Management of streptococcal pharyngitis

Severe hemobilia after blunt hepatic trauma is one of the limits for a conservative medical treatment. Urgent percutaneous highly selective embolization of the bleeding vessel is the treatment of choice today. Failures of radiological treatment require surgery. Primary direct ligation of the bleeding vessel carries a risk of recurrence and prevents subsequent embolization. Under these conditions, when the surgeon prefers a conservative approach, preoperative embolization using permanent material can be performed as reported in our case study.     

Acute pharyngitis, tonsillitis and tonsillectomy

Respiratory infections are the most common group of diseases experienced in the community and treated by doctors. Tonsillitis and pharyngitis, sometimes referred to together as acute sore throat, are among the most common of the individual respiratory infections.     

The economic cost of a streptococcal tonsillitis episode

OBJECTIVE: To estimate the cost of a streptococcal tonsillitis episode from the data of a questionnaire. SETTING: Five primary health centres in the west of Sweden. PARTICIPANTS: 101 consecutive patients treated for streptococcal tonsillitis. MAIN OUTCOME MEASURE: The cost estimation included costs for physician visit and drug, travel costs to and from the primary health centre, cost of lost production resulting from the patient's or the guardian's absence from work for physician visit or sick-leave, and cost of telephone consultation with a physician or nurse. RESULTS: The period of illness was on average seven days, time to recovery after treatment five days, and the mean period of sick-leave 2.5 days. The total cost of a tonsillitis episode was about SEK 3,300 (385 USD). Of this sum, the cost for the antibiotic accounted for only 3% and loss of production for 75%. CONCLUSION: Differences in the cost of drugs only have a minor influence on the total cost, while factors causing loss of production, such as efficacy and side effects of the drug, have a greater influence. Economic evaluation of pharmaceuticals will be more relevant in the future, and in the search for the most effective treatment, cost effective studies will be integrated with clinical trials.     

Food-borne outbreak of streptococcal pharyngitis in an Israeli Airforce Base

OBJECTIVE: To determine if maternal hematocrit and serum albumin can predict intrauterine growth retardation and/or preterm delivery. METHODS: Analyses were performed during each trimester of pregnancy to evaluate the predictive value of these two common laboratory parameters as predictors of intrauterine growth retardation and/or prematurity. RESULTS: 1468 women participated in the study. Intrauterine growth retardation occurred in 9.9% and preterm delivery in 6.1%. A significant inverse correlation between hematocrit and albumin and birth weight was found (r = -0.005, p = 0.04, and r = -0.07, p = 0.007, respectively), albumin being a stronger predictor as demonstrated by multiple regression. Low hematocrit at the third visit was associated with a longer pregnancy duration (r = -0.06, p = 0.02). Woman with higher serum albumin levels at the second visit, had a longer pregnancy duration, possibly reflecting a better nutritional status (r = 0.057, p = 0.03). To determine the predictive value of hematocrit and serum albumin, the prevalence of intrauterine growth retardation and premature delivery in the highest quartiles were compared with the lowest, and no significant differences were observed (p > 0.1). CONCLUSION: Maternal hematocrit and serum albumin concentration cannot be used as useful predictors of intrauterine growth retardation or preterm delivery.     

Comparison of clarithromycin suspension and amoxycillin syrup for the treatment of children with pharyngitis and/or tonsillitis

A community-based logitudinal study conducted in Matlab, a rural area in Bangladesh, investigated acute respiratory infections (ARI) among children. A cohort of 696 children under 5 years of age was followed for 1 year yielding 183,865 child-days of observation. Trained field workers visited the study children every fourth day. Data on symptoms suggesting ARI, such as fever, cough, and nasal discharge, were collected for the preceding 3 days by recall. To determine the type and severity of ARI, the field workers conducted physical examinations (temperature, rate of respiration, and chest indrawing) of children reporting cough and/or fever. The overall incidence of ARI was 5.5 episodes per child-year observed; the prevalence was 35.4 per hundred days observed. Most of the episodes (96 per cent) were upper respiratory infections (URI). The incidence of acute lower respiratory infections (ALRI) was 0.23 per child per year. The incidence of URI was highest in 18-23-month-old children, followed by infants 6-11 months old. The highest incidence of ALRI was observed in 0-5-month-old infants followed by 12-17-month-old children. Among 559 children who were followed for 6 months or longer, about 9 per cent did not suffer any URI episode and about 16 per cent suffered one or more ALRI episodes. About 46 per cent of URI and 65 per cent of ALRI episodes lasted 15 days or more. The incidence rates of URI were higher during the monsoon and pre-winter periods, and that of ALRI at the end of the monsoon and during the pre-winter periods. Sociodemographic variables were not associated with the incidence of URI or ALRI. The study documents ARI to be a major cause of morbidity among rural Bangladeshi children.     

Five-day cefdinir treatment for streptococcal pharyngitis. Cefdinir Pharyngitis Study Group

A multicenter, randomized, controlled, investigator-blind study was performed to evaluate the safety and efficacy of oral cefdinir versus oral penicillin V for the treatment of pharyngitis due to group A beta-hemolytic streptococci (GABHS). Patients 13 years of age and older were randomized to receive either oral cefdinir (300 mg twice a day) for 5 days followed by placebo for 5 days or oral penicillin V (250 mg four times a day) for 10 days. Throat cultures were obtained, and signs and symptoms of pharyngitis were recorded at study admission and follow-up visits on study days 11 to 15, 16 to 20, and 25 to 31. Patients kept a diary to record medication intake and their assessment of throat pain at admission and at each day of study treatment. Five hundred fifty-eight patients were enrolled, of whom 432 (77.4%) were clinically and microbiologically evaluable. The GABHS eradication rates 5 to 10 days after completion of therapy were 193 of 218 (88.5%) in the cefdinir group and 176 of 214 (82.2%) in the penicillin group (P = 0.053). Clinical cure rates were 89.0 and 84.6%, respectively (P = 0.80). By the time of the long-term follow-up visit, 2 to 3 weeks after completion of treatment, 156 of 191 (81.7%) of the assessable cefdinir patients and 152 of 195 (77.9%) of the penicillin patients remained free of GABHS. Both treatments were well tolerated, with adverse reaction rates of 18.3% in the cefdinir study arm and 15.0% in the penicillin study arm (P = 0.278). Five-day treatment with cefdinir is safe and effective therapy for GABHS pharyngitis. Based on its twice-a-day dosage and shorter course of therapy, leading to potentially greater patient compliance, cefdinir may be considered for use in the treatment of pharyngitis caused by GABHS.     

Significance of normal oropharyngeal flora in the development of streptococcal pharyngitis and outcome of penicillin therapy

Pharyngitis is one of the most frequent diseases in children. The most important of the bacterial infections is due to Streptococcus pyogenes. For many years, penicillin is considered to be the drug of choice for streptococcal pharyngitis, although failure rates of up to 20% have been reported. One of possible explanations for penicillin treatment failure is presence of other species of bacteria in the normal oropharyngeal flora that can interfere with colonization and growth of Streptococcus pyogenes and influence the development of pharyngitis. A wide variety of microorganisms, including alpha-haemolytic streptococci and anaerobic bacteria, are present within the oropharynx (table 1). The strain of alpha-haemolytic streptococci is in interference with Streptococcus pyogenes. By producing bacteriocins, they inhibit colonization and growth of Streptococcus pyogenes and assist in its eradication. Anaerobic bacteria may play a direct or indirect role in development of pharyngitis. They may be directly responsible for specific forms of pharyngitis or contribute indirectly with possibility of synergy between them and Streptococcus pyogenes. Beta-lactamase-producing aerobic and anaerobic organisms may contribute to penicillin treatment failure. By producing beta-lactamase within the tonsillar tissue, they destroy penicillin and protect streptococci from the antibacterial effect of penicillin. Pharyngeal bacterial flora may vary according to the state of the patient (Figure 1). During an acute infection and in the cases of treatment failure and recurrent pharyngitis the number of alpha-haemolytic streptococci declines, while there is an increase in the number of anaerobic and beta-lactamase-producing organisms. After successful treatment the number and type of bacteria is similar to those found within normal tissue. Knowing the distribution and changes in pharyngeal bacterial flora is important for choosing the optimal drug for treatment of streptococcal pharyngitis. Although penicillin reduces the number of interfering beta-haemolytic streptococci, because of its advantages, if remains the drug of choice for the treatment of streptococcal pharyngitis. In cases of treatment failure and recurrent infections cephalosporins and macrolides may be a useful alternative to penicillin because they possess relatively poor activity against alpha-haemolytic streptococci, resistance to beta-lactamase and because of better penetration into tonsilar tissue.     

Plea for an evaluation of beta hemolytic streptococcal tonsillitis: from diagnosis to treatment

The poor state of Aboriginal and Torres Strait Islander health has been documented in many ways, most obviously by comparing the relatively higher age-specific mortality and morbidity rates. This paper demonstrates the use of acute hospital separation data as a way to identify potential deficiencies in providing appropriate primary health care services for Aboriginal and Torres Strait Islander populations. It does so by using 'ambulatory sensitive conditions': those conditions (and procedures) for which high-quality appropriate primary health services deliverable under ideal circumstances are though to potentially reduce or eliminate the need for hospitalisation. Potential or realised access to primary care is not analysed directly using primary health service data. In this study, 1993-94 acute hospital separation data from NSW, Queensland, South Australia, Western Australia and the Northern Territory were used to calculate separation rates and odds ratios for Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander populations. Age-specific acute hospital separation rates for ambulatory sensitive conditions were 1.7 to 11 times higher for the Aboriginal and Torres Strait Islander populations studied. This supports clinical contentions that much Aboriginal and Torres Strait Islander morbidity and mortality is preventable and that further consideration is needed to service delivery reform at all levels in the health system and the distribution of funding.     

The effect of a rapid kit for detection of streptococcal pharyngitis on the accuracy of the physicians' diagnoses

BACKGROUND: In the last decade, the accuracy of rapid tests for detection of group A streptococcal antigen was evaluated in laboratory and clinical settings, and the tests were suggested as an alternative to the traditional throat culture. METHODS: We evaluated 19 patients with a preliminary diagnosis of nonstreptococcal pharyngitis and 13 patients with a preliminary diagnosis of streptococcal pharyngitis. The physician performed a rapid latex agglutination test (Detect A Strep), took throat culture from all of the patients, reconsidered the preliminary diagnosis, and made a working diagnosis. A clinical score was calculated for each patient during data analysis. The accuracy of the physicians' preliminary diagnoses was compared with the accuracy of the scoring system, with the accuracy of the latex agglutination test, and with the accuracy of the physicians' working diagnoses. RESULTS: The scoring system, the physicians' preliminary diagnoses, the latex agglutination test, and the physicians' working diagnoses correlated significantly with throat culture results (p < or = 0.05). The efficiency of the physicians' preliminary diagnoses was 75% compared with an efficiency of 69% of the clinical scoring system, an efficiency of 66% of the latex agglutination test, and an efficiency of 69% of the physicians' working diagnoses. The physician changed the preliminary diagnosis only for two patients as a result of the latex agglutination test results; ironically, however, the preliminary diagnosis was correct in both of these cases. CONCLUSION: The use of a rapid test for the diagnosis of group A streptococcal antigen under normal working conditions did not improve the accuracy of the physician's diagnosis, so the use of the latex agglutination test in this study was not cost-effective.     

Macrolides and drug interactions: review of the literature]

Annexin I is a member of the annexin family of calcium-dependent membrane binding proteins. The core domain of these proteins is similar in all annexins but the N-terminal domain is specific for each member. This domain is thought to regulate annexin function through phosphorylation. In annexin I, Ser-27 is one of the amino acids that can be phosphorylated by protein kinase C. Phosphorylations are thought to regulate some annexin I functions by increasing calcium requirement. Two mutants were prepared in this study: S27E and S27A proteins. The first mimics phosphorylation while the second prevents phosphorylation at residue 27. Wild-type annexin I and S27A mutant protein showed the same calcium dependence for phospholipid vesicles aggregation, while S27E mutant protein showed a higher calcium requirement and a low maximal extent of aggregation. By contrast, liposome binding and self-association required identical calcium concentrations for the wild-type and the two mutant proteins. To examine whether the regulation observed is due to modification of the N-terminal structure, we investigated conformational changes by using two approaches. Firstly we analysed proteinase sensibility. Limited proteolysis of the N-terminal tail showed similar patterns for the three proteins. Using drastic conditions of proteolysis, we observed strong resistance of the core domain to digestion in the presence of calcium. Secondly, since Ser-27 is located on the N-terminal domain that contains a tryptophan located at position 12, the fluorescence of this residue was analysed during Ca2+-binding of wild-type annexin I and S27E mutant protein. The results demonstrated that Ca2+ induces a slight change in the Trp environment of wild-type annexin I, corresponding to a burying of the residue. No changes in fluorescence features were observed with S27E mutant protein. The results obtained show that phosphorylation of the N-terminal tail plays a regulatory role in phospholipid vesicle aggregation, which is based on a mechanism distinct from protein self-association. This phosphorylation induces a conformational change in the tail probably related to aggregation property.     

Practice variation in the management of pharyngitis: the importance of variability in patients' clinical characteristics and in physicians' responses to them

The objective of this study was to assess whether geographic differences in antibiotic-prescribing rates for patients with pharyngitis could be explained by intersite differences in patients' clinical characteristics and in how physicians responded to these clinical cues when making decisions. As part of the initial phase of a prospective controlled trial to improve physicians' diagnostic ability, the authors enrolled cohorts of consecutive patients seen at staff-model--HMO student health services in Pennsylvania and Nebraska. Physicians' decisions whether to prescribe antibiotics for 310 consecutive patients presenting with pharyngitis to the former and 214 such patients presenting to the latter at the time of the initial visit were examined. There was a large discrepancy between the antibiotic-prescribing rates at the student health services in Pennsylvania, 106/310, 32.4%, and Nebraska, 156/214, 72.9%. The clinical variables significantly independently associated with treatment at both sites in a logistic regression model were fever, adjusted odds ratio = 2.1 (95% CI = 1.1, 3.8); exudates, 5.4 (2.8, 10); palatine petechiae, 6.5 (1.5, 28); rhinorrhea, 0.46, (0.25, 0.85); and high risk of complications, 3.8 (1.04, 14). There was a significant interaction between site and anterior cervical adenopathy, 5.5 (1.6, 19); and a borderline interaction between site and rhinorrhea, 2.4 (0.89, 6.7). Site was not a significant independent predictor of treatment, 1.8 (0.45, 6.6.). Practice variation was related to geographic differences in patients' clinical characteristics and in how physicians responded to these factors when prescribing antibiotics. How physicians weight patients' clinical characteristics when making decisions may be an important element of their "practice styles."     

Beta-lactamase-producing bacteria in recurrent childhood tonsillitis

Angiotensin converting enzyme is a key component of the renin angiotensin system that plays an important role in cardiovascular regulation. It seems to modulate cardiovascular growth by virtue of its role in the conversion of angiotensin I to angiotensin II and degradation of kinins. A deletion polymorphism localized in intron 16 of the human angiotensin converting enzyme gene, corresponding to a 287 bp long Alu repetitive sequence, was found to be associated with increased risk of myocardial infarction in various subgroups, including European, French and Japanese coronary patients. This angiotensin converting enzyme gene I/D polymorphism was examined by the polymerase chain reaction in a cross-sectional study of 201 healthy Indian subjects and 150 patients (angiographically proven cases of coronary artery disease) whose serum angiotensin converting enzyme levels were concomitantly measured. The D/D, I/D and I/I genotypes were found in 20.66%, 46.66% and 32.66% of the Indian coronary heart disease patients and in 23.38%, 49.75% and 26.86% of controls respectively. One of the reasons for not finding an association between the D allele and coronary artery disease in this study could be the ethnic heterogeneity and disease status heterogeneity among the patients and controls. However the phenotypic variance of serum angiotensin converting enzyme levels is strongly influenced by this polymorphism. In the Indian population, the angiotensin converting enzyme gene I/D polymorphism is not associated with risk for coronary artery disease although it is associated with plasma angiotensin converting enzyme activity. Hence the angiotensin converting enzyme gene I/D polymorphism does not seem to be a useful marker for coronary artery disease in the Indian population.     

On the treatment of recurrent tonsillitis by vaccination

OBJECTIVE: To analyze the use of Cyclosporine (CyA) in nephrotic syndrome. METHODS: Thirty five children of mean age of 5.9 years with steroid dependent (n = 26) or steroid resistant (n = 9) primary nephrotic syndrome with normal renal functions and who received CyA were studied. CyA was used at a dosage of 6-7 mg/kg/day orally in two divided doses. The mean duration of therapy was 9.6 weeks. All received a minimum of 8 weeks of CyA therapy. In a few who received longer therapy, the dose was reduced to 4 mg/kg/day. All patients were monitored serially for hepatotoxicity and nephrotoxicity. The nephrotic state was evaluated serially with biochemical tests and followed up for a mean period of 2.55 years. RESULTS: Thirty one patients completed the study. The response to therapy was categorized into 5 groups-no response (4 patients), good response (4 patients), partial response (4 patients), cyclosporine dependence (16 patients), and infrequent relapsers (3 patients). Good response was defined as complete remission lasting for at least one year after cessation of therapy. Patients who showed partial response had reduction in quantitative proteinuria and needed less diuretics. Sixteen patients went into complete remission while on therapy but relapsed within 3 months of discontinuation (CyA dependence). The response to CyA correlated more with steroid-responsiveness than with the underlying histopathology. The drug was well tolerated. CONCLUSION: In steroid-dependent or steroid-resistant nephrotic children with normal renal functions, CyA therapy may be considered as one of the possible therapeutic options. Our results suggest that a longer duration of CyA therapy may possibly be indicated in these cases.     

Possibilities of using surgical laser in the treatment of chronic tonsillitis

A novel technique of surgical treatment of chronic tonsillitis is presented. It implies the use of Ne-YAG laser in contract regimen. Good results were obtained in experiments on the exposure of distal tonsils to intralacunar laser radiation.     

The role of macrolides in Streptococcus pyogenes pharyngitis

PURPOSE: This study was undertaken to compare functional results, complications, preoperative durations of disease, and rates of dysplasia and neoplasia between older and younger chronic ulcerative colitis patients undergoing restorative proctocolectomy (RPC) with mucosectomy. METHODS: A total of 392 patients with a preoperative diagnosis of chronic ulcerative colitis underwent elective RPC with mucosection and handsewn ileoanal anastomosis. Pathologic reports were reviewed, with specific reference to findings of dysplasia or cancer. Functional results concerning the number of bowel movements per 24 hour period and the incidence of fecal soilage were obtained by direct or telephone patient interview. FINDINGS: Group I consisted of 326 patients aged 5 to 49 (mean, 30.9) years and 160 women. Group II comprised 66 patients aged 50 to 74 (mean, 56.9) years and 29 women. Duration of disease was significantly longer in the older group (6.2 vs. 15.6 years; P < 0.001). The older group had significantly higher rates of dysplasia (29/326 vs. 19/66; P < 0.0001) and malignancy (14/326 vs. 9/66; P = 0.003). Rates of complication, hospital days following RPC, and total hospital days for all causes were comparable between groups. Perfect day-time continence was observed in 81.6 percent of Group I and 80 percent of Group II patients (213/261 vs. 40/50; P = 0.79). Perfect continence during sleep was observed in 65.1 percent of Group I and 62 percent of Group II patients (170/261 vs. 31/50; P = 0.67). Mean number of bowel movements per 24 hour period for Group I was 6.3 +/- 0.2 and for Group II was 7.4 +/- 0.5. Mean difference, one movement per 24 hours, was not significant (95 percent confidence interval, -0.02 to 2.1; t = 1.95, P = 0.055). CONCLUSIONS: We conclude that patients older than 50 years are suitable candidates for RPC with mucosectomy. Functional results and complication rates are similar to those observed among younger patients. Patients older than 50 years have a significantly higher rate of concurrent dysplasia and malignant degeneration than younger patients, most probably because of a longer duration of disease. RPC with mucosal excision potentially lowers this risk by elimination of all colorectal mucosa.