Minimum protein intake for the preterm neonate determined by protein and amino acid kinetics

Lower limits of protein needs in prematurely born neonates have not been adequately studied, yet providing protein in amounts maximizing accretion without excess is a goal in these infants' nutritional care. We hypothesized that with the use of amino acid oxidation methodology, it would be possible to define minimum protein requirement. Our objective was to investigate protein kinetics during short-term changes in protein intake by measurement of nitrogen balance and amino acid flux and oxidation using [(15)N]glycine, [(13)C]phenylalanine, and [(13)C]leucine tracers. Protein kinetics were examined in 21 preterm infants (gestational age: 29 +/- 3 wk; birth weight: 1091 +/- 324 g) at five protein intakes (1.0, 1.5, 2.0, 2.5, and 3.0 g x kg(-1) x d(-1)) with 1 d of adaptation to the test intakes. From nitrogen balance data, a protein need of 0.74 g x kg(-1 x -1) was estimated to achieve zero balance. For all three amino acids, flux and oxidation estimates were not different across protein intakes. Whole-body protein synthesis and breakdown estimates from [(15)N]ammonia data were 14.6 +/- 3.4 and 14.4 +/- 4.1 g x kg(-1) x d(-1), respectively. Glycine flux (680 +/- 168 micromol x kg(-1) x h(-1)) was greater than leucine flux (323 +/- 115 micromol x kg(-1) x h(-1)), which was greater than phenylalanine flux (84.3 +/- 35.2 micromol x kg(-1) x h(-1)). Leucine oxidation (36.7 +/- 15.6 micromol x kg(-1) x h(-1)) was also greater than phenylalanine oxidation (6.64 +/- 4.41 micromol x kg(-1) x h(-1)). Infants in our study were able to adapt to short-term changes in protein intake with little consequence to the overall whole-body protein economy, as measured by the three test amino acids.     

Systematic review and evidence-based consensus guideline on prevention of allergy and atopic eczema of the German Network on Allergy Prevention (ABAP)

Allergies are a meaningful public-health problem. Until now no evidence-based recommendations for allergy prevention exist. An evidence based guideline for primary and secondary prevention of allergies was developed in the course of the German Network on Allergy Prevention (Aktionsbündnis Allergiepr?ven-tion, ABAP) with support of the German Ministry of Health. Results of the systematic evidence search and the consented recommendations are presented here. After an appropriate search strategy was developed, a systematic literature search was performed in electronic databases (Cochrane library, MEDLINE, EMBASE). Furthermore four selected journals were hand-searched and reference lists of actual reviews as well as grey literature was screened. Some 3 500 references were retrieved initially and a two-stage filter process on the relevance was applied by screening titles and abstracts and subsequently full-text papers. For the critical methodological appraisal modifications of international checklists were used. A total of 323 studies were included and evaluated. These comprised 3 Cochrane Reviews, 7 meta-analyses, 37 randomized controlled trials (RCTs) as well as 102 cohort and 174 case-control-studies. The following levels of evidence were applied: 3x1a, 21x1b, 5x2a, 59x2b, 1x3a, 45x3b, 189x4. These studies were summarized in a form of a systematic review and corresponding recommendations were formulated. The latter were consented by members of the abap steering committee in two consensus meeting where the method of a nominal group process was applied. For the first time recommendations for the prevention of allergies were developed on a high methodological standard. The content and modifications reflect the existing evidence.     

Neonatal and maternal platelet cytosolic calcium in normotensive and hypertensive pregnancies.

A prospective study investigated platelet cytosolic calcium in non-pregnant volunteers (n = 30) and samples from the umbilical veins of babies from both normotensive (n = 18) and hypertensive (n = 15) primigravidae, and their mothers. There was no significant difference between the neonatal umbilical venous platelet cytosolic calcium concentration (p[Ca2+]i) in babies born to normotensive primigravidae or to those whose pregnancies were complicated by gestational hypertension (88 x 9 (SE) 2 x 5) in normotensive primagravidae, 80 x 6 (2 x 8) in pregnancy induced hypertension without proteinuria, and 89 x 3 (3 x 2) nmol/l in pre-eclampsia. There was also no significant difference in the p[Ca2+]i from the umbilical veins of the pregnancies studied and those of non-pregnant female volunteers in the follicular phase of their menstrual cycle. This was despite a gradual and significant rise in p[Ca2+]i with increasing severity of disease in the mothers of the babies studied (119 x 9 (4 x 1) in normotensive primagravidae, 130 x 8 (7 x 3) in pregnancy induced hypertension without proteinuria, and 148 x 2 (4 x 5 ) nmol/l in pre-eclampsia). The mean maternal p[Ca2+]i in the three samples returned to concentrations comparable with those in non-pregnant subjects by 12 weeks after birth. These data demonstrate no significant difference between the mean p[Ca2+]i in non-pregnant women and those obtained from the umbilical venous blood of normotensive or hypertensive primigravidae. They suggest that the functional hypoactivity of neonatal platelets is probably not secondary to a decrease in basal p[Ca2+]i. They also suggest that the progressively raised p[Ca2+]i in normal and hypertensive pregnancies might be due to a pregnancy specific factor that does not cross the placenta,     

The effect of short-term dimethylglycine treatment on oxygen consumption in cytochrome oxidase deficiency: a double-blind randomized crossover clinical trial

OBJECTIVE: To study the effectiveness of dimethylglycine (DMG) on oxygen consumption (VO(2)) in children with Saguenay-Lac-Saint-Jean cytochrome-c oxidase (SLSJ-COX) deficiency (OMIM 220111). STUDY DESIGN: In a crossover randomized double-blind clinical trial, 5 children with SLSJ-COX deficiency, who were stable and old enough to comply with VO(2) measurement, were treated with placebo or DMG for 3 days, and with the alternate treatment after a 2-week washout period. VO(2) was measured by indirect calorimetry before and after treatment. Dietary caloric intake was calculated for 3 days before each measurement. Mean caloric intakes per day were 1562 and 1342 kcal x m(-2) before and during placebo, 1,336 and 1,380 before and during DMG, respectively. RESULTS: DMG was well tolerated and, in all cases, resulted in markedly increased blood DMG levels (617 + 203 mmol x L(-1)), versus 0 to 2 mmol x L(-1) without treatment. Mean VO(2) was lower after administration of either DMG (-1 +/- 3 mL x min(-1) x m(-2)) or placebo (-6 +/- 4), but neither difference was statistically significant. There was no detectable effect of DMG treatment on blood levels of lactate, pyruvate, bicarbonate, or pH. VO(2) values of patients (range, 101-135 mL x min(-1) x m(-2)) were lower than published norms (150-160 mL x min(-1) x m(-2)). CONCLUSION: This study suggests that treatment with DMG does not substantially change VO(2) in children with SLSJ-COX deficiency.     

Validation of a [13C]bicarbonate tracer technique to measure neonatal energy expenditure

The use of a stable isotope-labeled [13C]bicarbonate infusion to measure energy expenditure is advantageous, as a complete collection of expired air is not required. This technique allows for facile measurements of energy expenditure in intubated neonates. The aim of the present study was to determine the accuracy of energy expenditure estimates in postsurgical neonates by using the [13C]bicarbonate method compared with the current standard, indirect calorimetry. Eight neonates who were receiving total parenteral nutrition [98 +/- 21 (SD) kcal x kg(-1) x d(-1); 3.1 +/- 0.7 (SD) protein g x kg(-1) x d(-1)] were studied on postoperative d 15.5 +/- 11.9. A primed continuous 3-h intravenous infusion of NaH13CO3 and indirect calorimetry were performed simultaneously. Energy expenditure was calculated separately from the Weir equation and from the dilution of 13CO2 in the breath in combination with the individual energy equivalents of CO2 from the diet. The rate of CO2 appearance and energy expenditure calculated from the bicarbonate method (0.725 +/- 0.021 mol x kg(-1) x d(-1); 89.5 +/- 2.5 kcal x kg(-1) x d(-1)) highly correlated (r = 0.94 and 0.98, respectively) with the CO2 excretion and energy expenditure determined by indirect calorimetry (0.489 +/- 0.016 mol x kg(-1) x d(-1); 60.2 +/- 2.0 kcal x kg(-1) x d(-1)) when analyzed nonproportionately to weight. Bland-Altman analysis demonstrated the 95% confidence interval to be +/- 8.2 kcal x kg(-1) x d(-1). Linear regression analysis revealed a highly statistically significant equation relating the two energy expenditures: Indircal (kcal/d) = -9.341 + [0.705 x Bicarb (dcal/d)]; p < 0.001, r2 = 96.4%. We conclude that energy expenditure in neonates can be accurately determined using the [13C]bicarbonate method and a regression equation. Therefore, the bicarbonate method may be useful for determining energy expenditure in neonates not readily accessible to indirect calorimetry, such as those being mechanically ventilated or on extracorporeal life support.     

Adaptation of glucose production and gluconeogenesis to diminishing glucose infusion in preterm infants at varying gestational ages

In preterm infants low plasma glucose concentrations are frequently observed. We hypothesized that the infants' ability to adapt endogenous glucose production to diminishing exogenous supply is disturbed, but will improve with increasing gestational age. Glucose production rate and gluconeogenesis were measured using stable isotope techniques with [6,6-2H2]glucose and [2-13C]glycerol in 19 preterm infants (10 < or = 30 wk and nine >30 wk gestational age) on d 5.0 +/- 1.4 of life. Exogenous glucose was administered at a rate of 33 micromol x kg-1 x min-1 followed by 22 micromol x kg-1 x min-1. In the first 2 h after the decrease in exogenous supply, plasma glucose concentration declined comparably in both groups: < or =30 wk, from 4.3 +/- 1.2 to 3.2 +/- 0.9 mM; >30 wk, from 3.7 +/- 0.7 to 3.0 +/- 0.6 mM. Thereafter, only in infants >30 wk an increase was observed, to 3.4 +/- 0.8 mM. Glucose production rate increased comparably in both groups: < or =30 wk, from 6.0 +/- 4.1 to 8.8 +/- 3.4 micromol x kg-1 x min-1; >30 wk, from 7.8 +/- 4.6 to 11.6 +/- 5.2 micromol x kg-1 x min-1. This increase was equivalent to approximately 30% of the decline in exogenous glucose. Gluconeogenesis increased comparably in both groups: <30 wk, from 3.2 +/- 1.2 to 4.5 +/- 1.3 micromol x kg-1 x min-1; >30 wk, from 4.3 +/- 1.9 to 6.8 +/- 2.9 micromol x kg-1 x min-1. We conclude that preterm infants can only partly compensate a decline in exogenous glucose supply by increasing endogenous glucose production rate, probably because of limitations in the final common pathway of intracellular glucose metabolism (i.e. glucose-6-phosphatase). The ability to maintain the plasma glucose concentration after a decrease in exogenous supply is better preserved in infants >30 wk owing to more efficient adaptation of peripheral glucose utilization.     

Pulsed Doppler sonographic determination of absolute flow velocities in the anterior cerebral artery in infants with hydrocephalus in comparison with a healthy patient sample

In 52 infants (weight: 3174 +/- 1165 g; gestational age: 41.3 +/- 6.5 weeks) with hydrocephalus pulsed doppler recordings were obtained in the anterior cerebral arteries. For comparison 52 healthy infants (weight: 3148 +/- 1118 g; gestational age: 40.6 +/- 5.7 weeks) were investigated. In all children the maximal systolic velocity, the end-systolic velocity, the end-diastolic velocity and the pulsatility-index were measured. In the healthy control group the maximal systolic velocity was 43 +/- 14 cm x s-1, the end-systolic velocity 20 +/- 8 cm x s-1, the end-diastolic velocity 11 +/- 5 cm x s-1 and the pulsatility index was 0.75 +/- 0.10. All 9 children with minimal ventricular dilation without progression showed normal flow profiles with normal flow velocities and pulsatility-index in the anterior cerebral arteries. 17 infants with moderate, slowly progressive ventricular enlargement showed significant increase of the maximal systolic velocity (60 +/- 27 cm x s-1) and the pulsatility-index PI (0.82 +/- 0.14). There was no difference in the end-systolic and end-diastolic velocities to the healthy control group. 26 children with marked and rapid progressive hydrocephalus showed significant decrease of the end-systolic and end-diastolic velocities and an increase in the pulsatility-index. The end-systolic velocity was 15 +/- 7 cm x s-1, the end-diastolic velocity was 4 +/- 7 cm x s-1 and the pulsatility-index measured 0.91 +/- 0.18. There was no difference in the maximal systolic velocity which measured 41 +/- 17 cm x s-1. All children with increased intracranial pressure showed a pathological flow profile with a decrease of diastolic forward flow. Absent or retrograde diastolic flow in rapid progressive hydrocephalus may lead to a decrease of brain perfusion resulting in hypoxemic ischemic brain lesions. After implantation of a ventriculo-atrial shunt an increase in the end-systolic and end-diastolic velocities and a decrease of the pulsatility-index could be shown. Shunt insufficiency can be shown early by a decrease in diastolic forward flow.     

Sodium and potassium metabolism in infancy]

BACKGROUND: Recommendations for the concentration of most nutrients in infant formulas are based on their concentration in human milk. Industry succeeded in adapting sodium and potassium content in infant formulas to concentration found in human milk. Whether this adaptation affects on infants' mineral balances was studied in breast-fed and artificially-fed infants. METHODS: Sodium and potassium balances were performed in 16 term male infants from their 3rd until their 17th week of life. The balances were performed at home and comprised up to five periods in intervals of three to four weeks. Each balance period consisted of subsequent three 24 h collections of milk, stool and urine samples. Ten infants were breast-fed, six received an adapted infant formula supplemented with copper, zinc and iron. RESULTS: The breast-fed infants got a mean intake of 1 mmol Na/kg b w x day and a mean intake of 1.8 mmol K/kg b w x day. Man retention was 0.4 mmol Na and 0.7 mmol K/kg b w x day. The formula-fed infants received 1.9 mmol Na/kg b w x day and 2.1 mmol K/kg b w x day. Na- and K-retention in this group was 0.5 and 0.6 mmol/kg b w x day respectively. Although sodium intake in the formula-fed infants was nearly twice as much as in the breast-fed infants the difference in sodium retention was only small (0.4 vs 0.5 mmol/kg b w x day). The formula-fed infants got more potassium than the breast-fed infants, but potassium retention was the same in both groups. CONCLUSIONS: With the adapted infant formula of this study the artificially fed infant was as well supplied with sodium and potassium as the breast-fed infant. A further reduction of the sodium concentration seems not to be useful.     

Tubular adenoma of the breast in a pregnant girl: report on a case.

A rare case of a tubular breast adenoma in a 13-year-old pregnant girl is presented. The tumor which developed during pregnancy measured 10 x 8 x 4 cm, was well demarcated and could be totally removed.     

Normal thyroid volume by ultrasonography in healthy children

With the objective of creating standards for the volume of the thyroid gland by ultrasonography in the 0-16-year age group, thyroid volumes of 302 healthy children (150 boys, 152 girls) were measured by ultrasonography. The transverse (x), sagittal (y) and anteroposterior (z) lengths of the right and left lobes and isthmus were measured. Volumes of these were calculated by the ellipsoid volume formula [V = (pi/6) x x x y x z]. Statistical analysis was done using the Kruskal-Wallis and Student t tests. The cases were divided into six and eight groups by age and height, respectively. There was a significant positive correlation between thyroid volume, age, height and weight. Thyroid volumes in children of 12 years and over were significantly different from those in the younger age groups.     

Peripheral blood stem cell transplantation in young children: experience with harvesting, mobilization and engraftment

The purpose of this study was to determine the feasibility and assess optimal timing of harvesting peripheral blood stem cells (PBSC) for transplantation in young children. Thirteen children with body weight less than 25 kg, mean age of 3.9 years (1-9 yrs) who had recurrent solid tumors and leukemia were given tumor specific chemotherapy followed by i.v. rhG-CSF (5 microg/kg/d) for stem cell mobilization. Cytaphereses were done through a central venous line (CVL) during the marrow recovery phase (WBC >0.5 x 10(9)/l). The phereses were analyzed separately and assigned to three groups depending on the WBC at the time of the pheresis: Group I (WBC <1.0 x 10(9)/l), Group II [WBC in the range 1.0-3.0 x 10(9)/l] and Group III (WBC >3.0 x 10(9)/l). Samples from each harvest were assayed for cell count, CFU-GM, BFU-E, CD34+ cell count, and tumor cell immunocytology in patients with neuroblastoma (NBL). A median of 3.2 x 10(8) mononuclear cells per kg (MNC/kg), [mean 2.8 x 10(8) MNC/kg, standard error of the mean (SEM) +/- 0.74 (1.1-4.7)] were infused following myeloablative therapy. 78 phereses were performed in 13 children with a median weight of 18 kg (10-25 kg). A median of 5 phereses were performed per patient. There were no significant differences in the percentage and number of CD34+ cells, CFU-GM or BFU-E colonies assayed by plating 0.5 x 10(5) cells. Differences could be found in the total number of MNC (p<0.008) and the number of MNC/kg (p<0.001) between Groups II and III. No tumor cell contamination was detected in the NBL patients by immunocytology. All patients were rescued with PBSC and achieved sustained white cell engraftment (ANC >0.5 x 10(9)/l) at a median of 13.5 d (10-25 d) and platelet engraftment (untransfused platelet count >20.0 x 10(9)/l) at a median of 29 d (12-63 d). The only toxicity encountered during the phereses was thrombocytopenia in 4 patients whose median post-pheresis platelet count was 6.0 x 10(9)/l (3.0-9.01). It is concluded that collection of PBSC in young children is feasible and safe and can be performed through a cuffed CVL at the time of WBC recovery post mobilization with chemotherapy and G-CSF. Cytopheresis can be effectively performed when the peripheral WBC count approaches 1.0 x 10(9)/l. Following stem cell infusion, engraftment was prompt and durable.     

An unusual cause for massive upper gastrointestinal bleeding in children: Dieulafoy’s lesion

Dieulafoys lesion is a rare cause of severe upper gastrointestinal hemorrhage in children and predominantly occurs in the proximal stomach. We report a case of massive upper gastrointestinal bleeding in a 3-year-old boy that originated from a Dieulafoys lesion and was treated by epinephrine injection.     

Acute psychosis in an adolescent girl during treatment for advanced nodular lymphocyte-predominant Hodgkin's lymphom

A 16,5 year old female adolescent was diagnosed with nodular lymphocyte-predominant Hodgkin lymphoma (nLPHL), presenting bilateral inguinal and right iliac lymphadenopathy accompanied by B-symptoms. The patient was due to treatment according to the German Interim Guidelines of HD 2002-Pilot Study with 2x OPPA (vincristine, adriamycine, prednisone, procarbacine) and 2x COPP (cyclophosphamide, vincristine, prednisone, procarbazine) and radiotherapy. After 2x OPPA the patient presented a severe episode of a presumably prednisone-induced acute psychosis with need for psychiatric treatment and change of therapy regimen. She was successfully treated with a chimeric monoclonal anti-CD20 antibody (rituximab) and subsequent radiotherapy.     

Effect of human milk and epidermal growth factor on growth of human intestinal Caco-2 cells

BACKGROUND: Epidermal growth factor (EGF) in human milk has been thought to be mitogenic for cell growth. This study investigated the effects of human milk and EGF on the growth of human intestinal Caco-2 cells to determine whether the action occurred through regulation of the cell cycle or through c-jun expression. METHODS: Cells were incubated with 5% human milk, 0.375 nmol/L EGF (relevant to EGF concentration in 5% human milk, 0.05 x EGF), 7.5 nmol/L EGF (1 x EGF), or 75 nmol/L EGF (10 x EGF). Cell numbers; cellular RNA, DNA, and protein concentrations; DNA content in the cell cycle, and expressions of c-Jun protein and mRNA were analyzed. RESULTS: Cell numbers increased in the 1 x and 10 x EGF groups at 48 hours. Cellular RNA increased in the 5% human milk and 10 x EGF groups. DNA and protein contents increased in the 1 x and 10 x EGF groups. The 1 x and 10 x EGF groups increased DNA content in the G1 phase compared with the 5% human milk group at 24 hours. The greatest c-jun protein expression was 2.6, 1.4, 1.8, and 1.9 times the control, and the c-jun mRNA increased by 202%, 14%, 150%, and 181%, respectively, in the 5% human milk, 0.05 x, 1 x, and 10 x EGF groups. CONCLUSIONS: In a dose-dependent manner, EGF stimulated intestinal growth in vitro, by increasing DNA content in the G1 phase and c-jun mRNA expression. However, low concentrations of human milk (5%) and its equivalent EGF did not affect cell growth.     

Accuracy of blood pressure measurement by the Dinamap monitor in infants and children

Indirect BPs measured by the Dinamap monitor, an oscillometric device, and the conventional auscultatory method were compared with the direct radial artery pressure in infants and children. There were 29 patients in the Dinamap group with a median age of 18 months (ranges 1 month to 16 years) and 20 patients in the auscultatory group with a median age of 3.5 years (ranges 3 months to 16 years). The direct radial artery pressures were recorded on a strip chart and the ranges of pressures were obtained for systolic, diastolic, and mean pressures. The range of the direct readings was converted to a weighted single reading, and comparisons were made between the direct and indirect readings. The linear regression equation between the direct (x) and the Dinamap (y) readings (with correlation coefficient) was y = 1.05x - 5.36 (r = .97) for systolic, y = 1.10x - 4.65 (r = .903) for diastolic, and y = 1.06x - 4.21 (r = .917) for mean pressures. The linear regression equation (with correlation coefficient) for the auscultatory pressure was y = 1.60x - 68.23 (r = .872) and y = 1.38x - 16.47 (r = .874) for diastolic pressures. The error was defined as the indirect reading minus the direct reading. The mean error +/- SD was -0.24 +/- 3.26 for systolic, 1.28 +/- 4.74 for diastolic, and 0.10 +/- 4.56 mm Hg for mean pressures by the Dinamap method. It was -1.65 +/- 6.68 for systolic, and 8.70 +/- 5.97 for diastolic pressures by the auscultatory method.(ABSTRACT TRUNCATED AT 250 WORDS)     

Delayed separation of the umbilical cord and partial deficiency of sialyl lewis X antigen

A 5-week-old male infant presented with failure of separation of the umbilical cord. He was evaluated for the presence of integrin and selectin ligand leukocyte adhesion molecules on his neutrophils and monocytes. Integrin molecules appeared to be normally expressed, but expression of sialyl Lewis X (sLe(x)) was decreased. The expression of sLe(x) gradually increased, and the umbilical cord separated at 10 weeks of age. Further study revealed decreased numbers of sLe(x)-positive neutrophils with a lower mean fluorescence intensity on neutrophils from cord blood compared to neutrophils in adult peripheral blood. This study indicates that this patient had an uncommonly low level of sLe(x) expression and infers that adequate expression may be required for the inflammatory reaction needed for umbilical cord separation.     

A pilot trial of tandem autologous peripheral blood progenitor cell transplantation following high-dose thiotepa and carboplatin in children with poor-risk central nervous system tumors

This is a pilot study performed to determine the maximum tolerated number of courses of high-dose thiotepa and carboplatin with autologous peripheral blood progenitor cell (PBPC) transplantation in poor-risk pediatric central nervous system (CNS) tumor patients. Twelve patients were enrolled and a total of 24 PBPC transplants were performed. The median age was 7.7 years. All patients had CNS tumors: 4 relapsed CNS PNET, 2 high-risk PNET in first remission, 2 relapsed/progressive brainstem tumor, 2 relapsed/progressive anaplastic astrocytoma, 1 relapsed GBM, and 1 recurrent ependymoma. The regimen consisted of thiotepa 250 mg/m2/day x 3 days and carboplatin 400 mg/m2/day x 3 days. No toxic deaths occurred. All patients were hospitalized for a median duration of 17 days. The median number of CD34 cells infused was 5.4 x 10(6)/kg (2.1-29.7 x 10(6)/kg) per course. Median time to ANC > 0.5 x 10(9)/L was 9 days, and platelets > 20 x 10(9)/L was 13.5 days. Four patients came off protocol after only one course of PBPC (2 had tumor progression, 2 parental choice); 4 patients underwent two, and 4 patients three courses of PBPC. Major nonhematologic complications were mucositis that necessitated infusion of narcotics (11/24 courses), fever of unknown origin (12/24), documented infection (9/24), and hemorrhagic cystitis (3/24). TPN was administered during 22 of 24 courses with a median duration of 15 days. It isfeasible to administer 2-3 courses of tandem high-dose thiotepa and carboplatin with PBPC transplant with prompt engraftment and manageable toxicities in pediatric CNS tumor patients.     

The IgG subclass level in children and adolescents with malignant diseases]

Children with malignant disease have an increased risk for bacterial infections. We investigated a possible correlation between septic episodes and decreased IgG subclass levels in 63 patients. At diagnosis 13 of 50 children showed decreased IgG subclass levels: 10x IgG4, 2x IgG1, and 1x IgG3 + IgG4 were reduced. Bone marrow infiltration by tumor cells did not increase the frequency of subclass reductions (4/25 with, 9/25 without bone marrow infiltration). The time course of subclass levels was followed during 37 febrile episodes (mainly fever of unknown origin, septicemia, pneumonia) of 23 children under cytostatic therapy. 6 patients showed transient low IgG subclasses: 2x IgG4, 1x IgG1, 1x IgG3, 1x IgG2 + IgG4, and 1x IgG1 + IgG3 + IgG4. Children with decreased IgG subclass levels appeared to occur more independently of leucopenia. In general, febrile episodes in children with subclass decreases did not last a longer period and did not occur more frequently than in children without IgG subclass deficiencies. In conclusion, the determination of IgG subclasses in cancer children at diagnosis or during chemotherapy did not add substantial information of prognostic or therapeutic relevance.     

Value of serum sialic acid determination in children]

In order to find out whether sialic acid (SA) is suitable as a tumor marker this compound was determined in the sera of 48 healthy and of 168 sick children. In healthy children under six months of age lower concentrations of SA were found (x = 41 +/- 5 mg/dl) than in subjects aged six months to 18 years (x = 68 +/- 8 mg/dl). Inflammatory diseases of various etiologies lead to a significant increase in both age groups (x = 93 +/- 28 mg/dl), the same could be observed in subjects up to 14 days after surgery. In children with malignant disorders the concentration of SA was significantly higher (x = 83 +/- 27 mg/dl) than in the healthy subjects, but not higher than in patients with inflammatory diseases. We conclude that SA might play a role in the follow up protocol of patients with malignant tumors.     

Changes in left ventricular strain parameters following pediatric heart transplantation

STE is increasingly utilized to assess strain in a variety of pathologies. Strain measurements have demonstrated utility following HT x and may aid in the detection of rejection and CAV . Strain parameters have not been well defined in the pediatric HT x population. This study aimed to describe strain in pediatric HT x recipients compared to controls and assess changes over time. All pediatric HT x recipients with available echocardiograms (2004‐2015) without rejection or CAV were identified. Longitudinal and circumferential strain was measured at <1 month, 1 year, 3 years, and 5 years post‐transplant and compared to controls. A total of 218 echocardiograms were analyzed in 79 HT x recipients. At <1 month post‐transplant, there was a significant decrement in longitudinal strain (GLS ?14.6 vs ?19.2, P  < .001) with concurrent augmentation of circumferential strain (GCS ?27.3 vs ?24.3, P  = .005). By 1 year post‐HT x, all strain parameters normalized and were not significantly different from the control population. In the absence of graft complications, strain parameters did not change up to 5 years post‐transplant. Abnormal longitudinal strain parameters are present in the early post‐HT x period with a compensatory increase in circumferential strain. These changes normalize by 1 year post‐transplant and do not change over time in the absence of graft complications.