Aetiology and outcome of severe community-acquired pneumonia in children admitted to a paediatric intensive care unit.

OBJECTIVE: To determine the aetiological agents and outcome of severe community-acquired pneumonia (SCAP) in children admitted to the paediatric intensive care unit (PICU) at Kalafong Hospital, Pretoria. PATIENTS AND METHODS: An audit was done after a protocol was implemented to identify the aetiological agents in children with life-threatening SCAP admitted to the PICU from the emergency room. The following investigations were done as per protocol: blood culture, culture of the tracheal aspirate, immunofluorescence and culture of the nasopharyngeal aspirate, microscopy and culture of the gastric juice for Mycobacterium tuberculosis, and determination of HIV status. The following data, documented prospectively, were obtained from patient records: date of admission, age, gender, weight, duration of ventilation, duration of stay in the PICU, survival or death, and severity of illness as determined by means of the score for acute neonatal physiology (SNAP) or paediatric risk of mortality (PRISM) score depending on the child's age. RESULTS: Twenty-three children were admitted over a 1-year period (1 November 1994-30 October 1995). Their median age was 10 weeks (range 2 weeks-5 years) and the sex distribution was equal. Two children were HIV-infected. Twenty children received mechanical ventilation for a median period of 6.5 days (range 2-16 days). Aetiological agents were identified in 15/23 children (65%). Respiratory syncytial virus (RSV) was the most common pathogen, identified in 7/23 children, Klebsiella pneumoniae was the most common bacterial pathogen, identified in 5 children (2 blood cultures and 3 tracheal aspirates). Tuberculosis was not diagnosed. The mean PRISM score was similar in survivors and children who died. The case fatality rate was 30%. The 7 children who died had a median arterial oxygen tension/fraction of inspired oxygen (PaO2/FiO2) ratio of 94 (range 32-111) and the 16 survivors had a median ratio of 146 (range 51-252) (P = 0.01) on admission. Both HIV-infected children died and postmortem examination showed a pneumonia due to Pneumocystis carinii and cytomegalovirus. CONCLUSIONS: SCAP occurs in very young children. One or more pathogens were isolated in 65% of cases. Viral pathogens predominated, with RSV being the most common. The yield of positive blood cultures was low at 17%. Streptococcus pneumoniae and Haemophilus influenzae were not found. The case fatality rate was 30% and death was more likely with a low PaO2/FiO2 ratio on admission.     

Maxillary sinus puncture and culture in the diagnosis of acute rhinosinusitis: the case for pursuing alternative culture methods.

OBJECTIVE: Traditional assessments of the microbial flora associated with acute bacterial rhinosinusitis have relied on maxillary sinus punctures (taps) and culture. These taps are now considered the gold standard for obtaining cultures and are used as the method of identifying bacterial pathogens in antimicrobial trials. Maxillary sinus taps are limited by discomfort to the patients and technical concerns. Because of these factors, the standard of performing taps has limited antibiotic trials and microbial surveillance. Alternatives to maxillary sinus taps have been explored. STUDY DESIGN: We conducted a retrospective, systematic review of the literature from 1950 to 2000 of articles comparing culture techniques in the nose and paranasal sinuses for acute bacterial rhinosinusitis. RESULTS: Nasal cultures have poor correlation to maxillary sinus cultures, whereas there is 60% to 85% concordance between endoscopically guided middle meatal cultures and maxillary sinus cultures. These studies, however, are all limited by small sample sizes and therefore are inadequate to make any concrete recommendations regarding the relative role of endoscopically guided middle meatal cultures as a formal method of pathogen identification in acute bacterial rhinosinusitis. CONCLUSION: A formal prospective study with sufficient sample size to assess the concordance between the microbial flora of the maxillary sinus punctures and middle meatal cultures in acute rhinosinusitis is recommended.     

No impact of repeated endoscopic screens on gastric cancer mortality in a prospectively followed Chinese population at high risk.

BACKGROUND: Gastric cancer (GC) is the leading cause of cancer deaths in China. Our study prospectively evaluated the impact of repeated endoscopic screens on GC mortality in a high-risk population in China. METHODS: Between 1989 and 1999, a population-based gastroscopic screening was conducted in 4,394 residents of Linqu County, China, a region with the highest rates of GC worldwide. Residents ages 35 to 64 years received initial gastroscopies with biopsies in 1989. Repeated endoscopies were performed in 1994 and 1999. Cancer occurrences and deaths were actively monitored throughout the entire period until July 2000. Mortality from GC was compared with expected values based on mortality rates obtained for Linqu in the 1990-1992 Chinese Cancer Mortality Survey. RESULTS: Between March 1989 and July 2000, 39,303 person-years were accumulated; 85 new GCs occurred, 29 (34.5%) were in early stage. Fifty-eight cases (68%) were identified at one of the screens. The number of observed deaths from GC (37) was close to the expected (36.8). The standardized mortality ratio was 1.01 (95% CI 0.72-1.37) for the entire cohort, 1.13 (95% CI 0.77-1.57) for males, and 0.65 (95% CI 0.26-1.32) for females. CONCLUSIONS: Despite high population coverage with repeated screens, no reduction in GC mortality was observed in this high-risk population in China.     

Enteritis necroticans in Port Moresby--report of three cases

Three cases of enteritis necroticans seen at Port Moresby General Hospital are described. All three cases proved diagnostic problems and in all three the diagnosis was made only at laparotomy. While the condition is uncommon in Port Moresby, these cases indicate that it must now be considered earlier rather than later.     

Primary papillary serous cystadenocarcinoma of broad ligament

A rare case of an advanced primary broad ligament carcinoma is discussed, with a review of the literature regarding its incidence, presentation and management. This patient showed a complete response to adjuvant cisplatin-based chemotherapy following panhysterectomy and is presently without any evidence of disease, 15 months after completion of her treatment.     

Changes in outcome with sphincter preserving surgery for rectal cancer in Korea, 1991-2000.

AIM: To report the clinical and oncological data of patients operated on for rectal cancers 3-5 cm from the AV over a 10 year period, including the Sphincter preservation (SP) rate. METHODS: We reviewed medical records of 304 patients with rectal cancers 3-5 cm from the AV who underwent surgical resection from January 1991 through December 2000. The 10 years were divided into three periods based on the introduction of new surgical techniques, specifically, ultralow anterior resection (ULAR) with double stapling in March 1994 and ULAR with coloanal anastomosis in April 1997. The rates of SP, complications and patient survival during these periods were compared. RESULTS: The SP rate increased significantly over the 10 years, from 16.4% in period I (January 1991-February 1994), to 53.0% in period II (March 1994-March 1997), to 86.5% in period III (April 1997-December 2000) (p<0.001). Over time, the age of the patients increased (p=0.004), the length of the distal resection margin became shorter (p=0.005), and the rate of lymph node metastasis increased (p=0.016). The factors significantly influencing SP were the period (p<0.001) and the distance from the AV (p<0.001). Over time, morbidity did not increase, and overall and disease free survival rates did not decrease. In contrast, the overall survival of N2 cases significantly increased over time (p=0.0492). CONCLUSION: Over 10 years, the SP rate in rectal cancers 3-5 cm from the AV was significantly increased by the introduction of the double stapling and coloanal anastomosis techniques. These surgical methods, however, had no effect on morbidity, disease free survival and overall survival rates.     

Angiotensin I conversion and coronary constriction by angiotensin II in ischemic and hypoxic isolated rat hearts.

Dose-response curves of angiotensin I (AI, 1.0-1000.0 pmol) and angiotensin II (AII, 1.25-1250.00 pmol) were obtained in isolated rat hearts subjected to control conditions, mild hypoxia (PO2 = 145 mm Hg), reoxygenation, ischemic (perfusion pressure = 35 mm Hg) and reperfusion. Both AI and AII caused dose-dependent coronary flow (CF) of 26 +/- 3 and 27 +/- 2%, respectively. The effects of both AI and AII were substantially attenuated during hypoxia, but were fully restored upon reoxygenation. During ischemia, the effect of AII was unaltered while the effect of AI was enhanced compared to the control (P less than 0.05). This enhancement was reversible on reperfusion. Cardiac conversion of AI, calculated from ED50 values for AI and AII, was significantly increased during ischemia (P less than 0.05). Infusion of saralasin (0.5-5.0 micrograms/min) did not increase CF in any of the groups. We conclude that (1) the coronary vasoconstrictive effect of AII is preserved in ischemia but attenuated in hypoxia and (2) cardiac conversion of AI to AII is enhanced in hearts injured by ischemia.