New method for packing the external auditory canal, middle ear space, and mastoid cavities after otologic surgery.

Since its introduction in 1945, an absorbable gelatin sponge, Gelfoam, has long been a staple used for packing in otologic surgery. The present method commonly employed at the University of Manitoba teaching hospitals requires that operating room nurses carefully prepare extremely small pieces of both compressed and noncompressed Gelfoam. These pieces are then selectively soaked in an antibiotic solution and carefully placed, one by one, into the appropriate position. We describe a new paste preparation of Gelfoam powder, Thrombostat, acetic acid, and Bacitracin ointment, which can very quickly be injected from a syringe into the operated cavity. Our preliminary study indicates that this preparation reduces operating time, while making the process of packing easier for the surgeon. In addition, it ensures a more evenly packed cavity while still fulfilling the requirements of middle ear packing. Postoperatively, it was found to be easier to debride from the operative cavity in the office, decreasing patient discomfort and procedure time. Reported below is a preliminary clinical patient series report comparing this new method to the old method.

Diphtheria-tetanus toxoids-pertussis vaccination does not increase the risk of hospitalization with an infectious illness.

The purpose of this study was to determine whether children hospitalized with a primary diagnosis of infection were more likely than matched controls to have had a diphtheria-tetanus toxoids-pertussis immunization in the 30 days before hospitalization of the case. Cases were less likely than controls to have received an immunization (P = 0.003). They were also less likely to have been breast-fed (P < 0.001) and to have had a well-child care clinic visit (P = 0.01). Cases were significantly more likely to be preterm (< 38 weeks gestation), low birth weight (< 2500 g) and attending day care than their matched nonhospitalized controls (P = 0.003, 0.03 and 0.002, respectively). This study demonstrates no association between receipt of diphtheria-tetanus toxoids-pertussis immunization and subsequent hospitalization for an infectious illness.

Syringe preparation technique and minor adverse reactions to diphtheria-tetanus-pertussis immunization.

Minor local reactions and subcutaneous abscesses following diphtheria, tetanus and pertussis immunization have been attributed to vaccine left in the subcutaneous needle path from vaccine coating the needle. Various syringe preparation techniques have therefore been advocated to prevent reactions. To evaluate these recommendations we compared rates of minor reactions in 200 children randomly assigned to one of three groups that differed only in the handling of the filled syringe: in Group 1 the needle was changed before injection; in Group 2 the needle was wiped with sterile gauze before injection; in Group 3 the same needle was used to draw up and to inject the dose and was not wiped. Overall 27% of children had febrile (greater than 38 degrees C) reactions, 62% became fussy and 79% had a local reaction. Rates of reactions were nearly identical in the three groups, except that children in group 2 receiving their second dose or more of diphtheria-tetanus toxoid-pertussis vaccine were more likely to become febrile at greater than 38 degrees C (32%) or fussy (78%) (P less than 0.05 and P less than 0.02, respectively). We conclude that changing needles does not reduce the rate of minor local and systemic reactions. Wiping needles may increase the rate of reactions.

Toxic shock syndrome. I. Clinical exclusion of other syndromes by strict and screening definitions.

Several clinical definitions of toxic shock syndrome have been proposed and used in extensive epidemiologic and clinical studies. Most of these definitions suggest (but usually do not require) that there be sufficient laboratory studies to exclude other potentially similar syndromes. Simplified definitions which broaden the spectrum of toxic shock syndrome illness have also been proposed but not validated. In this study, clinical findings of consecutive hospitalized patients were compared: nine with toxic shock syndrome (confirmed by a modification of the collaborative strict case definition) and 120 with potentially similar diagnoses (bacteremia with shock, meningococcemia, Staphylococcus aureus bacteremia, scarlet fever, toxic epidermal necrolysis, acute rheumatic fever, leptospirosis, Rocky Mountain spotted fever, rubeola, Kawasaki syndrome, erythema multiforme, and Stevens-Johnson syndrome). None of the 120 controls satisfied the clinical criteria of the modified strict definition of toxic shock syndrome, demonstrating its exclusionary properties even in the absence of additional laboratory data. A "simplified" screening definition was constructed which might be applied early in illness (i.e., at admission) and this definition distinguished all the patients with toxic shock syndrome from all but three (2.5%) of the 117 analyzable patients with other mucocutaneous or potential infectious shock syndromes. Applied prospectively in the state of Colorado passive/active reporting system, the screening definition identified 24 potential toxic shock syndrome cases of which 19 (76%) eventually were confirmed as toxic shock syndrome. Before being adopted and widely used, clinical syndrome definitions should be documented to exclude other potentially overlapping syndromes or should require additional mandatory exclusionary laboratory data.

Toxic shock syndrome. II. Estimated occurrence in Colorado as influenced by case ascertainment methods.

Medical records for hospitalized patients between 30 days and 30 years of age at two hospitals, one in each of two Colorado counties, were reviewed for possible cases of toxic shock syndrome conforming to one or both of two clinical case definitions. Patients with toxic shock syndrome were detected in each year from 1970 through 1982. Fifty patients with possible toxic shock syndrome were identified; 14 were males, five were premenarchal females, and the remaining 31 were females of menstrual age of whom 21 (42% overall) were menstruating at the time of illness. The combined annual toxic shock syndrome incidence rate ranged between 0.8/100,000 population less than or equal to 30 years of age (1974) and 9.1/100,000 (1980) with a maximum of 15.8/100,000 (1980) in females between the ages of 10 and 30. Incidence curves for males, females less than or equal to 30 years of age, and females of menstrual age (10-30 years) fluctuated in a statistically (p less than 0.02) nonrandom fashion, each peaking in 1979-1980 and declining in 1981. In a separate statewide voluntary case reporting system, 103 cases of toxic shock syndrome of all ages were reported by health care providers with onset from 1970-1982. A minimum estimate of 26 (26%) of these were not menstrually-associated, occurring in five females prior to menarche, three following menopause, three postpartum, and 15 males. Total cases reached an annual peak in 1980, declined somewhat in 1981, and increased during 1982 to levels comparable to 1980. Less than half (46%) of the strictly defined cases actively ascertained in the retrospective hospitalized population study had been reported voluntarily to the statewide system. Jurisdictions depending primarily on passive toxic shock syndrome case ascertainment techniques, even with periodic active solicitations, may not be reliably detecting the majority of cases, and those cases which are so reported may be limited by physician perception of syndrome spectrum.

Corticosteroid therapy for patients with toxic shock syndrome.

A comparative retrospective analysis of 45 patients with toxic shock syndrome (TSS) was designed to evaluate the effect of corticosteroid therapy on outcome. All patients satisfied the collaborative strict case definition for TSS, were hospitalized, had shock or postural hypotension, had a potential focus of Staphylococcus aureus infection, and received appropriate antistaphylococcal antimicrobial therapy. Twenty-five patients received corticosteroid therapy during the acute phase of illness and 20 did not. The groups were comparable for age, sex, weight, year of admission, day of illness hospitalized, minimum systolic and diastolic blood pressure, severity of illness, co-intervention with antimicrobials and antipyretics, and amount of intravenous fluid received. Corticosteroid-treated patients had a significantly reduced severity of illness and duration of fever if treated within two to three days of onset of TSS.

Toxic shock syndrome in children aged 10 years or less.

Eight children aged 10 years or less had toxic shock syndrome, and medical records were reviewed for seven of them. There were four boys and three girls, ranging in age from 5 5/12 to 10 8/12 years; all seven met the Centers for Disease Control case definition of toxic shock syndrome. One boy died. The illness was generally characterized by fever, followed by erythroderma, gastrointestinal complaints, and mucous membrane hyperemia. Based on the need for supplemental oxygen or mechanical ventilation, the girls tended to have milder courses than the boys. In four of four cultures performed prior to the institution of antibiotic therapy. Staphylococcus aureus grew from one or more sites. One boy also met the case definition of Kawasaki syndrome and has had multiple coronary artery aneurysms demonstrated in early and late follow-up. Toxic shock syndrome in these children was similar to published descriptions of toxic shock syndrome in series of adult patients, except that, as a group, the children had a greater incidence of respiratory embarrassment.

A maternal-neonatal outbreak of infections due to an unusual group A beta-hemolytic streptococcus.

An outbreak of group A beta-hemolytic streptococcal infections involving three parturients, three newborns, and a nursery RN is reported. Six of six organisms available for serotyping were M-untypable, T-11, serum opacity reaction-negative. Propagation of the outbreak may have been fostered by the common use of a single sitz bath, although the evidence to support this is weak. The outbreak was rapidly controlled via strict cohorting, appropriate treatment and isolation of cases, and the routine use of triple dye for umbilical cord care.

Increase in Mycobacterium avium complex isolations among patients admitted to a general hospital.

In early 1979, an official of an Illinois hospital reported an increase in the number of patients from whom Mycobacterium avium complex recently had been recovered. Over the preceding 3 years specimens from a total of 51 patients were culture positive for M. avium complex: 7 in 1976, 8 in 1977, and 36 in 1978. Nine of 10 serotyped isolated were serotype 8. The increase was not attributable to an increase in the number of mycobacterial cultures performed. No other area hospitals had similar increases in rates of recovery of M. avium complex. Patients with M. avium complex were significantly more likely than patients with other mycobacteria to have been residents of the city where the hospital is located. The distribution of abnormalities in patients' chest films differed significantly between patients with M. avium complex in 1978 and patients with M. avium complex in 1976-77; in 1978, patients although equally likely to have infiltrates, nodules, or cavities, were more likely to have no abnormalities or abnormalities consistent with chronic obstructive pulmonary disease, and less likely to have other abnormalities. The data suggest that the increased rate of recovery of M. avium complex from patients could not be attributed to ascertainment bias or laboratory variation but may be due to an increase in the incidence of disease or colonization among persons living in the community where the hospital is located.

Multiply resistant pneumococcus causing meningitis: its epidemiology within a day-care centre.

An 11 month-old infant had meningitis caused by a strain of Streptococcus pneumoniae, serotype 6b, resistant to penicillin, chloramphenicol, and several other antimicrobials. The minimum inhibitory concentrations (MIC) by agar dilution were 1.0 microgram/ml for penicillin and 16 microgram/ml for chloramphenicol. The infant did not respond to high-dose intravenous penicillin G but was cured by a combination of ampicillin, chloramphenicol, and rifampicin. At the infant's day-care centre this multiply resistant strain was isolated from throat cultures of 27% of the children (age less than or equal to 26 months) assigned to the same room as the index case, and from 11% of older children and staff. There was a 33% carriage rate in family contacts of colonised children. Antibiotic use during the previous 2 months was more frequent among the carriers than among non-carriers. No resistant pneumococci were found in on hundred and twenty-five children and staff in six other Denver day-care centres, in 300 consecutive routine throat cultures processed by our clinical microbiology laboratory, or among 150 pneumococcal isolates collected from Denver area hospitals. The carriers were not treated, and there have been no other cases of infection due to this strain. The emergence of multiply resistant pneumococci in the United States indicates the need to screen important pneumococcal isolates for resistance to both penicillin and chloramphenicol, especially in cases of meningitis.

Isolation of Legionella pneumophila from hospital shower heads.

Legionella pneumophila serogroup 6 was isolated from nine of 16 shower heads in a Chicago hospital ward where three patients had contracted Legionnaires' disease caused by serogroup 6 L. pneumophila. Each patient had showered there 2 to 10 days before the onset of disease symptoms. We also isolated the bacteria in two other hospitals, and found the same serogroups as had been causing Legionnaires' disease in those hospitals: serogroup 1 in Pittsburgh and serogroups 1 and 4 in Los Angeles. However, showers from hospital wards where no patients had contracted Legionnaires' disease also yielded L. pneumophila. Shower heads at the Chicago hospital were sterilized with ethylene oxide but rapidly became recontaminated, suggesting that the potable water at these hospitals may have contained the organism. The question of whether aerosols of shower water or other exposures to potable water containing L. pneumophila may cause nosocomial Legionnaires' disease has not been resolved but deserves further study.

Risk factors for myocardial infarction associated with the Chicago snowstorm of jan 13- 15, 1979.

Sixty male survivors of acute myocardial infarction in the week after the Chicago blizzard of Jan 15, 1979, were matched by hospital and sex with 60 myocardial infarction survivors from a week without snowfall to determine whether a history of previous heart disease or of cardiac risk factors increased the risk of a postblizzard myocardial infarction. Cases did not differ significantly from control subjects with respect to age, percentage working full time, or percentage with a history of heart disease, hypertension, smoking, diabetes mellitus, obesity, or gout. Hypercholesterolemia was four times as common among cases as among controls.

Intestinal parasites in Southeast-Asian refugees. Prevalence in a community of Laotians.

In response to public concerns, 165 Meo Laotians had stools screened for intestinal parasites by the Illinois Department of Public Health. One hundred twenty-nine had at least one pathogenic parasite detected. Hookworm was detected most frequently, followed by Giardia lamblia, Trichuris trichiura, and Ascaris lumbricoides. Hookworm and overall infection were more frequent in persons 4 years of age and older, while giardiasis, ascariasis, and trichuriasis were most common in the 4- to 14-year age group. Most infections were helminthic and of no public health consequence in the United States. However, giardiasis was seven times as prevalent in refugee children as in the general US population, posing a potential public health risk in child-care settings.