Characteristics and Frequency of Pediatric Inflammatory Bowel Disease-Associated Pancreatitis: A Japanese Nationwide Survey

Acute pancreatitis (AP) develops in approximately 2% of patients with the diagnosis of inflammatory bowel disease (IBD), but the characteristics and frequency of childhood-onset IBD-associated AP in Japan have not been studied. The present study aimed to clarify the characteristics of IBD-associated AP in Japan.

Methods

A nationwide survey of pediatric patients with IBD (age, <17 years) was conducted from December 2012 to March 2013 at 683 hospitals and medical centers in Japan. A secondary survey was also sent to the centers with the target patients to evaluate their characteristics.

Results

The response rate to the first part of the survey was 61.2% (n = 418). In total, 871 patients with Crohn disease and 1671 patients with ulcerative colitis were enrolled. The second part of the survey found that 11 (1.3%) patients with Crohn disease and 23 (1.4%) patients with ulcerative colitis experienced IBD-associated AP caused by medication (n = 18, 53%), a primary disease (n = 11, 32%), autoimmune pancreatitis (n = 1, 3%), or an anatomical abnormality (n = 1, 3%). All the patients had only mild AP.

Conclusions

IBD-associated AP was not very frequent and was generally mild. The major cause of the pancreatitis was the medication used to treat the IBD.

Polyethylene glycol 3350 plus electrolytes for pediatric chronic constipation: An open-label clinical study in Japan

BACKGROUND

Despite the abundance of study evidence for its efficacy and tolerability for the treatment of constipation in other countries, polyethylene glycol 3350 plus electrolytes (PEG3350+E) was not available in Japan until recently. The purpose of this study was to establish the efficacy and safety of PEG3350+E for the treatment of functional constipation in children in Japan.

METHODS

Japanese children aged 2-14 years with a mean spontaneous bowel movement (SBM) frequency of 2 times/week or less for at least 2 months prior to informed consent were enrolled into the study. After a 2-week screening period, treatment with PEG3350+E was initiated on the day of enrollment and continued for 12 weeks. Change in SBM frequency from screening period week 2 (baseline) to treatment period week 2 was set as the primary endpoint. Secondary endpoints and adverse events were also examined.

RESULTS

Thirty-nine patients were enrolled and completed the 12-week study period. The SBM frequency (mean ± SD) at baseline and treatment period week 2 was 1.00 ± 0.89 and 6.54 ± 4.38, respectively. The change in SBM frequency was 5.54 ± 4.55 (one-sample t test, P < 0.0001) and remained stable through week 12. Stool consistency was also improved over the entire treatment period. Three mild adverse drug reactions were reported: decreased appetite, abdominal pain, and diarrhea (each in 1 of 39 [2.6%] patients).

CONCLUSION

PEG3350+E can be considered as a new treatment option for chronic constipation in children in Japan.

CLINICAL TRIAL REGISTRATION NUMBER

Japic CTI-163167.

Tacrolimus for ulcerative colitis in children: a multicenter survey in Japan

Background/Aims

Tacrolimus is effective for refractory ulcerative colitis in adults, while data for children is sparse. We aimed to evaluate the effectiveness and safety of tacrolimus for induction and maintenance therapy in Japanese children with ulcerative colitis.

Methods

We retrospectively reviewed the multicenter survey data of 67 patients with ulcerative colitis aged < 17 years treated with tacrolimus between 2000 and 2012. Patients’ characteristics, disease activity, Pediatric Ulcerative Colitis Activity Index (PUCAI) score, initial oral tacrolimus dose, short-term (2-week) and long-term (1-year) outcomes, steroid-sparing effects, and adverse events were evaluated. Clinical remission was defined as a PUCAI score < 10; treatment response was defined as a PUCAI score reduction of ≥ 20 points compared with baseline.

Results

Patients included 35 boys and 32 girls (median [interquartile range] at admission: 13 [11–15] years). Thirty-nine patients were steroid-dependent and 26 were steroidrefractory; 20 had severe colitis and 43 had moderate colitis. The initial tacrolimus dose was 0.09 mg/kg/day (range, 0.05–0.12 mg/kg/day). The short-term clinical remission rate was 47.8%, and the clinical response rate was 37.3%. The mean prednisolone dose was reduced from 19.2 mg/day at tacrolimus initiation to 5.7 mg/day at week 8 (P< 0.001). The adverse event rate was 53.7%; 6 patients required discontinuation of tacrolimus therapy.

Conclusions

Tacrolimus was a safe and effective second-line induction therapy for steroid-dependent and steroid-refractory ulcerative colitis in Japanese children.

Shwachman-Diamond syndrome: Nationwide survey and systematic review in Japan

BACKGROUND

Shwachman-Diamond syndrome (SDS) is a rare multisystem disorder associated with exocrine pancreatic insufficiency. The present study reports the results of a nationwide survey and a systematic review on SDS to develop consensus guidelines for intractable diarrhea including SDS.

METHODS

Questionnaires were sent to 616 departments of pediatrics or of pediatric surgery in Japan in a nationwide survey. A second questionnaire was sent to doctors who had treated SDS patients and included questions on clinical information. Additionally, a systematic review was performed using digital literature databases to assess the influence of medical (i.e. non-surgical) treatment on SDS prognosis.

RESULTS

Answers were received from 529 institutions (85.9%), which included information on 24 patients with SDS (median age, 10.4 years; male, n = 15) treated from January 2005 to December 2014. Although 75% of patients received pancreatic enzyme replacement therapy, there was no significant association between treatment and prognosis. Systematic review identified one clinical practice guideline, two case series, eight case reports and 26 reviews. Patient information from those studies was insufficient for meta-analysis.

CONCLUSIONS

The rarity of SDS makes it difficult to establish evidence-based treatment for SDS. According to the limited information from patients and published reports, medical treatment for malabsorption due to SDS should be performed to improve fat absorption and stool condition, but it is not clear whether this treatment improves the prognosis of malabsorption.

Japanese clinical practice guidelines for allied disorders of Hirschsprung's disease, 2017

BACKGROUND

Despite the presence of ganglion cells in the rectum, some patients have symptoms similar to those of Hirschsprung's disease. A consensus has yet to be established regarding the terminology for these diseases. We defined this group of diseases as "allied disorders of Hirschsprung's disease" and compiled these guidelines to facilitate accurate clinician diagnosis and provide appropriate treatment strategies for each disease.

METHODS

These guidelines were developed using the methodologies in the Medical Information Network Distribution System (MINDS). Of seven allied disorders, isolated hypoganglionosis; megacystis-microcolon-intestinal hypoperistalsis syndrome; and chronic idiopathic intestinal pseudo-obstruction were selected as targets of clinical questions (CQ). In a comprehensive search of the Japanese- and English-language articles in PubMed and Ichu-Shi Web, 836 pieces of evidence related to the CQ were extracted from 288 articles; these pieces of evidence were summarized in an evidence table.

RESULTS

We herein outline the newly established Japanese clinical practice guidelines for allied disorders of Hirschsprung's disease. Given that the target diseases are rare and intractable, most evidence was drawn from case reports and case series. In the CQ, the diagnosis, medication, nutritional support, surgical therapy, and prognosis for each disease are given. We emphasize the importance of full-thickness intestinal biopsy specimens for the histopathological evaluation of enteric ganglia. Considering the practicality of the guidelines, the recommendations for each CQ were created with protracted discussions among specialists.

CONCLUSIONS

Clinical practice recommendations for allied disorders of Hirschprung's disease are given for each CQ, along with an assessment of the current evidence. We hope that the information will be helpful in daily practice and future studies.

Japanese physicians' attitudes towards enteral nutrition treatment for pediatric patients with Crohn's disease: a questionnaire survey

Background/Aims

Enteral nutrition (EN) is recommended for the treatment of pediatric Crohn's disease (CD) in Japan. However, the indications and treatment protocols for EN vary among hospitals. In the present study, we aimed to determine how EN was administered to pediatric patients and whether physicians followed treatment guidelines in their practices.

Methods

Two types of questionnaires were administered to 32 physicians who were involved in the treatment of pediatric CD. The consensus questionnaire evaluated the physicians' attitudes towards EN, whereas the efficacy questionnaire collected data on patients with CD, aged <17 years, who had undergone induction therapy between 2006 and 2011.

Results

A total of 23 physicians responded to the questionnaires. The results of the consensus questionnaire indicated that 82% and 59% of study participants recommended EN treatment for all newly diagnosed pediatric patients with CD and all relapsed patients, respectively. Exclusive EN (EEN) and elemental formula were recommended by 84% and 85% of physicians, respectively. The efficacy questionnaire revealed that 57 of the 58 patients received EN. Elemental formula was used in 39 of 40 patients who were treated with EEN. Of these 40 patients, 27 were treated with EEN alone; of these, 22 (81%) achieved remission without any other treatment. The mean duration of EEN was 15.9 days.

Conclusions

EN is widely recommended by physicians treating pediatric CD in Japan. In contrast to Western countries, clinicians used elemental formula more often and with a shorter EEN treatment duration.

Immunosuppressive medication is not associated with surgical site infection after surgery for intractable ulcerative colitis in children

Pediatric ulcerative colitis (UC) sometimes progresses to an intractable condition for medical therapy. The surgical management of UC is challenging because of difficult procedures and frequent infectious complications. The aim of this study was to survey surgical procedures and infectious complications in pediatric patients with UC in Japan and to assess the relationship between preoperatively administered immunosuppressive drugs and postoperative surgical site infection (SSI). A survey of pediatric patients treated from 2000 to 2012 was sent to 683 facilities nationwide. Secondary questionnaires were sent to physicians who followed up patients with UC who had undergone surgery with the aim of assessing the relationships between postoperative SSI and selected preoperative patient characteristics, disease severity, medications, and operative procedures. Data for 136 patients (77 boys and 59 girls) were assessed. Median age at surgery was 14.1 years (range: 2.4-18.9 years). Surgery was performed in one stage in 35 cases, two stages in 57 cases, and three stages in 44 cases. SSI occurred in 36/136 patients (26%). According to multiple logistic regression analysis, there were statistically significant associations between SSI and staged surgery (three/one, OR: 6.7, 95% CI: 2.1-25.5, p = 0.0007; three/two, OR: 3.4, 95% CI: 1.4-8.6, p = 0.0069) and female sex (OR: 2.3, 95% CI: 1.0-5.4, p = 0.0434). Preoperative medications and incidence of SSI were not significantly associated. Preoperative immunosuppressive medication does not affect the incidence of SSI. Three-stage surgery and female sex are independent predictors of development of postoperative SSIs in pediatric patients with UC.

Fecal retention in childhood: Evaluation on ultrasonography

BACKGROUND

To assess the usefulness of rectal diameter measurement on ultrasonography as a diagnostic tool for fecal retention in children.

METHODS

One hundred children (median age, 5.0 years), consisting of 80 with functional constipation and 20 without constipation, participated in the study. All patients underwent physical examination that included digital rectal examination. Forty-five children underwent ultrasonography in three differential planes: transection above the symphysis; under the ischial spine; and at the bladder neck. The measurement of the rectal diameter at the transection above the symphysis could most easily detect fecal retention and had the closest correlations with retention among the three planes.

RESULTS

Rectal diameter was wider at all measuring points (35.2 vs 20.9 mm above the symphysis, P < 0.0001; 35.7 vs 24.0 mm under the ischial spine, P < 0.0001; and 19.4 vs 8.7 mm at the bladder neck, P < 0.0001) in children with fecal retention than in those with no fecal retention. With regard to presence of constipation, children with fecal retention had a wider rectal diameter above the symphysis than those with no fecal retention (children with functional constipation, 35.3 vs 20.0 mm, P < 0.0001; children without constipation: 32.6 vs 14.6 mm, P = 0.0026). The cut-off for the rectal diameter measured above the symphysis to identify fecal retention was 27 mm, with high sensitivity and specificity (95.5% and 94.1%, respectively).

CONCLUSION

Ultrasound rectal diameter measurement can be used to detect fecal retention in children.

Treatment with infliximab for pediatric Crohn's disease: Nationwide survey of Japan

BACKGROUND AND AIM

Childhood-onset inflammatory bowel disease (IBD) is characterized by extensive intestinal involvement and rapid early progression. Infliximab (IFX), cyclosporin (CYA), and tacrolimus (FK506) are increasingly used to treat pediatric IBD; however, their long-term effects and adverse events have not been properly investigated in pediatric patients. The aim of this study was to characterize the effects of these biologics and immunomodulators on pediatric IBD patients in Japan. Additionally, we assessed IFX use in pediatric patients with Crohn's disease (CD).

METHODS

A national survey of IFX, adalimumab, CYA, and FK506 use in pediatric IBD patients (< 17 years of age) was sent to 683 facilities in Japan from December 2012 to March 2013. Secondary questionnaires were sent to pediatric and adult practitioners with the aim of assessing the effectiveness and safety of IFX for pediatric CD patients.

RESULTS

The response rate for the primary survey was 61.2% (N  =  418). Among 871 pediatric CD patients, 284 (31.5%), 24, 4, and 15 received IFX (31.5%), adalimumab, CYA, and FK506, respectively, from 2000 to 2012. According to the secondary survey, extensive colitis (L3, Paris classification) was diagnosed in 69.4% of pediatric CD patients who received IFX. Regarding the effectiveness of IFX in this population, 54.7% (99/181) of patients were in remission, and 42.0% (76/181) were on maintenance therapy. However, 32.0% (58/181) of patients experienced adverse events, and one patient died of septic shock.

CONCLUSIONS

Infliximab is reasonably safe and effective in pediatric CD patients and should therefore be administered in refractory cases.

Descriptive epidemiology of children hospitalized for inflammatory bowel disease in Japan: Inpatient database analysis

BACKGROUND

Inflammatory bowel disease (IBD) - Crohn's disease (CD) and ulcerative colitis (UC) - are chronic inflammatory disorders of the intestine. Patients with IBD are at risk of hospitalization for disease exacerbation or IBD-associated complications. In the pediatric population, however, there are limited data on IBD hospitalizations. We therefore investigated the descriptive epidemiology of hospitalizations relevant to pediatric IBD.

METHODS

The national inpatient claims database in Japan was searched for children (≤ 18 years old) with a diagnosis of IBD. The study period was 2007-2010. Data on demographic characteristics and descriptive statistics of the hospital course were extracted and analyzed.

RESULTS

A total of 3559 admissions of 2175 patients met the definition of pediatric IBD: there were 1999 admissions for CD and 1560 admissions for UC. Internists were responsible for patient care in 56.6% of admissions, followed by pediatricians (27.5%). Of 3559 admissions, unscheduled hospitalizations accounted for 79.7%, and 7.6% of hospitalizations were attributable to complications of IBD, including intestinal, extraintestinal and other manifestations. The median age at first admission was 16 years (IQR, 13-17 years), in both the CD and UC groups. Compared with UC patients, CD patients had a higher number of hospitalizations (P < 0.001), but hospital stay was shorter (median: 6 vs 16 days, P < 0.001). There were seven fatal cases of IBD, accounting for 0.32% in the present series, and sepsis was the cause in five.

CONCLUSIONS

This study provides a description of pediatric inpatients with IBD and their hospital course in Japan.

Pediatric chronic intestinal pseudo-obstruction is a rare, serious, and intractable disease: a report of a nationwide survey in Japan

BACKGROUND/PURPOSE

A nationwide survey was conducted to identify the clinical presentation of pediatric chronic intestinal pseudo-obstruction (CIPO) in Japan.

METHODS

Data were collected via a questionnaire, ensuring patient anonymity, from facilities that treat pediatric gastrointestinal diseases in Japan.

RESULTS

Ninety-two responses were collected from forty-seven facilities. Sixty-two patients (28 males, 34 females) met formal diagnostic criteria for CIPO. The estimated pediatric prevalence was 3.7 in 1 million individuals. More than half the children (56.5%) developed CIPO in the neonatal period. Full-thickness intestinal specimens were available for histopathology assessment in forty-five patients (72.6%). Forty-one (91.1%) had no pathological abnormalities and were considered to be idiopathic. Patients were treated according to the local protocol of each facility. Forty-one patients (66.1%) had restricted oral intake of ordinary diets, and twenty-nine (46.8%) depended on parenteral nutrition. No therapeutic intervention, including medication and surgery, successfully improved oral food intake or obstructive symptoms. Only three patients (4.8%) died from enteritis or sepsis.

CONCLUSIONS

In Japan, pediatric CIPO is a rare, serious, and intractable disease. The prognosis with respect to survival is good, but unsatisfactory because of the need for prolonged parenteral nutrition and associated potential for restricted quality of life.

Serum magnesium concentration in children with functional constipation treated with magnesium oxide

AIM: To determine whether hypermagnesemia recently reported in adult patients possibly develops in children with functional constipation taking daily magnesium oxide.

METHODS: We enrolled 120 patients (57 male and 63 female) aged 1-14 years old (median: 4.7 years) with functional constipation from 13 hospitals and two private clinics. All patients fulfilled the Rome III criteria for functional constipation and were treated with daily oral magnesium oxide for at least 1 mo. The median treatment dose was 600 (500-800) mg/d. Patients were assessed by an interview and laboratory examination to determine possible hypermagnesemia. Serum magnesium concentration was also measured in sex- and age-matched control subjects (n = 38).

RESULTS: In the constipation group, serum magnesium concentration [2.4 (2.3-2.5) mg/dL, median and interquartile range] was significantly greater than that of the control group [2.2 (2.0-2.2) mg/dL] (P < 0.001). The highest value was 3.2 mg/dL. Renal magnesium clearance was significantly increased in the constipation group. Serum magnesium concentration in the constipation group decreased significantly with age (P < 0.01). There was no significant correlation between the serum level of magnesium and the duration of treatment with magnesium oxide or the daily dose. None of the patients had side effects associated with hypermagnesemia.

CONCLUSION: Serum magnesium concentration increased significantly, but not critically, after daily treatment with magnesium oxide in constipated children with normal renal function.

Efficacy and safety of pulse steroid therapy in Japanese pediatric patients with ulcerative colitis: a survey of the Japanese Society for Pediatric Inflammatory Bowel Disease

AIMS

We have evaluated the therapeutic efficacy and safety of pulse steroid therapy for ulcerative colitis (UC) in a Japanese pediatric population by means of a survey.

METHODS

A questionnaire on UC patients treated with therapy between 2002 and 2006 was sent to 37 members of the Japanese Society for Pediatric Inflammatory Bowel Disease.

RESULTS

21 of 62 cases in 6 of 19 centers registered in this study had been treated with pulse steroid therapy. The success rate of remission induction with this treatment was 55%, and improvement was observed in all cases in which remission was not achieved. There were no reports of any obvious side effects. The most common reason for using pulse steroid therapy was for remission induction in relapsed cases. Over the course of 12 (or fewer) months, the number of cases in which remission was maintained was only 1 in 4. However, the amount of concomitant steroid use had significantly decreased after 1 year.

CONCLUSIONS

This survey shows that in Japan, pulse steroid therapy is used for a relatively large number of children with UC and is as an effective method of remission induction that has few side effects.

Histological findings in the livers of patients with neonatal intrahepatic cholestasis caused by citrin deficiency

AIM

To characterize the histological features of the livers of patients with neonatal intrahepatic cholestasis caused by citrin deficiency (NICCD), we studied specimens from 30 patients diagnosed with NICCD by genetically analyzing the SLC25A13 gene.

METHODS

Liver biopsy specimens were subjected to hematoxylin-eosin, Azan, and Berlin-blue staining.

RESULTS

Most specimens showed varying degrees of fibrosis. The degree of inflammation varied among the specimens, with half showing moderate or severe inflammatory changes. Fat deposition in hepatocytes was observed in almost all of the specimens, and severe fatty liver was noted in 20 (67%) of them. There was a mixture of two types of hepatocytes with macrovesicular or microvesicular fat droplets, and cholestasis was observed at a rate of 77%. Hemosiderin deposition, mostly mild and localized in periportal hepatocytes and macrophages in portal areas, was observed in 57% of the specimens.

CONCLUSION

A combination of mixed macrovesicular and microvesicular fatty hepatocytes and the above-described findings, such as fatty liver, cholestasis, necroinflammatory reaction and iron deposition, are almost never observed in other liver diseases in infants and adults. We believe that NICCD is a disease with characteristic hepatopathological features.

Interobserver variability in antroduodenal manometry

Interobserver variability affects investigations involving assessment of complex visual data, such as histopathology, radiology and motility. This study assessed interobserver variation for interpretation of antroduodenal manometry (ADM), as this has not been previously investigated. Thirty-five ADM recordings from children aged 0.3-18 years were independently evaluated by five experienced paediatric gastroenterologists who were blinded to cases' clinical histories. Intra-class correlation (ICC) was analysed for detection and measurement of phase three of the migrating motor complex (MMC) and Cohen's kappa statistic was calculated between observer pairs for detection of specific motility features and final diagnosis. Observers were unanimous on the differentiation of normal and abnormal motility in 63% of cases. There was excellent interobserver agreement for the number of phase three of the MMC in fasting (ICC = 0.82, P < 0.0001) and for measurements of phase three of the MMC (ICC = 0.9999, P < 0.0001). Detection of other normal and abnormal motility patterns varied more. Objective findings such as the presence of phase three of the MMC correlated more closely than findings that involved the integration of several variables, such as final diagnosis. However, these data overall indicate that agreement between expert observers for the distinction of normal and abnormal antroduodenal motility compares favourably with other standard medical assessments.

The effects of intestinal ischemia on colonic motility in conscious rats

BACKGROUND

The present study aimed to examine whether and how colonic motility is affected by mild ischemia-induced intestinal injury in conscious rats through in vivo monitoring of colonic contractions, specifically with regard to the interstitial cells of Cajal (ICC) and the effect of nitric oxide (NO).

METHODS

Using miniature strain-gauge transducers, colonic motility with or without ischemia was recorded in conscious rats on the 4th, 7th, and 14th days after surgery. Histological examination for c-kit-positive cells was performed.

RESULTS

In control nonischemic rats, the number and duration of contractions (NC and DC, respectively) decreased gradually, but the mean amplitude of contractions (MC) and motility index (MI) did not change. On the 7th day, the NC in the ischemic group increased significantly when compared with that in the control group (P = 0.037). The DC in the ischemic group was lower than that in the control group; the difference was significant on the 4th day (P = 0.008). The MIs in the ischemic group were lower than those in the control group. In both groups, administration of NGnitro-L: -arginine methyl ester on the 7th day increased only the resting cecal motility. Pathological examinations revealed c-kit-positive cells in both groups.

CONCLUSIONS

Changes such as increased NC with shortened DC accompanied with decreased MI must have occurred at the ischemic site and might have been induced by an ischemic event. However, there exists a possibility that ICC and NO do not play a role in mild ischemia-induced dysmotility.

Effects of pectin liquid on gastroesophageal reflux disease in children with cerebral palsy

Background

The use of thickeners is a standard therapy for decreasing episodes of regurgitation or vomiting in infants. However, it remains to be investigated whether thickener is effective for vomiting and/or chronic respiratory symptoms in children with cerebral palsy.

Methods

We enrolled 18 neurologically impaired children caused by cerebral palsy, with gastroesophageal reflux disease. In the first part of this study (pH monitoring), subjects were randomly allocated to two groups: fed with a high-pectin diet [enteral formula: pectin liquid = 2:1 (v/v)], or a low-pectin diet [enteral formula: pectin liquid = 3:1 (v/v)]. Two-channel esophageal pH monitoring was performed over 48 h. In the second part (clinical trial), subjects were fed a high- or low-pectin diet and non-pectin diet for 4 weeks in a crossover manner. Nurses recorded the feeding volume, number of episodes of vomiting, volume of gastric residue, episodes of cough and wheeze, frequency of using oxygen for dyspnea, and the day when the child could return to school. Cough and wheeze were recorded as a cough-score.

Results

The median value for the % time pH < 4 at the lower and upper esophagus was significantly decreased with a high-pectin diet [9.2% (6.2–22.6) vs. 5.0% (3.1–13.1); P < 0.01, 3.8% (2.9–11.2) vs. 1.6% (0.9–8.9); P < 0.01 (interquartile range), non-pectin and high-pectin, respectively]. The number of reflux episodes per day and duration of longest reflux were decreased significantly with a high-pectin, but not with a low-pectin diet. The median number of episodes of vomiting decreased significantly with a high-pectin diet [2.5/week (1.0–5.0) vs. 1.0 (1.0–1.5), P < 0.05]. The median cough-score was significantly decreased by both concentrations of pectin [8.5/week (1.0–11.5) vs. 2.0/week (0.0–3.0), fed with a high-pectin diet; 7.0/week (1.0–14.5) vs. 1.0/w (0.0–5.0), fed with a low-pectin diet, P < 0.05].

Conclusion

Pectin liquid partially decreased gastroesophageal reflux as measured by eshophageal pH monitoring, and might improve vomiting and respiratory symptoms in children with cerebral palsy.

Trial registration

ISRCTN19787793

Pemphigus vulgaris as a possible cause of protein-losing gastroenteropathy: a case report

We present a case of pemphigus vulgaris (PV) accompanied with protein-losing gastroenteropathy (PLE). A 9-year-old girl developed multiple oral ulcerations and erosions. She was first treated with oral antibiotics and a topical steroid without improvement. Laboratory data showed eosinophilia (absolute eosinophil count 1.08 x 10(9)/L) and hypoproteinemia (total serum protein 3.9 g/dL, albumin 2.2 g/dL). A biopsy specimen from the ileum showed intense eosinophil infiltration and albumin scintigraphy demonstrated protein exduation from the same site. Endoscopic examination of the oesophagus showed multiple ulcerations and erosions, and biopsy specimen showed eosinophilic spongiosis and immunohistologic staining demonstrated deposits of IgG and C3 in the intercellular space. Antidesmoglein-3 antibody elevated, she was diagnosed as PV complicated with PLE. Immunofluorescence study of a biopsy specimen from the terminal ileum showed no significant immunoglobulin or complement deposition, and autoantibody against intestinal mucosa was unclear in this case. Gastrointestinal evaluations should be considered in patients with hypoproteinemia associated with PV.

Effect of formula thickened with reduced concentration of locust bean gum on gastroesophageal reflux

AIM

Previous studies showed that HL-350, a formula thickened with a reduced concentration of locust bean gum, decreased frequent regurgitation in 4-month old infants with reflux. In this study, we investigated the effect of HL-350 in younger infants.

METHODS

We studied 20 infants less than 2 months old who had three or more episodes of regurgitation or vomiting per day. Ten infants (group A) were fed with HL-350 for the first week, and with control milk, HL-00, for the following week. The other 10 infants (group B) were fed in reverse order. Mothers recorded number of regurgitation episodes, feeding volume and time and number of bowel movements. To evaluate gastric emptying we measured antral cross sectional areas ultrasonographically at various time points after feeding.

RESULTS

The median number of regurgitation episodes decreased significantly with feeding of HL-350 (2.3/day) compared to feeding with control milk (5.2/day) (p = 0.00048). No significant difference was evident in feeding volume and time, body weight gain, or gastric emptying rate between HL-350 and control milk.

CONCLUSION

HL-350 decreased the number of regurgitation episodes without affecting gastric emptying delay in very young infants with recurrent vomiting.

Effect of formula thickened with locust bean gum on gastric emptying in infants

AIM

We investigated the effects of milk-based formulas thickened with two different concentrations of locust bean gum on gastric emptying in infants with recurrent regurgitation episodes.

METHODS

Thirty-nine infants with three or more episodes of regurgitation per day but no complications who were fed mainly with infant formula were studied. We first compared gastric emptying in infants fed with formulas thickened with two different concentrations of locust bean gum (HL-350, 0.35 g/100 mL; HL-450, 0.45 g/100 mL) or a regular formula (HL-00). To evaluate gastric emptying, we measured antral cross-sectional areas ultrasonographically at various time points after feeding. Next, to investigate the clinical effect of thickened formulas on regurgitation episodes, 27 infants with episodes were assigned randomly to receive HL-350 and HL-00 or HL-450 and HL-00 for 1 week each.

RESULTS

Antral cross-sectional areas at 60, 90, 120 and 150 min with HL-450, and at 60 min with HL-350, were greater than with HL-00. The median gastric emptying rate at 120 min with HL-450 (52.8%) was lower than with HL-00 (97.9%; P = 0.0019), while HL-350 (80.3%) and HL-00 did not differ significantly. The mean number of regurgitation episodes was significantly smaller when infants were fed with either HL-350 or HL-450 than with HL-00.

CONCLUSIONS

HL-450, a thickened formula with typical commercially available concentrations of locust bean gum, slowed gastric emptying in infants with gastroesophageal reflux.

A multicenter prospective randomized trial of corticosteroids in primary therapy for Kawasaki disease: clinical course and coronary artery outcome

OBJECTIVE

To investigate the role of corticosteroids in the initial treatment of Kawasaki disease (KD).

STUDY DESIGN

Between September 2000 and March 2005, we randomly assigned 178 KD patients from 12 hospitals to either an intravenous immunoglobulin (IVIG) group (n = 88; 1 g/kg for 2 consecutive days) or an IVIG plus corticosteroid (IVIG+PSL) group (n = 90). The primary endpoint was coronary artery abnormality (CAA) before a 1-month echocardiographic assessment. Secondary endpoints included duration of fever, time to normalization of serum C-reactive protein (CRP), and initial treatment failure requiring additional therapy. Analyses were based on intention to treat.

RESULTS

Baseline characteristics of groups were similar. Fewer IVIG+PSL patients than IVIG patients had a CAA before 1 month (2.2% vs 11.4%; P = .017). The duration of fever was shorter (P < .001) and CRP decreased more rapidly in the IVIG+PSL group than in the IVIG group (P = .001). Moreover, initial treatment failure was less frequent (5.6% vs 18.2%; P = .010) in the IVIG+PSL group. All patients assigned to the IVIG+PSL group completed treatment without major side effects.

CONCLUSIONS

A combination of corticosteroids and IVIG improved clinical course and coronary artery outcome without causing untoward effects in children with acute KD.

Guidelines for the treatment of Crohn's disease in children

This paper shows guidelines for the treatment of Crohn's disease in children by the Working Group of the Japanese Society for Pediatric Gastroenterology, Hepatology and Nutrition (Chair: Yuichiro Yamashiro) and the Japanese Society for Pediatric Inflammatory Bowel Disease (Chair: Akio Kobayashi). The points in which these guidelines differ from those for adult patients are as follows. (i) Total enteral nutrition in the form of an elemental formula is indicated as primary therapy for children with Crohn's disease at onset as well as the active stage. Oral mesalazine is used together. (ii) Total parenteral nutrition (TPN) with oral mesalazine is required for children with serious illness. The use of a corticosteroid should be withheld for at least 1 week after TPN has been started. (iii) When TPN is not considered to be effective, additional corticosteroid is used. Full doses of corticosteroid should be used for at least 2 weeks after clinical improvement has been achieved, and then the dose of the corticosteroid should be tapered carefully. (iv) When surgery is indicated in pediatric patients with stricture or fistula formation and complicated by persistent growth failure despite medical therapy, the optimum time for surgery is thought to be before epiphyseal plates have been closed.

Prediction of intravenous immunoglobulin unresponsiveness in patients with Kawasaki disease

BACKGROUND

In the present study, we developed models to predict unresponsiveness to intravenous immunoglobulin (IVIG) in Kawasaki disease (KD).

METHODS AND RESULTS

We reviewed clinical records of 546 consecutive KD patients (development dataset) and 204 subsequent KD patients (validation dataset). All received IVIG for treatment of KD. IVIG nonresponders were defined by fever persisting beyond 24 hours or recrudescent fever associated with KD symptoms after an afebrile period. A 7-variable logistic model was constructed, including day of illness at initial treatment, age in months, percentage of white blood cells representing neutrophils, platelet count, and serum aspartate aminotransferase, sodium, and C-reactive protein, which generated an area under the receiver-operating-characteristics curve of 0.84 and 0.90 for the development and validation datasets, respectively. Using both datasets, the 7 variables were used to generate a simple scoring model that gave an area under the receiver-operating-characteristics curve of 0.85. For a cutoff of 0.15 or more in the logistic regression model and 4 points or more in the simple scoring model, sensitivity and specificity were 86% and 67% in the logistic model and 86% and 68% in the simple scoring model. The kappa statistic is 0.67, indicating good agreement between the logistic and simple scoring models.

CONCLUSIONS

Our predictive models showed high sensitivity and specificity in identifying IVIG nonresponders among KD patients.

Possible involvement of adrenomedullin in lipopolysaccharide-induced small-intestinal motility changes in conscious rats

BACKGROUND

Adrenomedullin is a vasodilator peptide that displays a variety of effects, such as hypotension and vasodilatation. The aim of this study was to test the effect of intravenous adrenomedullin on the motility pattern of the small intestine, and the functional involvement of adrenomedullin in endotoxin-induced small-intestinal motility disturbance.

METHODS

Jejunal motility was recorded in fasted conscious rats, using miniature strain-gauge force transducers sutured to the serosal surface of the small-intestinal wall.

RESULTS

Intravenous administration of adrenomedullin at doses of 3, 6, and 10 microg/kg per min over 30 min disrupted phase 3 of the migrating motor complex, with the disruption lasting for 61.9 +/- 5.1, 52.2 +/- 10.6, and 74.1 +/- 25.2 min, respectively. The interval from drug administration to the onset of disruption decreased as the dose of adrenomedullin increased to 41.5 +/- 11.0, 11.6 +/- 3.4, and 0 min, respectively (P < 0.05). An increase in the motility index was also dose-dependent (P < 0.05) at these doses of adrenomedullin. Lipopolysaccharide (50 microg/kg) induced disruption of phase 3, which lasted for 138.7 +/- 5.4 min. Previous administration of the putative adrenomedullin-receptor antagonist, AM (22-52), at a 50 microg/kg dose, attenuated the disruption induced by lipopolysaccharide to 74.4 +/- 3.5 min (P < 0.01).

CONCLUSIONS

Our findings (1) suggest that intravenous adrenomedullin causes small-intestinal motility disturbances, and (2) support the hypothesis that adrenomedullin overproduction plays an important role in lipopolysaccharide-induced disruption of the motility pattern in the small intestine in rats.

In vivo recording of colonic motility in conscious rats with deficiency of interstitial cells of Cajal, with special reference to the effects of nitric oxide on colonic motility

BACKGROUND

We recorded in vivo colonic motility in rats with a deficiency of interstitial cells of Cajal (ICC) (Ws/Ws rats) and in wild-type rats (+/+ rats), with special reference to the effects of nitric oxide (NO) on colonic motility in both types of rats, in order to ascertain the role of ICC in colonic motility, and the relationship between NO and ICC in regard to colonic motility.

METHODS

Miniature strain-gauge force transducers were sutured on the surface of the ascending and sigmoid colon of Ws/Ws rats and +/+ rats as controls. After 1 week and a fasting period of 24 h, colonic motility in +/+ and Ws/Ws rats was recorded. We also studied the effect of NO on colonic motility in both types of rats, by means of the administration of N-nitro-L-arginine methyl ester (L-NAME) or L-arginine.

RESULTS

In +/+ rats, there were contractions with high amplitude and long duration in both the ascending and sigmoid colon. The number, amplitude, and duration of contractions in the ascending colon were 9.9/20 min, 6.1 g, and 22.7 s, respectively. These findings in the sigmoid colon were 5.2/20 min, 5.2 g, and 23.0 s, respectively. The number of contractions in the ascending and sigmoid colon in Ws/Ws rats (2.3 and 1.0/20 min) was significantly lower than that in +/+ rats (P < 0.05). The number of contractions in the ascending and sigmoid colon in +/+ rats (9.7 and 5.1/20 min before treatment) was significantly increased by L-NAME administration (28.7 and 13.9/40-60 min after treatment; P < 0.05), but that in Ws/Ws rats was not influenced. The number of contractions in the ascending and sigmoid colon in +/+ rats (10.2 and 5.2/20 min before treatment) was significantly decreased by L-arginine administration (3.6 and 2.1/40-60 min after treatment; P < 0.05), but that in Ws/Ws rats was not influenced.

CONCLUSIONS

ICC must be related to the occurrence of a normal number of colonic contractions. NO may be involved in the inhibitory regulation of colonic motility, and the effect of NO on the occurrence of contractions appears to be mediated by ICC.

[Guidelines for treatment of ulcerative colitis in children]

Guidelines for treatment of ulcerative colitis in children have been created by the working group of the Japanese Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the Japanese Society for Pediatric Inflammatory Bowel Disease. The ideas of these guidelines, with regard to the fundamental differences in medical treatment between children and adults, included (1) for children, intensive medical treatment including appropriate systemic management is important during the acute phase of illness. (2) Treatment with steroids, which can cause growth disturbances, should not be continued for long period of time. (3) Pulsed steroid therapy, selective removal of blood cells, and intravenous infusion of cyclosporin are included in the therapeutic option for severe and fluminant cases.

Risk of hypervitaminosis D from prolonged feeding of high vitamin D premature infant formula

BACKGROUND

Most premature infant formulas marketed in Japan have high vitamin D content. Potential for vitamin D intoxication was assessed in premature infants with prolonged feeding of such a premature formula vitamin D content, 2700 IU/L.

METHODS

Serum vitamin D, calcium and phosphorus, and urinary calcium, were measured in 12 very premature infants fed premature infant formula, regular formula (vitamin D content; 460 IU/L), and/or mother's milk.

RESULTS

Concentrations of 25(OH)D in sera associated with sole feeding of premature infant formula (n = 40) were significantly higher than sera corresponding to regular formula or breast milk (n = 25; 175 versus 115 nmol/L, P <0.0001). No sample showed a serum 25(OH)D concentration below 25 nmol/L. Of 65 samples, 49 (75.4%) showed 25(OH)D concentrations exceeding 100 nmol/L, but serum calcium and phosphorus concentrations were normal. Unexpectedly, urinary calcium correlated negatively with serum 25(OH)D.

CONCLUSION

In prolonged feeding of premature infant formula with high vitamin D, it was concluded that it could cause a high blood concentration of vitamin D in premature infants, and also that in these infants urine calcium is not a reliable indicator of excessive vitamin D intake.

Guidelines for treatment of ulcerative colitis in children

This paper introduces the guidelines for treatment of ulcerative colitis in children, created by the working group of the Japanese Society for Pediatric Gastroenterology, Hepatology and Nutrition (Chair: Yuichiro Yamashiro) and the Japanese Society for Pediatric Inflammatory Bowel Disease (IBD) (Chair: Akio Kobayashi). The ideas of the working group, with regard to the fundamental differences in medical treatment between children and adults, included: (1) for children, intensive medical treatment including appropriate systemic management is important during the acute phase of illness. (2) Treatment with steroids, which can cause growth disturbances, should not be continued for long periods of time. (3) Pulsed steroid therapy, selective removal of blood cells, and intravenous infusion of cyclosporin should be included in the therapeutic option for severe and fluminant cases.

Gastrointestinal manometric findings in a patient with total intestinal aganglionosis

BACKGROUND/PURPOSE

The authors studied gastrointestinal motility in a patient with total intestinal aganglionosis (TIA) and the effect of octreotide (OCT) on ileal motility in this patient.

METHODS

The 3200-g girl received ileostomy at 50 cm proximal to the ileocecal site and jejunostomy at 15 cm distal to the ligament of Treitz because of severe ileus owing to TIA. Histology of the intestines, including jejunostomy, showed no ganglion cells. Gastro-duodeno-jejunal and distal ileal manometries were done 8 months after birth.

RESULTS

In upper gastrointestinal manometry, sporadic contractions and clusters consisting of 3 to 5 contractions were observed in the duodenum and jejunum, but no typical phase 3 was observed during the 3-hour recording period. In ileal manometry, long-lasting repetitive contractions were recorded at 2 distal sites. In the most proximal ileum, the frequency of contractions was less than in the 2 distal sites. OCT administration induced a decrease in the amplitude of contractions during the first 20 minutes. The amplitude increased thereafter and reached a level higher than that before OCT administration.

CONCLUSIONS

In this patient, the predominant manometry finding was the remarkable hypermotility of the ileum. OCT induced a transient decrease in ileal motility and an increase in motility thereafter.

Effect of locust bean gum in anti-regurgitant milk on the regurgitation in uncomplicated gastroesophageal reflux

OBJECTIVES

To evaluate the efficacy of anti-regurgitant milk (AR milk) with reduced concentration of locust bean gum (LBG) compared with the usual commercially available concentration of this thickener.

METHODS

Thirty infants with daily regurgitation but no other medical problems were randomly assigned to one of two groups. Infants in group A (n = 16) were fed either HL-450, an AR milk thickened with a commonly used concentration of LBG (0.45 g/100 mL) or control milk (HL-00; no LBG) in a crossover manner for periods of 1 week. The order of milk was randomly chosen for each subject. Infants in group B (n = 14) were fed HL-350, an AR milk with a reduced LBG concentration (0.35 g/100 mL), or HL-00 in the same crossover fashion. The number of episodes of regurgitation, feeding time, and body weight gain were recorded. Three infants in group B did not complete the protocol and were excluded.

RESULTS

Both AR formulas decreased the number of regurgitation episodes by approximately 50% compared with control. Five mothers who gave their infants HL-450 and no mothers who fed their children HL-350 reported that the infants had difficulty sucking the formula through the nipple. Thirteen (81.3%) mothers who used HL-450 and 9 (81.8%) mothers who used HL-350 preferred the AR milk to the control milk.

CONCLUSIONS

An AR milk with reduced LBG was as effective in reducing regurgitation as one with the usually available concentration of LBG.

Serum procalcitonin concentration in patients with Kawasaki disease

BACKGROUND

Procalcitonin (PCT) is a new parameter of inflammation, the clinical usefulness of which is currently being evaluated.

MATERIALS AND METHODS

We determined simultaneously the serum concentrations of PCT and C-reactive protein (CRP) as well as the white blood cell (WBC) count in 25 patients with Kawasaki disease (KD), 17 with bacterial infections, 10 with systemic autoimmune diseases, 17 with viral infections and 18 healthy children. The optimal cut-off value of each parameter for predicting coronary aneurysms was determined using receiver operating characteristic curves.

RESULTS

Significantly higher serum concentrations of PCT were observed in patients with KD (2.3 +/- 3.0 ng/ml) and bacterial infections (2.2 +/- 2.9 ng/ml) than in patients with autoimmune diseases (0.4 +/- 0.4 ng/ml) or viral infections (0.4 +/- 0.3 ng/ml), or in healthy children (0.2 +/- 0.1 ng/ml). The serum PCT but not the WBC count or CRP, differentiated the KD patients from the patients with autoimmune diseases. The optimal cut-off value of 3.0 ng/ml of PCT increased the prediction rate of coronary aneurysms that subsequently occurred in 4 (16%) patients with KD.

CONCLUSIONS

The serum PCT may be clinically useful for determining the severity of KD and for narrowing the differential diagnosis of patients with inflammatory diseases.

Pharmacobezoar complicating treatment with sodium alginate

We encountered a gastric bezoar that had developed in a 9-year-old girl treated with sodium alginate (Alloid G) for acute gastritis associated with systemic lupus erythematosus. A hard mass palpated in the left upper abdomen proved, upon gastric endoscopy, to be an intragastric foreign body. Sodium alginate was detected in an analysis of a sample from this bezoar. In an in vitro simulation, sodium alginate solidified when mixed with the patient's other medicines. The bezoar caused no complications, and disappeared spontaneously after discontinuation of the medications. This case indicates that this sodium alginate preparation, Alloid G, can be a cause of pharmacobezoar.

Determinants of prognosis of acute transverse myelitis in children

BACKGROUND

Acute transverse myelitis (ATM) is a severe disorder; recovery requires several months and often leaves neurologic residua. To determine what features of patients with acute transverse myelitis significantly influence prognosis, the authors reviewed reports of ATM in Japanese children published in the last 15 years (from 1987 to 2001).

METHODS

The authors studied reports of 50 Japanese patients (17 boys, 26 girls, 7 children of unspecified sex; mean age +/- SD, 8.0 +/- 3.8 years). Acute-phase and demographic features including age, increased deep tendon reflexes, Babinski reflex, sex, preceding infection, decreased deep tendon reflexes, time course of peak neurologic impairment, treatment with prednisolone and/or high-dose methylprednisolone, and the day of illness when treatment was started were used as independent variables in a regression analysis. The dependent variable was long-term persistence of neurologic deficits.

RESULTS

Younger patients and those without increased deep tendon reflexes or a Babinski reflex were more likely to have residual neurologic deficits such as paraplegia or tetraplegia, sensory loss and sphincter disturbance. No relationship was seen between prognosis and sex, preceding infections, decreased deep tendon reflexes, time course of peak neurologic impairment, treatment with prednisolone or high-dose methylprednisolone, or timing of treatment initiation.

CONCLUSIONS

Age at onset and neurologic features were important for outcome prediction in ATM. Steroid therapy did not associate with better outcome.

Measurement of tricuspid annular diastolic velocities by Doppler tissue imaging to assess right ventricular function in patients with congenital heart disease

We assessed the clinical utility of using diastolic tricuspid annular velocities obtained by Doppler tissue imaging as a noninvasive index of right ventricular function in patients with congenital heart disease. Doppler tissue imaging at the tricuspid annulus and pulsed Doppler echocardiography of the right ventricular inflow were performed in 71 children with congenital heart disease, with and without elevated right ventricular pressure. Cardiac catheterization was performed in all patients with congenital heart disease, and the hemodynamic determinants of the tricuspid annular and inflow velocities were determined. In patients with congenital heart disease, the ratio of the late-to-early diastolic tricuspid annular velocity (Aa/Ea) showed a highly significant correlation with right ventricle pressure/left ventricle pressure (r = 0.79, p < 0.0001), right ventricular end diastolic pressure (r = 0.46, p < 0.0001), and the first derivatives of the change in right ventricle pressure during diastole (r = 0.72, p < 0.0001). However, the late-to-early diastolic tricuspid inflow velocity (A/E) did not correlate with any invasively measured index of right ventricular function. Aa/Ea, derived from tricuspid annular velocities as measured by Doppler tissue imaging, is a valuable, noninvasive tool for detecting an elevated right ventricular pressure in patients with congenital heart disease.

Effect of corticosteroids in addition to intravenous gamma globulin therapy on serum cytokine levels in the acute phase of Kawasaki disease in children

OBJECTIVE

The aim of this multicenter prospective and randomized study was to determine the effect of adding corticosteroids to intravenous gamma globulin (i.v.GG) therapy on serum cytokine levels, as well as to see its effect on the clinical course in children in the acute phase of Kawasaki disease (KD).

STUDY DESIGN

Patients with KD (n=32) were randomized to receive either i.v.GG alone (G group) or i.v.GG plus corticosteroids (G+S group). The clinical course and cytokine responses between groups were compared.

RESULTS

The pretreatment serum levels of interleukin (IL)-2, IL-6, IL-8, and IL-10 were significantly higher in patients with KD than in healthy controls. Although i.v.GG alone failed to reduce cytokine concentrations within 24 hours of i.v.GG administration, corticosteroids plus i.v.GG reduced IL-2, IL-6, IL-8, and IL-10 levels. The levels of IL-2, IL-6, IL-8, and IL-10 within 24 hours after initiating i.v.GG therapy were significantly lower in the G+S group than in the G group. The duration of fever was shorter, and the C-reactive protein concentration decreased more quickly in the G+S group than in the G group.

CONCLUSIONS

These findings suggest that corticosteroids rapidly ameliorate symptoms by reducing cytokine levels in children with KD.

Percutaneous hydrodynamic thrombectomy for femoral arterial thrombosis after arterial catheterization

We report on a 3-year-old boy in whom a complete occlusive thrombus in the right femoral artery was removed rapidly and successfully using a hydrodynamic thrombectomy catheter. There was no bleeding complication, reocclusion, vascular injury, or loss of motor or sensory function. Hydrodynamic thrombectomy can be an important part of the treatment of thrombosis in children.

Granulocyte adsorptive apheresis for pediatric patients with ulcerative colitis

Granulocytapheresis (GCAP) has produced efficacy in adult patients with ulcerative colitis (UC) by adsorbing activated granulocytes and monocytes/macrophages. We retrospectively investigated efficacy and safety of GCAP in pediatric patients with active UC. Twelve steroid-refractory children (12.2 +/- 3.1 years old) were treated with GCAP, one session/week for 5-10 consecutive weeks. In 8 patients, clinical symptoms improved after two GCAP sessions. Normal body temperature, stool frequency, and disappearance of blood in stool were seen after 24.3 +/- 11.5 days. The endoscopic grade improved from 2.6 +/- 0.3 to 0.4 +/- 0.2. One patient who initially responded, developed bloody diarrhea later and 2 cases remained unchanged. The dose of steroid was tapered during GCAP therapy by 50%. No serious adverse effects were noted. Four of 8 cases relapsed 3.5 +/- 2.2 months after the last GCAP while on maintenance therapy, the other 4 were in remission up to 22.8 +/- 18.1 months. In conclusion, GCAP appears to be effective and well tolerated in children with steroid-refractory UC.

Developmental changes in cyclo-oxygenase mRNA induction by hypoxia in rat kidney

BACKGROUND

Prostaglandins, synthesized by cyclo-oxygenase (COX), regulate renal hemodynamics and also epithelial water and solute transport. Developmental changes occur in COX-2 mRNA expression and its response to lipopolysaccharide stimulation in rats. We examined age-related changes in COX mRNA expression induced by hypoxia in the renal cortex and medulla of developing rats.

METHODS

Total RNA was extracted from 1- and 4-week-old male Wistar rats exposed to one or 4 h of hypoxia (8% O2). Cyclo-oxygenase mRNA was quantitatively analyzed using a real-time polymerase chain reaction with dual-labeled fluorogenic probes.

RESULTS

Expression of COX-1 mRNA did not change in response to hypoxia in the cortex or medulla in either infantile or adult rats. In infantile rats, COX-2 mRNA expression was not induced by one or 4 h of hypoxia. In adults, 1- and 4-h exposures to hypoxia induced COX-2 mRNA in the renal cortex, and 1-h of exposure induced COX-2 mRNA in the medulla.

CONCLUSIONS

Response of expression of COX-2 mRNA in rats exposed to acute hypoxia show age-related variability treated by acute hypoxia. Cyclo-oxygenase-2 might not play a major role in the hypoxic infantile rat kidney.

Prevalence of gastro-esophageal reflux-related symptoms in Japanese infants

BACKGROUND

To obtain precise information on the natural course of gastro-esophageal reflux (GER)-related symptoms in Japanese children, we surveyed the prevalence of regurgitation or vomiting and other GER-related symptoms and complications in infants visiting for healthy baby check-ups.

METHODS

We interviewed the mothers of 921 infants who had visited for baby check-ups at 1, 4, 7 and 12 months after birth, about the number of regurgitation or vomiting episodes per day, other GER-related symptoms, milk volume, feeding interval, and the body position after feeding.

RESULTS

Of 1-month-old infants, 47.1% had one or more regurgitation or vomiting episode per day. This proportion decreased to 28.8% at 4 months old and 6.4% at 7 months old. The proportion of infants with three or more episodes of these symptoms per day showed a similar pattern. There was no significant difference in the prevalence of regurgitation or vomiting between breast-fed infants and formula-fed or mixed-feeding infants either at 1 or 4 months of age. There was no significant difference in the bodyweight gain of 3-month-old infants among those with various degrees of regurgitation. There was no significant difference in the frequency of regurgitation or vomiting episodes between infants placed in a vertical position and those placed in a horizontal position after feeding. No infant had a history of chronic coughing, wheezing, bleeding or other serious conditions.

CONCLUSIONS

Regurgitation is a common symptom in Japanese infants and decreases spontaneously with age. The natural history of GER must be taken into consideration when deciding the treatment.

Endosonographic diagnosis of pneumatosis cystoides intestinalis in infancy

We report pneumatosis cystoides intestinalis in a 10-month-old girl who developed bloody diarrhea following chemotherapy for leukemia. The diagnosis was made only by colonic endoscopic ultrasonography, whereas the abdominal plain radiogram and computed tomography failed to elucidate the diagnosis. She was successfully treated with hyperbaric oxygen therapy. Wider application of endoscopic ultrasonography may lead to the more frequent detection of pneumatosis cystoides intestinalis, currently a rare disorder.

Successful treatment of severe hyperammonemia using sodium phenylacetate powder prepared in hospital pharmacy

In order to treat a hyperammonemic patient with adult-onset type-II citrullinemia (CTLN2), sodium phenylacetate powder was prepared from chemical reagent grade phenylacetic acid in Gunma University Hospital. After purification by recrystalization, phenylacetic acid was neutralized with sodium carbonate and dried at 70 degrees C under reduced pressure. A solution of the prepared powder produced a single peak of m/z=181.0 (M+Na+) in electrospray-ionization-MS spectrogram. The content of phenylacetate was 74% of theoretical value, suggesting the existence of water of crystallization. The content of phenylacetate remained constant for 5 months under dark conditions at room temperature. The prepared sodium phenylacetate powder was orally administered to a 16-year-old patient with CTLN2 at a dosage of 12 g/d. The serum ammonia concentration of the patient, who did not show adequate response to intravenous arginine or oral sodium benzoic acid decreased remarkably to less than 100 microg/dl. Sodium phenylacetate powder should be an essential drug for the treatment of hyperammonemia caused by an inborn error of the urea cycle.

Involvement of serotonin and nitric oxide in endotoxin-induced gastric motility changes in conscious rats

Severe bacterial infection causes gastrointestinal dysmotility by an unknown mechanism. We investigated the possible involvement of serotonin (5-HT) and nitric oxide (NO) in endotoxin-induced motility disturbance, using an in vivo rat model. Six days prior to the experiment, a force transducer was sutured to the gastric antrum of rats. Lipopolysaccharide induced strong repetitive contractions in the gastric antrum within 2 to 3 min in all rats tested. After 15 min of hypermotility, motility decreased and remained low for more than 60 min. The initial increase in motility was suppressed by atropine, FK1052, or SB204070, whereas it was not affected by granisetron. The subsequent decrease was inhibited by L-NAME and S-methylisothiourea sulfate. These results indicate that in conscious rats, lipopolysaccharide induces a transient increase in gastric motility followed by suppression. The increase might be mediated by 5-HT4 receptors, and the decrease by inducible NOS.

Efficacy of phenytoin against hyponatremic seizures due to SIADH after administration of anticancer drugs in a neonate

A neonate with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) developed refractory hyponatremic seizures following administration of anticancer drugs. The seizures did not respond to diazepam, phenobarbital, or lidocaine, but resolved immediately with administration of phenytoin. The low water-excretion capacity in neonates should be taken into consideration when fluid loading is attempted, to avoid renal damage upon administration of drugs such as cisplatin that have a potential damaging effect on the kidney. Phenytoin could be the therapy of choice for SIADH and resulting seizures in the neonatal period.

Developmental changes in cyclooxygenase mRNA expression in the gastric mucosa of rats

BACKGROUND

In newborn rats, gastric mucosa is more susceptible to various damaging agents and recovers from injury more quickly than in older animals. To determine whether metabolism of prostaglandins is responsible for this mucosal protective mechanism in developing rats, we studied cyclooxygenase (COX) mRNA expression in the mucosa using quantitative real-time polymerase chain reaction (PRC).

METHODS

Cyclooxygenase-1 and COX-2 mRNA was extracted from the gastric mucosa of rats of various ages and quantitatively analyzed using real-time PCR with dual-labeled fluorogenic probes. The copy numbers of cDNA for COX-1 and COX-2 were standardized to glyceraldehyde-3-phosphate dehydrogenase from the same sample.

RESULTS

Cyclooxygenase-1 mRNA expression was lowest in 1-week-old rats and highest in 4-week-old rats. Mucosal damage produced by 150 mmol/L HCl and 60% ethyl alcohol did not increase COX-1 mRNA expression in any age group. Cyclooxygenase-2 mRNA expression increased significantly with age. Mucosal injury increased COX-2 mRNA in each age group, especially in 1-week-old rats. Intraperitoneal lipopolysaccharide also increased COX-2 mRNA in both 1- and 4-week old rats.

CONCLUSION

The high level of COX-2 mRNA expression in the gastric mucosa of 1-week-old rats may be responsible for the physiologic characteristics of gastric mucosal defenses in this age group.

Divided right atrium associated with extensive coronary vein abnormalities

This report describes a case of a divided right atrium associated with coronary vein abnormalities. An 18-year-old woman who had a past history of surgery for repair of a divided right atrium and atrial septal defect developed exertional dyspnea 8 years after the surgery. Selective coronary angiography showed a dilated right coronary artery with a fistulous communication to the right atrium, tortuous coronary veins draining directly into the cardiac chambers, and the absence of the coronary sinus. Embryologically, regression failure of the right venous valve is hypothesized to have created both the divided right atrium and extensive coronary vein abnormalities.

Results of bowel plication in addition to primary anastomosis in patients with jejunal atresia

BACKGROUND/PURPOSE

Disturbed intestinal transit (DIT) associated with bowel dilation occurs in some postoperative patients with jejunal atresia. Bowel plication (BP) has been introduced to prevent the DIT, but the long-term results of BP are unclear.

METHODS

The authors reviewed the preoperative and operative records and postoperative clinical courses (for 2.3 to 7.0 years; mean period, 3.7 years) of 19 jejunal atresia patients, 4 of whom had undergone additional BP with primary anastomosis after dilated bowel resection or tapering jejunoplasty at neonatal surgery. The degree of DIT was evaluated by the clinical symptoms, weight gain, whether reoperation was performed, and duration from the operation to receiving an oral feeding volume of at least 130 mL/kg/d. The patients then were assigned 4 grades (0 to 3). To determine the presence or absence of bowel dilation at the BP site, the plain abdominal x-rays were reviewed.

RESULTS

(1) Within 2 months after surgery, 4 patients without BP underwent operation because of severe DIT. The degree of postoperative DIT in patients who had received additional BP at neonatal surgery was less than that in patients without BP (mean grade, 0.50 v. 2.08). (2) The preoperative clinical features, operative method, and postoperative weight gain were almost similar in patients with and without BP. (3) On abdominal x-ray the bowel dilation remained 6 to 12 months after the operation, but was not observed over 1 year after the operation.

CONCLUSIONS

In this preliminary study, the addition of BP after tapering jejunoplasty or resection of dilated bowel may be effective in preventing early postoperative DIT. Further study is necessary to evaluate the long-term results of additional BP at neonatal surgery. J Pediatr Surg 36:1752-1756.

Plasmapheresis in fulminant acute disseminated encephalomyelitis

We report an 11-year-old girl with acute disseminated encephalomyelitis (ADEM) who developed respiratory failure and coma despite the use of corticosteroid and intravenous immunoglobulin. We performed plasmapheresis four times, which improved her level of consciousness, hyperesthesia, external ophthalmoplegia and muscle weakness, and led to the normalization of brain and spinal cord MRI. Plasmapheresis might be an effective treatment in cases of fulminant ADEM.