The Spectrum of Duodenal Histologic Findings in Patients With Trisomy 21: A Multicenter Study

OBJECTIVES

Patients with Trisomy 21 (T21) commonly have gastrointestinal symptoms and diseases that prompt evaluation with esophagogastroduodenoscopy (EGD). Our objective is to characterize duodenal histological abnormalities in these patients when undergoing EGD. A secondary aim is to explore associations of histologic findings with different therapies.

METHODS

Patients 30 years old or younger with T21 who underwent EGD from 2000 to 2020 at 6 hospitals were included in this retrospective cohort study. Duodenal biopsies were categorized based on reported histopathology findings as normal or abnormal. Abnormal pathology reports were reviewed and categorized into villous atrophy (VA) and duodenitis without VA. The VA group was further categorized based on the presence or absence of celiac disease (CD).

RESULTS

We identified 836 patients with T21 who underwent EGD, 419 (50.1%) of whom had duodenal histologic abnormalities. At the time of the first (index) abnormal duodenal biopsy, 290 of 419 had VA and of those, 172 of 290 met CD diagnostic criteria, while 118 of 290 did not meet CD criteria (nonspecific VA). Among the patients with an abnormal biopsy, acid suppression at the time of the index biopsy was less common in patients with VA-CD compared to patients without VA or patients with nonspecific VA (12.2% vs 45.7% vs 44.9%).

CONCLUSIONS

Half of the T21 patients in this cohort had abnormal duodenal biopsies including a subgroup with nonspecific VA. In this cohort, acid suppression use was more prevalent in patients with abnormalities other than CD.

A Quantitative Assessment of Gluten Cross-contact in the School Environment for Children With Celiac Disease

OBJECTIVES

A gluten-free (GF) diet is the primary treatment for celiac disease (CD). Gluten is used in schools, particularly in early childhood, art, and home-economics classrooms. This study aimed to measure gluten transfer from school supplies to GF foods that a child with CD may eat. Also, to measure efficacy of washing techniques to remove gluten from hands and tables.

METHODS

Five experiments measured potential gluten cross-contact in classrooms: Play-Doh (n = 30); baking project (n = 30); paper mâché (n = 10); dry pasta in sensory table (n = 10); cooked pasta in sensory table (n = 10). Thirty participants ages 2 to 18 were enrolled. Following activities, gluten levels were measured on separate slices of GF bread rubbed on participant's hands and table surfaces. Participants were assigned 1 of 3 handwashing methods (soap and water, water alone, or wet wipe). Repeat gluten transfer measurements were taken from hands and tables. Gluten measurements made using R-Biopharm R7001 R5-ELISA Sandwich assay.

RESULTS

Paper mâché, cooked pasta in sensory tables, and baking project resulted in rates of gluten transfer far greater than the 20 ppm threshold set by Codex Alimentarius Commission. Play-Doh and dry pasta, however, resulted in few gluten transfers to GF bread >20 ppm. Soap and water was consistently the most effective method for removing gluten, although other methods proved as effective in certain scenarios.

CONCLUSIONS

The potential for gluten exposure at school is high for some materials and low for others. For high-risk materials, schools should provide GF supplies and have a robust strategy to prevent gluten cross-contact with food.

Psychological Needs and Services in a Pediatric Multidisciplinary Celiac Disease Clinic

This study aims to describe the psychological needs in children with celiac disease (CD) and to examine the feasibility of psychological consultation in a multidisciplinary clinic. Participants (N = 69) included children with CD and their parents who completed a pre-clinic mental health survey and a 30-min psychological consultation as part of a multidisciplinary clinic (including gastroenterology, nutrition, education, neurology, and neuropsychology). Quantitative and qualitative analyses examined psychological needs, experiences, and satisfaction. The psychologist identified clinically significant symptoms and provided referrals in 49% of children. There were no significant differences by time since CD diagnosis. During the psychology consultation, families discussed emotional adjustment, impact on life and physical well-being, and management of the gluten-free diet. Parents reported high levels of satisfaction from the clinic visit. We identified frequent psychological needs in pediatric CD. The multidisciplinary approach may be a feasible model for specialized, optimal treatment in this population.

Anorexia nervosa and depression in a 5-year-old girl: Treatment with focused family play therapy and medication

OBJECTIVE

The current case presentation examines the treatment and recovery of a 5-year-old girl diagnosed with comorbid anorexia nervosa and major depressive disorder. Researchers have shown that children as young as 3-years-old may be dissatisfied with their bodies and have concerns about their weight. This case presentation of a 5-year-old child demonstrates that the age range defining early onset of eating disorders can span into early childhood, which requires treatment tailored to the developmental level of these young children.

METHOD

A new method "focused family play therapy" was applied. It goes beyond free play or structured play therapy, in that the therapist involves the parents in the play and not only models the situation which creates the child's fears, but also shows through dolls how to be brave and overcome the fears.

RESULTS

The current case report demonstrates how the combination of refeeding the child during family meals, participating in focused family play therapy to help the child overcome her fears of eating, and prescribing sertraline to treat her depression was an effective treatment for both the anorexia nervosa and depression.

DISCUSSION

This technique may be effective with children ranging in age from 3 to 6 years.

A Functional Approach to Feeding Difficulties in Children

PURPOSE OF REVIEW

This review provides an approach for resolving a variety of feeding difficulties in children, ranging from normal eating behavior that is misperceived as a problem to substantial feeding disorders.

RECENT FINDINGS

Criteria to identify pediatric feeding disorders have been thoroughly addressed in the newly established designations of avoidant restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD). These diagnostic criteria improve the accuracy of identifying, classifying, and managing significant feeding disorders in young children. While recent definitions of feeding difficulties are particularly appropriate in multidisciplinary settings, in this paper, we advocate for a progressive approach of managing feeding problems in all clinical settings. It begins by identifying red flags indicative of serious threats to the child, screening for oral motor dysfunction, stabilizing nutrient intake, and eliminating aversive feeding practices. The next step, if eating behavior does not improve, involves strategies that target specific eating behaviors and parental feeding styles. In severe or resistant cases, referral to specialists or interdisciplinary feeding teams is advised.

A practical approach to classifying and managing feeding difficulties

Many young children are thought by their parents to eat poorly. Although the majority of these children are mildly affected, a small percentage have a serious feeding disorder. Nevertheless, even mildly affected children whose anxious parents adopt inappropriate feeding practices may experience consequences. Therefore, pediatricians must take all parental concerns seriously and offer appropriate guidance. This requires a workable classification of feeding problems and a systematic approach. The classification and approach we describe incorporate more recent considerations by specialists, both medical and psychological. In our model, children are categorized under the 3 principal eating behaviors that concern parents: limited appetite, selective intake, and fear of feeding. Each category includes a range from normal (misperceived) to severe (behavioral and organic). The feeding styles of caregivers (responsive, controlling, indulgent, and neglectful) are also incorporated. The objective is to allow the physician to efficiently sort out the wide variety of conditions, categorize them for therapy, and where necessary refer to specialists in the field.

Two single group, prospective, baseline-controlled feeding studies in infants and children with chronic diarrhea fed a hypoallergenic free amino acid-based formula

Background

Infants and children with chronic diarrhea (CD) often require specialized foods or parenteral nutrition (PN) to achieve adequate nutrient intakes to support growth and development. We assessed the efficacy of an amino acid-based formula (AAF) in supporting growth and improving symptoms in infants and children with CD from multiple etiologies.

Methods

Two studies were conducted: CD study in children (CD-C) and CD study in infants (CD-I). Each was a single group, baseline-controlled study in which each subject served as his/her own control. At enrollment, all subjects had CD lasting > 2 weeks and had ≥ 4 stools/day. Subjects were fed an AAF for 80 days starting at SD5, and were assessed at SD 28 and 84.

Results

CD-C: 18 of 19 subjects completed the study. At enrollment, the mean age was 5.6 ± 0.7 years, the most common diagnosis was short bowel syndrome (SBS) (n = 13), and 5 subjects with SBS were on PN. Subjects achieved significant increases in weight-for-age z-scores (p = 0.026). Over 50% of subjects achieved improvements in clinical outcomes targeted most frequently by their physicians. Of the five subjects on PN at enrollment, four had substantial weight gain and four had their PN requirements decreased. CD-I: 22 of 27 subjects completed the study. At enrollment, the mean age was 3.3 ± 0.3 months, the most common diagnosis was food allergy (n = 20), and no subjects were on PN. Subjects achieved significant increases in weight-for-age z-scores (p = 0.0023), significant decreases in the number of stools/day (p = 0.0012), and improvements in stool consistency (p = 0.0024). Over 80% of subjects achieved improvements in the clinical outcomes targeted most frequently by their physicians.

Conclusions

Infants and children with CD fed an AAF for three months displayed significant improvements in weight-for-age z-scores and clinical symptoms. Children dependent on PN also grew well and four of five decreased their dependence on PN.

Trial registration

Both trials were registered on ClinTrials.gov (CD-C, NCT01812629; CD-I, NCT01820494).

Factors that determine risk for surgery in pediatric patients with Crohn's disease

BACKGROUND & AIMS

We examined the incidence of Crohn's disease (CD)-related surgery in a multi-center, inception cohort of pediatric patients with CD. We also examined the effect of starting immunomodulator therapy within 30 days of diagnosis.

METHODS

Data from 854 children with CD from the Pediatric Inflammatory Bowel Disease Collaborative Research Group who were diagnosed with CD between 2002 and 2008 were analyzed.

RESULTS

Overall, 76 (9%) underwent a first CD-related surgery, 57 (7%) underwent a first bowel surgery (bowel resection, ostomy, strictureplasty, or appendectomy), and 19 (2%) underwent a first non-bowel surgery (abscess drainage or fistulotomy). The cumulative risks for bowel surgery, non-bowel surgery, and all CD-related surgeries were 3.4%, 1.4%, and 4.8%, respectively, at 1 year after diagnosis and 13.8%, 4.5%, and 17.7%, respectively, at 5 years after diagnosis. Older age at diagnosis, greater disease severity, and stricturing or penetrating disease increased the risk of bowel surgery. Disease between the transverse colon and rectum decreased the risk. Initiation of immunomodulator therapy within 30 days of diagnosis, sex, race, and family history of inflammatory bowel disease did not influence the risk of bowel surgery.

CONCLUSIONS

In an analysis of pediatric patients with CD, the 5-year cumulative risk of bowel surgery was lower than that reported in recent studies of adult and pediatric patients but similar to that of a recent retrospective pediatric study. Initiation of immunomodulator therapy at diagnosis did not alter the risk of surgery within 5 years of diagnosis.

Efficacy and safety of ezetimibe coadministered with statins: randomised, placebo-controlled, blinded experience in 2382 patients with primary hypercholesterolemia

We assessed pooled safety and lipid-regulating efficacy data from four similarly designed trials of ezetimibe coadministered with statins in 2382 patients with primary hypercholesterolemia. Patients were randomised to one of the following double-blind treatments for 12 weeks: placebo; ezetimibe 10 mg; statin; or statin + ezetimibe. Statin doses tested were 10, 20, 40 mg/day (atorvastatin, simvastatin, pravastatin or lovastatin) or 80 mg/day (atorvastatin, simvastatin). Treatment with ezetimibe + statin led to significantly greater reductions in low-density lipoprotein cholesterol (LDL-C), total cholesterol, triglycerides, non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B and increases in HDL-C, compared to statin alone. At each statin dose, treatment with ezetimibe + statin led to a greater LDL-C reduction compared to the next highest statin monotherapy dose. Ezetimibe + statin had a safety profile similar to statin monotherapy. Coadministration of ezetimibe + statin offers a well-tolerated, highly efficacious new treatment strategy for patients with hypercholesterolemia.

Failure to thrive and cognitive development in toddlers with infantile anorexia

OBJECTIVE

The goal of this study was to examine the relative contributions of growth deficiency and psychosocial factors to cognitive development in toddlers with infantile anorexia.

METHODS

Eighty-eight toddlers, ranging in age from 12 to 33 months, were enrolled in this study. Toddlers were evaluated by 2 child psychiatrists and placed into 1 of 3 groups: infantile anorexia, picky eater, and healthy eater. All 3 groups were matched for age, race, gender, and socioeconomic status (SES). Toddlers underwent nutritional evaluations and cognitive assessments with the Bayley Scales of Infant Development. Toddlers and their mothers were also videotaped during feeding and play interactions, which later were rated independently by 2 observers.

RESULTS

On average, toddlers with infantile anorexia performed within the normal range of cognitive development. However, the Mental Developmental Index (MDI) scores of the healthy eater group (MDI = 110) were significantly higher than those of the infantile anorexia (MDI = 99) and picky eater (MDI = 96) groups. Within the infantile anorexia group, correlations between MDI scores and the toddlers' percentage of ideal body weight approached statistical significance (r =.32). Across all groups, the toddlers' MDI scores were associated with the quality of mother-child interactions, SES level, and maternal education level. Collectively, these variables explained 22% of the variance in MDI scores.

CONCLUSIONS

This study demonstrated that psychosocial factors, such as mother-toddler interactions, maternal education level, and SES level, are related to the cognitive development of toddlers with feeding problems and explain more unique variance in MDI scores than nutritional status.

Inflammatory bowel disease in children and young adults: correlation of sonographic and clinical parameters during treatment

OBJECTIVE

The objective of this study was to evaluate the sonographic findings of inflammatory bowel disease activity in children undergoing treatment.

SUBJECTS AND METHODS

Eighty-eight sonograms were obtained of 23 bowel segments in 17 children and young adults (age range, 10-21 years; mean, 16 years) with new or recurrent inflammatory bowel disease. Sixteen segments were involved with Crohn's disease and seven with ulcerative colitis. Serial sonography (range, two to eight examinations; mean, four per segment) was performed while patients underwent treatment. Bowel wall thickness measurements and color and power Doppler sonography grading were recorded and compared with clinical data.

RESULTS

All 17 patients had at least one abnormal bowel segment on initial sonography. The correlation was significant (p < 0.01). Agreement was 91% on direction of change over time between bowel wall thickness and Doppler grades, with 100% correlation between color and power Doppler sonography grades. In patients with Crohn's disease, the correlation was significant (p < 0.05) between bowel wall thickness and Doppler grades with two of seven and four of seven clinical parameters, respectively. In patients with ulcerative colitis, the correlation was significant (p < 0.05) between bowel wall thickness and Doppler sonography grades with four of seven and three of seven clinical parameters, respectively. The erythrocyte sedimentation rate correlated with all sonographic measurements in both patient groups. Combining bowel wall thickness and Doppler sonography, the percentage of agreement was significant in the direction of change, with five of seven clinical parameters in both patient groups.

CONCLUSION

Gray-scale and color or power Doppler sonography can show changes in disease activity in children and young adults undergoing treatment for inflammatory bowel disease.

Ipecac toxicity in "Munchausen syndrome by proxy"

The authors report a case that offers insight into the diagnostic challenges of "Munchausen Syndrome by Proxy." Initial presentation with history of fever and later with intractable vomiting led to invasive and expensive diagnostic evaluation before confirming the diagnosis. Certain toxic effects of emetine were clinically noted. Biochemical and clinical improvement were clearly demonstrated after withdrawal of the toxic agent.

Preliminary assessment of glycine conjugation of para-aminobenzoic acid as a quantitative test of liver function

OBJECTIVES

Our hypothesis is that because of its hepatic metabolism paraaminobenzoic acid (PABA) could be a test of liver function.

DESIGN AND METHODS

PABA is well absorbed by the gastrointestinal tract and acetylated and conjugated in the liver to glycine before being excreted. Its three major metabolites include para-acetoamidobenzoic acid (PAABA), paraaminohippuric acid (PAHA), and paraacetamidohippuric acid (PAAHA). In this study, we measured the metabolism of lidocaine to monoethylglycinexylidide (MEGX) and PABA to PAHA+PAAHA/PABA+PAABA+PAHA+PAAHA (hippurate ratio) in 14 patients with liver disease and 12 control subjects.

RESULTS

Comparison of the total bilirubin with the hippurate ratio (at 30 min) and the conventional MEGX test (at 15 min) was assessed. The 30 min hippurate ratio correlated well with the 15 min MEGX results (r = 0.69).

CONCLUSIONS

While these results are preliminary the PABA test appears to be equally sensitive to MEGX and has the distinct advantage over the MEGX test of being administered orally versus the intravenous administration of lidocaine which is often associated with unwanted side-effects such as hypotension, drowsiness and paresthesias.

Biliary copper excretion in the neonatal rat: role of glutathione and metallothionein

Metallothionein (MT) and glutathione (GSH) have been implicated as two major copper-binding agents involved in the hepatobiliary copper metabolism in the adult rat. This study was designed to explore their potential role in facilitating copper export from the copper-laden hepatocyte of the newborn rat. Biliary and hepatic copper, GSH, and immunoreactive MT-I concentrations were measured in Sprague-Dawley rats at 1, 2, 3, 4, and 8 weeks of age. Bile was collected by duct cannulation for 90 minutes before the rats were killed. Liver was removed, weighed, and freeze-dried. The bile flow rate (BFR) doubled and the liver weight increased 14-fold during maturation. Hepatic and biliary copper and MT-I concentrations were significantly higher in the suckling than in the weanling. The total biliary output of copper per 24 hours was low at 1 week and increased significantly by 8 weeks of age. MT-I-bound copper represented a maximum of only 3.4% of biliary copper at 1 week and 0.5% at 8 weeks. GSH was not detected in bile until 2 weeks and then increased 15-fold by 8 weeks, while hepatic GSH levels remained unchanged. Therefore, GSH levels did not correlate with the high biliary copper concentration at week 1, although there was a close correlation between the total daily biliary excretion of copper and GSH at 2 weeks and beyond. We conclude that the net biliary copper excretion per day is relatively low in the first week of life and is independent of MT and GSH secretion. It increases significantly once GSH is available in bile.(ABSTRACT TRUNCATED AT 250 WORDS)

Early changes in the permeability of the blood-brain barrier produced by toxins associated with liver failure

Our study was designed to determine whether substances that appear in the serum during the course of liver failure have a detrimental effect on the passive permeability of the blood-brain [blood-cerebrospinal fluid (CSF)] barrier. Lactic acid, octanoic acid, and ammonia were infused into rabbits for 4 h. The permeability changes of the blood-brain barrier were quantified by infusing polyethylene glycol 400 (PEG 400) and measuring the quantity and average mol wt of the PEG 400 that entered the CSF. The lipid solubility and effective diffusional radius of the PEG molecules were also quantified to provide greater precision for measurements using this probe. None of the animals receiving toxic infusions became seriously ill during the infusions. Low dose infusions of lactic acid, octanoic acid, and ammonia increased the effective pore diameter of the blood-brain barrier from 7.3 A to an average of 8.5 A. The amount of PEG entering the CSF increased from 1.7 to 4.0 (p less than 0.025), 4.7 (p less than 0.025), and 6.7 (p less than 0.001) mmol/L, respectively. Rabbits with galactosamine-induced liver failure had 10.1 mmol/L PEG 400 in the CSF (P less than 0.001) before any evidence of cerebral edema. These changes occur soon after these toxins accumulate in the plasma and may alone or together with other toxins account for the permeability changes that allow neurotoxic substances to enter the brain during hepatic disease and encephalopathies such as Reye's syndrome.

Feeding disorders and gastroesophageal reflux in infants with chronic renal failure

Twenty-two infants (mean age 7.5 months) with chronic renal failure (CRF) were studied for their nutrition, growth, and upper gastrointestinal function. Most infants had a history of poor caloric intake and 7 had received supplemental feeding (SF) prior to the investigation. All infants were undergrown, underweight, and malnourished. The infants were characterized as having only a fair interest in food, refusing feedings, and vomiting excessively. Sixteen of 22 infants (73%) had significant gastroesophageal (GE) reflux demonstrated by 24-h esophageal pH monitoring. Gastroesophageal scintiscans were less sensitive and specific in detecting the reflux. Infants with GE reflux were significantly younger and more often required SF than those without GE reflux. There were no significant differences in the degree of renal failure, growth failure, caloric intake, protein intake, or nutritional status between the infants with and without GE reflux. From these studies we conclude that GE reflux should be considered as one of the factors contributing to the feeding problems of infants with CRF.

Influence of saccharide length on polysaccharide appetite in the rat

The appetite of female rats for saccharides of different chain lengths was assessed in brief (5-min) one-bottle acceptance and two-bottle preference tests. The saccharides (and their lengths in glucose units) included glucose (1), maltose (2), maltotriose (3), maltooligosaccharide (4-8), maltopolysaccharide (average length 43), and Polycose (1 to 30+); 0.0125 and 0.025 molar solutions of these saccharides were tested. The results revealed that the rats' order of preference for these saccharides was as follows: maltooligosaccharide greater than maltotriose = maltose greater than glucose; and maltooligosaccharide greater than Polycose = maltopolysaccharide greater than maltose. Thus, as saccharide chain length increased from 1 to 4-8 glucose units palatability increased, but with further increases in chain length palatability declined somewhat. Previous findings have suggested that rats have a "polysaccharide" taste receptor and the present results indicate that the receptor is maximally (or near-maximally) stimulated by saccharides of 4-8 glucose units in length.

Absorption and oxidation of glucose polymers of different lengths in young infants

Because mucosal glucoamylase is most active against glucose polymers less than 10 glucose units in length, longer chain polymers may not be completely absorbed by young infants. In order to investigate this possibility, the absorption and oxidation of 13C-rich glucose, short-chain (3 to 8 glucose units in length) and long-chain (average length 43 units) glucose polymers (GP) were compared in 12 healthy, 1-month-old infants. Recovery of the GP and glucose in stool was measured by determining the 13C enrichment of stool. The oxidation of the GP was measured by tracing the increase in breath 13CO2 after GP were fed. Carbohydrate malabsorbed in the small bowel was assessed by measurement of breath H2, a gas formed from the fermentation of carbohydrate in the colon. Analysis of the infants' stools revealed that one infant excreted 9.7% of the dose of glucose, another 6.7% of the dose of short-chain GP, and five infants excreted 2.6 to 18.5% (mean 8.4%) of the dose of long-chain GP. The percent of the administered dose recovered in breath was similar among substrates (mean = 28.7% of the dose fed). A rise in breath H2 greater than 20 ppm was found in four of the 12 infants after the feeding of glucose, in five of 12 after the short-chain GP, and in six of 12 after the long-chain GP. None of the infants developed diarrhea. The results suggest that healthy young infants do not absorb long-chain GP as completely as they absorb short-chain GP.(ABSTRACT TRUNCATED AT 250 WORDS)

Absorption of glucose polymers from canine jejunum deprived of pancreatic amylase

We evaluated the absorption of glucose polymers in canine jejunal Thiry-Vella fistulas proven to be free of pancreatic amylase. Medium-length oligomers with degrees of polymerization of 6 through 10 glucose units (DP 6-10) and long-chain material (DPavg23) were isolated from a cornstarch hydrolysate. We perfused 90, 180, and 360 mg/dl solutions of glucose, DP 6-10, and DPavg23 at 0.4, 1.9, and 3.4 ml/min. At all perfusion rates carbohydrate absorption decreased as the chain length of the oligomers increased, and these differences persisted even at the slowest perfusion rate employed. In two additional animals the fistulas were perfused at 3.4 ml/min with the three test carbohydrates at concentrations of 90, 180, 225, 270, 315, 360, 405, and 450 mg/dl. At this flow rate, the assimilative process of DP 6-10 and the long-chain fraction appeared to be saturated at carbohydrate concentrations above 360 mg/dl, whereas the absorption of glucose was linearly related to concentration throughout the range studied. With both groups of polymers, the fluid emerging from the fistula was virtually free of glucose, a finding that suggests that polymer digestion, not glucose absorption, is the rate-limiting step for polymer assimilation.

The contribution of salivary amylase to glucose polymer hydrolysis in premature infants

To determine whether salivary amylase of premature infants can function as a surrogate for pancreatic amylase, we evaluated its production in the infant, acid resistance, and hydrolytic potency in a simulated oropharyngeal, gastric, and intestinal environment. The activity of salivary amylase in 11 prematures varied between 1 and 33 U/ml; the isozymic profile and acid resistance of the premature salivary amylase were identical to those of the enzyme of adults. A "modular" formula containing 7 g/dl of a 14C labeled long chain glucose polymer with degrees of polymerization ranging between 18 and 29 glucose units was prepared. Salivary amylase, 1.1 U/ml, was added to this formula. The progressive breakdown of the 14C polymers as the milk was subjected to oropharyngeal, gastric, and intestinal phase environments was evaluated by quantifying the liberation of short-chain oligomers from the 14C labeled substrates. The gastric pH was varied between 2 and 5 and the gastric incubation time was either 5 or 180 min. Substantial gastric phase breakdown only occurred after 3 h of exposure at the higher pHs of 4 (12%) and 5 (32%). During the intestinal phase, salivary amylase activity resumed. Prior gastric phase pH affected ultimate intestinal phase breakdown, p less than 0.001; after 5-min gastric phases at pHs ranging from 2 to 5, the intestinal phase breakdown ranged from 17 to 55%. We conclude that the limited salivary amylase in the saliva of premature infants can produce significant glucose polymer digestion in both the stomach and small intestine but the digestion falls substantially short of that accomplished by usual concentrations of pancreatic amylase.

Chronic nonspecific diarrhea: the value of a preliminary observation period to assess diet therapy

Eighteen children with chronic, nonspecific diarrhea were evaluated prospectively to determine "basal" fat consumption and the response of their diarrhea to diets containing either 25% or 50% of total calories as fat. In the observation period, prior to initiating any alteration in dietary fat content, diarrhea subsided. Only five of the 18 patients had a low fat intake (less than 27% of total calories) at the outset of the study, and spontaneous resolution of the diarrhea precluded an assessment of the effect of altering fat intake on stool frequency. We are, therefore, impressed that a preliminary observation period, in which details of the diarrhea are documented, is essential to evaluate any treatment modality for this poorly defined condition.

Large scale production of glucose oligomers and polymers for physiological studies in humans

Methods for isolating relatively large quantities of glucose oligomer and polymer subfractions from a partial corn starch hydrolysate (PCSH) are described. To ensure that the products are suitable for physiological studies in humans, potentially toxic substances were excluded from the preparative processes. For long chain glucose polymer fractions with degrees of polymerization (DP) averaging 43 glucose units, we employed molecular filtration through Amicon YM5 membranes. For fractions containing glucose oligomers with DP's 3 through 8, we employed yeast fermentation followed by ethanol fractionation.

Efficient storage system for breath hydrogen

Recommended materials for breath hydrogen collection (plastic syringes with twist lock closure) are only adequate for relatively brief periods because of gradual hydrogen loss and considerable variability between duplicate samples. To document the most favorable storage conditions for breath hydrogen, we compared hydrogen retention in plastic syringes using a conventional twist-in-lock closure versus a simple, inexpensive syringe closure, a Critocap. Hydrogen retention was studied at 25, 5, and -20 degrees C in two different syringe brands over 72 h of storage. An analysis of variance confirms the superiority of Critocaps over twist-in-lock closures (p less than 0.001). Reliability was maximal when samples were placed in environments less than 5 degrees C. When storage time was extended to 7 days, mean hydrogen retention was 86 +/- 6% (means +/- SD).

Large scale preparation of selected glucose oligomers and polymers by gel filtration chromatography

A method for isolating relatively large quantities of glucose oligomer and polymer subfractions from a corn starch hydrolysate is described. Employing large columns of Bio-Gel P-2 (40-80 microns) at room temperature, we can prepare each day 0.5 to 1.2 grams of oligomeric fractions containing three to four adjacent homologues. The columns are homemade, require no flow adapters, and are operated by gravity elution with water as the solvent. The means for avoiding and overcoming potential difficulties, such as microbial contamination and declining flow rate, are described. With the use of the described method, we can operate a single column continuously for up to twelve months.

Antibiotic management of complicated appendicitis

A prospective, randomized, double-blind clinical trial was undertaken comparing gentamicin, ampicillin, and clindamycin (GAC) to gentamicin, ampicillin, and placebo (GAP) in children with complicated appendicitis. Of the 64 patients enrolled in this study, 33 were assigned to the GAC group and 31 received GAP. A single GAC patient (3%) was considered a therapeutic failure in comparison to seven children (23%) in the GAP group (P less than 0.05). Duration of fever was significantly prolonged in the GAP patients (4.7 +/- .8 days versus 2.9 +/- .5 days) when compared to the clindamycin treated children (P less than 0.05). Duration of leukocytosis was 3.2 +/- .4 days for GAC patients and 4.9 +/- .9 days for those on the GAP protocol (P = 0.08). On the basis of this experience the routine use of gentamicin, ampicillin, and clindamycin is recommended for all children with complicated appendicitis.

Thin-layer and gel permeation chromatographic separation of low molecular weight polyethylene glycol oligomers

We describe a gel permeation and a thin-layer chromatographic technique for the complete resolution of oligomers of ethylene glycol up to a chain length of fourteen ethylene oxide [OCH2CH2] units. We employed columns of Bio-Gel P-2 with 0.02 mol/l ammonium acetate as the eluant to prepare milligram quantities of each of the individual oligomers. Thin-layer chromatography on silica gel G plates with an ethyl acetate/methanol/water solvent provides a sensitive and simple method for monitoring multiple specimens. We determined the flame ionization detector response of purified individual ethylene glycol oligomers relative to tetraethylene glycol. These data permit the accurate quantification of the oligomeric profile of commercially available mixtures of low molecular weight polyethylene glycols (PEG). When PEG 400 is administered orally to normal subjects, aged three months through adulthood, they excrete in their urine a mixture of unmetabolized oligomers with a mean molecular weight of 360 +/- 14 daltons. The ability to measure absolute, rather than relative, amounts of ethylene glycol oligomers will permit more accurate studies of passive intestinal permeability in human subjects.

A new micromethod for the quantification of low molecular weight oligomers of polyethylene glycol

We describe a gas-liquid chromatographic technique for quantifying the low molecular weight (Mr 106-634) oligomers of polyethylene glycol (PEG) in clinical specimens. The deionized sample, containing tetra-ethylene glycol as an internal standard, is applied on column. This technique readily quantifies as little as 2.5 micrograms of an individual oligomer; with such a quantity, the coefficient of variation is +/- 2.5 percent (N = 25 analyses). Small volumes (250 microliter) of urine are conveniently analyzed, and a single column can be utilized for the analysis of approximately three hundred specimens. We have analyzed timed urine specimens from humans who received 0.15 g of PEG 400 per kilogram. Individuals varied markedly with regard to the total amount of PEG excreted into the urine; each subject, however, consistently excretes a uniform percentage of the ingested dose. The urinary oligomeric profile of PEG does not vary from subject to subject nor from hour to hour, during the first six hours following oral administration, so that a random urine obtained during this period provides a reliable clinical specimen. This technique should facilitate clinical studies that utilize polyethylene glycol 400 as an index of passive intestinal transport.

Acetylthiocholinesterase staining activity of rectal mucosa. Its use in the diagnosis of Hirschsprung's disease

Increased acetylthiocholinesterase (AchE) reactivity in the rectal lamina propria and lamina muscularis mucosae was used to diagnose Hirschsprung's disease. We processed 131 specimens with the AchE reaction; 43 were suction biopsy specimens and the rest were full-thickness specimens. Of the 68 specimens in which neurocytes were present, none demonstrated a diffuse increase in the number of nerve fibers. However, 15 showed focal increases in the numbers of fibers that were not large enough to be regarded as indicative of Hirschsprung's disease. All patients with a diffuse increase in nerve fibers, regardless of the type of biopsy, were shown to have Hirschsprung's disease. The AchE staining reaction did, however, produce a 29% rate of false-negative reactions (16 of 56 specimens) in patients with Hirschsprung's disease. These data demonstrate that an abnormal pattern of AchE reaction is diagnostic of aganglionic megacolon, whereas a normal pattern does not exclude the disease.

Thyroid status and muscarinic receptor density and affinity in rat intestinal smooth muscle

Hypothyroid and hyperthyroid states are associated with constipation and diarrhea, respectively. To determine the possible involvement of the cholinergic system in these disorders we studied the effect of thyroid status (thyroidectomy or thyroxin injection for 10-20 weeks) on intestinal smooth muscle muscarinic receptors. Receptor density and affinity were determined in the ileum and colon with [3H]-quinuclidinyl benzilate (QNB), and compared with the responsiveness of isolated muscle strips to cumulative doses of bethanechol. Neither the affinity nor the density of muscarinic receptors was significantly altered by chronic hypo- or hyperthyroidism: KD approximately 1nM; Bmax approximately 200 fmole/mg protein. Similarly, there was no change in functional response of the ileum or colon to cholinergic stimulation. The results suggest that chronic hypothyroidism or hyperthyroidism do not alter muscarinic receptors in rat ileal or colonic muscle.

Variations in glycerol kinetics in Reye's syndrome

Glycerol kinetics and adverse affects were studied in nine patients with Reye's syndrome. Glycerol was given by continuous infusion over 2 hr, half over the first 0.5 hr and the remainder over the next 1.5 hr. The dose was adjusted to keep intracranial pressure less than or equal to 15 mmHg. At steady state, serial blood samples were collected during glycerol infusion and analyzed by an enzymatic assay specific for glycerol. At 0.75 to 1.75 gm/kg/2 hr glycerol doses, the serum levels ranged from 1.48 to 5.83 mg/ml. Total body clearance ranged from 1.99 to 5.1 ml/kg/min. Glycerol clearance was not related to serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), or serum ammonia levels. Glycerol provided effective control of intracranial pressure in all patients. Temporary elevation of serum creatinine and blood urea nitrogen (BUN) and presence of hemolysis in two patients, appeared to be related to glycerol.

The jejunal absorption of glucose oligomers in the absence of pancreatic enzymes

We compared the absorption of carbohydrate from solutions of glucose oligomers and glucose in jejunal Thiry-Vella fistulae, a preparation deprived of pancreatic secretions. The studies were performed with two concentrations (90 and 360 mg/dl) of both glucose and the glucose oligomers. Carbohydrate absorption from glucose solutions (33.1 +/- 2.8, 115.9 +/- 8.9 micrograms/cm/min) was significantly greater (P less than 0.025; P less than 0.005) than that from oligomer solutions (26.6 +/- 2.1 and 92.4 +/- 9.0 micrograms/cm/min). Thin-layer analyses of the perfusates demonstrate digestion of oligomers with a chain length up to eleven and suggest digestion of oligomers of even greater chain length. Atrophy of the jejunal mucosa occurred over the course of the study as evidenced by a decrease in the ratio of villous height to crypt depth from 3.8 to 0.3, and by a 80% decrease in the activity of maltase, sucrase, and lactase. Atrophy was accompanied by a significant decline in the absorption of both glucose oligomers (P less than 0.005) and glucose (P less than 0.01) from the more concentrated solutions but the decrement in absorption of both carbohydrates was similar: glucose oligomers, 79.3 +/- 19.4 micrograms/cm/min; and glucose, 69.8 +/- 14 micrograms/cm/min (P greater than 0.20). Water absorption was enhanced by both carbohydrates, but there was no demonstrable difference between solutions of glucose and glucose oligomers. The osmolality of the solutions clearly influenced water absorption (P less than 0.025) but failed to effect the absorption of carbohydrates.

Ileovesical fistula. Failure of T.P.N. role of oral 14C PEG (polyethylene glycol) and charcoal in diagnosis

A patient with regional enteritis presenting with symptoms of fecaluria and pneumaturia is presented. Most of the established technics such as upper gastrointestinal series, cystography, cystoscopy and colonoscopy failed to demonstrate the fistula in this patient. 14C PEG as a nonabsorbable marker was given by mouth and a seven-fold increase in the counts at the fourth hour of urine collection confirmed the presence of an ileovesical fistula. This increase in counts was not seen when 14C PEG test was repeated after closure of this fistula surgically and was also not seen in a similar disease control patient and a healthy normal volunteer. Total parenteral nutrition with intralipids, Freamine II and glucose given in a peripheral vein for 45 days failed to close this fistula.

Double-blind evaluation of deanol in tardive dyskinesia

We administered deanol acetamidobenzoate, 2.0 g/day for four weeks, a double-blind, placebo-controlled crossover trial, to 14 patients with tardive dyskineasia. The patient population included both inpatients and outpatients. The response was evaluated by subjective clinical impression and scoring of filmed sequences. Patients' conditions improved significantly from baseline scores while receiving both deanol and placebo, but there was no distinction between the two treatments.

Effect of lithium on plasma chlorpromazine levels

The interaction of lithium and chlorpromazine (CPZ) was studied in healthy volunteers in a randomized crossover study. Each subject ingested two doses of CPZ (100 mg) as the liquid concentrate: (1) without concurrent lithium therapy and (2) after a 7-day treatment with lithium carbonate (900 mg/day). When CPZ was administered with lithium, peak plasma CPZ levels were 40.3% (mean) lower than those without lithium (p = 0.006), and the area under the CPZ plasma concentration time curve was 26.6% smaller (p = 0.08). The time to reach peak plasma CPZ levels was similar in both groups. All subjects slept for 4 to 6 hr after oral CPZ and had a maximum fall in both systolic (8 to 32 mg Hg) and diastolic (5 to 23 mg Hg) blood pressure at the time of peak plasma CPZ concentration. This lithium-CPZ interaction may explain the low plasma CPZ levels reported previously in psychiatric patients taking both lithium and CPZ.

Clinical, laboratory, and epidemiologic features of a viral gastroenteritis in infants and children

We studied 27 infants admitted to the hospital with acute diarrhea caused by human rotavirus (HRV) and obtained additional data on fecal excretion from ten outpatients with the same infection. The disease was characterized by watery diarrhea with fever and vomiting at the onset, isotonic dehydration, compensated metabolic acidosis, and increased concentrations of sodium and chloride but low concentrations of sugar in stools. Diarrhea usually ceased in three to four days when oral feedings were reduced or stopped but recurred mildly in four patients. Of 57 household contacts, 12 were symptomatic, 6 had HRV in their stools, and 19 had significantly increased serum HRV antibody titers. These features of the disease accord with available information on the pathogenesis of HRV infection. Knowledge of the clinical pattern of this newly diagnosable infection should help physicians to recognize and treat quickly this highly infectious, potentially dangerous illness.