Where''s the cash?

This study was done to analyze the epidemiology of invasive Haemophilus influenzae disease in Bochum city area. Forty-eight children with invasive Haemophilus influenzae infections were treated at the University Children's Hospital in Bochum during the study period from January 1971 to June 1992. Clinical manifestations included meningitis (n = 34), epiglottitis (n = 8), pneumonia (n = 2), bacteremia (n = 2), cellulitis (n = 1) and osteomyelitis (n = 1). The overall yearly incidence rate for all invasive Haemophilus influenzae infections was 13 per 100,000 children younger than five years of age, with a marked increase in the last six years. Haemophilus influenzae meningitis showed no significant change during the study period with an overall yearly incidence of 9 per 100,000 children younger than five years. Twenty-eight cases (58%) of all invasive Haemophilus influenzae infections occurred in patients under two years of age and five cases (10%) were younger than six months. Invasive Haemophilus influenzae disease showed no seasonal prevalence. All isolates were susceptible to ampicillin. No deaths occurred, but severe bilateral deafness resulted in one patient with meningitis. Prospective epidemiologic studies are needed to estimate clinical efficacy of the Haemophilus influenzae type b immunization program in Germany.     

Pyogenic bacterial pneumonia in human immunodeficiency virus-infected inpatients: a clinical, radiological, microbiological, and epidemiological study

We prospectively studied features of pyogenic bacterial pneumonia in 263 consecutive human immunodeficiency virus-infected inpatients over a 6-month study period. Risk factors for bacterial pneumonia were examined by a case-control study that included 33 cases who presented with at least one episode of bacterial pneumonia and 80 controls without bacterial pneumonia. The estimated cumulative incidence of bacterial pneumonia per year was 12.5 cases per 100 inpatients (95% confidence interval [CI], 8.8-17.2). The 38 episodes of bacterial pneumonia that occurred in the 33 inpatients were mainly unilateral, but 32 episodes were patchy lobar or diffuse infiltrates. Microbiological etiologies were obtained in 33 of the 38 episodes of bacterial pneumonia. Thirty-seven pathogens were identified, including Streptococcus pneumoniae (16, of which 12 had a decreased susceptibility to penicillin), Haemophilus influenzae (6), and Pseudomonas aeruginosa (6). The risk factors for bacterial pneumonia that were identified after logistic regression included prior sinusitis within 1 month before admission (odds ratio [OR], 3.2; 95% CI, 1.1-9.1) and prior bacterial infection of the lower respiratory tract within 6 months before admission (OR, 3.1; 95% CI, 1.1-8.3).     

Systemic Haemophilus influenzae infection in childhood

Forty-nine children who had systemic Haemophilus infection and were treated at the Westmead Centre, Sydney, over a two-year period are described. The majority (29 of 49 children) were aged two years or less. Epiglottis and meningitis accounted for 77% of these infections. All H. influenzae isolates associated with clinical disease were of the capsular type b. Eight per cent (four of 50) of H. influenzae infections were caused by beta-lactamase producing strains. There was no geographic clustering or seasonal variation. There was no mortality. Major morbidity included two patients who had epiglottis and required tracheostomy, and two patients who had meningitis developed bilateral profound sensorineural deafness. No secondary cases were detected in household contacts of 21 patients with H. influenzae meningitis during the study period. Epiglottis frequently occurs in very young children. The rapid response to antibiotic treatment suggests that early cases of epiglottis may be undiagnosed, but treated with antibiotic agents in the community.     

Clinical characteristics and natural history of human immunodeficiency virus infected patients seen at a general hospital in Singapore

The number of patients with human immunodeficiency virus (HIV) infection in Singapore has risen over the years. A considerable proportion of them present with acquired immunodeficiency syndrome (AIDS). In this study, we document the clinical characteristics and natural history of a consecutive series of 50 patients who were found to have HIV infection when they were seen at a tertiary care hospital. The majority were in the 30 to 49 age group and the most common mode of acquisition was heterosexual contact. The patients presented with a variety of symptoms to 11 different clinical departments. Fifty-eight per cent of the patients had AIDS-defining illnesses at presentation, with Pneumocystis carinii pneumonia being the most common. On follow-up, the most frequently occurring opportunistic infection that developed was Cytomegalovirus retinitis. Most patients had multiple subsequent admissions--for both AIDS-defining and non AIDS-defining conditions. The median CD4 count of the cohort at presentation was 72/mm3. The median survival was 399 and 822 days in those who had and those who did not have an AIDS-defining illness at presentation, respectively. Mortality was most commonly attributed to pneumonia. HIV infection has protean manifestations and patients may present to various specialty departments; hence, doctors need to be aware of the spectrum of disease in order to make a diagnosis.     

The clinical significance of senile cardiac amyloidosis: a prospective clinico-pathological study

The heart was screened for amyloid deposits in an unselected post-mortem series of 244 patients over 60 who had been admitted to a geriatric department. Cardiac amyloidosis was found in 121 cases (49-6 per cent) but was limited to minor atrial involvement in 55 (22-5 per cent). The prevalence and severity of cardiac amyloidosis were significantly related to age and sex, females having the higher prevalence (56 per cent compared with 37 1/2 per cent). Cardiac amyloidosis was also significantly correlated with the occurrence of atrial fibrillation and of cardiac failure during the period of admission to hospital. Cardiac amyloidosis showed no significant correlations with other factors studied which included ECG evidence of left ventricular hypertrophy, ischaemia and bundle branch block, pathological evidence of cardiac enlargement or ischaemia, diagnosis of malignant disease, generalized wasting and the occurrence of digitalis toxicity.     

Long-term results of total hip replacement in young patients who had ankylosing spondylitis. Eighteen to thirty-year results with survivorship analysis

We determined the long-term results of total hip replacement in a series of young patients who had ankylosing spondylitis. Between 1966 and 1978, forty-three Charnley low-friction arthroplasties were performed in twenty-four patients who had an average age of 28.8 years (range, nineteen to thirty-nine years) at the time of the operation. There were seventeen men and seven women. The average duration of follow-up for the series was 22.7 years (range, one month [a perioperative death] to 30.3 years). Four patients (seven hips) had died an average of 12.6 years (range, one month to 18.7 years) after the operation. The twenty surviving patients had clinical and radiographic follow-up until the time of writing or until both of the original components had been revised. All patients had substantial relief of pain and improvement of function and the range of motion of the joint. Twenty-one patients (88 per cent; thirty-nine hips) were completely free of pain (6 points, according to the scale of Merle d'Aubigne and Postel), and the remainder had only slight discomfort (5 points). Ten acetabular components and one femoral component were revised because of aseptic loosening, and one patient had a revision of both components because of late deep infection. Three additional femoral components were revised during a revision operation for a loose acetabular component. Although the femoral components were not loose, they had been in place for more than ten years and it was thought likely that the bearing surface was damaged. The average time to revision was 13.3 years (range, 4.0 to 20.3 years). At an average of 22.7 years, thirty-eight (88 per cent) of the original femoral components and thirty-two (74 per cent) of the original acetabular components remained in situ. The average annual rate of acetabular wear was 0.12 millimeter for the entire series. Only six hips (14 per cent) had minor heterotopic ossification, and none of the hips had clinically important ossification (class III or IV according to the system of Brooker et al.). To our knowledge, the present report describes the largest series of total hip arthroplasties, with the longest duration of follow-up, in young patients who had ankylosing spondylitis. Survivorship analysis with use of the Kaplan-Meier method revealed that the probability of survival of the femoral component (with 95 per cent confidence intervals) was 91 per cent (83 to 99 per cent) at twenty years and 83 per cent (72 to 94 per cent) at thirty years. The probability of survival of the acetabular components was 73 per cent (61 to 84 per cent) at twenty years and 70 per cent (57 to 83 per cent) at thirty years. The probability that both components would survive was 91 per cent (82 to 100 per cent) at ten years, 73 per cent (61 to 84 per cent) at twenty years, and 70 per cent (57 to 83 per cent) at thirty years. The Charnley low-friction arthroplasty provided consistently good long-term results, with a low rate of complications and revisions, in this group of young patients.     

Five-year audit of the acute complications of diverticular disease

BACKGROUND: The objective of this study was to audit the presentation and outcome for patients admitted with an acute complication of diverticular disease. METHODS: This study was a retrospective review of 418 admissions with an acute complication of diverticular disease over a 5-year interval. RESULTS: Of the 418 admissions, 15 patients were eventually found to have an alternative diagnosis. Some 403 patients were studied further. The overall mortality rate in this group was 5.7 per cent. A total of 113 patients (28.0 per cent) required an operation and in this group the mortality rate was 17.7 per cent. All deaths occurred in patients who had surgery for septic complications or bowel obstruction. Of the patients who had surgery, 90.2 per cent had a resection of the involved colon. One-third of these had a primary anastomosis; the remainder underwent Hartmann's procedure. Some 83 patients had a stoma fashioned and of these 72 went on to have the stoma closed. The median age of those who died after operation was 80 years. An American Society of Anesthesiologists (ASA) score of 3 or more, concurrent medical disease and shock on admission were all associated with a high mortality rate (P < 0.001). Some 30 per cent of patients were readmitted during this study with a further complication of diverticular disease. CONCLUSION: The mortality rate after surgery for acute diverticular disease remains excessive and a high-risk group can be identified before operation. A policy of resection and anastomosis appears justified for selected patients. Adopting a practice of interval elective sigmoid colectomy after admission with acute diverticulitis might prevent readmission with further complications.     

Pitfalls of hyperfractionation: theoretical considerations of effect of repair time on late radiation damage]

We conducted a 3-year Taiwan-wide hospital-based survey of invasive Haemophilus influenzae infections in children less than 15 years of age. From January 1992 to December 1994, 105 cases (57 boys, 48 girls) were reported. Seventy-three patients (69.5%) had meningitis and 32 patients had other diseases (12 pneumonia, 10 sepsis, 7 cellulitis, 3 arthritis). Fourteen patients (13%) died, all of whom had meningitis or sepsis. Among the 63 patients who survived meningitis, 17 (27%) had neurologic sequelae and eight (47%) had hearing impairment. The number of cases of H. influenzae meningitis (30%) and other H. influenzae diseases (29%) peaked in children between 6 and 12 months of age. Patients with invasive infections (82%) and meningitis (73%) were younger than 24 months of age. Only 12 patients (11%) were older than 5 years of age and four had underlying diseases. The annual incidence of invasive H. influenzae infections in children less than 5 years old was 1.9 per 100,000 per year. During the same period a survey of purulent meningitis in children younger than 15 years of age was also conducted in 20 hospitals. A total of 198 patients, in whom the causative organisms were identified, were included; 94 patients were 2 months of age or under and the most frequent pathogen was group B streptococci (35 cases, 37%). Among the 104 patients who were older than 2 months of age, H. influenzae was the leading cause (38 cases, 37%). In conclusion, invasive H. influenzae type b (Hib) diseases exist in Taiwan but have an incidence lower than in Western countries. Hib meningitis is still the most common cause of purulent meningitis in children in Taiwan and is an important cause of mortality and morbidity. Continuous active surveillance of invasive H. influenzae infections is suggested to determine the best time to introduce an Hib conjugate vaccine in Taiwan.     

Myasthenia gravis presenting as isolated respiratory failure

We present 2 cases of idiopathic CD4+ T-lymphocytopenia (ICL) in elderly patients. Case 1, a 73-year-old man, with pneumonia had received several antibiotics with unsuccessful results at another hospital. On admission, his CD4+ T-lymphocyte count was 109/microl and Pneumocystis carinii was detected by bronchoalveolar lavage fluid staining. No evidence of human immunodeficiency virus (HIV) infection was found. Despite therapy, the patient died of respiratory failure. Case 2, a 72-year-old man, contracted severe pneumonia, and Hemophillus influenzae was believed to be the pathogen. On admission, his CD4+ T-lymphocyte count was 238/microl. No evidence of HIV infection was found. He received antibiotics and improved successfully. We suggest that ICL may currently be incubating in a number of elderly pneumonia patients.     

Abnormal cervical cytology in pregnancy: experience of 811 cases

An audit of day surgery was carried out by the Royal College of Surgeons (Eng.) Comparative Audit service. Data from 121 respondents on over 3,962 day cases were analysed from both retrospective information and from prospective individual patient proformas. The day surgery rate is 31 per cent. The variability of facilities for day-surgery, the timing of lists, type of anaesthetic used and case-mix are discussed. Outcome and the reasons for admission to an overnight bed are analysed. The overall admission rate was found to be 2.8 per cent (range 0.6-19.5 per cent between consultants). Seventy per cent of ENT day-surgery was performed on morning lists which have a lower admission rate than afternoon lists. The main reasons for admission are vomiting 30 per cent, haemorrhage 20 per cent and inadequate recovery from anaesthetic 22 per cent. A more detailed analysis of reasons for admission were given for tonsillectomy, adenoidectomy, FESS, and grommets. Recommendations are given which might increase the scope of safe day-surgery and reduce admission rate.     

Risk factors for mortality among hospitalized children with persistent diarrhoea in Pakistan

We evaluated factors associated with mortality among a cohort of malnourished children with persistent diarrhoea (PD) admitted for nutritional rehabilitation with a defined rice-lentil (Khitchri) and yoghurt diet. Of 302 children consecutively admitted with PD, 13 (4 per cent) died, mostly (62 per cent) within 72 h of admission. Univariate analysis of risk factors at admission associated with mortality indicated significantly increased risk of death with severe stunting [relative risk (RR) 3.1, 95 per cent confidence interval (CI) 1.1-9.0], hypoalbuminaemia (RR 4.3, 95 per cent CI 1.5-12.3), stool frequency > 12/day (RR 6.0, 96 per cent CI 2.0-17.6), stool volume > 100 g/kg/day (RR 10.7, 95 per cent CI 3.0-37.6) and severe dehydration (RR 7.5, 95 per cent CI 2.6-21.8). Children who died also had comparatively shorter duration of diarrhoea at admission, and were also associated with higher rate of bacteremia at admission (Fisher's exact test P < 0.01). The logistic regression model evaluating multivariate risk of mortality identified weight-for-age z-score and sepsis as significant risk factors. Our data suggest that severe malnutrition and sepsis are associated with significantly increased risk of mortality in children with PD. Stringent screening for infections and recognition of subgroups with severe malnutrition and severe diarrhoea may improve screening and case management strategies for this disorder.     

Bacterial meningitis in a rural Kenyan hospital

In a prospective study to investigate mortality and antibiotic resistance in meningitis patients, thirty two meningitis cases were seen over a three month period. Mean age was 11.3 years (range one month-60 years). Cerebrospinal fluid cultures were positive in 26 patients (81.3%). S.pneumoniae was responsible for 15 cases (46.9%), followed by H.influenzae in seven (21.9%). Salmonella infection was seen in two patients, and E.coli and N.meningitidis in one each. Twelve patients (37.5%) died during hospitalisation with most of the deaths occurring within 48 hours after admission. No patients presented with atypical signs of meningitis. No significant differences were found between delay and outcome. Malaria parasites were found in blood of thirteen patients (41%), but did not contribute to higher mortality. Three of H.influenzae isolates (42.9%) were resistant to ampicillin and penicillin. Reduced sensitivity to penicillin was found in two (13.3%) of S.pneumoniae isolates.     

Review of 1198 cases of penetrating cardiac trauma

BACKGROUND: This study was a clinicoforensic analysis of the prevalence and outcome of traumatic cardiac injuries in Durban. METHODS: Between 1990 and 1992, 1198 patients sustained cardiac trauma. Seventy (6 per cent) reached hospital alive and 1128 (94 per cent) were taken directly to the mortuary. Seven hundred victims had suffered stab wounds, 494 gunshot wounds and four blast injuries. Gunshot injuries increased from 34 per cent in 1990 to 50 per cent in 1992. The mean (s.d.) age was 30.5 (5.4) years and the majority (91 per cent) were men. RESULTS: Thirty-five (50 per cent) of those who reached hospital alive died, including all four gunshot victims. Significant factors associated with survival were isolated injury, the presence of cardiac tamponade (univariate and multivariate analysis), right ventricular injury, single cardiac chamber injury and absence of pleural breach (univariate analysis alone). Delay in operative intervention was associated with a higher mortality rate. When analysing the patients who did not reach hospital alive, 202 (18 per cent) with tamponade due to an isolated stab wound were identified as a subset who might have been saved with prompt treatment. CONCLUSION: An increasing number of gunshot injuries in combination with delays in reaching hospital and in receiving treatment accounted for the high mortality rate in this unselected series.     

Patterns of relapse and late toxicity after resection and whole-brain radiotherapy for solitary brain metastases

One hundred and twenty-seven children who presented with features of acute hepatitis during the period February 1995 to January 1996 were studied. Specific aetiologic agents were identified in 89 per cent. Of these, 67.7 per cent were due to a single virus, whereas 21.3 per cent were due to two or more hepatitis viruses. Hepatitis A virus (HAV) was the sole infecting agent in 38.6 per cent of cases, hepatitis B virus (HBV) in 13.4 per cent of cases, and hepatitis E virus (HEV) in 15.7 per cent of cases. Mixed infections were due to HAV and HBV co-infection (7.1 per cent), HAV and HEV (13.4 per cent), and the combination of HAV, HBV, and HEV (0.8 per cent). In 11 per cent, none of the markers (HAV to HEV) were identified. Acute sporadic hepatitis in children can occur due to a single hepatitis virus type or, at times, due to co-infection with a combination of two enterally transmitted viruses or enteral and parenterally transmitted viruses. Improving personal hygiene and active immunization are essential in the prevention of these viral illnesses. This study was done in a referral centre and hence we report a higher morbidity (13.4 per cent) and mortality (12.6 per cent) rate in all groups of infection. Hence, apart from the viruses, factors such as the age of the child, nutritional status, and treatment taken prior to hospitalization should be taken into consideration to predict the prognosis in a given child.     

Haemophilus influenzae: an underrated cause of vulvovaginitis in young girls

AIMS: To establish the common pathogens associated with infective vulvovaginitis in young girls in the local population and to determine current management of this condition. METHODS: A prospective laboratory based survey was carried out over 19 months. A questionnaire was then sent to local general practitioners and hospital doctors. RESULTS: One hundred and six swabs were received during the study period of which 43 (40.5%) yielded organisms recognised as causes of vulvovaginitis. The most common pathogen was group A beta haemolytic streptococcus (19), with Haemophilus influenzae the second most common (11). Candida was isolated on nine occasions. The users' questionnaire had an overall response rate of 52%. Forty one per cent of respondents nominated candida as the most common cause of this condition. Forty six per cent were aware that beta haemolytic streptococci caused juvenile vulvovaginitis, but only four (3.6%) knew that H influenzae was a possible pathogen. The most popular agent for empirical treatment of vulvovaginitis was topical clotrimazole cream, although 24 respondents (22%) prescribed antibiotics that are active against both group A beta haemolytic streptococci and H influenzae. CONCLUSIONS: Although H influenzae is the second most common infective cause of juvenile vulvovaginitis in the local population, most doctors managing these patients were unaware of its importance and may not be prescribing appropriate empirical treatment.     

Liver histology in a ''normal'' population--examinations of 503 consecutive fatal traffic casualties

Sensori-neural hearing loss after H. influenzae meningitis in children has been reported to occur more frequently after treatment with ampicillin than with chloramphenicol. In the present survey, hearing was assessed clinically and, in most cases, audiometrically in 47 children seen after H. influenzae meningitis. Three children were found to have some sensori-neural hearing loss. In no case was this severe or suspected prior to examination. One was among 27 children treated with ampicillin; one was among eight treated with ampicillin and chloramphenicol; and one was treated with chloramphenicol and streptomycin. Most of the children received ampicillin in a dose of 250mg/kg/day or less, but the two who were treated with ampicillin and developed hearing loss were among five children who received higher doses, suggesting that ampicillin may be ototoxic when given in very high doses.     

Interdisciplinary centers for tobacco-related cancer research--a health policy issue

The role of barbiturate therapy in the development of pneumonia in head trauma patients in the intensive care unit of a university hospital was studied retrospectively. A total of 151 ventilated head trauma patients were included in the study. Intravenous thiopentone was administered to 75 patients (Group A), and 76 patients were managed without thiopentone therapy (Group B). Pneumonia was diagnosed when a new persistent pulmonary infiltrate appeared, with at least two of the following: (a) fever greater than 38 degrees C, (b) a white blood cell count greater than 15,000/mm3, or (c) the presence of purulent bronchial secretions. On admission, there were no differences in the acute physiology and chronic health evaluation 2 revision (APACHE II) and Glasgow Coma Score between Groups A and B. Fifty-three per cent of the patients treated with thiopentone (Group A) developed pneumonia compared with 35% in Group B (odds ratio 1.85, 95% confidence interval 0.97-3.51). Gram-negative and Staphylococcus aureus organisms were the most frequently isolated in all cases. No differences in age, sex, APACHE II, Glasgow Coma Score, nutritional status or dexamethasone treatment were observed between the groups with and without pulmonary infection. In the multivariate analysis, prolonged mechanical ventilation before pneumonia and thiopentone treatment remained as the only independent risk factors for the appearance of pneumonia in head trauma patients (p = 0.001 for both). Nevertheless, thiopentone did not increase the rate of mortality in patients with pneumonia. In conclusion, head trauma victims treated with thiopentone have a greater risk for the development of nosocomial pneumonia independent of mechanical ventilation.     

Extravesical repair of primary vesicoureteral reflux in children

An operative procedure for the repair of primary vesicoureteral reflux in 51 children (83 renal units) is described, its merits are discussed and its advantages are stressed. Reflux was prevented in 90.2 per cent of the children and 74.5 per cent of the patients remained free of infection. No obstruction has occurred in our series as compared to a 5 per cent incidence rate in cases of ureteroneocystostomy. Our procedure is not recommended for megaureters with reflux or for recurrent vesicoureteral reflux.     

Clinico-echoencephalographic-electroencephalographic-angiographic correlations in supratentorial glioma

Complete evaluation of the aortoiliac femoropopliteal system is necessary for the proper evaluation of lower extremity peripheal vascular ischemic disease. We have used a modified infrarenal translumbar approach since it is both safely and rapidly performed. An analysis of 212 consecutive cases (the last 182 with translumbar technic) revealed that 72 per cent of patients had significant atherosclerotic involvement of the aorta or one or more common or external iliac arteries, 43 per cent had significant bilateral involvement, and it was judged that retrograde femoral catheterization would have been difficult or impossible in 38 per cent. Biplane aortoiliac evaluation was added in our last seventy-nine studies. This provided additional diagnostic help in thirty-six of these cases and revealed an abnormality not otherwise visible in six of these patients. There were no serious complications in this series.