Shorter Duration Of Fever Research Articles

Incidence, Etiology, and Risk Factors for Fever Following Acute Spinal Cord Injury

Objective: To identify the incidence, etiology, and risk factors for fevers in individuals with traumatic spinal cord injury (SCI).Design: A retrospective review of the medical records of consecutive adult traumatic SCI patients over a 2- year period was performed.Setting: The study was performed at a tertiary care, Level I trauma center.Participants: Consecutive adult traumatic SCI admissions to acute care (n = 48) and rehabilitation (n = 40) were included in the study.Main Outcome Measures: Incidence, etiology, mean maximum temperature elevation, and duration of fevers (temperature >99.9 F) were measured.Results: The incidence of fever was 60.4% and 50% (acute care and rehabilitation, respectively). Total number of fevers was 58 and 66, acute and rehabilitation, respectively. Respiratory and urinary tract were the most common identifiable fever etiologies. Unidentified fever etiologies were numerous in both the acute and rehabilitation groups, representing 66% and 56% of cases, respectively. Significant differences (P < 0.05) were found between identified vs unidentified fever etiology groups for mean maximal temperature (102.5°F vs 101.1°F on acute and 101.5°F vs 100.7°F on rehabilitation), duration of fever (10.3 days vs 2.2 on acute and 2.8 days vs 1.3 on rehabilitation), fevers above 101.4°F (75% vs 29% on acute and 40% vs 8% on rehabilitation), cause of injury (gunshot wound on acute care) and completeness of injury (American Spinal Injury Association classification A on rehabilitation).Conclusions: This study suggests that fevers occur commonly in patients with SCI, with respiratory and genitourinary system etiologies most commonly identified. Unidentified etiologies were common and were associated with lower temperature elevation and shorter fever duration. Injury etiology and completeness of injury may comprise additional risk factors. These factors should be taken into account when initiating cost- efficient fever workup in individuals with SCI.

Laparoscopically assisted distal gastrectomy with standard radical lymph node dissection for gastric cancer

Laparoscopically assisted distal gastrectomy (LADG) with limited lymph node dissection (D1+alpha) has been used to treat a subset of patients with early gastric cancer. Technical advances have expanded indications for LADG to more advanced gastric cancers. However, little data are available on the feasibility or advantages of LADG with standard radical D2 lymph node dissection for patients with gastric cancer. This study reviewed the clinical features of 37 patients who underwent LADG with D2 lymph node dissection for preoperatively diagnosed gastric carcinoma, then compared the results with the features of 31 patients who underwent conventional open distal gastrectomy (ODG) with D2 lymph node dissection. The laparoscopic procedure was not converted to laparotomy in any patient. There was no operative mortality and no serious morbidity among the patients who underwent LADG with D2 lymph node dissection. As compared with the ODG group, the LADG group had less operative blood loss (p < 0.001), earlier recovery of bowel activity (p = 0.012), and a shorter duration of fever after surgery (p = 0.015), despite the longer operation time (p = 0.007). According to this study, LADG with D2 lymph node dissection is feasible and provides several advantages similar to those of limited lymph node dissection (D1+alpha). Depending on surgeons' technical proficiency, LADG can be used with standard radical lymph node dissection for patients with gastric cancers.

Parvovirus B19 infections serological diagnostics in rheumatic diseases

Objective. To study contamination with parvovirus B19 of a group of patients with rheumatic diseases (RD). Methods. 77 pts with RD (mean age 42,5 years, 79% female) admitted to Institute of Rheumatology of RAMS were examined. 34 of them had rheumatoid arthritis (RA), 11 - systemic lupus erythematosus (SLE) and Sjogren's disease (SD), 15 with osteoarthritis (OA) and seronegative spondyloarthritides (SS) and 17 with early (before a year) undifferentiated arthritis (EUA). Quantitative determination of IgM and IgG serum antibodies to parvovirus BI9 was performed by I FA with IBL kits (Hamburg, Germany). Results. Anti-B19 IgG antibodies were found in 52% of pts, IgM antibodies - only in one case. Mean antibodies values in pts with RD of disease duration less then 6 months were significantly higher then in pts with longer disease duration (21,5+36 U/ml and 8,4+14.7 U/ml respectively, p<0,05). Anti-B 19 antibodies were present in 62% of pts with RA, 53% of pts with EUA, 45% of pts with SD, 33% of pts with OA and SS. High levels of antibodies (4-10 times higher positivity threshold) were revealed in 13 pts with different RD with short duration of joint syndrome (6,3±7,6 months) and fever at presentation. A case of B19 parvovirus infection in a boy of 3 years age accompanied by symptoms of Still's disease is described.

Pθdiatrie au quotidien

The adverse effects of vaccines include local reactions and systemic symptoms or illnesses. Local reactions are frequent, most often presenting as transient pain, redness, edema and/or nodule. Fever of short duration is the main systemic symptom, generally occurring within 24-48 hours following vaccination. Some vaccines have recognized specific adverse effects such as thrombocytopenic purpura for the measles-mumps-rubella vaccine, and febrile convulsions for the pertussis vaccine. Hepatitis B vaccine and Haemophilus influenzae type b vaccine have been respectively suspected to be responsible for neurological demyelinating disease and insulin-dependent diabetes mellitus, but large-scale epidemiological studies have failed to confirm these allegations.

ACUTE PYELONEPHRITIS IN HOSPITALIZED WOMEN

The epidemiologic and clinical characteristics of 201 hospitalized women with acute pyelonephritis in northern Israel were recorded. The mean age was 61 years, with 74% older than 50 years. Young women (< 50 years) had more urinary tract infectionrelated symptoms than did older women and had a shorter duration of fever after hospitalization. By a univariant analysis, four factors were associated with duration of fever: age, positive blood cultures, grade of pyuria, and serum urea levels. However, a multivariant analysis showed that age of > 50 years was the only independent factor which influenced the length of fever. Only three older diabetic women with bacteremia (1.5%) died.

Croup syndrome in children: five-year experience.

To investigate the etiology and clinical features of croup syndrome, clinical records of hospitalized children with a diagnosis of croup syndrome were reviewed from April 1990 to January 1996. There was a total of 132 children, aged between three months and seven years with a mean age of 21.3 +/- 16.8 months. A diagnosis of laryngotracheobronchitis was made in 123 (93.2 percent) children. Twenty-three pathogens were identified in twenty-two of them, including seven parainfluenza viruses, five respiratory syncytial viruses, four influenza A viruses, four Mycoplasma pneumoniae, and three adenoviruses. Bacterial tracheitis was confirmed by bronchoscopic examination in seven cases (5.3 percent). Cultures of the respiratory secretions yielded viridans streptococci in six and Staphylococcus aureus in one child. Two children (1.5 percent) had spasmodic croup. No case with epiglottitis was noted in the present study. A fever lasting for more than three days was noted in five (71 percent) children with bacterial tracheitis and thirty-five (28 percent) children with laryngotracheobronchitis (p = 0.048). Among children with laryngotracheobronchitis, an associated diagnosis of pneumonia, acute otitis media, or paranasal sinusitis was more frequently observed in those with fever > 3 days (40 percent) than those with a shorter duration of fever (17 percent, p = 0.013). In conclusion, a child with a longer duration of fever and more severe manifestations of airway obstruction probably has a bacterial cause of croup syndrome or a bacterial complication. Bacterial tracheitis is more common than epiglottitis in Taiwan.

The impact of intraoperative culture on treatment and outcome in children with perforated appendicitis

Background: Most protocols for the operative treatment of perforated appendicitis use a routine culture. Although isolated studies suggest that routine culture may not be necessary, these recommendations generally are not based on objective outcome data.Methods: The authors reviewed the records of 308 children who underwent operative treatment for perforated appendicitis between 1988 and 1998 to determine if information gained from routine culture changes the management or improves outcome. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation.Results: Mean patient age was 7.5 years, 51% were boys, and there was no mortality. The majority of children (96%) underwent culture that was positive for either aerobes (21%), anaerobes (19%), or both (57%). Antibiotics were changed in only 16% of the patients in response to culture results. The use of empiric antibiotics, as compared with modified antibiotics, was associated with a lower incidence of infectious complication, shorter fever duration, and decreased length of hospitalization. We also investigated the relationship between culture isolates and antibiotic regimens with regard to outcome. The utilization of antibiotics suitable for the respective culture isolate or organism sensitivity was associated with an increased incidence of infectious complication and longer duration of both fever and length of hospitalization. Finally, the initial culture correlated poorly with subsequent intraabdominal culture (positive predictive value, 11%).Conclusion: These outcome data strongly suggest that the practice of obtaining routine cultures can be abandoned, and empiric broad spectrum antibiotic coverage directed at likely organisms is completely adequate for treatment of perforated appendicitis in children.

Perforated appendicitis in children: Risk factors for the development of complications

Background: Many aspects of the management of perforated appendicitis in children remain controversial. The objective of this study was to define risk factors associated with the development of postoperative complications in children undergoing treatment for perforated appendicitis. Methods: We reviewed all children (age < 16 years) who were treated for perforated appendicitis at Cardinal Glennon Children's Hospital between 1988 and 1997. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation. Results: Of 285 children with perforated appendicitis, 279 underwent immediate operative treatment. Mean patient age was 7.7 years and there were no deaths. Major postoperative complications included intra-abdominal abscess (n = 17), ileus (n = 7), mechanical intestinal obstruction (n = 6), and wound infection (n = 4). All children who had a postoperative abscess had more than 5 days of symptoms before operation. Within this subgroup, drain placement was associated with not only decreased postoperative abscess formation and but also shorter duration of fever and length of hospitalization. The incidence of mechanical obstruction or ileus was not increased and the rate of wound infection was actually lower after drainage. Conclusions: Drain placement appears to be helpful in children with late diagnosis but is of little benefit when the duration of symptoms is less than 5 days. Thus it is likely that drains are most useful in patients with well-established and localized abscess cavities. (Surgery 1998;124:619-26.)

Evaluation of four interventions to improve prescription pattern in short duration fever— A multicentric study

Evaluation of four interventions to improve prescription pattern in short duration fever— A multicentric study

Infant influenza.

Reports on the symptoms of infant influenza (less than 1 year of age) are very few. From 1989 to 1996, 105 infants with influenza were examined. The symptoms, nutrition and source of infection of the 105 patients were investigated in Sakuma Pediatric Clinic and viral studies were performed at the Kitakyushu City Institute of Environmental Sciences. The symptoms of patients under 6 months old are very mild, with a low maximum body temperature and a short duration of fever. Other complications are few. The symptoms gradually become more severe with each month of age. The ratio of patients displaying a diphasic fever with two peak temperatures increases with each month of age. Over 50% of patients over 9 months old have this diphasic fever with two peak temperatures. It is inconclusive whether an anti-infective factor in human milk exists or not. Of the 105 patients in this study, 28 were under 4 months of age: of these 28, all but 3 were infected by family members.

Management of the young febrile child: a commentary on recent practice guidelines.

Recently published “practice guidelines”1,2 and randomized antibiotic trials3,4 reflect a climate of increased diagnostic testing, more frequent treatment, and more invasive (ie, parenteral rather than oral) treatment of febrile children 3 to 36 months of age. For children in this age group with a temperature ≥39.0°C, the guidelines1,2 suggest a white blood cell (WBC) count and provide two options with respect to obtaining a blood culture: all such children or those whose WBC count is ≥15 000/mm2. Culture of urine obtained by catheterization or suprapubic aspiration is recommended for all boys <6 months and all girls <24 months. The guidelines recommend empiric treatment with ceftriaxone, once again with two options: treat all such children or those whose WBC count is ≥15 000/mm2. These practice guidelines are based on a meta-analysis that pooled data from both randomized controlled trials and observational (nonexperimental) studies of clinical outcomes in young febrile children, and on the views of an expert panel chosen by the senior author.1,2 Although the guidelines have not been officially endorsed by any professional organization, they were developed by authors who are widely recognized in the field and thus could have an important impact on both clinical practice and health care policy. The clinical setting is that of a child with acute onset (≤4 days) of fever who does not appear “toxic” (ie, seriously ill) and has no apparent focus of bacterial infection (otitis media, pneumonia, osteomyelitis/septic arthritis, lymphadenitis, cellulitis, dysentery-like enteritis, or meningitis) after a history is obtained and a physical examination is performed. When confronted with such a child, the clinician must make a series of decisions: 1. Should she obtain diagnostic tests to identify an “occult” bacterial infection [such as pneumonia, bacteremia, meningitis, or urinary …

C-Reactive protein is more sensitive than erythrocyte sedimentation rate for diagnosis of infective endocarditis

The objective of this study was to evaluate the sensitivity of C-reactive protein (CRP) elevation compared to erythrocyte sedimentation rate (ESR), leucocyte count and thrombocyte count in the diagnosis of infective endocarditis (IE). It was designed as a prospective study of suspected episodes of IE in adults in tertiary care at a university-affiliated department of infectious diseases. In 89 episodes of IE, CRP was available from the start of treatment. Median age was 66 years, 45 were men and 44 women. Median CRP concentration was found to be 90 (range 0-357) mg/l with only 4% normal values. Episodes involving native valves had higher CRP than episodes occurring with prosthetic valves. Staphylococcal origin, short duration of symptoms, short duration of fever and highest recorded temperature all correlated to higher CRP levels. The CRP response was also prominent among patients > 70 years old. Among non-responders, a few cases with simultaneous cirrhosis were noted. ESR was less sensitive than CRP, with a normal level in 28% of the episodes. It was concluded that CRP determination is superior to erythrocyte sedimentation rate, leucocyte count and thrombocyte count in the diagnosis of infective endocarditis.

Causes of Fever in Patients Infected with Human Immunodeficiency Virus Who Were Admitted to Boston City Hospital

We prospectively studied causes of fever in patients with human immunodeficiency virus (HIV) infection that required admission to a municipal hospital. A total of 168 HIV-infected persons were admitted for 220 episodes of fever: 72% were male, 80% were nonwhite, 65% reported prior injection drug use, and 74% had a baseline CD4 lymphocyte count of < 200/mm3. Bacterial infections, principally pneumonia, accounted for > 60% of the episodes; Streptococcus pneumoniae and Staphylococcus aureus were most commonly isolated. Pneumocystis carinii pneumonia (PCP) and disseminated infection with Mycobacterium avium complex (MAC) comprised 53% of the remaining sources of fever. In comparison with episodes of fever due to nonbacterial causes, those associated with common bacterial infections were significantly more likely to involve patients with a history of injection drug use (P = .02), higher admission leukocyte count (P < .004), shorter duration of fever (P = .003), shorter hospital stays (P = .0001), and a CD4 count of > 100/mm3 (P = .002). We conclude that bacterial infection, especially pneumonia, is a common cause of fever in HIV-infected patients admitted to our hospital. Patients with bacterial infections are more likely to report a history of injection drug use and have CD4 counts of > 100/mm3, shorter duration of fever, decreased length of hospitalization, and lower mortality than patients with fever due to PCP, disseminated MAC infection, or other causes.

Social smile and occult bacteremia.

The presence of a social smile as a clinical aid in determining that a child does not have a serious infection was debated in three recent communications.1-3 In the first two reports meningitis was the infection in question and the authors offered only anecdotal observations. Although we are in agreement that most children with meningitis do not have a social smile, we are not aware of any report that provides data confirming this observation. The third report relates social smile to the presence or absence of serious illnesses including meningitis and other illnesses as well. The author cites an earlier study of 312 febrile children in which he was a participant4 where all of 26 febrile children with serious illnesses had absent or impaired social smiles (sensitivity, 100%) and no child who smiled normally had a serious illness (negative predictive value, 100%). However, fewer than 20% of children who did not smile normally had a serious illness (positive predictive value, <20%). In this study only three patients had meningitis and two had bacteremia. Occult bacteremia is a serious bacterial infection that can progress to fulminent septicemia and death or focal infection such as meningitis, although it may subside spontaneously or after antimicrobial therapy. In a study we recently reported5 comparing oral vs. parenteral antimicrobial treatment of children with occult bacteremia, the presence or absence of a social smile was specifically documented as a part of the baseline and follow-up evaluation of all patients. The relationship between social smile and occult bacteremia was not addressed in that report. This analysis is the subject of our report. Methods. The study was a multicenter cooperative investigation with prospective design. Study patients were children 3 to 36 months of age with fever of ≥39.5°C and a white blood cell count ≥15 × 109/l or fever ≥40°C regardless of the result of the white blood cell count, a normal chest radiograph and urinalysis and no focus of infection on examination. Blood culture was obtained and demographic and clinical data were tabulated, including the presence or absence of a social smile, at the initial clinic evaluation. Statistical analysis. Differences of continuous variables (age, degree of fever, duration of fever and white blood cell count) between subjects with and without smiles were analyzed by unpaired t tests. For categorical variables (gender, presence or absence or bacteremia) contingency table analysis with Fisher's exact tests were performed. Statistical significance was defined as P ≤ 0.05. Results. Of 519 patients studied data concerning the presence or absence of a social smile was not recorded for 7 subjects. Of these 7 patients 5 had no growth from their blood cultures and 2 grew Streptococcus pneumoniae. Of the 512 (11%) subjects for whom social smile data were recorded at the initial evaluation, 58 had bacteremia. Social smile was present in 26 of the 58 (45%) bacteremic subjects and in 224 of the 454 (49%) subjects without bacteremia. This difference is not significant (P = 0.58). Of the bacteremic patients social smile was present in 24 of 49 (49%) with S. pneumoniae, 2 of 6 (33%) with Haemophilus influenzae type b, 0 of 2 with Neisseria meningitidis and 0 of 1 with group B Streptococcus. Table 1 shows the percentages by gender and the mean age, mean white blood cell count, mean temperature and duration of fever for subjects with and without a social smile. The only significant difference noted is that subjects without a social smile had a shorter duration of fever than those who had a social smile. Discussion. We conclude that a social smile is commonly present in sick febrile children and that it is equally common in those who have or do not have occult bacteremia. In our study patients the presence of a social smile did not vary with gender, age, presence of bacteremia and white blood cell count; however, it was significantly less common in those with a shorter duration of fever. Assessment of social smile alone has little or no value in predicting occult bacteremia. James W. Bass, M.D., M.P.H.; Robert R. Wittler, M.D.; Martin E. Weisse, M.D. Department of Pediatrics Tripler Army Medical Center Honolulu, HI (JWB) Department of Pediatrics University of Kansas School of Medicine Wichita, KS (RRW) Department of Pediatrics Robert C. Byrd Health Sciences Center of West Virginia University Morgantown, WV

Erythrocyte sedimentation rate, white blood cell count and serum C-reactive protein in assessing etiologic diagnosis of acute lower respiratory infections in children.

The clinical signs, symptoms and host responses (erythrocyte sedimentation rate, white blood cell count and C-reactive protein) were studied to distinguish bacterial from viral acute lower respiratory infection (ALRI) in 121 children hospitalized for ALRI. Etiologic diagnosis was based on blood culture, antibody assays and antigen detection. Children with bacterial involvement only were older than those with viral involvement alone (mean, 5.1 vs. 2.5 years), and their duration of respiratory symptoms had lasted longer (mean, 4.6 vs. 3.3 days). Children with unknown etiology had a shorter duration of fever before hospitalization than those with etiology identified with the methods used (mean, 1.6 vs. 2.9 days). The host response ranged widely within etiologic groups. The mean erythrocyte sedimentation rate did not differ significantly between the bacterial and viral ALRI (38 vs. 28 mm/hour); neither did white blood cell count (13.2 vs. 13.6 x 10(9)/liter) or C-reactive protein (68 vs. 49 mg/liter). No combination of clinical signs and host responses or any cutoff values could be shown to differentiate reliably bacterial from viral ALRI.

Feasibility of outpatient management of fever in cancer patients with low-risk neutropenia: Results of a prospective randomized trial

We recently demonstrated the efficacy of single-agent oral ofloxacin in the management of hospitalized neutropenic febrile patients. Ofloxacin was particularly effective in patients with short duration of neutropenia and fever of undetermined origin. These results prompted us to study the feasibility of outpatient management of neutropenic febrile patients who are otherwise at low risk of morbidity and mortality. This multi-institutional, prospective, randomized trial included 182 low-risk neutropenic febrile episodes. After an initial work-up for fever, patients were randomized to receive oral ofloxacin 400 mg immediately and twice daily thereafter in the hospital or as outpatients. Close monitoring and follow-up were carried out in all patients. Those who failed to respond and remained febrile were given parenteral antibiotics. Nonresponding outpatients were admitted to the hospital for parenteral therapy. One hundred sixty-nine episodes were evaluable. The hospital and outpatient treatment groups had comparable clinical characteristics. Pyrexias of undetermined origin (PUO) comprised 69% of episodes managed in hospital and 73% of episodes treated outside. The success rate with PUO was similar with inpatient and outpatient management. Patients with clinical and microbiologic infections fared less well than those with PUO. Overall, 78% of inpatient and 77% of outpatient fevers resolved with no modification of the initial treatment. Twenty-one percent of patients originally assigned to outside management required hospitalization. Mortality was 2% among inpatients and 4% among outpatients. One early death in a nonhospitalized patient underscores the need for close monitoring and surveillance in these cases. Outpatient management of low-risk neutropenic febrile patients with ofloxacin is as effective as inpatient management with the same agent. This approach should be limited to the subset of patients with low-risk factors who are not otherwise on quinolone prophylaxis.

A prospective study of recurrent febrile seizures.

Febrile seizures occur in about 2 to 4 percent of all children, approximately one third of whom will have recurrent febrile seizures. Little is known about predictors of recurrence. In this prospective study, we identified 347 children (1 month to 10 years of age) who presented with a first febrile seizure at one of four pediatric emergency departments. Information about these children was collected from medical records and interviews with the parents, and the children were followed for a median of 20 months to ascertain whether febrile seizures recurred. Recurrent febrile seizures occurred in 94 of the 347 children (27 percent) with a cumulative risk of 25 percent at one year and 30 percent at two years. The duration of fever before the initial seizure was associated with the risk of recurrence at one year: for fever lasting less than 1 hour, the risk of recurrence was 44 percent; for fever lasting 1 to 24 hours, 23 percent; and for fever lasting more than 24 hours, 13 percent (P less than 0.001). With each degree of increase in temperature (in degrees Fahrenheit), from 101 degrees F (38.3 degrees C) to greater than or equal to 105 degrees F (40.6 degrees C), the risk of recurrence at one year declined, from 35 percent to 30, 26, 20, and 13 percent (P for trend = 0.024). An age of less than 18 months and a family history of febrile seizures were also associated with an increased risk of recurrence. A family history of epilepsy, complex febrile seizures, and neurodevelopmental abnormalities did not increase the risk of recurrent febrile seizures. A shorter duration of fever before the initial febrile seizure and a lower temperature are associated with an increased risk of recurrence in children who have febrile seizures.

Epidemiological basis for clinical diagnosis of childhood malaria in endemic zone in West Africa

It is difficult to distinguish childhood malaria from other common febrile disorders by parasite count alone, because of the wide variation in tolerance of parasitaemia among individuals. We postulated that the proportion of febrile episodes among young children that can be attributed to parasitaemia varies according to simple clinical criteria. We studied 1114 children aged 2-9 years, who attended a dispensary in the Republic of Niger, with a case-control approach; each of 557 febrile children was matched with a non-febrile control by sex, age, ethnic group, and day of presentation. Febrile episodes were classified according to three clinical criteria: the presence of a likely non-malarial cause; the duration (less than 3 or more than 3 days before presentation); and the intensity (below 39°C or 39°C and above). There was no evidence for an association between febrile episodes and parasite count during the dry, low-transmission, season. During the rainy, high-transmission, season, by contrast, there was a highly significant relation (p<0·0001) between the likelihood of fever and the parasite count; each clinical criterion strengthened the association. There was no association between parasitaemia and low intensity fevers, with an obvious cause, that started 3 or more days before presentation, even in the rainy season; however, the relative risk of a fever that met all three criteria developing in those with vs those without parasitaemia was 27·5. The proportion of febrile cases attributable to detectable parasitaemia (population attributable risk) ranged from 0 to 0·92. Our results suggest that simple clinical criteria may be valuable in the selection of febrile patients for antimalarial treatment. In this geographic area, high fever of short duration and with no other obvious cause that occurs during the rainy season is most likely to be malaria.

Cerebrospinal Fluid Prostaglandins, Interleukin 1β, and Tumor Necrosis Factor in Bacterial Meningitis

Prostaglandins (PGs), interleukin 1 beta (IL-1 beta), and tumor necrosis factor alpha (TNF alpha) are likely mediators of local inflammatory reactions. We measured PGE2, PGI2, IL-1 beta, and TNF concentrations in paired cerebrospinal fluid (CSF) samples (on admission, CSF1, and 18 to 30 hours later, CSF2) from 80 infants and children with bacterial meningitis. Forty patients received dexamethasone sodium (0.6 mg/kg per day in four intravenous doses) and 40 received an intravenous saline placebo. In CSF1, PGE2, PGI2, IL-1 beta, and TNF were detected in 90%, 56%, 98%, and 71% of specimens with mean (+/- SEM) concentrations of 462 +/- 65, 377 +/- 62, 1266 +/- 242, and 799 +/- 227 pg/mL, respectively. Concentrations of PGE2 correlated significantly with PGI2, IL-1 beta, TNF, and lactate and inversely correlated with glucose concentrations in the first CSF specimens. The PGE2, PGI2, IL-1 beta, and TNF were still detected in 40%, 18%, 97%, and 60%, respectively, of second CSF specimens obtained from placebo-treated patients. Compared with patients who had detectable PGI2 or TNF alpha concentrations in CSF2 specimens, those placebo-treated patients with no detectable PGI2 or TNF alpha activity in CSF2 had a lower incidence of neurological sequelae. Dexamethasone-treated patients had significantly lower PGE2, IL-1 beta, and lactate concentrations and higher glucose concentrations in CSF 18 to 30 hours later, shorter duration of fever, and a lower incidence of neurological sequelae than did placebo-treated patients.

The immunization of adults against diphtheria in Sweden

Two hundred and three women who disclaimed vaccination against diphtheria were divided into four groups and injected with either 2·0 or 6·25 Lf of a routine diphtheria toxoid or of a more purified preparation. One hundred and twenty-six of these women who did not show a secondary antibody response were given a second and a third injection one month and one year, respectively, after the first injection. Prebooster (third injection) antitoxin titres of ⩾0·01 IU ml −1 (the minimum level tor protection) were found in 22 and 37% of those who received 2·0 and 6·25 Lf, respectively. Postbooster titres of ⩾1·0 IU ml −1 (calculated to give a protection of at least ten years of duration) were found in 23 and 58% of those who received 2·0 and 6·25 Lf, respectively. The rate of untoward reactions was low. Fever of short duration occurred in five women. Four out of the five women received 6·25 Lf of the more purified diphtheria toxoid and one 2 Lf of the routine toxoid. Local reactions >10 cm were observed in three women. All received the higher dose, 6·25 Lf of diphtheria toxoid. Local reactions >5 but ⩽10 cm occurred in up to 13% (6·25 Lf of diphtheria toxoid). No significant difference between the groups of women vaccinated with routine or more purified toxoid was found. It was concluded that the diphtheria toxoids in the two doses of 2 Lf and 6·25 Lf did not induce a satisfactory immune response. To induce adequate protection the dose of diphtheria vaccine needs to be the same for adults and children, i.e. 12·5 Lf.