Vesicoureteric reflux: segregation analysis.

Complex segregation analysis was applied to data from 88 families containing at least one person with vesicoureteric reflux. Analysis showed that a single major locus was the most important causal factor in this condition, with the mutant allele being dominant to the normal allele and having a gene frequency of about 0.16%. Forty-five percent of gene carriers will have vesicoureteric reflux and/or reflux nephropathy as adults and 15% will develop renal failure, compared to 0.05% and 0.001%, respectively, for those not carrying the gene. This analysis confirms the importance of screening close relatives of persons with proven vesicoureteric reflux or reflux nephropathy.

Degradation of lignin in wheat straw during growth of the oyster mushroom (Pleurotus ostreatus) using off-line thermochemolysis with tetramethylammonium hydroxide and solid-state (13)C NMR.

The oyster mushroom (Pleurotus ostreatus) is widely cultivated on wheat straw (Triticum aestivum); however, there is a need to better understand the relationship between the chemical composition of the compost and mushroom growth. Wheat straw was degraded over a period of 63 days by P. ostreatus during which time it was sampled at weekly intervals. Off-line thermochemolysis with tetramethylammonium hydroxide and solid-state (13)C NMR were then used in the molecular characterization of the undegraded wheat straw and the degraded samples. The degraded wheat straw samples had a lower proportion of syringyl- to guaiacyl-derived moieties and cinnamyl- to guaiacyl-derived moieties than the undegraded control. There were increases in both guaiacyl and syringyl acid to aldehyde ratios with composting time, which showed that side-chain oxidation has been mediated by P. ostreatus. The (13)C NMR spectra confirmed the increase in carboxyl content but indicated that the overall lignin and methoxyl contents remained relatively constant, although some nonsystematic variations were observed. The spectra also showed a decrease in amorphous noncellulosic polysaccharides in relation to the crystalline cellulose upon degradation.

D-lactic acidosis in short bowel syndrome.

Short bowel syndrome can present many complex management issues and may be complicated by various metabolic problems. D-lactic acidosis in the setting of short bowel syndrome has been described only rarely in children. A further case is presented with a review of typical clinical manifestations of D-lactic acidosis and reported management options. Early recognition and appropriate management is essential to avoid morbidity secondary to this complication of short bowel syndrome. Probiotic therapies may have an increasing role in prevention and management of this complication.

A paediatric day unit: the first year's experience.

In June 1989 a day unit was introduced into the paediatric department of Christchurch Hospital. Over the subsequent year, 1308 admissions occurred to the unit. Five hundred and thirty (40.6%) of the children were discharged home on the day of referral, only 22 (4%), were readmitted to the inpatient facility within a week of their first assessment. The common conditions dealt with were asthma and acute respiratory tract infection and the pattern generally reflected that normally seen in the inpatient wards. The average stay in the day unit was four hours thirty minutes. The day unit has proved to be effective in reducing overnight inpatient admissions but it requires a higher staff ratio than allocated to ensure rapid and efficient turnover. Utilisation on the weekends and wider use by other specialities dealing with children would increase the units effectiveness further.

Growth patterns and outcomes in congenital adrenal hyperplasia; effect of chronic treatment regimens.

AIM: To assess outcome (final height and sexual maturation), growth patterns and blood pressure in 16 children with congenital adrenal hyperplasia treated at one institution over a 30 year period. METHODS: Growth patterns and maturation were determined by retrospective review (median follow up period 14 years). Dose adjustment of corticosteroid replacement treatment, sufficient to maintain normal levels of adrenal precursor secretion, was determined using assays of urinary pregnanetriol excretion (up to 1975) or early morning measurements of plasma 17 hydroxy progesterone and plasma renin activity at intervals of 4-6 months. RESULTS: In 7 of 15 patients the growth pattern during infancy was retarded--13 not exceeding the population mean. Catchup growth as steroid dose fell with age was not usually observed. In boys, height potential was further compromised by a significant reduction in growth velocity during puberty. None of nine patients evaluated at final height had attained the target height. During the first year of life, plasma renin activity was suppressed below the reference range in six of nine infants. Despite this, and lower than normal levels of plasma renin activity in childhood, most children were normotensive. CONCLUSIONS: Avoiding salt depletion in infancy and excessive androgen secretion during childhood do not ensure normal growth patterns or normal final height. Impaired final height in congenital adrenal hyperplasia is more likely to be due to over treatment, particularly in infancy when lower doses of corticosteroids may improve height prognosis.

Aerodigestive tract foreign bodies in children: one year's experience at Christchurch Hospital emergency department.

AIM: To review the children who presented to Christchurch Hospital emergency department with aerodigestive tract foreign bodies during 1994. METHOD: The emergency department, and impatient notes were retrospectively reviewed for all children presenting with a complaint of an aspirated or ingested foreign body, for the period 1 January 1994 to 31 December 1994. One hundred and thirty-nine children were identified as being eligible for study. A telephone followup interview to determine outcome was also conducted. RESULTS: The 139 children had a median age of 3 years, 2 months and an even gender-distribution. The foreign bodies implicated were 47 coins, 23 sharp objects, 4 button batteries and a wide variety of blunt, noncorrosive foreign bodies. Twelve of the foreign bodies required removal (5 oesophagoscopies, 4 bronchoscopies, 2 indirect laryngoscopies and 1 laparotomy). Forty-five of 139 children had no significant symptoms at any time and these children had a total of 43 x-rays and 5 followup visits, none of which changed management. No child assessed by followup interviews had suffered complications requiring further evaluation or treatment. CONCLUSION: Children who have ingested blunt, noncorrosive foreign bodies, and who have had no significant symptoms at anytime require no investigations after exclusion of oesophageal impaction but should be reviewed if symptoms develop.

Whooping cough: Christchurch 1982.

Whooping cough continues to be a major health problem in New Zealand. In a twelve month period, 64 cases were admitted to the paediatric wards of Christchurch Hospital. Of these 64 patients, 24 (37.5%) were fully immunised. The possible explanations for the large number of children contracting whooping cough, who have been immunised according to the schedule used in New Zealand, is discussed.

Antimicrobial prescribing errors in children.

During a 120 day period, the charts of patients who had received antimicrobial agents were examined. This group numbered 255 and comprised 52% of children admitted with infections. Patients treated by family doctors and/or hospital staff predominantly had respiratory infections and the ampicillin/amoxycillin group of drugs was most commonly prescribed. Of the 203 antimicrobial agents prescribed by hospital staff, 64% were considered to be prescribed appropriately. The major errors related to dosage, the most potentially serious relating to the prescribing of aminoglycosides and chloramphenicol. Of the 203 antimicrobial agents prescribed for 171 children in the community, 11% were considered to be appropriately prescribed or without error. The major error was the prescribing of these drugs for syndromes of known viral aetiology. Errors were also frequent in relation to dosage, duration and choice of antimicrobial agents.

An evaluation of a structured case record in a paediatric department.

Two hundred and thirty-four paediatric medical records from August 1985 and 257 from August 1986, were evaluated and compared by criteria audit in order to assess the effects of the introduction of a structured admission form. The presence or absence of predetermined items of clinical relevance were recorded. A statistically significant improvement in the recording of 12 of 23 key items occurred following the introduction of a structured format. However, two of these items were recorded less frequently in the new notes. Changing working hours for house officers and an increase in overseas graduates had no significant influence on the results. Structured case records can improve information gathering, but careful design and reevaluation are important.

Single dose gentamicin treatment of urinary infections in children.

Sixty-nine children with urinary tract infections were randomly allocated to single dose gentamicin therapy (n = 39) or a seven day course of an appropriate antibiotic (n = 30). During the following six weeks the response to treatments did not differ and this was not altered by the child's clinical diagnosis, past history of infection or presence of radiological abnormalities. The poorest response was in those children with a history of recurrent infections (p less than 0.01) and/or radiological abnormality (p less than 0.02). Single dose therapy had significantly less suppression upon rectal (p less than 0.001) and periurethral (p less than 0.02) flora. There was a tendency for those not cured by single dose treatment to relapse whereas those treated by conventional therapy tended to be reinfected.

Bacterial meningitis in childhood: a 13 year review.

One hundred and forty-five episodes of acute bacterial meningitis in children seen over a 13 year period are reviewed. The mortality rate was 1.4%. Over the study period H influenzae type b remained as the dominant causative organism, with 11% of the isolates being beta-lactamase positive. The difficulties in diagnosis in children, the sequelae of sensorineural deafness and continued morbidity in this disorder are stressed.

A paediatric day ward: parental expectations, perceptions, and satisfaction.

OBJECT: to evaluate an acute paediatric day ward service from the parental perspective. METHODS: parental interview using structured questionnaire. RESULTS: overall satisfaction with the day ward concept and practice was high. Specific delays in the admission and management process were highlighted, as were concerns over practical issues such as parking facilities, pharmacy support, and perceived staff workload. CONCLUSIONS: the broad aims of the unit are being met. Areas for potential improvement are defined and discussed.

Ondansetron antiemetic therapy for chemotherapy and radiotherapy induced vomiting in children.

AIM: To evaluate ondansetron as the sole antiemetic in children treated with emetogenic chemotherapy and irradiation. METHODS: Fifteen children aged 3-11 years were studied. Seven had acute lymphoblastic leukaemia, two acute myeloid leukaemia, two lymphoma and four had other tumours. Ondansetron 5 mg/m2 IV or 4 mg by mouth was given immediately before chemotherapy or radiation treatment and continued eight hourly for 24 hours. Nausea and vomiting was assessed during treatment and for the next 48 hours, and graded using WHO criteria. RESULTS: Thirty-eight courses of chemotherapy were assessed, 27 severely emetogenic and 11 moderately emetogenic. Two included total body irradiation. The most severe nausea and vomiting was grade 2 (transient vomiting) reported in six children. Nausea and vomiting was abolished on subsequent courses in four of these children by increasing the ondansetron dose frequency to six hourly. The remaining children experienced no nausea or vomiting (n = 7) or only nausea (n = 2). Nausea and vomiting were each completely controlled in 27 courses. CONCLUSIONS: Ondansetron is a cost effective and safe antiemetic in children receiving chemotherapy and total body irradiation, minimises weight loss on treatment and enables outpatient chemotherapy in some cases.

Ceftriaxone for paediatric bacterial meningitis: a report of 62 children and a review of the literature.

AIM: The purpose of this prospective study was to document the efficacy of ceftriaxone in the treatment of childhood bacterial meningitis in a general paediatric unit. METHODS: All children presenting with bacterial meningitis to Christchurch Hospital between January 1987 and June 1991 were enrolled in this prospective study and received ceftriaxone 100 mg/kg/d for seven days. Outcome was defined by parameters including mean time to fever defervescence, prolonged fever, days in hospital, seizures, and other acute neurological sequelae, requirement for ventilation, mortality and morbidity. Audiology was performed at six weeks and again at three months if abnormal. Neurodevelopmental assessment was performed at three months. Side effects were recorded. RESULTS: There were 62 evaluable children. The mortality rate was 4.8% (3 children). Two children (3.4%) had clinically detectable neurological sequelae at the three month assessment. The mean duration of stay was 8.7 nights. Five children (8%) required ventilation. Mild self limiting diarrhoea occurred in 29%. CONCLUSIONS: Ceftriaxone is an effective, safe and well tolerated antimicrobial for the treatment of childhood meningitis. It compares favourably with other equipotent antimicrobials. With a relatively long half life once daily administration is possible with a cost advantage.

Anti-endomysial and anti-gliadin antibodies in screening for coeliac disease in children at greater risk of developing coeliac disease.

AIMS: To determine the prevalence of coeliac disease in selected groups of children presenting to a paediatric department. METHODS: Children presenting to the Paediatric Department at Christchurch Hospital were enrolled upon identification of one or more factors associated with increased risk of coeliac disease. All subjects were screened with anti-endomysial antibody and antigliadin antibody tests. Those children with positive tests underwent small bowel biopsy. RESULTS: 36 of 153 children had abnormal antibody tests. Seven (4.5%) of 34 children who underwent small bowel biopsies were found to have histological findings consistent with coeliac disease. Five of these children had presented with symptoms not classically ascribed to coeliac disease (failure to gain weight or non-specific abdominal pain). CONCLUSIONS: The possibility of coeliac disease should be considered in children with atypical symptoms and the diagnosis excluded by appropriate testing. Recognition of the variable presentations associated with coeliac disease in children is clinically relevant.

Acute respiratory tract infections of children in hospital: a viral and Mycoplasma pneumoniae profile.

Respiratory specimens and blood were collected from all infants and children admitted with acute respiratory illness to a paediatric unit in Christchurch from May to November (late autumn, winter and spring) 1983, to define the viral aetiological agents involved. A virus or Mycoplasma pneumoniae was identified in 160 (50%) of 317 children studied by the rapid indirect immunofluorescence, virus culture and/or serological techniques. Aetiological agents were detected in 71% of children with bronchiolitis, 57% with pneumonia, 53% with bronchitis, 40% with laryngotracheitis (croup), and 45% with upper respiratory tract illness. Respiratory syncytial virus was the most frequently identified virus, confirming the importance of this virus as a cause of respiratory illness requiring hospitalisation of young children in Christchurch. An epidemic due to influenza A/Dunedin/7/83 (HINI) and A/New Caledonia/4/83 (HINI) viruses occurred during the study period.

Acute epiglottitis in childhood, Christchurch 1970-84.

The case records of 31 children presenting to Christchurch Hospital with acute epiglottitis over the last 15 years have been reviewed. There has been a significant increase in incidence over this period (p less than 0.05). Despite generally classical presenting features the disease was recognised in only 26% of children when seen by general practitioners prior to admission. The increasing problem of ampicillin resistance to Haemophilus influenzae type b locally has resulted in a change in first line antibiotic therapy in recent years. Changes have also occurred in methods of airway management with elective nasotracheal intubation now the usual procedure.

Acute respiratory infection in childhood: the factors which influence hospital admission.

A study of 100 children admitted to hospital with acute respiratory infection revealed that general practitioners remain the major referral source. Changing financial factors do not appear to have influenced this process. Sixty percent of children had a mild illness, requiring a short period hospital stay, but their referral was on a medical rather than a social basis.

General practitioner prescribing practices for childhood respiratory infection.

Prescribing practices for respiratory infection during the first three years were studied in a birth cohort of Christchurch children. Of the 5630 consultations studied 39 percent were treated with antimicrobial therapy only, 23 percent by antimicrobials supplemented by other medication, 22 percent by other medication only and 16 received no medication. There were only 27 return consultations because of the iatrogenic effects of medication prescribed for respiratory infection and all of these involved adverse reactions to antimicrobial treatment. However, in no case did these reactions require further treatment other than withdrawing or changing the child's medication. The implications of the high rate of antimicrobial prescribing present for this sample are discussed.

Morbidity associated with gastrostomy placement in children demands an ongoing integrated approach to care.

AIMS: To evaluate the short and long term morbidity of gastrostomy insertion, and to identify ongoing management requirements. METHODS: A retrospective review was undertaken of the hospital casenotes of children aged up to fifteen years who had a gastrostomy placed in Christchurch over a six year period to March 1998. RESULTS: 42 children had a gastrostomy fashioned, 35 in the last three years of the period reviewed. The most common underlying diagnosis was neurological disease (48%), and the most common indication for tube placement was failure to feed orally. Complications were frequent but minor. Morbidity was related to local erythema and infection around the stoma (85 episodes in 23 children), persistent and major gastric fluid leakage (three episodes), and mechanical failure of the tube (21 episodes). Gastro-oesophageal reflux was seen in fourteen children, nine of whom had primary neurological disease. Complications were seen more after open gastrostomy than after percutaneous endoscopic placement (6.6:4.7). There was no mortality related directly to the gastrostomy tube or tube placement. CONCLUSIONS: An increase in the frequency of gastrostomy placements has been seen over this period. As the number of children with a gastrostomy increases, so too have the demands on medical and nursing staff to care for and manage the devices. The frequency of minor ongoing problems necessitates ongoing support of the child and care of the gastrostomy. A close working relationship between outreach nursing staff, stoma therapists and medical staff is required if morbidity is to be minimised. Education, audit and review remain important additional aspects of care.