Five vs. ten days of antibiotic therapy for acute otitis media in young children

BACKGROUND

Many publications in recent years have argued in favor of shortened therapy for acute otitis media. However, doubt persists regarding children younger than 2 years, and some authors therefore restrict short course therapy to children older than 2 years.

METHODS

In a prospective, comparative, double blind, randomized, multicenter trial we compared cefpodoxime-proxetil, 8 mg/kg/day in two divided doses for 10 days, with an identical 5-day regimen followed by a 5-day placebo period.

RESULTS

Between October, 1996, and April, 1997, 450 children (mean age, 14.3 months) were enrolled, 227 in the 5-day group and 223 in the 10-day group. In the per protocol analysis clinical success was obtained on Days 12 to 14 after the beginning of treatment (main analysis) in 175 (84.1%) of the 208 children receiving the 5-day regimen and 194 (92.4%) of the 210 children receiving the 10-day regimen (P = 0.009). The superiority of the standard regimen was more marked among children cared for outside their homes (92.5% vs. 81.5%). Clinical success persisted on Days 28 to 42 among 134 (85.4%) of the 157 assessable patients in the 5-day group and 144 (83.7%) of the 172 assessable patients in the 10-day group (P = 0.68).

CONCLUSIONS

The 10-day regimen resulted in a higher success rate at the conclusion of therapy, but there were no differences between the two study groups 4 to 6 weeks after enrollment in the study protocol.

Antiemetic efficacy of single-dose oral granisetron (1 mg vs 2 mg) with moderately emetogenic chemotherapy

PURPOSE

To compare the efficacy of oral granisetron, 1 mg and 2 mg, administered as one dose in patients who receive moderately emetogenic chemotherapy.

PATIENTS AND METHODS

Chemotherapy-naïve patients, scheduled to receive intravenous cyclophosphamide (500 to 1200 mg/m2) or carboplatin (> or = 300 mg/m2), were stratified by dexamethasone/methylprednisolone use (+ DEX, n = 92) or nonuse (- DEX, n = 5). Patients were randomized to one dose of either 1 mg (n = 48) or 2 mg (n = 49) of granisetron administered 60 minutes before chemotherapy. Known important prognostic variables (gender, age, alcohol) were well balanced between groups.

RESULTS

Using the most rigorous criterion of total control (no emetic episodes, no nausea, no rescue therapy during the first 24 hours), response rates were 54.2% (26/48) and 57.1% (28/49) in patients receiving 1 mg and 2 mg of granisetron, respectively (95% confidence interval, -0.17, 0.23). Total control rates in patients who received 1 mg and 2 mg of granisetron + DEX were also comparable: 57.8% (26/45) and 55.3% (26/47), respectively. Response rates were similar for the parameters of nausea, emesis, and complete response (no emetic episodes, no more than mild nausea, no antiemetic rescue). Among all patients, one (2.1%) who received 1 mg of granisetron and three (6.1%) who received 2 mg experienced severe nausea. The proportions of 1- and 2-mg-treated patients who received rescue therapy within the first 24 hours were 31.3% (15/48) and 34.7% (17/49), respectively. Reported adverse experiences were generally mild in severity.

DISCUSSION

The results of this trial demonstrate good control of emesis with a single 1-mg dose of oral granisetron, with efficacy that compares favorably with that of a 2-mg dose.

A survey of the teaching of undergraduate psychiatry in Israel

BACKGROUND

The 1960-70s saw significant advances in the teaching of psychiatry in medical schools. Subsequently there have been developments in the structure of health care and in the methods and goals of medical education.

METHOD

All four departments of undergraduate teaching of psychiatry in Israel and single departments in Greece, UK and US were asked to respond to a questionnaire about the structure and content of their teaching program.

RESULTS

The amount and content of preclinical and clinical teaching have not changed over the last two decades. There has not been a significant "move into the community" and the nucleus of the program, particularly in Israel, is still in-patient psychiatry. None of the departments approached are evaluating clinical skills using performance-based techniques.

CONCLUSIONS

The increased awareness of the need for physicians to have knowledge and skills in psychiatry has not lead to an increase in the teaching of psychiatry to medical students. Further, the content of teaching carried out in most of the centers studied does not meet the needs of physicians, particularly those in primary care, who have to identify and manage a wide range of psychopathology.

Preoperative calcitonin levels are predictive of tumor size and postoperative calcitonin normalization in medullary thyroid carcinoma. Groupe d'Etudes des Tumeurs a Calcitonine (GETC)

Medullary thyroid carcinoma (MTC) is a calcitonin (CT)-secreting endocrine tumor. Although plasma CT level is a specific and sensitive marker of MTC, its preoperative usefulness in predicting tumor size and postoperative CT normalization has not been documented. From a nationwide database set up by the French CT Tumor Study Group, 226 MTC patients were selected according to the following criteria: preoperative CT level determination by an immunoradiometric assay (normal value, < 10 pg/mL) within the 6 months prior to surgery, total thyroidectomy and diagnosis of MTC ascertained by histological report including tumor size. Patients were 129 females and 97 males (female/male ratio, 1.3). One hundred and twelve patients (49.6%) had the sporadic variety of the disease, 74 (32.7%) had multiple endocrine neoplasia 2A, three (1.3%) had multiple endocrine neoplasia 2B, and 37 (16.4%) had familial MTC. Median age at diagnosis was 44.8 yr (range, 4.9-80.1 yr). Complete neck dissection was performed in 159 patients (70.4%). Postoperative CT normalization was ascertained by negative response of CT to pentagastrin stimulation (< 10 pg/mL) in 94 patients. Seventy-one patients were considered as not cured because of residual tumor tissue and/or elevated CT levels. Median tumor size was 11.0 mm (range, 0.2-80.0 mm), significantly larger in females (15.0 vs. 8.0 mm, P < 0.05), and in sporadic forms (15.0 vs. 7.0 mm, P < 0.05). Tumor size was significantly correlated (r2 = 0.52, P < 0.01) with preoperative CT levels, the relationship being more straight in familial (r2 = 0.71) than in sporadic (r2 = 0.36) forms. Furthermore, preoperative CT levels under 50 pg/mL appeared to be predictive of postoperative CT normalization (44 of 45 patients). However, higher CT levels did not mean absence of postoperative CT normalization (50 of 120 patients). We conclude that low preoperative CT levels are predictive of tumor size and postoperative CT normalization.

Increasing trends in the use of breast-conserving surgery in California

OBJECTIVES

The purpose of this study was to determine temporal trends in breast-conserving surgery in California from 1988 through 1995.

METHODS

Logistic regression was used to analyze data on 104,466 cases of early-stage breast cancer reported to the California Cancer Registry.

RESULTS

A monotonically increasing trend in breast-conserving surgery was detected after adjustment for age, race/ethnicity, stage at diagnosis, and neighborhood education level. Breast-conserving surgery increased at similar rates among all racial/ethnic groups. Older age, Asian or Hispanic race/ethnicity, late-stage diagnosis, and residence in an undereducated neighborhood were factors associated with lower use of breast-conserving surgery.

CONCLUSIONS

Although disparities are evident, use of breast-conserving surgery increased steadily in all groups examined in this study.

Phase I studies of anti-epidermal growth factor receptor chimeric antibody C225 alone and in combination with cisplatin

PURPOSE

The epidermal growth factor (EGF) receptor is frequently overexpressed in epithelial tumors. C225 is a human-to-murine chimeric monoclonal antibody that binds to the receptor and inhibits growth of cancer cells expressing the receptor. We evaluated the pharmacokinetics and toxicity of C225 in patients with advanced tumors overexpressing EGF receptors.

PATIENTS AND METHODS

We treated 52 patients in three successive phase I clinical trials of C225 as a single dose (n = 13), weekly multiple dose (n = 17), and weekly multiple dose with cisplatin (n = 22). C225 dose levels were 5, 20, 50, and 100 mg/m(2). In the study combining C225 with cisplatin, limited to patients with either head and neck or non-small-cell lung cancer, C225 was further escalated to 200 and 400 mg/m(2). Cisplatin was given at a dose of 60 mg/m(2) once every 4 weeks, and treatment was continued for up to 12 weeks if no disease progression occurred.

RESULTS

C225 displayed nonlinear pharmacokinetics, with antibody doses in the range of 200 to 400 mg/m(2) being associated with complete saturation of systemic clearance. C225 clearance did not change with repeated administration or with coadministration of cisplatin. Antibodies against C225 were detected in only one patient, and C225-associated toxicity was minimal. Patients experiencing disease stabilization were seen in all studies. In the study combining C225 and cisplatin, nine (69%) of 13 patients treated with antibody doses >/= 50 mg/m(2) completed 12 weeks of therapy, and two partial responses were observed.

CONCLUSION

C225 has dose-dependent pharmacokinetics, and doses that achieve saturation of systemic clearance are well tolerated. C225 given in combination with cisplatin has biologic activity at pharmacologically relevant doses.

Evaluation of a workshop to teach clinical bioethics in the clinical setting

That the teaching of medical ethics must extend into the clinical years in order for medical students to effectively acquire the knowledge and skills required for dealing with clinical bioethical issues has been widely recognized. A limiting factor has been the lack of physicians able to teach bioethics in the clinical setting. This paper describes the structure and evaluation of a workshop for teaching clinicians how to teach bioethics in the clinical setting. 80 physicians participated in 4 workshops in which they were provided with the ethical principles needed to deal with clinical bioethical issues and appropriate teaching methods. Methods such as paper cases, videotaped standardized patient interactions and live standardized patients were presented. The workshops have been highly evaluated. Post workshop evaluation showed that a significant number of physicians taught ethical issues during rounds and seminars. The frequency of teaching ranged from once per month to one or more times per week.

Determining working memory from ERP topography

Event-related potentials were recorded during a delayed matching-to-sample design from 17 volunteers (5 f) using high-resolution (65 channels) EEG-recordings. In the two-stimulus paradigm, the 500-ms stimulus S1 comprised a visual pattern of two diamonds differing in size, angular rotation and location; in the delay period, Working Memory (WM) load was varied in the following way: a stimulus-free interval of 1 s was followed by a 6-s presentation either of a pattern identical to the S1 (low WM load) or of a pattern differing from S1 (high WM load). The 500-ms stimulus S2 comprised one diamond; the subject's task was to indicate by left- or right-hand (respectively) button press, whether the S2 matched the (a) left- or (b) right-positioned S1-diamond, or (c) did not match at all (NoGo). The topographical distribution of activity in the time intervals (a) following S1-offset, (b) during the WM manipulation interval and (c) prior to S2 were evaluated in the signal (scalp potential) and source (Minimum Norm) space. Following S1-offset the ERP pattern was characterised by negativity over posterior areas, slightly more so over the right hemisphere. In the subsequent 6-s interval high WM load elicited a larger negative slow ERP than low WM load, the negativity increase due to high WM load being larger over frontal than central areas. Source modelling indicated activity in anterior areas under high, and posterior activity under low WM load. Asymmetry of activity, although indicating a shift to left-hemispheric activity under high compared to low WM load, varied considerably between subjects. Results suggest that high-resolution ERP recordings allow to examine cortical activity during WM challenge.

Integrated Management of Sudden Wilt in Melons, Caused by Monosporascus cannonballus, Using Grafting and Reduced Rates of Methyl Bromide

Sudden wilt of melons induced by Monosporascus cannonballus is a worldwide problem, mainly in arid and semi-arid regions. Soil disinfestation by fumigation with methyl bromide is a common and very effective treatment for disease control. However, methyl bromide is expected to be banned from use within the next 5 to 10 years; therefore, alternative measures for disease management are urgently needed. In this study, the efficacy of methyl bromide at a reduced rate (15 g/m² instead of 50 g/m²) and grafted plants, alone or in combination, was examined. Experiments were conducted in the 'Arava region in southern Israel in naturally infested fields. First, various rootstock accessions were tested in three experiments. Of the eight rootstocks evaluated, cv. Brava (Cucurbita maxima) was selected to serve as a rootstock in the subsequent experiments due to its effects on wilt reduction (63 to 100% reduction in two experiments and 35% reduction in one experiment) and its horticultural performance. Next, integration of grafting and a reduced rate of methyl bromide was tested in two experiments. The reduced methyl bromide rate suppressed disease, but results were variable (32 and 91% reduction in the two experiments). Grafting, when used alone, significantly reduced wilt incidence by 84 to 87% compared to untreated plots. Integration of the two control measures provided adequate and reliable results and wilt incidence was always significantly lower (75 to 100% reduction) than incidence in untreated plots. Because control by each measure alone varies, integrated application is preferable.

A new model for recognizing and rewarding the educational accomplishments of surgery faculty

Faculty members' educational endeavors have generally not received adequate recognition. The Association for Surgical Education in 1993 established a task force to determine the magnitude of this problem and to create a model to address the challenges and opportunities identified. To obtain baseline information, the task force reviewed information from national sources and the literature on recognizing and rewarding faculty members for educational accomplishments. The group also developed and mailed to surgery departments at all U.S. and Canadian medical schools a questionnaire asking about the educational endeavors of the surgery faculty and their recognition for such activities. The response rate after two mailings was only 56%, but the responses reaffirmed the inadequacy of systems for rewarding and recognizing surgeon-teachers and surgeon-educators, and confirmed that the distinction between the roles of teacher and educator was rarely made. The task force created a four-tier hierarchical model based on the designations teacher, master teacher, educator, and master educator as a framework to offer appropriate recognition and rewards to the faculty, and endorsed a broad definition of educational scholarship. Criteria for various levels of achievement, ways to demonstrate and document educational contributions, appropriate support and recognition, and suggested faculty ranks were defined for these levels. The task force recommended that each surgery department have within its faculty ranks a cadre of trained teachers, a few master teachers, and at least one educator. Departments with a major commitment to education should consider supporting a master educator to serve as a resource not only for the department but also for the department's medical school and other medical schools. Although this model was created for surgery departments, it is generalizable to other disciplines.

Efficacy of Fluazinam in Suppression of Monosporascus cannonballus, the Causal Agent of Sudden Wilt of Melons

Sudden wilt (vine decline) of melon, caused by Monosporascus cannonballus, is a worldwide problem in arid and semi-arid regions. Soil disinfestation by fumigation with methyl bromide before planting is a common treatment for disease management but, because methyl bromide is expected to be banned from use within the next 10 years, alternative measures for disease suppression are needed. The efficacy of 29 fungicides against M. cannonballus was evaluated in vitro. Among the fungicides tested, fluazinam and kresoxim methyl were the most effective and both totally inhibited the growth of M. cannonballus in culture at concentrations of 10 μg a.i /ml. Because fluazinam also was effective in inhibition of Pythium aphnidermatum, which also may be involved in sudden wilt syndrome, and kresoxim methyl was not, fluazinam was chosen for further tests. The effective dose of fluazinam for M. cannonballus that reduced mycelial growth by 50% was 0.09 μg a.i./ml. Fluazinam efficacy was evaluated in three field experiments conducted in the spring and in the late summer cropping seasons. In two of the experiments, applications of fluazinam resulted in approximately 87% wilt reduction, whereas in the third experiment it was only 32%. The mobility of fluazinam in soil was determined in samples taken from the field. Fungicide mobility in soil was relatively limited; most of the compound was adsorbed to soil particles, resulting in a zone of high concentration that decreased with depth and distance from the application site. Nevertheless, rates measured even at a depth of 25 cm were sufficient to control M. cannonballus. This study shows that fluazinam may be used as one component in an integrated approach for suppression of sudden wilt of melons.

[Quality specifications and allowable standards for validation of methods used in clinical biochemistry]

The purpose of this work is to provide, for a large number of analysis in the field of clinical biochemistry, appropriate criteria for the evaluation of the performance of in vitro diagnostic methods. Based on a first set of data established in 1986 and the experience cumulated by organisers in charge of internal and external quality assessment surveys, an expert group has proposed acceptable limits for a large list of analysis (n = 116). Data are reported and presented in tables divided into 7 chapters including: general biochemistry, enzymes, proteins, tumour markers, hormones, drugs (and toxic), and urinary analysis. For each analysis are given: analytical and reference ranges, three concentration levels for control specimens to be used during evaluations and the range of values within which they can be chosen, reproducibility and repeatability limits expressed as CV%. Maximal tolerable systematic error and inaccuracy are given for control and biological specimens and compared to those obtained using a reference or validated method. These data are essential for evaluations using the protocol designed by the SFBC and can serve as quality criteria for the choice and validation of in vitro diagnostic systems.

Factors contributing to physicians' success in the advanced trauma life support program in Israel

BACKGROUND

Since its introduction in Israel, more than 4,000 physicians from various specialties and diverse medical backgrounds have participated in the Advanced Trauma Life Support course.

OBJECTIVES

To analyze the factors that influence the success of physicians in the ATLS written tests.

METHODS

A retrospective study was conducted of 4,475 physicians participating in the Israeli ATLS training program between 1990 and 1996. Several variables in the records of these physicians were related to their success or failure in the final written examination of the course.

RESULTS

Age, the region of medical schooling, and the medical specialty were found to significantly influence the successful completion of the ATLS course.

CONCLUSIONS

Physicians younger than 45 years of age or with a surgical specialty are more likely to graduate the ATLS course. The success rate could be improved if the program's text and questionnaires were translated into Hebrew.

Effects of an amino acid dialysate on leucine metabolism in continuous ambulatory peritoneal dialysis patients

BACKGROUND

Protein-energy malnutrition is frequent in continuous ambulatory peritoneal dialysis (CAPD) patients. The use of amino acids in the dialysate could improve the protein balance, especially if associated to a concomitant energy intake.

METHODS

A 1.1% amino acid solution for peritoneal dialysis was administered to CAPD patients over 30 minutes during concomitant absorption of 600 ml water (control study) or of a 600 kcal meal/600 ml. Leucine metabolism was studied using the combination of intravenous [2H3] and intraperitoneal [13C] leucine.

RESULTS

The rate of leucine appearance was stimulated by 56 and 53% (control and meal) at 45 minutes. The rates of leucine appearance and disappearance were lower from 180 to 300 minutes during the meal versus control study (P < 0.05). Proteolysis was unaffected during the control study and was inhibited by 25% during the meal study (P < 0.05). During the five-hour cycle dialysis with or without a meal, 80% of the leucine administered into the peritoneum was absorbed. Forty-one percent was retained in the splanchnic bed. Forty-three percent was used for protein synthesis, and 16% was oxidized.

CONCLUSIONS

This amino acids solution is efficaciously utilized for protein synthesis in CAPD patients with no effect on protein breakdown. The concomitant ingestion of a carbohydrate-lipid meal inhibits protein breakdown and reinforces a positive effect of the amino acids solution on protein balance.

Clinical implications of fluorescence in situ hybridization analysis in 13 chronic myeloid leukemia cases: Ph-negative and variant Ph-positive

Thirteen chronic myeloid leukemia (CML) patients, 10 with variant Philadelphia (Ph) translocations and 3 Ph negative cases, were analyzed by fluorescence in situ hybridization (FISH) with the use of BCR and ABL cosmid probes and a chromosome 22 painting probe. In the variant Ph translocations, the BCR-ABL fusion gene was located on the Ph chromosome; in 1 CML Ph-negative patient, the BCR-ABL fusion gene was located on the Ph chromosome; and, in 2 patients, it was located on chromosome 9. The chromosome 22 painting probe was detected on the third-party chromosome of the variant translocation, and in none of the variant translocations was there any detectable signal on chromosome 9. In CML patients with clonal evolution of a simple Ph, a signal of the chromosome 22 painting probe was detected on the der(9) of the Ph translocation. It was concluded that the variant Ph translocations evolved simultaneously in a three-way rearrangement. The clinical parameters of the 13 patients were similar to those of a large group of CML patients with a simple Ph translocation. It is suggested that, to determine the prognosis of CML patients with a complex karyotype, FISH analysis with a chromosome 22 painting probe be performed.

The type 2 family: a setting for development and treatment of adolescent type 2 diabetes mellitus

OBJECTIVE

To identify physical, behavioral, and environmental features of adolescents (aged 11-17 years) with type 2 diabetes mellitus and their families to define the involvement of known risk factors and to define a profile of at-risk individuals.

DESIGN AND METHODS

A total of 42 subjects from 11 families with an adolescent in whom type 2 diabetes was previously diagnosed participated. All subjects underwent anthropometric measurement and completed food frequency and eating disorder questionnaires, and were classified according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. In addition, laboratory tests to determine levels of hemoglobin A1c, fasting glucose, C peptide, insulin, and proinsulin were performed.

RESULTS

Type 2 diabetes had been diagnosed in 5 of 11 mothers and 4 of 11 fathers before the study. Type 2 diabetes was diagnosed in 3 of the remaining 7 fathers during the study. In 3 families, both parents were affected with type 2 diabetes. As a group, participants were obese, with a body mass index higher than the 95th percentile for probands and fathers, and higher than the 85th percentile for mothers and siblings. The sum of skin fold measurements was above the 95th percentile for the probands, their siblings, and the parents. All groups had high fat intake and low fiber intake. None of the subjects participated in a structured or routine exercise program, and most reported no regular physical activity. Three of the probands met the criteria for binge-eating disorder, and 6 additional patients had notable characteristics of the disorder. Mothers affected with type 2 diabetes had markedly abnormal hemoglobin A1c levels, indicating poor control. There were no group differences in fasting concentrations of insulin, proinsulin, or C peptide. However, a third of the mothers with type 2 diabetes, and all but 1 of the siblings, had evidence of insulin resistance.

CONCLUSIONS

Adolescents in whom type 2 diabetes has been diagnosed, as well as their first-degree family members, are obese. In addition, the incidence of diagnosed and undiagnosed type 2 diabetes or of insulin resistance in the families of adolescents with type 2 diabetes is striking. Probands and other family members have lifestyles characterized by high fat intake, minimal physical activity, and a high incidence of binge eating. These findings indicate that the families of adolescents with type 2 diabetes share many anthropometric and lifestyle risk factors. The design of treatment programs for adolescents with type 2 diabetes will need to address the lifestyle and health habits of the entire family.

Successful endoscopic drainage of a posttraumatic pancreatic pseudocyst in a child

The successful endoscopic drainage of a posttraumatic pancreatic pseudocyst in a 9-year-old boy is described. This case study suggests that there is a role for endoscopic placement of stents in the treatment of pancreatic pseudocysts in children.

Acute hyperphosphatemia caused by sodium phosphate enema in a patient with liver dysfunction and chronic renal failure

We report a case of acute hyperphosphatemia secondary to rectal administration of sodium phosphate and sodium biphosphate (Fleet enema). Parathyroid hormone and calcitonin levels were measured along with phosphate clearance and the tubular reabsorption of phosphate.

Alteration of the leptin network in late morbid obesity induced in mice by brain infection with canine distemper virus

Viruses can induce progressive neurologic disorders associated with diverse pathological manifestations, and therefore, viral infection of the brain can impair differentiated neural functions, depending on the initial viral tropism. We have previously reported that canine distemper virus (CDV) targets certain mouse brain structures, including the hypothalamus, early and selectively. Infected mice exhibit acute encephalitis, with late disease, characterized by motor impairment or obesity syndrome, appearing in some of the surviving mice several months after the initial viral replication. In the present study, we show viral persistence in the hypothalami of obese mice, as demonstrated by low, but still significant, levels of CDV nucleoprotein transcripts, associated with a dramatic decrease in F gene mRNAs. Given the pivotal role of the hypothalamus in obesity (eating behavior, energy consumption, and neuroendocrine function) and that of leptin, the adipose tissue-derived satiety factor acting through hypothalamic receptors, we analyzed the leptin networks in both obese and nonobese mice. The discrepancy found between the chronic and dramatic increase in blood leptin levels and the occurrence of obesity may be due to leptin resistance in the brain. In fact, expression of the long leptin receptor isoform, representing the functional leptin receptor, was specifically downregulated in the hypothalami of obese mice, explaining their inability to generate an adequate response to leptin in the brain. Intriguingly, during the acute phase of infection, its expression was increased in CDV-targeted structures in all infected mice and remained high in obese mice in all CDV-targeted structures, except for the hypothalamus. The biphasic change in hypothalamic leptin receptor expression seen during the progression of CDV-induced obesity provides a new paradigm for understanding mechanisms of neuroendocrinological, virus-induced abnormalities.