Decline in emergency department visits during the COVID-19 quarantine

BACKGROUND

Emergency department (ED) visits can be divided into urgent and non-urgent. A delay in seeking medical help, especially in urgent cases, can lead to fatal consequences, along with a higher rate of complications and morbidity. Coronavirus disease 2019 (COVID-19) pandemic spread led to restrictions and eventually quarantines. We investigated the impact of the COVID-19 spread and quarantine on ED visits rates comparing to parallel periods in preceding years (2013-2019). In addition, we compared this decrease to holidays and weekends, times in which a decrease in ED visits is seen.

METHODS

This was a descriptive retrospective study. Causes of ED referrals were divided into urgent and non-urgent, then into different subcategories including infectious, cardiac, etc. RESULTS: For the spring COVID-192020 quarantine period, a 56.3% decrease of mean ED visits per day was seen, as compared to preceding years (55.7% and 98.9% respectively). This decrease was also statistically evident when comparing the urgent and non-urgent causes separately and for all sub-categories. This pattern of decrease also showed statistical evidence of fewer ED visits during holidays for most comparisons, in which lower ED visit rates are expected. Significantly lower rates of ED visits were demonstrated during the COVID-19 quarantine period, as compared to preceding years and main holidays and weekends, a decrease that was also demonstrated for urgent life-threatening causes.

CONCLUSION

Our findings can be used to inform a wide range of stakeholders, including regional planners, historians, sociologists, and international healthcare organizations. Healthcare providers should understand the reasons for this ED visit decline pattern, attempt to address patients' concerns, and increase awareness regarding alarming symptoms in urgent medical situations.

Parathyroid Cystic Adenoma: A Systematic Review and Meta-Analysis

OBJECTIVE

To review diagnostic imaging modalities for parathyroid cystic adenomas (PCA). Since PCAs are a rare (0.5%-1%) subclass of parathyroid adenomas, and due to their cystic component, imaging modalities known to be efficient for diagnosing solid adenomas might fail in localizing them.

METHODS

We conducted a systematic review using the PubMed and Cochrane databases for English articles on PCAs published between 1995 and 2020. A meta-analysis of the retrieved data was performed.

RESULTS

Overall, 39 studies, reporting on a total of 160 patients, were included in the analysis. Two thirds (68%) of the patients were female, with a mean age of 53.9 years. A single cystic adenoma was detected in 98.1% of cases. The mean blood calcium corrected for albumin level was 12.6 ± 2.7 mg/dL, and the mean parathyroid hormone level was 565.5 ± 523.8 pg/mL. The mean PCA sizes as measured by ultrasound (US), computed tomography (CT), and ex vivo measurement were 4.8 ± 3.6, 5.2 ± 3.2, and 3.5 cm, respectively. The median weight was 8.1 g. PCA was detected in 86% of US examinations; 100% of US-guided fine needle aspiration, 4-dimensional computed tomography (4D-CT), or magnetic resonance imaging examinations; and 61% of 99m-technetium sestamibi scan with single-photon emission computed tomography ((99m)Tc-SPECT). (99m)Tc-SPECT showed a significantly lower diagnostic rate than US (odds ratio, 3.589), US-guided fine needle aspiration, CT combined with 4D-CT, and the combination of US, CT, 4D-CT, and magnetic resonance imaging (P < .001).

CONCLUSION

Although US and 4D-CT showed a significantly high rate in diagnosing PCA, (99m)Tc-SPECT showed a lower PCA diagnostic rate. These findings suggest that larger cystic lesions suspected as PCAs should be further evaluated using 4D-CT rather than (99m)Tc-SPECT.

Cross-cultural adaptation of the Hebrew Nasal Obstruction Symptom Evaluation (NOSE) scale

Objective

Nasal obstruction is a common complaint. The Nasal Obstruction Symptom Evaluation scale (NOSE) is a reliable validated tool used to assess the quality of life of patients with nasal obstruction. The purpose of this study is to validate the Hebrew version of the NOSE scale (He-NOSE).

Methods

A prospective instrument validation was conducted. The NOSE scale was translated primarily from English to Hebrew and then back from Hebrew to English according to the accepted guidelines of the cross-cultural adaptation process. The study group included surgery candidates suffering from nasal obstruction due to a deviated nasal septum and/or inferior turbinate hypertrophy. The study group completed the validated He-NOSE questionnaire twice prior to the surgery and once again, a month post-surgery. A control group of individuals with no history of nasal complaints or surgeries was asked to complete the questionnaire once. Reliability, internal consistency, validity, and responsiveness to change of the He-NOSE were evaluated.

Results

Fifty-three patients and 100 controls were included in this study. The scale showed excellent ability to discriminate between the study and the control group, exhibiting significantly lower scores in the control group (73.8 and 7 average scores respectively, p < .001). Good internal consistency (Cronbach's alpha .71 and .76) and test-retest reliability (Spearman rank correlation r = .752, p < .0001) were measured. Moreover, the scale revealed remarkable responsiveness to change (p < .00001).

Conclusion

The translated and adapted He-NOSE scale can be a useful tool to be applied in both clinical and research fields when assessing nasal obstruction.

Level of evidence

N/A.

Reasons underlying the intention to vaccinate children aged 5-11 against COVID-19: A cross-sectional study of parents in Israel, November 2021

Vaccination is a key tool to mitigate impacts of the COVID-19 pandemic. In Israel, COVID-19 vaccines became available to adults in December 2020 and to 5-11-year-old children in November 2021. Ahead of the vaccine roll-out in children, we aimed to determine whether surveyed parents intended to vaccinate their children and describe reasons for their intentions. We collected information on parental socio-demographic characteristics, COVID-19 vaccine history, intention to vaccinate their children against COVID-19, and reasons for parental decisions using an anonymous online survey. We identified associations between parental characteristics and plans to vaccinate children using a logistic regression model and described reasons for intentions to vaccinate or not. Parental non-vaccination and having experienced major vaccination side effects were strongly associated with non-intention to vaccinate their children (OR 0.09 and 0.18 respectively, p < .001). Parents who were younger, lived in the socio-economically deprived periphery, and belonged to the Arab population had lower intentions to vaccinate their children. Reasons for non-intention to vaccinate included concerns about vaccine safety and efficacy (53%, 95%CI 50-56) and the belief that COVID-19 is a mild disease (73%, 95%CI 73-79), while a frequent motive for vaccination was the return to normal social and educational life (89%, 95%CI 87-91). Understanding rationales for COVID-19 vaccine rejection or acceptance, as well as parental demographic data, can pave the way for intentional educational campaigns to encourage not only vaccination against COVID-19, but also regular childhood vaccine programming.

Factors Associated With The Covid-19 Infection Severity In Patients With Mental Disorders

Introduction

Recent research showed that persons with mental disorders may represent a population at increased risk for coronavirus disease (COVID-19) infection with more adverse outcomes.

Objectives

We aimed to analyze clinical profile of psychiatric inpatients during their infection with COVID-19, and to explore factors associated with the disease progression.

Methods

We analyzed retrospectively the medical records of 32 psychiatric inpatients, hospitalized in psychiatry “B” department at Hedi Chaker hospital (Sfax, Tunisia), and who contracted the COVID-19 infection. We used “Charlson Comorbidity Index Score” (CCIS), predicting 10-year survival in patients with multiple comorbidities.

Results

Somatic history was reported in 50% of patients. The CCIS ranged between 0 and 4. Psychiatric diagnosis was schizophrenia in 81.3% and bipolar disorder in 18.7% of cases. The clinical symptoms reported were fever (50%), dry cough (75%); dyspnea (34.4%). Biological assessment showed a lymphopenia in 40.6% and a high C-Reactive Protein (CRP) in 53.1%. Among our patients, 37,5% needed oxygen, and 25% were transferred to the intensive care unit. The COVID-19 complications were mostly bacterial pulmonary superinfections (21.9%) and pulmonary embolism (9.4%). Only three (9.4%) patients died from the virus. Patients with medical history were more likely to need oxygen (p<0.001). Clinical and paraclinical parameters associated with oxygen need were: fever (p<0.001); dyspnea (p<0.001); lymphopenia (p<0.001); high CRP (p=0.001). Patients presenting pulmonary superinfection or embolism were more likely to require oxygen (p=0.006 and p=0.044 respectively).

Conclusions

This study highlighted factors that may worsen the COVID-19 infection evolution, and which require special attention, in order to improve the prognosis of this disease.

Disclosure

No significant relationships.

Bidirectional Associations Between Covid-19 Infection And Mental Disorders

Introduction

The COVID-19 pandemic brought unbearable psychological pressure to people worldwide, because of serious threats to one’s physical health and life. From early stages of this pandemic, concerns have been raised about its effect on mental health. However, we still know little whether pre-existing psychiatric disorder (PD) affects the susceptibility and evolution of this infection.

Objectives

We aimed to assess the interactions between COVID-19 infection and PD.

Methods

We conducted a litterature review through pubmed database, using the keywords :«COVID 19», «psychiatry», «mental disorders», « schizophrenia », « anxiety », « depression », «insomnia».

Results

On one hand, prior surveys suggested that the infection is associated with increased incidence of a first psychiatric symptom. Mental health disturbances mostly include anxiety, depression, sleep disturbances, cognitive impairment and post-traumatic stress disorder. On the other hand, recent studies showed that patients with pre-existing mental disorders were associated with high susceptibility to be infected, increased risk of intensive care unit admission and a high mortality. The susceptibility to contracting COVID-19 was associated with pre-existing mood disorders, anxiety, and attention-deficit hyperactivity disorder. Infection severity was associated with pre-existing or subsequent mood disorders and sleep disturbances; or a pre-extisting schizophrenia. Mortality is increased in patients diagnosed with schizophrenia.

Conclusions

The complicated interactions between COVID-19 infection and PD have several implications. Enhanced psychiatric follow-up should be considered for survivors of COVID-19. Besides, early detection and intervention for PD are needed to control morbidity and mortality induced by the COVID-19 infection.

Disclosure

No significant relationships.

Disease Burden Of Co-Occurring Borderline Personality Disorder In Patients With Bipolar Disorder

Introduction

In recent years, advances in the areas of both bipolar disorder (BD) and borderline personality disorder (BPD) have generated considerable interest in the relationship between these two conditions, since that they are commonly comorbid.

Objectives

We aimed to investigate the impact of BPD on course of illness in patients with BP.

Methods

We conducted a cross-sectional, descriptive and analytical study among 30 psychiatric outpatients diagnosed with BD in the Psychiatry « B » department, Hedi Chaker Hospital (Sfax, Tunisia). The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) was used to screen for BPD. Clinical outcomes (hospital stays, comorbidities, suicidality…) were compared between BD- patients with or without BPD comorbidity.

Results

The mean age was 41.63 years, with a sex ratio of ½. Among the patients, 2/3 were diagnosed with BD-I, while 1/3 presented a BD-II. Physical comorbidities, comorbid anxious and eating disorders were noted respectively in 36.7%; 16.7% and 43.3% of patients. Suicidal attempts were reported in 46.7% of cases. According to MSI-BPD, a comorbid BPD was noted in 30% of our sample. Patients with BD-II were significantly more likely to present BDP traits (50%) than those with BD-I (20%) (p<0.001). Patients with BPD were significantly more likely to attempt suicide (p=0.033), and to present physical comorbidities (p<0.001) and comorbid eating disorders (p<0.001).

Conclusions

Our study showed that BPD darkens the prognosis of BD, because of worse outcomes related to suicide, physical and psychiatric comorbidities. Thus, its co-occurrence complicates the management of BD.

Disclosure

No significant relationships.

Pre-infection 25-hydroxyvitamin D3 levels and association with severity of COVID-19 illness

Objective

Studies have demonstrated a potential correlation between low vitamin D status and both an increased risk of infection with SARS-CoV-2 and poorer clinical outcomes. This retrospective study examines if, and to what degree, a relationship exists between pre-infection serum 25-hydroxyvitamin D (25(OH)D) level and disease severity and mortality due to SARS-CoV-2.

Participants

The records of individuals admitted between April 7^th, 2020 and February 4^th, 2021 to the Galilee Medical Center (GMC) in Nahariya, Israel, with positive polymerase chain reaction (PCR) tests for SARS-CoV-2 (COVID-19) were searched for historical 25(OH)D levels measured 14 to 730 days prior to the positive PCR test.

Design

Patients admitted to GMC with COVID-19 were categorized according to disease severity and level of 25(OH)D. An association between pre-infection 25(OH)D levels, divided between four categories (deficient, insufficient, adequate, and high-normal), and COVID-19 severity was ascertained utilizing a multivariable regression analysis. To isolate the possible influence of the sinusoidal pattern of seasonal 25(OH)D changes throughout the year, a cosinor model was used.

Results

Of 1176 patients admitted, 253 had records of a 25(OH)D level prior to COVID-19 infection. A lower vitamin D status was more common in patients with the severe or critical disease (<20 ng/mL [87.4%]) than in individuals with mild or moderate disease (<20 ng/mL [34.3%] p < 0.001). Patients with vitamin D deficiency (<20 ng/mL) were 14 times more likely to have severe or critical disease than patients with 25(OH)D ≥40 ng/mL (odds ratio [OR], 14; 95% confidence interval [CI], 4 to 51; p < 0.001).

Conclusions

Among hospitalized COVID-19 patients, pre-infection deficiency of vitamin D was associated with increased disease severity and mortality.

Auditory Performance in Recovered SARS-COV-2 Patients

OBJECTIVE

While COVID-19 symptoms impact rhinology (anosmia) and laryngology (airways), two major disciplines of the otolaryngology armamentarium, the virus has seemed to spare the auditory system. A recent study, however, reported changes in otoacoustic emission (OAE) signals measured in SARS-COV-2 positive patients. We sought to assess the effect of COVID-19 infection on auditory performance in a cohort of recovered SARS-COV-2 patients and controls. To avoid a potential bias of previous audiological dysfunction not related to SARS-COV-2 infection, the study encompasses patients with normal auditory history. We hypothesized that if SARS-COV-2 infection predisposes to hearing loss, we would observe subtle and early audiometric deficits in our cohort in the form of subclinical auditory changes.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary referral center.

PATIENTS

The Institutional Review Board approved the study and we recruited participants who had been positive for SARS-COV-2 infection, according to an Reverse Transcription Polymerase Chain Reaction (RT-PCR) test on two nasopharyngeal swabs. The patients included in this study were asymptomatic for the SARS-COV-2 infection and were evaluated following recovery, confirmed by repeated swab testing. The control group comprised healthy individuals matched for age and sex, and with a normal auditory and otologic history.

INTERVENTIONS

The eligibility to participate in this study included a normal audiogram, no previous auditory symptoms, normal otoscopy examination with an intact tympanic membrane, and bilateral tympanometry type A. None of our volunteers reported any new auditory symptoms following SARS-COV-2 infection. Ototacoustic emissions (OAE) and auditory brainstem response (ABR) measurements were used to evaluate the auditory function.

MAIN OUTCOME MEASURES

OAE and ABR measurements.

RESULTS

We have found no significant differences between recovered asymptomatic SARS-COV-2 patients and controls in any of transitory evoked otoacoustic emission (TEOAE), distortion product otoacoustic emissions (DPOAE), or ABR responses.

CONCLUSIONS

There is no cochlear dysfunction represented by ABR, TEOAE, and DPOAE responses in recovered COVID-19 asymptomatic patients. Retrocochlear function was also preserved as evident by the ABR responses. A long-term evaluation of a larger cohort of SARS-COV-2 patients will help to identify a possible contribution of SARS-COV-2 infection to recently published anecdotal auditory symptoms associated with COVID-19.

Vaccine hesitancy due to vaccine country of origin, vaccine technology, and certification

Vaccine hesitancy is a global health threat which may hinder the widespread acceptance of several COVID-19 vaccines. Following the collection of 2470 responses from an anonymous questionnaire distributed between October and November 2020 across Israel, we analyzed the responses of physicians, life science graduates (biology, virology, chemistry, etc.), and the general public to whether they would obtain a COVID-19 vaccine with particular vaccine characteristics such as vaccine country of origin, technology, side effect profile, efficacy, and other attributes. Physicians and life science graduates were least likely to accept a vaccine based on mRNA technology (30%) while the general population seemed to adopt any vaccine technology if the declared efficacy is above 90% and the country of manufacturing is the USA/UK rather than China or Russia. However, current inoculation rates in Israel far outpace our predicted rate. Our results highlight the importance of tailored vaccine educational campaigns based on population demographic details and specific vaccine concerns.

Local Delivery of Mometasone Furoate from an Eluting Endotracheal Tube Reduces Airway Morbidity Following Long-Term Animal Intubation

BACKGROUND

upper airway complications are common sequelae of endotracheal tube (ETT) intubation, and systemic corticosteroids are considered a mainstay treatment for this problem. Drug-eluting ETT may present an attractive option for topical steroid delivery while avoiding systemic side effects and improving the therapeutic outcome. The objective of the present study is to evaluate the reduction of tube-related tracheal morbidity via a self-designed steroid-eluting ETT with controlled sustained release properties in an animal model.

METHODS

steroid-eluting ETTs were coated by poly(lactic-co-glycolic acid) -electrospun nanofibers loaded with mometasone furoate (MF) as a model drug. Animals were randomly assigned into three equal groups: non-intubated, blank-ETT, and loaded-ETT. The intubation interval was 1 week. Specimens were analyzed by histology, specific fibrosis staining, and scanning electron microscopy (SEM).

RESULTS

the blank-ETT group exhibited a significant increase in tracheal mucosal thickness compared to the loaded-ETT and control groups. Average tracheal mucosal thickness was 112 ± 34, 242 ± 49, and 113 ± 43 μm in the control, blank-ETT, and loaded-ETT groups, respectively. The blank-ETT group exhibited a significant increase in tracheal fibrosis compared to the loaded-ETT and control groups. Relative fibrosis values were 0.07 ± 0.05, 0.154 ± 0.1, and 0.0984 ± 0.084% for the control, blank-ETT, and loaded-ETT groups, respectively. While SEM imaging showed normal surface structures in the control group, intubated blank-ETT rats showed severe surface structural damage, whereas only mild damage was observed in the loaded-ETT group.

CONCLUSIONS

local sustained release of MF via a self-designed drug-eluting ETT is a potential therapeutic approach which may significantly reduce tube-related upper airway morbidity.

COVID-19 Vaccine Acceptance Among Dental Professionals Based on Employment Status During the Pandemic

The COVID-19 pandemic spread rapidly across the globe, leading governments to impose prolonged lockdowns on both movement and commerce. Although lockdowns decrease the rates of novel infections, they can have devastating consequences on the economy and employment levels. One of the most severely affected sectors during this crisis has been dental medicine. Dental professionals are uniquely exposed to environments with high levels of occupational hazards, conferring additional risks of viral exposure and transmission. We analyzed 506 anonymous questionnaires completed by dentists and residents regarding acceptance of a future potential SARS-CoV-2 vaccine. Our results demonstrate a statistically significant correlation between the individual's unemployment rate and their willingness to inoculate with a SARS-CoV-2 vaccine when it becomes available. This information can be used to predict trends of vaccine acceptance or rejection based on economic burden during the COVID-19 pandemic by different sectors as part of the preparedness toward global vaccination programs.

United by Hope, Divided by Access: Country Mapping of COVID-19 Information Accessibility and Its Consequences on Pandemic Eradication

Many government websites and mobile content are inaccessible for people with vision, hearing, cognitive, and motor impairments. The COVID-19 pandemic highlighted these disparities when health authority website information, critical in providing resources for curbing the spread of the virus, remained inaccessible for numerous disabled populations. The Web Content Accessibility Guidelines provide comparatively universally accepted guidelines for website accessibility. We utilized these parameters to examine the number of countries with or without accessible health authority websites. The resulting data indicate a dearth of countries with websites accessible for persons with disabilities. Methods of information dissemination must take into consideration individuals with disabilities, particularly in times of global health crises.

A novel rat model for tracheal mucosal damage assessment of following long term intubation

OBJECTIVE

Tracheal mucosal damage is a well-known complication of endo-tracheal intubation and animal models are essential for studying the underlying cellular injury cascade. The novel rat model described here is based on retrograde intubation via tracheotomy and suture fixation of the tube. It aims to simulate the common clinical scenario of tube-related airway damage due to long term intubation.

STUDY DESIGN

Prospective randomized control pilot study.

METHODS

Male Sprague-Dawley were randomly assigned into two groups: control (no intubation, n = 10), one week of intubation (n = 13). The animals were then euthanized and the trachea was sent for histological analysis. Epithelial damage, mucosal thickness, mucosal gland hypertrophy and fibrosis were reviewed.

RESULTS

Intubation procedure survival rate was 84.6% (11/13) and 100% in the control (10/10). The damaged ciliary mechanism was a common finding in the intubated group compared to the preserved normal ciliary architecture in almost all control rats. Average tracheal mucosal thickness was 119.0 ± 21.8 μm for the control group and 254.6 ± 22.8 μm for the intubated group, (p < 0.001). The ciliary damage score was 1.00 ± 0.02 in the intubated group, and 0 ± 0.02 in the control group. (p < 0.001). The (objective) average total tracheal mucosal gland area was 19,530 ± 24,606 in the intubated group and 10,031 ± 23,461 in the control group (p < 0,05). Collagen deposition seems higher in the intubated trachea compared to the control.

CONCLUSIONS

We describe a novel rat-based animal model for simulating tracheal mucosal damage following long term intubation. This animal model is easy to carry out, reproducible and involves containable animal mortality rates.

LEVEL OF EVIDENCE

I.

Four-week cold acclimation in adult humans shifts uncoupling thermogenesis from skeletal muscles to brown adipose tissue

KEY POINTS

Muscle-derived thermogenesis during acute cold exposure in humans consists of a combination of cold-induced increases in skeletal muscle proton leak and shivering. Daily cold exposure results in an increase in brown adipose tissue oxidative capacity coupled with a decrease in the cold-induced skeletal muscle proton leak and shivering intensity. Improved coupling between electromyography-determined muscle activity and whole-body heat production following cold acclimation suggests a maintenance of ATPase-dependent thermogenesis and decrease in skeletal muscle ATPase independent thermogenesis. Although daily cold exposure did not change the fibre composition of the vastus lateralis, the fibre composition was a strong predictor of the shivering pattern evoked during acute cold exposure.

ABSTRACT

We previously showed that 4 weeks of daily cold exposure in humans can increase brown adipose tissue (BAT) volume by 45% and oxidative metabolism by 182%. Surprisingly, we did not find a reciprocal reduction in shivering intensity when exposed to a mild cold (18°C). The present study aimed to determine whether changes in skeletal muscle oxidative metabolism or shivering activity could account for these unexpected findings. Nine men participated in a 4 week cold acclimation intervention (10°C water circulating in liquid-conditioned suit, 2 h day^-1 , 5 days week^-1 ). Shivering intensity and pattern were measured continuously during controlled cold exposure (150 min at 4 °C) before and after the acclimation. Muscle biopsies from the m. vastus lateralis were obtained to measure oxygen consumption rate and proton leak of permeabilized muscle fibres. Cold acclimation elicited a modest 21% (P < 0.05) decrease in whole-body and m. vastus lateralis shivering intensity. Furthermore, cold acclimation abolished the acute cold-induced increase in proton leak. Although daily cold exposure did not change the fibre composition of the m. vastus lateralis, fibre composition was a strong predictor of the shivering pattern evoked during acute cold. We conclude that muscle-derived thermogenesis during acute cold exposure in humans is not only limited to shivering, but also includes cold-induced increases in proton leak. The efficiency of muscle oxidative phosphorylation improves with cold acclimation, suggesting that reduced muscle thermogenesis occurs through decreased proton leak, in addition to decreased shivering intensity as BAT capacity and activity increase. These changes occur with no net difference in whole-body thermogenesis.

Diagnostic markers for neonatal sepsis: comparing C-reactive protein, interleukin-6 and immunoglobulin M

This clinical study was conducted to evaluate the diagnostic value of C-reactive protein (CRP), interlekin-6 (IL-6) and immunoglobulin M (IgM) in the early diagnosis of neonatal sepsis. The diagnostic values of each marker separately or in combinations were evaluated. The optimal cut-off values of each marker in the diagnosis of neonatal sepsis were defined. Between December 2004 and March 2005, a total of 78 neonates at different ages with different diagnoses in a neonatal intensive care unit in North Jordan were enrolled. Patients were classified into 'sepsis' group, 'probable sepsis' group and 'no sepsis' group. Blood samples were collected for CRP, IL-6 and IgM determination. A CRP value of 5 mg/l was the best among the three parameters with 95% sensitivity and 98% negative predictive value. Combination between parameters was helpful in enhancing the ability to diagnose sepsis. The best combination was CRP > or = 5 mg/l and/or IgM of > or =20 mg/dl. We conclude that CRP, IL-6 and IgM are helpful in the early diagnosis of Gram-negative neonatal sepsis. However, CRP continues to be the best single test. The use of both CRP and IgM in combination was the most helpful in predicting Gram-negative neonatal sepsis. We speculate a significant role of this combination in making decisions regarding antibiotics treatment and upgrading the level of medical care and observation in a setting where Gram-negative micro-organisms are causing the majority of neonatal infections.

Synthesis, DTA, IR and Raman spectra of penthylenediammonium hexachlorostannate NH3(CH2)5NH3SnCl6

The Raman and IR spectra of NH3(CH2)5NH3SnCl6 have been measured at ambient temperature. It is shown that the cations in the compound assume a symmetry lower than C2v. Combination bands observed in the 2100-1800 cm(-1) region in the IR spectrum of NH3(CH2)5NH3SnCl6 indicate that the compound contains the C-NH3 grouping, the bands are discussed and their assignment are suggested. No evidence of existence of hydrogen bonding is found from the infrared spectrum in the region of 2800-3200 cm(-1); anions and cations are found not connected by hydrogen bonding and are therfore isolated. The Raman spectrum of anions can be interpreted in terms of disordered groups, not clearly showing the predicted splitting of bands.

Clinical sinusitis in children attending primary care centers

OBJECTIVES

To determine the proportion of children who meet the clinical criteria for the diagnosis of sinusitis among all children attending primary care pediatric practices, to explore the relationship between passive smoking and the occurrence of sinusitis and to study the role of antibiotics in the management of sinusitis.

DESIGN

A prospective observational cohort study.

SETTING

Outpatient Pediatric Clinics of Jordan University of Science and Technology and Princess Rahma Teaching Hospital. Patients. All children ages 1 to 10 years presenting for any reason to participating practices.

METHODS

Physicians participating in this study completed a questionnaire on all children attending the primary care centers, detailing the presence of nasal congestion or discharge, the duration of symptoms, daytime cough and whether symptoms were improving. The presence or absence of smokers in the family was also recorded. Children meeting our clinical criteria for sinusitis were further evaluated for other signs and symptoms including the type of medication prescribed. The severity of symptoms was reassessed at 10-day follow-up after the first visit.

RESULTS

The study population was composed of 3001 children, of whom 249 met our clinical criteria for diagnosis of sinusitis (8.3%; 95% confidence interval, 7.3 to 9.3%). The prevalence rate of clinical sinusitis was greater among children age 5 years and older than among those younger (9.3% vs. 7.2%, P = 0.04). Children exposed to passive smoking in the household had clinical sinusitis significantly more than those not exposed (68.8% vs. 1.2%, P = 0.00). Antibiotics were prescribed for 80% of children who fulfilled the clinical criteria for diagnosis of sinusitis. Marked improvement of symptoms at the 10-day follow-up visit was reported among those who received antibiotics compared with those who did not (91% vs. 21.4%, P = 0.00).

CONCLUSIONS

Sinusitis is not an uncommon problem in children, passive smoking might be a contributing factor and a course of antibiotic therapy is beneficial.

[Experience of ambulatory anesthesia in Charles Nicolle hospital]

The authors report the experience of ambulatory surgery at Charles Nicoll's hospital on ophthalmology and ORL surgery in which 90% and 60% of acts can be realized on ambulatory. The organisation by means of structures and hospital workers makes an important gain. The anesthetic consultation, very important in this organisation, enable to avoid to rescue a patient at the last time.

Neonatal exchange transfusion: a Jordanian experience

The aetiology and complications of exchange transfusion (ET) were studied over a 6-year period in northern Jordan. During that time, 336 neonates (0.46% of total live births) underwent 386 ETs. There was a yearly reduction in the number of ETs, varying from 8.2% in the 1st year of the study to 2.7% in the last year. Thirty-nine (11.9%) required more than one ET. Twenty-five (7.4%) were preterm babies and the remainder full-term. The commonest cause of ET overall was G6PD deficiency, either alone or concomitant with ABO incompatibility (38.1%). ET complications occurred in 51 neonates (15.2%), the commonest being anaemia and bradycardia. Septicaemia occurred in only 3% of cases. Only one baby died. G6PD deficiency, either alone or concomitant with ABO isoimmunization, is the most common cause of ET in northern Jordan. Fewer preterm babies require ET and there is a low incidence of septicaemia following ET.

Henoch-Schonlein purpura and streptococcal infection: a prospective case-control study

A prospective, matched, case-control study conducted over a period of 3 years was designed to examine the association of group A beta-haemolytic streptococcal infections and Henoch-Schonlein purpura. Demographic and clinical data were collected as well as measurement of antistreptolysin O titres and throat swab culture on all children admitted with Henoch-Schonlein purpura, as well as their matched controls. Antistreptolysin O titre positivity was associated with a 10-fold increase in the risk of Henoch-Schonlein purpura. Renal involvement was common among cases with positive antistreptolysin O titres (27%) compared with cases with a negative titre (8%) but this difference has no statistical significance.

Distribution and ecology of ticks (Acari: Ixodidae) infesting livestock in Tunisia: an overview of eighth years field collections

Ticks (Ixodidae) play a significant role as vectors of pathogens of domestic animals in Tunisia. The major losses caused by ticks are related to transmission of protozoan parasites. These include agents of tropical theileriosis and babesiosis in ruminants. Since 1991, we conducted research studies on tick population of livestock in Tunisia. This overview reports a synthesis on tick distribution, their biology and their role as vectors of pathogens in domestic animals, particularly cattle. During the whole period of the study about 15,000 tick specimens were collected from different zones of the country. A total of 14 species were identified. Hyalomma detritum detritum was the most abundant and important (vector of Theileria annulata) species infesting cattle. Hyalomma dromedarii and Hyalomma impeltatum were collected on domestic ruminants in the arid and desertic zones. Hyalomma marginatum marginatum and Hyalomma anatolicum excavatum were widespread and found on livestock hosts. Ixodes ricinus, vector of Babesia divergens and Borrelia burgdorferi sl, colonises mainly the humid zone. Boophilus annulatus and Rhipicephalus bursa infesting cattle, sheep and goats were found in the sub-humid and semi-arid zones. Haemaphysalis sulcata and Hae. punctata were collected in humid and sub-humid zones on cattle and sheep. Rhipicephalus turanicus were collected in different regions, on different animal species. Rhipicephalus sanguineus, tick of dogs, were often collected on livestock. Only few specimens of Hyalomma marginatum rufipes and Hyalomma franchinii were collected.

The effectiveness of BCG vaccination: the Jordanian experience

The objective of the present study was to evaluate the effectiveness of BCG vaccination against tuberculosis (TB). TB cases occurring before 1 January 1995 among the birth cohorts 1980-1986 were identified from the Central TB Registry in Amman, Jordan and their BCG vaccination status determined. The proportion of vaccinated and unvaccinated children by age at vaccination and birth cohort was obtained from the Directorate of Chest Diseases based on the surveys conducted by the Directorate. A total of 429 cases of TB occurred among the above birth cohorts during the follow-up period. The overall BCG effectiveness against TB was 87 per cent (95 per cent CL 0.81-0.91). BCG was highly effective against pulmonary TB (85 per cent, 95 per cent CL 0.78-0.90) as well as extrapulmonary TB (95 per cent, 95 per cent CL 0.82-0.99). Our data suggest that BCG vaccination should continue to be considered as an important component of the strategy of TB prevention and call for improvement of coverage with this vaccine.

[Hemorrhagic surgery in two Jehova's witness children refusing programmed autotransfusion: a place for erythropoietin]

We report two cases of haemorrhagic surgery in a 6-year-old and 16-year-old girl, respectively, whose parents were Jehovah's witnesses and therefore opposed to preoperative blood donation, but accepting intraoperative blood salvage. Erythropoietin and intravenous iron were administered preoperatively to increase red cell mass. Intraoperative blood salvage, including normovolaemic haemodilution and intraoperative autologous transfusion, avoided homologous blood transfusion.

Safety and cost effectiveness of a 10 x 10(9)/L trigger for prophylactic platelet transfusions compared with the traditional 20 x 10(9)/L trigger: a prospective comparative trial in 105 patients with acute myeloid leukemia

In 105 consecutive patients with de novo acute myeloid leukemia (French-American-British M3 excluded), we compared prospectively the risk of bleeding complications, the number of platelet and red blood cell transfusions administered, and the costs of transfusions using two different prophylactic platelet transfusion protocols. Two hundred sixteen cycles of induction or consolidation chemotherapy and 3,843 days of thrombocytopenia less than 25 x 10(9)/L were evaluated. At the start of the study, each of the 17 participating centers decided whether they would use a 10 x 10(9)/L prophylactic platelet transfusion trigger (group A/8 centers) or a 20 x 10(9)/L trigger (group B/9 centers). Bleeding complications (World Health Organization grade 2-4) during treatment cycles were comparable in the two groups: 20 of 110 (18%) in group A and 18 of 106 (17%) in group B (P = .8). Serious bleeding events (grade 3-4) were generally not related to the patient's platelet count but were the consequence of local lesions and plasma coagulation factor deficiencies due to sepsis. Eighty-six percent of the serious bleeding episodes occurred during induction chemotherapy. No patient died of a bleeding complication. There were no significant differences in the number of red blood cell transfusions administered between the two groups, but there were significant differences in the number of platelet transfusions administered per treatment cycle: pooled random donor platelet concentrates averaged 15.4 versus 25.4 (P < .01) and apheresis platelets averaged 3.0 versus 4.8 (P < .05) for group A versus group B, respectively. This resulted in the cost of platelet therapy being one third lower in group A compared with group B without any associated increase in bleeding risk.

Myositis ossificans: report of seven cases in children

The clinical features of seven children with myositis ossificans (circumscripta and progressiva) and radiographic signs of the disease are described. We recommend systematic radiological examination to seek other skeletal malformations for congenital hallux valgus in young children, for it may be the first sign of a myositis ossificans progressiva. The "zone phenomenon" observed on histology, along with differential diagnosis and evolution, is documented. The necessity of a biopsy and different forms of treatment are discussed.

[Tuberculosis and immigrants. A study of its prevalence in the Umbria region]

In 1995, 463 patients were admitted in the medical service of Perugia (Sanitary District n. 6). Only 20% of them were enrolled in the TBC programme. Mantoux was: < 10 mm in 35%, 10-15 mm in 25%, > 15 mm in 40%. Chest Rx in 30 subjects demonstrated: normality in 19; old TBC in 7, active TBC in 4 (miliary, bilateral upper lobe pneumonitis, left subapical upper lobe pneumonitis and right lobitis of the upper lobe). All patients were admitted in hospital and showed positive sputum culture for Mycobacterium Tuberculosis. They were treated with isoniazid, rifampin, pyrazinamide, ethambutol/streptomycin for 2 months and with isoniazid, rifampin for other 4-8 months. Two patients showed Mycobacterium tuberculosis with isoniazid resistance. Seven patients were treated with isoniazid chemoprophylaxis without side effects. Migrants should receive information about health care service and be encourage to register themselves with a general practitioner. Skin test screening and chest radiographs for those with positive results should be provided at a convenient location.

Neonatal meningitis due to Moraxella catarrhalis and review of the literature

Moraxella catarrhalis has been reported with increasing frequency to be the aetiological agent of serious systemic infection in both children and adults. The first case of neonatal meningitis due to this organism is described herein. The fatal outcome and causes of failure of response to antimicrobial therapy are also discussed. A brief review of the literature describing the disease entities with which M. catarrhalis has been associated is presented.