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which data were negativeStatistical comparison with Crombie and colleagues’ study is not possible but there is little doubt that the Dundee children were also better nourished. So far three studies have described a sample sub-set with a poor diet, that responds to supplementation (ref 4, Schoenthaler et al, and this study). In other studies, reporting beneficial responses, the sample was chosen on the basis of dietary problemsor for social disadvantage such that nutritional problems might have existed.3 Thus the picture that is emerging is a subset of children, consuming a poor diet, who benefit from vitamin/mineral supplementation. We thank

localised and the timing, in May to July, need to be elucidated. Are these patterns connected with bird behaviour or with other local environmental factors? Case-control studies are underway. Department of Microbiology, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK

S. J.

Gateshead Health Authority

A. O. SOBO

Civic Centre, Gateshead

K. RUSSEL

Public Health Laboratory, Newcastle

N. F. LIGHTFOOT

HUDSON

Cyanamid-Benelux for its support.

Department of Psychology, University College, Swansea SA2 8PP, UK

D. BENTON

Department of Paediatrics, University Catholique de Louvain, Brussels, Belgium

J.-P. BUTS

1. Benton D, Roberts G. Effect of vitamin and mineral supplementation on intelligence of a sample of schoolchildren. Lancet 1988; i: 140-43. 2. Colgan M, Colgan L. Do nutrient supplements and dietary changes affect learning and emotional reactions of children with learning difficulties? a controlled series of 16 cases. Nutr Health 1984; 3: 69-77. 3. Boggs UR, Scheaf A, Santoro D, Ritzman R. The effects of nutrient supplements on the biological and psychological characteristics of low IQ preschool children.

J Orthomol Psychiat 1985; 14: 97-127. 4. Schoenthaler S. Malnutrition and maladaptive behavior: two correlational analyses and a double-blind placebo-controlled challenge in five states. In: Essman WB ed. Nutrients and brain function. Karger: Basel 1987. 5. Nelson M, Naismith DJ, Burley V, Gatenby S, Geddes N. Nutrient intake vitamin/mineral supplementation and intelligence in British shoolchildren. Br J Nutr (in press).

as potential source of milk-borne Campylobacter jejuni infection

Jackdaws

SIR,-Since 1981 Campylobacter jejuni has been the most commonly reported cause of acute diarrhoea in the UKl yet only rarely has the source of infection been proved. Few routes by which infection may be transferred from animals to man have been defined, yet campylobacters are widely distributed as commensals in poultry, swine, sheep, cattle, dogs, cats, and wild birds.2 During routine surveillance of campylobacter enteritis in Gateshead a cluster of 58 cases was identified over a 3-month period in a rural part of the district. Most of the cases could remember, in the week before onset of symptoms, drinking cold milk from bottles whose tops had been pecked by birds. Food histories obtained by environmental health officers showed that milk delivered to the doorstep was the only common food in all cases; the cases all lived in a housing development adjacent to open countryside and many had seen members of the crow family, notably magpies, pecking milk bottle tops; and cases within the same household had onset dates more than 7 days apart, suggesting a regular source of infection rather than an isolated incident. Environmental health officers and the local newspapers photographed jackdaws attacking milk bottles. Five pecked bottles as well as four intact ones were submitted to the Public Health Laboratory. C jejuni was isolated from two damaged bottles. No undamaged bottle showed any evidence of campylobacter. Two isolates from cases were serotyped--one was Lior non-typable/ Penner serogroup 35 and the other was Lior serogroup 1/Penner non-typable. The only isolate from milk that was available for serogrouping was Lior serogroup 20/Penner non-typable. In previous milkborne outbreaks where C jejuni has been isolated either from cases or milk filters several types have been isolated.3 Wild birds constitute an extensive reservoir of C jejuni.4 Serotypes from the two cases and the one from milk were not identical. The heterogeneity of C jejuni serotypes may be related to the wide distribution of this organism in nature. Further work is in progress to identify species of birds carrying C jejuni and to determine the mode of transmission by birds. C jejuni has been isolated from the beaks and cloacae of jackdaws (N. F. L., personal communication). Also the reasons for the outbreak being

1. Galbraith NS. Campylobacter enteritis. Br Med J 1988; 297: 1219-20. 2. Smibert RM. The genus Campylobacter. Annu Rev Microbiol 1978; 32: 673-705. 3. Robinson DA, Jones DM. Milkborne campylobacter infection. Br Med J 1981; 282: 1374-76. 4. Kapperud G, Rosef O. Avian wildlife reservoir of Campylobacter fetus subsp jejunt, Yersinia spp and Salmonella spp in Norway. Appl Environ Microbiol 1983; 45: 375-80.

hepatitis in children and hepatitis C virus testing

Autoimmune

SIR,-In children autoimmune hepatitis is a severe inflammatory disease of the liver characterised by the presence of high serum titres of non-organ specific autoantibodies. Two main subgroups of the disease have been defined, according to the presence of serum antibodies to actin cable or liver-kidney microsome (anti-LKMj).2,J The cause of this condition is unknown. However, Dr Lenzi and colleagues report (Feb 3, p 258) a high prevalence of hepatitis C virus (HCV) antibody positivity in adults with anti-LKM, - associated chronic liver disease, and suggest that HCV infection might trigger autoimmune responses. In their series,1 of 3 children was also anti-HCV positive. We have tested 55 serum samples, stored at - 20°C, from 33 French and 5 Italian children with autoimmune hepatitis. 16 children were positive for anti-LKM, 18 for anti-actin, and 4 for the newly described liver cytosol (anti-LC1) autoantibody.’’ Serum immunofluorescence autoantibody titres in all children were 100 or more before treatment in all children. None had received any transfusion of blood or blood-derived products. Thirty-six samples were obtained before treatment and nineteen during immunosuppressive therapy with prednisone and azathioprine (fifteen while the child was in clinical and biochemical remission, and four during relapse). Sera were available before and during immunosuppressive treatment in 17 children. Anti-HCV testing was done with a commercially available enzyme-linked immunosorbent assay (Ortho Diagnostic, USA). The table shows the test results. Twenty-three of the thrity-six sera (64%) obtained before treatment were anti-HCV positrive.

Only four of the nineteen sera obtained during immunosuppressive treatment were positive for anti-HCV: two had a borderline positivity and the other two were obtained during relapse. Of the 17i children studied before and during treatment, 1 was negative in both instances, 16 were positive at diagnosis, but 13 were anti-HCV negative while on immunosuppressive therapy. These results show a high frequency of positive anti-HCV tests in children with untreated autoimmune hepatitis. Anti-HCV positivity was not restricted to anti- LKM1 positive patients and was also seen in children with actin cable or LCi autoantibodies. In addition, anti-HCV tests were more often positive in children with ANTI-HCV TESTING IN CHILDREN WITH AUTOIMMUNE HEPATITIS

*2 of 3 patients In relapse † Borderlme posrtrvity

†Borderline positivity

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anti-actin than in children with anti-LKM1. Anti-HCV tests

were

negative in all but 2 children in remission. A positive anti-HCV test in such children may be related to the cause of the disease or may reflect a non-specific occurrence. A positive anti-HCV test may be attributable to actual HCV infection, as Lenzi et al suggest. Alternatively, defective immune regulation with non-specific polyclonal activation of B lymphocytes, which is known to occur in autoimmune hepatitis, may lead to the production of cross-reacting antibodies against a viral or bacterial epitope antigenically related to HCV. In this respect, age could be important for HCV positivity since children with anti-LKM1 are younger and mean age at diagnosis is significantly lower than in anti-actin positive children.3 Moreover, the almost constant negative test results during remission suggests that cautious interpretation of a positive HCV test is needed in a child with hypergammaglobulinaemia since the positivity of the test might be related to serum gammaglobulin concentrations; these are very high in children with autoimmune hepatitis before treatment or during relapse and return to normal during remission on treatment. Virology Laboratory, INSERM U56, and Service of Paediatric Hepatology, Hôpital de Bicêtre, 94275 Le Kremiln-Bicêtre, France Paediatric Clinic and Clinic for Infectious Diseases, IRCCS Policlinico San Matteo,

Pavia, Italy Virology Laboratory, INSERM U56, and Service of Paediatric Hepatology, Hôpital de Bicêtre

ELISABETH DUSSAIX GIUSEPPE MAGGIORE COSTANTINO DE GIACOMO MARIO MONDELLI PASCALE MARTRES FERNANDO ALVAREZ

1. Maggiore G, Bernard O, Hadchouel M, Hadchouel P, Odièvre M, Alagille D. Treatment of autoimmune chronic active hepatitis m childhood. J Pediatr 1984; 104: 839-44. 2. Odièvre M, Maggiore G, Homberg JC, et al. Seroimmunologic classification of chronic hepatitis in 57 children. Hepatology 1983; 3: 407-09. 3 Maggiore G, Bernard O, Homberg JC, et al. Liver disease associated with anti-liver-kidney microsome antibody in children. J Pediatr 1986; 198: 399-401. 4. Martini E, Abuaf N, Cavalli F, Durand V, Johanet C, Homberg JC. Antibody to liver cytosol (anti-LC1) m patients with autoimmune chronic active hepatitis type 2. Hepatology 1988; 8: 1662-66.

Prevention of peritonitis in continuous

ambulatory peritoneal dialysis Sip,—The working party of the British Society of Antimicrobial Chemotherapy has emphasised the importance of aseptic technique in the prevention of infective peritonitis in continuous ambulatory peritoneal dialysis (CAPD),’ but little has been published on the value of any specific measure. Two preventive programmes in progress at St Thomas’ unit since 1987 have achieved dramatic reductions in the peritonitis rates (table). All episodes of peritonitis (without exclusion of relapses, of arbitrary and variable definition) were included. The peritonitis rate before this time was equivalent to the rate for other UK units (1 episode per 3-6 patient-months in 1985)..2 The first programme addressed the prevention of Tenckhoff catheter wound infections, which are most commonly caused by Staphylococcus aureus and Pseudomonas aeruginosa.3 This programme, based on stringent aseptic wound care, was begun in 1987 and had achieved a ten-fold reduction in the infection rate by 1989.* Such infection caused by these organisms is an important risk factor for peritonitis, and is attributable to migration of the organisms into the peritoneal cavity along the subcutaneous catheter track.-6 Thus, the peritonitis rates for S aureus and P aerugznosa, which were previously stable, showed a similarly striking fall from 1987 (table). The second programme aimed to minimise contact of the CAPD system with household water, which is an abundant source of microorganisms, principally gram-negative bacilli. Foremost among these are Pseudomonas spp (although P aeruginosa is rarely found).’ From 1988 patients were discouraged from warming bags of dialysate in water and encouraged to wash carefully at a

CAPD PERITONITIS RATES AT ST THOMAS’ HOSPITAL, 1986-89

*p

Autoimmune hepatitis in children and hepatitis C virus testing.

1160 which data were negativeStatistical comparison with Crombie and colleagues’ study is not possible but there is little doubt that the Dundee chil...
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