Bacterial septicemia and herpesvirus infection in Antarctic fur seals (Arctocephalus gazella) stranded in the São Paulo coast, Brazil.

In August 2021, two juvenile male Antarctic fur seals (Arctocephalus gazella) stranded in the southeastern Brazilian coast and were referred to rehabilitation centers. The animals presented increased body temperature, prostration, respiratory distress and despite treatment died. A necropsy following a standardized protocol was performed, and formalin-fixed tissues were processed for microscopic examination. Samples were screened for morbillivirus, herpesvirus, and Brucella spp. by molecular analyses (PCR, RT-PCR). Bacteriological culture was performed in samples collected from the lungs, trachea, and lymph nodes of both cases. The main histopathologic findings were of infectious nature, including multifocal necrotizing and fibrinous mixed interstitial pneumonia, bronchiolitis, and bronchitis, with intralesional myriad bacteria associated with vascular fibrinoid necrosis. Pseudomonas aeruginosa was isolated from tracheal and lung swabs of Case 1, and Klebsiella oxytoca was found in nostril swabs, tracheobronchial lymph nodes, and lung of Case 2. Gammaherpesvirus infection was detected in both cases, and the sequences retrieved were classified into the genus Percavirus. All tested samples were PCR-negative for Brucella spp. and morbillivirus. We hypothesize that the deficient immunological status in association with starvation predisposed the reactivation of herpesvirus and secondary bacterial co-infections. To the authors' knowledge, this is the first molecular detection of herpesvirus in an Antarctic pinniped. These findings reinforce that Otariid gammaherpesvirus circulating in the Southern Hemisphere are likely endemic in the Arctocephalus genus. This report contributes to the current knowledge of health aspects affecting wild pinnipeds, especially in the poorly studied Antarctic species.

Computer-assisted femoral head reduction osteotomies: an approach for anatomic reconstruction of severely deformed Legg-Calvé-Perthes hips. A pilot study of six patients.

BACKGROUND: Legg-Calvé-Perthes (LCP) is a common orthopedic childhood disease that causes a deformity of the femoral head and to an adaptive deformity of the acetabulum. The altered joint biomechanics can result in early joint degeneration that requires total hip arthroplasty. In 2002, Ganz et al. introduced the femoral head reduction osteotomy (FHRO) as a direct joint-preserving treatment. The procedure remains one of the most challenging in hip surgery. Computer-based 3D preoperative planning and patient-specific navigation instruments have been successfully used to reduce technical complexity in other anatomies. The purpose of this study was to report the first results in the treatment of 6 patients to investigate whether our approach is feasible and safe. METHODS: In this retrospective pilot study, 6 LCP patients were treated with FHRO in multiple centers between May 2017 and June 2019. Based on patient-specific 3D-models of the hips, the surgeries were simulated in a step-wise fashion. Patient-specific instruments tailored for FHRO were designed, 3D-printed and used in the surgeries for navigating the osteotomies. The results were assessed radiographically [diameter index, sphericity index, Stulberg classification, extrusion index, LCE-, Tönnis-, CCD-angle and Shenton line] and the time and costs were recorded. Radiologic values were tested for normal distribution using the Shapiro-Wilk test and for significance using Wilcoxon signed-rank test. RESULTS: The sphericity index improved postoperatively by 20% (p = 0.028). The postoperative diameter of the femoral head differed by only 1.8% (p = 0.043) from the contralateral side and Stulberg grading improved from poor coxarthrosis outcome to good outcome (p = 0.026). All patients underwent acetabular reorientation by periacetabular osteotomy. The average time (in minutes) for preliminary analysis, computer simulation and patient-specific instrument design was 63 (±48), 156 (±64) and 105 (±68.5), respectively. CONCLUSION: The clinical feasibility of our approach to FHRO has been demonstrated. The results showed significant improvement compared to the preoperative situation. All operations were performed by experienced surgeons; nevertheless, three complications occurred, showing that FHRO remains one of the most complex hip surgeries even with computer assistance. However, none of the complications were directly related to the simulation or the navigation technique.

Do farming conditions influence brominated flame retardant levels in pig and poultry products?

Brominated flame retardants (BFR) are primarily used as flame retardant additives in insulating materials. These lipophilic compounds can bioaccumulate in animal tissues, leading to human exposure via food ingestion. Although their concentration in food is not yet regulated, several of these products are recognised as persistent organic pollutants; they are thought to act as endocrine disruptors. The present study aimed to characterise the occurrence of two families of BFRs (hexabromocyclododecane (HBCDD) and polybrominated diphenyl ethers (PBDE)) in hen eggs and broiler or pig meat in relation to their rearing environments. Epidemiological studies were carried out on 60 hen egg farms (34 without an open-air range, 26 free-range), 57 broiler farms (27 without an open-air range, 30 free-range) and 42 pig farms without an open-air range in France from 2013 to 2015. For each farm, composite samples from either 12 eggs, five broiler pectoral muscles or three pig tenderloins were obtained. Eight PBDE congeners and three HBCDD stereoisomers were quantified in product fat using gas chromatography-high-resolution mass spectrometry, or high-performance liquid chromatography-tandem mass spectrometry, respectively. The frequencies of PBDE detection were 28% for eggs (median concentration 0.278 ng/g fat), 72% for broiler muscle (0.392 ng/g fat) and 49% for pig muscle (0.403 ng/g fat). At least one HBCDD stereoisomer was detected in 17% of eggs (0.526 ng/g fat), 46% of broiler muscle (0.799 ng/g fat) and 36% of pig muscle (0.616 ng/g fat). Results were similar in concentration to those obtained in French surveillance surveys from 2012 to 2016. Nevertheless, the contamination of free-range eggs and broilers was found to be more frequent than that of conventional ones, suggesting that access to an open-air range could be an additional source of exposure to BFRs for animals. However, the concentration of BFRs in all products remained generally very low. No direct relationship could be established between the occurrence of BFRs in eggs and meat and the characteristics of farm buildings (age, building materials). The potential presence of BFRs in insulating materials is not likely to constitute a significant source of animal exposure as long as the animals do not have direct access to these materials.

Water-fat Dixon sequences in the evaluation of breast implants: proposal of a time effective rapid approach in the clinical practice.

AIM: To evaluate the diagnostic accuracy achieved from a fat-water Dixon sequence alone compared to a combination of a silicone-specific magnetic resonance imaging (MRI) sequence and a water-specific MRI sequence in the assessment of breast implants. MATERIALS AND METHODS: In this institutional review board (IRB)-approved study the integrity of breast implants was assessed retrospectively in 27 patients undergoing breast MRI at 3 T. A qualitative evaluation of (set 1) a silicon-selective water-saturated short tau inversion recovery (STIR) sequence in combination with a water-only Dixon dataset (total acquisition time 7 minutes 17 seconds), and of (set 2) fat-only and water-only Dixon datasets (4 minutes 8 seconds) was performed by two readers independently evaluating the following features: margin definition of the implant, water suppression homogeneity, image quality, presence of artefacts and their effects on the imaging interpretation, and diagnostic confidence. Diagnostic accuracy in implant rupture detection was determined and either surgical confirmation or diagnosis from the radiological report was used as a standard of reference. RESULTS: In both sequences, margin definition of the implant wall, water suppression homogeneity, and overall image quality were rated good-excellent in most of cases. Water suppression homogeneity was moderate-poor in a greater number of cases in set 1. Movement artefacts were more frequent in set 1 whereas five cases (18.5%) exhibited swap artefacts between silicone and water in set 2. Diagnostic confidence was rated high-very high with both sequences in most of cases. Diagnostic accuracy was 100% for both readers using set 1 and 96.2% and 100% using set 2. CONCLUSION: A single Dixon sequence allows an accurate diagnostic evaluation of breast implants and concomitant shortening of the overall acquisition time.

Age- and Level-Dependence of Fatty Infiltration in Lumbar Paravertebral Muscles of Healthy Volunteers.

BACKGROUND AND PURPOSE: Normative age-related decline in paravertebral muscle quality is important for reference to disease and risk identification in patients. We aimed to establish age- and vertebral level-dependence of paravertebral (multifidus and erector spinae) muscle volume and fat content in healthy adult volunteers. MATERIALS AND METHODS: In this prospective study multifidus and erector spinae fat signal fraction and volume at lumbar levels L1-L5 were measured in 80 healthy volunteers (10 women and men per decade, 20-62 years of age) by 2-point Dixon 3T MR imaging. ANOVA with post hoc Bonferroni correction compared fat signal fraction and volume among subgroups. Pearson and Spearman analysis were used for correlations (P < .05). RESULTS: Fat signal fraction was higher in women (17.8% ± 10.7%) than men (14.7% ± 7.8%; P < .001) and increased with age. Multifidus and erector spinae volume was lower in women (565.4 ± 83.8 cm(3)) than in men (811.6 ± 98.9 cm(3); P < .001) and was age-independent. No differences in fat signal fraction were shown between the right and left paravertebral muscles or among the L1, L2, and L3 lumbar levels. The fat signal fraction was highest at L5 (women, 31.9% ± 9.3%; men, 25.7% ± 8.0%; P < .001). The fat signal fraction at L4 correlated best with total lumbar fat signal fraction (women, r = 0.95; men, r = 0.92, P < .001). Total fat signal fraction was higher in the multifidus compared with erector spinae muscles at L1-L4 for both sexes (P < .001). CONCLUSIONS: Lumbar paravertebral muscle fat content increases with aging, independent of volume, in healthy volunteers 20-62 years of age. Women, low lumbar levels, and the multifidus muscle are most affected. Further study examining younger and older subjects and the functional impact of fatty infiltrated paravertebral muscles are warranted.

Association between advanced oxidation protein products and 5-year mortality risk among amazon riparian elderly population.

Proteins are important targets of several modifications caused by oxidative stress, leading to structural changes and consequently partial or total loss of their functions. The oxidized proteins include advanced oxidation protein products (AOPP) derived from oxidation-modified albumin, as well as fibrinogen and lipoproteins. An increase in AOPP levels indicates an oxidative stress state and the presence of coexisting inflammation. Several investigations have also suggested an association between high AOPP levels and aging-related diseases. However, the link between elevated AOPP levels and elderly mortality risk has not yet been investigated. Here, we report on a 5-year longitudinal study that investigated the potential association between AOPP levels and mortality using a population-based representative sample of riparian elders living in Brazilian Amazon region (Maués-AM). Age, sex, socioeconomic and cultural conditions, chronic morbidities, polypharmacy, and previous morbidities were also tested as potential confounders. The AOPP levels were measured in 540 (84.78%) individuals, all of whom were followed over a 5-year period in order to establish the mortality rate. Within this study period, 74 (13.7%) elders died and 466 (86.3%) survived. The AOPP levels were higher among the elders who died within the 5-year period (46.27 ± 40.6 mmol/L) compared with those who survived (36.79 ± 20.84 mmol/L) (p = 0.002). The analysis confirmed the link between high AOPP levels and mortality risk, independent of other intervenient factors. These results suggest that elevated AOPP levels could be used to predict mortality risk in elderly patients.

Analysis and improvement of organizational models for the management of patients with type 2 diabetes mellitus: a case study in north-east Italy.

PURPOSE: The study aimed to establish whether the organization for the management of type 2 diabetes mellitus at 9 diabetic units (DUs), in 5 neighboring local health authorities (LHAs), was able to (a) comply with the organizational model prescribed by specific regional standards; (b) ensure adequate clinical management of diabetic patients; (c) assess whether the relationship between primary care physicians (PCPs) and diabetologists (SDs) was instrumental to the needs of patients; (d) optimize specialist treatment at the DUs; (e) optimize drug management; and (f) check whether organizational changes led to variations in clinical results. METHODS: This 6-stage study analyzed procedures, precoded actions, and recordable processes. Stage (1) Defining clinical and organizational endpoints; (2) Drafting flowcharts to describe the actions and work procedures implemented within each LHA; (3) Comparing the flowcharts with the data obtained from related literature; (4) Establishing a protocol shared with PCPs for the management and treatment of patients with type 2 diabetes; (5) Changing the procedures at the DUs; and (6) Evaluating the results. The data were assessed before and after establishing a shared protocol for SDs and PCPs (year 2009 vs 2011). RESULTS: The study shows inconsistencies in the organization of work in the 5 LHAs; however, collaboration with PCPs has guaranteed: (a) unchanged hemoglobin A1C values before and after applying the protocol; (b) a percentage increase in the number of patients with type 2 diabetes who were identified thanks to these protocols; (c) an increase in the use of biguanides compared to the preprotocol period; and (d) no change in the number of patients hospitalized because of acute complications from type 2 diabetes mellitus. CONCLUSIONS: This study confirms how adequate collaboration between SDs and PCPs keeps the risk of complications stable. Nevertheless, shared protocols and clearly defined roles are required.

Nutritional intervention for amyotrophic lateral sclerosis.

AIM: The aim of the study was to assess the consequences of early and systematic nutritional intervention on the clinical conditions of amyotrophic lateral sclerosis (ALS) patients and on the opportunity to maintain a good nutritional status for as long as possible. METHODS: Thirty-three subjects with ALS. Protocol Group: 12 subjects (9 M and 3 F) monitored according to a precise nutritional intervention protocol. CONTROL GROUP: 21 subjects (10 M and 11 F) monitored before applying the protocol. RESULTS: Data recorded at the time of initial assessment were compared and expressed as the mean ± standard deviation for the Protocol Group vs. the CONTROL GROUP: BMI (kg/m2) 23.6 ± 4.1 vs. 21.6 ± 3.5; weight loss as a percentage of usual weight 6.6 ± 7.9 vs. 16.3 ± 8.8 (P=0.003). At six months: weight loss as a percentage of usual weight 4.9 ± 6.2 vs. 16.9 ± 10.2 (P=0.002). At 12 months: weight loss as a percentage of usual weight 7.3 ± 7.1 vs. 17.5 ± 11.1 (P=0.03). At the first follow-up visit, fewer patients in the Protocol Group were receiving enteral nutrition (25%) than patients in the CONTROL GROUP (60%). At six-month follow-up visit: 30% vs. 68%. Standard enteral nutrition formulas were used. One year after initial assessment, the mortality rate was 17% for the Protocol Group, whereas it was 24% at six months and 33% after one year for the CONTROL GROUP. CONCLUSION: If patients are treated before any significant weight loss occurs, early and specific nutritional intervention allows good nutritional status to be maintained for a longer period; if artificial nutrition is required, standard diets are able to ensure adequate clinical results.

[Organisational aspects of a donated breast milk bank: experience of the Treviso hospital]. / Aspetti organizzativi di una banca di latte umano donato: l'esperienza dell'Ospedale di Treviso.

AIM: This study analyses the organisational aspects and the volume of milk managed by the donated breast milk bank (banca del latte umano donato, BLUD) in Treviso. METHODS: The data gathered refer to the years 2003, 2004 and 2005. In particular the hygiene methodology is described in order to obtain a high-quality product from a clinical point of view which is in line with the recent norms regarding the management of food products. RESULTS: During the three-year study 5,647 L of milk were collected (on average: 155 L/month; 5 L/day). Seventy-two percent of breast milk collected was from mothers for their own children; the remaining 28% of milk was from ''donors for the pool''. In the same period 5,053 L of milk was pasteurised and distributed (pool=31%; frozen breast milk=61%; chilled unpasteurized breast milk =8%). Microbiological data show total effectiveness of the methods of pasteurisation used (Holder method). The tracking of the product is possible through the BLUD organisation. CONCLUSION: We propose: 1) that scientific organisations and legislators try to optimise the control of this important product by providing guidelines, indications, microbiological parameters and legal obligations for the correct continuation of the work carried out by BLUDs; 2) that BLUDs create a network for rapid communication, integration and possible collaboration; 3) that a study be carried out regarding BLUDs and population density in order to balance costs and benefits.

Biopsychosocial approach to home enteral nutrition: measure of subjective satisfaction and quality of life.

AIM: Home enteral nutrition (HEN) has become a therapeutic option used to prolong considerably the life of those patients who were previously doomed to malnutrition. The recent biopsychosocial suggests to consider the person in a global vision that takes into account not only the physiological but also the psychological and social implications of any treatment we use. In such a vision the wellness of the patients treated in HEN has to be considered in a more general view that considers the effect of the therapy related to quality of life of the person itself. In this study the effects of HEN on the quality of life of the patients and of their primary caregivers was assessed. METHODS: Twenty patients, 12 males and 8 females, were included in the study. Twelve patients were excluded from the study due to their inability to give informed consent due to a decrease in consciousness and/or cognitive functioning. The 20 patients' mean age was 59.5+14 years with average of 7 years of school education. Twenty-nine caregivers, 25 females and 4 males (mean age = 55.3+/-9 years), were also considered. RESULTS: The patients' condition was good since none showed symptoms related to the therapy. Of the 20 patients, 14 were hospitalized in the past 12 months and since their clinical conditions were stable they were sent back home, while 4 were hospitalized because of HEN issues. None of the patients showed gastro-enteric complications related to their disease state during the previous 12 months, although 5 patients had constipation, and 2 had temporary diarrhea (spontaneously receded) which reduced the infused caloric intake for 2-3 days from the symptom onset. CONCLUSIONS: The biopsychosocial approach we used in this study shows that aspects traditionally treated as ''positive'' and desirable by health-care professionals (i.e. the possibility to provide home care) do not have a straightforward correspondence in the emotional sphere of the patient undergoing HEN. On the contrary, in some cases, the subjective perception of the health related quality of life tends to be lower than expected, since the patient endures a treatment which appears to be essentially ineffective in modifying the prognosis of the basal disease.

Vegetarian diets in hepatic encephalopathy: facts or fantasies?

Diet treatment characterized by a reduction in or a selection of food proteins is currently suggested in hepatic encephalopathy. This article is a review of the present knowledge about the characteristics and the rationale of vegetarian diets in cirrhotic patients with overt or latent encephalopathy. In addition, evidence relating diet and encephalopathy and the nutritional features and needs of cirrhotic patients is reported. Finally, the rationale of a diet based on vegetable and milk-derived proteins that may overcome the limits and the possible adverse effects of a strict vegetarian diet is presented.

Pharmacokinetics of orally administered omeprazole in children. International Pediatric Omeprazole Pharmacokinetic Group.

OBJECTIVES: The aim of this study was to examine the pharmacokinetics of orally administered omeprazole in children. METHODS: Plasma concentrations of omeprazole were measured at steady state over a 6-h period after administration of the drug. Patients were a subset of those in a multicenter study to determine the dose, safety, efficacy, and tolerability of omeprazole in the treatment of erosive reflux esophagitis in children. Children were 1-16 yr of age, with erosive esophagitis and pathological acid reflux on 24 h-intraesophageal pH study. The "healing dose" of omeprazole was that at which subsequent intraesophageal pH study normalized. Children remained on this dose for 3 months, and during this period the pharmacokinetics were measured. RESULTS: A total of 57 children were enrolled in the overall healing phase of the study. Pharmacokinetic study was optional for subjects and was performed in 25 of the 57 enrolled. The doses of omeprazole required were substantially higher doses per kilogram of body weight than in adults. Values of the pharmacokinetic parameters of omeprazole were generally within the ranges previously reported in adults. However, the plasma levels, area under the plasma concentration versus time curve (AUC), plasma half-life (t(1/2)), and maximal plasma concentration (Cmax), were lower in the younger age group, when the AUC and Cmax were normalized to a dose of 1 mg/kg. Furthermore, within the group as a whole, these values showed a gradation from lowest in the children 1-6 yr of age to higher in the older age groups. CONCLUSIONS: The pharmacokinetics of omeprazole in children showed a trend toward higher metabolic capacity with decreasing age, being highest at 1-6 yr of age. This may explain the need for higher doses of omeprazole on a per kilogram basis, not only in children overall compared with adults but, in many cases, particularly in younger children.

Gastric metaplasia: a frequently overlooked feature of duodenal biopsy specimens in untreated celiac disease.

BACKGROUND: Duodenal gastric metaplasia is rarely reported in untreated celiac disease, although it is seen in 60% to 100% of duodenal biopsy specimens in nonceliac patients with histologic duodenitis. The low incidence could represent underreporting, a decreased incidence in pediatric patients generally, or the more distal sampling site that is customary for most biopsy specimens that are obtained to diagnose celiac disease. It could also be a unique feature of the inflammatory reaction that characterizes this disease. The purpose of this study was to examine the incidence of gastric metaplasia in duodenal specimens from children with untreated celiac disease with special reference to patient age and biopsy site. METHOD: Formalin-fixed paraffin-embedded specimens of duodenal mucosa were selected from the pathology department's archival material. Sections were either stained histochemically or by immunochemical methods, according to an antigen-retrieval protocol. Forty-four duodenal specimens from untreated patients with celiac disease (n = 22) and control subjects of similar age with normal histology (n = 22) were examined. Ten of each were obtained during upper endoscopy from the proximal duodenum (proximal site) and 12 of each by Crosby capsule near the ligament of Treitz (distal site). RESULTS: All specimens from patients with celiac disease exhibited marked villous atrophy. None had been noted to have gastric metaplasia during routine examination of sections stained by hematoxylin and eosin. Fifteen (68%) of 22 of the celiac specimens and 2 of 22 (9%) control specimens contained gastric metaplasia, identified as patches of gastric-type cells containing MUC5AC (gastric mucin), pS2 (gastric trefoil factor) and neutral (periodic acid-Schiff-positive) mucin. Five of the seven celiac specimens that had no metaplasia showed increased numbers of goblet cells expressing gastric markers. The incidence of gastric metaplasia was not different for endoscopic (70%) or capsule (67%) specimens. Sixty-eight percent (7/11) of patients aged less than 3 years had gastric metaplasia. CONCLUSION: The presence of gastric metaplasia has been previously underreported in celiac disease specimens. Detection would be improved by the routine use of period acid-Schiff/ alcian blue staining. The incidence of gastric metaplasia in celiac disease is not significantly influenced by biopsy site or age at time of the biopsy.

Lactulose feeding in piglets: a model for persistent diarrhea and colitis induced by severe sugar malabsorption.

We sought to determine, in a piglet model, whether severe sugar malabsorption causes colonic injury or inflammation. Twenty-four piglets were randomized to receive either control formula (CON) or CON supplemented with lactulose (LAC) (N = 12 each group). After seven days, inflammation, apoptosis, and crypt cell proliferation were assessed in the proximal colon (cecum). Lactulose feeding caused persistent diarrhea. In both groups, breath H2 concentration was low, suggesting no increased fermentation in the LAC group. Weight gain/volume formula intake was identical in the CON and LAC groups (0.09+/-0.13 and 0.09+/-0.11 g/ml) respectively. Injury to the colon did not occur, but inflammation of the colon (scale 0-5) was greater in LAC (score of 1.5+/-1.38) than in CON (0.42+/-0.79; P<0.05). Cell proliferation at the basal 40% of the crypt was 92% increased in CON (labeling index 22.8+/-9.9 vs. 11.9+/-2.8; P<0.05). We conclude that persistent feeding during severe sugar malabsorption permits weight gain but may cause colitis.

Chronic recurrent multifocal osteomyelitis associated with chronic inflammatory bowel disease in children.

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare disease of children characterized by aseptic inflammation of the long bones and clavicles. No infectious etiology has been identified, and CRMO has been associated with a number of autoimmune diseases (including Wegener's granulomatosis and psoriasis). The relationship between CRMO and inflammatory bowel disease is poorly described. Through an internet bulletin board subscribed to by 500 pediatric gastroenterologists, we identified six inflammatory bowel disease patients (two with ulcerative colitis, four with Crohn's colitis) with confirmed CRMO. In all cases, onset of the bony lesions preceded the onset of bowel symptoms by as much as five years. Immunosuppressive therapy for the bowel disease generally resulted in improvement of the bone inflammation. Chronic recurrent multifocal osteomyelitis should be considered in any inflammatory bowel disease patient with unexplained bone pain or areas of uptake on bone scan. CRMO may be a rare extraintestinal manifestation of inflammatory bowel disease; alternatively, certain individuals may be genetically predisposed to the development of both diseases.

Management of fibrosing pancreatitis in children presenting with obstructive jaundice.

BACKGROUND: Children with fibrosing pancreatitis are conventionally treated surgically to relieve common bile duct (CBD) obstruction caused by pancreatic compression. Residual pancreatic function has not been formally tested in these patients. AIMS: To evaluate the usefulness of non-surgical temporary drainage in children with fibrosing pancreatitis and to assess pancreatic function after resolution of their CBD obstruction. PATIENTS: Four children (1.5-13 years; three girls). METHODS AND RESULTS: Abdominal sonography and computed tomography revealed diffuse enlargement of the pancreas, predominantly the head. The CBD was dilated due to compression by the head of the pancreas. Pancreatic biopsy specimens obtained in three patients showed notable acinar cell atrophy and extensive fibrosis. Cystic fibrosis was excluded. No other cause of pancreatitis was identified. Pancreatic tissue from one patient contained viral DNA sequences for parvovirus B19 detected by polymerase chain reaction; serum IgM to parvovirus was positive. Three patients had temporary drainage of the CBD and one patient underwent a choledochojejunostomy. Serial imaging studies revealed resolution of the CBD obstruction with reduction in pancreatic size. Exocrine pancreatic function deteriorated. Three patients developed pancreatic insufficiency within two to four months of presentation. The fourth patient has notably diminished pancreatic function, but remains pancreatic sufficient. None has diabetes mellitus. CONCLUSIONS: Temporary drainage of the CBD obstruction is recommended in fibrosing pancreatitis in children along with close monitoring of the clinical course, before considering surgery.

Radiological evidence of subclinical dysphagia in motor neuron disease.

Dysphagia in motor neuron disease (MND) may lead to dangerous complications such as cachexia and aspiration pneumonia. Functional evaluation of the oropharyngeal tract is crucial for identifying specific swallowing dysfunctions and planning appropriate rehabilitation. As part of a multidisciplinary study on the treatment of dysphagia in patients with neuromuscular diseases, 23 MND patients with different degrees of dysphagia underwent videofluoroscopy, videopharyngolaryngoscopy and pharyngo-oesophageal manometry. The results of the three instrumental investigations were analysed in order (1) to define the pattern of swallowing in MND patients complaining of dysphagia; (2) to evaluate whether subclinical abnormalities may be detected; and (3) to assess the role of videofluoroscopy, videopharyngolaryngoscopy and manometry in the evaluation of MND patients with deglutition problems. Correlations between the instrumental findings and clinical features (age of the patients, duration and severity of the disease, presence and degree of dysphagia) were also assessed. The results of our study showed that: (1) The oral phase of deglutition was compromised most often, followed by the pharyngeal phase. (2) In all patients without clinical evidence of dysphagia, subclinical videofluoroscopic alterations were present in a pattern similar to that found in the dysphagic group. (3) Videofluoroscopy was the most sensitive technique in identifying oropharyngeal alterations of swallowing. Impairment of the oral phase, abnormal pharyngo-oesophageal motility and incomplete relaxation of the upper oesophageal sphincter were the changes most sensitive in detecting dysphagia. Videofluoroscopy was also capable of detecting preclinical abnormalities in non-dysphagic patients who later developed dysphagia. Practical guidelines for the use of instrumental investigations in the assessment and management of dysphagia in MND patients are proposed.

Positive correlation of CTG expansion and pharyngoesophageal alterations in myotonic dystrophy patients.

Alteration of the pharyngoesophageal musculature is a common finding in patients with myotonic dystrophy (MD), regardless of the presence of dysphagia. The aim of the present study was to determine whether a specific pattern of swallowing abnormalities could be identified in MD patients, and the possible correlation with the size of CTG repeats. Fifteen MD patients, 8 of whom were asymptomatic for dysphagia, underwent a videofluoroscopic study of swallowing. Alterations of the pharyngoesophageal phase of swallowing were detected in 12 of 15 patients, 6 without clinical evidence of dysphagia. Incomplete relaxation of the upper esophageal sphincter (UES) and esophageal hypotonia were the most common alterations. We found a significant correlation between the number of radiological alterations and the size of CTG repeats. A typical radiological pattern of swallowing has also been identified. The role of videofluoroscopy in evaluation of MD patients is briefly discussed.

Advances in the diagnosis and treatment of gastroesophageal reflux disease.

Pathophysiology and treatment of gastroesophageal reflux (GER) in children have often been extrapolated from studies in adult patients. Fortunately, many groups are now addressing GER specifically in relation to children. Abnormalities in gastrointestinal motility are described in gastroesophageal reflux GER, and there are several new studies looking at this issue in infantile GER. An international working group has put together recommendations for management of infantile GER. The results of a large pediatric study using omeprazole and a review of the use of the prokinetic cisapride in pediatrics are summarized. Several papers review recent experiences with laparoscopic fundoplication. New diagnostic modalities used to investigate GER in infants and children are discussed. These studies aid in both our understanding of possible pathogenesis of GER as well as treatment of the young patient with GER.