Biomedical subjects
Publications and source records attributed to R M Barkin.
The management of acute diarrheal disease in children must consider potential etiologic agents and their common presentation. The workup and assessment should be tailored to the clinical condition of the patient and the most likely pathogen. Management must primarily focus on fluid therapy and dietary manipulation. Antibiotics have a very restricted role as do antidiarrheal agents.
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Acute otitis media is a common pediatric infection that requires appropriate evaluation of the young child to assure that there are no accompanying systemic infections or complications. The examination of the ear must not only assess the appearance of the tympanic membrane, but determine its mobility. Treatment should be initiated with antibiotics and symptomatic relief. Good follow-up must be arranged.
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In developing guidelines for the optimal schedule of DTP vaccine administration, it is imperative to explore alternative regimens to the current U.S. primary series of DTP vaccine at two, four, and six months and a booster at 18 months of age. Two approaches to primary immunization that reduce the total number of pertussis mouse protective units administered were studied in an effort to reduce adverse reactions. A modified, reduced (0.25 ml) dosage of each inoculation of DTP vaccine was compared with the usual immunization schedule. The reduced dosage group had consistently fewer adverse reactions with a significant reduction in febrile reactions and acute behavioural changes during the primary series at two, four, and six months and the booster at 18 months and fewer local reactions noted during the primary series (p less than 0.05). Geometric mean titers of pertussis agglutinins were higher after the primary series in vaccine recipients immunized with the recommended schedule but were similar in the two study groups before and after the 18 month immunization. An alternative approach studied the response following the administration of only two DTP immunizations of 0.5 ml, using a number of schedules to determine if lengthening the interval between the first and second pertussis inoculation would enhance the response to the pertussis antigen. Irrespective of whether the DTP vaccine was the first, second, or third of the primary series, the adverse reactions were similar. After the second DTP immunization, little difference was noted in the serologic response to pertussis. All agglutinin titers were significantly lower than that achieved after three standard doses of DTP vaccine (p less than 0.01).
Facial and periorbital cellulitis require emergent recognition and treatment. Hemophilus influenzae type B is the most common pathogen, with Streptococcus pneumoniae being cultured less frequently. Infections following injury are usually caused by Staphylococcus aureus and group A streptococci. Initial evaluation must exclude more severe orbital involvement. Appropriate bacteriological specimens should be obtained. Management requires parenteral antibiotics and careful monitoring for a clinical response or dissemination to other sites of infection.
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In a double-blind study, infants received standard (0.5 ml) or modified (0.25 ml) doses of DTP vaccine for the primary series of three immunizations administered at 2, 4, and 6 months of age and the booster immunization at 18 months. Side effects and antibody responses were determined in 80 children who completed the primary series and 73 who received the booster. The modified regimen was associated with significantly reduced febrile reactions and behavioral changes after the primary series and booster inoculation: 63.2% of those who received the standard dose had febrile reactions, compared to 42.3% who received the modified dose during the primary series; a similar difference was observed with the booster. Only 47.2% of the reduced dosage recipients demonstrated marked behavioral changes, and 62.4% of the standard vaccine recipients had comparable reactions. An even larger difference (33.3% vs 64.7%) was noted at the time of the booster. The modified vaccine produced a local reaction incidence of 58.5%, compared to 72.6% in the control population during the primary immunization series; no differences were noted in local reactions with the booster dose. All patients had serologic evidence of protective titers against diphtheria and tetanus. After the primary immunization series, 97.6% and 97.3% of the infants given the modified and standard doses, respectively, had pertussis agglutinin titers of greater than or equal to 1:16. One patient who received the standard dosage had a titer of less than 1:16 one month after the booster immunization, whereas all those given the modified dose had titers greater than or equal to 1:16. Geometric mean titers of pertussis agglutinins were higher in the standard vaccine recipients after the primary series, but were similar in the two study groups before and after the 18-month immunization.
A systematic and expeditious approach to the emergency in the pediatric patient requires strict attention to prioritization of activities, assessment, and treatment. Only then can the clinician approach the patient with competency while maintaining sensitivity toward the unique needs of children.
An incidence of postoperative infection of up to 15 percent has been reported following middle ear ventilation tube surgery. This rate of complication would be considered unacceptable following most other operative procedures. A controlled prospective study of 107 children undergoing tympanostomy and tube surgery over a 1-year period was undertaken. Subjects were randomly assigned to receive antibiotic-steroid otic drops at the time of surgery and for 1 week afterward, oral ampicillin for 24 hours preceding and 3 days following surgery, or no prophylactic treatment. The overall infection rate within four weeks of surgery was 12 percent. Purulent otorrhea occurred in 18 percent of those receiving no prophylactic treatment, in 13 percent receiving ampicillin, and in 6 percent receiving antibiotic-steroid otic drops. Postoperative infection was related to preoperative history of status otitis media and to previous placement of ventilation tubes.
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Surgical intervention utilizing the Kasai hepatic portoenterostomy has improved the outcome of patients with biliary atresia and provided a population of patients with unique health problems. The clinical course of 21 children followed for three years or longer was reviewed, focusing on their medical management. Ten (47.6%) had successful bile drainage following surgery and experienced a number of specific problems including recurrent cholangitis, nutritional and growth deficiencies, delayed developmental landmarks, portal hypertension, osteomalacia and osteoporosis, and social and psychiatric difficulties. These complications responded to aggressive medical therapy and support. Although the overall three-year survival of this series was 38.1%, in children who were operated upon prior to 2 months of age and in whom the enteric conduit was externalized the three-year survival rate was 66.7%.
Defects in host defences may provide a partial explanation for the increased incidence of infection in individuals with Down syndrome. Neutrophil and monocyte cellular and humoral chemotaxis were evaluated to explore phagocytic function. Fourteen individuals with Down syndrome and fifteen matched institutionalised controls were studied. In addition, a non-matched comparison normal group was investigated, representing a non-institutionalised young adult population. Neutrophil chemotaxis in institutionalised individuals (both Down syndrome and matched controls) was significantly impaired. Monocyte chemotaxis in this group was lower than in comparison normals. Evaluation of humoral components of neutrophil chemotaxis revealed no significant differences between individuals with Down syndrome and those with no known chromosomal abnormality. Down syndrome subjects had diminished humoral monocyte chemotactic responses compared with institutionalised controls and normal subjects.
Bactericidal capacity was investigated to delineate the impairment of phagocytic function. Fourteen individuals with Down syndrome and fifteen matched institutionalised controls were studied. A non-matched comparison normal group was also evaluated, representing a non-institutionalised young adult population. Neutrophil bactericidal capacity was impaired in institutionalised subjects, the defect being most apparent in Down syndrome. Monocyte bactericidal capacity was identical in institutionalised and non-institutionalised subjects. Humoral functions revealed no differences. Neutrophil phagocytosis was diminished in institutionalised individuals, Down syndrome subjects being the least effective. Monocytes had normal phagocytosis, but opsonisation was defective in both the Down syndrome and matched institutionalised groups. Neutrophils were more efficient at phagocytosis than monocytes. No physiologically significant differences were noted in neutrophil or monocyte intracellular killing.
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Effective management of acute diarrheal disease depends on an understanding of the mechanisms and the pathogens responsible for diminished absorption of water from the intestines or increased secretion of water and electrolytes into the intestines. Initial therapy consists of fluid management, with hospitalization if dehydration is significant. Antibiotics are useful in treating specific disease entities, such as shigellosis. Careful attention to clinical status and follow-up is essential.
Parents from four practices were surveyed to ascertain reactions of children to diphtheria-pertussis-tetanus (DPT) vaccine in the 48 hours after immunization. Vaccines were administered according to current recommendations. Responses were scored in three categories: temperature, behavioral changes, and local reactions. Questionnaires were returned by 1,232 (84.9%) patients. Only 7.0% reported no reaction, while 336 (27.3%) reported mild, 722 (58.6%) moderate, and 88 (7.1%) severe reactions. Over 50% experienced temperatures of at least 100 F, and 80% noted behavioral changes; 72.2% had local reactions. No encephalitis, seizures, or hospitalizations were reported. Reactogenicity was similar for the five immunizations of the recommended series and the two manufacturers evaluated. Reported reactions in the control group were significantly lower than in the study group. These reaction rates underline the need to reevaluate present DPT vaccines.