Infection due to Moraxella osloensis: case report and review of the literature

We describe the successful treatment of Moraxella osloensis bacteremia in a 2-year-old boy who presented with fever, petechial rash, and exacerbation of reactive airway disease. We also review the 12 cases previously reported in the literature.

Vancomycin use in pediatric neurosurgery patients

OBJECTIVE

The objective of this article is to describe a pediatric neurosurgery patient population receiving vancomycin and examine the indications for and appropriateness of vancomycin use.

METHODS

A cross-sectional study was performed on the pediatric neurosurgery patients at Egleston Children's Hospital who received vancomycin from January 1 through December 31, 1996. Vancomycin use was compared with the Centers for Disease Control and Prevention Hospital Infection Control Practices Advisory Committee recommendations for vancomycin use.

RESULTS

Thirty patients received 115 doses of vancomycin. The median patient age was 8.0 years, and 17 (56.7%) were male. Vancomycin was used for prophylaxis in 28 (93.3%) patients and empiric therapy in 3 (10.0%) patients; one patient received vancomycin for surgical prophylaxis followed by empiric therapy for suspected meningitis. Vancomycin prophylaxis was initiated after the incision in 6 (21.4%) patients and was continued as prophylaxis for more than one dose in 26 (92.9%) patients.

CONCLUSIONS

Vancomycin was used primarily as surgical prophylaxis in pediatric neurosurgery patients, and use was not consistent with the Hospital Infection Control Practices Advisory Committee recommendations. These data suggest that for certain subpopulations, such as pediatric neurosurgery patients, there is a need for more specialized recommendations. Furthermore, prudent vancomycin use is warranted to successfully decrease the risk of further emergence of vancomycin resistance. Because vancomycin use may be prevalent in this population, assessment of vancomycin use in pediatric neurosurgery patients followed by establishment of vancomycin clinical guidelines may help improve the appropriateness of vancomycin use in this population.

Bacteremia, meningitis, and brain abscesses in a hospitalized infant: complications of Pseudomonas aeruginosa conjunctivitis

This report describes a preterm infant hospitalized in a neonatal intensive care unit who developed Pseudomonas aeruginosa conjunctivitis associated with bacteremia, meningitis, and multiple brain abscesses. P. aeruginosa conjunctivitis can rapidly progress to an invasive eye infection, such as corneal ulceration or endophthalmitis, leading to poor vision or blindness. Progression of this infection may lead to systemic disease. However, as illustrated in this report, P. aeruginosa conjunctivitis may be associated with the development of systemic complications such as bacteremia and meningitis in the absence of invasive eye disease. P. aeruginosa is a relatively common cause of conjunctivitis in hospitalized preterm and low birth weight infants. Given the severity of the ocular and systemic complications of Pseudomonas conjunctivitis, clinicians are reminded that prompt detection and treatment of neonatal conjunctivitis is critical.

Toxicity of topical anesthetic agents to human keratocytes in vivo

PURPOSE

To test the potential toxicity on human keratocytes of topical anesthetic agents used after photorefractive keratectomy (PRK) to reduce or eliminate pain.

SETTING

Department of Ophthalmology, Doheny Eye Institute, University of Southern California, Los Angeles, California, USA.

METHODS

Cultured human keratocytes were incubated with commercially available tetracaine and proparacaine at reduced concentrations of 0.001%, 0.01%, 0.1%, and 0.25%. Evaluations were performed by phase-contrast microscopy and tetrazolium salt colorimetric assay every 2 hours for 12 hours after adding 1 of the anesthetic agents to the media.

RESULTS

After time of incubation and concentration were adjusted, both drugs reduced overall cell viability; however, tetracaine produced a larger decrease in cell viability than proparacaine (P = .008). For both drugs, significant differences were found among concentrations for and across time (P < .001 and P = .004, respectively).

CONCLUSION

Both tetracaine and proparacaine had toxic effects on stromal keratocytes related not only to drug concentrations but also to time exposure. These findings underscore the widespread concern that anesthetic drugs may affect corneal stromal wound healing after PRK.

Increasing incidence of gram-negative rod bacteremia in a newborn intensive care unit

OBJECTIVES

To determine whether there has been an increase in the incidence or a change in the epidemiology of gram-negative rod (GNR) bacteremia in patients in a newborn special care unit.

METHODS

Retrospective review of GNR bacteremia in patients hospitalized in the NBSCU at Yale-New Haven Hospital during a 10-year period.

RESULTS

There were 120 isolates from 113 episodes of GNR bacteremia during the study period. The incidence of GNR bacteremia increased from a mean of 10.2 to 25.5 (P = 0.017) episodes of GNR bacteremia per 1000 admissions per year between the time periods 1988 to 1994 and 1995 to 1997, respectively, paralleling an increase in the overall incidence of bacteremia. The increase in GNR bacteremia in these two groups was not related to changes in the patient population, the number of admissions or duration of hospitalization. Stepwise multivariate analysis identified two independent variables associated with infants who had GNR bacteremia during the period 1995 to 1997 as compared with 1988 to 1994, maternal intrapartum antibiotics (odds ratio, 4.9; 95% confidence interval, 1.9 to 12.6) and the presence of a percutaneous central venous catheter (odds ratio, 4.6; 95% confidence interval, 1.8 to 11.8).

CONCLUSIONS

We observed changes in clinical obstetric and neonatal care that paralleled the increase in GNR bacteremia at our institution. A prospective study is needed to elucidate the impact of these changes on the incidence of GNR bacteremia in this population.

Cigarette smoke potentiates house dust mite allergen-induced increase in the permeability of human bronchial epithelial cells in vitro

Although studies have suggested that exposure to cigarette smoke (CS) may be associated with the development of atopy, the mechanisms underlying this are not clearly understood. It has been suggested that CS impairs the barrier function of the airway epithelium, leading to increased access of allergens such as those of the house dust mite (HDM) Dermatophagoides pteronyssinus (Der p) to antigen-presenting cells, with subsequent allergic sensitization. In order to test this hypothesis, we established primary explant cultures of human bronchial epithelial cells (HBEC) in cell culture inserts, and exposed these for 20 min, 1 h, 3 h, and 6 h to CS or air in the absence or presence of 300 ng/ml Der p, and then further incubated the cultures over a period of 24 h. The HBEC cultures were assessed for changes in permeability as measured by changes in: (1) electrical resistance (ER); and (2) passage of 14C-labeled bovine serum albumin (14C-BSA) and Der p allergens across the HBEC cultures. We also assessed the effects of protease inhibitors and the antioxidant glutathione (GSH) in this experimental system. Damage to HBEC cultures was assessed by the release of [51Cr]sodium chromate from prelabeled cells, and by release of lactate dehydrogenase (LDH). Twenty minutes of exposure to CS as compared with exposure to air did not significantly alter either the ER or passage of 14C-BSA across the HBEC cultures. In contrast, incubation with Der p led to a significant increase in the permeability of HBEC cultures, an effect that was enhanced by exposure to CS but was abrogated by the specific protease inhibitors and GSH. Passage of Der p was also increased by exposure to CS. Exposure of HBEC cultures to CS led to a significant release of 51Cr and LDH from these cells as compared with cells exposed to air. This effect was augmented further when HBEC cultures were incubated with Der p. Exposure of HBEC cultures for 1 h, 3 h, and 6 h to CS led to a markedly significant dose- and time-dependent increase in the permeability of these cells. These results suggest that exposure to CS significantly enhances Der p-induced decreases in electrical resistance and the increased passage across HBEC cultures of 14C-BSA and of the Der p allergen itself.

PRK-induced anisometropia in the rabbit as a model of myopia

BACKGROUND

Current animal models of myopia, such as the chick and the tree shrew, have characteristics that limit their applicability to human myopia and/or their use among researchers. The purpose of this study was to establish a rabbit model of myopia based on photorefractive keratectomy (PRK)-induced anisometropia.

METHODS

A group of five pigmented rabbits was treated with a monocular -5 D PRK at 5 weeks of age. At 10 weeks of age, two of the eyes were retreated with a second -5 D PRK procedure to compensate for partial regression of the refractive effect. A second group of six pigmented rabbits was treated with a monocular -6 D PRK at 10 weeks of age. Longitudinal measurements of corneal curvature, refraction, and axial length were performed until the rabbits were 13 and 21 weeks of age in groups 1 and 2, respectively. The rabbits in each group were from the same litter.

RESULTS

Keratometry and retinoscopy measurements confirmed the refractive effect of the PRK procedures. At the final measurement point in group 1, the PRK-treated eyes were significantly longer than the untreated eyes (16.01 +/- 0.45 mm vs 15.45 +/- 0.56 mm). In group 2, the PRK-treated eyes were significantly longer by 0.19 mm and 0.20 mm at ages 19 and 21 weeks, respectively.

CONCLUSIONS

PRK-induced anisometropia is an effective technique to induce hyperopic error compensation in the rabbit as a model of myopic development. The technique is effective if the PRK procedure is performed at either 5 or 10 weeks of age. However, after PRK at 5 weeks of age, partial retreatment may be necessary due to regression of the PRK effect.

Photorefractive keratectomy using the summit SVS Apex laser with or without astigmatic keratotomy

PURPOSE

The purpose of this study was to evaluate the results of myopic photorefractive keratectomy (PRK) with or without astigmatic keratotomy (AK) for different levels of intended correction by using the SVS Apex laser.

METHODS

This is a retrospective cohort study of 226 eyes that had PRK for myopia ranging from -1.0 to -7.6 diopters and 6 months of follow-up. In addition, 64 of these eyes had AK for naturally occurring or laser-induced astigmatism. Uncorrected visual acuity, spectacle-corrected visual acuity, and corneal topography with quantitative descriptors of surface regularity (SRI) and surface asymmetry (SAI) were used to monitor the results of PRK with or without AK.

RESULTS

At 6 months, 95.6% eyes had an uncorrected visual acuity of 20/40 or better, 90% eyes were within +/-1.0 diopter of emmetropia, and 3.1% eyes lost two lines of best-corrected vision. No eyes lost more than two lines of best-corrected vision. Mean refractive astigmatism was reduced, but mean SAI and SRI were increased, 6 months after PRK. Uncorrected vision, best-corrected vision, and predictability decreased, whereas SAI and SRI increased, with increasing attempted correction.

CONCLUSION

PRK, with or without AK, effectively reduced myopia in all eyes by 6 months after surgery. Predictability tended to decrease with increasing attempted correction, even for eyes with relatively low to moderate myopia. PRK may induce surface asymmetry and irregularity at 6 months, and these alterations tend to be greater as the attempted correction increases.

Atrial flutter complicating neonatal Coxsackie B2 myocarditis

A neonate presented with atrial flutter complicating acute Coxsackie B2 myocarditis. The tachyarrhythmia was successfully terminated with electrocardioversion followed by digoxin administration. The infant survived with no long-term cardiac sequelae. Atrial flutter is an unusual complication of Coxsackie myocarditis that has not previously been reported.

Vitamin D deficiency in pregnancy is not associated with obstructed labor. A study among Pakistani women in Karachi

BACKGROUND

Vitamin D deficiency is widespread among pregnant Pakistanis in Norway. It may cause osteomalacia with destruction of maternal pelvis, and thus be a risk factor for cephalopelvic disproportion. This study was performed to determine whether vitamin D deficiency is common among pregnant Pakistanis in Pakistan, and to test the hypothesis that vitamin D deficiency in nulliparous pregnant women is associated with mechanical dystocia.

METHODS

The study was carried out at the Civil Hospital, in a poor area of Karachi, and had a case-referent design. Thirty-seven nulliparous parturients with Cesarean section due to mechanical dystocia served as cases, and 80 nulliparous parturients with uncomplicated vaginal delivery were their referents. All blood samples were drawn before parturition.

RESULTS

The mothers with obstructed labor were shorter (on average 150 vs. 155 cm, p= 0.0001) and lighter (on average 58 vs. 60.5 kg, p=0.005) than their referents. Seventy-one percent (83/117) of all the participants had marginal or low vitamin D status defined as serum level of calcidiol (25-OH vitamin D3) below 30 nmol/l. Vitamin D deficiency was, however, not more widespread among the mothers with obstructed labor (20/37 vs. 63/80). Furthermore, there were no significant differences in the serum levels of the carboxyterminal telopeptide of type I collagen, a sensitive biochemical marker of bone resorption, (7.2 vs. 6.6 microg/l), and bone specific alkaline phosphate (18.1 vs. 22.0 U/l) a sensitive marker of bone formation.

CONCLUSIONS

Vitamin D deficiency in pregnancy is common in Karachi, but is not associated with mechanical dystocia.

Complications of conjunctivitis caused by Pseudomonas aeruginosa in a newborn intensive care unit

BACKGROUND

In infancy Pseudomonas aeruginosa conjunctivitis may lead to a rapidly progressive invasive eye infection. In some cases this destructive eye disease is associated with or followed by infection at other sites. We observed seven hospitalized infants with P. aeruginosa conjunctivitis who developed systemic complications of P. aeruginosa infection without evidence of invasive eye disease, prompting us to examine the characteristics of this infection and its associated systemic complications in hospitalized infants.

METHODS

We reviewed retrospectively the course, treatment and outcome of infants with nonepidemic P. aeruginosa conjunctivitis in the Newborn Special Care Unit at Yale-New Haven Hospital during a 10-year period from November 1, 1986, to October 31, 1996.

RESULTS

Eighteen infants with P. aeruginosa conjunctivitis had mean birth weights and gestational ages of 29.3 weeks and 1380 g, respectively. The average postnatal age at onset of P. aeruginosa conjunctivitis was 17 days. No infant had invasive eye disease. Systemic complications occurred in seven (39%) infants and included bacteremia, meningitis, brain abscess and death. Infants who developed systemic complications had lower mean birth weights (850 g vs. 1716 g, P = 0.04) and lower mean gestational ages (26.4 vs. 31.2 weeks, P = 0.02) than infants who did not. Six of seven infants weighing < 1000 g developed systemic complications; two of these infants died.

CONCLUSIONS

In hospitalized infants P. aeruginosa conjunctivitis may be associated with systemic complications with or without invasive eye infection, emphasizing the need for early detection and treatment of this infection in this population.

Seroprevalence of hepatitis A virus in Mumbai, and immunogenicity and safety of hepatitis A vaccine

OBJECTIVES

Since epidemiologic trends of hepatitis A are changing worldwide, we studied its seroprevalence in Mumbai, which is thought to be a high-endemicity area. The immunogenicity and safety of a hepatitis A vaccine were also studied.

METHODS

Six hundred and seventy subjects (456 men; age range 6 mo-60 y) answered a questionnaire on social and medical history. Qualitative analysis of total anti-HAV was performed in all subjects by ELISA. One hundred and seven of 147 anti-HAV negative subjects received hepatitis A vaccine at months 0, 1 and 6. Subjects were followed up (months 1, 2, 6, 7) to look for side-effects and seroconversion.

RESULTS

The seroprevalence of HAV was 523/670 (78%); 38% of children < 5 years were anti-HAV negative. Seroprevalence rates of 80% were reached by 15 years. Prevalence was lower in the higher socio-economic group (151/234; 64.5%) compared with the lower socio-economic group (372/436; 85%) (p < 0.001). One month after doses 1, 2 and 3 of the hepatitis A vaccine, seropositivity was 92%, 99% and 100%, respectively. Minor self-limited side-effects occurred in 19.5% of subjects; there were no major side-effects.

CONCLUSIONS

The seroprevalence of anti-HAV is high in Mumbai. Seroprevalence is lower in the higher socio-economic groups. The hepatitis A vaccine is safe and immunogenic.

Neonatal sepsis due to echovirus 18 infection

Clinical manifestations of neonatal echovirus type 18 infections include a nonspecific febrile illness, diarrhea, and meningitis with or without exanthem. We report a successful outcome in a case of neonatal sepsis with shock caused by echovirus type 18, a complication not previously associated with this serotype.

Pediatric hyperfibrotic myelodysplasia: an unusual clinicopathologic entity

This study is presented to highlight a rare pediatric bone marrow pathology in which features of bone marrow dysplasia coexist with severe fibrosis in a clinical setting of fever, anemia, and organomegaly. Fourteen children (nine males, five females) clinically presented with fever, anemia, and hepatosplenomegaly. Extensive bone marrow fibrosis with dysplastic features was seen in their marrow precursor cells. Peripheral blood smears showed teardrop poikilocytes thrombocytopenia, and occasional blasts. In conclusion, pediatric hyperfibrotic myelodysplasia is a distinct clinicopathologic entity. Myeloproliferative and dysmyelopoietic syndromes are complex disorders that are interrelated and not always easily diagnosed only on morphologic grounds.

Solubilization of Amphiphilic Hemicyanine Dyes by a Cationic Surfactant, Cetyltrimethylammonium Bromide

The solubilization of amphiphilic hemicyanine dyes by the micelles of a cationic surfactant, cetyltrimethylammonium bromide (CTAB), was studied as a function of surfactant concentration above the critical micelle concentration (CMC). The micelle-water partition coefficient, Kx, and the standard free energy of solubilization, DeltaG0, of these dyes in CTAB micelles was determined at 25.0&deg;C by a differential spectroscopic method. The CMCs of CTAB in the presence of small amounts of these dyes were determined by a conductivity method at 25.0&deg;C. The values of Kx and DeltaG0 for all six dyes were determined by an improved method that incorporates both conductance and differential absorbance data.

Odontogenic keratocysts in the pediatric population

OBJECTIVE

To review the characteristics and treatment of odontogenic keratocysts in the pediatric population at our institution in light of a comprehensive literature review of odontogenic keratocysts in the general population in the hope of elucidating clinical, radiological, or pathological factors that would suggest a different therapeutic approach to odontogenic keratocysts in the pediatric as opposed to the adult population.

DESIGN

A 19-year retrospective medical chart review of children with mandibular or maxillary masses of odontogenic keratocyst origin.

SETTING

Two academic tertiary care institutions.

PATIENTS

Eleven children had pathologically confirmed odontogenic keratocysts. Age at diagnosis ranged from 8 to 18 years (mean, 13.4 years).

RESULTS

A cystic mass with dentition displacement was characteristic clinically and radiographically. Treatment principally consisted of enucleation with or without extraction of teeth. Follow-up ranged from 1 to 8 years. Seven patients remained free of disease. Recurrences or second primary lesions occurred in 4 patients, all of whom had a family history of nevoid basal cell carcinoma syndrome or multiple cysts suggestive of this diagnosis. The maximum 8-year interval between initial treatment and recurrence is noteworthy.

CONCLUSIONS

The diagnosis of odontogenic keratocyst deserves consideration in children who have a mass of the mandible or maxilla. The clinical behavior of this lesion in its initial occurrence and response to conservative treatment seems to be similar to that reported in adults. Odontogenic keratocysts, especially those that are multiple or recurrent, should alert the clinician to the possible underlying diagnosis of nevoid basal cell carcinoma syndrome.

Cerebrovascular complications of HIV in children

Two uncommon but important cerebrovascular manifestations of human immunodeficiency virus (HIV) infection in children are arteritis with formation of fusiform aneurysms and arterial sclerosis with vascular occlusion. We studied the CT and MR imaging features of HIV in two girls and one boy (9 to 18 years old) and compared them with autopsy findings in two patients. One of the children had findings consistent with small areas of subacute infarction and the other two had fusiform dilatation of the major vessels of the circle of Willis. The ischemic lesions and arteriopathy were confirmed at autopsy. In one patient, an incidental B-cell lymphoma (not visible on the imaging studies) was diagnosed.

Combined pulmonary and thoracic wall resection for stage III lung cancer

BACKGROUND

Carcinoma of the lung with thoracic wall involvement constitutes stage III disease. The management of patients with this condition is complicated. However, improvement in perioperative care coupled with advances in surgical technique have enabled a more aggressive approach to the problem to be adopted.

METHODS

A retrospective review was carried out of 58 patients (40 men) of mean age 63 years who underwent thoracotomy for lung cancer with chest wall invasion between 1980 and 1993.

RESULTS

Chest wall resection was performed in 55 patients (94.8%); in three patients the discovery of N2 disease at operation precluded resection. The TNM status was T3N0M0 in 38 patients, T3N1M0 in 13, and T3N2M0 in seven. Squamous cell carcinoma was the commonest cell type (26 patients). Reconstruction of the chest wall was performed in 29 patients (Marlex mesh in six, Marlex-methacrylate in 22, myocutaneous flap in one patient). The morbidity and mortality were 22.4% and 3.4% respectively. Follow up was complete in 51 patients. Nineteen (37.2%) survived > or = 5 years. The absolute five year survival for N0 and N1 disease was 44.7% and 38.4%, respectively. No patients with N2 disease survived five years.

CONCLUSIONS

In patients with carcinoma of the lung and chest wall invasion, combined pulmonary and thoracic wall resection offers the prospect of cure with minimal morbidity and mortality. The prognosis of patients with coexistent N2 disease remains poor.

Cefoperazone monotherapy for serious infections in hospitalized patients--an initial Indian experience

Cefoperazone sodium is a broad spectrum third generation Cephalosporin recently introduced in India. This was used as a monotherapy to treat severe infections in hospitalized patients. These infections were due to various gram positive and gram negative organisms. Of the 22 evaluable patients, 21 (95%) were clinically cured and 1 (5%) improved. 18 pathogens were isolated from 17 patients. Microbiologic eradication was 100%. Symptomatic improvement occurred within 48-72 hours of onset of therapy with complete relief by 4-5 days. Dual mode of excretion makes this drug safe in presence of renal insufficiency. Anti-microbial activity against a wide spectrum of organisms and twice daily dosage schedule qualify Cefoperazone as a single antibiotic of choice in severe infections in critically ill patients.