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Recent isolations of strains of Haemophilus influenzae resistant to ampicillin necessitate the development of a rapid, dependable, reproducible method of determining their antibiotic susceptibility. An agar-dilution method permitting susceptibility determinations on clinical specimens within 6-18 hours of specimen collection was designed. Chocolate agar biplates were made with one side having no additive and the other containing 2 mug/ml ampicillin. Seventy clinical specimens (cerebrospinal fluid, joint fluid, ear fluid, pleural fluid, blood culture broth) were streaked directly onto both sides of the plates when received in the laboratory and incubated at 35-37 C in 10% CO2. Reliable, readable results were usually available within 6-18 hours of receipt of the specimen and correlated completely with minimum inhibitory concentrations (MIC) determined by the agar-dilution plate method, although standard disk susceptibilities occasionally indicated false resistance. Susceptible strains (MIC less than 2 mug/ml) grew on the antibiotic-free side of the biplate only. The rapid determination of ampicillin susceptibility allows optimal antibiotic selection for the treatment of Haemophilus influenzae infections with early discontinuation of potentially toxic supplementary drugs.

To describe the rationale and design of a randomized trial of the impact of improved services for the treatment of sexually transmitted diseases (STD) on the incidence of HIV infection in Mwanza Region, Tanzania.The likely impact of improved STD treatment services on HIV incidence, and the need for empirical information on the effectiveness of this intervention strategy, are discussed. The rationale and design of such an intervention programme in Mwanza Region, and of a community-randomized trial to measure the impact of the programme on HIV and other STD, are presented. Problems in the design and interpretation of the trial are reviewed.Results of the baseline survey of the cohort of over 12,000 adults in 12 communities are presented in a companion paper.There is an urgent need for effective preventive measures against the HIV epidemic in sub-Saharan Africa and other developing regions. Improved STD treatment has been promoted as a potentially effective strategy, but there is little empirical information on its impact. The trial in Mwanza Region is the first randomized study of this intervention and should provide valuable data for health policy makers.Given the likelihood that other sexually transmitted diseases (STDs) act as co-factors in the sexual transmission of human immunodeficiency virus (HIV) in Africa, programs to improve the diagnosis and treatment of STDs may be an important component of acquired immunodeficiency syndrome (AIDS) control. To evaluate the impact of such a strategy, a randomized trial involving the integration of improved STD treatment into the existing primary health care system was initiated in Tanzania's Mwanza Region in late 1991. Program components include health personnel training, development of syndromic treatment algorithms, regular drug deliveries, supervisory visits to health facilities, and establishment of an STD reference clinic. The region's rural population was targeted due to its low yet increasing HIV prevalence, high prevalence of STDs, and amenability to a community-randomized study design. Twelve communities, defined as the population served by a health center and its satellite dispensaries, were selected for the trial and formed into six matched pairs on the basis of geographic area, HIV prevalence, and pre-existing levels of STD attendance. One set of communities was randomly selected to receive the intervention during the first year of the trial; the others will receive services at the end of the two-year follow-up period. Program outcome--defined as the incidence of HIV infection in intervention and control communities during the two-year follow-up--will be measured in a cohort of 12,000 randomly selected adults (1000 per community). This sample size offers a high power of detecting a halving of the annual HIV incidence rate from 1% to 0.5%.

The rate of decline in anti-PRP antibody levels was measured in two groups of Gambian children who had been given PRP-OMPC at 1 and 3 months or 2 and 4 months of age. In the younger group (n = 70), the geometric mean titre fell from 1.32 micrograms/ml at 4 months to 0.44 micrograms/ml at 18 months. In the older group (n = 54), the geometric mean titre fell from 1.18 micrograms/ml at 5 months to 0.46 micrograms/ml at 18 months. The proportion of vaccinated children with antibody levels over 1.0 microgram/ml fell from 54% 1 month after the second dose of vaccine to 27% at the age of 18 months, while the proportion with levels over 0.15 micrograms/ml fell from 82% to 60%, with no significant differences observed between the vaccination groups. For those children who did not show evidence of environmental boosting, the half-life of anti-PRP antibody was about 100 days. This did not differ between the groups. These findings suggest that to provide lasting immunity PRP-OMPC should be given with a late booster dose at 12-15 months, as is the current practice in the USA. The need for a late booster dose may limit the value of this vaccine in developing countries where vaccination of children is difficult after the 1st year of life.

Background Data on the burden of dysglycemia among HIV-infected patients on antiretroviral therapy (ART) in Africa are limited. We determined the prevalence of pre-diabetes and diabetes among HIV-infected patients who started ART when malnourished 2 to 3 years previously and investigated the association of dysglycemia with body composition. Methods Malnourished (body mass index (BMI)

Background Uptake of couples’ HIV counseling and testing (couples’ HCT) services remains largely low in most settings. We report the effect of a demand-creation intervention trial on couples’ HCT uptake among married or cohabiting individuals who had never received couples’ HCT. Methods This was a cluster-randomized intervention trial implemented in three study regions with differing HIV prevalence levels (range: 9–43 %) in Rakai district, southwestern Uganda, between February and September 2014. We randomly assigned six clusters (1:1) to receive the intervention or serve as the comparison arm using computer-generated random numbers. In the intervention clusters, individuals attended small group, couple and male-focused interactive sessions, reinforced with testimonies from ‘expert couples’, and received invitation coupons to test together with their partners at designated health facilities. In the comparison clusters, participants attended general adult health education sessions but received no invitation coupons. The primary outcome was couples’ HCT uptake, measured 12 months post-baseline. Baseline data were collected between November 2013 and February 2014 while follow-up data were collected between March and April 2015. We conducted intention-to-treat analysis using a mixed effects Poisson regression model to assess for differences in couples’ HCT uptake between the intervention and comparison clusters. Data analysis was conducted using STATA statistical software, version 14.1. Results Of 2135 married or cohabiting individuals interviewed at baseline, 42 % (n = 846) had ever received couples’ HCT. Of those who had never received couples’ HCT (n = 1,174), 697 were interviewed in the intervention clusters while 477 were interviewed in the comparison clusters. 73.6 % (n = 513) of those interviewed in the intervention and 82.6 % (n = 394) of those interviewed in the comparison cluster were interviewed at follow-up. Of those interviewed, 72.3 % (n = 371) in the intervention and 65.2 % (n = 257) in the comparison clusters received HCT. Couples’ HCT uptake was higher in the intervention than in the comparison clusters (20.3 % versus 13.7 %; adjusted prevalence ratio (aPR) = 1.43, 95 % CI: 1.02, 2.01, P = 0.04). Conclusion Our findings show that a small group, couple and male-focused, demand-creation intervention reinforced with testimonies from ‘expert couples’, improved uptake of couples’ HCT in this rural setting. Trial registration ClinicalTrials.gov, NCT02492061. Date of registration: June 14, 2015. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1720-y) contains supplementary material, which is available to authorized users.

To evaluate the impact of improved case management for sexually transmitted diseases (STD) at the primary health care level on the incidence and prevalence of STD.Community-randomized controlled trial.Mwanza region, Tanzania.A random cohort of about 1000 adults aged 15-54 years from each of 12 communities, in six matched pairs. One member of each pair was assigned at random to receive the intervention, and the others served as a comparison community. This cohort was surveyed at baseline and at follow-up 2 years later. About 100 antenatal clinic attenders were also studied in each community on two occasions: the first shortly after the implementation of the intervention, and the second approximately 1 year later.Improved services were established for the management of STD, using the syndromic approach, in rural health units.A total of 12,534 individuals were enrolled in the cohort study, of whom 8844 (71%) were seen again 2 years later. The prevalence of serological syphilis (rapid plasma reagin titreor = 1:8, Treponema pallidum haemagglutinin assay positive) was 6.2% in both intervention and comparison communities at baseline. At follow-up it was 5.0% in the intervention community and 7.0% in the comparison community [adjusted relative risk (RR), 0.71; 95% confidence interval (CI), 0.54-0.93; P0.02]. The prevalence of urethritis in males did not differ significantly between intervention and comparison groups at follow-up, but the prevalence of symptomatic urethritis was reduced by about 50% (adjusted RR, 0.51; 95% CI, 0.24-1.10; P = 0.08). There was no significant difference between the groups in the incidence of self-reported STD symptoms over the last year of the follow-up period, or in the prevalence of any STD in antenatal clinic attenders.The reduction in HIV incidence previously reported in this intervention study can be attributed to a reduction in the duration, and hence the prevalence of symptomatic STD.A community-randomized controlled trial was conducted in Mwanza region, Tanzania, to assess the impact of improved case management for sexually transmitted diseases (STDs) at the primary health care level on the incidence and prevalence of STD. A random cohort of about 1000 adults aged 15-54 years from each of 12 communities, in 6 matched pairs, participated, with 1 member of each pair receiving the intervention and the others serving as controls. The intervention consisted of improved services to manage STDs, using the syndromic approach, in rural health units. 12,534 people were enrolled in the study, of whom 8844 were seen again 2 years later at follow-up. The prevalence of serological syphilis was 6.2% in the intervention and comparison communities at baseline. However, at follow-up, the prevalence was 5.0% in the intervention community and 7.0% in the comparison community. The prevalence of urethritis in males did not differ significantly between intervention and comparison groups at follow-up, but the prevalence of symptomatic urethritis was nonetheless reduced by about 50%. No significant difference was observed between the incidence and control groups in the incidence of self-reported STD symptoms during the last year of the follow-up period or in the prevalence of any STD in antenatal clinic attenders.

BACKGROUND: Kenya's human resources for health shortage is well documented, yet in line with the new constitution, responsibility for health service delivery will be devolved to 47 new county administrations. This work describes the public sector nursing workforce likely to be inherited by the counties, and examines the relationships between nursing workforce density and key indicators. METHODS: National nursing deployment data linked to nursing supply data were used and analyzed using statistical and geographical analysis software. Data on nurses deployed in national referral hospitals and on nurses deployed in non-public sector facilities were excluded from main analyses. The densities and characteristics of the public sector nurses across the counties were obtained and examined against an index of county remoteness, and the nursing densities were correlated with five key indicators. RESULTS: Of the 16,371 nurses in the public non-tertiary sector, 76% are women and 53% are registered nurses, with 35% of the nurses aged 40 to 49 years. The nursing densities across counties range from 1.2 to 0.08 per 1,000 population. There are statistically significant associations of the nursing densities with a measure of health spending per capita (P value = 0.0028) and immunization rates (P value = 0.0018). A higher county remoteness index is associated with explaining lower female to male ratio of public sector nurses across counties (P value

OBJECTIVE: To obtain baseline information on sexually transmitted diseases (STDs) in the Rwandan refugees camps in Tanzania, prior to establishment of STD services. SETTING: The largest camps of Rwandan refugees in the Ngara District of Tanzania (estimated population 300,000). The study was carried out in 8 days in August 1994. SUBJECTS AND METHODS: A rapid assessment technique was used to measure STD prevalences among: (i) 100 antenatal clinic attenders (ANC); (ii) 239 men from outpatient clinics (OPD); and (iii) 289 men from the community. Interviews (by questionnaire) and genital examination were performed for all participants; sampling for females included genital swabs for the the diagnosis of Neisseria gonorrhoeae (NG), Candida albicans (CA), Trichomonas vaginalis (TV), bacterial vaginosis (BV) and a blood sample for syphilis serology. Men provided urine samples which were screened for leucocytes using the leucocyte esterase (LE) dipstick; urethral swabs for Gram stain were taken from men with a reactive LE test and from those with symptoms or signs of urethritis. OPD males provided a blood sample for syphilis serology. RESULTS: All groups reported frequent experience with STDs and engaging in risky sexual behaviour prior to the survey. During the establishment of the camps, sexual activity was reportedly low. Over 50% of ANC attenders were infected with agents causing vaginitis (TV/BV/CA) and 3% were infected with NG. The prevalence of active syphilis was 4%. In the male outpatients, the prevalence of urethritis was 2.6% and of serological syphilis was 6.1%. Among males in the community, the prevalence of urethritis was 2.9% (the majority being asymptomatic infections). We noted frequent over-reporting of STD symptoms, unconfirmed clinically or biologically. CONCLUSIONS: STD case detection and management should be improved by training health workers in using the WHO syndromic approach, and through IEC campaigns encouraging attendance at clinics. Rapid epidemiological methods provide quick and useful information at low cost in refugee camps.

Background Despite the introduction of free antiretroviral therapy (ART), the use of voluntary counselling and testing (VCT) services remains persistently low in many African countries. This study investigates how prior experience of HIV and VCT, and knowledge about HIV and ART influence VCT use in rural Tanzania. Methods In 2006–7, VCT was offered to study participants during the fifth survey round of an HIV community cohort study that includes HIV testing for research purposes without results disclosure, and a questionnaire covering knowledge, attitudes and practices around HIV infection and HIV services. Categorical variables were created for HIV knowledge and ART knowledge, with “good” HIV and ART knowledge defined as correctly answering at least 4/6 and 5/7 questions about HIV and ART respectively. Experience of HIV was defined as knowing people living with HIV, or having died from AIDS. Logistic regression methods were used to assess how HIV and ART knowledge, and prior experiences of HIV and VCT were associated with VCT uptake, with adjustment for HIV status and socio-demographic confounders. Results 2,695/3,886 (69%) men and 2,708/5,575 women (49%) had “good” HIV knowledge, while 613/3,886 (16%) men and 585/5575 (10%) women had “good” ART knowledge. Misconceptions about HIV transmission were common, including through kissing (55% of women, 43% of men), or mosquito bites (42% of women, 34% of men). 19% of men and 16% of women used VCT during the survey. After controlling for HIV status and socio-demographic factors, the odds of VCT use were lower among those with poor HIV knowledge (aOR = 0.5; p = 0.01 for men and aOR = 0.6; p Conclusions Two years after the introduction of free ART in this setting, misconceptions regarding HIV transmission remain rife and knowledge regarding treatment is worryingly poor, especially among women and HIV-positive people. Further HIV-related information, education and communication activities are urgently needed to improve VCT uptake in rural Tanzania.

To determine the effect of counselling on condom use by prostitutes.Cohort study.Field-based study in The Gambia.Thirty-one (12 HIV-positive and 19 HIV-negative) prostitutes.Post-test HIV counselling.Levels of condom use.Overall, counselling had no effect on condom use.Scarce resources should be directed towards providing condoms in bars rather than counselling.HIV infection is much more prevalent in prostitution than in the general population of the Gambia (26.2 vs. 1.7%, respectively, in 1988). The short-and long-term effects of counseling on condom use by prostitutes was examined by determining condom use in 29 prostitutes, 11 HIV-positive (group 1) and 18 HIV-negative (group 2), before and 1 month after counseling and in 31 prostitutes, 12 HIV-positive group 3) and 19 HIV-negative (group 4), before and 2-5 month after counseling. HIV-positive women were told that reinfection would increase their chances of developing AIDS as well as lead to transmission of the virus. 3515 sexual contacts were recorded before counseling, 1252 after 1 month, and 4949 at 2-5 months later. Group 1 women reported an 89.3% rate of use before counseling; 1 month later, 9 maintained their rate, 1 increased use from 56 to 81%, and 1 decreased use from 31 to 26%. Group 2 women had 88% use before and, in 11 of the 12 women, 90% use after counseling; the 12th woman reduced use to 66% and was observed to increase her alcohol intake significantly. In both groups, 4 increased use and 3 reduced use. In Group 3, condom use declined insignificantly from 89.3 to 83.5%. 4 women maintained 90% use, 6 reduced use, and 2 increased it. Group 4 women decreased use insignificantly from 88% before to 84.4% after counseling. 8 women maintained original levels of use, 4 increased, and 7 decreased (1 from 90% to as low as 17%). In groups 3 and 4, 74% had 90% use precounseling; this fell to 69% at 1 month and 36% at 2-5 months after counseling, a significant decrease in usage. In all of the prostitutes, condom use increased in the first month after counseling and fell 2-5 months later. Counseling, therefore, failed to increase overall condom use. Possible reasons for this failure include the Senegalese backgrounds of many of the women (they were accustomed to health checks and free condoms); the low number of AIDS deaths in the Gambia, which keeps the disease a distant possibility instead of a pressing reality for the prostitutes; and the consideration of condom use as primarily a method to prevent contraction of the traditional sexually transmitted diseases. When resources are scarce, it may be more important to provide free condoms in bars frequented by prostitutes than to provide counseling.

To the Editor.— The case reports presented by E. Dale Everett, MD (242:542, 1979), purports to describe adult cases of mucocutaneous lymph node syndrome (Kawasaki disease). Before this association becomes ingrained in the general medical literature, I would like to urge a note of caution. Mucocutaneous lymph node syndrome was originally described in Japanese children, and its epidemiology in Japan strongly emphasizes its rarity in persons older than 5 years. Its diagnostic criteria are sufficiently broad to include many other distinct clinical entities (eg, Stevens-Johnson's syndrome, scarlet fever, and leptospirosis) if clinical criteria are interpreted too liberally or a full etiologic evaluation is not completed. Even from the case descriptions given, Everett's patients differ from those with Kawasaki disease in a number of the following important ways: they are adult and female, and they have a more acute and severe multisystem illness. In most respects, these cases are far more

Physicians vary considerably in their opinion as to the duration of hospitalization and degree of surgical intervention for children with pneumococcal empyema. The development of pneumatoceles and persistence of fever or loculated pleural fluid are causes of debate and concern. We reviewed the records of 21 children with confirmed pneumococcal pneumonia. Ten of the 12 with no pleural fluid became afebrile within 48 hours of appropriate antibiotic therapy, whereas the nine with empyema remained febrile an average of 7.1 days (minimum estimate) in spite of documented sterile cultures within 24 hour in five of the patients. Although chest tube and thoracentesis drainage could not remove all the pleural fluid, and pneumatoceles developed in five of the nine children, long-term follow-up studies including chest roentgenograms and pulmonary function testing demonstrated a gradual but complete recovery that did not require long-term hospitalization, continued parenteral antibiotic therapy, or invasive surgical procedures.

From May 1973 through April 1974, a total of 83 children with severe Haemophilus influenzae infections were treated in three Denver pediatric hospitals. Although meningitis was the most common clinical manifestation (45 cases), other foci of infection were also noted (pneumonia, 12 cases; cheek cellulitis, eight cases; epiglottitis, eight cases; empyema, seven cases; pericarditis, three cases; arthritis, one case; periorbital cellulitis, one case; and abscess, one case). Nine children had positive blood cultures with H influenzae without an initial detectable focus of infection. Two patients developed clinically apparent sites of infection (osteomyelitis and scalp abscesses).

1054 INFLUENCE OF INOCULUM SIZE ON INTERPRETATION OF SUSCEPTIBILITY TESTING OF HAEMOPHILUS INFLUENZAE: MOXALACTAM VS. AMPICILLIN

Case records of all newborns with positive blood cultures were reviewed for 51 consecutive months to determine the clinical significance of a negative culture at 48 hrs. incubation. All cultures were monitored by the early subculture technique. Patients were considered to have clinically documented bacteremia if: (A) one blood culture was positive plus the same organism grew from a second blood culture (80 pts.), or from CSF, abscess, surgical, or urine cultures (14 pts.); (B) one positive blood culture grew a usual pathogen and the patient responded to antibiotic therapy appropriate for that organism (17 pts.). Records were available for 204 cultures on 158 neonates. Organisms growing from 111 (55%) represented significant bacteremia. The remaining 93 (45%) were considered contaminants (only one culture positive, and symptoms resolving without appropriate antibiotic therapy). 96% of all clinically significant blood cultures from newborns not pretreated with antibiotics were positive by 48 hrs. To reduce the risks of antibiotic use in the nursery, serious consideration should be given to discontinuing therapy in newborns with negative blood (and other) cultures at 48 hrs.

• Four children with acute febrile mucocutaneous lymph node syndrome (MLNS) were hospitalized in Denver over a two-year period. The children had most of the principle features of this recently described syndrome, including prolonged fever unresponsive to antibiotics, an erythematous rash, conjunctivitis, pharyngitis, and nonsuppurative cervical lymphadenitis. Three of the children exhibited characteristic desquamation from the fingertips or toes during convalescence. None developed clinical or electrocardiographic evidence of coronary thromboarteritis, the most serious complication of the disease. Additional cases undoubtedly will be reported in the United States as physicians become familiar with this new syndrome and learn to distinguish it from the other acute febrile exanthems. ( Am J Dis Child 130:610-612, 1976)

Epidemiologically, patients with toxic shock syndrome (TSS) often have focal infections (abscess, menstrual), the conditions of which may play a role in inducing particular S. aureus strains to cause disease. Individuals colonized (e.g. nasopharynx) with these same strains may develop immunity without developing disease. Three children with TSS and definite non-menstrual focal infections (abscess, empyema, septic arthritis) were studied. Samples from their foci demonstrated: pH 6.75-6.82, pCO2 46-51 torr, pO2 63-123 torr, Toxic Shock Toxin-I (TSST-I) 4-53 ng/ml, protease activity .10-.24 units, and grew S. aureus. The isolated S. aureus strains each had a typical TSS phenotype (protease+, TSST-I+) which was optimally expressed in vitro (extracellular protein excretion, TSST-I production, protease activity) when grown under conditions similar to those documented in vivo (4-8% CO2, pH 7.0, 21% O2). Increased glucose levels and decreased pCO2 resulted in decreased production of TSS markers without any change in quantitative organism growth. Anaerobic conditions, often assumed to be present in abscesses but not found in our patients, are also known to decrease TSST-I production in vitro. The unique in vivo focal conditions found in our TSS patients have in vitro correlates which may play an important role in the expression of organism phenotype and pathogenesis of TSS.

A comparative retrospective analysis of 45 patients with toxic shock syndrome (TSS) was designed to evaluate the effect of corticosteroid therapy on outcome. All patients satisfied the collaborative strict case definition for TSS, were hospitalized, had shock or postural hypotension, had a potential focus ofStaphylococcus aureusinfection, and received appropriate antistaphylococcal antimicrobial therapy. Twenty-five patients received corticosteroid therapy during the acute phase of illness and 20 did not. The groups were comparable for age, sex, weight, year of admission, day of illness hospitalized, minimum systolic and diastolic blood pressure, severity of illness, co-intervention with antimicrobials and antipyretics, and amount of intravenous fluid received. Corticosteroid-treated patients had a significantly reduced severity of illness and duration of fever if treated within two to three days of onset of TSS. (JAMA1984;252:3399-3402)

• One hundred ninety-five consecutive children with Haemophilus influenzae meningitis were retrospectively reviewed to identify those patients at high risk of death or severe sequelae using a previously described clinical scoring system. One hundred sixty-nine children (86.7%) had prognostic scores less than or equal to 4.0 and all survived. Twenty-six patients (13.3%) had prognostic scores greater than or equal to 4.5 points. Five of these high-risk patients (2.6% overall) died as a direct result of their acute meningitis. Of the remaining 21 survivors, 15 were available for prospective, observer-blinded, follow-up evaluation, as compared with 15 low-risk control patients matched for age, sex, and year of admission. High-risk patients were significantly more likely to have more serious sequelae (2.0± 2.1) as compared with low-risk controls (0.5 ±0.7). Those high-risk patients who by the choice of their treating physicians had received corticosteroids (and usually osmotic therapy as well) appeared to have outcomes similar to their matched lowrisk controls and significantly better than those high-risk patients who did not receive such additional therapy. ( AJDC .1989;143:307-311)

The diagnostic value of the white blood cell (WBC) and differential cell counts in 939 children hospitalized with acute illness was determined. Statistically significant conclusions include the following: (1) the absolute numbers of polymorphonuclear neutrophils (PMNs) per cubic millimeter or nonsegmented PMNs per cubic millimeter are more sensitive in detecting patients with bacterial infections than the more conventional WBCs per cubic millimeter, percent PMNs, or percent nonsegmented PMNs. (2) Children with > 10,000 PMNs per cubic millimeter or > 500 nonsegmented PMNs per cubic millimeter or both have an 80% chance of having a severe bacterial infection. (3) Patients with > 10,000 PMNs per cubic millimeter only are likely to have a Gram-positive bacterial infection, while those with > 500 nonsegmented PMNs per cubic millimeter only are likely to have a Gram-negative bacterial infection.

Staphylococcal scalded skin syndrome (SSSS) and toxic shock syndrome (TSS) appear to be toxin mediated diseases caused by different strains of S. aureus. We reviewed all cases of TSS (defined by the collaborative strict case definition) and SSSS (acute fever, painful erythroderma, positive Nikolsky sign) at The Children's Hospital of Denver for the years 1979-84. Of the 16 TSS cases, 13 (81%) were female compared to a balanced distribution of 5 (50%) of 10 hospitalized SSSS cases (p=0.22). The mean age was significantly greater (p=0.0007) for TSS compared to SSSS females (13.8±5.8 vs 2.4±2.5 years) but not males (7.1±0.8 vs 3.6±4.2 years). The likelihood of a potential focus of sequestered infection (vagina, abscess) was significantly greater (p=0.0003) in the TSS group. All 10 postmenarchal females with TSS were menstruating, grew S. aureus from vaginal cultures, and were using tampons at the time of clinical onset. Of the remaining 6 TSS patients (3 female), 4 had distinct loci of infection (bacteremia, cervical abscess, wound abscess, cervical adenitis) compared to only 1 (bacteremia) of 10 SSSS patients (p=0.07). These clinical differences suggest that S. aureus strains capable of causing TSS may require different host potentiating conditions than SSSS strains (focal infection vs nasopharyngeal colonization) to cause disease.

To the Editor.— The recent reports of toxic shock syndrome (TSS) during influenza outbreaks 1,2 may not imply a unique association with the influenza virus, but are more probably due to secondary focal staphylococcal infections including sinusitis—a frequent complication of influenza. The patient reported by Sperber and Francis 1 had clear-cut pneumonia, as did two of the nine patients reported by MacDonald et al 2 ; the remainder could have had occult sinus infection. In either situation, it would not be unusual to culture Staphylococcus aureus from respiratory secretions. Such focal infections appear to be linked both epidemiologically and microbiologically to the pathogenesis of TSS. 3 During the last two influenza outbreaks in Denver, we have noted a large number of patients with secondary sinusitis. Growth of a toxin producing S aureus in a sinus (or in a lung) may provide conditions for toxin production that may not ordinarily be present

Optimal positioning of the endotracheal tube (ETT) during mechanical ventilation of the newborn is essential to avoid extubation or inadvertent right or left main stem bronchial intubation. Using a new prototype fiberoptic bronchoscope (FOB)(O.D. 1.8mm) we examined ETT position in 34 infants (birthweight 715g-3500g, gestational ages 26-42 weeks). The tracheal length (TL), defined by distance from vocal cords to carina, was measured in neutral (N), flexion (F), and extension (E) head positions. ETT movements in right lateral (RL), left lateral (LL), F, and E positions were also measured. In. infants 1750g. Relative to the N position, the ETT moved maximally 3.5cm cephalad with E, and 1.8cm caudad with F. Corresponding TL changes were +3.lcm (+62% of TL in N position) with E and -0.9cm (-16% of TL in N position) with F. We concluded: due to small TL in infants

• The efficiency of group A Streptococcus detection and identification in an office practice was studied using a selective blood agar plate containing sulfamethoxazole and trimethoprim and primary plate bacitracin disk speciation. All results were confirmed by conventional bacteriologic and immunologic techniques the next day by a reference laboratory. In all, 1,591 cultures were processed, of which 156 (10%) could be confirmed the next morning to have group A Streptococcus by primary disk susceptibility interpretation. Bacitracinresistant β-hemolytic colonies, which could be immunologically confirmed as group A Streptococcus grew from only three cultures (0.1%). Fifty-six (3%) of the cultures had too few β-hemolytic colonies to determine bacitracin susceptibility, of which 47 were later proved to be group A Streptococcus . On all preliminary negative cultures, 1% demonstrated group A Streptococcus after incubation for an additional 24 hours. If a selective blood agar plate with primary bacitracin disk susceptibility speciation is used in an office laboratory setting, 99% of all cultures can be accurately interpreted within 24 hours of incubation, providing that those plates with limited growth of β-hemolytic colonies are thereafter immunologically tested for group A Streptococcus antigen. ( AJDC 1984;138:589-591)

In patients with prior antimicrobial therapy recovery of microorganisms present in the blood is often delayed or prevented. Our clinical trial tested the usefulness of the Antibiotic Removal Device (ARD) in a pediatric population. Equal volumes of blood were inoculated in a sequentially randomized fashion into ARD and standard (STD) pediatric blood culture bottles. Each was independently processed and monitored by the early subculture technique. Clinical relevance of all isolates was independently determined by predefined criteria. Of a total of 966 cultures, 61 (6.3%) were positive.

• Of 1,352 positive pediatric blood cultures during a 3.6-year period, two or more microorganisms grew from 72 cultures (5.3%), representing 60 patients. Based on predefined operational criteria for clinical interpretation of blood cultures, these cases were retrospectively classified as polymicrobial bacteremia (each organism, ie, a pathogen, 30%), mixed bacteremia/contaminant (20%), or multiple contaminants (50%). Considered individually, gram-positive organisms were isolated more frequently but were more often judged to be contaminants than the less common gram-negative organisms, which were more often thought to be true pathogens. Although one child did have a combined Streptococcus pneumoniae/Hemophilus influenzae bacteremia, these more common pediatric pathogens were underrepresented in those patients with polymicrobial bacteremia, from whom Enterobacterlaceae, streptococci, staphylococci, and anaerobes were more commonly Isolated. Hospitalization for a predisposing Illness and/or a focus of Infection occurred In 88% of the children with confirmed polymicrobial bacteremia. ( AJDC 1984;138:266-269)

Newborn infants suffering from severe generalized neuromuscular disorders at birth usually represent a diagnostic dilemma for the clinician. Not uncommonly they are given low Apgar scores and develop early signs of respiratory failure requiring ventilatory assistance. Frequently, the floppiness and muscle weakness is attributed initially to birth asphyxia. In this study we report our experience with 7 neonates diagnosed as having generalized muscle disorder - Congenital Muscular Dystrophy (3), Congenital Myotonic Dystrophy (1), Myotubular Myopathy (2), Undefined Congenital Myopathy (1) - in whom the chest x-ray revealed markedly thin ribs as a striking and consistent finding. This finding was not present in term infants with severe hypotonia as the result of acute hypoxia at birth. Normal values for rib width were established for infants of different birth weights in an attempt to provide an objective means of defining thin ribs. Based on the consistency of this finding in severe cases of neuromuscular disorder we consider this as a useful radiological sign in differentiating muscle disease from other causes of neonatal hyptonia and respiratory insufficiency while waiting for more definitive studies.

Spontaneous lower-extremity venous thrombosis, although common in adults, is not mentioned in current pediatric textbooks. Case records from 1952 to 1972 at the Children's Hospital of Denver were reviewed, and 28 cases of venous thrombosis unrelated to local venous catheterization or venous surgery were identified. Local infection, trauma, and immobilization were the most important predisposing factors. The most frequent diagnostic findings were local tenderness and increased size of the involved extremity. Complications developed in seven of 28 cases, including three suspected cases of pulmonary emboli and three cases of staphylococcal septicemia. There was one fatality. Specific conclusions about therapy from this study could not be made. However, with venous thrombosis in children, it is recommended to identify local predisposing infections, obtain blood cultures, and treat with antibiotics when indicated.

Diagnostic studies may suffer design deficiencies which obfuscate conclusions. A design-evaluation model was developed and validated to identify common errors. Thirty-five original research publications focusing on diagnostic testing were characterized for ultimate validity by independent editorial assessment. Each publication was evaluated for 31 elements of basic design, test technology, data analysis, and clinical application. Six biometricians ranked model items, of which 6 were considered critically important and the remainder conditionally important. Raw publication scores significantly (p

A strain of S. pneumoniae resistant to multiple antibiotics was isolated from an 11-month-old infant with meningitis. CSF obtained after 96 hours of high-dose penicillin-G continued to grow a beta-lactamase negative pneumococcus, type 6. When treatment was changed to ampicillin, chloramphenicol, and rifampin, the child improved; and CSF was sterile within 24 hours. Agar dilution MIC's were: pen-G 1 μg/ml; chloro, 16 μg/ml; ampicillin 0.5 μg/ml; tetracycline, 16 μg/ml; rifampin, 0.03 μg/ml. A cultural survey of day-care center contacts utilized two selective media; one containing pen-G, 0.125 μg/ml, the other chloro, 4.0 μg/ml. 4/14 children

Although McCarthy and co-workers put a great deal of clinical effort into their study of children less than 24 months of age who had a temperature of 40°C more (Pediatrics 59:663, May 1977), their insufficient statistical analysis brings us no closer to an appropriate outpatient approach to such children. Their comparison of the sensitivity and predictive value of each test in an independent fashion is similar to trying to predict the winner of a long-distance race without knowing who has the fewest laps to go.

Objective: To evaluate the effect of Highly Active AntiRetroviral Therapy (HAART) and cotrimoxazole prophylaxis usage (CTX) on incidence of morbidity within the first year of HAART-eligibility. Methods: Between July 1999 and April 2006, we collected information on morbidity from an open cohort of HAARTeligible patients (according to WHO criteria). We compared morbidity among patients initiating HAART to morbidity before the stepwise introduction of HAART and CTX. We used available patients on HAART to select randomly a historical group of HAART-naive but eligible patients who had proportionally the same WHO stage and sex distribution. Patients aged 16 years or older, visited the study team 6-monthly and when ill. Patients’ demographics, WHO stage, HAART status, CTX, any new morbidity event (disease, drug-related and recurrent), haemoglobin and CD4 counts were collected from the beginning of follow up to the first year after initiating HAART or becoming HAART-eligible. We estimated the overall effect of HAART onmorbidity; adjusted for the effect of CTX by Mantel-Haenszel methods and adjusted for the effect of other confounders by negative binomial regression. Results: 219 HAART patients (median age 37 years; 73% women; 85% CTX; median Hb 11.7 g/dl and median CD4 131 cells/ul) experienced 94 events. They contributed 127 Person-Years of Observations (PYOs). 616 HAART-naive patients (median age 33 years; 70% women; 33% CTX; median Hb 11.2 g/dl and median CD4 131 cells/ml) experienced 862 events. They contributed 474 PYOs. The overall morbidity among HAART patients during their first year of treatment was 78% lower (HR = 0.22, 95% CI: 0.15—0.31) than the overall incidence among HAART-naive patients in unadjusted analysis. CTX also had a protective effect against morbidity (adjusted HR = 0.55, 95% CI: 0.38—0.79). Conclusions: Morbidity reduced significantly within the first year of initiating HAART in this setting. CTX had additional significant protection against morbidity.

of results We analyzed 2,892 patients with median age of 32 years; 2,055 (71%) women; 1,569 (54%) WHO stage 3; 974 (34%) anaemia; 472 (16%) low BMI; and 1,242 (43%) with CD4 counts