Health care and its costs for children with perinatally acquired HIV infection

Objective : To describe survival patterns, use of health services and related costs for Australian children with perinatally acquired human immunodeficiency virus (HIV) infection.
Methodology : A retrospective cross-sectional survey was made of 20 children with HIV infection (91% of those diagnosed) and 13 children with maternal antibodies who subsequently seroreverted, treated at 10 medical centres. Details of disease progression and use of health services were obtained from hospital medical records. Monthly costs for three phases of infection were estimated by linking service usage rates with estimates of the unit cost of each service. The average lifetime cost was estimated by combining monthly costs and phase duration estimates from the literature.
Results : Patterns of disease progression were similar to those reported internationally, with a median survival of 8 years. Use, of health services increased with severity of illness. Mean monthly costs were $120 per month (1992 Australian dollars) for children with maternal antibodies who subsequently seroreverted, $320 per month for children with HIV infection but no acquired immunodeficiency syndrome (AIDS)-defining illness, and $1830 per month for children with AIDS. The present value of total lifetime cost for a child with HIV infection was $48174,46% of which was for treatment of AIDS.
Discussion : The mean lifetime cost for a perinatally infected child was just over half that for a man with HIV in Australia. Health service usage and costs were lower for Australian than American children with HIV.     

Molecular analysis of PKU in Ireland

Classical phenylketonuria (PKU: McKusick No. 261600) is caused by mutations occurring at the phenylalanine hydroxylase (PAH) locus on chromosome 12 and has a prevalence in Ireland of 1 in 4500. We examined 304 independent alleles from 350 patients for the presence of six mutations and have characterized VNTR alleles within the minisatellite region 3' to the PAH gene in patients carrying the most prevalent mutation. R408W was the most common mutation found, with a relative frequency of 42%. All other mutations had relative frequencies of <10%. VNTR analysis showed that the R408W mutation is associated with the VNTR-8 allele in the Irish population, indicating that R408W is associated with RFLP haplotype 1. This differs from that reported from eastern Europe where R408W is associated with RFLP haplotype 2/VNTR-3; an observation which has led several groups to propose a Balto-Slavic origin for this mutation. These results support the hypothesis of a second, independent founding event for the R408W mutation on an RFLP haplotype 1 VNTR-8 chromsome background in the Irish/Celtic population.     

Secretory diarrhea following a dog bite

Summary Overwhelming sepsis is rarely complicated by secretory diarrhea. We present a case of fulminant sepsis associated with dermatologic manifestations, disseminated intravascular coagulation (DIC), and a severe secretory diarrhea that has not previously been described. This followed a dog bite, and the patient was otherwise healthy. The combination of septic shock, skin lesions, and DIC occurring after a dog bite has been attributed to dysgonic fermentor 2 organisms, now calledCapnocytophaga canimorsus, but none were cultured in this case (7). Dysgonic fermentor-2 may be a new cause of secretory diarrhea and should be considered in the differential     

The incidence of septic arthritis in Malawian children

The incidence of septic arthritis in Malawian children was estimated by assessing the incidence in the relatively enclosed district of Chikwawa. We found an incidence of approximately one in 5,000 in the under-five age group and one in 13,000 in the 5–15 age group.

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Résumé La fréquence des arthrites septiques chez les enfants Malawiens a été estimée dans le district relativement clos de Chikwawa. Nous avons trouvé une fréquence dapproximativement 1 sur 5,000 dans le groupe de moins de 5 ans et 1 sur 13,000 dans la groupe de 5 à 15 ans.

     

Primary lung tumor mimicking acute type A aortic dissection

A 64-year-old man presented with clinical features and echocardiographic diagnosis of an acute type A dissection. He underwent median sternotomy for definitive surgical treatment. On external examination of the aorta, other intrapericardial structures, and the right lung, it was evident that the patient had an advanced lung tumor. This was confirmed by frozen-section and histopathologic examinations. Epiaortic scanning showed beyond doubt the presence of a mobile intraaortic mass that had misled us in making the preoperative diagnosis of an acute type A dissection.     

Venovenous extracorporeal membrane oxygenation for respiratory failure in inotrope dependent neonates

It is often stated that venovenous extracorporeal membrane oxygenation (VV ECMO) should not be used in inotrope dependent patients. It is our practice to use VV ECMO in most patients with respiratory failure even though many of these patients are receiving significant doses of inotropes. Our objective was to review the mode of ECMO in relation to precannulation doses of inotropes administered to neonates treated with ECMO for respiratory failure. Forty-three consecutive case notes were reviewed. Data were collected for basic demographic and ECMO parameters. Inotropic doses were converted to a single score for ease of comparison, with one point equivalent to 1 microg/kg/min dopamine. Forty-three neonates were studied; 37(86%) were treated with VV ECMO and 6 (14%) were treated with VA ECMO. Significant pre-ECMO inotropic support (score > 10) was present in 30 (70%) of the 43 cases. Of these patients, 26 were treated via VV ECMO with a survival rate of 84%, while 4 were treated with VA ECMO with a survival of 75%. Inotrope scores fell to nonsignificant levels (< 10) within 24 hours, regardless of ECMO mode. Mean arterial blood pressure remained above precannulation levels in both groups. VV ECMO allows safe treatment of neonatal respiratory failure in the presence of significant inotropic support. We recommend VV ECMO for neonatal respiratory failure in all cases except where double lumen cannulation is impossible or when septic shock is refractory to inotropic support (i.e., mean blood pressure < 35 mm Hg despite inotrope score of > 100).     

Carbon monoxide disposition and permeability-surface area product in the foetal circulation of the perfused term human placenta

In order to estimate the placental barrier to gas transfer, a novel carbon monoxide (CO) wash-in method was used to estimate the permeability-surface area (PS) product for the transfer of gas across the foetal circulation in the perfused human term placenta. The PS product for CO was 0.0096+/-0.006 ml/s/g or 0.012+/-0.007 ml/s/g using compartmental or Crone-Renkin analysis, respectively. Using this result and a published estimate of the placental capillary surface area, the permeability coefficient to CO across the foetal circulation was found to be approximately 4 x 10(-5)cm/s. This result is compatible with the hypothesis that the foetal circulation of the human placenta imposes a potentially significant barrier to gas transfer.     

A case of diphtheria in the Netherlands due to an infection with Corynebacterium ulcerans

A 58-year-old woman was admitted due to a pseudomembranous pharyngitis. The patient had not been vaccinated against diphtheria. Corynebacterium ulcerans was cultured from a throat swab. The production of diphtheria toxin by these bacteria was demonstrated with PCR and an immunoprecipitation test. The patient was cared for in respiratory isolation and was treated with benzylpenicillin. She quickly recovered and was discharged four days after admission. A contact investigation did not reveal any dissemination of the toxin-producing C. ulcerans and a source was not found. In spite of the large-scale vaccination against diphtheria which has taken place in the Netherlands since 1953, a physician has to consider diphtheria in the differential diagnosis of patients who present with a clinical syndrome compatible with this disease. Either Corynebacterium diphtheriae or C. ulcerans could be the pathogen responsible.