Management of benign, giant gastric ulcers.

Giant gastric ulcers (greater than 3 cm in diameter) have traditionally been considered to be refractory to medical therapy and were commonly thought to initially appear as life-threatening hemorrhage requiring emergent operative therapy. This study was undertaken to evaluate the results of medical and surgical treatment of benign, giant gastric ulcers and the validity of these traditional teachings. A retrospective review of 44 patients with giant gastric ulcers was performed to evaluate the results of medical and surgical therapy at Hartford Hospital (Hartford, CT). The majority of these patients received medical therapy. Over 57 per cent received only medical therapy, while 25 per cent received primary, operative therapy. Contrary to popular belief, the authors found that patients who received initial medical therapy did not have high morbidity or mortality rates. Therefore, while the necessity of early surgical intervention following perforation or in patients with signs of hemorrhagic shock can not be refuted, the authors conclude that medical therapy of benign, giant gastric ulcers is often effective and not unduly hazardous. Giant gastric ulcers, in and of themselves, are not an indication for surgery.

Detection of Pseudomonas mesophilica as a source of nosocomial infections in a bone marrow transplant unit.

Pseudomonas mesophilica was isolated from fungal blood cultures of two bone marrow transplant recipients who consecutively occupied the same room. The isolation of P. mesophilica was temporally associated with febrile illness in these two granulocytopenic patients at 1 and 3 weeks posttransplant. A third patient, housed separately on the same bone marrow transplant unit, had nasopharyngeal colonization by this organism. Epidemiologic risk factors in common included staff, medications, and oral and perineal irrigations with tap water. Surveillance cultures detected P. mesophilica in none of 24 pharmaceutical preparations and in 10 of 40 tap water samples (100 to 600 CFU/ml) from implicated and control rooms on the same floor. Antimicrobial susceptibility testing of 14 patients and environmental isolates by agar dilution revealed similar profiles; some environmental isolates exhibited higher MICs. Because of restrictive nutritional and temperature requirements, P. mesophilica is undetected by many clinical laboratory protocols and may represent a previously undetected source of febrile illness in neutropenic patients.

Serum salicylate concentrations in Reye's disease. A study of 130 biopsy-proven cases.

Serum salicylate concentration was measured at admission in 130 children with liver-biopsy-confirmed Reye's disease. Mean serum salicylate was 12.3 mg/dl and mean salicylate concentrations by neurological grade (Lovejoy) were: stage I, 12, stage II, 13, stage III, 11, stage IV, 13, and stage V, 13 mg/dl. However, mean serum salicylate (15 mg/dl) at admission in 21 patients who died or had serious neurological deficits was significantly higher than that in 103 patients who survived without neurological sequelae (10 mg/dl). Serum salicylate in a group of 27 age-matched, community-matched control children collected consecutively over the period 1978-80 was less than 2 mg/dl, and children with varicella or influenza had salicylate concentrations indistinguishable from apparently well classmates or siblings. It is impossible to determine from this data whether salicylates are involved in the aetiology of or in determining the outcome of Reye's disease. Increased concentrations of salicylates at admission could be the result of excessive dosage because of a greater severity of the prodromal illness, or to diminished excretion because of impaired hepatic metabolism. It seems likely that serum salicylate concentrations entered the toxic range in many patients with Reye's disease before they presented for treatment. Most had been vomiting and had diminished oral intake for 33-55 h before hospital admission. Since the average number of hours from the beginning of vomiting to admission was no different in non-comatose and comatose cases, the time at which salicylate concentration was measured in relation to the last dose was probably similar in the two groups and therefore does not account for the higher levels in children with poor outcome. Salicylates are mitochondrial toxins and mitochondria are known to be significantly injured in Reye's disease; therefore, it seems wise to avoid the use of aspirin in children during outbreaks of Reye's disease.

Prepubertal gonorrhea: a multidisciplinary approach.

Forty-six children less than 12 years of age with gonorrhea were studied over a 4 1/2-year period. The investigation was conducted by a multidisciplinary team including physicians, social workers, and health department representatives. Extensive interviewing and routine culturing of contacts eventually identified the source of gonorrhea in 38/46 (83%) children. Males, both adult and preadolescent, were implicated as the source of gonorrhea almost twice as often as the child's mother. Nineteen children were victims of sexual assault, but only four of them had a hymenal orifice larger than one fingerbreadth. Compliance, both in pursuing the history and obtaining cultures of contacts, was significantly increased by admission to the hospital. A Gram stain and culture for gonorrhea should be done in all children presenting with vaginal discharge regardless of history. Hospitalization of children with suspected gonorrhea greatly facilitates the contact identification.