HOW TO APPROACH THE CHILD SUSPECTED OF MALABSORPTION Experience from a Prospective Investigation of Suspected Malabsorption in Children 1968–1976 in Malmö

ABSTRACT. 180 children (mean age 20 months) suspected of malabsorption because of failure to thrive, abnormal stools more than 3 weeks, vomiting, an/or abdominal distension were investigated with peroral small intestinal biopsy at duodeno-jejunal flexure (172 children) and/or duodenal intubation for analysis of trypsin and amylase activity in duodenal juice before and after a test meal of water (76 children). Results of xylose tolerance test, lactose tolerance test, faecal fat, B-folate, S-iron, and S-albumin were related to morphology of mucosa. A normal finding of one of these tests means in 15–26% a normal mucosa (diagnostic sensitivity). An abnormal finding means in 40–85% a severely damaged mucosa and in 85–100% a slightly, moderately, or severely damaged mucosa (diagnostic specificity). Combinations of these tests increase the diagnostic sensitivity 10–15%. Faecal chymotrypsin seems to be a reliable screening test for exocrine pancreatic function. Border values or low values indicate a direct evaluation of exocrine pancreatic function. The simple test meal (water) method with determination of trypsin in duodenal juice gives, from a practical point of view, good information of the exocrine pancreatic function.
The following plan of investigation is proposed: Step 1. careful clinical history and examination; Step 2. analysis of faeces for Giardia lamblia, entero-pathogenic microorganisms, and chymotrypsin, sweat test; Step 3. peroral small intestinal biopsy and/or duodenal juice analysis, and finally—if steps 2 and 3 give normal results; Step 4. re-evaluation of dietary history and tests to detect any food intolerance (e.g. carbohydrate).     

RENAL FUNCTION IN CYSTIC FIBROSIS WITH SPECIAL REFERENCE TO THE RENAL SODIUM HANDLING

ABSTRACT. Renal function was studied in 16 patients with cystic fibrosis, aged 5 to 19 years. The mean glomerular filtration rate and filtration fraction were increased compared to those in controls. Basal urinafy sodium excretion as well as renal responses to oral and intravenous sodium loads were low, indicating an increased renal sodium reabsorption. Diluting capacity, measured as free water clearance, was decreased because of a low distal sodium delivery which might indicate an increased proximal sodium reabsorption.     

Thoracic epidural analgesia in aortocoronary bypass surgery II: effects on the endocrine metabolic response

Thoracic epidural analgesia (TEA) may offer haemodynamic benefits for patients with coronary heart disease going through major surgery. This may – in part – be secondary to an effect on the endocrine and metabolic response to surgery. We therefore investigated the effect of TEA on the endocrine metabolic response to aortocoronary bypass surgery (ACBS).
Thirty male patients (age < 65 years, ejection fraction > 0.5) were randomized into 3 groups; the HF group receiving a high dose fentanyl (55 μg–kg^-1) anaesthesia, the HF + TEA group with the same fentanyl dose + TEA with 10 ml bupivacain 5 mg ml^-1, followed by 4 ml every hour, and the LF + TEA group receiving fentanyl 15 μg kg^-1 + TEA. Adrenalin, noradrenalin, systemic vascular resistance (SVR), glucose, Cortisol, lactate and free fatty acids were followed during the operation and for 20 h postoperatively.
A significant increase in adrenalin, noradrenalin and SVR was found in the HF group whereas this increase was blocked in both epidural groups. An increase in glucose and Cortisol was noticed in all groups, but the increase was delayed in the epidural groups.
Our results suggest that a more effective blockade of the stress response during ACBS is obtained when TEA is added to general anaesthesia than with high dose fentanyl anaesthesia alone.     

A survey of pediatric caudal extradural anesthesia practice

Background:  Caudal extradural blockade is one of the most commonly performed procedures in pediatric anesthesia. However, there is little information available on variations in clinical practice.
Objectives:  To perform a survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland who undertake caudal anesthesia.
Methods:  An 'online' World Wide Web questionnaire collected information on various aspects of clinical practice. The survey ran from April to June 2008.
Results:  There were 366 questionnaires completed. The majority of respondents had >5 years of pediatric experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. There was a trend toward the use of a cannula in those anesthetists with <15 years experience, while those with >15 years experience tended to use a needle. Most anesthetists (91.5%) did not believe that there was a significant risk of implantation of dermoid tissue into the caudal extradural space. The majority used a combination of clinical methods to confirm correct placement. Only 27 respondents used ultrasound. The most popular local anesthetics were bupivacaine (43.4%) and levobupivacaine (41.7%). The most common additives were clonidine (42.3%) and ketamine (37.5%). The caudal catheter technique was used by 43.6%. Most anesthetists (74%) wear gloves for a single shot caudal injection.
Conclusions:  This survey provides a snapshot of current practice and acts a useful reference for the development of enhanced techniques and new equipment in the future.     

Production and characterization of a monoclonal antibody reactive with a specific neoantigenic determinant (comprising B beta 54-118) in degradation products of fibrin and of fibrinogen

Balb/c mice were immunized with a mixture of fibrin degradation products (XDPs) prepared by complete lysis of a human blood clot by tissue-type plasminogen activator and purified by immunoaffinity chromatography. Spleen cells of the mice were fused with P3 X 63 Ag 8653 myeloma cells. A clone (FDP 14) was selected that produces monoclonal antibodies (MoAbs) of the IgG1 kappa type that react with a neoantigenic determinant exposed in these XDPs, but not in intact fibrinogen or in fibrin monomers. Furthermore, the MoAb is reactive with some pure, individual degradation products of fibrinogen (fragments X, Y, E, and the N-terminal disulphide knot) and with the fibrinogen B beta-chain but not with A alpha- and gamma-chains or with fragments D, FCB-2 and FCB-3. Comparison of the known primary structures of these fibrinogen fragments indicates that the stretch B beta 54-118 comprises at least an important part of the epitope recognized by FDP-14. Apparently, this stretch contributes importantly to a neoantigenic determinant that is not functional in intact fibrinogen and fibrin monomer and that can be made functional by reduction of fibrinogen, or by digestion with plasmin or CNBr.     

Training in Controlled Drinking for Early-stage Problem Drinkers

Forty-eight early-stage problem drinkers were recruited through a newspaper announcement and randomly assigned to one of four outpatient treatment groups: (1) Bibliotherapy- Behavioral Self-Control Training (BSCT), (2) BSCT-therapist directed, (3) Training in Coping Skills and (4) a combination of BSCT and Coping Skill Training. The weekly alcohol consumption in all groups decreased significantly from intake to 3, 6 and 12 month follow-up. There were no significant differences among the groups. At the same time the number of life problems decreased significantly. The majority of the clients reduced their alcohol consumption during the assessment period, before treatment started. The absence of a non-treatment control group means that we cannot be sure about the reasons for this early change. Theoretical implications of these results are discussed.     

Spondylometaphyseal dysplasia, corner fracture type: a heritable condition associated with coxa vara

The authors present the radiographic features of a previously incompletely delineated bone dysplasia, which they call spondylometaphyseal dysplasia, corner fracture type. This is a dominant heritable condition associated with short stature and developmental coxa vara. The progressive hip deformity usually causes significant disability requiring surgical correction. Developmental coxa vara, simulated corner fractures of long tubular bones, and vertebral body abnormalities result in a diagnostic constellation. Knowledge of these distinctive radiologic features allows accurate diagnosis, which in turn should lead to appropriate genetic counseling and possibly to earlier, more efficacious surgical treatment of the coxa vara.     

Cuff Pressures and Doppler Gradients after Coarctectomy A Long-term Follow-up

ABSTRACT. Fourty-six adult patients operated on as chidren with resection and end to end anastomosis because of coarctation of the aorta were studied. The age at operation was 7 to 13 years (mean age 10 years) and at follow-up 18 to 28 years (mean age 21 years). Arm and thigh cuff pressure was measured at rest, during and immediately after submaximal exercise. The systolic gradients were also estimated using continuous wave Doppler. Systolic blood pressure at rest was 150 mmHg or more in 12 patients (26%). The cuff pressure at rest correlated well with arm-leg gradients at rest and at work, and also with the Doppler gradients at rest. Doppler gradients slightly underestimated invasively measured gradients. The results imply that postoperative hypertension was explained by residual mechanical obstruction.