Growth in human milk-Fed very low birth weight infants receiving a new human milk fortifier

BACKGROUND/AIMS

Human milk fortification has been advocated to enhance premature infants' growth. We, therefore, undertook this study of a new human milk fortifier containing more protein than a reference one.

METHODS

Open, randomized, controlled, multiclinic trial, with weekly growth parameters and safety evaluations in premature infants <1,500 g.

RESULTS

The 2 groups did not differ in demographic and baseline characteristics. The adjusted daily milk intake was significantly higher in the infants fed reference human milk fortifier (n = 29; 154.2 +/- 2.1 vs. 144.4 +/- 2.5 ml/kg/day, mean +/- SE; p < 0.05). Both human milk fortifiers produced increases over baseline in weight, length, and head circumference, with greater gains observed in the new human milk fortifier-fed infants for the former two parameters (weight gain 26.8 +/- 1.3 and 20.4 +/- 1.2 g/day, p < 0.05; head circumference 1.0 +/- 0.1 and 0.8 +/- 0.1 cm/week; length 0.9 +/- 0.1 and 0.8 +/- 0.1 cm/week, respectively). Serum chemistries were normal and acceptable for age. Study events were typical for premature infants and similar in both groups.

CONCLUSIONS

This new human milk fortifier had comparable safety to the reference human milk fortifier and promoted faster weight gain and head circumference growth.

Randomized multicenter trial documenting the efficacy and safety of a lactose-free and a lactose-containing formula for term infants

OBJECTIVE

To evaluate the efficacy and safety of a new lactose-free infant formula.

DESIGN

Randomized, prospective, double-blind, controlled, outpatient, multicenter, parallel 12-week trial.

SETTING

Ambulatory-care facilities of the participating centers.

SUBJECTS

137 healthy term infants (approximately 7 days old at the time of study enrollment).

INTERVENTION

Healthy term infants, whose mothers had decided not to breast-feed, were randomly assigned 1 of the 2 study formulas.

MAIN OUTCOME MEASURES

Weight, length, and occipitofrontal circumference measurements were obtained at baseline and when the infant was 2, 4, 8, and 12 weeks old. Formula acceptance and tolerance were also assessed at weeks 2, 4, 8, and 12. Serum albumin concentration, creatirune level, and blood urea nitrogen were determined at baseline and week 12. Adverse events were assessed throughout the study.

STATISTICAL ANALYSES PERFORMED

Each baseline anthropometric and laboratory variable was analyzed for comparability between groups using the Student t test and was also analyzed using a repeated-measures analysis of variance method. Covariance analysis was applied to the final laboratory data using the respective baseline data as covariates. Decisions about equality of mean responses to formula effects were based on the .05 level of significance in all cases.

RESULTS

One hundred four infants completed the study. No significant differences between the 2 formula groups were noted for any of the growth and blood parameters.

APPLICATIONS

This new formula is an effective and safe lactose-free nutrition alternative for infants who require such a diet.

A metabolic balance study in term infants fed lactose-containing or lactose-free formula

Lactose-free (L-) formulas are recommended for infants with conditions affecting lactose digestion. Cows' milk protein-based formulas containing other carbohydrate sources are most often used for such infants. This study compared fat absorption and absorption and retention of nitrogen, calcium, phosphorus, and magnesium in term infants fed either a L- or standard lactose-containing (L+) bovine milk protein-based formula. Data from three single-centre, double-blind, randomized, parallel-group metabolic balance studies were combined. After a 4-7-d equilibration period on either L- or L+ formula, a 72-h balance study was performed. Twenty infants received L- and 21 received L+ formula. Besides the L- group having a higher percentage of males (65%) and the L+ group a higher percentage of females (52.4%), other baseline measurements were similar. The majority of nutrient balance data was similar between the two groups. Exceptions were relative nitrogen absorption, calcium intake and calcium retention, magnesium retention, and faecal phosphorus excretion, all of which were significantly higher in the L- group. Vitamin D supplementation did not significantly affect either calcium or phosphorus data. This new L- formula provided similar nutrients and is a suitable alternative to a L+ formula in term infants requiring L- feedings.

Assessment of feeding different amounts of arachidonic and docosahexaenoic acids in preterm infant formulas on the fatty acid content of lipoprotein lipids

This study evaluated preterm infants of less than 2.3 kg birth weight fed commercial formula (Preemie SMA) devoid of arachidonic acid (AA) and docosahexaenoic acid (DHA) and compared this control group with similar infant groups fed one of three formulas containing a range of 0.32-1.1% AA and 0.24-0.75% DHA in the fat component of the formula. An analogous group of infants fed on their mothers' breast milk and a breast milk fortifier was also studied. Individual lipoprotein fractions were isolated from blood samples collected at 12 d of age and after a further 4 wk of feeding. The fatty acid content of individual lipid components, isolated from each lipoprotein fraction was quantitatively determined in order to identify change in marker pools of essential fatty acid. The high density lipoproteins (HDL) and low density lipoproteins (LDL) phospholipid and cholesterol ester fractions contain most of the AA and DHA found in the lipoprotein fractions (total of 0.49% and 0.35%, respectively). Infants fed a formula without AA and DHA showed a reduction in AA level in the phospholipid fraction of all lipoproteins and in the HDL and LDL cholesterol ester fraction. A reduced level of DHA was also observed primarily in the lipoprotein phospholipid fraction in comparison with infants fed breast milk or infant formula containing AA and DHA. Supplementing infant formula with increasing levels of AA and DHA produced a clear dose response in the level of AA found in the HDL and LDL phospholipid fraction. From comparison of the fatty acid levels present in the lipoproteins it appears that a formula level of 0.49% AA and 0.35% DHA provides sufficient levels of these fatty acids to achieve a similar fatty acid content to that of infants fed breast milk for the major lipoprotein fractions examined.

Upper respiratory tract complications of gastroesophageal reflux in adult and pediatric-age patients

Upper airway complications of gastroesophageal reflux occur much less frequently than those abroad to the upper esophageal sphincter; however, laryngitis, laryngeal and/or tracheal stenosis, globus syndrome, oropharyngeal dysphagia, otitis media, sinusitis, and rhinitis can all be associated with significant morbidity and occasional mortality in both adult and pediatric patients. Sudden infant death and apparent life-threatening events, both found only in pediatric patients, are even less frequently associated with gastroesophageal reflux. Today, excellent diagnostic methods are available, such as proximal 24-hour pH probe evaluations or scintigraphy, making proper diagnosis much easier than previously. Although today's medical and surgical methods do not affect the underlying pathophysiology, they are frequently very effective in controlling signs and symptoms, allowing the patients to return to resume their normal life-styles and livelihoods.

Assessment of the efficacious dose of arachidonic and docosahexaenoic acids in preterm infant formulas: fatty acid composition of erythrocyte membrane lipids

The nutritional requirements of preterm infants for the long chain polyunsaturated essential fatty acids, arachidonic acid (AA) and docosahexaenoic acid (DHA), have not been clearly defined. The present study evaluated preterm infants of less than 2.3 kg birth weight fed a commercial formula (Preemie SMA) devoid of AA and DHA and compared this control group with similar infant groups fed one of three formulas containing a range of 0.32 to 1.1% AA and 0.24 to 0.76% DHA. An analogous group of infants fed their mothers' breast milk and a breast milk fortifier (when indicated) was also studied. Erythrocyte membrane phospholipids were isolated from blood samples collected at 12 d of age and after a further 4 wk of feeding. Infants fed the formula without AA and DHA showed a reduction in AA level in erythrocyte phosphatidylcholine, and a reduced level of DHA in phosphatidylethanolamine in comparison with infants fed breast milk or infant formula containing AA and DHA. Supplementing infant formula with increasing levels of AA and DHA produced a clear dose response in the levels of AA and DHA found in erythrocyte membrane phospholipids. From comparison of membrane phospholipid fatty acid composition it appears that a formula level of 0.32-1.1% AA and 0.24-0.76% DHA provides sufficient levels of these fatty acids to achieve a similar fatty acid composition to that of infants fed human milk for most of the lipid fractions examined.

Parenteral control of gastric acid hypersecretion in patients with Zollinger-Ellison syndrome

Parenteral control of gastric acid hypersecretion in patients with Zollinger-Ellison syndrome is increasingly required; however, existing methods of determining the required dose are cumbersome and not applicable in all centers. A previous study suggested that the required parenteral dose of histamine H2-receptor antagonists correlated with the previous oral dose. In the present study, in 31 patients with Zollinger-Ellison syndrome we evaluated the hypothesis that an effective parenteral histamine H2-receptor antagonist dose could be predicted from the previous oral dose. Twenty-three patients were taking oral ranitidine (mean 1.3 g/day), six patients famotidine (152 mg/day), and two patients cimetidine (1.8 g/day). Each patient was treated with a continuous intravenous infusion of the equivalent dose of ranitidine (mean dose 1 mg/kg/hr with 35% requiring 0.5 mg/kg/hr, 49% 1 mg/kg/hr, 3% 1.5 mg/kg/hr, 10% 2 mg/kg/hr, and 3% 2.5 mg/kg/hr. This dose of ranitidine acutely controlled acid secretion (< 10 meq/hr) in all patients. To evaluate long-term efficacy and safety, 20 patients were maintained on this dose through the peri- and postoperative periods. Mean duration was 7.1 days with 25% treated 3-5 days, 40% 6-8 days, 30% 8-10 days, and 5% > 10 days. The predicted dose continued to control acid secretion in 95% of patients with one patient requiring one dose adjustment. No biochemical, clinical, or hematological toxicity was seen, although ranitidine was stopped in one patient because of skin rash. These results demonstrate that the parenteral dose of ranitidine required to control acid secretion in patients with Zollinger-Ellison syndrome can be predicted from the oral dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastric acid suppression is greater during intravenous ranitidine infusion versus bolus injections of famotidine

It has been proposed that famotidine may be effective in maintaining intragastric pH > or = 4 for up to 12 h with a single i.v. 20 mg bolus injection and thereby prevent acute stress-related mucosal haemorrhage. The present study was designed to compare a ranitidine continuous i.v. infusion (6.25 mg/h) vs. famotidine bolus injection (20 mg every 12 h) on 24-h intragastric pH and gastric acid secretion. Twenty-eight healthy volunteers (15 males, 13 females; 20-56 years) participated in two 24-h treatment periods; each test was in random order separated by 7-10 days. After an overnight fast, subjects were intubated and gastric pH and acid secretion measured hourly. Whereas ranitidine maintained gastric pH above 4 for the entire 24-h period, mean pH steadily decreased to a nadir of 2.9 and 3.7, respectively, 12 h after each famotidine injection (P < 0.01 vs. ranitidine). Furthermore, gastric acid secretion increased to 4.4 +/- 1.2 mmol/h 12 h after famotidine injection compared to 1.1 +/- 0.3 mmol/h with ranitidine (P < 0.01). We conclude that ranitidine delivered as a continuous i.v. infusion (6.25 mg/h) is superior to bolus famotidine injections (20 mg) at 12-h intervals in suppressing gastric acid secretion and maintaining an intragastric pH > or = 4. More frequent famotidine dosing, or delivery by continuous i.v. infusion, may be required to provide prolonged acid suppression.

Ranitidine 300 mg at bedtime is effective for gastric ulcers: a 12-wk, multicenter, randomized, double-blind, placebo-controlled comparison. The Ranitidine 300 mg HS Gastric Ulcer Study Group

Ranitidine 150 mg twice daily is effective for the treatment of gastric ulcers. We proposed that ranitidine 300 mg once daily would also be effective. In a randomized, double-blind, placebo-controlled, multicenter, parallel-group study, adults with an endoscopically verified acute gastric ulcer > or = 5 mm were treated with either ranitidine 300 mg (n = 183) or placebo (n = 178) at bedtime for up to 12 wk. Gastric ulcer healing, determined by endoscopy, was achieved in 65% and 89% of ranitidine-treated patients by 6 and 12 wk, compared with 45% and 72% of placebo-treated patients by 6 wk and 12 wk (p < 0.001). Throughout the 12-wk study, ranitidine 300 mg was significantly more effective than placebo in relieving pain (p < 0.05), with ranitidine-treated patients also using fewer antacid tablets. Ranitidine 300 mg had a safety profile similar to that of placebo. We conclude that ranitidine 300 mg at bedtime is safe and effective for healing acute gastric ulcers.

Ranitidine is effective therapy for erosive esophagitis

Two ranitidine dosages were compared for the treatment of erosive esophagitis in a multicenter, double-blind, randomized, parallel-group, placebo-controlled study. Adults with endoscopically verified erosive esophagitis were treated with either ranitidine 150 mg four times daily (n = 106), ranitidine 300 mg four times daily (n = 106), or placebo (n = 116) for up to 12 wk. Patients were also encouraged to adhere to lifestyle modifications (e.g., to elevate the head of bed, etc). Erosive esophagitis healing, determined by endoscopy, was achieved in 69% and 62% of ranitidine-treated patients by 8 wk and in 79% and 74% by 12 wk (150 mg and 300 mg, respectively) compared with 28% of placebo-treated patients by 8 wk and 40% by 12 wk (p < 0.001 ranitidine vs. placebo). Onset of heartburn relief occurred within 24 h of initiating either ranitidine dosage, and relief was maintained throughout the 12-wk study. Both ranitidine dosages displayed safety profiles similar to that of placebo. We conclude that ranitidine 150 mg or 300 mg administered four times daily is effective for healing erosive esophagitis and relieving its symptoms.

A 4-week, multicenter, duodenal ulcer healing trial comparing four escalating doses of ranitidine

In a randomized double-blind 4-wk trial, ranitidine doses of 300 mg at bedtime (hs), twice daily (bid), three times daily (tid), and four times daily (qid) were compared in 629 patients with endoscopically confirmed duodenal ulcer(s). Endoscopies were performed at baseline and after 4 wk of therapy. Per protocol analysis revealed wk 4 healing rates that were significantly increased (p < or = 0.001) for the bid, tid, and qid groups, compared with the hs group. All treatments provided early symptomatic (ulcer pain) relief. No significant differences in adverse events or laboratory abnormalities were observed between groups. Ranitidine 300 mg bid provides an alternative therapeutic approach for patient populations at risk for ulcer complications. These patients include those with the following: a past history of an upper gastrointestinal hemorrhage, perforation, obstruction, penetration, or giant (> 2.0 cm) duodenal ulcer. The elderly and those with chronic unresponsive ulcerations may also be included in this population.

The safety of ranitidine in elderly versus non-elderly patients

The authors conducted a retrospective review of 21 United States trials of ranitidine in acid peptic diseases and compared the adverse events in elderly (> or = 65 years) and nonelderly (< 65 years) patients. Ranitidine dosages ranged from 150 mg/day to 300 mg twice daily for treatment periods of 4 to 52 weeks. Of the 4041 patients included in this review, 402 elderly and 2188 nonelderly patients received ranitidine and 245 elderly and 1206 nonelderly patients received placebo; 29%, 29%, 32%, and 26% of these patients, respectively, reported some type of adverse event. When only drug-related adverse events (as judged by the investigators under blinded conditions) were evaluated, these percentages dropped to 2%, 2%, and 1% and 2%, respectively. Gastrointestinal adverse events (e.g., nausea and diarrhea) and central nervous system adverse events (e.g., headache and dizziness) were the most common (0.7% and 0.8%, respectively), with comparable incidence rates in the elderly and nonelderly patients. The authors conclude that ranitidine is as safe in elderly patients as it is in nonelderly patients. No difference in the incidence of adverse events was found between older and younger patients who received ranitidine or placebo.

Ranitidine prevents duodenal ulcers associated with non-steroidal anti-inflammatory drug therapy

The results of four similarly designed, randomized, double-blind, placebo-controlled studies conducted to evaluate ranitidine as prophylaxis for NSAID-associated damage are reviewed. A total of 673 patients receiving therapeutic dosages of NSAIDs for arthritic or musculoskeletal conditions also received either ranitidine 150 mg twice daily (n = 343) or placebo (n = 330) for four weeks (two studies) or eight weeks (two studies). Endoscopic grading of mucosal lesions was based on a modified Lanza scoring system. All patients had normal baseline endoscopies. After four weeks of treatment a significant protective effect against duodenal mucosal lesions including duodenal ulcers (three studies) and gastric mucosal lesions including gastric ulcers (one study) was observed in patients who received ranitidine compared with those who received placebo. A meta-analysis of the four studies confirmed that significantly fewer patients receiving ranitidine than placebo developed duodenal ulcers (1% vs. 6%, P = 0.01). Endoscopic data at eight weeks from the two longer-term studies showed that duodenal ulcers occurred in ranitidine- and placebo-treated patients at a rate of 1% (2/137) vs. 8% (10/126) (P = 0.02), respectively, in one trial, and 0% (0/57) vs. 8% (4/49) (P = 0.02), respectively, in the other trial. No protective effect in the stomach was evident at eight weeks. We conclude that ranitidine is effective in preventing NSAID-associated duodenal ulcers and may be appropriate prophylaxis for certain high-risk patients.

Evaluation of two monkey species (Macaca mulatta and Macaca fascicularis) as possible models for human Helicobacter pylori disease

Endoscopic, histologic, and microbiologic evaluations of 21 cynomolgus and 34 rhesus monkeys for naturally occurring Helicobacter pylori infection were done. H. pylori was never isolated from any cynomolgus monkey, but was found in 12 rhesus monkeys. A general correlation existed between a positive culture and a gastric inflammatory response. Inoculation challenges were then undertaken. Four cynomolgus and five rhesus monkeys received two different H. pylori strains isolated from humans. Five rhesus monkeys received an isolate obtained from rhesus monkeys. Evaluation of the cynomolgus monkeys 7 and 14 days later revealed no H. pylori. Endoscopies of the rhesus monkeys were done 7, 14, 21, 28, and 56 days later. One rhesus monkey, which received the isolate from humans, became H. pylori positive at day 21 and remained positive through day 56. Restriction enzyme analysis of genomic DNA at day 56 revealed that the isolate was not identical to the challenge strain isolated from humans. All five rhesus monkeys that received the strain isolated from rhesus monkeys became H. pylori positive by day 14 and remained positive through day 56 Antral inflammation developed in all monkeys. Restriction enzyme analysis of genomic DNA on day 56 confirmed that four of five isolates were identical to the challenge strain isolated from rhesus monkeys. DNA hybridization documented homology between the challenge strains isolated from humans and rhesus monkeys plus those isolated at day 56. In this study, we showed that the rhesus monkey, if given a strain of H. pylori isolated from rhesus monkeys, develops a gastric infection with accompanying histological changes, making this model suitable for further development.

A report of three multiclinic trials evaluating arbaprostil in arthritic patients with ASA/NSAID gastric mucosal damage. The Upjohn Company Arbaprostil ASA/NSAID Gastric Mucosal Damage Treatment Study Groups

Three randomized, placebo-controlled multiclinic trials involving arbaprostil dosages of (a) 10 micrograms; (b) 25 micrograms; and (c) 10, 25, or 50 micrograms orally for 4 wk in patients older than 18 yr with rheumatoid arthritis or osteoarthritis who had endoscopically documented nonsteroidal antiinflammatory drug-associated gastric mucosal damage were conducted in the United States. All patients continued taking the nonsteroidal antiinflammatory drugs and were reendoscoped after 4 wk of therapy. Success at that time was defined as complete resolution of all gastric mucosal damage. Six hundred fifty-eight patients were enrolled in the three trials. Significantly more patients experienced healing in the arbaprostil treatment groups in all trials compared with those who received placebo. The healing rates in the various trials were 68% and 32% (10 micrograms vs. placebo; p = 0.007); 77% and 23% (25 micrograms vs. placebo; p less than 0.001); and 52%, 46%, 35%, and 16% (50, 25, and 10 micrograms vs. placebo; p less than 0.001, less than 0.001, and 0.002, respectively). Diarrhea, mostly of a mild nature, was the only arbaprostil-associated side effect and was found with the 25- and 50-microgram dosages (33% and 59%, respectively). No exacerbation of arthritis signs or symptoms was found. Arbaprostil at doses with varying effects on gastric acid secretion (25 and 50 micrograms) was documented in these trials to be an effective and safe agent for healing gastric mucosal damage associated with aspirin or other nonsteroidal antiinflammatory drugs in patients with either rheumatoid arthritis or osteoarthritis without adversely affecting joint symptomatology.

Gastric emptying and the pharmacokinetics of the cephalosporin antibiotic, cefpodoxime proxetil

The effects of gastric motility on the pharmacokinetics of cefpodoxime proxetil, an oral, broad spectrum, third-generation cephalosporin antibiotic were evaluated in 12 healthy subjects. In this open-label, crossover trial, each subject took a 200 mg dose (two 100 mg film-coated tablets) in each study period. There was an initial fasting period followed by a control period and then either a propantheline or metoclopramide period. Gastric motility was measured using [99mTc]-labeled sulfur colloid in oatmeal in the control, propantheline and metoclopramide periods. Treatment with propantheline or metoclopramide was given 30 min before dosing with the antibiotic and the radioisotope. Serial images with a gamma counter were made every 15 min for 2 h. Gastric emptying time was faster than control with metoclopramide, but generally slower with propantheline than control. The mean peak plasma concentration, mean area under plasma concentration time curve and mean half-life of cefpodoxime proxetil were similar in all groups as compared to control. The mean time to peak plasma concentration was delayed in the propantheline period and peak plasma concentrations were greater at all sampling times at six hours after dosing. This study utilized the gastric nuclear scan with modification of gastric motility by metoclopramide and propantheline and with simultaneous determination of the disposition of cefpodoxime proxetil to understand the absorption of the drug.

An evaluation of arbaprostil at multiple doses for the treatment of acute duodenal ulcer: a randomized double-blind placebo-controlled international trial

Six hundred and thirty patients were enrolled in a randomized double-blind placebo-controlled trial evaluating two arbaprostil dosages (25 micrograms and 50 micrograms) qid for 4 wk for the treatment of acute duodenal ulcers. The healing rates in the placebo, 25-micrograms, and 50-micrograms treatment groups were 39%, 51%, and 60%, respectively. Smoking was found to adversely affect the healing rates in all the treatment groups. Pain severity was less with either arbaprostil treatment. The only side effect found was diarrhea: 10%, 14%, and 32% in the placebo, 25-micrograms, and 50-micrograms treatment groups, respectively. Severe diarrhea occurred in 1% of those patients who received the 50-micrograms dosage regimen, but in none of the other two groups. Arbaprostil at these two dosage levels, when given for 4 wk, appears to be a safe and efficacious agent for the treatment of acute duodenal ulcers.

The effects of gastric pH and food on the pharmacokinetics of a new oral cephalosporin, cefpodoxime proxetil

The effects of alteration of gastric pH and food on the pharmacokinetics of 200 mg doses of cefpodoxime proxetil tablets were studied in two separate randomized, open label, crossover studies in healthy subjects. In the pH study (n = 17 subjects), there was a lead-in period done under fasting conditions, followed by randomization to a four-way crossover of pentagastrin (6 micrograms/kg, subcutaneously), ranitidine (150 mg orally, 10 and 2 hours before dosing with the antibiotic), sodium bicarbonate (12.6 gm), or aluminum hydroxide (120 cc). Gastric pH was determined by nasogastric aspirates before and 10 minutes after the intervention, just before the antibiotic was given. Peak plasma concentrations (Cmax) and area under plasma concentration-time curve (AUC) were highest in fasting and pentagastrin periods and were 35% to 50% lower for all of the other periods (p less than 0.0001). Gastric pH and Cmax and AUC were inversely related (r = 0.66 and r = 0.62; p less than 0.0001 for both). In the food study (n = 16 subjects), there were two lead-in periods, one done while subjects were fasting and one while they were normal diet, followed by randomization to a four-way crossover of either high or low protein diets, or high or low fat diets. There were six meals in each diet. Dosing with the antibiotic was done at the midpoint of the fourth meal. Cmax and AUC were 22% to 34% higher for all diets than for the fasting period (p less than 0.0001), whereas the time to Cmax was unchanged. These studies demonstrated that absorption of cefpodoxime proxetil is best at low gastric pH or in the presence of food, which suggests that the role of gastrointestinal function on the pharmacokinetic profile is complex.

Arbaprostil's [15(R)-15-methyl PGE2] effects on intrauterine pressure in the nonpregnant and pregnant human female--a report of four clinical trials

Four clinical trials evaluating arbaprostil's effects on the human uterus are reported. The initial two trials measured intrauterine pressures in nonpregnant and pregnant human females following arbaprostil doses of 10, 25, and/or 50 mcg. No statistical differences were found at any dosage level in either study for average uterine resting pressures, average peak pressures, the number of contractions or Montevideo units. Subsequently, two trials determined the abortifacient potential of arbaprostil in pregnant women during the first trimester. The first utilized total daily doses of 400 and 800 mcgs. while the second used total daily doses of 1200 and 1600 mcgs. Vaginal spotting was noted in one woman receiving 400 mcgs, three receiving 1200 mcgs. and in two receiving 1600 mcgs. One episode of moderate bleeding was seen in the latter study. Based on these studies, arbaprostil exhibits little potential for inducing abortifacient activity at these dosages in these patient populations.

Pharmacokinetic interactions between arbaprostil and aspirin in humans

Arbaprostil is an orally active prostaglandin E2 analogue. It has been developed as a drug to treat ulcers induced by non-steroidal anti-inflammatory drugs. In this study, pharmacokinetic interactions between arbaprostil and aspirin were examined in humans after chronic doses of both drugs. Subjects received either arbaprostil (50 micrograms), aspirin (975 mg) or arbaprostil (50 micrograms) and aspirin (975 mg) four times a day for 6 days and one dose on 7th day. Blood and urine samples were collected after the last dose for 6 h. Pharmacokinetic parameters of arbaprostil, aspirin, and salicylate were determined. Coadministration of arbaprostil significantly lowered the area under curve (5.09 +/- 0.32 micrograms hml-1 vs 5.78 +/- 0.29 micrograms hml-1, mean +/- SE, p less than 0.05) and time (0.45 +/- 0.07 h vs 0.70 +/- 0.12 h, p less than 0.05) to reach maximal plasma concentration of aspirin (acetylsalicylate). The pharmacokinetics of salicylate were not changed by arbaprostil, nor were the pharmacokinetics of arbaprostil affected by aspirin. Coadministration of these two drugs did not appear to potentiate the side-effects of either drug. The results suggest that arbaprostil and aspirin may be administered together without clinically significant changes in pharmacokinetics or adverse side-effects.

Arbaprostil [15(R)-15-methyl prostaglandin E2] in a single nighttime dose of either 50 or 100 micrograms in acute duodenal ulcer

To determine the efficacy of single nighttime doses of arbaprostil [15(R)-15-methyl prostaglandin E2], 50 or 100 micrograms for 4 wk, a double-blind randomized placebo-controlled multiclinic trial was undertaken. Success was defined as complete healing of the ulcer documented by endoscopy. Fifty-one of 64 patients enrolled were considered evaluable. Ulcer healing was documented in 64.3%, 85.7%, and 31.2% of the 100-micrograms arbaprostil, 50-micrograms arbaprostil, and placebo treatment groups (p value vs. placebo = 0.003 and 0.002, respectively). No difference in side effects or changes in laboratory parameters were found between the treatment groups except that diarrhea, usually mild, was found more often in the 100-micrograms arbaprostil group (60.0%) than in the 50-micrograms arbaprostil (31.8%) or placebo groups (23.5%) (p value 100 micrograms arbaprostil vs. placebo = 0.02). A single nighttime administration of arbaprostil seems to be a safe and efficacious agent for the treatment of acute duodenal ulcer.

A multiclinic trial evaluating arbaprostil [15(R)-15-methyl prostaglandin E2] as a therapeutic agent for gastric ulcer

A randomized, double-blind, placebo-controlled, multiclinic trial evaluated arbaprostil [15(R)-15 methyl prostaglandin E2] for the treatment of acute gastric ulcer, achieving an overall enrollment of 124 patients (of which 113 were considered evaluable). This 6-wk trial used an arbaprostil dose of 10 micrograms q.i.d., which has little gastric acid antisecretory activity. Endoscopies were performed after 21 and 42 days of treatment, at which times the arbaprostil and placebo healing rates, respectively, were 6/59 (10.2%) and 4/53 (7.6%) on day 21 and 25/59 (42.4%) and 16/50 (32.0%) on day 42. No significant differences between the treatment groups were found for pain relief, antacid consumption, and mucosal healing. This trial documents that a 10-micrograms dose of arbaprostil (which may be considered cytoprotective because of its small effect on gastric acid secretion), although safe and associated with no side effects, is not efficacious in healing acute gastric ulcers.

Morphological and functional effects of 16,16-dimethyl-prostaglandin-E2 on mucosal adaptation after massive distal small bowel resection in the rat

The ability of 16,16-dimethyl-prostaglandin-E2 (PGE) to augment mucosal adaptation 14 days after a 70% distal small bowel resection in the rat was evaluated. In resected (R) and sham operated (S) animals, subcutaneous PGE 75 mg/kg, 2 X/day, induced significant (p less than 0.05) increases in mucosal protein, DNA, and disaccharidase concentrations per centimetre of bowel. The respective per cent increases in the residual proximal small intestine compared with their respective untreated controls were: protein, R = 60%, S = 66%; DNA, R = 69%, S = 29%; maltase, R = 57%, S = 5%. The uptake of leucine by intestinal rings was significantly higher (50%) in the PGE treated group at a concentration of 2 mmol/l of substrate, while the uptake of glucose was similar in all groups. The drug appears to be an effective agent in stimulating morphological and functional adaptation after massive distal small bowel resection.

The effect of itazigrel and aspirin on the mucosa of the esophagus, stomach, and duodenum of normal subjects

The effects of aspirin, itazigrel (U-53,059; a new antiplatelet drug), and placebo on the mucosa of the esophagus, stomach, and duodenum were evaluated in this double-blind, randomized, placebo-controlled study. Six normal male subjects were included in each of five treatment groups: aspirin (325 mg each morning for five doses), aspirin (325 mg tid for 12 doses), itazigrel (25 mg each morning for five doses), itazigrel (50 mg tid for 12 doses), and placebo. Aspirin and itazigrel, at all doses investigated, significantly inhibited ex vivo, ionophore (A23187)-stimulated thromboxane B2 synthesis. Collagen-induced platelet aggregation was significantly inhibited on day 3 (P = .021) and day 5 (P = .002) in both aspirin and itazigrel groups as compared with placebo. Upper gastrointestinal endoscopy was performed before the first dose of drug (day 1) and two hours after the last dose (day 5) for each subject. A rating scale was used to score the amount of mucosal damage. The baseline (day 1) endoscopic scores revealed no significant differences between groups. On day 5, neither placebo nor itazigrel treatment groups showed any significant change compared with baseline. On day 5, both aspirin groups had significantly (P less than .001) more mucosal damage than the placebo group and either itazigrel group. It is concluded that in this relatively acute study, at doses that produce comparable inhibition of platelet aggregation and platelet cyclo-oxygenase, itazigrel was superior to aspirin in terms of toxicity to the upper gastrointestinal tract.

Failure of a cytoprotective dose of arbaprostil to heal acute duodenal ulcers. Results of a multiclinic trial

Previous therapeutic trials with prostaglandins have shown them to be effective in healing duodenal ulcers when used at doses that are highly effective suppressors of gastric acid secretion. We undertook this trial to determine if a cytoprotective dose of arbaprostil (10 micrograms q.i.d. for 4 wk) would also be efficacious in this disease state. Eighty-two patients between the ages of 19 and 72 yr with endoscopically documented duodenal ulcers were entered into this randomized double-blind placebo-controlled trial. The patients were monitored with biweekly endoscopies and laboratory examinations, weekly interviews during the period when drug was administered, and a follow-up interview plus laboratory examinations 1 wk after drug administration was completed. No statistically significant differences between the arbaprostil and placebo treatment groups were found for ulcer healing rates, pain relief, antacid consumption, side effects, or laboratory examinations. It is presumed that this prostaglandin may not have sufficient duodenal cytoprotective capacity to effectively heal duodenal ulcers, or that some suppression of gastric acid secretion may be required to achieve significant clinical efficacy.

Augmentation of mucosal adaptation following massive small-bowel resection by 16,16-dimethyl-prostaglandin E2 in the rat

Survival following massive resection of the small intestine is often possible due to substantial hyperplasia of the mucosal surface in the remaining small intestine. While nutrients provide the major stimulus for hyperplasia in the clinical setting, the availability of drugs to augment this process would have obvious therapeutic implications. We evaluated the ability of 16,16-dimethyl-prostaglandin E2 (PGE2 to augment mucosal hyperplasia following massive small bowel resection in the rat. Three groups of 7 Sprague-Dawley rats, 160 g body weight, were subjected to 70% jejunoileal resection. One group was given 150 micrograms/kg of 16,16-dimethyl-PGE2 intragastrically twice daily, a second group 75 micrograms/kg subcutaneously, and a third group was untreated. After 17 days, segmental evaluation of mucosal mass in the remaining small intestine was determined by measuring mucosal protein, DNA, and disaccharidase levels. A significantly greater increase in mucosal mass was developed in the duodenum proximal to the anastomosis in both treatment groups, but neither the proximal nor distal ileum demonstrated significantly more adaptation. Histological examination in the duodenum confirmed the presence of a greater adaptive response in both the intragastrically and subcutaneously treated animals. 16,16-dimethyl-PGE2 appears to augment mucosal adaptation following massive small bowel resection in the rat, primarily in the very proximal small intestine.

Lack of effect of arbaprostil on the human non-pregnant uterus

Arbaprostil ((15R)-15-methyl Prostaglandin E2) is being studied for the treatment of gastrointestinal illness. To determine its effect on the human uterus, eight sterilized pre-menopausal women were studied during the proliferative phase of their menstrual cycle. Using a microtransducer catheter, intra-uterine pressures were recorded for at least 30 minutes prior to and 2 hours after arbaprostil administration. Each subject was studied four times, at 48-hour intervals, receiving in a double-blind manner; 0, 10, 25, and 50 micrograms. Arbaprostil at does up to 50 micrograms was found not to have any clinically significant effects on the non-pregnant human uterus.

Transient hypergastrinemia of 2 years' duration in a young pediatric patient

A 24-month-old female child experienced watery diarrhea, growth failure, and abdominal pain from age 3 months. Hypergastrinemia, hypochlorhydria, and fundic gastritis were documented. A secretin stimulation test was normal but protein meal stimulation revealed an abnormal serum gastrin response. Antral biopsies revealed G cell hyperplasia. Chronic treatment with antacids and an anticholinergic agent was unsuccessful. Spontaneous recovery occurred at age 29 months. Gastrin stimulation tests, gastric acid secretory tests, antral mucosal biopsies, and multiple basal serum gastrin levels were repeated. All were normal. Follow-up of greater than 3 years has documented a completely normal clinical and laboratory course.

Gastric emptying times of water in infants and children: comparison of those with and without gastroesophageal reflux

Thirty children without and 15 with gastroesophageal reflux had 1-h gastric emptying rates of water determined by a double dilutional method. The rates were similar in each group at all time intervals. No correlation between age, weight, or surface area and emptying rates was found.

Gastric emptying in children: unusual patterns detected by scintigraphy

The time-activity curve of gastric emptying of milk was evaluated in 49 infants and children who were also being evaluated for gastrointestinal reflux. After oral ingestion of technetium-99m sulfur colloid in a milk formula, the normal 1 hr time-activity curve and normal values for percentage of gastric emptying in 1 hr were determined. Normal gastric emptying in infants was 48% (+/- 16%) and in children 51% (+/- 7%). Unusual emptying patterns were observed when an overlying duodenum was present, making accurate estimation of gastric emptying difficult. Three children with gastric outlet obstruction showed similar delayed plateau emptying patterns.

Gastroesophageal reflux--the acid test: scintigraphy or the pH probe?

The best established technique for diagnosing gastroesophageal reflux in children is the 24 hr esophageal pH probe test. No simultaneous comparison of this technique with radionuclide scans has been reported. Therefore, simultaneous 1 hr pH monitoring and gastroesophageal scintigraphy were performed in 49 infants and children with suspected gastroesophageal reflux. Forty-seven of these patients also were later monitored by the 24 hr pH probe test. Upper gastrointestinal series were performed on all patients. All patients with a positive 1 hr pH monitoring also had positive simultaneous scintigraphy. All patients with positive scintigraphy and pH probe monitoring also had a positive upper gastrointestinal series for reflux. The sensitivity of gastroesophageal scintigraphy, when compared to the 24 hr probe as a standard, was 79%; its specificity was 93%. The sensitivity of the upper gastrointestinal series was 86%, when compared to the 24 hr pH probe test. However, it specificity was only 21%.

Achalasia: diagnosis, management, and clinical course in 16 children

Clinical features, radiographic and esophageal manometry findings, and treatment results in 16 patients less than 15 years old with achalasia are described. Esophageal manometry performed in 15 patients showed results similar to those found in adults: (1) increased resting lower esophageal sphincter pressure, (2) incomplete or failure of relaxation of the lower esophageal sphincter on swallowing, and (3) ineffective or absence of peristalsis in all. The most common symptoms in the 16 patients were: dysphagia in 15, postprandial vomiting in 13, and retrosternal pain in five. The average duration from onset of symptoms to diagnosis was 28 months. The esophagram was diagnostic in all patients. Pneumatic dilation was the initial treatment in eight and was successful for more than 1 year in five. Two patients required two dilations and were then symptom-free for more than 1 year, but required a Heller myotomy. The remaining patients underwent Heller myotomy following failure of the second dilation. Three patients underwent myotomy and two patients had myotomy with fundoplication as initial treatment; only one remained symptomatic. Esophageal dilation using a pneumatic dilator should be the initial treatment of choice in school-aged children. However, if more than two dilations are required within 1 year, surgical management is recommended.

A diagnostic approach to vomiting in severely retarded patients

Vomiting is a considerable problem among severely retarded individuals. The majority have gastroesophageal reflux (GER). The incidence is increased in those who are nonambulatory or have scoliosis and/or spastic quadriplegia. In the absence of other symptoms, these persons should be kept in the upright position as much as possible. Persistent vomiting warrants a roentgenographic examination of the upper gastrointestinal tract. If GER is the only finding, upright positioning should be continued. The occurrence of complications attributable to GER is an indication for further diagnostic evaluation.

Effect of enteral feeding on the maintenance of gastric acid secretory function

The effects of enteral feeding on the maintenance of gastrointestinal function in human infants are unknown. The effects of enteral feeding on gastric acid secretory function were studied by investigating three groups of infants: infants fed normally, infants with gastrointestinal disease fed by a combination of enteral and parenteral means, and infants fed by total parenteral nutrition. In 14 infants with gastrointestinal disease fed with total parenteral nutrition for a mean of 7 mo (range 1.5-24 mo), basal gastric acid secretion and pentagastrin-stimulated maximal gastric acid secretion were significantly less than in 26 normal infants (p less than 0.01) and in 11 infants with gastrointestinal disease nourished with a combination of enteral and parenteral feeding (p less than 0.01). In each of seven infants fed with total parenteral nutrition for a mean of 5 mo (range 1.5-10 mo), basal and maximal gastric acid secretion increased after a 6-8-wk trial of enteral feeding, a highly significant difference. In one infant, the ability to secrete normal amounts of acid in response to pentagastrin (achieved after an initial trial of enteral feeding) was lost after a 4-mo enteral fast, but returned after a second trial of enteral feeding. These results demonstrate that, in human infants, enteral feedings are necessary for normal oxyntic mucosal secretory function.

Bacteremia in children following upper gastrointestinal endoscopy or colonoscopy

Fifty children undergoing upper gastrointestinal endoscopy and 25 undergoing colonoscopy were studied prospectively with aerobic and anaerobic blood cultures for the development of bacteremia. Twenty-six of the endoscopies and all the colonoscopies were done under general anesthesia. Cultures were obtained before, at 5 min, and at 30 min after the procedure. Only a single positive blood culture was obtained in an upper endoscopy patient. All cultures from the colonoscopy patients were negative. Biopsy or polypectomy were not important variables in the development of bacteremia. It is concluded that the risk of bacteremia in children following upper endoscopy or colonoscopy is minimal and should not be considered a contraindication to their performance.

Gastrointestinal symptoms in Rocky Mountain Spotted Fever. Histopathologic finding of ulcerative enteritis with vascular

Gastrointestinal symptoms are often in patients with Rocky Mountain Spotted Fever (RMSF), particularly early in the course of the illness. However, changes in the gastrointestinal tract have not been reported in a child who has survived. We document vasculitis in the terminal ileum of a child with RMSF who also had radiographic findings consistent with involvement of the entire small bowel. An appreciation for the gastrointestinal manifestations should facilitate a rational approach to their management and prevent a delay in diagnosis.

Body position and esophageal sphincter pressure in infants

Lower esophageal sphincter pressure was measured in infants in the supine, prone, right lateral, left lateral, and upright positions; 14 had gastroesophageal reflux and 16 did not. Position had no significant effect on pressure in either group. However, patients with reflux had significantly lower pressures in each position. The rationale for postural therapy in infants with reflux cannot be based on alterations in sphincter pressure but is more likely related to the effect of gravity on the gastric pool. Compared with roentgenograms of the upper gastrointestinal tract or esophageal manometry the one- and 24-hour pH probe tests best identified reflux in those patients who were first seen with symptoms compatible with this diagnosis.

Lymphoid polyps (focal lymphoid hyperplasia) of the colon in children

Lymphoid polyps (focal lymphoid hyperplasia) of the colon are rare in children. These lesions are benign, but must be differentiated from malignant lymphomas. Grasp biopsies of the lesion are inadequate for this purpose and the polyp should be submitted in toto for pathologic examination. No treatment other than local excision is warranted. Two cases are presented and the literature is reviewed.

Gastroesophageal reflux in the severely retarded who vomit: criteria for and results of surgical intervention in twenty-two patients

Forty-two severely retarded patients, ranging in age from 2 to 26 years, were referred for diagnostic evaluation because of chronic vomiting. The diagnosis of gastroesophageal reflux (GER) was made in 28 of the basis of reflux (grade III) on upper gastrointestinal series and the presence of esophagitis either grossly at endoscopy or on esophageal biopsy. Nissen fundoplication was performed in 22 because of the frequent occurrence of complications such as pneumonia, gastrointestinal blood loss, and malnutrition attributable to GER. The incidence of postoperative complications was 59%. However, during a mean follow-up period of 14.1 months, no further vomiting or gastrointestinal blood loss was encountered, and only one patient had a single episode of pneumonia. Weight gain in those who were malnourished was impressive. In addition, the already difficult care of the patients was greatly facilitated. Severely retarded patients with GER who suffer recurrent complications should be considered for Nissen fundoplication.

Pharyngoesophageal pulsion diverticulum (Zenker) in a ten-year-old boy

Posterior pharyngoesophageal pulsion diverticula are rare during the pediatric years. We present the third case (a 10-yr-old). Proper diagnosis was made during fiberoptic esophagoscopy.

The role of sigmoidoscopy, radiographs, and colonoscopy in the diagnostic evaluation of pediatric age patients with suspected juvenile polyps

Juvenile polyps are the most common cause of painless hematochezia in pediatric Age patients after the first year of life. This study evaluated the role of rigid proctosigmoidoscopy, air contrast barium enema examinations, and colonoscopy in the diagnostic approach to 43 such patients. During sigmoidoscopy, polyps were removed from 31 children. On subsequent barium enema examination, more proximal lesions were found in only 4 of these 31 patients, but were seen in 7 of the 12 children who had negative sigmoidoscopic evaluations. Fourteen children had colonoscopy performed. This group included the latter 12 patients plus 2 of the former 4 who again developed hematochezia. Polypectomies were done during 11 of these procedures. Eight of these 11 children had proximal lesions seen during radiographic studies. The diagnostic approach to pediatric age patients with painless hematochezia should include an initial rigid sigmoidoscopic examination. Barium enema evaluation should be reserved for those patients requiring colonoscopy. The latter examination should be performed in all children who have had negative sigmoidoscopic examinations plus those who have had polyps removed from the rectum and then again develop hematochezia.

Depressed neutrophil chemotaxis in infants with cow's milk and/or soy protein intolerance

Neutrophil chemotaxis and random migration were studied in 11 infants with active cow's milk and/or soy protein intolerance and in an additional four infants following clinical recovery. Results were compared to 15 age-matched control subjects. Infants with active intolerance exhibited depressed chemotaxis and enhanced random migration. The four recovered infants had values similar to those of control subjects.

Use of bethanechol for the treatment of gastroesophageal reflux

A double-blind crossover study utilizing bethanechol was performed among 45 pediatric-aged patients with gastroesophageal reflux. Thirty young children (age = less than 1 year) were studied. These infants did significantly better while taking bethanecol than when they were receiving placebo. Fifteen children (age greater than 1 year) were also studied. These patients also had significant clinical improvement while on the drug when compared to the period when they were receiving placebo. Esophageal pH probe testing after the oral administration of bethanecol showed a significant decrease in frequency and duration of episodes of gastroesophageal reflux. This improvement may be secondary to the increases in lower esophageal sphincter pressure and persistaltic activity seen during esophageal manometrics. Bethanechol should be considered for pediatric-aged patients who are not benefited by conventional medical therapeutic regimens.

Basal and pentagastrin-stimulated acid secretion in newborn human infants

Basal and pentagastrin-stimulated gastric acid secretion was measured in 26 healthy newborn infants on the 1st and 2nd days of life. Basal acid outputs (BAO) on day 1 (0.378 mEq/hr) and day 2 (0.388 mEq/hr) were similar and not significantly different from the maximal acid outputs (MAO) on day 1 (0.413 mEq/hr) and day 2 (0.452 mEq/hr). When calculated on a mEq/kg/hr basis, BAO on day 1 was 0.110 with an MAO of 0.122. The BAO on day 2 was 0.114 with an MAO of 0.133. Fasting serum gastrin levels obtained before the acid studies on each day were elevated (mean, day 1 = 100 pg/ml; mean, day 2 = 108 pg/ml). These findings suggest that either gastric acid secretion in the newborn is maximal under basal condition or that newborn parietal cells are unresponsive to pentagastrin on day 1 and 2 of life.