Enhancing Nursing Care for Children with Acute Gastroenteritis: Integrating Pediatric Early Warning Scores with the Situation-Background-Assessment-Recommendation System.

Background: Acute gastroenteritis is a frequently encountered diarrheal illness in children, often self-limiting but occasionally linked to substantial mortality and morbidity, demanding effective approaches for assessment and intervention. While the utilization of the Pediatric Early Warning Score (PEWS) and the Situation-Background-Assessment-Recommendation system (SBAR) in pediatric patient management is recognized as effective, research in this area remains limited. Objective: Our study aimed to investigate the potential impact of PEWS and SBAR systems on the outcomes of pediatric patients with acute gastroenteritis. Methods: We conducted a randomized controlled trial at our hospital, enrolling 124 children aged 3 to 12 years diagnosed with acute gastroenteritis. These participants were randomly assigned to either a control group (62 cases) or an intervention group (62 cases). Different outcomes were assessed, including the frequency and duration of diarrhea and vomiting, the Modified Vesikari Scale (MVS), the Clinical Dehydration Scale (CDS), and follow-up physician visits. We utilized a two-group independent sample t test to compare outcomes between the two groups. Results: Our study resulted in statistically significant findings favoring the intervention group regarding the frequency and duration of diarrhea and vomiting, the MVS, the CDS, and the need for repeat healthcare visits. Conclusions: The integration of PEWS with SBAR appears to offer improved outcomes for children afflicted with acute gastroenteritis.

Hospital Discharge Data Underascertain Enteric Bacterial Infections Among Children.

Many enteric pathogens disproportionately infect children. Hospital discharge data can provide information on severe infections, including cost. However, the diagnosis must be recorded on the discharge record and coded accurately. We estimated the rate of underascertainment in hospital discharge data among children with culture-confirmed Campylobacter, Salmonella, and Escherichia coli O157 infections using linked laboratory and hospital discharge data from an integrated health care organization. We reviewed the International Classification of Diseases, 9th and 10th Revisions, Clinical Modification (ICD-9/10-CM) diagnosis codes on each patient's discharge record. We determined the percentage of patients who had a pathogen-specific diagnosis code (for Campylobacter, Salmonella, or E. coli O157) or nonspecific gastroenteritis code. We included the first admission or positive test and calculated the number of days between specimen submission (outpatient ≤7 days before admission or inpatient) and hospital discharge. Of 65 hospitalized children with culture-confirmed Campylobacter (n = 30), Salmonella (n = 24), or E. coli O157 (n = 11) infections, 55% had that pathogen-specific diagnosis code listed on the discharge record (79% Salmonella, 54% E. coli O157, 37% Campylobacter). The discharge records of the 35 children with a specimen submitted for culture ≥3 days before discharge were 16 times more likely to have a pathogen-specific diagnosis than the records of the 30 children with a specimen submitted <3 days before discharge (83% vs. 23%; odds ratio 15.9, 95% confidence interval: 4.7-53.8). Overall, 34% of records of children with culture-confirmed infection had ≥1 nonspecific gastroenteritis code (Campylobacter 43%, Salmonella 29%, E. coli O157 18%), including 59% of those for children without a pathogen-specific diagnosis (Campylobacter 63%; Salmonella 60%; E. coli O157 40%). This study showed that hospital discharge data under-ascertain enteric illnesses in children even when the infections are culture confirmed, especially for infections that usually have a short length of stay.

[The 473rd case: renal failure, abdominal pain, and mental abnormality].

A 43-year-old male presented with elevated serum creatinine for 4 years and developed abdominal pain for 3 days. He started peritoneal dialysis 2 months ago. Dialysis-related peritonitis was ruled out and acute gastroenteritis was diagnosed. The patient was administrated with ertapenem 500 mg/d. An acute mental abnormality developed 3 days later. After excluded organic encephalopathy, ertapenem was discontinued for the suspicion of antibiotic-related encephalopathy. The frequency of peritoneal dialysis was increased to accelerate the clearance of antibiotics. However, the metal abnormality became even more severe. Then a diagnosis of Wernick-Korsakoff syndrome was considered. After the administration of high dose vitamin B(1), the mental disorder dramatically relieved. Vitamin B(1) 30 mg/d is maintained during peritoneal dialysis and the mental disorder does not relapse.

Endocannabinoids in the treatment of gasytrointestinal inflammation and symptoms.

The evolving policies regarding the use of therapeutic Cannabis have steadily increased the public interest in its use as a complementary and alternative medicine in several disorders, including inflammatory bowel disease. Endocannabinoids represent both an appealing therapeutic strategy and a captivating scientific dilemma. Results from clinical trials have to be carefully interpreted owing to possible reporting-biases related to cannabinoids psychotropic effects. Moreover, discriminating between symptomatic improvement and the real gain on the underlying inflammatory process is often challenging. This review summarizes the advances and latest discovery in this ever-changing field of investigation, highlighting the main limitations in the current use of these drugs in clinical practice and the possible future perspectives to overcome these flaws.

A model for rapid, active surveillance for medically-attended acute gastroenteritis within an integrated health care delivery system.

BACKGROUND: This study presents a novel methodology for estimating all-age, population-based incidence rates of norovirus and other pathogens that contribute to acute gastroenteritis in the United States using an integrated healthcare delivery system as a surveillance platform. METHODS: All cases of medically attended acute gastroenteritis within the delivery system were identified from April 1, 2014 through September 30, 2016. A sample of these eligible patients were selected to participate in two phone-based surveys and to self-collect a stool sample for laboratory testing. To ascertain household transmission patterns, information on household members with acute gastroenteritis was gathered from participants, and symptomatic household members were contacted to participate in a survey and provide stool sample as well. RESULTS: 54% of individuals who met enrollment criteria agreed to participate, and 76% of those individuals returned a stool sample. Among household members, 85% of eligible individuals agreed to participate, and 68% of those returned a stool sample. Participant demographics were similar to those of the eligible population, although minority racial/ethnic groups were somewhat underrepresented in the final sample. CONCLUSIONS: This study demonstrates the feasibility of conducting acute infectious disease research within an integrated health care delivery system. The surveillance, sampling, recruitment, and data collection methods described here are broadly applicable to conduct baseline and epidemiological assessments, as well as for other research requiring representative samples of stool specimens.

Introduction of Bovine-Based Nutrient Fortifier and Gastrointestinal Inflammation in Very Low Birth Weight Infants as Measured by Fecal Calprotectin.

BACKGROUND: Fecal calprotectin (fCP) is a biomarker of gastrointestinal tract (GIT) inflammation that is currently being used investigationally among very low birth weight (VLBW) infants. MATERIALS AND METHODS: Stool was collected weekly from 20 breastmilk-fed VLBW infants for up to 8 weeks after birth during the establishment and fortification of feeds, and fCP concentrations were measured. RESULTS: Mean fCP levels increased significantly in stools collected immediately following bovine-based nutrient fortification of feeds (p = 0.005). CONCLUSIONS: Addition of bovine fortifier to breastmilk feeds appeared to be associated with an acute increase in GIT inflammation.

Notes from the field: Fatal gastrointestinal mucormycosis in a premature infant associated with a contaminated dietary supplement--Connecticut, 2014.

In October 2014, a hospital in Connecticut notified CDC and the Connecticut Department of Public Health of a fatal case of gastrointestinal mucormycosis in a preterm infant. The infant, born at 29 weeks' gestation and weighing 1,400 grams (about 3 pounds), had developed signs and symptoms initially consistent with necrotizing enterocolitis approximately 1 week after birth. Exploratory laparotomy revealed complete ischemia of the gastrointestinal tract from the esophagus to the rectum; a portion of necrotic cecum was sent for microscopic examination. Following surgery, the infant developed multiple areas of vascular occlusion, including a large clot in the aorta, findings not usually associated with necrotizing enterocolitis. The infant died soon after. Histopathology results from the resected cecum revealed an angioinvasive fungal infection consistent with mucormycosis. Gastrointestinal mucormycosis is an extremely rare fungal infection caused by mold in the order Mucorales. It occurs predominantly in low birth weight infants, patients with diarrhea and malnutrition, and those receiving peritoneal dialysis; mortality is 85%. Local investigation revealed that the infant had received a dietary supplement, ABC Dophilus Powder, for 7 days, beginning on day 1 of life.

Motivations for avoiding wheat consumption in Australia: results from a population survey.

OBJECTIVE: To assess the prevalence of and explanations for wheat avoidance, including reported symptoms, diagnoses and information sources influencing the decision to avoid wheat, and to investigate potential psychological predictors of this behaviour. DESIGN: Cross-sectional population survey. SETTING: The study was conducted in Australia, using a nationwide postal omnibus survey. SUBJECTS: Adults aged 18 years and over (n 1184; 52·9% female) selected at random from the Australian Electoral Roll. RESULTS: With cases of stated and suspected coeliac disease (1·2%) excluded, 7·3% of the sample reported adverse physiological effects, predominantly gastrointestinal, that they associated with wheat consumption. Few among this group (5·7%) claimed a formally diagnosed intolerance or allergy requiring avoidance of wheat-based foods. Symptomatic wheat avoidance was highly correlated with dairy avoidance and predicted by gender (female), lesser receptiveness to conventional medicine and greater receptiveness to complementary medicine, but not by neuroticism, reasoning style or tendency to worry about illness. CONCLUSIONS: The data indicate that many adult Australians are consciously avoiding consumption of wheat foods, predominantly without any formal diagnosis. Reported symptoms suggest a physiological but not allergenic basis to this behaviour. Questions to be answered concern whether symptoms are attributed correctly to wheat, the agents (wheat components, dietary factors or additives) and physiological mechanism(s) involved, the nutritional adequacy of avoiders' diets, and the clinical and psychosocial processes that lead a substantial number of adults to avoid consuming wheat (or any other dietary factor) apparently independently of a medical diagnosis.

Proximal collagenous gastroenteritides: clinical management. A systematic review.

AIM: While collagenous colitis represents the most common form of the collagenous gastroenteritides, the collagenous entities affecting the proximal part of the gastrointestinal tract are much less recognized and possibly overlooked. The aim was to summarize the latest information through a systematic review of collagenous gastritis, collagenous sprue, and a combination thereof. METHOD: The search yielded 117 studies which were suitable for inclusion in the systematic review. Excluding repeated cases, 89 case reports and 28 case series were reported, whereas no prospective studies with or without control groups were identified. Further, no randomized, controlled trials were identified. The total number of patients with proximal collagenous gastroenteritides reported was 330. RESULTS: An overview of clinical presentations, prognosis, pathophysiology and histopathology, as well as management of these disorders is presented. The prognosis of both collagenous gastritis and sprue seems not to be as dismal as considered previously. Data point to involvement of immune or autoimmune mechanisms potentially driven by luminal antigens initiating the fibroinflammatory condition. CONCLUSIONS: To reach the diagnosis it is recommended that biopsies are obtained during gastroduodenoscopies. Therapies with anti-secretory strategies, glucocorticoids, and in some cases iron supplementation are suggested, although rational treatment options from randomized, controlled trials do not exist for these rare or even overlooked disorders.

[Two cases of eosinophilic gastroenteritis whose causative allergens are usefully diagnosed by patch test].

Case 1: 67-years-old woman with pollinosis noticed oppressive feeling of chest and back, and heart burn after accidental ingestion of her dental filling and dental treatment. Oral famotidine did not improve her symptom. Her peripheral blood eosinophils increased to 38.0%. As for the specific IgE, only cedar and cypress were positive. Case 2: a 42-years-old-woman with pollinosis and asthma repeated urticaria, heart burn, diarrhea and peripheral eosinophilia (25%). At her first visit to our department, her blood eosinophil increased to 52.9%, her serum IgG markedly increased in polyclonal pattern and overt all subclasses. The specific IgE was positive only for cypress. Because they revealed a remarkable infiltrates of eosinophils in the mucosa of alimentary tract, we diagnosed the 2 patient as eosinophilic gastroenteritis. In case 1, based on the history and patch-test-positive finding of formalin and 2-hydroxyethyl methacrylate, we diagnosed the two may be causative allergens. In case 2, based on the patch-test-positive finding of garlic and sesame and improvement after removal of the two allergens, we diagnosed the two may be causative allergens. Although causative allergens of eosinophilic gastroenteritis are almost unknown, some cases are reported to be determined the allergens of foods and drugs. In our cases, patch test was useful to identify the allergens.

[Clinical study of eosinophilic gastroenteritis].

OBJECTIVE: To study the clinical symptoms, diagnosis and treatment of eosinophilic gastroenteritis (EG). METHODS: A total of 44 cases of EG admitted to our hospital were studied respectively in clinical manifestations, laboratory examinations, endoscopic signs and treatment. RESULTS: (1) The presenting symptoms of EG patients was abdominal pain. (2) The endoscopic signs of EG were mucosal pathological changes of hyperemia, erosion and hyperplasia. A certain number of eosinophilic granulocytes were detected in pathological examination. (3) The hormones were effective and had quick onsets. While, based on different clinical symptoms, the traditional medicine was dosed by oral administration and intestinal enema. In TCM group (n = 22), 20 patients had a relief of clinical symptoms, 4 cases of recurrence and 16 of cure. In comparison, in hormone group (n = 18), 17 patients had a relief of clinical symptoms, 6 cases of recurrence and 12 of cure. The results showed that two groups had no statistical difference in relief of clinical symptoms, recurrence and hormonal cure (all P > 0.05). But it will be more readily accepted. CONCLUSIONS: The incidence of EG is low in clinical practice because of its non-specific clinical and endoscopic manifestations. An elevated count of eosinophilic granulocytes in peripheral blood, ascitic fluid and tissues of mucous membrane are key diagnostic points. The hormonal treatment is both fast and effective. But traditional medicine will have a brighter clinical prospect.

Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: are we masking alternative diagnoses?

STUDY OBJECTIVE: We evaluate the effect of ondansetron use in cases of suspected gastroenteritis on the proportion of hospital admissions and return visits and assess whether children who receive ondansetron on their initial visit to the pediatric emergency department (ED) for suspected gastroenteritis return with an alternative diagnosis more frequently than those who did not receive ondansetron. METHODS: This is a retrospective review of visits to 2 tertiary care pediatric EDs with an International Classification of Diseases, Ninth Revision diagnosis of vomiting or gastroenteritis. A logistic regression model was developed to determine the effect of ondansetron use during the initial pediatric ED visit on hospital admission, return to the pediatric ED within 72 hours, and admission on this return visit. For patients who returned within 72 hours and were admitted, hospital discharge records were reviewed. The proportions of alternative diagnoses, defined as a hospital discharge diagnosis that was not a continuation of gastroenteritis or vomiting, were compared between the groups. RESULTS: During the 3-year study period (2005 to 2007), 34,117 patients met study criteria. Ondansetron was used for 19,857 (58.2%) of these patients on their initial pediatric ED visit. After controlling for differences between the groups, patients who received ondansetron were admitted on their initial visit less often: odds ratio (OR) 0.47 (95% confidence interval [CI] 0.42 to 0.53). However, those who received ondansetron were more likely to return to the pediatric ED within 72 hours (OR 1.45; 95% CI 1.27 to 1.65) and be admitted on the return visit (OR 1.74; 95% CI 1.39 to 2.19). The proportions of alternative diagnoses at hospital discharge were not significantly different in the group that received ondansetron on the initial pediatric ED visit (14.9%) compared with the group that did not (22.4%) (absolute difference 7.5% [95% CI -0.5% to 16.4%). CONCLUSION: Ondansetron use in the pediatric ED reduces hospital admissions for suspected gastroenteritis and vomiting. However, children who receive ondansetron in the pediatric ED appear more likely to return to the pediatric ED and be admitted on this return visit than their counterparts. Furthermore, the use of ondansetron does not appear to be associated with increased risks of masking serious diagnoses in children.

Important bacterial gastrointestinal pathogens in children: a pathogenesis perspective.

This article focuses on the five most common bacterial enteropathogens of the developed world--Helicobacter pylori, Escherichia coli, Shigella, Salmonella, and Campylobacter--from the perspective of how they cause disease and how they relate to each other. Basic and recurring themes of bacterial pathogenesis, including mechanisms of entry, methods of adherence, sites of cellular injury, role of toxins, and how pathogens acquire particular virulence traits (and antimicrobial resistance), are discussed.

Artritis séptica por Salmonella no typhi: presentación de un caso y revisión de la bibliografía / Non-typhi Salmonella septic arthritis: case report and review of the literature

La artritis séptica por Salmonella no typhi representa menos del 2 por ciento del total de las artritis sépticas1. El serotipo etiológico más frecuente es Salmonella enteritidis. Su clínica, precedida o no de una gastroenteritis, no difiere de otras artritis sépticas, y se presenta con fiebre y sinovitis monoarticular, habitualmente en rodilla, cadera y hombro. La inmunosupresión (terapéutica, virus de la inmunodeficiencia humana [VIH], lupus eritematoso sistémico [LES], etc.) es el principal factor de riesgo en su desarrollo. La drepanocitosis, la hemofilia, las neoplasias y las edades extremas de la vida también predisponen a su aparición. El diagnóstico se realiza por cultivo de líquido sinovial. El tratamiento está condicionado por las resistencias descritas a múltiples antibióticos, incluso a los más actuales, como son las fluoroquinolonas. Las complicaciones locales más frecuentes son la limitación residual funcional y la osteomielitis. El pronóstico, marcado por la enfermedad de base, presenta una elevada mortalidad (AU)

[5-Fluorouracil-induced colitis--a review based upon consideration of 6 cases]. / 5-Fluorouracil-assoziierte Kolitis--eine Ubersicht unter Berücksichtigung einer eigenen Sammlung von 6 Fällen.

BACKGROUND: At increasing use of high-dose 5-fluorouracil-based chemotherapy for metastatic colorectal and gastric cancer complicated drug-induced colitis is observed more frequently. From May 1998 to November 2000 we observed 6 cases of 5-fluorouracil-induced colitis, in which we looked for involvement of small intestine. We report summing up on the 6 cases including both endoscopic and histological findings in both sites of the gut. CASE REPORTS: In 2 men and 4 women (age 49-78 years) with advanced colon (n = 2), gastric (n = 3 ) and gallbladder (n = 1) cancer a palliative weekly high-dose infusional 5-fluorouracil (2,6 g/m(2)/24 h) and folinic acid (500 mg/m(2)/2 h) chemotherapy was performed. Few days after 1-5 chemotherapy courses the patients were admitted to our hospital with abdominal pain and partly severe watery diarrhea (up to 20 times evacuations/per day). The stool cultures were negative and there were no proof both of clostridium difficile and his toxin A and B. In 4 patients colonoscopy showed different grades of colitis up to diffuse erythema and microlesions, 2 patients had no visible lesions. In 4 patients endoscopy of the upper GI-tract showed a severe inflammation (n = 1) and a fibrinopurulent exsudate, severe edema and isolated ulcerations (n = 3) of jejunum after gastrectomy or duodenum with intact stomach. In the histological assessment different grades of 5-FU-induced colitis without (n = 2) or with (n = 4) involvement of the upper small intestine destruction of the superficial mucosa and crypts (epitheliumapoptosis) were found. 5 patients were treated by antibiotics (vancomycin n = 2, metronidazole n = 3), glucocorticoids (n = 5) and Saccaromyces cerevisiae (n = 3). After 8-10 days the patients were complete free of symptoms. One patient died due to the enterocolitis. CONCLUSIONS: The present cases demonstrate that high-dose 5-fluorouracil-based chemotherapy not only induces a colitis but also may involve the upper small intestine tract. Consequently, it represents an increasing and serious adverse event of high-dose chemotherapy. The etiology of the enterocolitis (drug- or bacterial-induced) needs further investigations in order to find a causal therapy and/or prophylaxis.

Diarrea aguda: tratamiento nutricional / Acute diarrhea: nutrtional treatment

El tratamiento de la diarrea aguda consistirá básicamente en rehidratación oral si existiera deshidratación, realimentación precoz y excepcionalmente farmacológico. La rehidratación debe durar 4-6 horas, que se prolonga a 8-12 horas si la deshidratación es hipernatrémica, pasando posteriormente a la fase de mantenimiento. Las soluciones de rehidratación oral son las recomendadas, usándose en países en vías de desarrollo la solución de la OMS por las pérdidas importantes de sodio en las heces y soluciones con menor contenido de sodio en los países industrializados al ser las pérdidas de sodio menores. La realimentación debe ser lo mas precoz y equilibrada posible, recoméndandose la lactancia materna si es la forma de alimentación o la fórmula sin diluir si realiza lactancia artificial. No es aconsejable sistemáticamente las fórmulas sin lactosa. El uso de probióticos mejora el cuadro. No se precisa tratamiento farmacológico y los antibióticos sólo están indicados en pacientes inmunodeprimidos, cólera, lactantes menores de 3 meses con coprocultivos bacterianos positivos, enfermedad sistémica, infección por amebas, giardias, clostridium difficile y shigella que permanece sintomática (AU)

Implicación pronóstica de la sospecha clínica inicial en la disección de aorta torácica. Revisión de los métodos diagnósticos utilizados / Prognostic significance of the initial diagnostic suspicion in cases of thoracic aortic dissection. review of the diagnostic techniques

Objetivo. Analizar la importancia de la sospecha clínica inicial en el diagnóstico de la disección de aorta torácica y la influencia en su pronóstico, revisar los diferentes métodos complementarios utilizados. Material y métodos. Se estudiaron retrospectivamente 33 casos de disección de aorta torácica entre enero de 1993 y junio de 1998, valorándose parámetros clínico-epidemiológicos, diagnósticos de ingreso y pruebas complementarias. Los resultados cualitativos se valoraron mediante 2.Resultados. La sintomatología típica de disección (dolor torácico, abdominal e interescapular) se apreció en 19 (58 por ciento) casos. La sospecha clínica al ingreso se realizó en 9 (27 por ciento) de los pacientes, siendo diagnósticos tardíos/casuales 22 (67 por ciento ) casos. Se realizó el diagnóstico de disección a través de la necropsia en 2 (6 por ciento) ocasiones. Diagnósticos erróneos de ingreso fueron: cardiopatía isquémica en 9 casos; isquemia de miembros inferiores en 3. Se realizó el diagnóstico de cólico hepático, neumonía, gastroenteritis, síncope, cólico nefrítico, aneurisma de aorta abdominal, pancreatitis y dolor osteomuscular respectivamente en un caso. El retraso en el diagnóstico no influyó significativamente en la mortalidad. La prueba diagnóstica que se utiliza en nuestro medio en primer lugar es la tomografía axial computarizada (TAC). La aortografía se utiliza como prueba confirmatoria del diagnóstico. Conclusiones. No se valoran adecuadamente los datos de la clínica inicial. La mortalidad es mayor en el grupo de pacientes en el cual no hay sospecha clínica inicial de disección de aorta (AU)