Determination of the normal position of the anus in Taiwanese infants

BACKGROUND

Anterior displacement of the anus has been reported to be a cause of chronic constipation amongst young children. However, the normal position of the anus has not been studied in Taiwan.

PATIENTS AND METHODS

Normal anal positioning was studied in 200 neonates (100 males and 100 females). All of these individuals were non-constipated. The position of the anus was numerically defined by the anal position index (API), which is the distance from the center of the anus to the vagina or scrotum divided by the distance between the vagina or scrotum and the coccyx. Thirty non-constipated infants aged between 5 and 19 months (15 males and 15 females) were included in the study to compare the index between neonates and older infants.

RESULTS

The API values were 0.54 +/- 0.03 (95% CI, 0.48-0.60) for newborn males and 0.40 +/- 0.04 (95% CI, 0.32-0.47) for newborn females, 0.53 +/- 0.02 (95% CI, 0.49-0.57) for young boys and 0.39 +/- 0.06 (95% CI, 0.28-0.51) for young girls. The difference in indices between males and females was significant, but there was no significant difference in the indices between newborns and older infants.

CONCLUSIONS

The API is independent of age, and provides a constant and reliable parameter for determining the position of the anus.

Acute torsion of wandering spleen: report of one case

Wandering spleen is a rare condition that can lead to splenic infarction or rupture if torsion persists. Early diagnosis and intervention are necessary, and abdominal ultrasonography and abdominal computed tomography are well accepted as the diagnostic imaging modalities. In this study, we present a boy with nic infarction due to acute torsion of a wandering spleen, after initial failure to demonstrate an ectopic spleen. Instead, acute torsion of the wandering spleen with spontaneous partial detorsion was incidentally found by multi-detector row CT with angiography. The patient was managed by splenectomy instead of splenopexy, because poor reperfusion after Laparoscopic detorsion.

Sonogram before and after pyloromyotomy: the pyloric ratio in infantile hypertrophic pyloric stenosis

BACKGROUND

Sonography is used to diagnose infantile hypertrophic pyloric stenosis, but Little information is available about the appearance of postoperative sonographs. The purpose of this study was to evaluate the morphology of the pylorus in association with an obstruction before and after pyloromyotomy.

METHODS

Pyloric length, diameter, muscle thickness and intermuscular space were measured sonographically at diagnosis and daily after pyloromyotomy until discharge in 12 infants with infantile hypertrophic pyloric stenosis. The ratios of pyloric wall thickness and intermuscular space to the entire pyloric diameter were measured.

RESULTS

The pylorus still appeared hypertrophied after pyloromyotomy on the sonograms. The traditional measurement of linear dimensions of the pylorus was not significantly changed from the preoperative values by the time of discharge, except for muscle thickness. The intermuscular space increased from 4.8+/-0.8 mm preoperatively to 7.3+/-2.1 mm by postoperative day 3 (p=0.10). Lowe's pyloric ratio at diagnosis was a mean of 0.32, decreasing to 0.29 on postoperative day 3 and 0.29 on the day of discharge (p=0.82). The alternative pyloric ratio increased significantly by postoperative day 2 (0.24+/-0.09 on day 2 vs. 0.11+/-0.07 preoperatively, p=0.02).

CONCLUSION

The pyloric ratio appears to be a reliable parameter in evaluating the regression of pyloric stenosis after pyloromyotomy, and also aids in the diagnosis of pyloric stenosis.

Clinical significance in previously healthy children of Pseudomonas aeruginosa in the stool

BACKGROUND

Pseudomonas aeruginosa are normal flora in the human gastrointestinal (GI) tract, which on occasion cause GI tract infection.

METHODS

We evaluated the clinical significance of a pure growth of P. aeruginosa in fecal specimens in previously healthy children. The records of 45 previously healthy children under 15 years of age who were seen between June 2000 and August 2006 and who had a pure growth of P. aeruginosa in the stool were retrospectively reviewed.

RESULTS

Of the 45 children, 28 (62%) were infants, three of whom developed sepsis secondary to the pseudomonal infection; two of which died. Complications in another four included colonic perforation (in two), necrotizing enterocolitis (in one), and an anal ulcer resulting in anal stricture (in one). The seven children with complications were all infants. Although not all children in our study had complete data in laboratory determinations, the presence of bandemia, elevated C-reactive protein (CRP), anemia and hypoalbuminemia may be of clinical importance.

CONCLUSION

P. aeruginosa growing in the stool of otherwise healthy children may indicate actual infection by the organism and may be associated with severe or even fatal disease, particularly in infants. Bandemia, elevated CRP, anemia, and hypoalbuminemia give further warning in these patients.

Concomitant rotavirus and Salmonella infections in children with acute diarrhea

BACKGROUND AND PURPOSE

The incidence of concomitant rotavirus and Salmonella infection has been reported to be 1.3% to 7.4%. We designed this study to compare the clinical manifestations in children infected with rotavirus, Salmonella, or both.

METHODS

The medical records of admitted children with acute rotavirus or Salmonella gastroenteritis in 2001 were reviewed. They were divided into group R (rotavirus), group S (Salmonella) and group C (concomitant infection with both). The differences of clinical manifestations and laboratory data among the three groups were analyzed via chi-squared, analysis of variance (ANOVA), Bonferroni and Kruskal-Wallis tests, and odds ratios with 95% confidence intervals (95% CI).

RESULTS

Among the 895 cases reviewed, 550 were group R, 312 group S, and 33 (3.7%) group C. Group C had more vomiting compared with group S (p = 0.0017). Comparing with group R, group C had more prolonged and high fever (> or = 39 degrees C) (p < 0.05), more percentage of green coloration, with mucus and blood contained in the stool (p < 0.001). The C-reactive protein (CRP) value was significantly higher in group C (9.70 +/- 11.05 mg/dL) than in group R (1.33 +/- 3.62mg/dL) or S (5.22 +/- 6.11 mg/dL) (p < 0.05). Hypokalemia was found most frequently in group C (C: 30.0%, S: 8.8%, R: 7.3%) (p = 0.0026).

CONCLUSION

Concomitant rotavirus and Salmonella infections accounted for 3.7% of cases in this study. They had higher CRP as well as incidence of hypokalemia [corrected] In a child with rotavirus gastroenteritis, concomitant infection with Salmonella should be considered if the child has sustained a high fever (> or = 39 degrees C) for over 4 days and a green stool with mucus and blood.

Neonatal gastric perforation: report of 15 cases and review of the literature

BACKGROUND

Gastric perforation among neonates is a rare but frequently fatal condition of uncertain etiology. The aim of this study was to review the clinical course of neonatal gastric perforation and to evaluate possible prognostic factors.

METHODS

We retrospectively analyzed the medical records of 15 patients with neonatal gastric perforation over a 19-year period. Another 97 patients described in the medical literature, for whom the gestational ages and birth weights were clearly stated, were also reviewed.

RESULTS

In our series, there were three girls and 12 boys, nine of whom were full-term infants and six preterm infants. The most common initial manifestations were poor activity, abdominal distension, and respiratory distress. The overall mortality was 47% (7/15). Prematurity was the only statistically significant risk factor; 83% (5/6) of premature infants died compared with 22% (2/9) of term babies (p < 0.05). Combining our series with the patients reported in the literature, there were a total of 50 premature infants and 62 term infants. Gastric perforation occurred on postnatal days 2-7 and presented with nonspecific manifestations. The mortality was significantly higher in premature than in term infants (31/50, 62% vs. 16/62, 26%; p < 0.001). A trend towards higher mortality in infants with lower birth weights was observed (>2500 g, 28%; 1501-2500 g, 52%; 1000-1500 g, 60%; <1000 g, 100%). Infants with birth weights <2500 g had a significantly higher mortality than infants with birth weights >2500 g (32/58, 55% vs. 15/54, 28%; p<0.05).

CONCLUSION

Neonatal gastric perforation is associated with high mortality, particularly in premature infants. There is also a trend towards higher mortality in lower-birth-weight infants.

Cri-du-chat syndrome

BACKGROUND

Cri-du-chat syndrome is a genetic disorder associated with various sized deletions of the short arm of chromosome 5. There are typical physical features, but individual phenotypes vary considerably.

METHODS

The records of 23 patients with cri-du-chat syndrome admitted to Mackay Memorial Hospital from June 1984 to February 2006 were retrospectively reviewed. Data abstracted from the records included abnormal facial features and physical findings, results of echocardiography, bronchoscopy, auditory evoked potential, visual evoked potential, brain ultrasonography, and karyotype. We examined the various clinical phenotypes to see if there was an association with specific karyotypes.

RESULTS

Among congenital heart conditions, atrial septal defect (8/15, 53%) was the most common, followed by ventricular septal defect (4/15, 26%), tricuspid regurgitation (4/15, 26%) and patent ductus arteriosus (3/15, 20%). Laryngomalacia was the most frequent airway problem (8/23, 34%) and strabismus the commonest visual disorder (1/23). A high percentage of patients had impaired hearing (5/23, 21%). There was no clear relationship found between deletion size and major clinical manifestations in this study.

CONCLUSIONS

Karyotype is not a reliable indicator of specific organ involvement in cri-du-chat syndrome. However, karyotyping is still useful, particularly if parental translocation are found to be involved. It helps for prenatal diagnosis of next pregnancy.

Aberrant activation profile of cytokines and mitogen-activated protein kinases in type 2 diabetic patients with nephropathy

Cytokine-induced inflammation is involved in the pathogenesis of type 2 diabetes mellitus (DM). We investigated plasma concentrations and ex vivo production of cytokines and chemokines, and intracellular signalling molecules, mitogen-activated protein kinases (MAPK) in T helper (Th) cells and monocytes in 94 type 2 diabetic patients with or without nephropathy and 20 healthy controls. Plasma concentrations of inflammatory cytokines tumour necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-18 and chemokine CCL2 in patients with diabetic nephropathy (DN) were significantly higher than control subjects, while IL-10, CXCL8, CXCL9, CXCL10 and adiponectin concentrations of DN were significantly higher than patients without diabetic nephropathy (NDN) and control subjects (all P < 0.05). Plasma concentrations of TNF-alpha, IL-6, IL-10, IL-18, CCL2, CXCL8, CXCL9, CXCL10 and adiponectin exhibited significant positive correlation with urine albumin : creatinine ratio in DN patients. The percentage increases of ex vivo production of IL-6, CXCL8, CXCL10, CCL2 and CCL5 upon TNF-alpha activation were significantly higher in both NDN and DN patients than controls (all P < 0.05). The percentage increases in IL-18-induced phosphorylation of extracellular signal-regulated kinase (ERK) in Th cells of NDN and DN were significantly higher than controls (P < 0.05), while the percentage increase in TNF-alpha-induced phosphorylation of p38 MAPK in monocytes and IL-18-induced phosphorylation of p38 MAPK in Th cells and monocytes were significantly higher in NDN patients than controls. These results confirmed that the aberrant production of inflammatory cytokines and chemokines and differential activation of MAPK in different leucocytes are the underlying immunopathological mechanisms of type 2 DM patients with DN.

Clinical criteria for diagnosing perforated appendix in pediatric patients

OBJECTIVE

To determine predictive variables associated with a perforated appendix in pediatric patients with acute appendicitis.

METHODS

This is a retrospective, cross-sectional, observational study from a medical center with more than 2000 beds (230 beds in Department of Pediatrics and Pediatric Surgery), with a mean admission of more than 12000 cases and 2200 surgeries per year. The outcome variable was perforated appendix, and the predictive variables included demographic and clinical factors.

RESULTS

During a 6-year period, appendectomies were performed on 274 patients ranging in age from 1 to 18 years. Perforated appendix was found in 100 children (36.5%). Predictive factors significantly associated with perforated appendix were age younger than 9 years, abdominal pain of more than 2 days' duration, temperature of more than 37.9 degrees C, peritoneal signs, and erythrocyte sedimentation rate of more than 25 mm/h. Abdominal ultrasound was performed in 89 patients (32%). For perforated appendix, the ultrasound had a sensitivity of 35%, specificity of 98%, positive predictive value of 95%, and negative predictive value of 55%. Indications for an abdominal ultrasound were determined from a scoring system using the predictive variables significantly associated with perforated appendix.

CONCLUSION

The use of our proposed scoring system to determine the indications to perform an abdominal ultrasound may prove to assist in deciding treatment (medical vs surgical) for children with perforated appendix. Initial antibiotic treatment followed by interval appendectomy would become a more likely treatment option if our study results can be validated in a prospective study.

Biliary cysts in children--long-term follow-up in Taiwan

BACKGROUND

This study analyzed the clinical presentation, postoperative morbidity and mortality and incidence of associated extrahepatic biliary atresia in children with biliary cysts in Taiwan.

METHODS

We retrospectively reviewed the records of 158 pediatric patients with biliary cysts seen between June 1981 and July 2004, with follow-up ranging from 12 months to 22 years (mean, 11.2 +/- 6.1 years). Patients were divided into three groups: biliary atresia-associated biliary cyst (BABC, 21 patients), non-biliary atresia-associated choledochal cyst (NBACC) in infancy (37 patients), and late NBACC (> 1 year of age, 100 patients).

RESULTS

BABC accounted for 36.2% of the infantile biliary cysts in this study. Extrahepatic cysts in late NBACC had a greater mean diameter than those in infantile NBACC and BABC (21.5 mm vs. 16.0 mm vs. 7.9 mm, p < 0.001). Cholangitis was the most serious complication within 3 months postoperatively in all three groups, resulting in four deaths (two in the infantile NBACC group and one each in the other two groups). Liver cirrhosis developed during long-term follow-up in nine of the 21 patients with BABC, four of whom died. Three of these nine patients underwent liver transplantation and remained well during follow-up. Chronic complications in NBACC occurred mainly in late IVa cases, with persistent intrahepatic dilatation developing in 12 of 35 patients and intrahepatic stones in five. Elevation of serum alanine aminotransferase (ALT) was found preoperatively in 85% of late NBACC and 35% of infantile NBACC cases. Postoperative normalization of ALT occurred after a mean of 152 +/- 23 days and 158 +/- 67 days in late NBACC and infantile NBACC, respectively. Higher ALT levels before operation were associated with a longer period until normalization.

CONCLUSION

The possibility of BABC must be included in the differential diagnosis when a small extrahepatic cyst (< 8 mm in diameter) with prolonged jaundice is found in infancy. Postoperative follow-up is essential for patients with NBACC due to their frequently prolonged elevation of serum ALT and possibility of residual intrahepatic dilatation. Cholangitis was the major cause of death within 3 months postoperatively in this study.

Gastric volvulus in children

Gastric volvulus (GV) is a rare disease in children that may not be recognized early in its course. We retrospectively analyzed 15 patients under 18 years of age who presented to our medical center with GV between January 1995 and June 2005. Patients with complete volvulus and acute obstruction requiring immediate intervention were defined as acute GV. Chronic GV was diagnosed in the presence of partial volvulus with chronic, nonspecific symptoms and signs. Chronic GV (12/ 15) was more common than acute GV (3/15). Organoaxial GV was the most common type (9/15), and there was a high incidence (6/15) of associated anomalies that predisposed to the condition. None of our patients had Borchardt's triad (acute localized epigastric distension, unproductive retching, and the inability to pass a nasogastric tube) which is described in adults with acute GV. Acute GV was immediately treated surgically, but conservative management was successful in patients with chronic idiopathic GV. When acute GV in children fails to exhibit the full gamut of Borchardt's triad, the diagnosis may be delayed. Immediate surgical reduction is recommended for acute GV. For chronic idiopathic GV, the treatment may be based on the age at diagnosis, the severity of symptoms, and how patients are expected to comply with conservative measures.

Interference and blood sample preparation for a pyruvate enzymatic assay

BACKGROUND

To assess the severity of circulatory failure, a pyruvate enzymatic assay was performed on whole blood using lactate dehydrogenase to catalyze the conversion of pyruvate to lactate. We investigated factors related to blood sample collection and preparation that might influence the results, including the timing of blood deproteinization, temperature of sample storage, and hemolysis.

METHOD

A total of 25 whole blood specimens were collected for this study. Each sample was divided into 2 parts: one stored at room temperature (RT) and another kept on ice. The samples were deproteinizied by using 8% perchloric acid (PCA) at varying times after collection; the first deproteinization was immediately after the blood was drawn (0 h), then at 1 h intervals for 6 h and also in samples kept overnight. The supernatant samples were analyzed soon after deproteinization using a COBAS Centrifugal Analyzer. In another set of samples, the blood was immediately deproteinized, and the supernatants were stored at RT and 4 degrees C and assayed for pyruvate at varying times, as above. Finally, the effect of hemolysis on the blood pyruvate enzymatic assay was also evaluated.

RESULTS

When samples were stored at RT, pyruvate levels remained constant until the third h after deproteinization, when there was an approximately 13.3% increase in pyruvate concentration. When whole blood samples were kept at 4 degrees C before deproteinization, pyruvate levels were significantly reduced over time, ranging from 37.8% to 62.2% (paired t test showed a significant mean difference, P < 0.001). No significant differences in pyruvate concentration were observed in supernatant stored at either RT or 4 degrees C. Hemolysis caused a 33.7% increase in the pyruvate concentration, equivalent to 0.18 mg pyruvate per gram per deciliter of hemoglobin.

CONCLUSIONS

For a pyruvate enzymatic assay, keeping a whole blood sample at RT will not cause a significant difference in the pyruvate level as long as the sample is immediately deproteinized. Whole blood samples should not be stored in an ice bath for transport, nor should hemolyzed samples be used for a blood pyruvate enzymatic assay.

Negative effect of heat sterilization on the free amino acid concentrations in infant formula

Infant formulas are often heat sterilized in hospitals where water contamination or nosocomial infection is a concern, but there are few studies of the effect of high heat on the nutritional value of infant formula. In particular, the effect of heat sterilization on free amino acid (FAA) concentrations is seldom discussed. In view of the importance of these nutrients for infant growth, we investigated the FAA concentrations of infant formula after heat sterilization. Powdered infant formulas were reconstituted with hot water (80 degrees C) in glass bottles and placed in an autoclave for 5 min at 105 degrees C and 5600 kg/m2 of pressure. Additional samples of formula were prepared by conventional methods to serve as controls. After autoclaving, we measured the FAA concentrations with ion exchange chromatography. The results were compared with those obtained after conventional preparation. We found a 19.5% lower amount of total protein after autoclaving compared with conventional preparation. Concentrations of total FAA were significantly lower after autoclaving (696.5 +/- 101.4 vs 899.4 +/- 152.2 micromol/l, P = 0.01). The concentrations of individual amino acids were also lower in autoclaved infant formulas, with differences ranging from -4.1 to 71.5% (mean 22.6%). Concentrations of certain amino acids were more than 30% lower, such as valine (71.5%), citrulline (61.1%), glutamine (60.6%), ethanolamine (54%), and lysine (39.2%). Both essential and nonessential amino acids were similarly affected by autoclaving, 28.17 and 27.13%, respectively, lower than in controls (P = 0.37). The concentration of ammonia was significantly higher after autoclaving (645.2 +/- 76.2 vs 393.2 +/-140.7 micromol/l, P = 0.0003). However, the urea level was significantly lower after autoclaving than after conventional preparation (1110.8 +/- 162.7 vs 1426.5 +/- 209.5 micromol/l, P = 0.0004). The accumulation of ammonia may reflect degradation of protein and amino acids. Autoclaving clearly results in decreased concentrations of FAA in infant formula. The increased concentration of ammonia after autoclaving is of concern if it leads to deleterious effects.

A seroepidemiologic study of Helicobacter pylori and hepatitis A virus infection in primary school students in Taipei

Helicobacter pylori and hepatitis A virus (HAV) share a common fecal-oral transmission route. The aim of this study was to investigate the prevalence of and risk factors for H. pylori and HAV infection in primary school students in Taiwan. We studied 289 Grade 1 to 6 students from a single primary school in Taipei County in 2003. The students volunteered for blood tests for H. pylori immunoglobulin G (IgG) antibody and anti-hepatitis A antibody after consent from their parents. Questionnaires were administered to the parents to investigate possible risk factors. The seroprevalence rates of H. pylori IgG antibody and anti-hepatitis A antibody were 21.5% (62/289) and 1.4% (4/289), respectively. No statistically significant relationship was found between seropositivity for H. pylori and for HAV. If parents had knowledge of H. pylori and HAV, their children were significantly more likely to be seronegative for H. pylori (p=0.020, odds ratio [OR] 2.1, 95% confidence interval [CI] 1.2-3.7) and HAV (p=0.012, OR 11.2, 95% CI 1.5-83.4). Students whose family members had no history of HAV infection were significantly less likely to be seropositive for HAV (p=0.001, OR 0.04, 95% CI 0.004-0.5). No other factors were found to be significantly associated with seropositivity, including blood type; age; gender; family members' history of H. pylori infection; travel to China; parents' educational level; sources of water supply; family members' use of tobacco, alcohol, or betel nut; family members' history of peptic ulcer or gastritis; and students' history of recurrent abdominal pain. Lack of public health knowledge appears to be related to seroprevalence of H. pylori in primary school students. The low seroprevalence of anti-HAV antibodies demonstrates the lack of protection against this infection in school-age children in Taiwan and suggests that universal administration of HAV vaccine would be wise.

Serum cytokines in differentiating between viral and bacterial enterocolitis

It is difficult to distinguish clinically between bacterial and viral causes of enterocolitis. The aim of the study was to investigate if serum cytokines can distinguish bacterial from viral enterocolitis. We prospectively enrolled 147 paediatric in-patients with acute enterocolitis. Blood was taken for leucocyte count, CRP, ESR, IL-6, IL-8, IFN-alpha and TNF-alpha on the day of admission. A pathogen was identified in 115 of the 147 children, 72 of whom had a bacterial pathogen (bacterial group) and 43 rotavirus (viral group). Mean values of the serum markers IL-6, IL-8 and CRP were significantly higher in the bacterial group. Receiver-operating characteristic curves demonstrated that a cut-off of 15 pg/ml for IL-6 had a sensitivity of 0.75 and a specificity of 0.91 for bacterial diarrhoea. Comparable values for CRP at a cut-off of 13 mg/L demonstrated a sensitivity of 0.54 and a specificity of 0.72. Values for IL-8 at a cut-off of 80 pg/ml had a sensitivity of 0.46 and a specificity of 0.71. Despite the small sample size, our data suggest that serum IL-6, IL-8 and CRP are significantly elevated in children with bacterial enterocolitis. IL-6 has a higher sensitivity, specificity and positive predictive value than IL-8 and CRP. Determination of serum cytokines might be a useful way of differentiating viral from bacterial gastro-enteritis.

Endoscopic stenting for chronic recurrent pancreatitis in a child

Chronic pancreatitis in childhood is a rare but potentially debilitating disorder. Conservative therapy frequently fails, so that recurrent attacks are common. Traditional therapy often culminates in longitudinal pancreaticojejunostomy and distal pancreatectomy with Roux-en-Y pancreaticojejunostomy. We report a 9-year-old girl who had recurrent pancreatitis accompanied by multiple pancreatic cysts with stones in the pancreatic duct. She had been admitted complaining of abdominal pain. Abdominal sonography showed a dilated pancreatic duct and enlarged polycystic kidneys bilaterally. On abdominal computed tomography, there was a suspicion of a calcified shadow in a swollen pancreatic head, along with significant dilatation of the pancreatic duct in the body and the tail. With conservative treatment, the symptoms improved but relapsed 4 months later. Abdominal CT showed progressive abnormalities in the pancreas. ERCP with papillosphincterotomy was performed, resulting in the efflux of pus and stones. A stent was placed in the main pancreatic duct, which dramatically improved the patient's symptoms. We recommend endoscopic stent placement therapy in children with chronic pancreatitis with stones as an alternative to extensive surgery.

Free amino acids in full-term and pre-term human milk and infant formula

OBJECTIVE

Although the nutritional value of human milk has been thoroughly studied, few reports describing its free amino acid (FAA) content have been published. Although infant formulas are designed to approximate the nutrient composition of human milk, the content and concentration of free amino acids are unknown. We compared the FAA concentrations of milk from mothers of preterm and full-term infants with those in several infant formulas.

METHOD

Human milk was obtained during three different stages of lactation (colostral, transitional and mature milk). Sixty-seven samples were collected from 44 healthy mothers of term infants and 23 mothers of premature infants 29 to 36 weeks gestation (mean 33 weeks). Two brands of powdered term formula (TF-A and TF-B) and two brands designed for preterm infants (PTF-A and PTF-B )were also studied. Ion exchange chromatography was used for free amino acid analysis.

RESULTS

The mean concentration of total FAA in human milk was significantly higher than any of the infant formulas (8139 micromol/L for pre-term human milk; 3462 micromol/L for full term human milk; TF-A, 720 micromol/L; TF-B, 697 micromol/L; PTF-A, 820 micromol/L; PTF-B, 789 micromol/L) (P <0.01). FAA concentration in term and premature human colostral milk was significantly higher than in human transitional and mature milks (P <0.01). In comparing individual FAAs, there were significant differences in concentrations between term human milk and preterm milk except for phosphoethanolamine, hydroxyproline, asparagine, and alpha-amino-eta-butyric acid. There were significant differences in all FAA concentrations between all human milks and infant formulas (P <0.05), but no significant differences were found among the study formulas.

CONCLUSION

The concentration of FAA is high in human colostral milk and decreases through the transitional and mature milk stages. FAA is higher in all human milks than in infant formulas.

Diagnosis of Henoch-Schönlein purpura by sonography and radionuclear scanning in a child presenting with bilateral acute scrotum

Acute scrotum presenting as the only initial manifestation of Henoch-Schönlein purpura (HSP) is so unusual that the diagnosis can easily be missed. We report this condition in a 4-year-old boy admitted with bronchopneumonia. Bilateral painful scrotal swelling with ecchymosis occurred on the second day of hospitalization. Scrotal sonography was performed and a good blood supply was documented. Scrotal nuclear scanning was performed and was consistent with bilateral epididymoorchitis. Multiple purpuric lesions over the lower extremities and perineal region developed on the third day of hospitalization. Intermittent abdominal pain and knee pain developed thereafter. HSP was diagnosed and steroids were prescribed. The symptoms subsided gradually and no complication was noted. This case reminds us that an acute scrotum may be the only initial manifestation of HSP. Sonography and nuclear scanning can help rule out other diseases.

Feasibility of implementing a universal neonatal hearing screening programme using distortion product otoacoustic emission detection at a university hospital in Hong Kong

OBJECTIVE

To assess the feasibility of implementing a universal neonatal hearing screening programme using distortion product otoacoustic emission detection at a major teaching hospital in Hong Kong.

DESIGN

Descriptive study and questionnaire. SETTING. Teaching hospital, Hong Kong.

METHODS

A total of 1064 infants, together with their mothers, were successfully recruited for the study. The participation rate was 99.3%. A three-stage hearing screening protocol using distortion product otoacoustic emission detection was adopted. Each of the participating infants was screened on three separate occasions (day 1-4, day 5-14, and day 21-30 after birth), irrespective of the test results. A questionnaire was administered to 364 randomly selected mothers to determine whether as consumers of the hearing screening service, mothers would find screening desirable.

RESULTS

Results of the screening demonstrated an incidence of permanent bilateral hearing loss (>or=40 dB in the better ear) of 0.28%. The results also showed that 3.5% of the screened infants were referred for subsequent diagnostic audiological assessment, including those suspected with unilateral as well as bilateral hearing loss. Data obtained were comparable to other reported results obtained using multi-stage screening protocols. Taking both the false positive rate and the default rate into consideration, the most appropriate time for screening in this hospital setting appeared to be around day 5 to 14 when infants returned to the hospital's day centre as out-patients for routine medical follow-up. Since this day centre service is not generally provided by all maternity hospitals in Hong Kong, an alternative time for screening would be around day 21 to 30 when infants could return as out-patients solely for the hearing test. The results of the questionnaire suggested that most mothers thought a neonatal hearing screening would be desirable (91.35%). The majority (81.70%) indicated a preference for screening either within a few days of birth at the maternity ward prior to discharge from the hospital, or between 5 and 30 days when returning to the hospital as an out-patient.

CONCLUSION

It was concluded that a universal neonatal hearing screening programme could be readily implemented in a maternity hospital setting in Hong Kong.

Management of foreign body ingestion in children: experience with 42 cases

Ingestion of foreign bodies occurs frequently in children, but there are no definite management guidelines. We reviewed 42 pediatric cases of accidental ingestion of foreign bodies with or without symptoms during the past 10 years. In decreasing order of frequency, the foreign bodies included: coins, sharp objects (needle, pin), bones (fish and chicken bone), metal object, food, seeds, plastic material, magnets, jewelry ring, and others. The majority of children were 5 years old or younger. At the time of presentation, the vast majority of objects were located in the esophagus. Sixty percent of the patients had symptoms, such as abdominal pain, vomiting and cough. Management included observation, esophagoscopy, panendoscopy, and laparotomy. Four patients (9.5%) had complications. One patient who ingested a magnet suffered from esophageal perforation with mediastinitis. Two had deep neck abscess due to esophageal penetration by bones. Another patient had hemorrhagic gastritis after swallowing a coin. All patients discharged after treatment, and none died.

A scoring system to predict the need for liver transplantation for biliary atresia after Kasai portoenterostomy

A retrospective analysis was performed of the records of 133 patients with extrahepatic biliary atresia (EHBA) who had undergone a Kasai portoenterostomy. The patients were divided into a non-transplantation group who survived but did not receive liver transplantation after the procedure and a failure group of those who died or received liver transplantation. A score was calculated that assessed nine factors, including laboratory values and complications. The data were assessed at the time complications occurred. The scores were analysed by a trend analysis to see if serial scores predicted the evolution of liver disease. A receiver operating characteristic (ROC) curve was plotted to assess the optimal cut-point for the scoring system. There were 98 patients in the non-transplantation group and 35 in the failure group. The latter group had significantly higher post-operative bilirubin (9.3+/-7.2 mg/dl versus 3.5+/-3.1 mg/dl), ALT (136+/-89 U/l versus 92+/-88 U/l), prothrombin time, and incidence of cirrhosis, ascites, oesophageal varices, portal hypertension, cholangitis and sepsis than the non-transplantation group (P<0.05). A score of > or =8 had a high sensitivity (96.9%) and specificity (89.5%) for predicting the need for liver transplant.

CONCLUSION

Based on easily available clinical information, our scoring system can predict which patients with biliary atresia who have already undergone a Kasai procedure should be considered for liver transplantation.

Percutaneous endoscopic gastrostomy in children: 15 cases experience

For long-term tube feeding in children, percutaneous endoscopic gastrostomy (PEG) has the advantages of a short surgical time, early feeding following surgery, and lower rate of complications. From July 2000 to September 2002, we enrolled fifteen children (mean age: 8.2 years old) who underwent PEG placement for long-term nutritional support. Their underlying diseases included mucopolysaccharidosis (MPS) type II severe form, mitochondrial disease, Ehlers-Danlos syndrome associated with Robin sequence, spinal muscular atrophy (SMA) type II, nesidioblastosis, neurofibromatosis and other neurological disorders. We assessed the complications and outcome in these patients after PEG placement. There were no difficulties in PEG tube-feeding after procedure. One patient had a wound infection at the insertion site which required parenteral antibiotic therapy. Symptomatic gastroesophageal reflux (GER) occurred in two patients and was controlled with medication. One patient developed a gastrocutaneous fistula, requiring surgical removal of the PEG tube. One patient underwent laparoscopic gastrojejunostomy and Nissen fundoplication for persistent vomiting. Two patients with mitochondrial disease expired. The other eleven devices have continued to function on follow-up. Placement of a PEG is a simple, feasible procedure for children with swallowing difficulty who require long-term nutritional support. Although complications may sometimes occur, in our experience many can be managed conservatively.

Prediction of hyperbilirubinemia in near-term and term infants

OBJECTIVE

The purpose of this study was to determine whether end-tidal carbon monoxide (CO) corrected for ambient CO (ETCOc), as a single measurement or in combination with serum total bilirubin (STB) measurements, can predict the development of hyperbilirubinemia during the first 7 days of life.

METHODS

From nine multinational clinical sites, 1370 neonates completed this cohort study from February 20, 1998 through February 22, 1999. Measurements of both ETCOc and STB were performed at 30+/-6 hours of life; STB also was measured at 96+/-12 hours and subsequently following a flow diagram based on a table of hours of age-specific STB. An infant was defined as hyperbilirubinemic if the hours of age-specific STB was greater than or equal to the 95th percentile as defined by the table at any time during the study.

RESULTS

A total of 120 (8.8%) of the enrolled infants became hyperbilirubinemic. Mean STB in breast-fed infants was 8.92+/-4.37 mg/dl at 96 hours versus 7.63+/-3.58 mg/dl in those fed formula only. The mean ETCOc at 30+/-6 hours for the total population was 1.48+/-0.49 ppm, whereas those of nonhyperbilirubinemic and hyperbilirubinemic infants were 1.45+/-0.47 and 1.81+/-0.59 ppm, respectively. Seventy-six percent (92 of 120) of hyperbilirubinemic infants had ETCOc greater than the population mean. An ETCOc greater than the population mean at 30+/-6 hours yielded a 13.0% positive predictive value (PPV) and a 95.8% negative predictive value (NPV) for STB > or =95th percentile. When infants with STB > or =95th percentile at <36 hours of age were excluded, the STB at 30+/-6 hours yielded a 16.7% PPV and a 98.1% NPV for STB >75th percentile. The combination of these two measurements at 30+/-6 hours (either ETCOc more than the population mean or STB >75th percentile) had a 6.4% PPV with a 99.0% NPV.

CONCLUSIONS

This prospective cohort study supports previous observations that measuring STB before discharge may provide some assistance in predicting an infant's risk for developing hyperbilirubinemia. The addition of an ETCOc measurement provides insight into the processes that contribute to the condition but does not materially improve the predictive ability of an hours of age-specific STB in this study population. The combination of STB and ETCOc as early as 30+/-6 hours may identify infants with increased bilirubin production (eg, hemolysis) or decreased elimination (conjugation defects) as well as infants who require early follow-up after discharge for jaundice or other clinical problems such as late anemia. Depending on the incidence of hyperbilirubinemia within an institution, the criteria for decision making should vary according to its unique population.

Cytokine- and endotoxin-enhanced bilirubin cytotoxicity

AIM

To determine the effects of endotoxin and cytokines on the cytotoxic effects of bilirubin.

METHODS

A cell-culture model was developed to simulate the effect of an infection by adding endotoxin from E. coli (LPS) and pro-inflammatory cytokines (TNF-alpha, IL-Ialpha, IL-1beta, and IL-6) to the medium. The cytotoxic effects were measured by a modified MTT method. Four cell lines were tested; they were neuroblastoma, glioblastoma, liver, and endothelial cells.

RESULTS

Both endotoxin and pro-inflammatory cytokines were demonstrated to enhance bilirubin cytotoxicity on all the cell lines tested, as illustrated by endothelial cell from umbilical vein. Endotoxin and TNF-alpha also showed an additive effect. TNF-alpha concentrations at much lower than clinical sepsis levels have been shown to produce significant cytotoxic effects.

CONCLUSION

We speculate that in the jaundiced neonate, infection may increase the risk of tissue damage or kernicterus.

Use of cisapride with magnesium oxide in chronic pediatric constipation

Functional constipation in children is a common problem in daily practice, however there is currently no accepted optimal treatment of choice. This study investigated the effect of cisapride in the treatment of pediatric constipation when combined with magnesium oxide (MgO). This prospective study enrolled children with chronic constipation. They were randomly assigned to either MgO (125 mg three times a day for patients weighing less than 20 kg or 250 mg three times a day for those weighing more than 20 kg), or cisapride 0.2 mg/kg (max 5mg/dose) plus MgO for 4 weeks. Twenty-one doctors in 19 major medical centers or hospitals in Taiwan with well- established pediatric departments participated in this study from October 1999 to March 2000. 84 children (51 males, 33 females, 1-7 years of age) with fewer than 2 spontaneous bowel movements per week for at least one month completed the study. After 1 week of therapy, a good response, defined as 3 or more bowel movements per week, was achieved in 30 (68.2%) of children treated with cisapride and MgO compared with 23 (57.5%) children treated with MgO alone (p=n.s.). At the end of the 4-week treatment period, 90.9% of the children in cisapride group compared with 67.5% of the children in MgO group achieved a good response (p=0.013). There was no statistical difference between the two groups in terms of the side effects and stool characteristics. In conclusion, it appears that cisapride in combination with MgO may have a synergistic effect and improves the frequency of stool passage in pediatric functional constipation.

Monitoring patient satisfaction with university dental services under two fee-paying systems

AIMS

The aim of this survey was to study patients' satisfaction with the dental service of a university in Hong Kong under a recently introduced item-based fee-paying system and reasons for non-attendance at the clinic; and to compare results of the present survey with that of a similar survey of the same dental service under a time-based fee-paying system in 1996.

METHOD

A modified Dental Satisfaction Questionnaire was distributed to a random sample of students (n=194) in their lecture rooms and they were asked to complete the questionnaire on the spot. The same questionnaire was sent to a random sample of staff and their spouses (n=207) by mail.

RESULTS

Dental Satisfaction Index (DSI) scores calculated from the returned questionnaires were 66 for students and 70 for staff and their spouses. Compared to the scores in 1996, there was no significant difference for that of the students (DSI=65 in 1996) but there was a significant improvement in that of the staff and their spouses (DSI=66 in 1996). Moreover, in the present survey, "busy/no time" and "no perceived dental problem" were the major reasons for non-attendance, in contrast to "long waiting time for an appointment" in the 1996 survey, were the major reasons for non-attendance.

CONCLUSION

The recent attempts by the University Dental Clinic to shorten patient waiting time and the change in fee-paying system might have improved the patients' satisfaction with the service.

Prediction of hyperbilirubinemia in near-term and term infants

OBJECTIVE

The purpose of this study was to determine whether end-tidal carbon monoxide (CO) corrected for ambient CO (ETCOc), as a single measurement or in combination with serum total bilirubin (STB) measurements, can predict the development of hyperbilirubinemia during the first 7 days of life.

METHODS

From 9 multinational clinical sites, 1370 neonates completed this cohort study from February 20, 1998, through February 22, 1999. Measurements of both ETCOc and STB were performed at 30 +/- 6 hours of life; STB also was measured at 96 +/- 12 hours and subsequently following a flow diagram based on a table of hours of age-specific STB. An infant was defined as hyperbilirubinemic if the hours of age-specific STB was greater than or equal to the 95th percentile as defined by the table at any time during the study.

RESULTS

A total of 120 (8.8%) of the enrolled infants became hyperbilirubinemic. Mean STB in breastfed infants was 8.92 +/- 4.37 mg/dL at 96 hours versus 7.63 +/- 3.58 mg/dL in those fed formula only. The mean ETCOc at 30 +/- 6 hours for the total population was 1.48 +/- 0.49 ppm, whereas those of nonhyperbilirubinemic and hyperbilirubinemic infants were 1.45 +/- 0.47 ppm and 1.81 +/- 0.59 ppm, respectively. Seventy-six percent (92 of 120) of hyperbilirubinemic infants had ETCOc greater than the population mean. An ETCOc greater than the population mean at 30 +/- 6 hours yielded a 13.0% positive predictive value (PPV) and a 95.8% negative predictive value (NPV) for STB >/=95th percentile. When infants with STB >95th percentile at <36 hours of age were excluded, the STB at 30 +/- 6 hours yielded a 16.7% PPV and a 98.1% NPV for STB >75th percentile. The combination of these 2 measurements at 30 +/- 6 hours (either ETCOc more than the population mean or STB >75th percentile) had a 6.4% PPV with a 99.0% NPV. Conclusions. This prospective cohort study supports previous observations that measuring STB before discharge may provide some assistance in predicting an infant's risk for developing hyperbilirubinemia. The addition of an ETCOc measurement provides insight into the processes that contribute to the condition but does not materially improve the predictive ability of an hours of age-specific STB in this study population. The combination of STB and ETCOc as early as 30 +/- 6 hours may identify infants with increased bilirubin production (eg, hemolysis) or decreased elimination (conjugation defects) as well as infants who require early follow-up after discharge for jaundice or other clinical problems such as late anemia. Depending on the incidence of hyperbilirubinemia within an institution, the criteria for decision making should vary according to its unique population.

Capillary electrophoresis for the determination of albumin binding capacity and free bilirubin in jaundiced neonates

This study develops a capillary electrophoresis/frontal analysis (CE/FA) method to separate free bilirubin from its albumin bound complex, with only small-sized samples. Under our optimized conditions, CE/FA is proven to be a simple and accurate method in assaying the concentration of free bilirubin in the jaundiced serum. Upon saturation of albumin-binding, the amount of bilirubin added to the serum bears a linear relationship with the absorbance at OD44OnM (R = .9987, P < .00001). Application of this method to study jaundiced neonates has yielded precise data on the residual binding capacity, which may be of significant therapeutic implications. The CE/FA method we have developed appears to be promising and applicable for clinical use as it is highly reproducible and it only requires a small sample size for tests. Our method should be an invaluable adjunct to the neonatal management of hyperbilirubinaemia.

Surfactant tracheobronchial lavage for the management of a rabbit model of meconium aspiration syndrome

We evaluated the effect of tracheobronchial lavage with diluted surfactant solution (bovine lipid extract surfactant, bLES) in a rabbit model of meconium aspiration. All animals were anaesthetized, tracheotomized and given 3-4 ml/kg of 25% slurry of human meconium into the endotracheal tube and mechanically ventilated for 1 h. The animals were then randomly assigned to surfactant lavage (n = 12) with 15 ml/kg of diluted surfactant at a concentration of 5.4 mg phospholipid/ml administered in aliquots of 2 ml; or simple endotracheal suction (control n = 12) when the oxygenation index (OI) was >/=15. Changes in the arterial blood gases and the histomorphological and radiological appearances of the lungs were recorded. The OI and arterial/alveolar oxygen tension (a/A PO2) of the surfactant lavage group improved significantly at 5 min post-treatment, and these improvements were observed throughout the ensuing 4 h of ventilation. There was significantly more solid content recovered by surfactant lavage compared with the control group (p = 0.0001). Radiologically, the post-treatment air space opacification scores of the lavage group were significantly lower compared with the control (p = 0.002). The post-treatment radiographs of the lavage-treated rabbits were rated by the radiologist, who was blinded to the treatment groups, as much improved in 5 and improved in 4, whereas the control rabbits were rated as much worse in 3 and worse in 4. Histological examination showed the lungs of the lavaged rabbits had significantly more normal airway (p < 0.0001), more fields showing completely normal airspace (p = 0.0001) and less fields showing severe overdistension with meconium (p = 0.0005). We concluded that lavage with diluted surfactant solution effectively washed out the meconium, improved gases exchanges, and improved the histological and radiological appearances in the rabbit model of MAS.

Dilatation of the biliary tree in children: sonographic diagnosis and its clinical significance

We evaluated sonographically 162 children who met the criteria for biliary tract dilatation in the past 18 years. Of these, 131 patients were diagnosed as having anomalous dilatations of the biliary tree (including 112 with choledochal cysts and 19 with biliary duct dilatation and biliary atresia). Biliary tract dilatations in the other 31 patients were due to secondary causes or normal variants. All cases of intrahepatic biliary tree dilatation and those with both intra- and extrabiliary duct dilatations were anomalous. In 117 cases of extrahepatic biliary tract dilatation only, the mean diameter was widest in cases of choledochal cyst (21.4 +/- 12.1 mm, compared with cases of biliary tract dilatation with biliary atresia (10 +/- 2.4 mm), secondary biliary duct dilatation (8.5 +/- 1.5 mm), and normal variants (4.4 +/- 1.2 mm) (P < 0.001). Of the 43 infants with biliary tree dilatation, 24 (56%) had choledochal cysts and 19 (44%) had biliary tract dilatation associated with biliary atresia. Excluding cases associated with biliary atresia, the accuracy of diagnosing choledochal cysts in extrahepatic biliary tract dilatation was 71% and 97% using cutoffs of 7 mm and 10 mm as the minimum diameter, respectively.

Difference in susceptibilities of different cell lines to bilirubin damage

OBJECTIVE

To investigate if there are differences in susceptibilities to bilirubin toxicity of different cell lines.

METHODOLOGY

A modified 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) method was adopted to study the cytotoxic effect of bilirubin on several commercially available cell lines including human glioblastoma (ATCC CRL 1690, T98G), human neuroblastoma (ATCC HTB-10, SK-N-MC), human liver (ATCC CCL 13, Chang Liver, HeLa markers) and a mouse fibroblast (ATCC CCL-1, NCTC Colon 929).

RESULTS

Cytotoxicity was observed when certain bilirubin:albumin molar ratios were exceeded in the medium of a cell line in culture. Different cells exhibited different susceptibilities to the cytotoxic effects of bilirubin; neuroblastoma and glioblastoma were most susceptible, fibroblasts were the least vulnerable.

CONCLUSIONS

Our findings have confirmed the clinical impression that different cells sustain different degrees of cytotoxicities caused by bilirubin.

Capillary electrophoresis for determination of free and albumin-bound bilirubin and the investigation of drug interaction with bilirubin-bound albumin

Capillary electrophoresis (CE) is a promising technique for assessment of free bilirubin and its interaction with albumin, as it requires only a small sample volume and provides a rapid and efficient separation of free bilirubin from its albumin-bound complex in a one-phase system. In order to maintain the equilibrium without dissociation of bilirubin from the albumin/bilirubin complex as in real clinical conditions, the coupling of CE with frontal analysis (FA) was investigated. A very large sample plug was introduced hydrodynamically into the capillary (36 cm length, 50 microm inner diameter) at 15 psi x s to develop the frontal conditions during CE separation. The working conditions for CE/FA separation of bilirubin and albumin were optimized as follows: +20 kV; running buffer, 10 mmol/L phosphate and 1 mmol/L ethylenediaminetetraacetic acid (EDTA), pH 7.4. The working range for bilirubin was found to vary from 5 to 206 micromol/L; precision with relative standard deviation (RSD) <2.0% for n = 3 and detection limit (signal to noise, S/N = 2) was 2 micromol/L. The residual binding capacity of a simulated cord blood serum for bilirubin was 26 mg/100 mL at pH 7.4. Bilirubin was shown to be displaced from albumin when aspirin was added. The free bilirubin concentration was found to increase to clinical significant concentrations from 11.9 to 21.1% when increasing aspirin was added in the range of 5-50 mg/100 mL, respectively. Thus, the investigation of aspirin displacement of bilirubin from albumin is clinically important and the CE/ FA method is a suitable procedure for this purpose.

Characterization of group D1 non-typhoid Salmonella isolates by serotyping and pulsed field gel electrophoresis

Non-typhoid salmonella infection is not uncommon in immunocompetent patients in Taiwan. Bacterial factors may play an important role in the pathogenesis of such infections. In a previous study, Salmonella group D1 was found to have the tendency to cause bacteremia with a higher frequency than other serotypes. In the present study, we prospectively collected 94 Salmonella group D1 isolates for serotyping and molecular typing. Salmonella panama and Salmonella dublin seemed more invasive than other serotypes. Pulsed field gel electrophoresis was also done to characterize of Salmonella enteritidis and Salmonella dublin. PFGE type "a" of Salmonella dublin appeared to be more invasive than the other two PFGE types. All six Salmonella dublin isolates were Vi antigen negative. Further study using a larger number of isolates is needed to identify the tendency to invade blood stream of Salmonella dublin and Salmonella panama.

Variable levels of mosaicism for trisomy 21 in a non-immune hydropic infant with chylothorax

We report the first case of mosaic trisomy 21 with non-immune hydrops fetalis and bilateral chylothoraces. Prenatal fetal blood karyotype analysis of 15 fetal cells revealed a 46,XX karyotype. Aggressive prenatal management, including fetal thoracocentesis and pleuro-amniotic shunt, was performed. A clinical phenotype of Down syndrome was apparent after the gross oedema had subsided. Subsequent chromosome study of neonatal blood lymphocytes showed mosaic trisomy 21 with 23 per cent trisomic cells. Review of the initial fetal blood sample identified trisomy in 5 per cent of 134 cells. Follow-up study at five months showed no trisomy 21 in 100 cells. This case illustrates the variable levels of mosaicism manifest in the peripheral blood of an infant with obvious Down syndrome phenotype, and the limitation of cytogenetic analysis of peripheral lymphocytes alone in prenatal and postnatal detection of low levels of mosaicism.

Gastro-intestinal bleeding caused by leiomyoma of the small intestine in a child with neurofibromatosis

Gastro-intestinal bleeding is an uncommon presentation in children with neurofibromatosis. Gastro-intestinal involvement caused by jejunal leiomyoma has only been described in adults. To the best of our knowledge, this is the first paediatric case of jejunal leiomyoma associated with neurofibromatosis. We present a 10-year-old girl with a 9-month history of anaemia and low gastro-intestinal bleeding. Abdominal sonography and small bowel series showed a submucosal mass in the proximal jejunum. On surgery, a submucosal tumour was excised and histological examination suggested a diagnosis of "smooth muscle tumour of undetermined malignant potential". There were no recurrence of symptoms for 4 years after the operation.

CONCLUSION

Jejunal leiomyoma should be considered in a child with neurofibromatosis presenting with gastro-intestinal bleeding.

Surfactant lavage for meconium aspiration syndrome: a pilot study

OBJECTIVE

Meconium aspiration syndrome (MAS) is a major cause of respiratory morbidity and mortality in term infants. We reported our pilot experience on the use of diluted bovine lung surfactant lipid extract solution (Survanta [Ross Laboratories, Ohio, USA]) as a tracheobronchial lavage fluid for the treatment of infants with severe MAS. Our goal was to establish the safety and the effectiveness of this procedure before organizing a randomized controlled trial.

METHOD

Six infants with severe MAS necessitating mechanical ventilation with an oxygen index of >/=15 within 6 hours of life recruited consecutively during a 11/2-year period were treated with tracheobronchial lavage with 15 mL/kg of diluted surfactant solution (Survanta) at a phospholipid concentration of 5 mg/mL administered in 2-mL aliquots. The outcome of treatment was assessed by comparison with 6 consecutive historic control infants with equally severe MAS of similar inclusion criteria retrospectively.

RESULTS

The mean oxygen index, mean airway pressure, fraction of inspired oxygen, and arterial/alveolar oxygen tension ratio improved significantly within the first 48 hours after treatment in the lavage group. The duration of ventilation (mean +/- SEM, 55.3 +/- 4.6 hours vs 131 +/- 60 hours) and oxygen therapy (mean +/- SEM, 4.1 +/- 0.5 days vs 20.8 +/- 8.2 days) were also significantly reduced in the lavage-treated group compared with the control group. All 6 patients in the lavage group survived without sequelae whereas there were 2 deaths in the control group. The process of administering the surfactant lavage was well tolerated with no air leak complications.

CONCLUSIONS

Our experience suggested that surfactant lavage seems to be an effective and safe method for treatment of severe MAS. A multicenter randomized control trial is indicated to further study the efficacy of this treatment.

Additive effect of tumor necrosis factor-alpha and endotoxin on bilirubin cytotoxicity

Clinical observations suggest that sepsis may enhance the risk of kernicterus. This study investigated the combined effects of bilirubin, endotoxin, and tumor necrosis factor-alpha (TNF-alpha), which simulate sepsis in a jaundiced mouse fibroblast cell line. The horseradish peroxidase oxidation method was applied for bilirubin-albumin titration studies to test the effect of endotoxin and TNF-alpha on bilirubin-albumin binding. A modified 3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide method was used to study cytotoxicity. Bilirubin caused cytotoxicity in a dose-dependent manner in the cultured mouse fibroblasts. Such an effect was significantly amplified by TNF-alpha and endotoxin. TNF-alpha and endotoxin had no effect on the bilirubin-albumin titration curves. Our results have shown that TNF-alpha and endotoxin increase the cytotoxicity of bilirubin. These findings provide supportive evidence that sepsis would increase the risk of tissue damage by bilirubin.

End tidal carbon monoxide concentration in childhood haemolytic disorders

OBJECTIVES

Endogenous carbon monoxide (CO) is produced mainly by heme catabolism. As CO is excreted solely by the lung, a simple technique for measuring the end tidal carbon monoxide (ETCO) level was assessed as a method for screening for haemolytic disease in children.

METHODS

Two end expiratory breath samples were collected from normal children and from children with haemolytic disease using a one way valve connector between a mouth piece and an anaesthetic bag. The samples were analysed by gas chromatography for CO and carbon for dioxide (CO2). The CO2 value was used to normalise the CO value to an alveolar concentration. Carboxyhaemoglobin (HbCO) also was measured in the patient group for correlation analysis with ETCO.

RESULTS

A total of 21 children with beta thalassaemia major, 15 children with other haemolytic diseases (hereditary spherocytosis n=8, haemoglobin H disease n=3 and thalassaemia intermedia n=4) and 23 normal children were studied. The mean ETCO concentrations in the three groups were 3.21 p.p.m., 7.41 p.p.m. and 0.69 p.p.m., respectively, which were significantly different from each other (P<0.0001). There was a significant correlation between ETCO and HbCO in the patient groups (r=0.85; P<0.0001).

CONCLUSIONS

The end expiratory breath collection device is a simple and feasible sample collection method. The results confirm that ETCO can be used clinically to distinguish children with a variety of haemolytic disorders from normal subjects.

Nutritional management of regurgitation in infants

Infantile regurgitation is a frequently occurring problem. Throughout the world, anxious parents are imploring physicians to eliminate their infant's regurgitation. General practitioners, pediatricians and pediatric gastroenterologists strive to alleviate infantile regurgitation and its related parental stress. In this paper we define the scope of the problem and analyze the optimal, cost-efficient management approach to simple regurgitation in infants. The intent of this paper is to disseminate this information to practicing physicians and other health care professionals in an attempt to minimize the impact of this annoying problem of infancy and to eliminate confusion and expensive diagnostic tests and use of sub-optimal treatment modalities. Parental reassurance and dietary management by feeding thickened formula are important components in managing regurgitation in infants while maintaining optimal nutritional intake for adequate growth and development.

Modification of the MTT method for the study of bilirubin cytotoxicity

BACKGROUND

We propose a modification of the MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] method to study the cytotoxicity of bilirubin. The original method involves reading the intensity of a purplish blue color resulting from the conversion of MTT to formazan crystals by the mitochondria of viable cells. We have found that when the method is applied to study the effect of bilirubin on growing cells, precipitation of the yellow bilirubin pigment interferes with the colorimetric reading.

METHODS

A human liver cell line was used. The interference of bilirubin deposition on the MTT assay was investigated by comparing the value of optical density of the MTT solution in the presence and absence of bilirubin. The effect of 0.04 mol/L HCL-isopropanol on the bilirubin precipitate was tested by recovering the amount of bilirubin from the wells after the isopropanol treatment.

RESULTS

Bilirubin deposition increases MTT reading by 10-24%. Hydrochloride-isopropanol (0.04 mol/L) dissolves MTT formazan only without disturbing the bilirubin precipitates. The bilirubin extracted into the supernatant was less than 5% of the total bilirubin deposited.

DISCUSSION

This indirect MTT assay, as developed in this study, could eliminate the interference of bilirubin deposits and serve as a good method for the study of bilirubin cytotoxicity.

Sepsis during total parenteral nutrition: exploration of risk factors and determination of the effectiveness of peripherally inserted central venous catheters

BACKGROUND

Sepsis is the most frequent serious complication during total parenteral nutrition (TPN), resulting in increased morbidity, mortality and health care costs. Existing reports have not documented the risk factors of sepsis during TPN. The objectives of this study were to determine the rate of sepsis in our practice and to explore the risk factors for sepsis during TPN. We also determined the role and efficacy of using peripherally inserted central venous catheters (PCVC) as insertion catheters to administer TPN.

METHODS

From October, 1994, to May, 1996, we administered TPN to 378 pediatric patients hospitalized at Mackay Memorial Hospital. We followed all cases for the occurrences of any complications while administering TPN. We studied all patients who had fever, a clinical presentation of sepsis and a positive blood culture during their course of TPN.

RESULTS

During the 20-month period 378 patients received TPN for a total of 6562 days. Fifty-six patients presented with clinical sepsis and positive blood cultures. Significant features in the sepsis group included longer duration of TPN, age < 3 months, usage of central venous catheters, gastrointestinal diseases as indication for TPN, low birth weight and short gestational age in prematurity. Seven patients died despite prompt antimicrobial therapy. One hundred eleven patients received TPN via PCVC for a mean duration of 17.1 days, significantly longer than 10.4 days in the peripheral intravenous catheter group but no difference between the sepsis rates.

CONCLUSION

Considering the high incidence of sepsis during TPN, every attempt should be made to minimize the length of TPN therapy and encourage early enteral feeding. We also recommend the use of PCVC in patients requiring prolonged nutritional support.

Prevalence and genotypes of alpha- and beta-thalassemia carriers in Hong Kong -- implications for population screening

BACKGROUND

The thalassemias are common in southern China. We determined the prevalence of heterozygous carriers of these genetic disorders in Hong Kong and assessed the feasibility of a community-based screening program.

METHODS

An educational and screening program for the thalassemias was carried out in three high schools with a total of 2420 students. Seventy-five percent of the students agreed to undergo screening, which consisted of blood counts, hemoglobin electrophoresis, serum ferritin measurements, and DNA analyses.

RESULTS

Of the 1800 blood samples tested, 150 (8.3 percent) had microcytosis (mean corpuscular volume, <80 microm3). Ninety students (5.0 percent) were carriers of alpha-thalassemia, of whom 81 (4.5 percent) were carriers of the Southeast Asian type of deletion, in which both alpha-globin genes on the same chromosome 16 are deleted. Sixty-one students (3.4 percent) were carriers of either beta-thalassemia or the mutation coding for hemoglobin E. Six students were carriers of both alpha- and beta-thalassemias. On the basis of these figures, the estimated numbers of pregnancies in Hong Kong in which the fetus is at risk for homozygous alpha-thalassemia and beta-thalassemia major or intermedia are 145 and 80 per year, respectively. In Hong Kong the actual numbers of women referred for prenatal diagnoses of these disorders are approximately 95 and 40 per year, respectively.

CONCLUSIONS

Despite the availability of hospital-based screening and prenatal diagnosis for many years in Hong Kong, many women carrying fetuses at risk for thalassemia are not referred for genetic counseling. A community-based program of education, screening, and counseling is needed in Hong Kong and southern China.

Born small for gestational age: consequences for growth

A large number of studies have documented a strong correlation between size at birth and subsequent height, although the reported incidence of catch-up growth and consequently the impact on final height has varied with time and between countries. These variations may be real, but could also be related to a number of methodological problems. The aim of this study was to explore two important aspects related to postnatal growth after disturbed fetal growth: first, the definition of small for gestational age (SGA), including the selection of cut-off points in defining shortness; and, secondly, the importance of the general socio-economic status of the population with regard to the incidence of growth faltering in early life. Data were analysed from two longitudinal population-based studies, one from Sweden and one from Hong Kong. Of the Swedish cohort, 3.8% had a birth length below -2 SD scores; in the Hong Kong population the corresponding value was 11.9% (Swedish reference values were used in both studies). The following conclusions were made. Size at birth is important for postnatal growth, and the difference in length at birth of 9-10 cm between the two extreme birth length subgroups remains, on average, until maturity. This seems to be true for the two study populations with different degrees of socio-economic development. However, the rate of catch-up growth is highly dependent on the definition of SGA, on the rate of catch-up growth in early life and on the incidence of growth faltering between 6 and 18 months of age.

Pancreatitis in children--experience with 43 cases

Pancreatitis in children is not common and can be associated with severe morbidity and mortality. We encountered 43 children, ranging in age from 2 to 18 years, with pancreatitis over the past 10 years. The diagnosis of pancreatitis was made in those patients who showed: (1) significant intra-operative pathology or; (2) clinical findings of pancreatic inflammation and laboratory confirmation. More than one third (16 cases) of the cases were due to trauma, other causes included systemic disease (10), structural disease (8), and toxins or drugs (4). Five cases were classified as idiopathic. Most of the patients presented with abdominal pain (95%) and vomiting (56%). Jaundice was found in 7 patients and an abdominal mass in 2. Morbidity included pseudocyst (10), relapse (4), hyperglycaemia (4) and miscellaneous problems. Eight (50%) of the patients with trauma and 6 (86%) of the patients with structural diseases required surgery. Other patients were managed conservatively with bowel rest, gastric decompression, intravenous fluid and total parenteral nutrition. One case had a fatal outcome. All the survivors did well in long term follow up. Relevant literature has been reviewed and the sensitivity of various diagnostic modalities compared and discussed. A lesser known association between pancreatitis and structural anomalies such as choledochal cyst is discussed. To our knowledge, the present review is the first on pancreatitis in Chinese children.

CONCLUSION

Pancreatitis can occur from a wide variety of causes and may result in severe complications. Early diagnosis, close monitoring and aggressive intervention are mandatory to reduce morbidity and mortality.

Rapid detection of common Chinese glucose-6-phosphate dehydrogenase (G6PD) mutations by denaturing gradient gel electrophoresis (DGGE)

We describe here the use of denaturing gradient gel electrophoresis (DGGE) to detect the most common Chinese glucose-6-phosphate dehydrogenase (G6PD) variants, which are the single point mutations: G-->T at nt 1376, G-->A at 1388 both in exon 12 and A-->G at nt 95 in exon 02. In each case, the mutant allele resolves well from the normal allele(s). The distinct heteroduplex bands are characteristic of a particular genotype suggesting that this feature is very useful for identifying all heterozygous carriers for this and other X-linked diseases. When the analysis is extended to other exons, DGGE scans the gene and coupled with direct sequencing, it leads to the identification of new G6PD variation(s). With this approach, we identified a mutation in exon 9 which had not been reported in Hong Kong. Since DGGE can rapidly screen many unknown samples in one gel, this approach could be used to diagnose these G6PD mutations and to identify the at-risk for counselling.

Breath hydrogen (H2) analysis in southern Chinese children and infants by gas chromatography and a novel automatic sampling system

Breath hydrogen (H2) analysis was used to study lactose malabsorption in Southern Chinese children and infants. End-expired air was collected in 85 children using a modified anaesthesia bag system; while in infants, a novel automated end-expired sampling device was constructed and tested on 45 term and 27 preterm infants. Hydrogen and other respiratory gases were measured in the expired air using standard gas chromatograph equipped with a thermal conductivity detector. The system was found to have a detection limit of 0.5 ppm for H2. Both sampling methods were found to be reproducible, with intra-individual coefficient variations of less than 10%. Using 5% carbon dioxide as the expected alveolar concentration, the samples obtained by the bag system represented 85% of the end-expired air, while those obtained by the automated machine corresponded to 75%-100% end-tidal air. Taking 20 ppm rise in breath H2 as a cutoff criterion, the incidence of lactose malabsorption in the children was 78%; while in term and preterm infants this was 17.8% and 63% respectively.