Treatment of chronic digital septic tenosynovitis in 12 horses by modified open annular ligament desmotomy and passive open drainage

A modified open annular ligament desmotomy followed by passive open drainage was used to treat 12 horses with chronic digital septic tenosynovitis due to trauma in the form of open wounds or self-sealing punctures. The surgical approach included complete transection of the palmar/plantar annular ligament of the fetlock and proximal digital annular ligament, which facilitated the removal of fibrin, selective debridement and synovectomy, followed by lavage of the digital sheath. The incision was partially closed leaving a 2 cm gap open distally to allow for passive open drainage. Gentamicin was administered intrathecally during surgery. Postoperatively the horses received ceftiofur and non-steroidal anti-inflammatory drugs. A sterile bandage was used to protect the wound until the gap had healed completely by second intention. Infection was controlled in 11 of the horses which all returned to their previous levels of work, but one horse was euthanased as a result of the persistence of the infection and financial considerations.

Eradication of vancomycin resistant Enterococcus faecium from a paediatric oncology unit and prevalence of colonization in hospitalized and community-based children

We previously reported an outbreak of vancomycin resistant enterococci (VRE) in a paediatric oncology unit in December 1995 which was associated with widespread environmental contamination of the unit with VRE. We undertook this study to evaluate the effectiveness of the infection control policy instituted subsequent to the outbreak and to investigate the underlying prevalence of VRE colonization in hospitalized, outpatient and community-based children. We sought to establish the molecular similarity of VRE isolates from the study. Stool specimens were obtained from outpatients at risk of VRE, hospital inpatients and from healthy community-based children. VRE colonization was eradicated from the inpatient unit within 11 months, but in outpatients, 16 months after the outbreak, 4 of 137 (2.9 %) attending oncology outpatients, 5 of 65 (7.7%) with cystic fibrosis and 1 of 12 (8.3 %) with liver disease were found to be colonized with VRE. The isolates were all Enterococcus faecium, Van A phenotype except one E. casseliflavus of the Van C phenotype. All were unique in SmaI DNA macrorestriction patterns with the exception of two isolates, which were similar to the original outbreak strain and three further isolates of a single strain but which differed from the outbreak strain. Of 315 hospital inpatients, 2.5 % were colonized with VRE of the Van C resistance phenotype but VRE was not detected in 116 healthy, community-based children. We conclude that effective strategies can successfully control spread of VRE but despite a low prevalence of VRE colonization in hospital patients and in community-based children, outbreaks can occur when infection control practices are not optimal. Continued vigilance to detect VRE and limit spread within hospitals is therefore necessary.

An assessment of paediatric diabetes care in three centres in Russia and in Southampton, UK. The Paediatric Teams in Moscow, Tula, Tambov, Southampton

AIMS

Young people in Russia with diabetes have an increased morbidity and a 10-fold increase in mortality compared with many European countries. This joint international study was set up to compare of care and outcomes against published guidelines in three Russian centres and one UK centre.

METHODS

An assessment of the diabetic care of 368 children, based on the principles of the St Vincent Declaration, was undertaken in each centre. Data on prevalence, management, control and complications were collected in young people with diabetes < 16 years of age in each of the four centres over a 4-week period.

RESULTS

The prevalence of diabetes was greater in Southampton (1:702 vs. 1:1378). At diagnosis Russian children had a higher incidence of ketoacidosis (69 vs. 29%) and stayed in hospital longer (30 vs. 3 days). In management Russian children received more injections per day (5 vs. 2). There was no significant difference in insulin dose for those under 10 years between countries (Southampton 0.69 U/kg vs. Russian 0.73 U/kg, P=NS). Older Russian children did not increase their insulin dosage, while children over 10 years in Southampton received significantly more insulin than the Russian children (Southampton 1.0 U/kg vs. Russian 0.77 U/kg, P< or =0.001). Twenty-nine per cent of the Russian children reported that they had insufficient insulin and 14% had to buy extra. HbA1c was higher in the Russian children (9.8% vs. 8.3%), increasing significantly with age. The Russian children showed a height deficit which correlated with HbA1c and diabetes duration. The Southampton children were heavier and with a higher body-mass index and their HbA1c did not rise similarly as in Russia. Severe hypoglycaemia was more common in the Southampton children (32 vs. 12%). Retinopathy was reported in 12% of the Russian children (Southampton 0%) and systolic blood pressure > 95th centile in 21% (Southampton 8%).

CONCLUSIONS

This study demonstrates a significant difference in diabetic control and complications between the two countries which could be partially explained by a decreased availability and prescribing of insulin and blood glucose monitoring in Russia. Southampton has an education and management policy based on ambulatory care resulting in reduced hospital stay.

Depression, illness perception and coping in rheumatoid arthritis

This study aimed to establish the relationship between depression, illness perception, coping strategies, and adverse childhood events in rheumatoid arthritis patients. Sixty-two out-patients with rheumatoid arthritis (RA) completed the Hospital Anxiety and Depression Scale, Illness Perception Questionnaire, London Coping with Rheumatoid Arthritis Questionnaire, and Childhood Development Questionnaire, and underwent a clinical assessment of their physical state. Depressed patients were more disabled than the nondepressed, had a more negative view of their illness, and used more negative coping strategies. There was no association between depression and childhood adversity. Once disability was controlled for, there continued to be a significant correlation between depression and: (i) viewing the consequences of the illness negatively (Spearman's correlation coefficient [r]=0.37, p=0.003); and (ii) the perceived ability to control the illness (r= -0.26, p=0.04). The relationship between depression and negative coping strategies became insignificant. This study indicates the close relationship between depression and a negative view of the illness.

Extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a Dublin paediatric hospital

Klebsiella pneumoniae resistant to third-generation cephalosporins and gentamicin was isolated from two patients in a paediatric intensive care unit within a two-week period. The double-disc diffusion test indicated the presence of an extended-spectrum beta-lactamase (ESBL). The unit was closed to admissions, and stringent infection control procedures were implemented. Environmental screening and screening of staff and patients on the unit were commenced. Two weeks later, K. pneumoniae with an identical antibiogram was isolated from the urine of a patient in a different ward. Blood-culture isolates possessed the K16 antigen, while the urine isolate was non-typeable. The isolates were shown to be similar when banding patterns of XbaI chromosomal DNA digests were compared. The resistance to the extended-spectrum cephalosporins was shown to be transferable in association with a large plasmid > 98 mDa. Resistance to gentamicin always co-transferred with beta-lactamase resistance and appeared to be encoded by the same plasmid.

Guanosine tetraphosphate (ppGpp)-mediated inhibition of the activity of the bacteriophage lambda pR promoter in Escherichia coli

It was previously demonstrated that the activity of bacteriophage lambda promoter pR is decreased in wild-type Escherichia coli cells starved for amino acids (during the stringent response). Since pR activity is necessary for the transcriptional activation of ori lambda, this leads to inhibition of the replication of plasmids derived from phage lambda. These results led to the proposal that the pR promoter susceptible to control by the stringent response. However, subsequent studies demonstrated that this promoter is activated by the host dnaA gene product and since the dnaA promoter was reported to be controlled by the stringent response, it is possible that the inhibition of pR activity in amino acid-starved cells is indirect, and results from the impairment of DnaA-mediated transcriptional activation. Here we present evidence that pR is negatively regulated by ppGpp, even when DnaA protein is provided in excess as well as in cells devoid of DnaA function. We have checked that the level of ppGpp is increased during prolonged (up to 4 h) starvation for isoleucine in relA+ cells but not in the relA- mutant. At the same time we observed inhibition of lambda plasmid replication during the stringent, but not relaxed, response, even when DnaA was overproduced. Finally, we found that the activity of a pR-lacZ fusion is inhibited after gratuitously induced overproduction of ppGpp in unstarved cells, irrespective of the status of the dnaA gene product. We conclude that the activity of the pR promoter is inhibited directly by ppGpp.

Control of a nosocomial outbreak of vancomycin resistant Enterococcus faecium in a paediatric oncology unit: risk factors for colonisation

In order to determine the extent of vancomycin resistant enterococcus (VRE) colonisation within a paediatric oncology unit, the risk factors for the acquisition of the organism, the molecular epidemiology of the isolates and the impact of infection control measures, extensive patient and environmental surveillance was undertaken with identification, antibiotic susceptibility testing and pulsed-field gel electrophoresis (PFGE) of all VRE isolates. A matched case control study was carried out. Fourteen patients (19% of screened patients) with VRE colonisation were identified (12 with Enterococcus faecium). All isolates manifested the Van A phenotype. Extensive environmental contamination with VRE was present. PFGE of E. faecium isolates from 10 patients and from five of six environmental cultures revealed patterns suggesting genetic relatedness. Following comparison of the 14 cases with 41 controls matched for age (+/- 4 years) and cohabitation on the oncology unit, risk factors for colonisation with VRE included duration of neutropenia, (OR, 3.72; 95% CI, 1.0-13.1), and antibiotic therapy, (OR, 4.07; 95% CI, 1.08-15.3), the number of antibiotic agents received, (OR, 8.4; 95% CI, 1.34-34.3) and the duration of therapy with amikacin, (OR, 10.7; 95% CI, 1.4-81.5), ceftazidime, (OR, 11.5; 95% CI, 2.2 59.9) or teicoplanin, (OR, 12.3; 95% CI, 2.25-67.4). Implementation of stringent infection control measures reduced environmental contamination from 25% of samples in week 1 to none in week 11. Two additional colonised patients were identified during the subsequent 6 months.

CONCLUSION

Risk factors for VRE colonization in paediatric oncology patients included duration of neutropenia, duration of any antibiotic therapy, exposure to ceftazidime, amikacin or teicoplanin and the number of antibiotics used. The study suggests that environmental contamination played an important role in patient-to-patient transmission of VRE and interventions including implementation of infection control measures were associated with a decreased incidence of gastro-intestinal colonisation.

Guanosine tetra- and pentaphosphate promote accumulation of inorganic polyphosphate in Escherichia coli

High levels of guanosine tetraphosphate (ppGpp) and guanosine pentaphosphate (pppGpp), generated in response to amino acid starvation in Escherichia coli, lead to massive accumulations of inorganic polyphosphate (polyP). Inasmuch as the activities of the principal enzymes that synthesize and degrade polyP fluctuate only slightly, the polyP accumulation can be attributed to a singular and profound inhibition by pppGpp and/or ppGpp of the hydrolytic breakdown of polyP by exopolyphosphatase, thereby blocking the dynamic turnover of polyP. The Ki values of 10 microM for pppGpp and 200 microM for ppGpp are far below the concentrations of these nucleotides in nutritionally stressed cells. In the complex metabolic network of pppGpp and ppGpp, the greater inhibitory effect of pppGpp (compared with ppGpp) leading to the accumulation of polyP, may have some significance in the relative roles played by these regulatory compounds.

Gestational diabetes mellitus: antenatal variables as predictors of postpartum glucose intolerance

OBJECTIVE

To determine whether antepartum variables can predict postpartum glucose intolerance.

METHODS

Glucose tolerance was assessed 6 weeks postpartum in 94 of 238 women with gestational diabetes using a 2-hour, 75-g oral glucose tolerance test (GTT). Selected antepartum variables were analyzed for predictive ability for postpartum glucose intolerance.

RESULTS

Of 238 patients, 94 (39%) returned for a GTT. Those returning and those not returning were similar in all variables. Postpartum glucose intolerance occurred in 34%: impaired glucose tolerance in 18%, overt diabetes in 16%. No single maternal, intrapartum, or neonatal variable was predictive of postpartum glucose intolerance in all cases. Predictive variables included: requirement for insulin (insulin versus diet: 25 versus 3% impaired glucose tolerance, 26 versus 0% diabetes; P = .001), poor glycemic control (any 2-hour postprandial blood sugar level of 150 mg/dL or higher: 34 versus 5% diabetes; P = .005), and the 50-g GTT value (200 mg/dL or higher: 32 versus 6% diabetes; P = .01). For insulin requirement, the relative risk (RR) was 17.28 (95% confidence interval [CI] 2.46-121.45), and for the above three variables combined, the RR was 19.68 (95% CI 2.88-134.2). When the insulin dose was at least 100 U/day, all patients had abnormal glucose tolerance postpartum (RR = 34.00, 95% CI 4.93-234.39).

CONCLUSIONS

Postpartum glucose screening is not warranted for women at low risk who do not require insulin during pregnancy. The incidence of postpartum glucose intolerance in this group is very low. Women with risk factors should receive postpartum screening. Patients receiving at least 100 U/day of insulin have a 100% incidence of postpartum glucose intolerance.

Diabetes in childhood

Insulin-dependent diabetes mellitus is the most common endocrine disorder of childhood. Early diagnosis is important. A multidisciplinary team approach enables families to assume responsibility for self-management. The paediatric diabetes nurse specialist is a key member of the team.

Health after childbirth: a comparison of normal and assisted vaginal delivery

413 women were included in the study: 100 who had had a normal delivery and 313 who had participated in a randomised controlled comparison of forceps or ventouse delivery. The study comprised a questionnaire and assessment at 24-48 hours after delivery and a questionnaire in the second year after delivery. There was significantly more morbidity in the women in the instrumental delivery group compared to women in the normal delivery group at both the early assessment and long-term follow-up.

The nucleotide sequence of recG, the distal spo operon gene in Escherichia coli K-12

A gene is identified in the Escherichia coli K-12 spo operon as recG. Previously identified genes in the spo operon were spoS, alias rpoZ, encoding the omega (omega) subunit of RNA polymerase, as well as the spoT gene encoding the major cellular source of guanosine 3',5'-bispyrophosphate hydrolase activity. The gene order within the spo operon is: spoS (rpoZ), spoT, spoU, recG. A convergent gltS gene is present beyond the spo operon. Mutants bearing recG deletion-insertion alleles display mild sensitivities to both ultraviolet irradiation and to mitomycin C, which is expected to be due to a known recG insertion allele. Deletion-insertion mutations in upstream operon genes (spoT and spoU) show polar effects on these assays of recG function. The deduced 693-amino acid (aa) RecG sequence shows a weak, but significant, relatedness to aa sequence motifs previously reported for putative helicases involved in replication, recombination, and DNA repair.

Effects of in-utero exposure to oral hypoglycaemic drugs

The observation that several Mexican-American women were taking oral hypoglycaemic agents while pregnant led to a study to confirm reports of associations between these agents and congenital abnormalities. 20 non-insulin-dependent (NIDDM) pregnant diabetic women with exposure to oral hypoglycaemic drugs during embryogenesis and 40 pregnant NIDDM women matched for age, race, parity, weight, and glycaemic control but not exposed to oral hypoglycaemic drugs were followed up. 10 infants (50%) in the exposed group had congenital malformations, compared with only 6 (15%) in the control group (p less than 0.002). 5 (25%) infants in the exposed group had ear malformations, anomalies not commonly described in diabetic embryopathy. Hyperbilirubinemia (p less than 0.04), polycythaemia, and hyperviscosity requiring partial exchange transfusions (p less than 0.03) were commoner among babies in the exposed than in the control group. 3 babies in the exposed group but none in the comparison group had severe prolonged neonatal hypoglycaemia lasting 2, 4, and 7 days; 2 of the 3 had been exposed for 22 and 28 weeks during gestation, whereas the third had been exposed throughout the first trimester. Although exposure to oral hypoglycaemic drugs during fetal life seems to be associated with congenital malformations and neonatal hypoglycaemia, a large, prospective study is needed to exclude the confounding effect of maternal metabolic derangement secondary to diabetes.

rhlB, a new Escherichia coli K-12 gene with an RNA helicase-like protein sequence motif, one of at least five such possible genes in a prokaryote

A newly recognized gene we name rhlB, after RNA helicase-like genes, has been found in the 85-minute region of the Escherichia coli chromosome. This gene encodes protein sequence motifs similar to those known for "D-E-A-D box" gene products. Proteins in this gene family occur in eukaryotes as well as prokaryotes, and, as far as tested, have been found to participate in ATP-dependent RNA helicase or RNA-dependent ATPase activities. The functions of these enzymes are poorly understood. In yeast, mutant phenotypes of various D-E-A-D genes suggest that they function in RNA splicing, processing, or translation. We find that rhlB is necessary for viability only in some genetic backgrounds. Conditional rhlB lethality is not complemented by another E. coli RNA helicase-like gene (srmB). Using primers with homology to consensus sequences in D-E-A-D box proteins, we have recovered DNA fragments amplified from E. coli genomic DNA by polymerase chain reactions. Sequence analysis of these fragments suggests that E. coli possesses at least five RNA helicase-like (rhl) D-E-A-D box genes at widely separated chromosomal locations. The multiplicity of such genes in a prokaryote raises the possibility of important roles for the corresponding class of biologically widespread proteins.

Obstetrics without an on site paediatrician

A ten year review (1980-89) of Wexford perinatal statistics is presented. Particular emphasis was placed on neonatal deaths and transfer rates of normally formed infants. Increased visits by paediatricians in the last two years have been associated with an increased neonatal transfer rate to a regional unit 40 miles away. Neonatal mortality rates have not improved, though any beneficial effects on infant morbidity was not assessed. The case for on site paediatric expertise with at least two consultants to provide a continuous service is argued.

Forced relocation of hospitalized psychiatric patients

By virtue of their disability and hospital program requirements, severely and chronically mentally ill patients are subject to involuntary transfer from the community to hospitals, within hospitals, between hospitals, and from hospitals to the community. These forced relocations, no matter how humanely they were initially conceived to be, have become highly routine. The consequence is loss of the sense of the patient as a human being with individual needs. This research elicited the patients' own descriptions and the meanings they attached to the experience of forced relocation. The findings point to the need for greater success of programs designed to keep patients in their home communities to the greatest extent possible. The findings also suggest the need for hospital staff to eliminate or reduce intrahospital transfers and to develop and maintain humane transfer procedures when forced relocation becomes necessary.

Intrahospital relocation of psychiatric patients and effects on aggression

Aggression is a recurring problem with psychiatric patients and can pose special problems on inpatient units. The purpose of this study were to identify changes in patients aggression as a consequence of routine individual relocation and to identify the relationship of certain variables with patterns of aggression. Using an adaptation of the Overt Aggression Scale (Yudofsky, Silver, Jackson, Endicott, & Williams, 1986), data were collected from the patient records of 201 individuals who had been admitted to a state hospital and subsequently transferred to another ward in the same hospital. There was a phase by day interaction with the day-to-day pattern of aggression in the pretransfer phase differing significantly from that in the posttransfer phase. The highest mean aggression for a single day was the day following transfer; the second highest was the day before transfer. There were main effects for age and number of hospital admissions.