Cytokines and growth factors in children with burns, relation to burn surface area, sepsis and survival

Burn is a unique injury which is not only devastating for the patients but also puts a great burden on the society by consuming enormous health care resources. Despite improvements in burn wound care and treatment, understanding the role of pro-inflammatory, anti-inflamatory cytokines as well as the mechanisms responsible for the healing process remains to be clarified. Although leptin is regarded as a circulating hormone, it can exert direct effect on T cells and monocytes, causing the release of cytokines. It may induce angiogenesis or influence angiogenic factors. The aim of the present work is to determine serum levels of leptin, TNFalpha, IL-6, TGFalpha, and bFGF, PCT and CRP in a group of children with thermal burn and to determine the changes in these parameters in relation to the duration of hospital stay, the presence of infection and the total burn surface area. The study included 42 children with burns. They were 22 males and 20 females. Their ages ranged from 2 months to 7 years. The study also included 26 age matched controls. Beside full clinical assessment including assessment of total burn surface area [TBSA] and the presence or absence of sepsis, all the cases and controls had the following investigations done: CBC, C-reactive protein [CRP], IL-6, TNFalpha, procalcitonin [PCT], serum leptin, basic fibroblast growth factor [bFGF], and transforming growth factor alpha [TGFalpha]. The fatality rate in this study was 28.6%. Burn cases as a whole showed significantly higher values of WBC, CRP, PCT, TNFalpha, IL-6, leptin, bFGF, and TGFalpha than controls. Cases with sepsis showed significantly higher values of WBC, CRP, PCT, TNFalpha and lL-6 than cases without sepsis. They showed significantly lower values of TGFalpha than cases without sepsis. Patients with larger TBSA [>30%] showed significantly higher levels of WBC, CRP, PCT, TNFalpha and lL-6 and leptin than cases with smaller TBSA. They showed significantly lower levels of bFGF, and TGFa than cases with smaller TBSA. Nonsurvivors showed significantly higher levels of WBC, CRP, PCT, TNFalpha and IL-6 than survivors. They showed significantly lower levels of leptin, bFGF, and TGFalpha than survivors. Correlation studies showed significant positive correlation between TBSA and each of IL-6, TNFalpha and leptin. Cytokines and leptin were increased in severe burn cases, cases associated with sepsis as well as in fatal cases. bFGF and TGFalpha levels were lower in severe cases. This may point to the impaired healing and to the poor prognosis in such cases. Recommendations: It is highly recommended to monitor immunologic parameters such as PCT and/or IL-6 for early detection of infectious complications following thermal injury. Leptin can be regarded as a novel treatment modality to diminish burn induced inflammation, to reduce post burn immune dysfunction and to enhance burn healing

study on transfusion-transmitted viral infections in thalassemic children

Beta- thalassemia syndromes are the most common causes of chronic haemolytic anemia in Egypt. The disease appears early in life as a Variable degree of anaemia associated with splenomegaly, stunted growth, bone changes and mongoloid facies. Patients are usually treated with regular blood transfusion which leads to iron overload and therefore chelation therapy is very important to avoid iron overload and its complications. The patients may have immunological abnormalities mostly due to iron overload, repeated exposure to allogenic antigens and immunosuppressive viruses in blood transfusions, desferrioxamine chelation therapy and splenectomy. Infection has been reported to be one of the main causes of morbidity and mortality in beta-thalassemia. It is described as the second most common cause of death in these patients with a prevalence of 12-13%. Besides the well-known risks of blood-borne infections associated with multiple transfusions, a less familiar clinical problem is the increased susceptibility of these patients to infections, due to the coexistent immune deficiency. One of these infections may be parvovirus B19. Parvovirus B19 is a single-stranded DNA virus. The virus is classified as a member of the erythrovirus genus because replication occurs only in human erythrocyte precursors. This work was designed to study some transfusion related viral infections in thalassemic children attending the hematology unit of Pediatrics department of Assiut University and to discuss the possible predisposing and underlying factors. The study was carried out in the period between September 2004 and October 2005 in the departments of clinical pathology and pediatrics, Assiut university hospital, Egypt It included 50 individuals, 35 transfusion-dependant children with beta-thalassemia major, aged 2 to 15 years and 15 apparently healthy children as a control group. Patients recruited in the study had thorough history taking and complete clinical examination. In addition, the following laboratory investigations were performed for all cases and controls: complete blood picture including reticulocytic count and calculation of the reticulocytic index; liver functions, [iron status [including serum iron, TIBC and ferritin]; human parvovirus B19 IgG; Hepatitis C virus antigen by PCR and antibodies [HCV-Abs] by ELISA, hepatitis B virus surface antigen [HBsAg], and human immunodeficiency virus types 1 and 2 antibodies by ELISA. Thalassemic patients had significantly lower Hb, RBCs and TIBC and significantly higher reticulocytic count, reticulocytic index, serum iron, serum ferritin, serum bilirubin, AST and ALT than the controls. The studied patients had 83% positivity for Parvovirus lgG antibodies, 97% for Hepatitis C IgG antibodies, 80% for Hepatitis C antigen by PCR. Patients had significantly lower CD4 T lympocytes, higher CD8 T lymphocytes than the controls. CD4/CD8 ratio was also inverted in the patients. Parvovirus positive cases had significantly lower Hb, RBCs, reticulocytic count and index and significantly higher AST and ALT than parvovirus negative cases. Serum ferritin, parvovirus IgG, and CD8 T lymphocytes correlated positively with the number of blood transfusions. Parvovirus lgG correlated positively with AST and ALT and negatively with reticulocytic count. Infectious complications constitute an important part of the clinical spectrum of beta-thalassemia, being associated with significant morbidity and mortality. The recently recognized immune defects in these patients involve multiple components of the immune system and have been attributed to specific features of the disease, as well as to the therapeutic modalities applied. Iron overload, a primary complication of both thalassemia itself and transfusion therapy, is thought to be the main precipitating mechanism, due to the important immunoregulatory properties of iron and its binding proteins. Iron excess may derange the immune balance in favor of the growth of infectious organisms. Other factors include multiple transfusions, associated with constant allo-antigenic stimulation, as well as with transmission of immunosuppressive viruses including the parvovirus B19. Infection with this virus in thalassemic patients can lead to persistent anemia indicated by reticulocytpenia and decreased reticulocytic index. Surveillance for infections in patients with beta-thalassemia is crucial, while additional studies are required to establish more clearly the clinical significance of the suspected precipitating mechanisms, hence providing new methods for the further amelioration of the survival rate and quality of life. Blood or blood products intended for use in high-risk groups such as immunocompromised individuals and patients with underlying hematological problems should be screened for B19. New inactivation methods for blood or blood products should be implemented to reduce the transmission of the parvovirus B19 via blood transfusion. Screening of blood donors for B19 can be an alternative to viral inactivation. Regular chelation therapy is a must to prevent the effects of the iron overload on the immune response. lntroduction of parvovirus B19 vaccines particularly for the immunocompromised patients may be helpful in the near future

frequency of celiac disease, TB enteritis and giardiasis among children with chronic diarrhea

Chronic diarrhea is one of the most common causes of referral to a gastroenterology clinic. Chronic diarrhea may result from many different causes; celiac disease is one of them. Other important causes in our locality are infections such as TB and Giardiasis. This work was planned to determine the frequency of celiac disease, TB enteritis and Giardiasis among children referred to the gastroenterology unit with the complaint of chronic diarrhea and to evaluate the different methods used in the diagnosis of each disease. The study included 92 patients with chronic diarrhea. Their ages ranged from 6 months to 15 years. They were 56 males and 36 females, admitted to the Pediatric gastroenterology unit, Assiut University Hospital during the period from January 2005 to December 2006. Besides full history and thorough clinical examination, the following investigations were done for all cases: stool analysis for three consecutive days, CBC, ESR, total proteins and serum albumin, tuberculin test, accelerated BCG test [in tuberculin negative cases], serum antiendomysial antibodies. Upper GIT endoscopy with duodenal biopsy and aspiration and tissue staining by H and E and by immuno-histochemistry [anti-tTG moAbs] to detect tTG antigens in biopsy specimens. Lower GIT endoscopy with biopsy sampling and histopathological examination of biopsy specimens was also done. Out of the total patients, 18 cases [19.5%] were positive for celiac disease by AEM antibodies while 16 were positive by tTG immunostaining of biopsy specimens. Fourteen patients [15.2%] had tuberculous enterocolitis while 12 [13%] had biopsy proven Giardiasis. On the other hand 48 patients [52.1%] had other undiagnosed causes of chronic diarrhea. A very high index of suspicion for celiac disease should be maintained for patients who present with chronic diarrhea or iron deficiency anemia. The best method for diagnosis of celiac disease in such patients is serological testing followed by a small-bowel biopsy. The diagnosis of intestinal tuberculosis is difficult due to the lack of specific symptoms and signs. Colonoscopy with ileoscopy is a useful method for diagnosis of intestinal TB. Gastrointestinal endoscopy with biopsy examination is an important method of diagnosis and follows up of children with Giardiasis

Upper and lower gastrointestinal endoscopy in children attending Sohag University Hospital: indications and results

Gastrointestinal disorders in children represent a broad spectrum of acute and chronic conditions including congenital, infectious, inflammatory metabolic and rarely neoplastic disorders. The development of endoscopic instruments to evaluate different parts of the gastrointestinal tract improved significantly the information about diseases affecting the gastrointestinal tract and its management. The addition of endoscopic examination to the investigations of gastrointestinal disorders in children has greatly transformed the practice of pediatric gastroenterology. The present study included 197 children referred for endoscopic examination during the period of October 2002 to September 2005, aged from 3 months to 16 years [average 5.7 years] and 55% of them were males. Referral to the pediatric endoscopy unit was a part of investigating various gastrointestinal disorders. One hundred thirty two patients [67%] were referred for upper gastrointestinal endoscopy while 65 patients [33%] for lower endoscopy. The results showed that, out of 50 patients who presented with [UGIB, 34% had esophago gastric varices: 32% were esophageal and 2% fundal varices. Injection sclerotherapy was done successfully for 5 patients with varices. The second common endoscopic finding in patients with UGIB was erosive and/or hemorrhagic gastritis [28%] followed by duodenitis [8%] and esophagitis [6%]. A combination of esophago-gastro-duodenitis was detected in 6% of the patients. Out of the 30 patients presenting with unexplained vomiting gastritis was the most common endoscopic and histological findings followed by esophagitis and duodenitis. In patients with suspected malabsorption, upper endoscopy revealed pale mucosa in 32% and edematous mucosa in 28% of the cases. In 40% of the cases, no abnormalities could be found. Biopsy examination revealed villous atrophy in 64% and a picture compatible with Crohn's disease in 28%. However, in 8%, no histological abnormality was detected. In patients with unexplained recurrent abdominal pain, UGIE revealed abnormalities in 55% [30% gastritis, 15% duodenitis, and 10% duodenal ulcer]. However, in 45% no abnormality could be detected. Histological abnormalities were found in 90% of cases; 45% active gastritis and Helicobacter pylori [HP] organisms in the antral region, 30% active gastritis without HP and 15% active duodenitis with the HP in the antral region. Collectively, HP organisms were detected in 60% of cases with unexplained RAP. Esophagitis was detected endoscopically and histologically in all cases with dysphagia. In two cases, impacted foreign bodies [a coin and a hair pin] were detected and removed successfully during the same endoscopic examination. Bleeding per rectum was the most frequent cause to do colonoscopy in children. Endoscopically, polyps were the most common detected abnormality [47.37%] followed by colonic inflammation [31.58%]. Histologically, benign juvenile polyps were the most common [28.95%] followed by bilharzial polyps [18.42%], nonspecific colitis [15.79%] and lastly allergic colitis [15.79%]. Endoscopic examination of children with bloody diarrhea revealed various lesions including erythema, edema, mucosal ulceration and/or white exudate in the rectum and colon in 86.67% of the cases. Biopsy examination showed a picture of pseudo-membranous colitis in 53.33%, and ulcerative colitis in 13.33%. In 12 patients with unexplained lower abdominal pain, endoscopy revealed erythema, erosions and minute ulcers in 4 of them while biopsy examination revealed nonspecific proctocolitis in 8 cases. Pediatric gastrointestinal endoscopy is a valuable and informative diagnostic procedure and can be performed safely with the use of intravenous sedation. Therapeutic maneuvers can be also applied as foreign body removal, sclerotherapy and polypectomy. Gastrointestinal bleeding is the commonest indication for endoscopic examination in children. Variceal bleeding represents the major cause of upper gastrointestinal bleeding while colonic polyps are the commonest cause of lower gastrointestinal hemorrhage. Helicobacter pylori infection is increasingly recognized in children and needs further studies to identify its relations to different gastrointestinal complaints in such children. Antibiotics induced diarrhea and pseudo-membranous colitis represent a problem in pediatric practice particularly in infants. Hence, antibiotic prescription should be done according to standardized guidelines. Endoscopic examination can demonstrate definite organic lesions that are necessary for diagnosis. However, a negative endoscopy with normal findings has its role in either reassurance of parents and diagnosis of functional disorders

cardio-pulmonary study on thalassemic children: relation to oxidant antioxidant balance and iron overload

beta-Thalassemia major is a common inherited disorder of hemoglobin synthesis in which iron overloading from regular blood transfusions results in organ dysfunction. Heart and liver dysfunction in thalassemia have been extensively-studied owing to their early effect on survival. Pulmonary dysfunction on the other hand is one of the least understood complications of beta-thalassemia major and represents one of the least studied complications in thalassemic patients. The aim of this study was to define the spirometric pattern and the possible causes of lung impairment in thalassemic patients. The study included 39 thalassemic patients [19 females and 20 males], with an age range from 8 to 16 years. Eighteen controls of matched age and sex were included in the study. A complete history was taken and a thorough physical examination was performed. In addition, the following investigations were done before blood trans fusion: Hb, serum ferritin level, AST, ALT, erythrocytic thiobarbituric acid reactive substance [TBARS], super oxide dysmutase [SOD]'glutathione peroxidase [GPx], serum TBARS, SOD, glutathione [GSH], and vitamins A, C and E. Echocardiography was also done for all patients, the day before blood transfusion. Pulmonary function testing and arterial blood gases were performed prior to blood transfusion and 24 hours after blood transfusion. Restrictive lung pattern was predominant in beta-thalassemia major patients. This was manifested by a significantly lower FVC and a significantly higher FEV1/FVC in the studied patients than the controls. FVC carried significant negative correlation with ferritin. Patients had significantly higher values of TBARS and significantly lower values of serum SOD, GSH and the erythrocytic SOD and GPx and vitamins [E, A and C]. FVC carried significantly negative correlation with TBARS and significantly positive correlations with erythrocytic SOD, GPx, vitamins A and E. LVESD and LVEDD were significantly higher in the studied patients than the controls and both correlated negatively with FVC. EF, FS and PAT were significantly lower in the studied patients. EF and FAC correlated positively with FVC. L VESD and LVEDD correlated positively with ferritin and TBARS but negatively with GPx. restrictive lung disease was found to be the predominant pulmonary dysfunction in thalassemia major patients. This seems to be related to ferritin level, and might reflect the role of iron deposition and accumulation in the pathogenesis of pulmonary disease in thalassemia major. The restrictive pattern may also result from excess oxidative damage to the alveolar tissue or from cardiac changes that occurred in these patients. Accurate and early evaluation as well as follow up of pulmonary function and of bronchial reactivity is advisable for all patients with TM. Initial and follow up of cardiac performance in patients with thalassemia major is also important as it has a great impact on pulmonary functions in these patients. An ultimate goal in the management of thalassemia major is to design and try a combination of oral antioxidants and oral iron chelator to achieve good patient's compliance with the ease of administration for such patients who are living on repeated blood transfusion and hospital admission

Helicobacter pylori infection in children with refractory iron deficiency anemia [RIDA]

The prevalence of iron deficiency anemia [IDA] varies widely between developed and developing countries and is related to many factors. If iron therapy does not produce the expected results, patient compliance with the prescribed medication should be insured, and if confirmed, the diagnosis of IDA should be reevaluated. Continued iron therapy in the absence of iron deficiency can produce iron overload. Refractory Iron Deficiency Anemia accounts for about 15% of all IDA. Previous reports by many authors suggested that there was a relation between Helicobacter pylori [H. pylori] infection and IDA. The aim of the present work is to determine the prevalence of H. pylori infection among patients with RIDA, to describe the clinical presentation of H. pylori infection among these patients and to determine the value of serum immunoglobulin G, and immunohistochemistery in diagnosing H. pylori infection and finally to describe the histopathological changes in gasrtic biopsy of these patients. The study included 40 cases with RIDA [Hb < 10gm/dl, not responding to oral iron therapy for three months]. They were attending the Hematology unit and children hospital, Assuit University during the period June 2003 to May 2004. They were 31 males and 9 females and their ages ranged from 4 to 13 years. The study also included 10 apparently healthy children of matched age and sex as a control group. Children with positive Tuberculin test, PEM, malabsorption particularly Celiac disease, myeloproliferative, connective tissue disease and those with repeated overt blood loss were excluded from the study. In addition to careful history taking and thorough clinical examination, the following investigations were done: complete blood picture, urine analysis, stool analysis for three consecutive days, stool analysis for occult blood, serum iron, TIBC, serum ferritin, Hb electrophoresis and serum IgG for H. pylori. Patients were subjected to upper gastrointestinal endoscopy and gastric biopsies were taken for Monoclonal antibody against H. pylori [1HC], and for pathological changes by H and E stain. Identification of H. pylori using other stains namely Giemsa and Leung was also done. Triple therapy was given to eradicate H pylori infection and follow up by hem atological profile and iron status was done. Out of the cases with RIDA, 40% were 4 times during the study period. Serum IgG for H. pylori was positive in 32.5% of cases and in 20% of the control. IHC staining for H. pylori was positive in 50%. Sensitivity of IgG for H. pylori was 60%, specificity was 95%, positive predictive value was 92%, negative predictive value was 70% and accuracy was 76%. There was significantly higher frequency of RAP among cases positive for H. pylori IgG than among negative ones. There was also a significantly higher frequency of anemic heart failure and repeated blood transfusion among positive cases for IgG than the negative ones. H. pylori organisms were detected in 50% of the cases by IHC staining. There was significantly higher frequency of positive IHC for H. pylori among cases > 6 years and among males. There was significantly higher frequency of RAP in the positive cases for H. pylori by IHC than in the negative cases. In addition, the frequency of cases with Hb

Celiac disease, TB enterocolitis and giardiasis among children with chronic diarrhea: the accuracy of ANT-EMA and tTG expression in the diagnosis of celiac disease

Chronic diarrhea is one of the most common causes of referral to a gastroenterology clinic. Chronic diarrhea may result from many different causes; celiac disease is one of them. Other important causes in our locality are infections such as TB and Giardiasis. This work was planned to: 1-Determine the frequency of celiac disease, TB enteritis and Giardiasis among children referred to the gastroenterology unit with the complaint of chronic diarrhea and to evaluate the different methods used in the diagnosis of each disease. 2- Verifying the diagnostic accuracy of immunohistochemical tTG expression versus serum anti-endomysial antibodies [EMA] in celiac disease [CD] diagnosis. The study included 92 patients with chronic diarrhea. Their ages ranged from 6 months to 15 years. They were 56 males and 36 females, admitted to the Pediatric Gastroenterology Unit, Assiut University Hospital during the period from January 2005 to December 2006. Besides full history and thorough clinical examination, the following investigations were done for all cases: stool analysis for three consecutive days, CBC, ESR, total proteins and serum albumin, tuberculin test, accelerated BCG test [in tuberculin negative cases], serum anti-EMA. Upper GIT endoscopy with duodenal biopsy and aspiration and tissue staining by H and E and by Immunohistochemical [anti-tTG moAbs] to detect tTG antigens in biopsy specimens. Lower GIT endoscopy with biopsy sampling and histopathological examination of biopsy specimens was also done. Out of the total patients, 18 cases [19.5%] were positive for celiac disease AEM antibodies while 16 were positive by tTG immunostaining of biopsy specimens. Fourteen patients [15.2%] had tuberculous enterocolitis while 12 [13%] had biopsy proven Giardiasis. On the other hand 48 patients [52.1%] had other undiagnosed causes of chronic diarrhea. A very high index of suspicion for CD should be maintained for patients who present with chronic diarrhea or iron deficiency anemia. The best method for diagnosis of celiac disease in such patients is serological testing followed by a small-bowel biopsy. The diagnosis of intestinal tuberculosis is difficult due to the lack of specific symptoms and signs. Colonoscopy with ileoscopy is a useful method for diagnosis of intestinal TB. Gastrointestinal endoscopy with biopsy examination is an important method of diagnosis and follows up of children with Giardiasis

study on hemolytic uremic syndrome [HUS] among hospitalized children with shiga toxin producing E. coli 0157:H7 infection

Diarrhea continues to be a major cause of childhood mortality and morbidity in developing countries. Although mortality from diarrheal diseases is declining, morbidity is not. The hemolytic uremic syndrome [HUS] has been reported to be a common complication in bloody diarrhea particularly that caused by entero-hemorrhagic E. coli, a subset of E. coli that produces potent cytotoxins known as shiga like toxins [STx] and the organism is therefore called shiga toxin producing E. coli [STEC]. The exact mechanism responsible for HUS, however, remains speculative. Endothelial injury, acute inflammatory response to STEC or its STx has been blamed. The aim of this work is to study the percentage frequency of STEC infection and the percentage frequency of HUS in a group of hospitalized diarrheal children with and without blood in stools. We also aim to study some of the inflammatory cytokines [TNF alpha, IL-8], vascular endothelial factors such as Endothelin-1 [Et-1] and nitric oxide [NO], and the angiogenic peptide released in response to endothelial injury [bFGF] in these cases. The study included 200 patients less than 5 years of age having acute diarrhea. Cases with protozoal infection were excluded from the study. All cases besides having thorough clinical history and examination, had stool culture and serotying of STEC 0157:H7 on admission. For all cases renal function tests, full blood count and smear, serum sodium and potassium levels were measured. For cases with proven STEC 0157:H7 infection, TNf alpha, IL-8, Et1, NO and bFGF were determined. The percentage frequency of STEC 0157:H7 was 43%, of them 40% were in cases with blood in stools. The percentage frequency of HUS was 35%; all were cases with bloody diarrhea and STEC 0157: H7 infection. The percentage frequency of antibiotic administration among all cases was 67%. However among case with STEC infection that developed HUS 71% received antibiotics. Cases with STEC associated -HUS showed significantly younger mean age with significantly longer mean duration of hospitalization than the rest of case with STEC infection without HUS. They showed significantly higher percentage frequency of: fever >/= 38°C, vomiting, hematuria, anuria, hypertension, CNS complications [seizures, encephalopathy, intractranial hemorrhage and brain infarction], and deaths than the rest of the cases. They also showed significantly lower mean sodium, hemoglobin, platelets and nitric oxide values and significdantly higher mean potassium, urea, creatinine, WBC count, PMNL, and reticulocytic count, TNF alpha, IL-8, Et-1, and bFGF correlated positively with creatinine and WBC but negatively with platelets. NO correlated negatively with TNF alpha, IL-8, Et-1, and bFGF. STEC infection is higher among the studied cases, pointing to the role of cross transmission among hospitalized patients. Hemolytic uremic syndrome complicates 35% of these cases. Diarrheal cases with HUS were associated with more serious complications such as hypertension, encephalopathy, and intracranial hemorrhage. These complications may cause permanent disability and sometimes have fatal outcome. Furthermore the duration of hospital stay was considerably longer than cases without HUS. In STEC associated HUS with these complications, the prognosis is usually grave than in the absence of such complications. Bad prognostic signs of HUS include: younger age, leukocytosis >14,000, prolonged anuria and oliguria, persistent thrombocytopenia, as well as the presence of CNS complications

Delayed gastric emptying in children with type I diabetes mellitus

Diabetes mellitus is considered a cause of gastroparesis in 30-50% of children and it Is presented with various gastrointestinal symptoms. Erythromycin has a variable effect in treating gastroparesis and the increase in blood sugar can affect its effect. The aim of the work is to assess gastroparesis in diabetic children and to evaluate its relation to gastrointestinal symptoms and also to study the role of erythromycin in the treatment of gastroparesis. The study included 67 children suffered type I diabetes mellitus of moro than 5 years duration. Their ages ranged from 7-11 years. Ten children of matchable age and sex were taken as controls. Clinical history and examination were done with the measurement of glycosylated hemoglobin% and gastric emptying time by scintigraphy. Glycosylated hemoglobin% [HbA1c%] was significantly high in the diabetic patients in comparison to that of the controls [8.02 +/- 1.77 and 4.92 +/- 1.64 respectively]. Out of the 67 patients 31[46.26%] showed delayed gastric emptying time and 18 of them were with gastrointestinal symptoms. HbA1c% was significantly high in those patients with delayed gastric emptying time in comparison to those with normal gastric emptying time [8.48 +/- 1.92 and 7.06 +/- 0.81 respectively]. Also it is higher in those with symptoms than those without symptoms [9.64 +/- 1.75 and 6.89 +/- 0.39 respectively]. As regards the other possible complications that are found in diabetes, patients with neurological type showed significant higher HbA1c%and more delayed gastric emptying time than those without neurological complications [8.31 +/- 2.13 and 6.92 +/- 1.39 and 236.21 +/- 79.12 and 102.1 +/- 43.21 respectively]. By giving erythromycin to the symptomatized patients in a dose of 250, mg 3 times daily for 3 months, 8 out of 18 showed improvement. A positive correlation was found between HbA1c% and GET. In conclusion, gastroparesis could be found in diabetic patients even without symptoms. The presence of other complications especially the neurological type and the uncontrolled blood sugar augment gastroparesis. Therefore, the variable response to erythromycin in gastroparesis is multifactorial

Pulmonary dysfunctions in end stage chronic renal failure children on regular hemodialysis; possible risk factors

Lung and kidney functions are intimately related in both health and disease. In renal failure respiratory changes help to mitigate the systemic effects of renal acid-base disturbances. Changes in the function of the respiratory system are among the frequent complications of renal impairment. Alteration in the respiratory drive, mechanics, muscle function, lung volumes, gas exchange and hemodynamics are frequent and could occur in the lungs without obvious pulmonary symptoms. Their effects could be the way to pulmonary functional disorders. Patients with chronic renal failure treated with hemodialysis may exhibit various changes in ventilation and gas exchange. Moreover, hemodialysis and peritoneal dialysis may have their own impact on the respiratory functions. The main objectives of this work were to assess the pulmonary functions and arterial blood gases as well as assessment of echocardiographic changes in a group of children with chronic renal failure undergoing regular hemodialysis. We also aimed to explore possible risk factors that make these children more liable to disturbed pulmonary function. The study included 19 patients with CRF on regular hemodialysis during the period from January to March 2005. Their ages ranged from 8-17 years [mean 13.63 +/- 2.65]. They were 12 males and 7 females. These patients were attending the pediatric nephrology unit in Assiut University Hospital. The duration of dialysis varied from 1-5 years. Patients with known or recent cardiac, infectious, inflammatory or pulmonary diseases were excluded from the study, They were classified according to the duration of dialysis into two groups. Group [1]: 8 CRF children with duration of dialysis<3 years and Group [2]: 11 CRF children with duration of dialysis >/= 3 years, Fifteen apparently healthy children of matchable age, and sex were included as control group. All subjects had full clinical assessment including body weight, height, wt/ht ratio and full examination including: pulse, blood pressure measurement, chest and cardiac examination. The following investigations were also done: complete blood picture, total serum protein, albumin, urea, creatinine, calcium, phosphorus, and arterial blood gases [before and after a hemodialysis session]. Posteroanterior and lateral chest X-ray and echocardiographic examination. Spirometry was performed at the chest department of Assiut University hospital using sensor Medics [IBM] apparatus. The following parameters were obtained: Forced vital capacity [FVC]; Forced expiratory volume in one second [FEV1]; FEVI/FVC ratio; and Peak expiratory flow rate [PEFR]. Out of the studied patients, 15.79%had pulmonary venous congestion while 10.52%had pleural effusions. On the other hand 15.79%had pericardial effusion and a similar percent had cardiomegaly. Cases as a whole and also both subgroups [A and B] showed significantly lower mean levels of wt/ht ratio, Hb, albumin, Ca, and FS but significantly higher mean levels of systolic blood pressure, blood urea, creatinine, P, LVESD, LVEDD, and indexed LVM than controls. Cases as a whole showed significantly lower mean levels of FVC, FEV1 and PEFR than controls. Cases in group B showed significantly lower mean level of FVC and FEVI and PEFR than controls. Analysis of blood gases showed that cases as a whole and also both groups [A and B] had significantly lower mean levels of pH and HCO3 and base excess than controls. Furthermore both groups showed significantly lower PCO2 before and after a HD session. FVC, FEV1 and PEFR correlated positively with each of wt/ratio ratio, Hb, albumin, Ca and FS and negatively with the duration of the dialysis, creatinine, P, and indexed LVM. Restrictive pattern of pulmonary dysfunctions is frequent in ESCRF patients. Structural and functional cardiac abnormalities are very important among the many predisposing factors for pulmonary function disturbances. Other factors such as malnutrition, hypocalcemia, hyperphosphatemia and anemia may also affect the pulmonary functions indirectly through cardiac affection. Uremic toxins are important factors for both system dysfunctions and the longer the duration of the disease, the more are the disturbances of the pulmonary functions. Low PCO[2] in uremic patients may be a trial by the respiratory system to compensate for acidosis by CO[2] wash in order to elevate the pH to near normal. This is very important since the possible noxious effect of overcorrection of acidosis may lead to alkalosis in such patients who are liable to be alkalosis after dialysis. Although standard treatment of malnutrition in CRF, include measures such as early and adequate dialysis, nutritional counseling, oral protein and amino acid supplements, these interventions cannot restore the nutritional status in all malnourished uremic patients. Adequate management of anemia is critically needed for breaking the cycle connecting renal failure, anemia and cardiac disease [all are predisposing factors for pulmonary dysfunctions]. Adequate management of the cardiac problems as well as appropriate monitoring and follow up is necessary to ameliorate the effects on the lungs and may prevent or delay the occurrence of pulmonary dysfunctions. Hemodialysis itself has its own impact on various organs. This points to the importance of renal transplantation as a better therapeutic alternative particularly in children

Plasma nitric oxide, endothelin-1 and renin in children with acute renal parenchymal hypertension

Nitric oxide [NO], Endothetin-1 [FT-1] and plasma remin activity [PRA] in addition to complement component [C3], routine kidney function tests and peripheral hemogram, were studied in twenty four infants and children with acute renal parenchyma] hypertension [18 cases with post streptococcal glomerulonephritis and 6 cases with nephritis due to other causes diagnosed by renal biopsy]. Results were compared with those of 24 age and sex matched healthy controls. In patients group, both serum urea and creatinine levels revealed highly significant elevation compared to controls [p<0.001 for both], while glomerular filtration rate and C3 showed highly significant reduction compared to controls [p<0.001 for both]. Mean values of NO. FT-1 and PRA showed highly significant elevation [p<0.001 for all] in patients group compared to controls. No significant difference were found in biochemical tests studied in patients with posts-streptococcal in comparison to patients with nephritis due to other causes except for C[3] which reveated significant reduction in post-streptococcal glomerulonephritis compared to patients group with nephritis