Second‐look endoscopy with thermal coagulation or injections for peptic ulcer bleeding: A meta‐analysis

Background and Aims: In the management of peptic ulcer bleeding, the benefits of second‐look endoscopic treatment with thermal coagulation or injections in controlling recurrent bleeding is unsure. This study set out to compare efficacy of routine second‐look endoscopy with treatment using either thermal coagulation or injections versus single endoscopy by pooling data from published work. Methods: Full publications in the English‐language published work as well as abstracts in major international conferences were searched over the past 10 years, and six trials fulfilling the search criteria were found. Outcome measurements included: (i) recurrent bleeding; (ii) requirement of surgical intervention; and (iii) mortality. We examined heterogeneity of trials and pooled the effects by meta‐analysis. The quality of studies was graded according to the prospective randomization, methods of patient allocation, the list of exclusion criteria, outcome definitions and the predefined salvage procedures for uncontrolled bleeding. Results: Among 998 patients recruited in these five randomized trials, 119 received routine second‐look endoscopy with thermal coagulation, and 374 received second‐look with endoscopic injection and 505 had single endoscopic therapy. Less recurrent bleeding was reported after thermal coagulation (4.2%) than single endoscopy (15.7%) (relative risk [RR] = 0.29; 95% confidence interval [CI] = 0.11–0.73), but no reduction was reported for the requirement of surgical intervention and all‐cause mortality. Injection therapy did not reduce re‐bleeding (17.6%) when compared to single endoscopy (20.8%; RR = 0.85; 95% CI = 0.63–1.14), requirement for surgery and mortality. Conclusion: Routine second‐look endoscopy with thermal coagulation, but not injection therapy, reduced recurrent peptic ulcer bleeding. There is no proven benefit in reducing surgical intervention and overall mortality.     

Predicting and monitoring of growth in children with short stature during the first year of growth hormone treatment.

Fifteen prepubertal short stature children (10 girls, 5 boys), mean age 9.6 years (range 5.2-12.7 years), with normal response to growth hormone stimulation tests (group A) or partial growth hormone deficiency (GHD) of idiopathic nature (group B) were included in a controlled longitudinal study for evaluation of predictive parameters for the long-term growth response after administration of biosynthetic human growth hormone (B-hGH). The average knee-heel length velocity for the first 3 months was significantly correlated to total body height velocity during the following 9 months (p less than 0.0008). By contrast, this association could not be found for height velocity during the same period. The increase in serum values of alkaline phosphatase and insulin-like growth factor I (IGF-1) during the first month of treatment was not significantly correlated to height velocity during the first year. During one year of treatment with B-hGH the mean height velocity for groups A and B increased from 4.4 cm/year (range 2.5-6.5) to 7.6 cm/year (range 4.7-10.6). Bone age advanced by 1.08 +/- 0.60 per chronological year. The ratio between total height and knee-heel length prior to treatment was 3.34 +/- 0.10 and after one year 3.33 +/- 0.10, suggesting a proportional linear growth. An inverse relationship was observed between the ratio and chronological age. In conclusion, early knee-heel measurement may be a useful non-invasive predictor of long-term linear growth in children during treatment with growth hormone, and the ratio of total height to lower leg length may be of importance in detecting dysproportional growth.     

Effect of ethnic background on Danish hospital utilisation patterns

The aim of the study is to examine possible ethnic differences in the utilisation patterns of hospitalised immigrants versus patients born in Denmark. Data were obtained from the Register of Prevention at Statistics Denmark. This register includes both clinical and socio-demographic data. All patients discharged as inpatients during 1997 at Bispebjerg Hospital (a major hospital in Copenhagen) were identified through the Register of Prevention and linked to data concerning diagnosis, place of birth, age and gender. To compare immigrants with patients born in Denmark, a study group and a reference group were formed. The final study group consisted of all patients characterised by 22 major diagnostic categories and born outside the five Nordic countries (altogether 858 persons accounting for 976 inpatient contacts). The reference group consisted of 2004 patients accounting for 2432 inpatient contacts characterised by the same diagnostic categories among a random sample of 10,000 patients born in Denmark. The measure of utilisation employed was length of inpatient stay determined by the total number of days that each admission lasted. Data were analysed by a multiple regression analysis controlling for age, gender, diagnosis and place of birth. The results show that for some diagnostic groups, native Danes have longer inpatient stay compared to immigrants, whereas for other diagnostic groups immigrants have longer inpatient stay than native Danes. There was no overall effect of ethnicity on duration of hospital stay and consequently the utilisation patterns of inpatient care seem to reflect equal care for equal needs.     

Hepatic derangement following N‐Acetylcysteine enemas in an infant with cystic fibrosis

We discuss an infant with MI secondary to cystic fibrosis, who was managed surgically by a double barrel ileostomy for mid – small bowel atresia and developed severe faecal impaction in the post – operative period. The faecal impaction was treated successfully with oral NAC and 0.2% NAC contrast enemas. The patient's liver function tests revealed a dramatic increase in transaminases and bilirubin contemporaneous with the administration of the enemas. The levels showed a spontaneous improvement after discontinuation. This is only the second reported case of hepatotoxicity secondary to NAC enemas in the literature. While our experience offers modest support for the use of NAC, its efficacy is not yet proven and paediatric surgeons using NAC in the enema form need to closely monitor liver function contemporaneous with this agent's administration and adjust their treatment accordingly.     

Urinary albumin excretion rate and puberty in non-diabetic children and adolescents

Slightly elevated urinary albumin excretion rate (microalbuminuria) is a marker of early diabetic nephropathy, but it is unclear if the established definition of microalbuminuria (20–200 μg/min) is correct for children and adolescents. We investigated the albumin excretion rate, albumin/creatinine ratio and urinary albumin concentration in 150 healthy schoolchildren and adolescents to (a) obtain a reference value for albumin excretion rate, (b) relate albumin excretion to pubertal stages and (c) evaluate albumin/creatinine ratio and morning albumin concentration as screening methods for elevatcd albumin excretion rate. Albumin concentration was measured by immunoturbidimetry in timed overnight urine samples. The albumin excretion showed a skewed distribution (geometric mean 3.2 μg/min, 95 percentile 15.1 μg/min). In girls, a peak in the albumin excretion rate was found at the pubertal stage 4 (Tanner) and in boys at stage 5. Albumin/creatinine ratio of 2.5 mg/mmol as a scrccning level for elevatcd albumin cxcrction (15 μg/min) showed a high positivc (0.88) and negative (0.99) predictive value.     

Maternal fish oil supplementation in lactation and growth during the first 2.5 years of life

Fish oil addition to infant formulas has raised concern on whether increased intake of n-3 long-chain polyunsaturated fatty acid (n-3LCPUFA) affects infant growth. The objective of this study was to determine whether maternal fish oil supplementation during 0-4 mo of lactation influences growth in infancy and early childhood. In a randomized, blinded intervention trial, lactating Danish mothers with a fish intake below the population median were randomized to 4.5 g/d fish oil or olive oil. A reference group of 53 mothers with a fish intake in the highest quartile of the population and their infants were included in the study. Head circumference, weight, length, skinfold thickness, and waist circumference of children were measured at 2, 4, and 9 mo and at 2.5 y. One hundred children completed the intervention trial, and 72 were followed up at 2.5 y together with 29 from the reference group. Growth in weight, length, and head circumference did not differ between the randomized groups up to 9 mo, but at 2.5 y, body composition differed significantly. Children in the fish oil group had larger waist circumference body mass index (BMI; 0.6 kg/m(2); p = 0.022), and head circumference compared with those in the olive oil group. Adjusted for sex, ponderal index at birth and current energy intake, BMI at 2.5 y was associated with docosahexaenoic acid in maternal erythrocytes after the intervention. In conclusion, the n-3LCPUFA intake of lactating mothers may be important for growth of young children. The long-term effect on weight and BMI remains to be investigated.     

High intakes of skimmed milk, but not meat, increase serum IGF-I and IGFBP-3 in eight-year-old boys

OBJECTIVE: To examine whether a high protein intake (PI) from either milk or meat, at a level often seen in late infancy, could increase s-IGF-I and s-IGF-I/s-IGFBP-3 in healthy, prepubertal children. IGF-I levels are positively associated with growth velocity in children and some studies suggest that a high animal PI can stimulate growth. During protein deprivation IGF-I decrease, but it is unknown whether a high PI can increase s-IGF-I in well-nourished children. DESIGN: In all, 24 8-y-old boys were asked to take either 1.5 l of skimmed milk (n = 12) or the same amount of protein as 250 g low fat meat (n = 12) daily for 7 days. The remaining diet they could choose freely. At baseline and after 7 days, anthropometrical variables were measured, diet was registered (3-day weighed records), and s-IGF-I and s-IGFBP-3 (RIA) were determined after fast. RESULTS: PI increased by 61% in the milk group to 4.0 g/kg/day (P < 0.0001) and by 54% in the meat group to 3.8 g/kg/day (P = 0.001). The high milk intake increased s-IGF-I by 19% (P = 0.001) and s-IGF-I/s-IGFBP-3 by 13% (P < 0.0001). There were no increases in the meat group. CONCLUSIONS: High intake of milk and not meat, increased concentrations of s-IGF-I and s-IGF-I/s-IGFBP-3 significantly. Compounds in milk and not a high PI as such seem to stimulate IGF-I. This might explain the positive effect of milk intake on growth seen in some studies.