Martin E. Weisse

Prospective randomized double blind placebo-controlled evaluation of azithromycin for treatment of cat-scratch disease

OBJECTIVE To determine the efficacy of azithromycin in the treatment of patients with typical cat-scratch disease. DESIGN Prospective, randomized, double blind, placebo-controlled clinical trial. SETTING Large military medical center and its referring clinics. PATIENTS Active duty military members and their dependents with laboratory-confirmed, clinically typical cat-scratch disease. INTERVENTION Study participants assigned by randomization to treatment with oral azithromycin or placebo for 5 days. OUTCOME MEASURES Lymph node volume was calculated using three dimensional ultrasonography at entry and at weekly intervals. The ultrasonographer was blinded to the treatment groups. Endpoint evaluations were predetermined as time in days to 80% resolution of the initial total lymph node volume. RESULTS Demographic and clinical data showed that the azithromycin and placebo treatment groups were comparable at entry although the placebo group tended to be older. Eighty percent decrease of initial lymph node volume was documented in 7 of 14 azithromycin-treated patients compared with 1 of 15 placebo-treated controls during the first 30 days of observation (P = 0.026). After 30 days there was no significant difference in rate or degree of resolution between the two groups. CONCLUSIONS Treatment of patients with typical cat-scratch disease with oral azithromycin for five days affords significant clinical benefit as measured by total decrease in lymph node volume within the first month of treatment.

Wine as a digestive aid: comparative antimicrobial effects of bismuth salicylate and red and white wine

Abstract Objective:To test whether red and white wines are as potent as bismuth salicylate against the bacteria responsible for travellers diarrhoea to try to explain wines legendary reputation as a digestive aid. Design:Red and white wine, bismuth salicylate, two solutions containing ethanol (diluted absolute ethanol and tequila), and sterilised water were tested against suspensions of salmonella, shigella, and Escherichia coli to determine relative antibacterial activity. Suspensions of 107 colony forming units of shigella, salmonella, and E coli were added to the test solutions and plated on standard nutrient agar at 0, 10, 20, 30, 60, and 120 minutes and 24 hours. Dilutions of wine and bismuth salicylate were then tested with E coli as the test bacterium, and the experiment repeated. Main outcome measures:Exposure times necessary for eradication of organisms for the different solutions; decreases in colony counts at the different exposure times for dilutions of wine and bismuth salicylates. Results: Undiluted wine and bismuth salicylate were both effective in reducing the number of viable organisms (by 105-106 colony forming units) after 20-30 minutes. Dilutions of wine were much more effective in decreasing colony counts than were similar dilutions of bismuth salicylate. Conclusion:The antibacterial property of wine is largely responsible for wines reputation as a digestive aid.

Comparative Study of Clinical Evaluation of Heart Murmurs by General Pediatricians and Pediatric Cardiologists

In a study to compare the clinical diagnostic skills of academic general pediatricians and academic pediatric cardiologists in the evaluation of heart murmurs, a total of 128 patients (aged 1 month to 18 years) newly referred to a university pediatric cardiology clinic were evaluated by one of three general pediatricians and one of four pediatric cardiologists. The murmurs were clinically classified as innocent, pathologic, or possibly pathologic. The classification was revised after the review of electrocardiogram (EKG) and chest radiograph (CXR), if indicated. The definitive diagnosis was ascertained by echocardiography (94 normal, 34 abnormal). The general pediatricians identified as many pathologic heart murmurs as the pediatric cardiologists (27/34 vs. 29/34), with no difference in sensitivity, 79% vs. 85% (p=0.53). The similarity in sensitivity could be because the general pediatricians were more cautious in the classification of heart murmurs and had classified more innocent heart murmurs as pathologic than the pediatric cardiologists (13/39 vs. 3/23), 41% vs. 13% (p=0.02). The pediatric cardiologists correctly identified more innocent murmurs than general pediatricians (52/94 vs.72/94), with a better specificity, 55% vs. 76% (p=0.001); however, the accuracy of prediction of innocence was similar for both groups (52/59 vs. 72/77), 88% vs. 93% (p=0.36). The revision of diagnosis with review of EKG and CXR was more often misleading than helpful for either group. Academic general pediatricians would identify most of the pathologic murmurs and are no more likely than an academic pediatric cardiologist to misclassify a pathologic heart murmur as innocent. Clin Pediatr. 1999;38:511-518

Restructuring an Academic Pediatric Inpatient Service Using Concepts Developed by Hospitalists

In an effort to increase continuity of inpatient care by attending physicians, decrease use of hospital resources, and improve medical education without compromising quality of care, an inpatient pediatric ward service was restructured by using concepts developed by hospitalists. This reorganization reduced the number of yearly inpatient attendings, added a consistent 14-day call schedule, and eliminated attending outpatient responsibilities during their ward service. The restructured ward service attending acted as the attending of record for all general and specialty patients, excluding hematology/oncology, with the subspecialists fulfilling a consultant role. To evaluate the impact of this restructuring, a baseline year of the traditional ward service (TWS) was compared with a subsequent year of the restructured ward service (RWS). Our goal was to evaluate the impact of this new system on average costs of hospitalization, length of stay, resource utilization, inpatient mortality, and 7- and 31-day readmission rates. Hospital costs per patient were lower by 13% (p=0.018) in the restructured system. Average lengths of stay in an observation bed were significantly lower on the RWS (p=0.007), but there was no significant difference in admission length of stay. There was decreased resource utilization for laboratory and radiology tests (p<0.01) on the restructured service. Readmission rates were not significantly changed, and satisfaction among attendings, housestaff, students, and patients was uniformly high in both groups. A reorganized academic pediatric medical service, which allows specific attendings to focus on inpatient care and teaching, can decrease hospital resource utilization without compromising the quality of patient care or medical education.

Transverse Myelitis Associated with Probable Cat-Scratch Disease in a Previously Healthy Pediatric Patient

We evaluated a pediatric patient for transverse myelitis associated with Bartonella henselae infection. There was no adenopathy in our patient, but the diagnosis was made serologically. It is necessary to keep cat-scratch disease in mind even in the absence of typical findings.

The fourth disease, 1900-2000

Measles and scarlet fever were differentiated from one another in the 17th century. Rubella was accepted as the third distinct paediatric exanthem in 1881. Nil Filatow in 1885 and Clement Dukes in 1894 described two distinct forms of rubella, and in 1900 Dukes proposed that one of these forms of rubella was a separate entity which he called the fourth disease. For the past five decades, fourth disease has been considered a non-entity, perhaps a mild form of scarlet fever, but certainly not a distinct disease. In 1979 Keith Powell resurrected the idea of the fourth disease and argued that it was caused by exotoxin-producing Staphylococcus aureus. We present additional arguments for the existence of fourth disease, as well as information to link the disease to S. aureus.

A Recurrent Presentation of Hand, Foot, and Mouth Disease

Hand foot and mouth disease, a virus most commonly caused by coxsackievirus A16, is an illness usually affecting young children. It is a clinical diagnosis of multiple oral, hand, and foot lesions lasting roughly 7–10 days, resolving with symptomatic treatment only. Although uncommon, we report a case that reoccurred within four weeks and then again nine months after the original infection with dermatologic lesions located in the same distribution.

Persistent Pneumonia in a Boy with Systemic Lupus Erythematosus

rash, a positive antinuclear antibody (ANA), an antidsDNA titer of 1:10,240, and grade IV membranoproliferative glomerulonephritis by kidney biopsy. The patients mother was also diagnosed with SLE at the age of 18 and died at the age of 24 from complications of the disease. His therapy consisted of long-term prednisone 35 mg/day, hydroxychloroquine 200 mg/day, and high-dose intravenous cyclophosphamide. This immunosuppressive regimen was continued for the entire year, since he had relapses with any attempt to wean. A chest radiograph upon admission showed a developing right lower lobe infiltrate. Initially he was

Antigenuria after immunization with haemophilus influenzae oligosaccharide Crm197 conjugate (hboc) vaccine

We tested the urine of 30 infants 6 weeks to 7 months of age after they received standard 10-micrograms (0.5-ml) doses of HbOC (HibTITER) Haemophilus influenzae b (Hib) conjugate vaccine for the presence of Hib antigenuria using a commercially available latex particle agglutination assay (Directigen). Urines were collected within 1 hour, from 1 to 3 hours, at 24 hours and at 3, 6 and 9 days after vaccine administration and reactions were quantitated from 0 to 3+. In contrast to previous studies in older children which showed little or no antigenuria following HbOC vaccination, our study shows that in infants intense Hib antigenuria is evident within 2 to 3 hours and persists 3 days after vaccine administration and that less intense antigenuria may be detected in some infants for several days. With efficacious vaccines now being used in 2- to 6-month-old infants, invasive Hib disease may soon be limited to infants of this age just before their seroconversion. It should be recognized that antigenuria occurs for several days after vaccination with Hib conjugate vaccines and that it could be erroneously interpreted as evidence of invasive Hib infection.

Health Maintenance Deficits in a Fully Insured Population of Adolescents With Chronic Medical Conditions

The current national monitoring of routine wellness care and vaccine uptake does not provide data on health maintenance among pediatric populations with chronic medical conditions. In this case-control study that analyzes wellness visits and vaccine uptake among adolescents, ages 16 to 18 years, we identified 938 without (controls) and 74 with (cases) 1 of 12 specific chronic medical conditions. The PPSV23 (23-valent pneumococcal polysaccharide vaccine) is recommended by the Advisory Committee on Immunization Practices for these 12 conditions and served as a measure of uptake for medically indicated vaccines. Our controls were twice as likely as cases to have a documented well visit in the past year, and there was a significantly higher proportion of controls than cases vaccinated with Tdap (tetanus toxoid, reduced diphtheria toxoid, acellular pertussis), MCV-4 (quadrivalent meningococcal conjugate), and HPV (human papillomavirus), all P < .05. More than 60% of cases failed to receive PPSV23. Adolescents with chronic medical conditions are at high risk of neglecting routine health maintenance.