Celiac disease and glycogenic acanthosis: a new association?

UNLABELLED: A 6-y-old boy and an 8-y-old girl were admitted to our clinic with anaemia and failure to thrive. Laboratory tests revealed iron deficiency anaemia and positive antigliadin antibodies in both of the patients. Slightly raised grey-white plaques were observed on oesophageal mucosa during endoscopical investigation of the patients. While intestinal mucosal samples confirmed diagnosis of celiac disease histologically, histopathological assessment of oesophageal lesions demonstrated glycogenic acanthosis. Since glycogenic acanthosis associated with celiac disease hasn't been reported in the literature previously to our knowledge, case reports of our patients were presented. CONCLUSION: We suggest that glycogenic acanthosis needs to be investigated as a possible new association of celiac disease in greater paediatric series.

An educational intervention on promotion of breast feeding.

This study was designed to search for an effective method to promote exclusive breast feeding among Turkish city women delivering in hospitals. Four hundred and forty-two primiparae with uncomplicated deliveries and with healthy infants with birthweights of greater than 2500 g were exposed to a group educational session on breast feeding after birth, followed by one repeat session at home. Four hundred and ninety-nine women served as controls. All homes were visited monthly for 6 months by independent observers and data relevant to the feeding of the infants were collected. Weight measurements of 176 infants were taken at age 4 months. The study and control mothers were similar in sociodemographic characteristics which reflected a low socio-economic/educational background but relatively good housing conditions. Although significant differences in frequency of exclusive breast feeding were found between the study and control groups, the impact of the intervention was much lower than our expectations and short-lived. Type of feeding was not related to sex or birthweight of the infant, nor to maternal variables. Weight at age 4 months was within normal limits and similar in the study and control groups. It was concluded that lack of up-to-date information on infant feeding was the main obstacle to breast feeding in urban groups in Turkey, and that the impact of an educational intervention limited to the first week after delivery was lost within the first 2 months.

PIP: Between August 1986-December 1988, researchers enrolled at least 941 primiparous women infant pairs at a social security obstetric hospital in Instanbul, Turkey into a study intended to examine an educational model to promote exclusive breast feeding. Neither changes in hospital routine nor a continuing support program accompanied the short term intervention. Cases watched a video on oral rehydration therapy and domestic hygiene geared toward diarrhea prevention while in the hospital. They also watched a video on breast feeding followed by a discussion on breast feeding. On days 5-7, health students made home visits to discuss breast feeding and left a booklet on breast feeding. The controls only watched the film on diarrhea. Their home visits on days 5-7 centered on domestic hygiene and baby care. Health students visited each subject once a month for 6 months. Most mothers intended to breast feed (83.2%). More educated mothers (88%) originally planned to breast feed their infants than mothers with limited (81.5%) or no education (69.7%; p.01). By the end of the 1st week, only 47.1% of the cases and 12.4% of the controls were exclusively breast feeding. Supplements consisted on nonmilk liquids. Many mothers stated that they did not produce enough milk so they had to supplement. MOreover the number of cases exclusively breast feeding fell dramatically so that by the 3rd month almost no mother infant pairs practiced exclusive breast feeding. Still cases were significantly more likely to breast feed in the 1st 2 months than controls. Despite little change in behavior, most case mothers felt that the educational session influenced them and they learned the breast is best. In conclusion, the main obstacle was insufficient up to date information available to mothers, relatives, and health personnel.

An educational intervention on promotion of breast feeding complemented by continuing support.

The study, aiming to document the effect of continued support for mothers on frequency of exclusive breast feeding, was carried out by inclusion of breast feeding counselling in the context of well-baby care. One hundred and forty-six mothers who had been exposed to two educational sessions on breast feeding after delivery were given appointments to bring their baby to the paediatric hospital for well-baby care. The mother-infant pairs were followed by the same two residents for 4 months. Mean number of visits was six. A conscious effort was made during all visits to influence the mothers and their close relatives towards exclusive breast feeding. It was observed that in a large proportion of the infants, breast milk was being supplemented with water at the time of the first visit and no further effort was made to change this traditional behaviour. Comparison of the results with a group of mothers who had been exposed to similar educational sessions after delivery but without further support showed a striking increase in frequency of exclusive breast feeding (breast milk and water) in the supported group.

PIP: Researchers enrolled at least 96 primiparous women infant pairs in Instanbul, Turkey into a study intended to examine the effect of continued support of mothers on an educational model to promote exclusive breast feeding. Both the study group and the control group were exposed to the same educational sessions on breast feeding. The mothers received an appointment card during the 1st home visit for a follow up visit at the University Children's Hospital at 2 weeks. The same physician saw the same group of infants monthly for 4 months. The physicians discussed breast feeding and infant feeding with mother for 5-15 minutes. Further they encouraged mothers to telephone or visit whenever a problem occurred. They also suggested bringing a close family member with them, especially the mother in law. Indeed close relatives accompanied mothers on 90% of the visits. The deeply rooted tradition of supplementing breast milk with water manifested itself in 47.9% of the cases at 1 week. Since this was so deeply rooted, the researchers considered breast milk and water as exclusive breast feeding. 85.4% of the study group practiced exclusive breast feeding at 1 month compared to 60.9% for the control group. Even though the percentage of those in the study group who exclusively breast fed was lower at 4 months (60.9%), it was well above the comparable percentage for the control group (5%). Moreover by 4 months only 4.2% of case infants were completely weaned compared to 34.8% of the control infants. These results indicate that continuing support for mothers who breast feed plays an key role in promotion of breast feeding. Further it is preferable if the continuing support comes from the same health worker.

Oral rehydration therapy: studies on potassium balance.

The clinical response and changes in potassium balance were studied during oral rehydration therapy (ORT) with a solution containing 20 mmol potassium per litre in well-nourished and malnourished infants of 3 to 15 months of age as well as in neonates and young infants less than 2 months old (range 5-60 days). All infants were successfully rehydrated orally. The potassium intake considerably exceeded the potassium output in all groups during the entire rehydration period. The stool and urine potassium output were about the same in the 3 groups of patients. The retention of potassium increased during ORT in all groups at about the same rate. The study thus demonstrates that an oral rehydration solution (ORS) containing 20 mmol potassium per litre provides enough potassium to all patients. An increase in the potassium concentration of the ORT is therefore not recommended.

Salt and water homeostasis during oral rehydration therapy in neonates and young infants with acute diarrhoea. II. Rehydration with a solution containing 90 mmol sodium per litre (ORS90).

The clinical response and changes in water and salt homeostasis were studied during oral rehydration therapy (ORT) with a solution containing 90 mmol sodium per 1 (ORS90) in 9 infants less than 2 months old (range 2-60 days). Two infants were still dehydrated 36 hours after starting ORT and were excluded from the study. Fluid was retained more rapidly and also to a larger extent than in infants of the same age treated with a solution with a sodium concentration of 60 mmol/l (ORS60). The stool sodium output was higher than that found previously in infants of the same age treated with ORS60. We conclude that during ORT the gut plays an active role in the regulation of salt homeostasis. When the sodium intake is high the percentage of sodium remaining unabsorbed is higher than when the intake is low. This mechanism reduces the risk of hypernatremia in young infants treated with ORS90. The study thus demonstrates that ORS90 is effective and also seems to be safe in the treatment of neonates and young infants with dehydration secondary to diarrhoea if fluid intake is kept around 200 ml/kg/day during the rehydration period.

Oral rehydration therapy in neonates and young infants with infectious diarrhoea.

The clinical response and changes in water and salt homeostasis during ORT was studied in 15 infants less than 2 months old (range 2-50 days) with acute diarrhoea. Eight patients were neonates and 7 were 1-2 months old. The oral rehydration solution contained 60 mmol sodium per litre. All patients except one were successfully rehydrated. The fluid retention was significantly higher in neonates and young infants than in infants above 3 months of age treated in the same way. One patient in the group of neonates who had a normal sodium level on admission developed hypernatremia with a sodium level of 162 mmol/l 36 hours after the start of ORT. The urinary sodium excretion was lower in the neonates than in the young infants. The results show that neonates and young infants have a lower capacity than older infants to excrete water and salt and therefore run a great risk of developing fluid and salt retention during ORT. The risk is most pronounced in neonates who, due to immaturity of the renal function, are unable to excrete excess fluid and salt.

Oral rehydration therapy in malnourished infants with infectious diarrhoea.

The clinical response and changes in water and salt homeostasis was studied for 36 hours during oral rehydration therapy with a rehydration solution containing 60 mmol sodium/l (ORS60) in 14 malnourished 3- to 15-month-old Turkish infants with acute infectious diarrhoea. All patients were successfully rehydrated with this treatment. Sodium was efficiently absorbed from the gut and water balance was rapidly restored. Because of excess fluid retention following the initial rehydration period about 50% of the patients became oedematous. Urine volume and urinary sodium excretion were found to be much lower than in well-nourished patients of the same age with acute diarrhoea who were treated in the same way. In all of the malnourished infants the serum sodium level remained within the normal range during treatment. The results show that malnourished infants retain much more fluid and sodium than infants who are in a normal nutritional state. Excessive retention of water and salt seem to be due to an inability of the kidneys to control sodium and fluid homeostasis while orally administered sodium and fluid are being absorbed from the gut. The results show that ORT is safe and efficient in the treatment of malnourished infants with acute diarrhoea. But since these infants run a high risk of developing a severe retention of fluid and salt, and consequently may develop circulatory failure due to hypervolaemia during oral rehydration therapy, it is important to carefully monitor the volume of fluid that is given.

Unsuccessful oral rehydration therapy in an infant with enteropathogenic E. coli diarrhoea. Studies of fluid and electrolyte homeostasis.

A 4-month-old male infant with severe hyponatremic dehydration due to an enteropathogenic E. coli O125: B15-induced diarrhoea had continued very high stool fluid output with a very elevated sodium concentration after hospitalization and the institution of oral rehydration therapy (ORT). Thirty-six hours after start of ORT intravenous therapy was required. The results of studies of fluid and salt homeostasis in this patient have been compared with those obtained in 3 other patients who had acute diarrhoea of the same severity but caused by another strain of enteropathogenic E. coli (O111:B14) and who were successfully treated with ORT. On ORT the patient with treatment failure had a stool volume which was almost 8 times larger and a stool sodium output which was about 5 times higher than in the successfully treated patients. During the 36-hour-period of ORT fluid losses were about the same as the fluid intake. The results as regards urinary fractional sodium excretion and the urinary potassium/sodium quotient indicate that the severe sodium depletion which was present on admission in the unsuccessfully treated patient persisted during ORT. The reason for ORT failure may be that the infectious E. coli strain had bacilli-adherent qualities that cause damage of microvilli.

Hair manganese concentrations in newborns and their mothers.

The study was designed to investigate the manganese (Mn) status of mothers and their offspring at delivery. Hair Mn concentrations in 31 full-term, 18 preterm and 12 newborn infants with congenital malformations and their mothers were determined by the flameless atomic absorption technique. Both in infants with congenital malformations and their mothers, hair Mn levels were significantly lower than the full-term and preterm infant-mother pairs. With the exception of mothers of infants with congenital malformations, hair Mn concentrations in mothers were significantly higher as compared with their infants. Low hair Mn concentrations of infants with congenital malformations and their mothers may possibly reflect a state of Mn deficiency in these women. These results imply that 1) Mn deficiency may play a role as one potential factor in intrauterine malformations, 2) Mn is supplied to the fetus by a homeostatic mechanism which is mainly dependent on the Mn status of the mother, 3) prenatal Mn analysis in maternal hair may prove to be a reliable indicator for the risk of intrauterine malformations.

Hair chromium concentration and chromium excretion in tannery workers.

Hair and urine samples were collected from 34 male tannery workers and from 12 normal adults. Eighteen of the workers dealt directly with chromium and the remaining 16 (controls) worked in the offices and kitchen of the same factory. All were found to be clinically healthy. Chromium was determined by flameless atomic absorption spectroscopy. When compared with normal adult values, urinary chromium concentration, Cr/Creatinine ratio, daily chromium excretion, and hair chromium, concentrations were significantly higher and urinary beta 2-microglobulin/Cre ratios significantly lower in both tannery workers and in controls. A significant negative correlation was found between urinary beta 2-microglobulin/Cre and Cr/Cre ratios of tannery workers and controls. A significant positive correlation was shown between hair chromium and urinary Cr/Cre values in all workers. No correlations between the duration of exposure to chromium and hair and urinary chromium values were found. Nevertheless, high values observed in workers with short exposures show that chromium is readily absorbed through the respiratory system.

Alterations of chromium metabolism and effect of chromium supplementation in Turner's syndrome patients.

This study was conducted to investigate chromium metabolism and the effect of chromium supplementation in patients with Turner's syndrome, a condition noted for its high incidence of diabetes. Oral glucose tolerance tests were performed in 14 patients 8 to 19 yr of age. Eight of the 14 subjects were given 30 g of brewer's yeast containing 50 micrograms of chromium every day for 8 wk and glucose tolerance tests repeated. Urine samples were collected before and after each glucose load. Serum lipids were also investigated. Before supplementation, urinary chromium/creatinine ratio was high, and the urinary chromium response to oral glucose tolerance test was absent. Cholesterol and/or triglyceride levels were high in three of the patients. After supplementation, a decrease in urinary Cr/Cre ratio, and an improvement in glucose area index total were noted. A decrease in cholesterol and/or triglyceride levels occurred in the three patients with high initial levels as well as an increase in high-density lipoprotein cholesterol. These findings indicate a state of chromium deficiency and support the hypothesis that chromium deficiency may have a role in the pathogenesis of the abnormal glucose tolerance tests encountered in Turner patients.

Salt and water homeostasis during oral rehydration therapy.

Changes in sodium balance and urinary and stool output during orally administered rehydration therapy were studied in 22 well-nourished Turkish infants, aged 2 to 13 months, with acute diarrhea mainly of viral origin. The infants randomly received a rehydration solution containing either 90 mmol Na/L (ORS90) or 40 mmol Na/L (ORS40). Slight transient hypernatremia was noted in a few infants receiving ORS90, and slight transient hyponatremia in a few infants receiving ORS40. In both groups, sodium balance increased most rapidly during the first 12 hours of rehydration, and then more slowly because of increased urinary as well as stool sodium output. Sodium balance was always more positive after ORS90 than after ORS40, but the difference did not change much from 12 to 36 hours after therapy was started. Changes in fractional sodium excretion, urinary K/Na quotient, and urinary aldosterone-creatinine quotient were used as indexes of changes in sodium balance. All values were interpreted to indicate that the sodium deficit on admission was corrected within 12 to 18 hours after ORS90 and, in most cases, after 24 to 36 hours after ORS40. Both groups of infants responded well to orally administered rehydration therapy from the clinical viewpoint.

Urinary chromium excretion during pregnancy and its relationship with intravenous glucose loading.

This study was conducted to investigate the changes in urinary chromium excretion in the different stages of pregnancy and the effect of intravenous glucose tolerance test on urinary excretion of chromium in late pregnancy. Urine samples were collected from pregnant women cross-sectionally and longitudinally in different stages of pregnancy. Urinary chromium excretion before and after intravenous glucose tolerance test was also determined in nine women in their 3rd trimester of pregnancy. The results can be summarized as: 1) mean chromium/creatinine ratio in urine increased significantly with advancing pregnancy, 2) in late pregnancy, with the exception of one subject, urinary chromium/creatinine ratio showed a decrease after intravenous glucose tolerance test. The results obtained in this study have led us to conclude that the habitual dietary intake does not meet the increased chromium requirement and that prophylaxis may be of benefit and appears to be advisable in pregnancy.

The effect of parity on maternal hair chromium concentration and the changes during pregnancy.

The effect of parity of maternal hair chromium and the changes during pregnancy were investigated. Hair samples were collected from nulliparous and multiparous women and longitudinally from pregnant women. Chromium was determined by flameless atomic absorption. Mean hair chromium in multiparous women was low when compared with nulliparous women of comparable ages. No significant decrease in hair chromium was observed between multiparous women and women who had borne only one child. Mean hair chromium in longitudinal samples was observed to decrease with advancing pregnancy. When initial hair chromium values were below 200 ng/g, the significant decrease occurred only in the 3rd trimester of pregnancy. These results show that 1) hair chromium in multiparous women is lower than that in nulliparous women, 2) depending on chromium nutrition, hair chromium of pregnant woman shows a decrease with advancing pregnancy, 3) if adequate amounts of chromium are not taken during pregnancy, deficiency may result with increasing parity.

Effect of chromium on insulin secretion and glucose removal rate in the newborn.

The effect of chromium on glucose removal rate (GRR) was investigated in the first 48 hr of life in 22 full-term newborns. Intravenous glucose tolerance test was performed in all babies in the first 24 hr. GRR was found 1.22 +/- 0.17% min. Sixteen of 22 babies received orally 250 micrograms CrCl3 6 H2O and the other six served as controls (no chromium). Intravenous glucose tolerance test was repeated on the 2nd day in all subjects. In the chromium administered group GRR increased from 1.34 +/- 0.19 to 2.58 +/- 0.45% min (P less than 0.01). In the controls, GRR on 2 consecutive days were found 0.90 +/- 0.36 and 2.04 +/- 0.32% min, respectively (P less than 0.05). The ratio of the difference between two GRR values to initial GRR showed no significant difference between the chromium-administered group and the controls. Chromium did not cause a significant change in plasma insulin. The low GRR observed in the newborn irrespective of administered chromium may be taken as evidence that similar to the relative delay in insulin release, the active role of chromium in plasma as glucose tolerance factor may also be inadequate in the early newborn period.

The effect of glucose loading on urinary excretion of chromium in normal adults, in individuals from diabetic families and in diabetics.

This study was designed to investigate the effect of oral glucose tolerance tests (OGTT) on urinary chromium excretion in normal individuals, in individuals belonging to diabetic families, and in diabetics. The results can be summarized as: 1) eight of the 10 normal adults showed a significant increase both in terms of chromium per minute and chromium/creatinine (Cr/Cre) ratio after OGTT, and the difference between the mean values before and after OGTT was significant, 2) Of the 13 individuals from diabetic families, only five increased their chromium excretion and chromium/creatinine ratio after the glucose challenge (39%). However, the mean values for the group before and after OGTT remained statistically unchanged, 3) three of eight overt diabetic subjects (38%) showed moderate increase the chromium excretion and Cr/Cre ratio after OGTT, but the mean values were not effected. The creatinine values in urine remained constant before and after OGTT in all groups. These results suggest that a positive Cr/Cre response is more likely to occur in groups of normals than in groups of diabetics, and in individuals from diabetic families.

Urinary chromium excretion, diurnal changes, and relationship to creatinine excretion in healthy and sick individuals of different ages.

Since urine is the main excretory pathway for chromium, this study was conducted to compare in normal individuals the daily urinary chromium excretion with a 4 hr sample, to investigate diurnal fluctuations of urinary chromium and age-dependent relationship between urinary chromium and creatinine excretion. The results can be summarized as 1) there was no significant difference between the observed 24 hr chromium excretion and 24 hr excretion calculated from the one 4 hr samples, 2) a diurnal variation was observed when urinary excretion was expressed as chromium per minute, but no time-related variation could be established when chromium/creatinine (Cr/Cre) ratios in samples from three different periods of the same day were compared, although a significant positive correlation existed between urinary chromium and creatinine concentration, 3) the Cr/Cre ratio was found to be age-dependent, 4) in malnourished children the Cr/Cre ratio was very high and significantly different from that of normal infants, 5) This ratio for the eight diabetics was found to be significantly higher when compared with normal adults. On the basis of these results, it is suggested that morning 4 hr urinary chromium reflects the daily chromium excretion and that the Cr/Cre ratio of single urine samples obtained during this period is a reliable criterion in the evaluation of chromium nutrition of individuals in different conditions, provided that the influence of age is taken into consideration.