Dutch Chronic Pancreatitis Registry (CARE): design and rationale of a nationwide prospective evaluation and follow-up.

BACKGROUND: Chronic pancreatitis is a complex disease with many unanswered questions regarding the natural history and therapy. Prospective longitudinal studies with long-term follow-up are warranted. METHODS: The Dutch Chronic Pancreatitis Registry (CARE) is a nationwide registry aimed at prospective evaluation and follow-up of patients with chronic pancreatitis. All patients with (suspected) chronic or recurrent pancreatitis are eligible for CARE. Patients are followed-up by yearly questionnaires and review of medical records. Study outcomes are pain, disease complications, quality of life, and pancreatic function. The target sample size was set at 500 for the first year and 1000 patients within 3 years. RESULTS: A total of 1218 patients were included from February 2010 until June 2013 by 76 participating surgeons and gastroenterologist from 33 hospitals. Participation rate was 90% of eligible patients. Eight academic centers included 761 (62%) patients, while 25 community hospitals included 457 (38%). Patient centered outcomes were assessed by yearly questionnaires, which had a response rate of 85 and 82% for year 1 and 2, respectively. The median age of patients was 58 years, 814 (67%) were male, and 38% had symptoms for less than 5 years. DISCUSSION: The CARE registry has successfully recruited over 1200 patients with chronic and recurrent pancreatitis in about 3 years. The defined inclusion criteria ensure patients are included at an early disease stage. Participation and compliance rates are high. CARE offers a unique opportunity with sufficient power to investigate many clinical questions regarding natural course, complications, and efficacy and timing of treatment strategies.

Intestinal Permeability Measured by Urinary Sucrose Excretion Correlates with Serum Zonulin and Faecal Calprotectin Concentrations in UC Patients in Remission.

BACKGROUND AND AIMS: Ulcerative colitis (UC) is associated with an increased intestinal permeability, possibly through a dysbiosis of intestinal bacteria. We investigated which markers are most relevant to assess intestinal permeability in UC patients and whether probiotics had an effect on these markers. METHODS: In this twelve-week placebo-controlled randomized double-blind study, twenty-five subjects with UC in remission received either placebo or a multispecies probiotics. Samples of blood, urine, and faeces were taken at baseline, week 6, and week 12 to assess intestinal permeability and inflammation. Diaries and Bristol stool scale were kept to record stool frequency and consistency. Quality of life was scored from 32-224 with the inflammatory bowel disease questionnaire (IBD-Q). RESULTS: This group of UC patients, in clinical remission, did not show increased intestinal permeability at baseline of this study. During the study, no significant group or time effects were found for intestinal permeability measured by the 5-sugar absorption test, serum zonulin, and faecal zonulin. Likewise, the inflammatory markers C-reactive protein (CRP), calprotectin, and the cytokines IFNγ, TNFα, IL-6, and IL-10 were not significantly affected. Stool frequency and consistency were not significantly affected either. The IBD-Q score, 194 for the probiotics group and 195 for the placebo group, remained unaffected. Correlations were tested between all outcomes; urinary sucrose excretion was significantly correlated with serum zonulin (r = 0.62) and faecal calprotectin (r = 0.55). Faecal zonulin was not significantly correlated with any of the other markers. CONCLUSION: Serum zonulin may be a more relevant biomarker of intestinal permeability than faecal zonulin, due to its correlation with other biomarkers of intestinal permeability. UC patients in remission did not show an effect of the probiotic treatment or a change in gut permeability. This should not discourage further studies because effects might be present during active disease or shortly after a flare up.

[Probiotic prophylaxis in patients with predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial]. / Probioticaprofylaxe bij voorspeld ernstige acute pancreatitis: een gerandomiseerde, dubbelblinde, placebogecontroleerde trial.

OBJECTIVE: To evaluate whether enteral prophylaxis with probiotics in patients with predicted severe acute pancreatitis prevents infectious complications. DESIGN: Multicentre, randomised, double-blind, placebo-controlled trial. METHOD: A total of 296 patients with predicted severe acute pancreatitis (APACHE II score > or = 8, Imrie score > or = 3 or C-reactive protein concentration > 150 mg/l) were included and randomised to one of two groups. Within 72 hours after symptom onset, patients received a multispecies preparation of probiotics or placebo given twice daily via a jejunal catheter for 28 days. The primary endpoint was the occurrence of one of the following infections during admission and go-day follow-up: infected pancreatic necrosis, bacteraemia, pneumonia, urosepsis or infected ascites. Secondary endpoints were mortality and adverse reactions. The study registration number is ISRCTN38327949. RESULTS: Treatment groups were similar at baseline with regard to patient characteristics and disease severity. Infections occurred in 30% of patients in the probiotics group (46 of 152 patients) and 28% of those in the placebo group (41 of 144 patients; relative risk (RR): 1.1; 95% CI: 0.8-1.5). The mortality rate was 16% in the probiotics group (24 of 152 patients) and 6% (9 of 144 patients) in the placebo group (RR: 2.5; 95% CI: 1.2-5.3). In the probiotics group, 9 patients developed bowel ischaemia (of whom 8 patients died), compared with none in the placebo group (p = 0.004). CONCLUSION: In patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients.

Indirect vs direct assessment of gastric emptying: A randomized crossover trial comparing C-isotope breath analysis and MRI.

BACKGROUND: Indirect methods to assess gastric emptying (GE), such as 13 C breath tests (BT), are commonly used. However, BT usually use a sampling time of 4+ hours. The current study aims to assess the validity of BT for four liquid meals differing in physicochemical properties. To this aim, we compared them to MRI GE-measurements. METHODS: Fifteen healthy males (age 22.6 ± 2.4 years, BMI 22.6 ± 1.8 kg/m2 ) participated in a randomized 2 × 2 crossover experiment. Test foods were liquid meals, which were either thin/thick and 100/500 kcal, labeled with 100 mg of 13 C-octanoate. GE was measured with MRI and assessed by 13 C recovery from breath. Participants were scanned every 10 minutes and at six time points breath samples were collected up to t = 90 minutes. Two curves were fitted to the data to estimate emptying halftime (t50 Ghoos and t50 Bluck ). T50 times were ranked per participant and compared between methods. KEY RESULTS: On average, MRI and BT showed similar t50 rankings for the four liquid meals. In comparison to MRI, t50 Ghoos overestimated, while t50 Bluck underestimated GE time. Moreover, more viscous foods were overestimated. In most participants individual t50 time rankings differed significantly between methods. CONCLUSIONS & INFERENCES: BT can assess relative emptying differences on group level and collecting breath data for 90 minutes constitutes a lower burden for participants and the research facility. However, BT has severe shortcomings compared to MRI for individual GE assessment. Notably, food matrix effects should be considered when interpreting the results of BT.

Insufficient Protein Intakes is Highly Prevalent among Physically Active Elderly.

OBJECTIVES: Sufficient protein intake and habitual physical activity are key factors in the prevention and treatment of sarcopenia. In the present study, we assessed habitual dietary protein intake and the contribution of animal proteins in male versus female physically active elderly and identified determinants of protein intake. DESIGN: a cross-sectional study. SETTING: the study was performed within the Nijmegen Exercise Study. PARTICIPANTS: physically active elderly ≥ 65 yrs. MEASUREMENTS: Physical activity was assessed using the SQUASH questionnaire and expressed in Metabolic Equivalent of Task hours per week (METhr/wk). Dietary protein intake was determined using a validated food frequency questionnaire (FFQ). Multivariate linear regression analysis was used to determine whether age, sex, educational level, smoking, alcohol intake and physical activity were associated with protein intake (g/kg/d). RESULTS: A total of 910 participants (70±4 yrs, 70% male) were included and reported a habitual physical activity level of 85.0±53.5 METhr/wk. Protein intake was 1.1±0.3 g/kg/d with 57% animal-based proteins for males, and 1.2±0.3 g/kg/d with 59% animalbased proteins for females (both P<0.05). In total, 16%, 42% and 67% of the male elderly and 10%, 34% and 56% of the female elderly did not meet the recommended protein intake of 0.8, 1.0 and 1.2 g/kg/d, respectively. Female sex (ß=0.055, P=0.036) and more physical activity (ß=0.001, P=0.001) were associated with a higher daily protein intake (g/kg/d). CONCLUSION: The majority of physically active elderly and in particular males (i.e. 67%) does not reach a protein intake of 1.2 g/kg/d, which may offset the health benefits of an active lifestyle on muscle synthesis and prevention of sarcopenia. Intervention studies are warranted to assess whether protein supplementation may enhance muscle mass and strength in physically active elderly.

Oral cholera vaccination promotes homing of IgA+ memory B cells to the large intestine and the respiratory tract.

Oral cholera vaccination is used to induce immune responses in the intestines to protect against cholera infection. However, oral vaccination may also affect immune responses in other mucosal tissues. To study this, tissue-specific homing potential and kinetics of B-cell responses were characterized after oral cholera vaccination. Healthy adult volunteers received two doses of Dukoral® and blood, saliva, nasal wash, and fecal samples were collected over time to detect vaccine-specific antibodies. Additionally, homing potential of lymphocytes to small intestine, colon, airways, skin, and periphery was measured by expression of Integrin ß1 and ß7, CCR9, CCR10, CCR7, and CLA. After vaccination, antibody responses to cholera toxin B (CTB) and Dukoral® were detected in serum and nasal wash. CTB-specific memory B cells in peripheral blood and tissue homing profiles of memory B cells peaked at day 18. IgA+ memory B cells expressed markers that enable homing to the airways and colon, while IgA- memory B cells primarily expressed small-intestine-homing markers. These data show that oral cholera vaccination has a differential effect on immune responses in various mucosal sites, including the respiratory tract.

The effects of a multispecies probiotic on migraine and markers of intestinal permeability-results of a randomized placebo-controlled study.

BACKGROUND/OBJECTIVES: Migraine, associated with several gastrointestinal disorders, may result from increased intestinal permeability, allowing endotoxins to enter the bloodstream. We tested whether probiotics could reduce migraine through an effect on intestinal permeability and inflammation. SUBJECTS/METHODS: In total, 63 patients were randomly allocated to the probiotic (n=31) or the placebo group (n=32). Participants ingested a multispecies probiotic (5x109 colony-forming units) or placebo daily for 12 weeks. Migraine was assessed with the Migraine Disability Assessment Scale (MIDAS), the Headache Disability Inventory (HDI) and headache diaries. At baseline and 12 weeks, intestinal permeability was measured with the urinary lactulose/mannitol test and fecal and serum zonulin; inflammation was measured from interleukin (IL) -6, IL-10, tumor necrosis factor-α and C-reactive protein in serum. RESULTS: The MIDAS migraine intensity score significantly decreased in both groups (P<0.001) and the HDI score significantly decreased in the probiotic group (P=0.032) and borderline in the placebo group (P=0.053). In the probiotics group, patients had a median of 6 migraine days in the first month, 4 in the second month (P=0.002) and 5 in the last month, which was not significantly different from the 5, 4, and 4 days in the placebo group. A ⩾2day reduction in migraine days was seen in 12/31 patients in the probiotics group versus 7/29 in the placebo group (ns). Probiotic use did not significantly affect medication use, intestinal permeability or inflammation compared to placebo. CONCLUSIONS: In this study, we could not confirm significant benefit from a multispecies probiotic compared to a placebo on the outcome parameters of migraine and intestinal integrity.

How the concept of biochemical response influenced the management of primary biliary cholangitis over time.

BACKGROUND: Criteria assessing biochemical response to ursodeoxycholic acid (UDCA) are established risk stratification tools in primary biliary cholangitis (PBC). We aimed to evaluate to what extent liver tests influenced patient management during a three decade period, and whether this changed over time. METHODS: 851 Dutch PBC patients diagnosed between 1988 and 2012 were reviewed to assess patient management in relation to liver test results during UDCA treatment. To do so, biochemical response at one year was analysed retrospectively according to Paris-1 criteria. RESULTS: Response was assessable for 687/851 (81%) patients; 157/687 non-responders. During a follow-up of 8.8 years (IQR 4.8-13.9), 141 died and 30 underwent liver transplantation. Transplant-free survival of non-responders (60%) was significantly worse compared with responders (87%) (p < 0.0001). Management was modified in 46/157 (29%) non-responders. The most frequent change observed, noted in 26/46 patients, was an increase in UDCA dosage. Subsequently, 9/26 (35%) non-responders became responders within the next two years. Steroid treatment was started in one patient; 19 patients were referred to a tertiary centre. No trend towards more frequent changes in management over time was observed (p = 0.10). CONCLUSION: Changes in medical management occurred in a minority of non-responders. This can largely be explained by the lack of accepted response criteria and of established second-line treatments for PBC. Nevertheless, the observation that response-guided management did not increase over time suggests that awareness of the concept of biochemical response requires further attention,particularly since new treatment options for PBC will soon become available.

The effects of the multispecies probiotic mixture Ecologic®Barrier on migraine: results of an open-label pilot study.

Migraine prevalence is associated with gastrointestinal disorders. Possible underlying mechanisms could be increased gut permeability and inflammation. Probiotics may decrease intestinal permeability as well as inflammation, and therefore may reduce the frequency and/or intensity of migraine attacks. Therefore we assessed feasibility, possible clinical efficacy, and adverse reactions of probiotic treatment in migraine patients. 29 migraine patients took 2 g/d of a probiotic food supplement (Ecologic(®)Barrier, 2.5×10(9) cfu/g) during 12 weeks. Participants recorded frequency and intensity of migraine in a headache diary and completed the Migraine Disability Assessment Scale (MIDAS) and Henry Ford Hospital Headache Disability Inventory (HDI) at baseline and after 12 weeks of treatment. Compliance was measured every 4 weeks by counting the remaining sachets with probiotics. The study was completed by 27/29 (93%) patients who took 95% of the supplements. Obstipation was reported by 4 patients during the first 2 weeks of treatment only. The mean±standard deviation (SD) number of migraine days/month decreased significantly from 6.7±2.4 at baseline to 5.1±2.2 (P=0.008) in week 5-8 and 5.2±2.4 in week 9-12 (P=0.001). The mean±SD intensity of migraine decreased significantly from 6.3±1.5 at baseline to 5.5±1.9 after treatment (P=0.005). The MIDAS score improved from 24.8±25.5 to 16.6±13.5 (P=0.031). However, the mean HDI did not change significantly. In conclusion, probiotics may decrease migraine supporting a possible role for the intestine in migraine management. Feasibility and lack of adverse reactions justify further placebo-controlled studies.

Undefined malabsorption syndrome with villous atrophy successfully reversed by treatment with cyclosporine.

A 47-year-old man with a flat jejunal mucosa complicated by malabsorption, diarrhoea and lymphocytic colitis is presented. There was no response to gluten withdrawal alone, combination of a gluten-free diet and prednisone therapy, or total parenteral nutrition. Complete clinical remission was only achieved after simultaneous treatment with cyclosporine and a gluten-free diet. Rechallenge with a gluten-containing diet while cyclosporine treatment continued resulted in a relapse of diarrhoea and malabsorption. We conclude that cyclosporine may be an effective agent for the treatment of undefined, refractory forms of malabsorption.

Nutrient-specific effects of modified sham feeding on pancreatic polypeptide release.

OBJECTIVE: To study the effect of meal composition on pancreatic polypeptide release during modified sham feeding. DESIGN: In random order and on separate occasions, isocaloric, isothermic, isoosmotic, homogenized meals (1050 kJ; 250 kcal) either rich in fat (walnuts; 64 g fat, 7 g protein, 15 g starch per 100 g), protein (codfish, 1 g fat, 23 g protein per 100 g) or carbohydrates (bananas; 22 g starch, 1 g protein per 100 g) were sham-fed for 30 min by tasting and spitting out the meal. The plasma pancreatic polypeptide response was monitored by radioimmunoassay at 10 min intervals from 20 min before to 120 min after modified sham feeding. SETTING: Department of Gastroenterology and Hepatology of a University Hospital. SUBJECTS: Seven healthy volunteers: 3 male, 4 female; age 45 (range 30-77) years. RESULTS: Integrated plasma pancreatic polypeptide responses to modified sham feeding of codfish (1088 +/- 395 pM*120 min; P < 0.05) and walnuts (1200 +/- 542 pM*120 min) were distinctly higher (P < 0.05) than to modified sham feeding of bananas (-390 +/- 291 pM*120 min). CONCLUSIONS: These results demonstrate that the pancreatic polypeptide response to modified sham feeding is dependent on the composition of the meal.

Villous tumours of the duodenum. An analysis of the literature with emphasis on malignant transformation.

Until 1992, 192 patients with a villous tumour of the duodenum have been reported. The symptoms and signs of this tumour are mostly related to obstruction of the duodenal lumen or bile ducts. Radiological examination (e.g., hypotonic duodenography) may be of some help in diagnosing a villous tumour of the duodenum. In histological specimens, superficial parts of the tumour may appear benign while deeper parts may contain adenocarcinoma. Therefore, endoscopy with multiple biopsies or the use of electrocautery for removal of large fragments of the tumour should play a major role in obtaining an accurate preoperative diagnosis. Forty-two per cent of all reported villous tumours showed malignant changes at the time of presentation. Because of this great risk of malignant transformation, these tumours should always be resected. Unlike large bowel mucosa, small bowel mucosa contains lymphatics that course through the villi extending near the luminal surface, suggesting the possibility of early lymphatic spread before invading the muscularis mucosae. In 24 patients with intramucosal carcinoma, however, no metastases were found. For this reason, a mucosal resection of these tumours would appear to be an effective and safe treatment. Invasive carcinomas or recurrent villous tumours require more radical surgery. Depending on histological evaluation, location in the duodenum and intraoperative findings, segmental resection of the villous tumour or pancreaticoduodenectomy would seem to be an appropriate surgical procedure. A pedunculated villous tumour may be removed endoscopically. It is recommended that all patients who had their tumour resected locally, should be surveyed endoscopically.

Villous tumors of the duodenum. Presentation of five cases.

Five cases of villous tumors of the duodenum are reported. These tumors have a predilection for the periampullary region and tend to present with jaundice or obstruction of the duodenal lumen. In four of these patients, malignant transformation was seen. Endoscopy and biopsy play a major rôle in attempting to obtain an accurate preoperative diagnosis. Unfortunately, the diagnosis of malignant degeneration is frequently missed, even when multiple biopsies are taken. For this reason villous tumors should always be resected, and the strategy of treatment must depend on pre-, intra- and postoperative histological evaluation, location in the duodenum and intra-operative findings.

[Intestinal obstruction caused by non-absorbable tablets and Budd-Chiari syndrome in a patient with Crohn's disease]. / Darmobstructie door niet-resorbeerbare tabletten en Budd-Chiari-syndroom bij een patiënte met de ziekte van Crohn.

Crohn's disease is a chronic inflammatory granulomatous disorder affecting any part of the gastrointestinal tract, particularly the terminal ileum and the colon. Familiar complications are strictures, fistulae, perforation, haemorrhages and malabsorption due to multiple resections. A patient with two rare complications of Crohn's disease is described. A 16-year-old female with ileocaecal Crohn's disease presented with anaemia and ileus. This ileus was caused by some 40 tablets of ferrosulphate with a non-soluble matrix, in the presence of an existing stenosis of the ileum due to Crohn's disease. An ileocaecal resection was performed. During an exacerbation of Crohn's disease she developed hepatic vein thrombosis with a Budd-Chiari syndrome (upper abdominal pain, hepatomegaly and ascites). Prescription of tablets with a non-soluble matrix is contraindicated in patients with a partial stenosis of the intestine. Patients with active Crohn's disease are predisposed to thromboembolic complications. Hepatic vein thrombosis in our patient may have been the result of hypercoagulability during the exacerbation of her disease.

Right hemothorax: An unusual presentation of a Barrett's ulcer perforation.

INTRODUCTION: Despite improvements in detection and surgical techniques perforation of the esophagus are lifethreatening. In this case report a rare presentation esophageal perforation due to Barrett's ulceration into an aortic vessel is described. PRESENTATION OF CASE: We report a 42 year old man with known Barrett's esophagus presenting with abdominal pain. Further investigations showed an active intrathoracal hemorrhage due to esophageal perforation at exactly the same site of the known Barret's ulcer one year before. Thoracotomy with evacuation of blood was performed and an aortic branch as bleeding focus was found. DISCUSSION: Hemothorax due to esophageal perforation of a benign Barrett's ulcer is rare. The diagnosis of aortoesophageal fistula's can be complicated and its presentation is frequently unspecific and is simply confused with other disorders. Acute thoracotomy is necessary and choice of closure depends on the cause and size of the perforation. CONCLUSION: This case illustrates the need for maintaining a wide-ranging view of potential casus of hemothorax. The key to survival in patients with aorto-esophageal fistula is maintaining awareness of the condition to allow early diagnosis and operative management of this treatable lesion.

Rapid EPA and DHA incorporation and reduced PGE2 levels after one week intervention with a medical food in cancer patients receiving radiotherapy, a randomized trial.

BACKGROUND & AIMS: In cancer patients, metabolic alterations, reduced immune competence and anti-cancer treatment can increase the risk of infections. A rapid-acting nutritional intervention might reduce this risk and support overall treatment. The present study investigated whether one week of intervention with a specific medical food led to fatty acid incorporation and functional immunological changes. METHODS: In a randomized, double-blind study, 38 cancer patients receiving radiotherapy consumed daily for one week 400 ml of specific medical food, which is high in protein and leucine, and enriched with fish oil and specific oligosaccharides (Active group), or iso-caloric/iso-nitrogenous product (Control group). Blood samples were taken at day 0 (baseline) and day 7. RESULTS: After one week of intervention, the incorporation of EPA and DHA in white blood cells was significantly higher in the Active group (2.6% and 2.6% of total fatty acids) compared to the Control group (1.0% and 2.2% of total fatty acids) (p < 0.001 and p < 0.05). Serum PGE2 levels decreased in the Active group and increased in the Control group (p < 0.01). No differences were observed on cytokine production in LPS-stimulated whole blood cultures. CONCLUSIONS: In cancer patients receiving radiotherapy, nutritional intervention with a specific medical food rapidly increased the percentage EPA and DHA in white blood cell phospholipids and reduced serum levels of the inflammatory mediator PGE2 within one week. CLINICAL REGISTRATION NUMBER: NTR2121.

Induction of eruptive benign melanocytic naevi by immune suppressive agents, including biologicals.

BACKGROUND: Eruptive naevi have been described to potentially arise in immune compromised patients. OBJECTIVES: We describe three patients with eruptive benign melanocytic naevi during a phase of immunosuppressive therapy. METHODS/DIAGNOSIS: Two patients with Crohn disease were treated with either azathioprine monotherapy or a combination of azathioprine and infliximab, when eruptive naevi arose particularly at the palms and soles. Our third patient with plaque psoriasis developed eruptive naevi during two episodes of treatment: during a course with the biological agent alefacept and during etanercept therapy. CONCLUSIONS: We conclude that treatment with the recently available biological agents might be associated with the formation of eruptive naevi. Although positive evidence for the occurrence of malignant pigmented lesions is lacking, alertness to the development of eruptive melanocytic naevi during treatment with biological agents is indicated.

Effect of erythromycin on pancreatic polypeptide release: role of the vagal nerve.

To determine whether long vagal cholinergic pathways are involved in erythromycin-induced pancreatic polypeptide release, erythromycin was administered as an intravenous bolus injection to 9 healthy volunteers (group A) and to 13 patients (group B) with impaired vagal function as a result of truncal vagotomy or accidental vagotomy after antireflux surgery. In 7 of these patients (group B1) an antrectomy was also performed, while in the other 6 patients (group B2) the antrum was not removed. Pancreatic polypeptide was measured by radioimmunoassay at 5-min intervals twice before and at 2, 5, 10, 15, 30, 45 and 60 min after a 3.5 mg/kg bolus injection of erythromycin. On another day, a standard meal was administered and plasma pancreatic polypeptide was measured at 10-min intervals for 1 h. Erythromycin injection resulted in a lower integrated pancreatic polypeptide response in the patients of group B1 (247 +/- 89 pmol/l x 15 min; p = 0.005) and group B2 (497 +/- 111 pmol/l x 15 min; p = 0.05) when compared to the healthy subjects of group A (1,136 +/- 227 pmol/l x 15 min). The pancreatic polypeptide response to erythromycin in group B1 was reduced when compared to group B2, but the difference just failed to reach statistical significance (0.05 < p < 0.10). In the first 30 min after ingestion of a meal (cephalic phase) pancreatic polypeptide release was also markedly lower in group B1 (1,461 +/- 304 pmol/l x 30 min; p < 0.005) and group B2 (1,452 +/- 215 pmol/l x 30 min; p < 0.005) when compared to group A (3,541 +/- 452 pmol/l x 30 min).(ABSTRACT TRUNCATED AT 250 WORDS)