Efficacy of ofloxacin and other otic preparations for acute otitis media in patients with tympanostomy tubes.

Otorrhea occurs in 21 to 50% of all children with tympanostomy tubes in the United States. More than 1 million children annually undergo tubomyringotomy, constituting placement of more than 2 million tympanostomy tubes each year. The organisms typically responsible for otorrhea are the same as those that cause otitis media in very young children, including Streptococcus pneumonia, Haemophilus influenzae and Moraxella catarrhalis. Drainage from tympanostomy tubes in older children involves organisms that colonize the external auditory canal, the most common being Pseudomonas aeruginosa and Staphylococcus aureus. Ofloxacin (Floxin otic), a newer fluoroquinalone antibiotic, has several advantages over other agents available for the treatment of otorrhea caused by acute otitis media in patients with tympanostomy tubes. The twice daily dosing regimen encourages better patient adherence to therapy, which is likely to improve treatment efficacy. Ofloxacin has not been associated with ototoxicity in animal models or in children participating in the clinical trials. It provides coverages for a wide range of pathogens, including Pseudomonas sp., and is indicated for use in children > or =1 year old and currently approved for patients > or =12 years with chronic suppurative otitis media. Ofloxacin applied topically in children with tympanostomy tubes in place and purulent otorrhea is as efficacious as oral amoxicillin/clavulanate (Augmentin) therapy. Other currently available therapeutic options are discussed.

Use of a live attenuated varicella vaccine to boost varicella-specific immune responses in seropositive people 55 years of age and older: duration of booster effect.

Varicella-zoster virus (VZV)-specific T cell immunity was measured in 130 persons > or = 55 years of age 6 years after they received a live attenuated VZV vaccine. Circulating T cells, which proliferated in vitro in response to VZV antigen, were enumerated (VZV responder cell frequency assay). Six years after the booster vaccination, the VZV-responding cell frequency (1/61,000 circulating cells) was still significantly (P < .05) improved over the baseline measurements (1/70,000) and appears to have diminished the expected decline in frequency as these vaccinees aged (to 1/86,000). Ten herpes-zoster--like clinical events were recorded. Although the frequency of these events, approximately 1/100 patient-years, is within the expected range of such events for this age cohort, the number of lesions was small, there was very little pain, and there was no postherpetic neuralgia. These results support the development of a vaccine to prevent or attenuate herpes zoster.

Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes.

Acute otitis media (AOM) in children with tympanostomy tubes in place typically presents with otorrhea (draining ear). Because therapy is not standardized, various topical and systemic antibiotics of unproven efficacy and safety have been used in this indication. This study compared the safety and efficacy of ofloxacin otic solution, 0.3% (OFLX) with that of Augmentin oral suspension (AUG) in pediatric subjects 1-12 years of age with tympanostomy tubes and acute purulent otorrhea. Subjects were randomized to receive 10d of OFLX, 0.25 ml topically bid, or of AUG, 40 mg/kg per day. Audiometry was performed in subjects > or =4 years of age. Overall cure rate for clinically evaluable subjects was 76% with OFLX (n = 140) and 69% with AUG (n = 146; P = 0.169). Overall eradication rates for OFLX and AUG were similar for Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis and were superior with OFLX for Staphylococcus aureus and Pseudomonas aeruginosa (P<0.05 for both). OFLX had a greater overall pathogen eradication rate (96% vs. 67%; P<0.001). Treatment-related adverse event rates were 31% for AUG and 6% for OFLX (P<0.001). Neither treatment significantly altered hearing acuity. Topical ofloxacin 0.3% otic solution 0.25 ml bid was as effective and better tolerated than systemic therapy with Augmentin oral suspension 40 mg/kg per day in treating AOM in children with tympanostomy tubes.

Partner notification for sexually transmitted diseases: an overview of the evidence.

OBJECTIVE: To compare the effectiveness of alternative partner notification strategies for gonorrhea, chlamydia, syphilis, HIV and hepatitis B. DATA SOURCES: Studies were identified using MEDLINE, EMBASE, SCISEARCH and other databases, review of reference lists and personal contact with over 80 international experts. STUDY SELECTION: Studies with at least two comparison groups exposed to different partner notification strategies were included. DATA EXTRACTION: Methodological rigor was assessed, and information regarding study populations, interventions and outcomes was extracted independently by two reviewers. MAIN RESULTS: Twelve studies met our inclusion criteria; five were methodologically strong; seven provided data on the referral process; four provided data on trained interviewers compared with routine care providers; and three provided data on the interview process. CONCLUSIONS: Only limited, broad conclusions regarding the effectiveness of various partner notification approaches could be drawn from these comparative studies. Until newer data become available, practice guidelines must be based to a large extent on other grounds.

New approaches to addressing information needs in local public health agencies.

For local Public Health agencies to be fully responsive to community needs, staff must have ready access to up-to-date and accurate information. During the last several years, the Hamilton-Wentworth Department of Public Health Services (DPHS), a Teaching Health Unit affiliated with McMaster University, has been developing new information services including establishment of a specialized library on site; education sessions on the use of information stored in this library and in the Hamilton-Wentworth Health Library Network; innovative approaches to tailoring information services to staff needs including on-site access to on-line literature databases; and establishment of a group to retrieve and report community health data. In the initial three years of operation, surveys of Hamilton-Wentworth staff and a comparison health unit (Niagara) revealed that staff most frequently sought information from managers and support staff, as well as from personal books, articles and journals. Over half (57%) of the Hamilton-Wentworth staff reported use of the DPHS library, whereas 28% of Niagara Regional Health Unit staff reported use of their library. Other information services, for example, bibliographic indexes on population health, were less frequently used. Plans to increase their use are discussed.

Blood pressure in schoolchildren measured under standardized conditions.

The blood pressures of 6346 children who were between the ages of seven and 17 years were measured under standardized conditions. Blood pressures were similar in prepubertal boys and girls. After puberty, the systolic blood pressures of the girls remained unchanged whereas those of the boys continued to rise. The difference between the fourth and fifth Korotkoff sounds was 2 mm at both the 50th and 95th percentiles. The systolic blood pressure was observed to fall over a 10-min period by 4-9 mmHg at the 50th percentile and 9-15 mmHg at the 95th percentile. Over the same period of time, the diastolic blood pressure was seen to fall by 2-3 mmHg and 3-6 mmHg at the 50th and 95th percentiles, respectively. There was no further fall in blood pressure after 10 min. The conditions and timing of measurement are important in blood-pressure evaluation and may explain the differences in blood pressure that have been reported for different populations.

Dopamine pharmacokinetics in critically ill newborn infants.

To compare clinical responses with plasma concentrations of dopamine and to compare dopamine pharmacokinetics in infants of different gestational age or clinical condition, dopamine was administered under carefully controlled conditions of dose and rate of infusion. The dose was increased stepwise from 1 to 2, to 2 to 4, and 4 to 8 micrograms/kg/min. Plasma concentrations of catecholamines, including dopamine, were compared with blood pressure, heart rate, and Doppler cardiac output. The data were analyzed to determine the threshold or minimal plasma concentration of dopamine necessary to produce discernible effects. Plasma clearance rate was calculated from steady-state plasma concentrations. The average threshold for increases in mean arterial pressure was 50% below that for increases in heart rate. Improvements in arterial pressure were noted before and at lower thresholds than for increases in heart rate. Serial echocardiographic data showed dose-dependent increases in cardiac output and stroke volume without significant change in heart rate or systemic vascular resistance. Thresholds and plasma clearance values were similar in infants of gestational age 27 to 42 weeks and birth weights 900 to 4300 g. Administration of dopamine at initial dosages lower than commonly recommended, followed by incremental increase in dose, may be associated with improved left ventricular performance with avoidance of undesirable tachycardia and arrhythmias.

A composite three-dimensional echocardiographic technique for left ventricular volume estimation in children: comparison with angiography and established echographic methods.

A composite three-dimensional (3D) echographic left ventricular (LV) reconstruction to measure LV volumes was evaluated in 26 children. Four apical views, to minimize assumptions about LV shape, were used to obtain a "wire-cage" model of the LV in 3D. Numerical integration was used to make estimates of both end-diastolic and end-systolic volumes. Volume estimates obtained with echographic techniques and those obtained with the angiographic biplane method were compared. The echographic volume estimates were systematically smaller (p less than 0.005), and a consistent trend, though not significant, was observed indicating that this systematic error is less for the 3D method. One-way analysis of variance confirmed significant global geometric fluctuations. Hence, 3D reconstruction can be performed in a clinical setting, and the enhanced graphic representation of global LV geometry may contribute to improved patient management.

A non-invasive study of the third heart sound in children by phono and echo-cardiography.

There has been in the past and still is controversy over the genesis of the third heart sound (S3). Recent studies, however, strongly suggest that S3 is a manifestation of a sudden intrinsic limitation in the expansion of the L.V. The present study has aimed to explore that hypothesis further, using a spectral analysis technique. A FFT technique was used to determine the spectral distribution of S3 in 14 child subjects between the ages of 2 and 19 years. Spectral energies in 15 Hz frequency bandwidths were correlated with various 2D-echocardiographically derived parameters. This study has shown that the spectral energy of S3 is distributed in the lower frequency bands. Fifty percent (47 +/- 16%) is distributed in the 0-15 Hz band. Also it was found that: (i) as mitral orifice size increases, energy in the 0-15 Hz band of S3 decreases. (r = -0.53, p less than 0.05), (ii) S3 occurs earlier in the cardiac cycle with increase in age of the subject. (r = -0.76, p less than 0.005), (iii) the energy distribution of S3 tends towards the higher frequencies with increase in age. (r = 0.52, p less than 0.05). Further, the above results support the hypothesis that S3 is the result of an intrinsic limitation to the expansion of the L.V. due to an early diastolic pressure rise caused by an increased viscoelasticity of the myocardium. This, and the relation of the results in certain pathologies are also discussed.

Single-trunk anomalous origin of both coronary arteries from the pulmonary artery. Diagnosis and surgical management.

The cases of two infants with heart failure and myocardial infarction because of single-trunk anomalous origin of both coronary arteries from the pulmonary artery are reported. Electrocardiography and thallium 201 imaging indicated preoperative myocardial infarction. The diagnosis was confirmed by cardiac catheterization and angiography in each case. To our knowledge these are the first reports of this diagnosis being made during life prior to attempts at surgical correction. Both patients underwent cardiac operations and the operative techniques used are described. Corrective operations for this abnormality have not been attempted previously. At autopsy radiopaque contrast material injected into the aorta confirmed flow from the aorta to the coronary arteries.

A study of orifice shape effects in the determination of mitral valve area by two-dimensional echocardiography.

Real-time two-dimensional echocardiographic studies of the mitral valve in short-axis view were obtained from 10 normal subjects. Stop-action frames of the video-taped echocardiograms were then photographed to obtain diastolic cross-sectional images of the valve at maximal opening. Tracings from the interior of the leaflet echoes were then digitized to provide the perimeter and area of the mitral orifice. From the perimetric data, boundary integration was used to numerically calculate the orifice area corresponding to an elliptical boundary, for aspect ratios ranging from 0.5 to 1.0 (circle). It was found that the mean orifice areas determined echocardiographically and numerically are equal for an aspect ratio of 0.42. For aspect ratios greater than this value, the elliptical areas are larger, while for smaller aspect ratios, the elliptical areas are smaller.

Quantitative radionuclide angiocardiography for left-to-right cardiac shunts in children.

Pulmonary to systemic flow ratios (Qp/Qs) were estimated by quantitative radionuclide angiocardiography (QRAC) in 135 children. The Qp/Qs ratios were derived from pulmonary time/activity curves using a gamma variate model. Eighty-five of these children also had Qp/Qs ratios estimated by oximetry at cardiac catheterization. Left-to-right shunts with a Qp/Qs range of 1.2 to 3.0 were detected and quantitated by radionuclide angiography with an accuracy similar to that for oximetry. The correlation between Qp/Qs, determined by QRAC and by oximetry was good (r = .93; SEE .31). This relatively noninvasive technique has now been used to estimate the Qp/Qs ratio in 34 children with a clinically suspected left-to-right shunt, and postoperatively in 16 cases with residual murmurs; it has obviated the need for catheterization in many of these patients. The technique may also be used serially to determine changes in the Qp/Qs ratio in patients with known left-to-right shunts.

The progression of Duchenne muscular dystrophy: clinical trial of allopurinol therapy.

A 12-month clinical study of Duchenne muscular dystrophy was carried out during a double-blind trial of allopurinol therapy. The disease was monitored by assessment of muscle power and function, pulmonary function tests, and electrocardiography. Biochemical assessments were made of plasma creatine kinase, pyruvate kinase, uric acid, and urinary excretion of 3-methylhistidine and creatinine. Allopurinol did not alter the progression of the disease.

A large kindred with an INV(3)(p25q23): clinical, cytogenetic and genetic marker studies.

A large kindred in which an inv(3)(p25q23) is segregating is described. At least two malformed children with the recombinant chromosome rec(3)dup(q23 leads to qter)del(p25 leads to pter) have been produced, both of whom have the characteristic trisomy 3q syndrome. Genetic marker studies showed that Pl and GM are not linked to the inversion break points. The Pl-GM linkage group has been excluded from much of chromosome 3 by deletion mapping and linkage analysis of this kindred.