Bacteriology of sinusitis in human immunodeficiency virus-positive patients: Implications for management

The bacteriology of sinusitis in human immunodeficiency virus (HIV)-infected patients has been only sporadically reported. In this study, we report the results of cultures taken from 12 HIV patients with refractory chronic sinusitis who underwent surgery. Nine of the 12 patients had positive cultures with 16 isolates and 5 patients having multiple isolates. Five of the 12 patients grew out atypical or opportunistic infections not responsive to standard medical therapy, including 3 patients with cytomegalovirus, 1 with Aspergillus fumigatus, and 1 with Mycobacterium kansasii. These results suggest the need for aggressive medical care for HIV-infected patients with sinusitis and early intervention for tissue cultures in patients who do not respond to standard antibiotic regimens.     

Rhabdoid tumour of the kidney: a diagnostic challenge and a fatal outcome

Rhabdoid tumour of the kidney is not common. Presentation of such a lethal tumour along with blunt abdominal trauma is even rarer. We report such a case of Rhabdoid tumour of kidney which presented as renal trauma, and discuss the diagnostic difficulties and rapidly fatal outcome. Accepted: 3 February 1999     

Risk assessment and therapeutic indices of artesunate and artelinate in Plasmodium berghei-infected and uninfected rats

Artesunate (AS) is being developed as a potential agent for the treatment of severe and complicated malaria. A risk assessment of the therapeutic index and related hematological changes of AS and artelinate (AL) following daily intravenous injection for 3 days was conducted in Plasmodium berghei-infected and uninfected rats. The minimum doses of AS and AL for parasitemia suppression were 2.3 and 2.5 mg/kg, respectively, and the suppressive doses for half parasitemia (SD50) were 7.4 and 8.6 mg/kg, respectively. The maximum tolerated dose (MTD) for AS was 240 mg/kg with a therapeutic index of 32.6. The MTD for AL was 80 mg/kg with a therapeutic index of 9.3. Hematological changes were studied on days 1 and 8 after the final dosing. In both AS- and AL-treated rats, dose-dependent and rapidly reversible hematological changes (significant reductions in RBC, HCT, Hb, and reticulocyte levels) were seen in the peripheral blood. Bone marrow evaluation revealed a statistically significant reduction in the myeloid/erythroid ratio only at the highest dose of AS (240 mg/kg), albeit still within the normal ratio range (1.0-1.5:1.0). Looking at the respective therapeutic indices the authors have concluded that AS is much safer than AL. Both drugs induced hematological changes in rats that parallel the dose-dependent, reversible anemia and reticulocytopenia previously reported in animals and humans. However, no significant bone marrow depression was seen for either agent.     

Controversies in the diagnosis and management of urinary tract infections in children

Urinary tract infection (UTI) is one of the most common childhood bacterial infections, after upper respiratory tract and middle ear infections. The current goal of management is to prevent detrimental effects of UTI by early detection and treatment. Recommendations for the imaging of children depend upon age at presentation and sex. All children aged <5 years who have had a febrile UTI require a radiologic evaluation to identify any underlying genitourinary pathology. Older children can undergo a more tailored work-up depending on whether there is a febrile UTI or cystitis-type symptoms. Dysfunctional voiding and urge syndrome significantly increase the risk of developing UTIs in children. Vesicoureteral reflux can increase the risk of pyelonephritis and renal scarring in children with UTIs. For the most part, pyelonephritis can be diagnosed on clinical grounds in the majority of patients and a subsequent (99m)Tc-dimercaptosuccinic acid scan can be reserved to identify post-nephritic renal scarring. When renal scarring is identified, the child and parents need to be educated regarding the possibility of hypertension, proteinuria, progressive nephropathy, and the risk of complications in future pregnancies. Treatment of UTI is started in the unwell child before the culture results are available and subsequently changed to culture-specific antimicrobial therapy. A short course of treatment is required for acute uncomplicated UTIs. A child with acute pyelonephritis requires 10-14 days of antibacterial treatment. The oral route in young children often causes vomiting, which implies therapeutic delay, a well known risk factor for scarring.     

Do higher status and more autonomous women have longer birth intervals? Results from Cebu, Philippines

We look at whether women's status and autonomy affect birth-to-conception intervals using data from the Cebu Longitudinal Health and Nutrition Survey (CLHNS) in the Philippines. We followed 1123 married, fecund women, aged 25-49, for up to 5 years. In a 1994-1995 survey, women were asked about the timing of their last birth. In 1998-2000, women were asked about any pregnancies since the 1994-1995 survey. Using these two surveys, we calculated birth to conception intervals. Women were censored if they reached their 50th birthday during follow-up. We measure autonomy based on whether the wife has the final say in 10 household decisions as measured in the 1994-1995 survey. Using Cox proportional hazards models we find that women with more decision-making autonomy have significantly longer birth-to-conception intervals in unadjusted models. After adjustment for age, wealth, education, other socio-economic variables, and women's status, decision-making autonomy remained a significant predictor in all models. This effect remains even after adjusting for contraceptive use, implying that autonomy influences birth-to-conception intervals through other mechanisms above and beyond increased contraceptive use. Additionally, few of the women's status variables were significantly associated with time to next conception. Women who had their first birth later in life were more likely to conceive during the observation period suggesting that they may be having shorter birth intervals in order to "catch up" with their peers. Maternal and child health-care efforts can help women achieve their desired spacing goals by supporting women's autonomy-in addition to ensuring they have accurate information and a range of contraceptive options.     

Laser-assisted low-dose retinoic acid in oral cancer chemoprevention

OBJECTIVES: Systemic retinoic acid (RA) treatment for chemoprevention of squamous cell carcinoma of the head and neck (HNSCC) is limited by RA's toxic side effects at therapeutic doses. The pulsed-dye laser (PDL), through a mechanism of selective vascular targeting, may allow reduction of the RA dose to one that is better tolerated when these treatments are used in combination. This study tests our hypothesis that combination therapy of PDL irradiation and low-dose systemic RA is as effective as high-dose RA therapy alone in the chemoprevention of HNSCC. STUDY DESIGN: Randomized, prospective study in a hamster model. METHODS: Dysplastic lesions were induced in the cheek pouches of 48 hamsters by painting with topical 9,10-dimethl-1,2-benzanthrancene (DMBA). The hamsters were randomly divided into four treatment groups: 1) control (no treatment); 2) PDL irradiation only; 3) 5.0 mg RA (all-trans retinoid, 5.0 mg/kg per day, intraperitoneally [IP]); and (4) PDL + 0.5 mg RA (0.5 mg/kg per day, IP). The PDL irradiation was conducted at day 0 and 15, whereas the RA treatment was continued for 27 days. Tumor burden was measured over time. RESULTS: The lesions in all of three treatment groups grow more slowly than the untreated controls. The combination treatment of PDL and RA had the greatest inhibitory effect on tumors. CONCLUSION: This study suggests that combination treatment of PDL and low-dose RA is more effective than high-dose RA alone in the chemoprevention of HNSCC in a hamster cheek-pouch model, so that it should allow greatly improved tolerance of this regimen.     

Cling wrap, an innovative intervention for temperature maintenance and reduction of insensible water loss in very low-birthweight babies nursed under radiant warmers: a randomized, controlled trial

AIM: The value of polythene film ('cling wrap') to improve thermal control and reduce postnatal weight loss in preterm, very low-birthweight babies was investigated. METHODS: Consecutively born babies with birthweights between 750 and 1500 g were stratified by birthweight (<1250 g, 1251-1500 g) and randomised either to the cling wrap (CW) or no cling wrap (NCW) group. The baby bassinette of the RW was covered with cling wrap up to the level of the neck in the CW group for the 1st 7 days. The primary outcome variables were the incidence of hypothermia (axillary temperature < or = 36 degrees C) after initial stabilisation during the first 7 days and cumulative weight loss (percentage of birthweight) at 48 hours of age. RESULTS: Of 51 babies, 26 were randomised to the CW and 25 to the NCW group. None of the babies in the CW group developed hypothermia in the 1st 7 days but 36% in the NCW group (p = 0.001) did. Babies who were hypothermic on admission took less time to reach normal temperature in the CW group. Cumulative weight loss in the 1st 48 hours was 5.0 + 5.6% in the CW group and 8.6 + 7.0% in the NCW group (p = 0.06). CONCLUSION: Use of CW might be a simple method of maintaining temperature in very low-birthweight babies in developing countries.     

Continuous positive airway pressure - a gentler approach to ventilation

Continuous positive airway pressure (CPAP) has become a useful modality in management of respiratory distress, especially in preterm babies. Main indications for use of CPAP are respiratory distress syndrome (RDS) and apnea of prematurity. It decreases the need of invasive and costly mechanical ventilation. This review details the physiological effects of CPAP, its methods of delivery, and its need in a country like India. It also describes the guidelines for initiating and weaning CPAP. The review concludes that use of CPAP in respiratory distress syndrome is associated with lower rates of failed treatment, decreased incidence of chronic lung disease and lower overall mortality, specially in infants with birth weight above 1500 grams. Early use of CPAP is more beneficial, Surfactant and CPAP act in conjunction for babies with RDS. CPAP is a low-cost, simple and noninvasive option for a country like India, where most places lack facilities of mechanical ventilation. Systematic reviews, randomized and quasi-randomized trials by searching MEDLINE and the Cochrane Library formed the basis of this update.