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Fitzpatrick, M M; Shah, V; Trompeter, R S; Dillon, M J; Barratt, T M
doi: 10.1136/bmj.303.6801.489pmid: 1912857
OBJECTIVE--To evaluate the long term outcome of renal function in infants and children after diarrhoea associated haemolytic uraemic syndrome. SETTING--The Hospital for Sick Children, Great Ormond Street, and the Royal Free Hospital, London. SUBJECTS--103 children with the syndrome who presented between 1966 and 1985; 88 attended for follow up investigations (40 male, 48 female) with a mean age 11.6 (range 5.2-22.6) years and a mean duration of follow up of 8.5 (range 5.1-21.3) years. MAIN OUTCOME MEASURES--Blood pressure, ratio of early morning urine albumin to creatinine concentration, glomerular filtration rate, and plasma renin activity. RESULTS--The mean (SD) systolic blood pressure standard deviation score was 0.38 (0.67) and diastolic blood pressure SD score was 0.10 (0.76). The geometric mean ratio of overnight urine albumin to creatinine concentration was 1.27 (range 0.03-48.2), significantly higher than the value observed in 77 normal children (0.32 (0.05-1.95), p less than 0.0001). Glomerular filtration rate estimated from the plasma clearance of chromium-51 EDTA was 95.1 (22.7) ml/min/1.73 m2 surface area, and 16 children had a rate of less than or equal to 80 ml/min/1.73 m2. Significant negative correlations were found between glomerular filtration rate and urinary albumin to creatinine ratio (r = -0.41, p less than 0.0001) and glomerular filtration rate and systolic blood pressure SD score (r = -0.48, p less than 0.0001). A significant positive correlation was found between urinary albumin to creatinine ratio and systolic blood pressure SD score (r = 0.25, p = 0.02). CONCLUSIONS--After an acute episode of diarrhoea associated haemolytic uraemic syndrome 31% (27/88) of children had an increased albumin excretion, 18% (16/88) had a reduced glomerular filtration rate and 10% (9/88) had both, in association with a higher systolic blood pressure, indicating considerable residual nephropathy in this group.
doi: 10.1136/bmj.303.6801.493pmid: 1912858
OBJECTIVE--To determine the effect of breast feeding on the risk of xerophthalmia in children aged 6 months to 3 years attending a diarrhoea treatment centre in Bangladesh. DESIGN--Case-control study based on stratified analysis (Mantel-Haenszel) and multivariate analysis (logistic regression) of data from a treatment centre based surveillance system. SETTING--A large diarrhoea treatment centre in Dhaka, Bangladesh. PATIENTS--2687 children aged 6 months to 3 years representing a 4% systematic sample of all children in this age group treated yearly at the centre over three consecutive years. 66 of the children were cases of xerophthalmia (that is, they had Bitot's spots or corneal lesions or night blindness or night blindness plus conjunctival xerosis or any combination of these) and the remaining 2621 did not have signs or symptoms of vitamin A deficiency. This second group served as controls. MAIN OUTCOME MEASURE--Xerophthalmia and breast fed at onset of diarrhoea or presentation. RESULTS--The odds ratio relating breast feeding to vitamin A deficiency after adjustment for a large number of confounding variables (0.26 (95% confidence interval 0.14 to 0.49); p less than 0.001) reflected a 74% reduction in the risk of vitamin A deficiency among breast fed children. The estimated reduction of risk did not decline with age, and some 49% of children aged 24-35 months were still being breast fed. The odds ratio relating breast feeding to xerophthalmia in the third year of life (0.35 (95% confidence interval 0.35 to 0.86) reflected a 65% reduced risk of vitamin A deficiency. Other important risk factors or prognostic indicators for xerophthalmia as identified by multivariate analysis were recent measles, prolonged diarrhoea, severe protein energy malnutrition, and poor socioeconomic state. CONCLUSIONS--These results indicate that breast feeding was associated with a substantial reduction of the risk of vitamin A deficiency extending to the third year of life and support the recommendation that mothers in developing countries should be advised to breast feed for as long as possible.
doi: 10.1136/bmj.303.6801.497pmid: 1912859
OBJECTIVE--To describe the extracontractual referrals of residents of Merton and Sutton Health Authority during the first three months of the NHS reforms in terms of the nature of the referral (elective or emergency), the specialty referred to, and the source of and reason for referral. DESIGN--Descriptive analysis of all extracontractual referrals submitted to the health authority between 1 April and 30 June 1991. SETTING--Merton and Sutton Health Authority. RESULTS--247 extracontractual referrals were notified to Merton and Sutton Health Authority; 83 invoices for emergency treatment and 109 elective referrals were authorised at a total cost of 190,000 pounds. Of the elective referrals, 59 were to ear, nose, and throat; orthopaedic; or general surgery departments. Local general practitioners made only two thirds of the elective referrals, at least 15 of which were made at the patient's request. Four admissions accounted for a quarter of the total cost of the emergency admissions. CONCLUSIONS--Extracontractual referrals are unpredictable in terms of both their number and their cost. They provide a necessary safeguard for patient and general practitioner choice at the price of a considerable administrative workload. The fact that these referrals are income generating for providers means that additional safeguards may be necessary to prevent abuse of the system.
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