Lipid-Laden Alveolar Macrophages and pH Monitoring in Gastroesophageal Reflux-Related Respiratory Symptoms.

Lipid-laden alveolar macrophages and pH monitoring have been used in the diagnosis of chronic aspiration in children with gastroesophageal reflux (GER). This study was conducted to prove a correlation between the detection of alimentary pulmonary fat phagocytosis and an increasing amount of proximal gastroesophageal reflux. It was assumed that proximal gastroesophageal reflux better correlates with aspiration than distal GER. Patients from 6 months to 16 years with unexplained recurrent wheezy bronchitis and bronchial hyperreactivity, or recurrent pneumonia with chronic cough underwent 24-hour double-channel pH monitoring and bronchoscopy with bronchoalveolar lavage (BAL). Aspiration of gastric content was determined by counting lipid laden alveolar macrophages from BAL specimens. There were no correlations between any pH-monitoring parameters and counts of lipid-laden macrophages in the whole study population, even when restricting analysis to those with abnormal reflux index expressing clinically significant GER. Quantifying lipid-laden alveolar macrophages from BAL in children with gastroesophageal-related respiratory disorders does not have an acceptable specificity to prove chronic aspiration as an underlying etiology. Therefore, research for other markers of pulmonary aspiration is needed.

Water, electrolytes, vitamins and trace elements - Guidelines on Parenteral Nutrition, Chapter 7.

A close cooperation between medical teams is necessary when calculating the fluid intake of parenterally fed patients. Fluids supplied parenterally, orally and enterally, other infusions, and additional fluid losses (e.g. diarrhea) must be considered. Targeted diagnostic monitoring (volume status) is required in patients with disturbed water or electrolyte balance. Fluid requirements of adults with normal hydration status is approximately 30-40 ml/kg body weight/d, but fluid needs usually increase during fever. Serum electrolyte concentrations should be determined prior to PN, and patients with normal fluid and electrolyte balance should receive intakes follwing standard recommendations with PN. Additional requirements should usually be administered via separate infusion pumps. Concentrated potassium (1 mval/ml) or 20% NaCl solutions should be infused via a central venous catheter. Electrolyte intake should be adjusted according to the results of regular laboratory analyses. Individual determination of electrolyte intake is required when electrolyte balance is initially altered (e.g. due to chronic diarrhea, recurring vomiting, renal insufficiency etc.). Vitamins and trace elements should be generally substituted in PN, unless there are contraindications. The supplementation of vitamins and trace elements is obligatory after a PN of >1 week. A standard dosage of vitamins and trace elements based on current dietary reference intakes for oral feeding is generally recommended unless certain clinical situations require other intakes.

Amino acids - Guidelines on Parenteral Nutrition, Chapter 4.

Protein catabolism should be reduced and protein synthesis promoted with parenteral nutrion (PN). Amino acid (AA) solutions should always be infused with PN. Standard AA solutions are generally used, whereas specially adapted AA solutions may be required in certain conditions such as severe disorders of AA utilisation or in inborn errors of AA metabolism. An AA intake of 0.8 g/kg/day is generally recommended for adult patients with a normal metabolism, which may be increased to 1.2-1.5 g/kg/day, or to 2.0 or 2.5 g/kg/day in exceptional cases. Sufficient non-nitrogen energy sources should be added in order to assure adequate utilisation of AA. A nitrogen calorie ratio of 1:130 to 1:170 (g N/kcal) or 1:21 to 1:27 (g AA/kcal) is recommended under normal metabolic conditions. In critically ill patients glutamine should be administered parenterally if indicated in the form of peptides, for example 0.3-0.4 g glutamine dipeptide/kg body weight/day (=0.2-0.26 g glutamine/kg body weight/day). No recommendation can be made for glutamine supplementation in PN for patients with acute pancreatitis or after bone marrow transplantation (BMT), and in newborns. The application of arginine is currently not warranted as a supplement in PN in adults. N-acetyl AA are only of limited use as alternative AA sources. There is currently no indication for use of AA solutions with an increased content of glycine, branched-chain AAs (BCAA) and ornithine-alpha-ketoglutarate (OKG) in all patients receiving PN. AA solutions with an increased proportion of BCAA are recommended in the treatment of hepatic encephalopathy (III-IV).

High-molecular-mass ("biliary") isoenzyme of alkaline phosphatase and the diagnosis of liver dysfunction in cystic fibrosis.

The high-Mr isoenzyme of alkaline phosphatase (AP, EC 3.1.3.1), a highly sensitive index to cholestasis, was measured by liquid chromatography in 45 patients with cystic fibrosis. Results of serum tests for liver dysfunction--including gamma-glutamyltransferase, aspartate aminotransferase, alanine aminotransferase, total AP, bilirubin, and bile acids--were compared with those for high-Mr AP. Values for high-Mr AP were increased in 44.4% of our patient population, with activities ranging from 0.4 to 17.3 U/L. The upper limit in the control group was 2.5 U/L. We find increased high-Mr AP to be a more sensitive indicator of liver dysfunction in patients with cystic fibrosis than are other tests.

High-molecular-mass alkaline phosphatase: simplified and highly sensitive determination by liquid chromatography.

This simplified HPLC method for measurement of high-molecular-mass alkaline phosphatase (high-Mr AP; EC 3.1.3.1) in serum and bile is rapid (time for column preparation and separation 30 min), reproducible (CV 4.2%), and highly sensitive (detects high-Mr AP in healthy controls at 1-3% of total AP activity in serum), and is suitable for processing small batches of sample. We characterized high-Mr AP in serum and bile by incubating samples with L-phenylalanine, neuraminidase, 1-butanol, or wheat-germ lectin, and by determining stability to heat. High-Mr AP activity was determined in sera of patients with various liver diseases (4-32% of total AP serum activity) and results were compared with those by electrophoresis on agarose.

"Fragmented" isoenzymes of alkaline phosphatase in the diagnosis of transient hyperphosphatasemia.

We describe the appearance of "fragmented" isoenzymes of serum alkaline phosphatase (EC 3.1.3.1) in two cases of transient hyperphosphatasemia. We determined the isoenzymes by liquid chromatography, then characterized them by heat inactivation, inhibition with 5 mmol/L L-phenylalanine solution, and electrophoresis on cellulose acetate membranes. We suspect that a virus-induced decrease in clearance of the enzyme from serum is responsible for a similar increase of bone and liver isoenzyme activities and for the presence of these fragmented isoenzymes in transient hyperphosphatasemia.

Liquid-chromatographic determination of isoenzymes of alkaline phosphatase in serum and tissue homogenates.

We describe a new method for separating alkaline phosphatase (AP) isoenzymes by means of "high-performance" liquid chromatography. Isoenzymes are eluted from the column (Mono Q HR 5/5, a strong anion-exchanger) with a stepwise gradient of LiCl. The isoenzymes originating from small intestine, bone, liver, and bile were identified by use of tissue homogenates, pathological sera, and heat inactivation.