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Introduction/Background Several studies suggest that oncological surgery induce an acute inflammatory response, and that it may exacerbate certain mechanisms related to tumor growth and eventual dissemination. We propose to investigates whether the administration of Ketorolac (Taradyl)®, a nonsteroidal anti-inflammatory drug, given intraoperatively during surgery for ovarian, tubal, or peritoneal cancer, influences disease free survival (DFS) and Overall survival (OS). Methodology A Retrospective analysis of all the patients operated at Cliniques Universitaires Saint-Luc; Brussel between 2015 and 2017 for ovarian, fallopian tube or peritoneum cancer. All the patient were included from the UCLouvain Network of Gynaecological Oncology (UNGO), an academic network in Belgium for centralisation of the surgery for ovarian cancer patient. Results Of the 90 patients who met the inclusion criteria, 68% received Ketorolac intraoperatively. Only age was statistically different between the two groups (p Conclusion These results suggest that the intraoperative administration of Ketorolac during surgery for ovarian, tubal or peritoneal cancer has a positive effect on the risk of recurrence and median survival. Disclosure Nothing to disclose.

Author(s): St. Louis, Daniel; Iserson, Kenneth V.; Forget, Nicolas | Abstract: Introduction: Although the fascia iliaca compartment block (FICB) seems to be an ideal technique for femoral neck and shaft fractures occurring in resource-poor settings, it has been unclear how effective it is when used by emergency physicians (EP) with little training in the technique, using equipment, medications and methods that differ from those commonly available in developed countries. This series was designed to demonstrate that EPs in a resource-poor setting can provide effective analgesia for femur fractures with anatomic landmark-guided FICBs, clinician-compounded lidocaine-epinephrine (1:100,000), and a standard injection needle.Methods: Over a three-month period, patients ≥12 years old presenting to the emergency department with hip or femur fractures and a Likert visual analogue scale g4 had an EP-administered FICB. EPs used a standard intramuscular needle and a lidocaine-epinephrine solution they compounded at the bedside and located the injection site using only anatomic landmarks. EPs evaluated the patient’s pain level at 30 minutes and at two hours post-FICB. We also reviewed articles since 2016 that describe the FICB.Results: We enrolled a non-consecutive sample of 10 patients in the case series. Five had femoral neck (hip) fractures and five had femoral shaft fractures. All patients had a reduction in their pain levels after the FICB. On average, the block took effect about three minutes after injection. At 30 minutes all patients reported clinically meaningful pain reduction. The analgesic effect of the compounded agent lasted approximately 200 minutes. No adverse effects were reported. No published journal articles about FICB since 2016 were from resource-poor settings, and only one was from a developing country.Conclusion: This series suggests that the FICB is effective even when performed with the minimal materials that are usually available in resource-poor settings. Methods such as this, which use simplified clinical tests and techniques applicable in resource-poor settings, can assist global emergency medicine (EM). We can assist global EM by similarly finding methods to simplify useful clinical tests and techniques that can be used in resource-poor settings.

Objective To describe the epidemiology of Guyana9s road traffic injuries and perform the first geocoding of road traffic injuries in this setting. Methods This was a registry-based retrospective cross-sectional study investigating collisions resulting in serious and fatal injuries. Police reports from two police divisions were used to identify victim, second party (ie, non-victim) and collision characteristics of all serious and fatal collisions between January 2012 and June 2015. Collisions with available location data were geocoded using Geographic Information Systems. Distributions of characteristics were compared for urban and rural areas. Multivariable logistic regression was used to assess variables associated with fatal collisions. Results The study included 751 collisions, resulting in 1002 seriously or fatally injured victims. Fatally injured victims tended to be older, male and either pedestrians or cyclists. Fatal collisions tended to take place in rural areas, occur on weekends and involve speeding. Fifty-three per cent of fatalities occurred due to non-motorised road users being struck by motorised road users, and the most common fatal collision type was between pedestrians and motor vehicles (35%). The distribution of collisions was similar for urban (43.8%) and rural (56.2%) areas. Fatal collisions were more likely to occur in rural settings. Conclusions Road traffic injuries pose a considerable public health burden in Guyana. These results suggest a pattern of high mortality in rural collisions and a disproportionate burden of injuries on vulnerable road users. The spatial distribution of collisions should be considered in order to target interventions and improve road traffic safety.

Perioperative inflammation is now considered not only as a therapeutic target but is also included in new screening strategies, patient stratification, preoperative optimization, especially in cancer, and also in the frail patient at risk of infectious and ischemic complications.

Tetrahydrobiopterin-responsive phenylalanine hydroxylase deficiency in Dutch neonates.Spaapen LJ, Bakker JA, Velter C, Loots W, Rubio-Gonzalbo ME, Forget PP, Dorland L, De Koning TJ, Poll-The BT, Ploos van Amstel HK, Bekhof J, Blau N, Duran M.Department of Biochemical Genetics, Stichting Klinische Genetica Zuid-Oost Nederland, Maastricht. leo.spaapen@gen.unimaas.nlFour neonates with a positive phenylalanine screening test (Phe concentrations between 258 and 1250 micromol/L) were investigated further to differentiate between phenylalanine hydroxylase (PAH) deficiency and variant hyperphenylalaninaemia (HPA) forms. In patients 1 and 2 a tetrahydrobiopterin (BH4) load caused a significant decrease of the plasma Phe levels. A combined phenylalanine/BH4 loading test was performed in patients 2, 3 and 4. In the latter two patients, plasma Phe concentrations completely normalized within 8 h after the BH4 load (20 mg/kg). Basal urinary pterins were normal in all four patients. The activity of dihydropteridine reductase (DHPR) was normal in patients 1, 2 and 3 and 50% of control values in patient 4 (not in the range of DHPR-deficient patients). In patient 3 a subsequent phenylalanine loading test with concomitant analysis of plasma biopterins revealed a normal increase of biopterin, excluding a BH4 biosynthesis defect. Pterins and neurotransmitter metabolites in CSF of patients 1, 3 and 4 were normal. DNA mutations detected in the PAH gene of patients 1-4 were A313T, and L367fsinsC; V190A and R243X; A300S and A403V; R241C and A403V. The results are suggestive for mutant PAH enzymes with decreased affinity for the cofactor BH4.

Changes in pulmonary hyperinflation and bronchial hyperresponsiveness following treatment with lansoprazole in children with cystic fibrosis.Hendriks JJ, Kester AD, Donckerwolcke R, Forget PP, Wouters EF.Department of Paediatrics, University Hospital and University of Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands. jhe@skin.azm.nlSUMMARY. In this prospective open study of 14 children with cystic fibrosis (CF), we evaluated the effect of 1 year adjuvant therapy with lansoprazole, a proton pump inhibitor (PPI), on growth, fecal fat loss, body composition and lung function. Only stable patients with pancreatic insufficiency were included, and their data were compared to those of a large Dutch pediatric normal reference population. During the use of the PPI, mean weight and height did not change significantly, while body mass index improved (P < 0.05). An immediate significant and persistent reduction of fecal acid steatocrit (P < 0.05) was demonstrated. Compared to normal Dutch children, the CF patients showed significantly decreased standard deviation scores (SDS) for total body fat (TBF, -0.966) and fat-free mass (FFM, -1.826). Under lansoprazole, TBF improved significantly (P < 0.05), while mean FFM remained unchanged. A significant improvement in total lung capacity (P < 0.05), residual volume (P = 0.055), and maximal inspiratory mouth pressure (P = 0.002) was also demonstrated. Hyperinflation tended to decrease during the use of a PPI. Daily recordings of peak expiratory flow (PEF) showed a maximal diurnal variability of 28% of recent best PEF and minimal morning PEF of 72% of recent best PEF, confirming that bronchial hyperresponsiveness is increased in CF. We conclude that adjuvant therapy with lansoprazole in young CF patients with persistent fat malabsorption, decreased fat losses and improved total body fat. Lung hyperinflation decreased, which may partly explain the improvement in inspiratory muscle performance. The simultaneous improvements in body composition and lung hyperinflation suggest a relationship between these two parameters. Further research is necessary to confirm such a relationship and to elucidate the mechanisms involved. Copyright 2001 Wiley-Liss, Inc

Acid steatocrit during infancy.Van den Neucker A, Forget P, Veneberg JA, Schutten BJ, van Kreel B.Department of Paediatrics and Chemistry, University Hospital of Maastricht, The Netherlands.The faecal acid steatocrit is an improved steatocrit method for the evaluation of faecal fat. The present study was set up in order to establish reference values during the first year of life. Faecal acid steatocrit values were determined in 58 healthy full term and in 16 healthy prematurely born infants. Very high acid steatocrit results (above 60%) were found in all premature and many formula-fed term infants during the first 6 months of age, thereafter with values below 10%. In 40- to 120-day-old infants acid steatocrit results of human milk-fed infants were significantly lower than those of formula-fed infants (p < 0.01). We conclude that high acid steatocrit results after the age of 6 months are indicative of fat malabsorption, while before this age high values can be due to "physiological steatorrhoea". The acid steatocrit should be useful for the evaluation of milk fat absorption in infants.

Background Intimate partner violence (IPV) is prevalent throughout the world and is a devastating public health problem. Healthcare workers (HCWs) are tasked with treating victims of IPV but may be victims themselves. Guyana is a lower-middle income country in South America. This study sought to determine the knowledge and attitudes of Guyanese HCWs and their perceived barriers to providing care in addition to determining the prevalence of IPV victimization and perpetration among HCWs. Methods HCWs at the only tertiary care hospital in the Guyana completed an anonymous survey that comprised 30 questions relating to IPV. Results The survey was completed by 87.5% of eligible HCWs. Of the respondents, 81.8% were female, 49.9% had ever experienced abuse and 21% admitted to perpetrating violence. Multivariate analysis found that the age groups 31-40 years (OR 2.3, 95% CI 1.1-4.6) and 41-50 years (OR 2.3, 95% CI 1.2-4.7) had higher odds of accepting justification for physical violence, and so did nursing staff (OR 4.3, 95% CI 1.4-13.1). Overall, 29.9% of HCWs accepted justification for physical violence in at least one of the named scenarios. Conclusion This study demonstrates a high prevalence of IPV among HCWs and identifies prevailing attitudes regarding IPV. This knowledge is essential in developing effective, appropriate training programs and identifies a need to address IPV among the healthcare workforce. Language: en

In mice, immunological adaptation of the gut to microbial and nutritional antigens occurs at weaning in parallel with biochemical and morphological maturation. Because oral administration of spermine to neonatal rats has been shown to induce biochemical and morphological maturation, we investigated whether spermine also affects maturation of the mucosal immune system.Swiss mice 7, 12, and 27 days old were given spermine orally (0.5 mumol/g body weight) during 3 days. Intestinal length was measured, and lactase and sucrase activities were determined. The phenotype of intraepithelial and lamina propria lymphocytes was assessed by FACS analysis using markers for CD3, TCR alpha beta, TCR gamma delta, CD4, CD8 alpha, CD8 beta, CD5, CD18, CD54, and CD49d.Similar to what occurs during natural development, spermine treatment of neonatal mice increased intestinal length, decreased lactase activity, and increased sucrase activity. The percentage of intraepithelial lymphocytes expressing TCR alpha beta, CD4, CD5, and CD54, as well as the levels of expression of these antigens, increased after spermine treatment on day 12, similarly to natural maturation. The increase in expression of CD3, TCR gamma delta, CD18, and CD49d did not reach statistical significance. No effect was observed on CD8 expression. The phenotype of lamina propria lymphocytes was not affected. Spermine administration to 7- and 27-day-old mice had no effect on the phenotype of either intraepithelial or lamina propria lymphocytes.Oral spermine administration to neonatal mice induced, in parallel with biochemical maturation, precocious maturation of the murine intestinal immune system and particularly affected differentiation of the intraepithelial lymphocyte population.

Background With the recent growth of fellowships in international emergency medicine, the authors sought to evaluate medical students’ attitudes toward international emergency medicine and to determine the effects these attitudes have on their residency selection. Methods Study design: Cross-sectional survey. Data collection: An anonymous, eight-question online survey was distributed to all members of the American Academy of Emergency Medicine Resident and Student section. This survey was also distributed to fourth-year medical students rotating through the Emergency Department at Los Angeles County and the University of Southern California. Results Ninety-eight surveys were collected, 61 from rotating students and 37 from the AAEM mailing. There were no statistically significant differences in responses between the two groups. Of the respondents, 49.4% of have been exposed to IEM, and 46.9% have participated in international health projects. Ninety-four percent agree that IEM is an exciting career option. Seventy-nine percent said programs with IEM opportunities are more appealing than those without, and 45% said the presence of IEM opportunities would be an important factor in rank list; 53% believe that IEM requires formal public health training, and 63% believe it requires tropical medicine training; 68.3%of respondents speak a language in addition to English. This subset was more likely to have participated in IEM projects previously (p = 0.026) but not more likely to make match choices based on IEM. Conclusions Half of medical students surveyed had prior experience in international health, and most agree that international emergency medicine is an exciting career option. Over two thirds believe that the presence of IEM opportunities will be a factor in their match list decision.

Lipid, nitrogen, water and energy content of a single stool sample in healthy children and children with cystic fibrosis.Van den Neucker AM, Forget PP, van Kreel B.Department of Paediatrics, University Hospital Maastricht, P Debyelaan 25, 6229 HX Maastricht, The Netherlands. AVN@paed.azm.nlTo evaluate the usefulness of "single stool sample" analysis in the investigation of steatorrhoea instead of 72-h stool collection, we examined 57 stool samples of patients with cystic fibrosis (CF) while on pancreatic enzyme therapy and 29 stool samples of healthy children. We compared results of fat, nitrogen, water and energy content. Fat was determined by the method of Van de Kamer et al. and the Acid Steatocrit (AS) method, water by vacuum drying, nitrogen by the Dumas method and energy was obtained using a bomb calorimeter. Results (median) for CF patients and healthy controls were significantly different (P< or =0.0001) for fat respectively: 8.90 and 4.75/100 g wet weight (ww) stool as measured by the method of Van de Kamer et al. and 28.6% and 7.2% by the AS method. Energy results for energy were also significantly (P< or =0.0001) different: 742.96 and 549.32 kJ/100 g ww stool for CF patients and healthy controls respectively. Results of single stool sample water and nitrogen were similar in both groups. These results were comparable to those of a 3-day stool collection, as reported in the literature. CONCLUSION: Results from single stool samples yield clinically useful information concerning fat and energy. Single stool sample analysis is therefore useful for frequent monitoring of faecal fat and energy

Introduction: Academic departments of emergency medicine are becoming increasingly involved in assisting with the development of long-term emergency medicine training programs in low and middle-income countries. This article presents our 10-year experience working with local partners to improve emergency medical care education in Guyana. Methods: The Vanderbilt Department of Emergency Medicine has collaborated with the Georgetown Public Hospital Corporation on the development of Emergency Medicine skills followed by the implementation of an emergency medicine residency training program. Residency development included a needs assessment, proposed curriculum, internal and external partnerships, University of Guyana and Ministry of Health approval, and funding. Results: In our experience, we have found that our successful program initiation was due in large part to the pre-existing interest of several local partners and followed by long-term involvement within the country. As a newer specialty without significant local expertise, resident educational needs mandated a locally present full time EM trained attending to serve as the program director. Both external and internal funding was required to achieve this goal. Local educational efforts were best supplemented by robust distance learning. The program was developed to conform to local academic standards and to train the residents to the level of consultant physicians. Despite the best preparations, future challenges remain. Conclusion: While every program has unique challenges, it is likely many of the issues we havefaced are generalizable to other settings and will be useful to other programs considering or currentlyconducting this type of collaborative project. [West J Emerg Med. 2013;14(5):477–481.]

Incidence and clinical manifestation of cow's milk protein intolerance (CMPI) were studied in 1158 unselected newborn infants followed prospectively from birth to 1 year of age. No food changes were required in 914 infants who were used as healthy controls. When CMPI was suspected (211 infants), diagnostic dietary interventions according to a standard protocol were performed. After exclusion of lactose intolerance, two positive cow's milk elimination/challenge tests were considered diagnostic of CMPI. Two hundred and eleven symptomatic infants were examined for possible CMPI. A large group of 80 infants improved on a lactose reduced formula. In 87/211 infants CMPI was excluded (sick controls). Finally CMPI was proven in 26 infants. The calculated incidence rate for CMPI was 2.8%. The principal symptoms in infants with CMPI were gastrointestinal, dermatological and respiratory in 50%, 31% and 19% respectively. A positive family history for atopy (first or second degree relatives) was more frequent in either CMPI infants (65%), or sick controls (63%) when compared to either healthy controls (35%) or infants improving on a low lactose formula (51%). Differences between patients with CMPI and sick controls were only found for the presence of atopy in at least 2 first degree relatives [(5/26 in CMPI infants and 4/87 in sick controls (P

OBJECTIVES: To assess the collective hearing hazard entailed by occupational noise exposure. METHODS: The Late Audio-Sonometric Index (LASI) is a global score recommended for following up hearing loss in groups of workers exposed to traumatic noise, combining: daily noise exposure level (L(EX,8h) in dB(A)); individual hearing threshold level at 3kHz (HTL (3kHz) in dB); HTL(0)(3)(kHz) targeted at retirement; and 5 (or 10) years age bracket between 50 and 59 years of age. LASI=HTL(0)(3kHz) - HTL (3kHz)+10 log (age - 20) - 10 log (0.23×L(EX,8h) - 17.36). RESULTS: When L(EX,8h) exceeds 80dB(A) and HTL(0)(3kHz) is at 25dB, occasional audiometric surveillance may be recommended for workers exposed to hazardous impulse noise: e.g., should the median and the mean LASI values fall below 20 for men or 23 for women (indicative threshold values). CONCLUSION: This exponential model thus integrates the fact that daily exposure to impulse noise may be more harmful for hearing than eight hours exposure to continuous noise of equivalent energy. Language: en

Department of Pediatrics, University Hospital, Maastricht, The Netherlands.Magnetic resonance cholangiopancreaticography (MRCP) was used to visualize the biliary tract in two children, aged 7 weeks and 10 years, with a choledochal cyst. MRCP was successful in both cases and the findings were confirmed by intraoperative cholangiography.

The objective of this multicentre, randomised, open-label, general practice (GP) study was to evaluate the efficacy and tolerability of cefprozil (Cefzil(trade mark), Bristol-Myers Squibb) compared with that of cefuroxime axetil (Ceftin((R)), Glaxo Wellcome) in the treatment of adult subjects with acute sinusitis. Typical of the GP setting, diagnosis was made based solely on clinical signs and symptoms of acute disease. Sinus radiography was performed post-randomisation. A total of 381 adolescent and adult patients were randomly assigned to 10 days' treatment with either cefprozil, 500mg orally twice daily (n = 191), or cefuroxime axetil, 250mg orally twice daily (n = 190). Based on predefined criteria, treatments were found to be equally effective in terms of proportions of patients in the per-protocol population that were cured, improved or failed (p = 0.20). Similar results were observed when the evaluation was performed on the subset of patients with radiographic evidence of sinusitis and when the evaluation was based on the investigator's judgement. Similar rates of adverse events were observed in the two treatment groups. In summary, cefprozil 500mg twice daily is as well tolerated and as effective as cefuroxime axetil 250mg twice daily for the treatment of adolescent and adult patients with clinical signs and symptoms of acute sinusitis.

Small bowel permeability was investigated in 87 children with recurrent abdominal pain by measuring the 24-h urinary excretion of orally administered 51Cr-EDTA. The mean excretion was 3.64% +/- 1.49% per 24 h. The difference between the mean urinary excretion in children with recurrent abdominal pain and control children (2.51% +/- 0.70%), was significant (p less than 0.01, two sample t-test). The increased small bowel permeability in children with recurrent abdominal pain might indicate an intestinal etiology for the patients' complaints.

Making use of ({sup 51}Cr)EDTA as a permeability marker, we measured intestinal permeability in a group of 20 children with proven cow's milk intolerance (CMI), a group of 17 children with similar complaints where CMI was excluded (sick controls), and a group of 12 control children. ({sup 51}Cr)EDTA test results (mean +/- SD) were 6.85 +/- 3.64%, 3.42 +/- 0.94%, and 2.61 +/- 0.67% in the group with CMI, the sick control, and the control group, respectively. When compared to both control groups, patients with cow's milk intolerance (CMI) showed a significantly increased small bowel permeability. We conclude that the ({sup 51}Cr)EDTA test can be helpful for the diagnosis of cow's milk intolerance.

Over a period of 4 years, 88 infants with cow's milk protein intolerance (CMPI) were followed prospectively in order to evaluate the persistence of CMPI and its relationship between either serum IgE levels or RAST results for cow's milk. After exclusion of lactose intolerance, two positive cow's milk elimination challenge tests were considered diagnostic for CMPI. At the age of 1, 2, 3 and 4 years respectively, 85%, 78%, 49% and 33% of the children still were cow's milk intolerant. Initial serum values of IgE greater than or equal to 10 kU/l indicated a late development of tolerance to cow's milk proteins. At the age of 4 years, 90% of infants with initial IgE levels less than 10 kU/l had become tolerant to cow's milk while this was the case for only 47% of infants with initial IgE levels greater than or equal to 10 kU/l. Initial RAST results for cow's milk bore no obvious relationship to outcome.

In order to investigate the diagnostic value of ultrasound in children with recurrent abdominal pain and to estimate the clinical relevance of rare organic causes of abdominal pain in these patients, we prospectively examined 93 children aged between 5.5 and 12 years by means of abdominal ultrasound. In 3 patients (3.2%) an anatomic abnormality was detected, which could not account for the abdominal pain. We conclude that many organic abnormalities, that could be diagnosed by ultrasound, are clinically irrelevant as a cause of recurrent abdominal pain in children and therefore ultrasound does not significantly contribute to the diagnosis. However, ultrasound can still play a role in the work-up of children with recurrent abdominal pain in avoiding unnecessary radiologic X-ray procedures.

Department of Biochemistry and General Physiology, University of Liege, Belgium.The effect of oral administration of spermine on pancreatic maturation was investigated in the suckling rat. The treatment consisted of 0.3-0.4 mmol spermine kg-1 body weight given orally once a day for 3 days starting at day 11 after birth. Spermine administration does not adversely affect the growth of the pancreas (wet weight, protein and DNA contents remain unchanged). The proliferating cell nuclear antigen (PCNA) index decreases significantly in spermine-treated rats, indicating that spermine slows down the proliferation rate of the organ. The enzymatic activities of trypsin, chymotrypsin and alpha-amylase are increased significantly in the pancreas of spermine-treated rats. The morphology of the organ seems affected as shown by hematoxylin-eosin staining: a cytoplasm indicative of higher synthetic activity is visible after spermine treatment. We conclude that spermine treatment of unweaned rats can induce precocious biochemical and morphological maturation of the exocrine pancreas, pushing the organ forward in the process of differentiation (closer to the adult stage).

Malabsorption of fat is an important gastrointestinal cause of malnutrition and growth retardation in childhood. The gold standard for the evaluation of fat malabsorption is the faecal fat balance method. The acid steatocrit method has recently been introduced as a simple method to evaluate faecal fat. The present study was aimed at evaluating the acid steatocrit in clinical practice. Faecal fat excretion and acid steatocrit results were determined in 42 children, half with and half without fat malabsorption. Acid steatocrit results correlated significantly with both faecal fat excretion (p < 0.01) and faecal fat concentration (p < 0.001). Sensitivity and specificity of the acid steatocrit for the diagnosis of malabsorption were 90% and 100%, respectively. We consider the acid steatocrit method useful for the screening and monitoring of patients with steatorrhoea.

Extreme short bowel syndrome in a full-term neonate--a case report.Heemskerk J, Sie GH, Van den Neucker AM, Forget PP, Heineman E, van Heurn LW.Department of Surgery, Maastricht University Hospital, Maastricht, The Netherlands.Massive small bowel resection often leads to long-term parenteral nutrition. The authors present a term-born, 3-day-old boy with midgut volvulus in whom only 17 cm of small bowel was left after resection. This patient was weaned from parenteral nutrition after 7 months. Temporary parenteral nutrition-associated cholestasis was treated with ursodeoxycholic acid

The steatocrit method has recently been introduced as a simple screening test for steatorrhea. As it seemed likely that separation of fecal homogenate by centrifugation into a lipid phase, a watery phase, and a solid phase would be pH-dependent, we evaluated the effect of fecal acidification on steatocrit results. We also compared classical and acid steatocrit results in healthy children and in patients with cystic fibrosis and studied the relationship between two steatocrit methods and fecal fat content as measured by a reference chemical method. Steatocrit results increased with the degree of fecal acidification, and maximal results were obtained at the lowest fecal pH values. Means and SEM for classical and acid steatocrit values were 1.1 +/- 0.4% (classical) versus 3.8 +/- 1% (acid) in controls (n = 6) and 5.4 +/- 1.9% (classical) versus 26.9 +/- 4.3% (acid) in cystic fibrosis patients (n = 9). The correlations between fecal fat content measured chemically and steatocrit results were 0.18 (p = 0.35) and 0.81 (p < 0.0001) for classical and acid steatocrit, respectively. We conclude that acidification of fecal homogenates leads to a marked improvement in the steatocrit method.

As part of a large, prospective study we investigated the prevalence Helicobacter pylori serum antibodies in children with recurrent abdominal pain (RAP). All patients suffered from recurrent bouts of abdominal pain for at least 6 months and ranged in age from 6 to 12 years. H. pylori antibodies were detected using an enzyme-linked immunosorbent assay. The prevalence of H. pylori antibodies in the RAP group was compared to that of a control group which consisted predominantly of pre-operative children. None of the control group suffered or had suffered from RAP. Antibodies to H. pylori were found in 7 of 82 (8.5%) RAP patients and in 2 of 39 (5.1%) control children. The latter difference is not significant and suggests that RAP is only rarely caused in children by H. pylori infection.

In this study we investigated the presence of gastroesophageal reflux in children with recurrent abdominal pain and its possible relationship to food intolerance-associated duodenal inflammation. Twenty-four-hour intra-esophageal pH monitoring, an endoscopic duodenal biopsy and a small bowel 51Cr-EDTA permeability test were performed in 25 children with recurrent abdominal pain. In 14 cases (56%) the pH monitoring was abnormal, pointing to the presence of pathological gastroesophageal reflux. Treatment of gastroesophageal reflux in the latter patients resulted in resolution or improvement of abdominal pain in 10 cases (71%). Gastroesophageal reflux did not appear to be associated with either intestinal permeability to 51Cr-EDTA or duodenal biopsy findings. We conclude that pathological gastroesophageal reflex is a frequent finding in children with recurrent abdominal pain, that it is unrelated to duodenal inflammation and that there might be a causal relationship between pathological gastroesophageal reflux and recurrent abdominal pain in children.

Thirty nine children with recurrent abdominal pain aged between 5.5 and 12 years, underwent endoscopic duodenal biopsy to find out if there were any duodenal inflammatory changes, and if there was a relationship between duodenal inflammation and intestinal permeability to 51Cr-EDTA. Duodenal inflammation was graded by the duodenitis scale of Whitehead et al (grade 0, 1, 2, and 3). In 13 out of 39 patients (33%) definite signs of inflammation were found (grade 2 and 3). Intestinal permeability to 51Cr-EDTA in patients with duodenitis (grade 1, 2, and 3) was significantly higher (4.42 (1.73)%) than in patients with normal (grade 0) duodenal biopsy appearances (3.3 (0.9)%). A significant association was found between duodenal inflammation and abnormal intestinal permeability. Our results give further evidence that there is an intestinal origin of these patients' complaints.

A 7-year-old white girl presented with recurrent abdominal pain because of gastroesophageal reflux. At endoscopy, we found intestinal lymphangiectasia in the duodenal biopsy. There were no physical signs, nor any laboratory evidence of enteric protein loss.

Objectives: The objectives of this retrospective study were to evaluate long-term growth of children with CHD and to look for possible relationships between postsurgical catch-up growth and both severity of preoperative growth failure and operation age.

Influence of type of milk and age on fecal fat as measured by the acid steatocrit in infants. 513

NO production catalyzed by INOS (inducible NO synthase) is thought to take place mainly in macrophages after activation by inflammatory mediators. In the body NO is oxidized to nitrite and nitrate which is excreted in the urine. The concentration of inflammatory mediators in small bowel biopsy specimens in coeliac disease is increased. The latter could induce increase NO production by stimulation of intestinal macrophage INOS, resulting in high levels of urinary NO oxidation products, nitrite and nitrate (NOx). The aim of the present study was to evaluate the urinary NOx/creatinine ratios in children with active coeliac disease (n=12), in healthy control children (n=11) and in sick control children (n=18). The griess reagent method was used for the measurement of urinary NOx. Mean and standard deviation for the NOx/creatinine ratios in coeliac disease patients was 2,01 ± 1,37 (range 0,57-5,11). These values were 0,11 ± 0,07 (range 0,03-0,25) for the healthy control children and 0,20 ± 0,20 (range 0,03-0,71) for the sick control patients. Values for coeliac disease patients were significantly different from those of both healthy controls (p

Random fecal chymotrypsin activity and fecal alpha 1-antitrypsin (FA-1-AT) concentrations were determined in 11 children with cystic fibrosis, 5 children with Crohn's disease, 9 children with chronic aspecific diarrhea, 85 children with acute gastroenteritis, and 54 control children. Cystic fibrosis patients showed only very low fecal chymotrypsin values that did not overlap with values obtained in patients with either acute or chronic diarrhea. When compared with our control group, a significant increase of FA-1-AT concentrations was found only in children with Crohn's disease. Normal values were found in all patients with either chronic aspecific diarrhea or cystic fibrosis, while 12 of 85 children with acute gastroenteritis showed FA-1-AT concentrations above the 95th percentile of control children. We conclude that diarrhea (either acute or chronic) does not significantly decrease the clinical usefulness of fecal chymotrypsin activity measurements in the diagnosis of pancreatic insufficiency, while acute (gastroenteritis) but not chronic (chronic aspecific diarrhea, cystic fibrosis) diarrhea can give rise to protein losing and FA-1-AT concentrations similar to those found in Crohn's disease.

The lactulose-rhamnose intestinal permeability test was performed in 10 cystic fibrosis (CF) children. Urine was collected for 5 h after oral intake of the test solution. A single thin-layer chromatography followed by densitometry was used for the measurement of lactulose and rhamnose concentrations in the urine specimens. The excretion of each molecule was expressed as the percentage of the orally administered dose excreted and the lactulose-rhamnose ratio was the ratio of the percentage quantities of each probe molecule excreted. The mean lactulose-rhamnose excretion ratio in CF patients and controls was 0.16 and 0.038, respectively (p less than 0.001). The mean 5-h lactulose excretion was 2% and 0.28% in CF patients and control subjects, respectively (p less than 0.001). The mean 5-h rhamnose excretion was 12.8% and 7.6% in CF patients and control subjects (p less than 0.05). We conclude that CF patients have an increased intestinal permeability to lactulose and rhamnose. Further studies are needed in order to elucidate the mechanisms involved as well as the eventual nutritional implications.

Fifty-four children who had chronic bronchopulmonary disease (CBPD) were investigated for the incidence of gastroesophageal reflux (GER). An activity score for CBPD and a numerical reflux score using criteria from a pH probe study were established. Results of barium esophagography, endoscopy, and prolonged esophageal pH probe monitoring were abnormal in 67, 78, and 53% of the patients, respectively. A significant relationship was found between the CBPD activity score and the reflux score; this strongly suggests that, in the patients studied, GER was responsible for the bronchopulmonary symptoms. Antireflux therapy resulted in an improvement of the CBPD activity score in all patients who had abnormal reflux scores. The mean CBPD activity score was 4.4 and 1.3 before and after antireflux therapy, respectively (P less than 0.01). Most patients who had normal reflux scores did not improve on antireflux therapy.

In the present study, we aimed to induce precocious intestinal maturation in neonatal rats by the oral administration of polyamines. Groups of 5 rats received either saline, spermidine (10 mumol daily), or spermine (6 mumol daily) orally on the 12th, 13th, and 14th postnatal days. The rats were killed on the 15th postnatal day. After the small bowel was removed, a 1-cm distal ileal segment was removed for histologic examination and the remaining small bowel tissue was homogenized for further biochemical analysis. Polyamine administration was shown to induce structural and biochemical mucosal changes characteristic of postnatal maturation. Lactase, sucrase, and maltase specific activities (micromoles of substrate hydrolyzed per minute per gram of protein) were 80 +/- 10, 10 +/- 3, and 116 +/- 19 for the saline-treated rats; 51 +/- 7, 34 +/- 2, and 315 +/- 37 for the spermidine-treated rats; and 25 +/- 2, 46 +/- 5, and 419 +/- 63 for the spermine-treated rats, respectively. Similar results were obtained with rats, first treated with spermine (6 mumol) on the 7th postnatal day, receiving spermine (6 mumol) daily as described above and killed on the 10th postnatal day. Dose-response experiments performed as reported above in rats whose treatment began on the 12th postnatal day showed that the maturational effects of orally administered spermine are dose-dependent.

Intestinal permeability (IP) to /sup 51/Cr ethylenediamine tetraacetic acid was investigated in 47 children with chronic obstructive respiratory disease (CORD). Endoscopic duodenal biopsies were performed in 22 of these patients. IP was significantly increased in CORD patients when compared to either control children or adults (P less than 0.001). Mean +/- 1 SD were 4.3 +/- 1.71%, 2.5 +/- 0.78%, and 2.3 +/- 0.77% in the three groups, respectively. IP was not related to the presence of atopy. Significant differences in IP results were found between CORD children with abdominal pain (4.5 +/- 1.4%) and both control children and CORD patients without abdominal pain (2.5 +/- 0.78% and 3.2 +/- 1.49%, respectively). A significant correlation was found between small bowel injury on the one hand and IP on the other hand (P less than 0.02). Furthermore, small bowel injury was significantly related to the presence of abdominal pain (P less than 0.05). We speculate that in CORD patients with abdominal pain, a factor exists that causes small bowel injury responsible for both abdominal pain and increased small bowel permeability. Food intolerance could, presumably, play a role in the mucosal damage-linked IP increase found in the subset of CORD patients whomore » complain of abdominal pain.« less

The definition of "insufficient" small bowel lactase activity varies greatly among authors. The present study is aimed at redefining lactase insufficiency by comparing intestinal lactase activity and results of the lactose breath hydrogen test. Primary "insufficient" lactase activity was considered to be present when a child with a normal small bowel histology showed lactose malabsorption as measured by the lactose breath hydrogen test. The lactase activity of 22 "normal" children ranged from 0.77 to 4.57 U/g wet weight, while five children showed primary lactase insufficiency as defined above. Small bowel lactase activity in the latter patients was less than 0.74 U/g wet weight. Sucrase and maltase activities were similar in both groups of patients. We conclude that children with a normal small bowel histology should be considered to have primary lactase insufficiency when small bowel lactase activity is below 0.75 U/g wet weight.

Serum diamine oxidase (DAO) activities were measured in 9 pregnant women and in 33 neonates during the 1st week of life. The radiometric method was used. Very high values were found in the mothers (mean ± SE: 720 ± 143 pmol ml-1 h-1) Neonates showed significantly elevated values (mean ± SE: 178 ± 54 pmol ml-1 h-1) on the 1st postnatal day when compared to the 7th day values (mean ± SE: 27 ± 5.7 pmol ml-1 h-1)·Serial determinations showed a progressive decline from day 1 to day 7 after birth. We suggest the high serum DAO levels in neonates during the first days of life are due to leakage of placental enzyme into the circulation either at birth or during fetal life. Consequently, serum DAO cannot be used as a marker of small bowel functional integrity in the 1 st postnatal week.

Forget, P., Fernandes, J. and Haverkamp Begemann, P. (Department of Paediatrics, Sophia Children's Hospital and Neonatal Unit, Erasmus University, Rotterdam, the Netherlands). Utilization of fat emulsion during total parenteral nutrition in children. Acta Paediatr Scand, 64: 377, 1975.–Tolerance for Intralipid fat emulsion during total parenteral nutrition (PN) was studied in 6 children. The Intralipid dose was monitored by the daily determination of plasma Intralipid levels. Fat removal was investigated at the start of and during the PN period by the intravenous fat tolerance test (IVFTT) and by determining the plasma postheparin lipoprotein lipase (LPL) activity. When the plasma Intralipid levels exceeded a value of 100 mg/100 ml, hyper pre-βT lipoproteinaemia, hypertriglyceridaemia, hypercholesterolemia and hyperphospholipidaemia appeared. During PN most patients showed marked increases of postheparin LPL. Return to normal values occurred after discontinuation of PN. Maximal LPL activities were found to correlate significantly with total daily caloric intake (r=0·95, 0.05

Serum diamine oxidase (DAO) activities were measured in 20 control patients and in 24 patients with gastroenteritis. Results (mean +/- SE) were as follows: 1) control patients (n = 20), 36.2 +/- 5.7 pmol h-1 ml-1; 2) gastroenteritis (acute phase) (n = 11), 31 +/- 4.9 pmol h-1 ml-1; 3) gastroenteritis (healing phase) (n = 21), 18 +/- 1.9 pmol h-1 ml-1. Patients with gastroenteritis in the healing phase had significantly lower DAO values when compared to control patients (p less than 0.001) and to gastroenteritis patients in the acute phase (p less than 0.05). In eight patients where both acute and healing phase values could be measured, a significant decrease between acute and healing phase was found (p less than 0.001). Patients with severe gastroenteritis tended to have lower DAO activity values than patients with moderate gastroenteritis (p = 0.10). Our results support the hypothesis that serum DAO activity is a marker of the total mass of functional enterocytes, the decrease of which during gastroenteritis is reflected in a decrease of serum DAO activity values.

Forget, P. P. F. X., Fernandes, J. and Haverkamp Begemann, P. (Department of Paediatrics, Sophia Children's Hospital and Neonatal Unit, Erasmus University, Rotterdam, the Netherlands). Enhancement of fat utilization during prolonged intravenous feeding. AdaPaediatrScand, 63:750, 1974.-An 8-year-old girl with severe underweight caused by anorexia nervosa was treated with total intravenous nutrition for 4 weeks. During this period the Intralipid dose was stepwise increased, the doses of Vamin and glucose were kept constant. The Intralipid dose was monitored by the determination of the serum Intralipid levels. The fat utilization was investigated by intravenous fat tolerance tests and the estimation of postheparin lipoprotein lipase activity of the plasma. The Intralipid elimination constant increased from 796 to 2296/min, the postheparin lipoprotein lipase activity increased from 50 to 317 μEq fatty acid/min/l. These data enabled us to increase the Intralipid dose from 3 g fat/kg/per day to 8 g fat/kg/per day, without an increase of the triglyceride blood levels. We may conclude that lipoprotein lipase is an inducible enzyme. It is not clear which component of the hyper-caloric intravenous regime causes this induction.

A relationship between disaccharidase and diamine oxidase (DAO) activities was looked for by measuring these enzyme activities in histologically normal small intestinal biopsies of 18 children. The range for disaccharidase activities expressed in U g-1 wet weight was 0.1-5.7, 7.1-36.7, and 2.3-8.5 for lactase, maltase, and sucrase, respectively. The range for DAO activities expressed in nmol h-1 g-1 wet weight was 202-974. Significant correlations were found between disaccharidase and DAO activities (lactase versus DAO: n = 17, r = 0.80, P less than 0.001; maltase versus DAO: n = 18, r = 0.70, P less than 0.001; sucrase versus DAO: n = 18, r = 0.55, P less than 0.05). Our results further support the hypothesis that DAO is a marker of small intestinal functional integrity in children.

Evidence for cow's milk allergy was looked for prospectively in 15 children with recurrent vomiting. Whereas radiological examination showed gastro-oesophageal reflux to be present in all patients, 3 out of 15 children presented an enteropathy associated with an increased number of IgE plasmocytes in small intestinal biopsy tissue. These three patients did not improve with conventional medical therapy but a striking improvement occurred within 24 h on a cow's milk-free diet. We conclude that diagnostic confusion between gastro-oesophageal reflux and cow's milk allergy can occur and that the presence of IgE plasmocytes in small intestinal biopsy tissue indicates IgE-mediated cow's milk protein allergy. All cases of "intractable" gastro-oesophageal reflux should be suspected of cow's milk allergy and investigated accordingly.

Intestinal permeability was investigated in 10 normal young adults, in 11 control children and in 9 children presenting with either Berger disease (4 cases) or Henoch-Schönlein nephritis (5 cases), making use of (51 Cr) EDTA as a probe molecule. All subjects exhibited a normal creatinine clearance at the time of testing. After oral administration of (51 Cr) EDTA, 24-hour urine radioactivity was measured and results were expressed in percentage of the oral dose administered. Means and SD were 2.35% +/- 0.77, 2.51% +/- 0.70, and 5.10% +/- 2.35 for normal adults, control children and patients with IgA-associated nephropathies, respectively. The differences of permeability between controls and patients were statistically significant (p less than 0.01). In addition, a significant, direct, linear correlation has been established between the percentage of (51 Cr) EDTA excreted in 24-hour urine and IgA immune complex-plasma levels. Our results therefore support the hypothesis that increased gut permeability could play a role in the pathogenesis of IgA-associated nephropathies.

In the present study, the protective effect of PGE/sub 2/ on intestinal damage in indomethacin-treated adult rats was investigated. Ileal integrity was evaluated making use of different biochemical and histological parameters : activities of sucrase, maltase and diamine oxidase; concentrations of DNA, putrescine, spermidine and spermine; incorporation of /sup 3/H-thymidine into DNA; mitotic index and mucosal thickness. Results expressed per g of mucosal weight, showed that : - maltase and diamine oxidase activities as well as DNA, spermidine and spermine concentrations decreased markedly in indomethacin-treated rats when compared to control rats; - the decrease of maltase activity as well as DNA, spermidine and spermine concentration was less pronounced in PGE/sub 2/-treated rats when compared to indomethacin-treated rats; - /sup 3/H-thymidine incorporation into DNA and mitotic index values showed no significant variation in the course of different treatments; - mucosal thickness increased strongly, the PGE/sub 2/-protected rats. The authors suggest that PGE/sub 2/ could protect the rat's intestinal mucosa against the effects of indomethacin through a trophic action on intestinal villi. 15 references, 3 tables.