Prevalence, management and efficacy of treatment in portal vein obstruction after paediatric liver transplantation: protocol of the retrospective international multicentre PORTAL registry

INTRODUCTION

Portal vein obstruction (PVO) consists of anastomotic stenosis and thrombosis, which occurs due to a progression of the former. The aim of this large-scale international study is to assess the prevalence, current management practices and efficacy of treatment in patients with PVO.

METHODS AND ANALYSIS

The Portal vein Obstruction Revascularisation Therapy After Liver transplantation registry will facilitate an international, retrospective, multicentre, observational study, with 25 centres around the world already actively involved. Paediatric patients (aged <18 years) with a diagnosed PVO between 1 January 2001 and 1 January 2021 after liver transplantation will be eligible for inclusion. The primary endpoints are the prevalence of PVO, primary and secondary patency after PVO intervention and current management practices. Secondary endpoints are patient and graft survival, severe complications of PVO and technical success of revascularisation techniques.

ETHICS AND DISSEMINATION

Medical Ethics Review Board of the University Medical Center Groningen has approved the study (METc 2021/072). The results of this study will be disseminated via peer-reviewed publications and scientific presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NL9261).

International Consensus Recommendations for Eosinophilic Gastrointestinal Disease Nomenclature

BACKGROUND & AIMS

Substantial heterogeneity in terminology used for eosinophilic gastrointestinal diseases (EGIDs), particularly the catchall term "eosinophilic gastroenteritis," limits clinical and research advances. We aimed to achieve an international consensus for standardized EGID nomenclature.

METHODS

This consensus process utilized Delphi methodology. An initial naming framework was proposed and refined in iterative fashion, then assessed in a first round of Delphi voting. Results were discussed in 2 consensus meetings, and the framework was updated and reassessed in a second Delphi vote, with a 70% threshold set for agreement.

RESULTS

Of 91 experts participating, 85 (93%) completed the first and 82 (90%) completed the second Delphi surveys. Consensus was reached on all but 2 statements. "EGID" was the preferred umbrella term for disorders of gastrointestinal (GI) tract eosinophilic inflammation in the absence of secondary causes (100% agreement). Involved GI tract segments will be named specifically and use an "Eo" abbreviation convention: eosinophilic gastritis (now abbreviated EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC). The term "eosinophilic gastroenteritis" is no longer preferred as the overall name (96% agreement). When >2 GI tract areas are involved, the name should reflect all of the involved areas.

CONCLUSIONS

This international process resulted in consensus for updated EGID nomenclature for both clinical and research use. EGID will be the umbrella term, rather than "eosinophilic gastroenteritis," and specific naming conventions by location of GI tract involvement are recommended. As more data are developed, this framework can be updated to reflect best practices and the underlying science.

Early hepatic arterial thrombosis in liver transplantation: Systemic intravenous alteplase as a potential rescue treatment after failed surgical revascularization

eHAT is one of the most dreaded post-LT complication. Treatment approaches include retransplantation, revascularization, or observation. Systemic thrombolytic therapy is used in pediatric patients with thromboembolic events. However, there is no previous study reporting on the use of systemic r-tPA to treat eHAT. The treatment strategies used in patients with eHAT are described, focusing on two children who failed SR and were treated with systemic heparinization plus systemic r-tPA infusion. r-tPA-RP consists of intravenous systemic infusion at a dose of 0.3 mg/kg/h during 6 hours, for 5 days. First case (3-year) was transplanted with a whole liver, and second case (6-year) received a LLS from a living donor. HAT was diagnosed by doppler US and confirmed by angioCT scan in both patients in the first day after LT. They underwent SR and were clinically stable. Re-thrombosis occurred in both patients the day after, and r-TPA-RP was started-one patient required two r-TPA-RP for HAT recurrence. They presented minor bleeding, without repercussion. Hepatic artery recanalized after 10 and 3 days in the first and second patient, respectively. Retransplant was avoided, and one developed biliary strictures, successfully managed in the follow-up. r-TPA-RP avoided retransplantation after eHAT in these cases. To our knowledge, this is the first report of the use of systemic r-TPA to treat eHAT in children. This strategy may compose an algorithm to treat eHAT that failed SR in stable patients.

Autoimmune hepatitis in 828 Brazilian children and adolescents: clinical and laboratory findings, histological profile, treatments, and outcomes

OBJECTIVE

This large study with a long-term follow-up aimed to evaluate the clinical presentation, laboratory findings, histological profile, treatments, and outcomes of children and adolescents with autoimmune hepatitis.

METHODS

The medical records of 828 children and adolescents with autoimmune hepatitis were reviewed. A questionnaire was used to collect anonymous data on clinical presentation, biochemical and histological findings, and treatments.

RESULTS

Of all patients, 89.6% had autoimmune hepatitis-1 and 10.4% had autoimmune hepatitis-2. The female sex was predominant in both groups. The median age at symptom onset was 111.5 (6; 210) and 53.5 (8; 165) months in the patients with autoimmune hepatitis 1 and autoimmune hepatitis-2, respectively. Acute clinical onset was observed in 56.1% and 58.8% and insidious symptoms in 43.9% and 41.2% of the patients with autoimmune hepatitis-1 and autoimmune hepatitis-2, respectively. The risk of hepatic failure was 1.6-fold higher for autoimmune hepatitis-2. Fulminant hepatic failure occurred in 3.6% and 10.6% of the patients with autoimmune hepatitis-1 and autoimmune hepatitis-2, respectively; the risk was 3.1-fold higher for autoimmune hepatitis-2. The gamma globulin and immunoglobulin G levels were significantly higher in autoimmune hepatitis-1, while the immunoglobulin A and C3 levels were lower in autoimmune hepatitis-2. Cirrhosis was observed in 22.4% of the patients; biochemical remission was achieved in 76.2%. The actuarial survival rate was 93.0%. A total of 4.6% underwent liver transplantation, and 6.9% died (autoimmune hepatitis-1: 7.5%; autoimmune hepatitis-2: 2.4%).

CONCLUSIONS

In this large clinical series of Brazilian children and adolescents, autoimmune hepatitis-1 was more frequent, and patients with autoimmune hepatitis-2 exhibited higher disease remission rates with earlier response to treatment. Patients with autoimmune hepatitis-1 had a higher risk of death.

Fertility Life Table of Tetranychus palmarum Flechtmann & Noronha (Acari: Tetranychidae) in Oil Palm

Some species of spider mites belonging to the Tetranychidae family are known to associate with oil palm (Elaeis guineensis Jacq. - Arecaceae). The occurrence of Tetranychus palmarum Flechtmann & Noronha (Acari, Tetranychidae) was verified on oil palm seedlings under greenhouse conditions in the State of Pará in Northern Brazil. Plants with colonies of T. palmarum presented yellowish spots on leaflets and leaves with chlorosis. The objective of this study was to access the biology and fertility life table of T. palmarum in E. guineensis leaves. The experiment was conducted under four constant temperatures, 22, 25, 28, and 31°C, at 70 ± 10% RH under a 12:12 LD photoperiod. The duration of the egg-to-adult period was 18.4 and 9.8 days, at 22 and 31°C, respectively. The parameters of the fertility life table showed that 28°C is most suitable for the development and reproduction of T. palmarum, with higher values for reproductive parameters (R _o , r _m , and λ) and lower values for duplicating the population (TD). Therefore, it is apparent that the best temperature conditions for the development of T. palmarum are found in the warmer regions of Brazil, such as those observed in northern Brazil.

Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference

BACKGROUND & AIMS

Over the last decade, clinical experiences and research studies raised concerns regarding use of proton pump inhibitors (PPIs) as part of the diagnostic strategy for eosinophilic esophagitis (EoE). We aimed to clarify the use of PPIs in the evaluation and treatment of children and adults with suspected EoE to develop updated international consensus criteria for EoE diagnosis.

METHODS

A consensus conference was convened to address the issue of PPI use for esophageal eosinophilia using a process consistent with standards described in the Appraisal of Guidelines for Research and Evaluation II. Pediatric and adult physicians and researchers from gastroenterology, allergy, and pathology subspecialties representing 14 countries used online communications, teleconferences, and a face-to-face meeting to review the literature and clinical experiences.

RESULTS

Substantial evidence documented that PPIs reduce esophageal eosinophilia in children, adolescents, and adults, with several mechanisms potentially explaining the treatment effect. Based on these findings, an updated diagnostic algorithm for EoE was developed, with removal of the PPI trial requirement.

CONCLUSIONS

EoE should be diagnosed when there are symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field (or approximately 60 eosinophils per mm²) on esophageal biopsy and after a comprehensive assessment of non-EoE disorders that could cause or potentially contribute to esophageal eosinophilia. The evidence suggests that PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EoE than as a diagnostic criterion, and we have developed updated consensus criteria for EoE that reflect this change.

Diagnosis, misdiagnosis, and associated diseases of achalasia in children and adolescents: a twelve-year single center experience

PURPOSE

Although achalasia is a rare disorder in children, its symptom may mimic common childhood diseases. This study aimed to assess the diagnosis and management of achalasia in children and adolescents in a Brazilian single center during a 12-year period.

METHODS

Patients with achalasia were identified from a database built during the period of January 2000-January 2012 from a Pediatric Gastroenterology reference center. Information regarding demographic data, clinical symptoms, diagnosis, treatment, and long-term follow-up were described.

RESULTS

Thirteen patients were studied; median age was 7 (1-14) years. Most frequent symptoms were vomiting (84.6 %) and dysphagia (69.2 %). Weight loss occurred in 46.0 % of patients and chronic cough in 46.1 %. Associated disorders were Down's syndrome, Allgrove syndrome, and congenital central hypoventilation syndrome. Achalasia was misdiagnosed with anorexia nervosa. Six patients were previously treated as having gastroesophageal reflux disease and asthma. Five patients had pneumatic balloon dilation as initial therapy whereas five had esophageal myotomy. Finally, 11 patients had surgical therapy with a favorable follow-up.

CONCLUSION

Achalasia symptoms may mimic common diseases in children, and therefore, may delay the diagnosis. This study emphasizes the importance of the clinical symptoms for the diagnosis of achalasia, mainly in those cases with associated disorders.

Ghrelin, leptin and insulin in cirrhotic children and adolescents: relationship with cirrhosis severity and nutritional status

OBJECTIVE

Ghrelin, leptin, and insulin concentrations are involved in the control of food intake and they seem to be associated with anorexia-cachexia in cirrhotic patients. The present study aimed to investigate the relationship between the nutritional status and fasting ghrelin, leptin and insulin concentrations in pediatric cirrhotic patients.

METHODS

Thirty-nine patients with cirrhosis and 39 healthy controls aged 0-15 years matched by sex and age were enrolled. Severity of liver disease was assessed by Child-Pugh classification, and Pediatric for End Stage Liver Disease (PELD) or Model for End-stage Liver Disease (MELD) scores. Blood samples were collected from patients and controls to assay total ghrelin, acyl ghrelin, leptin and insulin by using a commercial ELISA kit. Anthropometry parameters used were standard deviation score of height-for-age and triceps skinfold thickness-for-age ratio. A multiple linear regression analysis was used to determine the correlation between dependent and independent variables.

RESULTS

Acyl ghrelin was significantly lower in cirrhotic patients than in controls [142 (93-278) pg/mL vs 275 (208-481) pg/mL, P=0.001]. After multiple linear regression analysis, total ghrelin and acyl ghrelin showed an inverse correlation with age; acyl ghrelin was associated with the severity of cirrhosis and des-acyl ghrelin with PELD or MELD scores ≥15. Leptin was positively correlated with gender and anthropometric parameters. Insulin was not associated with any variable.

CONCLUSION

Low acyl ghrelin and high des-acyl ghrelin concentrations were associated with cirrhosis severity, whereas low leptin concentration was associated with undernourishment in children and adolescents with cirrhosis.

Managing gastroesophageal reflux disease in children: The role of endoscopy

Gastroesophageal reflux disease (GERD) is a growing problem in the pediatric population and recent advances in diagnostics and therapeutics have improved their management, particularly the use of esophago-gastroduodenoscopy (EGD). Most of the current knowledge is derived from studies in adults; however there are distinct features between infant onset and adult onset GERD. Children are not just little adults and attention must be given to the stages of growth and development and how these stages impact the disease management. Although there is a lack of a gold standard test to diagnose GERD in children, EGD with biopsy is essential to assess the type and severity of tissue damage. To date, the role of endoscopy in adults and children has been to assess the extent of esophagitis and detect metaplastic changes complicating GERD; however the current knowledge points another role for the EGD with biopsy that is to rule out other potential causes of esophagitis in patients with GERD symptoms such as eosinophilic esophagitis. This review highlights special considerations about the role of EGD in the management of children with GERD.

Shifting susceptibility to hepatitis A among children and adolescents over the past decade

OBJECTIVES

To estimate the prevalence of anti-hepatitis A virus (anti-HAV) antibodies in serum samples from children and adolescents obtained at two clinical pathology laboratories in the city of Porto Alegre, south of Brazil, and to compare findings to those of a study carried out in the 1990s.

METHODS

In this cross-sectional study conducted between 2007 and 2008, 465 serum samples obtained from subjects aged 1-19 years were consecutively tested to determine the prevalence of total anti-HAV antibodies. Samples were provided by a public laboratory (group 1) that serves the Unified Health System exclusively, meant to represent the lowest socioeconomic strata, and by a private laboratory (group 2), meant to represent the higher socioeconomic classes. Tests were performed at a single laboratory using commercially available electrochemiluminescence kits. Antibody levels ≥ 20 UI/L were considered positive.

RESULTS

The seroprevalence of anti-HAV in Group 1 was 37.6%. The percentage of anti-HAV reactivity increased from 19.4% in the 1-to-4 group to 54.1% in the 15-to-19 group. In Group 2, overall anti-HAV positivity was 46.1% and was inversely correlated with age, declining from roughly 50% in the youngest groups to 29.1% in the 15-to-19 group. Comparison of sample findings to those reported in a 1990s study showed a significant reduction in anti-HAV prevalence among 5-to-9-year-olds in group 1 (p = 0.03).

CONCLUSIONS

The results suggest that the endemicity of hepatitis A in Porto Alegre has been declining over the past decade, and that children and adolescents, particularly those in the lowest socioeconomic strata, are more susceptible to the disease.

Hepatitis A acute liver failure: follow-up of paediatric patients in southern Brazil

We retrospectively analysed 33 children and adolescents who had been hospitalized in a liver transplant unit within the previous 10 years for acute liver failure (ALF). The patients' age varied between 2 months and 15 years of age (median 6.2 +/- 5.3), and 21 (63%) were male. Thirteen patients (39%) were immunoglobulin-M anti-hepatitis A virus (HAV) sero-positive. Eleven cases (33%) had an undetermined aetiology. The 13 children with HAV ALF were between 17 months and 15.6 years of age (median 5.8 +/- 4.6) and eight were male (61.5%). All were on a list for urgent liver transplant. Of these, five (38%) died while waiting for a liver. Only one patient recovered spontaneously. Seven patients received a liver transplant; three died in the immediate postoperative period and one died 45 days after transplant. Three children are alive 1, 2 and 5 years after transplant. We conclude that HAV was the most frequent cause of ALF, which had high mortality even when a liver transplant was possible. The results support universal HAV vaccination in this area.

Biliary atresia: we still operate too late

OBJECTIVE

To analyze the age at surgery for children with biliary atresia and their survival periods without need for liver transplantation. The study was performed at Hospital de Clínicas de Porto Alegre, in Porto Alegre, state of Rio Grande do Sul, Brazil.

METHODS

The medical records of patients operated between 1982 and 2007 who were residents of the state of Rio Grande do Sul were reviewed.

RESULTS

Of the 112 cases of children with biliary atresia studied, 38 (33.9%) occurred between 1982 and 1989, 46 (41.1%) between 1990 and 1999 and 28 (25.0%) after 2000. Portoenterostomy was not performed for 12 cases (10.7%). Age at surgery ranged from 25 to 297 days (median: 80.5; IQR25-75: 61.3-109.0 days); for 20.5% of cases, the age was below 60 days. There was no age difference at diagnosis for the three decades in the study. Patients from the countryside (median: 87.0; IQR25-75: 69.0-115.0 days) were referred significantly later (p = 0.007) than those living in Porto Alegre and the metropolitan area (median: 68.0; IQR25-75: 55.5-98.0 days). The ratio of patients younger than 60 days was significantly lower (p = 0.013) for those from the countryside. Survival periods with native liver for all patients was 46.2% in 2 years, falling continuously until reaching 15.3% in 20 years. Patients operated before reaching 60 days of age had longer survival periods with native livers (log rank < 0.0001).

CONCLUSIONS

Late performance of portoenterostomy was a constant in the past 25 years, and this delay led to shorter survival periods with native livers for biliary atresia patients.

Amplification of bacterial DNA does not distinguish patients with ascitic fluid infection from those colonized by bacteria

OBJECTIVE

To evaluate 16S ribosomal RNA (rRNA) gene amplification to diagnose spontaneous bacterial peritonitis (SBP).

PATIENTS AND METHODS

According to a retrospective protocol, 31 patients with portal hypertensive ascites (serum to ascites albumin gradient > or = 1.1 g/dL) were studied. Ascitic fluid was analyzed as follows: Gram stain, aerobic and anaerobic cultures, polymorphonuclear cell count, and biochemical tests. Bacterial DNA was detected by polymerase chain reaction.

RESULTS

There were 8 episodes of SBP and 4 episodes of bacterascites (BA). Culture was positive in 4 of 8 cases of SBP and bacterial DNA was positive in 7 of 8 cases of SBP. Bacterial DNA was positive in 3 of 4 cases of BA and in 8 of 28 cases of culture-negative non-neutrocytic ascites (CNNNA). The PELD score, serum to albumin ascites gradient, and mortality showed no statistical difference between patients with CNNNA and the result of the bacterial DNA analysis.

CONCLUSIONS

Although the 16S rRNA gene amplification was better than culture to diagnose SBP, bacterial DNA does not seem to allow a distinction between ascites infection and ascites colonization.

Ontogenetic changes in serum S100B in Down syndrome patients

BACKGROUND

It has been shown that Down syndrome (DS) patients have elevated S100B levels in brain tissue.

DESIGN

Measurements of S100B were performed in serum samples from 48 DS patients and 42 ostensibly healthy age-matched controls.

RESULTS

We observed higher levels of S100B in the DS group than in the control group. Moreover, serum S100B in DS patients was not age-dependent as it is in normal individuals.

CONCLUSION

The higher levels of S100B in DS patients may reflect a general and persistent increase in the extracellular space and may be associated with neurodegenerative lesions observed in DS patients.

Infected and noninfected ascites in pediatric patients

OBJECTIVES

To determine the prevalence of spontaneous bacterial peritonitis, ascites with bacterial infection and noninfected ascites in pediatric patients with portal hypertensive ascites and to compare the clinical and laboratory features of infected and noninfected ascites.

METHODS

Forty-one episodes of portal hypertensive ascites (serum-ascites albumin gradient >1.1 g/dL) in 31 patients were studied. Median age was 2.9 years. Twenty-four (77.4%) patients were cirrhotic and 20 (83.3%) were classified as Child-Pugh C. Median pediatric end-stage liver disease score was 18.5. The following ascites features were assessed: polymorphonuclear neutrophil cell count, cytology, pH, concentration of glucose, lactic dehydrogenase, total protein and albumin, Gram stain and bacteriological culture. Blood was sampled for complete blood count, coagulation studies, liver and renal function tests. Groups were compared by Mann-Whitney and chi tests (P < 0.05).

RESULTS

Noninfected ascites were observed in 29 of 41 samples, spontaneous bacterial peritonitis in eight of 41 and ascites with bacterial infection in four of 41. The most prevalent clinical features were fever, voluminous ascites and encephalopathy, but there were no significant differences in the clinical features of the groups. All patients with infected ascites were cirrhotic. There was no statistical difference in Child-Pugh or pediatric end-stage liver disease status between patients with infected and noninfected ascites. Culture of ascetic fluid was positive in four of eight cases of spontaneous bacterial peritonitis. Gram-negative rods were the most prevalent bacteria cultured. Except for serum albumin, no statistical differences in biochemical markers were observed between patients with infected and noninfected ascites.

CONCLUSIONS

The prevalence of infected ascites was 29.2%. With the exception of serum albumin, there were no differences in the clinical and biochemical features of patients with infected ascites and noninfected ascites.

[Prevalence of hepatitis A antibody in children and adolescents with chronic liver disease]

OBJECTIVE

To evaluate the prevalence of Hepatitis A virus (HAV) in children and adolescents with chronic liver disease in a unit of pediatric hepatology.

METHODS

Between May 1999 and February 2001, we studied the prevalence of anti-HAV in 60 children and adolescents with chronic liver disease, aged between 1 and 16 years, from the Unit of Pediatric Hepatology of the Hospital de Clínicas de Porto Alegre. The total anti-HAV was determined by a commercially available competitive ELISA method (Abbott), and compared with age, sex, race, etiologic diagnosis and family income of each patient.

RESULTS

A one-year old child was not included in the study because she presented twice with undetermined anti-HAV results. Among the other 59 patients, 14 (24%) presented a positive result of total anti-HAV. The ages of test-positive subjects varied between 1 and 16 years old (mean=7.7 years, median=8.5). The differences between positive and negative groups in relation to age, sex and race were not statistically significant. Family income was lower in anti-HAV positive patients, but this difference was not significant. The differences between the etiologies of liver diseases were probably more related to the age than to the etiologies of the diseases.

CONCLUSIONS

In the studied population, the majority (76%) of children and adolescents with chronic liver disease are susceptible to hepatitis A virus infection and, consequently, they could present a more severe disease or even fulminant hepatitis A. We strongly suggest that these subjects receive Hepatitis A inactivated vaccine.

[Liver transplantation]

OBJECTIVE: To review the clinical aspects and the theoretical basis of liver transplantation in children, focusing mainly pre and post surgical periods. METHODS: References were obtained from computerized search in the National Library of Medicine (Medline), recent review articles, and personal files. RESULTS: Great development has occurred in surgical techniques, in organ preservation, in postoperative care, and in immunosuppression methods after the first liver transplantation surgery took place in a child with biliary atresia in 1963. Liver transplantation has become an efficient therapy, widely accepted and used in all age groups. It is a very complex procedure, with many professionals involved and with several legal, ethical and economical implications. We review in this article the clinical aspects before transplantation, including indications, contraindications, clinical and laboratory evaluations, as well as postsurgical aspects, both in the immediate period, after the 1st week, and the long-term outcome, discussing the complications and the treatment of each. CONCLUSIONS: Liver transplantation has dramatically improved the survival of pediatric patients with chronic hepatic diseases. Patients of liver transplantation in the pediatric age group present today survival rates of 90% in the different transplantation centers.

[Pseudomembranous colitis]

OBJECTIVE: To alert about the pseudomembranous colitis in children, a consequence of the use of antibiotics. METHODS: This report is the result of the clinical follow-up of a patient with chronic diarrhea after the use of several antibiotics. The bibliography was obtained through Medline system. RESULTS: Case report of a girl two years and seven months old, previously healthy, with a clinical picture of chronic diarrhea with dysenteric characteristics after the use of antibiotics, associated with important weight lost and hypoproteinemia. The diagnosis of pseudomembranous was established clinically and was confirmed by colonoscopy and the presence of Clostridium difficile toxin A in the stools. CONCLUSIONS: It is necessary to consider the C. difficile infection in any child with diarrhea associated to the use of antibiotics. The antibiotics in pediatric patients should always be prescribed with caution and precise indications.

Category specificity in object agnosia: preservation of sensorimotor experiences related to objects

We report a case of semantic agnosia, characterized by category specificity. Object recognition, mainly involving visual representation, was severely impaired, whereas object recognition involving both visual and sensorimotor representations, was relatively well preserved. His ability to recognize gestures and produce appropriate gestural responses to objects was remarkable. These two factors lead the authors to form a hypothesis, in an attempt to explain the mechanisms involved in object recognition. It has been argued that manipulation of an object may give access to a certain amount of knowledge about it, and that preservation of sensorimotor experiences of objects might be important in recognizing some of them. This could account for the category specificity, described in object agnosia.

Separate visual pathways for perception of actions and objects: evidence from a case of apperceptive agnosia

Recognition of different kinds of visual stimuli was studied in a patient who acquired apperceptive visual agnosia after a bilateral occipitotemporal lesion which partially spared the primary visual cortex. Impairment in recognising static objects perceived visually sharply contrasts with the relatively well preserved ability to recognise objects from gestures illustrating their use, and to recognise actions shown in line drawings. It is suggested that the occipitoparieto-frontal pathway is involved in the recognition of actions, and in the recognition of objects when sensorimotor experience is evoked.

Optic aphasia with pure alexia: a mild form of visual associative agnosia? A case study

A single-case study is reported of a naming disorder selective to the visual modality. The patient showed intact access to structural knowledge of objects and letters, but impaired access to complete semantic knowledge of objects and alphabetical knowledge of letters from visual input. The impairment was most striking when the patient had to discriminate between semantically similar objects or within a given symbolic repertoire, i.e. letters. The co-occurrence of a partial deficit of visual recognition for objects and for letters indicated features of optic aphasia and pure alexia. This symmetric performance between object and letter processing may also constitute a mild form of visual associative agnosia.

Spatio-temporal working memory and frontal lesions in man

The delayed-response paradigm is thought to be a marker of the activity of the dorsolateral convexity of primates' prefrontal cortex, as this procedure requires the activation of working memory processes. Although the role of the dorsolateral prefrontal cortex (DLPC) in working memory seems to be well established, much remains to be understood about the processes this structure actually controls: encoding domain-specific information, its retention in short-term memory, its monitoring in working memory, or its selection and retrieval when a specific response program is required. To clarify the role of the DLPC in delayed-response tasks in humans, a set of sequencing paradigms was designed which incorporates the dissociation of (1) spatial and temporal parameters, (2) recall and recognition processes, and (3) the presence or absence of a delay. Performance of a group of patients with DLPC lesions (n = 8) was compared to that of age-matched normal subjects (n = 8). To verify the specificity of the results obtained for the DLPC lesioned patients, the performance of patients with a temporal lobotomy was also studied (n = 10). A significant effect of the delay was observed only in patients with DLPC lesions, affecting both their spatial and spatio-temporal recall, whereas their spatio-temporal recognition was normal. These findings suggest that the DLPC plays a role in the retrieval of visuospatial information for guiding a response program.

[Upper gastrointestinal endoscopy in children: indications and results]

OBJECTIVE: To present and discuss the indications, the endoscopic and histologic findings and the complications of upper digestive endoscopies carried out in children and adolescents.METHODS: We have done 228 endoscopies in pediatric patients with ages between 3 months to 19 years (x=5.7 y) during a period of 8 months. General anesthesia was used in 80% of patients (182). Biopsies were done in 210 patients and the Helicobacter pylori was searched for in 130 patients by antral biopsies with Hematoxylin-Eosin coloration.RESULTS: The endoscopy indication was diagnostic in all patients, and in 18 cases there was some therapeutic procedure. Fifty-eight percent of examinations presented endoscopic alteration and 84% had abnormal histologic findings. The most frequent endoscopic findings were esophagitis in 50 patients, gastritis in 44 and duodenitis in 29. Ten peptic ulcers were diagnosed. Between the histologic findings the most frequent ones were gastritis in 87 patients, esophagitis in 50 and atrophy of duodenal mucosa in 9. The H. pylori was positive in 25 (19.2%) patients.CONCLUSION: The upper digestive endoscopy has become an essential procedure to the pediatric gastroenterology practice, amplifying the available diagnostic means and enabling therapeutic endoscopy in the presence of upper digestive lesions. In the present report, 58% of the studied population presented some endoscopic lesion.

[Viral hepatitis: update]

OBJECTIVE

The authors present an update related to different types of viral hepatitis in infancy. The clinic-laboratorial and special outcome aspects are presented.

METHODS

The most important articles about viral hepatitis were selected through Medline. The epidemiologic and clinical characteristics related to the subject are reported with emphasis on Brazilian data.

RESULTS

This review analyzes the diseases caused by agents that have in common the viral origin and the hepatotropism, but the hepatitis are different particularly in those aspects related to outcome and prognosis. The B virus, for example, may be related to healthy asymptomatic carrier to acute hepatitis, chronic disease, cirrhosis and hepatocellular carcinoma. To date the known viruses are six: A, B, C, D, E and G.

CONCLUSIONS

Viral hepatitis is a disease caused by one of the 6 different hepatotropic viruses which originate a wide range of clinical presentations. The viral distribution in Brazil is irregular; in some regions the B virus is prevalent, in others it is rare. The viral infections are the most important and the most frequent causes of liver disease in Brazilian children. The present review is to update viral hepatitis in infancy.

Optic aphasia: evidence of the contribution of different neural systems to object and action naming

Visual stimulus naming was studied in a 66-year-old male patient with optic aphasia subsequent to left occipito-temporal infarction. While having difficulty in naming objects perceived visually, he was able to name objects by viewing gestures illustrating their use, and to name actions shown in pictures. These results suggest that naming performance depends on the kind of stimulus that is visually presented (object vs. action). The present findings lend support to congnitive models which postulate the existence of visual and functional semantic systems.

Category-specific anomia: implication of different neural networks in naming

The occurrence of anomia specifically affecting the ability to name animals is described in three patients. This deficit is contrasted with their capacity to name actions and tools. It is suggested that it is easier to access the names of 'operative' items, which were learned through both visual and sensorimotor experience, than the names of 'figurative' items, which were primarily learned through the visual modality. This hypothesis is consistent with the infero-temporal location of brain damage in these patients. Their ability to retrieve knowledge about operative items is assumed to be due to the sparing of the occipito-parietal area. Because the impairment also involves the recognition of animals, the likely locus of damage is the semantic component of the processing system.

[Follow-up of pediatric patients evaluated for liver transplantation]

OBJECTIVE

To analyze the evolution of pediatric patients chosen for hepatic transplantation.

METHODS

A review was made of the clinical charts of the first 65 children and adolescents with chronic liver disease, aged 5 months to 19 years (X = 6.8%), chosen for liver transplantation during the period of August 1994 to March 1996. Data refer to the patients' demographic characteristics, etiology of their liver disease, their psychosocial situation and of their parents, and their clinical and laboratorial evaluation. According to the severity of the disease, patients were classified as active (waiting for a donor), in evaluation, inactive (compensated liver disease), and excluded for psychosocial or medical conditions, or because of bad indication.

RESULTS

Eight patients (12%) received transplantation, and one of them died. Seven (11%) died when in evaluation or waiting for a donor. Ten patients (15%) were excluded from the waiting list: 6 for social problems, and 4 for medical problems. No patient was excluded for bad indication. Six patients are in the active list, waiting for donor. The other 23 patients (35%) are in evaluation, and 11 (17%) are classified as inactive in the waiting list.

CONCLUSIONS

Eleven patients (17%) were not operated on due to the advanced stage of the liver disease. We emphasize the necessity of organ donation, and the early contact of the patients with a reference center.

Effects of canatoxin on the Ca(2+)-ATPase of sarcoplasmic reticulum membranes

Canatoxin, a toxic protein isolated from the seeds of Canavalia ensiformis, was studied for its effects on the sarcoplasmic reticulum vesicles obtained from rabbit skeletal muscle. Canatoxin inhibited Ca2+ accumulation catalysed by the Ca(2+)-ATPase, without affecting the hydrolytic activity of this enzyme or membrane permeability to Ca2+. The effects of canatoxin were dose dependent, but not time dependent. It is concluded that canatoxin interacts with the Ca2+ pump and uncouples Ca2+ uptake from Ca(2+)-dependent ATP hydrolysis.