Transcutaneous PCO2 monitoring in infants hospitalized with viral bronchiolitis.

UNLABELLED: Our objective was to assess within a feasibility study the correlation and agreement of transcutaneous carbon dioxide (PtcCO2) monitoring with venous carbon dioxide (PvCO2) in infants with bronchiolitis in the emergency room (ER) and pediatric department. Sixty infants (aged 3.6 ± 3.3 months) admitted to our ER with bronchiolitis were included. PtcCO2 measurements (SenTec Digital Monitoring System) collected prospectively were compared with simultaneous PvCO2 drawn for patient care. Analysis included 100 measurements. The correlation of PtcCO2 and PvCO2 (r = 0.71, p < 0.001) was good, and the agreement (mean difference ± standard deviation of the differences 1.9 ± 7.0 mmHg) was adequate; average PtcCO2 was slightly lower than PvCO2. Changes in PtcCO2 and PvCO2 for consecutive measurements within each patient correlated (r = 0.41, p < 0.01). The level of PtcCO2 correlated with disease severity clinical score (p < 0.001). CONCLUSIONS: PtcCO2 monitoring was feasible in the ER and pediatric department and was found to have a good correlation and adequate agreement with PvCO2 in infants with bronchiolitis. Because the standard deviation of the differences was relatively high, though comparable to the literature, we suggest that PtcCO2 should not replace blood gas but rather serve as a complementary tool for trending and for real-time continuous assessment of the CO2 levels.

Toll-like receptor-4 expression in infants with pertussis infection.

PURPOSE: Our aim was to evaluate the expression of Toll-like receptor-4 (TLR-4) and the level of interferon-gamma (IFN-γ) and interleukin-10 (IL-10) in young infants infected by Bordetella pertussis and B. parapertussis. METHODS: Twenty-two infants under the age of 3.5 months with the clinical suspicion of pertussis were enrolled in the study. Nasopharyngeal secretions were obtained for laboratory testing, and blood samples were obtained for flow cytometry and cytokine level analysis. RESULTS: Six infants had positive PCR results for pertussis; the other 16 infants had infections attributable to another causal agent and were used as the control group. The mean fluorescence index, used as a measure of TLR-4 expression by monocytes, was significantly lower in infants with pertussis than in the control group infants (34.32 ± 18.58 vs. 63.14 ± 28, respectively; p = 0.041). The serum IFN-γ level was also significantly lower in infants with pertussis than in the control group patients (0.41 ± 0.58 vs. 1.36 ± 1.87, respectively; p = 0.04). No differences were found in the levels of IL-10. CONCLUSIONS: Based on these results, we suggest that TL4 expression by monocytes and serum INF-γ levels are lower in infants with positive PCR results for pertussis than in infants with a non-pertussis upper respiratory tract infection.

What is the clinical relevance of respiratory syncytial virus bronchiolitis?: findings from a multi-center, prospective study.

Acute bronchiolitis (AB) is caused primarily by respiratory syncytial virus (RSV). Recent laboratory tools have implicated a variety of other pathogens; however, their clinical relevance has not been clearly defined. The purpose of this study was to determine whether the etiological agents of AB affect its course. A multicenter prospective study was performed in previously healthy children <24 months of age who presented with <4 days duration of AB. Subjects were divided into the following groups: "only RSV," "also RSV," "no RSV," and "no pathogen." The clinical severity score on admission as well as the overall severity of disease was assessed. RSV was the most common cause of AB (77.5 %). "Only RSV" or "also RSV" patients had a higher clinical score on admission compared to those with "no RSV," p < 0.001 and p < 0.02, respectively. "Only RSV" and "also RSV" patients had a higher disease severity score when compared to patients with "no RSV," 5.9 ± 1.4 vs. 5.1 ± 1.5, p < 0.001, and 5.6 ± 1.4 vs. 5.1 ± 1.5, p < 0.02, respectively. Disease severity did not vary as a function of transfer to the pediatric intensive care unit (PICU) or duration of supplemental oxygen, yet, "only RSV" was associated with a longer length of stay (LOS) than "no RSV," p < 0.02. "Only RSV"-related AB was associated with a more severe initial clinical presentation and a longer LOS. There appears to be little immediate clinical benefit to diagnosing RSV AB to the individual patient, but the application of these diagnostic methods may have significant cost-saving implications and, thus, deserves consideration by medical professionals and health policy analysts.

Sexually transmitted infections among brothel-based sex workers in Tel-Aviv area, Israel: high prevalence of pharyngeal gonorrhoea.

Sex workers play a major role in spreading sexually transmitted infections (STIs). We studied the prevalence rates and risk factors for STIs among 300 brothel-based sex workers in Tel-Aviv. Throat swabs were cultured for Neisseria gonorrhoeae, urine samples were tested by polymerase chain reaction (PCR) for Chlamydia trachomatis and N. gonorrhoeae, and sera were tested for syphilis, human immunodeficiency virus (HIV) and type 2 herpes simplex virus (HSV) antibodies. N. gonorrhoeae was cultured from throat samples of 9.0% of participants; PCR testing of urine was positive for C. trachomatis in 6.3% and for N. gonorrhoeae in 5.0%. Syphilis serology was positive (Venereal Disease Research Laboratory [VDRL] titres > 1:8) in 1.3% of women, HSV-2-specific immunoglobulin G was detected in 60% and HIV serology was positive in a single case (0.3%). Having STI was significantly associated with age, number of years in Israel, number of clients a week and condom use for vaginal sex. In a multivariate analysis, having STI was significantly associated with number of clients per week and condom use for vaginal sex. The high prevalence of pharyngeal gonorrhoea reflects most probably the expanding demand of clients for oral sex and the insufficient condom use in this form of sex.

Correlation between levels of tumour necrosis factor-alpha and levels of pH, glucose, and lactate dehydrogenase in parapneumonic effusions.

OBJECTIVES: This study was undertaken to investigate the correlation, which has not been previously investigated, between levels of tumour necrosis factor-alpha (TNF) and levels of pH, glucose, and lactate dehydrogenase (LDH) in pleural fluid of patients with uncomplicated parapneumonic effusion (UCPPE), and patients with complicated parapneumonic effusion (CPPE). METHODS: Using a commercially-available high sensitivity ELISA kit, levels of TNF were measured in pleural fluid of patients with UCPPE (n = 23), and CPPE (n = 15), and were compared with levels of pH, glucose, and LDH in these two groups. RESULTS: The mean +/- SD values of pleural fluid TNF, pH, glucose, and LDH in the UCPPE group were 11.05 +/- 7.65 pg/ml, 7.41 +/- 0.08, 125 +/- 48 mg/dl, and 306 +/- 182 IU/l, respectively. In the CPPE group the values were 56.07 +/- 28.5 pg/ml, 6.82 +/- 0.25, 42 +/- 36 mg/dl, and 2096 +/- 1916 IU/l, respectively. The only significant correlation, which was negative, was found between levels of TNF and pH in the CPPE group (r = -0.62, P = 0.01). Levels of pleural fluid TNF and LDH were significantly higher, and levels of glucose were significantly lower in the CPPE group than in the UCPPE group (P < 0.0001). CONCLUSIONS: This study demonstrates, for the first time that TNF levels correlate inversely with levels of pH in pleural fluid of patients with CPPE but not of patients with UCPPE. This correlation may, in part, explain the pathophysiology of the pleural complications which occur in the presence of CPPE.

The prognostic value of cerebrospinal fluid characteristics in dogs without deep pain perception due to thoracolumbar disc herniation.

Providing a pre-operative prognosis for dogs presented with absent deep pain perception (DPP) is extremely challenging, as the overall recovery rates widely vary. This study assesses the possible correlation between the severity of spinal cord injury and CSF cytology in 31 paraplegic dogs presented with absent DPP due to acute thoracolumbar intervertebral disc herniation (TL-IVDH). All dogs underwent surgical decompression immediately following diagnosis. CSF TNCC, macrophage percentage and macrophage to monocyte (MΦ:M) ratio were significantly higher in dogs that failed to regain DPP within 10 days post-operatively and in dogs that failed to regain ambulation at the end of the study period (P< 0.05). MΦ:M of 0.73 and higher corresponded to a sensitivity of 54% and specificity of 100% for prediction of a negative long-term outcome. CSF TNCC, macrophage percentage and MΦ:M ratio effectively predicted regaining DPP and the long-term outcome in dogs that lost DPP due to acute TL-IVDH.

Virus burden in human immunodeficiency virus type 1-infected children: relationship to disease status and effect of antiviral therapy.

The human immunodeficiency virus type 1 (HIV-1) was isolated from the plasma and peripheral blood mononuclear cells (PBMCs) from each of 21 infected children. The mean titers in plasma were 7 and 165 tissue culture-infective doses per milliliter in 9 children with asymptomatic (P-1) and 12 with symptomatic (P-2) infection, respectively (P = .0013). Significantly higher viral titers were found in PBMCs obtained from P-2 compared with P-1 children: 1920 vs 25 tissue culture-infective doses per 10(6) PBMC (P = .0018). In symptomatic patients at least 1 in 520 circulating mononuclear cells harbored HIV-1. No correlation was found between the viral burden and CD4+ lymphocyte counts. A decrease in the HIV-1 titers was noted both in PBMCs and plasma of symptomatic patients treated with zidovudine for 2 to 7 months. It is concluded that symptomatic children harbor a higher amount of the virus in plasma and PBMCs than asymptomatic children. Zidovudine treatment for 2 months or more decreased the amount of HIV-1 in PBMCs and plasma.

Chlamydia trachomatis disguised as an asymptomatic scrotal mass in adolescents.

We present two cases of adolescents who presented with painless scrotal masses suggestive of testicular cancer. Diagnostic workup of both these patients revealed Chlamydia trachomatis and both patients were successfully treated with doxycycline. Both patients initially denied sexual activity. We suggest that a high index of suspicion is warranted in adolescent patients that present with asymptomatic scrotal masses and precise tests for C. trachomatis be done to rule out an infectious cause.

Isolation of Ureaplasma urealyticum and Mycoplasma hominis from public toilet bowls.

The presence of Ureaplasma urealyticum, Mycoplasma hominis, and Chlamydia trachomatis was explored in 50 public restroom toilet bowls. We used culture, antigen detection, polymerase chain reaction, and survival assay. Five bowls (10%) were contaminated with at least one organism. U. urealyticum was found in four bowls, M. hominis in three, and C. trachomatis in one. U. urealyticum survived on the toilet rim for up to 2 hours.

Acute primary Chlamydia trachomatis infection in male adolescents after their first sexual contact.

BACKGROUND: Chlamydia trachomatis infection occurs primarily among youth sexually active persons. Few studies have evaluated the kinetics of markers of infection in male adolescents after their first sexual contact. DESIGN: Primary C trachomitis infection in 4 young male adolescents after their first sexual contact was diagnosed by polymerase chain reaction and antigen detection in sequential first voiding urine and urethral specimens, respectively. Serial serum samples were assessed for the presence of specific IgA and IgG antibodies. RESULTS: Both polymerase chain reaction and antigen detection correctly identified all cases of primary C trachomatis infection. The polymerase chain reaction method was, however, an earlier marker of infection. Three patients were seronegative at presentation. Two of these subsequently seroconverted to either IgA or IgG, while the third remains seronegative. The time interval from onset of symptoms to seroconversion ranged from 10 to 25 days. CONCLUSIONS: Although polymerase chain reaction and antigen and serologic detection have previously been described in primary C trachomatis infection, this report documents the variability of these markers during the first phase of infection in non-sexually active young male adolescents. C trachomatis can be acquired by male adolescents after their first sexual contact; however, there is a prolonged period when the patient is seronegative, yet infections can occur.

Tumour necrosis factor alpha in the diagnostic assessment of pleural effusion.

We investigated the role of tumour necrosis factor-alpha (TNF) in the evaluation of pleural effusion aetiology. Using a commercially-available ELISA kit, concentrations of TNF were measured in the serum and pleural fluid of patients with malignant effusions (n=19), uncomplicated parapneumonic effusions (n=13), and exudative (n=13) and transudative (n=13) effusions due to congestive heart failure (CHFex and CHFtr, respectively). Serum TNF did not differ significantly between the four groups (p>0.05). In the group with malignancy, pleural fluid TNF was significantly higher than in the other groups (p<0.001), which were not significant different from each other (p>0.05). However, a considerable overlap between all four groups was found. Pleural fluid TNF was significantly higher than serum TNF in the malignant and the uncomplicated parapneumonic groups (p<0.001), and there was a significant positive correlation between serum TNF and pleural fluid TNF in the group with uncomplicated parapneumonic effusion (r=0.7, p<0.005), in the group with CHFex (r=0.54, p<0.01), and in the group with CHFtr (r=0. 8, p<0.005), but not in the group with malignancy. Pleural fluid TNF:serum TNF (TNF ratio) was significantly higher in the malignancy group than in the other groups (p<0.001); no significant difference was found between the other three groups (p>0.05). At an optimal cut-off point of 2.0 for TNF ratio, determined by ROC analysis for discrimination between malignant and non-malignant groups, sensitivity was 84%, specificity 90%, and total accuracy 88% (p<0. 0001). TNF ratio might be helpful in the diagnostic assessment of exudative pleural effusion.

Role of tumor necrosis factor-alpha in the differential diagnosis of parapneumonic effusion.

OBJECTIVE: This study was undertaken to investigate the role of tumor necrosis factor-a (TNF-a) in discriminating between uncomplicated parapneumonic effusion (UCPPE) and complicated parapneumonic effusion (CPPE). METHOD: Using a commercially available high sensitivity enzyme-linked immunosorbent assay (ELISA) kit, concentrations of TNF were measured in the serum (TNFs) and pleural fluid (TNFpf) of 21 patients with parapneumonic effusion (PPE), 13 patients with UCPPE, and 8 patients with nonempyemic CPPE. RESULTS: No significant difference in values of TNF concentration was found between the group with UCPPE and that with CPPE (P > 0.05). Concentration levels of TNFpf were significantly higher in the group with CPPE than in that with UCPPE (P = 0.0008). Levels of TNF in pleural fluid were significantly higher than in serum in both groups (P < 0.001). The ratio of TNF in pleural fluid to that in serum (TNFr) was significantly higher in the CPPE group than in the UCPPE group (P = 0.0002). At an optimal cutoff point of 10.7 pg/mL for TNFpf, the sensitivity was 87.5%, specificity was 92.3%, positive predictive value was 87.5%, negative predictive value was 93.3%, and total accuracy was 90.5% (P < 0.001). At an optimal cutoff point of 3.0 for TNFr, all values were 100% (P < 0.00001). CONCLUSIONS: The results of this study indicate that TNFpf, and particularly TNFr, may be helpful in discriminating between UCPPE and CPPE. However, further studies are needed in a larger population to confirm these findings.

Chronic otitis media treated topically with ciprofloxacin or tobramycin.

OBJECTIVE: To evaluate the efficacy of ciprofloxacin compared with tobramycin and placebo ear drops in the treatment of chronic suppurative otitis media without cholesteatoma. DESIGN: Sixty ears (in 51 patients) were randomly divided into 3 treatment groups: ciprofloxacin hydrochloride, tobramycin, and placebo interventions. SETTING: The otolaryngology department of a university teaching hospital. INTERVENTION: All ears were treated topically for 3 weeks. MAIN OUTCOME MEASURES: Each patient received a small, numbered bottle and was instructed to instill 5 drops 3 times daily for 3 weeks. The final clinical and bacteriologic assessment was made after 3 weeks. RESULTS: The organism most commonly isolated from the ear discharge was Pseudomonas aeruginosa. Its sensitivity to ciprofloxacin and tobramycin was 94.2% and 70.6%, respectively. The clinical response was 78.9%, 72.2%, and 41.2% in the ciprofloxacin, tobramycin, and placebo groups, respectively. The bacteriologic response rate was 66.7% for the ciprofloxacin and tobramycin groups and 20% for the placebo group. Treatment with ciprofloxacin ear drops seemed to be as effective as treatment with tobramycin. CONCLUSION: While the lack of ototoxicity of ciprofloxacin was not tested in our study, this treatment may be considered as a potential topical therapy for cases of chronic suppurative otitis media.

Lack of hepatitis E infection among backpackers to tropical countries.

Hepatitis E virus (HEV) is a feco-orally transmitted virus that occurs primarily among the indigenous populations of the Indian subcontinent, Central America and Africa. Most recognized cases of HEV occur after contamination of water supplies such as after monsoon flooding.1,2 In contrast with hepatitis A infection, secondary person-to-person spread is rare. Most cases of HEV are reported in epidemics, but sporadic cases also occur. Backpackers traveling from developed to developing countries are potentially at increased risk for acquisition of feco-orally transmitted organisms. The risk of acquisition of HEV among backpackers is unclear. We aimed at studying prospectively the rate of HEV in a group of backpackers and its association with lifestyle.

Pneumonia in the neonatal intensive care unit. Diagnosis by quantitative bacterial tracheal aspirate cultures.

Growth of > or = 10(5) colonies of bacteria per milliliter obtained at bronchoscopy in children and adults correlates with bacterial pneumonia. To determine whether quantitative tracheal aspirate cultures aid in diagnosis of pneumonia in the neonatal intensive care unit setting, tracheal aspirates were obtained from 25 infants who had recently undergone endotracheal intubation; 15 of the infants had suspected pneumonia and 10 control infants had undergone intubation for suspected apnea of prematurity (4 infants) or elective surgery (6 infants). Studies also were performed to detect Mycoplasma, Ureaplasma, viruses, and Pneumocystis. Tracheal aspirates from 2 of 15 infants with suspected pneumonia grew > or = 10(5) bacteria, and 1 was positive for respiratory syncytial virus. These infants were considered to have pneumonia. In 12 infants whose tracheal aspirates grew < 10(5) bacteria, respiratory decompensation later was explained by other causes in 11 infants, and there was one false-negative culture. There were three false-positive tracheal aspirates in the control group. We conclude that tracheal aspirates of infants who have recently had an endotracheal tube placed may be useful for diagnosing pneumonia and for identifying the causative agent.

Measles vaccine.

Administration of measles vaccine has sharply reduced the occurrence of measles. However, "mini epidemics" occurring at increasing intervals through 1989 brought about the need for a routine two-dose schedule of measles vaccination. The prevention of preschool cases and school-based cases are two major goals of this new schedule. A two-dose schedule will address the latter goal, however, it will not affect the more difficult problem of measles among preschoolers, a group with lower immunization rates than school-age children. The use of Edmonston-Zagreb measles vaccine in developing countries offers the promise of reducing worldwide disease rates in young infants in the future. However, the major goal in the United States and other developed countries is to increase levels of measles immunity.

[Incidence, antimicrobial resistance and mortality in bloodstream infections in the critically ill].

Bloodstream infections (BSI) are 7-fold more common in patients admitted to the intensive care unit (ICU) rather than to other hospital wards. The epidemiology of BSI in critically ill patients in Israel has not been systematically addressed. We examined the annual trends in BSI in patients in a general ICU of evolving patterns of antimicrobial resistance and associated mortality rates for the years 1994-1996. The presence of the systemic inflammatory response syndrome (SIRS) when the first positive blood cultures are taken was a prerequisite for its definition as clinically significant. The unit site, staff, practice guidelines, and type of patient were unchanged during the study period. Blood cultures were positive in 220.7-332.0 patients per 1000 ICU admissions, 18-22-fold more common than in regular ward patients. SIRS was a universal finding in these ICU patients. There was multi-drug resistance for the majority of species cultured, reaching 100% in some cases. Crude hospital mortality of ICU patients, with and without positive blood cultures, was 31-54% and 5-14%, respectively. The introduction of a new blood culture system (Bactec 9240) in 1996 was associated with a 61% increase in the rate of patients with positive blood cultures, accounted for mostly by increased isolation of coagulase-negative staphylococci. However the mortality rate for the latter decreased by 59%, suggesting the possibility of a selective increase in detection of contaminated cultures. Although highly prevalent in the study population and generally defining a patient group with high mortality risk, the specificity of SIRS-associated positive blood cultures may be species and culture-system dependent. These findings re-emphasize the need for both improved control measures for the epidemic proportions of BSI and multi-drug antimicrobial resistance, as well as more specific indicators of the clinical relevance of positive blood cultures in critically ill patients.

[Comparison of polymerase chain reaction and ELISA in the diagnosis of Chlamydia trachomatis infection].

Chlamydia trachomatis (CT) is the most frequent cause of sexually transmitted disease in the western world. However, only a few cases have been reported from Israel. Because of the frequent absence of symptoms, its high prevalence, rapid spread, and the seriousness of complications, the quality of the diagnostic test for this microorganism is very important. Cell culture has always been regarded as the "gold standard" in diagnosis. However, factors such as collection, transport time and storage can negatively influence the sensitivity of culturing. We evaluated a polymerase chain reaction (PCR) assay (Amplicor CT, Roche Molecular Systems) for the detection of CT. CT-PCR was compared with a non-culture method (ELISA) in cervical, urethral and first-void urine specimens in 30 patients attending our sexually transmitted disease clinic. There were 16 males and 14 females; in 16 of them (53%) CT-PCR was positive. However, in only 6 of the latter (38%) was CT-ELISA also positive. 7 urine specimens from males with non-specific urethritis had a positive CT-PCR and a negative CT-ELISA. There were discrepancies between ELISA and the PCR test in 10 (3 females) of the 30. We confirm other studies indicating the PCR to be a highly sensitive assay for detecting CT infection from urogenital specimens. CT-PCR from first-void urine provides a noninvasive technique for routine screening of CT infection in both symptomatic and asymptomatic males and females.