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Background: Incidence of methicillin-resistant Staphylococcus aureus (MRSA) is increasing in complicated skin and skin structure infection (cSSSI) presenting to emergency departments (EDs). Treatment is heterogeneous and can require inpatient admission to an observation unit (OU). Vancomycin is commonly used in the OU for treatment, but increasing MRSA resistance to vancomycin suggests the need for alternatives. Daptomycin is an alternative but it is not known how it compares with vancomycin., Objective: This study tested the hypothesis that daptomycin is noninferior to vancomycin for the treatment of cSSSI in an OU, using a relative risk (RR) of 1.3 as the noninferiority limit., Methods: Subjects admitted to an ED-based OU with a diagnosis of cSSSI were eligible. Consenting subjects were randomized 1:1 to intravenous (i.v.) vancomycin at 15 mg/kg dosing every 12 h or i.v. daptomycin at 4 mg/kg once. Subjects were followed until they met objective criteria for discharge home or hospital admission. Discharged patients were prescribed 10-14 days of oral cephalexin and trimethoprim-sulfamethoxazole, or clindamycin if allergic to either of these medications. The primary endpoint was meeting objective discharge criteria with no change in antibiotic therapy or return to the ED for the same cellulitis within 30 days of OU discharge., Results: There were 100 patients enrolled. RR for satisfying the endpoint was 1.07 (95% confidence interval 0.58-1.98) for daptomycin compared with vancomycin. Hospital admission rates were 36% and 32% for daptomycin and vancomycin treatment, respectively., Conclusion: Daptomycin was not inferior to vancomycin in the treatment of cSSSI in an OU., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Serial echocardiography was performed in 51 children with isolated secundum atrial septal defect before and after surgery to measure the effects of chronic right ventricular overload on ventricular function. Right ventricular dilation increased dramatically with growth and with size of the left to right shunt only in the youngest children (body surface area less than 0.5 m2). A lesser effect of growth and no significant effect of shunt size were noted in older children. Although an initial decrease in right ventricular size occurred in the first 3 months after operation, persistent right ventricular dilation remained up to 5 years after closure of the interatrial defect in more than 80 percent of patients. Preoperatively, the ratio of the right ventricular preejection period to ejection time was significantly less than that of normal children. This ratio increased dramatically after operation, exceeding normal values early in the postoperative period in 18 of 48 children and persisting in 6 of 22 after 3 months. Left ventricular dimensions were normal early and late after operation. Left ventricular function was apparently normal, although an exceptionally high shortening fraction was noted in 22 (44 percent) of 51 children after operation. Aortic systolic time interval ratios decreased after operation from high normal to low normal values. It is hypothesized that the persistent enlargement of the right ventricle after operation may be due to the chronic preoperative dilation secondary to chronic interatrial shunting. The abnormally high shortening fraction after operation may result from an abnormal left ventricular geometric configuration or abnormality of filling. It is suggested that surgical closure of the atrial defect in the first 3 years of life may prevent these abnormalities.

Serial echocardiograms of five children who had infective endocarditis were analyzed and correlated with the clinical course. Vegetations were visualized initially on M-mode in four and on two-dimensional echocardiograms in all patients. The appearance of the vegetation was unexpected in one. More accurate anatomic localization of the vegetation was possible using two-dimensional echography. Four of the five patients died despite vigorous medical treatment and valve replacement in two. Complete resolution of the vegetation was documented for the first time in a child following medical therapy. This study suggests that echocardiography plays an important role in the diagnosis of endocarditis, allows objective follow-up of the size of the vegetations and their effects on valve function, and, therefore, may prove helpful in the management of these patients.

The time interval between tricuspid valve closure and pulmonary valve opening, termed the isovolumic contraction time of the right ventricle, was evaluated echographically in 38 normal children and within 24 hours of cardiac catheterization in 53 children with congenital heart disease and normal conduction as assessed with the electrocardiogram. In the 53 patients with congenital heart disease, isovolumic contraction time was strongly influenced by right ventricular afterload, as defined by pulmonary arterial end-diastolic pressure (r = 0.87). It was possible to utilize isovolumic contraction time to separate patients with normal or elevated values for pulmonary arterial end-diastolic pressure. Similar correlations were demonstrated between isovolumic contraction time and mean pulmonary arterial pressure and calculated pulmonary vascular resistance. Evaluation of 15 children with complete right bundle branch block revealed values for isovolumic contraction time that did not significantly differ from those of patients with similar pulmonary arterial end-diastolic pressure but no conduction abnormalities. These findings indicate that serial echographic evaluation of the interval from tricuspid valve closure to pulmonary valve opening can give an accurate reproducible assessment of right ventricular afterload in many children with congenital heart disease and complete right bundle branch block

The effect of left-right shunting upon left ventricular and atrial dimensions was assessed by means of 129 serial echocardiographic studies in 37 premature infants with patent ductus arterisus. The cardiac dimensions of asymptomatic premature infants and those with pulmonary disease were similar and served as control subjects. Left cardiac dimensions were enlarged in infants with significant PDA. Dimensions were greatest in surgically treated infants (post-operatively they returned rapidly to normal) in contrast with the persistent enlargement observed in some medically treated infants. Serial echocardiography was a valuable adjunct to clinical assessment of the course of PDA in premature infants with pulmonary disease.

Left ventricular function was evaluated echocardiographically within 24 hours of cardiac catheterization in 45 children with fixed aortic stenosis. Left ventricular systolic time intervals, mean velocity of circumferential fiber shortening, left ventricular end-diastolic volume and shortening fraction were evaluated. Some patients with severe aortic stenosis had a shortened preejection period, prolonged ejection time and increased mean velocity of circumferential fiber shortening in comparison with normal subjects, but these findings were not consistent within the group with severe aortic stenosis or apparent in patients with mild or moderate aortic stenosis. Left ventricular end-diastolic volume was smaller in children with severe obstruction than in normal children. Evaluation of the shortening fraction provided good separation of patients with significant obstruction from those with mild disease. Further, there was a linear correlation between the shortening fraction and the left ventricular-aortic gradient demonstrated at cardiac catheterization. This correlation was also of use in evaluating the response of patients to surgical relief of obstruction. Pre- and postoperative echocardiographic evaluation of the shortening fraction appears to provide a readily available noninvasive method of assessing the course and severity of obstruction in fixed aortic stenosis in children.

Thirty children with malignant solid tumors receiving adriamycin had serial evaluation of left ventricular (LV) function by echocardiography. The echocardiographic studies showed a progressive decrease in myocardial contractility as evidenced by changes in several parameters of LV function with increasing cumulative doses of the drug. Using the patients as their own controls, serial echocardiography appears to be a reliable method for detecting early alteration of cardiac function in the asymptomatic patient. This technique may prove useful to prevent cardiomyopathy secondary to adriamycin and to prolong therapy beyond the currently established limits.