The impact of enteral feeding protocols on nutritional support in critically ill children.

BACKGROUND: Studies have shown that feeding protocols may assist in achieving optimal nutritional care in critically ill children. The present study aimed to assess the impact of enteral feeding protocols on nutritional support practices through a continuous auditing process over a defined period. MATERIALS AND METHODS: A prospective audit on nutritional practice was initiated in 1994-1995 on all ventilated patients who were admitted for more than a complete 24-h period in the paediatric intensive care unit. The audit was repeated 1997-1998, 2001 and 2005. The collection of data on outcomes included the time taken to initiate nutritional support, the proportion of patients fed via the enteral versus parenteral route, and the proportion of children reaching 50% and 70% of the estimated average requirement (EAR) by day 3. Feeding algorithms and protocols were introduced after each audit with a view to improving practices. RESULTS: Over the study period, time taken to initiate nutrition support was reduced from 15 h (1994-1995), 8 h (1997-1998), 5.5 h (2001) to 4.5 h (2005). The proportion of patients on parenteral feeds was reduced from 11% (1994-1995) to 4% (2005). An increase was also documented in the percentage of patients receiving a daily energy provision of 50% and 70% of the EAR by day 3 after the initiation of nutritional support (6% in 1994-1995 to 21% in 2005 for 70% of EAR). CONCLUSION: The present study demonstrates that feeding protocols improve nutritional practices in a paediatric intensive care unit. However, protocol introduction needs to be monitored regularly through audit.

Profound asphyxia in the premature infant: imaging findings.

PURPOSE: To investigate imaging findings in premature infants who had profound asphyxia. METHODS: CT (three patients), MR (three patients), and ultrasonography (four patients) studies of five patients who had profound asphyxia before the postconceptional age of 32 weeks were retrospectively reviewed. The patients ranged from 1 day to 4 months old at the time of the imaging studies. An autopsy report was available in one patient. The results were compared with reports in the literature of patients with similar injuries at similar ages. RESULTS: Abnormalities of the thalami and basal ganglia were present in all infants examined with CT or MR. CT showed low attenuation in the basal ganglia and high attenuation (blood or calcium) in the thalami; thalamic cavitation and low attenuation of the upper brain stem were present in one infant. MR showed T1 and T2 shortening in the thalami in all patients. Variable MR changes were noted in the basal ganglia, ranging from diminished size with normal signal intensity to T1 and T2 shortening with normal size and complete cavitation. T1 and T2 shortening were seen in the dorsal brain stem in one patient. Sonography showed transient or persistent hyperechogenicity in the thalami in three patients and cavitation of the thalami in one patient. Damage to the perirolandic cortex was not present in any patient. CONCLUSION: Profound asphyxia before 32 weeks gestational age shows consistent injury to the thalami, basal ganglia, and brain stem that can be detected by all three imaging modalities. The pattern of injury seems to differ from that of partial asphyxia in premature infants and of profound asphyxia in term infants.

Atovaquone suspension in HIV-infected volunteers: pharmacokinetics, pharmacodynamics, and TMP-SMX interaction study.

STUDY OBJECTIVE: To evaluate the pharmacokinetics and safety of atovaquone suspension in volunteers infected with the human immunodeficiency virus ((HIV). DESIGN: Open-label, nonrandomized study. SETTING: Two clinical research centers. PATIENTS: Twenty-two HIV-infected volunteers with a median CD4 cell count of 37 cells/mm3. INTERVENTIONS: Patients received atovaquone suspension fasting or fed for 2-week periods with crossover at dosages of 500 mg/day, and randomization to fasting or fed at dosages of 750 and 1000 mg/day. A subset of patients also received 750 mg twice/day with food, and a subset of those who received 1000 mg/day fasting also received 1000 mg with food. During a long-term dosing phase, a subset of subjects were evaluated for an interaction between atovaquone and trimethoprim-sulfamethoxazole (TMP-SMX). MEASUREMENTS AND MAIN RESULTS: Average steady-state atovaquone concentrations at 500 mg were 6.7 +/- 3.2 microg/ml fasted and 11.3 +/- 5.0 microg/ml with food; at 750 mg, 9.9 +/- 7.1 microg/ml fasted and 12.5 +/- 5.9 microg/ml with food; at 1000 mg, 9.7 +/- 4.3 microg/ml fasted and 13.6 +/- 5.0 microg/ml with food; and at 1500 mg, 21.1 +/- 5.0 microg/ml with food. Thus, plasma concentrations were not proportional to dose. Concomitant food ingestion resulted in a 1.3- to 1.7-fold increase in values. Average steady-state concentrations were less than 10 microg/ml in 21% and more than 15 microg/ml in 36% of patients at 1000 mg/day with food; at 750 mg twice/day, all five patients had levels above 15 microg/ml. Atovaquone suspension was well tolerated; diarrhea, nausea, fatigue, and rash were the most common adverse events. Concomitant administration of TMP-SMX did not change atovaquone concentrations and resulted in small decreases in concentrations of TMP (16%) and SMX (10%). CONCLUSION: Plasma concentrations are significantly higher when atovaquone suspension is administered with food compared with fasting. Total doses of 1500 mg/day are likely to achieve concentrations effective for prophylaxis of Pneumocystis carinii pneumonia.

Nutritional support of the mechanically ventilated patient.

Mechanically ventilated patients generally depend on artificial means for nutritional supplementation. In this article we review the magnitude, pathophysiology, and clinical significance of proteolysis, and evidence that nutritional repletion is beneficial. Methods for assessing nutritional status and response to nutritional intervention are briefly discussed, as well as basic principles of anabolic and anticatabolic therapy.

Impacts of swine manure pits on groundwater quality.

Manure deep-pits are commonly used to store manure at confined animal feeding operations. However, previous to this study little information had been collected on the impacts of deep-pits on groundwater quality to provide science-based guidance in formulating regulations and waste management strategies that address risks to human health and the environment. Groundwater quality has been monitored since January 1999 at two hog finishing facilities in Illinois that use deep-pit systems for manure storage. Groundwater samples were collected on a monthly basis and analyzed for inorganic and bacteriological constituent concentrations. The two sites are located in areas with geologic environments representing different vulnerabilities for local groundwater contamination. One site is underlain by more than 6 m of clayey silt, and 7-36 m of shale. Concentrations of chloride, ammonium, phosphate, and potassium indicated that local groundwater quality had not been significantly impacted by pit leakage from this facility. Nitrate concentrations were elevated near the pit, often exceeding the 10 mg N/l drinking water standard. Isotopic nitrate signatures suggested that the nitrate was likely derived from soil organic matter and fertilizer applied to adjacent crop fields. At the other site, sandstone is located 4.6-6.1 m below land surface. Chloride concentrations and delta15N and delta15O values of dissolved nitrate indicated that this facility may have limited and localized impacts on groundwater. Other constituents, including ammonia, potassium, phosphate, and sodium were generally at or less than background concentrations. Trace- and heavy-metal concentrations in groundwater samples collected from both facilities were at concentrations less than drinking water standards. The concentration of inorganic constituents in the groundwater would not likely impact human health. Fecal streptococcus bacteria were detected at least once in groundwater from all monitoring wells at both sites. Fecal streptococcus was more common and at greater concentrations than fecal coliform. The microbiological data suggest that filtration of bacteria by soils may not be as effective as commonly assumed. The presence of fecal bacteria in the shallow groundwater may pose a significant threat to human health if the ground water is used for drinking. Both facilities are less than 4 years old and the short-term impacts of these manure storage facilities on groundwater quality have been limited. Continued monitoring of these facilities will determine if they have a long-term impact on groundwater resources.

Mammographic changes following reduction mammaplasty.

Mammographic findings after reduction mammaplasty may be similar to those seen with carcinoma. A knowledge of the expected mammographic alterations would be helpful in differentiating postoperative changes from those seen with carcinoma of the breast. Accordingly, the clinical records and mammograms of patients who underwent reduction mammaplasty at the Dartmouth-Hitchcock Medical Center between March of 1977 and July of 1985 were analyzed. Forty-two patients had at least one mammographic examination following reduction mammaplasty. Periareolar soft-tissue changes and inferior pole alterations were present in almost all examinations of patients during the first 6 months after operation, but they decreased during the next few years. Asymmetrical densities were present in approximately half the patients throughout the follow-up period but decreased in degree. Parenchymal calcifications occurred later; few x-rays showed these calcifications during the first year, but 50 percent were apparent after 2 years. Evidence of fat necrosis occurred in approximately 10 percent. Four patients had biopsies for suspicious densities. Chronic inflammation and inclusion cyst were reported. We believe that changes after reduction mammaplasty are predictable and can usually be differentiated from those associated with cancer.

Hydrostatic balloon dilation of congenital esophageal stenoses associated with esophageal atresia.

It has been stated that congenital cartilage rings in the esophagus do not respond to dilation and should be resected. The authors report on 3 infants with congenital esophageal stenoses who were treated successfully with hydrostatic balloon dilation. Based on the appearance during dilation the authors believe that these stenoses were cartilage rings. The technique is described in detail. Balloon dilation is the treatment of choice for these patients. Resection should be reserved for those who do not respond to this form of therapy.

Chlorine Concentration and the Inoculation of Tomato Fruit in Packinghouse Dump Tanks.

Chlorine concentrations (pH 6 to 7 and 22 to 27°C) that killed arthrospores (spores) of Geotrichum candidum or sporangioles (spores) of Rhizopus stolonifer, causal agents of sour rot and Rhizopus rot, respectively, in moving water within 30 to 45 s did not prevent these pathogens from inoculating wounded tomatoes (Lycopersicon esculentum) in a water flume containing chlorine and spores. Free chlorine concentrations of 20 or 25 mg/liter were lethal to spores of G. candidum within 30 s in most in vitro tests, whereas spores of R. stolonifer were slightly less sensitive. Wounded tomatoes placed in a flume with free chlorine at 30 mg/liter and then exposed to spores for 1 min developed about 50% less decay incidence during storage at 24°C for 6 days than did fruit exposed to spores and water alone. In the absence of chlorine, incidence averaged 57% (range, 15 to 95%) for R. stolonifer and 38% (range, 17 to 58%) for G. candidum. Sporadic sour rot lesions were observed among fruit that had been treated with free chlorine at 75 mg/liter, whereas chlorine at up to 180 mg/liter failed to completely protect fruit from Rhizopus rot. A water-soluble dye rapidly penetrated wounds on tomato fruit. The dye framed the outlines of cells at the wound surface and appeared to penetrate into a few intercel-lular spaces. Application of 1% sodium hypochlorite decolorized the dye on the wound surface, whereas deposits located below the wound surface remained blue. Thus, spores suspended in moving water can escape the action of chlorine if carried into intercellular spaces by diffusion or by capillary movement of cell sap and water.

"Hyperacute" subdural hematoma: CT mimic of recurrent episodes of bleeding in the setting of child abuse.

Mixed density extraaxial hematomae on computed tomography (CT) scanning generally represent recurrent episodes of bleeding (chronic subdural hematoma with rebleeding). Hyperacute hemorrhages in which the patient is actively bleeding or has a coagulopathy have also been described as mixed density. We report a case of child abuse in a fourteen month old child who presented with a CT scan showing a mixed density subdural hematoma which was originally interpreted as recurrent episodes of hemorrhage, but who had evidence of only acute, active bleeding at surgery and by histologic examination. There is a proportionally high incidence of subdural hematoma in cases of child abuse, due in part to the increased susceptibility of the immature brain to trauma. Because the mechanism of injury is different for hemorrhage due to hyperacute subdural hematoma (SDH) and that of acute bleeding within a chronic SDH, the distinction between these entities has potentially important legal implications in cases of suspected child abuse. This potential pitfall in interpretation of the CT scan has not to our knowledge been reported in the forensic literature.

The 'other' sexually transmitted diseases. Chlamydial, herpes simplex virus, and human papillomavirus infections.

The incidence of sexually transmitted diseases continues to rise across the country. Because many cases are subclinical and asymptomatic, chlamydial, herpes simplex virus, and human papillomavirus (HPV) infections continue to spread at an alarming rate. These infections can lead to serious sequelae, such as pelvic inflammatory disease, infertility, and cervical dysplasia or carcinoma, so improved disease-control strategies are needed. Preventive efforts should include use of the latest diagnostic and therapeutic methods to uncover and eradicate subclinical chlamydial and HPV infections. In addition, notification of sexual partners should be encouraged. Education about prevention of sexually transmitted diseases should be incorporated into basic primary medical care for all sexually active patients.

Serious infections caused by coagulase-negative staphylococci in intravenous drug users.

While Staphylococcus aureus has been a well-recognized pathogen in patients who use illicit intravenous drugs, coagulase-negative staphylococci are not generally appreciated as causes of infectious complications in intravenous drug users. The authors present data suggesting the coagulase-negative staphylococci are potential pathogens in these high risk patients.

Spontaneous colonic ischemia in a patient with Riley-Day syndrome.

Familial dysautonomia, or Riley-Day syndrome, is a hereditary disturbance in the autonomic and peripheral sensory nervous systems, first described by Riley, Day, and colleagues in 1949 [1, 2]. Previous reports of myocardial infarction and avascular necrosis in bone suggest that these patients are at risk for ischemia at certain organ sites [3, 4]. We report a case of spontaneous colonic ischemia and stricture which resulted in colocutaneous fistula formation and eventual colonic resection in a child with Riley-Day syndrome.

Extralobar pulmonary sequestration receiving its arterial supply from the innominate artery.

Pulmonary sequestration is a rare bronchopulmonary foregut malformation, for which the arterial blood supply is usually derived from the descending thoracic or abdominal aorta. A 5-week-old infant is described with an extralobar pulmonary sequestration supplied by a large artery originating from the innominate artery, an arrangement only described once previously. Helical CT scan now makes arteriography unnecessary in the evaluation of these malformations.

Unilateral lymphangiectasis of the kidney: an unusual cause of renal enlargement in an infant.

We report on an infant with unilateral renal lymphangiectasia and the absence of small cysts in the renal parenchyma or renal hilum. We suggest that renal lymphangiectasia be part of the differential diagnosis in children who present with unilateral renal enlargement, especially when contrast enhanced computerized tomography shows preservation of a rim of renal cortex with decreased attenuation of the medulla and/or when ultrasound demonstrates increased echogenicity without displacement of the caliceal system.