Handwashing patterns in two dermatology clinics

BACKGROUND

The hands of health care workers are a major source of nosocomial infection. Studies conducted mainly in intensive-care units and emergency departments have shown low compliance with hand hygiene recommendation.

OBJECTIVE

To study hand hygiene practices in outpatient dermatology clinics in Israel.

METHODS

The fingers of 13 dermatologist physicians were sampled for bacterial cultures and their hand hygiene practices were monitored by two observers. In addition, 51 dermatologists attending a professional conference completed a questionnaire on hand hygiene practice.

RESULTS

All the physicians' hands were found to be contaminated. Staphylococcus aureus was isolated in 9 cases (69.2%), a methicillin-resistant S. aureus in 1 (7.7%). Monitoring revealed 555 opportunities for handwashing; the average compliance was 31.4%. In the questionnaire, the main reasons given for poor hand hygiene were excessive work schedule (58%), lack of awareness (35.3%), reaction to disinfectants (17.7%) and lack of readily available facilities (15.7%).

CONCLUSION

The hands of dermatologists are frequently colonized with microbial pathogens, but compliance with hand hygiene practice recommendations is low, despite a fairly high awareness of the importance. An active educational infection control program should be introduced in dermatology clinics.

Compliance of primary care doctors with asthma guidelines and related education programs: the employment factor

BACKGROUND

Primary care physicians' adherence to accepted asthma guidelines is necessary for the proper care of asthma patients.

OBJECTIVES

To investigate the compliance of primary care physicians with clinical guidelines for asthma treatment and their participation in related educational programs, and to evaluate the influence of their employment status.

METHODS

A questionnaire was administered to a random sample of 1,000 primary care practitioners (pediatricians and family physicians) in Israel.

RESULTS

The response rate was 64%. Of the physicians who participated, 473 (75%) had read and consulted the guidelines but only 192 (29%) had participated in an educational program on asthma management in the last 12 months. The younger the responding physician (fewer years in practice), the more likely his/her attendance in such a program (p < 0.0001). After consulting the guidelines 189 physicians (40%) had modified their treatment strategies. Significantly more self-employed than salaried physicians had read the guidelines and participated in educational programs; physicians who were both self-employed and salaried fell somewhere between these groups. This trend was not influenced by the number of years in practice.

CONCLUSIONS

All primary care physicians should update their knowledge more often. The publication of guidelines on asthma must be followed by their proper dissemination and utilization. Our study suggests that major efforts should be directed at the population of employed physicians.

Physicians', nurses', and parents' attitudes to and knowledge about fever in early childhood

This study investigated physicians', nurses' and parents' approach to fever in early childhood. A total of 2059 questionnaires was completed by the three groups. Though most of the responders (59.8%) believed that fever is a helpful bodily mechanism of the body, there was a significant difference between physicians (85.8%) and nurses and parents (63.9 and 43.1%, respectively) (P<0.001). The majority of parents (62.7%) believed it necessary to treat children with low-grade fever (<38 degrees C) without any other sign of illness, whereas the physicians and nurses did not (10.8 and 30.2%, respectively). Regarding antipyretic medication, 92.3% of the physicians and 84% of the nurses would start treatment for a fever 38-40 degrees C, whereas 38.8% of parents would do so for a fever of 37-38 degrees C. Febrile seizure served as a reason for antipyretic treatment for 34.3% of the nurses and 20% of the parents, compared to 8.7% of the physicians. Finally, fear of brain damage due to fever was noted in almost twice as many nurses as physicians (11.8% versus 7.2%) and in three times as many parents (24.0%) as physicians. Parents and some nurses consider fever a risk factor for serious morbidity, mostly febrile convulsions and brain damage, even though these associations have long since been disproven.

Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance

BACKGROUND

Recovery of myocardial function after revascularization of acutely occluded coronary arteries may require several days. During this critical time, patients in cardiogenic shock may have low output. A newly developed percutaneous left ventricular assist device (VAD) may offer effective treatment for these patients by providing active circulatory support.

METHODS AND RESULTS

Between May 2000 and May 2001, VADs were implanted in 18 consecutive patients who had cardiogenic shock after myocardial infarction. The device was connected to the patient's circulation by insertion of a 21F venous cannula into the left atrium by transseptal puncture; blood was returned to the iliac artery through an arterial cannula. Mean duration of cardiac assistance was 4+/-3 days. Mean flow of the VAD was 3.2+/-0.6 L/min. Before support, cardiac index was 1.7+/-0.3 L/min per m(2) and improved to 2.4+/-0.6 L/min per m(2) (P<0.001). Mean blood pressure increased from 63+/-8 mm Hg to 80+/-9 mm Hg (P<0.001). Pulmonary capillary wedge pressure, central venous pressure, and pulmonary artery pressure were reduced from 21+/-4, 13+/-4, and 31+/-8 mm Hg to 14+/-4, 9+/-3, and 23+/-6 mm Hg (all P<0.001), respectively. Overall 30-day mortality rate was 44%.

CONCLUSIONS

A newly developed VAD can be rapidly deployed in the catheterization laboratory setting. This device provides up to 4.0 L/min of assisted cardiac output, which may aid to revert cardiogenic shock. The left ventricle is unloaded by diverting blood from the left atrium to the systemic circulation, making recovery more likely after an ischemic event. The influence of this device on long-term prognosis warrants further investigation.

Efficacy of naturopathic extracts in the management of ear pain associated with acute otitis media

OBJECTIVE

To determine the efficacy and tolerance of Otikon Otic Solution (Healthy-On Ltd, Petach-Tikva, Israel), a naturopathic herbal extract (containing Allium sativum, Verbascum thapsus, Calendula flores, and Hypericum perforatum in olive oil), compared with Anaesthetic (Vitamed Pharmaceutical Ltd, Benyamina, Israel) ear drops (containing ametocaine and phenazone in glycerin) in the management of ear pain associated with acute otitis media (AOM).

DESIGN

Children between the ages of 6 and 18 years who experienced ear pain (otalgia) and who were diagnosed with eardrum problems associated with AOM were randomly assigned to be treated with Otikon or Anaesthetic ear drops, which were instilled into the external canal(s) of the affected ear(s). Ear pain was assessed using 2 visual analog scales: a linear scale and a color scale. Pain assessment took place throughout the course of 3 days. The mean score of pain reduction was used to measure outcome.

SETTING

Primary pediatric community ambulatory centers.

PARTICIPANTS

One hundred three children aged 6 to 18 years who were diagnosed with otalgia associated with AOM.

RESULTS

Each of the 2 treatment groups were comparable on the basis of age, sex, laterality of AOM, and the effectiveness of ameliorating symptoms of otalgia. The 2 groups were also comparable to each other in the initial ear pain score and in the scores at each application of Otikon or Anaesthetic drops. There was a statistically significant improvement in ear pain score throughout the course of the study period (P =.007).

CONCLUSIONS

Otikon, an ear drop formulation of naturopathic origin, is as effective as Anaesthetic ear drops and was proven appropriate for the management of AOM-associated ear pain.

Occurrence of supernumerary nipples in children with kidney and urinary tract malformations

The reported data on the association of kidney and urinary tract malformations with supernumerary nipples are contradictory. We examined 200 children, ages 1 month-16 years, who were being followed because of recurrent urinary tract infection for supernumerary nipples. The patients were divided into two groups: those who were found to have urinary tract malformations on radiographic studies (n=92) and those who were not (n=108). All children were examined for any abnormal pigmentation along the milk line, and the entire body was examined for ectopic supernumerary nipples. Two of the children with proved urinary tract pathology and two of the children with no urinary tract pathology had supernumerary nipples. The odds ratio for having supernumerary nipples among the first group was 1.18 (95% CI: 0.084-16.53, p=0.627). Our results indicate no association between kidney and urinary tract malformations and supernumerary nipples. We believe the message to the practicing physician is that there is no need for radiographic or ultrasonographic investigation of the urinary tract in asymptomatic children found to have supernumerary nipples on routine physical examination.

Immediate and one-year outcome in patients with coronary bifurcation lesions in the modern era (NHLBI dynamic registry)

Balloon angioplasty of bifurcation lesions has been associated with lower success and higher complication rates than most other lesion types. The development of alternative strategies such as debulking and stenting, either alone or in combination, are currently used relatively often. The relative role of these newer approaches in improving acute or long-term outcome, however, remains uncertain. Of the total of 2,436 patients treated between July 1997 to February 1998 in the National Heart, Lung, and Blood Institute Dynamic Registry, there were 321 patients (group 1) with bifurcation lesions and 2,115 patients without any bifurcation lesions attempted (group 2). Treatment strategies in terms of major devices used were significantly different between the 2 groups (group 1 vs 2): balloon angioplasty alone (23.1% vs 26.5%), balloon angioplasty and rotational atherectomy (6.9% vs 4.4%), balloon angioplasty and stent (55.8% vs 59.9%), and balloon angioplasty, rotational atherectomy, and stent (10.3% vs 7%) with p <0.01. There were no significant differences between the groups in terms of age, gender, and frequency of prior myocardial infarction (MI) or coronary artery bypass graft surgery (CABG). Complete angiographic success was achieved in only 86% of bifurcation lesions versus 93.5% of nonbifurcation lesions (p <0.001). In-hospital complication rates were increased in patients with bifurcation lesions compared with the nonbifurcation group: MI, 3.7% versus 2.6%; CABG, 2.2% versus 1.1%; side branch occlusion, 7.3% versus 2.3% (p <0.001); and the composite of death, MI, and any CABG, 7.2% versus 5.0%. At 1-year follow-up, major adverse cardiac events were 25% higher in group 1 than in group 2 (32.1% vs 25.7%, p <0.05). We conclude that despite the widespread use of newer percutaneous devices, treatment of bifurcation lesions remains difficult and is associated with decreased success and increased complication rates compared with nonbifurcation lesions.

Comparison of immediate and one-year outcome after coronary angioplasty of narrowing < 3 mm with those > or =3 mm ( the National Heart, Lung, and Blood Institute Dynamic Registry)

Balloon angioplasty of small coronary artery lesions has been associated with lower success and higher complication rates than large coronary artery lesions. This study evaluates the in-hospital and 1-year outcome of the treatment of small coronary artery lesions in the modern era of interventional cardiology and compares it with the outcome of treating large coronary artery lesions. Of 1,658 patients with a single lesion treated from July 1997 to February 1998 in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry, there were 587 patients with small coronary artery lesions (<3 mm) and 1,071 patients with large coronary artery lesions (> or =3 mm). Success, in-hospital, and 1-year outcomes between both groups were compared. Patients with lesions in small coronary arteries were more often women, insulin-treated diabetics, and had undergone more prior coronary bypass graft surgery. Conventional angioplasty alone was performed more often and angioplasty with stents was performed less often in the small coronary artery than in the large coronary artery group. Angiographic success was slightly lower in the small coronary artery group (94.2% vs 96.9%, p <0.05). Periprocedural and in-hospital complication rates were similar in both groups. Likewise, at 1-year follow-up, major adverse cardiac events including death, myocardial infarction, and coronary artery bypass graft surgery were relatively low and comparable between the 2 groups, although patients with small coronary arteries were more likely to undergo repeat revascularization (17.4% vs 13.6%, p <0.05). Treatment of lesions in small coronary arteries in the modern era is associated with high success and low complication rates, comparable to the treatment of large coronary artery lesions, although the incidence of repeat revascularization was significantly greater at follow-up even if stents were used.

Nocturnal acute laryngospasm in children: a possible epileptic phenomenon

Respiratory difficulties are not uncommon during epileptic activity in all age groups. Laryngospasm, as an isolated manifestation of epileptic disorder, is a rare phenomenon described previously in only two patients. We report our experience with five children in whom nocturnal laryngospasm was the only clinical manifestation of their epileptic disorder. All children underwent extensive workup and the diagnosis was made by sleep-deprived electroencephalography (two cases) and sleep study (three cases). All patients were treated with carbamezapine with prompt resolution of their laryngospasm.

Assessment of left internal mammary artery graft patency and flow reserve after minimally invasive direct coronary artery bypass

Despite its merits, minimally invasive direct coronary artery bypass surgery (MIDCAB) has been criticized for variable left internal mammary artery (LIMA) graft patency rates, prompting the frequent use of postoperative LIMA angiography. Noninvasive transthoracic Doppler interrogation of LIMA grafts has recently been shown to have utility for assessing patency and flow reserve after conventional bypass surgery, but data after MIDCAB has been limited. The objective of this study was to assess LIMA graft anatomy and physiology in 54 patients after MIDCAB using angiography and noninvasive LIMA Doppler imaging. The right internal mammary artery (RIMA) was studied as a control. LIMA flow reserve in response to adenosine was evaluated in a subgroup of 18 randomly chosen patients with patent grafts. LIMA angiographic patency was 93%. Forty-four patients (81%) had obtainable LIMA Doppler data. Patent grafts had a diastolic dominant flow pattern with a peak diastolic/systolic velocity ratio of 1.3 +/- 0.6 and a percent diastolic time-velocity integral (TVI) of 70 +/- 11%. These data were significantly different than the RIMA control values of 0.2 +/- 0.1 and 30 +/- 10%, respectively (p <0.05). Occluded grafts had absent flow or a systolic dominant pattern. Adenosine-induced increases in LIMA peak diastolic velocity from 48 +/- 20 to 105 +/-28 cm/s (p <0.05 vs baseline) and diastolic TVI from 21 +/- 10 to 37 +/- 19 cm (p <0.05 vs baseline), yielding adenosine/baseline ratios of 2.4 +/- 0.9 and 2.0 +/- 0.7, respectively, which was consistent with normal flow reserve. The diastolic flow velocity reserve response was inversely related to baseline diastolic flow (r = -0.69). In conclusion, MIDCAB can be associated with a high rate of LIMA potency and favorable physiologic Doppler flow patterns. Correlation of these findings to long-term patient outcome after MIDCAB is warranted.

Incidence and predictors of target vessel revascularization following percutaneous transluminal coronary angioplasty: a report from the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry

We sought to determine the rate of target vessel revascularization (TVR) after percutaneous transluminal coronary angioplasty (PTCA) and to determine factors that predispose to its occurrence. The 10-year outcome of 2,262 patients in the National Heart, Lung, and Blood institute PTCA Registry was analyzed to determine the incidence and characterize predictors of TVR. TVR was performed in 30.4% of patients. Male gender (relative risk [RR] 1.26; p <0.05), diabetes (RR 1.57; p <0.001), multiple discrete lesions (RR 1.38, p <0.01), diffuse lesions (RR 1.27; p <0.05), and calcium at the lesion site (RR 1.25; p <0.05) were predictors for TVR. TVR was performed early (< or = 1 year) in 18.3% and late (> 1 year) in 12.2%. Age > or = 65 years (RR 1.24; p <0.05), congestive heart failure (RR 1.70; p <0.05), acute coronary insufficiency (RR 1.28; p <0.05), and left anterior descending lesion location (RR 1.34, p <0.01) were significant predictors of early versus late TVR by multivariate analysis. Coronary artery bypass grafting (CABG) rather than PTCA was the TVR procedure in 21% of patients undergoing early TVR and 58% of those undergoing late TVR. Significant independent predictors of CABG as the TVR procedure were multivessel disease (RR 1.97; p <0.001), presence of collateral vessels (RR 1.81; p <0.05), diffuse (RR 1.89; p <0.01), or occluded (RR 1.82; p <0.05) target lesions, and a greater residual stenosis after the initial PTCA (RR 1.19; p <0.001). Age > or = 65 years (RR 0.65; p <0.05) conferred a lower risk for CABG.

Hypnotherapy: an effective treatment modality for trichotillomania

This study describes a non-pharmacological treatment modality for children with trichotillomania. Three children with trichotillomania were treated using a hypnotherapy technique. All patients were observed in the outpatient clinic for 8 consecutive weeks and subsequently followed for 12-18 months. All children were cooperative in performing the hypnotherapy technique (relaxation/mental imagery). Two patients reported complete resolution of their complaints after 7-8 weeks and 1 patient after 16 weeks. The latter, reporting recurrence of the complaint after 4 weeks due to stressful school problems, was resolved after successful retreatment over 3 weeks. During a mean follow-up period of 16 months, there were no recurrences. In conclusion, hypnotherapy may be considered as a primary treatment modality for trichotillomania in children without associated emotional disorders.

Alternative approach to multivessel coronary disease with integrated coronary revascularization

OBJECTIVE

Integrated coronary revascularization combines minimally invasive coronary artery bypass grafting (MICABG) with left internal thoracic artery-left anterior descending artery grafting and percutaneous coronary intervention. We hypothesized that integrated coronary revascularization could result in successful revascularization in suitable patients with multivessel coronary artery disease.

METHODS

Between September 1996 and January 1998, 31 consecutive patients underwent integrated coronary revascularization. Twenty-two were male; mean age was 69 years (46-86 years) and 42% were older than 75 years. Eight patients (26%) had a Parsonnet score greater than 20%. Left ventricular ejection fraction was 46.3% +/- 12%; 6 patients (19%) had a left ventricular ejection fraction less than 35%.

RESULTS

The anastomosis time for MICABG with the internal thoracic artery was 14.6 +/- 5.2 minutes and the operating time was 105 +/- 20 minutes; 28 patients (90%) were extubated in the operating room. The internal thoracic artery anastomosis was patent in all 31 patients (100%). Percutaneous coronary intervention was performed before MICABG in 2 patients (7%), on the same day of MICABG in 16 patients (52%), on postoperative day 1 in 3 patients (9%), and on postoperative days 2 to 4 in 10 patients (32%). Postprocedure length of stay in the hospital was 2.7 +/- 1.0 days and 13 patients (42%) were discharged home on postoperative day 1 or 2. Three patients (9.6%) required repeat target vessel revascularization in the distribution of the previous percutaneous coronary intervention. All patients are alive without angina at a follow-up of 10.8 +/- 3.8 months.

CONCLUSION

Our early results demonstrate that integrated coronary revascularization can be performed safely and effectively. Long-term results will be available from a prospective randomized trial now underway to compare integrated coronary revascularization with coronary artery bypass grafting for multivessel coronary artery disease.

Estrogen acutely abolishes abnormal cold-induced coronary constriction in men

BACKGROUND AND STUDY OBJECTIVE

Ambient cold exposure may induce myocardial ischemia by precipitating coronary artery constriction and a decrease in coronary blood flow. Estrogen has vasoactive properties that may prevent abnormal coronary constriction in a sex-independent manner. The purpose of this study is to determine whether estrogen acutely abolishes abnormal coronary responses to cold exposure in men.

DESIGN

Randomized, double-blinded placebo-controlled clinical trial.

SETTING

Cardiac catheterization laboratory.

PATIENTS

Men referred for routine diagnostic coronary angiography who exhibit abnormal coronary artery constriction in response to a 90-s cold pressor test (CPT).

INTERVENTION

Intravenous conjugated estrogens (1.25 mg) vs. placebo.

MEASUREMENTS AND RESULTS

Rate-pressure product, coronary cross-sectional area (CSA), and coronary blood flow responses to the CPT were measured before and 15 min after intervention. In 12 men with CPT-induced coronary constriction who were assigned to estrogen, CPT induced a mean 21.8% decrease in coronary CSA (p < 0.01) and a nonsignificant change in coronary flow. After estrogen, the repeated CPT induced a 16.3% increase in CSA (p < 0.01) and a 54.9% increase in flow (p < 0.01). CSA and coronary flow responses to CPT were significantly different before and after estrogen (p < 0.01). In contrast, placebo was not associated with changes in CSA or coronary flow responses to CPT in eight men.

CONCLUSIONS

In men, conjugated estrogens acutely abolish abnormal coronary constriction and improve coronary blood flow responses to an exogenous cold stimulus. These results suggest that estrogen favorably alters coronary vasoreactivity in men.

Preoperative risk models for minimally invasive coronary bypass: a preliminary study

OBJECTIVE

Available risk assessment models are designed for standard coronary artery bypass grafting. We hypothesized that minimally invasive coronary bypass could improve on predicted outcome in extremely high-risk patients (Parsonnet score > 20%) by the current risk models.

METHODS

From September 1996 to September 1997, 27 consecutive extremely high-risk patients underwent minimally invasive coronary bypass. Seventeen patients were male; age was 73 +/- 12 years, and 63% of patients were older than 75 years. Left ventricular ejection fraction was 33.7% +/- 15% and 63% had an ejection fraction of less than 35%. The predicted 30-day mortality according to the System 97 model was 25.6% +/- 11.3%. The Parsonnet risk score was 36.2% +/- 11%; the predicted length of stay in the hospital was 15.3 +/- 3 days. The predicted risk of stroke according to the Multicenter Perioperative Stroke Risk Index was 22.3% +/- 11.7%.

RESULTS

Minimally invasive coronary bypass was isolated in 20 patients and integrated with angioplasty and stenting in 7 patients. The observed 30-day mortality was 0% (P < .01 vs predicted): at an average follow-up of 10.8 +/- 4.1 months, 26 patients (96.3%) are alive without angina; one patient with acquired immunodeficiency syndrome died on postoperative day 40 of acute pancreatitis. No patient had a stroke or neurologic deficit (P < .01 vs predicted). Patency of internal thoracic artery anastomosis was confirmed by angiography in all 27 patients. No patient required reoperation. Eighteen patients (67%) were extubated in the operating room. The observed length of hospital stay after minimally invasive coronary bypass was 3.8 +/- 2.6 days (P < .01 vs predicted).

CONCLUSION

On the basis of our results on a relatively small series of patients, we suggest that risk models geared for standard coronary bypass grafting may not be appropriate for minimally invasive coronary bypass.

Feasibility of combined percutaneous transluminal angioplasty and minimally invasive direct coronary artery bypass in patients with multivessel coronary artery disease

BACKGROUND

Angioplasty has become an accepted treatment of patients with coronary artery disease and is now commonly used to treat patients with multivessel disease. The major disadvantage of angioplasty has been restenosis requiring repeat interventions with resultant loss of initial cost savings. Compared with the right and the circumflex coronary arteries, the left anterior descending artery (LAD) has been more adversely affected by restenosis. Recently, minimally invasive direct coronary artery bypass (MIDCAB) to the LAD through a small left anterior thoracotomy using the left internal mammary artery has been performed in some centers with excellent early results and with reduced costs compared with standard bypass surgery.

METHODS AND RESULTS

We retrospectively reviewed the first 31 consecutive patients treated in our institution with integrated coronary revascularization (ICR): MIDCAB to the LAD combined with PTCA of the other diseased vessels in patients with multivessel disease. Postoperative angiography in 84% of patients revealed a patent anastomosis and normal flow in the graft and bypassed vessel. Thirty-eight (97%) of 39 vessels were successfully treated percutaneously. At a mean follow-up of 7 months, all patients are currently asymptomatic. There have been 2 adverse clinical events, both related to angioplasty and not to MIDCAB. The average length of stay at the hospital after MIDCAB was 2.79+/-1.05 days.

CONCLUSIONS

These preliminary results with ICR are encouraging and suggest that a randomized, prospective clinical trial comparing ICR with standard coronary artery bypass surgery for the revascularization of symptomatic patients with multivessel disease involving the LAD is warranted.

Aurioscope earpieces--a potential vector of infection?

OBJECTIVES

to determine whether non disposable aurioscope earpieces used in community paediatric clinics harbored pathogenic micro-organisms, and to explore primary pediatrician perception of the possibility of cross infection from contaminated aurioscope earpieces and of how their aurioscope earpieced are cleaned.

DESIGN

randomized survey.

SETTING

four community pediatric clinics.

MATERIALS

42 pediatricians' aurioscope earpieces were cultured on blood agar and mannitol-salt-agar plates by two methods: (1) The earpieces were rolled for 5 s onto blood agar plates (TSA + 5% sheep blood, and a mannitol-salt-agar-plate). (2) The entire surface of the earpiece was swabbed with a sterile cotton tipped applicator moistened in sterile saline solution and was inoculated immediately onto a blood agar plate, and a mannitol-salt-agar-plate. The plates were incubated at 37 degrees C for 48 h and examined for colony growth at 24 and 48 h of incubation. Culture results were recorded as mean numbers of colony-forming units (CFUs).

RESULTS

36 from 42 (86%) of the aurioscope earpieces were colonized by micro-organisms. Heavily contaminated earpieces were found in six (14%). Staphylococci were isolated from 27 (64%) of the earpieces: 19 (45%) being Staphylococci aureus coagulase positive, 4 (9%) were methicillin resistant S. aureus (MRSA).

CONCLUSIONS

Non disposable earpieces can harbor potentially pathogenic bacteria including MRSA. The increased trend for children with immunodeficiency to be managed in an ambulatory setting, often by physicians who also work in hospital, might be a risk of spreading potentially serious infections to such patients. Non disposable earpieces should be regularly disinfected to minimize the spread of infection.

Poliomyelitis-like syndrome following asthmatic attack (Hopkins' syndrome)--recovery associated with i.v. gamma globulin treatment

A report on a 15-year-old male with a diagnosis of poliomyelitis-like syndrome (Hopkins' syndrome) following an asthmatic attack is presented. The prognosis of Hopkins' syndrome is usually poor and the patients remain with permanent paralysis of the affected limb. The outcome correlates with severity of the initial injury to the anterior horn cell as reflected by abnormal electrophysiologic studies. This is the first case report of treatment with i.v. gamma globulin in Hopkins' syndrome which resulted in a nearly complete recovery.

Local application of honey for treatment of neonatal postoperative wound infection

Honey has been described in ancient and modern medicine as being effective in the healing of various infected wounds. In this report we present our experience in nine infants with large, open, infected wounds that failed to heal with conventional treatment. Conventional treatment was defined as having failed if after > or = 14 d of intravenous antibiotic and cleaning the wound with chlorhexidine 0.05% W/V in aqueous solution and fusidic acid ointment the wound was still open, oozing pus, and swab cultures were positive. All infants showed marked clinical improvement after 5 d of treatment with topical application of 5-10 ml of fresh unprocessed honey twice daily. The wounds were closed, clean and sterile in all infants after 21 d of honey application. There were no adverse reactions to the treatment. We conclude that honey is useful in the treatment of post-surgical wounds that are infected and do not respond to conventional systemic and local antibiotic treatment.

Handwashing patterns in primary pediatric community clinics

Handwashing is acknowledged as a critical factor in the prevention of nosocomial infection. Nonetheless, health care personnel often wash their hands inadequately. The purpose of this study was to examine the flora of hands and the frequency of handwashing of physicians working in primary care pediatric community clinics. The fingers of the dominant hand of 55 physicians working in 12 clinics were sampled for bacterial cultures. Only 354/720 (49%) of the expected handwashings by 17 board-certified pediatricians were recorded as having been performed. None of them washed their hands after each contact with an examined child. All physicians' hands were found to be contaminated with microorganisms. Staphylococcus species were isolated from 47 (85.4%) of the physicians' hands. Methicillin-resistant Staphylococcus aureus was found on the hands of 9.1% of the physicians. Such contaminated hands may serve as a potential vector of community-acquired infection with highly resistant organisms. Compliance with handwashing recommendations among these physicians was low. An active educational infection control program must be introduced in ambulatory pediatric community clinics.

Stethoscopes and otoscopes--a potential vector of infection?

OBJECTIVES

We aimed to determine whether stethoscopes and otoscopes used in community paediatric clinics harboured pathogenic micro-organisms, and, if so, which measures could prevent this.

METHODS

Fifty-five stethoscopes belonging to paediatric physicians working in 12 community clinics were sampled for bacterial cultures by two methods: (i) direct impression of the diaphragm and bell section of each stethoscope for 5 seconds onto blood agar plates and a mannitol-salt-agar plate; (ii) swabbing the entire surface of the diaphragm of the stethoscope with a sterile cotton-tipped applicator. Forty-two otoscopes from the same physicians were sampled by rubbing the handles of the otoscopes with cotton-tipped swabs. The plates were incubated at 37 degrees C for 48 hours and examined for colony growth at 24 and 48 hours of incubation. Culture results were recorded as mean numbers of colony-forming units (CFUs). Eight additional stethoscope diaphragms were chosen at random at the participating clinics and cultured as described above. They were then wiped with alcohol swabs (isopropyl alcohol 70%), allowed to air dry for approximately 10 minutes and cultured a second time.

RESULTS

All the stethoscopes and 90% of the otoscope handles were colonized by microorganisms. Staphylococci were isolated from 85.4% of the stethoscopes and 83.3% of the otoscopes, with 54.5% and 45.2% respectively being S. Aureus. Methicillin-resistant S. aureus were found in four each of the stethoscopes (7.3%) and otoscopes (9.5%). Cleaning with alcohol reduced the colony count by an average of 96.3%.

CONCLUSIONS

Fomites can harbour potentially pathogenic bacteria, and with the increasing trend for children with more complex medical problems to be managed in an ambulatory setting, often by physicians who also work in hospitals, there is a real risk of spreading potentially serious infections to such patients. Simple cleansing with alcohol effectively eliminates the bacterial contamination of the fomites, and should be encouraged.

Primary herpes simplex virus type 1 gingivostomatitis in pediatric personnel

Herpetic gingivostomatitis is common in young children, but primary oral infection has also been described in adults. Herpetic whitlow as an occupational hazard of medical personnel has been well documented. Four cases of primary herpetic gingivostomatitis are reported in two pediatricians and two pediatric nurses who contracted the infection in their fourth decade of life. All suffered from sore throat and fever as presenting symptoms. Correct diagnosis was delayed for 4-5 days. In conclusion, pediatric personnel with pharyngitis and a negative history of herpetic gingivostomatitis or herpes labialis should bear the possibility of oral HSV infection in mind. Early diagnosis is essential to prevent the spread of the infection to their patients.