Robert D. Schremmer

Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis

OBJECTIVE. The goal of this study was to evaluate the effect of antibiotic administration before lumbar puncture on cerebrospinal fluid profiles in children with bacterial meningitis. METHODS. We reviewed the medical records of all children (1 month to 18 years of age) with bacterial meningitis who presented to 20 pediatric emergency departments between 2001 and 2004. Bacterial meningitis was defined by positive cerebrospinal fluid culture results for a bacterial pathogen or cerebrospinal fluid pleocytosis with positive blood culture and/or cerebrospinal fluid latex agglutination results. Probable bacterial meningitis was defined as positive cerebrospinal fluid Gram stain results with negative results of bacterial cultures of blood and cerebrospinal fluid. Antibiotic pretreatment was defined as any antibiotic administered within 72 hours before the lumbar puncture. RESULTS. We identified 231 patients with bacterial meningitis and another 14 with probable bacterial meningitis. Of those 245 patients, 85 (35%) had received antibiotic pretreatment. After adjustment for patient age, duration and severity of illness at presentation, and bacterial pathogen, longer duration of antibiotic pretreatment was not significantly associated with cerebrospinal fluid white blood cell count, cerebrospinal fluid absolute neutrophil count. However, antibiotic pretreatment was significantly associated with higher cerebrospinal fluid glucose and lower cerebrospinal fluid protein levels. Although these effects became apparent earlier, patients with ≥12 hours of pretreatment, compared with patients who either were not pretreated or were pretreated for <12 hours, had significantly higher median cerebrospinal fluid glucose levels (48 mg/dL vs 29 mg/dL) and lower median cerebrospinal fluid protein levels (121 vs 178 mg/dL). CONCLUSIONS. In patients with bacterial meningitis, antibiotic pretreatment is associated with higher cerebrospinal fluid glucose levels and lower cerebrospinal fluid protein levels, although pretreatment does not modify cerebrospinal fluid white blood cell count or absolute neutrophil count results.

Human immunodeficiency virus postexposure prophylaxis in child and adolescent victims of sexual assault.

Objectives: This study was performed at an urban childrens hospital to identify the characteristics of patients given human immunodeficiency virus (HIV) postexposure prophylaxis and describe the adherence and associated side effects of HIV prophylaxis in child and adolescent victims of sexual abuse. Methods: A retrospective review of all children presenting for evaluation of suspected sexual abuse who were provided HIV prophylaxis between February 1999 and March 2001 was performed. Measured variables included risk factors for transmission of HIV, antiretrovirals prescribed and their side effects, initial and follow-up laboratory results, and compliance. Results: The medical records of 34 patients were examined. Assault by a stranger was the most common risk factor prompting prophylaxis. Zidovudine and lamivudine were prescribed for 32 patients (94%). Only 17 patients (50%) kept at least 1 follow-up appointment; 8 patients (24%) finished the entire course of prophylaxis. Side effects were reported in 11 (65%) of 17 patients, but only 1 patient was known to have stopped prophylaxis because of subjective side effects, and 1 patient was removed from prophylaxis due to laboratory abnormality. Conclusions: Adherence to medication regimen and follow-up appointments in victims of suspected sexual abuse who are provided HIV prophylaxis is poor. The medications are associated with several side effects, but rarely do the side effects prohibit their use. Given difficulties with compliance, potential adverse effects of medications, and the high cost of treatment, care should be taken in offering prophylaxis to only those at increased risk for transmission of disease.

Ethical Concerns When Minors Act as Standardized Patients

Minors are sometimes recruited to help medical educators by acting as standardized patients. Are there risks? Should there be safeguards? When minors are asked to assist medical educators by acting as standardized patients (SPs), there is a potential for the minors to be exploited. Minors deserve protection from exploitation. Such protection has been written into regulations governing medical research and into child labor laws. But there are no similar guidelines for minors’ work in medical education. This article addresses the question of whether there should be rules. Should minors be required to give their informed consent or assent? Are there certain practices that could cause harm for the children who become SPs? We present a controversial case and ask a number of experts to consider the ethical issues that arise when minors are asked to act as SPs in medical education.

The Creation of a Model Pediatric Ward for African American Children in 1920s Kansas City

* Abbreviations: CMH — : Children’s Mercy Hospital WPH — : Wheatley-Provident Hospital The summer of 1919 is remembered for some of the worst race riots in American history. Dubbed the Red Summer by James Weldon Johnson, at least 25 major riots rocked American cities, and more than 52 African Americans were lynched.1 Although provocations varied, a root cause of the racial tension was the disappointment felt by African American World War I veterans. They had hoped that their military service would earn them equality at home. Instead they returned to a society where the majority of American states enforced Jim Crow racial segregation laws. As in many American cities, Kansas City hospitals, including Children’s Mercy Hospital (CMH), were racially segregated in the early 20th century. African Americans went to the “Negro hospitals,” where facilities were substandard and overcrowded.2 The mortality rate for Kansas City’s black population was nearly double that of the country’s.3 Children fared no better: the black infant mortality rate was close to double that of whites. Common causes of child death were prematurity, diarrhea, and pneumonia.4,5 Conditions were worsened by limited numbers of black physicians. The 1910 Flexner report prompted the closure of all but 2 African American medical schools, Howard University and Meharry Medical College. Although Flexner recommended coeducation for men and women, he accepted racial segregation in medical schools. Furthermore, education gaps between black and white physicians were widened when he recommended that black physicians be trained differently at a more basic level as “sanitarians” with an emphasis on “serving” their people.6,7 The overall effect was to reinforce segregated and unequal medical training, thereby limiting education and practice opportunities for African Americans.7 It was in this climate that physicians Katharine Berry Richardson and John Edward Perry … Address correspondence to Jane F. Knapp, MD, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: jknapp{at}cmh.edu

Harry Truman and Health Care Reform: The Debate Started Here

The signing of the Patient Protection and Affordable Care Act in March 2010 has not quelled the bitter debate over the issue of health care reform. National health insurance (NHI) plans have been considered by many presidential administrations since the beginning of the 20th century. Harry Truman (Fig 1) was the first US president to propose a system of NHI, however, when he addressed Congress on November 19, 1945.1 He had already included “the right to adequate medical care and the opportunity to achieve and enjoy good health” in his proposed Economic Bill of Rights. For Truman, the words did not go far enough. As a Jackson County, Missouri, judge, he had seen firsthand the disastrous effects that illness could have on a working family through his responsibility for the county poorhouse.2 He later learned that one-third of Selective Service registrants were rejected during World War II. In addition, many soldiers were discharged for health problems unrelated to combat, and still more were treated for conditions that predated their military induction. In his speech, Truman enumerated basic problems with health care delivery, including high costs and loss of earnings during illness. In response, he proposed compulsory NHI for all Americans and expanded social insurance systems to include replacement of lost earnings. FIGURE 1 President Harry S. Truman with March of Dimes children, 1950. Copyright unknown, courtesy of the Truman Library. NHI was not a new concept. Otto von Bismark initiated a compulsory health insurance program in Germany in 1883; its success led to the expansion of the concept of social insurance across Europe and the … Address correspondence to Robert D. Schremmer, MD, Division of Emergency Medical Services, Childrens Mercy Hospitals and Clinics, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: rschremmer{at}cmh.edu