Long-term effects of pyloromyotomy on pyloric motility and gastric emptying in humans

OBJECTIVE

The aim of this study was to determine the long term effects of pyloromyotomy for infantile hypertrophic pyloric stenosis (IHPS) on gastric emptying and pyloric motility.

METHODS

Concurrent measurements of gastric emptying and antropyloroduodenal pressures were performed in six volunteers (aged 24-26 yr) who had had pyloromyotomy performed in infancy because of IHPS, and in six normal subjects. Subjects were studied on 2 days, once sitting and once in the left lateral position. Gastric emptying of 300 ml 25% dextrose labeled with 20 MBq 99mTc sulfur colloid was measured. Antropyloroduodenal motility was evaluated with a sleeve/multiple sidehole manometric assembly, which was also used to deliver an intraduodenal triglyceride infusion at 1.1 kcal/min for 60 min, starting 30 min after ingestion of the dextrose.

RESULTS

In both body positions, gastric emptying and intragastric distribution of the drink did not differ between the two groups. In both groups and postures, the amount emptied was less during intraduodenal lipid infusion. The number (p<0.01) and amplitude (p<0.02) of isolated pyloric pressure waves (IPPWs) was greater in the control subjects, whereas basal pyloric pressure was greater in the pyloromyotomy subjects (p<0.02). In both groups, the rate of gastric emptying in the sitting position was related to the number of IPPWs (r> or =0.40, p<0.05), but not to basal pyloric pressure.

CONCLUSIONS

These results indicate that, in adults who have had pyloromyotomy for IHPS in infancy, patterns of pyloric motility are abnormal; pyloric tone is higher, whereas the number and amplitude of phasic pyloric pressure waves are less. In contrast, the overall rate of gastric emptying of a nutrient liquid meal is normal. These observations are consistent with the concept that the stomach has the capacity to compensate for changes in pyloric motility to minimize effects on gastric emptying.

Mechanism of gastroesophageal reflux in premature infants with chronic lung disease

BACKGROUND/PURPOSE

The aim of this study was to characterize the motor events responsible for gastroesophageal reflux (GER) and esophageal acid clearance in a cohort of preterm infants with chronic lung disease (CLD).

METHODS

Esophageal motility was recorded for 2 to 3 hours postprandially in 14 preterm infants with mild-moderate or moderate-severe CLD at 33 to 39 weeks postmenstrual age using a sleeve-side hole micromanometric assembly into which a pH probe had been installed.

RESULTS

Twenty-six acid GER episodes were recorded by pH probe. Of these, 22 (85%) were associated with transient lower esophageal sphincter (LES) relaxation. Transient LES relaxations were significantly longer in duration than single swallows (13.7 seconds v 4.6 seconds, P < .001) and had lower nadir pressures (1.1 mm Hg v 2.5 mm Hg, P < .001). During periods of esophageal acidification (pH below 4), peristaltic esophageal body pressure wave sequences cleared acid refluxate more effectively than nonperistaltic pressure wave sequences.

CONCLUSIONS

In preterm infants with CLD, transient LES relaxations are the predominant mechanism underlying GER, and esophageal clearance mechanisms are fully functional, which is similar to that seen in healthy preterm infants.

A child with hemimegalencephaly, hemihypertrophy, macrocephaly, cutaneous vascular malformation, psychomotor retardation and intestinal lymphangiectasia--a diagnostic dilemma

Although the clinical delineation of the majority of overgrowth syndromes is straightforward, we believe there is a subset of patients with overlapping features from a number of overgrowth syndromes. We report a patient with hemimegalencephaly, hemihypertrophy, macrocephaly, vascular lesions, psychomotor retardation and intestinal lymphangiectasia. The clinical history and findings posed a diagnostic dilemma as the features overlapped between several conditions, namely macrocephaly-cutis marmorata telangiectatica congenita (M-CMTC), Klippel-Trenaunay-Weber syndrome (KTWS), Proteus syndrome and a provisional unique syndrome described by Reardon et al. (1996, Am J Med Genet 66:144-149). We anticipate that only when the molecular basis is delineated will it become clear whether these disorders are separate entities or merely differing ends of the same spectrum.

Measurement of upper esophageal sphincter tone and relaxation during swallowing in premature infants

Upper esophageal sphincter (UES) motor function has not been previously evaluated in premature infants. The motor patterns associated with tonic activity and swallow-related relaxation of the UES were recorded for 1 h after completion of gavage feeding in 11 healthy preterm neonates (postmenstrual age 33-37 wk) with a micromanometric assembly, which included a sleeve sensor specifically adapted for UES recordings. A clearly defined UES high-pressure zone was observed in all premature infants studied. Resting UES pressure ranged from 2.3 to 26.2 mmHg and was higher during periods of irritability and apparent discomfort. During dry swallows, UES pressure relaxed from a resting pressure of 28.2 +/- 4.0 mmHg to a nadir of 1.1 +/- 3.3 mmHg. The mean UES relaxation interval (the time from relaxation onset to relaxation offset) was 0. 31 +/- 0.11 s. We conclude that in premature infants >/=33 wk postmenstrual age the motor mechanisms regulating UES resting pressure and the onset of UES relaxation are well developed.

Reproducibility of the 13C-octanoic acid breath test for assessment of gastric emptying in healthy preterm infants

BACKGROUND

The 13C-octanoic acid breath test has been used to measure gastric emptying in preterm infants, but the reproducibility of the test has not been evaluated in this population.

METHODS

Fifty-six paired breath test analyses were performed on 28 healthy preterm infants 1 to 5 days apart using the same food type, volume, and energy content for each paired sample. Breath samples were taken before the feeding, at 5-minute intervals after feeding for 30 minutes, then each 15 minutes for 4 hours. Samples were analyzed using an isotope-ratio mass spectrometer, and 3C recovery was used to calculate values for gastric-emptying coefficient and gastric half-emptying time.

RESULTS

There was no significant difference between test results on different days in the paired samples studied. gastric-emptying coefficients for the first and subsequent samples were 2.6+/-0.1 (mean+/-SEM) and 2.7+/-0.1, respectively, and half-emptying times were 44.5+/-3.7 minutes and 41.4+/-3.2 minutes.

CONCLUSION

The 13C-octanoic acid breath test is a reliable, noninvasive, and reproducible measure of gastric emptying in preterm infants that should have wide application for use in this population.

The analysis of beta-agonists by packed-column supercritical fluid chromatography with ultra-violet and atmospheric pressure chemical ionisation mass spectrometric detection

Packed-column supercritical fluid chromatography (pSFC) using ultra-violet (UV) and atmospheric pressure chemical ionisation (APCI) mass spectrometry (MS) provides a versatile method for the identification and quantification of beta-agonists. We have achieved good separation of clenbuterol, salbutamol, terbutaline and fenoterol with good resolution and reasonable retention times using a high concentration of methanol modifier in the supercritical CO2, together with small amounts of both acidic (trifluoroacetic acid, TFAA) and basic (triethylamine, TEA, or diethylamine, DEA) additives. APCI-MS gave unambiguous identification of the 4 analytes, and increasing cone voltage provided informative fragmentation patterns. The pSFC-MS technique was shown to be linear (R2 > or = 0.996) over the concentration range 1-50 micrograms ml-1. Single ion monitoring (SIM) gave detection limits (on-column) of 2.5 ng (clenbuterol), 0.83 ng (terbutaline), 7.6 ng (salbutamol) and 2.7 ng (fenoterol). The pSFC-MS system was shown to be reproducible within a day, between days, and between restrictors. Analysis of milk samples 'spiked' with beta-agonists showed that the matrix caused no interference, with detection limits of approximately 500 micrograms l-1 of beta-agonists. More dilute solutions could be analysed by pre-concentration before the SFC stage.

Formin defines a large family of morphoregulatory genes and functions in establishment of the polarising region

Formin was originally isolated as the gene affected by the murine limb deformity (ld) mutations, which disrupt the epithelial-mesenchymal interactions regulating patterning of the vertebrate limb autopod. More recently, a rapidly growing number of genes with similarity to formin have been isolated from many different species including fungi and plants. Genetic and biochemical analysis shows that formin family members function in cellular processes regulating either cytokinesis and/or cell polarisation. Another common feature among formin family members is their requirement in morphogenetic processes such as budding and conjugation of yeast, establishment of Drosophila oocyte polarity and vertebrate limb pattern formation. Vertebrate formins are predominantly nuclear proteins which control polarising activity in limb buds through establishment of the SHH/FGF-4 feedback loop. Formin acts in the limb bud mesenchyme to induce apical ectodermal ridge (AER) differentiation and FGF-4 expression in the posterior AER compartment. Finally, disruption of the epithelial-mesenchymal interactions controlling induction of metanephric kidneys in ld mutant embryos indicates that formin might function more generally in transduction of morphogenetic signals during embryonic pattern formation.

Pancreatic enzyme replacement therapy in cystic fibrosis: Australian guidelines. Pediatric Gastroenterological Society and the Dietitians Association of Australia

Pancreatic enzyme replacement therapy (PERT) is a major factor associated with achieving optimum growth and nutritional status in cystic fibrosis (CF) patients with pancreatic insufficiency and consequent malabsorption. Currently in Australian CF clinics policies for the usage of PERT vary considerably. This paper highlights the current issues related to fat absorption and use of PERT in CF. It also provides evidence to support the recommendation of a PERT dose based on a standard ratio of lipase units per gram of dietary fat consumed for individual patients. A consistent approach to PERT doses will facilitate identification of patients whose PERT intake increases their risk of fibrosing colonopathy and for whom gastroenterological review is warranted. Recent reports indicate that PERT intake can be reduced with a secondary improvement in growth and nutrition status as a consequence of increased dietetic input. These Australian guidelines for the judicious use of PERT in CF should lead not only to a refinement in nutritional management of patients with CF but should also facilitate an improvement in compliance with therapy due to sophistication in patient education materials. The Australian guidelines for the use of PERT in CF if correctly applied, will also provide patients and their families with a better understanding of the relationship between PERT and nutritional status.

Examination of the nickel site structure and reaction mechanism in Streptomyces seoulensis superoxide dismutase

Superoxide dismutases are metalloenzymes involved in protecting cells from oxidative damage arising from superoxide radical or reactive oxygen species produced from superoxide. Examples of enzymes containing Cu, Mn, and Fe as the redox-active metal have been characterized. Recently, a SOD containing one Ni atom per subunit was reported. The amino acid sequence of the NiSOD deduced from the nucleotide sequence of the structural gene sodN from Streptomyces seoulensis is reported and has no homology with other SODs. X-ray absorption spectroscopic studies coupled with EPR of the Ni center show that the Ni in the oxidized (as isolated) enzyme is in a five-coordinate site composed of three S-donor ligands, one N-donor, and one other O- or N-donor. This unique coordination environment is modified by the loss of one N- (or O-) donor ligand in the dithionite-reduced enzyme. The NiSOD activity was determined by pulse radiolysis, and a value of kcat = 1.3 x 10(9) M-1 s-1 per Ni was obtained. The rate is pH sensitive and drops off rapidly above pH 8. The results characterize a novel class of metal center active in catalyzing the redox chemistry of superoxide and, when placed in context with other nickel enzymes, suggest that thiolate ligation is a prerequisite for redox-active nickel sites in metalloenzymes.

Mechanisms of gastroesophageal reflux in healthy premature infants

OBJECTIVES

The aim of this study was to characterize the motor events responsible for gastroesophageal reflux (GER) and esophageal acid clearance in a cohort of healthy preterm infants.

STUDY DESIGN

Esophageal motility was recorded for 2 to 3 hours after a feeding in 24 preterm infants, 31 to 38 weeks' postmenstrual age, by using a sleeveside hole micromanometric assembly incorporating a pH probe.

RESULTS

Sixty acid GER episodes were recorded by pH probe, and 133 non-acid GER episodes were recorded manometrically by the presence of esophageal common cavities. Of the 193 GER episodes, 159 (82%) were associated with transient lower esophageal sphincter relaxation (TLESR). TLESRs were significantly longer in duration than single swallows (15.1 seconds vs 5.6 seconds, P < .001) and had lower nadir pressures (0.8 mm Hg vs 2.3 mm Hg, P < .001). A total of 3216 esophageal body pressure waves were analyzed; 70% of swallow-induced pressure waves were peristaltic in sequence compared with 5% of swallow-unrelated pressure waves. During periods of esophageal acidification (pH below 4), peristaltic esophageal body pressure wave sequences cleared acid refluxate more effectively than nonperistaltic pressure wave sequences.

CONCLUSIONS

In healthy preterm infants, TLESRs are the predominant mechanism underlying GER, and esophageal clearance mechanisms are well developed by at least 31 weeks' postmenstrual age.

Epithelial growth of the small intestine in human infants

BACKGROUND

Findings in studies in rodents have suggested that epithelial growth of the small intestine is dependent on activation of the immune system. The purpose of this study was to compare changes of postnatal epithelial growth with immunologic activity in humans.

METHODS

Duodenal biopsies were obtained by endoscopy from 74 infants. Villus area, crypt length, and mitotic count were measured, using a microdissection technique. Enterocyte height, intraepithelial lymphocytes and mucosal mast cells were recorded in histologic sections, and soluble interleukin-2 receptor levels were measured in sera. These data were compared with those from 77 adult control subjects.

RESULTS

Mean +/- SD villus area was similar in infants compared with that in adults (0.364 +/- 0.108 mm2 vs. 0.339 +/- 0.1 mm2); but mean crypt length was 31% longer (270 +/- 56 microm vs. 206 +/- 29 microm; p < 0.0001), and mitotic count was 68% higher (4.2 +/- 2.8 vs. 2.5 +/- 1 per crypt; p < 0.0001) in infants. Enterocyte height was lower during infancy (27.0 +/- 3.4 microm vs. 30.9 +/- 4.6 microm; p < 0.0001). There was no evidence of a trophic effect on the small intestine of breast feeding compared with the effect of bottle feeding. Counts of intraepithelial lymphocytes but not mucosal mast cells were significantly less in infants. Mean soluble interleukin-2 receptor levels peaked during early infancy, compared with levels in adults (1,820 +/- 596 U/ml vs. 695 +/- 359 U/ml).

CONCLUSION

These results indicate that epithelial proliferation is increased during infancy at an age when immunologic activity is high.

Mel 1a melatonin receptor expression is regulated by protein kinase C and an additional pathway addressed by the protein kinase C inhibitor Ro 31-8220 in ovine pars tuberalis cells

The expression of the melatonin receptor is positively regulated by cAMP and negatively regulated by melatonin in the ovine pars tuberalis (PT). Furthermore, when PT cells are dispersed in primary culture, both messenger RNA (mRNA) and protein levels spontaneously increase through a process that can be blocked by melatonin, but does not involve cAMP. This suggests that other second messengers may be regulated by melatonin, which, in turn, regulates melatonin receptor mRNA and protein levels. In this study using ribonuclease protection assays, ligand binding, protein kinase C (PKC), and cAMP analysis, we demonstrate that the levels of Mel 1a mRNA and protein expression in ovine PT are reduced by phorbol 12-myristate 13-acetate in a cAMP-independent process. This is indicative of an inhibitory role for PKC in receptor regulation. Melatonin, however, does not act through PKC activation to reduce Mel 1a mRNA or protein levels. Basal PKC activity in PT cells can be inhibited by the PKC inhibitor Ro 31-8220, and this suggests that basal PKC activity may suppress Mel 1a receptor expression. Paradoxically, however, Ro 31-8220 also inhibits melatonin receptor mRNA and protein levels in PT cells by a cAMP-independent mechanism. This suggests that other undefined pathways must play an important role in the physiological self-regulation of Mel 1a receptor expression by melatonin.

Mechanisms responsible for gastroesophageal reflux in children

BACKGROUND & AIMS

There is limited information about the motor mechanisms responsible for gastroesophageal reflux (GER) in children. The aim of this study was to evaluate the relationship between esophageal body and lower esophageal sphincter (LES) motor events and the occurrence of GER.

METHODS

Concurrent esophageal manometry and pH monitoring was conducted for 4 hours postprandially in 37 children referred for evaluation of suspected pathological GER. Presence of esophagitis and/or abnormal esophageal acid exposure was used to classify patients into two groups: those with pathological GER (group A; n = 24) and those in whom GER was not confirmed (group B; n = 13).

RESULTS

GER occurred during LES relaxations unassociated with swallowing within 5 seconds before and 2 seconds after the onset of LES relaxation in 58% (group A) and 69% (group B) of the analyzable episodes. These swallow-independent sphincter relaxations satisfied criteria for classification as transient LES relaxations. An additional 23% (group A) and 19% (group B) of reflux episodes could have been a result of transient LES relaxation associated with swallowing by chance. Persistent absence of LES tone was an infrequent association of reflux and was confined to group A patients (8% of episodes).

CONCLUSIONS

Transient LES relaxation is the most important cause of GER in children. Absent basal LES pressure is a relatively infrequent cause of reflux and only in children with pathological GER.

Narcotic regulation in the United States: taking the pain out of analgesic therapy

Maintaining accurate controlled substance records need not deter a veterinarian from obtaining and using opiate analgesics and anesthetics. Paperwork and behavior requirements for ordering, receiving, storing, administering, dispensing, and prescribing controlled substances are described in detail. Important regulatory information resources are also listed.

A preliminary study of the analysis of Cannabis by supercritical fluid chromatography with atmospheric pressure chemical ionisation mass spectroscopic detection

A rapid method is described for the analysis of Cannabis products by supercritical fluid chromatography (SFC) coupled to atmospheric pressure chemical ionization-mass spectroscopic (APCI-MS) detection. The method had a shorter analysis time than GC-MS methods, without the need for derivatization prior to analysis. It was also faster than HPLC methods, with better resolution and definitive identification. Linearity of detector response to cannabidiol, delta 8-tetrahydrocannabinol, delta 9-tetrahydrocannabinol and cannabinol was established, the detection limits for mass on column being 0.55 ng, 1.20 ng, 0.69 ng and 2.10 ng respectively. The technique offers a means by which Cannabis products can be definitively identified in a single chromatographic run. Application to casework samples is described.

Characterisation of relaxation of the lower oesophageal sphincter in healthy premature infants

BACKGROUND

Gastro-oesophageal reflux disease causes significant morbidity in premature infants, but the role of dysfunction of the lower oesophageal sphincter (LOS) in this condition is unclear.

METHODS

Oesophageal manometry was performed after gavage feeding in 13 healthy preterm neonates (postmenstrual age > or = 33 weeks) with a perfused sleeve with side hole assembly. Swallow related (both single and multiple) and transient LOS relaxations (TLOSRs) were identified and the characteristics of these events defined. Reflux was identified with manometric criteria (common cavity episodes).

RESULTS

Five hundred and eleven relaxation of the LOS were observed, 55% related to single swallows, 23% related to multiple swallows, and 22% TLOSRs. The time to maximal LOS relaxation was longer for TLOSRs than for single or multiple swallows (mean (SEM) 5.0 (0.3) s v 3.0 (0.1) s and 3.3 (0.1) s, p < 0.0001 and p < 0.005). The durations of multiple swallows and TLOSRs were longer than single swallows (12.2 (0.5) s and 11.2 (0.4) s v 5.3 (0.2) s, p < 0.0001). Most of the oesophageal body common cavity episodes (94%) occurred during TLOSRs.

CONCLUSIONS

In healthy preterm infants (postmenstrual age > or = 33 weeks) the motor events associated with LOS relaxation were similar to those seen in healthy adults. TLOSRs may be an important mechanism of reflux in premature infants.

Vascular peripheral resistance and compliance in the lobster Homarus americanus

The peripheral resistance to flow through each arterial bed (in actuality, the entire pathway from the heart back to the pericardial sinus) and the mechanical properties of the seven arteries leaving the lobster heart are measured and compared. Resistance is inversely proportional to artery radius and, for each pathway, the resistance falls non-linearly as flow rate increases. The resistance of the hepatic arterial system is lower than that predicted on the basis of its radius. Body-part posture and movement may affect the resistance to perfusion of that region. The total vascular resistance placed on the heart when each artery is perfused at a rate typical of in vivo flow rates is approximately 1.93 kPa s ml-1. All vessels exhibit adluminal layers of fibrils and are relatively compliant at pressures at or below heart systolic pressure. Arteries become stiffer at pressures greater than peak systolic pressure and at radii greater than twice the unpressurized radius. The dorsal abdominal artery possesses striated muscle in the lateral walls. This artery remains compliant over the entire range of hemolymph pressures expected in lobsters. These trends are illustrated when the incremental modulus of elasticity is compared among arteries. All arteries should function as Windkessels to damp the pulsatile pressures and flows generated by the heart. The dorsal abdominal artery may also actively regulate its flow.

Low blood pressure in Down's syndrome, A link with Alzheimer's disease?

Low blood pressure is reported in Down's syndrome (DS). To assess this and determine whether low pressure results from the disease or from long-term residence in hospital, we measured blood pressure with a random-zero sphygmomanometer in three groups of patients: 52 DS inpatients, 62 DS outpatients, and 60 outpatients with other forms of mental handicap. Relative to normal reference populations, blood pressure was low in both DS inpatients (systolic, score -33 mm Hg, P < .0001) and DS outpatients (-25 mm Hg, P < .0001). It was normal in non-DS outpatients (-4.0 mm Hg, P = .3). Blood pressure rose normally with age in the non-DS group but not in the DS group. We conclude that blood pressure is low in DS and that this is a feature of the disease rather than of the protected environment in which patients live. A mechanism related to trisomy 21 is likely, and there may be a link with Alzheimer's disease (AD) because blood pressure is also low in Alzheimer's and a high proportion of Ds patients develop this disease. If, as is likely, blood pressure is lowered in Alzheimer's by the neuropathy, the same neuropathy developing early in DS may also reduce blood pressure.