pediatric patients seen, staffing patterns, and pediatric equipment and supplies available. Most clinics were located in urban areas and were within 5 miles of a hospital. They were staffed primarily by physicians who were board certified in emergency medicine, internal medicine, or family medicine. Not all centers had registered nurses on duty and few used extended-role nurses or physicians's assistants. The centers saw an average of 18 patients younger than 18 years of age per day. Some ambulatory care centers received emergency medical service and private ambulance calls and encountered serious illness such as chest pain, seizures, and anaphylaxis; the majority, however, handled mainly minor injuries and illnesses. Although most had pediatric equipment and supplies, some did not have a complete set of pediatric resuscitation equipment even though they were part of the emergency system offering care to the pediatric population.

Emergency medical services and the pediatric patient: are the needs being met?

Emergency medical systems are being developed throughout the United States primarily to deal with myocardial infarction and trauma. These programs often fail to recognize the special needs of the critically ill child. Data collected in Los Angeles County from the LA County Trauma Surveys, Mobile Intensive Care Unit Rescue Reports, and Base Station Hospitals demonstrate that children represent approximately 10% of the paramedic calls. The calls are for medical problems as well as trauma. These data suggest that children have a higher death rate in the field than adults, and deaths occur more commonly in areas where there are no pediatric centers. Children are often secondarily transferred from emergency departments to other centers for definitive care. This study suggests that the needs of children in the prehospital setting are not being met.

Pediatric prehospital care in urban and rural areas.

There are limited data concerning pediatric prehospital care, although pediatric prehospital calls constitute 10% of emergency medical services activity. Data from 10,493 prehospital care reports in 11 counties of California (four emergency medical services systems in rural and urban areas) were collected and analyzed. Comparison of urban and rural data found few significant differences in parameters analyzed. Use of the emergency medical services system by pediatric patients increased with age, but 12.5% of all calls were for children younger than 2 years. Calls for medical problems were most common for patients younger than 5 years of age; trauma was a more common complaint in rural areas (64%, P = .0001). Frequency of vital sign assessment differed by region, as did hospital contact (P less than .0001). Complete assessment of young pediatric patients, with a full set of vital signs and neurologic assessment, was rarely performed. Advanced life support providers were often on the scene, but advanced life support treatments and procedures were infrequently used. This study suggests the need for additional data on which to base emergency medical services system design and some directions for education of prehospital care providers.

Relative importance of bacteremia and viremia in the course of acute fevers of unknown origin in outpatient children.

During a 12-month period 80 children greater than 3 months of age seen at an emergency room with acute fevers greater than or equal to 39.7 C (103.5 F) and no localizing signs of infection were studied using blood and buffy coat cultures to isolate bacteria and viruses. Bacteremia was identified in three children (3.8%): two with Streptococcus pneumoniae and one with Neisseria meningitidis. Two children with viremia were identified: both isolates were ECHO virus, types 11 and 21, respectively. Fifty-eight of the study children (72%) were seen again in 24 to 48 hours and 27/58 (46%) were afebrile and completely well. No differences in sex, age, or initial WBC count existed among these children who returned afebrile and well and those with either localized disease or those persistently febrile.

Pediatric emergency medicine education in emergency medicine training programs. SAEM Pediatric Education Training Task Force. Society for Academic Emergency Medicine.

BACKGROUND: The educational goal of emergency medicine (EM) programs has been to prepare its graduates to provide care for a diverse range of patients and presentations, including pediatric patients. OBJECTIVE: To evaluate the methods used to teach pediatric emergency medicine (PEM) to EM residents. METHODS: A written questionnaire was distributed to 118 EM programs. Demographic data were requested concerning the type of residency program, number of residents, required pediatric rotations, elective pediatric rotations, type of hospital and settings in which pediatric patients are seen, and procedures performed. Information was also requested on the educational methods used, proctoring EM received, and any formal curriculum used. RESULTS: Ninety-four percent (111/118) of the programs responded, with 80% of surveys completed by the residency director. Proctoring was primarily performed by PEM attendings and general EM attendings. Formal means of PEM education most often included the EM core curriculum (94%), journal club (95%), EM grand rounds (94%), and EM morbidity and mortality (M&M) conference (91%). Rotations and electives most often included the pediatric intensive care unit (PICU) and the emergency department (ED) (general and pediatric). CONCLUSIONS: Emergency medicine residents are exposed to PEM primarily by rotating through a general ED, the PED, and the PICU, being proctored by PEM and EM attendings and attending EM lectures and EM M&M conferences. Areas that may merit further attention for pediatric emergency training include experience in areas of neonatal resuscitation, pediatric M&M, and specific pediatric electives. This survey highlights the need to describe current educational strategies as a first step to assess perceived effectiveness.

Emergency medical services and the adolescent patient.

A study of 10,493 prehospital care report forms from 11 counties in California demonstrated that the adolescent age group (ages 12 to 18 years) accessed prehospital care through the emergency medical service (EMS) system more frequently than other pediatric patients (5978 reports). They did so most commonly for trauma (87.6%), but also for behavioral emergencies such as suicide and psychiatric problems. The most common cause of injury was automobiles, and care rendered was most commonly wound care and splinting. The most common substances given to adolescents in the prehospital setting were naloxone and 50% dextrose. EMS systems need to address the need for triage and care of adolescent patients.

Treatment of parasitic infections.

This article provides an extensive table of drugs and dosages for treatment of parasitic infections, listing the treatment regimen most commonly used. This is followed by a list of the recommended drugs, their preparations, toxicity, contraindications, and precautions.

Malaria.

Malaria continues to present staggering morbidity and mortality statistics. In this well-detailed article, the authors examine the increased incidence of malaria in many areas, describe the malarial parasites, discuss the clinical course, pathogenesis, diagnosis, and treatment, and address the issues of transfusion malaria, congenital malaria, immunity, chemoprophylaxis, and vaccine.

Out-of-hospital care of pediatric patients.

The out-of-hospital care of children has seen significant changes in the past 10 years. Much work has yet to be done to research interventions and prevention strategies that have a positive effect on the outcome of children. Physicians, nurses, and out-of-hospital providers must serve as advocates for children in their communities.

A survey of dental disease in children of Wuvulu Island, Papua New Guinea.

A convenience sample of 153 boys and girls, aged 3-16 years, inhabiting Wuvulu Island were examined for the prevalence of dental caries and periodontal disease and for oral hygiene status. Average df teeth and surface scores for the group were 2.08 and 3.35, respectively, while average DMF teeth and surface scores were 0.90 and 1.20, respectively. Of the sample, 30.7% were caries free. Oral hygiene was poor and males had significantly more periodontal disease than females. While primary teeth were about three times more susceptible to caries than permanent teeth, tooth loss due to caries was not a problem in primary teeth. The authors discuss findings of other researchers and reasons for the greater prevalence of caries in primary teeth.

The life cycle in vitro of Hymenolepis microstoma (Cestoda).

The cestode Hymenolepis microstoma was grown axenically from oncosphere to infective cysticercoid. Reducing agents were not essential for development and produced structural abnormalities in the organisms. Cysticercoids grown in vitro were excysted, placed in culture, and developed into adults containing gravid segments, thus completing the life cycle in vitro.

Axenic development of cysticercoids of Hymenolepis nana.

Cysticercoids of the tapeworm Hymenolepis nana were grown axenically in vitro, from oncospheres hatched in vitro to fully developed organisms infective to mice. A gas phase of 95 N2--5 CO2 was essential for normal development.

How we teach and how they learn.

Residents need to learn how to assess and accommodate to a variety of behaviors and affective styles presented by patients and their families. This requires those skills which enable them to facilitate interactions with people in a positive, effective, and efficient manner. The teaching of these interpersonal and communication skills should incorporate a multi-disciplinary model. The development and implementation of a successful resident training program requires careful attention to the establishment of goals and objectives, learning activities and evaluation strategies that will meet the needs of the resident. The utilization of a multi-teaching, multi-media, and collaborative team approach intensifies the effectiveness of the overall training program. This article describes a training program that focuses on communication skills while being mindful of the various settings in which residency training occurs. These include the use of video-tape of physician/patient interaction in continuing care clinic, communication with children in non-medical settings and audio-tape reviews of physicians telephone management in a pediatric emergency care setting. The evaluation instruments developed to assess interpersonal and communications skills are reviewed and discussed as an integral component of this educational and training model.