Evaluación del riesgo de infecciones alimentarias en pacientes internados en un hospital pediátrico de alta complejidad y su sistema de prevención / Risk assesment of food infections in patient in a pediatric tertiary-care hospital and its prevention

The Garrahan Hospital is a tertiary-care center for pediatrics patients with complex diseases. Infections, including food-borne infections, contribute considerably to the morbidity and mortality in this population at risk. In order to prevent food-borne infections, the Foodservice Area has developed a preventive process approach system of Hazard Analysis and Critical Control Point (process approach HACCP) in food production and service. Objective: To conduct a thorough review and assessment of risk from food borne pathogens according to the pathology of patients or the therapeutic practice used, and to standardize food production and service. With the criterion "degree of safety at the time of service" preventive measures were standardized. The food was classified into four levels of process. One or more food levels are indicated according to risk, and if necessary individual adjustments are made.

El hospital Garrahan brinda asistencia a pacientes pediátricos con patologías complejas. Las infecciones, incluidas las alimentarias, contribuyen considerablemente en la morbilidad y mortalidad en esta población en riesgo. Con la finalidad de prevenir infecciones alimentarias, el Área de Alimentación desarrolla un Sistema Preventivo de Análisis de Peligros y Puntos Críticos de Control con enfoque en procesos (HACCP process approach) en la producción y servicio de alimentos. Objetivo: realizar una exhaustiva revisión y evaluación de los patógenos alimentarios de riesgo según patología o práctica terapéutica de los pacientes y estandarizar la producción y servicio de alimentos. Con el criterio "grado de inocuidad al momento del servicio" se estandarizaron las medidas preventivas. La alimentación fue clasificada en cuatro niveles de proceso. A cada grupo de población asistida, según riesgo, se le indica uno o más niveles de alimentación y se realizan los ajustes individuales necesarios.

Morphological and physiological restorations of hereditary form of dilated cardiomyopathy by somatic gene therapy.

TO-2 strain hamsters with dilated cardiomyopathy, gene deletion of delta-sarcoglycan (SG) and no expression of alpha-, beta-, gamma-, and delta-SG proteins are useful for developing the potential gene therapy of intractable heart failure. We prepared recombinant adeno-associated virus vector including normal delta-SG gene driven by CMV promoter and intramurally administered in vivo. The transfected myocardium induced robust expression of both transcript and transgene for 2/3 period of the animal's life expectancy. Immunostaining demonstrated reexpression of not only delta-SG but also other three SGs in 40% cells in the transfected region and normalization of the diameter of transduced cardiomyocytes. Hemodynamic study revealed preferential amelioration of the diastolic indices (LVEDP, the dP/dt(min) and CVP). These results provide the first evidence that supplementation of a specific gene with efficient and sustained transfection capability restores the genetic, morphological, and functional deteriorations.

[Detection of prostate cancer in urological practice: clinical establishment of serum PSA reference values by age].

BACKGROUND: Determinations of serum levels of prostate specific antigen (PSA) are widely used for the detection of prostate cancer, but have not demonstrated sufficient sensitivity and specificity to be useful in urological practice. In order to enhance the diagnostic value of serum PSA, we studied the distribution of serum PSA levels by age in urological patients without clinical evidence of prostate cancer and determined clinical PSA reference values by age decades. METHODS: The study included a total of 590 male patients aged 40 to 89 years who visited our urological clinic complaining of voiding symptoms from January 1991 to October 1994, but had no clinically evident prostate cancer. We defined patients to be without clinical evidence of prostate cancer if they had negative test results in digital rectal examination, ultrasonography, and serum PSA assay, or had positive test results in one or more of these tests but had a nonmalignant prostate biopsy. Serum PSA levels were measured by E-Test Tosoh II (AIA-PACK PA, normal range; 0 to 5.3 ng/ml). The patients were grouped by age decades and serum PSA values were given as percentiles. RESULTS: Analyzed by Pearson's correlation coefficient, serum PSA levels were correlated significantly with patient age (r = 0.24, p < 0.001). Prostatic volume was correlated weakly but significantly with patient age (r = 0.12, p = 0.005), and PSA density was also correlated significantly with patient age (r = 0.20, p < 0.001). Thus, serum PSA levels were demonstrated to increase with advancing patient age. Factors other than benign prostatic hypertrophy were also suggested to explain the increase in serum PSA levels in older patients. With the 95th percentile for serum PSA as the upper limit, the clinical PSA reference values by age decades were determined to be 2.6 ng/ml for patients aged 40 to 49 years, 5.0 ng/ml for 50 to 59 years, 7.5 ng/ml for 60 to 69 years, 10.1 ng/ml for 70 to 79 years, and 12.4 ng/ml for 80 to 89 years. CONCLUSION: We found a significant increase in serum PSA levels with advancing patient age. Thus, it is appropriate to have serum PSA reference values by age decades. Prospective clinical trials are necessary to define the usefulness of the PSA reference values by patient age in urological practice.

[Combination chemotherapy with POMB/ACE (cisplatin, vincristine, methotrexate, bleomycin, actinomycin D, cyclophosphamide, etoposide) in advanced non-seminomatous testicular tumor].

Four cases with non-seminomatous testicular tumor in stage III completed chemotherapy with POMB/ACE. Of these 4 cases, metastasis to retroperitoneal lymph nodes was found in all of them. In addition, metastasis to the lung was noted in 3, and to the left supraclavicular lymph nodes in one. After orchiectomy, 5 courses of POMB/ACE therapy were given to each of the 4 cases. Tumor marker returned to normal value in all of the cases after 3-4 courses of treatment, with disappearance of metastasis to the lung and supraclavicular lymph nodes. However, the response rate in metastasis to retroperitoneal lymph nodes was CR in one case, and PR in 3. Therefore, retroperitoneal lymph nodes were excised in all 3 cases. Histologically, 2 of the 3 were found to have necrotic tissues. The remaining one patient had teratoma. An additional 1-3 courses of POMB/ACE therapy were given to these 3 cases. These 4 cases are alive without recurrence 6 years and 4 months, 5 years and 8 months, 4 years and 9 months, and 2 years 9 months, respectively, after orchiectomy. Thus POMB/ACE therapy is considered to be a useful method in the treatment of advanced testicular tumor.

[A study of tumor location and prognosis in renal pelvic and ureteral cancer].

A total of 245 patients with renal pelvic and ureteral cancer (transitional cell carcinoma) were retrospectively analysed for tumor location and prognosis. In 133 renal pelvic cancer patients, 34 patients (25.6%) had tumor in lower calyx, 33 patients (24.8%) in renal pelvis, 31 patient (23.3%) in upper calyx, 21 patients (15.8%) in whole renal pelvis and 7 patients (5.2%) in middle calyx, respectively. In 128 ureteral cancer patients, 60 patients (46.9%) had tumor in lower ureter, 27 patients (21.1%) in distal end of ureter, 26 patients (20.3%) in middle ureter, 12 patients (9.4%) in upper ureter and 3 patients (2.3%) in whole ureter. In combination of tumor location, 101 patients (41.2%) had tumor in only renal pelvis, 94 patients (38.4%) had in only ureter, 14 patients (5.7%) had in renal pelvis and ureter, 19 patients (7.8%) had in renal pelvis and bladder, 12 patients (4.9%) had in ureter and bladder, and 5 patients (2%) had in renal pelvis, ureter and bladder. Five year survival rate of renal pelvic cancer according to tumor location were 55.9% in upper calyx tumor, 60.8% in middle calyx tumor, 63.8% in lower calyx tumor, 60.2% in renal pelvic tumor and 63.8% in PUJ tumor, respectively. There were no significant difference between those 5 groups. Five years survival rate of ureteral cancer according to tumor location, 90% in upper ureteral tumor, 60.8% in middle ureteral tumor, 66.5% in lower ureteral tumor and 52.6% in tumor of distal end of ureter, respectively. Also in those 4 groups, there were no significant difference.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognostic factors in patients with stage 4B renal cell carcinoma following nephrectomy].

We studied on prognostic factors in 106 patients with stage 4B renal cell carcinoma having distant metastases at the diagnosis. In this study, we excluded patients who died after nephrectomy within 30 days and those who died without cancer. As the result, significant differences were observed upon the 8 factors in those patients as summarized bellow: 1) The histological malignancy (grade): there observed an improved survival in patients with grade II compared to those with grade III and IV. 2) The opportunity of diagnosis: we classified the patients into 4 types: patients with urinary symptoms, those with non-urinary symptoms, those with metastatic symptoms and those with tumours found incidentally. There observed an improved survival in patients with tumours found incidentally compared to those with urinary symptoms and non-urinary symptoms. 3) The number of 5 laboratory findings such as anaemia, positive reaction of C-reactive protein (CRP), elevation of erythrocyte sedimentation rate (ESR), elevation of alpha 2-globulin and immunosuppressive acidic protein (IAP): there observed an improved survival in patients with less than 2 abnormal laboratory findings compared to those with more than 3. 4) The regional lymph node metastasis: there observed an improved survival in patients without lymph node metastasis compared to those with lymph node metastasis. 5) The number of metastatic organ: there observed an improved survival in patients with one organ metastasis compared to those with more than two. 6) The treatment modality: there observed an improved survival in patients receiving interferon (IFN) therapy/IFN plus chemotherapy than those receiving chemotherapy alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Renal gluconeogenesis in man: comparison with rats and rabbits.

To provide evidence on renal gluconeogenesis in humans and to compare with rats and rabbits, glucose production from several substrates was determined using cortical slices of the three species. In humans, the normal parts of kidney tissue were obtained from six cases of transitional cell carcinoma of the renal pelvis and four cases of renal cell carcinoma. Renal cortical slices were incubated aerobically with or without substrates, and the glucose contents were assayed photometrically. The specificity of human kidneys was evaluated by comparison with the results obtained from rats and rabbits. The rank order of renal gluconeogenesis from various substrates was as follows: Humans: pyruvate > oxaloacetic acid > lactic acid > fructose-1,6-diphosphate > L-glutamine. Rats: pyruvate > fructose-1,6-diphosphate > oxaloacetic acid > lactic acid > L-glutamine. Rabbits: fructose-1,6-diphosphate > pyruvate > oxaloacetic acid > lactic acid >> L-glutamine = 0. In general, the human kidney can produce glucose at the lowest rate among the three species. The substrate specificity of humans was more or less similar to that of rats. These results suggest the existence of a species difference in renal gluconeogenesis both in substrate specificities and quantitative activities.

[Conservative surgery for renal cell carcinoma].

During the nine years period from April 1984 through March 1993, we performed conservative surgery on 26 kidneys in 25 patients with renal cell carcinoma. Of these 25 patients the indication was imperative in 8 patients (the imperative group) and elective in 17 patients (the elective group). Eight patients of imperative group consisted of 5 patients with bilateral renal cell carcinoma (3 synchronous and 2 asynchronous), 1 patient who had renal cell carcinoma on one side and renal pelvic carcinoma on the other side, and 2 patients with renal cell carcinoma in a solitary kidney. In these 8 patients of the imperative group, conservative surgery was performed on 9 kidneys since 1 of 3 patients with synchronous bilateral renal cell carcinoma underwent the conservative surgery for both kidneys. In the elective group, all 17 patients had a small renal cell carcinoma, with the contralateral kidney normal in all. Enucleation was conducted on 4 kidneys out of 9 kidneys in 8 patients of the imperative group. On a total of 22 kidneys consisting of the remaining 5 kidneys and 17 kidneys of the elective group partial nephrectomy was done. The tumor size ranged from 0.9 to 7.0 cm (mean: 3.5 cm) for the imperative group and from 0.8 to 3.0 cm (mean: 2.3 cm) for the elective group. Thus, the tumor size was less than 3.0 cm in all of these 17 cases. As to the histologic atypia, 12 patients were classified as grade 1 and 14 patients as grade 2. None of the patients were classified as grade 3.(ABSTRACT TRUNCATED AT 250 WORDS)

[Conservative surgery for synchronous bilateral renal cell carcinoma: report of two cases].

We present two cases of synchronous bilateral renal cell carcinoma treated at Daisan Hospital. Case 1. A 63-year-old man was hospitalized in August 1988 because of right flank pain and fever. Diagnostic imaging showed a large tumor on the right kidney extending into the inferior vena cava, and a smaller one (3.0 cm diameter) on the left middle part. The patient underwent right radical nephrectomy with vena cana resection, and left tumor enucleation at the same time. Histology demonstrated renal cell carcinoma on both sides. The patient is alive without recurrence and with normal renal function 5 years and 1 month after the operation. Case 2. A 62-year-old man was hospitalized in August 1992 because of a feeling of abdominal distension. Diagnostic imaging showed a 3.5 cm diameter tumor on the right kidney, a 6.0 cm diameter tumor on the left kidney. The patient underwent bilateral partial nephrectomy at the same time. Histology demonstrated renal cell carcinoma on both sides. The patient is well without recurrence at 10 months after the operation. Conservative surgery proved effective therapy for patients with bilateral renal cell carcinoma.

[Computed tomography in the diagnosis of transitional cell carcinoma of the renal pelvis].

CT scans were carried out on 25 patients with transitional cell carcinoma of the renal pelvis. Of the 25 patients, tumors were identified in 24 patients (96%) and not in one patient on CT scan. Of the 24 patients the tumor was delineated as a solid mass in the renal pelvis and/or calyx in 15 and as an infiltrating mass in the renal parenchyma in 8 on CT scan. The depth of invasion was correctly estimated by CT in 18 of the 25 patients (72%). Whereas the tunica muscularis of the renal pelvis or the renal parenchyma was found involved in 3 of 10 patients (30%) in whom the diagnosis was made that the tumor was limited to the renal pelvic mucosa, the correct diagnosis was possible in 22 of 25 patients (88%) in whom the tumor was confined to the renal pelvic wall (pTa-pT2) or more invasive (pT3-pT4). In 6 of 7 patients with lymph nodes matastases enlarged lymph nodes were seen on the CT scan. In all 7 cases the primary tumor was classified as a pT3 or pT4 invasive disease. Based on the results presented above, it may be concluded that CT scan is valuable in making the diagnosis of transitional cell carcinoma of the renal pelvis and also in determining whether the tumor has invaded beyond the renal pelvic wall, thereby providing guidelines for the adequate treatment.

[Partial colpocleisis for vesicovaginal fistulas].

Four patients with a vesicovaginal fistula were operated upon transvaginally using the Latzko technique of partial colpocleisis. In 3 of the 4 patients, the fistulas had been formed after total hysterectomy for myoma uteri or endometriosis. The periods from fistulization-to-surgery intervals in these 3 patients were 4 months, 12 months, and 4 years and 4 months, respectively. The fistulas in the remaining one patient had been formed after forceps delivery. The patient underwent surgery 8 days after delivery. An indwelling catheter was retained for 3 to 14 days after surgery. The 4 patients were all cured of vesicovaginal fistulas after a single operation. This paper describes our partial colpocleisis technique and discusses its clinical utility. The partial colpocleisis has the advantages of dispensing with such procedures as fistula excision, fistula opening suture, and suturation of the bladder musculature, and of closing the fistulas using a demucosated vaginal wall. Having minimal surgical invasiveness and being easy to perform and reliable, the technique appears to be excellent for coping with vesicovaginal fistulas.

[Evaluation of prognostic factors in patients with stage 1 renal cell carcinoma].

During the past thirty-five years, we treated 221 patients with stage 1 renal cell carcinoma. We classified these patients into two groups: 175 patients who did not show recurrence and 45 patients who showed recurrence (excluding one patient who died of other disease). We investigated factors which affect the recurrence after nephrectomy and the survival after recurrence in these two groups. We found two major factors such as tumor diameter and tumor grade which affected the recurrence of renal cell carcinoma. Of these two factors, the grade of malignancy affected the prognosis of the patients with stage 1. Furthermore, as a result of long-term observation, we found that patients with grade I showed good prognosis compared with these with grade II, III and IV. The patients who showed weight loss constituted the majority of recurrent patients. Anaemia, erythrocyte sedimentation rate and positive reaction of C-reactive protein in addition to weight loss were major factors affecting the prognosis of stage 1 patients. In an effort to analysing the features of recurrent patients, there observed that no significant difference of the non-recurrent rate was detected between the patients who showed cancer death after nephrectomy and the patients who were living after nephrectomy. In analysing metastatic lesions and numbers of metastatic foci, we detected relatively long-term survival especially in patients with less than 3 foci of metastases in the lung, compared to those with multiple foci. Furthermore, we found dimension of the metastasis depended on the grade of the primary lesion.

Clinical study of patients with renal carcinoma surviving for more than 10 years after nephrectomy.

Of 207 patients with renal carcinoma we studied 50 who survived for more than 10 years after nephrectomy. These 50 patients were younger than the others at the time of operation and included more females. They had lower stage and lower grade tumours. Recurrence was detected in 18/50 patients and 6 died from cancer. Recurrence developed approximately 10 years after nephrectomy. Eleven patients with recurrences had metastases to a single organ and 9 received multidisciplinary treatment, mainly surgery and radiotherapy. The survival rate 10 years after nephrectomy was lower in patients with recurrences than in those without recurrent tumours and there was a significant decrease in the survival rate 17 years after nephrectomy. Although the patients had low grade and low stage tumours 10 years after nephrectomy, careful follow-up is recommended in such cases as it is possible that they may have dormant tumours.

[Bilateral adrenal metastasis from renal cell carcinoma].

A case of renal cell carcinoma with synchronous bilateral adrenal metastasis occurring in a 76-year-old woman is reported. In our case, preoperative computed tomographic evaluation revealed the presence of bilateral adrenal metastasis, and simultaneous right radical nephrectomy and contralateral adrenalectomy were performed. Pathological examination revealed renal cell carcinoma of right kidney metastasizing to both adrenal glands. Bilateral adrenal metastasis from renal cell carcinoma is rare. Our case seems to be the fourth case in the Japanese literature.

[A comparative clinical trial of UFT treatment and intravesical adriamycin instillation to prevent recurrence of superficial bladder cancer].

UFT was administered to 27 patients with superficial bladder cancer and adriamycin administered intravesically to 26 patients with the same cancer as a measure to prevent the recurrence of the tumor following transurethral resection, and the rate of recurrence was compared between the two groups of patients. There was no significant difference between the two groups in background factors (e.g., primary or recurrent, single or multiple), histological malignancy and degree of infiltration. The non-relapsers accounted for 88.9% of patients at one year, 64.3% at two years, and 64.3% at three years in the UFT group and 96.2%, 76.8%, and 65.5%, respectively, in the adriamycin group. There was no significant difference in the rate of non-recurrence between the two groups; nor was there significant difference in the non-recurrence rate between them with respect to any of the background factors. UFT showed results which compared with those of adriamycin administered intravesically, and UFT was considered useful for preventing recurrence of superficial bladder cancer.

[Single-dose treatment of tosufloxacin (TFLX) for acute uncomplicated cystitis].

The effectiveness of a single 300-mg dose of tosufloxacin and of 3-day treatment with tosufloxacin (300 mg daily) were compared in a prospective trial in order to clarify the cost-effectiveness of tosufloxacin for acute uncomplicated cystitis. Fifty female patients (25 patients of each group) with acute uncomplicated cystitis received one of these treatment regimens, and the clinical data and follow-up culture results were analyzed. The effectiveness rates of single-dose treatment and 3-day treatment after 3 days were 100% and 96%, respectively. The recurrence rates of single-dose treatment and 3-day treatment after 14 or 28 days were 0% (0/13 patients) and 15% (2/13 patients), respectively. There was no significant difference in the effectiveness rate and the recurrence rate between these two groups, statistically. All isolated strains were eliminated in both regimens. From these results, it is suggested that single-dose treatment of tosufloxacin is effective enough for acute uncomplicated cystitis.

[Pyelolymphatic backflow complicating acute hemorrhagic cystitis: a case report].

The clinical course of a case of pyelolymphatic backflow complicated with acute hemorrhagic cystitis is reported. The patient was a 19-year-old woman. She had disturbed passage in the intravesical ureter due to acute hemorrhagic cystitis caused by adenovirus. Pyelolymphatic backflow occurred because of increased pelvic pressure.

Alterations of gluconeogenesis by ischemic renal injury in rats.

This study was designed to determine changes in one metabolic function, gluconeogenesis (GLG), after ischemic renal injury. Tubule suspensions were prepared by collagenase treatment of SD rat kidneys on 1, 3, and 7 days after left renal artery and vein occlusion for 0-90 min and incubated in Krebs-Henseleit buffer with or without 2 mM pyruvate or malate aerobically. Glucose contents were assayed photometrically. On days 1 and 3 after ischemia for longer than 60 min, serum creatinine levels rose significantly. The tendency of increase of GLG was observed on days 1 and 3 after 10-60 min of ischemia. GLG increased significantly on day 1 after 30-min ischemia. On the other hand, GLG decreased significantly on day 1 after 90-min treatment. Morphologic damage was limited to the corticomedullary region on days 1 and 3 after ischemic times of 30 and 60 min. These results suggest that renal GLG is stimulated to supply energy for ATP decrease by ischemia and for further regeneration in extraproximal segments along the nephron.

Adjuvant chemotherapy with vinblastine, adriamycin, and UFT for renal-cell carcinoma.

VAU therapy (vinblastine, Adriamycin, and UFT) was given postoperatively to 31 patients with stage I, II, or III renal-cell carcinoma, and the incidence of relapse as well as the survival of patients were studied. Administration was started at 7-14 days post-surgery; 5 mg/m2 vinblastine and 30 mg/m2 Adriamycin were given i.v. once every 4 weeks for a total of five courses, and three capsules of UFT (containing 300 mg tegafur) were given p.o. every day for 2-3 years. The postoperative observation period ranged from 2 years and 6 months to 7 years and 1 month (mean, 4 years and 2 months). The 1-year survival of patients was 100%, and the 3- and 5-year survival values were 96%. These results were significantly better (P less than 0.01) than the respective values (81%, 72%, and 60%) obtained for the historical controls, i.e., the 60 patients with stage I, II, or III renal-cell carcinoma who received no chemotherapy. Side effects such as alopecia, gastrointestinal symptoms, and myelosuppression were encountered, but all symptoms were so mild and transient that discontinuation of the treatment was not necessary. As VAU therapy might be useful as adjuvant chemotherapy for renal-cell carcinoma, it seems to merit further study.

[Study of the combined M-VAC therapy in invasive bladder cancer].

We carried out combined M-VAC therapy in 12 patients with invasive bladder cancer without metastatic foci, and studied mainly the pathohistological findings and side effects before and after chemotherapy. There were 9 male cases and 3 female cases who were between 53 and 76 years old, and 66 years old on the average. After admission, 1 or 2 courses of M-VAC therapy were performed after confirmation of the pathological tissues by transurethral resection of bladder tumor (TUR-BT), and then total cystectomy (in 6 cases) or TUR-BT (in 6 cases) was conducted after 15 days on the average. According to the combined M-VAC therapy, down-stage was noted in 6 cases (50%) and down-grade in 6 cases (50%). Side effects such as anorexia, nausea and leukopenia were noted in all cases, and depilation, vomiting and thrombopenia were frequently noted. However, all these cases were transient without any serious trouble. The usefulness of the combined M-VAC therapy in invasive bladder cancer was proven, and the possibility of elevating the therapeutic response by surgery with lesser invasion was suggested.