STOMACH AS RESERVOIR FOR RESPIRATORY PATHOGENS

1147 INTERMITTENT URETHRAL CATHETERISATION IN CHILDREN

SEQUELÆ OF COVERT BACTERIURIA IN SCHOOLGIRLS

SIR,-We take issue with the Cardiff and Oxford Bacteri-

"screening for occult bacteriuria canStudy Group not... be recommended in schoolgirls".’ In their study of 16 800 schoolgirls aged 5-12, 1.8% had bacteriuria, 255 of whom had intravenous pyelograms and micturating cystograms. (7 of these were excluded from the trial of chemotherapy but the reasons for this exclusion were not given. Was it because they required immediate surgical intervention or acute treatment?) Perhaps the most important result of the study was that all 12 girls with progressive scarring had vesicoureteric reflux (V.U.R.) as compared with an overall prevalence of v.u.R. of 34%. This is a powerful argument in favour of identifying girls with reflux with a view to possible reimplantation surgery. We have conducted a similar programme and we conclude that its continuation is justified. The screening programme has been in operation for two years, and is now entirely run by one part-time nursing sister. It is being conducted in all the high schools in one of the four health regions (pop. 660 000) of the city of Sydney. All girls aged 14 or over have been offered screening, this age being selected because after 14, reflux is not expected to spontaneously resolve and a proportion leave school. Each class is visited by the sister and the purpose of the programme discussed. A sterile container is handed out with instructions about collecting an early morning specimen and an explanatory note for the parents. The sister collects the specimens next morning (80% are returned). These are dipstick tested immediately (’Uriglox’, Kabi). A colour change reveals infection (absence of the normal trace of sugar in the overnight specimen). A one-way chromatogram for phenylketonuria and cystinuria is also done. The family of any girl with a positive uriglox specimen is visited by the sister and two midstream specimens are collected. Any girl with two specimens with 105 bacteria/ml is offered pyelography and is seen by the uria

that

pxdiatric nephrologist. Not all of these girls were symptom-free but none had been seen for urinary infections. Two girls not included in our results were being treated for gross scarring and v.u.R. Of the 12 000 girls tested, 105 were uriglox positive and 62 (0.5%) had bacteriuria in two specimens of 105/ml. 58 of these were investigated. 48 had normal intravenous pyelograms. 3 had renal scarring with grade 2-3 v.u.R. (2 reimplanted with no recurrence of V.U.R.; 1 awaiting operation). 3 had no scarring but persistent v.u.R. after therapy (all reimplanted; no recurrence of v.u.R. or bacteriuria). 3 had renal scarring without reflux. 1 each had neurogenic bladder, phenylketonuria (mildly retarded), and homozygous cystinuria (with bacteriuria, pyelography normal). This inexpensive urinary screening programme appears to have two major advantages: it identifies a number of girls with significant reflux with or without scarring who require surgical intervention (1:2000); it also identifies those with scarring with or without V.U.R. for long-term follow-up. The identification of those girls with bacteriuria without scarring or reflux may prove to be of benefit when they become pregnant. 20% can be expected to develop acute pyelonephritis if untreated and should this be associated with significant pyrexia, it may result in a baby with reduced head circumference2and presumably intellectual delay. GILLIAN TURNER

of Preventive Pædiatrics, Prince of Wales Children’s Hospital, Randwick and Health Commission, Southern Metropolitan Health Region, New South Wales, Australia

Department

ANDREW ROSENBERG ROBERT FARNSWORTH BRIDGET WILCKEN HAZEL ROBINSON

1. Cardiff-Oxford Bacteriuria Study Group. Lancet, 1978, i, 889. 2. Smith, D. W., Clarren, S. H., Harvey, M. A. S. J. Pediat. 1978,

,

SIR,-Iwas interested in the paper by Mr Withycombe and his colleagues (Nov. 4, p. 981) because, nearly two years ago, I adopted a similar method of managing urinary incontinence in children with paralysed bladders. In my experience the method has been successful in keeping these children dry. I have some suggestions which might improve the technique. If the bladder has a small capacity, because of detrusor muscle hypertrophy and high tone, catheterisation must be done frequently to prevent wetting. A cystometrogram will detect this state of affairs, which can be overcome by anticholinergic drugs. Propantheline and imipramine are the most effective and enable the interval between catheterisations to be increased to four hours. Thus all children in whom the method is to be tried are investigated by cystometrography (conveniently done at the same time as the cystogram). The penile urinal is unsuitable in boys with extensive paralysis affecting the lower limbs, particularly if they spend most of the day in a wheelchair. The obesity and spinal deformity which develop when they become older add to their difficulties. The urinal becomes persistently displaced so that the boys are frequently sitting in wet clothes. Intermittent catheterisation has completely changed this picture. Because a rigid catheter might damage the urethra or bladder if misused, I provide girls with catheters made from plastic tubing. They are easy to pass but have some flexibility. These Portex catheters come in sizes equivalent to Ch. 10, 12 and 14 and are supplied presterilised in plastic envelopes. The mothers are advised to immerse the catheters in ’Milton’ antiseptic solution overnight. The girls are given a plastic sheath, used as a container by the manufacturers of Foley catheters, to carry their catheters around in during the day. A fresh catheter is used every week to obviate the risk of obstruction to the lumen by accumulated deposit. Since the catheters are very cheap it would be possible to use them once only. The boys use plastic ’Nelaton’ catheters (Portex): again a fresh catheter is ’used every week. Most of the children have persistent bacteriuria, but provided that they have no symptoms and are emptying their bladders effectively, antibacterial drugs are not prescribed. As Withycombe et al. indicate, it is too soon to evaluate the long-term effects of intermittent catheterisation on the function of the upper urinary tract, but in the short term the method has converted children who are continuously wet to being dry during the day, and both they and their parents are very satisfied. It seems reasonable to hope that fewer urinary diversions will be required in the future, that fewer upper urinary tracts will deteriorate as a result, and that the cost of providing children with surface urinary diversion appliances will be much reduced. Department of Surgery, University of Newcastle upon Tyne, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP

STOMACH AS RESERVOIR FOR RESPIRATORY PATHOGENS .

SIR,-Iwas interested to read the paper by Dr Atherton and Mr White (Nov. 4, p. 968) because I have long thought that the stomach functions as a reservoir for bacterial growth which exacerbates-and, indeed, in some instances, causes or prolongs-respiratory failure in patients receiving intensive care.

In 1972,1 I recorded the fact that patients on artificial ventilation grew in their stomachs organisms virtually identical to those found by Atherton and White. I wrote about this in the context of the setiology of stress ulceration. I also found that the aspirate from the trachea, via the endotracheal or tracheostomy tube, contained organisms identical to those found 1.

92,

871.

JOHN E. S. SCOTT

Brooks, D. K. in Advances in Surgery (edited by J. D. Hardy); p. 289.

Chicago,

1972

1148 in the stomach.

Following this finding, alkalising substances recommended for stress ulceration and antibiotics, diluted in saline, were given via the nasogastric tube. The fact that the bacteria in the stomach could not only induce gastric bleeding but also initiate or prolong the respiratory infection itself was stated in my discussion of the actiology of stress ulceration earlier this year although we have worked on this principle with success for some time. The growth of bacteria in the stomach and their subsequent presence in the lungs seem to be associated with the rise in pH of the gastric contents.’ When the pH rises above 4.0, bacteria seem to grow unhindered. There is frequently no inorganic acid in the gastric contents and the pH is sometimes as high as 7.0. When the pH is lower, it seems to be due to organic acids (e.g., lactic and butyric, probably produced by the bacwere no

longer

’

teria). While bacterial growth is common in patients on prolonged artificial ventilation, it is seen in other conditions, and, as Atherton and White note, it may be detected as early as one or two days after surgery, as Margaret Ghilchik and I (unpublished) have noted. Besides antibiotics, the use of dilute HCI prophylactically and therapeutically is also of value. I have described22 one patient receiving dilute HCI, and a review of my records has revealed that two other patients received HCI when stress ulceration was threatened during artificial ventilation of the lungs. Treatment was successful in these patients. The solution used was 2 ml of 10% HCI diluted in 150-200 ml of water. This was given four to five times a day down the indwelling nasogastric tube either alone or before the patient was given a blended diet. I agree with Atherton and White that more attention should be paid to the gastric contents in patients who have either undergone surgery with subsequent ventilation of the lungs or have injuries from which they are slow to recover. A simple pH measurement of the gastric contents is an early warning sign. Bacterial growth can occur when the pH is 3.5or more and appears to be absent when it is 2-0 or less. In one patient both Escherichia coli and Pseudomonas sp. grew when the pH was

35.’ Besides

causing gastric bleeding after trauma and prolonged respiratory failure, bacterial growth in the stomach might, in theory, be responsible for the duodenal erosions that have been reported to follow prolonged cimetidine therapy, even when the patient’s original ulcer has healed.3 By reducing the gastric HCI content, cimetidine could pave the way for bacterial growth. It may, therefore, be necessary to give cimetidine intermittently for short periods if erosions are to be avoided. Department of Medicine, St. Mary’s Hospital,

DAVID K. BROOKS

London W9

A.C.T.H. IN

GUILLAIN-BARRÉ SYNDROME

p. 750) find that in a small prednisone dosage given for two weeks moderately to patients with acute polyneuropathy (Guillain-Barre syndrome) early in the course of the disease does not help, and, indeed, may worsen the outcome. They say nothing about the effect of large doses of A.C.T.H. given at a critical point later in the disease and maintained for a longer time. It is this treatment that many neurologists, including myself, would defend, having had repeated satisfactory experiences with A.C.T.H. in such cases. Perhaps yet another controlled trial is in order.

SIR,-Dr Hughes and colleagues (Oct. 7,

Department of Neurology, University of Mississippi Medical Center, Jackson, Mississippi 39216, U.S.A. 2.

Brooks, D. K. Br. med. J. 1978, i, 922. 3. Linaker, B. D., Hughes, S. ibid. p. 1278.

ROBERT D. CURRIER

TREATMENT OF EARLY BREAST CANCER

SIR,-You say (Sept. 30, p. 717) that "Probably none of the existing predictive tests is powerful enough to be used as a basis for treatment [for breast cancer]". You characterise as insensitive the metastatic status of axillary lymph-nodes per se. three nodes are involved, 65% of women decade of surgery, and if more nodes are involved 85% relapse’. Appearance of clinically detectable metastasis is tantamount to death because of the absence of curative regimens for this stage of the disease. Acceptance of a false-positive prediction of fatal outcome in 35% and 15%, respectively, though imprecise, does allow a course of action irretrievably lost if one delays. Such a course is desirable if it is effective and does not exact exorbitant costs from either the true or falsely positive patients. Both these circumstances obtain .for surgical adjuvant chemotherapy of breast cancer, about which you are cautious. The pioneer investigation of Cooper, beginning in 1968, involved the use of cyclophosphamide, methotrexate, fluorouracil, vincristine, and prednisone in intensive courses for nine months postoperatively in 73 women with four or more metastatic axillary nodes.2 At eight years, actuarial calculations show 68% are disease-free, with major therapeutic effects seen in both premenopausal and postmenopausal women. Contrasted with the high and unchanging mortality from breast cancer in patients presenting with regional metastasis,3 this treatment is highly effective. Death in population controls at eight years was 61% among a sample of 21084 American women. Only 9 of Cooper’s women have so far died. In prospective comparative clinical trials, Bonadonna and colleagues have shown that cyclophosphamide, methotrexate, and fluorouracil, given by a less intensive schedule than Cooper’s regimen, nonetheless caused a significant reduction of recurrence in pre-menopausal women with axillary-node metastasis, and significant extension of survival .4 Among those with recurrence, delay in median time to recurrence was equivalent in premenopausal and postmenopausal women. Thus, although in postmenopausal women the curves of recurrence for control and treated patients have converged at four years, evidence of subcurative drug activity, consisting of prolongation of the disease-free interval, is present before then. Nissen-Meyer and colleagues have reported a study of surgical adjuvant chemotherapy with cyclophosphamide alone. At seven years there is significantly longer disease-free interval in patients both with and without detectable axillary metastasis. The effect appears uninfluenced by menopausal status.s Trials of the Cancer and Leukemia Group B, comparing three different regimens of surgical adjuvant combination chemotherapy in women with axillary metastasis, show sharp reduction in anticipated recurrence-rates of premenopausal and postmenopausal women at three years (unpublished). Clinical research into the best regimen for adjuvant chemotherapy of regionally metastatic breast cancer is a high international priority. All who can should participate in the research; tens of thousands of patients who could benefit cannot participate, however. The advocacy of surgery alone, or surgery plus radiotherapy (repeatedly shown to be without survival benefit6) by confining use of adjuvant therapy to prospective trials, as you advise, is to disregard knowledge that can reduce recurrent disease and save lives. These benefits are obtained-often with the very chemotherapy that will be used when clinical metastasis appears-without the spectre of horrors that has been conjured up. Although leukxmogenesis,

If, however,

relapse

one to

within

a

1 Fisher, B., and others. Surg. Gynec. Obst. 1975, 140, 528. 2. Holland, J. F. Israel J. med. Sci. 1977, 13, 829. 3. Axtell, L. M., Cuttler, S. J., Meyers, M. H.: End Results in Cancer report no. 4 (D.H.E.W. publication no. (NIH) 73-272); p. 101. U.S. Government

Printing Office, 1972.

4. Bonadonna, G., and others in Adjuvant Therapy of Cancer Salmon and S. E. Jones). Amsterdam, 1971. 5. Nissen-Meyer, R., and others. Cancer, 1978, 41, 2088. 6 Stjernsward, J. Lancet, 1974, ii, 1285.

(edited by S. E.