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Introduction: Treatment and follow up of patients with Inflammatory Bowel Disease (IBD) is mainly based on clinical symptoms, laboratory tests, endoscopic and histologic findings. However these findings fail to reflect the patients' subjective experience of health. Health Related Quality of Life (HRQL) is an important outcome measure in Inflammatory Bowel Disease (IBD). We aimed to test the validity and reliability of the Anglicised PedsQlTM core module for children with IBD. Methods: Children aged 8-18 years (N=56) who fulfilled national IBD definitions of Crohns and Ulcerative Colitis and 50 of their parents completed the self report and proxy version of the PedsQlTM core module, along with an established HRQL measure specific to IBD (IMPACT III). An assessment of disease activity was made using severity ratings for ulcerative colitis and Crohn's Disease. PedsQlTM patient and parent scores were compared to those of healthy children (N=561) and their parents (N=272) and the questionnaires psychometric properties were tested as described below. Results: Alpha co-efficients for self and proxy report scales ranged from 0.70 to 0.94 confirming the scales' internal reliability. PedsQlTM scores showed significant correlation with scores on IMPACT (Pearson's R ranged from 0.32-0.76, P

Vitamin B-12 is absorbed from the terminal ileum, which is a commonly affected segment of gut in Crohn’s disease. Its absorption may be compromised in these children secondary to inflammatory lesions, ileal bacterial overgrowth, or mucosal damage caused by reflux of bacteria and surgical resection.1 Of these, surgical resection of large segments of terminal ileum remains the most important cause of B-12 malabsorption in such patients. Prolonged depletion leads to megaloblastic anaemia and ultimately neuropathy and myelopathy. Therefore, diagnosis and treatment of vitamin B-12 malabsorption in …

A scoring system for faecal loading was constructed by two experienced observers using the abdominal radiographs of 20 children. Four other observers independently graded the radiographs using this system and there was a high degree of agreement between all six observers (p < 0.001), suggesting that radiological assessment of constipation can be standardised.

A 2-year-old child underwent renal transplantation in the presence of a post-viral enteropathy rendering him dependent on total parenteral nutrition. As part of his immunosuppression, he was given a new oral formulation of cyclosporin A (Neoral), which he was able to absorb satisfactorily, using conventional doses, during the 6 weeks he was dependent on intravenous nutrition and in the face of intermittent severe diarrhoea. An unusual pharmacokinetic profile was observed.

A 16 year old boy presented soon after diagnosis of Crohn's disease with diffuse osteopenia of the lumbar spine with collapse of three vertebral bodies and grossly reduced bone mineral density noted on dual energy x ray absorptiometry scan. Treatment of the underlying Crohn's disease and induction of puberty resulted in marked improvement in bone mineralisation.

Urinary tract anomalies were prospectively investigated with ultrasound in 29 children with functional constipation. These children were compared before and after treatment with 451 age matched healthy controls without constipation. The bladder residue and upper renal tract dilatation after micturition were significantly increased in the group with constipation and improved after treatment.

Editor,—We were interested to read the article by Challacombe et al reported a declining incidence of coeliac disease in West Somerset.1 Our observations on the incidence of coeliac disease in South Glamorgan over a 15 year period have revealed no such decline. We determined the frequency of new cases of coeliac disease from 1981 to 1995 in patients resident in South Glamorgan (1995 total population 415 900; population 14 years or younger 83 500; total live births 5700 per year). Cases of coeliac disease were ascertained from hospital activity data, pathology, dermatology, and dietetic records, general practitioner lists, and the local coeliac society. All cases satisfied the revised ESPGAN diagnostic criteria.2 Over the three five-year periods (1981–85, 1986–90, 1991–95) the number of new cases in children younger than 14 were 8, 10, and 9, respectively—annual incidences of 2.08, 2.53, and 2.15 per 100 000. The incidence of childhood coeliac disease has therefore remained constant over the 15 year period at approximately 1 in 2500 to 1 in 3000 live births. In …

There are few data in children on the homeostatic responses of the colon to Na depletion. We have studied 8 ileostomy patients (median age 160d, range 45-1030, median weight 3.57 kg, range 3-11.5), before and after the ileostomy closure, using non-equilibrium rectal dialysis and 24hr Na balances. Rectal Na absorption and K secretion (nmol/min/cm2) were significantly higher in the children with a negative or low positive Na balance (n=7, median Na balance +0.05 mmol/kg/24hr; median Na absorption 238; median K secretion 89) compared with those with a large positive sodium balance (n=6, median Na balance +2.42 mmol/kg/24hr, p

The results from two matched operative groups with proven lumbar disc degeneration, who underwent full laminectomy or true fenestration have been compared. Two factors determine post operative prognosis in terms of back ache; the length of time between onset of symptoms and operation after a period of conservative care, and the presence of hypermobility at the operative level. The method of exposure of the affected level has no effect on the outcome of the removal of prolapsed disc material.

The results of sixty-five surgical corrections of secondary spinal deformities in spina bifida children are reported. Twenty-three patients had kyphectomies, and thirty-nine patients had anterior and posterior spinal fusions for scoliosis. There were three deaths. Patients in both groups showed functional improvement, though the effects on respiratory function were minimal. Patients with scoliosis should have their surgery before the curve reaches 100 degrees. Correction in these patients may have to be carried out very early if there is rapid curve progression. Kyphectomy ideally should be carried out between the ages of ten and fourteen years when bone size and quality are suitable for fixation.

The families of 11 children who had been operated for the correction of kyphosis and scoliosis not less than 12 months previously were visited. The anxieties and expectations of patients and parents were investigated and the results compared with a similar investigation in the schools of the children.

Forty six children presented with colitis between 1977 and 1981, and all 8 of those below the age of 2 years had food allergic colitis which resolved completely after exclusion of certain foods. In most of the 8 the onset was soon after starting foods other than breast milk. The most common offending food was cows' milk protein, but soya (3 cases) and beef (1 case) were also implicated. A history of allergy in the child or family was common as were blood eosinophilia, high concentrations of serum IgE, and positive IgE antibodies. Colonoscopic appearances were distinctive and biopsies showed a noticeable increase in eosinophils and IgE-containing cells in the lamina propria. We suggest that food allergy is the major cause of colitis in infancy and that an exclusion diet is the treatment of choice.

The varying patterns of motor behaviour of isolated and interposed jejunal and ileal segments in the rabbit and the dog previously reported (Jenkins and Macleod, 1970) were examined by selective denervation techniques. One hundred and twenty-three paired experiments were conducted on rabbits and 55 similar experiments were performed on dogs. Length-matched paired segments of proximal jejunum and distal ileum were isolated and filled with saline at a constant rate. Segmental resistance to filling was regarded as an index of tone. The influence of vagotomy and of sympathectomy on the tone of the segments was studied in segments supplied by one or by two vessels. Vagotomy caused a decrease in tone in the proximal jejunal segments, while sympathectomy had little effect. In segments of distal ileum sympathectomy resulted in segments behaving in a similar fashion, while vagotomy had an unpredictable effect on tone. The results suggest a uniform distribution of the vagus to the whole length of the small bowel in the rabit and the dog, serving to maintain the tone of the bowel. It is deduced that sympathetic supply to the proximal jejunum isabsent in these animkals and is distributed to the distal ileum only in an irregular fashion. The relevance of these observations to the clinical use of interposed small-bowel segments is considered.

Segments of jejunum and distal ileum of varying lengths and different vascular supply were isolated and interposed iso- and antiperistaltically. Pressures proximal to the interposed segment were recorded with a fine, soft, open-tipped cathether introduced via a Mann-Bollman fistula. The distal ileal segments supplied by a single vessel exhibit an unpredictable high degree of tone in some cases, and when these segments were interposed they caused a high degree of partial obstruction irrespective of whether they were interposed iso- or antiperistaltically. Distal ilcal segments supplied two or more vessels interposed antiperistaltically caused a degree of obstruction related to their lengths, and interposed isoperistaltically they caused no obstruction.Jejunal single-vessel segments of both polarities exhibited low obstructive qualities. Antiperistaltic jejunal segments of two or more vessels supply behaved in a similar manner to corresponding ileal segments in that the degree of obstruction was related to the length of the segment. Isoperistaltic segments supplied bt two or more vessels caused no obstruction.Possible mechanisms accounting for the differing findings in jejunum and ileum are discussed.Some clinical applications are discussed.

Rappaport, Konforti & Navon (1956) described a new medium for the isolation of salmonellas from infected material. This medium they claimed to be more effective in isolating salmonellas from faeces than selenite F broth or tetrathionate broth, provided that the inoculum was small. Three or four drops of a 1/1000 saline suspension of faeces in 5 ml. of the medium with subculture after 18 hr. at 37? C. on deoxycholate citrate agar was recommended. A larger inoculum was shown to yield fewer salmonellas. In order to assess the efficacy of the new medium for routine use, a trial was carried out on faecal specimens in a laboratory which receives for examination material from a general hospital, general practitioners and the public health authorities. Deoxycholate citrate agar, selenite F broth and Rappaport's medium were inoculated in parallel when culturing all faecal specimens received for a period of one year. METHODS

1. Seventy-four patients over the age of seventy with either subcapital or intertrochanteric fracture have been investigated for evidence of osteomalacia. To establish an index of suspicion the incidence of biochemically defined osteomalacia has been compared with quantitative histology in this group. 2. Whereas no significant difference in the incidence of the disease was noted in the comparison of subcapital with trochanteric fracture groups, there was a high incidence of osteomalacia overall. Furthermore, a subclinical form of the disease appears to exist. 3. The relevance of these observations is discussed with particular reference to the established diagnostic criteria of the condition.

periosteal stripping in the long lower limb bones of thirty children with shortening after poliomyelitis was performed. All have been followed up for five years. A relative increase in length attributable to the periosteal stripping procedure was seen in the majority. The conclusions are that this simple procedure is indicated in minor degrees of limb inequality in growing children, but that the haphazard response precludes any accurate estimation of the final outcome of such a procedure.

It has been possible to follow up 5 patients who underwent complete cervical laminectomy for cervical spondylotic myelopathy between 12 and 17 years ago. The operation was described by Rogers in 1961. Clinical examination findings, together with the radiological appearances, indicate that this procedure does not predispose to instability of the cervical spine. This relatively simple procedure achieved long-lasting improvement in the patients examined.

Two male infants with severe protracted diarrhoea presenting at 4 months (patient 1) and 10 weeks (patient 2) of age are reported. In both patients jejunal biopsy showed subtotal villous atrophy. Both had specific complement-fixing autoantibodies reacting by immunofluorescence with human duodenal, jejunal, and colonic epithelium. Patient 1 also had hypothyroidism and type 1 diabetes mellitus with thyroid and islet cell autoantibodies. His gut antibodies were of IgG class, reached a titre of 1:512, and remained positive throughout his illness. He died at 16 months of age. Patient 2 had gut antibodies of IgM class, which reached a titre of 1:128 and disappeared at the time of spontaneous recovery of the diarrhoea. The findings suggest that an autoimmune process was the basis for the enteropathy in these patients. We recommend that autoantibody tests should be performed in infants with unexplained protracted diarrhoea.

Summary Ventral hernia was induced surgically in sheep and either left unrepaired(5 animals), repaired with plastic mesh (20 animals) or with carbon fibre (20 animals). In unrepaired animals the hernia persisted. Three hernias recurred in the group repaired with plastic mesh, 2 as a consequence of sepsis. All the hernias repaired with carbon fibre remained sound over periods varying from 8 months to 2 years. There was a gradual invasion of the carbon fibres by collagenous tissue and thus a transition from one to the other of the stress of maintaining the abdominal wall intact.

Ruptures of the calcaneal tendon which present late may be repaired using carbon fibre to induce a neotendon. The operative technique is described and the results of five cases reviewed. The average muscle power obtained was 88% of normal, and the thickness of the neotendon was 148% of that of the normal side. It would appear that this tendon formation in man is comparable to that previously described in sheep.

An infant with congenital gingival epulis which spontaneously regressed over the first year of life is reported. A policy of conservative management should be adopted in this condition unless there are feeding problems in the newborn period or reasons to doubt the diagnosis.

A series of end-to-end everting colonic anastomoses were performed in 95 rabbits in order to assess the value of omental reinforcement. The animals were divided into three groups: (a) control animals, (b) animals with anastomoses reinforced by a free omental graft, and (c) animals with anastomoses reinforced by an omental pedicle. Reinforcement with a free omental graft carried a prohibitive increase in mortality. The use of an omental pedicle appeared to strengthen the anastomosis against forced disruption in the immediate postoperative period but it did not improve the survival rates and it may carry long-term dangers. The explanation for these findings is discussed. It is our view that there is no place for omental reinforcement in colonic surgery.

A hypothesis is advanced in which it is argued that variations in the extrinsic autonomic innervation of short small-bowel segments are responsible for the unpredictable behaviour of such segments. Experimental evidence is offered to substantiate the hypothesis.

The accuracy and postoperative morbidity of cannulation of the cystic duct in routine operative cholangiography were compared with those of needle puncture of the common bile duct. The results are comparable and a case is made for the simpler procedure of needle puncture of the common duct.

A regimen of three injections per day involving the NovoPen (Novo Laboratories Ltd, Basingstoke, Hants, UK) was assessed in eight adolescent diabetics (median age l3.5 years). Six months after the institution of this regimen there was an improvement in metabolic control (assessed by HbA1c measurements) and patient acceptability (assessed by questionnaire). This improvement was maintained for a further six-month period.

The case is reported of an elderly man with asymptomatic cervical spondylosis who sustained a minor hyperextension injury of the cervical spine when the brakes of a car were applied suddenly to avoid a collision. Within six hours marked swelling of the neck and severe dyspnoea developed, and a lateral radiograph showed the pharyngeal shadow displaced far forwards and a crack fracture of an anterior osteophyte. Tracheostomy and evacuation of a massive prevertebral haematoma were performed, with immediate relief. The case draws attention to the possibility of this serious complication of a "whiplash" type of injury.

We report an infant who developed cranial diabetes insipidus after septicaemic shock. This condition should be considered in any child who suffers an acute collapse and it may be more common in the high risk neonate than has previously been recognised.

A case is presented of neurofibromatosis of the large bowel associated with a primary adenocarcinoma of the colon. This is believed to be the first report of such an association.

Membrane transport processes are poorly developed in the kidney of the very preterm neonate resulting in reduced ability to acidify urine and increased Na+ loss. There are close homologies between the transport processes of the distal convoluted tubule and the L colon but little is known of the ontogeny of these processes. We have used non-equilibrium rectal dialysis to investigate rectal electrolyte transport in neonates of different gestational ages: 30-33 wks (A n=15), 34-36 wks (B n=14), 38-44 wks (C n=5), infants (D n=17) and older children (E n=19). Na+ absorption was highest in A (316±65 nmol/min/cm) and lowest in E (149±44, p

Studies of colonic electrolyte transport in adults and children suggest that anion (movement in vivo is only in part mediated by Cl−/HCO3− exchange mechanism. Using the technique of non-equilibrium dialysis of the rectum we have investigated anion (exchange by incubating solutions of differing electrolyte composition in children (2 premature infants and 1 neonate, age 33-42 weeks gestation = A, and 3 children aged 5-18 months =B). Using a plasma-like solution, absorption of Cl− and HCO− was greater in A compared with B (see table). As in B HCO3− secretion might have been expected, we investigated the effect of the electrochemical gradient on HCO3− movement by using a Cl− - free solution to remove anion exchange, and a Na+ -free solution to remove the etetrical drive for HCO3− absorption. With a Cl− - free solution HCO3− absorption increased in both A and B. With no electrical gradient, Cl− absorption decreased in both groups but only in B did HCO3− secretion occur. These data support our previous view that anion exchange is poorly developed in infancy, only accounting for 15% of Cl− absorption in infants and accounting for virtually no Cl− absorption in the preterm neonate. In addition it is clear that, in vivo, Cl− is absorbed by electrical coupling as well as anion exchange.

A major function of the colon is the conservation of salt and water which may be aided by short chain fatty acids. The only previous studies of the mechanisms involved in infants have been in vivo where electrical gradients influence ionic movements. We have carried out a more detailed study of transport in isolated human infant colon using an Ussing Chamber and voltage clamp procedure. Stripped L side colonic mucosa (n=6 pairs) was mounted and bathed in Krebs solution. Under short circuit conditions Na+ (3.45±1.53 umol/hr/cm2mean ISD) and Cl− (0.63±3.61) were absorbed and a residual ion flux consistent with HCO3− secretion, approximates Cl− absorption. Short-circuit current (3.8±0.28) approximates net Na+ movement. 60 mM acetate increased Na+ absorption (3.45±1.53 to 7.74±2.25, p

On the basis of eight years of experimental and clinical investigations, the author recommends carbon fiber on a trial basis to patients with chronic ligamentous instability and where function has been severely compromised because of the injury.

A major function of the colon is the conservation of salt and water and we have previously shown (Jenkins et al GUT 27; 1283, 1986) that in the human infant it plays a major homeostatic role. Colitis may therefore assume greater importance than in later life. We have carried out a detailed study of transport in normal and inflammed isolated human infant colon using an Ussing Chamber and a voltage clamp procedure. Stripped colonic mucosa histologically normal n=6 pairs and inflammed from patients with non-clostridial Hirschsprung's enterocolitis, n=5 pairs was mounted and bathed in Krebs2 solution. Under short-circuit conditions Na+ (3.45±1.53 umol/hr/cm mean ± ISD) and Cl−(0.63±3.61) were absorbed and a residual ion flux consistent with HCO3− secretion approximated Cl− absorption. Short circuit current (ISC) (3.8±0.28) was very similar to net Na+ movement and was markedly reduced by mucosal 10−4 M amiloride (0.61±0.7 p