Effectiveness of Amoxicillin/Clavulanate Potassium in the Treatment of
Acute Bacterial Sinusitis in Children
Ellen R. Wald, David Nash, and Jens Eickhoff
Pediatrics 2009;124 9-15

OBJECTIVE: The role of antibiotic therapy in managing acute bacterial sinusitis (ABS) in children is controversial. The purpose of this study was to determine the effectiveness of high-dose amoxicillin/potassium clavulanate in the treatment of children diagnosed with ABS.

METHODS: This was a randomized, double-blind, placebo-controlled study. Children 1 to 10 years of age with a clinical presentation compatible with ABS were eligible for participation. Patients were stratified according to age (<6 or 6 years) and clinical severity and randomly assigned to receive either amoxicillin (90 mg/kg) with potassium clavulanate (6.4 mg/kg) or placebo. A symptom survey was performed on days 0, 1, 2, 3, 5, 7, 10, 20, and 30. Patients were examined on day 14. Children’s conditions were rated as cured, improved, or failed according to scoring rules.

RESULTS: Two thousand one hundred thirty-five children with respiratory complaints were screened for enrollment; 139 (6.5%) had ABS. Fifty-eight patients were enrolled, and 56 were randomly assigned. The mean age was 66 ± 30 months. Fifty (89%) patients presented with persistent symptoms, and 6 (11%) presented with nonpersistent symptoms. In 24 (43%) children, the illness was classified as mild, whereas in the remaining 32 (57%) children it was severe. Of the 28 children who received the antibiotic, 14 (50%) were cured, 4 (14%) were improved, 4 (14%) experienced treatment failure, and 6 (21%) withdrew. Of the 28 children who received placebo, 4 (14%) were cured, 5 (18%) improved, and 19 (68%) experienced treatment failure. Children receiving the antibiotic were more likely to be cured (50% vs 14%) and less likely to have treatment failure (14% vs 68%) than children receiving the placebo.

CONCLUSIONS: ABS is a common complication of viral upper respiratory infections. Amoxicillin/potassium clavulanate results in significantly more cures and fewer failures than placebo, according to parental report of time to resolution of clinical symptoms.

Treatment of Kawasaki Disease: Analysis of 27 US Pediatric Hospitals From
2001 to 2006
Mary Beth F. Son, Kimberlee Gauvreau, Lin Ma, Annette L. Baker, Robert P.
Sundel, David R. Fulton, and Jane W. Newburger
Pediatrics 2009;124 1-8

OBJECTIVES: We sought to analyze trends in admissions and to describe therapies used for acute Kawasaki disease over a 6-year period.

METHODS: The Pediatric Health Information System provides patient data including demographic variables, International Classification of Diseases, Ninth Revision codes, and services billed to patients. Patient identifiers enable tracking of medication use in and across multiple admissions within a center. We analyzed data for patients with (1) a diagnosis code for Kawasaki disease, (2) intravenously administered immunoglobulin treatment during hospitalization, and (3) discharge between January 1, 2001, and December 30, 2006, from 27 hospitals contributing complete data over the study period.

RESULTS: During the study period, 5197 Kawasaki disease admissions were identified for 4811 patients; numbers increased 32.6% from 2001 (n = 678) to 2006 (n = 899). Retreatment with intravenous immunoglobulin was administered to 712 patients (14.8%) over the study period. Other antiinflammatory therapies included intravenously administered methylprednisolone (5.8%), orally administered prednisone (2.8%), and infliximab (1%). Use of infliximab steadily increased from 0.0% (0 of 678 patients) in 2001 to 2.3% (21 of 899 patients) in 2006. Coronary artery aneurysms were coded for 3.3% of patients. Male patients, patients <1 year of age, and Hispanic patients were significantly more likely to have coding for coronary artery aneurysms.

CONCLUSIONS: Our report provides the first large multicenter description of agents used in the treatment of intravenously administered immunoglobulin-resistant Kawasaki disease in the United States. Trends include increased numbers of admissions attributable to Kawasaki disease and increased usage of infliximab.

Estimation of Optimal CPR Chest Compression Depth in Children by Using
Computer Tomography
Matthew S. Braga, Troy E. Dominguez, Avrum N. Pollock, Dana Niles, Andrew
Meyer, Helge Myklebust, Jon Nysaether, and Vinay Nadkarni
Pediatrics 2009;124 e69-e74

OBJECTIVE: Pediatric consensus-driven cardiopulmonary resuscitation guidelines target chest compression (CC) depths of one third to one half anterior-posterior (AP) chest depth. Estimates for this target as assessed by computed tomography (CT) measurements of internal and external AP chest dimensions could direct future pediatric cardiopulmonary resuscitation guidelines.

METHODS: A total of 280 consecutive chest CT scans in permuted blocks of 20 for each of 14 age divisions between 0 and 8 years were reconstructed and analyzed. External and internal AP depths were measured at midsternum, and residual chest depth was calculated at simulated one-third and one-half AP compressions.

RESULTS: After a simulated compression calculation, one-half external AP depth CC would result in residual internal depth of <10 mm for 94% (263 of 280) of children 3 months to 8 years. For a one-third external AP CC, only 0.4% (1 of 280) of children 3 months to 8 years had a calculated residual internal chest depth <10 mm.

CONCLUSIONS: By using CT reconstruction estimates of chest dimensions across the developmental spectrum from 0 to 8 years of age, we demonstrated that a simulated CC targeting approximately one-third external AP chest depth seems radiographically appropriate for children aged 3 months to 8 years, whereas simulated CC targeting approximately one-half external AP chest depth seems radiographically to be too deep, resulting in residual internal chest depth of <10 mm for most patients of this age.

Clinical Predictors of Pneumonia Among Children With Wheezing
Bonnie Mathews, Sonal Shah, Robert H. Cleveland, Edward Y. Lee, Richard G.
Bachur, and Mark I. Neuman
Pediatrics 2009;124 e29-e36

OBJECTIVE: The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting.

METHODS: A prospective cohort study was performed with children ^< 21 years of age who were evaluated in the ED, were found to have wheezing on examination, and had chest radiography performed because of possible pneumonia. Historical features and examination findings were collected by treating physicians before knowledge of the chest radiograph results. Chest radiographs were read independently by 2 blinded radiologists.

RESULTS: A total of 526 patients met the inclusion criteria; the median age was 1.9 years (interquartile range: 0.7–4.5 years), and 36% were hospitalized. A history of wheezing was present for 247 patients (47%). Twenty-six patients (4.9% [95% confidence interval [CI]: 3.3–7.3]) had radiographic pneumonia. History of fever at home (positive likelihood ratio [LR]: 1.39 [95% CI: 1.13–1.70]), history of abdominal pain (positive LR: 2.85 [95% CI: 1.08–7.54]), triage temperature of 38°C (positive LR: 2.03 [95% CI: 1.34–3.07]), maximal temperature in the ED of 38°C (positive LR: 1.92 [95% CI: 1.48–2.49]), and triage oxygen saturation of <92% (positive LR: 3.06 [95% CI: 1.15–8.16]) were associated with increased risk of pneumonia. Among afebrile children (temperature of <38°C) with wheezing, the rate of pneumonia was very low (2.2% [95% CI: 1.0–4.7]).

CONCLUSIONS: Radiographic pneumonia among children with wheezing is uncommon. Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged.

Headache in Young Children in the Emergency Department: Use of Computed
Tomography
Tarannum M. Lateef, Mandeep Grewal, William McClintock, James Chamberlain,
Himanshu Kaulas, and Karin B. Nelson
Pediatrics 2009;124 e12-e17

Headache in Young Children in the Emergency Department: Use of Computed Tomography

Tarannum M. Lateef, MD^a, Mandeep Grewal, BS^a, William McClintock, MD^a, James Chamberlain, MD^b, Himanshu Kaulas, MBBS^a and Karin B. Nelson, MD^a,c

Departments of ^a Neurology
^b Emergency Medicine, Children’s National Medical Center and George Washington University School of Medicine, Washington, DC
^c National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland

OBJECTIVE: The goal was to determine whether computed tomographic (CT) scans led to better acute care of young children with headache presenting the emergency department (ED).

METHODS: We examined the records of 364 children 2 to 5 years of age who presented with headache to a large urban ED between July 1, 2003, and June 30, 2006. By reviewing initial history and examination findings, we first identified patients with secondary headaches (ie, with readily identifiable explanations such as ventriculoperitoneal shunts, known brain tumors, or acute illnesses, such as viral syndromes, fever, probable meningitis, or trauma). Charts for the remaining patients were reviewed for headache history, neurologic examination findings, laboratory and neuroimaging results, final diagnosis, and disposition.

RESULTS: On the basis of initial history and physical examination results, 306 children (84%) had secondary headaches. For 72% of those children, acute febrile illnesses and viral respiratory syndromes accounted for the headaches. Among the 58 children (16%) who had no recognized central nervous system disease or systemic illness at presentation, 28% had CT scans performed. Of those, 1 scan yielded abnormal results, showing a brainstem glioma; the patient demonstrated abnormal neurologic examination findings on the day of presentation. For 15 (94%) of 16 patients, the CT scans did not contribute to diagnosis or management. For 59% of children with apparently primary headaches, no family history was recorded.

CONCLUSION: For young children presenting to the ED with headache but normal neurologic examination findings and nonworrying history, CT scans seldom lead to diagnosis or contribute to immediate management.

47,000 Older Adults Treated in Emergency Departments Annually for Fall Injuries Related to Walkers and Canes

CDC:  http://www.cdc.gov/media/pressrel/2009/r090629.htm

Fractures most common injury; one in three injuries required hospitalization

From 2001 to 2006, an average of 129 Americans ages 65 and older were treated in emergency departments each day—a total of more than 47,000 each year—for injuries from falls that involved walkers and canes, according to a Centers for Disease Control and Prevention study published this month in the Journal of the American Geriatrics Society.

The study, which examined six years of emergency department medical records, found that, for older adults that had falls related to walkers- or canes, most of the injuries involved walkers (87 percent). People were seven times more likely to be injured in a fall with a walker as with a cane. Older women sustained more than three out of four walker-related injuries (78 percent) and two out of three cane-related injuries (66 percent).

“Walking aids are very important in helping many older adults maintain their mobility. However, it′s important to make sure people use these devices safely,” said Judy Stevens, Ph.D., the study′s lead author. “Walkers are often used by frail and vulnerable older adults; people for whom falls, if they occur, can have very serious health consequences.”

Other key findings include:

• For men and women who used walkers or canes, the chances of sustaining a fall increased with age, with the highest injury rates among those ages 85 and older.
• Fractures were the most common type of fall injury associated with walkers (38 percent) and canes (40 percent) and about a third of all injuries were to the lower trunk, such as the hip or pelvis.
• More than half of fall injuries associated with walkers (60 percent) and canes (56 percent) occurred at home.
• One in three people whose fall involved a walker and more than one in four (28 percent) whose fall involved a cane had to be hospitalized.

The study points out the importance of preventing falls related to walking aids. Some prevention strategies include:

• Encouraging professionals to spend more time with clients (or patients) fitting walking aids, and;
• Educating people how to use walkers and canes safely, for example, by having physical therapists provide counseling at health fairs.

Additional studies are needed to better understand fall risk factors for older adults who use walkers and canes, as well as to identify potential design problems and improve the design of walkers.

Falls are the leading cause of nonfatal injury in the United States, and falls among older adults can have especially serious consequences. To help reduce the risk of falling, CDC′s Injury Center recommends that adults ages 65 and older begin a regular exercise program, have their doctors review their medications, have their vision checked, and make their home surroundings safer.

For more information about CDC′s fall prevention efforts among older adults, please link to http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html.

For information about protecting children from falls, visit http://www.cdc.gov/HomeandRecreationalSafety/Falls/children.html.

For a full copy of the study, please visit the Journal of the American Geriatrics Society at http://www3.interscience.wiley.com/journal/119878233/issue.

http://www.who.int/entity/csr/don/Globalh1n1_20090629.png

Seasonal Influenza Weekly Report: Influenza Summary Update - CDC – June 26
During week 24 (June 14-20, 2009), influenza activity decreased in the United States, however, there were still higher levels of influenza-like illness than is normal for this time of year.

On this date in 1776, Virginia adopts the state constitution and makes Patrick Henry governor.  Well…actually…he was the politicians’ second choice.  The day before, they selected Bruce Wainwright, but they couldn’t locate the chap. Family and friends stated he was out tramping through the Appalachians.  Then it was discovered he was vacationing in the Cherokee Nation enjoying a rendevous with a certain Little Big Butt.

But I digress…..

A panel of experts has recommended to the FDA to approve Bepreve as an anti-itching drug for the “baby blues.”  The final decision may happen in September…typically when eyes stop itching.
http://omniphysicians.com/2009/06/29/bepreve-bepotastine-besilate/

Here’s a case of a kid who was swimming in a lake and caught a weird bacterium.  It’s costing him part of his face.  It’s a rare disease.  Fewer than 150
cases have been reported worldwide since 1927.
http://omniphysicians.com/2009/06/29/chromobacterium-violaceum/

A big cat was let out of the bag this Sunday when it was suggested that the Prez might allow taxation of employee benefits.  Well, I won’t say what I think about this until I hear what Rush wants me to think.
http://omniphysicians.com/2009/06/29/taxing-employee-benefits/

This USA Today article is citing stories about all the accidents Americans are having because they are doing their own repairs.  Because of the economy, instead of calling qualified workers, they are doing the jobs and hurting themselves…even surgeons.  So…where do they go?  You guessed it.  One guy came in with a bullet in his foot.  He wanted to kill his wife, but he couldn’t afford the “boys” from Detroit.  So he tried himself and missed.
http://omniphysicians.com/2009/06/29/its-the-economy-stupid/

Paul R.

http://www.forbes.com/feeds/ap/2009/06/26/ap6592794.html

AP, 6/27/09

“A panel of federal experts said Friday an anti-itching drug from eye care company Ista Pharmaceuticals is safe and effective, according to a government spokeswoman.

The unanimous vote from the seven members of the Food and Drug Administration’s opthalmic panel amounts to a recommendation for approval. Although the FDA is not required to follow the group’s advice, it usually does….

A final decision on the drug is expected by September.”

On ABC’s This Week (6/28, 10:00am EST), host George Stephanopoulos asks White House political adviser David Axelrod about paying for healthcare reform, specifically whether President Obama would approve a bill that includes taxing employee benefits.

When pressed, Axelrod does not rule out the possibility, saying, “The president had said in the past he doesn’t believe taxing healthcare benefits at any level, is necessarily the best way to go here. He still believes that. But there’s a number of formulations. And we’ll wait and see.” He adds, “One of the problems we’ve had in this town is people draw lines in the sand.” But, “that’s not the way the President approaches this,” he noted.

Link:  http://www.usatoday.com/news/health/2009-06-28-diy-injuries_N.htm

USA Today, 6/28/09

Cash-strapped homeowners are trying to cut costs by replacing the kitchen floor or fixing a pipe themselves rather than hiring a contractor. But some are ending up with a trip to the emergency room instead.Nick Jouriles, president of the American College of Emergency Physicians, says he has seen an increase in injuries from do-it-yourself projects in the past year, and he says it’s probably the result of homeowners trying to save money in a struggling economy.

 A member poll by Angie’s List, a website featuring user reviews of contractors, found that 83% of respondents choose to do projects themselves so they can save money. But often the savings can be lost when a homeowner is forced to hire someone to redo the job or ends up in the emergency room.

 Members of the website have reported injuries ranging from being hit in the eye by a falling hammer to slicing off half a thumb with a carpet cutter.

 One Angie’s List member, Matt Taylor, reported that a surgeon had to use pliers to pull a nail out of his arm after he accidentally shot himself with a nail gun while framing a pocket door.

No organization tracks do-it-yourself injuries, but anecdotes are rolling in:

 • Jouriles, an Akron-based emergency physician, says he saw a patient just last week who fell off a ladder while fixing his roof. The patient told him he should have hired someone to do the job, but he was trying to cut costs.

 • Arlo Weltge, an emergency room physician in Houston and spokesman for the emergency-physicians organization, says he sees injured do-it-yourselfers in the emergency room “all the time.” He says he has even seen someone die from a brain injury after falling off a ladder while cleaning the gutter.

 ”A lot of these things are well-intentioned and not necessarily difficult, but unfortunately we see a lot of these,” he says.

 • Jennifer Hussey, an Angie’s List member based in San Antonio, was almost blinded while trying to fix something on Mother’s Day weekend. She was hit in the eye when the hammer she was using to remove molding fell from a 10-foot ladder.

 Todd Taylor, a physician working for Microsoft in Tennessee, opted to make some roof repairs a few years ago. The former emergency room doctor ended up with two broken legs and had to use a wheelchair for two months after falling from a ladder.

 Jacqueline Agnew, director of the National Institute for Occupational Safety and Health’s education research center, says homeowners should consider the risks before starting a project.

 ”There’s no cost saving that’s going to make it worth risking a serious disability,” she says.

 Paul Zuch, president-elect of the National Association for the Remodeling Industry, says hiring a contractor can be a safer bet because it gives homeowners someone to blame if something goes wrong.

 ”They kind of shift the onus back to themselves when they take on these projects,” he says.

Date: Fri 26 Jun 2009
Source: WWAY NewsChannel 3 (North Carolina), Associated Press (AP) report
[edited]
<http://www.wwaytv3.com/nc_teenager_hospitalized_rare_infection/06/2009>

A 14 year old boy from North Carolina is in hospital with a rare infection
that cost him part of his nose and 5 teeth after swimming in a local lake.
The Fayetteville Observer reports that doctors at UNC [University of North
Carolina] Hospitals in Chapel Hill are treating the boy for an infection
caused by a bacterium called _Chromobacterium violaceum_, which was found
in Hope Mills Lake.

The Centers for Disease Control and Prevention says that fewer than 150
cases have been reported worldwide since 1927.

The patient’s father said his son is in serious condition but that
antibiotics are beginning to clear the infection from the teen’s blood.
Doctors had to remove the left side of [his] nose and palate, and his
father said he lost 5 teeth. Brian McKinney said doctors won’t consider
reconstructive surgery until the infection is gone.

Nocturnal Arrhythmias Across a Spectrum of Obstructive and Central Sleep-Disordered Breathing in Older Men

Outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study

Reena Mehra, MD, MS; Katie L. Stone, PhD; Paul D. Varosy, MD; Andrew R. Hoffman, MD; Gregory M. Marcus, MD, MAS; Terri Blackwell, MA; Osama A. Ibrahim, MD; Rawan Salem, RPSGT; Susan Redline, MD, MPH

Arch Intern Med. 2009;169(12):1147-1155.

Background  Rates of cardiac arrhythmias increase with age and may be associated with clinically significant morbidity. We studied the association between sleep-disordered breathing (SDB) with nocturnal atrial fibrillation or flutter (AF) and complex ventricular ectopy (CVE) in older men.

Methods  A total of 2911 participants in the Outcomes of Sleep Disorders in Older Men Study underwent unattended polysomnography. Nocturnal AF and CVE were ascertained by electrocardiogram-specific analysis of the polysomnographic data. Exposures were (1) SDB defined by respiratory disturbance index (RDI) quartile (a major index including all apneas and hypopneas), and ancillary definitions incorporating (2) obstructive events, obstructive sleep apnea (OSA; Obstructive Apnea Hypopnea Index quartile), or (3) central events, central sleep apnea (CSA; Central Apnea Index category), and (4) hypoxia (percentage of sleep time with <90% arterial oxygen percent saturation). Multivariable logistic regression analyses were performed.

Results  An increasing RDI quartile was associated with increased odds of AF and CVE (P values for trend, .01 and <.001, respectively). The highest RDI quartile was associated with increased odds of AF (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.19-3.89) and CVE (OR, 1.43; 95% CI, 1.12-1.82) compared with the lowest quartile. An increasing OSA quartile was significantly associated with increasing CVE (P value for trend, .01) but not AF. Central sleep apnea was more strongly associated with AF (OR, 2.69; 95% CI, 1.61-4.47) than CVE (OR, 1.27; 95% CI, 0.97-1.66). Hypoxia level was associated with CVE (P value for trend, <.001); those in the highest hypoxia category had an increased odds of CVE (OR, 1.62; 95% CI, 1.23-2.14) compared with the lowest quartile.

Conclusions  In this large cohort of older men, increasing severity of SDB was associated with a progressive increase in odds of AF and CVE. When SDB was characterized according to central or obstructive subtypes, CVE was associated most strongly with OSA and hypoxia, whereas AF was most strongly associated with CSA, suggesting that different sleep-related stresses may contribute to atrial and ventricular arrhythmogenesis in older men.