Streptococcus bovis Infection in young Infants

BACKGROUND

Sporadic cases of invasive Streptococcus bovis disease have been reported in young infants. However, little is known about the clinical manifestations or the conditions that predispose to S. bovis infection in this population.

OBJECTIVE

The objective of this case series and review of the literature was to describe cases of S. bovis infection treated at 2 children's hospitals and compare patients evaluated at our institutions with those reported in the literature.

RESULTS

Seven infants with S. bovis infection were treated at our institutions; 4 of the patients had S. bovis meningitis and 3 of these also had S. bovis bacteremia. Five of the patients had signs of gastrointestinal disturbance at presentation. None of the 7 patients died. Twenty-three patients with S. bovis infection reported in the literature had meningitis with concurrent bacteremia (n = 9), bacteremia alone (n = 9), meningitis alone (n = 4), and pneumonia with overwhelming sepsis (n = 1). Six (26%) of the patients reported in the literature died as a consequence of S. bovis infection. The difference in median age between our patients (14 days; range, 1-43 days) and those reported in the literature (3 days; range, 1-60 days) was not statistically significant (P = 0.49). Abdominal distention was more commonly noted among patients in our series (71%) than among patients reported in the literature (10%; odds ratio = 21.3; 95% confidence interval = 1.7-319.0).

CONCLUSIONS

Bacteremia and meningitis were the most common manifestations. Gastrointestinal disturbance was common among patients in our series. The mortality rate from S. bovis infection appears to be lower than suggested by previous reports.

Prediction of Lyme meningitis in children from a Lyme disease-endemic region: a logistic-regression model using history, physical, and laboratory findings

BACKGROUND

Differentiating Lyme meningitis (LM) from other forms of aseptic meningitis (AM) in children is a common diagnostic dilemma in Lyme disease-endemic regions. Prior studies have compared clinical characteristics of patients with LM versus patients with documented enteroviral infections. No large studies have compared patients with LM to all patients presenting with AM and attempted to define a clinical prediction model.

OBJECTIVE

To create a statistical model to predict LM versus AM in children based on history, physical, and laboratory findings during the initial presentation of meningitis.

METHODS

Children older than 2 years presenting to the Alfred I. duPont Hospital for Children between October 1999 and September 2004 were identified if both Lyme serology and cerebrospinal fluid (CSF) were collected during the same hospital encounter. Patients were considered to have Lyme disease only if they met Centers for Disease Control and Prevention criteria (documented erythema migrans and/or positive Lyme serology). Patients were eligible for study inclusion if they had documented meningitis (CSF white blood cell count: >8 per mm3). Retrospective chart review abstracted duration of headache and cranial neuritis (papilledema or cranial nerve palsy) on physical examination and percent CSF mononuclear cells. Using logistic-regression analysis, the type of meningitis (LM versus AM) was simultaneously regressed on these 3 variables. The Hosmer-Lemeshow test was performed and the area under the receiver operating characteristic curve was calculated.

RESULTS

A total of 175 children with meningitis were included in the final statistical model. Logistic-regression analysis included 27 patients with LM and 148 patients classified as having AM. Duration of headache, cranial neuritis, and percent CSF mononuclear cells independently predicted LM. The Hosmer-Lemeshow test revealed a good fit for the model, and the Nagelkerke R2 effect size demonstrated good predictive efficacy. Odds ratios based on the logistic-regression results were calculated for these variables. The final model was transformed into a clinical prediction model that allows practitioners to calculate the probability of a child having LM.

CONCLUSIONS

Longer duration of headache, presence of cranial neuritis, and predominance of CSF mononuclear cells are predictive of LM in children presenting with meningitis in a Lyme disease-endemic region. The clinical prediction model can help guide the clinician about the need for parenteral antibiotics while awaiting serology results.

Beyond Interviewing: A 21st-century Recruitment Process for Healthcare Quality Professionals

Interview techniques have evolved to include objective testing and situational assessment methods, and an applicant for a quality leadership role in today's market may encounter these new techniques. For an organization, the use of an updated interview process provides greater insight into an applicant's knowledge, skills, and abilities. This article offers an overview of these processes, insights for organizations and leaders to consider in developing assessment strategies, and tips for quality leaders who encounter testing and situational assessment methods during a career search. A case study is provided on the use of job simulations for recruitment of both a senior director for quality and performance improvement and a data management administrator in a regional medical center.

Musculoskeletal infections in children

Serious musculoskeletal infections in children include osteomyelitis, septic arthritis, pyomyositis, and necrotizing fasciitis. The epidemiology, pathophysiology, and microbiology of each of these infections are reviewed. Specific diagnostic studies and management strategies are discussed. Prompt recognition and treatment is emphasized to prevent potential long-term sequelae.

Diagnostic utility of Borrelia burgdorferi cerebrospinal fluid polymerase chain reaction in children with Lyme meningitis

BACKGROUND

Cerebrospinal fluid (CSF) laboratory tests are frequently collected to help differentiate Lyme meningitis from other causes of aseptic meningitis. Previous studies using Lyme CSF polymerase chain reaction (PCR) have yielded varied results (sensitivity between 10 and 90%). No studies have specifically examined the diagnostic utility of Lyme CSF-PCR in North American children with Lyme meningitis.

METHODS

Retrospective chart review of children presenting to a children's hospital in a Lyme-endemic region between October 1999 and September 2004. Patients were included if they had both Lyme serology and Lyme CSF-PCR performed during the same hospital encounter and had documented meningitis. Patients were considered to have Lyme meningitis if they had meningitis and met CDC criteria for Lyme disease. The Lyme CSF-PCR assay amplified a Borrelia burgdorferi DNA flagellin gene sequence.

RESULTS

Of 108 patients with meningitis who qualified for the study, 20 patients met criteria for Lyme meningitis and 88 were classified as aseptic meningitis. Positive Lyme CSF-PCR was found in 1 patient (1 of 20, 5%) with Lyme meningitis and one patient classified as aseptic meningitis (1 of 88, 1%). Lyme CSF-PCR had a sensitivity of 5% and a specificity of 99%. The only Lyme meningitis patient with positive Lyme CSF-PCR had the highest CSF white blood cell count and CSF protein values compared with the other Lyme meningitis patients.

CONCLUSIONS

This is the first study to evaluate Lyme CSF-PCR exclusively in North American children. This commercially available laboratory test is not generally helpful for identifying Lyme meningitis because of its low sensitivity.

A novel method to correct for pitch and yaw patient setup errors in helical tomotherapy

An accurate means of determining and correcting for daily patient setup errors is important to the cancer outcome in radiotherapy. While many tools have been developed to detect setup errors, difficulty may arise in accurately adjusting the patient to account for the rotational error components. A novel, automated method to correct for rotational patient setup errors in helical tomotherapy is proposed for a treatment couch that is restricted to motion along translational axes. In tomotherapy, only a narrow superior/inferior section of the target receives a dose at any instant, thus rotations in the sagittal and coronal planes may be approximately corrected for by very slow continuous couch motion in a direction perpendicular to the scanning direction. Results from proof-of-principle tests indicate that the method improves the accuracy of treatment delivery, especially for long and narrow targets. Rotational corrections about an axis perpendicular to the transverse plane continue to be implemented easily in tomotherapy by adjustment of the initial gantry angle.

Improving physician communication through an automated, integrated sign-out system

Communication failures among physicians are a leading cause of medical errors. The resident sign-out sheet is the primary tool used by house staff to facilitate the sign-out process. The resident sign-out sheet is a structured report, with patient-specific information including demographics, such a patient's name, age, sex, room number, and attending physician; problem list; medications; and allergies. Some physicians use handwritten notes to keep track of this information, while others use freestanding word processor or database programs. In a previous study, the authors described serious inaccuracies in a manually updated word-processor based resident sign-out sheet used by pediatric residents at a tertiary-care children's hospital. An automated and integrated sign-out system (AISS) was subsequently developed that retrieves pertinent patient information from a computerized provider order entry (CPOE) system. The AISS generates a resident sign-out sheet, which includes demographic information, weight, current medications, allergies, and diet orders, as well as optional free-text information. The AISS has proven to be enormously popular, increasing physician acceptance of CPOE throughout the organization. This paper discusses lessons learned, including technical, design, and workflow aspects of an integrated resident sign-out sheet. The authors recommend that all future commercial CPOE systems incorporate physician sign-out tools such as the one described in this article.

Endoscopic treatment of encephaloceles of the lateral wall of the sphenoid sinus

OBJECTIVE

The suitability of the endoscopic approach for the treatment of an encephalocele of the lateral wall of the sphenoid is discussed. This is a retrospective review of 4 cases diagnosed with temporosphenoidal encephalocele and having a history of CSF leak who were surgically treated using an endoscopic endonasal approach between January 2001 and June 2002 at the Department of Otolaryngology of Sant'Orsola-Malpighi University Hospital and the Department of Neurosurgery at Bellaria Hospital in Bologna.

METHODS

Three patients were female between 48 and 73 years of age (mean: 61 years). All patients had suffered from a CSF leak for 5 months to 18 years. None of the patients had a past medical history of head trauma. A fourth patient had undergone a previous microscopic approach for a previously misdiagnosed CSF leak wrongly ascribed to an empty sella. Three patients underwent an ethmoid-pterygo-sphenoidal endoscopic approach (EPSEA), while the patient who had undergone previous microscopic surgery, was treated using a transnasal transsphenoidal endoscopic approach.

RESULTS

The follow-up of the patients ranged from 10 to 26 months (mean: 18 months) and no case of a recurrent CSF leak was observed postoperatively.

CONCLUSIONS

In our report, the endoscopic approach was a useful tool for the treatment of encephaloceles of the lateral wall of the sphenoid sinus. In skilled hands, this technique permits both the resection of the encephalocele and the subsequent reconstruction of the defect also with a low rate of morbidity.

The measurement of radioactive noble gases by DWD in the frame of the Global Atmospheric Watch programme of WMO

The Deutscher Wetterdienst (DWD, German Meteorological Service) is integrated into the Global Atmospheric Watch programme (GAW) of the World Meteorological Organization (WMO). According to this programme a variety of chemical compounds and radionuclides are measured at global stations. At the research platform "Schneefernerhaus" 7Be, 222Rn, and its decay products, 14C in CO2, tritium as HTO, 85Kr and 133Xe are continuously monitored by the DWD or are sampled and then measured at the central laboratory in Offenbach. The results are used as additional information for studying atmospheric mixing processes or on the other hand as information about the background level of radioactivity. As a main subject of this paper the integration and partly the optimization of sampling and measuring procedures for the detection of noble gases are described. In particular, the methods of quality assurance are discussed for Kr and Xe.

Combined Use of Transesophageal ECHO and Fluoroscopy for the Placement of Left Ventricular Pacing Leads via the Coronary Sinus

Biventricular pacing is an emerging technology for treatment of congestive heart failure. Left ventricular leads are most commonly placed through the coronary sinus (CS) into an epicardial coronary vein. Cannulation of the CS can be difficult and standard guiding catheters have a tendency to displace during lead advancement. This study found that transesophageal echocardiography facilitated CS cannulation in complex cases requiring antecedent lead extraction.

Elastographic measurement of the area and volume of thermal lesions resulting from radiofrequency ablation: pathologic correlation

OBJECTIVE

Elastography is a promising tool for visualizing the zone of necrosis in liver tissue resulting from radiofrequency tumor ablation. Because heat-ablated tissues are stiffer than normal untreated tissue, elastography may prove useful for following up patients who undergo radiofrequency ablative therapy. We sought to report the initial evaluations of the reliability of elastography for delineating thermal lesion boundaries in liver tissue by comparing lesion dimensions determined by elastography with the findings at whole-mount pathology.

MATERIALS AND METHODS

Radiofrequency ablation was performed in vitro on liver tissue specimens encased in gelatin phantoms. The imaging plane for elastography was perpendicular to the axis of the radiofrequency electrode so that the ablated region was around the center of the plane. To obtain three-dimensional visualization of thermal lesions, we reconstructed the lesions from multiple elastograms by linearly translating the elastographic scanning plane. Pathology photographs were obtained in the same image plane used for elastography by slicing through the gelatin and tissue phantom using external markers. We used digitized gross pathology photographs obtained at a specified slice thickness to compute the areas and volumes of the lesions. These measurements were then compared to the measurements obtained from the elastograms.

RESULTS

In a sample of 40 thermal lesions, we obtained a correlation between in vitro elastographic and pathologic measurements of r = 0.9371 (p < 0.00001) for area estimates and r = 0.979 (p < 0.00001) for volume estimates.

CONCLUSION

We found excellent correlation between the measurements of the dimensions, areas, and volumes of thermal lesions that were based on elastographic images and the measurements that were based on digitized pathologic images. When compared with digitized pathologic measurements, elastographic measurements showed a tendency to slightly underestimate both the areas and volumes of lesions. Nevertheless, elastography is a reliable technique for delineating thermal lesions resulting from radiofrequency ablation.

Unexpected death and critical illness in Prader-Willi syndrome: Report of ten individuals

Individuals with Prader-Willi syndrome (PWS) generally survive into adulthood. Common causes of death are obesity related cor pulmonale and respiratory failure. We report on a case series of eight children and two adults with unexpected death or critical illness. Our data show age-specific characteristics of PWS patients with fatal or life-threatening illnesses. Under the age of 2 years, childhood illnesses in general were associated with high fever and rapid demise or near-demise. Hypothalamic dysfunction likely plays a role in exaggerated fever response, but also perhaps in central regulation of adrenal function. Below average sized adrenal glands were found in three children, which raises the possibility of unrecognized adrenal insufficiency in a subset of individuals with PWS and emphasizes the vital role of autopsy. The tub drowning death of an adult patient could be related to central hypersomnia, which has been reported in PWS. We suggest that increased risk for critical illness be considered in the discussion of anticipatory guidance for the care of infants with PWS. Since a number of children died while hospitalized, particularly close observation of PWS children who are ill enough to warrant hospital admission is recommended.

Temperature dependence of ultrasonic propagation speed and attenuation in canine tissue

Previously reported data on the temperature dependence of propagation speed in tissues generally span only temperature ranges up to 60 degrees C. However, with the emerging use of thermal ablative therapies, information on variation in this parameter over higher temperature ranges is needed. Measurements of the ultrasonic propagation speed and attenuation in tissue in vitro at discrete temperatures ranging from 25 to 95 degrees C was performed for canine liver, muscle, kidney and prostate using 3 and 5 MHz center frequencies. The objective was to produce information for calibrating temperature-monitoring algorithms during ablative therapy. Resulting curves of the propagation speed vs. temperature for these tissues can be divided into three regions. In the 25-40 degrees C range, the speed of sound increase rapidly with temperature. It increases moderately with temperature in the 40-70 degrees C range, and it then decreases with increasing temperature from 70-95 degrees C. Attenuation coefficient behavior with temperature is different for the various tissues. For liver, the attenuation coefficient is nearly constant with temperature. For kidney, attenuation increases approximately linearly with temperature, while for muscle and prostate tissue, curves of attenuation vs. temperature are flat in the 25-50 degrees C range, slowly rise at medium temperatures (50-70 degrees C), and level off at higher temperatures (70-90 degrees C). Measurements were also conducted on a distilled degassed water sample and the results closely follow values from the literature.

Eating-related concerns, mood, and personality traits in recovered bulimia nervosa subjects: a replication study

OBJECTIVE

Limited data suggest that eating-related concerns and behaviors, disturbances in mood, and altered temperament persist following recovery from bulimia nervosa (BN).

METHOD

In order to replicate and extend such findings, 11 women who were long-term recovered from BN (>1 year with no binging, purging, or restricting behaviors, normal weight, and regular menstrual cycles) were compared with 15 healthy volunteer women on the Eating Disorders Invertory-2 (EDI-2), the Beck Depression Inventory, the State Trait Anxiety Inventory, and the Multidimensional Personality Questionnaire (MPQ).

RESULTS

Compared with the control women, the recovered BN women showed elevated levels of the EDI-2 subscales of Drive for Thinness, Body Dissatisfaction, Ineffectiveness, Perfectionism, and Social Insecurity, greater depression and anxiety, elevated levels of the MPQ Stress Reaction dimension and the higher-order factor of Negative Emotionality, and lower levels of the MPQ Well Being and Closeness dimensions.

DISCUSSION

Core eating and weight-related concerns, dysphoric affect, social discomfort, and personality traits indicative of perfectionism persist following long-term recovery from BN.

Ultrasound monitoring of temperature change during radiofrequency ablation: preliminary in-vivo results

Radiofrequency (RF) ablation is an interstitial focal ablative therapy that can be used in a percutaneous fashion and permits in situ destruction of hepatic tumors. However, local tumor recurrence rates after RF ablative therapy are as high as 34% to 55%, which may be due in part to the inability to monitor accurately temperature profiles in the tissue being ablated, and to visualize the subsequent zone of necrosis (thermal lesion) formed. The goal of the work described in this paper was to investigate methods for the real-time and in vivo monitoring of the spatial distribution of heating and temperature elevation to achieve better control of the degree of tissue damage during RF ablation therapy. Temperature estimates are obtained using a cross-correlation algorithm applied to RF ultrasound (US) echo signal data acquired at discrete intervals during heating. These temperature maps were used to display the initial temperature rise and to continuously update a thermal map of the treated region. Temperature monitoring is currently performed using thermosensors on the prongs (tines) of the RF ablation probe. However, monitoring the spatial distribution of heating is necessary to control the degree of tissue damage produced.

Elastographic imaging using a handheld compressor

Elastography is an emerging imaging modality that allows noninvasive imaging of tissue stiffness changes and stiffness values associated with pathology or as a result of therapy. However, many currently-used systems for elastography rely on a fixed geometry transducer and compressor system for imaging. This configuration is disadvantageous for imaging difficult-to-reach regions that are currently accessible with conventional ultrasound. In this paper, we describe a handheld, portable stepper motor controlled system for elastography. This system may reduce motion and jitter errors that are prevalent in completely 'freehand elastography' that employs hand-induced compressions using the transducer. The latter also requires collection of large amounts of data and use of strain estimation algorithms that may not be sensitive to phase changes or use additional preprocessing to minimize decorrelation effects. The stepper motor controlled handheld system provides controlled compressions and synchronized data acquisition. Our technique yields elastograms of a low-contrast phantom that have contrast levels and contrast-to-noise ratios that are comparable to those obtained with a fixed geometry system.

Extended transsphenoidal approach

The authors have developed an extended transsphenoidal approach with submucosal posterior ethmoidectomy for resection of tumors located in the cavernous sinus or the suprasellar region that are difficult to remove via the conventional transsphenoidal approach. Surgery was performed using this approach in 14 patients with large pituitary adenomas, three patients with craniopharyngiomas, and one patient with a meningioma of the tuberculum sellae. The submucosal dissection of the nasal septum used in the conventional transsphenoidal approach was extended to the superior lateral wall of the nasal cavity to expose the bony surface of the superior turbinate lying under the nasal mucosa. Submucosal posterior ethmoidectomy widened the area visualized through the conventional transsphenoidal approach both superiorly and laterally. This provided a safer and less invasive access to lesions in the cavernous sinus or the suprasellar region through the sphenoid sinus. Using this approach the authors encountered no postoperative complications, such as olfactory disturbance, cranial nerve palsy, or arterial injury. In this article the authors present the surgical methods used in this approach.