Double-blind multicenter comparison of cyclacillin and amoxicillin for the treatment of acute otitis media

warmings were accomplished. The methods were warm air inhalation, trunk immersion, heating pads, plumbed garments, passive rewarming, body-to-body heat transfers, and combinations of inhalation/heating pads and inhalation/ plumbed garments. The parameters examined were "after drop," "recovery time" (ie, to presenting temperature after "after drop"), and rate of rewarming. Trunkal immersion was found to be the best by all parameters, while heating pads and plumbed garments were the worst. Inhalation of warmed air (O~) was found to be the next best, and because of its feasibility in the field was recommended by the authors as the treatment of choice for out-of-hospital resuscitations. Body-to-body heat exchange was discouraged in the severely hypothermic patient, although this was not addressed by the study. [Editor's note: The authors only cooled the patients to 35 C (95 F), not significant enough to differentiate rewarming parameters. Temperature below 32 C (90 F) should be utilized because this is a clinically significant level for morbidity] Kurt Zangerle, MD

TRA. Patients under age 65 with other positive x-ray findings and with TRA on aortography were also found on chest film to have widened mediastinum. The high correlation between widened mediastinum and TRA was not appreciated in patients over 65 years of age with TRA. Because of these data, the authors suggest that all elderly patients with blunt or decelerating chest trauma receive aortography. The presence of a heart murmur was the only clinical criterion in the study that had a statistically significant association with widening of the mediastinum after trauma, and is the best indication for performing arch aortography to diagnose TRA in patients under the age of 65 years. William H. Blahd, MD

ACUTE OTITIS MEDIA; CYCLACILLIN; AMOXICILLIN

Double-blind multicenter comparison of cyclacillin and amoxicillin for the treatment of acute otitis media McLinn SE, Goldberg F, Kramer R, et al

AORTOGRAPHY; BLUNT THORACIC TRAUMA, AORTOGRAPHY

Indications for aortography in blunt thoracic trauma: A reassessment Gundry ST, Williams S, Burney R, et al J Trauma 22:664-669

Aug 1982

Clinical findings as well as most roentgenographic associations with traumatic rupture of the aorta (TRA) may be subtle, frequently absent, and unreliable for diagnosis. In this retrospective study the authors determined which of the usual clinical and radiologic criteria for TRA were helpful in deciding who should undergo arch aortography. One hundred seventy-three trauma patients who had undergone arch aortography were included in this study. Nine x-ray criteria of TIC& were evaluated on their A-P films for correlation with TRA: 1) wide mediastinum, 2) hemothorax, 3) first or second rib fracture alone or with other rib fractures, 4) clavicle fracture, 5) pulmonary contusion or pneumothotax, 6) apical cap, 7) depression of the left mainstem bronchus, 8) displacement of the nasogastric tube to the right, and 9) multiple rib fractures. Nine clinical criteria were evaluated for correlation with TRA: 1) cardiac contusion, 2) upper extremity hypertension, 3) pulse pressure difference between the right and left arms, 4) presence of a murmur, 5) presence of a changing murmur, 6) sternal or precordial ecchymosis, 7) sternal fracture, 8) unexplained hypotension, and 9) involvement in a high-speed deceleration motor vehicle accident. Twenty-five of 173, or 14%, of these patients had sustained TRA. Forty-six of 173 x-rays were felt to evidence wide mediastinum. Of those, 20 (46%) had TRA on aortography. Nineteen of 25 were less than 65 years old, and six were 65 years or older. A widened mediastinum was the only radiographic criterion in the K 65 age group that was found to have a high predictive value (18 of 19 patients) for 12:2 February 1983

J Pediatr 101:617-621

Oct 1982

The authors report on a study comparing cyclacillin (Cyclapen W ~, Wyeth), a synthetic penicillin of the ampicillin class, and amoxicillin (Wymox~, Wyeth) in the treatment of acute otitis media in 363 children. The centers used clinical (otoscopic and pneumatic otoscopy) criteria for diagnosis and treatment evaluation. In addition, 140 patients underwent tympanocentesis. Patients with beta-lactamase-producing Haemophilus influenzae and patients with negative cultures were excluded from the study. Cyclacillin and amoxicillin were used at a dose of 50 mg/kg/day on a threetimes-a-day regimen for 10 days. Clinical success was achieved in 89% of the cyclacillin group and 93% of the amoxicillin group. Bacteriologic cure rates were 98% in both groups. Recurrence of infection was seen in 8% of the cyclacillin group and 12% of the amoxicillin group. None of the differences was statistically significant. Mean time for remission of symptoms was shorter for the cyclacillin group (3.1 days vs 4.3 days) and fewer drug-related adverse affects (specifically diarrhea) were seen in the cyclacillin group (1.7% vs 9.8%). These differences were statistically significant (P < .05, and P < .01, respectively). The study concludes that cyclacillin is as effective as amoxicillin, produces a more rapid resolution of symptoms, and has a lower incidence of side effects and therefore may be preferable to amoxicillin in the treatment of acute otitis media. [Editor's lzote: Cyclacillin joins a list of other medications advocated as a first-line drug in the treatment of acute otitis media in children. One consideration not mentioned by the authors is cost. A survey of l o c i pharmacies shows that a lO-day prescription of cyclacillin for a lO-kg child would cost more than the equivalant treatment with cefaclor (Ceclor ~, Lilly) or a combination of penicillin and sulfisoxazole, and nearly twice as much as amoxicillin.] Steve Seifert, MD

Annals of EmergencyMedicine

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