Job strain, occupation, and bladder health among women

OBJECTIVES

Lower urinary tract symptoms (LUTS) are common among employed women. An underexplored topic is whether characteristics of women's occupations may influence LUTS. The present study examined whether job strain and its individual components (psychological demands, decision latitude) were associated with greater LUTS and their impact and whether, compared to managerial and professional occupations, occupations characterized by manual labor, sales, service, nursing, and teaching were associated with greater LUTS and their impact.

METHODS

Coronary Artery Risk Development in Young Adults cohort study data were analyzed. Job strain and occupation were assessed in 1987-88 and 1995-96. In 2012-13, LUTS and their impact were assessed. LUTS/impact category (a composite variable ranging from bladder health to mild, moderate, and severe LUTS/impact) was regressed on job strain and occupation in separate analyses, adjusting for age, race, parity, education, and financial hardship (n = 1006).

RESULTS

Job strain and its individual components were not associated with LUTS/impact. In comparison to managerial and professional occupations, service occupations in 1987-88 and 1995-96 were both associated with greater odds of LUTS/impact in proportional odds logistic regression analyses. Employment as a nurse, health assistant, or health aide in 1995-96 was associated with greater odds of any LUTS/impact versus bladder health. Support positions in 1987-88 and sales positions in 1995-96 were associated with greater odds of moderate or severe LUTS/impact versus bladder health or mild LUTS/impact.

CONCLUSIONS

Future research should examine characteristics of workplaces that may promote or constrain bladder health (e.g., time and autonomy to void when desired, infrastructure to void).

Financial strain across 25 years and women's bladder health: a life course perspective

BACKGROUND

A small number of cross-sectional studies have found that financial insecurity-a social determinant of health-is associated with lower urinary tract symptoms.

OBJECTIVE

This study aimed to examine (1) whether women in the Coronary Artery Risk Development in Young Adult Study with higher levels of financial strain, assessed at 7 time points across 25 years beginning in 1985-1986, were more likely to report lower urinary tract symptoms and impact after the 2010-2011 financial strain assessment and (2) whether healthcare access and comorbidities mediated potential associations.

STUDY DESIGN

This prospective cohort study recruited Black and White participants aged 18 to 30 years at baseline (1985-1986) from the populations of 4 US cities. The analytical sample was composed of women with complete data for analyses involving financial strain trajectories across 7 assessments (n=841) and mediation tests of data collected at 4 assessments (n=886). The outcome variable was previously developed through a cluster analysis of urinary incontinence severity, urinary incontinence impact, other lower urinary tract symptoms severity, and their impact in 2012-2013, which yielded 4 lower urinary tract symptoms and impact cluster categories: women with no symptom or very mild symptoms and no impact vs women with mild, moderate, or severe symptoms and impact. Financial strain was defined as finding it "very hard," "hard," or "somewhat hard" (vs "not very hard") to pay for the very basics, such as food, heating, and medical care. Using proportional odds logistic regression, cluster categories were regressed on the financial strain trajectory group, adjusting for age, race, education, and parity. For mediation analyses, separate financial strain variables (difficulty paying for the very basics, such as food and heating, and difficulty paying for medical care) were created by combining 1995-1996 and 2000-2001 values. Two healthcare access variables (difficulty receiving care and underutilization of care) and a single comorbidity index (smoking, physical inactivity, body mass index, hypertension, diabetes mellitus, and depressive symptoms) were created by combining 2005-2006 and 2010-2011 values. Regression analyses and structural equation modeling were used to test whether healthcare access and comorbidities mediated associations between financial strain and lower urinary tract symptoms and impact cluster categories.

RESULTS

In comparison to women who were consistently not financially strained, women who were consistently strained (odds ratio, 2.10; 95% confidence interval, 1.13-3.91), shifted into being strained (odds ratio, 2.00; 95% confidence interval, 1.29-3.10), or experienced >1 shift in strain (odds ratio, 1.99; 95% confidence interval, 1.46-2.71) had roughly twice the odds of reporting greater lower urinary tract symptoms and impact. Underutilization of healthcare and comorbidities mediated the association between difficulty paying for medical care and lower urinary tract symptoms and impact. In the structural equation model, difficulty paying for medical care and underutilization of care were associated (β=.31; P<.01), as was underutilization of care and greater lower urinary tract symptoms and impact (β=.09; P<.01). Moreover, difficulty paying for medical care and the comorbidity index were associated (β=.34; P<.01), as was the comorbidity index and greater lower urinary tract symptoms and impact (β=.24; P<.01). Collectively, these mediation pathways eliminated a direct association between difficulty paying for medical care and lower urinary tract symptoms and impact.

CONCLUSION

Underutilization of healthcare and comorbidities explained an association between financial strain (difficulty paying for medical care) and lower urinary tract symptoms and impact. Research is needed to confirm the findings and examine other mechanisms that may further explain the association. Accumulated evidence may inform future policies and practices.

Discrimination and bladder health among women in the CARDIA cohort study: Life course and intersectionality perspectives

OBJECTIVE

This study examines whether discriminatory experiences are associated with lower urinary tract symptoms (LUTS) and their impact among 972 women in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study, which recruited participants from 4 cities in the United States.

METHOD

Exposure to discrimination was assessed 3 times (1992-93, 2000-01, 2010-11) and averaged across assessments. Participants separately reported whether they experienced discrimination on the basis of their gender, race or color, and socioeconomic position or social class. For each social identity, discrimination was assessed in 6-7 settings (e.g., when getting a job, medical care, or housing). At different time points, women who reported discriminatory experiences for a given social identity were asked how frequently the discrimination occurred and how stressful experience(s) were. Following the 2010-11 assessment, data on LUTS and their impact were collected. Women were classified into bladder health versus mild, moderate, or severe symptoms/impact clusters.

RESULTS

More Black than White women reported discriminatory experiences across all social identities and most settings. Perceived stress of discriminatory experiences did not differ between Black and White women. In analyses stratified by race and social identity, White women reported LUTS/impact with discriminatory experiences in more settings, more frequent discriminatory experiences across settings, and each additional social identity for which discrimination was experienced. Black women reported LUTS/impact with more frequent discriminatory experiences across settings. For Black women, greater perceived stress of both gender and race discrimination were associated with LUTS/impact. For White women, only greater perceived stress of race discrimination was associated with LUTS/impact.

CONCLUSIONS

This is one of the first studies to examine discrimination in relation to LUTS/impact. Additional research is needed to better understand differences in how discriminatory experiences based on potentially intersecting identities may be related to bladder health among women.

Trajectories of depressive symptoms over 20 years and subsequent lower urinary tract symptoms and impact among women

OBJECTIVE

The aim of the study is to examine the association between depressive symptoms and subsequent lower urinary tract symptoms (LUTS) and impact (a composite outcome) among women (N = 1,119) from the Coronary Artery Risk Development in Young Adults study.

METHODS

The Center for Epidemiologic Studies-Depression Scale (CES-D) was administered in 1990-1991 and every 5 years through 2010-2011. In 2012-2013, LUTS and impact data were collected for the first time. Accumulation of risk was examined in the following three ways: (1) mean CES-D score across 20 years (5 observations); (2) depressive symptom trajectory group, determined by group-based trajectory modeling; and (3) intercepts and slopes obtained from women's individual CES-D score trajectories through two-stage mixed effects modeling. For each approach, ordinal logistic regression analyses examined odds of having "greater LUTS/impact" for each unit change in a depressive symptom variable.

RESULTS

(1) With each one-unit increase in mean CES-D score over the 20-year period, women were 9% more likely to report greater LUTS/impact (odds ratio [OR] = 1.09, 95% CI = 1.07-1.11). (2) In comparison with women with consistently low depressive symptoms, women with consistently threshold depression or consistently high depressive symptoms were twice (OR = 2.07, 95% CI = 1.59-2.69) and over five times (OR = 5.55, 95% CI = 3.07-10.06) as likely, respectively, to report greater LUTS/impact. (3) Women's individual symptom intercept and slope interacted. Increases in depressive symptoms across 20 years (greater slopes) were associated with greater LUTS/impact when women's initial CES-D score (intercept) was in the moderate-to-high range relative to the sample.

CONCLUSIONS

Depressive symptoms over 20 years, examined with different degrees of nuance, were consistently associated with subsequently measured LUTS and impact.

Interpersonal Stressors and Resources for Support: Associations with Lower Urinary Tract Symptoms and Impact Among Women

Background: This study utilizes Coronary Artery Risk Development in Young Adults (CARDIA) data to examine whether women's perceived emotional support and interpersonal stressors are associated with lower urinary tract symptoms (LUTS) and their impact on quality of life. Materials and Methods: Emotional support was assessed at baseline/year 0 (1985-86), year 2 (1987-88), year 15 (2000-01), and year 20 (2005-06); interpersonal stressors were assessed at years 15 and 20. In 2012-13, LUTS and impact were assessed. LUTS/impact category (a composite variable ranging from bladder health to mild, moderate, and severe LUTS/impact) was regressed on trajectory groups of emotional support from years 0 to 20. Separately, LUTS/impact was regressed on mean emotional support and interpersonal stressors across years 15-20. Analyses were adjusted for age, race, education, and parity (n = 1104). Results: In comparison to women whose support trajectory from years 0 to 20 was consistently high, women whose support decreased from high to low had over twice the odds (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.76-4.20) of being classified into a more burdensome LUTS/impact category. Mean support and interpersonal stressors across years 15-20 were independently associated with lower odds (OR = 0.59; 95% CI = 0.44-0.77) and greater odds (OR = 1.52; 95% CI = 1.19-1.94), respectively, of being classified into a more burdensome LUTS/impact category. Conclusions: In the CARDIA cohort, quality of women's interpersonal relationships, assessed between 1985-86 and 2005-06, was associated with LUTS/impact assessed in 2012-13. Additional research collecting LUTS/impact data at multiple time points is needed to test potential bidirectional associations of emotional support and interpersonal stressors with LUTS/impact, as well as potential mechanisms of association.

Mutational survivorship bias: The case of PNKP

The molecular function of a protein relies on its structure. Understanding how variants alter structure and function in multidomain proteins is key to elucidate the generation of a pathological phenotype. However, one may fall into the logical bias of assessing protein damage only based on the variants that are visible (survivorship bias), which can lead to partial conclusions. This is the case of PNKP, an important nuclear and mitochondrial DNA repair enzyme with both kinase and phosphatase function. Most variants in PNKP are confined to the kinase domain, leading to a pathological spectrum of three apparently distinct clinical entities. Since proteins and domains may have a different tolerability to variation, we evaluated whether variants in PNKP are under survivorship bias. Here, we provide the evidence that supports a higher tolerance in the kinase domain even when all variants reported are deleterious. Instead, the phosphatase domain is less tolerant due to its lower variant rates, a higher degree of sequence conservation, lower dN/dS ratios, and the presence of more disease-propensity hotspots. Together, our results support previous experimental evidence that demonstrated that the phosphatase domain is functionally more necessary and relevant for DNA repair, especially in the context of the development of the central nervous system. Finally, we propose the term "Wald’s domain" for future studies analyzing the possible survivorship bias in multidomain proteins.

Otitis media across nine countries: disease burden and management

OBJECTIVE

To assess the perceived disease burden and management of otitis media (OM) among an international cohort of experienced physicians.

METHODS

A cross-sectional survey conducted in France, Germany, Spain, Poland, Argentina, Mexico, South Korea, Thailand and Saudi Arabia. Face-to-face interviews conducted with 1800 physicians (95% paediatricians, 5% family practitioners).Main outcome measures were the perceived burden on clinical practice (number of cases, complications and referrals) and first- and second-line management strategies for OM. Results are expressed as mean and range across the nine countries over three continents.

RESULTS

Respondents estimated an average annual caseload of 375 (range 128-1003) children under 5 years of age with OM; 54% (range 44-71%) with an initial episode and 38% (range 27-54%) with recurrent OM (ROM). OM with complications was estimated to be approximately 20 (range 7-49) cases per year and an estimated 15% (8-41%) of children with OM was recalled as needing specialist referral. There was high awareness of Streptococcus pneumoniae and Haemophilus influenzae as causative bacterial pathogens: 77% (range 65-91%) and 74% (range 68-83%), respectively, but less recognition of non-typeable H. influenzae (NTHi); 59% (range 45-67%). Although concern over antimicrobial resistance was widespread, empirical treatment with antibiotics was the most common first-line treatment (mean 81%, range 40-96%). The burden of disease is substantial enough that many physicians would consider vaccination to prevent OM (mean score 5.1, range 4.3-6.2 on 1-7 scale).

CONCLUSIONS

This large, multinational survey shows that OM remains a significant burden for clinical practice. Despite awareness of shortcomings, antimicrobial therapy remains the most frequent treatment for OM.

Safety and immunogenicity of one dose of MenACWY-CRM, an investigational quadrivalent meningococcal glycoconjugate vaccine, when administered to adolescents concomitantly or sequentially with Tdap and HPV vaccines

This Phase III study evaluates an investigational quadrivalent meningococcal CRM(197) conjugate vaccine, MenACWY-CRM (Novartis Vaccines), when administered concomitantly or sequentially with two other recommended adolescent vaccines; combined tetanus, reduced diphtheria and acellular pertussis (Tdap), and human papillomavirus (HPV) vaccine. In this single-centre study, 1620 subjects 11-18 years of age, were randomized to three groups (1:1:1) to receive MenACWY-CRM concomitantly or sequentially with Tdap and HPV. Meningococcal serogroup-specific serum bactericidal assay using human complement (hSBA), and antibodies to Tdap antigens and HPV virus-like particles were determined before and 1 month after study vaccinations. Proportions of subjects with hSBA titres > or =1:8 for all four meningococcal serogroups (A, C, W-135, Y) were non-inferior for both concomitant and sequential administration. Immune responses to Tdap and HPV antigens were comparable when these vaccines were given alone or concomitantly with MenACWY-CRM. All vaccines were well tolerated; concomitant or sequential administration did not increase reactogenicity. MenACWY-CRM was well tolerated and immunogenic in subjects 11-18 years of age, with comparable immune responses to the four serogroups when given alone or concomitantly with Tdap or HPV antigens. This is the first demonstration that these currently recommended adolescent vaccines could be administered concomitantly without causing increased reactogenicity.

Bacteriologic and clinical efficacy of high dose amoxicillin/clavulanate in children with acute otitis media

OBJECTIVES

To determine the bacteriologic and clinical efficacy of high dose amoxicillin/clavulanate (90/6.4 mg/kg/day) against common bacterial pathogens causing acute otitis media (AOM), including penicillin-resistant Streptococcus pneumoniae (PRSP).

METHODS

In this open label multicenter study, 521 infants and children with AOM [mean age, 18.6 months; age < 24 months, n = 375 (72%)] were treated with amoxicillin/clavulanate 90/6.4 mg/kg/day in two divided doses for 10 days. Bilateral otitis media, previous episodes of AOM, antibiotic treatment within 3 months and day-care attendance were recorded in 60.1, 35.7, 50.2 and 38.2% of the children, respectively. Tympanocentesis was performed before the first dose and repeated on Days 4 to 6 for all children with S. pneumoniae at 22 centers and for all children with any pathogen at 3 centers. Clinical response was assessed at end of therapy.

RESULTS

Pathogens were isolated from 355 (68%) of 521 enrolled children; 180 children underwent repeat tympanocentesis and were bacteriologically evaluable. Baseline pathogens were S. pneumoniae (n = 122 enrolled/93 bacteriologically evaluable), Haemophilus influenzae (n = 160/51), both (n = 37/32) and others (n = 36/4). Pathogens were eradicated from 172 (96%) of 180 bacteriologically evaluable children. Overall 122 (98%) of 125 isolates of S. pneumoniae were eradicated, including 31 (91%) of 34 PRSP isolates (penicillin MICs 2 to 4 micrograms/ml). Seventy-eight (94%) of 83 isolates of H. influenzae were eradicated. Symptoms and otoscopic signs of acute inflammation were completely resolved or improved on Days 12 to 15 in 263 (89%) of 295 clinically evaluable children with bacteriologically documented AOM.

CONCLUSIONS

On the basis of bacteriologic outcome on Days 4 to 6 and clinical outcome on Days 12 to 15, we found that high dose amoxicillin/clavulanate (90/6.4 mg/kg/day) was highly efficacious in children with AOM, including those most likely to fail treatment, namely children < 24 months of age and those with infectious caused by PRSP.

Microbiology of acute otitis media in Costa Rican children

BACKGROUND

Because of the increasing number of resistant middle ear pathogens reported from different centers worldwide, an active surveillance of the microbiology and susceptibility pattern of middle ear pathogens is required for proper antimicrobial recommendations among different regions of the world.

OBJECTIVE

To study the microbiology and susceptibility pattern of middle ear pathogens obtained from Costa Rican children with acute otitis media.

METHODS

Between 1992 and 1997 a diagnostic tympanocentesis was performed in 398 Costa Rican patients with acute otitis media. Middle ear fluid was obtained for culture and minimal inhibitory concentrations were determined by the E-test technique in those isolates obtained between October, 1995, and January, 1997.

RESULTS

The most common pathogens cultured were Streptococcus pneumoniae (30%), Haemophilus influenzae (14%), Staphylococcus aureus (4%) and Streptococcus pyogenes (4%). Moraxella catarrhalis was uncommon. Beta-lactamase production was low (3.7%) among the H. influenzae isolates but frequent among the Staphylococcus aureus (57.1%) and M. catarrhalis (100%) strains. Overall 9 of 46 S. pneumoniae isolates (19.6%) exhibited decreased susceptibility to penicillin of which 8 isolates (17.4%) showed intermediate and one strain (2.2%) high level resistance. Among the penicillin-susceptible S. pneumoniae isolates, susceptibility to the following antimicrobials was: 81%, azithromycin; 89%, clarithromycin; and 100%, ceftriaxone and trimethoprim-sulfamethoxazole (TMP-SMX). Among the penicillin-resistant S. pneumoniae isolates the percentage of susceptible strains was 89% for azithromycin, clarithromycin and ceftriaxone and 67% for TMP-SMX.

CONCLUSIONS

Based on this microbiologic information the agents considered first line drugs in the treatment of acute otitis media in Costa Rica remain amoxicillin or TMP-SMX.

Early detection of sequela-prone osteomyelitis in children with use of simple clinical and laboratory criteria

To determine which clinical or laboratory criteria best reflected the prognosis for 83 children with acute hematogenous osteomyelitis (AHO), they were compared with outcomes after a follow-up of at least 2 months (for 78%, > or = 6 months). Twenty-eight children (34%) developed sequelae. They had higher serum C-reactive protein (CRP) concentrations (days 1-6 of treatment; P = .0004 to .0001) and higher clinical scores (P = .0001) than did patients who had an uneventful recovery. The frequency of sequelae increased from 3% to 73% (P = .0001) when CRP concentrations exceeded the defined cutoff limits and the clinical scores were > or = 1. Age, the duration of symptoms at diagnosis, and the type and duration of intravenous antimicrobial therapy or surgical management did not differ (P > .05) between children with and without sequelae. Both CRP determinations and clinical evaluations with use of a scoring system enable early detection of sequela-prone AHO in children and are most accurate when used together.

Comparative trial of 3 days of azithromycin versus 10 days of clarithromycin in the treatment of children with acute otitis media with effusion

The authors compared the efficacy, safety and tolerance of azithromycin and clarithromycin in pediatric patients with acute otitis media. A randomized, open clinical trial was performed comparing azithromycin and clarithromycin in children aged 6 months to 12 years of age with acute otitis media with effusion. Patients were allocated to azithromycin at 10 mg/kg once daily for 3 days or to clarithromycin at 15 mg/kg day divided into two equal doses for 10 days. Clinical examinations and tympanometric evaluations were performed at baseline, day 3-5, day 10-14, day 28-30 and day 50-60. Tympanocentesis fluid cultures were collected at enrollment and urine and blood samples were obtained at baseline and day 10-14. Of 100 patients enrolled, 97 were considered evaluable. The most common middle ear pathogens were Streptococcus pneumoniae (60%), Haemophilus influenzae (15%) and Staphylococcus aureus (13%). Fifty patients (100%) treated with azithromycin and 45 (95.7%) patients treated with clarithromycin had a satisfactory clinical response. Rates of persistence of middle ear effusion and possible drug related side effects were comparable. Based on the efficacy and safety results, azithromycin for 3 days and clarithromycin for 10 days are considered to represent an attractive alternative for the treatment of children with acute otitis media.

An open, multicenter clinical trial of piperacillin/tazobactam in the treatment of pediatric patients with intra-abdominal infections

A total of 60 children with secondary peritonitis were enrolled in an open, non-comparative multicenter study designed to evaluate the safety, tolerance and efficacy of parenteral piperacillin/tazobactam (80/10 mg/kg every 8 hours) in young children. The most common diagnosis was perforated appendicitis (90%) and the three most common pathogens, obtained from the peritoneal cavity, were Escherichia coli (52 isolates), Pseudomonas aeruginosa (16 isolates) and Bacteroides sp. (19 isolates). Patients were examined daily during therapy, 4-14 days and 4-6 weeks post-therapy. Of the 60 patients, 43 were evaluable. The majority of patients had polymicrobial infections (36 patients). All the aerobic isolates were susceptible to piperacillin/tazobactam while 19 were resistant to piperacillin alone. Four of 43 clinically evaluable patients were considered a clinical failure and 3 of 40 bacteriologically evaluable patients were considered to have an unfavorable microbiological response. There were 2 clinically adverse events considered related to the study drug and several possibly related, mild and transitory, abnormalities in eosinophil counts and liver function tests. Based on the safety and efficacy results from this study, the advantages of using a single agent for the treatment of mixed infections of the peritoneal cavity and its potential activity against resistant organisms, we believe that further comparative clinical trials in children with intra-abdominal infections are warranted.

Paragonimus mexicanus pericarditis: report of two cases and review of the literature

The cases of two Costa Rican children with pericarditis due to Paragonimus mexicanus are reported. Clinical, epidemiological and laboratory tests are consistent with the disease. Treatment with praziquantel and bitheonol was associated with clinical cure. A review of the literature and a suggested table of diagnostic criteria are included.

Serial serum C-reactive protein to monitor recovery from acute hematogenous osteomyelitis in children

Serial C-reactive protein (CRP) and erythrocyte sedimentation rate determinations were compared with clinical course and outcome at 1 to 2 months in 63 children with acute hematogenous osteomyelitis. High CRP values (163 +/- 108 mg/liter) on admission began to descend after the second day of treatment. From the fourth day on higher (P = 0.03 to P = 0.0001) CRP values distinguished a complicated from an uneventful course of acute hematogenous osteomyelitis and the patients symptomatic at follow-up (P = 0.003 to P = 0.0001) from asymptomatic ones. Children who developed extensive radiographic changes had elevated CRP values for a longer time (32 +/- 13 days) than children with typical changes (11 +/- 6 days, P = 0.0001). Erythrocyte sedimentation rates did not identify the type of clinical course but higher values on Days 4 to 7 distinguished children symptomatic at follow-up (P = 0.02) from asymptomatic ones. Monitoring serial CRP values can alert the physician to complications and predict outcome earlier than clinical signs or roentgenograms.

Antimicrobial therapy for children with chronic suppurative otitis media without cholesteatoma

This study was designed to determine the middle ear bacterial pathogens, the frequency of serum immunoglobulin deficiency and the efficacy of medical management in patients with chronic suppurative otitis media without cholesteatoma. This was an open noncomparative clinical trial performed at the National Children's Hospital, San Jose, Costa Rica, and included 186 patients older than 2 months of age with a confirmed diagnosis of chronic suppurative otitis media without cholesteatoma. Middle ear cultures and serum for immunoglobulin determinations were obtained on admission. The first 40 patients were treated only with ceftazidime and from patient 41 and up, if a Gram-positive organism was cultured, oxacillin was added to (for combined infection) or replaced ceftazidime. Parenteral antibiotics and suction twice daily were continued until three days after the middle ear became dry. Trimethropimsulfamethoxazole prophylaxis was administered during the follow-up period. Middle ear bacterial cultures were positive in 166 patients. Pseudomonas sp. (35.6%), enteric Gram-negative organisms (28.7%) and Gram-positive cocci (26%) were the most common organisms. Immunoglobulin determinations were below normal in 3 of 69 (4.3%) evaluable patients. Dryness of the ear was achieved in 174 patients (93.5%) including 130 of 139 patients treated with ceftazidime, 28 of 28 patients treated with oxacillin and 14 of 14 patients treated with ceftazidime and oxacillin. Recurrent otorrhea developed in 39 (23.4%) patients. Twice-daily canal aspiration and parenteral ceftazidime for Gram-negative organisms and/or oxacillin for Gram-positive bacteria for 3 days after dryness of the middle ear followed by prophylactic oral antimicrobials are effective for treatment of most chronic suppurative otitis media without cholesteatoma patients.

Prevention of rheumatic fever in Costa Rica

During the beginning of the 1970s, major changes occurred in Costa Rica in the treatment of streptococcal throat infections. Because of poor compliance with regimens using orally administered agents, intramuscular administration of benzathine penicillin was selected as the standard treatment and throat cultures were eliminated as a prerequisite for prescribing antibiotics. A decline in the incidence of rheumatic fever then occurred. We believe that similar health intervention could be applied in other developing countries.

Parainfluenza type 3 meningitis. Report of two cases and review of the literature

The authors present two immunocompetent children with parainfluenza type 3 meningitis. In each case, the outcome was favorable without detectable complications. The authors reviewed the literature, showing that central nervous system (CNS) involvement by parainfluenza viruses has rarely been described but may present with a variety of neurologic syndromes. Pediatricians and laboratory personnel should recognize that these viruses, commonly known to produce respiratory syndromes, can also be a cause of CNS infections. If additional studies confirm these observations, clinicians and virology laboratories may consider whether early hemadsorption testing to detect myxoviruses is warranted.