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I appreciate the chance to clarify what may be a misconception of Dr Kepfer and also others who had read my recent article. The American Academy of Pediatrics Committee on Nutrition recommends that glucose electrolyte solutions be used for rehydration and maintenance therapy for children with acute diarrhea. One such solution is the oral rehydration salt (ORS) solution recommended by the World Health Organization and the United Nations International Children's Emergency Fund, but this solution is not readily available in the United States, as Dr Kepfer notes. However, as mentioned in the introduction to the paper, a number of successful clinical trials of other similar glucose electrolyte solutions have been reported in the United States.

Incidence and Risk Factors for Cholestasis in Neonates Receiving Total Parenteral Nutrition: 1995-98

In Reply.— The findings of Ms Simpson and Drs McIntyre and Ste-Marie are very interesting and raise some intriguing questions. What was the outcome of therapy in these children? Were there differences in outcome related to the therapy used? Their findings also raise the question of whether more optimal therapy would reduce admissions from their Emergency Room or return visits from children sent home. Such data would make an even stronger case for the need to improve case management practices.

Severe retardation of linear growth occurs in a minority of children with Crohn's disease. It appears to be associated with increased disease activity and decreased caloric intake. Why some children are affected and others are not is unknown, but some degree of growth retardation is probably more prevalent than is generally appreciated. The use of somatomedin-C levels may be of some future value in predicting which children will be affected. Growth failure is often difficult to treat and requires vigorous medical and nutritional support. No current treatment is without attendant problems. Proper and frequent assessment of growth and development will help ensure intervention while growth potential still exists in these children. Large cooperative studies are needed to compare the effects of various treatment plans on the growth velocity and ultimate stature of children with Crohn's disease-related growth retardation.

Serum electrolytes were measured for persons treated for diarrhoea at home with prepackaged or locally available sugar and salt oral rehydration therapy (ORT) solutions and for persons with diarrhoea who received no ORT but were treated according to local customs. No detrimental effect was found for persons treated with ORT at home; no significant difference was found in the frequency at which members of the groups had hypernatraemia. The rates of hyponatraemia and hypokalaemia were significantly lower for persons who took estimated appropriate volumes of ORT than for those who took less than appropriate volumes or for persons treated according to local customs without ORT. These laboratory results indicate that ORT administered in rural homes in Bangladesh was safe and effective under the conditions of our study.As part of an oral rehydration therapy (ORT) field trial, the serum electrolytes of 3 groups with diarrhea were analyzed: 1) persons receiving premixed packet fluids, 2) those receiving locally available salt (labon) and sugar (gur) fluids, and 3) those receiving no ORT intervention and treated according to local custom. Village workers provided instruction and supervision in the preparation of ORT during bimonthly home visits. Questionnaires and serum electrolyte measurements were available from 81 persons in the packet villages and 75 persons from the labon-gur villages. 5 persons treated with packet ORT (6%) and 3 persons treated with labon-gur ORT (4%) had electrolyte abnormalities, but all of them were taking less than appropriate volumes of ORT. In addition, serum electrolytes were evaluated in 489 persons admitted to a medical center after home treatment for diarrhea. No cases who took an appropriate volume of either type of ORT had hyponatremia or hypokalemia. There was no indication that electrolyte abnormalities varied by season or pathogen. Although the close supervision given to study participants and small size limit extrapolation of these results, the study suggests that ORT can be made and safely administered by villagers and that ORT administered at home may be a beneficial effect in preventing hyponatremia and hypokalemia.

Yersinia enterocolitica has been sought in stool and blood culture specimens by the Wisconsin State Laboratory of Hygiene (SLH) since 1973. Clinical information on symptoms, duration of illness, and use of antibiotics for 41 persons with Y. enterocolitica infections from January 1, 1979, to September 30, 1980, was obtained by telephone interviews. Diarrhea and abdominal pain were the most common symptoms of the ill persons; extraintestinal symptoms were infrequently reported. Ten infected persons (24 percent) had no illness. Review of a 10 percent sample of all stool specimens cultured at the SLH from June 20, 1977, to June 20, 1979, revealed that Salmonella was the most commonly isolated enteric pathogen (15.4 percent) followed by Shigella (2.0 percent) and Y. enterocolitica (0.7 percent). Several different biotypes and serotypes of Y. enterocolitica were associated with illness. Y. enterocolitica isolates were uniformly susceptible to a wide variety of antibiotics, and most isolates were resistant to ampicillin. Epidemiologic studies showed that persons with Y. enterocolitica infections were more likely to live in rural counties than were all persons sending stool samples or those having Salmonella infections; underlying illness was identified as a risk factor for infection.

To obtain information on the attitudes and practices concerning oral rehydration therapy in the United States and Canada, a questionnaire was sent to the chairmen of departments of pediatrics of 142 medical colleges. Some form of oral fluid therapy for treatment of diarrheal dehydration is used by the institutions of all 128 survey respondents. The most commonly used fluids, commercial sugar-electrolyte solutions (89%), clear liquids (78%), and fruit juices (58%) have very different compositions and concentrations of ingredients. Oral therapy is based on a specific written protocol at 30% of the institutions and is used most frequently to treat outpatients with mild dehydration. To determine a uniform and optimal approach to oral fluid treatment for diarrhea, comparative clinical trials are needed to assess which fluid compositions and concentrations are most effective in preventing dehydration and in treating dehydration once it has occurred.

Serum levels of equine-botulism antitoxin to toxin types A, B, and E were measured in four type-A botulism patients who had received equine-botulism antitoxin. High circulating levels capable of neutralizing in excess of 1 X 10(8), 9 X 10(7), and 6 X 10(6) 50% mouse lethal doses of toxin of types A, B, and E, respectively, were detected. There was little depletion of type-A antitoxin even though two of the patients had circulating type-A toxin before treatment. The half-life for antitoxin persistence for one patient was calculated as being 6.5, 7.6, and 5.3 days for antitoxin types A, B, and E, respectively. Antitoxin levels were not proportionate to the amount (range, 2-4 vials) injected and did not appear to be affected by whether the route of administration was iv or im. Peak serum levels of antitoxin were 10-1,000 times higher than amounts needed to neutralize the toxin measured in the serum of these and other patients with botulism.

In the period November 13-18, 1978, seven cases of type A botulism occurred in persons who had eaten in a restaurant in Colorado. The outbreak was recognized when two persons who had independently eaten at the restaurant were hospitalized with an illness compatible with botulism. Surveillance efforts identified five additional cases. Potato salad made at the restaurant and available for service during an 11-day period was epidemiologically incriminated as the vehicle of botulinal toxin transmission (p less than 0.00001). Laboratory studies showed that Clostridium botulinum spores on the surface of potatoes could survive baking in the manner used by the restaurant and that botulinal toxin could be produced in potatoes contaminated with C. botulinum spores.

Eosinophilic gastroenteritis is known to cause gastric outlet obstruction in adults, but has been reported only rarely in infants presenting with pyloric stenosis, a common form of gastric outlet obstruction in children. We describe two infants who presented with classic clinical and radiographic evidence of pyloric stenosis and who were found to have histologic evidence of eosinophilic gastroenteritis on gastric antral biopsies. Their presentation is compared with the clinical and laboratory findings of 47 other infants with pyloric stenosis.

To determine the modes of transmission of cholera in the regency of Pidie, Indonesia, and to consider strategies for its control, we set up a laboratory to identify Vibrio cholerae 01 from patients with severe diarrhea in all government clinics in the regency and questioned culture-positive cases and neighborhood controls about possible exposures to V. cholerae 01. Between 12 July and 15 August 1982, 63 of 138 suspected cholera cases were confirmed by the laboratory; 53 of these patients were seen and followed up. We were unable to identify a single, indisputable mode of transmission for cholera which was amenable to immediate control. Nonetheless, a number of factors, including exposure to water from the Tiro-Sigli River and consumption of ice, were associated with disease. Other findings bring into question the value of current practices of chlorinating dugwells and disinfecting homes with Lysol® during a cholera outbreak. The case-control approach to investigating the mode of transmision of cholera has distinct limitations when applied in endemic setting where there may not be a single predominant vehicle of transmission, or where the vehicle such as river water is used by all and is only periodically contaminated.

An invasive strain of Escherichia coli (ONT:NM) was isolated from stool specimens from 7 of 10 ill passengers who developed diarrhea during a 5-day ocean cruise. The ill passengers had shared no common exposures off the ship before or during the cruise. Three of the persons whose stools were cultured were part of a tour group of 219 persons, and a food consumption and health history questionnaire was completed by 190 members (87%) of this tour group. Forty-seven (25%) had had diarrhea during the cruise; other symptoms among those with diarrhea included nausea (72%), abdominal cramps (68%), headache (68%), chills (60%), dizziness (53%), myalgias (43%), subjective fever (36%), and vomiting (26%). The median duration of symptoms was 3 days. Eating at cold buffets on ship and eating potato salad, a buffet food item, were significantly associated with illness. No evidence of secondary spread of illness in household contacts of the ill person was found.

Only ten cases of cholera in US travelers have been reported since the current cholera pandemic began in 1961. No important risk factors were apparent from assessing the age, place of acquisition, duration or mode of travel before infection, or history of cholera vaccination of the travelers who acquired cholera. All of the patients received medical treatment and all recovered; there were no secondary cases. Nine of the ten were infected by Vibrio cholerae 01 El Tor, the strain responsible for the current pandemic. Using the number of US citizens returning to the United States by commercial air carrier from Asia, Africa, and Oceania to estimate the population at risk, we found that the chance of acquiring a reported case of cholera is less than one case per 500,000 returning travelers. ( JAMA 1982;247:2268-2269)

In September and October 1978, after a case of cholera had been discovered in southwestern Louisiana, 10 more Vibrio cholerae O-Group 1 infections were detected in four additional clusters. All 11 infected persons had recently eaten cooked crabs from five widely separated sites in the coastal marsh, and a matched-triplet case-control study showed a significant relation between cholera and eating such crabs (P = 0.007). V. cholerae O1 was isolated from estuarine water, from fresh shrimp, from a leftover cooked crab from a patient's refrigerator, and from sewage in six towns, including three without identified cases. All isolates in Louisiana and an isolate from a single unexplained case in Texas in 1973 were biotype El Tor and serotype inaba; they were hemolytic and of a phage type unique to the United States--suggesting that the organism persisted undetected along the Gulf Coast for at least five years.

To estimate the prevalence of residual paralysis from poliomyelitis in children in one area of rural Bangladesh, a survey of the amount and original cause of lameness was undertaken. The International Center for Diarrhoeal Disease Research, Bangladesh Matlab field area, which has been under demographic surveillance for 13 years, provided the study population of 25,000 children aged 5–14 years. The cause of the lameness identified for a child in the survey was based on criteria obtained from a health history questionnaire and a physical examination performed by a physician. The prevalence rate for residual paralysis of poliomyelitis estimated from the lameness survey was 0.84/1,000 children aged 5–14 years. Since lower extremity paralysis occurs in only about 80% of children with paralytic poliomyelitis, the prevalence rate for all cases of residual paralysis of poliomyelitis was calculated to be 1.05/1,000 children in this age group.

The report by Ho and colleagues1in this issue ofThe Journalprovides disturbing data on the mortality associated with diarrhea in the United States and raises two important issues for consideration. The magnitude of the deaths reported, an average of approximately 500 children (400 of whom are infants) each year, is troubling because effective therapy is widely available to treat acute diarrhea. As the authors reasonably ask, are these preventable deaths? An even more disturbing issue is the greatly increased rate of diarrheal deaths among black children. In considering the magnitude of the deaths and possible interventions, information about the duration of diarrhea, the nature, amount, and duration of therapy used, and the access to and utilization of health facilities is required. Because this study was a retrospective review of mortality surveillance data, only partial information on these factors is available. At least two thirds of the deaths

Measurable long-range effects of moose browsing were found in a boreal-type forest at Isle Royale National Park. Overall forest density decreased while average basal area per tree increased. Total basal area and reproduction density were unaffected. Balsam fir densities were drastically reduced, especially in younger age classes. For the most heavily used site, the oldest firs affected are linked to the time of moose arrival on Isle Royale. Mountain ash densities were also drastically reduced. White spruce, unpalatable to moose, increased in density, possibly due to reduced competition from fir. Birch and aspen densities were relatively unaffected. Their stems were mostly out of reach of moose when these animals first arrived. Reduction in fir and mountain ash densities accounts for the reduction in total tree density. Total cover in the shrub layer was unaffected by browsing, but averace stem height decreased. Taxus canadensis has almost disappeared on all browsed sites. Cover of low vascular plants and the ratio of windfalls to standing trees increased. INTRODUCTION The forests of Isle Royale National Park show several striking effects of moose (Alces alces andersoni) browsing. Many shrubs and tree saplings are truncated 1-1.5 m above the ,ground. Balsam fir (Abies balsamea) saplings appear scraggly and misshapen. Older firs exhibit a distinct browse line '2.5-3.5 m above the ground. Moose appear to be a maior ecological factor influencinz the successional development of the forest as well as the characteristics of the climax. The purpose of this study was to determine the extent of this influence. It is one phase of a comDrehensive research proiect aimed at investigating all maior aspects of the ecology of the upland boreal forest type in the park. It has been supnorted by the United States National Park Service and the Michigan Technological University. The effects of moose on a forest were studied by Berzerud and Manuel (1968) in the Noel Paul Drainage of Newfoundland where the forest type closely resembles that of Isle Royale. The emphasis in their study was on evaluating the effects on reproduction of tree sgecies and on determining the moose-carrying capacity of the area. Pimlott (1965) studied the effect of both moose and deer browsing upon major tree species in both Newfoundland and Anticosti Island. STUDY AREA Isle Royale National Park is an archipelago consisting of a large island about 72 km long and 14 km wide at its widest point and surrounded bv approximately 200 small islands. It lies in the western portion of Lake Superior 24 km SE of the Canadian shore and 72 km NW of Michigan's Keweenaw Peninsula. Uptilted layers of basaltic

This book is a collection of articles authored by 67 experts in the field of liver disease and presented at an international conference on extrahepatic biliary atresia in New York in November 1981. As such, it is the first book devoted entirely to a discussion of the cause, evaluation, medical, nutritional and surgical therapy, pathology, and current research of extrahepatic biliary atresia. The strengths of the book include its distinguished author list that numbers many of the preeminent experts in the field (eg, Alagille on liver histopathology, Kasai on the hepatic portoenterostomy, and Starzl on liver transplantation). Some topics are particularly well covered, including the spectrum of diagnostic studies available, surgical interventions and outcomes, and the therapeutic and nutritional aspects of biliary atresia. The section on research updates was a thoughtful addition but perhaps a bit narrow in scope. The reference lists have been updated in some cases to include