Search

A cross-sectional microbiological study of recurrent (secondary) dentinal caries was conducted. Freshly extracted human teeth containing amalgam restorations judged to be clinically intact were scrubbed with chlorhexidine soap and soaked in povidone-iodine solution. The teeth were then split to remove the fillings and examined for dentinal caries. Of 54 teeth examined, 22 (40%) were free of dentinal caries in the restored site. The remainder were assigned to arbitrary groups of questionable (15), initial (8) and active caries (9), based on the amount of dentinal decay observed. Comparison of pre-extraction bite-wing radiographs with the in situ findings revealed the sensitivity for secondary caries detection to be only about 50%. In contrast, the specificity for absence of caries was 73%. There was considerable variation in the numbers and types of micro-organisms found in dentine samples from lesions of comparable severity. Facultatively, anaerobic streptococci were the most numerous and most prevalent micro-organisms in the affected dentine, but no single species was significantly associated with recurrent caries. Mutans streptococci were found in 40% of sites with any degree of caries and in only 3 of the 9 sites with the most caries. Homofermentative lactobacilli were present in 18 of the 54 dentine samples, including 4 from caries-free sites. While the prevalence and numbers of lactobacilli increased with the degree of caries, they occurred in less than half of the affected dentine samples. Actinomyces occurred in 15 of 32 affected sites but only in 2 of the 9 most active sites. Their numbers never exceeded 3 x 10(3) CFU/mg.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital laryngeal clefts are rare. This paper reports on the management of 3 patients with Type 2 laryngo-tracheo-oesophageal cleft. One patient died following tracheopexy after successful cleft closure. Prognosis is related to the presence of other major anomalies, the early diagnosis of the lesion and institution of appropriate respiratory and nutritional care prior to correction of the defect. A greater awareness of the condition combined with aggressive diagnostic endoscopy should result in early diagnosis and improved survival.

Streptococcus sobrinus strain 6715-13-201 was inoculated into the oral cavity of a gnotobiotic rat and then reisolated from different portions of the gastrointestinal tract. Fourteen isolates, selected on the basis of their colonial morphology, were then screened for their ability to adhere to saliva-coated hydroxyapatite (SHA) in vitro, and their ability to produce extracellular polysaccharide from sucrose, and low pH in glucose broth. Certain isolates were also tested for their cariogenic potential as monoinfectants in gnotobiotic rats. All isolates differed in their abilities to adhere to SHA, with most showing an increased level of adhesion in the presence of sucrose, but this did not correlate with their ability to be aggregated by dextran. Most isolates were capable of producing glucosyltransferases (with only one exception) and dextranases (also one exception). There was more variability in the production of dextranase inhibitor. No isolate was capable of producing dextranase inhibitor in the absence of dextranase production. There were no correlations between the ability of isolates to adhere in vitro or produce/utilize polysaccharides and their ability to produce caries in vivo. Due to the differences between strains in their abilities to adhere, produce polysaccharides, utilize polysaccharides or produce a low pH and the lack of correlation between any of these parameters and cariogenicity, the results suggest that the ability of strains to colonize and produce caries depends on a number of different characteristics, no one of which is essential.

Gastrointestinal heterotopia in the tongue is a rare condition. A male newborn was noted to have a cystic swelling in the anterior part of the dorsum of the tongue. This was surgically excised. Histology revealed it to be a heterotopic gastrointestinal cyst. A literature review was undertaken because of the rarity of this lesion. As most of these cysts are present from birth, they are likely to be developmental in origin.

Extrarenal nephroblastoma (Wilms' tumor) is very rare with to date just 34 cases described. Two such cases out of a total of 61 patients with WT presenting to a single institution over a 10-year period are presented. Both children, a boy aged three years and a girl aged four years, both presented with an abdominal mass which had crossed the midline. Ultrasonography and contrast studies in the two patients revealed retroperitoneal tumors distinct from kidneys, but unilateral hydronephrosis was noted in both patients. Primary surgical excision was performed and both patients grouped as stage III favorable histology. Postoperative treatment included chemotherapy and radiotherapy as per UKCCSG protocols. The patients are clinically well with no evidence of disease 7 years and 20 months respectively from diagnosis. An individualized approach to treatment of extrarenal WT is advocated.

The role of an aggressive surgical policy in the management of neuroblastoma (NBL) was examined in a retrospective study from a total of 57 patients presenting to a single institution between 1979 and 1989. Surgery consisted of either primary excision of tumour or elective resection following intensive chemotherapy. Two year disease-free survival (DFS) for the entire group was 100% for Stage I patients (n = 2), 86% for Stage II (n = 7), 55% for Stage III (n = 11), 12% for stage IV (n = 33) and 50% for stage IVs (n = 4). In all long-term survivors, surgical excision of primary tumour had been achieved. Elective surgery of primary tumour was not performed in six patients with Stage IV disease; median survival for these patients was eight months compared with 19 months for those other patients with Stage IV disease who did have surgery +/- high dose melphalan and autologous bone marrow rescue. Postoperative complications were documented in 13 of 48 operated patients (27%), emphasising the technical challenges encountered in resection of NBL. Age at presentation and site of primary tumour were major factors affecting prognosis: patients who presented < 1 years of age (n = 15) achieved 80% DFS, > 1 year and < 2 years (n = 12), 33%, and > 2 years (n = 30) 13%; 10 of 11 patients (91%) with primary supradiaphragmatic disease are alive and well compared with 10 out of 46 (22%) with infradiaphragmatic disease (P = 0.01). Based on the experience from this centre, it would appear that surgery can be curative for patients with Stage I, II and III disease but can only, at best, prolong DFS for Stage IV patients. Alternative therapeutic strategies are indicated for this latter group of patients.

Problems with loss of correct orientation of the pull-through rectal pouch during posterior sagittal anorectoplasty (PSARP) for high imperforate anus can occur during laparotomy after perineal closure is complete. A simple modification of the de Vries-Peña technique is described that facilitates preservation of orientation and precise anatomical neomuscle construction. A slotted rubber tube preserves correct anatomical orientation of the neorectal pouch and allows accurate construction of the muscle complex around the tube.

Von Recklinghausen's neurofibromatosis (VRN) is a familial disorder characterised by a generalized neuroectodermal dysplasia--symptomatic involvement of the gastrointestinal tract is rare. We report on our experience with two children who had proven gastrointestinal neurofibromas and highlight the need for careful assessment in children with VRN who develop abdominal pain.

Heterotopic salivary tumours in the upper neck are rare. Three children, one with mucoepidermoid carcinoma and two with pleomorphic adenoma in ectopic cervical sites are presented. Local complete excision was successful in the patients with pleomorphic adenoma. More extensive surgery was undertaken for the mucoepidermoid carcinoma. All three patients remain disease free at 3-6 years follow-up. Oncogenesis of heterotopic salivary tissue entrapped in an upper cervical lymph node during embryogenesis is a possible etiological mechanism. In a patient with a cervical malignant salivary tumour, a careful search should be made to find a primary tumour. In the event of a negative search, this should be considered the primary tumour and treated appropriately.

In 1977 we started treating babies with isolated esophageal atresia by delayed primary anastomosis and in 1981 reported our early experience in five cases treated between 1977 and 1979. Since 1979, 11 further consecutive cases have been managed by initial gastrostomy followed by delayed primary esophageal anastomosis. Their mean gestation was 35 weeks (range, 28 to 40 weeks) and mean birth weight was 2,040 g (range, 1,140 to 2,720 g). The esophageal gap between the two ends when assessed initially at fluoroscopy ranged from 2.2 to 4.5 cm (mean, 3.2 cm). Age at delayed primary anastomosis ranged from 6 to 20 weeks. Anastomotic leak occurred in three babies in the immediate postoperative period and all were successfully managed conservatively. Eight of the 11 patients developed anastomotic strictures; seven cases required 1 to 5 esophageal dilatations. One patient who did not respond to multiple esophageal dilatations required resection of an esophageal stricture. One patient died at 15 months of age of unrelated causes. The 10 surviving patients have been followed-up from 18 months to 11 years. At follow-up, seven patients were eating normally. Three patients had swallowing difficulties and all three were found to have esophageal strictures on barium swallow, two of them also had gross esophageal reflux and hiatus hernia. The height and weight in the 10 patients varied from 3rd centile to 75th centile. Delayed primary anastomosis is feasible in cases of isolated esophageal atresia and the patient's own esophagus is the best. A more aggressive approach should be applied to gastroesophageal reflux in these patients.

The kinetics of lactate dehydrogenase from Leuconostoc lactis NCW1 were studied. The pH optimum for the enzyme depended on the concentration of pyruvate used in the assay and the enzyme displayed an ordered mechanism with respect to substrate binding. The Km for pyruvate and NADH and the Vmax of the enzyme decreased 20-, 30- and 6-fold respectively as the pH decreased from 8.0 to 5.0. No activators were found and none of the intermediates of the phosphoketolase pathway tested inhibited the enzyme. ATP, ADP, GTP and NAD+ were inhibitory. The intracellular volume (Vol(in)) and intracellular pH (pH(in)) decreased as the extracellular pH (pH(ex)) decreased. Co-metabolism of citrate and glucose affected the Vol(in) but did not affect the pH(in), which decreased by 0.6 units per unit change in pH(ex); at pH 7.0, the pH(in) and pH(ex) were equal. The results suggest that pH(in) may play a role in determining the production of diacetyl and acetoin at low pH by Leuconostoc.

Random urine samples were collected from 305 children aged from birth to 14 years and the values of hydroxymethoxymandelic acid, homovanillic acid, noradrenaline, adrenaline, and dopamine were measured by high-performance liquid chromatography with electrochemical detection. The results were reported relative to the urinary creatinine concentration and the values declined progressively with increasing age for each analyte with the exception of adrenaline. The results for each age group were not normally distributed and all values except outliers were retained in determining the upper reference limits.

Twenty-one children were admitted to a single paediatric institution between 1964-1990 with histologically proven primary liver tumours. The diagnosis was hepatoblastoma (HBL) in 15 patients, hepatocellular carcinoma (HCA) in 2, rhabdomyosarcoma (RMS) in 2, non-Hodgkin's lymphoma (NHL) in 1, and haemangioendothelioma (HE) in 1. The common presenting clinical features were anaemia, abdominal mass, and abdominal pain. Serum alpha-foetoprotein was useful in establishing a diagnosis in HBL and in monitoring disease activity. Computed tomographic (CT) scan, ultrasound, and angiography were useful preoperative investigations for assessing site and resectability of tumour. There were no survivors in patients with malignant hepatic tumours (n = 10) who had surgery alone prior to 1981. Of 7 patients with HBL diagnosed after 1981 who had adequate surgical resection and chemotherapy, 5(72%) are currently alive and disease free between 15 months and 8 years from diagnosis. We conclude that adequate surgical resection and adjuvant chemotherapy can improve disease free survival for children with HBL. Optimal treatment has yet to be devised for other malignant hepatic tumours.

A retrospective analysis was performed of 56 patients presenting to Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland, over a 25 year period with a diagnosis of rhabdomyosarcoma, in an effort to assess the changing role of surgery in the management of this disease. There were 38 males and 18 females; the age range at presentation was from birth to 13 years with a median of three years. Head and neck tumors occurred most frequently (23) followed by pelvic (14), paratesticular (6), extremities (6), gastrointestinal (4) and thoracic (3). Prior to 1971 there were no survivors while a doubling of survival has been observed within the past decade (31% to 63%). The minimum period of follow-up was four years. Surgical intervention ranged from total primary excision (20) to biopsy only (21) with total or subtotal resection performed electively in 15. Surgical evaluations, including examinations under anesthesia, staging laparotomy and second look laparotomy were also invaluable in assessing disease status. The incorporation of multiagent chemotherapy together with more selective use of radiotherapy has enabled a more conservative role to be adopted by the surgical oncologist thereby minimizing longterm sequelae.

Management of spina bifida is still controversial. At one extreme is the policy of total care in all cases while some form of selection is practised in many centres. We reviewed 104 patients treated over the last five years. Forty-nine patients, who had one or more adverse criteria, were managed conservatively. Twenty-four of these 49 patients required VP shunt insertions subsequently. Four patients had delayed closure of back lesions, three of them were followed by shunts. There was an overall increased (57%) incidence of surgical intervention in conservatively managed patients over the last five years as compared with 34% from our previous report. We found no difference in the timing of insertion of shunts in actively and conservatively managed patients in this study. The mortality in the actively and conservatively managed patients was 7% and 47% respectively. Eighty-five per cent of the patients who had no surgery died at an average age of 23 days. Patients who died without surgical intervention did not survive long enough to warrant surgery, while the mortality was 20% and had among those who survived surgical intervention. Paraplegia alone was not a predictor of high mortality but the presence of two or more adverse criteria were more accurate indicators of poor prognosis. As 78% of all the deaths in conservatively managed patients occurred within three months, reappraisal of management policy is necessary in the infants surviving beyond three months of age as death is less likely after this time.

Abdominal pain is a frequent symptom in the child with Henoch-Schönlein purpura and raises the suspicion of intussusception or perforation. One hundred and fifty two children with a diagnosis of Henoch-Schönlein purpura over 11 years were reviewed. Of these 60 had abdominal pain, 19 gastrointestinal bleeding, and nine were suspected intussusception. Intussusception was confirmed in two of these cases with ultrasonography. Ultrasound is an important tool in the early diagnosis of intussusception complicating Henoch-Schönlein purpura. Where the intussusception appears loose an expectant policy, with careful monitoring, may allow spontaneous reduction. It may also be used in monitoring patients for postoperative recurrence of intussusception, mural haematoma, and uncomplicated intestinal vasculitis with oedema.

Although extracorporeal shockwave lithotripsy (ESWL) has revolutionised the management of urinary calculous disease, the long-term effects of ESWL on renal function are not known. This study of 18 children demonstrated a mild, statistically insignificant decrease of 15% in DTPA measured glomerular filtration rate following ESWL. In view of this, we recommend that pretherapy and posttherapy estimates of renal function be obtained in all patients undergoing ESWL. Long-term follow-up is necessary to further quantify the effects of ESWL on the developing kidney.

Two management patterns were identified in 36 patients with exomphalos--primary surgical closure and initial topical therapy with delayed surgical closure. Primary surgical closure of minor exomphalos was well tolerated in 15 patients, but was associated with a high local and systemic morbidity rate in 14 patients with major defects. In contrast, initial topical therapy with silver sulphadiazine and delayed closure in seven matched patients with a major defect were well tolerated and did not prolong duration of hospitalization. Enteral feeding was more readily established and subsequent fascial closure facilitated in the conservatively treated group. It was suggested that this method should be more often considered in the management of all instances of major exomphalos.

Childhood pyogenic hepatic abscess is rare and remains a difficult diagnostic problem. Seven cases in six children were treated over a 13 year period. There was a recurrence in one patient 7 years after the first presentation. Four patients had identified predisposing factors, namely, chronic granulomatous disease, acute appendicitis, previous abdominal surgery and umbilical vein catheterization, while the other two were cryptogenic. There were no specific symptoms and signs but the combination of unexplained pyrexia, upper abdominal tenderness, hepatomegaly and leucocytosis should raise the suspicion of hepatic abscess. Four cases were diagnosed by ultrasound, one by radionuclide scan and the other two at laparotomy. Treatment in the earlier years was by transabdominal drainage. In the later part of the series, percutaneous catheter drainage using ultrasound guidance was achieved with satisfactory result. Ultrasonography can provide an early diagnosis and effective treatment can be achieved with percutaneous catheter drainage in combination with appropriate antibiotic therapy.

The management policy at Our Lady's Hospital for Sick Children, Crumlin, for newborn spina bifida infants consists of immediate operation for those considered likely to benefit and full nursery care for those who do not have early surgery. In the eleven years since this policy was first implemented, there have been 493 infants admitted with open myelomeningocele, of whom 260 (52.7%) were managed non-operatively. The mortality for all infants so managed was 78% at one year. 171 (66%) of this group died without further intervention. 89 (34%) survived long enough for some form of treatment to be instituted. 41 of these children are still alive and it is felt that their handicaps have not been increased by their early management. It is argued that an approach to management which considers the needs and interests of the individual infant is more acceptable than one that seeks to enforce total care, regardless of circumstances, or the impersonal assignment, by criteria, into "treatment" and "non-treatment" groups.

Incubation of saliva supernatant after three hours at 37 C revealed that salivary anionic proteins were susceptible to enzymatic attack by salivary enzymes not removable by centrifugation at 10,000 g. In the presence of washed suspensions of S mutans or S sanguis additional changes in electrophoretic behavior of anionic proteins occurred. Differences between organisms suggested a selectivity of attack on the anionic proteins.

In a prospective study of 410 children who had a non-perforated appendix removed, the mean postoperative stay was 46 hours and 80% of patients were discharged within 48 hours. Twenty-two patients were readmitted, but neither the temperature of the patient, nor bowel motions passed prior to discharge were of any prognostic value in predicting those who would develop postoperative complications. The cost saving and the patient benefit of earlier return to home environment recommend this policy.

Thirty one patients were treated for 43 laboratory proven shunt or CSF infections, between 1980 to 1986 inclusive. They required 63 separate treatments. Infective episodes were grouped retrospectively according to method of treatment employed i.e. 1) placement of external drainage system or 2) reservoir and tapping, 3) intravenous or intraventricular antibiotics alone, 4) total change of shunt prosthesis, 5) partial change of prosthesis or 6) removal of all the prosthesis. See Table II. The single most important factor in eradication of shunt infection was the entire removal of the total shunt system and achieved success in 80% of instances. Conversely utilization of any of the existing infected system failed in 77% of cases. Route of administration of antibiotics, choice or change of side, or method of treatment chosen did not appear to influence success greatly.

A case of ileocolic intussusception, associated with mid-gut volvulus and malrotation with bowel necrosis is reported. There is evidence to suggest that the intussusception preceded the volvulus.

Three neonates with spontaneous perforation of the common bile duct have been described. All were treated by laparotomy in the seventh week, with attempted closure of the perforation and a simple biliary diversion by cholecyst-jejunostomy with jejunojejunostomy below it. They have done well and represent 100% salvage of our cases to date. One is now 12 years of age. As far as we are aware, this method of dealing with the condition has not been described before.

Consideration of nutritional factors as determinants of oral microbial ecology leads to the conclusion that endogenous factors play a dominant role. It is the interactions between specific microorganisms and nutritional and other factors provided by the host that selectively determine the kinds of microorganisms which willinitially reside in the oral cavity and the sites which they will colonize. The persistence of these original "colonists" in their respective ecologic niches will depend in part on the accessibility of endogenous nutrients variously provided by saliva, tissue exudates, crevicular fluids, or degenerating host cells. It will also depend on their response to and interaction with microorganisms which immigrate to that site subsequently. The microbial ecology of a given site is therefore rarely uncomplicated, the notable exception occurring at the most microscopic level where one may encounter microcolonies of individual species within more heterogenous populations of microorganisms. The extent of this heterogeneity quantitatively and qualitatively is a reflection of the degree to which the interactions between the resident flora and the new arrivals, plus the local environmental changes which they both generate, serve to promote or to discourage the survival and growth of the individual species. This element of heterogeneity in a dynamic system with its inherent potential for variation makes it possible for relatively minor changes in local environmental conditions to result in significant differences in the microflora between one site and another even though they may be in close proximity to each other. Once this concept is appreciated it becomes easy to understand how disease processes such as dental caries may affect specific areas of a tooth while nearby areas are unaffected. The effects of exogenous nutrients on the ecology of the oral microbiota, nevertheless cannot be ignored. The diet may modulate such endogenous factors as the salivary secretions and the local resistance of the gingival tissues to infections. Although at our present state of knowledge the direct influence of dietary proteins and fats on the oral microbiota is thought to be of relatively minor consequence, dietary carbohydrates are of major ecological significance. Dietary sugars provide readily available substrates for the oral microorganisms, most of which depend on carbohydrates for energy sources. The metabolism of dietary sucrose by S. sanguis and S. mutans with the productions of acids and intracellular and extracellular polysaccharides has specific influence on the microbial composition, metabolic activities, and mass of coronal plaque. The ready availability of dietary carbohydrates undoubtedly influences the microflora of other parts of the oral cavity as well, eic species or indirectly through the interactions of other organisms with them...

We examined whether the anionic antimicrobial proteins in the saliva of certain caries-free (CF) individuals are immunologically cross-reactive with proteins in caries-active (CA) saliva which display identical isoelectric points but which exhibit growth-supportive properties for the oral streptococci. In the immunoblotting experiments reported here, the proteins present in CF and CA whole salivas reacted similarly with an antiserum prepared against the anionic inhibitory proteins. This antiserum also showed identical reactivity with the purified protein fraction containing the anionic proteins of interest from whole saliva of either CF or CA subjects. Additionally, an antiserum to CA saliva was found to react with the CF anionic inhibitory proteins. The fact that the inhibitory and noninhibitory proteins react similarly with the antisera used provides further evidence for similarity between both classes of proteins.

Following treatment with hydroxyapatite, clarified mixed saliva from one donor source lost much of its growth-supportive activity for S. mutans VA-29R (type c). Growth of the organism in a basal medium containing proteins desorbed from HA with 0.067 M potassium phosphate buffer, pH 8.0, was accompanied by the disappearance of some of the proteins, including those with isoelectric points of 4.90, 5.72, and 6.00. These proteins are among those known to be specifically attacked by S. mutans. These findings suggest that some of the proteins selectively adsorbed from saliva with HA may serve as specific growth substrates for the plaque-forming oral streptococci.

The sixth documented case of heterotopic gastric mucosa in the large bowel proximal to the rectum is described in a two year old girl with a neural tube defect and recurrent rectal bleeding. Unusual in itself, this case is unique in that the rectal bleeding has been controlled with an H2 receptor antagonist.

The purpose of this study is to draw attention to inflammatory disease of lumbar intervertebral discs in children as a source of referred abdominal pain. For three children presenting with abdominal pain the eventual diagnosis was discitis of the lumbar spine. Failure to examine the patient's backs at the initial examinations resulted in a delay in diagnosis ranging from 66 to 2 days. Treatment with antibiotics and spinal jacket was effective in all cases.

The growth response of Streptococcus mutans representing antigenic type a or d in a chemically defined medium was influenced by the oxygen concentration of the growth atmosphere. Under controlled aerobic (1.5% O(2)) conditions these cultures attained a greater density than when the atmosphere contained 0.006% O(2) or less. The growth of S. mutans strains representing antigenic types b or c in the defined medium was independent of the oxygen concentration of the growth environment. Under the conditions used in this study, none of the strains tested could utilize ammonium ion as a sole source of nitrogen for growth. The requirement for certain amino acids and inhibition by other amino acids varied with antigenic type and relative oxygen concentration of the growth environment. Under conditions where the atmospheric oxygen was reduced to 0.0006% O(2) or less, the amino acid requirements of the cultures became either more numerous or more stringent. S. mutans strains of type c generally required the least number of amino acids, whereas cultures of type d had more numerous requirements. Nearly every culture tested under the anaerobic atmosphere was inhibited by one of the branched-chain amino acids, leucine, valine, or isoleucine. Methionine and lysine were also found to be inhibitory, particularly toward the type c strains.

Hamsters infected with Streptococcus sobrinus (formerly Streptococcus mutans) strain 6715-1119 were given high-sucrose diet 2000. After 5 days, they were presented with 0.05 or 0.1 per cent w/v chlorhexidine gluconate (CHX) continuously in their drinking water, which was well-tolerated. Compared to infected but untreated controls, their caries scores were less by 84 and 97 per cent respectively after 42 days. Coronal dental plaque deposits were reduced in a dose-related fashion. Culture plates of oral swabs showed reductions in Strep. sobrinus and total streptococci after 10 and 35 days of CHX. Hamster oral streptococci were more sensitive to CHX than were lactobacilli but neither was completely eliminated. The incidence of stained tooth deposits after 0.1 per cent CHX was slightly but not significantly greater than in controls.

Mixed or parotid saliva from caries-active individuals consistently supported better growth of Streptococcus mutans (type c) than that from caries-free individuals. Electrophoretic studies revealed that certain proteins in caries-active salivas were susceptible to microbial attack, but similar proteins in caries-free salivas were refractory.