Prospective study of the risk of Clostridium difficile diarrhoea in elderly patients following treatment with cefotaxime or piperacillin-tazobactam

BACKGROUND: Rates of Clostridium difficile diarrhoea have recently been rising, with the elderly being at highest risk. AIM: To compare the incidence of C. difficile colonization and diarrhoea in elderly patients treated for presumed infection with either empirical cefotaxime (CTX) or piperacillin-tazobactam (PT). METHODS: A prospective, ward-based, crossover study was carried out on two well-matched care of the elderly wards at a UK tertiary care hospital, in patients requiring empirical broad-spectrum antibiotic treatment. RESULTS: There was a highly significant increased incidence of C. difficile colonization (26/34 vs. 3/14, P=0.001) and diarrhoea (18/34 vs. 1/14, P=0.006) in patients who received CTX as opposed to PT. DNA fingerprinting suggested that most infections arose from strains acquired from the hospital environment. CONCLUSIONS: Elderly patients are significantly less likely to develop C. difficile diarrhoea after treatment with PT than after CTX. The source of C. difficile appears to be predominantly from the ward environment.     

Respiratory syncytial virus infection in north-east England

During a period covering four winter epidemics 987 respiratory syncytial (RS) virus infections were identified in the children's wards that served a total population of about 875 000 in north-east England. The incidence of admission to hospital with RS virus infection tended to be twice as high among children in Tyneside as that among children from the rest of the catchment area. The risk of hospital admission with RS virus infection in the first year of life for city children was about 1 in 50. The risk tended to be increased when there was a high proportion of children in the population, overcrowded housing, and unemployment. There was no clear relation between climatic changes and the onset or progress of epidemics. Thirteen deaths associated with RS virus infection were identified, four of them sudden and unexpected at home, and nine of them in children with congenital or acquired abnormalities. Twelve children were admitted twice with distinct RS virus infections; the relative severity of their two illnesses depended on age. Hospital cross-infection accounted for 60 of the 987 illnesses. Large families and overcrowding among poorer families seem to lead to a higher incidence of RS virus infection, and measures to reduce overcrowding and improve housing should help to reduce the spread of infection. Breast-feeding also protects infants from infection, but further information is needed to pinpoint the infants at greater risk and how they may best be protected.     

Twenty years of childhood coeliac disease in the Netherlands: more diagnoses and a changed clinical picture

OBJECTIVE: To assess the incidence of childhood coeliac disease in the Netherlands and to study the clinical features. DESIGN: Prospective. SETTING: Leiden University Medical Centre, Leiden, the Netherlands. METHOD: Cases of childhood coeliac disease in the Netherlands in 1993-1995 were identified by means of the Dutch Paediatric Surveillance Unit. Inclusion criteria were: birth in the Netherlands, diagnosis with at least one small bowel biopsy in 1993-1995 and age at diagnosis 0-14 years. The data were cross checked with the Dutch Network and National Database of Pathology and compared with data from a previous study on childhood coeliac disease, 1975-1990. RESULTS: 297 Coeliac patients were identified by means of the Surveillance Unit, another 32 through the National Database of Pathology. The mean crude incidence rate of diagnosed childhood coeliac disease was 0.51/1000 live births, which was in the range of rates found in other West European countries and significantly higher than the mean crude incidence rate of 0.18/1000 live births found in the Netherlands in 1975-1990. The clinical presentation was classic up to 1990: chronic diarrhoea, abdominal distention and growth failure. From 1993 onward, however, the number of children with chronic diarrhoea and abdominal distention decreased significantly and the number with weight loss, anaemia and abdominal pain increased. Associated disorders were present in 13.7% of the cases. CONCLUSIONS: The incidence of diagnosed childhood coeliac disease in the Netherlands showed a tendency to increase significantly during the past decade. In a period of 20 years a significant trend toward change in the clinical presentation of coeliac disease in Dutch children was observed.     

Seasonal differences in neonatal jaundice

Cytomegalovirus is the main agent of congenital viral infections. The aim of this study was to compare the incidence of congenital cytomegalovirus infections of two groups of newborns of differing socioeconomic status. Cytomegalovirus was isolated from urine or oropharingeal secretions in 218 children born in a private clinic and 471 born in a public hospital. Positive viral isolates were confirmed with indirect immunofluorescence using monoclonal antibodies. Infection was detected in 12 children (1.82%), four coming from the private clinic (1.86%) and 8 coming from the public hospital (1.81%). Ninety two percent of infected children were asymptomatic. Urine and oropharingeal secretion samples had the same yield for viral isolation. It is concluded that the incidence of congenital cytomegalovirus infection is similar to that described in developed countries.     

Respiratory syncytial virus infection in tropical and developing countries

Little is known about the epidemiology of respiratory syncytial virus (RSV) infection in tropical and developing countries; the data currently available have been reviewed. In most studies, RSV was found to be the predominant viral cause of acute lower respiratory tract infections (ALRI) in childhood, being responsible for 27-96% of hospitalised cases (mean 65%) in which a virus was found. RSV infection is seasonal in most countries; outbreaks occur most frequently in the cold season in areas with temperate and Mediterranean climates and in the wet season in tropical countries with seasonal rainfall. The situation on islands and in areas of the inner tropics with perennial high rainfall is less clear-cut. The age group mainly affected by RSV in developing countries is children under 6 months of age (mean 39% of hospital patients with RSV). RSV-ALRI is slightly more common in boys than in girls. Very little information is available about the mortality of children infected with RSV, the frequency of bacterial co-infection, or the incidence of further wheezing after RSV. Further studies on RSV should address these questions in more detail. RSV is an important pathogen ill young children in tropical and developing countries and a frequent cause of hospital admission. Prevention of RSV infection by vaccination would have a significant impact on the incidence of ALRI in children in developing countries.     

The relationship of DSM-III-R personality disorder to clinical variables in patients with major depression: possible difference between personality disorder clusters

The authors evaluated in 1987-1994 the incidence of nosocomial rotavirus infections during hospitalization in 1718 junior children, 450 senior children and adults admitted with diarrhoeal diseases. Rotavirus infection was revealed in 6.2 and 1.3% of the patients resp. During hospitalization the rotaviruses were the most frequent causal agent of nosocomial infections. Hospital infection was contracted regardless of the initial diagnosis most frequently by patients aged 0-12 months. The majority of nosocomial rotavirus infections was associated with symptoms of diarrhoeal disease, on average symptomatic infections prolonged the hospitalization period by 4.2 days. The authors discuss the possibility to influence the incidence of these infections.     

Comparison between the lactulose/mannitol and 51Cr-ethylenediaminetetraacetic acid/14C-mannitol methods for intestinal permeability. Frequency distribution pattern and variability of markers and marker ratios in healthy subjects

OBJECTIVE: To determine the most efficient approach to the diagnosis of infective endocarditis (IE) in febrile parenteral drug users (PDUs) and evaluate possible effects of human immunodeficiency virus (HIV) infections or acquired immunodeficiency syndrome (AIDS) on susceptibility to IE and final outcome. DESIGN: A prospective study of appropriate patients admitted on 149 random sampling days during a 14-month period and review of past experience with IE, HIV, and AIDS admissions to hospital. SETTING: An urban university hospital. PATIENTS: Prospectively, 121 febrile PDUs plus an additional 16 found to have IE on nonsampling days during the study period. Retrospectively, all PDUs with IE from 1985 to 1991 and all patients with HIV infections with or without AIDS from July 1990 through December 1991. MEASUREMENTS: Physical examination, hemograms, urinalysis, blood cultures (plus other body fluids when indicated), echocardiography, laboratory testing for HIV status. MAIN RESULTS: Five categories of patients were identified: I. Infective endocarditis (n = 16); II. Other infections with bacteremia (n = 21); III. Bacteremia with unidentified source of infection (n = 14); IV. Infections without bacteremia (n = 52); V. Fever of unknown origin (n = 18). Physical findings and standard laboratory testing did not differentiate Group I from any of the other diagnostic categories. Adding additional IE cases from nonstudy days brought the total to 32. Vegetations were found on echocardiography in 94%; blood cultures, available in 30 of 32 instances, were all positive. HIV or AIDS status was not found to alter susceptibility to IE or influence mortality. While hospital admissions for HIV and especially AIDS have continued to increase among PDUs, the number of cases of IE has decreased since 1988 to 1989. CONCLUSIONS: Based on the high incidence of blood culture positivity and the sensitivity of echocardiography in detecting vegetations in IE, a simple algorithm has been developed for the initial diagnostic management of febrile PDUs admitted with the possible diagnosis of IE. HIV infection, with or without full-blown AIDS, does not appear to affect the incidence or outcome of IE among these patients. Current practices among PDUs may be effecting a decline in IE but not HIV infections.     

Paediatric HIV infection

HIV infection in children is a family disease, with social, economic and medical aspects that make it one of the most challenging diseases of our time. Knowledge about the factors involved in mother-to-child transmission and the natural history of the disease is gradually increasing although there is still much to understand. As the majority of children become infected through mother-to-child transmission, perinatally acquired infection will parallel increases in heterosexual transmission and the numbers of infected women of childbearing age. Current estimates of the rate of vertical transmission range from 14% to 39% in different studies. The relative proportion of transmission occurring in utero, peripartum or postpartum may vary in different localities and remains unclear. A study recently carried out in the USA showed that zidovudine given late in pregnancy, peripartum and in the neonatal period decreases HIV transmission from 25% to 8%. The clinical presentation of HIV infection in children depends in part on exposure to different infections. In developing countries the children usually present with nonspecific signs and symptoms, such as failure to thrive, chronic diarrhoea, cough and recurrent bacterial infections. Other common presentations include generalized lymphadenopathy, oropharyngeal candidiasis, dermatitis, enlargement of parotid glands and neurological problems, including delayed development.     

A clinical and epidemiological study of gastro-enteritis

Over a 13-year period, 2,903 Asian, Coloured and White children with gastro-enteritis were admitted to the Wilkins Infectious Diseases Hospital, Salisbury. During a pilot study of 250 patients conducted over the first 2 years, a definite seasonal variation in the occurrence of gastro-enteritis, with a peak incidence in winter, was noticed, and this led to a more detailed study of 2,653 patients over the next 11 years. Bacterial pathogens were recovered from 27% of patients, strains of Shigella accounting for 12% Salmonella for 7% and Escherichia coli for 8%. A severe outbreak of E. coli infection occurred between October 1971 and December 1972, and 4 of a total of 9 deaths occurred during this period, all in children suffering from E. coli 0111/B4 infections. The bacterial recovery rate was highest in the summer (40%) and lowest in the winter (12%). Winter diarrhoea broke out over 3-month periods during each year and accounted for 37% of the cases, but none of the children who contracted it died. The clinical picture of winter diarrhoea differed from the others and the most serious illness was that caused by enteropathogenic strains of E. coli. The over-all mortality in the series was 0,27%.     

Heart signal recognition by Hidden Markov Models: the ECG case

From December 1989 to May 1990, 315 faecal samples from children under 5 years old with diarrhoea (215) and without diarrhoea (100) seen at paediatric clinics were investigated for bacterial, viral and parasitic enteropathogens. Standard and recently described methods were used for the investigations, which revealed that 74.9% of children with diarrhoea were infected with enteropathogens compared with 28% of controls. In the diarrhoeal group, 59.1% had a bacterial, 26.5% a viral and 2.3% a parasitic aetiology. Rotavirus was the pathogen most frequently detected, accounting for 22.3% of positive findings in the group with diarrhoea versus 9% in the control group. Other important agents were: enterotoxigenic Escherichia coli (ETEC) (14.4 versus 6%), enteropathogenic E. coli (EPEC) (10.7 versus 5%), enteroadherent E. coli (EAEC) (9.3 versus 4%), enterohaemorrhagic E. coli (EHEC) (5.1 versus 3%) and Salmonella spp. (3.3 versus 1%). The following enteropathogens were detected exclusively in the diarrhoeal stools: Shigella spp. (5.1%), Yersinia enterocolitica (0.9%), Aeromonas hydrophila (1.4%), Entamoeba histolytica (0.5%), Giardia lamblia (0.5%), Trichomonas hominis (0.5) and Trichuris trichiura (0.9%). The detection rates of rotavirus, EPEC and EAEC were much greater in the diarrhoeal than in the control patients. No Vibrio cholerae, enteroinvasive E. coli (EIEC), Plesiomonas spp. or Cryptosporidium spp. were detected in this study. Our data suggest that both the traditional and newly recognised diarrhoeal agents are important causes of diarrhoea in the children under 5 years old in Lagos, Nigeria.     

Cryptosporidiosis in infancy and childhood mortality in Guinea Bissau, west Africa

OBJECTIVE: To investigate the epidemiology of and mortality from cryptosporidiosis in young children in Guinea Bissau, West Africa. DESIGN: Three year community study of an open cohort followed up weekly. SETTING: 301 randomly selected houses in a semi-urban area in the capital, Bissau. SUBJECTS: 1315 children aged less than 4 years. MAIN OUTCOME MEASURES: Cryptosporidium infection detected by examination of stools during episode of diarrhoea and death of a child. RESULTS: Cryptosporidium spp were found in 239 (7.4%) out of 3215 episodes of diarrhoea. The parasite was most common in younger children (median age 12 months) and at the beginning of the rainy seasons. The prevalence of cryptosporidiosis was 15% (77/513) in cases of persistent diarrhoea compared with 6.1% (148/2428) in diarrhoea lasting less than two weeks (p < 0.0001). Cryptosporidiosis was associated with excess mortality in children who had the infection in infancy, and this excess mortality persisted into the second year of life (relative mortality 2.9 (95% confidence interval 1.7 to 4.9)). The excess mortality could not be explained by malnutrition, or by socioeconomic factors, hygienic conditions, or breast feeding. CONCLUSIONS: Cryptosporidiosis is an important cause of death in otherwise healthy children in developing countries.     

Which vertebrae should be assessed in diagnosing osteoporosis by plain radiography? Comparative study of radiographic findings and bone mineral density measured by dual energy X-ray absorptiometry

OBJECTIVE: To determine rates of hospitalisation of young children for acute gastroenteritis in Australia, and to estimate the proportion of these admissions caused by rotavirus infection. DESIGN: Analysis of hospital admission records, and parallel, prospectively collected data on rotavirus-positive admissions. SETTING: Hospitals admitting young children in all Australian States and Territories in 1993-1996. PATIENTS: All children under five years admitted to hospital for acute gastroenteritis (International Classification of Diseases, ninth revision principal diagnosis codes 003.0, 004.0-009.3 and 558.9). MAIN OUTCOME MEASURES: Rate of hospital admission per 1000 children per year by State, and the proportion of admissions caused by rotavirus infection. RESULTS: There were almost 20,000 hospital admissions annually in Australia for acute gastroenteritis in children under five years, at an average rate of 15/1000. An estimated 50% of these were attributable to rotavirus infection, implying a rate of hospitalisation for rotavirus-related gastroenteritis of 7.5/1000/year. Among children under two years this rate was 11.6/1000. Rotavirus incidence rates generally followed a typical seasonal pattern in temperate regions of the country, with sharp peaks in mid to late winter. Rates of hospitalisation varied markedly, even between States with apparently similar patterns of disease, while the incidence in the Northern Territory was 3-5 times higher than other States. CONCLUSIONS: Rotavirus-related gastroenteritis is a major cause of hospital admissions in young children, and large savings to the healthcare system are possible if it can be prevented at reasonable cost. Variation in treatment practices between States may be worth studying in greater detail as another source of potential savings.     

Helicobacter pylori infection, gastric acid secretion, and infant growth

BACKGROUND: Helicobacter pylori infection is very common in Gambian infants and children, who are also at risk of chronic diarrhoea and undernutrition. Acute H. pylori infection is associated with depressed gastric acid secretion, and loss of the gastric acid barrier may predispose to enteric infections. METHODS: In a prospective study a noninvasive test of gastric acid output (measurement of change in urine acid output before and after a feed) was performed on a population of Gambian infants at high risk of H. pylori infection. The 13C urea breath tests was used to measure the prevalence of H. pylori infection and growth was measured by serial anthropometry. RESULTS: In 101 infants aged 3 to 12 months, there was a significant relation between H. pylori infection and depressed urine acid output in those aged 6 months, during weaning when growth failure and malnutrition begin. Those infants with sustained H. pylori infection grew less well than those without. CONCLUSIONS: We speculate that H. pylori, acquired in infancy, could be a "key that opens the door" to enteric infection in childhood, leading to recurrent diarrhoea, malnutrition, and growth failure.     

Prevention of nosocomial infection in a pediatric intensive care unit (PICU) through the use of selective digestive decontamination

OBJECTIVE: To assess the effectiveness of selective digestive decontamination (SDD) on the control of nosocomial infection (NI) in critically ill pediatric patients. DESIGN: A prospective, randomized, non-blinded and controlled clinical microbiology study. SETTING: The pediatric intensive care unit (PICU) of a tertiary level pediatric university hospital. CRITERIA FOR INCLUSION: Patients 1 month to 14 years old, who underwent some kind of manipulation or instrumentation (mechanical ventilation, vascular cannulation, monitoring of intracranial pressure, thoracic or abdominal drainage, bladder catheterization, peritoneal dialysis, etc.) and/or presented a neurological coma requiring a stay in the PICU of 3 or more days. PATIENTS: Over a period of 2 years, 244 patients met the inclusion criteria; 18 patients were withdrawn because of protocol violation. The treatment group comprised 116 patients and the control group, 110 patients. INTERVENTION: The treatment group received a triple therapy of colimycin, tobramycin and nystatin administered orally or via nasogastric tube every 6 hours. All patients with mechanical ventilation or immune-depression received decontamination treatment of the oropharyngeal cavity with hexitidine (Oraldine 0.5 mg/ml) every 6-8 hours in accordance with the PICU's conventional protocol. METHOD: Up to 10 types of nosocomial infection were diagnosed following criteria of the Centers for Disease Control (CDC). The severity and manipulation of the patients on admission was assessed using the therapeutic intervention scoring system (TISS) and multi-organ system failure scores (MOSF). MEASUREMENTS AND MAIN RESULTS: UNIVARIANT ANALYSIS: SDD did not significantly reduce the incidence of NI, antibiotic use, the length of stay, or mortality; although a small percentage of respiratory and urinary tract infections was detected, catheter-related bacteremia was the most common infection. MULTIVARIANT ANALYSIS: Controlling the risk factors for each child through log regression showed that SDD acted as a protective factor for more than 90% of the sample with respect to the appearance of respiratory and urinary tract infections, reducing the risk of such infections to 1/5 and 1/3, respectively. CONCLUSIONS: SDD was effective in controlling respiratory and urinary tract infections in children admitted to the PICU, but it did not reduce the incidence of other types of nosocomial infection.     

Nosocomial infections in surgical patients. Problems of measuring and comparing results

BACKGROUND: What is striking when studying the frequency of nosocomial infection (NI) is the variability of the study data. Different frequency indicators and infection criteria are used for estimates and these make it difficult to compare works. The aim of this work is to estimate the frequency of hospital infection by using different indicators to compare the results. METHODS: A market study was carried out including patients admitted to four surgical units over the period of one year. The following indicators were used: proportion of patients infected, cumulative number of cases of infection and density of number of cases. The infections were detected through active search and included those acquired in Intensive Care Units and those diagnosed after patients had been discharged from hospital. RESULTS: A total of 14.5% of the patients suffered NI and 5% of the infections were diagnosed after discharge from hospital. In 38.5% of the cases of infection a microbiological study was not requested. The General Surgery Unit had the highest figures for the three indicators. Nevertheless, the magnitude of the differences between services was modified in line with the indicator used. CONCLUSIONS: The real percentage of patients with NI is higher than the values given by the usual monitoring systems. Given the trend witnessed over recent years whereby the length of hospital stays is being reduced and early discharge programmes promoted with the aim of increasing efficiency, densities for the number of cases should be estimated and these should include the NI cases diagnosed after hospital discharge in order to make valid comparisons between different institutions and periods of time.     

Effect of psychotherapy on the course of Crohn''s disease. Results of the German prospective multicenter psychotherapy treatment study on Crohn''s disease. German Study Group on Psychosocial Intervention in Crohn''s Disease

OBJECTIVES: To determine whether a combination of ciprofloxacin hydrochloride and metronidazole hydrochloride would be as effective or more effective than a combination of gentamicin sulfate and metronidazole hydrochloride for preventing infection in patients with penetrating abdominal trauma, to evaluate the factors associated with increased risk of infection, and to determine the serum peak and trough levels of gentamicin with the dosage regimen of 2.5 mg/kg every 12 hours. DESIGN: Randomized double-blind study. SETTING: Level I trauma center. PATIENTS: Eighty-four patients with penetrating intra-abdominal injuries (gunshot wound, 69; stab wound, 15) thought to require laparotomy. INTERVENTIONS: The patients were randomized during treatment in the emergency department to be given a combination of ciprofloxacin hydrochloride, 400 mg every 12 hours, and metronidazole hydrochloride, 500 mg every 6 hours, or a combination of gentamicin sulfate, 2.5 mg/kg every 12 hours, and metronidazole hydrochloride, 500 mg every 6 hours. RESULTS: Of 68 patients with intra-abdominal injuries who could be observed for at least 48 hours after laparotomy, posttraumatic infections developed in 12 (18%), and nosocomial infections developed in 6 (9%). The incidence of posttraumatic infections in patients who were given gentamicin and metronidazole (5/33 [15%]) was not significantly lower than the incidence in patients who were given ciprofloxacin and metronidazole (7 of 35 [20%]; P=.75). The presence of any infection increased the mean+/-SD length of hospital stay from 8.7+/-3.5 days to 23.3+/-10.9 days and increased the mean+/-SD hospital charges from $24 507+/-$9860 to $104920+/-$49083 (P<.001). Univariate analysis showed the factors most significantly associated with infection were as follows: (1) the use of blood transfusions (P<.001), (2) the penetrating abdominal trauma index of 35 or more (P<.002), (3) injury to the colon requiring a colostomy (P=.004), and (4) a trauma score of less than 12 (P<.02). Multivariate analysis showed the only significant factor was the receipt of blood transfusions (F=10.165; P<.005). CONCLUSIONS: Ciprofloxacin and gentamicin, each in combination with metronidazole, were equivalent in their ability to prevent infections after penetrating abdominal trauma; other factors, especially the receipt of blood transfusions, had much more effect on the incidence of infection. Infection greatly increases the length of hospital stay and hospital charges. The use of an increased dosing regimen of 2.5 mg/kg every 12 hours of gentamicin sulfate was effective at obtaining a therapeutic peak serum concentration.     

Young Malaysian children with lower respiratory tract infections show low incidence of chlamydial infection

OBJECTIVE: The incidence of Chlamydia pneumoniae and Chlamydia trachomatis infection was studied among infants and young children admitted to hospital for the management of lower respiratory tract infections, over a 12 month period. METHODOLOGY: Respiratory secretions were examined for chlamydiae by cell culture, enzyme-linked immunosorbent assay and polymerase chain reaction-enzyme immunoassay. Sera were tested by micro-immunofluorescence for chlamydial IgG, IgM and IgA. Other bacterial and viral pathogens were also looked for by standard cultural and serological methods. RESULTS: Of 87 patients aged 2 months-3 years, an aetiologic diagnosis was made in 41 (47.1%). C. pneumoniae and C. trachomatis were each detected in 1 (1.2%) of the patients. Among common bacterial pathogens, Haemophilus influenzae (13.8%) and Streptococcus pneumoniae (8.1%) were the most frequently identified. Respiratory viruses and elevated Mycoplasma pneumoniae antibodies were found in 10.3% and 9.1% of patients, respectively. CONCLUSION: Chlamydiae are infrequent causes of community-acquired acute lower respiratory tract infections in infants and very young children in Malaysia.     

Acute ethanol intoxication increases the risk of infection following penetrating abdominal trauma

Acute alcohol (ETOH) intoxication as a risk factor for infection in trauma victims to our knowledge has not been previously reported. To determine if ETOH intoxication increases infection risk we examined data from 365 patients with penetrating abdominal trauma who were enrolled in a multi-center antibiotic study. Ninety-four patients sustained an injury to a hollow viscus. To separate acute from chronic ETOH effects, infections were divided into two categories: (1) trauma related; infections caused by bacterial contamination at the time of injury, while blood alcohol level (BAL) was elevated. (2) nosocomial; infections caused by bacteria acquired during hospital stay, after BAL had normalized. A BAL > or = 200 mg/dL was associated with a 2.6-fold increase in trauma-related infections. There was no association between BAL and subsequent nosocomial infection. Since infection rates for intoxicated patients were not higher after BAL had normalized, acute rather than chronic effects of ETOH appear to be responsible.     

Persistent diarrhoea: management in algorithmic approach using a low-cost rice-based diet in severely malnourished Bangladeshi children

Easy and successful dietary management of persistent diarrhoea has been a long desired goal. Finding an efficient diet which is economically feasible, and easy to prepare in poor homes of developing countries, has not been easy. A dietary algorithm was followed to test the clinical efficacy of an inexpensive and easy to prepare diet made up with rice powder, egg white, glucose, and soya oil. We studied a cohort of 100 severely malnourished children aged between 3 and 36 months with persistent diarrhoea in Dhaka Shisu (children's) Hospital, Bangladesh, during 1990. Initially on a milk-based diet, 26 children (26 per cent) improved while on a subsequent rice-based diet; 65 (88 per cent) of the remaining 74 children improved within a week, with a mean recovery period of 4 days. Patients who did not improve with the rice-based diet were weaned earlier than those who improved. Nine patients failed to improve on the rice-based diet. They were given a soya formula, and only two improved. The remaining seven patients finally improved when a comminuted chicken diet was given. Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia. This study offers a simple and effective algorithm on the management of persistent diarrhoea and also demonstrates the success of a rice-based diet, showing promising and feasible means of management of persistent diarrhoea in patients with severe malnutrition.     

Use of the dental dam in endodontic procedures in dogs

The role and influence of Chlamydia trachomatis on the development and course of acute respiratory virus infections (ARVI) in 130 children admitted to the hospital of the Research Institute of Children's Infections (St. Petersburg) was studied. The occurrence of respiratory Chlamydia infections in ARVI patients with an unfavorable premorbid background was 35-36%. The disease took its course simultaneously with the mixed infection of the respiratory tract with viruses, pneumococci and their associations with staphylococci and Haemophilus influenzae. Chlamydia infection in children had no influence on the character of the clinical manifestation of ARVI with the exception of the obstruction syndrome which was constantly observed in children with ARVI (p < 0.001).