Poisoning, stings and bites in children-- what is new? An experience from a tertiary care hospital in Kolkata.

Poisonings, stings and bites continue to be important cause of pediatric morbidity and hospitalization. The toxic product involved in the poisoning varies in different geographical areas and in same area over time. A retrospective study was conducted amongst the children of the age group up to 12 years admitted to a tertiary care hospital in Kolkata from January 2005 to December 2008. Total number of admissions was 17019 and that for accidental poisoning was 451 (2.65%). Kerosene constituted the largest group (54.55%). Mosquito coil and refill liquid were the new additions to the list of poisons and their ingestion was cause for admission of 15 (3.33%) children. The number of admissions due to stings and bites was 108 (0.63% of all admissions) during the above period. Of all the cases, 9 (1.83%) cases of accidental poisoning and 4 (3.7%) cases of stings and bites died.

Profile of pediatric dengue cases from a tertiary care hospital in Kolkata.

A study was conducted on the 52 serologically positive cases of dengue, admitted to the Dept. of Paediatrics, R.G. Kar Medical College & Hospital, from an outbreak in Kolkata. The most unusual feature observed in this study was that the rash in some cases was urticarial and intensely pruritic. The shock appeared early in the course of the disease and it was less commonly associated with bleeding (22%). One out of three dengue cases was a severe disease. It was not possible to predict a severe disease from the early symptomatology.

Circulating immune complexes in multiple sclerosis: relation with disease activity.

Two hundred fifty-four MS patients were studied for circulating immune complexes (CIC) by three different assays: Raji-RIA, Clq-PEG, and Conglutinin-BA. Thirty-five percent of the sera were positive by one or more of these tests; Raji-RIA had the highest sensitivity (29.4%). Incidence of CIC in acute relapse, progressive, remission, and stable state of MS was 33.3%, 30.2%, 26.1%, and 23.1%, respectively, by Raji-RIA, compared with 7.75% and 8.82% among normal and neurologic controls. The incidence of CIC in neurologic controls differed significantly from both acute relapse and progressive disease, and almost significantly from patients in remission. There was no significant difference between patients with stable MS and neurologic controls, and there was no association of CIC with HLA-B7.

Three polyethylene glycol dependent methods for the detection or circulating immune complexes in pathological sera: comparison with the Raji cell method.

A composite method using polyethylene glycol (PEG) and different markers for detecting circulating immune complexes (CIC) is described. The markers used are bovine conglutinin (RK-BA), C1q (C1q-BA) and IgG, IgM quantitation of PEG precipitate (RID-Ig). A composite scoring system is used in interpreting results from individual assays. The sensitivity of multiple PEG methods (MPM) was determined in 418 serum samples and compared with Raji cell assay in 204. Correlations between individual assays, viz., RK-BA-C1q-BA, RID-Ig and Raji cell test in several disease conditions including rheumatoid arthritis, glomerulonephritis, post-renal transplantation, maintenance haemodialysis, multiple sclerosis and normal pregnancies were computed. The relative discriminatory ability of a single PEG technique to differentiate normal from pathological sera in these disease states was observed in comparison with the composite PEG index. This index gives an improved assessment of abnormal sera, is simple and sensitive and has some advantages over biological techniques such as the Raji cell assay.U

A multicenter study of noncompliance with continuous ambulatory peritoneal dialysis exchanges in US and Canadian patients.

Recent evidence suggested that noncompliance (NC) with continuous ambulatory peritoneal dialysis (CAPD) exchanges may be more common in US than in Canadian dialysis centers. This issue was investigated using a questionnaire-based method in 656 CAPD patients at 14 centers in the United States and Canada. NC was defined as missing more than one exchange per week or more than two exchanges per month. Patients were ensured of the confidentiality of their individual results. Mean patient age was 56 +/- 16 years, 52% were women, and 39% had diabetes. The overall admitted rate of NC was 13%, with a rate of 18% in the United States and 7% in Canada (P < 0.001). NC was more common in younger patients (P < 0.0001), those without diabetes (P < 0.001), and employed patients (P < 0.05). It was also more common in black and Hispanic than in Asian and white patients (P < 0.001). NC was more common in patients prescribed more than four exchanges daily (P < 0.0001) but was not affected by dwell volume. On multiple regression analysis, the independent predictors of NC, in order of importance, were being prescribed more than four exchanges per day, black race, being employed, younger age, and not having diabetes. Being treated in a US unit did not quite achieve significance as a multivariate independent predictor. These findings suggest that NC is not uncommon in CAPD patients and is more frequent in US than in Canadian patients. However, country of residence is less powerful as a predictor of NC than a variety of other demographic and prescription factors.

Uric acid lithiasis associated with altered kinetics of hypoxanthine-guanine phosphoribosyltranferase.

1. A patient is described who had uric acid calculi which obstructed both kidneys. Serum uric acid was 34 mg/100 ml upon admission to hospital, and evidence of precipitation of uric acid in joints was obtained. 2. Total activity of hypoxanthine-guanine phosphoribosyltransferase in erythrocytes lysates from this patient was 44% of normal. Kinetic studies revealed that the apparent Michaelis constant of this enzyme for phosphoribosyl pyrophosphate was elevated 15-fold, while these values for hypoxanthine and guanine were in the normal range.

Antibodies to DNA in patients undergoing long-term hemodialysis.

It has been suggested that antibodies to native DNA occur with some frequency in patients treated by hemodialysis. This has been attributed to the use of the technique. We have investigated 48 patients on maintenance dialysis for the presence of antibodies to single stranded DNA (ss-DNA) and native DNA (n-DNA) compared to a control group of 25 nondialyzed patients with renal disease. In neither group of patients were antibodies to ss-DNA detected frequently. Antibodies to n-DNA were present in three of the dialyzed patients and in none of the control group. The frequency of antibodies in dialysis patients was insignificant in comparison to the same control group of non-dialyzed renal patients. There was no correlation between duration of dialysis and development of antibodies. A drug-induced lupus state is possible, but not established for two of the three patients on dialysis.

Myelin basic protein: a component of circulating immune complexes in multiple sclerosis.

Myelin basic protein (MBP) is an antigenic component of circulating immune complexes (CIC) in patients with multiple sclerosis (MS). Immune complexes were isolated from the sera by adsorption to Raji cells and then acid eluted. Final identification of MBP from Raji eluates was done by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) followed by MBP radioimmunoassay (RIA) of gel eluates and by an immunoblot technique.

Biofilms in peritoneal dialysis.

Microbial adhesions and biofilm bacterial growth have been implicated in serious infections associated with the use of bioprosthetic medical devices and indwelling catheters in humans. Biofilm bacterial growth also commonly occurs on peritoneal dialysis (PD) catheters from skin bacteria. Mature biofilms develop high antibiotic resistance and cause recurrent peritonitis and catheter loss in a subgroup of PD patients. That subgroup of patients can be identified by comparing the antibiotic sensitivities [minimum inhibitory concentrations (MICs)] of a biofilm culture and a routine microbiologic (planktonic) culture of the same PD effluent.

Use of streptokinase or urokinase in recurrent CAPD peritonitis.

In patients undergoing CAPD treatment, removal of peritoneal catheters has become a standard practice after two or more episodes of recurrent peritonitis which are refractory to antibiotic treatment. Immediate replacement of peritoneal catheters is not always safe in the presence of active peritonitis. Temporary institution of hemodialysis treatment in some of these patients may also be impossible because of unstable hemodynamic states or loss of vascular access sites. Successful continuation of CAPD treatment in some of these patients has been reported by using intraperitoneal (IP) administration of fibrinolytic agents such as streptokinase or urokinase as an adjunctive therapy to antibiotic treatment and as an outpatient procedure. Although numbers of cases reported are few in the literature and controlled studies in large numbers of patients are lacking, these reports emphasize the safety of IP use of these agents without any major systemic adverse effects. The reports are reviewed here to provide some practical guidelines for safe use of these agents in selected patients with recurrent CAPD-associated peritonitis.

Silver peritoneal catheters reduce bacterial colonization.

Bacterial colonization potentials by Staphylococcus aureus (Staph. aureus) were determined in silver peritoneal dialysis (PD) catheter materials and were compared to colonization of the same bacteria in silastic catheter materials. The bacteria were colonized in two different experimental systems: In Vitro: In an in vitro biofilm bacterial culture system with a modified Robbins' device (MRD), seven different clinical strains of Staph. aureus were grown in PD effluents on silver or silastic catheter discs, each 0.5 cm in diameter. In identical experimental conditions, reduced bacterial growth was detected in silver catheter discs compared to growth on silastic discs, but the results were not statistically different (p = 0.12). In Vivo: In a rabbit model of PD the, in vivo colonization potential of Staph. aureus was examined in two groups of rabbits using silver (n = 3) and silastic (n = 3) PD catheters. The exit sites of the PD catheters were inoculated with a single strain of Staph. aureus for six days, followed by PD for six days. The rabbits were then sacrificed. After sacrifice, comparison between the bacterial counts of identical segments of silver and silastic catheters showed that there had been a reduction in the growth of Staph. aureus in vivo on silver PD catheters, contrary to the increased growth on the silastic catheters (p < 0.05). Reduced bacterial growth on the silver PD catheters in vivo indicates that the release of silver in tissues over time cause antibacterial effects in vivo. Further in vivo experiments are needed before future clinical use of silver catheters in PD patients.

Catheter biofilms and recurrent CAPD peritonitis.

To study the significance of biofilm bacteria in CAPD peritonitis, in a preliminary study, we compared the growth of planktonic and biofilm bacteria by parallel cultures of the same PD effluent in 14 patients with CAPD-associated peritonitis. Planktonic bacteria were isolated by routine microbiologic culture techniques and biofilm bacteria by the use of a modified Robbins' device (MRD). Antibiotic sensitivity or MIC's of bacterial strains isolated by the two techniques were compared. This comparison of the IC identified a subgroup of patients who developed recurrent antibiotic resistant biofilm-induced peritonitis and their peritoneal catheters were subsequently removed.

Long-term survival and its relationship to membrane transport status in peritoneal dialysis.

We evaluated peritoneal membrane transport status (high, high-average, low-average, and low) of 35 patients on persistent peritoneal dialysis (PD) for 5-16 years. We noted that most of these patients (n = 21) had low-average transport by dialysate-to-plasma creatinine (D/PCr) ratio.

Rapid growth in the use of automated peritoneal dialysis (APD) in adult patients on peritoneal dialysis.

Inadequate dialysis dose is associated with poor patient-survival in peritoneal dialysis (PD). Most patients would require more than four exchanges a day after losing residual renal function. The use of automated peritoneal dialysis (APD) seems to be a practical way to provide extra dialysis for these patients. In our Dialysis Centre in Northern Alberta, we started to use APD for our adult patients only from 1993. When we evaluated our practice recently, we found that we are progressively increasing the use of APD (including cyclers and night exchange devices) from 3% to 21% for our total adult PD patients in the last 3 years. This increase in the use of APD is mostly to accommodate PD prescription changes and not changes in lifestyle. Increase in the use of APD was associated with decrease in the rate of our PD dropout to hemodialysis. We conclude that to maintain adequate dialysis, rapid growth of APD will become common in North American PD centers in the future and will reduce transfer to hemodialysis.

The effects of macrolide and quinolone antibiotics in methicillin-resistant Staphylococcus aureus biofilm growth.

Recent studies demonstrate that 14-membered macrolides increase permeability and destruction of Pseudomonas biofilms. The effect of a macrolide antibiotic, erythromycin, on methicillin-resistant Staphylococcus aureus (MRSA) biofilm on Silastic catheter materials in comparison with two different quinolone antibiotics, sparfloxacin (SPFX) and a new quinolone, SYN 1193, was examined. Two different MRSA strains were grown in biofilm, using Mueller-Hinton broth with and without the addition of 10% pooled normal human serum (PNHS), in a modified Robbins device, at 37 degrees C for 24, 48, and 72 hours. Two different clinical MRSA strains were used and minimum bactericidal concentration (MBC) were determined at the time intervals mentioned. Three different dosages of each antibiotic were tested: 5.0, 20.0, and 50.0 micrograms/mL. In addition, a constant dosage of SPFX and SYN 1193, in combination with varying dosages of erythromycin, was tested under similar experimental conditions. SYN 1193 demonstrated the highest MBC in comparison to SPFX; addition of PNHS did not alter the effect of SYN 1193. However, erythromycin alone and in combination with SPFX and SYN 1193 had no effect on MBC. We conclude that (1) macrolide antibiotic erythromycin has poor MRSA biofilm permeability and killing in comparison to SPFX and SYN 1193, and (2) SYN 1193 had the highest MBC to MRSA biofilm.

Significant reduction of peritonitis rate by the use of Twin-bag system in a Canadian regional CAPD program.

In a regional CAPD program in Northern Alberta, Canada, the peritonitis rates among patients undergoing CAPD treatment were quite high: 1/8.3 and 1/7.4 per patient month from a population of 75 and 76 patients in 1989 and 1990 respectively. Our patient population is comprised of different ethnic groups, separated widely from the dialysis centre; over half of them are above the age of 60 years. As it is not possible to change the patient characteristics in our centre, we switched to the Twin-bag disconnect system in 83 out of a total of 103 patients in 1991. With this change our overall peritonitis rate has significantly improved to 1/14 per patient months and 1/17 per patient months in patients using the Twin-bag system. This improvement in the peritonitis rate has occurred without any change in our patient characteristics. We find the improvement in our peritonitis rate is due to the use of the new Twin-bag system, which provides total disconnection with no spikes and thereby reduces peritonitis due to touch contamination.