incidence of out-of-hospital death from shunt failure?” That
Hart, MS, MD, FAAP
they observed no out-of-hospital deaths among their
meningomyelocele patients over a 12-year period is notable.5
Did the availability of current, baseline surveillance imaging
expedite the evaluation of subsequent, symptomatic
episodes of CSF shunt failure? The authors, all pediatricians,
did not consider this qualitative and distinctly neurosurgical
perspective. Did the aggressive treatment of asymptomatic
shunt failure reduce comorbidity from syringomyelia?
Syringomyelia is prevalent among patients with
meningomyelocele and is often asymptomatic, but it can
progress unpredictably to cause scoliosis and other neuro-
logical disabilities. Effective shunt treatment of hydro-
cephalus may minimize the risk of symptomatic progres-
sion of syringomyelia.6
The conclusion of this report—that surveillance CT scan-
ning is neither medically beneficial nor cost-effective—may
be true, but a randomized, controlled trial that considers a
more complete range of potential benefits is needed to con-
struct an evidence-based pathway for clinical management.
References
1. Fernell E, et al. Acta Paediatr. 1998;87:392-396.
2. Bondurant CP, et al. Pediatr Neurosurg. 1995;23:254-258.
3. Piatt JH, et al. Pediatr Neurosurg. 1993;19:233-241.
4. Drake JM, et al. Neurosurgery. 1998;43:294-303.
5. Iskandar BJ, et al. Pediatr Neurosurg. 1998;28:173-176.
6. La Marca F, et al. Pediatr Neurosurg. 1997;26:57-67.
GASTROENTEROLOGY AND NUTRITION
Plasma Nitrate May Be
a Marker for Infectious
Diarrhea
Source: Charmandari E, Meadows N, Patel M, et al. Plasma
nitrate concentrations in children with infectious and non-
infectious diarrhea. J Pediatr Gastroenterol Nutr. 2001;32:423-
427.
T
hese authors from the Royal London School of Medi-
cine studied plasma nitrate levels in 3 groups of
patients: those with acute infectious gastroenteritis
(14); those with non-infectious diarrhea (13); and healthy
controls (14). The investigators theorized that patients with
infectious diarrhea might have higher levels of plasma nitrate
concentrations than those with non-infectious diarrhea or
controls. Their data indicate that children with infectious
diarrhea had significantly higher (P<.0003) plasma nitrate
levels than those children with non-infectious diarrhea and
controls. This preliminary study did not include a sufficient
number of patients to establish an upper limit of normal
“cut-off” value for plasma nitrate concentration since the
range in infectious diarrhea was fairly large.
18
Commentary by Michael H.
Pediatric Gastroenterology, Carilion Roanoke Community Hospital, Roanoke, VA
We are becoming increasingly aware of the importance of
nitric oxide (NO) as a mediator of both physiologic and path-
ologic responses. Bacterial lipopolysaccharides and lipotei-
choic acids stimulate inducible NO synthase which, in turn,
results in increased plasma and urinary NO concentrations.1,2
NO levels appear to correlate with host response to infection,
as well as improved clinical outcome in one study of children
infected with falciparum malaria.1,3,4 Overproduction of NO
appears to play an important role in the pathogenesis of
acute and chronic inflammation. One of the above authors
has previously shown that plasma and urinary nitrate con-
centrations are elevated in infectious diarrhea.5 Further-
more, previous studies have shown that plasma nitrate is
elevated in inflammatory bowel disease (IBD) when com-
pared to control patients;6 however, bacterial and viral infec-
tions resulted in even higher elevated plasma and urinary
nitrate levels than IBD or controls. Plasma and urinary nitrate
levels are dependent on renal function and dietary nitrogen
intake during the infectious process, which may account for
some of the observed variability seen in the patients with
infectious diarrhea in this study. If validated with larger num-
bers of patients, this technique could provide a rapid and
potentially sensitive and specific method for distinguishing
infectious from non-infectious causes of diarrhea, perhaps
within minutes after being performed. Unfortunately, this
technique does not appear to differentiate bacterial from
viral causes of gastroenteritis. It may well be that the deter-
mination of urinary nitrate concentration is as useful as
plasma nitrate concentration; however, future studies are
necessary to examine this question.
Editors’ Note
There seems to be lots of movement when it comes to
identifying new serologic, urinary, and fecal markers for clas-
sifying the nature of diarrhea in children. Two months ago
(see AAP Grand Rounds, November 2001;6:52-53), we learned
that fecal calprotectin may help to differentiate the diarrhea
seen in inflammatory bowel disease from other etiologies.
Now we read that plasma and urinary nitrate levels may be
useful in determining whether or not the diarrhea is infec-
tious. These are only pilot studies and, therefore, we need to
follow future runs of these tests to learn their sensitivity,
specificity, positive and negative predictive values, and cost-
effectiveness.
References
1. Anstey NM, et al. J Exp Med. 1996;184:557-567.
2. Evans TG, et al. J Immunol. 1993;151:907-915.
3. Nicholson S, et al. J Exp Med. 1996;183:2293-2302.
4. MacMicking JD, et al. Proc Natl Acad Sci USA. 1997;94:5243-
4248.
5. Dykhuizen RS, et al. J Infect. 1995;31:73-75.
6. Dykhuizen RS, et al. Gut. 1996;39:393-395.
AAP Grand Rounds