Helicobacter pylori seroprevalence in children with sleep-disordered breathing.

OBJECTIVE: Chronic Helicobacter pylori (HP) infection is considered to be a factor involved in obstructive sleep apnea syndrome (OSAS). This cross-sectional study examined the seroprevalence of HP in children with sleep-disordered breathing (SDB) in respect to OSAS severity and in reference to other common pediatric medical conditions. METHODS: Overnight polysomnography with pH-metry (PSG) was performed at a Sleep Laboratory (in the years 2008-2011). OSAS severity was determined based on Obstructive Apnea Index (OAI). Subjects were classified into primary snoring group (OAI < 1/hours), mild - moderate OSAS (OAI: 1-5/hour), and severe OSAS (OAI: ≥5/hour). HP IgG was tested by an enzyme-linked immunosorbent assay in the SDB (n = 115) and reference (n = 387) groups [reference group consisted of 4 subgroups based on ICD-10 diagnoses encompassing conditions affecting the skin, respiratory system, food hypersensitivity, and gastrointestinal tract]. Analyses were performed by nonparametric statistical tests. RESULTS: HP seropositivity was 10.4% (12/115) in the SDB group and 11.6% (45/387) in the reference group. HP positive and negative subjects did not differ in PSG, acid gastro-esophageal reflux index nor in age, sex, nutritional status (BMI-z score), and hematological indices in the SDB group. Seropositivity was found in 16.7% of the primary snoring group, 10.2% of mild-moderate OSAS, and in 11.1% of severe OSAS (chi(2) p = 0.832). CONCLUSIONS: Children with SDB are not more predisposed to a chronic HP infection than children with other common chronic pediatric conditions. HP seropositivity does not influence OSAS severity but possible infection should none-the-less be considered on a case-by-case basis.

Activity of mitogen-activated protein kinases in the esophageal epithelium of patients with Barrett's esophagus.

Barrett's esophagus (BE), a complication of gastroesophageal reflux disease, is associated with an increased risk of esophageal cancer. Mitogen-activated protein kinases may play an important role in the pathogenesis of this process. We aimed to evaluate mitogen-activated protein kinases activity in esophageal mucosa of patients with BE and find possible relationship between reflux type and BE. Twenty-four patients (mean age: 59 years) with gastroesophageal reflux disease symptoms and endoscopically suspected esophageal metaplasia (ESEM) were prospectively enrolled for testing by a multichannel intraluminal impedance monitoring along with a Bilitec 2000. Endoscopic biopsies were taken from methylene blue-positive pit patterns (sites suggesting specialized intestinal metaplasia [SIM]), from 2 cm above the Z-line and from cardial parts of the stomach. The biopsies were analyzed for extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinase (JNK), p38 activity by Western blot. Seventeen ESEMs had histologically proven metaplasia: eight patients had SIM and nine had gastric-type epithelia (GE). Biliary reflux was more evident in SIM (P = 0.019) but not in GE (P = 0.019); non-biliary reflux was typical for GE (P = 0.005) but not for SIM (P = 0.04). Strong activations of ERK and p38 were found predominantly in SIM, but not in normal esophageal mucosa (NE) (P = 0.01 and P < 0.001 respectively). Strong signals for active JNK and p38 were detected in GE, but not in NE (P = 0.006 and P = 0.02 respectively). ERK activity was significantly higher than p38 activity in ESEM patients only with GE (P = 0.02). The strong activation of ERK, but not JNK is indicative of SIM. The presence of bile in gastroesophageal refluxate is predisposing to SIM, but not to GE in esophageal mucosa.

Cross allergic reactions in infants and toddlers with atopic dermatitis.

PURPOSE: Prevalence and clinical significance of cross sensitization in children up to 3 years old, diagnosed with atopic dermatitis. MATERIAL AND METHOD: The retrospective study included 69 children up to 3 years old with atopic dermatitis. Allergological diagnostics was performed based on skin tests, determination of total IgE concentration and allergen-specific IgE. RESULTS: Cross sensitization was found in 26% of children. Other patients were qualified to the control group. The sensitization to trees pollen and fruits as well as grass pollen and vegetables were the most frequent types of cross allergy. The patient's family history was positive with regard to atopy in 72% of children from the study group vs. 31% of children from the control group. The statistically higher prevalence of allergic rhinitis and bronchial asthma as well as co-existence of sensitization to house dust mite and animal dander were revealed in the study group. The total concentration of IgE, eosinophilia and SCORAD values were statistically higher in the study group. Children with cross sensitization required systemic steroid therapy more frequently. CONCLUSION: In children up to 3 years with atopic dermatitis and sensitization to plant pollen, the role of a pollen-food allergy syndrome must be taken into account in the pathogenesis of the disease. In children with cross sensitization, the course of atopic dermatitis is more severe; the symptoms from the respiratory and digestive system co-exist. The positive family history is a factor, predisposing to the development of cross sensitization in infants and toddlers.

The natural history of cow's milk allergy in north-eastern Poland.

PURPOSE: The rate of cow's milk allergy diminishes with age. There is not enough information concerning geographical trends in persistent cow's milk allergy in children. The objective of the study was to evaluate the prevalence of persistent cow's milk allergy in children previously diagnosed with IgE-mediated cow's milk allergy (CMA). MATERIAL/METHODS: Diagnosis of cow's milk allergy was established by a medical history of symptoms associated with exposure to cow's milk, positive skin prick tests with cow's milk, the presence of milk-specific IgE, and by a positive double- or single-blind placebo-controlled food challenge with milk confirmed by a positive open-controlled milk challenge. A second oral challenge was performed after at least one year of a milk-free diet and children with a positive oral milk rechallenge were diagnosed as having a persistent CMA. RESULTS: Two hundred ninety-one children, 2-14 years of age (mean 5.30±3.16 years, 95% CI, 5.02-5.62 years) completed the study. Persistent CMA was diagnosed in 79 patients (27.1%). Two hundred twelve children (72.9%) outgrew their allergy to cow's milk at a mean age of 5 years after an average time of 16.4±0.8 months on an elimination diet. Eighty percent of children below 3 years of age became milk tolerant. Milk-specific IgE (p=0.018) and history of paternal bronchial asthma and/or rhinitis (p=0.020) were associated with persistence of cow's milk allergy in regression analysis. CONCLUSIONS: An age above 3 years, as well as features of atopy, individual and familial, may be associated with a risk of delayed tolerance to milk in children.

Probiotic-induced apoptosis and its potential relevance to mucosal inflammation of gastrointestinal tract.

In this short review we attempt to establish and/or strengthen connections between probiotics administration and apoptotic pathway in gastrointestinal tract. The disturbance of apoptosis is mainly deliberated in the framework of insufficient removal of immuno-effector cells that may cause autoimmunity. In the context of the inflammatory bowel disease (IBD) and necrotizing enterocolitis (NEC), the commensal bacteria and their products effect on gut and immune cell survival are illustrated. The multitude of mechanisms of probiotics to induce cell death is shortly summarized and some aspects of it are being discussed in greater detail. The mechanism of intestinal cell death induced by probiotic administration and its influence on the immune system and potential benefits of apoptosis induction during probiotic therapy is indicated.

Serum interleukin--4 and tumor necrosis factor alpha concentrations in children with primary acid gastroesophageal reflux and acid gastroesophageal reflux secondary to cow's milk allergy.

AIM: The possible role of serum interleukin 4 (IL-4) and tumor necrosis factor alpha (TNF- α) in pathogenesis of the reflux symptoms in children with primary acid gastroesophageal reflux (GER) and acid GER secondary to cow's milk allergy (CMA). MATERIAL AND METHODS: Out of 264 children, 76 (28.8%) patients with primary GER and 62 (23.5%) patients with GER secondary to CMA (pH - monitoring) serum IL-4 and TNF- α concentrations were assessed before treatment, 1 and 2 years after the initiation of the periodically administered pharmacotherapy. RESULTS: Children with primary GER had mean IL-4 concentrations 0.17 ± 0.06 pg/ml before treatment, 0.08 ± 0.07 pg/ ml after 1-year and 0.07 ± 0.06 pg/ml after 2-years of treatment. The mean IL-4 concentrations were 1.07 ± 0.24, 0.5 ± 0.22 and 0.44 ± 0.19 pg/ml respectively in children with GER secondary to CMA. The mean serum TNF- α concentrations was 3.62 ± 1.30 pg/ml before treatment , 2.16 ± 1,35 pg/ ml after 1 year and 1.65 ± 1.16 pg/ml after 2 years of treatment in children with primary GER. In group with GER secondary to CMA mean serum TNF- α concentrations were 4.95 ± 1.88, 2.53 ± 0.80 and 2.02 ± 0.78 pg/ml respectively. Statistical analysis of the concentration of both cytokines showed their differentiation between them and in the study groups. CONCLUSIONS: The highest mean serum IL-4 and TNF-α concentrations were observed in children with GER secondary to CMA and in children in control group (with cow's milk allergy and/or other food allergy diagnosed - CMA/FA) before the treatment administration.

Serum gastrin concentrations in children with primary gastroesophageal reflux and gastroesophageal reflux secondary to cow's milk allergy.

PURPOSE: The assessment of the serum gastrin concentrations and the role of enterohormone in children with primary acid gastroesophageal reflux (GER) and GER secondary to cow's milk allergy (CMA). MATERIALS/METHODS: 138 children were diagnosed with pathological acid GER on the basis of pH-metric examination. 76 (28.8%) patients had primary GER and 62 (23.5%) patients had GER secondary to CMA.Serum gastrin concentration (fasting and postprandial) was assessed before treatment and 1 and 2 years after initiation of the therapy. RESULTS: The children with primary GER had the fasting gastrin concentration 69.46 ± 11.87 µU/ml before treatment, 77.86 ± 26.35 µU/ml after 1 year and 83.78 ± 25.21 µU/ml after 2 years of treatment. The children with GER secondary to CMA had gastrin concentrations 89.61 ± 26.75, 73.17 ± 19.49 and 73.90 ± 20.31 µU/ml respectively. The mean postprandial gastrin concentration after treatment was higher than before treatment in children with both primary and secondary GER. The primary GER group had postprandial gastrin concentration 96.07 ± 33.51 µU/ml before treatment and 116.06 ± 33.95 µU/ml and 118.48 ± 33.96 µU/ml after 1st and 2nd year of therapy respectively. The secondary GER group had postprandial gastrin concentration 85.33 ± 14.12 µU/ml before treatment and 106.55 ± 24.51 µU/ml and 110.36 ± 24.67 µU/ml after 1st and 2nd year of therapy respectively. CONCLUSIONS: The mean fasting serum gastrin concentrations in patients with primary and secondary GER were similar and mean postprandial concentrations were higher than fasting concentrations in both study groups.

Eosinophilic esophagitis in children: frequency, clinical manifestations, endoscopic findings, and seasonal distribution.

PURPOSE: Eosinophilic esophagitis (EoE) is a chronic disease characterized by eosinophilic infiltration of the esophageal mucosa, which is associated with clinical and endoscopic manifestations. The objective of our study was to determine the frequency of EoE and to outline the clinical manifestations of EoE in Polish children. MATERIAL/METHODS: Ten large regional pediatric gastroenterology centers participated in the study. A database of endoscopy reports from January 2004 till December 2009 was reviewed. A total of 35,631 esophagogastroduodenal endoscopy studies in children, aged from 4 months to 18 years, were performed. Data pertaining to the children's age, gender, indications for endoscopy, clinical findings and histopathology diagnosis were made. RESULTS: In 84 children (20 girls and 64 boys), aged between 4 months and 18 years, EoE was diagnosed. This constituted one case per 424 endoscopic studies. In children with changes in the esophageal mucosa the frequency of EoE was higher and reached one case per 73 children. The most frequent symptoms of EoE differed between the younger (1-6 years old) and older children (aged 13-18 years old). Feeding aversion, vomiting and/or regurgitation were most frequently observed in the younger children, while in older children: abdominal pain, dysphagia and chest pain. Granular mucosa, longitudinal furrows, and mucosal rings belong to the findings most often observed in endoscopic studies. EoE was more frequently diagnosed in the spring (45.2%) and summer (28.5%). CONCLUSIONS: EoE was diagnosed in every age, with frequency of 1/424 gastrointestinal endoscopies, more frequently in boys than in girls.

Atopy patch test in the diagnosis of food allergy in children with gastrointestinal symptoms.

PURPOSE: To evaluate the diagnostic accuracy of the atopy patch test (APT) in detection of delayed-type sensitization to different food allergens, in children with digestive symptoms and with/or without cow's milk allergy. MATERIAL AND METHODS: 28 children suspected of food allergy-related gastrointestinal symptoms were underwent diagnostic procedures as skin prick test (SPT), specific immunoglobulin E (sIgE), APT, oral food challenge and then divided into two groups according to the results of oral food challenge: A - 17 children with cow's milk allergy, B - 11 children without cow's milk allergy. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of APT were calculated. RESULTS: A positive challenge response to milk was found in 60,7% of examined children. No statistical difference in the prevalence of positive SPT and sIgE to milk has been found between the groups. The prevalence of positive APT to other food allergens was significantly higher in children with allergy to milk (p<0,005). No statistical difference of positive APT to other food allergens has been found in children with/or without cow's milk allergy. APT sensitivity and specificity in children with cow's milk allergy obtained on 77%/73%; where PPV obtained on 71%. CONCLUSIONS: High sensitivity and specificity of APT confirm its accuracy in diagnostics of delayed-type reactions in children with gastrointestinal symptoms. Combined atopy patch test and oral food challenge is essential for avoidance of unnecessary elimination diet. Delayed-type sensitization to other food allergens is common in children with cow's milk allergy.

Tumor necrosis factor alpha and its soluble receptors in obese children with NAFLD.

PURPOSE: To evaluate the serum levels of tumor necrosis factor (TNF) alpha and its soluble receptors in obese children with non-alcoholic fatty liver disease (NAFLD). MATERIAL/METHODS: Fasting serum levels of TNFalpha and its receptors were determined in 45 consecutive obese children with suspected liver disease and 20 lean controls. The degree of liver steatosis was graded in ultrasound according to Saverymuttu. 1H-MR spectroscopy was performed with 1.5T scanner with PRESS sequence. RESULTS: A fatty liver was confrmed in 32 children by ultrasonography (group I); 16 of them also had increased ALT activity (group Ia - NAFLD). Serum concentrations of TNFalpha and its receptors were significantly higher in obese children with NAFLD compared to controls. Significant correlation was found between ultrasonographic grade of liver steatosis and TNFalpha level but serum level of this adipokine was not significantly different in children with advanced liver steatosis (grade 2-3, n=13) compared to patients with mild steatosis (grade 1, n=19). The ability of TNFalpha and its receptors (R1, R2) to differentiate children with advanced liver steatosis from those with mild steatosis was insignificant. However, the ability of serum TNFalpha to differentiate obese children with liver steatosis from those without steatosis was significant (AUC=0.7448, p=0.0291). CONCLUSION: Although TNFalpha does not predict advanced liver steatosis, it may be suitable serum marker in predicting liver steatosis in obese children.

Inflammatory changes of the gastric mucosa and serum concentration of chosen growth factors in children.

PURPOSE: To assess whether there is a correlation between the severity of gastritis and concentration of chosen growth factors in the serum of children infected with H. pylori. MATERIAL AND METHODS: The study included 64 children of whom 50% (Group I) were infected with H. pylori and had gastritis; 18.7% (Group II) of the examined children had a positive titre of IgG against H. pylori and normal gastric mucosa. Controls (Group III) comprised 31.3%. The gastric mucosa was evaluated histopathologically according to the Sydney System. The serum concentrations of growth factors: EGF, TGF-alpha, VEGF, were determined using ELISA. RESULTS: Mean concentrations of the growth factors were also the highest in Group I compared to Group II and Group III (EGF - 137.3+/-10.4 pg/mL, TGF-alpha - 0.4+/-1.2 pg/mL, VEGF - 146.8 pg/mL). Analysis of correlations between growth factors and the severity of gastritis as well as the activity of antral gastric mucosa inflammation proved that mean EGF concentration in H. pylori infected children was the highest (149.5+/-84.8 pg/mL) in severe gastritis, whereas mean concentrations of TGF-alpha (2.0+/-4.3 pg/mL) and of VEGF (148.1+/-92.6 pg/mL) were the highest in moderate gastritis. Mean concentrations of EGF (155.1+/-116.4 pg/mL) and of VEGF (156.0+/-118.9 pg/mL) were the highest in high activity antral gastritis, whereas the mean concentration of TGF-alpha was the highest (2.0+/-4.2 pg/ml) in moderate activity gastritis. CONCLUSIONS: In the children with H. pylori infection, serum concentrations of EGF, TGF-alpha, VEGF were the highest in moderate and severe antral gastritis.

The ghrelin-positive cells number is increased in duodenum in children with celiac disease.

Ghrelin is predominately produced in the stomach, but new findings indicate that the intestinal wall is an important source of the hormone. In patients with shortbowel syndrome, reduction in the intestinal tissue resulted in a decrease in the circulating ghrelin levels. Since in celiac disease (CD) intestinal mucosa atrophy is the main finding, alterations in duodenal ghrelin-positive cell population can be expected. The aim of the study was to evaluate the density of ghrelin-positive cells in the duodenum of CD children and its relationship with body mass index (BMI) and clinical presentation. The study included 31 consecutive patients with newly diagnosed CD [BMI SD scores (BMISDS) -0.926+/-1.496]. The control group consisted of 21 children (BMISDS -0.517+/-1.186], diagnosed with growth retardation, anemia or abdominal pain. All the patients underwent endoscopy with biopsy samples taken from distal duodenum. Immunohistochemistry was performed using rabbit anti- ghrelin (human) antiserum. The number of ghrelin-positive cells in the duodenum was significantly higher in children with CD than in controls (14.82+/-11.12 vs 5.69+/-5.02, p<0.0013). The density of ghrelin-positive cells in the duodenum did not correlate with age, pubertal status, BMISDS or clinical presentation. In the duodenum of CD children, the number of ghrelin-positive cells is increased compared with the control patients. The population of ghrelin-positive cells in the duodenum does not simply reflect an altered mucosal morphology or failure to thrive but is under the influence of other conditions.

The EGFR expression in gastric mucosa of children infected with Helicobacter pylori.

PURPOSE: Epidermal growth factor receptor (EGFR) modulates balance between proliferation and apoptosis in gastric mucosa of the gastrointestinal tract. The aim of the study was to evaluate immunohistochemically the EGFR expression in epithelial and gland cells of antral mucosa in children infected with Helicobacter pylori (H. pylori). MATERIAL/METHODS: The study included 44 children, aged from 5 to 18 years (mean age 13+/-3.4 years) with dyspeptic symptoms, of whom 30 (68.2%) children were infected with H. pylori, 14 (31.8%) children constituted controls. Endoscopic and histopathological assessment of antral mucosa samples was performed according to the Sydney System. Samples taken from gastroscopy were prepared to evaluate EGFR expression in epithelial and gland cells of antrum mucosa according to the manual of a detection kit of EnVision+System-HRP (DAKO). RESULTS: In children H. pylori infected, the EGFR expression in epithelial cells of antral mucosa equaled on average 82.5+/-15 cells/mm2 and ranged from 45.0 to 98.0 cells/mm2 as well as differed statistically significantly when compared to controls (10.2+/-5.0 cells/mm2) (p<0.001). In children with H. pylori infection, the EGFR expression in gland cells of antral mucosa ranged from 2.0 to 85.0 cells/mm2 (mean 25.7+/-22.6 cells/mm2); was lower and differed statistically significantly from controls (54.2 +/- 29.6 cells/mm2) (p<0.001). In children H. pylori infected, there was a statistically significant difference (p<0.001) between the EGFR expression in epithelial and in gland cells of antral mucosa. CONCLUSION: The increased EGFR expression in epithelial cells in comparison with gland cells of antral mucosa in children with H. pylori infection may suggest its role in regeneration processes of gastric mucosa.

Serum concentration of adiponectin, leptin and resistin in obese children with non-alcoholic fatty liver disease.

PURPOSE: Obesity, insulin resistance and dyslipidemia are the most significant risk factors of non-alcoholic fatty liver disease (NAFLD) but the role of adipokines in patomechanism of this disease is not clear. The aim of the study was to evaluate the serum levels of leptin, adiponectin and resistin in obese children with NAFLD. MATERIAL/METHODS: The fasting serum levels of adipokines were determined in 44 consecutive obese children with suspected liver disease and in 24 lean controls. The degree of the ultrasound liver steatosis was graded according to Saverymuttu. RESULTS: The fatty liver was confirmed in 33 children by ultrasonography (16 of them also showed an increased ALT activity). The serum leptin level was significantly higher and adiponectin level was lower in the obese children with NAFLD when compared to controls. Only adiponectin correlated with homeostasis model assessment of insulin resistance (HOMA-IR). Significant negative correlations were found between the ultrasonographic grades of liver steatosis and adiponectin and resistin levels. Serum adiponectin and resistin levels were lower in children with an advanced liver steatosis (grade 3, n=10) compared to patients with a mild steatosis (grade 1-2, n=23). The ability of serum adiponectin and resistin to differentiate children with an advanced liver steatosis from those with mild steatosis was significant. CONCLUSIONS: These data suggest a role of both adiponectin and resistin in the pathogenesis of NAFLD in obese children and confirm the association between adiponectin and insulin resistance. Adiponectin and resistin may be suitable serum markers in predicting an advanced liver steatosis in children with NAFLD.

Assessment of risk factors for osteoporosis and fractures in children with meningomyelocele.

PURPOSE: Our objective was to assess bone and muscular mass in children with meningomyelocele (MMC), and to analyze risk factors for osteoporosis and fractures based on densitometric examination. MATERIAL AND METHODS: The study group included 30 patients (15 girls and 15 boys) with MMC, aged 6-17 years, treated in the Department of Pediatric Rehabilitation, University Hospital. Physiotherapeutic assessment and laboratory tests (serum parathormone, alkaline phosphatase levels, calcium, and phosphate levels, and urine calcium levels) were performed. Densitometry was measured by dual energy X-ray absorptiometry using a Lunar DPX-L apparatus. Lean mass (fat-free tissue content) and fat mass (% fat content) was evaluated. RESULTS: Femur fractures were the most common 12/30 (40%); 5/30 (17%) of the children with MMC had multiple fractures. The incidence of fractures correlated significantly with BMI and body fat content (p = 0.03) Children with MMC and fractures had a tendency toward higher BMI, despite the same absolute value of body mass, compared to those without fractures. Body fat levels were higher in MMC patients with fractures than in those without fractures (BMI R = 0.393, p = 0.03). Children with MMC and fractures had significantly higher 24 h calcuria values, despite normal renal function indices (p = 0.03). CONCLUSIONS: Low-energetic fractures in MMC children may result from metabolic disturbances that are a consequence of excessive renal calcium loss or excessive fatty tissue content.

Sleep-wake schedules in preschool children who snore.

PURPOSE: The aim of the study was to compare sleep-wake schedules between snoring and nonsnoring preschool age children. MATERIAL AND METHODS: Daytime and nighttime sleep duration, daytime and nighttime symptoms were assessed in 34 children at preschool age who snore (5.38+/-1.21 years) and in 66 age- and sex-matched nonsnorers (5.67+/-1.12 years). The snoring group consisted of children with obstructive sleep apnea (OSA) scores <+3.5 and >-1, the nonsnoring group with OSA score <-1. RESULTS: Children who snore differ from the nonsnorers in daytime sleep duration (51.62+/-28.9 minutes vs. 10.70+/-20.2 minutes; p<0.001), but not in nighttime sleep (10.97+/-0.52 hours vs. 9.83+/-1.34 hours; p>0.05). The percentage of children with daytime napping was higher in the snoring group than in the nonsnorers (47.1% vs. 9.1%; p<0.00004), and parents-reported behavioral problems were more frequent in children who snore (41.2% vs. 19.7%; p<0.02). Multivariate odds ratios, including variables for nighttime (sleep apnea) and daytime symptoms (daytime napping and oral breathing), showed that regular sleep during the day was the most predictive of snoring (OR=6.1; 95%CI 1.76-21.04; p<0.005). CONCLUSION: In preschool age children, when the daytime nap begins to disappear, snoring may have an effect on daytime schedule through an increased need for daytime sleep.

Acid gastroesophageal reflux and intensity of symptoms in children with gastroesophageal reflux disease. Comparison of primary gastroesophageal reflux and gastroesophageal reflux secondary to food allergy.

UNLABELLED: The ability to differentiate between primary and secondary causes of gastroesophageal reflux (GER) is extremely important during the diagnostic procedure. At the same time, the quality of symptoms and the intensity of the course of gastroesophageal reflux disease (GERD) should be estimated. Acid GER is assessed using 24-hour esophageal pH monitoring; the results of this diagnostic test should always be interpreted alongside the clinical picture. PURPOSE: To establish the interdependence between the intensity of the clinical symptoms and the acid reflux index in children with primary GER and GER secondary to cow's milk protein allergy (CMA) and/or other food allergies (FA). MATERIALS AND METHODS: A total of 138 children of various ages with symptoms of GERD were included in the study. The diagnostic procedure included 24-hour pH monitoring of the esophagus with a 2-channel probe (distal and proximal lead). For this purpose, ESPGAN diagnostic criteria were implemented. The type and intensity of typical manifestations of GERD were assessed with the help of our own scoring system. This diagnostic and therapeutic algorithm which includes an oral food challenge test, was applied to 138 children in order to differentiate primary GER from GER secondary to CMA/FA. RESULTS: Primary GERD was diagnosed in 76 patients (55.1%) with a mean age: x=25.20 months+/-27.28 (group 1) and GERD secondary to CMA/FA was confirmed in 62 children (44.9%) with a mean age: x=21.53 months+/-17.79 (group 2). The most important pH-metric parameter analyzed in study groups 1 and 2 was the GER index: total and supine. An assessment of the intensity of symptoms and a comparative analysis of intensity was evaluated against the GER index: total and supine. Among study group 1, the following gradation of symptoms was found: in 31 children (40.8%)-degree 3, in 33 children (43.4%)-degree 4, and in 12 children (15.8%)-degree 5, whereas among the patients in group 2:25 (40.3%) were in degree 3, 27 (43.6%) were in degree 4, and 10 (16.1%) were in degree 5. It was estimated that the higher the GER result in both total and supine positions (for both leads), the higher the level of symptoms noted. This interdependence was demonstrated for both groups. CONCLUSIONS: In seeking to determine any etiopathogenetic connection between primary GER or GER secondary to CMA/FA and their clinical consequences, 24-hour esophageal pH monitoring with a 2-channel probe is recommended, since it provides for better clinical control of GERD and its appropriate treatment.

Manometric study of lower esophageal sphincter in children with primary acid gastroesophageal reflux and acid gastroesophageal reflux secondary to food allergy.

PURPOSE: The comparison of values of selected lower esophageal sphincter (LES) manometric parameters measured in children suspected of gastroesophageal reflux disease (GERD) (preliminary study) and in children with primary acid GER and acid GER secondary to cow's milk allergy and/or other food (CMA/FA) in relation to the duration of the disease (prospective study). MATERIAL AND METHODS: A 24-hour esophageal pH monitoring was performed on 264 children of both sexes suspected of GERD (mean age x=20.78+/-17.23 months). Pathological acid gastroesophageal reflux (GER) was diagnosed and divided into primary and secondary reflux in 138 children (52.3%). 76 patients (28.8%) (x=25.2+/-27.28 months) with primary GER made up Group 1. Group 2 consisted of 62 patients (23.5%) (x=21.53+/-17.79 months) with GER secondary to CMA/FA. 32 patients (12.1%) (x=23.7+/-12.63 months) with CMA/FA symptoms made up Group 3 (reference group). Prospective assessment of LES manometric parameters, i.e. resting LES pressure and LES length, was performed on 138 children with GER. Manometric parameters, resting LES pressure and LES length, measured at the preliminary study (0) and control studies (after 1, 2 and 8 years), were prospectively assessed in 138 children. The assessment resulted from clinical observation and/or conservative treatment. RESULTS: The mean value of resting LES pressure (mm Hg) before treatment was x=11.75+/-3.98 in Group 1, x=11.05+/-3.31 in Group 2, and x=14.17+/-3.86 in Group 3 (reference group). After 2 years of clinical observation, the mean value of resting LES pressure accounted for x=13.71+/-3.88 in Group 1, x=13.01+/-2.94 in Group 2, and x=17.92+/-3.36 in Group 3. The mean LES length (cm) before treatment accounted for x=1.68+/-0.72 in Group 1, x=1.78+/-0.70 in Group 2, and x=2.0+/-0.86 in Group 3. After 2 years of clinical observation, the mean LES length was x=2.80+/-0.40 in Group 1, x=2.76+/-0.40 in Group 2, and x=2.97+/-0.48 in Group 3. 12 children with persistent GERD (Group 1) and 8 children with persistent GERD and food allergy (Group 2) underwent manometric evaluation of LES after 8 years. No statistical differentiation of the mean values of resting LES pressure and LES length were shown in examined children of Groups 1 and 2 during prospective studies. CONCLUSIONS: Manometric studies of LES assessing only resting LES pressure and its length in the examined children with acid GER do not clearly differentiate GER into primary and secondary refluxes to food allergy.

Impression cytology of the conjunctival epithelial cells in patients with cystic fibrosis.

PURPOSE: Cystic fibrosis (CF) is the most frequent lethal autosomal recessive hereditary disorder. The disease affects all secretory epithelia, including the eye, and belongs to the group of ocular surface epithelial diseases, termed keratoconjunctivitis sicca or dry eye syndrome. The aim of this study was to evaluate goblet cell population and conjunctival epithelial morphology in patients with CF. METHODS: A total of 20 CF patients and 20 controls underwent conjunctival impression cytology. RESULTS: Impression cytology showed conjunctival squamous metaplasia and goblet cell loss in patients with CF. CONCLUSION: Reduced goblet cell numbers and squamous metaplasia may be indicative of a higher degree of epithelial damage of conjunctival epithelial cells in CF patients, and the presence of neutrophils is a strong sign for an inflammatory background of this disease.In view of the simple, noninvasive nature of impression cytology, this technique may prove to be an important tool for the diagnosis and monitoring of dry eye changes in CF patients.

Fractures during growth: potential role of a milk-free diet.

UNLABELLED: Dietary calcium deficiency may increase fracture risk. In girls, 29.4% of fracture cases and 11.8% of controls without fracture had a history of milk-free diet. The odds ratio (OR) for fracture with a milk-free diet in girls was 4.6, p < 0.01. In boys, 23% of cases and 19% of controls had a history of a milk-free diet; OR = 1.3, NS). A milk-free diet due to cow's milk allergy is associated with increased fracture risk in girls. INTRODUCTION: An intake of calcium below the reference daily intake (RDI) of 800-1200 mg/day during growth is thought to increase fracture risk even though convincing evidence for this view is scarce. The paucity of evidence may be partly due to many trial participants being calcium replete. Children and adolescents with cow's milk allergy (CMA) avoid milk and have a calcium intake below the RDI. The aim of this study was to examine the association between consumption of a milk-free diet and fracture risk. METHODS: In this case-control study conducted in Poland, 57 boys and 34 girls aged 2.5-20 years with fractures (cases) were randomly matched by age and sex with 171 boys and 102 girls without fractures (controls). Weight and height were examined using standard methods. Bone mineral density (BMD) and body composition were measured using dual-energy X-ray absorptiometry. Conditional logistic regression and Bayesian analyses were used to determine the proportion of the fracture risk attributable to a milk-free diet. RESULTS: In girls, 29.4% of cases and 11.8% of controls had a history of milk-free diet producing an odds ratio (OR) for fracture associated with a milk-free diet of 4.6 (95% confidence interval [CI]: 1.4-15.5, p < 0.01). In boys, 23% of cases and 19% of controls had a history of a milk-free diet; OR = 1.3 (95% CI: 0.6-2.7, NS). If the prevalence of CMA in the population is 5%, only 6.7% of the fractures occurring are attributable to CMA and the associated nutritional deficit. CONCLUSIONS: Cow's milk allergy is associated with increased fracture risk in girls. Whether this association is due to the illness, calcium deficit or a deficit in other milk nutrients is uncertain. These data suggest that the contribution of milk-free diet to fracture liability among children and adolescents is modest.