Management of acute otitis media caused by resistant pneumococci in infants.

OBJECTIVES: To assess the clinical outcome and risk of failure after oral vs. intravenous treatment in otitis media caused by penicillin-resistant pneumococci. To determine the possible correlations between pneumococcal minimal inhibitory concentration (MIC) to penicillin and clinical outcome. DESIGN: Retrospective study of 156 cases collected between 1993 and 1995. Mean follow-up: 5 months. Setting. Two tertiary academic medical centers in Paris, France. PATIENTS AND METHODS: Pneumococcus was isolated from 191 of 570 ear samples obtained from children with otitis media and shown to be penicillin-resistant in 156. Medical history, antibiotic therapy during the previous 3 months and day-care center attendance were reviewed. For the current episode microbiologic characteristics of the isolated strains, type of treatment, therapy efficacy and clinical outcome were analyzed. Patients were predominantly young (76.3% were <1 year old) and bacteriologic samples were taken mainly because of previous treatment failure. RESULTS: Among 156 children with pneumococcal penicillin-resistant otitis media, 72.2% attended day-care centers, 71.8% had been previously treated with aminopenicillin and 52.5% with cephalosporins. Failure of previous empirical oral therapy was noted in 84% (one-third of these had been receiving amoxicillin-clavulanate). Patients treated intravenously had had a more protracted otitis but no greater number of previous episodes of acute otitis media than those receiving oral therapy. Acute mastoiditis occurred in 4 infants resulting in mastoidectomy. Oral treatment (mainly with high dose amoxicillin,120 to 150 mg/kg/day) and intravenous therapy (cephalosporin or glycopeptide) had been used in 59 and 41%, respectively. Mean duration of therapy was 10.7 days. Three failures (1.9%) and 10 recurrences (6.4%, average 28 days) occurred. No statistical difference was found between intravenous and oral therapy with respect to risk of recurrence. A high penicillin MIC value was correlated with previous antibiotic treatment but not with clinical outcome. CONCLUSIONS: Oral therapy appears to be as effective as intravenous therapy for the treatment of penicillin-resistant pneumococcal otitis media. Intravenous treatment should not necessarily be dictated by the penicillin susceptibility value but should be considered in cases of failure to thrive, persistent otitis or other complications.

[Cysts of the lacrimal tracts in the newborn infant]. / Kystes des voies lacrymales chez le nouveau-né.

At birth, a thin membrane often remains at the distal end of the nasolacrimal duct in the inferior meatus. The rupture is spontaneous during the first month of life. Sometimes this impatency can lead to a symptomatology usually limited to an uni or bilateral dacryocystitis. Exceptionally a cyst can develop in the nasolacrimal passageways. The authors describe three cases of intranasal occurrences, two of which brought about an obstructive dyspnea. Twelve cases have been described in the literature. This affliction predominantly occurs in young girls. Whenever the nasal obstruction is isolated, it is important to eliminate any other cause of intranasal tumor, especially an encephalocele, before any surgical intervention. Computerized tomographic scan is indispensable in order to eliminate any connection with the intracranial space. Magnetic resonance imaging appears promising. For the authors, the treatment must be surgical and must be kept simple. It consists in a cyst excision.

Tracheal rupture in a newborn during a complicated delivery. Diagnosis and surgical repair.

Rupture of the trachea is an exceptional obstetrical lesion. The infant reported in this paper, at 1 hour of age, developed respiratory distress with pneumomediastinum, bilateral pneumothorax and subcutaneous emphysema. This resulted from the fact that the trachea had ruptured, within 1 cm of the carina, during the difficult delivery. When the child was 23 days old, operation proved necessary because extubation was not feasible. The stenotic portion of the trachea was resected and continuity restored by end-to-end anastomosis. The tracheal lumen at the site of the anastomosis proved normal by bronchoscopic examination 4 months after the operation. There is only one similar case in the literature. The etiology of this rupture is discussed.

Laryngeal ultrasonography in infants and children: a new way of investigating. Normal and pathological findings.

Ultrasound of the larynx appears as a new way of imaging the larynx in infants and children. The normal sonographic anatomy is briefly described. The pathological findings of this method, its advantages and its drawbacks are discussed. It appears to be a very interesting method for functional disorders and space-occupying lesions.

[Balloon dilatation of tracheobronchial stenoses in children. Apropos of 4 cases]. / Dilatation au ballonnet des sténoses trachéobronchiques du nourrisson. A propos de 4 cas.

Long-lasting tracheal tubing in newborns and infants, associated with repeated tracheobronchial aspiration, is sometimes complicated by tracheal and/or bronchial stenoses. Many therapeutic methods have been described to treat this condition: use of dilatators, laser, surgery, insertion of prosthetic material. Dilatation with an angioplasty balloon has been recently described for the treatment of various stenoses. The authors report about 3 cases of acquired tracheobronchial stenosis which were successfully treated with this method, and 1 case of complex tracheal stenosis (with a double inflammatory and congenital nature) which required both dilatation and surgery. The technique is described. There is no morbidity and no mortality in this non-randomized series. Balloon dilatation is a simple and effective method, which may be proposed as a first-intention treatment for acquired tracheobronchial stenosis in newborns and infants.

[Severe subglottic hemangioma in the infant: corticotherapy, intubation or surgery?]. / Hémangiomes sous-glottiques graves du nourrisson: corticothérapie, intubation ou chirurgie?

In the case of sub-glottic hemangioma, with serious immediate or cortico-resistant dyspnea, it is not always possible to wait for the growth of the laryngo-tracheal skeleton and the spontaneous involution of the angioma. On the basis of a series of 25 cases, we propose in these serious forms the following therapeutic escalation: very high dose corticotherapy, with betamethasone at 0.12 to 0.48 mg/kg/day for 15 days, followed by a degressive treatment over 6 weeks to 3 months; intubation to overcome a difficult stage in the event of aggravation of the angioma with a rhinopharyngitis. Embolization and the use of the laser proved unsatisfactory in the extensive forms of angiomas. In the event of failure of the preceding treatment, we perform a tracheotomy, the duration of which can be reduced by the surgical exeresis of the angioma with a widening of the larynx.

Aryepiglottic fold excision for the treatment of severe laryngomalacia.

Laryngomalacia is the most common laryngeal anomaly. Clinical presentation is most often associated with stridor, which usually resolves spontaneously by the second year of life. Infrequently, laryngomalacia can be severe and cause dyspnea and feeding difficulties. These children require surgical treatment, including tracheostomy. A new procedure has been recently described for the endoscopic excision of the aryepiglottic folds. The authors report results in 39 patients who have been treated with this procedure. One failure required tracheostomy. No recurrence of dyspnea was noticed in the other children. Gastroesophageal reflux, associated with 50% of our cases, was also noted in our only failure. We advocate endoscopic treatment in children with severe laryngomalacia.

[The modification of high density lipoproteins by malondialdehyde changes their interaction with J774 macrophages and decreases cholesterol cell efflux]. / La modification des lipoprotéines de haute densité par le malondialdéhyde altère leur interaction avec les macrophages J774 et diminue l'efflux cellulaire du cholestérol.

The treatment of HDL3 with malondialdehyde (MDA) results in an increase of the electrophoretic mobility of the particle and in aggregation of the apolipoprotein AI. The binding of MDA-treated-HDL3 to murine macrophages J774 is decreased, as compared to native HDL3. The cholesterol efflux is also markedly reduced. In view of the fact that MDA is produced following plaquette aggregation or oxidative stress, the eventual existence of MDA-modified-HOL in vivo might accelerate the appearance of atherosclerotic lesions by reducing cellular cholesterol efflux.

Arachidonate cannot be released directly from diacyl-sn-glycero-3-phosphocholine in thrombin-stimulated platelets.

The origin of the arachidonate released from platelets on stimulation with thrombin was investigated by comparing the specific activities of released arachidonate and of arachidonoyl-containing phospholipids using rat platelets prelabelled with arachidonate. Quantification of the released arachidonate was determined in the presence of BW 755 C, a dual cyclo-oxygenase/lipoxygenase inhibitor, which was found not to modify the arachidonate mobilization between the platelet phospholipids. The phospholipid molecular species were analysed by h.p.l.c. of diradylglycerol benzoate derivatives of diacyl, alkylacyl and alkenylacyl classes. The labelled/unlabelled arachidonate ratio varied greatly in the phospholipids depending on whether an ether or acyl bond was present in sn-1 position of the glycerol, on the length and degree of unsaturation of this fatty chain and on the polar head group. Between 15 s and 5 min of stimulation by thrombin, the released arachidonate kept a constant specific activity which was considerably lower than the specific activity of diacyl-GPC. The specific activity of the released arachidonate was intermediate between the specific activities of the 16:0-20:4 and 18:0-20:4 species of diacyl-GPI and diacyl-GPE, and corresponded to the mean specific activity of alkylacyl-GPC. The data indicate that the released arachidonate cannot come directly from diacyl-GPC, and that two phospholipids in particular can act as direct precursors of the released arachidonate. These are (1) the alkylacyl-GPC and (2) the diacyl-GPE whose hydrolysis would induce an arachidonate transfer from diacyl-GPC.

Human placental microvilli as a source of antigen for the preparation of a polyclonal antibody directed against the LDL receptor.

Polyclonal antibodies were prepared by immunization of rabbits with partially purified LDL receptor obtained from human placental microvilli. The antiserum reacted with membranes from human placental microvilli and human fibroblasts, as assessed by immunobinding studies. It also reacted with purified LDL receptors of both origins. The antiserum markedly inhibited 125I-labeled LDL binding to cultured human fibroblasts.

[Congenital perilymphatic fistula in children]. / Fistules péri-lymphatiques congénitales chez l'enfant.

We report twenty case of perilymphatic fistulae in children. A fistula was discovered in every case where the cochlear aqueduct is larger than normal on high resolution CT scan of the temporal bone. The surgical treatment of these fistulae allowed only a significant improvement of hearing in the cases were an asymmetry or a dilatation of the cochlear aqueducts and a fluctuating deafness coexisted. Unfortunately these improvements do not look permanent.

[Our current experience with subglottic hemangioma in infants. Apropos of 29 new cases]. / Notre expérience actuelle des hémangiomes sous-glottiques du nourrisson. A propos de 29 nouveaux cas.

The authors report 29 cases of sub-glottic hemangioma in infants. Symptomatology was dominated by laryngeal dyspnea and the diagnosis was made on direct laryngoscopy. The symptomatology and endoscopic appearance enabled two groups to be distinguished: non obstructive hemangiomas (11 infants) and obstructive hemangiomas (18 infants). For non obstructive hemangiomas, the authors recommend close surveillance in combination with short term steroid therapy was prescribed from the start. In the event of failure of steroid therapy (8 infants) naso-tracheal intubation and selective embolization was carried out and gave the best results. In 4 infants failure of the above treatments led to tracheostomy.

[Tracheotomy in children. Apropos of 144 cases]. / Trachéotomie chez l'enfant. A propos de 144 cas.

For a long time pediatric tracheotomy has had a poor reputation. Its indications are incontestably restricted in view of improvements in anesthesia and pediatric intensive care. We analysed 144 cases for the period 1976-1986. While very few peri-operative complications were noted, thanks to a rigorous technique, a review of which may be worthwhile, secondary complications such as tube obstruction, accidental displacement and superinfection of the lower airways were often fatal. These could be prevented by better training of both the families and also hospital staff. On average, these children had a tracheostomy for one year. There were few difficulties associated with removal of the tracheostomy tube.