Anaesthesia in a parturient with systemic mastocytosis

Mastocytosis is characterized by clonal expansion of mast cells, with abnormal accumulation in different organs. Perioperatively, numerous stimuli may lead to the release of vasoactive substances by mast cells. Parturients with systemic mastocytosis pose a challenge to the anesthesiologist: on one hand, the pain and stress of labor may lead to greater mast cell activation and, on the other, the administration of drugs that may possibly trigger the release of mast cell mediators. The authors describe a case of a 34-year-old pregnant woman with systemic mastocytosis who requests labor analgesia. An epidural analgesia was performed after induction of labor, after considering anesthetic particularities. The epidural procedure, labor and delivery were uneventful. A review of systemic mastocytosis is provided and its anesthetic considerations are discussed.

Intraoperative pulmonary hyperdistention estimated by transthoracic lung ultrasound: A pilot study

INTRODUCTION

Transthoracic lung ultrasound can assess atelectasis reversal and is considered as unable to detect associated hyperdistention. In this study, we describe an ultrasound pattern highly suggestive of pulmonary hyperdistention.

METHODS

Eighteen patients with normal lungs undergoing lower abdominal surgery were studied. Electrical impedance tomography was calibrated, followed by anaesthetic induction, intubation and mechanical ventilation. To reverse posterior atelectasis, a recruitment manoeuvre was performed. Positive-end expiratory pressure (PEEP) titration was then obtained during a descending trial - 20, 18, 16, 14, 12, 10, 8, 6 and 4cmH₂O. Ultrasound and electrical impedance tomography data were collected at each PEEP level and interpreted by two independent observers. Spearman correlation test and receiving operating characteristic curve were used to compare lung ultrasound and electrical impedance tomography data.

RESULTS

The number of horizontal A lines increased linearly with PEEP: from 3 (0, 5) at PEEP 4cmH₂O to 10 (8, 13) at PEEP 20cmH₂O. The increase number of A lines was associated with a parallel and significant decrease in intercostal space thickness (p=0.001). The lung ultrasound threshold for detecting pulmonary hyperdistention was defined as the number of A lines counted at the PEEP preceding the PEEP providing the best respiratory compliance. Six A lines was the median threshold for detecting pulmonary hyperdistention. The area under the receiving operating characteristic curve was 0.947.

CONCLUSIONS

Intraoperative transthoracic lung ultrasound can detect lung hyperdistention during a PEEP descending trial. Six or more A lines detected in normally aerated regions can be considered as indicating lung hyperdistention.

TRIAL REGISTRATION

NCT02314845 Registered on ClinicalTrials.gov.

Family health and conditional cash transfer in Brazil and its effect on tuberculosis mortality

BACKGROUND

Social protection can reduce poverty and act on the determinants of tuberculosis (TB).

OBJECTIVE

To evaluate the impact of the Family Health Strategy (FHS) and the Bolsa Família Programme on TB-related mortality in Brazil.

METHODS

This was an ecological study in which the units of analysis were Brazilian municipalities between 2001 and 2012. The principal independent variables were the levels of coverage of the primary health care system and the conditional cash transfer programme. The dependent variable was TB mortality rate (obtained from national databases). Descriptive analysis and negative binomial regression based on panel data using fixed-effects models were performed. Crude and adjusted estimates were calculated for continuous and categorical variables.

RESULTS

A high FHS coverage was significantly associated with a reduction in the TB mortality rate (RR 0.80, 95%CI 0.72-0.89). An increase in the coverage of the Brazilian cash transfer programme was significantly associated with a reduction in the TB mortality rate (RR 0.87, 95%CI 0.81-0.96).

CONCLUSION

FHS and the Bolsa Família conditional cash transfer programme had a positive impact on the TB mortality rate in Brazil. Public policies should include economic support combined with health promotion.

Effect of Brazil's conditional cash transfer programme on tuberculosis incidence

OBJECTIVE

To evaluate the impact of the Brazilian cash transfer programme (Bolsa Família Programme, BFP) on tuberculosis (TB) incidence in Brazil from 2004 to 2012.

DESIGN

We studied tuberculosis surveillance data using a combination of an ecological multiple-group and time-trend design covering 2458 Brazilian municipalities. The main independent variable was BFP coverage and the outcome was the TB incidence rate. All study variables were obtained from national databases. We used fixed-effects negative binomial models for panel data adjusted for selected covariates and a variable representing time.

RESULTS

After controlling for covariates, TB incidence rates were significantly reduced in municipalities with high BFP coverage compared with those with low and intermediate coverage (in a model with a time variable incidence rate ratio = 0.96, 95%CI 0.93-0.99).

CONCLUSION

This was the first evidence of a statistically significant association between the increase in cash transfer programme coverage and a reduction in TB incidence rate. Our findings provide support for social protection interventions for tackling TB worldwide.

Masticatory performance and taste perception in patients submitted to cancer treatment

The aim of this study was to analyse mastication and the sense of taste in 39 patients submitted to cancer treatment in different areas of the body and to compare these variables with those of 44 control individuals within the same age range. The following aspects were assessed: dental status (DMFT); stimulated and non-stimulated salivary flow; sense of taste (salty, sweet, bitter and sour); and masticatory performance (MP), through the calculation of X(50). Logistic regression models were established to test the association between the independent variables and cancer treatment. Cancer patients had lesser stimulated salivary flow, a smaller number of teeth and occlusal units, worse MP, higher salty, sweet and sour taste scores and a lower bitter taste score (P < 0·05). A significant positive correlation was found between MP and the DMFT index in both groups (P < 0·05), meaning that a lower DMFT index value denoted a smaller X(50) value (better masticatory performance). The logistic regression model revealed that patients who had undergone cancer treatment had a greater probability of exhibiting a smaller number of teeth, higher salty and smaller bitter taste scores (P < 0·05). It was concluded that patients who were submitted to cancer treatment presented oral physiology alterations when compared with control subjects at the same age range.

A randomized comparative crossover study to assess the affect on circuit life of varying pre-dilution volume associated with CVVH and CVVHDF

OBJECTIVE

To determine if circuit life is influenced by a higher pre-dilution volume used in CVVH when compared with a lower pre-dilution volume approach in CVVHDF.

DESIGN

A comparative crossover study. Cases were randomized to receive either CVVH or CVVHDF followed by the alternative treatment.

SUBJECTS

All patients >or= 18 yrs of age who required CRRT while in ICU were eligible to participate, but excluded if coagulopathic, thrombocytopenic or unable to receive heparin. Based on an intention-to-treat, 45 patients were randomized to receive either CVVH or CVVHDF followed by the alternative treatment.

SETTING

A 24-bed, tertiary, medical and surgical adult intensive care unit (ICU).

INTERVENTION

Blood flow rate, vascular access device and insertion site, hemofilter, anticoagulation and machine hardware were standardized. An ultrafiltrate dose of 35 ml/ kg/h delivered pre-filter was used for CVVH. A fixed pre-dilution volume of 600 mls/h with a dialysate dose of 1 L was used for CVVHDF.

RESULTS

Thirty-one patients received CVVH or CVVHDF out of 45 participants followed by the alternative technique. There was a significant increase in circuit life in favor of CVVHDF (median=16 h 5 min, range=40 h 23 min) compared with CVVH (median=6 h 35 min, range=30 h 45 min). A Mann-Whitney U test was performed to compare circuit life between the two different CRRT modes (Z=-3.478, p<0.001). Measurements of circuit life on the 93 circuits which survived to clotting (50 CVVH and 43 CVVHDF) were log transformed prior to under taking a standard multiple regression analysis. None of the independent variables - activated prothrombin time (aPTT), platelet count, heparin dose, patient hematocrit or urea - had a coefficient partial correlation >0.09 (coefficient of the determination=0.117) or a linear relationship which could be associated with circuit life (p=0.228).

CONCLUSION

Pre-diluted CVVHDF appeared to have a longer circuit life when compared to high volume pre-diluted CVVH. The choice of CRRT mode may be an important independent determinant of circuit life.

Neonatal BCG protection against tuberculosis lasts for 20 years in Brazil

Bacille Calmette-Guérin (BCG) efficacy against pulmonary disease is highly variable; until very recently there was no evidence of protection after 10 years. In the control arm of a trial of efficacy of revaccination of schoolchildren in Brazil we found substantial protection (39%; 95%CI 9-58) of neonatal BCG against all forms of tuberculosis (TB) 15-20 years after vaccination, much longer than previously believed. This confirms recent findings from an earlier trial, and must be considered in the design of trials of new TB vaccines and in policy decisions based on assumed lack of neonatal BCG protection with time.

A comparison of dual skin test with mycobacterial antigens and tuberculin skin test alone in estimating prevalence of Mycobacterium tuberculosis infection from population surveys

SETTING

City of Manaus, Amazonas, Brazil.

OBJECTIVE

To compare estimates of Mycobacterium tuberculosis infection prevalence obtained using traditional tuberculin skin test (TST) criteria and dual skin test (DST) data.

METHODS

A total of 1070 schoolchildren received DST with tuberculin and four environmental mycobacteria sensitins. Responses were classified as sensitin-dominant, tuberculin-dominant or non-dominant. Positive predictive values (PPV) were defined using 'narrow' and 'wide' standards based on DST responses. These predictive values were derived for each category of tuberculin indurations, and were used to calculate the prevalence estimates.

RESULTS

Using DST data, the estimates of M. tuberculosis prevalence for scar-negative children were 7.4% (M. avium) and 7.8% (M. scrofulaceum) using the 'narrow' standard, and 16.9% (M. avium) and 15.2% (M. scrofulaceum) using the 'wide' standard. The percentage with TST > or =10 mm was 11.5%. Scar-positive children had higher estimates using both the 10 mm cut-off and DST data.

CONCLUSION

In settings with a relatively low prevalence of M. tuberculosis infection and high cross-reactivity with environmental mycobacteria, DST can help to assess the validity of traditional thresholds for estimating the prevalence of M. tuberculosis infection. DST data with environmental antigens and tuberculin do not distinguish BCG-induced cross-reactivity.

Sensitivity and specificity of BCG scar reading in Brazil

In a cross sectional survey within a community trial of BCG efficacy evaluation in Brazil, trained teams inspected children's upper arms and obtained information on BCG vaccination from guardian letters and vaccination cards. Nurses re-examined the sub-sample of children blindly. High agreement was found between the two scar readings (Kappa = 0.839). High sensitivity and low specificity was observed when guardian or card information was the gold standard. Sensitivity remained high when guardian and card information agreed. When disagreement occurred, sensitivity remained high and specificity was very low. BCG scar is a good indicator of BCG vaccination.

Skin test reactivity to mycobacterial antigens parallels the phylogenetic structure of their genus

SETTING

City of Manaus, Amazonas, Brazil.

OBJECTIVE

To explore the relationship between positivity to tuberculin and other environmental mycobacteria sensitins, according to a range of criteria and presence of BCG scar.

DESIGN

Dual skin testing with tuberculin and four mycobacterial sensitins, and BCG scar recording of 1070 schoolchildren aged 7-14. Four criteria for positivity were used: simple and dominant, with 5 and 10 mm cut-off points.

RESULTS

The standardised prevalence of reactions > or = 5 mm for BCG scar negative children was 58.3% for Mycobacterium avium, 54.2% for M. scrofulaceum, 26.8% for M. fortuitum, 17.9% for M. tuberculosis and 7.6% for M. kansasii. Correlations between tuberculin and each sensitin, for BCG scar negative children, were 0.47 for M. avium, 0.53 for M. scrofulaceum, 0.60 for M. kansasii and 0.22 for M. fortuitum (all with P < 0.01). BCG effect was particularly significant for tuberculin (odds ratio = 3.44 for reactions > or = 5 mm, P < 0.001) and influenced the balance between dominant/non-dominant reactions for all sensitins.

CONCLUSION

The correlation between tuberculin and each sensitin confirmed the separation of the rapidly (M. fortuitum) and slowly growing mycobacteria (M. tuberculosis, M. avium, M. scrofulaceum and M. kansasii). The influence of BCG on tuberculin reactions was more marked than on other mycobacterial sensitins.

Progression of cervical lesions in HIV-seropositive women: a cytological study

It has been reported that cervical intraepithelial lesions have a more aggressive course in HIV-seropositive than in HIV-seronegative women. In the present investigation, the progression of these cervical lesions was studied in a group of HIV-seropositive women. Of 1,587 patients, 200 (12.6%) had a cytological diagnosis of squamous intraepithelial lesion (SIL) or invasive carcinoma. In 409 patients, more than one cytological smear was collected in 3(1/2) years. Progression occurred in 39 cases. In 24 (61.5%), the first diagnosis was benign cellular changes (BCC) and the second was low-grade SIL (LSIL) (1-yr interval in 21 cases); in 11 (28.2%), the first was BCC, and the second, high-grade SIL (HSIL) (1-yr interval in 9 cases); in 2 (5.0%), the first diagnosis was LSIL. and the second, HSIL (1-yr interval); in 2 (5.0%), the first was HSIL, and the second, invasive carcinoma (2-yr interval). These results point to the importance of cervical cytologic surveillance in HIV-seropositive patients.

Cervical intraepithelial neoplasia in adolescents: study of cytological findings between 1987 and 1995 in São Paulo State-Brazil

The purpose of the present study was to ascertain the frequency of Pap smears abnormalities (SIL/carcinoma) in two populations in the State of S. Paulo (Brazil) who were screened for cervical cancer during the last nine years: adolescents (up to the age of 21) and adults (over 21). Statistical analysis showed a tendency to linear increase in frequency of abnormal Pap smears in both groups (adolescent: slope = 0.118 +/- 0.56; adult: slope = 0.079 +/- 0.021), being greater in the adolescent group (slope 0.039 +/- 0.038) than in the adult group. Between 1987 and 1995 the prevalence of abnormal smears tripled in the adult group (from 0.37 to 1.18) and almost quadruplicated in the adolescent group (from 0.64 to 2.10). Low grade squamous intraepithelial lesions (SIL) were the most frequent findings in cervical cytology in both groups: 92.3% in the adolescent group and 69.8% in the adult group. Few cases of high grade squamous intrapeithelial lesions (HSIL) (7.7%) and no cases of carcinoma were found in adolescent population. We suggested that sexually active adolescents should be included in cervical screening programs.

Study of organizer nucleolar regions by the argyrophil technique in cervical intraepithelial neoplasias

Thirty three biopsies of the uterine cervix were studied by the AgNOR method, that identifies the nucleolar organizer regions. These comprised 9 cases of cervicitis (with or without squamous metaplasia), 9 cases of cervical intraepithelial neoplasia grade I (CIN I), 8 CIN II and 10 CIN III. A hundred cells were counted and classified according to the number of AgNOR dots. We use a more practical and fast method of AgNOR dots counting in cervical intraepithelial neoplasia, in that we exclude the two basal layers and count only cells with 4 or more dots. Statistically significant differences for AgNOR dots were found between cervicitis or CIN I and CIN II cases (p < 0.02) and between CIN II and CIN III cases (p < 0.001). No statistical difference was found between the cases of cervicitis and CIN I. It was concluded that this method of AgNOR counting can be useful in the identification and classification of individual cases intraepithelial neoplasia and their differentiation from eventual difficult cases of cervicitis.

Role of viruses in acute gastroenteritis in infants and young children at Vellore, south India

The aetiological contribution of viral agents in the causation of acute diarrhoea was studied prospectively in 915 infants and young children aged 1-35 months. This was a hospital-based study, selection being carried out by proportionate random sampling; 587 matched controls were also investigated simultaneously. Methods of detection included direct electron microscopy, ELISA for rotaviruses and immune electron microscopy. Rotaviruses emerged as the single most important cause with highest prevalence in the 6-11-month age group. The contribution of other agents was negligible. Electron microscopy, though a "catch-all' technique, is not a cost-effective diagnostic method for developing countries.

Diastereoselective Propionitrile Oxide Cycloaddition Reactions With Some γ-Substituted α-Methylene-γ-butyrolactones

A number of γ-substituted α-methylene-γ-butyrolactone derivatives underwent 1,3-dipolar cycloaddition with propionitrile oxide to give spiro Δ2-isoxazolines. The reaction proceeded regiospecifically and with high diastereoselectivity. The products of anti addition predominated. The regiochemistry of addition and relative stereochemistry of the products were determined by a combination of n.O.e ., HETCOR and DOUBTFUL n.m.r. experiments. The assignment was confirmed in one case by X-ray crystallography.

Aetiology and clinical features of acute childhood diarrhoea in an outpatient clinic in Vellore, India

The aetiology of acute diarrhoea was investigated in 245 children less than 3 years old in a paediatric outpatient clinic in southern India. In 55% of the children organisms were found in the stools, and one quarter were infected with multiple organisms. Viruses, enteropathogenic E. coli, shigella and campylobacter species accounted for 75% of all isolates. Cholera and helminthiasis were rare, and no child had amoebiasis. Clinical findings were useful in the diagnosis of shigella and rotavirus infection only. Children with shigellosis had classical dysentery, and a greater number of stools; they were unlikely to be breast-fed, to be less than 6 months old, or to have watery stools. Rotavirus infections were characterized by vomiting. Only 20% of the 245 children had an infection which could be treated effectively with antimicrobials.

The influence of illnesses on the food intake of young children

The effect of illness on the food intake of 125 preschool children in a residential home was studied. The children had a mean of 6.8 episodes of illness per child per year. Upper respiratory infections, diarrhoeas and fevers depressed food intake by 15-20%. Measles resulted in prolonged and profound depression of appetite, and caused weight losses in the affected children. The number of days of depressed appetite due to illness had a cumulative effect on growth; poor increases in height and weight were seen in these children who had many days of reduced appetite due to illness. Measles vaccination is strongly recommended for improved growth and nutritional status of preschool children.

Pyomyositis in south Indian children

Thirty-two children with pyomyositis were studied. In 28 children, 23 boys and 5 girls, Staphylococcus aureus was the aetiological agent. The strains isolated were resistant to penicillin. The muscles of the thigh, back and upper arm were most frequently involved. Eight children had infections in other parts of the body, namely pneumonia, empyema, pericarditis, meningitis, osteomyelitis and arthritis. Two children died. At follow-up one child had chronic osteomyelitis. In four neonates, beta haemolytic streptococcus was the causative organism. All were septicaemic. One infant died.

The growth of exclusively breastfed infants

To determine the pattern of growth of exclusively breastfed babies and to establish their incremental weight gains, 329 babies attending a well baby clinic were studied. The weight gains were most rapid over the first 6 weeks and were of the order of 41.4 and 39.2 g/day in the boys and girls respectively. Underweight mothers did not produce lighter babies than mothers of desirable weight, nor did their nutritional status influence the weight gains of their infants over the first 6 weeks. Low birthweight infants doubled their weights by 9-10 weeks, while heavier babies took 15 to 18 weeks. The pattern of growth of exclusively breastfed infants appears to be different from that of artificially fed infants.

Poliovirus infection and Bell's palsy in children

During a 16-months study period at Vellore, South India, three out of five children presenting as 'Bell's palsy' were suffering from poliomyelitis. In polio-endemic countries, poliomyelitis should be considered when children present as 'Bell's palsy'.

[Cold lymphocytotoxins in schistosomiasis mansoni]

The serum of 134 patients infected with Schistosoma mansoni, including both acute and chronic forms of the disease, were tested for the presence of cold lymphocytotoxins. These were found in 4.5% of acute forms of the disease, in 88.4% of chronic infections and in only 9.8% of the uninfected control group (blood donors). An analysis of the results suggests a probable role for cold lymphocytotoxins in the immune response of the different phases of human schistosomiasis.

Latex agglutination: an appropriate technology for the diagnosis of bacterial meningitis in developing countries

We evaluated prospectively the utility of a latex agglutination technique for the diagnosis of Haemophilus influenzae type b meningitis in a paediatric ward in India. Eight of 44 children had H. influenzae grown from cerebrospinal fluid. These proven cases plus four additional cases of H. influenzae meningitis were detected by the latex agglutination test. There were no cross reactions with other organisms. The high degree of sensitivity and specificity, combined with the speed and simplicity of this technique make it an appropriate method for developing countries.

Evaluation of the opportunities for and contraindications to immunization in a tropical paediatric clinic

The immunization status and frequency of contraindications to immunization were studied in 446 children attending the paediatric clinic of a teaching hospital in south India. In all, 27% of the children were up to date in their immunizations, 19% had a contraindication, and 57% required and could safely be given immunizations. A policy of offering immunizations in paediatric clinics to all who require them and who do not have a contraindication would result in protection of a significant number of unimmunized children.

The pattern of medical renal disease in children in a south Indian hospital

A retrospective study of children admitted to a south Indian hospital during an 11 year period showed that 70% of the renal diseases encountered in children in this region are of types which have a good prognosis. Post-streptococcal glomerulonephritis was the most common. The relative prevalence of steroid-sensitive nephrotic syndrome and different histological types of idiopathic nephrotic syndrome was similar to that in developed Western countries. Haemolytic-uraemic syndrome complicating bacillary dysentery was the most common cause of acute renal failure.

Dosage of chloramphenicol in typhoid and paratyphoid in children

Over a period of 12 years, 109 children with salmonella enteric fever were treated with chloramphenicol: 65 children were given the drug at 50 mg/kg/24 h (Group A) and 44 received 100 mg/kg/24 h (Group B). Treatment failed in 63% with the lower dose and in 24% of children treated with the higher dose (P less than 0.001). In the children who received only chloramphenicol, the higher dose produced a clinical response in 5.4 (1.8) (mean (S.D.] days compared with 7 (2.6) days with the lower dose (P less than 0.01). Chloramphenicol in an initial dose of 100 mg/kg/24 h is recommended in the treatment of typhoid and paratyphoid in children.

Outcome of the haemolytic-uraemic syndrome complicating bacillary dysentery

Seventy-eight children were treated for the haemolytic-uraemic syndrome complicating bacillary dysentery over a ten-year period. Early dialysis favoured survival significantly. The renal status of 22 of the 28 survivors was re-evaluated 18-84 months after initial hospitalization. Complete recovery was found in all except two patients; one of them had neurological sequelae and the other a glomerulonephritic disease.

Physical growth and neurointegrative performance of survivors of protein--energy malnutrition

1. The anthropometric measurements and neurointegrative performance of seventy-nine children aged 6--12 years who had survived kwashiorkor in early childhood were compared to those of 142 children who served as controls. 2. For the boys the differences in height and weight between those who had survived protein--energy malnutrition (PEM) and the controls were significant (P less than 0.01). 3. For the girls the differences in height and weight between those who had survived PEM and the controls were not significant. 4. In the tests chosen, the performances of the survivors of PEM was significantly poorer than that of the controls. 5. There was no improvement in the performance when thirteen survivors were reassessed at 10 years of age. 6. There was a significant difference in scholastic performance between the survivors of PEM and the normal controls. The scholastic performance of the siblings of PEM survivors was also significantly better than that of the PEM survivors. 7. The dietary intakes at the time of reassessment were unsatisfactory in 25% of the survivors, but did not relate to their scholastic abilities.

A preliminary simulated iron fortification trial in South Indian preschool children

1. The effect of fortification of food with iron to provide 10 mg elemental Fe/child per d was studied in preschool children maintained on a cereal diet, over a 5-month period. 2. The absorption of 5 mg Fe as ferrous sulphate mixed in one meal was 3.3% of the test dose and when 3.3 mg was given with each of three meals over a 2 d period the corresponding value was 4.8%. 3. The mean absorption of a test dose of ferrous ascorbate studied in twenty-four children midway through the trial was 42%. 4. The only beneficial effect of Fe fortification in this time-period in the experimental group was the prevention of the decrease in packed cell volume which occurred in the control groups.

Jejunal microbial flora of southern indian infants in health and with acute gastroenteritis

The microbial flora of the jejunal lumen of 28 infants with acute gastroenteritis was compared with that of a group of 10 normal infants. The jejunum of control subjects harboured an "oral" type of flora and in a few instances enterobacteria in small numbers. The concentrations of all but one of the groups of organism were higher in the patients than in controls, and the differences were of statistical significance for enterobacteria and lactobacilli. In eight subjects, the same pathogen was identified in the jejunum and the stool. In six subjects with rotavirus infection, there were almost no Gram-negative aerobic rods in the jejunum. The possible role of other Gram-negative aerobic rods in producing gastroenteritis is discussed. It is suggested that studies of jejunal flora are of considerable importance in assigning an aetiological role to bacteria in the causation of acute gastroenteritis.

Faecal flora of South Indian infants and young children in health and with acute gastroenteritis

The faecal flora of 29 healthy infants and young children was compared with that of 49 children of similar age and socio-ecomonic status with acute gastroenteritis. In the healthy children the most common organisms in the faeces were bifidobacteria, veillonellae, enterobacteria and enterodocci with anaerobes outnumbering aerobes. Most members of the noraml faecal flora were present in the diarrhoeal stools, but anaerobes were signigicantly reduced in number and enterobacteria were significantly increased, thereby altering the ratio of anaerobes to aerobes. The alterations in the flora were not related to the nature of the aetiological agent or to the severity of the diarrhoea. The changes appeared to be a direct result of the altered colonic environment produced by the diarrhoeal state. In 13 of the 28 patients from whom bacterial pathogens were isolated, the pathogens were the predominant faecal organsims.

Studies in iron supplementation of preschool children

1. The effect of daily supplements of 20-30 mg inorganic iron as ferrous sulphate on the growth, activity and haematological status of preschool children was studied for 3.5, 7 and 12 months and compared to that of children who served as controls. All children were given their daily requirements of energy and protein. In addition, they received 5 microgram cyanocobalamin and 200 microgram folic acid. 2. Fe supplementation increased the haemoglobin, serum Fe and percentage saturation of transferrin and reduced the unsaturated Fe-binding capacity significantly compared to corresponding values for the controls. 3. Height and activity were unaffected by Fe supplements. 4. Of the children 45% had haemoglobin values below 110 g/l at the end of 7-12 months of Fe supplementation.

Aetiology of acute gastroenteritis in infancy and early childhood in southern India

The aetiology of acute gastroenteritis was studied in 50 infants and young children. Bacterial pathogens were isolated in 33, enteropathogenic E. coli (EPEC), Salmonella, and Shigella being the commonest isolates. Rotaviruses were detected in the stools of 13 of the cases. All children with gastroenteritis in whom rotavirus was detected were seen during the months July to December. In 30 children who served as controls, EPEC were isolated in 6, but rotavirus was detected in none. It is concluded that infection with rotaviruses is a significant cause of morbidity in children with gastroenteritis in southern India.

The beta carotene content of Indian edible green leaves

Thirtytwo varieties of edible green leaves were analysed for their beta carotene content in different seasons of the year. Several varieties were found to contain enough beta carotene to provide the daily requirements of vitamin A, even for an adult person, from a moderate serving (30g-100g).

Dietary intakes and food taboos of lactating women in a South Indian community

The diets of women, studied at regular intervals in the first year of lactation, showed that food taboos adversely affected the daily intake of energy, protein and some nutrients in the first month. Despite the poor intakes, the women breastfed their babies successfully and the weight gained by the babies in the early months was satisfactory. Breast feeding continued until the next pregnancy. Most women believed lactation prevented conception.