Applications of acute phase reactants in infectious diseases.

The elevation of acute phase reactants (APRs) is a nonspecific host response to infection, inflammation, and tissue injury. The major biologic function of APRs is to restore homeostasis and to improve survival. Measuring the alterations in APRs can be a useful clinical marker when an infection or inflammatory response is suspected. Serum levels of reactants like fibrinogen and complement proteins increase as part of the inflammatory response, but the increase is trivial and does not contribute to the differential diagnosis or the evaluation of therapeutic responsiveness. By contrast, C-reactive protein (CRP) concentrations increase markedly with acute invasive infections which parallel the severity of inflammation or tissue injury. This advantage makes CRP a useful marker for the presence of disease, response to therapy, and ultimate recovery.

Correcting the bias of clerkship timing on academic performance.

OBJECTIVES: To document the time-of-year bias in National Board of Medical Examiners subject examination (NBME) scores in a third-year pediatrics clerkship and to develop a grading method that neutralizes the bias. DESIGN: Interventional modeling of final grades. SETTING: University-based medical school. SUBJECTS AND METHODS: During each of the past 3 academic years, we conducted six 2-month pediatric clerkships for third-year students. To counter the time-of-year bias, NBME scores, clinical evaluations, and departmental examination scores for the current rotation were pooled with those from the rotations from the same time of year during the previous 2 years. Final grades for the current rotation were determined by cutoff points derived from that entire 3-year pool. We analyzed this approach by testing the time-of-year effects on NBME scores, clinical evaluations, and final grades while maintaining step 1 of the US Medical Licensing Examination as a preclinical baseline control. RESULTS: The scores for step 1 of the US Medical Licensing Examination did not differ significantly by time of year. Clinical evaluations and NBME scores showed significant upward trends as the academic year progressed. By contrast, according to design, final grades showed no significant time-of-year trend. CONCLUSIONS: Our results support previous reports of significant improvements in NBME scores across the academic year. Our method of computing final grades corrects for this time-of-year bias by judging students only in relation to those who took the rotation at the same time of year. It is our belief that the prevalence and significance of the time-of-year trend warrants such an adjustment in grading to help minimize the academic disadvantage faced by students early in their clinical training.

Assessing the value of pediatrics journals.

The pediatric literature comprises more than 500 journals. This paper reviews the relative impact of 63 pediatric journals and 26 highly cited journals that also publish pediatric articles. Using the objective measures of citation analysis and an understanding of the type of literature appropriate for one's purpose of study, physicians, scientists and students can avoid the pitfalls of information overload created by the proliferation of journals and information technology, while effectively extracting the clinical and basic science knowledge that will aid their reading and research. As the medical and scientific knowledge database continues to grow, knowing where to look for significant articles may likely become as important as knowing how to apply the information contained within them. Realizing that a significant portion of influential and important articles can be found in a relatively small group of journals can guide one's initial literature search, but one must also remember that equally valuable information can be found in other publications. Armed with the tools to minimize the field of less appropriate sources, one can more readily achieve the real purpose of a search, which is to uncover the bloom of knowledge and to nurture, cultivate and share it.

Human herpesvirus 6 infection.

Human herpesvirus 6 (HHV-6) was identified in 1986 and roseola infantum was the first disease linked to HHV-6. To date, a large variety of clinical syndromes have been associated with HHV-6. Age of the patient is the most important factor when considering HHV-6 as a possible cause of infection. It is a major pathogen for children aged 6 to 24 months. In addition, HHV-6 is an important pathogen in the immunocompromised host and may cause ailments of the central nervous system. These later two conditions are most likely to be benefited from the application of anti-viral drug when it becomes available. HHV-6 is an example that virus hides within the immunologic cells and displays a complex interaction with the host cells. The discovery of HHV-6 offers a lesson for clinicians to anticipate new viruses deriving from unexpected sites within the human body; furthermore, HHV-6 provides a model for studying the clinical role of a new herpesvirus.

Gonococcal abscess of the obturator internal muscle: use of new diagnostic tools may eliminate the need for surgical intervention.

Obturator internal muscle (OIM) abscess or pyomyositis, a poorly recognized intrapelvic infection, is characterized by limping, pain in the hip with limited movement, and the sciatic type of radiating leg pain. With the use of advanced diagnostic tools such as computed tomography (CT), magnetic resonance imaging, and radionuclide scans, several cases of OIM abscess have been diagnosed; these cases have recently been reported in the English-language literature. Staphylococcus aureus is the predominant organism isolated from OIM abscesses. Gonococcal abscess involving the OIM has not been reported. We describe a case of gonococcal OIM abscess in an adolescent female whose condition was successfully diagnosed and managed with the use of CT-guided needle aspiration and antibiotic therapy. We review the English-language literature regarding the use of newly developed tools in the diagnosis of OIM abscess.

Staphylococcus epidermidis meningitis and an intraspinal abscess associated with a midthoracic dermal sinus tract.

Congenital neuroectodermal defects are associated with meningitis that is unresponsive to conventional antibiotic therapy, recurrent bacterial meningitis, or meningitis due to an organism that is not usually the cause of this disease. Midthoracic dermoid and epidermoid cysts occur rarely and are easily overlooked. We report the case of a 13-month-old boy with meningitis that was unresponsive to antimicrobial therapy. We subsequently identified an intraspinal abscess, an infection due to Staphylococcus epidermidis, and a midthoracic dermoid cyst. We emphasize the need for clinicians to have a high index of suspicion and to make a careful physical examination when antibiotic treatment fails in patients with meningitis. We also provide a detailed anatomy of a midthoracic dermoid cyst and illustrate the usefulness of magnetic resonance imaging in preoperative diagnosis of congenital neuroectodermal defects.

AIDS and adolescents. How can you help them reduce their risk?

AIDS in adolescents (0.4% of all cases) is a problem of increasing importance in the United States. Infection with the human immunodeficiency virus (HIV) exists in high schools and on university campuses, and it presents a real and immediate threat to teenaged Americans who engage in drug abuse and sexual activity. Appropriately targeted educational efforts are needed to limit HIV transmission among adolescents. Most adolescents are aware of the high-risk activities that may lead to HIV transmission. However, only about one third alter their sexual behavior to avoid AIDS. It is important to move beyond imparting knowledge about AIDS transmission and to move toward changing risky behavior. Strategies for AIDS risk reduction in adolescents should be implemented now across the country. Appropriate support and intervention are urgently needed for adolescents at high risk.

Characteristic features of neonatal sepsis due to Haemophilus influenzae.

The number of cases of neonatal Haemophilus influenzae sepsis reported in the literature has increased. The predominant serotypes (80%) involved in neonates appear to be non-type b whereas in older infants type b is responsible for the great majority of cases. It appears that most cases of neonatal H. influenzae sepsis begin before or at the time of delivery, as the disease is strongly associated with early postnatal onset (83%), prematurity (83%), and a variety of maternal complications (44%). The mortality rate is 55.5% overall but 90% among babies born at less than or equal to 30 weeks of gestation.

Prolonged echoviral meningitis in a cancer patient with normal serum immunoglobulins.

This is a report of prolonged meningitis caused by echovirus type 20 in a patient with rhabdomyosarcoma. It represents one of the few documented cases of delayed clearance of echovirus in the cerebrospinal fluid in a patient with normal serum immunoglobulins. The case illustrates the prolonged clinical course of echoviral meningitis in a patient receiving cytotoxic drug therapy, and it suggests that factor(s) other than humoral antibodies may be involved in the elimination of echovirus from the central nervous system.

Spontaneous remission of cryptosporidiosis in a child with acute lymphocytic leukemia.

Cryptosporidiosis has been documented in pediatric patients with various forms of congenital and acquired immunodeficiency. This is a report of cryptosporidiosis in a child with acute lymphocytic leukemia. Cryptosporidiosis, an uncommon cause of diarrhea, may produce severe diarrhea in children with acute lymphocytic leukemia.

X-ray microanalysis of chloride in nails from cystic fibrosis and control patients.

Nail clippings from 60 individuals were examined. There were 34 "old" (greater than 16 years) controls, 16 "young" controls and 10 CF patients. In regard to elements found, Si and Al were considered as exogenous contamination. Other elements examined were variable in both control and CF. Examination of the Cl levels among the 3 groups showed a highly significant difference between the mean Cl integral values of the young controls (619 integral) and the CF patients (2956 integral). The results of the older control population ranged from 0-905 integral with a mean of 269 integral. We found no age or sex difference in the amount of Cl or any other element from either the CF or control population. Results show that the x-ray energy dispersive system (EDS) is very useful in studying the Cl in nails. We found that examination of nails frozen in liquid nitrogen followed by fracturing without prior washing was the preferred method. Although the results of this study clearly show statistically the value of EDS analysis of Cl in the diagnosis of CF, we must await further study of a larger group of patients to determine its usefulness in evaluating individual patients, particularly newborns.

Role of antiviral antibodies in resistance against coxsackievirus B3 infection: interaction between preexisting antibodies and an interferon inducer.

An experimental model of coxsackievirus B3 infection in newborn mice was utilized to examine the protective role of antiviral antibodies and an interferon inducer, polyinosinic acid-polycytidylic acid [poly(I:C)]. Subcutaneous administration to the infected mice of specific antiviral antibodies resulted in significant protection against coxsackievirus B3 infection. Antibody-treated animals had shortened viremia, early clearance of virus from tissues, and a reduced mortality rate. Dose response to antibodies was clearly demonstrated. However, the time of antibody administration in relation to the infection cycle was important. The protection was observed if antibodies were given before infection (24 h) or shortly after (2 h) infection. Administration of antibodies 24 h after infection resulted in no protection. The interferon inducer poly(I:C) prolonged the survival time of the infected mice, but this protective effect was incomplete and could only be demonstrated in animals treated before infection (24 h) or shortly after (2 h) infection. Enhanced protection against lethal coxsackievirus B3 infection was achieved in animals treated with a combination of antiviral antibodies and poly(I:C). These data confirm that antibody-mediated immunity plays a significant role in resistance against coxsackievirus B3 infection and suggest that antiviral antibodies may interact with poly(I:C) or work independently to produce an enhanced protective effect.

Bacterial endocarditis due to penicillin-resistant Streptococcus viridans.

Bacterial endocarditis remains a formidable diagnostic and therapeutic problem for clinicians. Streptococcus viridans still accounts for 45 to 50 per cent of all cases and between 5 to 10 per cent of all clinical isolates of Streptococcus viridans from patients with bacterial endocarditis may be relatively resistant to penicillin. The case of a 9-year-old child with Tetralogy of Fallot and a Waterston shunt who subsequently developed bacterial endocarditis due to penicillin-resistant Streptococcus viridans following failure of oral penicillin dental prophylaxis is presented. In the face of penicillin resistance, additional considerations for workup, including microbiological assays for antimicrobial synergism become necessary in the selection of a therapeutic regimen.