Management of Lithuanian children's acute diarrhoea with Gastrolit solution and dioctahedral smectite

OBJECTIVE: Acute gastroenteritis represents a major cause of morbidity and mortality worldwide among children, and rehydration treatment has been one of the cornerstones in the management strategy. The natural clay dioctahedral smectite (Smecta) increases intestinal barrier function and is effective against infectious diarrhoea in children. The purpose of this work was to compare the efficacy and tolerance of Lithuanian children's diarrhoea treatment with dioctahedral smectite combined with hypotonic oral rehydration solution (ORS)--Gastrolit--versus Gastrolit alone to establish the influence of Smecta on serum electrolyte balance in young children with diarrhoea and mild or moderate dehydration. METHODS: Smecta combined with ORS (study group) and ORS alone (control group) were evaluated in a multicentre, open, randomized trial in 54 children aged 6-48 months hospitalized for acute diarrhoea (mostly rotavirus aetiology) and signs of mild and moderate dehydration. The main outcomes examined were duration of diarrhoea, fever, number of vomiting episodes, and serum electrolyte balance before and after treatment. RESULTS: The mean duration of diarrhoea was significantly shorter in the study group (42.3 +/- 24.7 h) than in the control group (61.8 +/- 33.9 h). No side effects of Smecta were observed. The changes of sodium, potassium, chloride and calcium concentrations after treatment were minimal and in the normal range. CONCLUSIONS: Smecta significantly reduced the duration of diarrhoea, was safe and well tolerated, and had no impact on the adsorption of electrolytes. Smecta could be used together with ORS in children suffering from acute gastroenteritis (without uncontrollable vomiting) with mild and moderate dehydration.     

Effective treatment of diarrhoeal dehydration with an oral rehydration solution containing citrate

To compare the clinical efficacy of oral rehydration salts (ORS) from effervescent tablets containing citrate with the WHO recommended ORS for the treatment of dehydration due to acute diarrhoea, a randomized clinical trial was carried out in 57 adults and 58 children. These patients had mild or moderate degrees of dehydration and acidosis due to acute watery diarrhoea that was caused by enterotoxigenic Escherichia coli in 43-47% of the cases. Efficacies were compared by measuring oral fluid intake, stool output, gain in body weight, decrease in serum specific gravity and correction of acidosis during treatment. Successful rehydration and maintenance of hydration was achieved in 25 adults and 24 children treated with citrate containing ORS and 25 adults and 24 children treated with WHO ORS. The mean intake of ORS/kg body weight in children receiving WHO ORS was greater (p less than 0.05) and correction of acidosis was faster than the citrate group during the initial 24 h of therapy (p less than 0.05). By 48 h, however, both groups showed satisfactory and comparable intake of ORS and correction of acidosis. Thus ORS from effervescent tablets containing sodium citrate base is effective for management of diarrhoea in both adults and children and is a convenient stable form of ORS for use in the home and for travelers.     

Hyponatraemia in acute heart failure is a marker of increased mortality but not when associated with hyperglycaemia

Previous studies suggest that hyponatraemia is a marker of neurohormonal activation and increased mortality in patients with acute heart failure (AHF). Although diabetes is a common co-morbidity in heart failure, no prior study has considered the impact of serum glucose on this relationship. METHODS: Over four consecutive months we prospectively registered all patients admitted due to AHF. Sodium and glucose levels were determined immediately upon admission. Patients were followed through admission and for the next 6 months. Of 342 patients enrolled, complete data were available for 331 patients. RESULTS: Hyponatraemia (sodium <135 mmol/L) was detected in 22% of patients. However, 47% of patients with hyponatraemia had concomitant hyperglycaemia (glucose level >11 mmol/L). Hyponatraemia was associated with increased 6-month mortality (21 vs. 8%, p=0.002). This association was restricted to patients who had hyponatraemia without concomitant hyperglycaemia. The 6-month mortality of patients with and without hyponatraemia was 11% versus 10% (p=0.87) when hyperglycaemia was present versus 29% and 7% (p<0.001) when hyperglycaemia was absent. CONCLUSIONS: In this preliminary study, hyperglycaemia-associated hyponatraemia was present in a significant proportion of patients admitted with AHF. In patients with hyperglycaemia, hyponatraemia had no prognostic significance, whereas in patients without hyperglycaemia, hyponatraemia remained a powerful predictor of mortality. These results need confirmation in a larger study.     

Rotavirus infections in paediatric oncology patients: a matched-pairs analysis

OBJECTIVE: To conduct a systematic investigation of the clinical relevance of rotavirus infection in the setting of paediatric cancer patients receiving intensive chemotherapy. MATERIAL AND METHODS: Twenty-eight paediatric cancer patients with positive rotavirus antigen tests were eligible for a retrospective case-control study (January 1995-December 2004). Rota-positive patients were compared with 28 rota-negative patients matched for age, underlying disease and chemotherapy. The National Cancer Institute Common Toxicity Criteria were used to determine clinical severity. RESULTS: Median duration of rota-related symptoms (diarrhoea, fever and vomiting) was 7 days (range 4-34 days; 75th percentile 9 days). Median duration of viral shedding was 17 days (4-73 days; 75th percentile 39.5 days). The rota infection was nosocomially acquired in 19 patients (68%). The proportions of patients with diarrhoea > or =NCI II, fever >39 degrees C, clinically relevant dehydration, metabolic acidosis, mucositis and neutropenia were significantly higher in rota-positive patients. Rota-positive patients tended to have a prolonged period of hospitalization (median 8 versus 4 days; p=0.008). A higher proportion of rota-positive patients had to receive parenteral nutrition and tube feeding (p<0.001). CONCLUSIONS: Rotavirus is a clinically relevant but preventable pathogen in paediatric cancer patients, since many cases seem to be nosocomial in origin. Rapid microbiological testing and contact precautions should be strictly applied to any symptomatic patient and to their immediate contacts. Prolonged viral shedding in immunocompromised paediatric patients necessitates repeated testing in order to determine the duration of isolation.     

Efficacy of measuring BUN in assessing children with dehydration due to gastroenteritis

We conducted a prospective study of 50 consecutive cases of children with gastroenteritis and dehydration to assess the correlation of alterations in the blood urea nitrogen (BUN) concentration. Symptoms included 24 children with vomiting and 26 with vomiting and diarrhea. All children were estimably dehydrated-appearing on examination by traditionally used criteria and had metabolic acidosis (serum bicarbonate concentration of less than 20 mEq/L) and increased anion gap (more than 12 mEq/L). Of these 50 children, 44 (88%) had a BUN concentration within the limits of normal--17 were less than or equal to 10 mg/dL, 17 were between 11 and 14 mg/dL, and ten were between 14 and 18 mg/dL. We discuss the physiologic factors that influence the BUN concentration in conditions of dehydration. Although commonly used, measurement of the magnitude of the BUN concentration is not an accurate method for assessing the hydration status of children with dehydration due to gastroenteritis.     

Diagnosis and treatment of pancreatic islet cell tumors producing vasoactive intestinal polypeptide (VIPoma)

The incidence of VIPoma is approximately one per 10 million population. Thus in the Czech Republic this rare disease should be diagnosed once per year. The authors present their experience with the diagnosis and treatment of patient born in 1956, who suffered since 1990 from diarrhoea, at first episodically. In 1992-1994 the diarrhoea was profuse, caused dehydration, hypokalaemia and severe metabolic acidosis without an increase of the anion gap. As a result of dehydration the patient developed acute renal insufficiency. Due to hypokalaemia he developed paroxysmal atrial fibrillation. The diagnosis was based on the clinical finding and later confirmed on laboratory examination by a high VIP serum concentration. For treatment of diarrhoea Sandostatin was used. The tumour was located only after a scan with 123I-VIP in the cauda of the pancreas. Scintigraphy with labelled octreotide, similarly as other imaging methods (sono, X-ray and CT) were not effective. In 1994 left-sided hemipancreatectomy was performed. Although the patient was operated four years after the onset of the disease, no secondaries were detected. After surgery the diarrhoea stopped and no further treatment was necessary.     

Rotavirus disease in Finnish children: use of numerical scores for clinical severity of diarrhoeal episodes

65 episodes of rotavirus diarrhoea, detected during a longitudinal follow-up of 336 infants from birth to 24-32 months of age, were analyzed for clinical symptoms. Rotavirus gastroenteritis was characterized by watery diarrhoea, vomiting (particularly in older children), fever and dehydration. A 0-20 point numerical score was devised according to the distribution of clinical features in the patients. Using this system, the mean severity score for the 65 episodes of rotavirus diarrhoea was 11.0 +/- 3.7 as compared to 5.6 +/- 3.2 for the 183 episodes of non-rotavirus diarrhoea in the same population (p less than 0.0001, t-test). The 20 point score is proposed for analysis of efficacy studies of candidate rotavirus vaccines.     

McKittrick-Wheelock syndrome: a rare cause of diarrhoea

McKittrick-Wheelock syndrome is a rare disorder caused by fluid and electrolyte hypersecretion from a rectal tumour. The most frequently reported tumours are villous adenomas. Dehydration with severe hyponatremia, hypokalemia, metabolic acidosis, acute renal failure and watery diarrhoea is typical. The authors present a case of McKittrick-Wheelock syndrome caused by rectal adenocarcinoma.     

Metabolic alkalosis contributes to acute hypercapnic respiratory failure in adult cystic fibrosis

BACKGROUND: and study objectives: Patients with end-stage cystic fibrosis (CF) develop respiratory failure and hypercapnia. In contrast to COPD patients, altered electrolyte transport and malnutrition in CF patients may predispose them to metabolic alkalosis and, therefore, may contribute to hypercapnia. The aim of this study was to determine the prevalence of metabolic alkalosis in adults with hypercapnic respiratory failure in the setting of acute exacerbations of CF compared with COPD. DESIGN: Levels of arterial blood gases, plasma electrolytes, and serum albumin from 14 consecutive hypercapnic CF patients who had been admitted to the hospital with a respiratory exacerbation were compared with 49 consecutive hypercapnic patients with exacerbations of COPD. Hypercapnia was defined as a PaCO(2) of > or = 45 mm Hg. RESULTS: Despite similar PaCO(2) values, patients in the CF group were significantly more alkalotic than were those in the COPD group (mean [+/- SD] pH, 7.43 +/- 0.03 vs 7.37 +/- 0.05, respectively; p < 0.01). A mixed respiratory acidosis and metabolic alkalosis was evident in 71% of CF patients and 22% of COPD patients (p < 0.01). The mean concentrations of plasma chloride (95.1 +/- 4.9 vs 99.8 +/- 5.2 mmol/L, respectively; p < 0.01) and sodium (136.5 +/- 2.8 vs 140.4 +/- 4.5 mmol/L, respectively; p < 0.01) were significantly lower in the CF group, and the levels of serum albumin were significantly reduced (27.4 +/- 5.8 vs 33.7 +/- 4.8 mmol/L, respectively; p < 0.01). CONCLUSION: Metabolic alkalosis contributes to hypercapnic respiratory failure in adults with acute exacerbations of CF. This acid-base disturbance occurs in conjunction with reduced total body salt levels and hypoalbuminemia.     

Oral rehydration therapy: efficacy of sodium citrate equals to sodium bicarbonate for correction of acidosis in diarrhoea.

Forty patients with moderate degrees of dehydration and acidosis because of acute watery diarrhoea were successfully treated randomly with either WHO recommended oral rehydration solution containing 2.5 g sodium bicarbonate or an oral solution containing 2.94 g sodium citrate in place of sodium bicarbonate per litre of oral rehydration rehydration solution. Efficacies were compared by measuring oral fluid intake, stool and vomitus output, change in body weight, hydration status, and rate of correction of acidosis during a period of 48 hours. Seventy five per cent (21 cases) in the citrate group and 83% (19 cases) in the bicarbonate group were successfully rehydrated (p greater than 0.05). There were no significant differences in intake, output, gain in body weight, fall in haematocrit and plasma specific gravity, and correction of acidosis between the two groups of patients within 48 hours after initiation of therapy. The solution with sodium citrate base was as effective as WHO-oral rehydration solution for management of diarrhoea. This study shows the efficacy, safety, and acceptability of citrate containing oral rehydration solution for rehydration and correction of acidosis in diarrhoea.     

ORIGINAL ARTICLE: Severe hyponatraemia in elderly hospitalized patients: prevalence,aetiology and outcome

Background: Hyponatraemia is the commonest electrolyte disorder in the elderly. Data on severe hyponatraemia and the prevalence of cerebral salt wasting syndrome (CSWS) in elderly hospitalized patients are lacking. We studied the incidence, frequency of various aetiologies, outcome and the possible role of CSWS in severe hyponatraemia in elderly medical patients. Methods: A prospective, observational, non‐interventional study conducted over a 5‐month period in medical wards. Eighty‐six patients aged over 65 years with serum sodium levels ≤125 mEq/L were included. All patients were examined by one of the authors, who also evaluated potential contributing factors. Demographic, clinical and outcome data were extracted from the medical records. Results: The mean age of the patients was 82.1 + 8.7 years. The prevalence of hyponatraemia was 6.2% (8.1% women and 4.0% men (P < 0.001)). There was no increase in incidence of hyponatraemia with age. The leading cause of hyponatraemia was the syndrome of inappropriate antidiuretic hormone secretion (SIADH), whose aetiology could be determined in only 46% of cases. Aetiology was multifactorial in 51% of patients (1.7 aetiological factors per patient). All patients with thiazide‐induced hyponatraemia had other contributing factors. Hyperglycaemia and hypoalbuminaemia were predictors of neurological manifestations of hyponatraemia. Overall in‐hospital mortality was 19%. Only hypoalbuminaemia was found as an independent risk factor for death. In none of the patients was the hyponatraemia due to CSWS. Conclusion: Severe hyponatraemia in elderly hospitalized medical patients is more frequent in women and of multifactorial aetiology in 50% of cases. It is most commonly caused by SIADH; CSWS is an unlikely cause.     

Mediastinal ganglioneuroblastoma-secreting vasoactive intestinal peptide causing secretory diarrhoea

In this case report we describe a case of mediastinal ganglioneuroblastoma-secreting vasoactive intestinal peptide (VIP), causing secretory diarrhoea in an 18-month-old child.An 18-month-old girl presented with a 2-month history of diarrhoea, abdominal distension and weight loss. Investigations revealed secretory diarrhoea with hypokalaemia, hyponatraemia and hypochloraemia and metabolic acidosis. Her stool output was 2.5–3.l day^?1 with increased stool sodium. VIP levels were strikingly high with normal glucagon and gastrin levels. X-ray of the chest revealed a well-defined mass in the right upper zone with tracheal shift, which was confirmed with computed tomography (CT) of the chest. The mass was resected and the patient became asymptomatic.This case shows that secretory diarrhoea caused by VIP and produced by ganglioneuroblastoma indicates a favourable prognosis, provided it is resectable.     

Acute liver failure in under two year-olds - are there markers of metabolic disease on admission?

Introduction. The early establishment of an etiology for acute liver failure (ALF) in infants is essential for the start of adequate treatment in the shortest timeframe possible. Aim. To identify markers of inherited metabolic disease on admission in children under two years of age with ALF.Material and methods. A retrospective review of the medical records of all children (< 2 years old) with ALF admitted to the pediatric hepatology or intensive care units of a tertiary center over a twenty-three year period (January 1989 to December 2011) was done. Patients were divided into two groups: with (group A) or without (group B) a metabolic etiology. Clinical and laboratory parameters on admission were compared.Results. Twenty-three children met inclusion criteria. Twelve had ALF of metabolic origin (group A). The median age in this group was 2.25 (Q1-Q3: 0.63-4.65) months and in group B 8.0 (Q1-Q3: 1.5-15) months. History of failure to thrive and/or vomiting was more frequent in group A (p = 0.022). Age, gender, encephalopathy and left ventricular hypertrophy were similar in both groups (p = 0.147, p = 1.000, p = 0.637, p = 1.000, respectively). Laboratory tests on admission (plasma lactate, ammonia, cholesterol, phosphate, INR, glucose, bilirubin, ALT, base excess and the presence of reducing substances in urine) showed no statistically significant differences between groups.Conclusion. This study showed that although infants with inborn errors of metabolism showed a trend towards lower age at presentation, the only marker of inherited metabolic disease found on admission was history of vomiting and/or failure to thrive.     

Yam bean seed poisoning mimicking cyanide intoxication

Background: Yam bean is a common food in southern Taiwan. However, its seeds are rarely consumed. We describe five patients of yam bean seed poisoning in Taiwan, one of them life‐threatening. Clinical presentation: The five patients presented with perioral numbness, nausea and vomiting after eating a same soup made from yam bean seeds. One of them, a 54‐year‐old woman, had difficulty breathing and lost consciousness. Physical examination showed dilated pupils and coma with no focal neurological signs. The initial blood pressure was normal. Laboratory data showed a severe anion gap metabolic acidosis, with a serum lactate level of 185 mg/dL. An initial diagnosis of cyanide intoxication was considered and she was given sodium nitrite and sodium thiosulfate i.v. Hypotension ensued shortly afterwards and pulmonary artery catheterization showed a decreased cardiac index. Aggressive fluid and inotropic therapy were given and the patient eventually recovered. The other four patients suffered only minor gastrointestinal and neurological symptoms and received supportive treatment. Cyanide levels were negative in all five patients. Conclusion: Yam bean seed poisoning can cause acute metabolic acidosis and altered mental status, which could be confused with acute cyanide intoxication from a cyanogenic glycoside‐containing plant. To our knowledge, this is the first outbreak of yam bean seed poisoning reported in the English published work.     

Clinical relevance of hyponatraemia for the hospital outcome of cirrhotic patients

BACKGROUND: Hyponatraemia frequently develops in cirrhotic patients whose ability to excrete free water is impaired. The role of hyponatraemia in the prognosis of such patients is unclear. AIM: To evaluate prevalence, clinical associations and prognostic impact of hyponatraemia in cirrhotic inpatients. PATIENTS: A series of 156 cirrhotic patients consecutively admitted to our department, for a total of 191 admissions, were studied. METHODS: Serum sodium levels were determined at admission and repeated at least weekly in all patients. The clinical status and the survival of patients with hyponatraemia (< or = 130 mmol/l) were compared to those of patients with normal sodium levels. RESULTS: Hyponatraemia was found in 57 out of 191 admissions (29.8%). Bacterial infections, ascites, chronic diuretic therapy, but not gastrointestinal bleeding or renal failure, were more frequent in patients with hyponatraemia than in those with normal sodium levels. In 3 cases, none of these conditions were present and hyponatraemia was defined as "spontaneous". Hospital death rate was increased in patients with hyponatraemia (26.3% versus 8. 9%, chi2=8. 55, p=0.003). By multivariate analysis, the only parameters independently associated with survival were high serum bilirubin (p=0.006) and high serum urea levels (p=0.019). Twenty-five patients developed severe hyponatraemia (<125 mmol/l) during hospital stay. This event was associated with a concomitant bacterial infection in 21 cases. The mortality rate of these patients was very high (48%). CONCLUSIONS: Hyponatraemia is frequent in cirrhotic inpatients. It is seldom a spontaneous event but rather occurs in association with ascites, chronic use of diuretics or bacterial infections. It is a negative prognostic factor associated with increased short-term mortality.     

The characteristics of metabolic acidosis in aged patients with chronic renal failure

The present study was designed to clarify the characteristics of metabolic acidosis in aged patients with chronic renal failure. The subjects consisted of ambulatory cooperative patients (19 males and 18 females). Their values of creatinine clearance (Ccr) varied from 6.8 to 107.5 ml/min/1.73 m2. The relationship of Ccr to acid-base and electrolyte disturbances was investigated. The estimations of normal values in acid-base and electrolyte composition were based on the method of Hoffmann. The results are summarized as follows: 1. A high incidence of metabolic acidosis was demonstrated in patients whose Ccr values were below 20 ml/min/1.73 m2. 2. A significant positive correlation of Ccr values and plasma levels of bicarbonate (p less than 0.001) and a significant inverse correlation of Ccr values and serum levels of chloride (p less than 0.01) were observed. 3. The values of the anion gap did not change, irrespective of Ccr values. 4. Serum concentrations of potassium were inversely correlated with plasma levels of bicarbonate (p less than 0.01). Hyperchloremic normal anion gap acidosis with hyperpotassemia was the characteristic feature of metabolic acidosis in aged patients with chronic renal failure. The normal anion gap could be explained by normophosphatemia or mild hyperphosphatemia, even in the patients with advanced renal failure.     

The epidemiological and clinical characteristics and nutritional development of infants with acute diarrhoea, in north-eastern Brazil

In order to assess the epidemiological and clinical characteristics and changing nutritional status of infants suffering from acute diarrhoea, 103 infants with such diarrhoea and the same number of age-matched controls were investigated at the Universidade Federal do Rio Grande do Norte's Paediatric Hospital, in north-eastern Brazil. Each child with diarrhoea was given oral rehydration or, in the severe cases, intravenous rehydration. Each subject was checked for enteropathogens and his or her weight, height and weight-for-height, weight-for-age and height-for-age Z-scores were evaluated immediately after any clinical dehydration had been corrected and 30 days later. In the infants aged <6 months, a diet that included foods other than breast milk (odds ratio=9.41), including one in which breast milk was supplemented with other foods (odds ratio=4.69), was found to be statistically associated with diarrhoea. The enteropathogens found most commonly in the children with diarrhoea were rotavirus (36.9%), enteropathogenic Escherichia coli (11.6%) and Shigella (11.6%). Just four (5.2%) of the 77 cases with adequate follow-up showed persistent diarrhoea. At presentation or as soon as any clinical dehydration had been corrected, the infants with diarrhoea had significantly lower weights and weight-for-height and weight-for-age Z-scores than the controls. Thirty days later, however, the weight-for-height and weight-for-age Z-scores of the cases had increased significantly, to the point when they were not significantly different from the baseline values for the controls. The negative consequences of diarrhoea on weight-for-height and weight-for-age Z-scores and the recovery of these parameters after 30 days with rehydration reflect the acute but reversible influence of diarrhoea on infant nutritional status.     

Evaluation of simple laboratory investigations to predict fatal outcome in infants with severe malnutrition presenting in an urban diarrhoea treatment centre in Bangladesh

Objective To evaluate rapid and simple laboratory investigations to predict fatal outcome in infants presenting with diarrhoea and severe malnutrition. Method Retrospective chart analysis of infants with severe malnutrition and diarrhoea with (cases) and without fatal outcome (controls) admitted to the Special Care Ward in Dhaka Hospital at ICDDR,B between May 2005 and April 2006. All infants (n = 61) who underwent bedside blood glucose, full peripheral blood count, serum C‐reactive protein (CRP), and serum electrolyte tests were included. Results In logistic regression analyses, after adjusting for all available potential confounders (abnormal WBC count, higher CRP level, hyponatraemia, hypokalaemia, hypocalcaemia, and hypomagnesaemia), cases (n = 10) were significantly associated only with hypoglycaemia (measured using a portable bedside finger blood glucose test) (odds ratio 5.0, CI 1.1–23.0, P = 0.039) on admission. Conclusion A simple rapid bedside glucose test may be used to predict the outcome of diarrhoeal infants presenting with severe malnutrition.     

Significant metabolic acidosis induced by acetazolamide. Not a rare complication

Blood gas and serum electrolyte levels were measured in 27 elderly patients (mean age +/- SD, 63.3 +/- 13.5 years) who were receiving acetazolamide (250 to 1,000 mg/day) for glaucoma. Eleven glaucomatous patients (mean age, 69.1 +/- 7.4 years) who were not receiving acetazolamide served as a control group. In the acetazolamide-treated group, four patients (14.8%) had mild acidosis (7.29 greater than pH less than or equal to 7.31), ten (37%) had moderate acidosis (7.20 greater than pH less than or equal to 7.29), and one patient (3.7%) had severe acidosis (pH, 7.15). None of the patients in the control group had acidosis. It is concluded that moderate metabolic acidosis of potential clinical significance is common among glaucomatous elderly patients who receive acetazolamide. The exact clinical significance of our observations is yet to be determined.