Occupational vaccination of health care workers: uptake, attitudes and potential solutions.

OBJECTIVES: Occupational vaccination of health care workers is strongly recommended to prevent health care associated transmission but coverage in general remains suboptimal. The aim of this survey was to: 1. Estimate levels vaccination coverage for annual flu and MMR vaccines among hospital-based health care workers; 2. Explore the reasons behind low vaccination rates; and 3. Identify potential practical and policy solutions. STUDY DESIGN: A cross-sectional study. METHODS: An opportunistic survey was used to estimate MMR and flu vaccination coverage, and review attitudes and explore solutions. Staff from eight randomly selected wards, stratified by ward-level patient susceptibility, were invited to participate. RESULTS: In total 133 staff responded, an approximate response rate of 68%. Seventy one percent had ever received an MMR and 42% had received the most recent flu vaccination. Actively declining vaccination was more common for flu than MMR (29% and 7% respectively). Side-effects, insufficient knowledge and vaccine ineffectiveness were popular justifications for declining flu vaccination but not MMR. Not seeing vaccination as a professional responsibility was associated with declining flu vaccination (P < 0.001). Improving vaccination coverage with booster vaccines for new staff and immunity testing received strong support from staff working with vulnerable groups (82% and 74% respectively); 70% of this staff group also supported compulsory vaccination. CONCLUSIONS: Improving staff education may increase coverage. Clarification of the benefits of vaccination in specific staff groups may also improve uptake. Routine booster vaccinations and immunity testing were generally acceptable and compulsory vaccination of certain staff groups warrants further investigation.

Vertically acquired paediatric HIV infection: the challenges of providing comprehensive packages of care in resource-limited settings.

The successes achieved in paediatric disease management in well-resourced countries in recent years highlight the vast divide between the care options, and ultimately survival, between developed and developing areas of the world. Using an extensive literature review, we quantify recent achievements in terms of improved survival and quality of life, and examine current evidence of the effects of treatment on the survival and morbidity of HIV-infected children in developing countries. When provided with the same care as their counterparts in developed countries, children in developing countries show similar improvements in survival and general health, with 1-year survival rates exceeding 90% in many African settings. Despite the challenges of providing comprehensive packages of care in resource-limited settings, there is an urgent need to scale up prevention and treatment of HIV infections in children, focussing on strengthening Prevention of Mother-to-Child Transmission programmes in order to reduce the numbers of infants who are infected in addition to reducing morbidity and mortality among their mothers.

Two unusual cases of megacolons.

A 13-year-old boy with features of intestinal obstruction was found at laparotomy to have a sigmoid volvulus. A 7-year-old girl with a similar presentation had a tight stricture at the rectosigmoid junction causing obstruction. In both cases the proximal colon was grossly loaded with faeces. In the first child, a colostomy after resecting the sigmoid colon was considered the safer option, whereas in the second, an innovative method to decompress the proximal loaded colon using a sterilised colostomy bag was employed, enabling a primary anastomosis to be performed.

Surgical complications of the haemolytic uraemic syndrome.

During the first outbreak of haemolytic uraemic syndrome (HUS) to be reported in Australia, 22 children were admitted to the Women's and Children's Hospital, Adelaide. The outbreak was caused by an entero-haemorrhagic Escherichia coli strain (EHEC) of serotype 011:H-, a strain rarely implicated as a cause for HUS. In all 22 patients, the onset of HUS was preceded by a gastrointestinal (GI) prodrome. All patients had diarrhoea. In 17 (73%), the diarrhoea became bloody; in 20 (86%) there was vomiting; in 15 (65%) there was abdominal pain; and in 12 (50%) all three symptoms were present. Abdominal symptoms continued to complicate the course of 4 patients. Two of these underwent exploratory laparotomy, both had gangrenous colon excised, and both survived. The 2 remaining patients were successfully treated non-operatively. One further patient underwent appendicectomy before the diagnosis of HUS was made. There was 1 death during this epidemic. In patients with HUS and GI involvement, optimal surgical management requires careful consideration of the indications for, and the timing of, surgical intervention.

Primary neonatal Duhamel procedure using the ENDO GIA stapler.

The technique of performing the Duhamel procedure in the neonate with Hirschsprung's disease using the ENDO GIA stapler (originally designed for laparoscopic surgery) is described. This technique overcomes the problem of conventional staplers being too large to introduce into the neonatal anus.

Epidermolysis bullosa and severe ulcerative colitis in an infant.

An infant with epidermolysis bullosa simplex had diarrhea at 3 weeks of age; severe ulcerative colitis was subsequently diagnosed. Epidermolysis bullosa simplex has not been associated with gastrointestinal disease except for buccal ulceration.

Sudden death in early infancy due to delayed cardiac tamponade complicating central venous line insertion and cardiac catheterization.

Cardiac tamponade is an unusual cause of sudden death in the first weeks of life. We present two cases of cardiac tamponade in the neonatal period that caused death 5 to 6 days following the insertion of intracardiac lines, to draw attention to the possibility of a "delay phenomenon" between the time of the initial procedure and the occurrence of sudden and unexpected death. The presence of blood or clear fluid within the pericardial sac should prompt careful examination of the myocardium for small foci of traumatic damage, particularly when the fluid is under pressure or of large volume. Although the development of circulatory impairment or shock in the days following central line insertion or catheterization raises the possibility of tamponade, it should be noted that sudden death may occur in the absence of any significant antemortem symptoms or signs.

Surgical complications in acute leukemia in childhood: a 20 year experience.

A retrospective study of all patients presenting with acute leukemia to a single institution during the period 1968-1988 was undertaken to determine the type and incidence of surgical complications. One hundred twenty-eight of 296 patients were identified as requiring a surgical consultation for complications occurring during the course of the disease and many surgical disciplines were involved. Operative intervention was often required for these complications. Pediatric surgical specialists need to be aware of the range of surgical complications that can occur in children with acute leukemia and they must work in close co-operation with pediatric medical oncologists to ensure optimal treatment for all patients.

Abnormalities of peptide-containing nerve fibers in infantile hypertrophic pyloric stenosis.

The distributions of nerve cells and fibers with immunoreactivity for the peptides enkephalin, gastrin-releasing peptide, neuropeptide Y, somatostatin, substance P, and vasoactive intestinal peptide were examined in specimens of myenteric plexus and external muscle from the pylorus of 20 infants with hypertrophic pyloric stenosis. These were compared with peptide distributions in pyloric samples from unaffected infants and adults. In the normal pylorus the circular muscle was richly supplied with fibers reactive for enkephalin, neuropeptide Y, substance P, and vasoactive intestinal peptide. In pyloric stenosis, these immunoreactive fiber bundles were either missing or less than 5% of normal. In contrast, there were reactive cell bodies and nerve fibers in the myenteric plexuses of both normal and affected specimens. In the samples from cases of stenosis, swollen nerve fibers that appeared to be in the process of degeneration were frequently encountered. It is concluded that infantile hypertrophic pyloric stenosis is associated with a loss of peptide immunoreactivity in nerve fibers in the circular muscle, although the same peptides are still revealed in fibers and in nerve cell bodies in the myenteric plexus.

The improved ultrasound diagnosis of hypertrophic pyloric stenosis.

A prospective study of ultrasound in the diagnosis of idiopathic hypertrophic pyloric stenosis (IHPS) in 200 consecutive infants with persistent vomiting is reported. The criteria evaluated include measurements of the pyloric diameter, muscle thickness and canal length, and observing the function of the pylorus and gastric peristalsis in real-time. Using these ultrasonic criteria, the infants studied were assessed as 112 with IHPS and 88 normals. All the infants were followed up, and the method was 100% accurate, with no false positive or negative results. The statistics of the static measurements are included and show that the canal length is the only precise discriminator between a normal and an hypertrophied pylorus. The method is accurate, rapid and safe, allowing earlier diagnosis of IHPS. It should replace the barium meal in the evaluation of IHPS where the clinical diagnosis is in doubt.

Intussusception in childhood: a review of 139 cases.

A retrospective survey of 128 patients, representing 139 instances of proven intussusception is reviewed. An initial hydrostatic enema reduction attempt was performed in 75% of cases, with 50% of these being successful. A high recurrence rate of 18.4% followed the hydrostatically reduced cases, compared with 2.7% for the surgically treated. Hydrostatic reduction was particularly unsuccessful in infants less than six months of age, when the duration of symptoms exceeded 12 hours and when the presentation is painless. Earlier surgery is recommended for these children.

Complicated giant hemangioma: excision using cardiopulmonary bypass and deep hypothermia.

A child with a giant hemangioma of the left scalp, neck, and upper chest had severe complications including congestive cardiac failure. Surgical excision using cardiac bypass, deep hypothermia, and circulatory arrest was successfully carried out.