17†Development of a questionnaire to study fear and anxiety factors affecting patients and their families undergoing strabismus surgery.

Patients and their Families undergoing Strabismus Surgery. The aim of this study was to develop a questionnaire to identify perioperative fear and anxiety factors affecting pediatric strabismus surgery patients.First, we reviewed the literature to determine precipitants of fears and anxieties experienced by pediatric patients. Subsequently, we developed a questionnaire for pediatric patients undergoing strabismus surgery. This was a two part questionnaire, consisting of a 16-piece section for patients and a 22-piece section for parents. Finally, we piloted this questionnaire to validate its clinical use.Common anxiety factors for children include pain, minor clinical procedures requiring needles, separation from parents and engaging with medical professionals. We used this information to develop a two part questionnaire for patients and parents. The questionnaire elicited positive and negative aspects of the patient journey, corroborated fears reported in the literature, and identified anxiety inducing factors specific to strabismus patients.There is a lack of evidence regarding fear and anxiety specific to pediatric ophthalmology surgeries. Strabismus surgery carries unique fear inducing factors. Interventions which may alleviate the stress of pediatric surgery, therefore greatly benefit patient experience and surgical outcomes, and should be considered in the care of pediatric patients. Patient educational material is known to provide a sense of control to patients, helping to alleviate such fear.Evidenced by the literature and the pilot questionnaire, there still exists anxiety inducing factors in pediatric surgery. Investigation into patient fears regarding pediatric strabismus surgery is needed to better understand how clinical staff can support patients perioperatively.

An outbreak of Salmonella Infantis gastroenteritis in a residential aged care facility associated with thickened fluids.

Twenty-two confirmed cases of Salmonella Infantis were identified in 70 residents of high-level care areas of a residential aged care facility in Sydney in April 2010 during an outbreak of gastroenteritis. A retrospective cohort study was conducted to identify a possible cause. Consuming a soft diet, puréed diet, or thickened fluid were each independently associated with illness. A logistic regression showed consumption of thickened fluid to be the only significant exposure associated with illness (adjusted odds ratio 11·8, 95% confidence interval 1·9-75·9). It was postulated that the thickened fluid had been contaminated by chicken mince, a sample of which also cultured S. Infantis. This finding reinforces the need to educate food-handlers on the risk of potential cross-contamination; it also highlights the need to consider all dietary components, such as thickened fluids, as potential vehicles for transmission in an outbreak.

The CannTeen study: verbal episodic memory, spatial working memory, and response inhibition in adolescent and adult cannabis users and age-matched controls.

BACKGROUND: Preclinical and human studies suggest that adolescent cannabis use may be associated with worse cognitive outcomes than adult cannabis use. We investigated the associations between chronic cannabis use and cognitive function in adolescent and adult cannabis users and controls. We hypothesised user-status would be negatively associated with cognitive function and this relationship would be stronger in adolescents than adults. METHODS: As part of the 'CannTeen' project, this cross-sectional study assessed cognitive performance in adolescent cannabis users (n = 76; 16-17-year-olds), adolescent controls (n = 63), adult cannabis users (n = 71; 26-29-year-olds) and adult controls (n = 64). Users used cannabis 1-7 days/week. Adolescent and adult cannabis users were matched on cannabis use frequency (4 days/week) and time since last use (2.5 days). Verbal episodic memory (VEM) was assessed using the prose recall task, spatial working memory (SWM) was assessed using the spatial n-back task, and response inhibition was assessed with the stop-signal task. Primary outcome variables were: delayed recall, 3-back discriminability, and stop signal reaction time, respectively. RESULTS: Users had worse VEM than controls (F(1,268) = 7.423, p = 0.007). There were no significant differences between user-groups on SWM or response inhibition. Null differences were supported by Bayesian analyses. No significant interactions between age-group and user-group were found for VEM, SWM, or response inhibition. CONCLUSIONS: Consistent with previous research, there was an association between chronic cannabis use and poorer VEM, but chronic cannabis use was not associated with SWM or response inhibition. We did not find evidence for heightened adolescent vulnerability to cannabis-related cognitive impairment.

Balloon Eustachian tuboplasty for Eustachian tube dysfunction: report of long-term outcomes in a UK population.

BACKGROUND: Balloon Eustachian tuboplasty is a surgical management option for Eustachian tube dysfunction; it has shown promising results in studies worldwide, but has had limited uptake in the UK. This study reports long-term outcomes for patients offered balloon Eustachian tuboplasty for chronic dilatory and baro-challenge-induced Eustachian tube dysfunction, and describes practical experience gained from its implementation. METHODS: Balloon Eustachian tuboplasty was conducted in 25 patients (36 ears) with Eustachian tube dysfunction over three years. Information on presenting symptoms and signs, audiometric findings, tympanometry, and Eustachian Tube Dysfunction Questionnaire-7 scores were recorded pre- and post-operatively with a minimum follow up of one year. RESULTS: Sixteen (64 per cent) of the 25 patients demonstrated symptom resolution after balloon Eustachian tuboplasty according to the Eustachian Tube Dysfunction Questionnaire-7. Fourteen (64 per cent) of the 22 patients with a type B or C tympanogram pre-operatively, had a type A trace post-operatively. Fifteen (75 per cent) of 20 patients with pre-operative conductive hearing loss showed improvement post-operatively, and 11 (50 per cent) of 22 patients with pre-operative middle-ear effusion or tympanic membrane retraction showed resolution. CONCLUSION: Balloon Eustachian tuboplasty can improve subjective and objective measures of Eustachian tube dysfunction, and provide longer-term resolution.

Rapid differentiation between fluconazole-sensitive and -resistant species of Candida directly from positive blood-culture bottles by real-time PCR.

In view of both the delay in obtaining identification by conventional methods following blood-culture positivity in patients with candidaemia and the close relationship between species and fluconazole (FLC) susceptibility, early speciation of positive blood cultures has the potential to influence therapeutic decisions. The aim was to develop a rapid test to differentiate FLC-resistant from FLC-sensitive Candida species. Three TaqMan-based real-time PCR assays were developed to identify up to six Candida species directly from BacT/Alert blood-culture bottles that showed yeast cells on Gram staining at the time of initial positivity. Target sequences in the rRNA gene complex were amplified, using a consensus two-step PCR protocol, to identify Candida albicans, Candida parapsilosis, Candida tropicalis, Candida dubliniensis, Candida glabrata and Candida krusei; these are the most commonly encountered Candida species in blood cultures. The first four of these (the characteristically FLC-sensitive group) were identified in a single reaction tube using one fluorescent TaqMan probe targeting 18S rRNA sequences conserved in the four species. The FLC-resistant species C. krusei and C. glabrata were detected in two further reactions, each with species-specific probes. This method was validated with clinical specimens (blood cultures) positive for yeast (n=33 sets) and the results were 100 % concordant with those of phenotypic identification carried out concomitantly. The reported assay significantly reduces the time required to identify the presence of C. glabrata and C. krusei in comparison with a conventional phenotypic method, from approximately 72 to <3 h, and consequently allows optimization of the antifungal regimen at an earlier stage.

Longitudinal study of Salmonella 1,4,[5],12:i:- shedding in five Australian pig herds.

The shedding patterns of Salmonella spp. and MLVA profiles of Salmonella enterica subspecies enterica (I) serotype 1,4,[5],12:i:- were monitored in a 12-month longitudinal observational study of five pig herds to inform management; provide indications of potential hazard load at slaughter; and assist evaluation of MLVA for use by animal and public health practitioners. Twenty pooled faecal samples, stratified by age group, were collected quarterly. When Salmonella was cultured, multiple colonies were characterized by serotyping and where S. Typhimurium-like serovars were confirmed, isolates were further characterized by phage typing and multiple locus variable number tandem repeat analysis (MLVA). Salmonella was detected in 43% of samples. Salmonella 1,4,[5],12:i- was one of several serovars that persisted within the herds and was found among colonies from each production stage. Virtually all Salmonella 1,4,[5],12:i:- isolates were phage type 193, but exhibited 12 different, closely-related MLVA profiles. Salmonella 1,4,[5],12:i:- diversity within herds was low and MLVA profiles were stable indicating colonization throughout the herds and suggesting each farm had an endemic strain. High prevalence of S. 1,4,[5],12:i:- specific shedding among terminal animals indicated high hazard load at slaughter, suggesting that primary production may be an important pathway of S. 1,4,[5],12:i:- into the human food chain, this has implications for on-farm management and the application and targeting control measures and further evidence of the need for effective process control procedures to be in place during slaughter and in pork boning rooms. These findings have implications for animal health and food safety risk mitigation and risk management.

Stimulation of malignant growth in rodents by antidepressant drugs at clinically relevant doses.

Tricyclic antidepressants, such as amitriptyline (Elavil), and the nontricyclic agent, fluoxetine (Prozac), bind to growth-regulatory intracellular histamine receptors, associated with anti-estrogen binding sites in microsomes and nuclei. The prototype anti-estrogen binding site/intracellular histamine receptor ligand, N,N-diethyl-2-[4-(phenylmethyl)phenoxy]ethanamine HCl, inhibits normal cell proliferation in vitro but stimulates tumor growth in vivo. Because of their structural similarity to N,N-diethyl-2-[4-(phenylmethyl)phenoxy]ethanamine HCl, we carried out studies to determine whether amitriptyline and fluoxetine stimulate tumor growth and/or development in rodents at concentrations relevant to the treatment of human depression (equivalent human dose range, approximately 100-150 mg/day for amitriptyline and approximately 20-80 mg/day for fluoxetine). All experiments were performed blinded. In studies of growth stimulation of transplantable syngeneic tumors, groups of mice were inoculated s.c. with C-3 fibrosarcoma cells or given i.v. or s.c. injections of B16f10 melanoma cells, followed 24 h later by daily i.p. injections of saline, amitriptyline, or fluoxetine. Tumor latency (fibrosarcoma), aggregate tumor weight (s.c. injected melanoma), or time to death from pulmonary metastasis (i.v. injected melanoma) was determined; drug-induced stimulation of DNA synthesis in C-3 fibrosarcoma cells in vitro was correlated with tumor growth acceleration in vivo. In a mammary carcinogenesis model, the effects of chronic saline, amitriptyline, or fluoxetine administration on the rate and frequency of development of mammary tumors in rats fed dimethylbenzanthracene (DMBA) were compared. Eight of 20 amitriptyline- or fluoxetine-treated mice developed fibrosarcoma tumors by day 5, as compared to none of 20 saline controls (P less than 0.002). Similarly, 20 of 21 DMBA-treated rats receiving the antidepressant drugs developed 33 mammary tumors by week 15 as compared to 5 tumors in 4 of 7 DMBA-treated rats receiving saline (P less than 0.001). For both models, tumor latency decreased 30-40% and, in the DMBA model, tumor frequency increased greater than 2-fold in the antidepressant-treated rats as compared to controls. Stimulation of fibrosarcoma growth in vivo correlated with a corresponding bell-shaped drug-induced increase in DNA synthesis in vitro. While the median time to death from pulmonary metastases did not differ among groups given i.v. injections of melanoma cells, a significant (P less than 0.01) stimulation of growth of s.c. injected melanoma was observed in mice receiving the antidepressants.(ABSTRACT TRUNCATED AT 400 WORDS)

Insidious rifampin-associated renal failure with light-chain proteinuria.

A patient who was receiving rifampin treatment for tuberculosis developed heterogenous light-chain proteinuria and insidious renal failure after a period of fluid restriction. The renal damage was characterized pathologically by an interstitial nephritis with invasive tubular casts and an associated renal vein thrombosis. The possible role of the light-chain proteinuria in the pathogenesis of the renal failure is discussed.

Cerebrospinal fluid shunt infections in children.

We reviewed cerebrospinal fluid (CSF) shunt infections treated in the Royal Children's Hospital, Melbourne from 1981 to 1991. Forty-one episodes of CSF shunt infection were found after 900 shunt operations, an infection rate of 4.5%. Clinical symptoms were nonspecific in 31.7% of episodes, and in 17.1% of episodes the initial CSF sample was normal on microscopy and biochemistry, although a pathogen was isolated on culture. Most episodes occurred within 4 months of the last operation on the shunt, the exception being infections caused by Haemophilus influenzae. Four patients died during treatment, but none could be attributed to infection alone. Treatment of suspected CSF shunt infection should not be withheld because of lack of firm clinical diagnosis or normal CSF microscopy, and episodes occurring more than 4 months after the last operation on the CSF shunt should receive antibiotic cover for H. influenzae.

Randomized, controlled trial comparing once daily and three times daily gentamicin in children with urinary tract infections.

OBJECTIVE: To undertake population pharmacokinetic modeling and to determine the safety and efficacy of once daily (OD) gentamicin dosing in children with severe urinary tract infections (UTI). METHODS: An open, randomized, controlled trial comparing OD with three times daily (TD) gentamicin dosing in hospitalized children ages 1 month to 12 years with UTI. Daily doses (milligrams per kg per day) of gentamicin in both groups were 7.5 (<5 years old), 6.0 (5 to 10 years old) and 4.5 (>10 years old). RESULTS: There were 179 children enrolled (90 OD, 89 TD). Baseline clinical characteristics and pathogens were similar, except that circulatory compromise and renal cortical scintigraphic defects were more common in the OD group. Median gentamicin treatment durations were 3.0 (OD) and 2.7 (TD) days. Mean peak gentamicin concentrations were 17.3 (OD) vs. 6.4 (TD) mg/l; 99% of peak concentrations were >7 mg/l in the OD group whereas 16% of peak concentrations were <5 mg/l in the TD group. Mean trough concentrations were 0.35 (OD) vs. 0.55 (TD) mg/l. In the OD group 4% of trough concentrations were > or = 2 mg/l, whereas in the TD group only 0.7% were > or = 2 mg/l. Age or prior elevated peak concentrations did not predict high trough concentrations. Population pharmacokinetic modeling of the data fitted a one-compartment model with first order elimination. There were no clinical or bacteriologic failures. The two disease-related complications were confined to the OD group. No nephro- or ototoxicity was identified. CONCLUSIONS: With age-appropriate dosing and measurement of serum trough concentrations before the second dose, OD gentamicin is safe and effective for the treatment of UTI requiring parenteral treatment in children aged 1 month to 12 years.

Malignant lymphoepithelial lesion of the submandibular salivary gland.

A case of malignant lymphoepithelial lesion (MLEL) occurring in the submandibular salivary gland of an Eskimo woman is presented. These unusual carcinomas have a striking frequency in Eskimos but are usually in the parotid gland. Cytology of fine-needle aspirated material demonstrated the cell type found by histologic examination. Electron microscopy confirmed a squamous differentiation of the malignant cells.

Biotypes of Klebsiella pneumoniae (sensu lato) and Enterobacter aerogenes characterised by differential substrate metabolism: application of the technique.

A biochemical typing method is described for Klebsiella pneumoniae (sensu lato) and Enterobacter aerogenes. The technique depends on differences in metabolism of five carbon substrates--glycerol, inositol, lactose, glucose, and xylose--at two concentrations. Reproducibility is satisfactory and is monitored by the incorporation of control klebsiellae of known biotype. The method has been used for 12 months in the surveillance of urinary tract colonisation in this hospital. Gut carriage of klebsiellae, implicated by several workers as a source of infection, was common among staff and new admissions. Many biotypes were represented which were sensitive to most antibiotic except ampicillin. Klebsiellae, all multiply resistant, were isolated most frequently from urine specimens in two orthopaedic wards. In a longitudinal study in these wards, a sequential dominance in urinary tract colonisation by two klebsiella biotypes was shown, which suggested the presence of cross infection or an environmental reservoir. Confirmatory evidence was obtained from capsular serotypes and R-factor studies.

Value of charcoal media for recovering staphylococci incorporated in mupirocin ointment.

The use of charcoal blood agar supported a good recovery of staphylococci incorporated in Mupirocin ointment in a test in vitro system. The efficacy of this medium was particularly emphasised in the recovery of staphylococci damaged by six hours' exposure to Mupirocin. The media will be of value in following the progress of staphylococcal carriage or infection in patients or carriers being treated with topical Mupirocin.

Comparison of identification of Enterobacteriaceae by API 20E and Sensititre Autoidentification System.

Of 251 isolates of the Enterobacteriaceae identified to species level by API 20E, 208 (83%) were similarily identified by the Sensititre Autoidentification System. Both systems shared a common problem in that discrimination between species of the genera Klebsiella, Enterobacter, and Serratia was poor. The eight digit biocode generated by the Sensititre system for individual isolates is not reproducible and therefore not of epidemiological value.

Implications of endotracheal tube biofilm for ventilator-associated pneumonia.

OBJECTIVE: To determine the relationship between, and antibiotic resistance of, endotracheal tube (ET) biofilm and pulmonary pathogens in ventilator-associated pneumonia (VAP). SETTING: General intensive care units in two university teaching hospitals. DESIGN: The microbiology of ET biofilm and tracheal samples from patients with and without VAP were compared. For individual patients, matching pairs of pathogens were confirmed as identical and characterised for antibiotic susceptibility. PATIENTS: 40 intensive care unit patients - 20 with VAP, 20 without VAP as control. The duration of intubation (median and range) was 6.5 days (3-17) and 5 days (2-10), respectively. MEASUREMENTS AND RESULTS: Samples of tracheal secretions were taken during ventilation for bacteriological culture. Following extubation, ETs were examined for the presence of biofilm. Isolates of high pathogenic potential included Staphylococcus aureus, enterococci, Enterobacteriaceae, pseudomonads and Candida spp. Where the same microorganism was found on tracheal and ET samples by phenotyping, these were confirmed as identical by genotyping and characterised for antibiotic susceptibility in both the free floating and biofilm forms. Seventy per cent of patients with VAP had identical pathogens isolated from both ET biofilm and tracheal secretions. No pairing of pathogens was observed in control patients (p < 0.005). Susceptibility data for these pairs show that the ET acts as a reservoir for infecting microorganisms which exhibit significantly greater antibiotic resistance than their tracheal counterparts. CONCLUSION: This investigation provides further evidence for the role of ET biofilm in VAP. The difficulty in eradicating an established microbial biofilm using antibiotics implies that increased attention must be directed towards modification of the ET to prevent or substantially reduce biofilm formation.

Multiple outbreaks of Norwalk-like virus gastro-enteritis associated with a Mediterranean-style restaurant.

The role of diverse infectious agents, particularly Norwalk-like viruses (NLV), in three successive gastro-enteritis outbreaks in one setting (a restaurant) was evaluated. Methods included standard bacteriological tests, specific tests for Escherichia coli, tests for verocytotoxins, electron microscopy (EM) for viruses and reverse transcription-PCR (RT-PCR) methodology for NLV. No pathogenic bacteria were detected. Verocytotoxin genes, although detected by PCR in the first outbreak, could not be confirmed in the E. coli isolated, so they did not appear to be of significance. NLV was the main agent detected in each of the three outbreaks. DNA sequencing and phylogenetic analysis of the amplified products obtained from the RT-PCR positive specimens indicated that only one NLV strain was involved in each outbreak, but the NLV strains responsible for the three outbreaks were different from each other. PCR technology for detection of NLV proved highly sensitive, but failed to detect one specimen which was positive by EM. The restaurant associated with the outbreaks is a Mediterranean-style restaurant where food from a common platter is typically eaten with fingers. The findings indicate that NLV was introduced by guests or staff and was not due to a long-term reservoir within the setting.

The actinic cheilitis of hereditary polymorphic light eruption.

Sixty-four North American Indians with hereditary polymorphic light eruption (HPLE), or a family history of HPLE, had chronic, recurrent, exudative, and exfoliative cheilitis. Fifty-two had the cheilitis by the age of 10 years. Microscopically, the epithelium was either thickened, or thinned and covered by a thick crust. The dermis had a dense infiltration of inflammatory cells, mostly lymphocytes and plasma cells. The condition was not premalignant. The HPLE has to be differentiated from the chronic actinic cheilitis caused by long exposure to sunlight with out any element of hypersensitivity. The latter is potentially premalignant. Chronic recurrent actinic cheilitis associated with hereditary polymorphic light eruption appears to be a specific characteristic of photosensitivity occurring in American Indians. Plasma cell infiltration is not specific for either type of cheilitis.

Hereditary multiple fibrofolliculomas with trichodiscomas and acrochordons.

In a sibship of nine, six members had hereditary medullary carcinoma of the thyroid. Two of those with thyroid neoplasms and two without had numerous small papular skin lesions. These proved to be a type of pilar tumor that we named fibrofolliculoma. Further investigation of the total kindred of 70 showed no other evidence of thyroid neoplasm. Skin tumors only appeared after the age of 25 years. Fifteen of 37 members older than the age of 25 years exhibited the typical skin lesions. Obviously, the original sibship was the repository of two dominantly inherited traits. The fibrofolliculoma is characterized by abnormal hair follicles with epithelial strands extending out from the infundibulum of the hair follicle into a hyperplastic mantle of specialized firbrous tissue. Associated skin lesions in this kindred were trichodiscomas and acrochordons.

Contamination of multi-use closed tracheal suction catheters: an in-vitro study.

The use of closed multi-use tracheal suction systems in ventilated patients is increasingly popular as it offers a number of potential physiological and microbiological advantages. As the use of these systems has been associated with an increased prevalence of tracheal colonization, effective self-cleaning mechanisms employed in these catheters are necessary. Using an in-vitro model we assessed the degree of catheter colonization in two multi-use catheter systems; Stericath and Trach-Care. Fifty of each catheter type were tested for colonization with five challenge organisms: Staphylococcus aureus (NCTC 6571); Pseudomonas aeruginosa (NCTC 10662); Haemophilus influenzae type b; S. epidermidis (slime producer); and S. epidermidis (slime non-producer). All five challenge strains had colonized both catheter types after 24 h and all 100 catheter tips were colonized. The extent and density of colonization was variable and interspecies variation in the pattern of catheter colonization was observed. The mean colonized lengths of Stericath catheters was 10.9 +/- 1.4 cm and of Trach-Care 2.7 +/- 1.3 cm (P < 0.0001).