Time trend prevalence of helicobacter pylori infection and endoscopic findings in symptomatic children in Portugal: A retrospective study based on three time points in 2009, 2014, and 2019

BACKGROUND

Helicobacter pylori infection acquisition occurs mainly in childhood and may be a critical factor in developing long-term complications. In contrast to other developed countries, previous studies have reported a relatively high H. pylori infection prevalence in Portugal, both in children and adults. However, there are no recent data concerning pediatric population.

MATERIALS AND METHODS

We performed a retrospective observational study concerning an 11 years period (2009, 2014, 2019), that included patients under 18 years old who underwent upper endoscopy at a pediatric tertiary center. Demographic, clinical-pathological, and microbiological data were collected.

RESULTS

Four hundred and sixty one children were included. The average age was 11.7 ± 4.4 years. In total, H. pylori infection was confirmed in 37.3% of cases (histology and/or culture) and a decreasing infection trend was observed (p = .027). The most common indication for endoscopy was abdominal pain, which was a good predictor of infection. Antral nodularity was present in 72.2% of the infected children (p < .001). In the oldest age groups, moderate/severe chronic inflammation, H. pylori density and lymphoid aggregates/follicles were positive predictors for the presence of antral nodularity. For all ages, the presence of antral nodularity, neutrophilic activity in the antrum and corpus and lymphoid follicles/aggregates in the antrum were positive predictors for the presence of H. pylori infection. Among the 139 strains tested for antibiotic susceptibility, 48.9% were susceptible to all tested antibiotics. Resistance to clarithromycin, metronidazole, and both was detected in 23.0%, 12.9%, and 6.5% of the strains, respectively; furthermore, resistance to ciprofloxacin and to amoxicillin was observed in 5.0% and 1.4% of the strains, respectively.

CONCLUSIONS

The present study reports (for the first time in Portugal) a significant decreasing trend in the prevalence of pediatric H. pylori infection, although it remains relatively high compared to the recently reported prevalence in other South European countries. We confirmed a previously recognized positive association of some endoscopic and histological features with H. pylori infection, as well as a high prevalence rate of resistance to clarithromycin and to metronidazole. The clinical relevance of these findings requires confirmation with further studies at a national level, taking into account the high incidence rate of gastric cancer in Portugal and the potential need for country-specific intervention strategies.

Management of Helicobacter pylori infection in paediatric patients in Europe: results from the EuroPedHp Registry

Purpose

The EuroPedHp-registry aims to monitor guideline-conform management, antibiotic resistance, and eradication success of 2-week triple therapy tailored to antibiotic susceptibility (TTT) in Helicobacter pylori-infected children.

Methods

From 2017 to 2020, 30 centres from 17 European countries reported anonymized demographic, clinical, antibiotic susceptibility, treatment, and follow-up data. Multivariable logistic regression identified factors associated with treatment failure.

Results

Of 1605 patients, 873 had follow-up data (53.2% female, median age 13.0 years, 7.5% with ulcer), thereof 741 (85%) treatment naïve (group A) and 132 (15%) after failed therapy (group B). Resistance to metronidazole was present in 21% (A: 17.7%, B: 40.2%), clarithromycin in 28.8% (A: 25%, B: 51.4%), and both in 7.1% (A: 3.8%, B: 26.5%). The majority received 2-week tailored triple therapy combining proton pump inhibitor (PPI), amoxicillin with clarithromycin (PAC) or metronidazole (PAM). Dosing was lower than recommended for PPI (A: 49%, B: 41%) and amoxicillin (A: 6%, B: 56%). In treatment naïve patients, eradication reached 90% (n = 503, 95% CI 87–93%) and 93% in compliant children (n = 447, 95% CI 90–95%). Tailored triple therapy cured 59% patients after failed therapy (n = 69, 95% CI 48–71%). Treatment failure was associated with PAM in single clarithromycin resistance (OR = 2.47, 95% CI 1.10–5.53), with PAC in single metronidazole resistance (OR = 3.44, 95% CI 1.47–8.08), and with low compliance (OR = 5.89, 95% CI 2.49–13.95).

Conclusions

Guideline-conform 2-weeks therapy with PPI, amoxicillin, clarithromycin or metronidazole tailored to antibiotic susceptibility achieves primary eradication of ≥ 90%. Higher failure rates in single-resistant strains despite tailored treatment indicate missed resistance by sampling error.

Bile acids profile and redox status in healthy infants

BACKGROUND

At birth, human neonates are more likely to develop cholestasis and oxidative stress due to immaturity or other causes. We aimed to search for a potential association between bile acids profile, redox status, and type of diet in healthy infants.

METHODS

A cross-sectional, exploratory study enrolled 2-month-old full-term infants (n = 32). We measured plasma bile acids (total and conjugated), and red blood cell (RBC) oxidative stress biomarkers. The type of diet (breastfeeding, mixed, formula) was used as an independent variable.

RESULTS

Plasma total bile acids medium value was 14.80 µmol/L (IQR: 9.25-18.00). The plasma-conjugated chenodeoxycholic acid percentage (CDCA%) correlated significantly and negatively with RBCs membrane-bound hemoglobin percentage (MBH%) (r = -0.635, p < 0.01) and with RBC-oxidized glutathione (r = -0.403, p < 0.05) levels. RBC oxidative stress biomarkers (especially MBH%) were predictors of conjugated CDCA%, and this predictive ability was enhanced when adjusted for the type of diet (MBH, r = 0.452, p < 0.001).

CONCLUSIONS

Our data suggest that the bile acid profile might play a role in the regulation of redox status (or vice versa) in early postnatal life. Eventually, the type of diet may have some impact on this process.

IMPACT

The conjugated CDCA% in plasma is negatively correlated with biomarkers of RBC oxidative stress in healthy infants. Specific biomarkers of RBC oxidative stress (e.g. MBH, GSH, GSSG) may be promising predictors of conjugated CDCA% in plasma. The type of diet may influence the predictive ability of hit RBC oxidative stress biomarkers (e.g. MBH, GSH, GSSG). Our findings suggest a link between plasma bile acids profile and the RBC redox status in healthy infants, eventually modulated by the type of diet. The recognition of this link may contribute to the development of preventive and therapeutic strategies for neonatal cholestasis.

Emergency endoscopy in pediatrics during the SARS-CoV-2 pandemic in a tertiary center - A changing pattern?

A retrospective analysis of admissions to the pediatric emergency department that required emergency endoscopy was performed, to evaluate if changes in the lifestyle and hospital practices imposed by the pandemic had an impact on the frequency and profile of the emergency endoscopy. The first 6 months of the pandemic (Group A) were compared with the homologous period of the previous year (Group B). Eight-nine cases were analyzed. Most emergency endoscopies occurred in children under the age of two (28%) and most of these were in Group A (p = 0.009). More foreign bodies were removed in Group A (p = 0.026). There were no statistically significant differences in the time to reach the emergency department (p = 0.934) or in the time delay since emergency room admission until the endoscopic procedure (p = 0.266). Overall, the pandemic did not seem to affect the quality of healthcare practice regarding emergency endoscopic procedures.

Battery Ingestion in Children, an Ongoing Challenge: Recent Experience of a Tertiary Center

INTRODUCTION

Morbidity related to childhood battery ingestions (BI) has increased recently due to the expanding use of larger lithium cells. A prompt endoscopic removal is vital to prevent severe complications in cases of esophageal batteries (EB).

MATERIALS AND METHODS

A retrospective, descriptive study of admissions for BI requiring endoscopic removal in a tertiary hospital's pediatric emergency department (Jan. 2011/Dec. 2020).

RESULTS

We had 35 cases, with an increasing incidence in the last 6 years; median age, 26 m (8 m-10 years), witnessed ingestion in 86%. On the X-ray: 14 (40%) had an EB, 21 (60%), a gastric battery (GB). Symptoms were present in 57% (100% EB/24% GB), and vomiting was the most frequent (50%). Endoscopy revealed: EB, 13 (37%); GB, 17 (49%); duodenal battery, 1 (3%); no battery, 4 (11%). Median time to removal: EB, 7 h (2 h-21days); GB, 12 h (2 h-3 days). All the patients with EB on the X-ray (14) had severe mucosal injury (Zargar classification): Grade IIIa, 7 (50%); IIIb, 5 (36%); IV, 2 (14%). CT-scan showed perforation in 2 patients (total, 4; 29% of EB). In patients with GB (21), 14 (67%) had mucosal damage; 13 (93%), mild (< Grade III, two esophageal erosions); 1 (7%) IIIa (esophageal ulceration). A statistically significant association between exposure time, younger age or battery size and severity of endoscopic lesions was found in EB location. There were no mortality cases. Acute complications occurred in 57% of EB: infection, 50%; perforation, 29%; pneumomediastinum/stridor, 14%; pneumothorax/subglottic stenosis/hemodynamic instability, 7 vs. 0% GB. Stenosis subsequently developed in 6 (43%) of EB: mild, 4 cases (29%); severe, 2 cases (14%, one resolved after endoscopic dilation; one needed a gastrostomy and esophagocoloplasty).

CONCLUSION

We verified recent increase in admissions due to battery ingestions and associated complications, despite the availability of an emergency pediatric endoscopy team. The patients with EB had more severe mucosal injury and poorer short/long-term outcomes. Children with GB had milder lesions, although the presence of a GB did not exclude esophageal injury. The availability of actual data from national referral centers will support advocacy efforts among stakeholders, including industry representatives and policy makers, in preventing worldwide button battery injury.

The role of minor salivary glands' biopsy in the diagnosis of Sjögren's syndrome and other systemic diseases

BACKGROUND

The minor salivary glands' biopsy is a minimally invasive procedure used for the diagnosis of Sjögren's syndrome. Its significance has also been reported in other inflammatory/infiltrative diseases. The objectives are to investigate its use in the diagnosis of Sjögren's syndrome, as well as to evaluate its role in the diagnosis of amyloidosis and sarcoidosis.

METHODS

A retrospective analysis was carried out on patients who underwent minor salivary glands' biopsies between April of 2014 and December of 2017.

RESULTS

A total of 173 patients were identified. Of the patients with suspected Sjögren's syndrome, in 40% of the cases there was evidence of lymphocytic sialadenitis. The antibodies against SSA, antinuclear antibodies and the Rheumatoid Factor correlated significantly with the presence of lymphocytic sialadenitis. The result of the minor salivary glands' biopsies allowed an increase of 12.4% of patients who met the criteria defined by the American - European Consensus Group. Of the patients with suspected amyloidosis (25%), the biopsies were positive in 4 patients.

CONCLUSION

The minor salivary glands' biopsy is a simple procedure with effectiveness in the diagnosis of Sjögren's syndrome and amyloidosis. In this study, its use increased the number of patients who met the Sjögren's syndrome classification criteria. It also appears to be useful in the diagnosis of amyloidosis.

The Stool Color Card as a Screening Tool for Biliary Atresia in the Digital Version of the Portuguese Child and Youth Health Booklet

N/a.

The Challenge of Skin Lesions in Systemic Diseases

A 47-year-old man, obese, without medical problems, presented with a 15-day history of painful erythematous nodular lesions on the anterior side of lower limbs. He had no improvement with antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs). He developed migratory and symmetric arthralgias (ankles, knees, elbows) and low-grade fever. The skin lesions progressed to the upper limbs. On physical examination, a mild swelling and tenderness in both ankles was noted, and lesions suggestive of erythema nodosum were seen.[...]

Which cues influence the perceived usefulness and credibility of an online review? A conjoint analysis

Purpose

This study aims to assess the relative importance of the argument strength, argument sidedness, writing quality, number of arguments, rated review usefulness, summary review rating and number of reviews in determining the perceived usefulness and credibility of an online review. Additionally, the authors use insights from the elaboration likelihood model (ELM) to explore the effect of consumers' product category involvement on the cues' relative importance.

Design/methodology/approach

A conjoint analysis (N = 287) is used to study the relative importance of the seven previously mentioned attributes. A balanced orthogonal design generated eight cards that correspond to individual reviews. Respondents scored all eight cards in a random order for perceived usefulness and credibility.

Findings

Overall, argument strength is the most important cue, while summary review rating and the number of reviews are the least important for perceived review usefulness and credibility. The number of arguments is more important for people who are more highly involved with the product, while writing quality and rated review usefulness are relatively more important for the low-involvement group.

Originality/value

This study provides a comprehensive test of how consumers perceive online reviews, as it the first to the authors’ knowledge to simultaneously investigate a large set of cues using conjoint analysis. This method allows for the implicit valuation (utility) of the individual cues, revealing the cues' relative importance, in a setting that comes close to a real-life context. Besides, insights of the ELM are used to understand how the relative importance of cues differs depending on the level of review readers' product category involvement.

Portuguese Consensus on Diagnosis, Treatment, and Management of Anemia in Pediatric Inflammatory Bowel Disease

Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD), both in pediatric and in adult patients. Iron deficiency is the main cause of anemia in patients with IBD. Anemia is a clinically relevant comorbidity, with impact on patients' quality of life and it should be timely diagnosed and adequately treated. Currently, an active treatment approach is the recommended strategy, with evidence showing efficacy and safety of intravenous iron formulations. However, evidence in pediatric age remains scarce and no clinical recommendations exist for the diagnosis and treatment of this particular age group. The present document represents the first national consensus on the management of anemia in pediatric IBD and is therefore particularly relevant. The authors anticipate that the proposed recommendations will be useful in daily clinical practice for diagnosing and managing iron deficiency and iron-deficiency anemia in the pediatric population with IBD.

Neonatal Cholestasis Over Time: Changes in Epidemiology and Outcome in a Cohort of 154 Patients From a Portuguese Tertiary Center

Introduction: In the last two decades there have been advances in the diagnosis and management of neonatal cholestasis, which may have changed its epidemiology, diagnostic accuracy, outcomes, and survival. Our goal was to characterize these changes over time in our setting. Methods: Retrospective cohort study in a tertiary center, enrolling patients born between January 1985 and October 2019. The cohort was divided into two periods, before (A; n = 67) and after (B; n = 87) the year 2000; and in two groups, according to patient's outcome (favorable, unfavorable). Overall survival and survival with and without orthotopic liver transplant (OLT) were evaluated in the two periods (A and B) and in different subgroups of underlying entities. Results: We found that the age of cholestasis recognition decreased significantly from period A to period B [median 43 days and 22 days, respectively, (p < 0.001)]; the changes in epidemiology were relevant, with a significant decrease in alpha-1-antitrypsin deficiency (p < 0.001) and an increase in transient cholestasis (p = 0.004). A next-generation sequencing (NGS) panel available since mid-2017 was applied to 13 patients with contributory results in 7, but, so far, only in 2 patients led to conclusive diagnosis of underlying entities. The number of cases of idiopathic cholestasis did not vary significantly. Over time there was no significant change in the outcome (p = 0.116). Overall survival and survival without OLT had no significant improvement during the period of observation (in periods A and B, 86 vs. 88%, and 85 vs. 87%, respectively). However, in period B, with OLT we achieved the goal of 100% of survival rate. Conclusions: Our data suggest that transient cholestasis became a very important subset of neonatal cholestasis, requiring specific guidance. The NGS panels can provide important inputs on disease diagnosis but, if applied without strict criteria and expertise, they can open a Pandora's box due to misinterpretation. Despite all the advances in accurate diagnosis and timely management-including early recognition of cholestasis-the improvement in patient outcomes and survival were still not significant.

Major Cardiac Events in Patients Admitted to Intensive Care After Vascular Noncardiac Surgery: A Retrospective Cohort

Introduction. Patients proposed to vascular noncardiac surgery (VS) have several comorbidities associated with major adverse cardiac events (MACE). We evaluated incidence, predictors, and outcomes, and compared different scores to predict MACE after VS. Methods. We included all patients admitted from 2006 to 2013. Perioperative MACE included cardiac arrhythmias, myocardial infarction (MI), cardiogenic pulmonary edema (CPE), acute heart failure (AHF), and cardiac arrest (CA). Lee Revised Cardiac Risk Index (RCRI), Vascular Quality Initiative (VQI-CRI), Vascular Study Group of New England (VSG-CRI), and South African Vascular Surgical (SAVS-CRI) Cardiac Risk Indexes were calculated and analyzed. We performed multivariate logistic regression to assess independent predictors with calculation of odds ratio (OR) and 95% confidence interval (CI). To reduce overfitting, we used leave-one-out cross-validation approach. The Predictive ability of scores was tested using area under receiver operating characteristic curve (AUROC). Results. A total of 928 patients were included. We observed 81 MACE (28 MI, 22 arrhythmias, 10 CPE, 9 AHF, 12 CA) in 60 patients (6.5%): 3.3% in intermediate-risk surgery and 9.8% in high-risk surgery. Previous history of coronary artery disease (OR = 3.2, CI = 1.8-5.7), atrial fibrillation (OR = 5.1, CI = 2.4-11.0), insulin-treated diabetes mellitus (OR = 3.26, CI = 1.51-7.06), mechanical ventilation (OR = 2.75, CI = 1.41-4.63), and heart rate (OR = 1.02, CI = 1.01-1.03) at admission were considered independent risk factors in multivariate analysis. The AUROC of our model was 0.79, compared with RCRI (0.66), VSG-CRI (0.69), VQI-CRI (0.71), and SAVS-CRI (0.73). Conclusions. Observed MACE were within predicted range (1% to 5% after intermediate-risk surgery and >5% after high-risk surgery). SAVS-CRI and VQI-CRI had slightly better predictive capacity than VSG-CRI or RCRI.

Clinical practices among healthcare professionals concerning neonatal jaundice and pale stools

Jaundice and pale stools are major indicators of neonatal liver disease. Prognosis depends on timely diagnosis and management. We evaluated the clinical practices among healthcare professionals concerning jaundiced newborns and their ability to recognize pale stools. We supplied a questionnaire and a panel with eight photographs of stools, both locally validated, to physicians and nurses of the National Healthcare Service. Analysis was conducted according to professional status, specialization and years of experience of professionals and level of healthcare. Questionnaires were administered to 266 participants (100 physicians, 166 nurses). The decision to send patients to medical observation depended on the intensity of jaundice for a significant percentage of nurses. Concerning jaundiced newborns breastfed and otherwise healthy, 28.9% of physicians would never request a conjugated bilirubin assay, and only 43.3% would request it after 14 days old; for those with other signs/symptoms of disease, only 69.1% of physicians would request it immediately. Multiple linear regression analysis identified specialization as an independent variable significantly associated with the ability to recognize pale stools.

CONCLUSION

A significant percentage of healthcare professionals assumed clinical practices that preclude the timely recognition of cholestasis/pale stools, reinforcing the idea of educational needs. Specialization, rather than years of experience of professionals, was associated with better skills and practices. What is Known: • Neonatal cholestasis is a condition with some rare underlying entities having high mortality and morbidity. Early diagnosis is crucial to improve prognosis. Yet, many cases remain late recognized and referred. • Studies evaluating the ability of healthcare professionals to recognize neonatal cholestasis are scarce. What is New: • In this study, a significant percentage of professionals assumed clinical practices that preclude timely recognition of neonatal cholestasis and pale stools, reinforcing the idea of educational needs. • Specialization of professionals was associated with better skills and practices.

Pediatric Crohn's disease, iron deficiency anemia and intravenous iron treatment: a follow-up study

BACKGROUND AND AIMS

Increasing evidence in adults demonstrates efficacy and safety of IV iron in inflammatory Bowel disease (IBD) associated iron deficiency anemia; however, evidence in pediatric patients is yet scarce and no previous study has included a long follow-up. This study aimed to evaluate safety and efficacy of IV iron (primary end point), and the need of re-treatment (secondary end point), in this setting.

METHODS

Prospective recruitment (40 months); PCDAI determined before and after treatment; anemia defined according to WHO criteria; IV iron treatment included iron sucrose and ferric carboxymaltose. Primary and secondary endpoints included hemoglobin, serum ferritin, transferrin saturation at baseline and 4-6 weeks after treatment; and the need of re-treatment during the median follow-up period (18 months), respectively.

RESULTS

Nineteen patients (median age: 15.5 years) with remissive/mild disease were included. At recruitment, the median hemoglobin was 10.5 g/dl, (median s-ferritin: 20.1 ug/l, median transferrin saturation; 6%) and 4-6 weeks after treatment was 12.7 g/dl. Median hemoglobin according to age groups before vs. after treatment: <12 years:11 vs. 12.0 g/dl; females ≥12 years:9.9 vs. 12.6 g/dl; and males ≥12 years:11.1 vs. 13.3 g/dl. Patients with remissive vs. mild disease had median Hb of 10.5 g/dl vs. 10.6 g/dl, and median s-ferritin: 6.8 ug/dl vs. 43.3 ug/dl, respectively). Nine patients were treated with iron sucrose (median dose 672.6 mg/dl) and 10 patients with ferric carboxymaltose (median dose 811.5 mg/dl). No major adverse reactions occurred. Six patients needed re-treatment after a median 15.5 months period.

CONCLUSIONS

Our prospective study, concerning pediatric IBD anemia patients with remission/mild disease and a significant follow-up, emphasizes efficacy and safety of IV-iron and the importance of long-term follow-up of iron status.

SUMMARY

In pediatric IBD iron anemia, the evidence supporting the efficacy and safety of IV-iron is scare. This prospective study aims to evaluate the safety and efficacy (short and long term) of IV-iron in these patients. Nineteen pediatric CD patients were evaluated before and after IV iron treatment (40-month period).The median Hb before and after IV iron was 10.5 and 12.7 g/dl, respectively. No major adverse reactions were documented. Six patients needed re-treatment (median period of 15.5 months). This study further demonstrates the efficacy and safety of IV iron. It reinforces the importance of long-term follow-up of the iron status in pediatric CD patients.

Surgery in Pediatric Crohn Disease: Case Series from a Single Tertiary Referral Center

Introduction

There is a recognized increase of lifelong surgery risk in Crohn disease (CD). Outcome data concerning surgery in children, particularly in the biological era, are limited.

Aim

To characterize the clinical profile and the clinical outcome in children and adolescents with CD who underwent surgical intervention, in a single tertiary referral center.

Methods

Retrospective, cross-sectional study, including pediatric patients with CD undergoing intra-abdominal surgery in the last 11 years.

Results

Included eight of 50 CD total patients (16%); six female; median age at CD diagnosis of 12.0 years; Paris classification: (a) location: ileocolonic (5), colonic (1), upper disease (1), ileocolonic/upper disease (1); (b) behavior: stricturing (4), nonstricturing nonpenetrating (2), penetrating (1), both penetrating and stricturing disease (1); growth delay (2). Six children received thiopurines, five mesalazine, three corticosteroids and four anti-TNF therapy, preoperatively. Surgery followed diagnosis by a median of 2.9 years. Median PCDAI at the time of surgery was 35.0. Elective surgery was performed in six patients and emergency surgery in two, without major complications. Five children received anti-TNF and three thiopurines post-operatively. Within the follow-up period (median 1.7 years), relapse occurred in one child (3.2 years after intervention); the remaining seven patients persist in clinical remission. Median PCDAI in the last evaluation was 6.3. Weight and height recovery was observed in seven patients, at last follow-up.

Conclusion

Surgical treatment of CD is a valid alternative in selected cases, contributing to the resolution of acute complications and maintenance of remission, allowing disease-free interval and nutritional recovery.

Peutz-Jeghers syndrome: early clinical expression of a new STK11 gene variant

Genetic heterogeneity has been recognised in Peutz-Jeghers syndrome (PJS) (over 230 STK11 gene mutations reported). We report a rare PJS phenotype with early extensive gastrointestinal (GI) presentation and a new genetic variant. The case presented as haematochezia and mucocutaneous pigmentation (the patient was 3 years of age). Endoscopy showed several polyps throughout the stomach/colon (PJ-type hamartomas); the larger polyps were resected. Small bowel imaging detected multiple jejunum/ileum small polyps. During 8 years of follow-up of this asymptomatic patient, an increasing number of diffusely distributed polyps was observed and polypectomies were performed. Subsequently, the patient failed consultations; when the patient was 13 years of age, emergency surgery was required due to small bowel intussusception (ileal polyp). A STK11 gene study identified two missense variants in heterozygous (yet unknown significance but probably pathogenic): c.854T>A (exon 6) and c.446C>T* (exon 2) (*not previously reported). We report two STK11 gene variants (one not previously described) of yet undetermined causality in a paediatric patient presenting with extensive GI involvement at a very early age, with no family medical history. Structural and functional repercussion of the newly described variants should be further investigated.

Autoimmune gastritis presenting as iron deficiency anemia in childhood

AIM: To characterize clinical, laboratorial, and histological profile of pediatric autoimmune gastritis in the setting of unexplained iron deficiency anemia investigation.

METHODS: A descriptive, observational study including pediatric patients with a diagnosis of autoimmune gastritis (positive parietal cell antibody and gastric corpus atrophy) established in a 6 year period (2006-2011) in the setting of refractory iron deficiency anemia (refractoriness to oral iron therapy for at least 6 mo and requirement for intravenous iron therapy) investigation, after exclusion of other potentially contributing causes of anemia. Helicobacter pylori (H. pylori) infection and anti-secretory therapy were also excluded. Data were retrospectively collected from clinical files, including: demographic data (age, gender, and ethnic background), past medical history, gastrointestinal symptoms, familial history, laboratorial evaluation (Hb, serum ferritin, serum gastrin, pepsinogen I/ pepsinogen II, B12 vitamin, intrinsic factor autoantibodies, thyroid autoantibodies, and anti-transglutaminase antibodies), and endoscopic and histological findings (HE, Periodic Acid-Schiff/Alcian blue, gastrin, chromogranin A and immunochemistry analysis for CD3, CD20 and CD68). Descriptive statistical analysis was performed (mean, median, and standard deviation).

RESULTS: We report a case-series concerning 3 girls and 2 boys with a mean age of 13.6 ± 2.8 years (3 Caucasian and 2 African). One girl had type I diabetes. Familial history was positive in 4/5 cases, respectively for autoimmune thyroiditis (2/5), sarcoidosis (1/5) and multiple myeloma (1/5). Laboratorial evaluation on admission included: Hb: 9.5 ± 0.7 g/dL; serum ferritin: 4.0 ± 0.9 ng/mL; serum gastrin: 393 ± 286 pg/mL; low pepsinogen I/ pepsinogen II ratio in 1/5 patients; normal vitamin B12 levels (analyzed in 3 patients). Endoscopy findings included: duodenal nodularity (2/5) and gastric fold softening (2/5), and histological evaluation showed corpus atrophic gastritis with lymphocytic infiltration (5/5), patchy oxyntic gland mononuclear cell infiltration (5/5), intestinal and/or pseudo-pyloric metaplasia in corpus mucosa (4/5), and enterochromaffin cell hyperplasia (4/5). Immunochemistry for gastrin on corpus biopsies was negative in all cases. Duodenal histology was normal. All biopsies were negative for H. pylori (Giemsa staining and cultural examination).

CONCLUSION: We highlight autoimmune gastritis as a diagnosis to be considered when investigating refractory iron deficiency anemia in children, particularly in the setting of a personal/familial history of autoimmune disease, as well as the diagnostic contribution of a careful immunohistological evaluation.

Helicobacter pylori infection - recent developments in diagnosis

Considering the recommended indications for Helicobacter pylori (H. pylori) eradication therapy and the broad spectrum of available diagnostic methods, a reliable diagnosis is mandatory both before and after eradication therapy. Only highly accurate tests should be used in clinical practice, and the sensitivity and specificity of an adequate test should exceed 90%. The choice of tests should take into account clinical circumstances, the likelihood ratio of positive and negative tests, the cost-effectiveness of the testing strategy and the availability of the tests. This review concerns some of the most recent developments in diagnostic methods of H. pylori infection, namely the contribution of novel endoscopic evaluation methodologies for the diagnosis of H. pylori infection, such as magnifying endoscopy techniques and chromoendoscopy. In addition, the diagnostic contribution of histology and the urea breath test was explored recently in specific clinical settings and patient groups. Recent studies recommend enhancing the number of biopsy fragments for the rapid urease test. Bacterial culture from the gastric biopsy is the gold standard technique, and is recommended for antibiotic susceptibility test. Serology is used for initial screening and the stool antigen test is particularly used when the urea breath test is not available, while molecular methods have gained attention mostly for detecting antibiotic resistance.

Hemangioma Hepático Infantil Gigante: Que Opções Terapêuticas?

Infantile Hepatic Hemagioma is the third most frequent liver tumor in children and the most common below 6 months of age. Therapeutic options depend on clinical manifestations and should be tailored on an individual patient basis. We present the case of a 4 year old boy with neonatal diagnosis of large vascularized liver tumor with imagiological criteria of Infantile Hepatic Hemagioma. We highlight the occurrence of heart failure and Kasabach-Merrit syndrome (thrombocytopenia, anemia) that have spontaneously regressed. During follow up, sequential imaging (ultrasound with Doppler, magnetic resonance imaging, dynamic contrast enhancement computed tomography) confirmed the hypothesis of IHH, allowing vascular mapping of the lesion. From the first year on, we observed a favorablecourse with progressive tumor regression. In the present case, a conservative approach has been maintained, but the best therapeutic option remains unclear. We highlight the specific features of this case, discussing the most cost - effective approach.

[Giant infantile hepatic hemangioma: which therapeutic options?]

Infantile hepatic hemangioma is the third most frequent liver tumor in children and the most common below 6 months of age. Therapeutic options depend on clinical manifestations and should be tailored on an individual patient basis. We present the case of a 4 year old boy with neonatal diagnosis of large vascularized liver tumor with imagiological criteria of infantile hepatic hemangioma. We highlight the occurrence of heart failure and Kasabach-Merrit syndrome (thrombocytopenia, anemia) that have spontaneously regressed. During follow up, sequential imaging (ultrasound with Doppler, magnetic resonance imaging, dynamic contrast enhancement computed tomography) confirmed the hypothesis of IHH, allowing vascular mapping of the lesion. From the first year on, we observed a favorable course with progressive tumor regression. In the present case, a conservative approach has been maintained, but the best therapeutic option remains unclear. We highlight the specific features of this case, discussing the most cost-effective approach.

Distribution of the - 13910C>T polymorphism in the general population of Portugal and in subjects with gastrointestinal complaints associated with milk consumption

BACKGROUND

The - 13910C>T polymorphism has been associated with lactase persistence (LP) in European populations.

AIM

To assess - 13910C>T genotypes across Portugal and in adult individuals with unspecific gastrointestinal complaints associated with milk consumption.

SUBJECTS AND METHODS

This study genotyped - 13910C>T in the general population from Northern (n = 64), Central (n = 70) and Southern (n = 65) Portugal and in 40 subjects with gastrointestinal symptoms. Additionally, the concordance was evaluated between breath-hydrogen test and - 13910C>T genotypes in 65 samples.

RESULTS

An overall frequency of 0.349 for the LP - 13910*T allele was estimated in the general population, with a noticeable decrease in the South (0.269) compared with North (0.383) and Centre (0.393). Among the symptomatic group, the frequency of the - 13910*T allele (0.363) was not significantly different from the general population. A 94% concordance was found between the breath-hydrogen and the molecular tests.

CONCLUSIONS

This study suggests that (i) the distribution of the LP polymorphism is not uniform across the country, (ii) genotyping - 13910C>T is a good diagnostic tool for lactase status in the Portuguese population and (iii) self-reported gastrointestinal complaints are not good predictors of the LP status, implying that a significant part of those complaints may not be related to hypolactasia.

Protein-losing gastropathy associated with cytomegalovirus infection in a child

Protein-losing gastropathy is a rare entity. Unlike the disease in adults, it usually is benign and self-limited in children. The aetiological contribution of cytomegalovirus has been insufficiently documented and the immunological status of patients was rarely described in most reports. The authors report an 11-year-old boy with generalised oedema and hypoproteinemia. Upper endoscopy with biopsies showed marked hypertrophy of gastric folds and foveolar hyperplasia involving the body and fundus. The presence of cytomegalovirus in gastric tissue was well documented through identification of intranuclear inclusions, immunohistochemistry and PCR. Immunodeficiency was clearly ruled out. Protein-losing gastropathy should be considered in children with oedema and hypoproteinemia. The aetiological diagnosis should be confirmed by endoscopy-based methods.

Esofagite eosinofílica: diversidade de expressão clínica em idade pediátrica

Eosinophilic esophagitis is an emerging chronic oesophageal inflammatory disease, increasingly recognized both in children and in adults. It is presently accepted that this entity has a chronic course with persistent or relapsing symptoms and a wide range of clinical manifestations at different age groups: in children it is responsible for feeding disorders, vomiting or abdominal pain; in teenagers and adults it causes dysphagia and oesophageal food impaction. The etiopathogenesis of eosinophilic esophagitis has not been yet well established, but immuno-allergic mechanisms associated with a Th2 immune response have been proposed. Diagnosis is based both on clinical and histological grounds, requiring that oesophageal mucosal biopsy specimens obtained from different oesophageal locations contain more than 15 intraepithelial eosinophils per high power field and the exclusion of gastroesophageal reflux disease. Currently proposed effective treatments rely on eviction of putative allergens through dietary exclusion and on treatment with swallowed steroids. We describe two cases (a young child and a teenager) illustrative of the clinical spectrum and course variability of eosinophilic esophagitis at pediatric age. A brief review of current knowledge concerning this puzzling clinical entity is presented, emphasizing specific diagnostic dilemmas and questions concerning its long-term follow-up.

[Eosinophilic esophagitis: clinical expression at pediatric age]

Eosinophilic esophagitis is an emerging chronic oesophageal inflammatory disease, increasingly recognized both in children and in adults. It is presently accepted that this entity has a chronic course with persistent or relapsing symptoms and a wide range of clinical manifestations at different age groups: in children it is responsible for feeding disorders, vomiting or abdominal pain; in teenagers and adults it causes dysphagia and oesophageal food impaction. The etiopathogenesis of eosinophilic esophagitis has not been yet well established, but immuno-allergic mechanisms associated with a Th2 immune response have been proposed. Diagnosis is based both on clinical and histological grounds, requiring that oesophageal mucosal biopsy specimens obtained from different oesophageal locations contain more than 15 intraepithelial eosinophils per high power field and the exclusion of gastroesophageal reflux disease. Currently proposed effective treatments rely on eviction of putative allergens through dietary exclusion and on treatment with swallowed steroids. We describe two cases (a young child and a teenager) illustrative of the clinical spectrum and course variability of eosinophilic esophagitis at pediatric age. A brief review of current knowledge concerning this puzzling clinical entity is presented, emphasizing specific diagnostic dilemmas and questions concerning its long-term follow-up.

Prevalence and incidence of Helicobacter pylori Infection in a healthy pediatric population in the Lisbon area

BACKGROUND

Helicobacter pylori is mainly acquired in childhood. Although adult studies reported a high prevalence of H. pylori infection in Portugal, the actual rate in children remains unknown. This study aimed to determine the prevalence and the incidence of H. pylori infection in an asymptomatic pediatric population of the Lisbon area and to correlate prevalence with sociodemographic determinants.

MATERIALS AND METHODS

Helicobacter pylori infection was determined by stool antigen test in 844 asymptomatic children (age 0-15 years; 49.4% boys). For the incidence study, H. pylori-negative children in the prevalence study were followed-up every 6 months over a 3-year period.

RESULTS

The global prevalence of H. pylori infection was 31.6%, increasing with age (19.9, 37.0 and 51.5%, in age groups 0-5, 6-10, and 11-15, respectively), but was similar among genders (34.5% in boys and 28.4% in girls). Older age and attendance of nursery/kindergarten during preschool constituted independent risk factors. The overall estimated incidence was 11.6 per 100 child-years (CY). Although 47.5% of children acquired H. pylori infection before 5 years of age, the mean age of acquisition was 6.3. The incidence of infection was similar among the three age groups (11.5, 13.0, and 10.5 per 100 CY, in age groups 0-5, 6-10, and 11-15, respectively).

CONCLUSIONS

The prevalence of H. pylori infection in the Portuguese pediatric population is still high. Although this study confirmed that the highest acquisition rate occurs at young age, it showed that in high-prevalence populations, older children can also acquire H. pylori infection at a rate similar to that of young children.

Successful endoscopic resolution of a large gastric bezoar in a child

Bezoars are masses or concretions of indigestible materials found in the gastrointestinal tract, usually in the stomach. Case reports of childhood gastric bezoars (particularly phytobezoars) are rare. In this age group they represent a therapeutic challenge, because of the combination of hard consistency and great size. The present report concerns an 8-year-old boy with a history of high fruit intake, presenting with abdominal complaints due to a large gastric phytobezoar. Successful endoscopic fragmentation coupled with suction removal was accomplished, using a standard-channel endoscope. Although laborious, it has been shown to be an efficacious and safe procedure, completed in one session. Endoscopic techniques for pediatric bezoar management may thus be cost effective, taking into account the avoidance of surgery, the length of the hospital stay and the number of endoscopic sessions.

Faecal and serum levels of eosinophil cationic protein in a healthy paediatric population

BACKGROUND

Eosinophil cationic protein (ECP) has been regarded as an excellent marker of eosinophil activation in various diseases where eosinophil-mediated inflammation plays a role. Recently, it has been suggested as a faecal marker of intestinal inflammation in several immune-mediated diseases with gastrointestinal expression. Owing to the scarcity of information at paediatric age, the establishment of reference values is necessary before further clinical studies.

OBJECTIVE

To determine faecal and serum ECP levels in healthy children and their association with other biological parameters, thereby providing background additional validation data for this age group.

METHODS

Faecal and serum ECP levels were available from healthy Caucasian children recruited at a regular outpatient clinic. Exclusion criteria were: chronic illnesses, acute illness, mucosal bleeding and recent pharmacological medication. Faecal and serum ECP levels and faecal a1AT were determined by commercial radioimmunoassay and serum IgE by fluoroenzyme immunoassay Uni-CAP.

RESULTS

Mean and median faecal ECP levels were 1.93 microg/g and 1.20 microg/g, respectively (range 0.41-22.20),while the corresponding serum ECP levels were 13.50 microg/L and 9.54 microg/L, respectively (range 0.20-74.8). The cut-offs found were 2.80 microg/g and 16.89 microg/L for faecal and serum ECP, respectively. A significant (p=0.001) increase in serum, but not in faecal, ECP levels was found among patients with high peripheral eosinophil blood count. Neither faecal nor serum ECP levels were influenced by serum IgE levels.

CONCLUSIONS

Faecal and serum ECP levels, as determined in the present study, add background information concerning reference levels at paediatric age for further studies indifferent clinical settings.

Mucosal lymphocyte subsets and HLA-DR antigen expression in paediatric Helicobacter pylori-associated gastritis

Paediatric studies may provide important insights into the immunopathology of Helicobacter pylori-associated gastritis, as mucosal changes reflect different stages of the immunoinflammatory response. We characterized, by quantitative immunohistochemistry, gastric mucosal lymphocyte phenotype and HLA-DR antigen expression and evaluated correlation with histopathology, in H. pylori-infected (Hp+ve) and uninfected children (Hp-ve). In the infected group, lamina propria CD3+ and IgA plasmocyte cell numbers were significantly higher and a trend for predominance of CD8+ over CD4+ was observed both in epithelium and lamina propria. A correlation of inflammation score with lamina propria CD3+ and CD4+ cell numbers and of CD45RO+ T lymphocytes with density of colonization was observed. The proportion of epithelial cells expressing HLA-DR antigen was significantly higher in the Hp+ve group and furthermore, glandular HLA-DR expression correlated with lamina propria CD3+ cell numbers, emphasizing the potential role of epithelial cells as antigen-presenting cells at this stage of infection.

Relationship among serum pepsinogens, serum gastrin, gastric mucosal histology and H. pylori virulence factors in a paediatric population

OBJECTIVE

Serum pepsinogens and gastrin have been proposed as markers of gastritis, but have seldom been studied in children. In this study the aim was to identify host- and Helicobacter pylori-related factors linked to variations in serum gastrin, PGI, PGII, and to evaluate the potential of these biomarkers for diagnosing gastritis, whether H. pylori-associated or not.

MATERIAL AND METHODS

Ninety-two dyspeptic children referred for endoscopy (peptic ulcer exclusion) were included in the study. H. pylori status (urease, culture, histology) was assessed, and genotype determined (PCR) in H. pylori-positive subjects. Serum gastrin, PGI and PGII levels were measured by standard radioimmunoassay (RIA).

RESULTS

PGI and PGII levels were significantly higher in H. pylori-positive subjects (p=0.007; p=0.012, respectively). Gastrin levels were significantly higher in H. pylori-negative subjects (p=0.035). PGI and PGII were associated significantly with higher antrum inflammation scores (p=0.002; p=0.016, respectively); only PGI was associated with age, after controlling for inflammation (p=0.033) and for activity (p=0.037). The contribution of virulence factors could not be assessed owing to the low number of virulent strains. After multivariate analysis, only antrum inflammation was independently associated with PGI level (p=0.012). Receiver operating characteristic (ROC) analysis showed a low PGI and PGII discriminant power for predicting antrum inflammation.

CONCLUSIONS

Pepsinogen levels as measured in this study seem predominantly to reflect antral inflammation, but they are not an effective screening test for gastritis (H. pylori-positive or -negative) in dyspeptic children.

Evaluation of rapid test Assure Helicobacter pylori for diagnosis of H. pylori in pediatric population

Non-invasive tests are needed to assess Helicobacter pylori infection, especially to screen a pediatric population. Assure H. pylori Rapid Test (Genelabs Diagnostics, Singapore) is an immunochromatographic assay device intended for the rapid detection of antibodies to H. pylori in human serum, plasma or whole blood. The aim of this study was to evaluate the performance of the rapid test, Assure H. pylori, in the diagnosis of H. pylori infection in children, using a Portuguese pediatric population. The study group included 130 children with age ranging from 1 to 14 years old (average age 9.2+/-3.1 years). According to the gold standard, 70 of the 130 patients studied were H. pylori positive and 60 were H. pylori negative. Using Assure H. pylori Rapid Test (Genelabs Diagnostics, Singapore), 53 sera had a positive result after 15 min (resulting in 17 false negatives) and 57 sera a negative result (resulting in 3 false positives). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the test were 75.7%, 95.0%, 94.6% and 77.0% respectively. When a longer read time of 45 min is considered, the rapid test revealed a good performance (sensitivity 98.6% and specificity 95%) in the evaluation of the H. pylori infection in a pediatric population. In conclusion, the test showed a good performance, suggesting its applicability as a screening method for the H. pylori infection.

Microsatellite variation and evolution of human lactase persistence

The levels of haplotype diversity within the lineages defined by two single-nucleotide polymorphisms (SNPs) (-13910 C/T and -22018 G/A) associated with human lactase persistence were assessed with four fast-evolving microsatellite loci in 794 chromosomes from Portugal, Italy, Fulbe from Cameroon, São Tomé and Mozambique. Age estimates based on the intraallelic microsatellite variation indicate that the -13910*T allele, which is more tightly associated with lactase persistence, originated in Eurasia before the Neolithic and after the emergence of modern humans outside Africa. We detected significant departures from neutrality for the -13910*T variant in geographically and evolutionary distant populations from southern Europe (Portuguese and Italians) and Africa (Fulbe) by using a neutrality test based on the congruence between the frequency of the allele and the levels of intraallelic variability measured by the number of mutations in adjacent microsatellites. This result supports the role of selection in the evolution of lactase persistence, ruling out possible confounding effects from recombination suppression and population history. Reevaluation of the available evidence on variation of the -13910 and -22018 loci indicates that lactase persistence probably originated from different mutations in Europe and most of Africa, even if 13910*T is not the causal allele, suggesting that selective pressure could have promoted the convergent evolution of the trait. Our study shows that a limited number of microsatellite loci may provide sufficient resolution to reconstruct key aspects of the evolutionary history of lactase persistence, providing an alternative to approaches based on large numbers of SNPs.

Antibiotic-resistant Helicobacter pylori strains in Portuguese children

BACKGROUND

Data concerning the effectiveness of Helicobacter pylori eradication regimens based in antibiotic susceptibility testing are scanty in children.

AIMS

To identify the prevalence of antibiotic resistance in H. pylori strains isolated from Portuguese children in 1999-2003; to evaluate eradication rate after antibiotic susceptibility testing-based treatment; and to identify factors associated with resistance and eradication outcome.

METHODS

Included were 109 children with a gastric biopsy culture positive for H. pylori. First treatment (amoxicillin, omeprazole and clarithromycin or metronidazole) was guided by susceptibility testing (E test), and eradication was assessed by [C]urea breath test.

RESULTS

Strains were susceptible to amoxicillin and tetracycline; 39.4% were resistant to clarithromycin, 16.5% to metronidazole and 4.5% to ciprofloxacin. No significant association was found between resistance and sex, age, clinical status, gastritis scores, H. pylori density scores and genotype. Clarithromycin resistance was significantly associated with European origin [odds ratio (OR), 3.9], previous H. pylori empiric therapy (OR 2.8) and amoxicillin minimal inhibitory concentration, > or =0.016 (OR 6.0). Eradication rate after susceptibility-based treatment was 74.7% (59 of 79; 95% confidence interval, 65.9-82.9), and a significant association was found between eradication failure and presence of resistance to 1 or more antibiotics (P < 0.05).

CONCLUSIONS

The prevalence of H. pylori antibiotic resistance was high in the studied population. The modest therapeutic success of clarithromycin and metronidazole susceptibility-based regimens suggests that in addition to resistance, other factors may be involved. The need of susceptibility-based treatment studies in children and of antimicrobial resistance surveillance in high prevalence areas for H. pylori are emphasized.

Helicobacter pylori virulence genotypes in Portuguese children and adults with gastroduodenal pathology

The aim of this study was to evaluate the prevalence of virulence genotypes, namely cagA, vacA and babA2, of Helicobacter pylori strains isolated from Portuguese adults and children presenting gastroduodenal pathology. One hundred thirty-six strains were studied, 82 isolated from adult patients (50 with nonulcerative gastritis and 32 with active peptic ulcer) and 58 isolated from children (54 with nonulcerative gastritis and 4 with duodenal ulcer). Genotyping of cagA, vacA and babA2 was assessed by polymerase chain reaction. Overall, Helicobacter pylori strains carrying more virulent genotypes were much more prevalent in adults than in children, particularly the type I ( vacAs1- and cagA-positive) and the triple-positive ( vacAs1-, cagA- and babA2-positive) strains ( P<0.001). A subpopulation of adults and children with nonulcerative gastritis was also studied, and differences in the prevalence of virulent genotypes were observed, either for individual genotypes ( P=0.017 for cagA, P=0.010 for vacAs1) or in combinations, i.e. the type I genotype ( P=0.005) and the triple-positive strains ( P=0.031). There was no difference between the two populations in the distribution of babA2 and m1/m2 genotypes. Considering the cohort effect in the epidemiology of Helicobacter pylori infection, these results suggest that different strains might circulate during different periods of time, or that, after infection in childhood, individual strains will undergo changes during the course of infection.

Evaluation of a Western blot test, Helico blot 2.1, in the diagnosis of Helicobacter pylori infection in a pediatric population

BACKGROUND

Noninvasive diagnostic tests are useful as screening tools for Helicobacter pylori infection in pediatric populations. The aim of this study was to evaluate performance of the immunoblot assay, Helico Blot 2.1, for the diagnosis of H. pylori infection in symptomatic children.

MATERIALS AND METHODS

Immunoblot assay was used for detection of IgG antibodies to specific H. pylori proteins and to a recombinant H. pylori antigen, CIM marker. The study was performed on sera collected from 134 symptomatic, untreated children (mean age, 9.1 +/- 3.2 years; range, 1-14 years). H. pylori infection status was determined by culture, histology and rapid urease test.

RESULTS

Immunoblot assay yielded a positive result in 71 of the 72 infected patients (sensitivity 98.6%) and in eight of the 62 noninfected ones (specificity 87.1%). The predictive values for a positive and a negative result were 89.9% and 98.2%, respectively. The performance of the CIM band alone, as a marker for H. pylori infection status, was also evaluated. This band was present on the blot of 71 infected patients and on four of the 62 H. pylori-negative patients. The sensitivity, specificity, PPV and NPV of the CIM antigen were 98.6%, 93.5%, 94.7% and 98.3%, respectively.

CONCLUSIONS

The immunoblot assay Helico Blot 2.1 is a suitable noninvasive test for the serodiagnosis of H. pylori infection in children. The good level of performance demonstrated by the novel recombinant antigen CIM suggests it may be a useful contribution to the qualitative and quantitative performance of the Helico Blot 2.1 in pediatric populations.

IgG subclasses serum concentrations in a population of children with Down syndrome: comparative study with siblings and general population

Serum total IgG and subclasses were determined in three different groups of children: with Down syndrome, their siblings and general pediatric population. Several cases of IgG2 and IgG4 deficiency were identified, predominantly in children with Down syndrome. The differences, considering three age groups, were statistically significant for both groups in relation to the general population group, with an increase of IgG1 and IgG3 and a decrease in serum concentrations of IgG2 and IgG4. Down syndrome children and their siblings tend o have a similar variation of the IgG4 serum concentration levels (P < 0.05). The mechanisms of this concordance are not well understood. The results point out that an adequate strategy to improve the immune status of Down syndrome children could have a positive manifestation in the immune profile of their brothers.

Features and trends in Helicobacter pylori antibiotic resistance in Lisbon area, Portugal (1990-1999)

The features of Helicobacter pylori antibiotic resistance in Lisbon from 1990 to 1999 were studied. Overall resistance rates to amoxycillin, tetracycline, metronidazole, clarithromycin and ciprofloxacin were 0, 0, 30.6, 19.0 and 9.6%, respectively. The incidence of resistance to clarithromycin was much higher in isolates from children (44.8%) than adults (14.6%). For metronidazole, the contrary was observed (children: 19.0%, adults: 32.3%). Ciprofloxacin-resistant isolates were all from adult patients. Concerning the adult population, the resistance rate to metronidazole showed a slight increase during the decade, while for clarithromycin and ciprofloxacin a significant increase was observed (4.6 to 22.0% and 0 to 20.9%, respectively).

[Hereditary fructose intolerance]

Hereditary fructose intolerance (HFI) is a rare autosomal recessive, metabolic disorder, that results from a deficiency of aldolase B (fructose-biphosphate aldolase) in the liver, kidney and intestine. Recent molecular studies have identified the mutation A149P in most European patients. We describe the first case of HFI with molecular analysis in a Portuguese child, presenting the same mutation of the aldolase B gene. The role of molecular studies in the diagnosis of HFI risk patients and their families is emphasized.

[A methodology for the diagnosis and follow-up of the evolution of acute hepatitis in childhood. The Working Group of the Section of Pediatric Gastroenterology and Nutrition of the Portuguese Pediatrics Society]

The Working Group of the Section of Paediatric Gastroenterology and Nutrition of the Portuguese Society of Paediatrics established a protocol for the investigation of children with acute hepatitis. The main purpose of this proposal is to allow appropriate etiologic investigations and avoid unnecessary tests that are expensive and do not add relevant information for the correct follow-up of these patients.