Improved maintenance of remission in ulcerative colitis by balsalazide 4 g/day compared with 2 g/day

The efficacy of two doses of balsalazide for the maintenance of remission in patients with ulcerative colitis was compared in a double-blind multicentre trial. Sixty-five patients received a 2 g daily dose, and 68 a 4 g dose. The patient groups were similar at entry for sex, age, and disease distribution. Clinical assessment was carried out at 3-monthly intervals, with sigmoidoscopy, rectal biopsy, and blood tests on entry and at 26 and 52 weeks. Clinical relapse over twelve months was significantly less common on the 4 g dose (36%), than on the 2 g dose (55%), P less than 0.01. There were eight withdrawals on 2 g daily and 13 on 4 g daily, six and nine respectively being mainly due to gastrointestinal intolerance. It is concluded that balsalazide is a well-tolerated drug, and is effective for the maintenance of remission in patients with ulcerative colitis, the optimal dose being greater than 2 g daily.

Rabies. A second Australian case, with a long incubation period

OBJECTIVE

The description of a second case of rabies in Australia, stressing the clinical features and that long incubation periods are possible.

CLINICAL FEATURES

A 10-year-old Vietnamese girl presented with fever, shoulder pain, subcutaneous emphysema, swallowing difficulty and agitation. After a period of maniacal behaviour all peripheral and central nervous system function was lost.

INTERVENTION AND OUTCOME

Despite maximal intensive care, the patient died. The diagnosis of rabies was made at autopsy.

CONCLUSIONS

Rabies occurs in Australia and needs to be considered in the differential diagnosis of acute encephalitis and/or the Guillain-Barré syndrome. Incubation periods of more than six years can occur.

Invasive Haemophilus influenzae type b disease in Sydney children 1985-1987: a population-based study

OBJECTIVE

To determine the incidence and age distribution of invasive Haemophilus influenzae type b (Hib) disease in children (0-14 years) in the Sydney Statistical Division (SSD).

DESIGN

Retrospective ascertainment from a defined population, 1985-1987. Eligible cases had Hib isolated from a normally sterile site or endoscopically proven epiglottitis.

SETTING

Sydney Statistical Division, which had a population of children aged 0-4 years of 229 165 in 1986.

PATIENTS

Cases were identified from all potential sources of relevant recorded information.

MAIN OUTCOMES

There were 292 eligible cases. Among 284 previously well children, those under 18 months of age contributed 81 of 143 cases (57%) of meningitis and 22 of 71 (71%) of cellulitis/arthritis but only 8 of 91 (11%) of epiglottitis and 4 of 18 (22%) of infection in other foci. Overall, 9% of cases had occurred by 6 months of age, 42% by 18 months and 55% by 24 months. The annual incidence of invasive Hib disease was 38.5 per 100,000 children aged 0-4 years. In areas with the lowest proportion of young children (less than 5.5%), the incidence of Hib disease in the first 12 months of life was significantly lower than in the remainder of Sydney, although there were no differences in overall disease incidence in the age group 0-4 years.

CONCLUSIONS

This study indicates that approximately 1 in 500 urban Australian children develop invasive Hib disease by their fifth birthday. Vaccination of children in Sydney with a conjugate Hib vaccine at 18 months of age would result in a greater potential reduction in Hib disease than in the United States, where universal vaccination at this age is current policy.

Subdural and epidural empyema: diagnostic and therapeutic problems

OBJECTIVE

A clinical and microbiological review of cases of subdural and epidural empyema.

DESIGN, SETTING, PATIENTS

A 10-year retrospective review of patients with subdural and epidural empyema in all Brisbane hospitals with neurosurgical units. In this period there were 14 cases.

RESULTS

The paranasal sinuses were the primary focus in 8 of the 14 cases, the middle ear in 3 and a surgical or traumatic wound in 2. One case occurred as a complication of Haemophilus influenzae meningitis. Streptococci, particularly Streptococcus milleri, were the causative organisms in all cases of sinus origin, most of which occurred in the second decade of life. An intracranial collection was considered in the differential diagnosis within 24 hours of admission in all 3 cases of otic origin but in only 2 of the 10 sinus or post-traumatic cases. The most common initial diagnosis was viral or partially-treated bacterial meningitis (8 of 13 cases). The initial computed tomographic (CT) scan was not diagnostic in 3 of 11 patients. No patient was successfully treated without surgery, and all 3 deaths in the series were associated with delayed surgery.

CONCLUSIONS

Subdural and epidural empyema is an uncommon condition. The majority of the cases in this series were associated with sinusitis, and Streptococcus milleri was the commonest organism identified. The condition remains a diagnostic challenge; CT scanning cannot be relied upon although the use of intravenous contrast and more modern scanners has improved the diagnostic yield. Surgical drainage and early aggressive antimicrobial therapy are essential to avoid significant morbidity and mortality.

Unsuspected bacterial infections in febrile convulsions

In a 12-month prospective study in 1984, blood and urinary cultures were obtained as a routine from 307 children who presented with fever and convulsions to the Mater Misericordiae Children's Hospital, Brisbane, and the results were compared with data from 1981-1983 when cultures were not taken as a routine. In the prospective study, bacteraemia was found in 12 (4.3%) of 282 patients but was not suspected clinically in half of these; urinary-tract infection was found in seven (2.6%) of 272 patients and in six of these it was not suspected clinically. All 12 patients with unsuspected bacteraemia or urinary-tract infection had persistent fever; of these, nine patients suffered simple convulsions and all cases of urinary-tract infection occurred in female patients. Bacteraemia was significantly more common in patients of less than two years of age, in children who were selected for lumbar puncture and in the study period compared with the retrospective period, 1981-1983. Leukocytosis (white-cell count, more than 15.0 X 10(9)/L) was a sensitive (75%) diagnostic aid but was poorly specific (59%) for bacteraemia. Bacterial meningitis was not diagnosed initially in four of the nine cases which occurred among children who presented with fever and convulsions between 1981 and 1984; in all four children, the cerebrospinal fluid appeared normal at hospital admission. We conclude that bacteraemia and urinary-tract infections are detected more frequently in children who are admitted to hospital with febrile convulsions when cultures are performed as a routine. In the at-risk group (children of less than two years of age), the prevalence of urinary-tract infection is increased in female patients and the prevalence of bacteraemia is increased in those patients who are selected for lumbar puncture. The use of leukocytosis as a criterion to determine the need for blood cultures improves the diagnostic yield but would result in increased costs and additional venepuncture. Bacterial meningitis was rare in our case series and the performance of a lumbar puncture as a routine at admission to hospital would not have led to its earlier diagnosis.

Balsalazide in the maintenance treatment of patients with ulcerative colitis, a double-blind comparison with sulphasalazine

Balsalazide (BSZ) is a pro-drug which releases 5-aminosalicylic acid (5ASA) and 4-aminobenzoyl-beta-alanine (an inert carrier) in the colon of various species including man. BSZ was compared with sulphasalazine (SASP) (both 1 g b.d. orally) in the maintenance of remission in patients with ulcerative colitis (UC). Seventy-nine patients (53 male, 26 female), mean age 49 years (range 19-79 years), with UC were randomly allocated to either treatment (41 BSZ, 38 SASP) for 6 months. The groups were similar in respect of age, sex, duration and extent of disease. Seven patients defaulted (3 BSZ, 4 SASP) leaving 38 on BSZ and 34 on SASP. Two male patients, both receiving SASP, were withdrawn because of severe side-effects. One of these patients, with an exfoliative rash, was maintained satisfactorily on open BSZ. Remission rates at 6 months (51% BSZ, 63% SASP) were not significantly different (life-table analysis P less than 0.1). Twelve patients (15%) reported troublesome side-effects (2 BSZ 5%, 10 SASP 26%, P = 0.017 Fisher Exact Test). Mean haemoglobin concentrations, similar on entry, increased after 6 months with BSZ (0.2 g/dl) but decreased with SASP (0.5 g/dl) (P less than 0.0002). BSZ was not significantly different from SASP in maintaining remission in patients with UC but had fewer side-effects.

Blood cultures in hospitalized children

The results of 2439 blood cultures that were taken in an acute children's hospital over a two-year period were reviewed. Three hundred and twenty-two organisms were cultured from 310 patients. One hundred and thirty-five (5.5%) isolates were considered to be pathogenic and 187 (7.7%) isolates were considered to be contaminants. Coagulase-positive staphylococci and enteric Gram-negative organisms were the isolates of which the significance was most difficult to determine. Community-acquired bacteraemia that affected children of less than five years of age was caused by Haemophilus influenzae in 65% of cases. Staphylococcus aureus was the major pathogen in older children. In 20% of cases, antimicrobial agents were commenced or changed after blood culture results. Delayed or inappropriate therapy was significantly more common in patients without an apparent focus of infection. The results of our study suggest that narrow spectrum antimicrobial agents can be used as appropriate empiric therapy for unlocalized infections in previously-well children. In children of between three months and five years of age, treatment should be directed against Haem. influenzae and Streptococcus pneumoniae, and in children of over five years of age, antistaphylococcal therapy should also be included.

Prednisolone absorption in inflammatory bowel disease: correlation with anatomical site and extent

Prednisolone absorption was studied in 13 normal subjects, eight patients with ulcerative colitis and 21 patients with Crohn's disease, by measuring plasma levels after a single oral dose. Absorption of the drug was delayed in all patient groups. The peak plasma level of the drug was lower in patients with extensive small bowel Crohn's disease. Patients in this category may need higher doses of oral prednisolone than other patients with inflammatory bowel disease.

Mycetoma associated with Acremonium falciforme infection

A patient from Vanuatu with a mycetoma of the foot of 25 years' duration is described. Culture of a biopsy specimen from the foot grew a fungus which was identified as Acremonium falciforme. This agent has not been described previously in association with mycetomas in the Pacific region.

Tuberculosis in pregnancy--implications for antenatal screening in Australia

Two cases of tuberculosis have been seen over the past two years in southeast Asian women who had recently emigrated to Australia and who attended a single maternity hospital in Brisbane. One patient died of tuberculous meningitis and the other had an asymptomatic tuberculous pleural effusion. Both cases illustrate some of the difficulties in the diagnosis of extrapulmonary tuberculosis, particularly in pregnant women, and the low level of awareness of this condition. Antenatal screening for tuberculosis is not performed as a routine in Australia. Pregnant women who have emigrated recently from areas of high prevalence constitute a group at increased risk for tuberculosis who should be screened selectively with tuberculin tests and chest x-ray examinations.

Patients with a high jejunostomy do not need a special diet

Absorption from a chemically defined liquid feed consisting of small peptides, oligosaccharides, and little fat (half medium-chain triglycerides) was compared with that from a feed of whole protein, polysaccharides, and long-chain triglycerides in 7 patients with less than 150 cm of jejunum ending in a stoma. Comparisons of absorption from three solid food diets varying in their fiber and fat content but containing equal amounts of nitrogen and minerals were also made in 4 of the patients. There were no consistent differences between the two liquid or three solid-food diets in percentage of calorie, nitrogen, or fat absorption. The absolute loss of fat depended on the fat intake, but larger losses did not appear detrimental. A liquid diet consisting of peptides, oligosaccharides, and medium-chain triglycerides is not more beneficial than a polymeric diet in patients with a high jejunostomy. A liberal attitude is appropriate toward the fat and fiber content of the diet. Electrolyte supplements, especially sodium and magnesium, are often needed.

Controlled trial of bowel rest in the treatment of severe acute colitis

In a prospective, randomised clinical trial, 47 patients with severe, acute, non-infective colitis treated with 60 mg intravenous prednisolone daily, received either bowel rest with parenteral nutrition or oral diet. Although those who received 'bowel rest' experienced a reduction in daily stool weight, there were no differences in the operation or mortality rates between the groups. Fourteen of the 27 patients with ulcerative colitis, but none of the 16 patients with Crohn's disease required urgent surgery. Bowel rest did not affect the outcome in severe ulcerative colitis treated with intravenous prednisolone. Ulcerative colitis and Crohn's colitis behaved differently in the acute attack.

Therapeutic benefits from a poorly absorbed prednisolone enema in distal colitis

A double blind controlled trial has been conducted in 40 patients to compare the therapeutic effects of prednisolone metasulphobenzoate enemas with those of prednisolone-21-phosphate enemas. Both enemas brought about improvement in symptoms and sigmoidoscopic appearances in more than 70% of patients treated. The absorption of prednisolone from the metasulphobenzoate enema in three patients was less than from the 21-phosphate enema. In view of the low plasma prednisolone concentrations obtained, there are theoretical advantages in using a poorly absorbed enema to avoid the possibility of systemic steroid effects in patients requiring long term steroid treatment.

Effect of Different Drinks on Fluid and Electrolyte Losses from a Jejunostomy

The effectiveness of 5 different solutions on the absorption of fluid and electrolytes was tested in 7 patients with a proximal intestinal stoma and large fluid losses, all of whom previously needed intravenous infusions to maintain balance. In 4 patients it proved possible to replace the intravenous infusions with an enteral supplement. The WHO glucose/electrolyte solution without added potassium (NaCl 3.5 g, NaHCO3 2.5 g, glucose 20 g/l) gave satisfactory results, though was slightly less effective than a solution containing more sodium in which maltose was substituted for glucose. Neither sucrose nor an oligosaccharide*** (Caloreen) gave an advantage over glucose in the formulations used. In 3 patients losses were so great, and absorption of sodium from oral solutions so small, that intravenous supplements had to be continued. These 3 patients could be distinguished from the other 4 by the fact that more than 250 ml emerged from the stoma during the 3 hours after a drink of 500 ml of glucose/electrolyte solution. In all patients a drink of water or tea led to a loss of sodium from the stoma; water should be restricted in such patients and replaced by a glucose/electrolyte solution.

Management of Severe Acute Colitis in District Hospitals

Among 10 hospitals of the North East Thames Region, 84 patients were operated on for inflammatory bowel disease in the years 1977–81. There was one death in the 51 patients treated electively. The postoperative mortality was 24% in 33 patients coming to urgent surgery. The factors leading to this continuing high mortality are analysed as a contribution to an improvement in management.

Management of enterocutaneous fistulas: a review of 132 cases

The development of an enterocutaneous fistula has frequently been reported as being attended by a high morbidity and mortality, particularly in patients with inflammatory bowel disease who have high output, small bowel fistulas. We report a series of 114 patients who required treatment for 132 fistulas during the period 1976-1981. Fifty-one fistulas originated in the jejunum and ileum, and forty-eight patients had Crohn's disease. The majority of patients required surgical intervention and parenteral nutrition was required in forty-eight cases. Using an integrated programme of nursing, medical and surgical care, the overall healing rate was 90.9 per cent and the mortality 5.3 per cent. With the therapeutic methods currently available, an unacceptably high mortality rate in these patients can be avoided.

Nocturnal nasogastric tube feeding at home

Five malnourished patients who consistently failed to maintain or gain weight with other oral diets have been taught to give themselves a nocturnal nasogastric tube feed at home to supplement their dietary intake by day. All patients gained weight at a rate of about 0.5 kg per week. Nasogastric tube feeding at home can be an acceptable, safe, economical and efficient treatment for nutritional depletion, particularly in patients with a short functional length of small intestine for whom simpler dietary manipulation has been unsuccessful.

A radiological study after parenteral nutrition through silicone rubber catheters: Fibrin sleeves without thrombosis

Injection of contrast material through 38 central silicone rubber catheters at the time of withdrawal after a mean catheter life of 55 days (range 5-369) has shown no evidence of occult venous thrombosis despite the presence of a fibrin sleeve around the whole length of the intravascular portion in 37 cases. The presence of this fibrin sleeve appears to have been harmless. The absence of thrombosis suggests that silicone rubber is the material of choice for central venous feeding catheters and that the addition of heparin to the infusion fluid is unnecessary.

Crohn's disease of the mouth: an indicator of intestinal involvement

Nineteen patients with clinical evidence of oral Crohn's disease but no intestinal symptoms were studied. Oral lesions in all patients were shown histologically to have lymphoedema with or without chronic granulomas consistent with Crohn's disease. Seven patients (37%) had demonstrable intestinal disease on rectal biopsy and four of these had abnormal bowel radiology. All seven had evidence of nutritional deficiency. Patients with clinical features suggesting oral Crohn's disease may have evidence of Crohn's disease in the intestine, although this may not be clinically apparent.