Illegality as risk factor: a survey of unauthorized migrant patients in a Berlin clinic

Unauthorized migrants face health disadvantages in many receiving nations. However, few studies have explored precisely how the condition of "illegality" influences illness experiences, medical treatment, and convalescence. This article presents a case study from Germany (2004-2006 and 2008), where unauthorized migrants face limited access to health care and the threat of deportation results in avoidance of services and treatment delays. This is confounded by unique laws which essentially criminalize health care workers for aiding migrants. This article provides a snapshot of 183 patients who attended a Berlin clinic that functions as the single largest source of medical assistance for unauthorized persons in Germany. The demographic information sketches a picture of labor migrants with a mean age of approximately 29 years. More women than men presented at this clinic, a result of its ability to successfully arrange prenatal care and delivery as well as a reflection of local labor markets. The diversity of countries of origin (n=55) is surprising, underscoring the utility of using illegal status as a unifying variable to highlight migrants' shared position in the global economy and the resulting barriers to basic medical services. Patients presented with a range of illnesses typical for their age group. However, the effects of illegal status resulted in four areas of disparities: 1) limits to the overall quality and quantity of care for mothers and infants; 2) delayed presentation and difficulties accessing a regular supply of medication for patients with chronic illnesses; 3) difficulties in accessing immediate medical attention for unpredictable injuries and other acute health concerns; and 4) a lack of mental health care options for generalized stress and anxiety affecting health. In Germany, an incoherent policy environment contributes to inadequate services and treatment delays. Solutions must address these legal ambiguities, which represent a primary barrier to equity in a nation with otherwise universal health coverage.

[Birth defects in a cohort of uninfected children born to HIV-infected women]

INTRODUCTION

Mother-to-Child HIV transmission is now just 1% in western countries, due to prevention measures. Antiretroviral Treatment (ART) drugs do have adverse effects, anaemia and myelosupression caused by cidovudina being the most commonly observed effects. In the present study, we have analysed the proportion and characteristics of congenital malformations (CM) or birth defects (BD) in a cohort of uninfected children born to HIV-infected women.

METHODS

A total of 623 uninfected children belonging to the FIPSE cohort were followed up according to standardised protocols. This cohort includes 8 public hospitals from Madrid and follows up HIV-infected pregnant women and their children. Children were classified according to prematurity, ethnic origin, birth weight, withdrawal syndrome, in-utero treatment. Birth defects were described and defined according to the EUROCAT, the European registry for BD. Mild errors of morphogenesis were excluded from the analysis. Categorical variables were compared with the X(2) or the Fisher test.

RESULTS

A total of 78% (486) of the mothers were of Caucasian origin; 18.8% (117) used some illicit drug (heroine, cocaine or methadone) during gestation; 51 mothers (8.1%) received no ART, 10 (1.6%) received monotherapy and 469 (75.3%) received HAART. BD were seen in 52 children, with the most frequent being genitourinary and cardiological. Anaemia in the first trimester was an associated risk for BD (17.9% vs. 8.1%, P = 0,04). Similarly, mothers who used any illicit drug (plus methadone), had a slightly higher risk for BD in their offspring (13.8% vs. 7.6%, P = 0,04) There was no increased risk for BD significantly associated with any of the in-utero used antiretrovirals, although Nevirapine use in-utero showed a protective effect. Children born to mothers who received ART in the first trimester had the same rate of BD (7.4%) as those whose mothers started ART in the second trimester (8.8%), P = 0,67.

CONCLUSIONS

The proportion of BD that we have observed seems higher than those shown in other European teratogenicity studies and also higher than those shown in cohorts with HIV and antiretroviral exposed infants. This may be due to the fact that our series show the results of an active surveillance system (that includes ultrasound), where BD classically appear in a higher proportion. Immunovirological characteristics of the mother did not influence the proportion of BD, but anaemia in the fist trimester and the use of illicit drugs (or methadone) did. No specific antiretroviral drug was associated with an increase in BD, although Nevirapine showed a possible protective effect in the statistical analysis. Mothers who started antiretrovirals in the first trimester do not have more BD in their offspring than mothers who started on antiretrovirals later on.

[Mutation of Gap junction protein beta 2 gene and treatment outcome of cochlear implantation in cochlear implantation recipients]

OBJECTIVE

To investigate the Gap junction protein beta 2 (GJB2) gene mutation in cochlear implantation (CI) recipients and the treatment outcome of CI in the CI recipients with GJB2 gene mutation.

METHODS

Peripheral blood samples were collected from 253 CI recipients with autosomal recessive non-syndromic hearing impairment (NSHI), 174 males and 79 females, aged (8 +/- 9) (112 months-52.7 years), and 301 children with normal hearing level as controls. PCR was used to detect the GJB2 mutations. The auditory threshold with CI and speech recognition of the CI recipients with GJB2 mutation were compared with those of the CI recipients without GJB2 mutation (control group). Questionnaire survey, with meaningful auditory integration scale (MAIS), categories of auditory performance (CAP), and speech intelligibility rating (SIR), was used for young infants.

RESULTS

Sixty-seven of the 253 CI recipients (26.5%) were found to have GJB2 mutations. One novel mutation, GJB2 235delC/598G > A, was identified. The detection rates of GJB2 mutations in the CI recipients were significantly higher than those among the controls (all P < 0.05). The postoperative outcomes of CI in both the GJB2 gene mutation positive and negative groups were very good, however, without significant differences among these 2 groups (all P > 0.05).

CONCLUSION

GJB2 gene mutation is one of the major causes for CI recipients with autosomal recessive NSHI. The treatment outcomes of CI recipients with GJB2 gene mutations under 7 years old are satisfying.

A 10 year study of the cause of death in children under 15 years in Manhiça, Mozambique

BACKGROUND

Approximately 46 million of the estimated 60 million deaths that occur in the world each year take place in developing countries. Further, this mortality is highest in Sub-Saharan Africa, although causes of mortality in this region are not well documented. The objective of this study is to describe the most frequent causes of mortality in children under 15 years of age in the demographic surveillance area of the Manhiça Health Research Centre, between 1997 and 2006, using the verbal autopsy tool.

METHODS

Verbal autopsy interviews for causes of death in children began in 1997. Each questionnaire was reviewed independently by three physicians with experience in tropical paediatrics, who assigned the cause of death according to the International Classification of Diseases (ICD-10). Each medical doctor attributed a minimum of one and a maximum of 2 causes. A final diagnosis is reached when at least two physicians agreed on the cause of death.

RESULTS

From January 1997 to December 2006, 568,499 person-year at risk (pyrs) and 10,037 deaths were recorded in the Manhiça DSS. 3,730 deaths with 246,658 pyrs were recorded for children under 15 years of age. Verbal autopsy interviews were conducted on 3,002 (80.4%) of these deaths. 73.6% of deaths were attributed to communicable diseases, non-communicable diseases accounted for 9.5% of the defined causes of death, and injuries for 3.9% of causes of deaths. Malaria was the single largest cause, accounting for 21.8% of cases. Pneumonia with 9.8% was the second leading cause of death, followed by HIV/AIDS (8.3%) and diarrhoeal diseases with 8%.

CONCLUSION

The results of this study stand out the big challenges that lie ahead in the fight against infectious diseases in the study area. The pattern of childhood mortality in Manhiça area is typical of developing countries where malaria, pneumonia and HIV/AIDS are important causes of death.

American association of poison control centers database characterization of human tilmicosin exposures, 2001-2005

BACKGROUND

Tilmicosin is a veterinary antibiotic with significant human toxicity at doses commonly used in animals, but the parenteral dose-response relationship has not been well characterized.

METHODS

Human exposures to tilmicosin in the database of the American Association of Poison Control Centers (AAPCC) from 2001 to 2005 were analyzed for demographic associations, exposure dose, clinical effects and outcomes.

RESULTS

Over the 5-year period, there were 1,291 single-substance human exposures to tilmicosin. The mean age was 39.1 years, and 80% were male. By route there were 768 (54%) parenteral exposures. Patients with parenteral exposures had a significantly increased likelihood of being seen at a healthcare facility, admission, and admission to an ICU. With nonparenteral exposure, most had no clinical effects or minor effects, and there were no major effects or deaths. With parenteral exposure, moderate effects occurred in 46 (6%), major effects in 2 (0.3%) and there were 4 (0.5%) deaths, two of which were suicides. A dose-response relationship could be demonstrated. Clinical effect durations of up to a week occurred at even the lowest dose range.

CONCLUSIONS

Over 250 cases of human tilmicosin exposure are reported to poison centers per year and over 150 of those are parenteral. Most exposures produce no or minor effects, but fatalities have occurred with parenteral exposure. The case fatality rate in parenteral exposures is 10 times the case fatality rate for all human exposures in the AAPCC database. Significant adverse and prolonged effects are reported at parenteral doses > 0.5 mL, suggesting that all parenteral exposures should be referred for healthcare facility evaluation.

Transcranial Doppler ultrasonography in the assessment of cerebral circulation arrest: improving sensitivity by transcervical and transorbital carotid insonation and serial examinations

INTRODUCTION

Transcranial Doppler (TCD) can detect the cerebral circulation arrest (CCA) in brain death. TCD is highly specific, but less sensitive because of false-negatives accounting for up to 10%. The aim of the study was to explore the diagnostic accuracy of TCD and to determine whether it can be augmented by strategies such as the insonation of the extracranial internal carotid artery (ICA) and sequential examinations.

METHODS

Data of 184 patients, who met clinical criteria of brain death, observed from 1998 through 2006, were retrospectively reviewed. The study of cerebral arteries was performed through the transtemporal approach, suboccipital insonation of the vertebro-basilar system, transorbital insonation of the ICA and ophthalmic artery, and transcervical insonation of the extracranial ICA. Repeated exams were performed in cases of persistent diastolic flow.

RESULTS

The specificity of the testing was 100%, no false-positive cases were recorded. The sensitivity of conventional TCD examination was 82.1%. The insonation of the extracranial ICA increased sensitivity to 88% allowing the detection of CCA in those patients lacking temporal windows; serial examinations further increased sensitivity to 95.6%.

CONCLUSIONS

The addition of insonation of the cervical ICA and of the siphon increased sensitivity of TCD. Nevertheless, a CCA flow patterns may appear later on those segments. Serial examinations, may be needed in those cases.

[Trabeculotomy on primary congenital glaucoma: a retrospective study of 164 cases (257 eyes)]

OBJECTIVE

To study the relationship of long-term effect of trabeculotomy on primary congenital glaucoma and the related risk factors.

METHOD

164 consecutive patients with primary congenital glaucoma (257 eyes), underwent initial surgery of trabeculotomy between 1996 and 2007. Follow-up was conducted for 30.9 (8.6 - 58.3) months, with a follow-up rate of 89.02%. Multivariate analysis by Logistic regression was conducted to analyze the relation of the factors including age of onset, time between onset and operation, preoperative intraocular pressure, clarity of cornea, and corneal diameter to the failure of surgery. Cox proportional hazards regression modeling was used to analyze the factors related to success of surgery.

RESULT

Multivariate logistic regression showed that the preoperative intraocular pressure (IOP) and clarity of cornea were independent risk factors for final outcome (OR(IOP) = 1.408, P = 0.047, and OR(CLA) = 1.691, P = 0.019). Cox regression showed that clarity of cornea was the factor related to the surgery success time (OR(CLA) = 1.632, P = 0.008).

CONCLUSION

Clarity of cornea reflexes the condition of primary congenital glaucoma more stably than IOP. It is possible to prognosticate the surgical outcome to combine the clarity of cornea with the IOP value before operation.

The impact of CD14 polymorphisms on the development of soluble CD14 levels during infancy

CD14 is a receptor involved in the recognition of lipopolysaccharide and other bacterial wall components that may be involved in the balance between infectious and allergic disease and the early polarization towards TH1. Our group has shown an association between polymorphisms in the 5' flanking region of the CD14 gene and plasma soluble CD14 (sCD14) levels at 11 years of age. However, whether this association is present at birth and in infancy remains to be determined. In this study, we measured sCD14 levels in plasma from the umbilical cord (n = 387) and at 3 months (n = 357) and 1 year (n = 312) of age in non-selected healthy infants to assess their relationship with CD14 genotypes at -4190, -2838, -1720 and -260 (relative to translation start site). There was no relation of CD14 genotypes with sCD14 at birth. However, there was a significant association between CD14 genotypes and sCD14 as early as 3 months. Longitudinal analysis suggests that CD14 polymorphisms modulate sCD14 levels up to 1 year of age. This association early in life may have an impact on TH1 polarization and subsequent protection against allergic disease.

The effects of normoxic versus hyperoxic cardiopulmonary bypass on oxidative stress and inflammatory response in cyanotic pediatric patients undergoing open cardiac surgery: a randomized controlled trial

OBJECTIVES

This study investigates the effects of controlled reoxygenation cardiopulmonary bypass on oxidative stress, inflammatory response, and organ function in children undergoing repair of cyanotic congenital heart defects.

METHODS

Sixty-seven cyanotic patients (median age 15 months, interquartile range 6-49 months) undergoing corrective cardiac surgery were randomized to receive either controlled normoxic (50-0 mm Hg; n = 35) or hyperoxic (150-180 mm Hg; n = 32) cardiopulmonary bypass. Troponin I and 8-isoprostane, C3a, interleukins 6, 8, and 10, cortisol, protein S100, and alpha-glutamate transferase were measured preoperatively and 10 and 30 minutes after starting bypass, on removal of the aortic crossclamp, and 12 and 24 hours thereafter.

RESULTS

Overall, troponin I and 8-isoprostane levels were lower in the controlled normoxic group (-29%, 95% CI -48% to -3%, P = .03, and -26%, 95% CI -44% to -2%, P = .03, respectively). Protein S100 release was also lower in the normoxic group 10 minutes after starting bypass (-26%, 95% CI -40% to -9%, P = .005) and 10 minutes after aortic crossclamp removal (-23%, 95% CI -38% to -3%, P = .02, respectively), but similar at other time points in the two groups (P >or= .17). The alpha-glutamate transferase release was significantly lower in the normoxic group 10 minutes after aortic crossclamp removal (-28%, 95% CI -44% to -9%, P = .006, respectively) but was similar at other times (P >or= .11). Release of C3a, interleukins 6, 8, and 10, and cortisol was similar in the two groups throughout (P >or= .15).

CONCLUSION

Controlled reoxygenation on starting cardiopulmonary bypass is associated with reduced myocardial damage, oxidative stress, and cerebral and hepatic injury compared with hyperoxic bypass and similar whole body inflammatory and stress response in cyanotic children undergoing open cardiac surgery.

[Clinical variability and diagnosis steps in childhood mitochondrial disease]

OBJECTIVES

Mitochondrial respiratory chain deficiencies are known for their high clinical variability. Difficult to diagnose, the prevalence of these diseases is probably underestimated.

METHODS

We report 18 children diagnosed with respiratory chain deficiency at the Tours University Hospital over the past 10 years.

RESULTS

Three clinical profiles can be distinguished depending on the age at onset of the first symptoms: the neonatal period (4 cases), between 1 month and 2 years of age (10 cases), and after 10 years (4 cases). However, no clinical feature appears specific of any age group. In contrast, respiratory chain analysis on liver biopsy was very informative for all our patients at any age and with any clinical presentation, even with predominant neurological symptoms.

CONCLUSIONS

These biochemical analyses support the diagnosis of mitochondrial disorders in view of molecular analysis, which nevertheless frequently remains inconclusive. These investigations should benefit from the new molecular screening technologies based on DNA chips that can identify the genomic mutations responsible for these severe and relatively frequent diseases.

Long-term followup of dextranomer/hyaluronic acid injection for vesicoureteral reflux: late failure warrants continued followup

PURPOSE

Dextranomer/hyaluronic acid injection of ureteral orifices is a popular option in the treatment of vesicoureteral reflux, with success rates ranging from 69% to 89%. We found only 1 study that followed patients beyond the initial postoperative voiding cystourethrogram, which describes a 96% success rate at 2 to 5 years but defines success as "nondilating" reflux. We examined our dextranomer/hyaluronic acid series to evaluate the long-term (1-year) outcome in children who had resolution of reflux on initial postoperative voiding cystourethrography.

MATERIALS AND METHODS

We retrospectively reviewed our dextranomer/hyaluronic acid experience from February of 2002 to December of 2005. We determined initial success on early (6 to 12-week) postoperative voiding cystourethrogram. We then evaluated long-term success by obtaining a voiding cystourethrogram at 1 year postoperatively in patients who were initially cured of reflux. In addition, success rates between the first and second halves of our experience were evaluated to account for surgeon experience and modification of technique.

RESULTS

Our total success rate at initial voiding cystourethrogram was 73% (246 of 337 total ureters). The success rate in the first half of our experience was 65.9% (112 of 170 ureters) and in the second half was 80.2% (134 of 167). A total of 150 ureteral units with initial successful dextranomer/hyaluronic acid treatment were evaluated at 1 year by voiding cystourethrogram. Of these ureters 111 had continued resolution of vesicoureteral reflux, for a long-term success rate of 74%. Including initial postoperative failures, the complete 1-year total success rate was 46.1% (111 of 241 ureters).

CONCLUSIONS

Although the reflux resolution rates at initial postoperative voiding cystourethrogram approach those of open surgery, there is a significant failure rate at 1 year, which warrants long-term followup.

Epidemiological investigation of nosocomial outbreak of staphylococcal skin diseases in neonatal ward

During a 1-month period, eight neonates developed staphylococcal skin disease diagnosed as a bullous impetigo in the maternity unit of the Provincial Hospital in Gdansk. An epidemiological investigation based on phenotyping and genotyping methods was performed. All neonates involved in the outbreak, their mothers and 15 staff members were screened for carriage of Staphylococcus aureus by nasal swabs. Isolated strains were compared with strains cultured from affected skin and purulent conjunctiva of infected newborns. Isolates were analyzed for the presence of the etA and etB genes using polymerase chain reaction and genotyped by pulsed-field gel electrophoresis (PFGE) and coa gene polymorphism. The analyzed S. aureus strains were methicillin-sensitive and could be divided into two groups according to antibiotyping, phage typing, coa polymorphism and PFGE pattern. The first group consisted of etA and etB negative strains, and the second one involved only the etB positive ones. Our results have shown that there were two different clusters of infection caused by two populations of S. aureus strains. Among the 15 medical staff members screened we have found seven carriers. However, phage typing revealed that distinct strains unrelated to the outbreak isolates were carried. Although we have not been able to establish the source of bacteria involved in the outbreak, our results suggest that for both groups, mothers could be the source of the infecting strains.

Allele loss at 16q defines poorer prognosis Wilms tumour irrespective of treatment approach in the UKW1-3 clinical trials: a Children's Cancer and Leukaemia Group (CCLG) Study

Survival from Wilms tumour is excellent. Hence, better markers are required to restrict treatments causing late sequelae to those at highest risk of relapse. We investigated the prognostic significance of loss of heterozygosity (LOH) on 1p and 16q in 426 favourable histology Wilms tumours treated with either immediate nephrectomy (63%) or preoperative chemotherapy (37%). Four years RFS and OS were 84.6% and 92.0%, respectively. 10.3% tumours had LOH 1p, 14.6% LOH 16q, with 2.6% at both loci. In multivariate analysis, LOH 16q was associated with an increased risk of relapse (hazard ratio (HR) 2.69, 95%CI: 1.47-4.92) and death (HR 2.67, 95%CI: 1.17-6.06). LOH 1p showed no significant associations. These results were not influenced by treatment approach. LOH 16q is an adverse risk factor in favourable histology Wilms tumour, regardless of initial approach to therapy. Its relationship with histological risk groups defined after neo-adjuvant chemotherapy requires analysis in a larger series, and is the subject of the current SIOP WT 2001 trial.

Centers for Disease Control and Prevention (CDC). Progress toward measles elimination--European Region, 2005--2008

In 2002, the World Health Organization (WHO) Regional Committee for the European Region (EUR) revised earlier targets to eliminate indigenous measles and achieve rubella control by resolving to 1) eliminate both diseases in EUR member states by 2010, using a combination of routine and supplementary immunization strategies, and 2) monitor progress toward this goal through improved surveillance. This report summarizes progress toward measles elimination during 2005--2008 and updates a previous report from 2005. In 2005 and 2006, large-scale outbreaks occurred in the eastern EUR member states. However, in 2007 and 2008, overall measles incidence in EUR declined to a historic low of <10 cases per 1 million population, with the majority of cases reported from Western Europe. During 2005-2007, routine vaccination coverage with 1 dose of measles-containing vaccine (MCV) among children aged 12--23 months in EUR reached a high of 93%-94%, up from 90%-91% during 2000-2004. Nevertheless, two major challenges to measles elimination remain: 1) suboptimal vaccination coverage in many countries, which has led to continued outbreaks and the resurgence of indigenous measles in some Western European countries, and 2) setbacks with implementation of supplementary immunization activities (SIAs) in Eastern Europe in 2008. Achieving the measles elimination goal by 2010 will require 1) development of approaches to sustain and increase vaccination coverage, 2) promotion of effective outbreak prevention and control measures, and 3) further strengthening of surveillance.

Patient-specific dose estimation for pediatric chest CT

Current methods for organ and effective dose estimations in pediatric CT are largely patient generic. Physical phantoms and computer models have only been developed for standard/limited patient sizes at discrete ages (e.g., 0, 1, 5, 10, 15 years old) and do not reflect the variability of patient anatomy and body habitus within the same size/age group. In this investigation, full-body computer models of seven pediatric patients in the same size/protocol group (weight: 11.9-18.2 kg) were created based on the patients' actual multi-detector array CT (MDCT) data. Organs and structures in the scan coverage were individually segmented. Other organs and structures were created by morphing existing adult models (developed from visible human data) to match the framework defined by the segmented organs, referencing the organ volume and anthropometry data in ICRP Publication 89. Organ and effective dose of these patients from a chest MDCT scan protocol (64 slice LightSpeed VCT scanner, 120 kVp, 70 or 75 mA, 0.4 s gantry rotation period, pitch of 1.375, 20 mm beam collimation, and small body scan field-of-view) was calculated using a Monte Carlo program previously developed and validated to simulate radiation transport in the same CT system. The seven patients had normalized effective dose of 3.7-5.3 mSv/100 mAs (coefficient of variation: 10.8%). Normalized lung dose and heart dose were 10.4-12.6 mGy/100 mAs and 11.2-13.3 mGy/100 mAs, respectively. Organ dose variations across the patients were generally small for large organs in the scan coverage (<7%), but large for small organs in the scan coverage (9%-18%) and for partially or indirectly exposed organs (11%-77%). Normalized effective dose correlated weakly with body weight (correlation coefficient: r=-0.80). Normalized lung dose and heart dose correlated strongly with mid-chest equivalent diameter (lung: r=-0.99, heart: r=-0.93); these strong correlation relationships can be used to estimate patient-specific organ dose for any other patient in the same size/protocol group who undergoes the chest scan. In summary, this work reported the first assessment of dose variations across pediatric CT patients in the same size/protocol group due to the variability of patient anatomy and body habitus and provided a previously unavailable method for patient-specific organ dose estimation, which will help in assessing patient risk and optimizing dose reduction strategies, including the development of scan protocols.

[Factors impacting public acceptance of medical radiation exposure]

We undertook a survey to determine the public acceptance of medical radiation exposure throughout Japan, and 1,357 responses (67.9% response rate) were obtained using a two-stage systematic stratified random sampling method. The acceptance of exposure of children was generally similar to that of adults. For each of the attributes, 45-60% of the participants were accepting of exposure for cancer treatment and diagnosis, but only 30% were accepting of exposure for X-ray diagnoses of bone fractures and dental caries. In general, the presence of a child did not markedly affect women's acceptance of exposure. Factor analyses identified 3 factors influencing the acceptance of child exposure: symptomatic diseases to determine treatment, the possibility of high-risk diseases (or major organ diseases), and the association with cancer. Cluster analysis showed 4 clusters: a positive group regarding children's exposure for the diagnosis of bone fractures and dental caries (12.9% of all participants), a positive group for major organ disease and cancer (15.5%), a negative group excluding cancer (55.2%), and a positive group for all cases (16.4%). The cluster distributions revealed that mothers with 10-to 18-year-old firstborn children showed a tendency to accept the medical radiation exposure of their children in all cases.

Weekend emergency department visits in Nebraska: higher utilization, lower acuity

BACKGROUND

We know very little about differences in Emergency Department (ED) utilization and acuity on weekends compared with weekdays. Understanding such differences may help elucidate the role of the ED in the health care delivery system.

STUDY OBJECTIVE

To compare patterns of ED use on weekends with weekdays and analyze the differences between these two groups.

METHODS

The Health Care Utilization Project (HCUP) is a national state-by-state billing database from acute-care, non-federal hospitals. Data from Nebraska in 2004 was used to compare ED-only patient visits (patients discharged home or transferred to another health care facility) and ED-admitted visits (patients admitted to the same hospital after an ED visit) for weekend vs. weekday frequency, billed charges, sex, age, and primary payer.

RESULTS

Of all non-admitted patients who visited the ED, 34.5% came in on weekends. This yielded ED utilization rates of 25 visits/1,000 people on weekdays and 33 visits/1,000 people on weekends, an increase of 32% on weekends. Weekend-only ED patients of all ages and payer categories were charged lower hospital facility fees than weekday-only ED patients; USD 777 vs. USD 921, respectively (p < 0.001). Weekend ED patients were less likely to be admitted and less likely to die while in the ED (2 deaths/1000 ED visits for weekend-only patients vs. 3 deaths/1000 ED visits for weekday-only [p < 0.001]).

CONCLUSIONS

In Nebraska, EDs care for a greater number of low-acuity patients on weekends than on weekdays. This highlights the important role EDs play within the ambulatory care delivery system.

Risk factors for sporadic Campylobacter infection: an all-Ireland case-control study

We report the findings of the first case-control study conducted in both the Republic of Ireland and Northern Ireland to determine risk factors for sporadic Campylobacter infections. A total of 197 cases and 296 case-nominated controls matched for age, were included. Based on Population Attributable Fraction (PAF), the most important risk factors were consuming chicken [adjusted matched (am) OR 6.8; 95%CI 2.1-21.9], consuming lettuce (amOR 3.3; 95%CI 1.5-7.1) and eating in takeaways (amOR=3.1; 95%CI 1.4-6.6). Contact with sheep (amOR=11; 95%CI 1.6-78), peptic ulcer (amOR=19; 95%CI 3.8-93.7), hiatus hernia (amOR=20.3; 95%CI 2.3-183.3), lower bowel problems (amOR=4.5; 95%CI 1.2-16.8) were also independently associated with infection. Mains water supply showed protective effect (amOR=0.2; 95 CI 0.1-0.9). The findings highlight the continued need for consumer food safety education and further control measures throughout the food chain on the island of Ireland.

[Children born with a cleft: treatment at the CHUV in Lausanne]

A cleft can be labial, labial-maxillary, unilateral or bilateral labial-maxillary-palatal, or isolated palatal. A multidisciplinary team includes several specialists who will handle the diverse problems of children born with a cleft. This team will follow the child through each developmental stage and assemble an optimal treatment plan, thus reducing the onus on the family. Depending on the type of cleft and the age of the child, feeding, speech, ORL, dental, orthodontic, esthetic and possibly also psychological problems will be taken care of. This is why cleft treatment starts at the time it is diagnosed, before or after birth, and ends when the child is fully grown. It requires a complete interdisciplinary team and the collaboration with obstetricians and geneticians.

[Etiology of infections in the wounded victims of Wenchuan Earthquake]

OBJECTIVE

To analyze the etiology of infections in the wounded victims of Wenchuan Earthquake.

METHODS

2135 smears of secretion were made from 1823 hospitalized wounded victims of Wenchuan Earthquake to detect the pathogens. Specimens were delivered to be cultured. The bacteria thus obtained were identified. Drug sensitivity test was conducted.

RESULTS

2002 specimens, 1243 specimens of secretion (62.1%), 600 blood specimens (30.0%), 102 specimens of pus or secretion of respiratory tract (5.1%), 45 specimens from catheter (2.2%), and 12 urine specimens (0.5%). Pathogens were found in 725 cases. The top five pathogenic bacteria isolated within 1 month after the quake were Acinetobacter baumannii (16.7%), Staphylococcus haemolyticus (16.7%), Escherichia coli (12.5%), Klebsiella pneumoniae (12.5%), and Candida tropicalis (8.3%), quite different from the pathogen spectrum of the common in-patients within one month before the quake: Escherichia coli (18.2%), Staphylococcus aureus (11.4%), Candida glabrata (11.4%), Klebsiella pneumoniae (11.4%) and Staphylococcus epidermidis (9.1%). The isolation rate of methicillin resistant Staphylococcus aureus after the earthquake was significantly lower, and the isolation rates of extended spectrum beta-lactamase-producing Escherichia coli, Klebsiella pneumoniae, and Klebsiella oxytoca were all significantly higher than those from the common surgical patients before the quake (all P < 0.05). There were not significant differences in the isolation rates of multi-drug resistant Pseudomonas alcaligenes and Acinetobacter baumannii before and after the quake.

CONCLUSION

Infection is frequent after natural disasters. It is necessary to summarize the changes of spectrum of pathogens and drug-resistant spectrum.

[Neutrophil activation and protease imbalance in respiratory tract of infants with respiratory syncytial virus bronchiolitis]

OBJECTIVE

To better understand the neutrophil activation and protease imbalance in respiratory syncytial virus (RSV) bronchiolitis.

METHODS

Pediatric patients with RSV bronchiolitis were collected, 11 with the Lowell scores > or = 10 (severe group), and 19 with the Lowell scores < 10 (mild group). 20 RSV bronchiolitis patients in convalescent group, 24 patients with bacterial pneumonia, and 15 patients as control group. The percentages of neutrophils were detected. ELISA was used to detect the concentration of neutrophil elastase (NE) and interleukin (IL)-8, and the elastase inhibition capacity (EIC)/free neutrophil elastase activity were detected by colorimetry. Immunohistochemistry was used to examine the expression of alpha(1) antitrypsin (alpha(1)AT).

RESULTS

The neutrophil percentage, the NE and IL-8 concentration of the RSV bronchiolitis group (0.528, 6.39 x 10(7) kg/L and 13.62 x 10(9) kg/L)were all significantly higher than those of the control (0.074, 2.53 x 10(7) kg/L and 2.64 x 10(9) kg/L) and convalescent groups (0.306, 1.23 x 10(7) kg/L and 5.95 x 10(9) kg/L, all P < 0.05). The neutrophil percentage and IL-8 concentration of the convalescent group were both significantly higher than those of the control group (both P < 0.05). Increased expression of alpha(1)AT in RSV bronchiolitis was found when compared with convalescent infants (0.49 vs 0.09, P < 0.05). The free elastase activity level of the bronchiolitis group was 6/30, not different with 7/24 of pneumonia group, and it was only one in convalescent infants.

CONCLUSION

Mass of neutrophil aggregation and activation exist in RSV bronchiolitis, as well as protease system imbalance, and may play an important role in the inflammatory response and pathogenesis of RSV bronchiolitis.

[Cerebral polymicrogyria and 22q11 deletion syndrome]

INTRODUCTION

Chromosome 22q11 microdeletion syndrome, DiGeorge syndrome or CATCH 22 spectrum, is characterised by conotruncal heart malformations, facial dysmorphisms, cleft palate, velopharyngeal insufficiency, transient hypocalcemia and T cell disorders. Furthermore, a significant number of patients may present autism-type developmental disorders, learning disabilities, attention deficit hyperactivity disorder or schizophrenia-like psychiatric problems.

CASE REPORT

A girl with congenital heart disease that had been treated surgically in the neonatal period, who presented psychomotor retardation, dysmorphic features and microcephaly. The conventional karyotype study that was performed at birth was normal. The physical examination revealed subtle signs of left hemiparesis. A neuroimaging study showed polymicrogyria-type cortical dysplasia that involved the right frontotemporal cortex. A chromosomal study was conducted and findings showed a 22q11.2 chromosome deletion.

CONCLUSIONS

Brain malformations in children with deletion of the 22q11.2 chromosome have been reported previously, but their real prevalence and the most frequent type of malformation have not been properly determined. The authors conclude that brain malformations should be studied in all patients with 22q11.2 deletion and it should be borne in mind that all patients with cortical dysplasias may present this deletion.

The phenotype of persons having mosaicism for trisomy 21/Down syndrome reflects the percentage of trisomic cells present in different tissues

Little is known about the pathogenesis of the phenotype in individuals with trisomy 21 mosaicism and Down syndrome. The primary goal of this study was to identify factors contributing to the observed phenotypic variation by evaluating 107 individuals having trisomy 21 mosaicism. To investigate a potential "threshold" effect due to trisomic imbalance, lymphocyte and buccal mucosa nuclei were scored using FISH. Overall, buccal cells showed a significantly higher frequency of trisomy than lymphocytes (P < 0.0001). Using latent class analysis, two phenotypic classes were identified based on the clinical findings of the propositi. Patients from class 1 had significantly fewer traits and a lower percentage of trisomic cells (mean of 37.3% lymphocytes; 34.5% buccal mucosa cells) when compared to those stratified into class 2 (54.0% lymphocytes; 53.4% buccal mucosa cells). Tissue-specific influences were also detected, with buccal mucosa trisomy levels being significantly correlated with IQ (P = 0.0094; both ectodermal derivatives), while congenital heart defects were significantly correlated with lymphocytes (P = 0.0286; both mesodermal embryonic derivatives). In conclusion, allowing for the distinction of two groups, we observed variation in phenotype, associated with the percentage of trisomic cells. We also observed tissue-specific effects on phenotype. The results of this study should enable geneticists and other health care professionals to provide information regarding optimal diagnostic approaches and anticipated clinical outcomes.

[Treatment of urinary tract calculi in preschool children with endoscopy]

OBJECTIVES

To investigate the safety and feasibility of endoscopy in treating urinary tract calculi in preschool children.

METHODS

From August 2004 to August 2008, 28 preschool children with urinary tract calculi were treated by endoscopy, 11 cases received ureterolithotripsy (URL) and 17 cases received minimally invasive percutaneous nephrolithotomy (MPCNL).

RESULTS

Of 11 cases with ureteric calculi, 5 cases were rendered stone free in the first session, the other 6 cases received passive dilation by indwelling of ureteric stents for 1 to 3 weeks and underwent successful ureteroscopy with a 8/9.8 Fr rigid ureteroscope. Seventeen cases with renal calculi received MPCNL and were rendered stone free.

CONCLUSION

Our study shows that endoscopy in treating urinary tract calculi is safe and feasible in preschool children.

Mapping of fluoride endemic areas and assessment of fluoride exposure

The prevalence of fluorosis is mainly due to the consumption of more fluoride through drinking water. It is necessary to find out the fluoride endemic areas to adopt remedial measures to the people on the risk of fluorosis. The objectives of this study are to estimate the fluoride exposure through drinking water from people of different age group and to elucidate the fluoride endemic areas through mapping. Assessment of fluoride exposure was achieved through the estimation fluoride level in drinking water using fluoride ion selective electrode method. Google earth and isopleth technique were used for mapping of fluoride endemic areas. From the study it was observed that Nilakottai block of Dindigul district in Tamil Nadu is highly fluoride endemic. About 88% of the villages in this block have fluoride level more than the prescribed permissible limit in drinking water. Exposure of fluoride among different age groups was calculated in this block, which comprises 32 villages. The maximum estimated exposure doses were 0.19 mg/kg/day for infants, 0.17 mg/kg/day for children and 0.10 mg/kg/day for adults. When compared with adequate intake of minimal safe level exposure dose of 0.01 mg/kg/day for infants and 0.05 mg/kg/day for other age groups, a health risk due to fluorosis to the people in Nilakottai block has become evident. From the results, the people in Nilakottai block are advised to consume drinking water with fluoride level less than 1 mg/l. It has been recommended to the government authorities to take serious steps to supply drinking water with low fluoride concern for the fluorosis affected villages.

Pre-referral rectal artesunate to prevent death and disability in severe malaria: a placebo-controlled trial

BACKGROUND

Most malaria deaths occur in rural areas. Rapid progression from illness to death can be interrupted by prompt, effective medication. Antimalarial treatment cannot rescue terminally ill patients but could be effective if given earlier. If patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate can be given before referral and acts rapidly on parasites. We investigated whether this intervention reduced mortality and permanent disability.

METHODS

In Bangladesh, Ghana, and Tanzania, patients with suspected severe malaria who could not be treated orally were allocated randomly to a single artesunate (n=8954) or placebo (n=8872) suppository by taking the next numbered box, then referred to clinics at which injections could be given. Those with antimalarial injections or negative blood smears before randomisation were excluded, leaving 12 068 patients (6072 artesunate, 5996 placebo) for analysis. Primary endpoints were mortality, assessed 7-30 days later, and permanent disability, reassessed periodically. All investigators were masked to group assignment. Analysis was by intention to treat. This study is registered in all three countries, numbers ISRCTN83979018, 46343627, and 76987662.

RESULTS

Mortality was 154 of 6072 artesunate versus 177 of 5996 placebo (2.5%vs 3.0%, p=0.1). Two versus 13 (0.03%vs 0.22%, p=0.0020) were permanently disabled; total dead or disabled: 156 versus 190 (2.6%vs 3.2%, p=0.0484). There was no reduction in early mortality (56 vs 51 deaths within 6 h; median 2 h). In patients reaching clinic within 6 h (median 3 h), pre-referral artesunate had no significant effect on death after 6 h or permanent disability (71/4450 [1.6%] vs 82/4426 [1.9%], risk ratio 0.86 [95% CI 0.63-1.18], p=0.35). In patients still not in clinic after more than 6 h, however, half were still not there after more than 15 h, and pre-referral rectal artesunate significantly reduced death or permanent disability (29/1566 [1.9%] vs 57/1519 [3.8%], risk ratio 0.49 [95% CI 0.32-0.77], p=0.0013).

INTERPRETATION

If patients with severe malaria cannot be treated orally and access to injections will take several hours, a single inexpensive artesunate suppository at the time of referral substantially reduces the risk of death or permanent disability.

FUNDING

UNICEF/UNDP/World Bank Special Programme for Research and Training in Tropical Diseases (WHO/TDR); WHO Global Malaria Programme (WHO/GMP); Sall Family Foundation; the European Union (QLRT-2000-01430); the UK Medical Research Council; USAID; Irish Aid; the Karolinska Institute; and the University of Oxford Clinical Trial Service Unit (CTSU).

Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study

BACKGROUND

Critically ill infants and children often develop hyperglycaemia, which is associated with adverse outcome; however, whether lowering blood glucose concentrations to age-adjusted normal fasting values improves outcome is unknown. We investigated the effect of targeting age-adjusted normoglycaemia with insulin infusion in critically ill infants and children on outcome.

METHODS

In a prospective, randomised controlled study, we enrolled 700 critically ill patients, 317 infants (aged <1 year) and 383 children (aged >or=1 year), who were admitted to the paediatric intensive care unit (PICU) of the University Hospital of Leuven, Belgium. Patients were randomly assigned by blinded envelopes to target blood glucose concentrations of 2.8-4.4 mmol/L in infants and 3.9-5.6 mmol/L in children with insulin infusion throughout PICU stay (intensive group [n=349]), or to insulin infusion only to prevent blood glucose from exceeding 11.9 mmol/L (conventional group [n=351]). Patients and laboratory staff were blinded to treatment allocation. Primary endpoints were duration of PICU stay and inflammation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00214916.

FINDINGS

Mean blood glucose concentrations were lower in the intensive group than in the conventional group (infants: 4.8 [SD 1.2] mmol/L vs 6.4 [1.2] mmol/L, p<0.0001; children: 5.3 [1.1] mmol/L vs 8.2 [3.3] mmol/L, p<0.0001). Hypoglycaemia (defined as blood glucose <or=2.2 mmol/L) occurred in 87 (25%) patients in the intensive group (p<0.0001) versus five (1%) patients in the conventional group; hypoglycaemia defined as blood glucose less than 1.7 mmol/L arose in 17 (5%) patients versus three (1%) (p=0.001). Duration of PICU stay was shortest in the intensively treated group (5.51 days [95% CI 4.65-6.37] vs 6.15 days [5.25-7.05], p=0.017). The inflammatory response was attenuated at day 5, as indicated by lower C-reactive protein in the intensive group compared with baseline (-9.75 mg/L [95% CI -19.93 to 0.43] vs 8.97 mg/L [-0.9 to 18.84], p=0.007). The number of patients with extended (>median) stay in PICU was 132 (38%) in the intensive group versus 165 (47%) in the conventional group (p=0.013). Nine (3%) patients died in the intensively treated group versus 20 (6%) in the conventional group (p=0.038).

INTERPRETATION

Targeting of blood glucose concentrations to age-adjusted normal fasting concentrations improved short-term outcome of patients in PICU. The effect on long-term survival, morbidity, and neurocognitive development needs to be investigated.

FUNDING

Research Foundation (Belgium); Research Fund of the University of Leuven (Belgium) and the EU Information Society Technologies Integrated project "CLINICIP"; and Institute for Science and Technology (Belgium).

Centers for Disease Control and Prevention (CDC). Increase in Coccidioidomycosis - California, 2000-2007

Coccidioidomycosis is an infection resulting from inhalation of airborne spores of Coccidioides immitis or Coccidioides posadasii, soil-dwelling fungi endemic to California's San Joaquin Valley; southern regions of Arizona, Utah, Nevada, and New Mexico; western Texas; and regions of Mexico and Central and South America. Of an estimated 150,000 new infections annually in the United States, approximately 60% are asymptomatic. Patients with symptoms usually experience a self-limited influenza-like illness (ILI), although some develop severe pneumonia. Fewer than 1% of patients develop disseminated disease. Infection usually produces immunity to reinfection. During 1995--2000, the number of reported coccidioidomycosis cases in California averaged 2.5 per 100,000 population annually. However, from 2000 to 2006, the incidence rate more than tripled, increasing from 2.4 to 8.0 per 100,000 population. To characterize this increase, the California Department of Public Health (CDPH) analyzed case and hospitalization data for the period 2000--2007 and preliminary case report data for 2008. The results indicated that, during 2000--2006, the number of reported cases and hospitalizations for coccidioidomycosis in California increased each year, before decreasing in 2007. Annual incidence during 2000--2007 was highest in Kern County (150.0 cases per 100,000 population), and the hospitalization rate was highest among non-Hispanic blacks, increasing from 3.0 to 7.5 per 100,000 population. Health-care providers should maintain heightened suspicion for coccidioidomycosis in patients who live or have traveled in areas where the disease is endemic and who have signs of ILI, pneumonia, or disseminated infection.

Anaphylactic deaths in Maryland (United States) and Shanghai (China): a review of forensic autopsy cases from 2004 to 2006

Anaphylaxis is a life threatening allergic reaction that is rapid in onset and may cause sudden death. A retrospective study was performed using the database from the Office of the Chief Medical Examiner (OCME) in the State of Maryland and the Department of Forensic Medicine in Shanghai Medical College (DFM-SMC) to examine the etiology and forensic investigation findings of anaphylactic deaths from 2004 to 2006. Details of the medical history, agent responsible for the allergic reaction, death scene investigation and postmortem examination findings were reviewed for all cases. A total of 28 cases of anaphylactic death were identified for the study period, 17 from Maryland and 11 from Shanghai. Of the 17 Maryland cases, 6 (35%) involved allergic reaction to food, 5 (25%) to drugs, 2 to bee stings, 1 to hair dye, and 3 to unknown allergens. Investigation revealed that 9 of 17 cases had a history of asthma and 8 had previous allergic reactions to certain foods and / or drugs. In Shanghai, all 11 deaths resulted from anaphylactic reaction to antibiotics, 10 of which occurred in clinics illegally operated by unlicensed physicians. The interval between the onset of symptoms and death ranged from less than 1 min to 3 days after initially contacting the allergen. In the majority (68%) of cases, death occurred within 8h after the onset of symptoms. Postmortem findings were relatively non-specific, and included pharyngeal/laryngeal edema 14/28 (50%), mucus plugging in the airways 11/28 (39%), and pulmonary congestion and edema 28/28 (100%). Serum tryptase concentrations were measured in 14 cases in Maryland and the concentration ranged from 3.3 ng/ml to 200 ng/ml. There were significant differences with regards to allergen type and the circumstances of death between these two regions. Inappropriate use of antibiotics and illegal medical practices were the main causes of identified anaphylactic death in Shanghai. In Maryland anaphylactic deaths were mainly caused by food reactions. This study indicates that the postmortem diagnosis of anaphylactic death is usually based on exclusion and circumstantial evidence. Knowledge of the patient's history and circumstances of death is of major importance for the forensic pathologist when investigating suspected anaphylactic death.

Differences in early gesture explain SES disparities in child vocabulary size at school entry

Children from low-socioeconomic status (SES) families, on average, arrive at school with smaller vocabularies than children from high-SES families. In an effort to identify precursors to, and possible remedies for, this inequality, we videotaped 50 children from families with a range of different SES interacting with parents at 14 months and assessed their vocabulary skills at 54 months. We found that children from high-SES families frequently used gesture to communicate at 14 months, a relation that was explained by parent gesture use (with speech controlled). In turn, the fact that children from high-SES families have large vocabularies at 54 months was explained by children's gesture use at 14 months. Thus, differences in early gesture help to explain the disparities in vocabulary that children bring with them to school.

The individual blood cell telomere attrition rate is telomere length dependent

Age-associated telomere shortening is a well documented feature of peripheral blood cells in human population studies, but it is not known to what extent these data can be transferred to the individual level. Telomere length (TL) in two blood samples taken at approximately 10 years interval from 959 individuals was investigated using real-time PCR. TL was also measured in 13 families from a multigenerational cohort. As expected, we found an age-related decline in TL over time (r = -0.164, P<0.001, n = 959). However, approximately one-third of the individuals exhibited a stable or increased TL over a decade. The individual telomere attrition rate was inversely correlated with initial TL at a highly significant level (r = -0.752, P<0.001), indicating that the attrition rate was most pronounced in individuals with long telomeres at baseline. In accordance, the age-associated telomere attrition rate was more prominent in families with members displaying longer telomeres at a young age (r = -0.691, P<0.001). Abnormal blood TL has been reported at diagnosis of various malignancies, but in the present study there was no association between individual telomere attrition rate or prediagnostic TL and later tumor development. The collected data strongly suggest a TL maintenance mechanism acting in vivo, providing protection of short telomeres as previously demonstrated in vitro. Our findings might challenge the hypothesis that individual TL can predict possible life span or later tumor development.

The ten commandments of giving medications to children: the questions you should get answers to by your physician or pharmacist before giving any medication to your child

Medications may be important to improve or maintain your child's health. However, quite often errors are made while giving medications to babies and children. Here are questions parents should ask to avoid such errors. It is important for parents to write down the answers, so they can read them as often as they feel needed.

Clinical utility of computed tomography screening of chest, abdomen, and sinuses before hematopoietic stem cell transplantation: the St. Jude experience

All allogeneic (allo) and autologous (auto) hematopoietic stem cell transplantation (HSCT) recipients at St. Jude Children's Research Hospital undergo pre-HSCT computed tomography (CT) of the sinuses, chest, and abdomen because they are at significant risk for opportunistic infections. We studied whether this extensive routine imaging is warranted to detect infection despite the risk of additional radiation exposure. We reviewed the medical records of all children receiving allo- and auto-HSCT at St. Jude in 2004 and 2005. Of the 184 eligible patients who received 187 transplants, 131 received allografts and 56 autografts. Solid tumors and lymphomas were removed from the final analysis of the chest and abdomen CT as this imaging is typically warranted as part of disease restaging; thus, 111 allogeneic participants were included in this analysis. Both auto- and allo-recipients were evaluated by sinus CT and included in this final analysis. Most allo- and auto-HSCT recipients (> or =80%) did not have sinus, pulmonary, cardiac, or gastrointestinal symptoms; >85% of the evaluable allo-recipients had no prior fungal infection. Eighty-eight allo- and 31 auto-HSCT recipients had abnormal sinus CT findings, all unrelated to the underlying disease. Sixty-two (55.9%) of the allo-recipients had normal chest CT and 85 (76.6%) had normal abdominal CT. Of the 18 allo-recipients who began new therapy based on these findings, only 2 (11.1%) were related to chest CT findings and the other 16 were related to sinus findings. Our findings suggest that pre-HSCT routine CT imaging of the abdomen may not be warranted in a subset of allogeneic recipients who are asymptomatic and without previous infectious findings. Thus, these patients may be spared unnecessary radiation exposure. Recipients undergoing auto-HSCT or allo-HSCT for lymphomas or solid tumors will routinely undergo chest and abdominal CT imaging as part of their disease evaluation. The decision to perform chest CT should be made judiciously based on a careful history and physical examination. Sinus imaging, which was frequently abnormal, may be justified in all patients to plan post-HSCT care.