Michael R. Weir

Stress reaction of the pars interarticularis leading spondylolysis: A cause of adolescent low back pain

We report an adolescent with progression from a stress reaction of the pars interarticularis without radiographic findings, to radiographic fracture and spondylolysis, illustrating the evolution of spondylolysis in an athletically active early adolescent. Gymnastics, diving, pole vaulting, or collision/contact sports such as football, soccer, hockey, and la crosse are common sports with a disproportional frequency of spondylolysis. Rotational forces around the long axis of the spine with load bearing hyperextension are important in etiology. Low back pain in the active adolescent or preadolescent, even with normal oblique lumbar radiographs, may have a treatable origin--stress reaction or fracture of a lumbar pars interarticularis. Screening evaluation is the standing one-leg extension maneuver. Liberal use of nuclear studies for minimal back symptoms in athletic adolescents may help exclude this relatively common, potentially treatable condition, spondylolysis of the pars interarticularis.

Optimal Dosing Interval for Penicillin Treatment of Streptococcal Pharyngitis

One-hundred-forty-two children with symptomatic pharyngitis had throat cultures positive for group A beta-hemolytic streptococci (GABHA). All were treated orally with penicillin V for ten days. Patients were randomly assigned to receive daily doses of 250 mg four times daily, 500 mg twice daily, or 1000 mg once daily. They were followed four weeks for either recurrent symptomatic pharyngitis or asymptomatic repeat positive throat culture. Patients treated two or four times daily had comparable outcomes. Children given penicillin once daily were more likely to have persistent positive culture after 48 hours treatment (5 of 48 or 10.4% vs. none of 94, p=.004) and more likely to have recurrent positive cultures after end of treatment (10 of 43 or 23% vs. 8 of 94 or 8%, p=.04). The treatment regime of penicillin V 500 mg twice daily is recommended for treatment of pharyngitis due to GABHS.

Intravascular Injuries from Intramuscular Penicillin

Benzathine penicillin, procaine penicillin, and mixtures of both are opaque preparations for intramuscular injection. Visualization of aspirated blood, the fail-safe for avoiding intravascular injection, is predictably problematic. A spectrum of injuries, sometimes permanent, to the gluteal region, distal extremities, perineum, and spinal cord probably results from inadvertent intra-arterial injection, possibly due to vascular occlusion by large crystals of the penicillin salt(s). Since the arterial injuries disproportionately affect infants, use of these preparations in that age group should be minimized. The corresponding intravenous injection probably is Hoignes syndrome, a procaine-induced central nervous system syndrome. Though usually brief and transient complications may be profound, including coma, convulsions, and death. Careful attention to details of anatomy and manufacturers recommendations is critical.

Progression of Tympanometry and Acoustic Reflectometry Findings in Children With Acute Otitis Media

The presence of middle ear effusion (MEE) following acute otitis media (AOM) has been assessed by impedance tympanometry and acoustic reflectometry but has not been assessed serially from the time of presentation for AOM in the same group of patients. This descriptive study examined serial measurements by tympanometry and reflectometry in children with clinical AOM at the time of diagnosis, 3 to 5 days later, and at final follow-up 12 to 15 days after diagnosis. The study entry criteria were conservative in order to represent obvious cases of AOM and included 90 patients representing 107 ears. The objective was to describe the evolution of instrumental findings and to attempt to identify unique patient subpopulations with differing prognoses. We found that combined use of initial tympanometry and reflectometry, while yielding intriguing results, does not allow for identification of subpopulations with good or poor progression for MEE clearance at 2-week follow-up. It is our conclusion that initial tympanometry and reflectometry add to the cost of AOM diagnosis without clear benefit for the individual patient.