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The purpose of this pilot project was to assess the feasibility and acceptability of voluntary counselling and HIV testing (VCT) by pregnant women using community volunteers in Zimbabwe to prevent mother to child transmission (MTCT) of HIV. From July 1999 to June 2001, a short-course zidovudine (ZDV)-based perinatal HIV prevention programme was initiated in two antenatal clinics. Community volunteers, recruited from local community organizations, underwent a two-week training course in VCT, which included HIV/AIDS facts, systematic counselling approach, and practical counselling techniques using scripts and role-play. Rapid HIV testing was performed after informed consent. Lay counsellors conducted individual pre- and post-test counselling for HIV. A total of 35 women community volunteers were trained in VCT; 34 graduated and committed to work four hours per week in the clinic. Of the 6051 pregnant women presenting for antenatal clinics (ANC), 1824 (30%) underwent pre-test counselling and 1547 (26%) were tested, and 429 (28%) were HIV infected. Overall, 1283 (83%) returned for their test results including 406 (95%) of HIV-infected women. Of the 406 HIV-infected women who collected their test results, only 203 (50%) opted for ZDV prophylaxis to prevent MTCT of HIV. Over the two-year study period, two counsellors died and three sought employment at other organizations. Adherence to duty roster was 97% and no breach of confidentiality was reported. Despite many challenges, VCT delivered by community volunteers is feasible and acceptable for pregnant women aiming to reduce their risk of transmitting HIV to their infants. This programme is being implemented at several urban and rural MTCT sites in Zimbabwe and can serve as a model for other resource-poor countries.

Single-dose nevirapine reduces intrapartum human immunodeficiency virus 1 type (HIV-1) transmission but may also select for nonnucleoside reverse-transcriptase inhibitor (NNRTI) resistance in breast milk (BM) and plasma. Among 32 Zimbabwean women, median 8-week postpartum plasma and BM HIV-1 RNA levels were 4.57 and 2.13 log(10) copies/mL, respectively. BM samples from women with laboratory-diagnosed mastitis (defined as elevated BM Na(+) levels) were 5.4-fold more likely to have HIV-1 RNA levels above the median. BM RT sequences were not obtained for 12 women with BM HIV-1 RNA levels below the lower limit of detection of the assay used. In 20 paired BM and plasma samples, 65% of BM and 50% of plasma RT sequences had NNRTI-resistance mutations, with divergent mutation patterns.

Objective: To examine the prevalence of psychological morbidity in HIV-infected and uninfected pregnant women seeking antenatal care in Zimbabwe. Methods: Pregnant women were screened for psychological morbidity at the initial antenatal care visit using the 14-item Shona Symptom Questionnaire (SSQ) before voluntary HIV counseling and testing (VCT). The primary outcome measure was “cases,” as determined by a SSQ score of= 8. Demographic characteristics and HIV status were compared between cases and noncases to determine the risk factors for psychological morbidity. Results: Of the 437 participants, psychological morbidity was detected in 73 (17%) women before undergoing VCT. Risk factors for psychological morbidity included having a spouse older than 35 years of age. HIV infection by itself was not a risk factor for psychological morbidity for women. Conclusions: There is a high burden of psychological morbidity among pregnant women in Zimbabwe. Mental health services should be integrated into antenatal care to improve psychological health for all women in Zimbabwe.

Perinatal transmission of human immunodeficiency virus type 1 (HIV-1) is the primary cause of pediatric HIV infections. In recent years, perinatal HIV-1 transmission rates in the United States have declined markedly because of several factors that include enhanced voluntary counseling and HIV-1 testing (VCT) for pregnant women, widespread use of antiretroviral prophylaxis or combination antiretroviral therapy, avoidance of breastfeeding, and elective cesarean delivery. However, perinatal transmission of HIV-1 still occurs, and 300 to 400 infected infants are born annually, primarily because of missed prevention opportunities. The pediatrician plays a vital role in the prevention of perinatal transmission of HIV-1 by identifying newborns born to infected mothers who were not tested during pregnancy, administering antiretroviral prophylaxis, and ensuring follow-up to confirm or exclude the diagnosis of HIV-1 infection in early infancy. This article reviews recent advances in the prevention of perinatal transmission of HIV-1, discusses evaluation and treatment of infants exposed to HIV-1, and highlights certain unique features of HIV-1 infections in infants, with a focus on early diagnosis, clinical manifestations, treatment, and prognosis.

After completing this article, readers should be able to: 1. Describe the impact of antiretroviral prophylactic regimens on mother-to-child transmission of HIV-1. 2. Delineate United States Public Health Service Task Force guidelines for preventing perinatal transmission of HIV-1. 3. Describe efforts being taken to prevent the transmission of HIV-1 in human milk. Significant advances have occurred in the prevention of perinatal transmission of human immunodeficiency virus type 1 (HIV-1) during the last decade in the United States and Europe. (1) In 1994, the Pediatric AIDS Clinical Trials Group (PACTG) 076 published data showing that a long course of zidovudine (ZDV) prophylaxis given to HIV-1 infected mothers during the antepartum and intrapartum periods and postnatally to the baby significantly reduced perinatal HIV-1 transmission. (2) Since then, rates of perinatal HIV-1 transmission have decreased to less than 2% in resource-rich countries due to widespread implementation of universal prenatal HIV-1 testing, antiretroviral prophylaxis, elective cesarean section, and avoidance of breastfeeding. (1)(3) Currently, fewer than 400 infants acquire HIV-1 from their mothers in the United States. (1)(3) In contrast, prevention of perinatal transmission of HIV-1 is a major public health challenge in many resource-limited countries. (4) Each day, more than 2,000 infants are born infected with HIV-1 globally, and by the end of 2002, approximately 3.2 million children were living with HIV-1. (5) More than 90% of affected children reside in resource-limited countries. (1) Although many effective, simple, and less expensive antiretroviral prophylaxis regimens are available to prevent mother-to-child HIV-1 transmission, these interventions have not been implemented on a large scale in resource-limited settings. (1) This article reviews advances in the prevention of perinatal HIV-1 transmission, highlights progress made in resource-rich countries, and discusses challenges faced by resource-limited countries. Mother-to-child transmission (MTCT) of HIV-1 can take place in utero, during labor and …

Probiotic strains of lactobacilli are increasingly being used in clinical practice because of their many health benefits. Infections associated with probiotic strains of lactobacilli are extremely rare. We describe 2 patients who received probiotic lactobacilli and subsequently developed bacteremia and sepsis attributable to Lactobacillus species. Molecular DNA fingerprinting analysis showed that the Lactobacillus strain isolated from blood samples was indistinguishable from the probiotic strain ingested by the patients. This report indicates, for the first time, that invasive disease can be associated with probiotic lactobacilli. This report should not discourage the appropriate use of Lactobacillus or other probiotic agents but should serve as a reminder that these agents can cause invasive disease in certain populations.

The differential diagnosis of bilateral parotid gland enlargement in children includes infectious, inflammatory, and neoplastic disorders. We present the case of a 13-year-old male who presented with a 5-week history of bilateral parotid swelling. On exam, both parotid glands were nontender, smooth, and diffusely enlarged. He had slightly elevated inflammatory markers, but other lab results were normal. A neck CT revealed symmetric enlargement of the parotid, submandibular, and sublingual glands. A chest CT revealed scattered peripheral pulmonary nodules and bilateral hilar adenopathy. A parotid gland biopsy showed multiple noncaseating granulomas with multinucleated giant cells surrounded by lymphocytes, consistent with the diagnosis of sarcoidosis. Special stains for acid-fast and fungal organisms were negative. Using this illustrative case, we discuss the differential diagnosis of bilateral salivary gland enlargement in children and review the etiology, diagnosis, clinical manifestations, and treatment of pediatric sarcoidosis.

1. Abraham Gedalia, MD* 2. Avinash K. Shetty, MD† 1. *Professor of Pediatrics and Head, Division of Pediatric Rheumatology, Louisiana State University Health Sciences Center and Children’s Hospital, New Orleans, La 2. †Assistant Professor of Pediatrics, Division of Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC After completing this article, readers should be able to: 1. Describe the mechanism of action, list indications for therapy, and discuss the adverse effects of corticosteroid therapy in children. 2. Delineate the mechanism of action and adverse effects of other immunosuppressive agents frequently used in children. 3. Discuss the immunization recommendations for children receiving immunosuppressive therapy. Corticosteroids are the most potent, naturally occurring anti-inflammatory agents known. Despite more than 50 years of controversy regarding their clinical use, risks, and benefits, corticosteroids still play a significant role in the management of a wide variety of diseases. They have reduced the morbidity and mortality significantly in children afflicted with leukemia, asthma, rheumatic diseases, and other inflammatory disorders. In this article, we review the mechanism of action, clinical indications, and adverse effects of corticosteroids and other commonly used immunosuppressive agents in children. We also review immunization recommendations for children receiving immunosuppressive therapy. Corticosteroids have a diverse role in the human body at the physiologic level. The actions of glucocorticoids include: 1) negative feedback modulation of corticotropin-releasing factor and adrenocorticotropic hormone; 2) regulation of blood glucose and liver glycogen levels; 3) maintenance of water-electrolyte homeostasis; 4) influence on the metabolism of protein, fat, and purine; 5) maintenance of normal cardiovascular, central nervous system (CNS), and renal functions; 6) influence on circadian rhythmicity; 7) maintenance of bone and muscle work capacity; and 8) protection of the body against moderate stress. Glucocorticoids also have pharmacologic properties that are used in the treatment of rheumatic and other inflammatory diseases. Cellular receptors for cortisol are ubiquitous in cell cytoplasm, reflecting the critical role of the hormone in maintaining cell homeostasis. The type 1 glucocorticoid receptor, known as the mineralocorticoid receptor, has high affinity for aldosterone. The type 2 glucocorticoid receptor, known as the glucocorticoid receptor, exhibits strong affinity for dexamethasone. Although …

Septic arthritis in children remains a serious disease with the potential for significant systemic and musculoskeletal morbidity. Staphlococcus aureus is the most common cause of bone and joint infections in all age groups. Microbial invasion of the synovial space occurs typically results from hematogenous seeding. Diagnosis in neonates and young infants can be difficult since the clinical signs are much less specific in these age groups. Early diagnosis by needle aspiration of the affected joint and prompt initiation of appropriate antimicrobial therapy in conjunction with drainage of the affected joint is critical to avoid destruction of the articular cartilage and prevent disability. Septic arthritis in infants and children should always be managed by a pediatrician in close consultation with an orthopedic surgeon. Empiric antibiotic regimens should always include adequate anti-staphylococcal coverage. Antibiotic treatment should be started with appropriate doses of intravenous antibiotics. Switch to oral antibiotic therapy can be made when patient demonstrates clinical improvement. A minimum of 3-4 weeks of therapy is recommended. Close follow-up is warranted to monitor the growth of the affected limb until skeletal maturity.

We surveyed infant feeding knowledge, attitudes, and practices in Zimbabwe to determine whether knowledge of HIV seropositivity influences infant feeding behavior. Questionnaires were administered to 97 women 1 and 4 weeks postpartum and prospective data on infant feeding practices were collected. Participants were pregnant women who consented to a HIV test. A total of 116 women participated of whom 99 women underwent voluntary HIV counseling and testing (VCT); 17 women agreed to blinded HIV testing but did not opt for VCT. The responses to questionnaires on infant feeding practices of HIV-positive and HIV-negative women who knew and did not know their HIV status at day 1 and week 4 postpartum were compared. We found that HIV-positive women who did not learn their status breastfed their infants less, introduced supplementary foods sooner, and planned to wean their babies earlier compared to other women (p = 0.005, p = NS, p= 0.02). HIV-positive women (30/97) more frequently reported a prior history of infant death and AIDS-related symptoms compared to HIV-negative women. We conclude that HIV-positive women who did not know their status made incorrect decisions with respect to infant feeding. These women may have suspected themselves to be HIV-positive and consequently underfed their infants or because these women were more symptomatic may have been less likely to breastfeed; decreased intake may increase the risk for malnutrition. Knowledge of HIV status may influence infant feeding decisions and reveal an urgent need to address infant feeding practices of pregnant women in Zimbabwe.

Despite the success of antiretroviral prophylaxis in reducing mother-to-child HIV-1 transmission, postpartum transmission through breast milk remains a problem. Antiretroviral administration to the infant during the period of breast-feeding could protect against postnatal transmission. An open-label phase 1/2 study was designed to assess the safety and trough concentrations of nevirapine (NVP) given once weekly (OW), twice weekly (TW), or once daily (OD) to HIV-exposed breast-feeding infants for 24 weeks. Following maternal dosing with 200 mg NVP orally at onset of labor, breast-feeding infants were randomized within 48 hours of birth to 1 of 3 regimens: arm 1, NVP given OW (4 mg/kg from birth to 14 days, upward arrow to 8 mg/kg from 15 days to 24 weeks), arm 2, NVP given TW (4 mg/kg from birth to 14 days, upward arrow to 8 mg/kg from 15 days to 24 weeks), and arm 3, NVP given OD (2 mg/kg from birth to 14 days, upward arrow to 4 mg/kg from 15 days to 24 weeks). Trough NVP concentrations and clinical and laboratory abnormalities were monitored. Of the 75 infants randomized (26 to OW, 25 to TW, and 24 to OD dosing), 63 completed the 32-week follow-up visit. No severe skin, hepatic, or renal toxicity related to NVP was observed. Neutropenia occurred in 8 infants. Trough NVP levels were lower than the therapeutic target (100 ng/mL) in 48 of 75 (64.0%) samples from infants in the OW arm, 3 of 65 (4.6%) samples in the TW arm, and 0 of 72 samples in the OD arm. Median (range) trough NVP concentrations were 64 ng/mL (range

Objective. Because of the widespread availability of rapid viral antigen testing, many institutions never adopted a routine practice of ordering viral cultures to detect community-acquired respiratory viruses (CRVs). The ease of performing complete viral studies in our on site laboratory allowed us to assess the clinical implications of the absence of conventional culture results in previously healthy hospitalized children with CRV infections. Methods. From June 1997 through May 2000, the results of direct immunofluorescence assay (DFA) of 1069 nasopharyngeal swab (NP) specimens were compared with simultaneously inoculated conventional tube cell cultures for detection of CRVs. In addition the medical records of 140 previously healthy infants and children hospitalized for management of lower respiratory tract infections caused by culture-proved CRVs were reviewed. Results. Viruses were isolated or detected by DFA or viral culture or both in 468 (30%) of the 1557 NP samples evaluated. The most common CRV isolated was respiratory syncytial virus (49%), followed by parainfluenza viruses (15%), influenza A viruses (14%), rhinoviruses (8%), adenoviruses (4%), enteroviruses (4%) and influenza B viruses (1%). Of the 1069 NP specimens for which both viral culture and rapid antigen testing were performed, 190 specimens were DFA-positive and culture-positive, 7 specimens were DFA-positive and culture-negative, 35 specimens were DFA-negative and culture-positive and 837 specimens were DFA-negative and culture-negative. The overall sensitivity, specificity, positive predictive value and negative predictive value of DFA were 84, 99, 96 and 96%, respectively. Of the 140 hospitalized patients with culture-proved viral cultures (89 respiratory syncytial virus, 22 influenza A, 20 parainfluenza virus and 9 adenovirus), the mean duration of hospital stay was 3.6 days, and the mean time for viral cultures to become positive was 7.7 days (P < 0.001, signed rank test). One hundred twenty (86%) viral cultures did not become positive until after the patient had been discharged from the hospital. In no case was the clinical decision regarding the patient's treatment or discharge from the hospital based on the results of viral culture. Conclusions. We conclude that positive viral cultures have no impact on clinical decision making and management of healthy children during hospitalization for illness attributable to community-acquired respiratory viruses.

Our objective was to investigate the relationship between demographic factors, nutrition, stool gas production, and the existence of infantile colic (IC) syndrome. Hydrogen and methane production from stool specimens of infants with and without infantile colic was quantified at two separate time points, the age at presentation of colic ( 2 ppm by 15.3% of the infants at age 6 months. The mean methane concentrations produced by stool increased with age (0.95 ± 0.58 ppm at 3 months of age vs 1.29 ± 0.65 ppm at 6 months of age. There was no difference in stool hydrogen concentration between infants with and without IC. In contrast, the mean methane level at 3 and 6 months of age was higher in infants without IC than with IC, but reached statistical significance only at 6 months of age (0.97 ± 0.68 vs 0.93 ± 0.46) (NS) at 3 months of age, and 1.56 ± 0.55 vs 0.93 ± 0.62 (P

Internationally, the orphan crisis caused by the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pandemic remains a serious issue with long-term social consequences. At the end of 2001, an estimated 14 million children worldwide had lost their mother or both parents to AIDS or related causes. Sub-Saharan Africa is the most severely affected, accounting for more than 80 percent of those orphaned as a result of AIDS. Without the care of parents or an appointed caregiver, children are likely to face extraordinary risks of malnutrition, poor health, inadequate schooling, migration, homelessness, and abuse. Strengthening existing family and community capacity to assist orphans in Africa should be the first priority. Community support must be coupled with support for education for orphans. Combining local and international responses to deliver protection and services to all orphans and vulnerable children is critical. In addition, saving the lives of parents through access to antiretroviral therapies in resource-poor countries in conjunction with bold support for alleviation of poverty and education must be an integral part of the global response to the orphan crisis in sub-Saharan Africa.

Dciscovered by Duggar 50 years ago following a systematic screening of soil samples for antimicrobial activity,1 the tetracyclines remain one of the most widely used antibiotic classes in the world.2 Since 1970, the use of tetracyclines in children was strongly discouraged in the United States following concerns over adverse effects, especially dental staining and delayed bone growth, and the availability of effective, safer alternatives, such as P-lactams.3 The appearance of new or emerging pathogens, the increase in tick-borne infections, and the global problem of antimicrobial resistance, especially that in gram-positive bacteria during the 1990s, has led to renewed interest in many of the older antimicrobial agents such as tetracyclines and chloramphenicol.4 This article addresses the role of tetracyclines in children in the 21st century, including their spectrum of antimicrobial activity, mechanisms of bacterial resistance, pharmacokinetics, types of adverse reactions, and potential

Background: Happiness has been defined as the degree to which an individual judges the overall quality of his or her life as favourable. The happiness of a society, depends on its individual members. So, the study was designed to assess happiness among rural adults and to identify various socio- demographic, family and health determinants affecting happiness.Methods: It was a cross sectional study conducted in the field practice area of Department of Community Medicine, KMC Manipal. The study included 403 permanent residents of field practice area, aged ≥20 years, of both gender and willing to participate in the study. Information pertaining to socio-demographic characteristics, details pertaining to co-morbidities, habits and family particulars were collected by personal interviews using a pre-designed questionnaire. Happiness was assessed using the Oxford happiness questionnaire.Results: A total of 403 subjects participated in the study and among them 82% of the respondents were happy and 17.6% were unhappy, as per the Oxford happiness questionnaire. Over half of the participants belonged to 30-60 years and two-thirds were females (66.5%). There was no gender difference in reported happiness. Almost all the people who had cordial relationship with family members (99.1%) and neighbourhood (97.9%), owning a house (94%) and being without co-morbidities (56%) were happy. Past hospitalization, concerns about child marriage and employment made people less happy.Conclusions: Good relationship with family members and neighbourhood, absence of co-morbidities was positive determinants of happiness, while hospitalization, concerns about employment and marriage of their children contributed to unhappiness.

Community-associated methicillin-resistant Staphylococcus aureus (MRSA) is increasingly recognized as a cause of invasive disease in children. Orbital cellulitis typically occurs in older children, but it can occasionally affect infants and neonates. We report 2 infants with sepsis and orbital cellulitis caused by community-associated MRSA and review the relevant literature.

After completing this article, readers should be able to: 1. Identify the primary modes of mother-to-child transmission of human immunodeficiency virus-1 (HIV-1). 2. List the major risk factors for mother-to-child transmission of HIV-1. 3. List the primary strategies employed to prevent vertical transmission of HIV-1. During the past decade, significant advances have been made in the United States and the rest of the industrialized world in preventing transmission of perinatal human immunodeficiency virus type 1 (HIV-1).1,2,3,4,5,6 In 1994, prevention of perinatal HIV-1 transmission became a reality, when the Pediatric AIDS Clinical Trials Group Protocol 076 (PACTG 076) showed that a three-part zidovudine (ZDV) regimen given during pregnancy and labor and to the neonate significantly reduced perinatal HIV-1 transmission.7 In 1995, the United States Public Health Service (USPHS) issued guidelines recommending universal counseling and testing for pregnant women and use of ZDV to reduce perinatal transmission.8 A steep and sustained decline in pediatric acquired immune deficiency syndrome (AIDS) cases has been noted following rapid implementation of these guidelines and increased prenatal HIV counseling and testing.9,10,11 It is now known that the use of ZDV prophylaxis in combination with elective cesarean section delivery or treatment with combination antiretroviral therapy that reduces maternal viral load to undetectable levels can reduce the rate of perinatal transmission to less than 2%.12,13,14 Despite these advances, perinatal HIV-1 transmission continues to occur for a variety of reasons, including new infections, rare prophylaxis failure, and missed prevention opportunities in pregnant women who do not receive prenatal care.2 In this article, we briefly review the recent advances in the prevention of perinatal transmission of HIV-1 with regard to risk factors, antiretroviral therapy, and the role of elective cesarean …

After completing this article, readers should be able to: 1. Describe the prevalence of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) among all women in the United States and among those who are pregnant. 2. Describe the changing epidemiology of perinatal HIV infection. 3. List the barriers to prevention of perinatal HIV infection. The human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) pandemic has had a formidable impact on maternal and child health and survival, with global public health consequences. The Joint United Nations Program on HIV/AIDS estimated that there are more than 15 million women and 1.1 million children living with HIV/AIDS worldwide.1 Since the initial reports of AIDS cases among children in 1982 in the United States,2,3 HIV-1 infection has become one of the leading causes of morbidity and mortality among children worldwide.1,4 In the United States, HIV/AIDS was ranked as the seventh leading cause of childhood mortality among children 1 to 4 years of age in 1996.5 Perinatal transmission accounts for more than 90% of all pediatric AIDS cases and almost all new HIV-1 infections in children.6 In the United States and other developed countries, enormous progress has been made in preventing perinatal HIV-1 transmission, especially in the past 7 years. In 1994, the Pediatric AIDS Clinical Trials Group Protocol 076 (PACTG 076) report on the use of zidovudine (ZDV) in pregnant women who had HIV-1 infection and their infants revolutionized the prevention of perinatal HIV-1 transmission.7 The rate of perinatal transmission of HIV-1 was reduced significantly by an extended regimen of ZDV given during pregnancy, labor, and to the neonate.7 In 1995, the United States Public Health Service (USPHS) issued guidelines recommending universal counseling and testing for pregnant women and the use of ZDV to reduce perinatal transmission.8 …

After completing this article, readers should be able to: 1. Compare the rates of vertical human immunodeficiency virus-1 (HIV-1) transmission in industrialized and nonindustrialized countries. 2. Describe the antiretroviral regimens being investigated to prevent mother-to-child transmission of HIV-1. 3. List barriers to implementation of prevention programs in resource-poor countries. 4. Describe the impact of feeding choices on vertical transmission of HIV-1. Globally, the human immunodeficiency virus (HIV)-1 pandemic continues to advance at an alarming rate. The latest estimates from the Joint United Nations Program on HIV/AIDS indicate that approximately 34.7 million people worldwide were infected with HIV-1 at the end of 2000 (Table 1⇓).1 More than 95% of the global total of HIV-infected individuals live in the developing world, predominantly in sub-Saharan Africa. The pediatric HIV-1 epidemic is driven by maternal HIV-1 infection, with the vast majority of infants acquiring infection from their mothers. Limited data from countries in sub-Saharan Africa show that HIV-1 seroprevalence rates among women of childbearing age have exceeded 25% in many urban populations.2 With an estimated 2.4 million infected women giving birth annually, 600,000 children worldwide acquired HIV-1 infection during 2000 alone, primarily through mother-to-child transmission. Current estimates suggest that more than 1,600 infants become infected with HIV-1 each day.1 View this table: Table 1. Global Disease Burden Associated with HIV-1 Infection (December 2000)1 Prevention of mother-to-child transmission of HIV-1 is a major public health challenge in many resource-poor countries. Important issues include limited access to antenatal care and HIV-1 testing and counseling services as well as postnatal HIV-1 transmission through breastfeeding. Poor funding, social and cultural norms, and lack of political power compound the dilemma further. This article examines current understanding of mother-to-child transmission of HIV-1 in resource-poor countries, with particular emphasis on transmission through human milk. In addition, results of recent antiretroviral and nonantiretroviral intervention trials …

Effective utilisation and understanding of the clinical bacteriology laboratory can greatly aid in the diagnosis of infectious diseases. Although described more than a century ago, the Gram stain remains the most frequently used rapid diagnostic test, and in conjunction with various biochemical tests is the cornerstone of the clinical laboratory. First described by Danish pathologist Christian Gram in 18841 2 and later slightly modified, the Gram stain easily divides bacteria into two groups, Gram positive and Gram negative, on the basis of their cell wall and cell membrane permeability to organic solvents (box 1).3-5 Information derived from a Gram stain and several simple biochemical tests can be enormous, often providing a presumptive diagnosis and significantly influencing patient care. Unfortunately the training for correctly interpreting the Gram stain is disappearing.6 The goal of this article is to review the utility of the clinical bacteriology laboratory and discuss its role in the diagnosis of common clinical pathogens. The Gram stain classifies bacteria (fig 1) phenotypically based on differences in cell wall thickness with differing glycosaminopeptide and lipoprotein compositions: Gram positive bacteria have a peptidoglycan layer 10–15 times thicker than Gram negative bacteria. The cell wall, synonymous with the peptidoglycan layer, is a rigid framework of cross linked peptidoglycan forming the outermost component of the cell. The more complex Gram negative bacteria also have an outer membrane beyond the peptidoglycan layer that consists of lipopolysaccharide (endotoxin), lipoprotein, and phospholipids. In some Gram negative species there also exists a periplasmic space between the outer membrane and the inner cytoplasmic membrane with β-lactamases that degrade β-lactam antibiotics.#### Box 1: Gram stain technique (1) : Air dry specimen and fix with methanol or heat. (2) : Add crystal violet stain. (3) : Rinse with water to wash unbound dye, add mordant (for example, iodine: potassium iodide). …

The study objective was to determine the clinical value of positive antinuclear antibody (ANA) and ANA profile tests in children with autoimmune disorders. A retrospective chart review was carried out of all patients under 18 years of age with a positive ANA test (HEp-2 cell substrate, titreor =1:40) and ANA profile (ELISA) referred to the paediatric rheumatology service at the authors' institution between 1992 and 1996. Of 245 children with a positive ANA test, 134 (55%) had an autoimmune disease, including juvenile rheumatoid arthritis (n = 49), systemic lupus erythematosus (SLE) (n = 40) and others (n = 45). The remaining 111 patients did not have identifiable autoimmune diseases. Patients with autoimmune disorders had significantly higher ANA titres ofor = 1:160 (chi2 = 16, P0.0001). In addition, of the 245 patients with a positive ANA test, 86 had an ANA profile performed; this was positive in 32 and negative in 54. All 32 patients with a positive ANA profile (100%) had an autoimmune disorder, compared to 22 (41%) of 54 with a negative ANA profile who had autoimmune disorders. Of 22 SLE patients with a positive ANA profile, 16 (73%) had positive anti-dsDNA and 15 (68%) had positive anti-Sm and positive anti-RNP. A positive ANA profile correlated strongly with an ANA titreor = 1:640 (chi2 = 5.7 , P0.02). The study demonstrated that only 55% of children with a positive ANA test had a definitive diagnosis of autoimmune disorder. These children tend to have higher ANA titres ofor =1:160. However, a positive ANA profile was strongly correlated with an ANA titreor =1:640 and highly indicative of an autoimmune disorder (100%). We suggest that in order to reduce cost, an ANA profile should not be performed on all patients with positive ANA, but reserved for those with an ANA titre ofor =1:640 and/or those with a high clinical index of suspicion for autoimmune disorder, especially SLE.

We report on the effectiveness of intravenous ribavirin for severe adenoviral pneumonia in a 10-month-old male following orthotopic liver transplantation. On day 20 post-transplantation, he developed high fever, marked respiratory compromise, and hypoxemia. The chest radiograph showed bilateral pulmonary infiltrates. Samples of bronchoalveolar lavage fluid grew adenovirus, serotype 1. Marked clinical and radiological improvement was noted after intravenous ribavirin therapy. A prospective clinical trial is needed to determine the efficacy of ribavirin therapy for severe adenovirus disease. Pediatr Pulmonol. 2000; 29:69–73. © 2000 Wiley-Liss, Inc.

Liver involvement is commonly observed in patients with typhoid fever. However, a hepatitis-like picture with fever and jaundice is unusual and infrequently reported in the paediatric literature. Our aim was to characterize the clinical picture, biochemical features, and prognosis of typhoid hepatitis. One hundred cases of typhoid fever (age 0 to 12 years), proven by positive blood cultures to Salmonella typhi, were studied with special reference to hepatic dysfunction. Of these, eight patients were found to have hepatitis during the course of their illness. All had high fever, tender hepatomegaly, elevated serum bilirubin (in the range of 2.5-5.8 mg/dl), and elevated serum alanine transaminase levels (in the range 100-620 IU/l). All the eight patients showed complete clinical and biochemical recovery in response to appropriate antibiotics. The clinical picture of typhoid hepatitis frequently mimics acute viral hepatitis. In tropical areas, the differential diagnosis of a child presenting with fever and jaundice should include typhoid hepatitis.

Pseudozyma aphidis is a heterobasidiomycetous yeast related to the smut fungi in the genus Ustilago. Pseudozyma species are usually isolated from plants and rarely from clinical specimens. We report what is believed to be the first paediatric case of central venous catheter (CVC)-related fungaemia associated with P. aphidis. Prompt removal of the CVC in conjunction with anti-fungal therapy resulted in a successful outcome.

Childhood sarcoidosis is a rare multisystemic granulomatous disease of unknown etiology. The clinical presentation can vary greatly depending upon the organs involved. Two distinct forms of sarcoidosis exist in children. Older children usually present with a multisystem disease similar to the adult manifestation, with frequent hilar lymphadenopathy and pulmonary infiltration. Early-onset childhood sarcoidosis is a unique form of the disease characterized by the triad of rash, uveitis, and arthritis in patients presenting before age 4 years. The diagnosis of sarcoidosis is confirmed by demonstrating a typical noncaseating granuloma on a biopsy specimen. The current therapy of choice for childhood sarcoidosis with multisystem involvement is corticosteroids. Methotrexate given orally in low doses is effective and safe and has steroid-sparing properties.

Septic arthritis in children is a true medical emergency and poses a unique clinical challenge to the pediatrician, rheumatologist, and orthopedic surgeon. The disease is more commonly seen in children than in adults. The term septic arthritis refers to microbial invasion of the joint space, not associated with contiguous osteomyelitis. Acute septic arthritis is bacterial, regardless of age, and is the most common form of infectious arthritis. Early diagnosis and subsequent appropriate medical and surgical intervention is imperative to avoid destruction of the articular cartilage, thus preventing permanent disability. The authors review the epidemiology, pathogenesis, clinical, and microbiological characteristics of septic arthritis in children and examine the current approaches to diagnosis and treatment of this condition.

A discussion of a 5-year-old child with congenital hemolytic anemia and severe hypotonia caused by triosephosphate (TPI) deficiency is presented. The complexities in the diagnosis and management of this condition is discussed and the relevant literature is reviewed.

Roseomonas is a newly described genus of pink-pigmented, gram-negative bacteria. Human infections caused by Roseomonas species are very rare. We report two cases of central venous catheter-related bacteremia associated with Roseomonas species (one case with R. gilardii and one with R. fauriae), and review the clinical spectrum of previously reported cases in the literature. Clinicals should be aware that Roseomonas species may cause serious infections in children.

Hemorrhagic pleural effusion associated with Kawasaki disease KD is very rare and has not been reported in the medical literature. We describe a 5-year-old male with incomplete (atypical) KD who presented with fever and severe respiratory distress due to bilateral pleural effusions. Other features included unilateral cervical lymphadenopathy, swelling of the hands and feet followed by periungual desquamation, elevated erythrocyte sedimentation rate, thrombocytosis and sterile pyuria. Pleural fluid analysis revealed a hemorrhagic exudative effusion. Therapy with high-dose i.v. immunoglobulin resulted in dramatic clinical improvement and resolution of pleural effusion. An echocardiogram obtained at presentation and at 6 weeks of illness was normal. Pediatricians should be aware that hemorrhagic pleural effusion can be a presenting manifestation of KD.

BACKGROUND Invasive meningococcal infections can be devastating. Substantial endotoxemia releases mature and immature neutrophils. Endothelial margination of mature neutrophils may increase the immature-to-total neutrophil ratio (ITR). These changes have not been previously well-described in invasive meningococcal disease. METHODS Using 2001 to 2011 data from the US Multicenter Meningococcal Surveillance Study, the diagnostic sensitivity and clinical correlates of white blood cell count, absolute neutrophil count (ANC), immature neutrophil count (INC) and ITR were evaluated alone and in combination at the time of diagnosis of invasive meningococcal disease. RESULTS Two hundred sixteen patients were evaluated: meningococcemia (65), meningitis (145) and other foci (6). ANC ≤1000/mm(3) or ≥10,000/mm(3) was present in 137 (63%), INC ≥500/mm(3) in 170 (79%) and ITR ≥0.20 in 139 (64%). One or more of these 3 criteria were met in 204 of the 216 (94%). Results were similar for meningococcemia and meningitis subgroups. All 13 cases with mildest disease met 1 or more of the 3 criteria. Eight children presented with ANCs

Background Neonatal ventilator-associated pneumonia (VAP) is associated with increased morbidity and mortality. In adults on mechanical ventilation, timed oral care decreases the frequency of VAP, but this approach has not been studied in neonates. Objectives To evaluate the feasibility of a randomized trial of timed oral care with Biotene OralBalance® gel and estimate the required sample size for such a trial. Methods Infants were eligible for enrollment if they were born before 28 weeks of gestation, and were mechanically ventilated between 7 and 10 postnatal days. Infants were randomized to receive timed oral care with Biotene OralBalance® gel or sterile water. All subjects were treated with a standard bundle of procedures to reduce the risk of VAP. Results We enrolled 41 of 46 eligible infants (89%). Compliance with timed oral care protocol was 97%. No local oral side effects of Biotene OralBalance® gel were observed. There were no significant group differences in mortality or short-term outcomes, except length of hospital stay which was significantly shorter in the Sterile water group (p = 0.02). A lower rate of VAP was found in the Biotene group, although the difference was not statistically significant (9/1000 ventilator-days versus 17/1000 ventilator-days in the Sterile water group, respectively; p = 0.16). Conclusions The results of this pilot study support the feasibility of a randomized trial of timed oral care with Biotene OralBalance® gel for prevention of VAP in mechanically ventilated neonates.

Vaccines are considered one of the most effective public health achievements of the twentieth century. In the USA the incidence of most childhood vaccine-preventable diseases (VPDs) is at historic lows, while the number of diseases prevented by vaccines has increased steadily in the past few years. Development of vaccines is a complex, multistep process requiring the collaboration of multiple partners from basic science research through vaccine delivery and outcome monitoring. Advances in new sciences such as genomics, structural biology, novel adjuvant formulations, live vector vaccines, and computational studies have led to more detailed understanding of microbes and the host immune response. These advances offer great promise in the design of future generation of effective and safe vaccines against a host of infectious diseases. In addition, development of nontraditional vaccines against cancer, autoimmune disorders, and chronic diseases of ageing are currently being explored. Vaccine safety remains an integral component of the US immunization system involving several federal agencies such as the US Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and other federal agencies working in close partnerships with vaccine resources in the public and private sectors. Despite significant advances, there are many scientific, implementation, and policy challenges to modern vaccine development. Educating the public about vaccines and vaccine preventable diseases is crucial to improve vaccine acceptance and use. A trusting relationship between patients, parents, and health care providers is a must to effectively communicate vaccine risk–benefit issues.

Background Septic cavernous sinus thrombosis is a rare complication of paranasal sinusitis. Objective To familiarize the clinician with the pathogenesis, diagnosis, and appropriate management of septic cavernous sinus thrombosis. Design Case report and literature review. Setting Pediatric intensive care unit in a university hospital. Patient We present a 12-yr-old female with a 1 wk history of an upper respiratory tract infection with worsening dyspnea, cough, and swelling of the left eye progressing to adult respiratory distress syndrome. Secondary to the need for significant mechanical ventilatory support, venovenous extracorporeal membrane oxygenation was initiated. Computed tomography scan of the head and neck with contrast revealed bilateral cavernous sinus thrombosis. After broad-spectrum intravenous antibiotics and aggressive supportive care in conjunction with surgical intervention (maxillary sinus lavage and right orbital exploration) and anticoagulation therapy, the patient recovered. Blood cultures were positive for Viridans streptococcus. At discharge 3 wks later, the patient had improved, but had right-eye blindness. Conclusions The diagnosis of septic cavernous sinus thrombosis requires a high index of suspicion and confirmation by imaging; early diagnosis and surgical drainage of the underlying primary source of infection in conjunction with long-term intravenous antibiotic therapy are critical for an optimal clinical outcome.

Hypertension is a premier risk factor for cardiovascular disease which can be recognized if sought and treated effectively. Effective management of high blood pressure is possible when the magnitude of the problem is identified. So, a cross-sectional community based survey among 1,239 respondents aged ≥30 years was designed to estimate the prevalence and the sociodemographic correlates of hypertension among adults aged ≥30 years. Data was collected by personal interviews, followed by anthropometric and blood pressure measurements. Analysis was done using Statistical Package for the Social Sciences (SPSS) version 11.5. The prevalence of hypertension was 43.3%, with the prevalence being more among males (51.6%) as compared to females (38.9%). Of the total prevalence 23.1% (287) were known cases, and 20.2% (250) were newly detected cases. Based on the seventh report of the Joint National Committee (JNC VII) on high blood pressure, prehypertension was noted among 38.7%. Advancing age, male gender, current diabetic status, central obesity, overweight and obesity as defined by body mass index, and family history of hypertension were identified as significant correlates for hypertension by multivariate logistic regression.

In the past 3 decades, the number of immunocompromised children has increased steadily because of dramatic improvement in survival rates in certain malignancies as a result of intensive curative treatment regimens and an increase in the number of children undergoing life-saving hematopoietic stem cell transplantation (HSCT). Children receiving immunosuppressive therapy for cancer, as well as HSCT recipients, will benefit from vaccination but warrant close evaluation for a variety of reasons, such as the risk of developing severe infections, serious adverse events following certain vaccines, and decreased vaccine efficacy caused by poor immune response to vaccination. Various professional organizations have published vaccination guidelines for immunocompromised patients. Given their heterogeneity, recommendations for the immunization of immunocompromised patients may not be universally applicable. The safety of many commonly used vaccines has not been established in immunocompromised children. In addition, no large-scale vaccine studies have evaluated the clinical outcome of disease prevention in this population. All killed vaccines are generally safe, while live vaccines may be administered to immunocompromised children in select circumstances, depending on the degree of altered immunocompetence and the underlying primary condition. Healthcare providers should be knowledgeable about the indications, contraindications, and precautions for vaccine administration in immunocompromised patients. To protect immunocompromised patients, all family, household contacts, and healthcare workers should also be immunized with all routinely recommended vaccines. Pediatricians play a crucial role in identifying and effectively communicating the risks and benefits of vaccines to immunocompromised patients and their parents.

The emergence of oseltamivir-resistant 2009 H1N1 influenza virus (conferred by the H275Y substitution in NA) during therapy or prophylaxis in immunocompromised patients is a serious concern. The optimal therapy for immunosuppressed patients with oseltamivir-resistant 2009 H1N1 influenza virus is unknown and few options exist. We report a 10-yr-old recipient of kidney transplant who was hospitalized with oseltamivir-resistant 2009 H1N1 influenza pneumonia complicated by severe respiratory failure, ARDS, and renal failure requiring institution of ECMO and CRRT. On presentation, treatment with oseltamivir (second course) and broad-spectrum antibiotics was initiated. Immunosuppressive agents were stopped on hospital day (d) 2. On hospital d 7, given his critical status, immunocompromised state, and difficulty in obtaining intravenous zanamivir, after obtaining ethical approval and parental consent, he was treated with intravenous peramivir (through an Emergency Investigational New Drug Application) for two wk. He tolerated the regimen well and his clinical status improved gradually. Several factors may have contributed to virus clearance and survival including recovery of the immune system, aggressive critical care support, and administration of peramivir. Ongoing surveillance is essential to monitor how oseltamivir-resistant H275Y mutant viruses may evolve in the future.

Nevirapine and cotrimoxazole are associated with hematologic toxicities and skin-rash. Safety of their concurrent use for prophylaxis over extended periods among HIV-exposed uninfected infants has not been previously assessed.Secondary data analysis of the 'HIV Prevention Trials Network-046 protocol' (version 2.0), a phase-III, randomized, placebo-controlled trial that assessed efficacy and safety of nevirapine prophylaxis against breast milk transmission of HIV-1.Trial infants received 6-month study nevirapine/placebo, and standard-of-care peripartum single-dose nevirapine+/- zidovudine 'tail', and cotrimoxazole prophylaxis from 6 weeks through breastfeeding cessation. Adverse events were monitored using United States Division of AIDS Toxicity Tables (2004). Risk of neutropenia, anemia and skin-rash in the cotrimoxazole + nevirapine and the cotrimoxazole + placebo groups were compared using negative-binomial regression.Incidence of neutropenia and/or anemia, and skin-rash was highest during the first 6 weeks of life and declined, thereafter, regardless of study group. Time to first adverse event after 6 weeks was similar in cotrimoxazole + nevirapine and cotrimoxazole + placebo groups: hazard ratio (95% confidence interval) was 1.26 (0.96-1.66) for neutropenia and/or anemia (all grades), 1.27 (0.80-2.03) for neutropenia and/or anemia (grade ≥3) and 1.16 (0.46-2.90) for skin-rash (grade ≥2). There were no statistically significant differences in immediate (6 weeks-6 months) and long-term (6-12 months) adverse event risk among infants on cotrimoxazole + nevirapine versus cotrimoxazole + placebo.Extended nevirapine and cotrimoxazole prophylaxis through 6 months of age among HIV-exposed uninfected infants did not appear to increase the immediate or long-term risk of neutropenia, anemia or skin-rash. Concurrent use beyond 6 months, however, needs to be evaluated.

Postpartum Depression: Prevalence and Associated Factors among Women in India Postpartum depression is a major public health problem in both resource-rich and resource-limited countries. Postpartum depression affects 10-15% of mothers in resource-rich settings. In contrast, the prevalence ranges from 11% to 42% in resource-limited settings. Studies have identified many psychosocial and biologic risk factors associated with PPD. The determinants of postpartum depression in resource-rich and resource-limited settings share themes cross-culturally.

Background Rocky Mountain spotted fever (RMSF) is a well-described, potentially lethal, tick-borne zoonotic infection and has very effective therapy. However, the diagnosis might not be made early enough, often leading to worse outcomes. Objective Our aim was to discuss the diagnostic dilemmas facing the physician when evaluating patients with suspected RMSF. Methods We report a case of RMSF in a 6-year-old girl who presented to our hospital with a 7-day history of fever, headache, and a petechial rash. After blood cultures were obtained, the patient was treated empirically with doxycycline, vancomycin, and ceftriaxone. During the next 24 h, her clinical status worsened, with acute onset of altered mental status, posturing, and fixed and dilated pupils. A computed tomography scan of the brain demonstrated diffuse cerebral edema with evidence of tonsillar herniation. She died 24 h after admission. A serum specimen tested positive for immunoglobulin G to Rickettsia rickettsii at a titer of 128 dilutions, confirming recent infection. Conclusions We present this case to raise awareness of RMSF in patients who present with a nonspecific febrile illness in tick-endemic areas in the United States. Early diagnosis and treatment with doxycycline before day 5 of illness is essential and can prevent morbidity and mortality.

BACKGROUND: Poliovirus eradication is dependent on maintaining adequate community-wide levels of serologic protection. Many African countries with conditions that favor continued wild poliovirus propagation also have a high prevalence of pediatric human immunodeficiency virus (HIV) infection. Data are limited regarding the degree of serologic immunity conferred on HIV-infected children after immunization with oral polio vaccine (OPV). METHODS: This was a cross-sectional study correlating HIV infection and neutralizing antibodies against poliovirus serotypes 1 2 and 3 in 95 Zimbabwean children 2 months to 2 years of age born to HIV-infected mothers who received OPV according to the national schedule. RESULTS: HIV-infected children had significantly lower rates of seroconversion to all 3 poliovirus serotypes than HIV-uninfected children (60% 67% and 47% vs. 96% 100% and 82% P = 0.001 0.0003 and 0.015 for serotypes 1 2 and 3 in HIV-infected and uninfected children respectively after >/=3 OPV doses). Among poliovirus seroconverters HIV-infected children also had significantly lower geometric mean titers against serotypes 1 and 2 than HIV-uninfected children (geometric mean titers: 198 and 317 vs. 1193 and 1056 P = 0.032 and 0.050 for serotypes 1 and 2 respectively after >/=3 OPV doses). In addition HIV-infected children had significantly higher levels of total IgG and significantly lower CD4% and mean weight than HIV-uninfected children. Of note none of the HIV-infected children were receiving antiretroviral therapy and 71% had a CD4% indicating severe immunodeficiency. CONCLUSIONS: Pediatric HIV infection is associated with a poor serologic response to OPV which could pose an obstacle to global polio eradication.