Minimum incidence and diagnostic rate of first urinary tract infection.

OBJECTIVE: To study awareness of urinary tract infections (UTIs) by determining the diagnostic rate of first UTI in children <2 years of age and to estimate the minimum incidence. METHODS: Twenty-six of a total of 43 pediatric centers participated in the study. Sixty-four percent of the total childhood population <2 years of age was covered. The number of all children included in the study was used to calculate the diagnostic rate. Only UTI confirmed by either suprapubic aspiration (any growth) or midstream or bag samples with >/=100 000 bacteria/mL, together with a positive nitrite reaction, was used to estimate the minimum incidence. RESULTS: The mean diagnostic rate was 1.5% for boys (range, 0.7%-3.0%) and 1.7% for girls (range, 0.7%-2.9%). The diagnostic rate was significantly higher in June than in December. The mean incidence was 1.0% for both boys and girls (range, 0.3%-3.0% and 0.4%-2.9%, respectively). The minimum cumulative incidence at 2 years of age was estimated to be 2.2% for boys and 2.1% for girls. CONCLUSION: This study suggests a high UTI awareness in Sweden as indicated by a higher diagnostic rate and, despite stricter diagnostic criteria, a higher incidence of UTI in children <2 years of age than previously reported. It is suggested that a high UTI awareness may reduce chronic renal failure because of pyelonephritic renal scarring.

Low level of bacterial contamination of mist tents used in home treatment of cystic fibrosis patients.

Mist tents are recommended by the Stockholm cystic fibrosis (CF) centre for small children with CF. Daily disinfection of some parts of the tent with 2% acetic acid is recommended, and for other parts boiling water followed by air-drying without rinsing. The plastic tent is discarded each day. We have studied whether these prescribed routines are followed by the patients and whether they are sufficient to prevent bacterial contamination. The mist tent equipment of 20 CF patients (mean age 7 years, range 1-15 years), two of whom were chronically colonized with Pseudomonas aeruginosa, were investigated. All patients were visited at home in the morning after 6-12 hours aerosol therapy. Liquid from the nebulizing chambers and swabs from the aerosol tube were examined by culture on four different media. Seventeen of 20 patients claimed that they cleaned and disinfected the tubes every day, two patients every other day and one once a week. Seventeen of 19 claimed they cleaned and disinfected the chambers daily, one once a week and, one twice a week. No or insignificant growth was found in 16/20 aerosol tubes: moulds in three, Pseudomonas species in one. Twelve of 19 chambers showed no or insignificant growth: moulds or yeasts were present in three and Pseudomonas sp. in four. In four of the seven patients moulds or yeasts and/or Pseudomonas sp. grew both from chambers and from aerosol tubes; in the remaining three only from chambers. None of these seven patients had followed our prescribed cleaning and disinfection recommendations, the other 13 claimed they had. Of the patients whose equipment yielded Pseudomonas sp, none was colonized with these strains, although one had P. aeruginosa. We conclude that our disinfection recommendations are adequate when followed. However, our disinfection recommendations concerning the nebulizing chamber had not been followed satisfactorily. The different forms of non-compliance would not have been detected without a home visit, emphasizing the importance of such visits. The importance of drying the equipment and of using the correct concentration of acetic acid is stressed.

Low bacterial contamination of nebulizers in home treatment of cystic fibrosis patients.

Many reports have shown bacterial contamination of nebulizers used by patients with cystic fibrosis (CF) at home. At the Stockholm CF centre we recommend dismantling the equipment, washing, rinsing and drying it after each use, and disinfecting it once daily by boiling water or by 2% acetic acid followed by drying without rinsing. We studied whether patients comply with these recommendations and whether they are sufficient to prevent bacterial contamination. Nebulizers from 49 CF patients were investigated, 21 of whom are chronically colonized with Pseudomonas aeruginosa and one with Burkholderia cepacia. All patients were visited at home. Thirty-nine patients (79%) disinfected their equipment after the latest use in accordance with our recommendations. Thirty-eight pieces showed no, or only scanty, growth of micro-organisms belonging to the normal oropharyngeal flora. A moderate growth of alpha-streptococci was observed from a further five pieces. Four of these had not been cleaned after the latest inhalation occasion, and one was visibly dirty. Pseudomonads were observed from three pieces; two of these had been disinfected by boiling water and one by acetic acid, followed by rinsing in tap water. All three had been inadequately dried. Pseudomonads could not be cultured simultaneously from the sputum of these three patients. In conclusion, most patients comply with our cleaning and disinfection recommendations and these recommendations appear satisfactory in preventing bacterial contamination.

Hepatic vascular occlusion combined with adriamycin given by the hepatic artery in rats with adenocarcinoma in the liver.

Rats with an adenocarcinoma of the colon implanted into the liver were treated by a bolus injection of adriamycin by the hepatic artery. In addition, vascular occlusions were performed in the following three ways. 1. The hepatic artery was ligated (HAL) immediately after adriamycin injection. 2. The portal venous branch nourishing the tumor was ligated immediately after adriamycin injection. 3. The Pringle maneuvre (clamping of the hepatic artery, the portal vein and the common bile duct) was performed during 5 min before and 10 min after injection. Tumor size was measured at operation and 6 and 12 days later in the first experiment, 7 days later in the other two experiments. The combination of adriamycin and HAL retarded tumor growth at day 6 as compared to controls, adriamycin alone and HAL alone. The differences were not significant at day 12. The other vascular occlusions did not improve the antitumor effect of adriamycin.

Effect of N-phosphonacetyl-L-aspartate and D-glucosamine on the incorporation of 5-fluorouridine into normal tissues and an adenocarcinoma in the rat.

Cytostatic treatment of liver metastases from colorectal cancer has been of limited value. Higher drug levels in the target substances of the tumor may improve the results. It was the aim of this investigation to examine the effect of PALA (N-phosphonacetyl-L-aspartate) and D-glucosamine on the level of uracil nucleotides in the liver and in an N-methyl-N-nitrosoguanidine-induced adenocarcinoma of the colon transplanted to the liver of rats, and on the incorporation of 3H-FUrd into the acid-soluble fraction, the RNA and the DNA of the tumor and of several normal tissues. Combined treatment with PALA and D-glucosamine reduced the UTP pool in the liver and the tumor. D-glucosamine alone increased UDP-N-acetyl-hexosamine in liver tissue. Pretreatment with PALA and D-glucosamine increased incorporation of 3H-FUrd into RNA of the liver and kidney, and into the DNA fraction of the liver, but had no effect on 3H-FUrd incorporation in the tumor.

Degradable starch microspheres in cytostatic treatment of a liver carcinoma; experimental studies in rats with 5-fluorouracil, tauromustine, carmustine, doxorubicin and RSU-1069.

The degradable starch microspheres (DSM) used have a size of 45 microns and are dissolved by amylase in blood. After intraarterial administration of a mixture of DSM and cytostatic drugs the coinjected drugs remain for a longer time in the target tissue/tumor. A transient hypoxia occurs. Systemic exposure of drugs is decreased. Rats with a carcinoma implanted into the liver were given DSM and drugs via the hepatic artery. DSM did not significantly increase the incorporation of 5-fluorouracil (5-FU) into liver tumor RNA. The incorporation of 5-FU into intestinal and bone marrow RNA increased. DSM increased the antitumor effect of doxorubicin, tauromustine, carmustine and RSU-1069 (aziridine 2-nitroimidazole). Side effects, such as liver and gastric necroses and body weight loss, appeared in some rats. The toxic overspill to the stomach seemed to be reduced by giving the DSM in two parts, with all the cytotoxic drug in the first part. The effect on liver and tumor was not decreased by this procedure. DSM alone had no anti-tumor effect. DSM alone decreased liver UDP-glucuronic acid in tumor-free rats, given either by the hepatic artery or, in the double dose, by the portal vein. DSM alone did not increase liver NADPH-cytochrome c reductase activity or serum ASAT (aspartate-aminotransferase) or ALAT (alanine-aminotransferase), indicating that the DSM are inert to the liver, when infused into the tributary vessels.

Modulation of 5-fluorouracil and 5-fluorouridine toxicity by membrane transport inhibitors in normal tissues of rats with liver adenocarcinoma.

The cytotoxicity of 5-FU and 5-FUrd, given via the hepatic artery, was measured by its incorpotation into the acid soluble fraction, RNA and DNA in normal tissues and an adenocarcinoma transplanted into the liver in rats. Drugs inhibiting the membrane transport of, especially, nucleosides were simultaneously administered by a femoral vein to modulate the cytotoxicity. None of them (dipyridamole, lidoflazine nor dilazep) had any statistically significant influence on the tumour. Dipyridamole and lidoflazine decreased the incorporation of 5-FU into the acid soluble fraction, RNA and DNA of the intestine. Dipyridamole probably decreased the incorporation of 5-FUrd into the acid soluble fraction and RNA of the intestine. Lidoflazine has not been tested with 5-FUrd. Dipyridamole increased the incorporation of 5-FU into the acid soluble fraction of liver, bone marrow and kidney, and of 5-FUrd into the acid soluble fraction of liver and bone marrow and liver RNA. Lidoflazine had fewer adverse effects. Both dipyridamole and lidoflazine increased the combined peak of UTP and FUTP in the liver, and dipyridamole also in the intestine of 5-FU treated rats. Dipyridamole which undergoes an enterohepatic circulation increased the combined peak of UDP-glucuronic acid and FUDP-glucuronic acid in 5-FU and 5-FUrd treated rats, as well as UDP-glucuronic acid in rats given neither 5-FU nor 5-FUrd in the liver. Membrane transport inhibitors seem to offer the opportunity to protect normal tissues from the cytotoxicity of 5-fluoropyrimidines, but the tissues can also be more exposed.

Tumour antigen heterogeneity within melanoma metastases--an evaluation by immunohistochemistry.

Fifty-eight metastases of malignant melanoma in 27 consecutive patients were evaluated by immunohistochemistry using monoclonal antibodies (MAb) 96.5, 48.7 and 4.2, all with a high specificity for melanoma tumour associated antigens. MAb OKT3 directed to human T-lymphocytes was used as control and normal mouse serum as background. Different degrees and patterns of staining were recorded using a scale of 0 to 4. 85% of the metastases were positive (score greater than +2) to 96.5 or 48.7 and 78% to antibody 4.2. All metastases were positive for at least one of the three antibodies, 93% for two, and 59% for all three antibodies. No substantial heterogeneity (more than +1 difference) was found in two sections approximately 5 mm apart within the same metastasis (one out of 39 metastases). In 15 patients in whom more than one tumour was examined, heterogeneity between individual metastases was found in one patient for antibody 96.5, three for 48.7 and none for 4.2. The existence of immunological heterogeneity in melanoma metastases must be taken into account when designing techniques for radioimmunoimaging and radioimmunotherapy.

Nucleic acid labeling with [3H]orotic acid and nucleotide profile in rats in protein deprivation, enteral and parenteral essential amino acid administration, and 5-fluorouracil treatment.

Rats were fed a 0% casein diet for 1 week, with or without enteral or parenteral administration of essential amino acids, or a 25% casein diet, in one group supplemented with 5-fluorouracil treatment. Ninety minutes before sacrifice the rats were given a tracer of [3H]orotic acid. Incorporation into the acid soluble fraction, RNA, and DNA was determined in liver, small intestine, bone marrow, and kidney. Nucleotide profile was examined in liver and intestine. Protein deficiency caused inter alia a decrease in body weight; a decrease in RNA/DNA ratio and an increase in the specific RNA labeling in liver and kidney; an altered nucleotide profile in the liver; an increase in the nucleotide/DNA and RNA/DNA ratios and a decrease in the specific labeling of the acid soluble fraction, RNA, and DNA in the bone marrow. These changes were prevented to the same extent by giving essential amino acids, either orally or intravenously. The minor changes in intestinal nucleotide profile in protein deprivation were prevented to a slightly larger extent by amino acids orally than parenterally. 5-Fluorouracil treatment gave a decrease in the RNA/DNA ratio in the liver and kidney but an increase in the nucleotide/DNA and RNA/DNA ratios in the bone marrow. Nucleotide profiles were unaltered. The amount of DNA per gram of tissue decreased in bone marrow and increased in kidney. Parenteral administration per se resulted in almost no changes.

Modulation of 5-fluorouracil toxicity by uridine, deoxyuridine, orotate and dipyridamole in normal tissues of rats with liver adenocarcinoma.

The cytotoxicity of 5-FU, given by the hepatic artery, was measured by its incorporation into the acid soluble fraction, RNA and DNA in normal tissues and an adenocarcinoma transplanted into the liver in rats. Other substances were simultaneously administered by the portal vein to modulate the cytotoxicity. None of them had any significant influence on the incorporation of 5-FU into tumor. Dipyridamole decreased the incorporation of 5-FU into liver RNA and increased the nucleotide/DNA and RNA/DNA ratios so that the incorporation into mg RNA per liver cell was unchanged. Dipyridamole decreased the incorporation into the acid soluble fraction, RNA and DNA of the small intestine and also into RNA per mg DNA. It increased the nucleotide/RNA and RNA/DNA ratios in the bone marrow. Orotate decreased the incorporation into liver and intestinal RNA. Uridine increased the incorporation into liver RNA. The results obtained with dipyridamole were the most pronounced. Studies are continuing with this and other membrane transport inhibitors.

Incorporation of 5-fluorouracil into RNA of normal tissues and an adenocarcinoma in protein-deprived rats.

One of the main cytotoxic effects of 5-FU is its incorporation into RNA. In rats, protein deprivation increases the incorporation of labelled precursors into liver RNA. We examined the effect of protein deprivation on the incorporation of a therapeutic dose of 5-FU into the liver, small intestine, kidney and bone marrow and into an adenocarcinoma transplanted to the liver in the rat. The rats were fed either on a 25% or a 0% casein diet for one week. Some rats from both groups were given amino acids or glucose parenterally. Therapeutic 5-[3H]-FU was given in a 2 h infusion by the hepatic artery and the rats were sacrificed one h later. Incorporation into liver and intestinal RNA increased significantly with protein deprivation. The increase was largely eliminated by parenteral feeding of amino acids. No differences were found in incorporation into tumor and bone marrow RNA in protein deprivation. Incorporation into the acid soluble fraction and DNA is also reported.

Improved cooperation in vocational rehabilitation with systematic rehabilitation group meetings.

PURPOSE: The present aim was to investigate the communicative pattern in two rehabilitation groups. The rehabilitation group consisted of the client, a supervisor, an employer representative, an occupational health physician, a rehabilitation counsellor from the national social insurance office and a support person. METHOD: Participatory observation of 22 rehabilitation meetings. The communication was tape-recorded and transcribed word for word. The transcripts were coded and analysed both qualitatively and quantitatively. RESULTS AND CONCLUSION: The client made the most utterances in the groups, but most often in the form of answers to questions from the other actors. Following the client, the physician made the next most frequent utterances, most often as questions. The subjects most discussed concerned the client's situation regarding work, health and material support. None of the "professionals" dominated the meetings, although one picture that emerged was that the physician and employer representative played more prominent roles as takers of initiative and as coordinators while the client was more passive than the other actors. The discussions were calm and much latitude was allowed for the participants to put forward their own requirements, thoughts and feelings. The rehabilitation group may be viewed as a meeting place for "experts" and clients. The further management of the rehabilitation was by the actor the client most immediately needed. In this, rehabilitation in the rehabilitation group differs from the "case management" common in the rehabilitation field.

Studies of the radon concentration in drinking water from the horst Söderåsen in southern Sweden.

The radon activity concentration in ground water from drilled and dug wells on the horst Söderåsen in Southern Sweden has been determined with two different methods, gamma activity measurements with a germanium HPGe detector and alpha activity measurements with plastic track detectors. The results are consistent. High activity concentration is connected to granite bedrock. Dug wells have low concentrations and no trivial correlation between concentration and depth of the well is found. Large local variations exist. Activity concentrations > 700 Bq/l appear to be associated with leakage from layers of volcanic origin. The concentration from drilled wells is found to be quite constant over a 3 year period but short time variations appear to be significant. Evaporation from the open surface of a normal cooking vessel is slow with an activity gradient delta A/A of about 0.1-0.2 per hour at room temperature whereas even modest heating of water in e.g. a coffee machine is very efficient and reduces the radon activity concentration by > 90% in one process.

Imaging of renal scarring.

Children with urinary tract infection should be investigated and followed up, as those with pyelonephritis may develop renal scarring. In this review, after discussing the advantages and disadvantages of various imaging modalities for diagnosis of renal scarring, it is concluded that DMSA scintigraphy and urography can both be used to detect significant renal scarring. With DMSA scintigraphy, small renal lesions (functional uptake defects) not seen at urography will also be detected. The long-term clinical significance of these lesions is, as yet, unknown. A normal DMSA scintigraphy after infection indicates low risk for clinically significant damage. In order to allow acute, reversible lesions to first disappear, a follow-up DMSA examination should not be performed until at least 6 mo after the acute infection. Ultrasonography in isolation cannot be recommended for the diagnosis of renal scarring.

Vesico-ureteric reflux: occurrence and long-term risks.

The prevalence of vesico-ureteric reflux in the general population is unknown, but it is increased in risk groups, such as children with symptomatic urinary tract infection, schoolgirls with asymptomatic bacteriuria, first-degree relatives of patients with reflux and children with prenatal dilatation of their upper urinary tract. Children and adults with pyelonephritic renal scarring are at risk of serious long-term complications, e.g. hypertension and renal failure. Modern paediatric care, with early detection and treatment of urinary tract infections and reflux during childhood and adolescence, may improve long-term prognosis. In the adult patient with established pyelonephritic renal scarring, careful control of hypertension may retard the rate of progression, and angiotensin converting enzyme inhibitors may have renal protective properties.

Vesico-ureteric reflux and other risk factors for renal damage: identification of high- and low-risk children.

This article reviews the literature with respect to various risk factors for permanent renal damage in children with urinary tract infection. Vesico-ureteric reflux is an important risk factor, but renal damage can occur in the absence of reflux. Renal damage does not always occur in the presence of gross reflux. Renal scars always develop at the same site as a previous infection in the kidney. Recurrent pyelonephritis and delay in therapy increase the likelihood of renal damage, although it is not known how long a delay is dangerous to the human kidney. Recent studies using 99mtechnetium-dimercaptosuccinic acid (DMSA) scintigraphy have not confirmed the findings of previous studies showing that children below 1 y of age are more vulnerable to renal damage. It is more likely that all children run the risk of renal scarring in cases of acute pyelonephritis. The role of bladder pressure is still not entirely understood. Therefore more studies are needed in order to determine the relationship between high voiding pressures in some, otherwise healthy, children with urinary tract infection and renal scarring. The importance of bacterial virulence in the development of renal scarring is unclear. DMSA scintigraphy and voiding cystourethrography are the most reliable tools for identifying children at risk of renal scarring. As a single method DMSA scintigraphy appears to be better than voiding cystourethrography.

Transplantation of cultured autologous epithelium after meningococcal septicaemia in a 4-year-old with 35% skin loss.

A 4-year-old girl with scattered full-thickness skin and soft tissue wounds mainly on the extremities and corresponding to roughly 35% of the total body surface area was treated with early excision and transplantation of cultured autologous epidermal grafts. The transplantation was accomplished in one stage, three weeks after admission. The epidermal cells were cultured in Stockholm, Sweden and the time of transportation of the grafts to Reykjavik, Iceland (seven hours) did not seem to affect the quality, as 85% had taken one week after transplantation. The patient healed completely without further transplantation, but a few local skin flaps were needed to cover exposed articular surfaces. The patient was discharged from hospital with stable grafts five weeks after transplantation.