Clinical standards for drug-susceptible TB in children and adolescents.

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

Paediatric tuberculosis among the foreign-born: utility of the Canadian TB immigration medical surveillance programme.

BACKGROUND: There are few data on the utility of screening paediatric immigrants for tuberculosis (TB) in low TB burden countries. OBJECTIVE: To evaluate the utility of the Canadian immigration medical examination and TB Medical Surveillance (TBMS) for detecting paediatric TB disease. DESIGN: A 10-year population-based retrospective cohort study of foreign-born children (ages 0-10 years) and adolescents (ages 11-17 years) immigrating to Ontario, Canada, using linked immigration and public health databases. RESULTS: Among 232 169 individuals (median follow-up of 5.7 years), active TB was diagnosed at or after immigration in 125 cases (20 children and 105 adolescents), at an overall rate of 54/100 000 (14/100 000 children, 116/100 000 adolescents). All cases originated from 34 countries. Active TB was diagnosed in 0/419 children and 10/418 adolescents referred for medical surveillance, representing only 8.0% of all cases. TBMS referrals were correlated with a previous diagnosis of TB (κ = 0.8) and were driven by country of origin (e.g., hazard ratio 31.2 for the Philippines). Rates of pre-immigration TB diagnosis varied considerably among high TB burden countries. CONCLUSIONS: The current Canadian system detects little TB disease, and reveals very different rates of pre-immigration paediatric TB diagnosis in different high TB burden countries. These data provide a basis for improving TB screening strategies for immigrants to low TB burden countries.

Transmission of Mycobacterium tuberculosis from an infant.

SETTING: This report investigates the unusual transmission of Mycobacterium tuberculosis from a 12-week-old infant with nosocomially acquired tuberculosis (TB). Compliance with recommendations on the post-exposure management of young children is described. DESIGN: Contacts of an infant case of TB were identified and recommended to undergo baseline and post-exposure tuberculin skin tests (TST) as per Canadian TB standards. TST conversion was measured at least 8 weeks post exposure. Children aged <6 years were recommended to initiate preventive treatment with isoniazid (INH) until their post-exposure TST. Information on TST results and adherence to therapy were analysed from existing medical records. RESULTS: Overall, 17 TST conversions were documented among 732 contacts: both parents, two health care workers (HCWs) who provided close care, and several patients, visitors and one staff member without obvious close contact. Of 65 eligible children, 46% completed post-exposure therapy as recommended. The most common reasons for treatment failure were concern about side effects, perception of low risk and lack of physician support. CONCLUSION: This investigation suggests that all children, including infants, with cough and numerous bacilli or extensive pulmonary disease should be considered infectious. Health care provider education is necessary to resolve the observed low compliance with current post-exposure management guidelines.

A randomized trial of 72- versus 24-hour intravenous tubing set changes in newborns receiving lipid therapy.

OBJECTIVE: To compare the microbial contamination rate of infusate in the intravenous tubing of newborns receiving lipid therapy, replacing the intravenous delivery system at 72-hour versus 24-hour intervals. DESIGN: Infants requiring intravenous lipid therapy were randomly assigned to have intravenous sets changed on a 72- or a 24-hour schedule, in a 3:1 ratio, in order to compare the infusate contamination rates in an equivalent number of tubing sets. SETTING: A 35-bed, teaching, referral, neonatal intensive-care unit (NICU). PARTICIPANTS: All neonates admitted to the NICU for whom intravenous lipid was ordered. METHODS: Patients were randomized in pharmacy, on receipt of the order for intravenous lipid therapy, to either 72- or 24-hour administration set changes, and followed until 1 week after discontinuation of lipids or discharge from the NICU. Microbial contamination of the infusate was assessed in both groups at the time of administration set changes. Contamination rates were analyzed separately for the lipid and amino acid-glucose tubing sets. Patient charts were reviewed for clinical and epidemiological data, including birth weight, gestational age, gender, age at start of lipid therapy, duration of parenteral nutrition, and type of intravenous access. RESULTS: During the study period, 1,101 and 1,112 sets were sampled in the 72- and 24-hour groups, respectively. Microbial contamination rates were higher in the 72-hour group than the 24-hour group for lipid infusions (39/1,101 [3.54%] vs 15/1,112 [1.35%]; P=.001) and for amino acid infusions (12/1,093 [1.10%] vs 4/1,103 [0.36%]; P=.076). Logistic regression analysis controlling for birth weight, gestational age, and type of venous access showed that only the tubing change interval was significantly associated with lipid set contaminations (odds ratio, 2.69; P=.0013). The rate of blood cultures ordered was higher in the 72- versus the 24-hour group (6.11 vs 4.99 per 100 patient days of total parenteral nutrition; P=.017), and a higher proportion of infants randomized to the 72-hour group died (8% vs 4%; P=.05), although the excess deaths could not clearly be attributed to bacteremia. CONCLUSION: Microbial contamination of infusion sets is significantly more frequent with 72- than with 24-hour set changes in neonates receiving lipid solutions. This may be associated with an increased mortality rate.

[Photochemical reactions in bone tissue induced by excimer laser ultraviolet]. / O proiavleniiakh fotokhimicheskikh reaktsi'i v kostno'i tkani pod de'istviem ul'trafioletovogo izlucheniia eksimernogo lasera.

A phenomenological model of an increase in ultraviolet absorption in bone tissue induced by ultraviolet radiation of excimer laser has been developed. It is assumed that the increase in absorption is related to photochemical reactions in collagen. The model accounts for changes in the intensity of laser radiation due to its absorption inside the specimen. From the comparison of experimental and calculated results the parameters of the photochemical model were estimated. The temperature fields in the specimen were calculated with regard to laser-induced changes in absorption coefficient. The limits of applicability of the model are discussed.

Cytomegalovirus infections in Toronto child-care centers: a prospective study of viral excretion in children and seroconversion among day-care providers.

OBJECTIVES: To prospectively determine the rate of cytomegalovirus shedding in children and the rate of seroconversion to cytomegalovirus in providers at 38 infant-toddler day care centers in Toronto, Canada. METHODS: Urine was collected for shell vial assay in 471 children between the ages of 3 and 42 months. Providers (n = 206) were tested for the presence of cytomegalovirus antibody by latex agglutination. Of the 68 providers who were seronegative, 56 were retested approximately 1 year later. RESULTS: Viruria was documented in 79 (17%) children and antibody in 67% of providers. Seropositivity was significantly related to country of birth outside Canada, presence of children at home < 5 years of age and increased household size. Seroconversion was documented in 12.5% (n = 7). Of these providers 71% worked at centers where workers never wore gloves for diaper changing vs. 33% of those who did not seroconvert (P = 0.06), and all were younger than 30 years vs. 59% of those who did not seroconvert (P = 0.04). In centers with viruria the association of seroconversion with lack of glove use was enhanced (P = 0.04). Seroconversion was marginally more likely in providers working with infants only than with infants and toddlers or with toddlers alone. Logistic regression confirmed that seroprevalence was more likely in providers who were born outside Canada, had children younger than age 5 years in the household and with an increased number of people in the household. Seroconversion was more likely if the provider worked at centers not using gloves for diaper changes, worked with infants only rather than with toddlers and infants and was < 30 years old, with each factor contributing independently to the model. CONCLUSIONS: Cytomegalovirus infection is common in children and providers in Toronto day-care centers.

Seroprevalence of toxoplasma antibody in a Toronto population.

OBJECTIVE: To determine the prevalence of infection with toxoplasmosis by country of birth and age in a sample of convenience. DESIGN: Banked sera and the computerized data base of demographic and other factors from an earlier epidemiological study were retrieved. SETTING: Thirty-eight infant-toddler day care centres in Toronto. POPULATION: Day care providers from whom informed consent was obtained and banked sera were available. MAIN RESULTS: Of the 124 providers whose serum was tested, 16 (12.9%) were seropositive. Of those providers born in Canada, 8.2% were seropositive, while of those born outside of Canada, 19.6% were positive (P=0.067, OR 2.68, 95% CI 0.91, 7.94). While there was no significant association of seropositivity with age, the association of seropositivity with country of birth was different in the providers under 30 years of age. Among those born in Canada, 4.6% were seropositive, while among those born outside of Canada 23.1% were seropositive. CONCLUSIONS: The data supplement the limited existing data on toxoplasmosis infection in Canada. Among Canadians, those born outside of Canada were more likely to be seropositive than those born in Canada, suggesting that there may be a differential risk of congenital infection for infants whose parents were born outside of Canada.

An economic evaluation of varicella vaccine for pediatric liver and kidney transplant recipients.

To evaluate the potential benefit of varicella vaccine for pediatric liver and kidney transplant patients, we determined the consequences of varicella susceptibility for a cohort of susceptible children (n = 44) who received transplants between July 1986 and June 1990 at the Hospital for Sick Children, Toronto. Costs of these consequences were compared with costs with a hypothetical varicella vaccination program in place. The median follow-up was 11.4 months (range, 2-50 months). Total costs in Canadian dollars to the health service without a program were for varicella-related hospital stay ($135,675) and varicella-zoster immune globulin ($4,322). Costs to parents were for lost time ($13,590) and transport ($414). Assuming a vaccine cost of $30/dose and a 90% vaccine efficacy, a pretransplantation vaccination program would have cost $16,205 and saved $3,132/child ($304 for families and $2,828 for the health service) during the study period. Varicella vaccination prior to solid organ transplantation should reduce morbidity in pediatric recipients and provide considerable savings for families and the health system.

Value of the history and stool occult blood test in selection of patients for upper endoscopy in Zimbabwe.

Patients with abdominal pain and no definite diagnosis referred for endoscopy were studied to define discriminating features in the history, and the value of a stool occult blood test, in predicting the presence of upper gastrointestinal disease. Endoscopy was performed in 116 patients; pathology was seen in 32 (duodenal ulcer 17, gastric carcinoma 4, gastric ulcer 3, miscellaneous 8) and no pathology was seen in 84 patients. Features that predicted upper gastrointestinal pathology were, in descending order of rank: a positive pointing sign, a positive stool Fecult test, a history of vomiting, loss of weight, and alcohol intake. Using these discriminating features together it was possible to correctly predict 95% of patients with abnormal endoscopy and 82% of patients with a normal endoscopy. The history and the stool occult blood test are useful predictors of the presence of upper gastrointestinal pathology and may aid rational selection of patients for endoscopy.

Community acquired staphylococcal skin infections in rural areas of Zimbabwe.

Swabs from superficial skin or wound infection in 254 outpatients at rural clinics and hospitals in the Eastern Districts of Zimbabwe were examined for microorganisms. The most common site of infection was on the limbs, with infected wounds or abscesses being the most common complaint. Staphylococcus aureus was by far the most common pathogen being isolated from almost half the specimens. Coliforms were obtained from 36pc and streptococci from 18pc of swabs. Over two-thirds of the staphylococcal isolates showed in-vitro resistance to penicillin and there was an indication that penicillin resistant strains occurred more frequently in specimens from the Mozambique border areas. Resistance to other antibiotics occurred only rarely in these isolates, and in particular we found only three strains showing methicillin resistance, with one of these also showing resistance to gentamicin. The value of penicillinase sensitive penicillins in treating superficial wound infections is questioned.

Tuberculosis presenting as corticosteroid responsive wheezing in infancy.

A nine-month-old child received intermittent oral prednisolone over a 6 month period because of persistent wheezing. This therapy had appeared to improve his symptoms. At 15 months of age, a chest X-ray and culture of tracheal aspirate revealed disseminated pulmonary tuberculosis. Response to antituberculous therapy was slow, and withdrawal of steroids produced marked worsening of wheeze and respiratory distress. Corticosteroids are recognised adjuncts in the management of bronchial-lymph node tuberculosis. Responsiveness of wheezing to prednisolone does not imply that its cause is hyperreactive airways disease, and other causes should be sought particularly in developing countries.