Adding glucose to food and solutions to enhance fructose absorption is not effective in preventing fructose-induced functional gastrointestinal symptoms: randomised controlled trials in patients with fructose malabsorption.

BACKGROUND: In healthy individuals, the absorption of fructose in excess of glucose in solution is enhanced by the addition of glucose. The present study aimed to assess the effects of glucose addition to fructose or fructans on absorption patterns and genesis of gastrointestinal symptoms in patients with functional bowel disorders. METHODS: Randomised, blinded, cross-over studies were performed in healthy subjects and functional bowel disorder patients with fructose malabsorption. The area-under-the-curve (AUC) was determined for breath hydrogen and symptom responses to: (i) six sugar solutions (fructose in solution) (glucose; sucrose; fructose; fructose + glucose; fructan; fructan + glucose) and (ii) whole foods (fructose in foods) containing fructose in excess of glucose given with and without additional glucose. Intake of fermentable short chain carbohydrates (FODMAPs; fermentable, oligo-, di-, monosaccharides and polyols) was controlled. RESULTS: For the fructose in solution study, in 26 patients with functional bowel disorders, breath hydrogen was reduced after glucose was added to fructose compared to fructose alone [mean (SD) AUC 92 (107) versus 859 (980) ppm 4 h-1 , respectively; P = 0.034). Glucose had no effect on breath hydrogen response to fructans (P = 1.000). The six healthy controls showed breath hydrogen patterns similar to those with functional bowel disorders. No differences in symptoms were experienced with the addition of glucose, except more nausea when glucose was added to fructose (P = 0.049). In the fructose in foods study, glucose addition to whole foods containing fructose in excess of glucose in nine patients with functional bowel disorders and nine healthy controls had no significant effect on breath hydrogen production or symptom response. CONCLUSIONS: The absence of a favourable response on symptoms does not support the concomitant intake of glucose with foods high in either fructose or fructans in patients with functional bowel disorders.

Pubertal stage and hypoglycaemia counterregulation in type 1 diabetes.

AIMS: To compare physiological and autonomic responses to acute hypoglycaemia in diabetic children in pre-, mid-, and post-pubertal stages of development. METHODS: Twenty seven children (8 pre-pubertal, 7 mid-pubertal, 12 post-pubertal) with type 1 diabetes were studied. Hypoglycaemia was induced by insulin infusion until an autonomic reaction (R) was identified. Counterregulatory hormone levels were measured at baseline, R, R+15, and R+30 minutes. Haemodynamic changes and sweat production were measured. RESULTS: The mean blood glucose level at R was lower in pre-pubertal than mid-pubertal children (2.0 v 2.5 mmol/l), and was positively correlated with HbA1c. Glucagon and noradrenaline responses to hypoglycaemia were minimal in all children. A brisk increase in pancreatic polypeptide (PP) concentration only occurred in post-pubertal children. Only two children showed a sweating response to hypoglycaemia. CONCLUSIONS: The blood glucose level at which sympatho-adrenal responses to hypoglycaemia were activated was associated with glycaemic control, and varied with pubertal stage. As in adults, the glucagon response to hypoglycaemia was deficient within a few years of developing diabetes. However, sweating and secretion of PP in response to hypoglycaemia did not occur until after puberty, indicating some qualitative differences from adults.

Adenoviral infections and a prospective trial of cidofovir in pediatric hematopoietic stem cell transplantation.

Adenoviral (ADV) infections are increasingly recognized as a cause of morbidity and mortality in pediatric hematopoietic stem cell transplantation (HSCT). We reviewed our experience with ADV infections in HSCT patients hospitalized for transplantation at Childrens Hospital Los Angeles January 1998 through December 1998. ADV was detected in 47% of patients, with recipients of HSCT from alternative donors (matched unrelated, unrelated cord, and mismatched related donors) being more frequently culture positive than recipients of HSCT from matched siblings (62% versus 27%, P = .04). Detection of ADV from 2 or more sites was associated with organ injury, eg, hemorrhagic cystitis, enteritis, and hepatitis. Because of the high incidence of ADV culture-positive patients and the lack of effective anti-ADV therapy, we initiated a prospective trial to evaluate cidofovir (CDV) in the treatment of ADV infections in HSCT recipients. Eight patients were enrolled on a dosage schedule of 1 mg/kg 3 times weekly. AD of these patients eventually achieved long-term viral suppression and clinical improvement, although 6 patients needed prolonged CDV therapy for up to 8 months before CDV could be stopped without ADV recurrence. We did not observe dose-limiting nephrotoxicity, and the discontinuation of the drug was not required in any patients. Prospective controlled trials to further define the role of CDV in the treatment of ADV infections in HSCT patients are warranted.

Child and parental mental ability and glycaemic control in children with Type 1 diabetes.

AIMS: Many psycho-social factors can affect the glycaemic control of children with Type 1 diabetes, but the influence of the intelligence of the child and their parents has not been reported. METHODS: Seventy-eight children and adolescents with Type 1 diabetes and their mothers performed standardized tests to assess psychometric intelligence. The children were aged (median (range)) 12.0 (5-17) years with duration of diabetes 5.0 (1.0-13.0) years and required an insulin dose of (mean +/- SD) 1.0 +/- 0.3 U/kg per day. The children completed the Wide Range Achievement Test 3 reading test (WRAT3) and Raven's Standard Progressive Matrices (RSPM). A mean annual HbA1c was calculated for each subject (8.6 +/- 1.4%). The mothers performed the National Adult Reading Test (NART) and provided details of the occupation of the main wage-earner in the family from which social class (SC) was derived. RESULTS: The HbA1c of the child correlated with their age (r = 0.26, P = 0.02), SC (Kendall's rank correlation, tau = 0.17, P = 0.03) and with the NART error score of their mother (r = 0.28, P = 0.01), but no correlation was observed with the child's WRAT3 or RSPM score. Stepwise regression revealed that age and NART error score were the strongest independent determinants of glycaemic control (total adjusted r2 = 0.117). CONCLUSIONS: Parental intelligence appears to have a significant influence on the glycaemic control of a child with Type 1 diabetes, accounting for 7.6% of the reliable variance in HbA1c.

Paecilomyces variotii in a pediatric patient with lung transplantation.

Aspergillus has been noted to be the most common species of filamentous fungus isolated from the airways of lung transplantation (Tx) patients. In general, the bronchi are colonized asymptomatically with Aspergillus but this places such a patient population at greater risk of invasive infection. Other filamentous fungal species may also assume importance in this patient population. Here we report the post-transplant isolation of Paecilomyces variotii from the airways of a pediatric patient with cystic fibrosis (CF) who underwent bilateral living-donor lobar lung Tx. This is the first report of isolation of P. variotii in the pediatric lung Tx population. The isolation of filamentous fungi, such as Paecilomyces, with variable in vitro susceptibility to currently available antifungal agents further complicates the approach to post-transplant antifungal therapy in patients with lung Tx.

Familial glomerulonephropathy in a litter of beagles.

Membranoproliferative glomerulonephropathy was diagnosed in 5 of 7 adult Beagles from the same litter. Dogs were raised in more than 1 area of the United States. One died without evidence of renal disease when it was 3 years old. At 8 years of age, 2 dogs developed signs of uremia, including polyuria, polydipsia, and infrequent episodes of anorexia and vomiting. Serum biochemical variables and urine specific gravity values were consistent with renal azotemia. Both dogs had proteinuria. Although healthy, 3 of the 4 remaining Beagles had proteinuria. Of these 3, only 1 was azotemic. Membranoproliferative glomerulonephritis was diagnosed on the basis of results of histologic examination of renal biopsy specimens from 4 of the dogs. Electron microscopy performed on 3 of the renal biopsy specimens revealed identical lesions, consisting of an extremely thickened glomerular basement membrane with multilaminar splitting. Immunoglobulin or amyloid deposits were not detected. On the basis of similar clinicopathologic abnormalities, common genetic background, and identical histopathologic and electron microscopic findings, familial renal disease was diagnosed. Additional studies involving other related Beagles are needed to identify the hereditary nature of membranoproliferative glomerulonephropathy in Beagles.

Psychological effects of hormone replacement therapy: a comparison of tibolone and a sequential estrogen therapy.

Hormone replacement therapy (HRT) is effective in alleviating vasomotor symptoms but the effect on psychological symptoms is less clear. This study aimed to compare the psychological effects of two regimens of HRT in perimenopausal women in a randomized, initially double-blind, controlled trial. Thirty-eight women reporting climacteric symptoms were randomly allocated into either oral conjugated equine estrogen 0.625 mg daily plus progestogen (norgestrel) 150 micrograms for the last 12 days of each 28 day cycle, or tibolone 2.5 mg/day for 28 days. They were assessed using standardized psychological assessments. There were no significant differences in changes from baseline between the two types of therapy. For both groups combined there were significant improvements compared with baseline in vasomotor symptoms in the first month, plus anxiety, sleep, memory and somatic dysfunction by the second and third months, but not in scores of depression. Log linear analysis of weekly scores showed that depression scores were significantly related to improvement in vasomotor scores independent of type of therapy and time on HRT. Memory problems were related to vasomotor symptoms independent of depression. No difference between the two types of therapy was found, nor any direct effect of HRT on anxiety or depression. The results support the domino theory, suggesting that psychological improvement follows alleviation of vasomotor symptoms.

Hypoglycaemic symptoms reported by children with type 1 diabetes mellitus and by their parents.

To compare the hypoglycaemic symptoms reported by children with Type 1 diabetes and signs observed by and symptoms reported to their parents, 101 pairs, consisting of a child with diabetes and one of their parents, were asked to report the frequency with which they experienced, or witnessed, each of 31 symptoms during hypoglycaemia. The hypoglycaemic symptoms reported by the children and the reported symptoms and signs observed by their parents were classified, using multivariate statistical analyses, and compared. Close agreement was observed between the children and their respective parents' scores for frequencies of most symptoms/signs, as demonstrated by Spearman's rank correlations (median tau s = 0.25, p < 0.02). Principal Components Analysis of the symptoms/signs observed by the parents showed three factors: autonomic, neuroglycopenic, and behavioural disturbance. Analysis of the symptoms experienced by the children also identified three factors: behavioural disturbance, malaise and a third factor consisting of a combination of autonomic and neuroglycopenic symptoms. The parents could differentiate three separate groups of reported hypoglycaemic symptoms and signs (autonomic, neuroglycopenic, and behavioural disturbance) in their children. The children reported a similar group of behavioural symptoms but did not discriminate between autonomic and neuroglycopenic symptoms. These findings have important implications for the education of parents and children with Type 1 diabetes regarding the symptoms and signs of hypoglycaemia.

Myelopathy resulting from invasive aspergillosis.

Aspergillus, a ubiquitous mold, may cause invasive and fatal disease in immunosuppressed patients. Myelopathy is an uncommon presentation of invasive aspergillosis. This report describes three children admitted to the hospital between 1988 and 1995 who developed myelopathy as the first evidence of invasive aspergillosis. All had advanced leukemia and were profoundly immunosuppressed because of chemotherapy and broad-spectrum antibiotics. Weakness and pain presented first; then, sensation to pain and temperature was lost 2 to 6 days later, followed by complete myelopathy. Multiple brain lesions were seen on magnetic resonance imaging in one patient. Despite antifungal therapy, aspergillosis proved fatal within 1 month of onset of myelopathy in all patients. Physicians caring for immunocompromised children should be aware of myelopathy as a presentation of invasive aspergillosis.

Elderly patients' perceptions of their spiritual needs and care: a pilot study.

This paper describes a pilot study, in a small sample of elderly patients, designed to ascertain their perceptions of their spiritual needs and care. According to the nursing literature, spiritual care is part of the nurse's role. But it is not clear what spiritual needs are or how nurses are expected to give spiritual care. Ten patients from a care of the elderly assessment unit located in a hospital in Edinburgh, Scotland were interviewed about their spiritual needs in the summer of 1995. Eight patients admitted to having experienced spiritual needs at some time in their lives, six while in hospital. The types of needs experienced related to religion, meaning, love and belonging, morality, and death and dying. Their spiritual needs could have been better met if, for example, a quiet room for reflection/prayer had been available and if they had been told about hospital church services and provided with transport to attend. Although limited, the findings contribute to our understanding of spiritual need and spiritual care from the elderly in-patients' view point. Further research, however, is needed to explore the type of spiritual help other elderly patients and other patient groups in different geographical locations feel they would like.

Computed tomography and magnetic resonance imaging of cavernous sinus enlargement in a dog with unilateral exophthalmos.

Computed tomography (CT), magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) were performed on a dog with a two year history of unilateral exophthalmos occurring two years following head trauma. On CT images, an expansile enhancing mass was present along the right intracranial cavernous sinus and extended through the orbital fissure into the retrobulbar space. With MRI, the structure appeared as a signal void due to the presence of rapidly flowing blood. Gadolinium enhancement of the adjacent brain was not present. A vascular origin of the lesion was confirmed with MRA. Based on the CT and MRI findings, the enlarged cavernous sinus and associated ophthalmic plexus were believed to represent an arterialized aneurysm, most likely the result of traumatic arteriovenous fistulization. Treatment consisted of surgical enucleation. At the time of this report, 29 months later, the dog remains free of clinical signs.

Teaching spiritual care to nurses.

In this paper a number of issues related to the teaching of spiritual care to nurses are considered. The spiritual dimension influences health and well-being. Research shows that patients considered their spiritual needs of importance. Nurses held a similar view but felt the need for further education to help them give spiritual care. The nursing literature suggests that spiritual care is part of the nurse's role and guidelines for nurse education state that it should be taught to nurses. It is not clear, however, if or how the subject is taught or how effective such teaching is in helping nurses to give spiritual care. The ways in which spiritual care could be taught are explored.

Household contact study of Bordetella pertussis infections.

Household contacts of primary pertussis cases were evaluated. Infection was determined by culture, direct fluorescent antibody assay, and serological criteria. Agglutinin titers and values of ELISA IgG and IgA antibodies to lymphocytosis-promoting factor, filamentous hemagglutinin, and pertactin were determined. In 39 households 255 subjects were exposed; 114 remained well (group 1), 53 had mild illness (group 2), and 88 had pertussis (group 3). The infection rates were 46% (group 1), 43% (group 2), and 80% (group 3). In a subgroup of subjects seen within 14-28 days of exposure, it was found that none with clinical pertussis had a value of IgG antibody to pertactin in acute-phase sera of > or = 50 ELISA units (EU) per mL or an agglutinin titer of > 256. Of the primary cases, 53% were > or = 13 years of age. These data point out the importance of Bordetella pertussis infections in adolescents and adults as a source of infection in young children. Our subgroup data suggest that high values of antibody to pertactin and high agglutinin titers may be predictive of protection against clinical pertussis.

Tibolone and climacteric symptoms.

Tibolone (Livial) has advantages over other forms of hormone replacement therapy (HRT); it is easy to use and does not induce withdrawal bleeding in postmenopausal women. The evidence for the effect of tibolone on climacteric symptoms is reviewed and shows that tibolone is effective in reducing vasomotor symptoms and vaginal dryness. Tibolone's effect on a range of other symptoms such as headache and insomnia is unclear. There are reports that tibolone improves mood and libido but much of this research is methodologically flawed. Methodologically sound research is required to investigate tibolone's effect on mood and libido; such a study is in progress.

A comparative study of transfusion-acquired human immunodeficiency virus-infected children with and without disseminated Mycobacterium avium complex.

For identification of the features of disseminated Mycobacterium avium complex (DMAC) in human immunodeficiency virus (HIV)-infected children, a retrospective medical record review of 31 long-term survivors with transfusion-acquired HIV was conducted. Nine patients developed DMAC defined as positive isolation of M. avium complex from peripheral blood. DMAC was diagnosed in patients 51 to 132 months of age (mean, 101). The time from HIV-infecting transfusion to DMAC diagnosis ranged from 37 to 132 months (mean, 92) and survival from the time of DMAC diagnosis ranged from 4 to 21 months (mean, 10). Selected laboratory and clinical measures in DMAC-positive and DMAC-negative subjects were compared. DMAC-positive patients had significantly lower CD4+ T cell counts and higher HIV p24 antigen concentrations than DMAC-negative patients at comparable times. Increased percentages of circulating leukocyte band forms and increased aspartate aminotransferase values were seen more often in DMAC-positive patients. Fever and abdominal pain were the only clinical features seen more often in DMAC-positive than in DMAC-negative patients. At the end of the study period overall survival of DMAC-positive patients was less than that of DMAC-negative children, at 33% vs. 73%. DMAC occurs in profoundly immunocompromised children with advanced HIV disease and significantly affects survival. The clinical and laboratory features of DMAC are relatively nonspecific and a high index of suspicion in patients with markedly reduced CD4+ T cells is essential.

Orally administered clarithromycin for the treatment of systemic Mycobacterium avium complex infection in children with acquired immunodeficiency syndrome.

OBJECTIVE: To determine the safety, tolerance, pharmacokinetics, and antimycobacterial activity of orally administered clarithromycin in children with acquired immunodeficiency syndrome and disseminated Mycobacterium avium complex (MAC) infection. DESIGN: Phase I study with a 10-day pharmacokinetic phase followed by a 12-week continuation therapy phase. PATIENTS: Twenty-five patients with a median age of 8.3 years were enrolled. Ten were receiving zidovudine and 13 were receiving didanosine at the time of enrollment. INTERVENTION: Clarithromycin suspension was administered to each patient at one of three dose levels: 3.75, 7.5, and 15 mg/kg per dose every 12 hours. Clarithromycin and antiretroviral pharmacokinetics were measured during single-drug and concurrent-drug administration. Clinical and laboratory monitoring was performed biweekly. MEASUREMENTS AND MAIN RESULTS: Clarithromycin was well tolerated at all dose levels. Plasma clarithromycin concentrations increased proportionately with increasing doses, and significant pharmacokinetic interactions were not observed during concurrent administration with zidovudine or didanosine. Decreases in mycobacterial load in blood were observed only at the highest clarithromycin dose level. Decreased susceptibility to clarithromycin developed rapidly (within 12 to 16 weeks) in the majority of MAC strains isolated from study patients.

Aspergillosis of the posterior mediastinum.

Invasive pulmonary Aspergillus, although rare in the general population, represents an important cause of morbidity and mortality among immunosuppressed patients. However, mediastinal invasion by Aspergillus is very uncommon, with few cases documented in the literature. Among 13 immunosuppressed pediatric patients recently diagnosed with invasive pulmonary aspergillosis, 3 have had posterior mediastinal invasion with severe complications. Rupture of a mycotic aortic aneurysm occurred in 2 patients, one of whom was operated on successfully. The infection involved the spinal cord with severe neurologic sequelae in 2 patients. We report our experience to make our colleagues aware of this problematic disease, which may be more prevalent in the current population of highly immunosuppressed pediatric patients.

Investigation of an epidemic of invasive aspergillosis: utility of molecular typing with the use of random amplified polymorphic DNA probes.

When seven immunocompromised patients developed invasive aspergillosis during construction at a hospital, new methods were performed to compare fungal isolates and a case-control study was conducted to determine risks for infection. Typing of Aspergillus flavus with the use of restriction endonuclease analysis and restriction fragment length polymorphism using random amplified polymorphic DNA reactions to generate DNA probes revealed different patterns between isolates from two patients and a similar pattern among those from one patient, a health care worker, and an environmental source. Case patients were more likely than controls to have longer periods of hospitalization (median, 83 vs. 24 days; P < 0.01), neutropenia (median, 33 vs. 6 days; P < 0.05), and exposure to broad spectrum antimicrobials (median, 56 vs. 15 days; P = 0.08). No patients restricted to protected areas developed aspergillosis. Risk of exposure of immunocompromised patients to opportunistic organisms stirred up by construction activity may be decreased by admitting these patients to protected areas away from construction activity and by restricting traffic from construction sites to these areas. Although typing of A. flavus isolates did not reveal a single type or source of organism responsible for infection, this method may facilitate epidemiologic investigation of possible nosocomial sources and transmission in similar settings.