Inactivation of the bacterial pathogens Staphylococcus pseudintermedius and Acinetobacter baumannii by butanoic acid.

AIMS: This study was performed to evaluate the efficacy of butanoic acid against bacterial pathogens including Acinetobacter baumannii and Staphylococcus pseudintermedius. METHODS AND RESULTS: Vegetative bacteria were exposed to butanoic acid in vitro and log reduction was quantified using viable count assays. The maximum (8 and 9) log inactivation was determined by qualitatively assaying for growth/no-growth after a 48-h incubation (37°C). Membrane integrity after exposure to butanoic acid was determined by propidium iodide staining, scanning electron microscopy, membrane depolarization and inductively coupled plasma analysis. Cytosolic pH was measured by 5-(6-)carboxyfluorescein succinimidyl ester. CONCLUSIONS: Inhibitory concentrations of butanoic acid ranged between 11 and 21 mmol l-1 for Gram-positive and Gram-negative species tested. The maximum log reduction of A. baumannii was achieved with a 10-s exposure of 0·50 mol l-1 of butanoic acid. Staphylococcus pseudintermedius required 0·40 mol l-1 of butanoic acid to achieve the same level of reduction in the same time period. Inactivation was associated with membrane permeability and acidification of the cytosol. SIGNIFICANCE AND IMPACT OF THE STUDY: Antibiotic resistance among bacterial pathogens necessitates the utilization of novel therapeutics for disinfection and biological control. These results may facilitate the development of butanoic acid as an effective agent against a broad-spectrum of antibiotic-resistant bacterial pathogens.

Transanal endoscopic microsurgery for rectal carcinoids: the largest reported United States experience.

AIM: Rectal carcinoids are often inadequately resected by snare excision during colonoscopy. Transanal endoscopic microsurgery is a minimally invasive procedure with low morbidity that offers full-thickness excision with a low rate of negative margins. It presents an excellent alternative to radical surgery for mid and proximally located lesions. We report the largest United States (US) experience in the use of transanal endoscopic microsurgery for rectal carcinoids. METHOD: Data of patients who had undergone transanal endoscopic microsurgery for rectal carcinoids were prospectively collected and retrospectively analyzed. Patient and tumour characteristics, operative and perioperative details, as well as oncological outcomes were reviewed. RESULTS: Over a 12-year period, 24 patients underwent transanal endoscopic microsurgery for rectal carcinoids. Of these, six (25%) were primary surgical resections and 18 (75%) were performed after incomplete snare excisions during colonoscopy. Three (17%) patients who underwent full-thickness resection after snare excision had residual tumour on histopathological examination. Negative margins were obtained in all cases. No recurrences were noted. CONCLUSION: Transanal endoscopic microsurgery is effective and safe for the surgical resection of rectal carcinoids<2 cm in diameter, with typical features and located more than 5 cm from the anal verge. Transanal endoscopic microsurgery can be used for primary resection or for resection after incomplete colonoscopic snare excision.

A case manager intervention to reduce readmissions.

BACKGROUND: Acute hospitalizations represent substantial financial liability to closed health care systems. Among hospitalized patients, those with repeated admissions are high-cost users. Most managed care plans employ case management to control hospital use. This technique attempts to detect and fulfill unmet medical and social needs, intensify postdischarge care, identify and mobilize effective community services, and enhance primary care access. Despite the popularity of case management to control hospital use, few trials have examined its efficacy. METHODS: We conducted a randomized controlled trial of an intervention of case managers at a university-affiliated Veterans Affairs medical center. Six hundred sixty-eight patients aged 45 years or older who were discharged from the general medicine inpatient service, who had access to a telephone, and who received primary care at the hospital's clinics were randomized to the intervention (N = 333) and control (N = 335) groups. Within 24 hours of discharge, case managers mailed educational materials and access information to intervention patients, and within 5 days they called to review and resolve unmet needs, early warning signs, barriers to keeping appointments, and any readmissions. Case managers contacted intervention patients if they made no visits for 30 days. This resulted in a total of 6260 patient-case manager contacts. Control and intervention patients were followed up for 12 months. RESULTS: Intervention patients had more frequent visits per patient per month to the general medicine clinic (0.30 +/- 0.23 vs 0.26 +/- 0.22, P = .008), but we detected no significant differences between groups in nonelective readmissions, readmission days, or total readmissions. CONCLUSIONS: Frequent contacts for education, care, and accessibility by case managers using protocols were ineffective in reducing nonelective readmissions.

The dental attitudes, knowledge and health practices of patients with Juvenile Idiopathic Arthritis.

AIM: To investigate the dental attitudes, knowledge and dental health practices of children and adults with a previous diagnosis of Juvenile Idiopathic Arthritis (JIA). STUDY DESIGN: A self-completion questionnaire. METHODS: Ninety-one children and 82 adults with JIA were age and gender matched with 152 healthy controls. For those below the age of 16 years, the parents' attitude, knowledge and dental health practices were investigated by the questionnaire. The adult subjects and controls completed an identical questionnaire assessing their own attitude, knowledge and dental health practices. RESULTS: Response rates of 84% and 75% were achieved for the subject and controls respectively. Both groups responded similarly to questions assessing perception of different medical conditions. The majority of respondents thought leukaemia was a very serious condition. Twenty-seven percent of subjects and 34% of controls felt dental decay was "slightly or not serious". Ninety percent of subjects and 93% of controls knew having sweet snacks during the day would harm teeth, but fewer were sure that eating sweet foods at mealtimes only would help reduce decay. The majority of respondents (63% and 56% respectively) did not know whether children should receive fluoride tablets but the majority of subjects in both groups had attended a dentist within the last year. STATISTICS: Descriptive analyses and chi-squared analysis were undertaken. A p-value of < or =0.01 was taken as strong evidence of a difference between groups. CONCLUSION: The perception of health and illness by both groups was appropriate. The questions investigating dental knowledge revealed understanding of the basic messages of prevention of dental disease, but finer detail appeared less well understood. Responses concerning dental health confirmed positive attitudes towards good dental health habits. The benefits of brushing with fluoride toothpaste were known, and the majority toothbrushed daily and received dental care within the previous year.

Helicobacter pylori infection in recurrent abdominal pain in childhood: comparison of diagnostic tests and therapy.

OBJECTIVE: To determine the role of Helicobacter pylori infection in children with recurrent abdominal pain and the usefulness of serologic tests in screening H pylori infection and monitoring treatment of H pylori-associated gastritis. METHODS: During a 3 year period, we investigated the presence of serum immunoglobulin G (IgG) antibody to H pylori in 456 children using the high-molecular-weight cell-associated protein H pylori enzyme immunoassay kit. Among the 456 children studied, 218 (age range, 3 to 18 years; mean age, 9.5 years) had symptoms of recurrent abdominal pain (RAP syndrome) with or without vomiting, and the remaining 238 (age range, 3 to 18 years; mean age, 9.8 years) had no RAP (non-RAP syndrome). We performed upper gastrointestinal endoscopy on 111 consecutive children of the 218 with RAP syndrome and obtained mucosal biopsies for culture, histologic analysis, CLO test (Delta West, Perth, Australia), and H pylori detection by polymerase chain reaction. RESULTS: Thirty-eight (17.4%) of 218 children in the RAP group and 25 (10.5%) of 238 children in the non-RAP group were seropositive for H pylori. Of the 111 children endoscoped, 95 were found to be negative, and 12 were positive by all five assays. Specimens from 2 children were negative by culture and the CLO test but positive by the other three assays. Specimens from 1 child were negative by histologic analysis but positive by all other tests. The remaining child was positive for anti-H pylori IgG but negative by all of the other four assays. Upper gastrointestinal endoscopy detected 14 children with peptic ulcer disease (9 duodenal ulcer and 5 gastric ulcer) and 12 with antral nodular gastritis. Only 4 of the 14 diagnosed with peptic ulcer were H pylori positive by all five assays, whereas all 12 children with antral nodular gastritis were H pylori positive. Nine of the 12 H pylori-positive children were treated with a combination of bismuth subsalicylate, amoxicillin, and metronidazole for 2 weeks. Sera obtained at 2, 4, and 6 months after treatment from all 9 children showed a decrease in anti-H pylori IgG titer. Three H pylori-infected children who did not receive any treatment served as control children, and their IgG levels remained elevated or increased over time. CONCLUSION: The results from our study indicate that screening for the serum IgG antibody to H pylori is a practical method for diagnosing H pylori infection in children, and that serial measurements of the H pylori IgG antibody are useful for monitoring treatment of H pylori because of its high sensitivity and ease of performance. Only 4 of the 14 children diagnosed with peptic ulcer disease were confirmed to be infected with H pylori, whereas all 12 children with antral nodular gastritis were found to be infected by H pylori. These observations suggest that H pylori infection is more frequently associated with gastritis than with peptic ulcer disease in children, and that H pylori gastritis is a cause of RAP syndrome in children.

Gastrointestinal abnormalities: a significant cause of feeding difficulties and failure to thrive in Brachmann-de Lange syndrome.

Gastroesophageal abnormalities occur with increased frequency in patients with Brachmann-de Lange syndrome (BDLS) and contribute to problems with feeding, emesis and failure to thrive. Comprehensive evaluation including longitudinal assessment of growth and development of 8 patients with BDLS was performed. Clinically significant feeding problems occurred in 6 of the 8 patients and the affected children were subsequently evaluated for gastrointestinal abnormalities. Findings in these patients included tracheal aspiration, esophageal dysmotility, gastroesophageal reflux, hiatal hernia, and esophagitis. Medical treatment was instituted where appropriate, and surgical treatment was performed if the problems did not resolve with medical treatment. Improvement in weight centiles occurred in all patients fed by nasogastric or feeding gastrostomy tube but only one patient appeared to experience increase in rate of linear growth. Careful monitoring of symptoms and growth parameters, and prompt institution of appropriate medical and surgical measures can improve the health and physical outcome of many patients with BDLS.

The efficacy of hepatoportoenterostomy in biliary atresia.

This report describes the treatment and outcome of 66 infants with biliary atresia. Mean age was 79.8 +/- 33.2 days. Diagnosis was achieved by 99mTc DISIDA scanning. Hepatoportoenterostomy (HPE) was performed in 48 cases and hepatoportocholecystostomy in four, with microscopic ducts at the porta hepatis. Fourteen infants without microscopic ducts did not undergo HPE. Patients were staged according to the postoperative result. HPE was successful in 25% of patients (group A), resulted in improvement in 19% (group B), failed in 43% (group C), and was short-term in 13% (group D). In patients less than 90 days of age, the HPE success rate was 31%; 23% improved, and 33% showed no improvement. Age (less than 90 days) and bile clearance were prognostic determinants of success. Reoperation was useful only in patients with a previously successful HPE. Ten of 20 patients referred for liver transplantation survived (50%) (7/11) survived after liver transplantation and 3/9 on the waiting list). Fourteen of 15 patients in group A remain anicteric and well without liver transplantation. Patients in group B have had extended survival (greater than 3 years) but eventually required transplantation. Patients in group C and children more than 90 days old at diagnosis require early liver transplantation. HPE is a useful procedure when performed in infants less than 90 days of age who have biliary atresia.

Gastroesophageal reflux in infants and children. Diagnosis and management.

Eighty-three infants and children underwent surgical correction of gastroesophageal reflux (GER) from 1973 to 1978. Fifty-four patients had coexistent brain damage (most commonly due to cerebral palsy), eight were previously treated for esophageal atresia, and four had gastroschisis or omphalocele repair. Clinical presentation included failure to thrive in 64 patients, vomiting in 59, and recurrent bouts of aspiration pneumonitis in 43. Barium roentgenography showed GER in 61 patients, whereas additional tests (particularly pH monitoring) were required for detection of GER in 22 patients. After failure of medical management, transabdominal Nissen fundoplication was performed in 80 cases and a Hill repair in three cases. The surgical mortality was zero, but there were five late deaths. Results were considered excellent in 54 patients, good in 22 patients, and poor in seven. Ten of 12 patients with preoperative stricture responded to dilation after fundoplication. Nissen fundoplication was a safe and effective antireflux procedure in 76 of the 83 cases.

Lack of interaction between levofloxacin and oxycodone: pharmacokinetics and drug disposition.

Previous studies have demonstrated a significant reduction in the oral bioavailability of trovafloxacin and ciprofloxacin when administered concomitantly with an intravenous opiate such as morphine. This decrease in absorption results in a 36% and 50% lower AUC for trovafloxacin and ciprofloxacin, respectively, which could cause clinical failures. The authors investigated the possibility of a similar interaction between oxycodone and levofloxacin. Eight healthy volunteers were randomized in an open-label, two-way crossover study to receive oxycodone, 5 mg p.o. Q4H, and levofloxacin, 500 mg p.o. 1 hour after starting the oxycodone or levofloxacin 500 mg p.o. alone. Blood samples were drawn at 0, 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 18, and 24 hours for Cmax, tmax, and AUC determinations. There was not a significant difference (p > 0.05) in AUC (48.59 +/- 8.52 vs. 49.9 +/- 9.93), Cmax (7.73 +/- 2.6 vs. 6.6 +/- 2.0), and tmax (1.1 +/- 0.6 vs. 1.6 +/- 1.1) for levofloxacin versus levofloxacin/oxycodone regimens. It was concluded that oral oxycodone and levofloxacin can be administered concomitantly without a significant decrease in AUC, Cmax, or tmax.

Confirmation of serum salicylate levels in Reye's syndrome: a comparison between the Natelson colorimetric method and high performance liquid chromatography.

Serum was obtained from 11 patients with Reye's syndrome at admission and analyzed for the presence of salicylates by the Natelson colorimetric technique and high performance liquid chromatography. Salicylate levels obtained by the Natelson method had a mean of 6.00 mg/dl +/- 4.58; the mean HPLC salicylic acid level was 5.09 mg/dl +/- 5.14. The correlation coefficient was 0.985 with a linear regression line y = 0.8788x + 1.527. No other salicylate metabolites nor interfering substances were identified. Once the accuracy of the Natelson method was confirmed, the charts of 82 patients were reviewed for admission salicylate levels. The overall mean was 8.63 mg/dl (survivors, 8.45 mg/dl +/- 8.56; fatalities, 9.28 mg/dl +/- 5.34). There was no correlation found between admission salicylate level and peak ammonia level, another important index of disease severity.

Determination of disaccharides in feces by permethylation and gas chromatography: rapid screening for carbohydrate intolerance in children.

Disaccharides can be identified and determined quantitatively in fecal specimens by permethylation of the components in crude supernatants followed by isothermal gas chromatographic separation on OV-17 columns. The method provides a rapid screening procedure for detecting patients suspected of having a carbohydrate intolerance secondary to intestinal disaccharidase deficiency.

Vitamin E sufficiency in children with cholestasis: a comparison between erythrocyte peroxide hemolysis and serum alpha-tocopherol.

Vitamin E sufficiency was assessed in 19 children with chronic cholestasis by determining both erythrocyte peroxide hemolysis (EPH) and serum alpha-tocopherol (alpha-T) levels. Eight had normal alpha-T (1.19 +/- 0.67 mg/dl; normal greater than 0.5). The mean EPH in this group was 13.1 +/- 14.3% (normal less than 20%). The remaining 11 patients had low alpha-T levels (0.25 +/- 0.15 mg/dl) and elevated EPH (83.9 +/- 17.1%). Children found to be vitamin E deficient received either oral alpha-T (50-100 IU/kg per day) or parenteral alpha-tocopherol acetate in sesame oil every 2-4 wk (200-300 mg). This permitted serial monitoring of EPH and alpha-T. We found that normalization of the EPH was uniformly accompanied by normalization of the alpha-T level. However, normal alpha-T levels occurred with elevated EPH (between 20% and 80%) on 11 occasions. EPH greater than 80% correctly identified vitamin E deficiency in all cases. Hence, EPH is a satisfactory screening test of vitamin E sufficiently. When the EPH is less than 20%, the patient is vitamin E sufficient. Conversely, when the EPH is greater than 80%, the patient is vitamin E deficient. Serum alpha-T measurements are needed to determine vitamin E sufficiency when the EPH is greater than 20% and less than 80%.

Prognostic determinants after hepatoportoenterostomy for biliary atresia.

Hepatic secretory functions were measured postoperatively in 17 infants undergoing hepatoportoenterostomy for biliary atresia. These studies were compared in surviving and nonsurviving infants to attempt early identification of infants who might require reoperation. Statistically significant differences between surviving and nonsurviving infants were found in alkaline phosphatase clearances at 1, 4, 12 and 24 weeks postoperatively. In addition, bilirubin clearance and secreted 24 hour bilirubin measurements were significantly increased in survivors 12 and 24 weeks postoperatively. Iodine-131 rose bengal excretion, measured 6 months postoperatively, was likewise significantly increased in survivors. Six of the 10 surviving infants required reoperation when their secretory functions deteriorated; all improved postoperatively. None of the seven nonsurviving infants underwent reoperation. Biliary secretory functions have early prognostic significance and apparently can predict which infants require reoperation. Reexploration and higher transection of atretic ducts may improve survival.

Portal hypertension in infants and children with histiocytosis X.

Histiocytosis X describes a disease characterized by histiocytic infiltration of the reticuloendothelial system, skin, bones, and pituitary gland. The disseminated form frequently occurs in infants and children. Chemotherapy has significantly improved the prognosis in this disorder. Sixty-three per cent of survivors, however, have some residual disability related to fibrosis of tissues previously infiltrated by histiocytes. In instances of liver involvement, healing by fibrosis may result in cirrhosis with portal hypertension and bleeding esophageal varices. Clinical findings include hepatosplenomegaly, jaundice, ascites, hypoalbuminemia, prolonged prothrombin time, and Bromsulphalein retention. Histologic examination of the liver shows a characteristic dense "macronodular" periportal cirrhotic pattern. Three children with portal hypertension and bleeding varices due to healed histiocytosis X were sucessfully managed by portosystemic shunt procedures. Portacaval, mesocaval, and central splenorenal shunts were equally effective in relieving poral hypertension. These children had neither recurrence of bleeding nor evidence of encephalopathy. Two children remain well whereas in one patient a primary hepatoma developed fourteen years posthung and he died of pulmonary metastases. Portosystemic shunt procedures effectively relieve the threat of potentially fatal variceal hemorrhage and improve the opportunity for long-term survival in children with cirrhosis and portal hypertension due to healed histiocytosis X.

Specialized formulas and feedings for infants with malabsorption or formula intolerance.

The composition of specialized formulas for infants who experience malabsorption or formula intolerance is described in detail. The limited studies of efficacy, as well as a rationale for selecting an appropriate formula for infants with malabsorption or formula intolerance, are discussed. Infants with symptoms of diarrhea or emesis may have intolerance to milk lactose or milk protein. Soy formulas contain no lactose or cow's milk and should be the first choice of an alternative feeding because of cost and convenience. Some infants may be intolerant of soy as well as cow's milk protein. They benefit from formula containing neither cow's milk nor soy protein or from a specially processed milk-based formula containing hydrolyzed casein. A carbohydrate-free formula to which the desired type of carbohydrate is added may be helpful in the diagnosis and treatment of disaccharidase deficiencies and monosaccharide intolerances. Infants with extensive intestinal resections or intractable diarrhea may require specialized infant formulas with qualitative/quantitative modifications of fat, carbohydrate, and protein. Formulas with medium-chain triglycerides may be useful for infants with steatorrhea. "Preterm" formulas or milk from the infant's mother are preferred for preterm infants, since such feedings promote improved fat and carbohydrate absorption and better meet the infant's nutrient requirements.

Emulsion stability in total nutrient admixtures containing a pediatric amino acid formulation.

Emulsion stability of total nutrient admixtures containing TrophAmine amino acid injection admixed with Intralipid, Nutrilipid, and Liposyn II was studied. High and low electrolyte concentrations were added to each total nutrient admixture before storage at 4 degrees C for 48 hours then at 20-22 degrees C for 24 hours. Stability studies were also performed on total nutrient admixtures containing higher concentrations of fat emulsion and total nutrient admixtures with added cysteine hydrochloride and carnitine. High electrolyte concentrations only were added to these total nutrient admixtures before being stored refrigerated for 24 hours then at room temperature for 24 hours. Visual assessment, pH determination, and particle size analysis were performed immediately after compounding and after refrigerated and room temperature storage. Particle size was assessed by measuring the mean diameter of the fat emulsion and the percent of oil volume in particles greater than 5 microns. Repeated-measures analyses of variance were used to determine significance of type or concentration of fat emulsion, electrolyte concentrations, or time on mean diameter or percent particles greater than 5 microns. There were minimal changes in pH values over time. Creaming was observed in all total nutrient admixtures at all sampling times except time zero. This was reversible upon agitation. Results of particle size analysis over time indicated little change in mean diameter or percent particles greater than 5 microns. These minimal changes did not seem to be clinically significant. It is concluded that total nutrient admixtures prepared with this pediatric amino acid formulation are stable when prepared and stored as reported.

A usage evaluation of total parenteral nutrition in pediatric patients.

Records of 20 consecutive pediatric patients receiving total parenteral nutrition over a 1-month period were reviewed for appropriateness of nutritional assessment and management. Each patient was monitored until total parenteral nutrition was discontinued or for a maximum of 2 weeks. A total of 124 therapy days were reviewed. Results demonstrated that only 35% of these patients had a nutritional assessment performed prior to initiation of therapy, and only 65% had nutritional goals determined. Nutritional goals were defined as patient-specific goals for fluid volume (FV), calories, protein, and fat emulsion. Analysis of data demonstrated that goals for FV were met on 62% of therapy days. Of the days on which FV goals were met, goals for calories, protein, and fat emulsion were met on 54%, 59%, and 51% of therapy days, respectively. Baseline serum triglyceride levels were measured in one of 20 patients. Serial laboratory monitoring was adequate, with the exception of hepatic enzymes and serum triglycerides, which were measured in 14 and 9 patients, respectively. Recommendations for pediatric parenteral nutrition therapy are discussed, as well as methods to implement these recommendations.

Case report of an allergic reaction to parenteral nutrition in a pediatric patient.

We report a 34-month-old girl with stage IV neuroblastoma who developed hives when parenteral nutrition (PN) containing amino acids, dextrose, electrolytes, minerals, vitamins, and trace elements was infused. Administration of diphenhydramine resulted in disappearance of the rash. Infusion of the PN solution without intravenous fat emulsion produced a similar rash with itching. The pediatric multiple vitamin (PMV) preparation was removed from the PN formula and the formula was infused without incident. The patient was maintained on PN and an oral vitamin supplement with no further complaints. Inadvertent administration of a PN solution containing PMV resulted in a recurrence of hives. Absence of any adverse reactions when the PMV preparation was removed from the PN solution and an allergic reaction when the multivitamin was added to the PN solution support the possibility that the allergic reaction was related to the infusion of the multiple vitamin preparation.

The stability of amikacin, gentamicin, and tobramycin in total nutrient admixtures.

Amikacin (A), gentamicin (G), and tobramycin (T) were added to eight different total nutrient admixtures (TNA) with varying concentrations of dextrose, amino acid, and fat emulsion to determine drug and emulsion stability. All TNA were prepared aseptically and stored at room temperature under normal room lighting for 12 hr before drug addition. One volume of each drug was added to an equal volume of each of the eight TNAs to simulate 1:1 piggyback contact volumes. Samples were left at room temperature for 6 hr. Drug concentrations were analyzed by fluorescence polarization immunoassay. TNA/drug admixtures were pH tested and visually inspected before and after centrifugation in microhematocrit tubes, noting signs of emulsion stability at 1 and 6 hr. Emulsion particle size was determined at 1 and 6 hr using interference contrast microscopy. All three drugs retained their immunoreactivity in all TNAs for at least 6 hr. G and T were stable in all eight TNAs for at least 6 hr with no significant effect on emulsion particle size or stability after centrifugation. A was incompatible with all eight TNAs, resulting in visual breaking of all emulsions within 1 hr. Therefore, G and T, but not A, can be administered via piggyback method with the eight TNAs tested if the infusion is completed within 6 hr.

Cholestatic disorders of infancy.

We no longer view the infant with persistent cholestasis with a "wait and see" strategy. Identification of the cause of "neonatal hepatitis" may allow specific treatment. Improved surgical techniques for portoenterostomy have provided early hope for patients with biliary atresia. Rapidly advancing nutritional strategies allow many portoenterostomy failures an additional further option, that is, hepatic transplantation. I express my thanks to the many investigators who have contributed and are continuing to advance the progress recounted in this review. Perusal of the references cited in this review makes clear the identity of these investigators.