Morbidity associated with gastrostomy placement in children demands an ongoing integrated approach to care

AIMS: To evaluate the short and long term morbidity of gastrostomy insertion, and to identify ongoing management requirements. METHODS: A retrospective review was undertaken of the hospital casenotes of children aged up to fifteen years who had a gastrostomy placed in Christchurch over a six year period to March 1998. RESULTS: 42 children had a gastrostomy fashioned, 35 in the last three years of the period reviewed. The most common underlying diagnosis was neurological disease (48%), and the most common indication for tube placement was failure to feed orally. Complications were frequent but minor. Morbidity was related to local erythema and infection around the stoma (85 episodes in 23 children), persistent and major gastric fluid leakage (three episodes), and mechanical failure of the tube (21 episodes). Gastro-oesophageal reflux was seen in fourteen children, nine of whom had primary neurological disease. Complications were seen more after open gastrostomy than after percutaneous endoscopic placement (6.6:4.7). There was no mortality related directly to the gastrostomy tube or tube placement. CONCLUSIONS: An increase in the frequency of gastrostomy placements has been seen over this period. As the number of children with a gastrostomy increases, so too have the demands on medical and nursing staff to care for and manage the devices. The frequency of minor ongoing problems necessitates ongoing support of the child and care of the gastrostomy. A close working relationship between outreach nursing staff, stoma therapists and medical staff is required if morbidity is to be minimised. Education, audit and review remain important additional aspects of care.     

Cardiac safety parameters of olanzapine: comparison with other atypical and typical antipsychotics

Alterations of electrocardiogram results and cases of sudden cardiac death have been reported since the beginning of neuroleptic treatment. In particular, a temporal association exists between some antipsychotics and prolongation of the heart rate-corrected QT interval (QTc), an event that may increase the risk for developing a potentially fatal ventricular tachycardia arrhythmia known as torsades de pointes if it significantly exceeds normal intraindividual and interindividual variation. Although the incidence of serious adverse cardiac events in response to antipsychotic medications is relatively low, any possibility for the occurrence of cardiotoxicity warrants continued study. The present article reviews important differences among antipsychotic drugs in the potential for, and occurrence of, serious adverse cardiac outcomes and suggests that olanzapine, as therapeutically administered to patients with schizophrenia and related psychoses, does not contribute significantly to a QTc prolongation that could result in potentially fatal ventricular arrhythmias.     

Effects of starvation in rats with elevated DDT and dieldrin tissue levels

Summary Weanling, adult and old Osborne-Mendel strain rats were fed for 4 weeks diets supplemented with 50 ppm DDT, 7.5 ppm aldrin, or a combination of 50 ppm DDT plus 7.5 ppm aldrin. They were subsequently starved for 6 days, with free access to water. This period of starvation resulted in marked loss of body weight, marked loss of total body lipids, decreased liver-to-body-weight ratio, and a decreased total body-lipid-to-body-weight ratio.As a result of severe starvation, total DDT (simple summation of DDT, DDE and DDD) and dieldrin concentrations decreased in the blood of male and female rats of all ages, regardless of the pesticide supplement fed before starvation, but only in weanling male and female rats were reductions marked and statistically significant.There was no distinct pattern to the effects of starvation on the concentration and retention of pesticides in the brain and kidney of male and female rats of all ages.In general, in all rats, except for adult and old females, starvation induced a decrease in both the concentration and the total quantity of total DDT and dieldrin in the liver. In the two groups of females, the opposite occurred. Particularly in male rats, there was a marked conversion of DDT to DDD in the liver as a result of starvation.The total quantity of pesticides (DDT, DDE, DDD, dieldrin) in the total body decreased during the period of severe starvation, regardless of sex, age, or the pesticide supplement fed before starvation. On the whole, the effects were most marked in weanlings and least marked in old rats.In females of all ages, starvation induced from a moderate to a marked increase in the concentrations of DDT, its metabolites, and dieldrin in the abdominal fat. In male rats, total DDT increased, but dieldrin decreased in the abdominal fat. With the exception of weanling male rats, starvation increased hepatic microsomal enzyme activity for the substrates tested: EPN, p-nitroanisole and methyl orange.Feeding of the DDT and/or aldrin supplement for 4 weeks to male and female weanling rats resulted in a significant increase in growth rate above that of weanling rats fed the control diet.Presented in part at the Tenth Annual Meeting of the Society of Toxicology, Washington, D.C., March 7–10, 1971.This investigation was supported by U.S. Public Health Service Grant No. 5 P01 ES00052, 5–7.     

The surgical management of neonatal necrotizing enterocolitis, 1975–1984

A review was conducted of 202 neonates with necrotizing enterocolitis (NEC) seen at the Royal Children's Hospital, Melbourne, over a 10-year period. The study population was biased towards the more severe cases and those requiring surgical intervention for complications. Most cases had one or more obstetric or perinatal stress factors present. Radiology was important in confirming the diagnosis and identifying those who required surgery. The indications for surgical intervention and the selection of the appropriate surgical procedure are discussed. Surgery was required for acute disease in 72 cases. In most of these, necrotic bowel was excised and temporary ostomies constructed. During the period of study the overall mortality decreased from 41% to 24%. Post-NEC strictures occurred in 18 patients, of whom 6 presented with bowel obstruction. The transverse and left colon seemed particularly susceptible to stricture formation. The diagnosis and management are described in detail. Offprints request to: A. W. Auldist at the above address     

Inflammatory bowel disease and predisposition to osteopenia

The prevalence of osteopenia in children with inflammatory bowel disease (IBD) is unknown. The effect of nutritional state, disease activity, and steroid therapy on bone mineral content (BMC) of whole body, lumbar spine, and left femoral neck measured by dual energy x ray absorptiometry in 32 children with IBD was assessed by comparison with 58 healthy local school children. Using the control data, a predicted BMC was calculated taking into account bone area, age, height, weight, and pubertal stage. The measured BMC in children with IBD was expressed as a percentage of this predicted value (% BMC). Mean (SD) % BMC was significantly reduced for the whole body and left femoral neck in the children with IBD (97.0 (4.5)% and 93.1 (12.0)% respectively, p < 0.05). Of the children with IBD, 41% had a % BMC less than 1 SD below the mean for the whole body and 47% at the femoral neck. Reduction in % BMC was associated with steroid usage but not with the magnitude of steroid dose, disease activity, or biochemical markers of bone metabolism. In conclusion, osteopenia is relatively common in childhood IBD and may be partly related to the previous use of steroids.