A rare case of paediatric stridor caused by achalasia.

OBJECTIVE: This paper reports a case of achalasia in a 12-year-old girl who presented with stridor. CASE REPORT: An otherwise healthy 12-year-old girl presented to the ENT clinic with an 18-month history of dysphagia and noisy breathing on eating. Flexible fibre-optic examination showed a normal larynx with normal vocal fold movements. Fibre-optic endoscopic evaluation of swallowing was normal initially, but biphasic stridor occurred after several swallows. Microlaryngoscopy, bronchoscopy and upper oesophagoscopy showed a dilated oesophagus with normal mucosa. Bronchoscopy showed tracheomalacia of the distal trachea, which reduced the airway by approximately 75 per cent. This was caused by posterior compression from redundant oesophageal mucosa with dilatation as a result of retained fluids. Videofluoroscopy suggested achalasia, which was confirmed by oesophageal manometry. Her symptoms improved following a Heller's myotomy. CONCLUSION: This is the first paediatric case in the English literature of achalasia presenting with stridor. The condition was correctable with surgical intervention.

The relationship of birthweight, muscle size at birth and post-natal growth to grip strength in 9-year-old Indian children: findings from the Mysore Parthenon study.

Foetal development may permanently affect muscle function. Indian newborns have a low mean birthweight, predominantly due to low lean tissue and muscle mass. We aimed to examine the relationship of birthweight, and arm muscle area (AMA) at birth and post-natal growth to handgrip strength in Indian children. Grip strength was measured in 574 children aged 9 years, who had detailed anthropometry at birth and every 6-12 months post-natally. Mean (standard deviation (s.d.)) birthweight was 2863 (446) g. At 9 years, the children were short (mean height s.d. -0.6) and light (mean weight s.d. -1.1) compared with the World Health Organization growth reference. Mean (s.d.) grip strength was 12.7 (2.2) kg (boys) and 11.0 (2.0) kg (girls). Weight, length and AMA at birth, but not skinfold measurements at birth, were positively related to 9-year grip strength (ß = 0.40 kg/s.d. increase in birthweight, P < 0.001; and ß = 0.41 kg/s.d. increase in AMA, P < 0.001). Grip strength was positively related to 9-year height, body mass index and AMA and to gains in these measurements from birth to 2 years, 2-5 years and 5-9 years (P < 0.001 for all). The associations between birth size and grip strength were attenuated but remained statistically significant for AMA after adjusting for 9-year size. We conclude that larger overall size and muscle mass at birth are associated with greater muscle strength in childhood, and that this is mediated mainly through greater post-natal size. Poorer muscle development in utero is associated with reduced childhood muscle strength.

Automated entry of hospital infection surveillance data.

OBJECTIVE: To assess the accuracy of an automated data entry system employing optical scanning technology and to provide an analysis of its costs as compared to manual data entry. DESIGN: The accuracy and cost of automated data entry of 100 surgical-wound infection surveillance questionnaires was compared to manual entry. SETTING: The Surgical Directorate, The Royal Hospitals, Belfast, Northern Ireland. RESULTS: The use of optical scanning technology greatly improved the speed and accuracy of data entry. The time spent by the keyboard operator on data entry was reduced substantially. For each surgical-wound infection questionnaire automatically processed, there was a saving in clerical time equivalent to $0.63. The automated data entry process resulted in a 22-fold productivity increase compared to manual data entry with validation. After validation, an error rate of < 0.2 errors per 1,000 responses was detected in automatically entered data compared to a rate of 12.4 errors per 1,000 responses for manually entered data. The automated system, including validation, provided a seven-fold productivity increase compared to "quick-and-dirty" manual data entry without validation. CONCLUSION: Hospital information technology systems may achieve total integration of data management, but realistically this would appear to be very much in the future. Until then, in view of the accuracy and substantial savings in time and money, we recommend the use of automated data entry technology. This system would be especially useful where data are transported from outlying hospitals to a central receiving center for collation and analysis.

Microbiological quality of ice in hospital and community.

A survey was undertaken in response to a report of a clinical infection which had been related to an ice-making machine on a hospital ward. A detailed study of the ice microflora of 27 ice-making machines was performed. In a subsequent survey, ice samples (N = 194) from establishments such as bars and hotels were examined for bacterial indicators of hygiene. Samples from hospital ice-making machines yielded low numbers of a wide range of potentially opportunistic micro-organisms, many of environmental rather than clinical origin. For ice sampled in the community, the total aerobic plate count (TAPC) at 37 degrees C for 95% of the samples was < 500 cfu/mL, and at 22 degrees C 75% had < 500 cfu/mL. Examination for coliforms showed that 69% of samples contained no coliforms, but 20% contained > 100 coliforms/100 mL. Escherichia coli was detected in three samples but in very low numbers. This report investigates the relevance of ice machines to the control of hospital infection, the hygiene of ice in the community, discusses the microbiological quality of ice and proposes possible guidelines.

An assessment of the hidden and total antibiotic costs of four parenteral cephalosporins.

The aim of this study was to compare the hidden costs, and their impact on total antibiotic costs, of ceftriaxone therapy with those of cefotaxime, ceftazidime and cefuroxime in nosocomial infection. The total antibiotic costs of 7-day standard courses of the 4 cephalosporins were compared. The costs were divided into 3 parts: (i) the cost of the drug itself; (ii) the preparation and administration (labour) costs; and (iii) the consumables and waste costs. The latter 2 costs together comprised the hidden cost of an antibiotic course. Hidden costs were higher for cefotaxime, ceftazidime and cefuroxime, which are normally administered 3 times a day, than for ceftriaxone, which is administered once daily. The percentage contribution of hidden costs to total antibiotic costs increased with decreasing antibiotic cost, and were lower with higher dosages of all antibiotics. With cefotaxime, ceftazidime and cefuroxime, and with ceftriaxone at the lower dosage given by bolus intravenous (IV) injection, the labour component of hidden costs exceeded the consumables/waste component. However, when costs were calculated for ceftriaxone administered at the higher dosage by IV infusion, the costs of consumables and waste were greater than the labour costs. Ceftriaxone had the lowest hidden costs of all the antibiotics studied. The total antibiotic cost of low dosage ceftriaxone (1 g per dose) was comparable with that of cefuroxime, and was substantially less than the costs of cefotaxime and ceftazidime. At the high ceftriaxone dosage (2g per dose), the total antibiotic cost of cefuroxime was less than that of ceftriaxone; however, the total antibiotic cost of ceftriaxone remained substantially less than that of cefotaxime or ceftazidime.

Detection of bacteraemia by the continuously monitoring BacT/Alert system.

AIMS: To analyse a continuously monitoring blood culture system with respect to the time to detection of various groups of organisms, their clinical importance, and the relative efficacy of the aerobic and anaerobic bottles. METHODS: Four thousand blood cultures were monitored and the information relating to the positive cultures was noted and analysed. RESULTS: Four hundred and seventy seven blood cultures were detected as positive, 81% (387/477) of which were detected within 48 hours. The most pathogenic organisms were detected in the shortest period, less pathogenic later and those generally regarded as contaminants last. Clinically important isolates were also detected earlier. Many positive blood cultures were detected in only one bottle of the set, even those regarded as clinically important. CONCLUSIONS: The management of continuously monitoring blood culture systems could be improved by considering time to detection trends. Clinicians should be aware of the relatively rapid detection of clinically important, positive blood cultures in relation to patient treatment.

Surveillance and management of infection in a haematology unit: use of an in-house clinical database.

An effective infection control surveillance programme is essential for the management of patients in a haematology unit. The programme can contribute to the production of antibiotic policies, the monitoring of current clinical practice and has potential in the cost analysis of infection. The use of a computerized database facilitates the management of such a programme. We describe an infection control database using dBASE IV software which runs on a personal computer. The system can accept data sets from other relevant databases and allows the generation of infection control data appropriate to the unit.

Computerised calculation of the true costs of antibiotic therapy.

A system for computerised calculation of the drug costs and hidden costs of antibiotic therapy is described. A previously developed method for costing antibiotic therapy was used to quantify hidden costs arising from intravenous administration, labour, serum antibiotic assays, monitoring of haematological and biochemical indices, and disposal of sharp instruments. These calculations were installed into a software system using spreadsheets (Microsoft Excel/Windows). Cost calculations were simplified as a result of automated calculation with centralised cost updating, a facility for new antibiotics, a facility for atypical regimens, availability to a number of users, password protection and a facility for multiple courses of intravenous antibiotic therapy.

Colonic bacteria and bacterial translocation in experimental colitis.

The indigenous intestinal flora and an intact mucosa are vital components of body defences against luminal pathogenic bacteria. Disruption of these defences in inflammatory bowel disease may permit bacterial translocation and contribute to disease severity. Support for this hypothesis comes from this study of a hapten-induced rat model of colitis. Induction of colitis was associated with a significantly increased colonic Gram-negative aerobic bacilli count. The results, expressed as log10 [colony-forming units per gram tissue] were: colitic 6.97-8.86 versus control 4.90-6.69 (P < 0.05). Colitis was also associated with a decreased Gram-positive cocci count at 4.00-8.04 versus control 6.45-8.30 (P < 0.05). Bacteria translocated to the mesenteric lymph nodes in five of eight colitic rats (P = 0.01), to the spleen in four (P = 0.04) and to the liver in five (P = 0.01) but to these organs in none of the eight control animals. There was a positive correlation between the severity of colonic inflammation and extent of bacterial translocation in colitic animals (rs = 0.86, P = 0.007).

Antibiotic pharmacoeconomics: an attempt to find the real cost of hospital antibiotic prescribing.

Antibiotics account for a large part of all hospital pharmacy budgets, but the actual cost of their prescription is unknown. These costs include intravenous administration, labour, serum antibiotic assay, monitoring of haematological and biochemical indices, disposal of sharps and adverse effects. An in-house method of costing antibiotic therapy is presented, to quantify these hidden expenses. Since not only an awareness, but an accurate quantification, of hidden costs is required, a study of various hospital procedures relating directly to antibiotic therapy was undertaken in an acute medical ward; this involved the identification of particular staff members performing various procedures, consumables used and time taken. The cost of five-day courses of gentamicin, penicillin G, ampicillin, flucloxacillin, cefuroxime, ceftotaxime and erythromycin has been calculated; drug and hidden costs for each are presented graphically for comparison. The breakdown cost for gentamicin is presented to illustrate the method. The costing of adverse effects has not been attempted. We suggest that costings of this sort are used in cost-benefit analysis of antibiotic use. These calculations have been incorporated into a computer spreadsheet and this costing service will be offered to clinical areas of our hospital.

Technique for calculation of the true costs of antibiotic therapy.

An in-house method for costing antibiotic therapy is presented which quantifies hidden costs including costs arising from intravenous administration, labour, serum antibiotic assay, monitoring of haematological and biochemical indices and disposal of sharp instruments. A study of various hospital procedures relating directly to antibiotic therapy was undertaken in an acute medical ward, which involved determination of staff members performing various procedures, consumables used and time taken. Results of this study facilitated accurate quantification of hidden costs of i.v. antibiotic therapy in this ward. Using these results, the cost of five-day courses of gentamicin, cefuroxime, penicillin G, flucloxacillin and erythromycin were calculated. The costing of adverse effects was not attempted. It is recommended that a costing technique of this sort is used in cost-benefit analysis of antibiotic use, as the cost of the drug alone is misleading.

Epidemiology of Pseudomonas aeruginosa in an intensive care unit using selective decontamination of the digestive tract.

Selective decontamination of the digestive tract (SDD) aims to reduce the rate of nosocomial infections in critical care patients. Pseudomonas spp. are common nosocomial pathogens and in this study isolates collected from patients and the environment during an SDD trial were examined. The study enrolled 161 SDD cases and 170 controls. Pseudomonads were isolated from 27% of SDD patients and 30% of controls. SDD partially suppressed colonization in the 'gastro-respiratory' mucosae but not in the rectum. A total of 108 isolates of pseudomonads were recovered from the environment. Resistance in rectal isolates was minimal but isolates from 'gastro-respiratory' sites showed increasing aminoglycoside resistance. Eighty-six per cent of aminoglycoside-resistant isolates from both patient groups and environment were pyocine type 1x. Episodes of infection were reduced in the SDD patients (6) compared with the controls (16), aminoglycoside-resistant strains being associated with zero episodes in SDD patients but with five in the control group.

Glucose and amino acid metabolism in chronic renal failure: effect of insulin and amino acids.

The effects of hyperinsulinemia and hyperaminoacidemia on glucose and amino acid metabolism were examined in 16 control and 13 chronic renal failure (CRF) patients under two conditions: 1) euglycemic hyperinsulinemia and 2) amino acid infusion. All studies were performed with continuous indirect calorimetry and [1-14C]leucine infusion. In CRF patients insulin-mediated whole body glucose metabolism was reduced by 35% (4.41 +/- 0.50 vs. 6.76 +/- 0.73 mg.kg-1.min-1, P less than 0.01), primarily due to a decrease in nonoxidative glucose disposal (1.70 +/- 0.70 vs. 4.32 +/- 0.60 mg.kg-1.min-1, P less than 0.01); glucose oxidation was similar in both groups. In the postabsorptive state total leucine turnover (1.56 +/- 0.06 vs. 1.75 +/- 0.06), leucine oxidation (0.25 +/- 0.01 vs. 0.30 +/- 0.01), and nonoxidative leucine disposal (1.29 +/- 0.06 vs. 1.40 +/- 0.07 mumol.kg-1.min-1) were reduced in CRF vs. control subjects (all P less than 0.05). In response to hyperinsulinemia, endogenous leucine flux (index of proteolysis), leucine oxidation, nonoxidative leucine disposal (NOLD) (index of protein synthesis), and net leucine flux into protein were similar in CRF and control subjects. In contrast, the ability of hyperaminoacidemia to enhance NOLD (1.54 +/- 0.11 vs. 2.10 +/- 0.10 mumol.kg-1.min-1, P less than 0.01) and net leucine balance (0.27 +/- 0.05 vs. 0.41 +/- 0.05, P less than 0.05) was reduced in CRF patients.(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro antimicrobial activity of imipenem in combination with vancomycin or teicoplanin against Staphylococcus aureus and Staphylococcus epidermidis.

The interaction between imipenem and two glycopeptides against staphylococci was examined for potential synergy. Imipenem in combination with vancomycin or teicoplanin exerted a synergistic or additive effect against a majority of Staphylococcus aureus and Staphylococcus epidermidis isolates tested by the checkerboard method. Synergistic inhibitory effects were frequently accompanied by synergistic bactericidal effects. For a proportion of bacterial isolates of both species, the demonstration of synergy by the checkerboard method was confirmed by time-kill studies using antibiotic combinations at the MICs or at achievable serum antibiotic levels. Only with a single isolate of Staphylococcus epidermidis was antagonism with either antibiotic combination recorded.

Comparison of identification of Enterobacteriaceae by API 20E and Sensititre Autoidentification System.

Of 251 isolates of the Enterobacteriaceae identified to species level by API 20E, 208 (83%) were similarily identified by the Sensititre Autoidentification System. Both systems shared a common problem in that discrimination between species of the genera Klebsiella, Enterobacter, and Serratia was poor. The eight digit biocode generated by the Sensititre system for individual isolates is not reproducible and therefore not of epidemiological value.