Letters to the Editor
Granulocytes in Spontaneous
trophil functions with cirrhosis. Res Med Sci. 1987;5:403-406.
Bacterial Peritonitis Associated with Chronic Liver Disease To The Editor: I have read with interest Leggiadro and Lazar’s article entitled &dquo;Spontaneous Bacterial Peritonitis Due to Neisseria meningitidis Serogroup Z in an Infant with Liver Failure&dquo; (Clinical Pediatr. 1991;30: 350-352). For the pathogenesis of spontaneous bacterial peritonitis (SBP) in chronic liver diseases, the authors mentioned complement deficiency, but they did not bring up defective neutrophil chemotaxis, depressed hexose monophosphate shunt stimulation, decreased bactericidal capacity, and nitroblue tetrazolium reduction~~>2 Some of these granulocyte functions could be corrected by giving zinc/ which we have shown to be decreased in liver tissue in chronic liver disorders.’ In addition, it should be mentioned that granulocyte bone marrow reserve is decreased’ in chronic liver disorders as are the granulocyte-macrophage progenitorS5 and impaired monocyte6 and accessory cell functions.’’ I believe all these factors should also be taken into account in the pathogenesis of SBP. Sinasi Ozsolu, M.D. Professor of Pediatrics and Hematology
Hacettepe University Faculty of Medicine Department of Pediatrics Hematology Unit and Hacettepe Children’s Hospital Ankara, Turkey 1.
Ozsolu S, Akgun N. Defective neutrophil motility. Am J Dis Child. 1985; 139:10.
2.
190
Ozsolu S, Akgun N, Yetgin S et al.
Neu-
3.
4.
Turk J
Goksu N, Ozsoylu S. Hepatic and serum level of zinc, copper, and magnesium in childhood cirrhosis. J Pediatr Gastroenterol Nutr. 1986;5:459-462.
Cambiaghi G, Paina S. Defect in bone granulocyte reserve in liver cir-
marrow
rhosis evaluated with etiocholcholnolone. Acta Haematol. 1978; 60:291-295. 5.
Ponassi A, Morra L, Caristo G, et al. Blood granulocyte macrophage progenitor cell concentrations and differentiation in vitro in patients with hepatic cirrhosis. Acta Haematol.
6.
Hassner
1984;72:388-394. A, Kletter Y, Jedvab M, et al. Impaired monocyte function in liver cirrhosis. Lancet. 1979;1:329-330. 7. Rimola A, Soto R, Bory F, et al. Reticuloendothelial system phagocytic activity in cirrhosis and its relation to bacterial infection and prognosis. Hepatology.
1984;4:53-58. The authors reply: We appreciate Dr. Ozsolu’s comments on additional potential host defense mechanisms relevant to spontaneous bacterial peritonitis. In the case of the meningococcus, however, substantial evidence exists to support the unique role of complement-dependent serum bactericidal activity in prevention of disease caused by this pathogen.~1 Bactericidal activity against meningococci is also dependent on a specific antibody response, although the role of this antibody in the opsonophagocytosis of this organism is less clearly defined. Robert J. Leggiadro, M.D. Linda F. Lazar, M.D. University of Tennessee Health Science Center Memphis, Tennessee 1.
Densen P. Infectious disassociated with complement deficiencies. Clin Microbiol Rev. 1991; 4:359-395.
Figueroa JE, eases
The Cost-Benefit Threshold To The Editor: The current climate of managing health-care costs has increased physicians’ awareness of cost-benefit analysis. In the expensive area of caring for very-low-birth-weight infants, a new parameter is introduced below, the cost-benefit threshold, or CBT. The CBT occurs on a variable day after birth when the cost of medical care has compounded to exceed a calculated amount as a function of increasing body weight and the relative worth of a standardized tangible asset. For example, the information provided by Shaffer et all allows an approximate prediction of weight on any subsequent day of life for low-birth-weight infants. Using five days of age as the nadir of weight loss, the lowest weight can be calculated:
WtDay5 = (0.033 BW + 0.83)
x
BW
where BW is the birth weight in kilograms. After five days, the weight on the day of CBT (Day CBT) can be estimated by adding 15 g/kg/day of subsequent linear growth to this lowest weight: Wt Day CBT BW x
WtDay 5 + 0.015 x (Day CBT - 5)
=
Furthermore, the total accumulat-
ing
cost
mated
of
care can
by using
be
approxi-
average cost per for neonatal intensive day (CPD) care. At tertiary-care centers in this region, the cost per day is approximately $1,500 for ventilated premature infants. Similarly, Hack and Fanaroff found that extremely-low-birthweight survivors from 1982 to 1985 had mean hospital stays of 137
Downloaded from cpj.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 17, 2015
an
at a mean CPD of $158,800, $1,160 per day, which approximates $1,500 per day when ad-
days, or
justed for inflation. Eventually, on the day of CBT, the total accumulating be
(CPD
cost
equal
to
the
x
Day CBT)
will
product:
WtDay CBT 2.2 lb/kg x 16 oz/lb x 1.1 oz troy/oz avoirdupois x POG where POG represents the price of gold in dollars per troy ounce. SubX
stituting for WtDay CBT, one can simplify the equation and solve for the day of CBT thus: Day CBT
=
POGxBWx(l.3xBWx29) CPD - (0.58 + POG + BW)
for a 1.0 kg-newCPD of $1,500 and an assumed POG of $350 per troy ounce, the day of CBT would be
As
an
born,
example,
at a
day eight. Physicians who care for very-low birth-weight infants might calculate the CBT day for each newborn, using the birth weight, the POG, and a $1,500 cost per day (or the average cost per day at their local neonatal intensive CBT
care
unit). The
golden anniversary day for very-low-birth-weight infants: It is the day when the baby is, in fact, worth his weight in gold! represents
a
Albert L. Mehl, M.D. Colorado Permanente Medical Group Boulder, Colorado 1.
Shaffer S, Quimiro C, Anderson J, et al. Postnatal weight changes in low birth weight infants. Pediatrics. 1987;79:702-
705. 2.
Hack M, Fanaroff AA. Changes in the delivery room care of the extremely small infant. NEnglJ Med, 1986;314:660-664.
tant limitations to their findings. Although they show that both direct and diaper urine specimens yield similar results when testing is done via urine dipstick for blood, protein, and glucose determinations, as well as microscopic examination for RBCs, they also state that no significant differences were found when looking at WBCs, casts, and epithelial cells. In each of the 17 direct speci-
studied, there were between and four WBCs and zero and two casts noted. In addition, there were few to no epithelial cells prese nt in each specimen. By not presenting any patients who had significant amounts of white cells or casts present on direct specimen, we do not know if the diaper specimen results would be as accurate as those provided by direct specimens in patients with positive findings. The authors do state that there were no false-positives (after controlling for artifacts) but cannot comment on false-negative results. As such, their findings regarding the usefulness of diaper specimens for microscopic examination are limited. Another limitation which was not discussed is that the diaper mens
zero
specimens were all collected within 10 minutes. This may not reflect the time when the average practitioner is likely to obtain a urine sample from a diaper. It is possible that a longer time period before obtaining urine will give differing results. Further study is needed to answer
this
Miele,
M.D.
Department of Pediatrics University of Rochester School of Medicine and Dentistry Strong Memorial Hospital
Urinalysis: Direct Vs Diaper Collection
Rochester, New York
To The Editor: In the article by Beeram and Dhanireddy,’ the authors fail to mention and discuss two impor-
1.
Beeram MR, Dhanireddy R. Urinalysis: direct versus diaper collection. Clinical Pediatr. 1991;30:278-280.
The authors
adult volunteers
reply: We appreciate
was
divided into
three
aliquots of 12 mL each. One aliquot (12 mL) of urine was poured on each of the three diawere left open and servo-controlled at 34°C under the radiant warmer (Air Shields Model UM 780 IN, Air Shields Inc., Hatboro, PA). The diapers were removed from under the
pers that
warmer,
one
at a
time,
at zero,
30,
and 60 minutes, and urine re-collected for analysis. Room temperature was between 22°C and 25°C, and relative humidity was between 35% and 44% during radiant warmer experiments. Electro-
lytes, creatinine, urea, osmolality, pH, and specific gravity were meadescribed before.’ Microexamination was not done on scopic these samples. The data were compared by analysis of variance for sured
question. Niel F.
the helpful comments of Dr. Miele. We agree with Dr. Miele regarding the limitation of microscopic examination findings of diaper urine as presented in our paper. As there were no urine specimens that contained a significant number of casts, leukocytes, and epithelial cells, we cannot comment on falsenegative results in urine collected from a diaper for these findings. Regarding the value of diaper urine collected later than 10 minutes, we evaluated the effect of urine remaining in the diaper under a radiant warmer for up to 60 minutes. Six separate sets of experiments using three diapers (Premature Infant Pampers; Procter and Gamble, Cincinnati, OH) each were carried out. For each set, 36 mL of single-void urine from
as
repeated measures. All urine samples were found, to be negative for proMultistix, by tein, blood, glucose, ketones, bilirubin, urobilinogen, and nitrites. Urine weight decreased by 11.7% ± 1.36% and 23.4% ± 2.22% at 30 and 60 minutes, respectively, under the
Downloaded from cpj.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 17, 2015
191
Granulocytes in Spontaneous
trophil functions with cirrhosis. Res Med Sci. 1987;5:403-406.
Bacterial Peritonitis Associated with Chronic Liver Disease To The Editor: I have read with interest Leggiadro and Lazar’s article entitled &dquo;Spontaneous Bacterial Peritonitis Due to Neisseria meningitidis Serogroup Z in an Infant with Liver Failure&dquo; (Clinical Pediatr. 1991;30: 350-352). For the pathogenesis of spontaneous bacterial peritonitis (SBP) in chronic liver diseases, the authors mentioned complement deficiency, but they did not bring up defective neutrophil chemotaxis, depressed hexose monophosphate shunt stimulation, decreased bactericidal capacity, and nitroblue tetrazolium reduction~~>2 Some of these granulocyte functions could be corrected by giving zinc/ which we have shown to be decreased in liver tissue in chronic liver disorders.’ In addition, it should be mentioned that granulocyte bone marrow reserve is decreased’ in chronic liver disorders as are the granulocyte-macrophage progenitorS5 and impaired monocyte6 and accessory cell functions.’’ I believe all these factors should also be taken into account in the pathogenesis of SBP. Sinasi Ozsolu, M.D. Professor of Pediatrics and Hematology
Hacettepe University Faculty of Medicine Department of Pediatrics Hematology Unit and Hacettepe Children’s Hospital Ankara, Turkey 1.
Ozsolu S, Akgun N. Defective neutrophil motility. Am J Dis Child. 1985; 139:10.
2.
190
Ozsolu S, Akgun N, Yetgin S et al.
Neu-
3.
4.
Turk J
Goksu N, Ozsoylu S. Hepatic and serum level of zinc, copper, and magnesium in childhood cirrhosis. J Pediatr Gastroenterol Nutr. 1986;5:459-462.
Cambiaghi G, Paina S. Defect in bone granulocyte reserve in liver cir-
marrow
rhosis evaluated with etiocholcholnolone. Acta Haematol. 1978; 60:291-295. 5.
Ponassi A, Morra L, Caristo G, et al. Blood granulocyte macrophage progenitor cell concentrations and differentiation in vitro in patients with hepatic cirrhosis. Acta Haematol.
6.
Hassner
1984;72:388-394. A, Kletter Y, Jedvab M, et al. Impaired monocyte function in liver cirrhosis. Lancet. 1979;1:329-330. 7. Rimola A, Soto R, Bory F, et al. Reticuloendothelial system phagocytic activity in cirrhosis and its relation to bacterial infection and prognosis. Hepatology.
1984;4:53-58. The authors reply: We appreciate Dr. Ozsolu’s comments on additional potential host defense mechanisms relevant to spontaneous bacterial peritonitis. In the case of the meningococcus, however, substantial evidence exists to support the unique role of complement-dependent serum bactericidal activity in prevention of disease caused by this pathogen.~1 Bactericidal activity against meningococci is also dependent on a specific antibody response, although the role of this antibody in the opsonophagocytosis of this organism is less clearly defined. Robert J. Leggiadro, M.D. Linda F. Lazar, M.D. University of Tennessee Health Science Center Memphis, Tennessee 1.
Densen P. Infectious disassociated with complement deficiencies. Clin Microbiol Rev. 1991; 4:359-395.
Figueroa JE, eases
The Cost-Benefit Threshold To The Editor: The current climate of managing health-care costs has increased physicians’ awareness of cost-benefit analysis. In the expensive area of caring for very-low-birth-weight infants, a new parameter is introduced below, the cost-benefit threshold, or CBT. The CBT occurs on a variable day after birth when the cost of medical care has compounded to exceed a calculated amount as a function of increasing body weight and the relative worth of a standardized tangible asset. For example, the information provided by Shaffer et all allows an approximate prediction of weight on any subsequent day of life for low-birth-weight infants. Using five days of age as the nadir of weight loss, the lowest weight can be calculated:
WtDay5 = (0.033 BW + 0.83)
x
BW
where BW is the birth weight in kilograms. After five days, the weight on the day of CBT (Day CBT) can be estimated by adding 15 g/kg/day of subsequent linear growth to this lowest weight: Wt Day CBT BW x
WtDay 5 + 0.015 x (Day CBT - 5)
=
Furthermore, the total accumulat-
ing
cost
mated
of
care can
by using
be
approxi-
average cost per for neonatal intensive day (CPD) care. At tertiary-care centers in this region, the cost per day is approximately $1,500 for ventilated premature infants. Similarly, Hack and Fanaroff found that extremely-low-birthweight survivors from 1982 to 1985 had mean hospital stays of 137
Downloaded from cpj.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 17, 2015
an
at a mean CPD of $158,800, $1,160 per day, which approximates $1,500 per day when ad-
days, or
justed for inflation. Eventually, on the day of CBT, the total accumulating be
(CPD
cost
equal
to
the
x
Day CBT)
will
product:
WtDay CBT 2.2 lb/kg x 16 oz/lb x 1.1 oz troy/oz avoirdupois x POG where POG represents the price of gold in dollars per troy ounce. SubX
stituting for WtDay CBT, one can simplify the equation and solve for the day of CBT thus: Day CBT
=
POGxBWx(l.3xBWx29) CPD - (0.58 + POG + BW)
for a 1.0 kg-newCPD of $1,500 and an assumed POG of $350 per troy ounce, the day of CBT would be
As
an
born,
example,
at a
day eight. Physicians who care for very-low birth-weight infants might calculate the CBT day for each newborn, using the birth weight, the POG, and a $1,500 cost per day (or the average cost per day at their local neonatal intensive CBT
care
unit). The
golden anniversary day for very-low-birth-weight infants: It is the day when the baby is, in fact, worth his weight in gold! represents
a
Albert L. Mehl, M.D. Colorado Permanente Medical Group Boulder, Colorado 1.
Shaffer S, Quimiro C, Anderson J, et al. Postnatal weight changes in low birth weight infants. Pediatrics. 1987;79:702-
705. 2.
Hack M, Fanaroff AA. Changes in the delivery room care of the extremely small infant. NEnglJ Med, 1986;314:660-664.
tant limitations to their findings. Although they show that both direct and diaper urine specimens yield similar results when testing is done via urine dipstick for blood, protein, and glucose determinations, as well as microscopic examination for RBCs, they also state that no significant differences were found when looking at WBCs, casts, and epithelial cells. In each of the 17 direct speci-
studied, there were between and four WBCs and zero and two casts noted. In addition, there were few to no epithelial cells prese nt in each specimen. By not presenting any patients who had significant amounts of white cells or casts present on direct specimen, we do not know if the diaper specimen results would be as accurate as those provided by direct specimens in patients with positive findings. The authors do state that there were no false-positives (after controlling for artifacts) but cannot comment on false-negative results. As such, their findings regarding the usefulness of diaper specimens for microscopic examination are limited. Another limitation which was not discussed is that the diaper mens
zero
specimens were all collected within 10 minutes. This may not reflect the time when the average practitioner is likely to obtain a urine sample from a diaper. It is possible that a longer time period before obtaining urine will give differing results. Further study is needed to answer
this
Miele,
M.D.
Department of Pediatrics University of Rochester School of Medicine and Dentistry Strong Memorial Hospital
Urinalysis: Direct Vs Diaper Collection
Rochester, New York
To The Editor: In the article by Beeram and Dhanireddy,’ the authors fail to mention and discuss two impor-
1.
Beeram MR, Dhanireddy R. Urinalysis: direct versus diaper collection. Clinical Pediatr. 1991;30:278-280.
The authors
adult volunteers
reply: We appreciate
was
divided into
three
aliquots of 12 mL each. One aliquot (12 mL) of urine was poured on each of the three diawere left open and servo-controlled at 34°C under the radiant warmer (Air Shields Model UM 780 IN, Air Shields Inc., Hatboro, PA). The diapers were removed from under the
pers that
warmer,
one
at a
time,
at zero,
30,
and 60 minutes, and urine re-collected for analysis. Room temperature was between 22°C and 25°C, and relative humidity was between 35% and 44% during radiant warmer experiments. Electro-
lytes, creatinine, urea, osmolality, pH, and specific gravity were meadescribed before.’ Microexamination was not done on scopic these samples. The data were compared by analysis of variance for sured
question. Niel F.
the helpful comments of Dr. Miele. We agree with Dr. Miele regarding the limitation of microscopic examination findings of diaper urine as presented in our paper. As there were no urine specimens that contained a significant number of casts, leukocytes, and epithelial cells, we cannot comment on falsenegative results in urine collected from a diaper for these findings. Regarding the value of diaper urine collected later than 10 minutes, we evaluated the effect of urine remaining in the diaper under a radiant warmer for up to 60 minutes. Six separate sets of experiments using three diapers (Premature Infant Pampers; Procter and Gamble, Cincinnati, OH) each were carried out. For each set, 36 mL of single-void urine from
as
repeated measures. All urine samples were found, to be negative for proMultistix, by tein, blood, glucose, ketones, bilirubin, urobilinogen, and nitrites. Urine weight decreased by 11.7% ± 1.36% and 23.4% ± 2.22% at 30 and 60 minutes, respectively, under the
Downloaded from cpj.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 17, 2015
191
