Risk factors for Clostridium difficile-associated diarrhoea in HIV-infected patients

OBJECTIVE: To identify risk factors associated with a first episode of Clostridium difficile-associated diarrhoea (CDAD) in patients with HIV infection. DESIGN: A case-control study. SETTING: University teaching hospital HIV inpatient unit. PATIENTS AND METHODS: Nineteen HIV-infected patients with CDAD, defined as diarrhoea with positive stool culture for Clostridium difficile (CD) and positive stool cytotoxin B assay, were compared with 38 randomly selected controls (HIV-infected patients hospitalized on the ward on the day the matched case was diagnosed). CD isolates were phenotyped by electrophoretic protein patterns. RESULTS: The incidence of CDAD among HIV-infected patients was 4.1/100 of patient-admissions. On univariate analysis, cases were more likely to have used clindamycin [11 out of 19 compared with four out of 38; odds ratio (OR) 19; 95% confidence interval (CI), 2-160; P = 0.0007], and pyrimethamine (14 out of 19 compared with 13 out of 38; OR, 4.8; 95% CI, 1.4-16, P = 0.02) in the month before diagnosis, and to have had cerebral toxoplasmosis (12 out of 19 compared with 13 out of 38; OR, 2.8; 95% CI, 0.9-8.6; P = 0.09). There was also a significant increase of the risk of CDAD as duration of hospitalization in the ward increased (chi 2 for trend, P = 0.007). Multivariate models associated two risk factors with CDAD: clindamycin use (OR, 42; 95% CI, 2-813; P = 0.01), and prolonged hospitalization in the ward (OR, 3.6 per week in the ward; 95% CI, 1-13, P = 0.048). Of 18 available CD isolates, 15 (83%) had identical electrophoretic protein pattern. CONCLUSIONS: Clindamycin use and prolonged hospitalization in the ward were the main risk factors associated with CDAD in this study. These observations, together with the occurrence of one major phenotype of CD, suggest nosocomial transmission of CD in the ward.     

Clostridium difficile-associated diarrhea: epidemiology, risk factors, and infection control

OBJECTIVES: To evaluate the effectiveness of specific infection control measures on the incidence of Clostridium difficile-associated diarrhea (CDAD) and to identify risk factors for its development. SETTING: 370-bed, tertiary-care teaching hospital with approximately 12,000 to 15,000 admissions per year. METHODS: Several infection control measures were implemented in 1991 and 1992, and the attack rates of CDAD were calculated quarterly. Antibiotic use for 1988 through 1993 was analyzed. A case-control study was conducted from January 1992 to December 1992 to identify risk factors for acquisition of CDAD. RESULTS: From 1989 to 1992, the attack rate of CDAD increased from 0.49% to 2.25%. An increase in antibiotic use preceded the rise in the incidence of CDAD in 1991. Despite implementation of various infection control measures, the attack rate decreased to 1.32% in 1993, but did not return to baseline. Ninety-two cases and 78 controls (patients with diarrhea but with negative toxin assay) were studied. By univariate analysis, history of prior respiratory tract infections (odds ratio [OR], 3.6; 95% confidence interval [CI95], 1.2-10.4), the number of antibiotics, and the duration of exposure to second-generation cephalosporins (OR, 3.55; CI95, 1.47-9.41) and to ciprofloxacin (OR, 7.27; CI95, 1.13-166.0) were related significantly to the development of CDAD. By stepwise logistic regression analysis, only exposure to antibiotics and prior respiratory tract infections (P = .0001 and .0203, respectively) were found to be significant. CONCLUSION: Antibiotic pressure might have contributed to failure of infection control measures to reduce the incidence of CDAD to baseline.     

Epidemiology, clinical manifestations, and outcome of Clostridium difficile-associated diarrhea

OBJECTIVE: Clostridium difficile gastrointestinal disease is an important nosocomial infection and is associated with recent antibiotic use. This study evaluated C. difficile-associated diarrhea (CDAD) over a 2-yr period. METHODS: All 60 patients with C. difficile enterotoxin in their stools, and diarrhea, were retrospectively analyzed at a 615-bed teaching hospital. Institution antibiotic usage and discharge medical diagnoses were correlated with the study patients. RESULTS: Thirty-eight study patients (53%) had major or extreme admitting symptoms. Only four (7%) had no co-morbid illness. The incidence of CDAD increased significantly (p < 0.05) after 4 wk of hospitalization. No demographic or temporal clustering was discovered. Leukocytosis (60%), leftward polymorphonuclear shift (47%), dehydration (30%), weight loss (23%), and oliguria (12%) were the major clinical findings. Among these subject 51 (85%) had been on ceftriaxone and/or ceftazidime in the preceding 6 wk; ceftriaxone/ceftazidime was highly significantly associated (p < 0.01) with more cases than expected by usage alone. No patient on ticarcillin/clavulanate developed CDAD, although it was the most commonly used antibiotic (p < 0.00001). Higher mortality was associated with older debilitated nursing home residents. CONCLUSIONS: Third-generation cephalosporin use correlated with the development of CDAD; ticarcillin/clavulanate usage did not. Morbidity and mortality associated with CDAD is significant, is worse in debilitated older nursing home patients, and is more likely to occur in hospitalizations lasting longer than 4 wk.     

Clostridium difficile colitis associated with chronic renal failure

BACKGROUND: Clostridium difficile-associated diarrhoea (CDAD) is a potentially life-threatening illness which has been shown to be more common and more severe in patients with chronic renal failure (CRF) than in other groups. A review of CDAD in our nephrology unit was carried out. METHODS: A review of microbiology and histology records identified 32 cases of CDAD in the nephrology unit over a 24-month period. Patient notes were reviewed to identify risk factors, clinical features and outcome. Available isolates of C. difficile underwent 16S ribosomal RNA typing. RESULTS: The incidence of CDAD in the nephrology unit was 10.7 per 1000 admissions, compared to 2.7 per 1000 in other areas of the hospital (P<0.0001). CDAD was considered the sole or principal cause of death in six (19%) and was considered a contributing factor in a further seven (22%). Mortality was significantly higher among patients with established CRF (P=0.04). Seven cases occurred as a cluster, over a 1-month period. Isolates from this cluster, along with comparative strains from other areas of the hospital, were found to be PCR type 1. Diarrhoea occurred in 28 (89%) of cases, pyrexia in 17 (53%) and ileus or abdominal pain in 14 (44%). Six patients responded to discontinuation of antibiotics alone and 22 required metronidazole and/or vancomycin. Three patients had colectomy and one caecostomy because of toxic megacolon. Four patients died before specific therapy could be given and in two of these cases the diagnosis was made at autopsy. Twenty-six patients had a record of recent antibiotic therapy. Of these, 15 had at least one agent considered to be inappropriate (excessively broad spectrum agent in 11, excessive duration of therapy in four). Nine patients had only received antibiotics prior to admission. CONCLUSIONS: CDAD carries a high mortality in nephrology patients, especially those with established CRF. The diagnosis may be missed if a careful antibiotic history is not taken, including agents received prior to admission. Rational antibiotic prescribing and adherence to infection control measures are vital to reduce the incidence of this serious condition.     

Reduced E-cadherin expression correlates with unfavorable prognosis in adenoid cystic carcinoma of salivary glands of the oral cavity

OBJECTIVE: To describe the epidemiology, diagnosis, risk factors, patient impact, and treatment strategies for recurrent Clostridium difficile-associated disease (CDAD). DESIGN: Data were collected as part of a blinded, placebo-controlled clinical trial testing a new combination treatment for recurrent CDAD. Retrospective data regarding prior CDAD episodes were collected from interviews and medical-chart review. Prospective data on the current CDAD episode, risk factors, and recurrence rates were collected during a 2-month follow-up. SETTINGS: National referral study. PARTICIPANTS: Patients with recurrent CDAD. INTERVENTIONS: Treatment with a 10-day course of low-dose (500 mg/d) or high-dose (2 g/d) vancomycin or metronidazole (1 g/d). RESULTS: Recurrent CDAD was found to have a lengthy course involving multiple episodes of diarrhea, abdominal cramping, nausea, and fever. CDAD may recur over several years despite frequent treatment with antibiotics. Recurrence rates were similar regardless of the choice or dose of antibiotic. Recurrent CDAD is not a trivial disease: patients may have multiple episodes (as many as 14), may require hospitalization, and the mean lifetime cost of direct medical care was $10,970 per patient. Fortunately, the disease does not become progressively more severe as the number of episodes increase. Two risk factors predictive for recurrent CDAD were found: increasing age and a decreased quality-of-life score at enrollment. CONCLUSIONS: Recurrent CDAD is a persistent disease that may result in prolonged hospital stays, additional medical costs, and rare serious complications.     

Systematic detection of toxigenic strains of Clostridium difficile--is it useful?

The incidence of Clostridium difficile (Cd) infection is rising and Cd in fact is now endemic in many hospitals. During the past 4 years we analyzed our data concerning diarrhea caused by Cd in our 700 beds hospital. A positive case was defined as a Cd cytotoxine positive with or without positive culture for Cd. In the present study 120 episodes of Cd associated diarrhea occurred in 102 patients. 1101 stools were cultured from 921 patients. Since 1995 we choose to systematically evaluate Cd in diarrheal stools from hospitalized patients. 120 stool were positives (102 patients), we observed a significant difference between the 2 study periods: Cd was recovered from 16.9% of stool specimen during 1993-1994 and from 9.6% since 1995. This study clearly confirm the common role of Cd in our hospitalized patients as in all positive case, Cd was the only enteropathogen isolated. We suggest the systematic investigation of Cd in hospitalized patients.     

Nosocomial gastroenteritis in two infant wards over 26 months

We retrospectively reviewed 209 cases of nosocomial diarrhea in two infant wards at St G?ran's Children's Hospital. They occurred from April 1987 to May 1989, when 3105 patients spent 26,355 hospital days. The hospital is a 250-bed tertiary center with university affiliation. Fourteen percent of patients at risk developed nosocomial diarrhea, and the relative attack rate was 1.1 episodes per 100 hospital days. A probable viral etiology was found in 47% of patients. Rotavirus was most frequent and occurred during the community rotavirus seasons. Also small, round, structured viruses were common, and two outbreaks of astrovirus gastroenteritis occurred. Failure to detect a virus was particularly common among infants younger than 4 months. However, a seasonal distribution and peaks concordant with defined clusters in older patients, suggest also that some of these detection-negative cases may have a viral etiology.     

Incidence of photosensitive epilepsy: a prospective national study

We undertook a prospective nationwide study to determine the incidence of photosensitive epilepsy (PE). Virtually all EEG departments in Great Britain (providing approximately 90% coverage of all EEGs performed on people with newly diagnosed seizures) screened cases referred to them over a 3 month period and identified all new cases of epilepsy (defined as one or more recognised seizures) whose first EEG showed a photoparoxysmal response (PPR) on intermittent photic stimulation (IPS). 191 cases were identified, 143 of whom had type 4 PPRs (generalised spike and wave on IPS) on their first EEG. The annual incidence of cases of epilepsy with type 4 PPRs on their first EEG was conservatively estimated to be 1.1 per 100,000, representing approximately 2% of all new cases of epilepsy. When restricted to the age range 7-19 years, the annual incidence rose to 5.7 per 100,000-approximately 10% of all new cases of epilepsy presenting in this age range. To ascertain if there was a significant seasonal variation in PE, 5 EEG departments (which together contributed 15% of cases in the first study period) were visited during a second 3 month study period to identify all new cases of epilepsy with type 4 PPRs on their first EEG. No significant seasonal variation in incidence between summer and winter was found.     

Toxic-shock syndrome: epidemiologic features, recurrence, risk factors, and prevention

Surveillance for toxic-shock syndrome (TSS) in Wisconsin detected 38 cases with onsets from September 1975 through June 1980. Thirty-seven of the cases occurred after January 1, 1979; 37 of the patients were women, 35 cases occurred during menses; 38 patients were white; and one patient died. Cervical or vaginal cultures were obtained before antibiotic therapy in 23 patients, and 17 cultures were positive for Staphylococcus aureus. Ten patients had at least one recurrent episode during subsequent menstrual periods. The recurrence rate was lower in patients who had been treated with beta-lactamase-resistant antibiotics. Thirty-five patients were matched for age and menstruation to 105 controls: 34 of 35 cases (versus 80 of 105 controls) used tampons during every menstrual period (P < 0.01); nine of 35 cases (versus 64 of 105 controls) practiced contraception (P < 0.001). In Wisconsin the minimum incidence of TSS as defined by clinical criteria is 6.2 cases per 100,000 menstruating women per year. The rate of TSS among menstruating women younger than 30 years was 2.4 to 3.3 times the rate among those who were 30 or older.     

Does colonoscopic polypectomy reduce the incidence of colorectal carcinoma?

The study's objective was to examine whether there is evidence that colonoscopic polypectomy reduces the incidence of colorectal cancer. The records of all patients who underwent colonoscopic polypectomy by a single surgeon between 1974 and 1991 were reviewed. Patients with colorectal cancer diagnosed at the initial colonoscopy, with a history of colorectal cancer, inflammatory bowel disease or familial adenomatous polyposis or with only hyperplastic polyps were excluded. There were 1008 remaining patients, of whom 645 have attended at least one follow-up colonoscopic examination, and these 645 patients from the basis of the study, because the incidence of cancer is known exactly in this group. The mean period of follow up was 4.4 years and the mean number of follow-up colonoscopic examinations was 2.2. There was a total of 2847 person-years of colonoscopic follow up. The expected incidence of cancer, age and sex adjusted, is calculated using Australian epidemiological figures. The observed incidence of cancer was 3 cases (all asymptomatic) per 2847 person-years, which is indistinguishable from the general population's risk of 3.75 cases per 2847 person-years. Analysis of previous publications suggests that patients with adenomas are at an increased risk of developing colorectal cancer of about 2.5 times the general population's risk. If correct, then the observed incidence of 3 cases per 2847 person-years is less than the expected incidence of 9.4 cases per 2847 person-years. This analysis suggests colonoscopic polypectomy does reduce the incidence of colorectal cancer.     

Central venous catheter-related bloodstream infections: an analysis of incidence and risk factors in a cohort of 400 patients

OBJECTIVE: To determine the incidence of central catheter-related bloodstream infection (CR-BSI) and to compare patient and catheter characteristics of those with and without CR-BSI from a clinically suspected subgroup. Secondly, to assess the efficacy of the acridine orange leucocyte cytospin test (AOLC) as a rapid in situ method of detecting central venous catheter (CVC) infection. DESIGN: One-year prospective audit. SETTING: Intensive care unit/high dependency unit (ICU/HDU) and general wards of a tertiary referral hospital. PATIENTS AND PARTICIPANTS: 400 patients with non-tunnelled CVCs. Interventions: Daily surveillance, blood culture from peripheral venepuncture, blood sample from the CVC for assessment of the AOLC test and removal of suspected CVCs were carried out on patients clinically suspected of having CR-BSI. MEASUREMENTS AND RESULTS: CR-BSI was diagnosed using well defined criteria. Infection rate was calculated by dividing the number of definitive catheter associated infections by the total number of appropriate catheter in situ days. The AOLC test was performed on all those with suspected CR-BSI. A total of 499 CVCs in 400 patients were assessed, representing 3014 catheter in situ days. Over 80 % of patients were from our ICU/HDU, representing 404 CVCs and 1901 catheter in situ days. A total of 49/499 (9.8%) CVCs in the same number of patients were suspected of being infected subsequently 12/499 (2.4 %) CVCs [95% confidence interval (CI) 1.25 to 4.16] in 12 separate patients were demonstrated to be the direct cause of the patient's BSI. Rates of CR-BSI per 1000 catheter days were 3.98 (95 % CI 2.06 to 6.96) for the whole cohort and 4.20 (95 % CI 1.81 to 8.29) for the ICU/HDU subgroup. In the group suspected of having CR-BSI, CVCs were removed unnecessarily in 55 %, and no patient or catheter variables measured were predictive of the development of CR-BSI. The AOLC test was negative in all 12 catheters subsequently shown to be the definitive cause of BSI. CONCLUSIONS: We have defined the incidence of CR-BSI in a cohort of patients from a tertiary referral hospital, the rates comparing favourably with those reported for similar populations. We were unable to demonstrate significant differences in any patient or catheter variables between those with and without CR-BSI. The AOLC test used alone was unhelpful as a method to diagnose in situ CVC infection in this patient population.     

Discordant splenic uptake of Tc-99m colloid and Tc-99m denatured RBC in candidiasis-endocrinopathy syndrome

The aim of this study was to estimate the incidence of melanoma in the Paris region in 1994 and analyse the main clinical and histological characteristics of these lesions. It took the form of a prospective inquiry, mailed to public and private pathology laboratories, to count as accurately as possible the number of new cases diagnosed by pathologists in the region during the 1994 calendar year. In all, 1089 newly diagnosed Clark level I to V melanomas (excluding precancerous melanosis of Dubreuilh) were studied. Parameters recorded included age, sex, Clark level and Breslow's thickness. The incidence per 100,000 inhabitants was 9.93 for melanoma and 8.62 for invasive melanoma. The female to male ratio was 1.6. Clark level I or thin (< 0.75 mm) melanomas represented 64.8% of the lesions. At the time of diagnosis, the females were significantly younger than the males (P = 0.004). Breslow's thickness increased with age and was significantly lower in women (P = 0.00005), especially those between 40 and 49 years old. The incidence of melanoma in the Paris region in 1994 was close to that observed during the preceding 5 years in England, Scotland and the French department of Haut-Rhin. It was 2.32 times higher for males and 1.69 times higher for females than the rates estimated for France for the period 1978-1982.     

Clinical implications of microsatellite instability in colorectal cancers

BACKGROUND: Microsatellite instability (MI) has been reported in some sporadic colon tumors and in cases of hereditary nonpolyposis colorectal cancer (HNPCC). The criteria for HNPCC have not been fully defined, and clinical criteria are used to identify as many HNPCC patients as possible. To clarify the conformity of these criteria with the identification of eligible HNPCC cases, we analyzed MI in HNPCC patients diagnosed using clinical criteria. METHODS: Genomic DNA was extracted from surgical specimens of 56 colorectal cancers, including 36 from patients diagnosed with HNPCC using the clinical criteria. We analyzed four microsatellite loci using 32P-labeled primers. RESULTS: Among HNPCC patients diagnosed using clinical criteria, patients who were positive for MI accounted for 62% of Group A (a confirmed group) and 35% of Group B (a high risk group); only 5% of randomly selected colorectal cancer patients (Group C), were positive for MI. Furthermore, MI-positive tumors were found in patients who had a tendency for tumors to involve the right side of the colon, an association with cancers in other organs, a lower incidence of p53 protein positivity, and a higher proportion of poorly differentiated cancers. CONCLUSIONS: The presence of MI, in concert with modified clinical criteria, may identify legitimate cases of HNPCC in patients who might otherwise be excluded by the minimum criteria.     

Results of culture form colonoscopically obtained specimens for bacteria and fungi in HIV-infected patients with diarrhea

BACKGROUND: The aim of our study was to determine the diagnostic yield of culture for bacteria and fungi from colonic biopsy specimens in 290 consecutive HIV-infected patients with diarrhea. METHODS: During each colonoscopy, three biopsy specimens were homogenized and cultured on media for Salmonella and Shigella and for Campylobacter and Yersinia, on Loewenstein medium and on Sabouraud medium. RESULTS: Cultures were found positive for one (n = 32) or two (n = 5) infectious agents in 37 cases, i.e., in 12.8% of the patients. Bacteria were isolated in 24 cases, and identified as Campylobacter jejunl-coli (n = 14), Salmonella (n = 2), Shigella (n = 1), or Pseudomonas aeruginosa (n = 7). Among the 14 patients with C. jejuni-coli intestinal infection, 11 had normal-appearing mucosa at colonoscopy, and 3 had a concomitant stool culture negative for Campylobacter. Mycobacterial cultures were positive for Mycobacterium avium intracellulare in 6 patients, who were already known as having a disseminated M. avium intracellulare infection from positive blood cultures. Fungal cultures were positive for Candida in 10 cases, without clear clinical significance. CONCLUSIONS: The overall yield of culture for bacterial pathogens from colonic tissue in HIV-infected patients with diarrhea is low, but some individual cases of C. jejuni-coli infections may be detected from colonic tissue culture and not diagnosed by concomitant stool culture.     

Cutaneous malignant melanoma in Scotland: incidence, survival, and mortality, 1979-94. The Scottish Melanoma Group

OBJECTIVE: To determine the changing incidence of and mortality from cutaneous malignant melanoma in Scotland from 1979 to 1994. DESIGN: Detailed registration of clinical and pathological features, surgical and other treatment, and follow up of all cases of cutaneous malignant melanoma diagnosed from 1979 to 1994 and registered with specialist database for Scotland. SETTING: Scotland. SUBJECTS: 6288 patients with invasive primary cutaneous malignant melanoma diagnosed between 1 January 1979 and 31 December 1994. RESULTS: The annual age standardised incidence of cutaneous malignant melanoma rose significantly from 3.5 to 7.8 per 100,000 per year in men and from 6.8 to 12.3 per 100,000 per year in women (P < 0.001 for both). World standardised rates increased from 2.7 to 6.0 per 100,000 per year in men and 4.6 to 8.50 per 100,000 in women. The incidence of melanoma continued to increase significantly in men of all ages during the study, but the rate stabilised in women after 1986. Mortality from cutaneous malignant melanoma was 1.3 per million per annum in men in 1979, rising to 2.3 per million per annum in 1994 (P < 0.01); it was 2.4 per million per annum in women in 1979, falling to 1.9 per million per annum in 1994 (P = 0.09). The underlying mortality trends showed a continuing rise for men but a downward trend for women that was not significant (P = 0.09). In men, melanoma free survival was 69% at 5 years and 61% at 10 years; in women the corresponding rates were 82% and 75%. Younger patients had higher survival rates, which were not entirely explained by thinner tumours. Over the 15 year period, survival rates improved by 12% overall, only partly owing to thinner tumours. CONCLUSIONS: In Scotland the incidence of melanoma in women has stabilised, while mortality associated with melanoma in women shows a downward trend.     

Benign seizures associated with mild diarrhea: clinical analysis of 20 cases

Even without electrolyte imbalance, dehydration and fever, seizures are found occasionally in the cases of mild diarrhea. Such patients have shown favorable outcome during long-term follow-up. Twenty cases (10 boys and 10 girls) of benign seizure with mild diarrhea have been diagnosed at the Pediatric Department of Cathay General Hospital from January 1987 to March 1991. Ages-of-onset ranged from 3 months to 43 months (mean 19 months). Most cases were found between December and March (16 cases, 80%). Most seizure episodes were from 2 to 5 times (10 cases, 50%); the durations of seizures were mostly within a 5-minute period (16 cases, 80%). All seizures were generalized and symmetric, including tonic-clonic (13 cases, 65%), tonic (5 cases, 25%), and clonic (2 cases, 10%). Six out of 11 cases (54.5%) showed Rotazyme (Latex agglutination) positive. After six month to four year follow up, no patient had suffered any type of epilepsy, and psychomotor development was normal in all. Further discussion of clinical features is provided.     

Fetal assessment based on fetal biophysical profile scoring. VIII. The incidence of cerebral palsy in tested and untested perinates

OBJECTIVE: The intent of this comparative clinical study was fourfold: (1) to determine the incidence of cerebral palsy in a large obstetric population, (2) to compare the incidence of cerebral palsy in patients at high risk referred for and managed according to the fetal biophysical profile score result with the incidence among unreferred and untested patients, (3) to determine the relationship, if any, between the last fetal biophysical profile score and the incidence of cerebral palsy, and (4) to categorize cases of cerebral palsy according to the clinical parameters and the probable time and nature of the damaging insult. STUDY DESIGN: In this retrospective 5-year comparative study (1987 to 1991) the incidence of cerebral palsy was determined by analysis of International Classification of Diseases, Ninth Revision, -coded related medical services. The clinical records were then sought and reviewed in index cases and obstetric, neonatal, and postnatal clinical data were abstracted. Cross-correlation with partial registries was done to confirm completeness of capture of index cases. The population of referred high-risk patients who received serial fetal biophysical profile scoring and were managed according to test results was determined by review of a prospective computer-stored database and by review of patient log books. The population of untested patients was calculated as the residual of total cases minus tested cases. The rate of cerebral palsy for all patients and for the tested and untested population was calculated and compared. The tested and untested perinates were compared for birth age, weight, and assigned timing or etiology of cerebral palsy. In the tested population the distribution of test results by last recorded biophysical profile score was determined and the relationship between the last test result and cerebral palsy and predictive accuracy parameters of the fetal biophysical profile score were calculated. RESULTS: The incidence of cerebral palsy among the 84,947 live births was 3.68 per 1000 live births (313 cases). The rate of cerebral palsy in the 26,290 referred high-risk tested patients was 1.33 per 1000 (35 cases) compared with a rate of 4.74 per 1000 live births in the 58,657 untested mixed low-risk/high-risk patients (278 cases). These differences were highly significant. A significant declining trend in the annual incidence of cerebral palsy was observed in the total population and the untested population, whereas the rate in the tested population remained relatively constant over the 5-year study interval. The differences in the cerebral palsy rate between the tested and untested population were not related to differences in gestational age, birth weight, or assigned timing or etiology category. In the tested population the relationship between the incidence of cerebral palsy and the last test fetal biophysical profile score was inverse, exponential, and highly significant. CONCLUSIONS: Antepartum assessment by fetal biophysical profile scoring is associated with a significant reduction in the incidence of cerebral palsy compared with untested patients. The relationship between the last test score and the incidence of cerebral palsy is inverse and exponential, suggesting that antenatal asphyxia is an important and potentially avoidable cause of cerebral palsy.     

Collagenous colitis: presentation of 12 cases

Collagenous colitis (CC) is a cause of chronic aqueous diarrhea with normal radiologic study and endoscopic appearance of the colonic mucosa. Histologically, it is defined by the presence of a thickened subepithelial collagenous band and inflammatory changes of the mucosa. The cause of CC is currently unknown, although several mechanisms have been proposed, such as an inflammatory, autoimmune, origin, disregulation in collagen synthesis, plasma vasculosis and a possible role of bacterial or drug toxins. The clinicopathological data of 12 patients (9 females and 3 males) with a mean age of 52.4 years diagnosed by histologic criteria are presented. Aqueous diarrhea was observed in all the patients with a mean number of 5.4 stools/day during a time period between 3 weeks and 10 years (mean, 14.7 months). In a 6 patients allergies and/or associated diseases, mainly rheumatologic diseases were found. Laboratory and endoscopic data were normal or unspecific, with colon biopsy being carried out in all the patients. Several treatments were tested with good response with sulphasalazine derivatives, corticoids, antibiotics, and mebeverine, with no solution to the diarrhea in 2 patients. A review of the literature is also provided.     

A methodology for sampling and accessing homeless individuals in Melbourne, 1995-96

BACKGROUND: After resection of advanced abdominal neuroblastoma, children may have persistent postoperative diarrhea. Until recently, the magnitude of this problem had not been appreciated. METHODS: To assess the incidence, severity, and management of chronic postoperative diarrhea in these patients, we reviewed the case notes of all children with stage III or IV abdominal and pelvic neuroblastoma who underwent tumor resection in our hospital between January 1985 and September 1996. We classified the severity of diarrhea as follows: mild, less than 3 loose stools per day; moderate, 3 to 5 loose stools per day; and severe, more than 5 loose stools per day and/or urgency, incontinence, or nocturnal diarrhea. RESULTS: Seventy-seven children underwent resection during this period, and 23 (30%) had postoperative diarrhea, classified as mild in 11 patients, moderate in 7, and severe in 5. Dissection around the superior mesenteric and celiac arteries was associated with a significantly higher incidence of diarrhea. Fifteen children (65%) received treatment with loperamide, which reduced but did not abolish symptoms. Twelve children subsequently died of progressive neuroblastoma. Of the 11 surviving children (mean duration of follow-up, 8.4 years), 8 have persistent loose stools. CONCLUSIONS: Diarrhea, probably resulting from disruption of the autonomic nerve supply to the gut during clearance of tumor from the major vessels of the retroperitoneum, is common after resection of advanced abdominal neuroblastoma. Many children require long-term treatment to slow intestinal peristalsis, and a few have severe and unremitting diarrhea. More effective medical management of this complication is needed.