Shepard Schwartz

Efficacy of corticosteroids in acute bronchiolitis : Short-term and long-term follow-up

Corticosteroids continue to be used by many physicians to treat infants with bronchiolitis. The aim of this study was to examine the short‐term and long‐term efficacy of oral corticosteroid therapy when added to β2‐agonists in infants with mild to moderate bronchiolitis (defined as the first episode of wheezing associated with low grade fever, rhinitis, tachypnea, and increased respiratory effort in a previously healthy infant during the winter months). Infants with mild to moderate bronchiolitis, were randomly assigned to receive either oral prednisone (2 mg/kg/day) or placebo for 3 days. All patients received nebulized albuterol q.i.d. during this period. Upon admission and after 3 days of therapy, a clinical score was assigned based on respiratory rate, use of accessory muscle, and the presence of wheeze. Oxygen saturation (SaO2) was also measured. On day 7, we inquired as to the well‐being of each child. Two years later, the development of chronic respiratory symptoms was assessed. Thirty‐eight infants were enrolled in the study; 20 received prednisone and 18 received placebo. Both groups were similar in terms of age, duration of illness prior to enrollment, pretrial medication use, clinical severity of bronchiolitis, history of atopy, and family history of atopy.

A Week by Week Analysis of the Low Risk Criteria for Serious Bacterial Infection in Febrile Neonates

Objective: To examine the reliability of “low-risk” criteria (LRC) to exclude serious bacterial infection (SBI) in febrile neonates (⩽28 days), according to age in weeks. Design: Epidemiological and clinical data and final diagnosis of all febrile neonates presenting to the emergency room from June 1997 to May 2006 were reviewed. Neonates who fulfilled specific LRC for the presence of SBI were classified as LRC+. The prevalence of SBI and the percentage of LRC+ neonates who had SBI were calculated for each of the first 4 weeks of life. Results: A total of 449 neonates were evaluated. Eighty-seven (19.4%) neonates had an SBI. The prevalence of SBI among infants 3–7, 8–14, 15–21 and 22–28 days of age was 21.6%, 26.1%, 17.9% and 12.1%, respectively (p = 0.007 for linear trend after second week of life). Of the 226 LRC+ neonates, 14 (6.2%) had an SBI, including one case of bacteraemia and meningitis and 13 cases of urinary tract infection (UTI). The negative predictive value (NPV) of the LRC for SBI was 93.8% (95% CI 90.1% to 96.4%). The prevalence of SBI among LRC+ infants 3–7, 8–14, 15–21 and 22–28 days of age was similar, with rates of 15%, 6.3%, 3.0% and 6.7%, respectively. Conclusion: LRC are not sufficiently reliable to exclude the presence of SBI, including bacteraemia and meningitis in febrile neonates of all ages. All febrile neonates should therefore be hospitalised, undergo a full “sepsis evaluation” and receive empirical intravenous antibiotic therapy.

Fatal pneumococcal sepsis following flexible bronchoscopy in an immunocompromised infant

A 5‐month‐old boy who suffered from a leukocyte chemotactic defect underwent flexible bronchoscopy for persistent right upper lobe atelectasis and tachypnea. Ten hours after the procedure he developed fulminant sepsis, and he died 16 hrs after bronchoscopy. Streptococcus pneumoniae (serotype 23) grew from the bronchoalveolar lavage fluid and from the blood culture taken during the sepsis work‐up. We, therefore, suggest administering prophylactic antimicrobial therapy immediately following bronchoscopy to immunosuppressed children, even when an acute respiratory infection is not suspected, in order to prevent bacteremia and sepsis. Pediatr Pulmonol. 1998; 25:390–392.

Does sweat volume influence the sweat test result

Objective Low volume sweat samples are considered unreliable for the diagnosis of cystic fibrosis, based on the assertion that sweat conductivity and chloride are reduced at lower sweating rates. We aimed to re-evaluate the relationship between sweat volume and test results. Design We reviewed all sweat tests performed in our institution to assess the relationship between sweat volume and conductivity, and between sweat volume and sweat chloride. We also compared results between pairs of sweat tests taken simultaneously from a single patient, one with sweat volume below and the other above the currently accepted minimum volume (15 µl). Results A weak inverse relationship between sweat volume and sweat conductivity was found (n=1500, R2=0.105, p<0.001). There was no correlation between sweat volume and sweat chloride (n=463, R2=0.002, p>0.05). In discordant pairs (one below and one exceeding the accepted minimum volume), the mean test result in the low volume sample was slightly higher than its counterpart. In 76 such pairs, mean conductivity was 41.1±14.6 mmol/l in the lower volume sample, compared with 36.8±16.0 mmol/l in the higher volume sample (p<0.001). Similarly, in 33 of the pairs, mean sweat chloride was 28.4±15.7 mmol/l in the lower volume sample compared with 25.1±15.2 mmol/l in the higher volume sample (p=0.004). Conclusion A normal sweat conductivity and/or chloride value from a sweat volume <15 µl in a patient whose clinical symptoms are not very suggestive of cystic fibrosis, renders this diagnosis unlikely. In contrast, elevated sweat chloride or conductivity measured from a sample whose volume is <15 µl may represent an artefact related to the low volume.

Automatic 3-Dimensional Visualization of Peripheral Blood Slides: A New Approach for the Detection of Infection/Inflammation at the Point of Care

CONTEXT The identification and quantitation of the intensity of the acute-phase response at the point of care might be of clinical relevance. OBJECTIVE To report the possibility of automatic screening of unstained peripheral blood slides by using a 3-dimensional image analysis system. DESIGN Peripheral venous blood was obtained from children with acute inflammation/infection and examined by an automatic 3-dimensional image analyzer to detect the number of white blood cells as well as to reveal the degree of erythrocyte aggregation, a marker of the humoral phase response. RESULTS We included 66 children with acute bacterial infections and 59 with nonbacterial inflammation/infection; mean ages of the 2 groups were 4.3 +/- 3.9 years and 4.2 +/- 3.7 years, respectively (P = .91). The percentages of correct classifications based on discriminant analysis in predicting between bacterial and nonbacterial inflammation/infection were 61.3% by using the white blood cell count, 64.5% by using the percentage of granulocytes, 61.6% by using the degree of erythrocyte aggregation, and 59.2% by using the number of leukocytes counted on the unstained slides. The results of the receiver-operated characteristic curve analysis yielded an area under the curve of 0.714 (P < .001) for the number of granulocytes, 0.699 (P < .001) for the white blood cell count, 0.685 (P < .001) for the number of leukocytes on the slides, and 0.685 (P = .001) for the degree of erythrocyte aggregation. The correlation between the number of leukocytes by the electronic cell analyzer and the number of cells counted on the slides was highly significant (r = 0.85, P < .001). CONCLUSIONS It is feasible to use an automatic 3-dimensional image analyzer to reveal the different intensities of the acute-phase response between a group of children with an acute bacterial infection and another with nonbacterial inflammation/infection. These findings might be relevant for potential application at the point of care.

Investigation of unexplained infant deaths in Jerusalem, Israel 1996–2003

Background: Sudden infant death syndrome (SIDS) is a diagnosis of exclusion that may be assigned only after investigations including a forensic autopsy are performed to exclude possible organic and environmental causes of death. Israeli society is influenced by the Jewish and Islamic faiths, which permit autopsy only under selected circumstances. Against this background, we carried out a study to determine what examinations are performed to investigate unexplained infant deaths in Jerusalem, Israel. Methods: We examined hospital, Ministry of Health and Ministry of Interior records of unexplained infant deaths in the Jerusalem district from the years 1996–2003. Results: Ninety six cases were identified from all sources. Forty nine (51%) infants were brought to a hospital at or near the time of death. Studies to determine the cause of death were performed in 54% of cases for which medical records were available for review. These studies included bacterial cultures (44%), skeletal surveys (12%), computerised tomography (3%) and metabolic studies (3%). Only one forensic autopsy was performed, and in no instance was the death site examined by medical personnel. There was a high rate of retrospective review by district health physicians. The most frequently assigned cause of death was SIDS. Conclusions: : The capacity of public health officials and forensic pathologists to investigate unexplained infant deaths is strongly affected by the legal, religious and political milieu in which they work. Efforts should be made to develop socially acceptable methods of improving the quality of infant death investigations in Jerusalem.