Treatment of chronic hepatitis C virus infection in children

Hepatitis C virus (HCV) infection may occur in infants and children, although it is much less common than it is in adults. The main transmission routes include mother-to-infant transmission, use of HCV infected blood products, unsterile needles or syringes and other invasive procedures. The natural course of HCV infection in children is variable: some (20-40%) develop an acute resolving infection and spontaneous regression occurs in approximately one-third of infants of HCV infected mothers before 2 years of age. Approximately 60-80% of HCV infected children develop a chronic infection with varying degrees of activity and fibrosis, mostly mild during childhood. However, the potential risks of liver cirrhosis and hepatoma during later life are obvious. Interferon is the main agent used to treat HCV infection in children. The response to interferon at the end of 4-12 months of therapy ranges from 25-90%. A sustained response was found in 36-56% of children 6-36 months after the end of therapy. The duration of therapy is recommended to be 12 months. At the end of 3 months, an evaluation of the response is indicated in the majority of children, except those with thalassemia, in whom evaluation of response should be conducted at the end of 6 months of therapy. The benefit of other therapies, such as combination therapy with interferon and ribavirin in children with hepatitis C is currently under investigation.

Saposins A, B, C, and D in plasma of patients with lysosomal storage disorders

BACKGROUND

Early diagnosis of lysosomal storage disorders (LSDs), before the onset of irreversible pathology, will be critical for maximum efficacy of many current and proposed therapies. To search for potential markers of LSDs, we measured saposins A, B, C, and D in patients with these disorders.

METHODS

Four time-delayed fluorescence immunoquantification assays were used to measure each of the saposins in plasma from 111 unaffected individuals and 334 LSD-affected individuals, representing 28 different disorders.

RESULTS

Saposin A was increased above the 95th centile of the control population in 59% of LSD patients; saposins B, C, and D were increased in 25%, 61%, and 57%, respectively. Saposins were increased in patients from several LSD groups that in previous studies did not show an increase of lysosome-associated membrane protein-1 (LAMP-1).

CONCLUSION

Saposins may be useful markers for LSDs when used in conjunction with LAMP-1.

Carnitine transport defect presenting with hyperammonemia: report of one case

Carnitine (beta-hydroxy-gamma-trimethylaminobutyric acid) is involved in the transport of long-chain fatty acids into the mitochondrial matrix and removal of potentially toxic acylcarnitine esters. Carnitine transport defect is a very rare metabolic disease. A 7-month-old female infant was found to have consciousness disturbance, hyperammonemia, hepatomegaly and elevated transaminases. Both the concentrations of free carnitine and acylcarnitines in her blood were very low. The diagnosis of carnitine transport defect was confirmed by assays of carnitine uptake and transport in skin fibroblasts. She responded dramatically to carnitine therapy, and there was no hyperammonemia attack for more than 3 years. Her cardiac function also remained normal.

Choledochal cyst in infancy: a follow-up study

From January 1980 to February 1997, 19 cases, 8 males and 11 females, of choledochal cyst were diagnosed before one year old. The majority of patients were diagnosed by ultrasonography before 6 months old (15/19; 79%), including two diagnosed prenatally. According to Todani's classification, type Ia was the most common (74%), followed by type Ic (26%). Fourteen patients underwent Roux-en-Y choledocho- or hepatico-jejunostomy and cyst excision, 3 patients underwent Kasai operation, and I patient underwent external biliary drainage only. The remaining one patient with Trisomy 18 anomaly refused operation. Four of the 10 patients in whom liver histologic examinations were performed, had liver cirrhosis. The follow-up period of these patients ranged from 6 months to 9 years, with a mean of 4.1 years. We divided these 19 cases into 2 groups, according to the presence or absence of biliary atresia. In the 7 infants with biliary atresia (37%), all presented with jaundice and alcoholic stool. Two patients died due to delayed presentation and surgery, both had liver cirrhosis. One patient is living with liver cirrhosis. Another patient was lost to follow-up, but frequent cholangitis was noted till 8 months old. The remaining 3 patients are living and well. In the 12 without biliary atresia, 9 patients are living and well. Two patients died, one due to Trisomy 18 anomaly and the other with delayed surgery and liver cirrhosis. One case was lost to follow-up. In summary: 1-) a possibility of the association of biliary atresia in infants with choledochal cyst should be carefully searched and considered as a unique group; 2) ultrasonography is a good diagnostic tool in choledochal cyst during prenatal or infancy period; 3) the mortality cases were characterized by prolonged bile stasis, biliary cirrhosis, delayed surgery, or multiple anomalies; 4) surgery should be performed as early as possible for those with persistent jaundice and light colored stools.

Prospects for hepatitis B virus eradication and control of hepatocellular carcinoma

Hepatitis B virus infection is the most common cause of chronic hepatitis, liver cirrhosis and hepatocellular carcinoma worldwide. In areas hyperendemic for HBV infection, the related complications occur mostly during adulthood. However, nearly half of all primary infection in chronic carriers occurs in the perinatal period through maternal transmission, the other half arising from horizontal transmission mainly through intrafamilial spread or injection using unsterilized needles. A universal vaccination programme is better than immunization for at-risk groups. Hepatitis B vaccination should be integrated into the Expanded Programme on Immunization in children. Universal immunization against hepatitis B virus has proved to be effective in reducing the hepatitis B carrier rate to one-tenth of the prevalence before the vaccination programme in highly endemic areas, and the incidence of hepatocellular carcinoma in children has also been shown to be significantly reduced. Continued efforts to implement universal vaccination programmes worldwide will very likely reduce the incidence of hepatitis B virus-related diseases, particularly liver cirrhosis and hepatocellular carcinoma.

Cytokine release of peripheral blood mononuclear cells in children with chronic hepatitis B virus infection

BACKGROUND

Immune response to hepatitis B virus (HBV) antigens or mitogens in Asian children with chronic HBV infection who are mainly perinatally infected has not been studied in connection with the production of various cytokines, although these patients are considered to be less responsive to antiviral therapy.

METHODS

The production of the cytokines interferon (IFN)-gamma, lymphotoxin, interleukin (IL)-4, tumor necrosis factor (TNF)-alpha, and interleukin (IL)-1beta by peripheral blood mononuclear cells (PBMCs) was studied in 17 hepatitis B surface antigen (HBsAg) carrier children with raised alanine transferase levels (group 1), 17 HBsAg carrier children with normal alanine transferase levels (group 2), and 20 healthy noncarrier control subjects (group 3).

RESULTS

Hepatitis B core antigen (HBcAg)-stimulated IFN-gamma production was significantly higher in group 1 than in groups 2 and 3, serum HBeAg cleared within 1 year in five of eight children in group 1 with stimulation indexes higher than 3, and HBcAg-induced IL-4 secretion was minimal in all groups. Interferon-gamma produced by PBMCs stimulated by purified HBsAg did not differ among the three groups. Higher lymphotoxin production by PBMCs stimulated by HBcAg was also noted in groups 1 and 2 than in group 3. Lipopolysaccharide (LPS)-stimulated TNF-alpha production by PBMCs was significantly higher in group 1 than in group 2. There was no association between HBeAg-anti-HBe status and production of various cytokines. No differences were seen in the profile of cytokines induced by HBV antigens or LPS in children of carrier mothers compared with children of HBsAg-negative mothers.

CONCLUSION

Increased IFN-gamma production resulting from HBcAg-specific T-helper lymphocyte type 1 response, and increased TNF-alpha production may contribute to cell-mediated antiviral immune response in children with chronic hepatitis B. In HBV carrier children, the ability to produce the studied cytokines is related to whether an endogenous immune attempt to eliminate HBV infection emerges in the patients but is not related to the different modes of acquisition of HBV infection.

Steroids used to desensitize penicillamine allergy in Wilson disease

Patients with Wilson disease require life-long treatment and penicillamine is the drug of choice. We present a 14-year-old boy with Wilson disease who developed hypersensitivity reaction 2 days after starting penicillamine therapy. His symptoms included fever, maculopapular rash and lip edema. The allergic reaction disappeared when penicillamine was discontinued, but relapsed after reinstituting penicillamine at a lower dose. Desensitization was attempted by introducing steroid therapy, the dose of 0.7 mg per kilogram per day of prednisolone for 2 days, then penicillamine was successfully tolerated. Subsequent tapering of the daily prednisolone dose was performed till it was discontinued one month after treatment began. We suggest that concomitant use of steroid and penicillamine should be used for the treatment of patients who develop penicillamine intolerance.

Changes of hepatitis B surface antigen variants in carrier children before and after universal vaccination in Taiwan

Mutants of a determinant of hepatitis B surface antigen (HBsAg) identified in vaccinated children pose a potential threat to long-term success of vaccination programs. We examined the mutants of a determinant (residues 110-160) of HBsAg in hepatitis B virus (HBV) DNA-positive children identified during previous serosurveys in Taipei undertaken just before (1984), 5 years after (1989), and 10 years after (1994) universal vaccination began. In HBV DNA-positive children from 3 surveys, the prevalence of a determinant mutants increased from 8 of 103 (7.8%) in 1984 to 10 of 51(19.6%) in 1989 and 9 of 32 (28.1%) in 1994 and was higher in those fully-vaccinated than unvaccinated (12/33 vs. 15/153, P =. 0003). Most amino acid changes of the variants clustered in residues 125-129 and 140-149. In all 27 children with detectable mutants, the mean age of those vaccinated was younger than those unvaccinated (4. 8 +/- 3.8 vs. 7.9 +/- 2.3 yrs, P <.05); and mutations occurred in a region with greatest local hydrophilicity (residues 140-149) more frequently in those vaccinated than in those unvaccinated (10/12 vs. 6/15, P =.0253). More mutated residues and more mutations at neutralizing epitopes, such as N146, C147, T148, and C149, were found in the 1994 survey. Vaccinated children may contract variant infections through vertical or horizontal transmission. Universal vaccination has accelerated an accumulation of HBsAg a determinant mutants with amino acid changes critical for immune escape in vaccinated children who became carriers, suggesting that new vaccination strategies should be considered.

Protamine enhances the efficiency of liposome-mediated gene transfer in a cultured human hepatoma cell line

Protamine, used clinically as an antidote for heparin, is a small protein with high arginine content and is potent in folding DNA. Protamine and DNA can form a compact structure, protecting DNA from digestion by intracellular enzymes. Protamine may, therefore, enhance the efficiency of gene transfer. In this study, we tested the ability of protamine to improve liposome-mediated gene transfer efficiency in a human hepatoma cell line. The results of a preliminary gel retardation assay indicated that 10 micrograms was the minimal amount of protamine sulfate needed to completely bind 5 micrograms of a plasmid containing a reporter gene, green fluorescent protein (GFP). For transfection assays, protamine (0, 10, 50, 100, and 500 micrograms) was added to a DNA-liposome mixture (5 micrograms DNA and 20 micrograms of a mixed formulation of 2,3-dioleyloxy-N-[2(sperminecarboxamido)ethyl]-N, N-dimethyl-1-propanaminium trifluoroacetate and dioleoylphosphatidylethanolamine) to transfect cultured Huh7 cells. Transfected cells (those expressing GFP) were counted by using flow cytometry. The expression index (EI) was calculated as the transfection efficiency (% of transfected cells) with protamine divided by the transfection efficiency with DNA and liposome only. Our results show that protamine sulfate (in a range of 10-100, 10 micrograms being most efficient) addition to the liposome-DNA mixture significantly increases the EI, and transfection efficiency of GFP in Huh7 cells.

Four new triterpenes from the heartwood of melaleuca leucadendron

Four new triterpenes, eupha-7,24-diene-3beta,22beta-diol (1), 20-taraxastene-3alpha,28-diol (2), 3alpha,27-dihydroxy-28, 20beta-taraxastanolide (3), and 3alpha-hydroxy-13(18)-oleanene-27, 28-dioic acid (4) have been isolated from the heartwood of Melaleuca leucadendron. The structures and stereochemistry of 1-4 have been determined by spectroscopic analysis, with compounds 3 and 4 being investigated in the forms of their diacetate (3a) and dimethyl (4a) derivative, respectively.

Decreased diversity of hepatitis C virus quasispecies during bone marrow transplantation

To elucidate the role of host immune status in the evolution and complexity of hepatitis C virus (HCV) quasispecies, three chronic HCV-infected patients who underwent bone marrow transplantation (BMT) were studied. The three transplanted patients' sera were sampled at pre-BMT, 3 months after BMT, and 12 months after BMT and the nucleotide diversity and substitution of the hypervariable region (HVR) of HCV quasispecies were analyzed. The nucleotide diversity was high at the pre-BMT period (28.2-43.4 x 10(-2) nucleotide difference/site). HVR of HCV quasispecies then became homogeneous in the first 3 months after BMT (0.11-6.40 x 10(-2) nucleotide difference/site). The nucleotide diversity of HVR at 12 months after BMT of all three patients was higher than that of 3 months after BMT but still lower than that of pre-BMT (2.09-6.40 x 10(-2) nucleotide difference/site). The analysis on nucleotide substitution rate showed a higher value between pre-BMT and 3 months after BMT (0.624-0.708 nucleotide difference/site per year) than that between 3 months and 12 months after BMT (0.072-0.127 nucleotide difference/site per year). HCV RNA titer decreased when the host had a low white cell count and increased accordingly. It was concluded that the evolution of HVR of HCV quasispecies related to the immune status of the host during BMT: after immunosuppression, an initial increase of viral populations was followed by the emergence of a dominant strain while the quasispecies gradually recovered as the immunity of the host gained its competence.

Immunogenicity and reactogenicity of two recombinant hepatitis B vaccines in healthy adolescents on two-dose schedule

This is an open, randomized study to compare the immunogenicity and reactogenicity of two recombinant hepatitis B virus (HBV) vaccines. The HBV-NF is a new formulation with a new adjuvant phenoxyethanol which replaced the conventional adjuvant of a commercially available recombinant HBV vaccine (Engerix-B). These two vaccines had the same 20 micrograms hepatitis B surface antigen (HBsAg). They were administered to the deltoid muscle of 116 healthy adolescents, aged between twelve and eighteen years, according to the 0, 6-month schedule. Serum was taken at month 0, 1, 6, and 7. Antibody to HBsAg was tested by radioimmunoassay. Geometric mean titers of both vaccines displayed no significant difference at month 1, 6, and 7. Following the second dose of vaccine, the seroprotection titer (10 mIU/ml) rates at month 7 were 90.9% in HBV-NF and 93.4% in Engerix-B, respectively (p = 0.43). The incidences of local and general adverse reactions were from 3% to 7% without significant difference between the two vaccines and the reactions were all mild and tolerable. Based on this study, regimens of this two-dose schedule proved to be safe and immunogenic, which may provide a cost-effective alternative for HBV mass vaccination program in adolescents.

Long term immune response of universal hepatitis B vaccination in infancy: a community-based study in Taiwan

OBJECTIVES

To evaluate the long term immunity provided by a universal hepatitis B vaccination program in infancy and the booster effect on school age children who had no protective antibody titers to hepatitis B surface antigen.

METHODS

We conducted a community-based seroepidemiologic study of 1337 healthy 7-year-old children in Taiwan one decade after the implementation of a mass hepatitis B vaccination program. A booster vaccination was suggested for noncarrier children who did not have protective titers of surface antibody. Serologic responses and infection rates were compared with those of the nonboostered children. In a nonselected group of 39 volunteer noncarrier vaccinees, quantitative serologic response was determined before, 1 month after a booster vaccination and 1 year later.

RESULTS

A total of 572 children (42.8%) had low concentrations of surface antibody, and 9 were hepatitis B surface antigen carriers (0.7%). Eighty-two percent of "nonprotected" vaccinees showed immunologic memory to a booster dose and developed protective antibody titers 1 month later; 60.6% maintained protective titers 1 year later. The frequency of new hepatitis B virus infection was similar for those who received a booster and those who did not as investigated by the core antibody seroconversion during 1-year follow-up. However, the risk was low, with annual incidences of <1% in both groups, and none became chronic carriers.

CONCLUSION

According to these data a universal vaccination program in infancy provides adequate protection against hepatitis B virus infection for school age children and a booster vaccination is not recommended.

Primary sclerosing cholangitis in a child

Primary sclerosing cholangitis (PSC) is a rare disease in Taiwan and has not been described in Taiwanese children previously. We report a 4-year-old girl who presented with prolonged fever, eosinophilia (11%), hepatomegaly, and markedly elevated serum levels of alkaline phosphatase (3,318 IU/L) and gamma-glutamyl transpeptidase (475 IU/L). Subsequent investigations including endoscopic retrograde cholangiopancreatography and liver histology confirmed the diagnosis fo PSC. Treatment with a low dose of prednisolone for 2 months and ursodeoxycholic acid during 32 months of follow-up resulted in clinical remission and halted disease progression. A high index of suspicion is necessary for physicians to diagnose this disorder in children with chronic liver disease. Our experience in this case indicates that therapy with prednisolone and ursodeoxycholic acid may be helpful for the treatment of PSC in children, and suggests the need for more trials of combined therapy.

Long-term response to hepatitis B vaccination and response to booster in children born to mothers with hepatitis B e antigen

Hepatitis B (HB) vaccine provides an uncertain duration of protection and the optimal timing of booster vaccine remains unclear. This study examined the immune response at 10 years of 118 children who had developed protective anti-HB surface (anti-HBs) levels after a primary series of HB immunizations in infancy. All of the children were born to hepatitis B e Antigen (HBeAg)-positive hepatitis B surface antigen (HBsAg) carrier mothers. HB markers in all subjects and cellular immune response in some were determined. A booster was given to all subjects after the collection of samples and another blood sample was collected 4 weeks later. The results showed that a total of 39 (33%) of the children were seronegative for anti-HBs. T-cell proliferative response to HBsAg was noted in 47% of children. On HBsAg stimulation, leukocyte samples from a significantly higher proportion of subjects produced cytokines (81% of T cells produced interleukin-2 [IL-2] and 100% produced IL-5). The booster dose of HB vaccine induced the production of a protective level of anti-HBs (>/=10 mIU/mL) in all subjects. Cellular immunity was augmented with a positive rate of 58%, 90%, and 100% for HBsAg-induced T-cell proliferation, IL-2 production, and IL-5 production, respectively. Although 14 (11.9%) of the subjects were HB core antibody positive at 10 years of age, no new HBsAg carrier was detected. The results of this study show that protection afforded by HB vaccination persisted to the age of 10 years in all vaccinees. Immunologic memory was detected in all subjects including those who had lost their anti-HBs seropositivity. These results suggest that no booster vaccination is needed before 10 years of age. The most sensitive marker of immunologic memory is IL-5 production of T cells. (HEPATOLOGY 1999;29:954-959.)

Isolation of Eikenella corrodens from polymicrobial hepatic abscess: report of one case

Eikenella corrodens is a rare cause of hepatic abscess. We report a case of a hepatic abscess caused by (1) Bacteroides fragilis, (2) Streptococcus constellatus and (3) E. corrodens, which illustrates potential problems of antibiotic coverage due to the presence of Eikenella species. The infection followed an episode of acute gastroenteritis and the clinical course appeared indolent evolving over one week. Besides empirical antibiotics, initial percutaneous aspiration was performed and yielded pus which grew E. corrodens concomitantly with Streptococcus species. E. corrodens was sensitive to penicillin but resistant to clindamycin and metronidazole. But B. fragilis was resistant to penicillin. So the antibiotics were switched to amoxicillin/clavulanate. Unfortunately fever persisted and the abscess increased in size. Therefore echo-guided percutaneous drainage with pigtail catheter was installed. Fever subsided 5 days later. After 21 days treatment of antibiotics, the patient was discharged in good condition despite having some sterile fluid in the residual abscess cavity. Two months after discharge the follow-up echogram confirmed complete resolution of the residual abscess. This patient shows us the existence of E. corrodens in pediatric patients, especially when the hepatic abscess is very likely from the spread of an oral or abdominal infection.

Synthesis and evaluation of 2 beta-oxyimino and alkenylpenicillanic acid sulfone derivatives as beta-lactamase inhibitors

The synthesis and in vitro synergies of 2 beta-alkenyl and oxyiminopenam sulfone derivatives are described. Most of the compounds synthesized exhibited good inhibitory activities and synergistic antibacterial activities with piperacillin and ceftriaxone, respectively, against several beta-lactamase producing strains. Particularly the 2 beta-alkenylpenam sulfone derivatives. 1e and 1g, showed good synergistic activity with ceftriaxone against Citrobacter freundi NIH 10018-68 and Proteus vulgaris 20. Also the compounds 2a, 2c, and 2f, 2 beta-oxyiminopenam sulfone derivatives, exhibited improved synergistic activity with piperacillin against Citrobacter freundi NIH 10018-68.

Hepatitis A vaccine in healthy adults: a comparison of immunogenicity and reactogenicity between two- and three-dose regimens

Inactivated hepatitis A virus (HAV) vaccine was administered to 55 healthy seronegative adult volunteers to evaluate the immunogenicity and adverse reactions of two doses of HAV vaccination (25 units) in comparison with a three-dose regimen. The volunteers were randomly assigned to receive one of the two regimens: 26 were vaccinated with two doses at 0 and 24 weeks (Group 1), and 29 were vaccinated with three doses at 0, 2, and 24 weeks (Group 2). The vaccine was well tolerated and there was no serious adverse reaction. In both groups, the seroconversion rate was 100% at week 28. At week 52, all remained positive for anti-HAV regardless of a two- or three-dose regimen. No statistically significant difference in seroconversion rates and geometric mean titers could be demonstrated between the two groups. Thus, the two-dose regimen may be favorable to save cost and time for active immunization against hepatitis A.

Shock in the pediatric emergency service: five years' experience

We undertook a retrospective study of the risk factors determining outcome of nontraumatic patients with shock in the pediatric emergency service. From October 1992 through September 1997, 22 patients with the diagnosis of shock were identified, including 11 with septic shock (50%), 7 with hypovolemic shock (32%) and 4 with cardiogenic shock (18%). Their age ranged from 2 months to 19 years old. Among the cases, 14 patients (64%) had other underlying diseases. Gram-negative bacterial sepsis (6/11, 55%), dilated cardiomyopathy (2/4, 50%) and acute gastroenteritis (7/7, 100%) were the most frequent causes of septic, cardiogenic and hypovolemic shock, respectively. In total, 12 patients (55%) died. The mortality rate was high in septic shock (9/11, 82%) and cardiogenic shock patients (3/4, 75%), but low in hypovolemic shock patients (0/7, 0%). The risk factors of poor outcome in patients with shock included thrombocytopenia, prolonged prothrombin time and partial thromboplastin time. Patients with leukopenia, a higher level of C-reactive protein, or under 2 years of age tended to have poor outcome.

Long-term follow-up of duodenal ulcer in children before and after eradication of Helicobacter pylori

BACKGROUND

Helicobacter pylori is a well-known cause of chronic antral gastritis and plays an important role in the pathogenesis of peptic ulcer disease in adults. However, because of the relatively low incidence of duodenal ulcer in childhood, few studies have been directed specifically at the relation between the treatment of H. pylori infection and duodenal ulcer in children. An evaluation in a larger patient population is necessary to draw a conclusion.

METHODS

Twenty-six children with duodenal ulcer and H. pylori antral gastritis received triple therapy (amoxicillin, bismuth, and metronidazole) to investigate whether eradication of the organisms can promote healing and prevent relapse of the ulcers in children. Endoscopic examinations were performed before, 2 months, and 12 months after the beginning of treatment.

RESULTS

H. pylori infection was eradicated in 25 (96%) of the 26 patients who underwent upper endoscopic follow-up. Clinical improvement and ulcer healing were achieved in 24 (92%) of 26 children. During a mean follow-up of nearly 2 years, the annual ulcer relapse rate was estimated to be 9%.

CONCLUSIONS

Triple therapy is the treatment of choice for endoscopically proven duodenal ulcer and histologically proven H. pylori antral gastritis in children. It strongly supports a causal relation between H. pylori and duodenal ulcer disease in children.

Cardiovascular disease risk factors and preventive practices among adults--United States, 1994: a behavioral risk factor atlas. Behavioral Risk Factor Surveillance System State Coordinators

PROBLEM/CONDITIONS: Cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke, is the leading cause of death in the United States, and state rates of CVD vary by state and by region of the country. Several behavioral risk factors (i.e., overweight, physical inactivity, smoking, hypertension, and diabetes mellitus) and preventive practices (i.e., weight loss and smoking cessation) are associated with the development of CVD and also vary geographically. This summary displays and analyzes geographic variation in the prevalences of selected CVD risk factors.

REPORTING PERIOD

1994 (1992 for prevalence of hypertension).

DESCRIPTION OF SYSTEM

The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based random-digit-dialing telephone survey of noninstitutionalized adults aged > or =18 years; 50 states and the District of Columbia participated in BRFSS in 1994, and 48 states and the District of Columbia participated in 1992.

METHODS

Several different analyses were conducted: a) analysis of state risk factor and preventive practice prevalences by sex and race (i.e., black and white); b) mapping; c) cluster analysis; d) correlations of state prevalence rates by sex and race; and e) regression of state risk factor prevalences on state CHD and stroke mortality rates.

RESULTS

Mapping the prevalence of selected CVD risk factors and preventive health practices indicates substantial geographic variation for black and white men and women, as confirmed by cluster analysis. Data for blacks are limited by small sample size, especially in western states. Geographic clustering is found for physical inactivity, smoking, and risk factor combinations. Risk factor prevalences are generally lower in the West and higher in the East. White men and white women are more similar in state risk factor rates than other race-sex pairs; white women and black women ranked second in similarity. State prevalences of physical inactivity and hypertension are strongly associated with state mortality rates of CVD.

INTERPRETATION

Geographic patterns of risk factor prevalence suggest the presence (or absence) of sociocultural environments that promote (or inhibit) the given risk factor or preventive behavior. Because the risk factors examined in this summary are associated with CVD, further exploration of the reasons underlying observed geographic patterns might be useful. The BRFSS will continue to provide geographic data about cardiovascular health behaviors with a possible emphasis on more data-based small- area analyses and mapping. This will permit states to more adequately monitor trends that affect the burden of CVD in their regions and the United States. Mapping also facilitates the exploration of patterns of morbidity, health-care use, and mortality, as well as the epidemiology of risk factors. Finally, by identifying those segments of the population with high levels of these risk factors and lower levels of the preventive health practices, public health personnel can better allocate resources and target intervention efforts for the prevention of CVD.

Pediatric percutaneous endoscopic jejunostomy by J-tube extension through a preexisting gastrostomy site: a preliminary report

A prematurely born 5-year-old boy with chronic lung disease, hypoxic-ischemic encephalopathy, cerebral palsy, repeated aspiration pneumonia, and stroke underwent percutaneous endoscopic jejunostomy (PEJ) to alleviate repeated aspiration pneumonia. Studies, including 24-hour esophageal pH monitoring, 99mTc gastric emptying time, upper gastroesophageal barium radiography, and endoscopic examinations showed severe gastroesophageal reflux and prolonged gastric emptying. Percutaneous endoscopic gastrostomy (PEG) was performed first, followed by placement of a polyurethane J-tube (9 French) through the preexisting gastrostomy site. We passed the style-guided J-tube through the pyloric ring endoscopically and advanced it to the jejunum. The position of the J-tube was confirmed by radiologic study. Feeding with an elemental formula, 20 mL/hour, commenced immediately after the procedure, and the rate was gradually increased to 50 mL/hour. No further episodes of aspiration pneumonia have occurred since J-tube placement. Our initial experience with jejunal feeding through a PEJ is encouraging.

Hepatocellular carcinoma in children

Hepatocellular carcinoma (HCC) is one of the most frequent malignancies in humans. Although it occurs mainly in adults of 40 to 60 years of age, it may develop in children. It mainly occurs in children older than six years of age, with male predominance. Children with chronic hepatitis B virus (HBV) infection and underlying metabolic diseases are the two main high risk groups for childhood HCC. HBV infection is the main cause of childhood HCC in areas hyperendemic for HBV infection. In Taiwan, nearly 100% of HCC children were hepatitis B surface antigen seropositive. Maternal transmission (94%) is the most important route of transmission of HBV infection in HCC children. For HBV related HCC in children, immunization is the most effective way for the control of childhood HCC. The first universal vaccination against HBV in the world was launched in Taiwan in July 1984. The prevalence of hepatitis B surface antigenemia in children declined from 10% in 1984, prior to the vaccination program, to < 1% in 1994, 10 years after the implementation of the program, in children less than 9 years of age. The annual incidence of HCC in children aged 6 to 9 years of age also decreased from 0.52 per 100,000 born in 1974-1984 to 0.13 per 100,000 born in 1984-1986.

Viral etiology of intussusception in Taiwanese childhood

BACKGROUND

Adenovirus infection and lymphoid hyperplasia have been associated with childhood intussusception. However, the extent of other viruses involved in this condition remains unclear. This prospective study investigates the relationship between some lymphotropic viruses and current childhood intussusception.

METHODS

Patients with intussusception encountered in a pediatric emergency department in a recent 3-year period were studied. Healthy infants and toddlers of comparable age served as controls. Throat and rectal viral cultures were performed in patients and controls. Viral antibodies against adenovirus, cytomegalovirus, human herpesvirus (HHV)-6, HHV-7 and Epstein-Barr virus (EBV) were tested in paired sera from the patients. Acute stage serum from each patient and mesenteric lymph nodes from patients requiring surgery were studied for the presence of adenovirus genome by PCR.

RESULTS

Twenty-seven of 61 (44.3%) intussusception patients, but only 2 of 52 (3.8%) healthy controls shed nonenteric adenovirus in throat and rectal specimens (P < 0.001). Of the 27 (74.1%) patients who shed adenovirus, 20 were older than 1 year old, whereas only 1 of 15 (6.7%) similarly aged patients in a previous study from the same area three decades ago did so (P = 0.001). Among 43 patients with available paired sera, acute primary viral infection was found in 17 (39.5%) by adenovirus, 4 (9.3%) by HHV-6, 5 (11.6%) by HHV-7, 2 (4.7%) by EBV and none by cytomegalovirus. Multiple viral infections occurred in 6 patients. Adenovirus genome was detected in 4 of 9 mesenteric lymph nodes and in only 3 of 60 (5%) acute phase sera.

CONCLUSIONS

Primary nonenteric adenovirus infection contributes to current childhood intussusception. Acute primary HHV-6, HHV-7 and EBV infections also play etiologic roles.

Magnetic resonance cholangiography for evaluation of cholestatic jaundice in neonates and infants

Distinguishing extrahepatic biliary atresia from other causes of cholestasis in neonates and infants is important because surgical intervention before 2 months of age allows for long-term survival. The purpose of this prospective study was to evaluate the usefulness of magnetic resonance (MR) cholangiography in differentiating biliary atresia from other causes of cholestatic jaundice in neonates and infants. Nine anicteric infants (control group) aged 10 to 224 days (mean +/- SD, 8 +/- 65 days) and 15 neonates and infants with cholestatic jaundice, aged 22 to 142 days (mean +/- SD, 71 +/- 37) underwent MR cholangiography. The final diagnosis of extrabiliary atresia (6 patients) was based on laparotomy findings (4 patients) or autopsy (2 patients), while neonatal hepatitis (9 patients) was diagnosed according to the liver biopsy findings and clinical recovery during follow-up. Percutaneous liver biopsies were performed in all 15 patients. Results showed that the gall bladder and common bile duct (CBD) could be visualized using MR cholangiography in all patients in the control group. Nonvisualization of the CBD (6/6 patients) and demonstration of a small gall bladder (6/6 patients) characterized MR cholangiography findings in patients with biliary atresia. MR cholangiography failed to depict the CBD in one infant with hepatitis. We conclude that demonstration of the CBD by MR cholangiography in neonates and infants with cholestasis can be used to exclude the diagnosis of biliary atresia. In patients with cholestatic jaundice considered for exploratory laparotomy, preoperative MR cholangiography is recommended to avoid unnecessary surgery.

Antibodies to E2 protein of hepatitis G virus in children: different responses according to age at infection

OBJECTIVES

To study viral persistence and antibody responses after hepatitis G virus (HGV) infection in children of various ages.

STUDY DESIGN

We performed an enzyme immunoassay for antibodies to E2 protein (anti-E2) of HGV and reverse-transcription polymerase chain reaction assay for HGV RNA on serum samples.

RESULTS

Of 28 infants born to HGV RNA-positive mothers, 17 were found to be positive for HGV RNA. None were positive for anti-E2. All 17 infected infants continued to have viremia except 1 who converted to HGV RNA-negative status at 24 months. Six infants had mild elevations of alanine aminotransferase levels (5 HGV-positive and 1 HGV-negative). An additional 14 HGV-infected children (aged 6 months to 14 years) with posttransfusion HGV infection were tested for anti-E2 3 months and 12 months after blood transfusion. None of the HGV RNA-positive serum samples were positive for anti-E2; however, 4 of the 8 children with resolving HGV infection were positive for anti-E2 1 year later.

CONCLUSIONS

Mother-to-infant transmission of HGV resulted in a high viral persistence rate and lack of immune responses to HGV. In contrast, anti-E2 appeared in children who recovered from posttransfusion HGV infection. Mode of transmission and age at infection may be important factors in determining persistent HGV infection and defective immune response to HGV.

Hepatitis B surface antigenemia at birth: a long-term follow-up study

OBJECTIVE

To investigate the prevalence and outcome of hepatitis B surface antigenemia in newborns of hepatitis B e antigen (HBeAg)-positive hepatitis B surface antigen (HBsAg) carrier mothers under the current immunoprophylaxis program.

STUDY DESIGN

From 1984 to 1993, 665 high-risk newborns born to HBeAg-positive HBsAg carrier mothers were prospectively recruited. The newborns were tested for HBsAg soon after birth, before hepatitis B immune globulin administration. All newborns received hepatitis B immune globulin within 24 hours after birth plus subsequent hepatitis B vaccination. Those who were seropositive for HBsAg at birth were regularly followed up for their hepatitis B virus (HBV) markers, liver function profiles, and alpha-fetoprotein levels from 1984 to 1996.

RESULTS

Sixteen (2.4%) of the 665 subjects were found to be seropositive for HBsAg at birth, and all remained HBsAg-positive at 6 months of age. Twelve of the 16 received long-term follow-up care, and all were confirmed to have chronic HBV infection. Of the 12, 2 had HBeAg seroconversion, and 1 had alanine aminotransferase flares without HBeAg seroconversion. Delayed appearance of hepatitis B core antibody (anti-HBc) occurred in 2 without alanine aminotransferase elevation.

CONCLUSIONS

Current immunoprophylaxis strategy does not protect newborns with surface antigenemia, apparently acquired in utero, from becoming HBV carriers. Immunologic attempts to eliminate HBV may occur in carrier children infected in utero, despite their profound immune tolerance to HBV.

Oral drug of choice in carpal tunnel syndrome

BACKGROUND

Conservative treatment of mild to moderate carpal tunnel syndrome (CTS) is variable.

OBJECTIVE

To evaluate the effectiveness of commonly used oral medications such as diuretics, nonsteroid anti-inflammatory drugs (NSAIDs), and steroids in the treatment of CTS.

METHODS

Prospective, randomized, double-blind and placebo-controlled study of patients with clinical symptoms and signs of CTS, confirmed by standard electrodiagnosis. Baseline assessments included a standardized symptom questionnaire, rating five categories of symptoms (pain, numbness, paresthesia, weakness/clumsiness, and nocturnal awakening) on a scale from 0 (no symptoms) to 10 (severe). The total score in each of the five categories was termed the global symptom score (GSS). After baseline assessment, patients were randomized to the following treatment arms: 1) 4 weeks of placebo (n = 16); 2) 4 weeks of diuretic (trichlormethiazide, 2 mg daily; n = 16); 3) 4 weeks of NSAID-slow release (SR) (tenoxicam-SR, 20 mg daily; n = 18); and 4) 2 weeks of prednisolone, 20 mg daily, followed by another 2-week dosage of 10 mg daily (n = 23). Results of follow-up assessments in the second and the fourth weeks were identical to baseline scores. The changes in GSS were analyzed to determine the statistical difference.

RESULTS

No significant reduction from baseline GSS was seen at second, and fourth weeks in the placebo, NSAID-SR, and diuretic groups. However, the mean score at 4 weeks in the steroid group decreased significantly from a baseline of 27.9 +/- 6.9 to 10 +/- 7.4.

CONCLUSION

For patients with mild to moderate CTS who opt for conservative treatment, corticosteroids are of greater benefit.

Precore stop codon mutant in chronic hepatitis B virus infection in children: its relation to hepatitis B e seroconversion and maternal hepatitis B surface antigen

BACKGROUND/AIMS

The aims of this study were to investigate the significance of the precore stop codon mutant in the natural course of hepatitis B virus infection in children, and the influence of maternal transmission.

METHODS

Sequential sera from 80 hepatitis B virus carrier children both before and after e seroconversion during long-term follow-up were studied using the polymerase chain reaction-amplification created restriction site method. Direct sequencing of the precore region was performed in 89 sera from 32 of the 80 children.

RESULTS

The precore stop codon mutant coexisting with wild strain was found in 10% of children initially, and later in 25% of children before e seroconversion. After e seroconversion, wild type was still present in 75% and mutant in 39% of children at the end of follow-up. The mutant alone was present in 15% of anti-HBe positive children without concomitant aminotransferase elevation. Children with earlier emergence of this mutant tended to have higher peak aminotransferase levels. This mutant emerged less frequently in children of hepatitis B virus carrier mothers (37.5%) than in those of non-carrier mothers (65%) (p<0.05).

CONCLUSIONS

These observations suggest that this mutant is selected by host immune pressure, but is not an initiator in the loss of immune tolerance during childhood chronic hepatitis B virus infection.

Purification and properties of beta-N-Acetylhexosaminidase from cabbage

beta-N-Acetylhexosaminidase was purified from the extract of cabbage by sequential steps of ammonium sulfate fractionation, chromatofocusing, DEAE-Sepharose CL-6B ion exchange chromatography and Sephacryl S-200 HR gel filtration. By these steps, the purity of the enzyme increased by 256 fold with a recovery of 8%. The purified enzyme was homogeneous as examined by native PAGE. It showed an optimal pH of 4, an optimal temperature of 60 degrees C and a Km of 0.94 mM for hydrolysis of pNp-beta-GlcNAc. The molecular mass of the enzyme determined from filtration through Sephacryl S-200 was 150 kDa. Three subunits with molecular mass of 64, 57 and 51 kDa were observed as determined by SDS-PAGE. NBS (0.025 mM), DEPC (3 mM) and WRK (30 mM) significantly inhibited the activity of the enzyme. The enzyme also showed activity toward pNp-beta-GalNAc, N,N'-diacetylchitobiose, N,N',N"-triacetylchitotriose and N,N',N",N"'-tetraacetyl chitotetraose but showed no activity toward pNp-alpha-GlcNAc, chitin and ethylene glycol chitin.

Ca2+ uptake and Cd2+ accumulation in larval tilapia (Oreochromis mossambicus) acclimated to waterborne Cd2+

The present study compares the rates of Ca2+ uptake and Cd2+ accumulation in tilapia (Oreochromis mossambicus) between larvae preexposed to Cd2+ and naive larvae. Preexposure to Cd2+ induces some form of adaptation that attenuates the effects of Cd2+ later on. Exposure to Cd2+ decreased the uptake of Ca2+ but did not suppress the accumulation rate of Cd2+. A 12-fold increase in 96-h half-maximal lethal concentration was found in tilapia larvae preexposed to 0.45 microM Cd2+ from hatching for 3 days in comparison with naive 3-day-old larvae. The effects of Cd2+ on Ca2+ influx kinetics in larvae preexposed to 0.18 microM Cd2+ for 3 days were examined. The Michaelis constant for Ca2+ in the 0.18 microM Cd2+ preexposed larvae did not change significantly in the presence of Cd2+, whereas maximal velocity increased by approximately 23%. An enhanced Ca2+ uptake efficiency ( approximately 18%) was found in these Cd2+-acclimated larvae. The criterion that determines the survival of tilapia larvae encountering Cd2+ challenge is the degree of interference with Ca2+ homeostasis instead of the absolute amount of Cd2+ accumulated.

The prevalence of risk factors among women in the United States by race and age, 1992-1994: opportunities for primary and secondary prevention

OBJECTIVE

To analyze the prevalence of 11 modifiable behavioral risk factors, including multiple risk factors, among white, black, Asian and Pacific Islander, American Indian, and Hispanic women in the United States.

DESIGN

We used Behavioral Risk Factor Surveillance System (BRFSS) data for 1992 to 1994 to examine risk factors (smoking; obesity; diabetes; heavy alcohol consumption; sedentary lifestyle; and inadequate use of seat belts, pap smears, consumption of fruits or vegetables, mammography and colorectal screening, and immunization), among women age 18 to 49, 50 to 64, and 65 and older. We also conducted a multiple regression analysis, comparing the odds of having either 1-2 versus 0 or 3 or more versus 0 risk factors among racial/ethnic groups, controlling for education and family income, to see if racial/ethnic differences can be attributed to socioeconomic differences.

RESULTS

US women engage in a variety of behaviors that place them at risk for many causes of morbidity and mortality. Risk profiles vary substantially among racial/ethnic populations: Pacific Islanders have relatively low prevalences of most major risk factors, while blacks and American Indians have relatively high prevalences of many major risk factors. Prevalence differences among racial/ethnic populations are diminished but not eliminated when socioeconomic factors are accounted for.

CONCLUSIONS

Appropriately designed programs to help women reduce their behavioral risk factors are needed. Action by health care providers, communities, and policy makers can substantially improve the health of women in the United States.

Mother-to-infant transmission of GB virus C/hepatitis G virus: the role of high-titered maternal viremia and mode of delivery

To study mother-to-infant transmission of GB virus C/hepatitis G virus (GBV-C/HGV), blood samples of infants born to carrier mothers were collected beginning 3 months after birth and were tested for GBV-C/HGV RNA until 1 year of age. Of 2046 mothers, 2.1% were positive for GBV-C/HGV RNA, and 25 of their infants were followed for a median of 12 months. Thirteen infants (52%) were viremic, and infection became persistent in all. Maternal GBV-C/HGV RNA levels of this group were >10(7) copies/mL. Nucleotide sequence comparison in 5 viremic mother-infant pairs revealed a homology of 93%-98.2%, and none delivered by elective cesarean section. In comparison, of the 12 uninfected infants' mothers, 10 had lower GBV-C/HGV RNA levels (mean, 5 x 10(4) copies/mL), and the remaining 2 high-titered mothers had elective cesarean section. Thus, high-titered maternal viremia and mode of delivery are closely associated with the mother-to-infant transmission of GBV-C/HGV to infants, and the infection usually becomes persistent.

Chronic hepatitis virus infection in children

Hepatitis B and C viruses (HBV and HCV) are the two main hepatitis viruses causing chronic liver diseases in children. In hyperendemic areas, nearly half of the primary infection in chronic HBV carriers occurs during the perinatal period through the transmission from hepatitis B e antigen (HBeAg)-positive mothers. The other half are from horizontal transmission mainly through intrafamilial spread or injection using unsterilized needles. During the natural course of chronic HBV infection, spontaneous HBeAg/anti-HBe seroconversion occurs very rarely (2% annually) before 3 years of age. After 3 years of age, the HBeAg seroconversion rate increases gradually to 5% per year. Those with mothers who are hepatitis B carriers tend to clear HBeAg slower than those whose mothers are non-carriers. Transplacental HBeAg may cause T cell tolerance in infected children. Universal HBV immunization programmes have been effective in reducing the hepatitis B carrier rate more than 10-fold, and the incidence of hepatocellular carcinoma in children has also been decreased significantly. Hepatitis C virus infection occurs mainly in high-risk children, such as those who received blood products (blood diseases, malignancies, post-open heart surgery etc.), children of HCV-infected mothers, and in hyperendemic areas, from injection using unsterile needles. Mother-to-infant transmission occurs on average in 5% of infants of viraemic mothers. The maternal HCV-RNA titre is the most important factor determining the infectivity. Chronicity developed in 60-80% of HCV-infected children. Although transient or persistent elevation of aminotransferases occurs frequently in chronically HCV-infected children, liver histology showed minimal or mild changes only. The most prevalent genotype of HCV in children is Ib. Screening of the blood products for HCV antibody has markedly reduced the rate of HCV infection in children at risk. However, vaccine development is needed to prevent mother-to-infant transmission and other routes of infections.

"Hotness" stability of chicken hot-wing products as affected by preparation methods and storage

Chicken hot-drumettes containing 2% cayenne pepper were prepared using three different cooking methods and stored under two different temperatures for "hotness" evaluation. Results demonstrated that the hotness of the samples were highest when products were cooked in a microwave oven, followed by convection oven, and least hot by deep-fat frying. Regardless of the cooking method, the degree of hotness of the hot-drumette decreased drastically during refrigerated storage. Results also indicated that the loss of hotness was associated with the increase of 2-thiobarbituric acid (TBA) values in the product. The addition of antioxidants such as butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), rosemary, and sodium nitrate during preparation or vacuum packaging retarded lipid oxidation of chicken hot-drumettes and retarded the loss of hotness of the products during refrigerated storage.

Hepatitis B: long-term outcome and benefits from mass vaccination in children

Hepatitis B viruses can cause chronic liver diseases in both children and adults. In hyperendemic areas, although most related complications occur during adulthood, nearly half of the primary infection in chronic hepatitis B virus carriers occurs in perinatal period through maternal transmission and the other half are from horizontal transmission mainly through intrafamilial spread or injection using unsterilized needles. Children with chronic hepatitis B virus infection are mostly asymptomatic. They are generally active and growing well with very rare exceptions. Even with acute exacerbation of liver function and active inflammation, jaundice or growth failure is uncommon. Mild histologic abnormalities in the liver begins early in life and may progress to severe liver impairment in later life. Severe liver damage, with bridging hepatic necrosis or fibrosis, or cirrhosis of the liver may occur, but is rare during childhood. Universal immunization program of hepatitis B virus has been proved to be effective in reducing hepatitis B carrier rate for more than 10 folds, and the incidence of hepatocellular carcinoma in children has also been reduced significantly.

Successful arterial switch operation in a low-birth-weight neonate who had transposition of the great arteries and advanced necrotizing enterocolitis

A low-birth-weight (LBW; 1,940 g) girl was born at the gestational age of 36 weeks without any perinatal insult. Transposition of the great arteries (TGA) with a large patent ductus arteriosus (PDA) and interatrial shunt was detected. Stage IIIB necrotizing enterocolitis (NEC) developed 46 hours after birth. She received ileostomy and drainage. Arterial switch operation was successfully performed at 23 days of age when her weight was 1,900 g. The enterostomy was successfully repaired at 104 days of age.

A follow-up study of annular pancreas in infants and children

Fifteen pediatric patients undergoing surgery for annular pancreas from 1984 to 1996 were analyzed. Vomiting was the most common presenting symptom. Twelve patients (80%) had associated anomalies including malrotation (40%), intrinsic duodenal obstruction (33%), Down syndrome (27%) and duodenal bands (27%). Their ages at operation were between 5 hours and 8.5 years, with a median of 4 days. Surgical treatment included duodenojejunostomy in nine, duodenoduodenostomy in five and duodenotomy with duodenoplasty in one. The mean duration for reestablishment of bowel transit was 17.9 days, with 22.8 days for duodenojejunostomy and 12.3 days for duodenoduodenostomy. All cases received postoperative follow-up, but only 11 of them were long-term followed until April 1997, with a duration ranging from 1 year and 2 months to 11 years, with a median of 7 years and 5 months. The survival was 100%, but 12 cases (80%) developed postoperative complications including cholestatic jaundice (53%), upper gastrointestinal motility disorder (47%), failure to thrive (40%) and chronic diarrhea (33%). Annular pancreas divisum was noted in one case with chronic relapsing pancreatitis. At the end of follow-up (April 1997), when final ages ranged from 1 year and 2 months to 18 years and 9 months with a median of 7 years and 5 months, there were still problems: steatorrhea in 1, diarrhea after fatty diet in 3, malnutrition in 4, failure to thrive in 3 and lower concentration of stool trypsin in 3 cases. In conclusion, close long-term follow-up is essential for infants treated for annular pancreas because many of them can be expected to develop complications, even if the initial postoperative period is uncomplicated and survival is excellent.

Follow-up immunogenicity of an inactivated hepatitis A virus vaccine in healthy children: results after 5 years

Long-term persistence of hepatitis A virus (HAV) serum antibody in vaccinated children has not been demonstrated in previous studies. To study the long-term immunogenicity to HAV vaccine, three doses of strain HM 175 HAV vaccine with 360 enzyme-linked immunosorbent assay units were administered to 107 children, aged from 1.0 to 6.8 years, at 0, 1, and 6 months. The administration of one vaccine dose induced seropositivity (anti-HAV titer > or = 20 mIU ml-1) in 95% of all vaccinees at month 1. All subjects remained seropositive until month 6. The titers of HAV antibody remained above 20 mIU ml-1 in all subjects followed up to 60 months. The geometric mean titer (GMT) reached its peak (3802 mIU ml-1) at month 7, i.e. 1 month after the booster dose, and then declined until the end of follow-up at month 60 (661 mIU ml-1). A trend of higher GMT in female subjects persisted up to month 60. The changes of the GMT over time were best described by the regression equation: log (GMT) = 3.26-0.08 x (age in years) (r = -0.95, P = 0.014). According to this equation, the geometric mean concentration would reach 20 mIU ml-1 at around 24.5 years after the beginning of vaccination. In conclusion, those who completed the recommended three-dose inactivated HAV vaccination series remained seroprotective for at least 5 years. Theoretically, such a vaccination program can provide a protective period of over 20 years in children. This paper may be the first to describe at least 5-year immunogenicity of inactivated HAV vaccination in healthy children.

Hepatitis G virus infection in normal and prospectively followed posttransfusion children

A recently identified RNA virus, hepatitis G virus (HGV), has been investigated for its role in causing non-A-E hepatitis. The frequency and clinical outcome of HGV infection in children was studied. Two hundred apparently healthy children aged 6 mo to 12 y, and 90 children who had undergone open heart surgery in a prospective study for posttransfusion hepatitis were included in this study. The serum samples were tested for HGV RNA by nested reverse transcription-PCR with primers from the 5'-untranslated region. The HGV RNA viremic rate was found to be 1% (2/200) in apparently healthy children, 30% in children after open heart surgery. Among the 90 children, three were HGV-infected before the surgery. Twenty-four (28%) of the remaining 87 children tested positive for HGV RNA within 6 mo after the surgery. Sixty-five percents of these viremic children eventually became persistently infected at 1 y after surgery. No HGV RNA-positive children exhibited elevated alanine aminotransferase levels during the follow-up period. No coinfections of HGV with the hepatitis C virus or hepatitis B virus were found. Patients of younger age appeared more likely to become chronic carriers. Anti-HCV screening did not reduce the prevalence of HGV infection. In conclusion, in children with open heart surgery, the risk of transfusion-transmitted HGV infection and the chronicity rate have been found to be high. Young age is a risk factor of persistent infection.

Non-A, non-B, non-C hepatitis: its significance in pediatric patients and the role of GB virus-C

OBJECTIVES

To delineate the importance of non-A, non-B, non-C (non-ABC) hepatitis, and the role of GB virus C (GBV-C) in children.

METHODS

From 1980 to 1995, acute-onset viral hepatitis was diagnosed in 166 inpatients and categorized into type A, B, C, and non-ABC hepatitis according to the serologic markers or the results of polymerase chain reaction assay for HBV DNA or HCV ribonucleic acid (RNA) in the National Taiwan University Hospital. Non-ABC hepatitis was diagnosed in 57 patients (34%). GBV-C RNA was investigated by reverse transcription and nested polymerase chain reaction in 32 of the 57 patients with non-ABC hepatitis. The clinical and laboratory features of patients with acute non-ABC hepatitis were compared with the features of those with acute hepatitis A and B.

RESULTS

The degree of abnormality in aminotransferase activities was milder in patients with non-ABC hepatitis than in those with hepatitis B; chronicity was noted in 12%. Fulminant hepatitis occurred in 16%, and the mortality rate was 56%. Young age carried a significantly higher risk of having a fulminant course (1.9 +/- 0.2 years of age vs 6.4 +/- 5.1 years of age in acute course; p < 0.05). Compared with fulminant hepatitis B, fulminant non-ABC hepatitis had a trend of a longer interval from onset to death (119.2 +/- 144.8 vs 15.2 +/- 8.4 days; p = 0.079). GBV-C RNA was detected in only two of the patients tested, both of whom had received transfusions; one had persistent viremia and fluctuating aminotransferase values.

CONCLUSIONS

Non-ABC hepatitis plays an important role in the etiology of pediatric viral hepatitis; however, the role of GBV-C is minor. A search for other unknown viral agent(s) responsible for non-ABCG hepatitis is needed.

Congenital short bowel syndrome with left acheiria: report of one case

A case of congenital short bowel syndrome with left acheiria, hemivertebra and dextrocardia is described. Dilatation of the fetal bowel was observed at the 24th week of gestation during a routine ultrasonic scan of a healthy 23-year-old primigravida from a non-consanguineous marriage. Amniocentesis and chorionic villus sampling were denied. The baby was delivered at 38 weeks of gestational age. After delivery, multiple anomalies were noted: left acheiria, congenital short bowel syndrome (15 cm in length of the ileum), pseudo-obstruction of intestine, dextrocardia, and hemivertebrae. We suspected these abnormalities might be due to a vascular accident or failure of lateralization during the early gestational period. To our knowledge, these combinations have not been reported previously in English literature.

Bone fractures in children with chronic cholestasis

The clinical features, biochemical data, roentgenographical bone changes and liver histological studies of four children with fractures related to chronic cholestasis are described. Two of them had Alagille syndrome and the other two, biliary atresia. Only one patient presented with forearm fracture associated with typical radiographic evidence of rickets. The others revealed generalized osteopenia together with fractures in arms, forearms, and wrists respectively. Of these, one with rickets had hypocalcemia and hypophosphatemia; one had decreased parathyroid hormone with mild hypocalcemia and hyperphosphatemia; one had hyperphosphatemia solely. Eucalcemia and euphosphatemia were noted in the remaining patient. Their bone lesions deteriorated in spite of treatment, except for the one with clinical rickets. All the patients succumbed eventually. It was concluded that the real pathogenesis of bone lesions in end-stage liver disease of chronic cholestatic children remains unclear. However, because rickets may intervene, continuing efforts to supply vitamin D and calcium since diagnosis of chronic cholestasis on a long-term basis, to prevent fracture, is still mandatory.

Surface gene mutants of hepatitis B virus in infants who develop acute or chronic infections despite immunoprophylaxis

Serum hepatitis B virus (HBV) DNA from 4 infants with fulminant hepatitis B, 3 infants with acute self-limited hepatitis B, and 15 infants with chronic HBV infection were amplified by polymerase chain reaction followed by direct sequencing of the region of HBV genome encoding the major antigenic epitopes of hepatitis B surface antigen (HBsAg). All infants were born to carrier mothers and administered immunoprophylaxis from birth. Serum HBV DNA from 13 carrier children born to carrier mothers who did not receive immunoprophylaxis and had comparable length of infection were studied as controls. An S mutant (residue 126, Thr to Ala) initially found in an infant with fulminant hepatitis was replaced by another S mutant (residue 145, Gly to Arg) 4 days later. In a girl with chronic hepatitis B, Ala-126 variant and Arg-145 variant were found at 17 and 25 months of age, respectively. The Arg-145 variant persisted for 8 years in an asymptomatic male carrier and for 1 year in an infant with chronic hepatitis B. The Ala-126 variant persisted for 11 years in one child who had an early loss of hepatitis B e antigen. In the majority of the infants' mothers, corresponding mutations in HBsAg were not detected in serum by direct sequencing. The S mutants detected in three carrier infants were not found in their mothers' serum after cloning and sequencing of 10 DNA clones from each maternal sample. None of the 13 control patients had detectable S mutants. These results suggest that S variants emerge or are selected under the immune pressure generated by the host or by administration of hepatitis B immune globulin and hepatitis B vaccination. An S mutant (residue 129, Gln to Arg) found in one mother-infant pair suggested a direct maternal-infant transmission, resulting in immunoprophylaxis failure. None of the family members of children infected with Arg-145 variant had the same variant infection, implying this variant's low transmissability.

Putaminal petechial haemorrhage as the cause of chorea: a neuroimaging study

OBJECTIVES

A hyperintense putamen on either CT or MRI as a finding associated with chorea has occasionally been described and is almost always associated with non-ketotic hyperglycaemia. The cause of the hyperintensity of the striatum in these images is still controversial. Some reports have found that calcification was responsible whereas others have advocated petechial haemorrhage as the cause. The purpose of this study was to determine whether hyperintense striata are caused by petechial haemorrhage or calcification, with the sequential imaging changes.

SUBJECTS AND METHODS

Five patients presenting with an acute onset of either hemichorea or generalised chorea and showed either unilateral or bilateral hyperdense striatum on the initial CT were assessed. Neuroimaging studies including sequential CT and MRI examinations and detailed biochemical tests were performed.

RESULTS

Three patients had pronounced hyperglycaemia and the other two patients had no biochemical abnormalities. In all patients, the first CT scans, performed within two weeks of the onset of chorea, showed a high density over the striatum contralateral to the chorea, which diminished or disappeared two months later. T1 weighted imaging disclosed hypersignal intensities over the striatum contralateral to the chorea on admission which diminished two months later. T2 weighted imaging at two months showed hyposignal intensity changes corresponding to the area with hypersignal changes on T1 weighted images, implying haemosiderin deposition.

CONCLUSION

Based on the evolution of clinical manifestations and the findings of neuroimaging, putaminal petechial haemorrhage might be a new entity causing either hemichorea or generalised chorea.