Ultrasonographic predictors of esophageal varices.

OBJECTIVE: The aim of this study was to identify ultrasonographic predictors of esophageal varices (EVs) in children and adolescents with chronic liver disease (CLD) and extrahepatic portal venous obstruction (EHPVO). METHODS: This study evaluates 53 patients younger than 20 years with CLD or EHPVO and no history of bleeding or prophylactic EVs treatment. They were divided into 2 groups: group I (35 with CLD) and group II (18 with EHPVO). Splenorenal shunt (SS), gallbladder wall varices, gallbladder wall thickening (GT), and lesser omental thickness (LOT) were compared with the presence of EVs, gastric varices, and portal hypertensive gastropathy (PHG). Univariate (χ² test, Fisher exact test, and Wilcoxon signed rank test) and multivariate (logistic regression) analyses were performed. The area under the receiver operating curve was calculated. RESULTS: EVs were observed in 48.5% of patients with CLD and in 83.3% of patients with EHPVO. SS (P = 0.0329) and LOT (P = 0.0151) predicted EV among patients with CLD. A median of 5.3 mm of LOT was considered a predictor of EVs among these patients. Multivariate analysis showed SS as an independent predictor of EVs in patients with EHPVO (odds ratio 15). Gallbladder varices (P = 0.0245) and GT (P = 0.0289) predicted EVs among patients with EHPVO. PHG occurred more often among patients with CLD who had SS (P = 0.0384) and greater LOT (P = 0.0226). CONCLUSIONS: SS and a greater LOT were indicative of EV among children and adolescents with CLD. Gallbladder varices and GT were indicative of EVs among patients with EHPVO. SS and a greater LOT were indicative of PHG among patients with CLD.

Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002.

OBJECTIVE: To use publicly available secondary data to assess the impact of Brazil's Family Health Program on state level infant mortality rates (IMR) during the 1990s. DESIGN: Longitudinal ecological analysis using panel data from secondary sources. Analyses controlled for state level measures of access to clean water and sanitation, average income, women's literacy and fertility, physicians and nurses per 10,000 population, and hospital beds per 1,000 population. Additional analyses controlled for immunisation coverage and tested interactions between Family Health Program and proportionate mortality from diarrhoea and acute respiratory infections. SETTING: 13 years (1990-2002) of data from 27 Brazilian states. MAIN RESULTS: From 1990 to 2002 IMR declined from 49.7 to 28.9 per 1,000 live births. During the same period average Family Health Program coverage increased from 0% to 36%. A 10% increase in Family Health Program coverage was associated with a 4.5% decrease in IMR, controlling for all other health determinants (p<0.01). Access to clean water and hospital beds per 1,000 were negatively associated with IMR, while female illiteracy, fertility rates, and mean income were positively associated with IMR. Examination of interactions between Family Health Program coverage and diarrhoea deaths suggests the programme may reduce IMR at least partly through reductions in diarrhoea deaths. Interactions with deaths from acute respiratory infections were ambiguous. CONCLUSIONS: The Family Health Program is associated with reduced IMR, suggesting it is an important, although not unique, contributor to declining infant mortality in Brazil. Existing secondary datasets provide an important tool for evaluation of the effectiveness of health services in Brazil.

Vancomycin-resistant Enterococcus faecium isolates causing hospital outbreaks in northern Italy belong to the multilocus sequence typing C1 lineage.

Multilocus sequence typing (MLST) was used to obtain insights into the genetic relationships between 14 vancomycin-resistant Enterococcus faecium (VREF) isolates from humans (hospitalized patients, 5 strains) and nonhuman sources (meat and poultry, 9 strains) in northern Italy over the period 1993-2001. The typing scheme (Homan et al., 2002, J. Clin. Microb., 40:1963-1971) based on seven housekeeping genes--adk (adenylate kinase), atpA (ATP synthase, alpha subunit), ddl (D-alanine-D-alanine ligase), gyd (glyceraldehyde-3-phosphate dehydrogenase), gdh (glucose-6-phosphate dehydrogenase), purK (phosphoribosylaminoimidazole carboxylase ATPase subunit), and pstS (phosphate ATP-binding cassette transporter)--was used. In the 14 VREF analyzed, the number of unique alleles ranged from 1 (gyd) to 8 (atpA). Isolates from hospitalized patients were defined by the unique allele purK 1. Nine sequence types (STs) were identified. All of the epidemic strains isolated over the period 2000-2001 showed identical or closely related pulsed-field gel electrophoresis (PFGE) patterns and clustered in the same ST78. These strains shared six of the seven alleles with the strain CA20 representative of the 1993-1999 outbreaks, which PFGE indicated as being unrelated to those of the recent outbreaks. MLST confirmed the unrelatedness of human and nonhuman strains already detected by PFGE. All isolates clustered in three main genetic lineages: group A comprised two of the three isolates from meat; group C the human strains of all outbreaks and one poultry strain; and group B four of the five poultry strains and one meat strain. All human strains carried the esp gene and clustered in the C1 sublineage that has been described as having emerged recently worldwide.

Evaluation of the VITEK 2 system for identification and antimicrobial susceptibility testing of medically relevant gram-positive cocci.

A study was conducted to evaluate the new VITEK 2 system (bioMérieux) for identification and antibiotic susceptibility testing of gram-positive cocci. Clinical isolates of Staphylococcus aureus (n = 100), coagulase-negative staphylococci (CNS) (n = 100), Enterococcus spp. (n = 89), Streptococcus agalactiae (n = 29), and Streptococcus pneumoniae (n = 66) were examined with the ID-GPC identification card and with the AST-P515 (for staphylococci), AST-P516 (for enterococci and S. agalactiae) and AST-P506 (for pneumococci) susceptibility cards. The identification comparison methods were the API Staph for staphylococci and the API 20 Strep for streptococci and enterococci; for antimicrobial susceptibility testing, the agar dilution method according to the procedure of the National Committee for Clinical Laboratory Standards (NCCLS) was used. The VITEK 2 system correctly identified to the species level (only one choice or after simple supplementary tests) 99% of S. aureus, 96.5% of S. agalactiae, 96.9% of S. pneumoniae, 92.7% of Enterococcus faecalis, 91.3% of Staphylococcus haemolyticus, and 88% of Staphylococcus epidermidis but was least able to identify Enterococcus faecium (71.4% correct). More than 90% of gram-positive cocci were identified within 3 h. According to the NCCLS breakpoints, antimicrobial susceptibility testing with the VITEK 2 system gave 96% correct category agreement, 0.82% very major errors, 0.17% major errors, and 2.7% minor errors. Antimicrobial susceptibility testing showed category agreement from 94 to 100% for S. aureus, from 90 to 100% for CNS, from 91 to 100% for enterococci, from 96 to 100% for S. agalactiae, and from 91 to 100% for S. pneumoniae. Microorganism-antibiotic combinations that gave very major errors were CNS-erythromycin, CNS-oxacillin, enterococci-teicoplanin, and enterococci-high-concentration gentamicin. Major errors were observed for CNS-oxacillin and S. agalactiae-tetracycline combinations. In conclusion the results of this study indicate that the VITEK 2 system represents an accurate and acceptable means for performing identification and antibiotic susceptibility tests with medically relevant gram-positive cocci.