Feeding difficulties in children with food allergies: An EAACI Task Force Report

The term "feeding difficulties" refers to a spectrum of phenotypes characterized by suboptimal intake of food and/or lack of age-appropriate eating habits. While it is evident that feeding difficulties are prevalent within healthy children, no consensus has been reached for those with food allergies. The aim of this study was to systematically review all the available literature reporting the prevalence of feeding difficulties within food allergic children. We searched eight international electronic databases for all published studies until June 2022. International experts in the field were also contacted for unpublished and ongoing studies. All publications were screened against pre-defined eligibility criteria and critically appraised by established instruments. The substantial heterogeneity of included studies precluded meta-analyses, so narrative synthesis of quantitative data was performed. A total of 2059 abstracts were assessed, out of which 21 underwent full-text screening and 10 studies met the study criteria. In these, 12 different terms to define feeding difficulties and 11 diagnostic tools were used. Five papers included data of feeding difficulty prevalence in children with food allergies, ranging from 13.6% to 40%. Higher prevalence was associated with multiple food allergies. The current literature suggests that feeding difficulties are prevalent within food allergic children, particularly those with multiple food allergies. However, the heterogeneity of terminologies and diagnostic tools makes drawing conclusions challenging. Consensus guidelines for the diagnosis and management of feeding difficulties within food allergic children and further research on the development and perpetuation of feeding difficulties are needed to appropriately manage such patients.

Joint ESPGHAN/NASPGHAN Guidelines on Childhood Eosinophilic Gastrointestinal Disorders Beyond Eosinophilic Esophagitis

INTRODUCTION

Eosinophilic gastrointestinal disorders beyond eosinophilic esophagitis (non-EoE EGIDs) are rare chronic inflammatory disorders of the gastrointestinal (GI) tract. Diagnosis is based on clinical symptoms and histologic findings of eosinophilic inflammation after exclusion of a secondary cause or systemic disease. Currently, no guidelines exist for the evaluation of non-EoE EGIDs. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) formed a task force group to provide consensus guidelines for childhood non-EoE EGIDs.

METHODS

The working group was composed of pediatric gastroenterologists, adult gastroenterologists, allergists/immunologists, and pathologists. An extensive electronic literature search of the MEDLINE, EMBASE, and Cochrane databases was conducted up to February 2022. General methodology was used in the formulation of recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to meet current standards of evidence assessment.

RESULTS

The guidelines provide information on the current concept of non-EoE EGIDs, disease pathogenesis, epidemiology, clinical manifestations, diagnostic and disease surveillance procedures, and current treatment options. Thirty-four statements based on available evidence and 41 recommendations based on expert opinion and best clinical practices were developed.

CONCLUSION

Non-EoE EGIDs literature is limited in scope and depth, making clear recommendations difficult. These consensus-based clinical practice guidelines are intended to assist clinicians caring for children affected by non-EoE EGIDs and to facilitate high-quality randomized controlled trials of various treatment modalities using standardized, uniform disease definitions.

Physical and physiological soybean seed qualities stored under different environmental conditions and storage bag depths

The Brazilian Midwest is responsible for 54.3% of the country's soybean production. Adequate storage technologies are essential to maintain physical, physiological, and sanitary seed qualities while also minimizing deterioration processes and consequent germination and vigor declines. In this context, the aim of the present study was to evaluate the physiological potential and physical qualities of soybean seeds stored under different environmental conditions and storage bag depths. Assays were carried out in September 2021 employing Foco 74i77 RSF IPRO cultivar seeds stored from April to August 2021 under three conditions, as follows: chilled at an average temperature of ≤20 °C, at an average temperature of ≤25 °C using a with blanket, and in without blanket warehouse structure at an average temperature of ≥25 °C with no with blanket. A completely randomized 3x3 factorial experimental design was applied, comprising three storage environments and three bag positions (top, middle, and bottom), with three replication each. Physical, physiological, and biochemical tests were performed on the stored seeds. The findings indicate better seed preservation in the chilled environment or when using a with blanket, with significant differences noted for seeds stored the middle of the storage bag. Therefore, soybean seed storage in a chilled environment or using a with blanket aids in slowing down the seed deterioration processes, preserving physiological quality and vigor compared to a conventional storage environment. Additionally, the quality of soybean seeds stored under these conditions in the middle of storage bags is maintained.

The Remaining Challenge to Diagnose and Manage Cow's Milk Allergy: An Opinion Paper to Daily Clinical Practice

Guidelines and recommendations for the diagnosis and management of cow's milk allergy (CMA) in childhood are based on scientific review of the available evidence. While this approach is the most rigorous, guidelines may not fully address all scenarios encountered by clinicians. Many symptoms of CMA overlap with other common childhood illnesses and are subjectively reported by the caregivers of the infant, as is the interpretation of the dietary interventions. Additionally, many healthcare professionals and caregivers do not follow the recommendations to perform an oral food challenge or reintroduction of cow's milk after a diagnostic elimination diet because (1) the infant is doing well and (2) the carer's fear of symptoms relapsing with this procedure. As a result, CMA in infants may be either under-diagnosed leading to reduced quality of life for families or over-diagnosed, resulting in unnecessary long-term elimination diets and increasing the risk for nutritional deficiencies. This paper discusses some of these controversial topics, focusing on misdiagnosis and mismanagement in clinical practice. The lack of objective diagnostic criteria can hamper the diagnosis and management of CMA in daily practice.

The role of online symptom questionnaires to support the diagnosis of cow's milk allergy in children for healthcare professionals - A Delphi consensus study

BACKGROUND

Cow's milk allergy (CMA) is one of the most common food allergies world-wide. The emergence of online CMA symptom questionnaires, aimed at parents and/or healthcare professionals (HCP), may raise awareness about the possible diagnosis of CMA, but also increases the risk for overdiagnosis leading to unnecessary dietary restriction impacting on growth and nutrition. This publication sets out to establish the availability of these CMA symptom questionnaires and critically assesses the development and validity.

METHODS

Thirteen HCP working in the field of CMA, from different countries, were recruited to participate. A combination of a Pubmed and CINAHL literature and online review using the Google search engine in English language was used. Symptoms in the questionnaires were assessed, using the European Academy for Allergy and Clinical Immunology guidelines for food allergy. Following the assessment of both the questionnaires and literature, the authors followed the modified Delphi approach to generate consensus statements.

RESULTS

Six hundred and fifty-one publications were identified, of which 29 were suitable for inclusion, with 26 being associated with the Cow's Milk-Related Symptoms Score. The online search yielded 10 available questionnaires: 7/10 were sponsored by formula milk companies and 7/10 were aimed at parents and three at HCP. Following the assessment of data, 19 statements were generated in two rounds of anonymous voting reaching 100% agreement.

CONCLUSIONS

Online CMA questionnaires, available to parents and HCP's, are varied in symptoms, and most were not validated. The overarching consensus generated from authors is that these questionnaires should not be used without the involvement of HCP.

Characteristics associated with antenatally unidentified small-for-gestational-age fetuses: prospective cohort study nested within DESiGN randomized controlled trial

OBJECTIVE

To identify the clinical characteristics and patterns of ultrasound use amongst pregnancies with an antenatally unidentified small-for-gestational-age (SGA) fetus, compared with those in which SGA is identified, to understand how to design interventions that improve antenatal SGA identification.

METHODS

This was a prospective cohort study of singleton, non-anomalous SGA (birth weight < 10th centile) neonates born after 24 + 0 gestational weeks at 13 UK sites, recruited for the baseline period and control arm of the DESiGN trial. Pregnancy with antenatally unidentified SGA was defined if there was no scan or if the final scan showed estimated fetal weight (EFW) at the 10th centile or above. Identified SGA was defined if EFW was below the 10th centile at the last scan. Maternal and fetal sociodemographic and clinical characteristics were studied for associations with unidentified SGA using unadjusted and adjusted logistic regression models. Ultrasound parameters (gestational age at first growth scan, number and frequency of ultrasound scans) were described, stratified by presence of indication for serial ultrasound. Associations of unidentified SGA with absolute centile and percentage weight difference between the last scan and birth were also studied on unadjusted and adjusted logistic regression, according to time between the last scan and birth.

RESULTS

Of the 15 784 SGA babies included, SGA was not identified antenatally in 78.7% of cases. Of pregnancies with unidentified SGA, 47.1% had no recorded growth scan. Amongst 9410 pregnancies with complete data on key maternal comorbidities and antenatal complications, the risk of unidentified SGA was lower for women with any indication for serial scans (adjusted odds ratio (aOR), 0.56 (95% CI, 0.49-0.64)), for Asian compared with white women (aOR, 0.80 (95% CI, 0.69-0.93)) and for those with non-cephalic presentation at birth (aOR, 0.58 (95% CI, 0.46-0.73)). The risk of unidentified SGA was highest among women with a body mass index (BMI) of 25.0-29.9 kg/m2 (aOR, 1.15 (95% CI, 1.01-1.32)) and lowest in those with underweight BMI (aOR, 0.61 (95% CI, 0.48-0.76)) compared to women with BMI of 18.5-24.9 kg/m2 . Compared to women with identified SGA, those with unidentified SGA had fetuses of higher SGA birth-weight centile (adjusted odds for unidentified SGA increased by 1.21 (95% CI, 1.18-1.23) per one-centile increase between the 0th and 10th centiles). Duration between the last scan and birth increased with advancing gestation in pregnancies with unidentified SGA. SGA babies born within a week of the last growth scan had a mean difference between EFW and birth-weight centiles of 19.5 (SD, 13.8) centiles for the unidentified-SGA group and 0.2 (SD, 3.3) centiles for the identified-SGA group (adjusted mean difference between groups, 19.0 (95% CI, 17.8-20.1) centiles).

CONCLUSIONS

Unidentified SGA was more common amongst women without an indication for serial ultrasound, and in those with cephalic presentation at birth, BMI of 25.0-29.9 kg/m2 and less severe SGA. Ultrasound EFW was overestimated in women with unidentified SGA. This demonstrates the importance of improving the accuracy of SGA screening strategies in low-risk populations and continuing performance of ultrasound scans for term pregnancies. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

International Consensus Recommendations for Eosinophilic Gastrointestinal Disease Nomenclature

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnosis and management of food allergy-associated gastroesophageal reflux disease in young children-EAACI position paper

Gastro-oesophageal reflux (GOR) and food allergy (FA) are common conditions, especially during the first 12 months of life. When GOR leads to troublesome symptoms, that affect the daily functioning of the infant and family, it is referred to as GOR disease (GORD). The role of food allergens as a cause of GORD remains controversial. This European Academy of Allergy and Clinical Immunology (EAACI) position paper aims to review the evidence for FA-associated GORD in young children and translate this into clinical practice that guides healthcare professionals through the diagnosis of suspected FA-associated GORD and medical and dietary management. The task force (TF) on non-IgE mediated allergy consists of EAACI experts in paediatric gastroenterology, allergy, dietetics and psychology from Europe, United Kingdom, United States, Turkey and Brazil. Six clinical questions were formulated, amended and approved by the TF to guide this publication. A systematic literature search using PubMed, Cochrane and EMBASE databases (until June 2021) using predefined inclusion criteria based on the 6 questions was used. The TF also gained access to the database from the European Society of Paediatric Gastroenterology and Hepatology working group, who published guidelines on GORD and ensured that all publications used within that position paper were included. For each of the 6 questions, practice points were formulated, followed by a modified Delphi method consisting of anonymous web-based voting that was repeated with modified practice points where required, until at least 80% consensus for each practice point was achieved. This TF position paper shares the process, the discussion and consensus on all practice points on FA-associated GORD.

Development of a core outcome set for therapeutic studies in eosinophilic esophagitis (COREOS)

BACKGROUND

End points used to determine treatment efficacy in eosinophilic esophagitis (EoE) have evolved over time. With multiple novel therapies in development for EoE, harmonization of outcomes measures will facilitate evidence synthesis and appraisal when comparing different treatments.

OBJECTIVE

We sought to develop a core outcome set (COS) for controlled and observational studies of pharmacologic and diet interventions in adult and pediatric patients with EoE.

METHODS

Candidate outcomes were generated from systematic literature reviews and patient engagement interviews and surveys. Consensus was established using an iterative Delphi process, with items voted on using a 9-point Likert scale and with feedback from other participants to allow score refinement. Consensus meetings were held to ratify the outcome domains of importance and the core outcome measures. Stakeholders were recruited internationally and included adult and pediatric gastroenterologists, allergists, dieticians, pathologists, psychologists, researchers, and methodologists.

RESULTS

The COS consists of 4 outcome domains for controlled and observational studies: histopathology, endoscopy, patient-reported symptoms, and EoE-specific quality of life. A total of 69 stakeholders (response rate 95.8%) prioritized 42 outcomes in a 2-round Delphi process, and the final ratification meeting generated consensus on 33 outcome measures. These included measurement of the peak eosinophil count, Eosinophilic Esophagitis Histology Scoring System, Eosinophilic Esophagitis Endoscopic Reference Score, and patient-reported measures of dysphagia and quality of life.

CONCLUSIONS

This interdisciplinary collaboration involving global stakeholders has produced a COS that can be applied to adult and pediatric studies of pharmacologic and diet therapies for EoE and will facilitate meaningful treatment comparisons and improve the quality of data synthesis.

Current Guidelines and Future Strategies for the Management of Cow's Milk Allergy

Abstract

Exclusive breast feeding is recommended in all guidelines as the first choice feeding. Cow milk allergy (CMA) can be diagnosed by a diagnostic elimination diet for 2 to 4 weeks with a hypo-allergenic formula, followed by a challenge test with intact cow milk protein. The most often used hypo-allergenic formula for the diagnostic elimination diet and the therapeutic diet is a CM based extensive hydrolysate. CM-based partial hydrolysates cannot be recommended in the management of CMA because of insufficient efficacy and possible reactions, but about half of the infants with CMA may tolerate a partial hydrolysate. The pros and cons of other dietary options are discussed in this paper. The use of an amino acid-based formula and/or rice based hydrolysate formula during the diagnostic elimination and therapeutic diet is debated. When available, there is sufficient evidence to consider rice hydrolysates as an adequate alternative to CM-based hydrolysates, since some infants will still react to the CM hydrolysate. The pros and cons of dietary options such as soy formula, buckwheat, almond, pea or other plant based dietary products are discussed. Although the majority of the plant-based beverages are nutritionally inadequate, some are nutritionally adapted for toddlers. However, accessibility and content vary by country and, thus far there is insufficient evidence on the efficacy and tolerance of these plant-based drinks (except for soy formula and rice hydrolysates) to provide an opinion on them.

Conclusion

A diagnostic elimination diet, followed by a challenge remains the diagnostic standard. The use of an awareness tool may result in a decrease of delayed diagnosis. Breastmilk remains the ideal source of nutrition and when not available a CM extensively hydrolyzed formula, rice hydrolysate or amino acid formula should be recommended. More evidence is needed regarding plant-based drinks.

Diagnosis and management of Non-IgE gastrointestinal allergies in breastfed infants-An EAACI Position Paper

It is well-established that food proteins, such as egg, soya, cow's milk and wheat, are detectable in breastmilk for many hours or days after ingestion. Exposure to these proteins is important to the process of developing tolerance but can also sometimes elicit IgE-mediated and non-IgE-mediated allergic symptoms in breastfed infants. Non-IgE-mediated allergy, outside of food protein-induced allergic proctocolitis and eosinophilic oesophagitis, is not well understood, leading to variations in the diagnosis and management thereof. A primary objective of the European Academy for Allergy and Clinical Immunology is to support breastfeeding in all infants, including those with food allergies. A Task Force was established, to explore the clinical spectrum of non-IgE-mediated allergies, and part of its objectives was to establish diagnosis and management of non-IgE-mediated allergies in breastfed infants. Eight questions were formulated using the Patient, Intervention, Comparison, Outcome (PICO) system and Scottish Intercollegiate Guideline Network (SIGN) criteria for data inclusion, and consensus was achieved on practice points through the Delphi method. This publication aims to provide a comprehensive overview on this topic with practice points for healthcare professionals.

An update to the Milk Allergy in Primary Care guideline

The Milk Allergy in Primary (MAP) Care guideline was first published in 2013 in this journal. MAP aimed to provide simple and accessible algorithms for UK clinicians in primary care, detailing all the steps between initial presentation, through diagnosis, management and tolerance development. Despite its UK focus, it soon became clear that MAP was being accessed internationally and thus an updated International Milk Allergy in Primary Care (iMAP) guideline was published in 2017. Both guidelines used existing international consensus guidelines to develop accessible algorithms accompanied by patient information leaflets. In 2018, the guidelines were criticised for 3 distinct reasons: promoting the overdiagnosis of cow’s milk allergy (CMA), negatively impacting breastfeeding and the possibility of industry influence on the guidelines. The authors address these criticisms using available evidence and, in the context of this and in consultation with patient groups, members of the General Practice Infant Feeding Network and other infant feeding healthcare leads, have collaboratively produced updated algorithms and an information leaflet to support breastfeeding. We believe iMAP is now closer to its original aim of facilitating early and accurate diagnosis of CMA, whilst minimising, as far as possible, any concerns around overdiagnosis or a risk to breastfeeding rates. We continue to welcome open and constructive engagement about how best to achieve these aims to provide evidence-based, practical guidelines for the primary care practitioner.

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Better recognition, diagnosis and management of non-IgE-mediated cow's milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline

Cow’s milk allergy (CMA) is one of the most common presentations of food allergy seen in early childhood. It is also one of the most complex food allergies, being implicated in IgE-mediated food allergy as well as diverse manifestations of non-IgE-mediated food allergy. For example, gastrointestinal CMA may present as food protein induced enteropathy, enterocolitis or proctocolitis. Concerns regarding the early and timely diagnosis of CMA have been highlighted over the years. In response to these, guideline papers from the United Kingdom (UK), Australia, Europe, the Americas and the World Allergy Organisation have been published. The UK guideline, ‘Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy—a UK primary care practical guide’ was published in this journal in 2013. This Milk Allergy in Primary Care (MAP) guideline outlines in simple algorithmic form, both the varying presentations of cow’s milk allergy and also focuses on the practical management of the most common presentation, namely mild-to-moderate non-IgE-mediated allergy. Based on the international uptake of the MAP guideline, it became clear that there was a need for practical guidance beyond the UK. Consequently, this paper presents an international interpretation of the MAP guideline to help practitioners in primary care settings around the world. It incorporates further published UK guidance, feedback from UK healthcare professionals and affected families and, importantly, also international guidance and expertise.

Pediatrician's knowledge on the approach of functional constipation

OBJECTIVE

To evaluate the pediatrician's knowledge regarding the diagnostic and therapeutic approach of childhood functional constipation.

METHODS

A descriptive cross-sectional study was performed with the application of a self-administered questionnaire concerning a hypothetical clinical case of childhood functional constipation with fecal incontinence to physicians (n=297) randomly interviewed at the 36th Brazilian Congress of Pediatrics in 2013.

RESULTS

The majority of the participants were females, the mean age was 44.1 years, the mean time of professional practice was 18.8 years; 56.9% were Board Certified by the Brazilian Society of Pediatrics. Additional tests were ordered by 40.4%; including abdominal radiography (19.5%), barium enema (10.4%), laboratory tests (9.8%), abdominal ultrasound (6.7%), colonoscopy (2.4%), manometry and rectal biopsy (both 1.7%). The most common interventions included lactulose (26.6%), mineral oil (17.5%), polyethylene glycol (14.5%), fiber supplement (9.1%) and milk of magnesia (5.4%). Nutritional guidance (84.8%), fecal disimpaction (17.2%) and toilet training (19.5%) were also indicated.

CONCLUSIONS

Our results show that pediatricians do not adhere to current recommendations for the management of childhood functional constipation, as unnecessary tests were ordered and the first-line treatment was not prescribed.

Intravarietal polymorphisms reveal possible common ancestor of native Schinus terebinthifolius Raddi populations in Brazil

Schinus terebinthifolius Raddi is a perennial native from Atlantic forest. It is of high ecological plasticity and is used in traditional medicine. Based on promising reports concerning its bioactivity, it was included as a species of great interest for distribution through the National Health System. A number of agronomic studies to guide its crop production are therefore underway. This study examined diversity and phylogenetic relationships among native S. terebinthifolius populations from different Brazilian ecosystems: Cerrado; sandbanks; dense rainforest; and deciduous forest. The intergenic regions rpl20-5'rps12, trnH-psbA, and trnS-trnG were sequenced from cpDNA and aligned using BLASTn. There were few fragments for comparison in GenBank and so only region trnS-trnG was informative. There were variations among and within populations with intravarietal polymorphisms and three distinct haplotypes (HpSM, HpDDO, HpNE), once populations from NE (sandbanks and rainforest) clustered together. Sequences from HpSM, HpNE, and HpDDO returned greater similarity to haplotypes A (AY928398.1), B (AY928399.1), and C (AY928400.1), respectively. A network, built by median-joining among native haplotypes and 10 available on GenBank, revealed HpSM as the origin of all other haplogroups. HpDDO showed the most mutations and was closely related to haplogroups from Argentina. While this could indicate hybridization, we believe that the polymorphisms resulted from adaptation to events such as deforestation, fire, rising temperature, and seasonal drought during the transition from Atlantic forest to Cerrado. While more detailed phylogeographical studies are needed, these results indicate eligible groups for distinct climates as an important step for pre-breeding programs before field propagation.

Phenolic compounds of Hibiscus sabdariffa and influence of organic residues on its antioxidant and antitumoral properties

The aim of this study was to evaluate the phenolic and flavonoids contents and the antioxidant and antitumoral activity of leaf and calyx methanolic extracts from Hibiscus sabdariffa (roselle) cultivated with poultry litter and organosuper® under three modes of application. The total phenolic content in the each extract was determined using the Folin-Ciocalteu reagent and for aluminium chloride flavonoids. The antioxidant parameters were analyzed using a 2, 2-diphenyl-1-picrylhydrazyl (DPPH.) free radical scavenging assay. An antitumor colorimetric assay using sulforhodamine B. The highest contents of phenolic and flavonoids were observed in leaf extracts (389.98 and 104.52 mg g-1, respectively) and calyx extracts (474.09 and 148.35 mg g-1, respectively) from plants cultivated with organosuper®, although these values did not differ significantly from those observed for the other treatments. The average IC50 of leaves (43.48 μg mL-1) and calyces (37.15 μg mL-1) demonstrated that both have substances that may contribute to free radical scavenging action. The methanol extract from calyces showed significant selective activity against a leukemia line (K-562), with IC50 values of 0.12 mg mL-1 (organosuper®) and 1.16 mg mL-1 (poultry litter), with concentration-dependent, cytotoxic and cytocidal effects.

Network meta-analysis of longitudinal data using fractional polynomials

Network meta-analysis of randomized controlled trials (RCTs) are often based on one treatment effect measure per study. However, many studies report data at multiple time points. Furthermore, not all studies measure the outcomes at the same time points. As an alternative to a network meta-analysis based on a synthesis of the results at one time point, a network meta-analysis method is presented that allows for the simultaneous analysis of outcomes at multiple time points. The development of outcomes over time of interventions compared in an RCT is modeled with fractional polynomials, and the differences between the parameters of these polynomials within a trial are synthesized across studies with a Bayesian network meta-analysis. The proposed models are illustrated with an analysis of RCTs evaluating interventions for osteoarthritis of the knee. Fixed and random effects second order fractional polynomials were applied to the case study. Network meta-analysis with models that represent the treatment effects in terms of several parameters using fractional polynomials can be considered a useful addition to models for network meta-analysis of repeated measures previously proposed. When RCTs report treatment effects at multiple follow-up times, these models can be used to synthesize the results even if reporting times differ across the studies.

In vitro biological screening of the anticholinesterase and antiproliferative activities of medicinal plants belonging to Annonaceae

The aim of this research was to investigate the antiproliferative and anticholinesterase activities of 11 extracts from 5 Annonaceae species in vitro. Antiproliferative activity was assessed using 10 human cancer cell lines. Thin-layer chromatography and a microplate assay were used to screen the extracts for acetylcholinesterase (AchE) inhibitors using Ellman's reagent. The chemical compositions of the active extracts were investigated using high performance liquid chromatography. Eleven extracts obtained from five Annonaceae plant species were active and were particularly effective against the UA251, NCI-470 lung, HT-29, NCI/ADR, and K-562 cell lines with growth inhibition (GI₅₀) values of 0.04-0.06, 0.02-0.50, 0.01-0.12, 0.10-0.27, and 0.02-0.04 µg/mL, respectively. In addition, the Annona crassiflora and A. coriacea seed extracts were the most active among the tested extracts and the most effective against the tumor cell lines, with GI₅₀ values below 8.90 µg/mL. The A. cacans extract displayed the lowest activity. Based on the microplate assay, the percent AchE inhibition of the extracts ranged from 12 to 52%, and the A. coriacea seed extract resulted in the greatest inhibition (52%). Caffeic acid, sinapic acid, and rutin were present at higher concentrations in the A. crassiflora seed samples. The A. coriacea seeds contained ferulic and sinapic acid. Overall, the results indicated that A. crassiflora and A. coriacea extracts have antiproliferative and anticholinesterase properties, which opens up new possibilities for alternative pharmacotherapy drugs.

Physical activity overcomes the effects of cumulative work time on hypertension prevalence among Brazilian taxi drivers

AIM

The aim of this study was to assess the physical activity profile of taxi drivers and its relationship with hypertension prevalence in this group of workers.

METHODS

Cross sectional exploratory study. Between November 2008 and April 2009, 491 taxi drivers from Rio de Janeiro, Brazil, answered a questionnaire focusing on previous hypertension diagnosis, occupational characteristics and physical activity habits. Two logistic models were developed to determine risk factors related to hypertension and to find variables associated with a higher probability of sedentarism.

RESULTS

Hypertension prevalence was 22.6%. The workload of the group investigated was high. Results indicate that 'age', 'body mass index', 'physical activity', and 'years as a taxi driver' are related to the probability of hypertension. Physical activity was shown to be a protection factor for hypertension, even considering the deleterious effect of time as a taxi driver. Our results also determined that the practice of physical activity is influenced by age, level of education and workload.

CONCLUSIONS

It is recommended that programs to combat sedentary lifestyles as well as measures to reduce workloads be developed as strategies to prevent hypertension.

Effects of Methanolic Extracts of Annona Species on the Development and Reproduction of Spodoptera frugiperda (J.E. Smith) (Lepidoptera: Noctuidae)

Spodoptera frugiperda (J.E. Smith) (Lepidoptera: Noctuidae) causes significant losses in corn crops and necessitates the use of alternative control strategies, such as the application of bioinsecticides. We report the effect of methanolic leaf extracts of Annona dioica, Annona cacans, and Annona coriacea on the development and reproduction of S. frugiperda. A quantitative analysis was carried out to determine the total concentration of phenolics, flavonoids, and condensed tannin (CT) in leaf extracts. Corn leaves were immersed in a 1% methanolic leaf extract solution and fed to second instars of S. frugiperda. Leaf disks dipped in the synthetic insecticide Connect® (Bayer CropScience Ltda) composed of a neonicotinoid (imidacloprid) and a pyrethroid (β-cyfluthrin), which are harmful to S. frugiperda, was used as positive control. Distilled water was used as a negative control treatment. The leaf extract of A. coriacea decreased larval survivorship, arrested pupal development, and affected the weight gain of S. frugiperda. A. dioica also affected larval survivorship, but its effects were more pronounced for the adult stage, as fecundity, fertility, egg hatchability, and embryonic development were severely affected. Leaf extracts from A. cacans had no effect on S. frugiperda. The leaf extracts of A. dioica and A. coriacea showed a higher content of flavonoids and phenols, respectively. Our results indicated that both A. dioica and A. coriacea have the potential for development as botanical insecticides.

Chemical composition and free radical-scavenging, anticancer and anti-inflammatory activities of the essential oil from Ocimum kilimandscharicum

OBJECTIVE

The essential oil from the leaves of Ocimum kilimandscharicum (EOOK), collected in Dourados-MS, was investigated for anticancer, anti-inflammatory and antioxidant activity and chemical composition.

MATERIALS AND METHODS

The essential oil was extracted by hydrodistillation, and the chemical composition was performed by gas chromatography-mass spectrometry. The essential oil was evaluated for free radical-scavenging activity using the DPPH assay and was tested in an anticancer assay against ten human cancer cell lines. The response parameter (GI50) was calculated for the cell lines tested. The anti-inflammatory activity was evaluated using carrageenan-induced pleurisy in mice.

RESULTS

The chemical composition showed 45 components with a predominance of monoterpenes, such as camphor (51.81%), 1,8 cineole (20.13%) and limonene (11.23%). The EOOK exhibited potent free radical-scavenging activity by the DPPH assay with a GI50 of 8.31 μg/ml. The major constituents, pure camphor (IC50=12.56 μg/ml) and mixture of the limonene: 1, 8 cineole (IC50=23.25 μg/ml) displayed a potent activity. The oral administration of EOOK (at 30 and 100 mg kg(-1)), as well as the pure camphor or a mixture of 1,8 cineole with limonene, significantly inhibited the carrageenan (Cg) induced pleurisy, reducing the migration of total leukocytes in mice by 82 ± 4% (30 mg kg(-1) of EOOK), 95 ± 4% (100 mg kg(-1) of EOOK), 83 ± 9% (camphor) and 80 ± 5% (mixture of 1,8 cineole:limonene 1:1). In vitro cytotoxicity screening against a human ovarian cancer cell line displayed high selectivity and potent anticancer activity with GI50=31.90 mg ml(-1). This work describes the anti-inflammatory, anticancer and antioxidant effects of EOOK for the first time.

CONCLUSIONS

The essential oil exhibited marked anti-inflammatory, antioxidant and anticancer effects, an effect that can be attributed the presence of majorital compounds, and the response profiles from chemical composition differed from other oils collected in different locales.

Effects of domperidone on QTc interval in infants

AIM

To prospectively evaluate the effects of oral domperidone on the QTc interval in infants.

METHODS

Infants (0-1 year) with a diagnosis of gastro-oesophageal reflux (GOR) disease were included. A 12-lead electrocardiography (ECG) was performed in all infants at baseline and 1 h after the intake of domperidone after 7-14 days; the corrected QTc interval was calculated by one investigator (MV) according to Bazett's formula.

RESULTS

Forty-five infants were enrolled in this study. The mean gestational age was of 38.6 weeks (35.5-42.0), and the mean age at the start of domperidone was 75.3 days (19-218 days). No statistically significant difference in corrected QTc was observed between baseline and the second ECG (0.389 ± 0.02 vs. 0.397 ± 0.31; p 0.130)). A trend was observed regarding gender: Although there was no difference in QTc change in girls (p 0.622), there was a strong trend in boys (p 0.051). Two infants (both boys) had a clinically significant QTc prolongation (> 460 msec) without symptoms. The Spearman correlation test showed no relation between the QTc change and age (r: -0.05822; p 0.7284). There was no relation between domperidone dosage and QTc change.

CONCLUSION

Overall, the group-analysis showed no statistical significant difference in QTc duration induced by domperidone. However, 2/45 (4.4%) infants had a prolonged QTc interval (> 460 msec) induced by domperidone. As a consequence, QTc measurement should be recommended in routine in infants when domperidone is started.

Probiotics and zinc in acute infectious gastroenteritis in children: are they effective?

OBJECTIVE

Several studies in recent decades have assessed the effects of different probiotics in acute gastroenteritis, showing that specific strains of Lactobacilli (mainly Lactobacillus casei GG) and Saccharomyces boulardii may exert some beneficial therapeutic actions, mainly when used in rotavirus gastroenteritis, at a high dose, and in the early phase. The mechanisms of action of probiotics are not completely elucidated but seem to involve a complex interaction among epithelial, molecular, metabolic, and immune responses. Data on the prevention of community-acquired, nosocomial, and travelers' diarrhea are currently conflicting. Because each micro-organism has different properties, an accurate selection of the strain, dose, and patient should be cautiously considered.

METHODS AND RESULTS

Several reports from developing countries have demonstrated that supplements of zinc also provide significant reduction in stool output and duration, persistency, and severity of diarrhea. In view of the published data and of the different actions of zinc (such as improvement of the immune status, intestinal permeability, epithelial and enzymatic function, and electrolyte transport), the use of zinc as adjunctive therapy to oral rehydration solution has the potential to improve the management of diarrhea and decrease complications in children worldwide. In contrast to probiotics, which most trials in the developed world have used, there has been no trial with zinc performed in developed countries.

CONCLUSION

Data on the effect of a combined administration of zinc and probiotics in acute gastroenteritis are urgently needed.

Will esophageal impedance replace pH monitoring?

Esophageal impedance, a technique based on the fact that the passage of a bolus changes the impedance between esophageal segments, is being used more and more. Multiple esophageal impedance combined with pH monitoring is advocated to become the preferred technique to measure acid and nonacid gastroesophageal reflux. Compared with pH monitoring, impedance has the advantage of being independent of pH and, as a consequence, is better adapted to measure reflux (especially in the postprandial period when reflux is buffered) and detect symptoms associated with nonacid- or weakly acid-reflux episodes. Conversely, the analysis of an impedance tracing requires more time and knowledge than a pH tracing and is possibly subjected to higher interobserver variability. Day-to-day reproducibility and interobserver variability are considerable. Episodes detected only by pH monitoring or impedance are numerous in pediatrics; therefore, pH monitoring and impedance should be associated in analyses of multiple esophageal impedance combined with pH monitoring. Up to now, there has been a striking absence of literature showing attempts to link data from diagnostic procedures to clinical outcome in symptomatic patients. Furthermore, data suggesting that impedance does offer a clear-cut benefit in pediatric clinical routine are missing. High cost of the material and the investment in time necessary for interpretation of the recording remain a handicap. However, because pH monitoring is part of impedance technology, it is likely that the latter will soon replace pH monitoring despite the current need of scientific evidence demonstrating a relation between symptoms, esophageal damage or response to reflux treatment, and results of multiple esophageal impedance combined with pH monitoring.

Diagnostic methods for the detection of anterograde aspiration in enterally fed patients

PURPOSE OF REVIEW

The diagnosis of aspiration and its origin in patients on enteral tube feeding is challenging to the physician and provides an important means to prevent pneumonia. This review examines the most recent studies and developments in the field with an approach to the technical aspects of diagnostic methods.

RECENT FINDINGS

The methods more commonly used to detect anterograde aspiration in clinical practice are fiberoptic endoscopic evaluation of swallowing and modified barium swallowing. Recent studies have shown that although these methods may provide the diagnosis of aspiration, their use for clinical monitoring is not appropriate. The studies comparing fiberoptic endoscopic evaluation of swallowing and modified barium swallowing have demonstrated that both tests present similar sensitivity, specificity and predictive values.

SUMMARY

The different methods used to diagnose anterograde aspiration are appropriate for clinical practice, with a low complication rate and few contraindications. In most instances, the early diagnosis of aspiration and evaluation of other factors such as laryngeal sensibility, may predict the occurrence of aspiration pneumonia.

Anatomic study of the tricuspid valve in children

We performed an anatomic study of the right atrioventricular valve in children under one year of age using a conservative method of dissection of the heart valve. The main aspects studied were the number of cusps and their morphometric characteristics, such as the width of the base and the depth of the cusps. Other parameters studied were the number of papillary muscles, number of tendinous cords, and diameter of the fibrous ring and the last one were divided in three regions, anterior, posterior and septal for localization of cusps. Our results showed that the number of cusps varied from two to four. Three cusps was the commonest finding and the fourth cusp, if present, was classified as anterolateral in location. The anterior and septal cusps had bases bigger than those of the posterior and anterolateral cusps; the septal cusp was deeper than the others; and the number of tendinous cords was greater for the anterior and septal cusps than for the posterior and anterolateral cusps. In addition, the posterior region showed great variability: in 35.7% it was occupied by undeveloped valve tissue and the posterior valve in these cases was located anteriorly.

Kinetic parameters estimation for ascorbic acid degradation in fruit nectar using the Partial Equivalent Isothermal Exposures (PEIE) method under non-isothermal continuous heating conditions

With the purpose of testing the Paired Equivalent Isothermal Exposures (PEIE) method to determine reaction kinetic parameters under non-isothermal conditions, continuous pasteurizations were carried out with a tropical fruit nectar [25% cupuaçu (Theobroma grandiflorum) pulp and 15% sugar] to estimate the ascorbic acid thermal degradation kinetic parameters. Fifteen continuous thermal exposures were studied, with seven being cycled. The experimental ascorbic acid thermal degradation kinetic parameters were estimated by the PEIE method (E(a) = 73 +/- 9 kJ/mol, k(8)(0)( degrees )(C) = 0.017 +/- 0.001 min(-)(1)). These values compared very well to the previously determined values for the same product under isothermal conditions (E(a) = 73 +/- 7 kJ/mol, k(8)(0)( degrees )(C) = 0.020 +/- 0.001 min(-)(1)). The predicted extents of reaction presented a good fit to the experimental data, although the cycled thermal treatments presented some deviation. In addition to being easier and faster than the Isothermal method, the PEIE method can be a more reliable method to estimate first-order reaction kinetic parameters when continuous heating is considered.

Thermal inactivation of Alicyclobacillus acidoterrestris spores under different temperature, soluble solids and pH conditions for the design of fruit processes

Alicyclobacillus acidoterrestris, a thermoacidophilic, non-pathogenic and spore-forming bacterium has been detected in several spoiled commercial pasteurised fruit juices. A. acidoterrestris spores, besides being resistant to the pasteurisation treatment conditions normally applied to acidic fruit products, can germinate and grow causing spoilage. Therefore, this microorganism was suggested as the target to be used in the design of adequate pasteurisation processes. The objectives of this work were to investigate the influence of temperature (T: 85-97 degrees C), total soluble solids (SS: 5-60 degrees Brix or % by weight) and pH (2.5-6.0) on D-values (decimal reduction time) of Alicyclobacillus acidoterrestris (type strain, NCIMB 13137) spores, and to fit a model using response surface methodology. A central composite face-centred experimental design was used, and the response, D-value determined in malt extract broth, ranged between 0.498+/-0.045 and 94.9+/-6.7 min. Within the factor ranges studied, temperature was the parameter that most affected the D-value. Following this was the SS and, lastly, the pH value. A linear decrease in D-value was observed with decreasing SS and pH, and a non-linear decrease in D-value was noticed with increasing temperature. A second order polynomial was successfully fitted to the data (R2 = 0.98). In general, D-values measured in real fruit systems, such as orange, apple and grape juices, blackcurrant concentrates, cupuaçu (exotic fruit) extract and orange juice drink, were higher than those predicted by the malt extract broth model. This result emphasises the importance of experimental validation of any model-derived process.

[Angiography of the coronary venous system. Use in clinical electrophysiology]

PURPOSE

To study the angiographic anatomy of human coronary veins and the possibility of epicardial venous mapping through microelectrode catheters.

METHODS

We evaluated 30 patients with sustained ventricular tachycardia using a catheter which provided occlusion of the coronary sinus ostium during venous angiography. They were 25 males, 5 females, ages ranging from 24 to 76 years (mean = 52.7). The veins were studied according to their number, caliber and distribution in the anterior and posterior wall of the left ventricle.

RESULTS

Coronary sinus was catheterized in all patients. No discomfort or complication were observed. The number of veins from posterior wall of the left ventricle was 3.1 and anterior wall, 1.9, p < 0.05. The caliber of the coronary veins were: anterior interventricular vein (distal segment = 1.19 +/- 0.22 mm, middle segment = 1.65 +/- 0.35 mm), posterior interventricular vein (distal segment = 1.83 +/- 0.47 mm, middle segment = 2.00 +/- 0.52 mm), left posterior vein (distal segment = 1.45 +/- 0.25 mm, middle segment = 2.49 +/- 0.92 mm); p < 0.05.

CONCLUSION

The balloon occlusion technique for coronary venous angiography is feasible and safe. The number and the caliber (distal and middle) of the veins from the posterior wall of the left ventricle were significantly greater than those from the anterior wall. Anatomic conditions for venous epicardial mapping are more adequate in the posterior wall of the left ventricle.

Adsorption of protein from several commercial lipase preparations onto a hollow-fiber membrane module

Ten commercially available crude preparations of lipase from various microbial sources were adsorbed from aqueous buffers at several initial concentrations onto a bundle of hydrophobic hollow fibers made of poly(propylene) at pH 7.0 and 40 degrees C. The kinetics of adsorption were evaluated from measurements at various times of the protein content of the supernatant solution (using BSA as equivalent) in a well-mixed reservoir placed in series with the hollow fiber module. Preliminary tracer experiments have indicated that the module and the tank can be simulated as a system consisting of a plug flow reactor in series with a continuous stirred tank reactor. A mechanistic model based on the hydrodynamic assumptions associated with this system coupled with the postulation of two reversible first-order steps for the adsorption of protein was successfully fitted to the experimental data via nonlinear regression analysis. The statistical significance of the model was checked using tests for lack of fit. This work is useful in predicting the time period required to immobilize a (crude) lipase by adsorption onto a hydrophobic hollow fiber module, a configuration which has proved successful in the recent past for the performance of lipase-catalyzed reactions.

Linear growth after colectomy for ulcerative colitis in childhood

Eighteen children and adolescents, of a total of 90 treated in our unit between 1982 and 1992, underwent colectomy for ulceractive colitis. Six (6.7%) of the 90 patients had short stature, i.e., a height below the 3rd centile, and 8 of the 18 who had surgery had a subnormal height velocity, i.e., below the 25th centile for age at the time of surgery. Surgery was performed for resistance to medical therapy (n = 13) or toxic megacolon (n = 5). Surgery was followed by catch-up growth, i.e., increasing height velocity, in eight subjects and cessation of the trend of diminishing height velocity, but without catch-up growth, in five. In 11 of the subjects who were prepubertal, the median height velocity increased from 3.85 cm/year preoperatively to 7.35 cm/year postoperatively (p < 0.01). One year after surgery, 14 of the 18 patients were either asymptomatic or substantially improved. Surgery therefore led to improved linear growth and a prolonged symptom-free period in most of the children and adolescents with ulcerative colitis undergoing this treatment.

Effect of protein kinase inhibitors on the invasion process of macrophages by Trypanosoma cruzi

The interaction of Trypanosoma cruzi with different vertebrate cells involves two distinct steps, attachment and internalization. Genistein and staurosporine, drugs which inhibit protein kinases, specially tyrosine kinase, are able to block the infection of macrophages by T. cruzi, suggesting that protein phosphorylation is a key event on this process.

The recurrent laryngeal nerve in relation to the inferior constrictor muscle of the pharynx

The point of penetration of the recurrent laryngeal nerve into the larynx is recognized as the most frequent site of injury to the nerve during surgical procedures of the thyroid gland. The anatomical relationships of 25 right and left recurrent laryngeal nerves in 25 anatomical blocks from formalin-fixed human corpses have been studied. In 34 cases (68%), the recurrent laryngeal nerve penetrated into the larynx below the lower fibers of the inferior constrictor muscle of the pharynx (type 1 of penetration). In the remaining 16 cases (32%), the nerve crossed through those muscle fibers to penetrate into the larynx (type 2 of penetration). The thyroid gland was found to involve the recurrent laryngeal nerve at the penetration point into the larynx in 19 of 50 cases (38%).

Morphological study of one septal trabecula carnea of the left ventricle

This work was carried out in 50 hearts of human adult cadavers of both sexes, whose obit causes were not related to diseases which could have been directly involved with the heart. The septal trabecula carnea was identified in 45 hearts (90%), with origin in the superior portion of the interventricular septum and the other extremity was sited in 33 cases (61.1%) in the base of the anterior papillary muscle. It was unique in 37 hearts (82.2%) and dissociated in 8 hearts (17.8%). The more frequent length and width was 40 mm and 3 mm, respectively.

[Regional irrigation of the pericardium in children]

PURPOSE

To investigate the irrigation of both fibrous pericardium and the parietal layer of serosal pericardium in children.

PATIENTS AND METHODS

The cadavers of 10 children of both sexes, under the age of one. In this study we adopted the regional divisions described by DI Dio, which considers a plane between the two phrenic nerves that divides the areas of pericardium into ventral and dorsal regions. We also refer to these regions as antephrenic and retrophrenic respectively. In addition, we consider the inferior pericardium to be that portion of pericardial sac related to the diaphragm.

RESULTS

The pericardium ventralis was more frequently irrigated by branches of the following arteries: thoracicae internae dextra and sinistra, pericardiacophrenica dextra in 9 cases; pericardiacophrenica sinistra in 8 cases; and less frequently, by branches of the arteriae phrenicae inferiores dextra and sinistra, epigastrica superior sinistra, thimica, rami thimici of the a. thoracica interna dextra, and rami thimicus and esophagealis of the a. subclavia dextra. The pericardium dorsalis was more frequently supplied b the following arterial branches: bronchiales in 9 cases; esophagealis of the aorta in 8 cases; and in a frequency inferior than 4 cases, we observed the following arteries: thyroidea inferior sinistra, intercostalis suprema, pericardiacophrenicae dextra and sinistra, subclavia sinistra, coronariae dextra and sinistra, phrenicae superior and inferior sinistra, thoracica interna dextra, intercostales posteriores primae dextra and sinistra, truncus costocervalis and rami esophageales of the a. gastrica sinistra. The pericardium inferior was irrigated by branches of the arteriae phrenicae inferiores dextra in 10 cases and sinistra in 9 cases.

CONCLUSION

Analysis of the results demonstrated that similar behavior in the pericardium regional irrigation offers a standard for intervention in the pericardium.

Anatomical study of the human tricuspid valve

An anatomical study of the tricuspid valve was carried out in 50 human hearts of both female and male individuals using a method of dissection which preserves the integrity of the valve. Morphometric criteria such as area of cusp, width of cusp base, relation between commissure depth and cusp depth and morphological criteria such as the presence of atrioventricular cusp node, number of tendinous cords, perimeter of fibrous ring, and properties of papillary m. were adopted for characterization of a cusp. In 64% of cases, commissural cusps were present independent of the number of tricuspid cusps. The tricuspid valve was not consistently tricuspid, but was observed to present 2, 4, 5 or 6 cusps in 72% of cases.