Acid suppression does not change respiratory symptoms in children with asthma and gastro-oesophageal reflux disease.

BACKGROUND: Epidemiological studies have shown an association between gastro-oesophageal reflux disease (GORD) and asthma, and oesophageal acid perfusion may cause bronchial constriction. However, no causative relation has been proven. AIM: To assess whether acid suppression would lead to reduced asthma symptoms in children with concomitant asthma and GORD. METHODS: Thirty eight children (mean age 10.8 years, range 7.2-16.8; 29 males) with asthma and a reflux index > or =5.0 assessed by 24 hour oesophageal pH monitoring were randomised to 12 weeks of treatment with omeprazole 20 mg daily or placebo. The groups were similar in age, gender, mean reflux index, and asthma severity. Primary endpoints were asthma symptoms (daytime wheeze, symptoms at night, in the morning, and during exercise) and quality of life (PAQLQ). Secondary endpoints were changes in lung function and the use of short acting bronchodilators. At the end of the study a repeated pH study was performed to confirm the efficacy of acid suppression. RESULTS: The change in total symptom score did not differ significantly between the omeprazole and the placebo group, and decreased by 1.28 (95% CI -0.1 to 2.65) and 1.28 (95% CI -0.72 to 3.27) respectively. The PAQLQ score increased by 0.62 (95% CI 0.29 to 0.95) in the omeprazole group compared to 0.50 (95% CI 0.29 to 0.70) in the placebo group. Change in lung function and use of short acting bronchodilators were similar in the groups. The acid suppression was adequate (reflux index <5.0) under omeprazole treatment. CONCLUSION: Omeprazole treatment did not improve asthma symptoms or lung function in children with asthma and GORD.

Recurrent abdominal pain in children revisited: irritable bowel syndrome and psychosomatic aspects. A prospective study.

BACKGROUND: Since Apley, more than 40 years ago, concluded that less than 10% of cases with recurrent abdominal pain (RAP) are of organic origin, medical technology has improved, the knowledge has expanded and new methods of investigation have been developed. The lack of organic findings in many children with RAP has led to the conclusion that psychological factors are important. METHODS: Forty-four children with RAP underwent an investigation programme to find organic abnormalities that might explain the symptoms. Current criteria for irritable bowel syndrome (IBS) in children were used to find out what proportion fulfilled these criteria, irrespective of the organic findings on clinical investigation. A standardized questionnaire, the CBCL (Child Behaviour Checklist), was used to evaluate emotional and behavioural disturbances in children referred for RAP. RESULTS: Thirteen out of 26 (50%) children with no signs of organic disease fulfilled the IBS criteria as opposed to 7 out of 18 (39%) children in the group with organic findings (P = 0.68). The total score for the CBCL was in the normal range for 32 out of 36 of the children. CONCLUSIONS: We found a high proportion of children fulfilling the IBS criteria in both groups, thus organic abnormalities have to be excluded before making the IBS diagnosis. The results of the CBCL forms did not show any difference between children with organic versus those with non-organic abnormalities, both groups within the normal range.

Recurrent abdominal pain in school children revisited: fitting adverse food reactions into the puzzle.

UNLABELLED: The diagnostic work-up of children seeking health care because of recurrent abdominal pain is a clinical challenge. Food hypersensitivity might be one of the aetiologies behind this symptom. Neither the understanding of possible immune mechanisms nor endoscopic or histological findings have yet contributed to reliable diagnostic tests. CONCLUSION: The possibility of adverse food reactions should be evaluated among other abnormalities behind recurrent abdominal pain in children. Still, the diagnosis of immunemediated food reactions depends on open or blinded food challenge.

Incidence of inflammatory bowel disease in children in southeastern Norway: a prospective population-based study 1990-94.

BACKGROUND: Most incidence studies of ulcerative colitis (UC) and Crohn disease (CD) have dealt with adults and there are have been few population-based prospective studies of the incidence of inflammatory bowel disease (IBD) in children. The aim of this study was to determine the incidence after re-evaluation of the diagnosis of UC and CD in childhood and adolescence in a prospective population-based survey. METHODS: From 1 January 1990 to 31 December 1993, all newly diagnosed patients with UC and CD under the age of 16 years were registered. On 1 January 1992 there were 174,482 children in the study population. The diagnosis was based on internationally accepted criteria and all clinical data were reviewed by two gastroenterologists independently of each other. All patients were subjected to a second evaluation 1 year after inclusion in the study. Patients initially diagnosed as indeterminate colitis (IND) were also reassessed. RESULTS: A total of 14 cases of UC, 13 cases of CD and 2 cases of IND were registered during the study period. At re-evaluation of the two patients diagnosed as IND, one was reclassified as having UC and one as having CD. This yielded a mean annual incidence of 2.14 (95% CI 1.20-3.54) per 100,000 for UC and 2.00 (95% CI 1.10-3.36) per 100,000 for CD. The male:female ratio in UC was 4.0 and 1.8 in CD. Median time interval from onset of symptoms to diagnosis was 4 months for UC and 5 months for CD. A high proportion of the children with UC (80%; 12/15) had extensive colitis. Four patients with CD had a first-degree relative with IBD. CONCLUSION: This study does not support an increased incidence of paediatric CD over the past decade. The incidence of paediatric UC seems to have remained stable over the past 30 years. In the CD group, we find a high incidence of IBD in first-degree relatives.

Evaluation of effect of 3D video glasses on perceived pain and unpleasantness induced by restorative dental treatment.

Previous studies on modulation of anxiety, pain and unpleasantness have documented a positive effect of video glasses (I-Glasses, Virtual i-O, Seattle, USA) on the perceived pain and unpleasantness under different laboratory and clinical conditions. The aim of this study was to evaluate whether distraction induced by video glasses also had an effect on the perceived intensity of pain and unpleasantness during dental treatment. Pain and unpleasantness was evoked by the preparation (drilling) of a minor dental cavity (class I). Twenty-three patients (17 female and six male, age range 20-49 years) with a need for an occlusal dental restoration in two homologous teeth participated in the study. In this split-mouth design, the patient received the dental treatment wearing 3D video glasses and without video glasses (control situation) in a randomized order. The tooth cavities were prepared in accordance with conventional techniques after mounting the video glasses. The patient rated the intensity of pain and unpleasantness on 100 mm visual analogue scales (VASs) after preparation of the first cavity; immediately after, the opposite tooth was prepared and again the volunteer rated the intensity of pain and unpleasantness. The cavities were then filled using a routine composite technique. Eventually, the patient indicated whether she would prefer video glasses or not if she were to have another filling and what the expectations of the effect had been. Differences in VAS ratings in the video and control situation were tested by Student's t-test. There was no statistically significant effect on the perceived pain (p=0.90) or unpleasantness (p=0.39), but the majority (74%) of the patients would still prefer to wear video glasses if they were to have another dental filling, and 73% had expected a positive effect of the video glasses. These findings suggest that perceived intensity of dental pain is resistant to a simple distraction technique.

Organic abnormalities in recurrent abdominal pain in children.

UNLABELLED: Using an investigation protocol, the aim of this study was to determine the frequency of organic abnormalities in children with recurrent abdominal pain, as new diagnostic approaches may reveal a higher prevalence of organic disease in this group than has been found in most studies. Included in the study were 44 children (mean age 8.3 y; 2-15) with more than three bouts of abdominal pain severe enough to affect the daily activities of the child and lasting more than 3 mo. The investigation covered a detailed medical story, a physical examination, blood, urine and stool samples. The somatic investigation was completed by abdominal X-ray and ultrasound, lactose-breath-hydrogen test and 24-h pH monitoring in the lower oesophagus. A Child Behaviour Checklist was completed to assess psychosocial aspects of the illness. The blood, urine and stool samples were normal, and abdominal ultrasound did not give any results related to the symptoms. Constipation was diagnosed in 7 patients (16%); 9 patients (21%) had gastro-oesophageal reflux and oesophagitis was found in another 3 children. One child had nodular antral gastritis with colonization by Helicobacter pylori, and three children had pathological lactose-breath-hydrogen tests. Twenty-four children (55%) did not have any signs of organic disease. The total score for the CBCL was in the normal range in 89%. CONCLUSION: Our observations indicate a higher proportion of organic abnormalities in recurrent abdominal pain than has been found in most previously reported studies, though a multicausal approach seems important.

[Tetany--a first symptom of celiac disease]. / Tetani--debutsymptom ved cøliaki.

BACKGROUND: Seizures in children are usually caused by fever or epilepsy, though they may also be caused by electrolyte, vitamin or mineral disturbances. We describe a case of hypocalcaemic tetany with hypovitaminosis D. MATERIAL AND METHODS: The patient was a previously healthy eight months old girl of Indian origin. RESULTS: Investigations revealed that she suffered from coeliac disease. INTERPRETATION: Coeliac disease is a well-known disorder, characterised by enteropathy and malabsorption causing symptoms such as vomiting, diarrhoea and failure to thrive. Enteropathy and specific malnutrition may occur in the total absence of gastrointestinal symptoms.

[Reflux disease and 24-hour esophageal pH monitoring in children]. / Reflukssykdom og 24-timers pH-måling i spiserøret hos barn.

Gastrooesophageal reflux disease has a variety of symptoms in children. 24-hour pH monitoring in the lower oesophagus is the gold standard for documenting gastrooesophageal reflux. We present our experience with 24-hour pH monitoring in children. 150 pH recordings in 120 children were performed. Clinical background and results from pH monitoring were recorded, in addition to supplementary examinations and treatment. No complications were recorded, but ten recordings (8.3%) were unsuccessful. Mean age was 3.5 years (median 13 months; range one month to 15 years). 44% had a pathological reflux index. Indications for pH monitoring were dominated by regurgitation/vomiting (63%), failure to thrive (45%) and respiratory symptoms (32%). Of the supplementary examinations performed, upper gastrointestinal contrast series provided no additional information (34 children), while endoscopy (20 children) showed oesophagitis in 11. Medical treatment was prescribed in 66% of the cases based on the pH monitoring results and clinical evaluation. Five patients were given anti-reflux surgery, and ten received gastrostomy. Our experience with this recording technique is good. pH monitoring should be available in paediatric departments, as a large number of the recordings had clinical consequences for the patient.

The hypoalgesic effect of 3-D video glasses on cold pressor pain: reproducibility and importance of information.

The first aim of the study was to evaluate whether it was possible to manipulate the distraction effect induced by 3-D video glasses on the perceived pain and unpleasantness of the subjects by giving them different information about the expected effect. Second, the study aimed to determine the reproducibility of the effect. Forty-five students enrolled, 39 students participated in the study (24 women and 15 men, median age 23 years, range 19-28 years) because 6 did not show up for the first trial, and 37 completed the study because 2 subjects did not show up for the second trial. The subjects were randomized into 3 groups, balanced with respect to age and sex, that received different information about the effect of 3-D video on pain and unpleasantness: the first group received positive information, the second group received neutral information, and the third group received negative information. Once assigned to a group, there were no crossovers between the groups. A cold pressor stimulus was used to induce experimental pain, and the volunteers rated the intensity of pain and unpleasantness on 100-mm visual analogue scales. A new generation of video glasses were used in the study. Each volunteer was exposed to the cold pressor test in 2 randomized trials (video and control) after the information was given, and the 2 trials were repeated in a second session after 4 weeks. There was no significant difference in the effect of video glasses on perceived pain (P = .74) nor on the perceived unpleasantness (P = .84) among the 3 information groups. The data were therefore pooled. The results of the pooled data showed a significant effect of 3-D video on perceived pain (P = .03) but not on unpleasantness (P = .18). After 4 weeks, the study was repeated, and there were no significant changes in the effect of video glasses. The median visual analogue scale scores were reduced in both the video and the control trials compared with the first session.

Questions you didn't ask? COOP/WONCA Charts in clinical work and research. World Organization of Colleges, Academies and Academic Associations of General Practitioners/Family Physicists.

OBJECTIVE: COOP/WONCA Functional Assessment Charts are widely in use in research and clinical work. They originally evolved from Dartmouth COOP Functional Assessment Charts. Our objective is to describe our experiences with COOP/WONCA Charts and to provide data on reliability and reference data from a normal population. METHOD: A test-retest study comprising 40 randomly selected patients attending GPs' surgeries was conducted. Eight GPs took part in this study. The response rate for the questionnaire was 100%. In a second study, 245 asthma patents who consulted 53 different GPs were consecutively included; 171 of these repeated completion of the charts after 6 months. Mean scores from a random sample of 2864 persons in the total population of the municipality of Ullensaker in Norway are given as reference values. There was a postal return rate of 64%. RESULTS AND CONCLUSIONS: The reliability of the charts is good, and nine out of ten of the patients gave clinically meaningful answers after 2-3 days. The scores of the 171 asthma patients were nearly identical after 6 months. The reference values are presented. A standardized method for reliability testing is discussed, and the use of COOP/WONCA Functional Assessment Charts is commented on.

The effect of a new type of video glasses on the perceived intensity of pain and unpleasantness evoked by a cold pressor test.

The aim of the study was to evaluate whether distraction induced by a new generation of video glasses (I-Glasses, Virtual i-O, Seattle, WA) has an effect on the perceived intensity of pain and unpleasantness. The effects of three-dimensional video, two-dimensional video, and no video glasses (control) were compared in two groups of healthy volunteers (13 males and 11 females) in a randomized, controlled trial. A cold pressor stimulus (1-2 degrees C chilled water) was used to induce experimental pain, and the volunteers rated the intensity of pain and unpleasantness on 100-mm visual analogue scales. The ratings were statistically compared using the Wilcoxon signed-rank test. Between the groups (males and females), there was a significant difference (P < .01) in the rating of unpleasantness in the three-dimensional video condition, while there were no significant differences between the genders in the other conditions (two-dimensional, control). Three-dimensional video provided a significant reduction in both pain and unpleasantness (P < .01) compared with the control condition in the male group. However, in the female group, there was a significant reduction in unpleasantness with two-dimensional video compared with the control (P < .05). This suggests that the use of distraction by means of video glasses is able to reduce the perceived intensity of pain and unpleasantness.

Childhood Crohn's disease and the efficacy of enteral diets.

Enteral diets, both elemental and, more recently, polymeric (whole protein), are used as primary therapy in Crohn's disease and can induce disease remission without the concomitant use of immunosuppressive drugs. Controlled trials comparing enteral nutrition with corticosteroid therapy have given mixed results but suggest, at least in children, that they are as effective as corticosteroids in inducing remission. There is no clear consensus as to which dietary therapy is best. Elemental diets do not seem to be superior to polymeric whole protein-based diets, although further work is necessary. The effect of enteral diets does not seem to be related to the site of intestinal inflammation. Enteral nutrition is particularly appropriate in children and adolescents with Crohn's disease, improving nutrition and promoting growth and pubertal development, and avoiding the systemic toxicity of corticosteroid therapy. Most centers will use it as a first line of treatment. Supplementary enteral nutrition after primary therapy and remission induction may be associated with the prolongation of remission and promotion of linear growth. Pathways by which enteral diets may affect mucosal inflammation are discussed. Enteral diets may inhibit intestinal immune responses by reducing the number of cytokine-producing cells. Enteral nutrition may also boost immunosuppressive pathways, which then endogenously suppress ongoing inflammation. Enteral diets may promote epithelial healing and reepithelialization of Crohn's ulcers and may also reduce the bacterial load in the small bowel.

[Assessment of one's own functional status. COOP-WONCA questionnaire charts in clinical practice and research]. / Vurdering av egen funksjonsevne COOP-WONCAs spørreskjemaer i klinikk og forskning.

Primary health care has needed an instrument that can be used to assess patients functional health status. Since 1988 the Classification Committee of WONCA, the World Organisation of Family Doctors, has been working on a revised edition of the Dartmouth COOP Functional Status Assessment Charts. The six COOP-WONCA Charts are described: physical fitness, feelings, daily activities, social activities, change in health and overall health. The charts have been tested against many other instruments and the validity has been found to be good. A Norwegian test-retest reliability study, the first on the revised COOP-WONCA Charts, showed good reliability. For 35 out of 40 of the office patients included in the study, either the answers were the same at test-retest, or "change of health" was consistent with changes in other variables. A study in a group of 171 asthma patients showed unchanged mean scores after six months. The results from a population study in the municipality of Ullensaker, comprising 2,864 persons, are presented as a basis for comparison. The COOP-WONCA instrument is simple and easy to use and understand. It meets the requirements for a useful tool in clinical practice and research and seems to provide valuable, additional information in daily practice. The COOP-WONCA Charts represent a simple and good method for assessing functional status.

ICPC as a standard classification in Norway.

BACKGROUND: The International Classification for Primary Care (ICPC) has been the standard classification for diagnoses on sickness certificates and bills for services to the National Insurance Administration in Norway since 1992. Coding according to ICPC is compulsory for all general practitioners. OBJECTIVE: The objective of the present study was to describe the introduction of ICPC in Norway, to comment on introduction problems, and to examine the compliance and validity of coding. METHODS: The study was based on statistics for episodes of sickness certification in the National Benefit Absence Register. RESULTS: In 1994, the underlying medical diagnosis was coded in 98% of the sickness absence episodes lasting more than 2 weeks. Component 1 codes (symptom codes) were used in 23% of episodes, compared with 26-31% in practice studies. CONCLUSIONS: ICPC-coded data in a large Norwegian register appear promising. Most doctors do accurate and careful work in coding, and data appear to be of acceptable quality for further analysis. It is a matter of concern, however, that as many as 23% of episodes had component 1 codes, since these certificates were issued during follow-up encounters. The introduction of ICPC coding has enabled researchers to use diagnoses in the analyses of sickness absence. The growing use of ICPC in general practice has made multi-practice studies possible. The introduction of criteria is mandatory for the improvement of validity in diagnostic coding.

Classification of severity of health problems in family/general practice: an international field trial.

BACKGROUND: A methodology is needed for classification of health problems by severity. OBJECTIVES: We aimed to test the Duke Severity of Illness Checklist (DUSOI) for feasibility and usefulness. METHOD: The DUSOI was field tested internationally by 22 family/general practitioners in 9 countries. RESULTS: The DUSOI was found to be feasible for rating severity of illness of health problems in family/general practice. The measure was shown to be clinically useful in older patients and those with chronic and more severe health problems. Variability of severity ratings was less within the same rater than between different raters (i.e. higher intrarater than interrater reliability). Clinical face validity was supported by the finding that DUSOI ratings classified patients with the same diagnosis and those with different diagnoses according to the severity differences that would be expected clinically. CONCLUSIONS: Although research is needed to improve reliability and to test validity further, the DUSOI was shown in the present study to be a methodology that is reasonable for consideration as an international classification of health problems by their severity in primary care patients.

Cellular and regional expression of transcripts of the plasma membrane calcium pump PMCA1 in rabbit intestine.

The plasma membrane Ca(2+)-pumping adenosinetriphosphatase (PMCA) is the energy-dependent step in the active vitamin D-dependent absorption of dietary Ca2+ by the enterocyte. Studies of the various PMCA genes and splicing variants in humans and rats have indicated that the isoform known as PMCA1b is the predominant form expressed in small intestine. Using an oligonucleotide probe, we have studied the regional and cellular distribution of PMCA1 transcripts in rabbit intestinal tissues by in situ hybridization. On small intestinal RNA blots, this hybridized to species similar in size to those detected by PMCA1-specific cDNA probes; an additional larger transcript was present in rabbit than in rat or human. In situ hybridization signals were principally in the enterocyte population of the mucosa and were maximal in differentiating enterocytes on the lower part of the villus, a pattern similar to that previously demonstrated for other nutrient transporters. Reflecting the capacity of the different small intestinal segments to transport Ca2+, much higher levels of transcript were detected by both methods proximally (in duodenum) than distally (in jejunum and ileum) and were also higher in cecum and ascending colon mucosa than in descending colon. We conclude that as enterocytes differentiate in regions that absorb Ca2+, they express high levels of mRNA for PMCA1. These results confirm the importance of transcriptional regulation of this gene for active Ca2+ absorption.

H+/di-tripeptide transporter (PepT1) expression in the rabbit intestine.

In order to examine the intestinal expression of the recently cloned H+/di-tripeptide transporter (PepT1), oligonucleotide probes were synthesized and their specificity confirmed by Northern blot analysis of rabbit jejunal RNA. In situ hybridization studies, using these probes, show that PepT1 is expressed all along the small intestine and at a very much reduced level in the colon. In contrast, PepT1 mRNA was not detected in the stomach, sacculus rotundus or caecum. Microscopic examination of tissue sections showed PepT1 expression to be restricted to intestinal epithelium with no detectable expression in the lamina propria, muscularis mucosae, muscularis or serosa. The accumulation of PepT1 mRNA along the crypt-villus axis was also investigated. In all regions of the small intestine (in duodenum, jejunum and ileum), PepT1 mRNA was undetectable in deeper epithelial cells of the crypts. Expression was first detectable at or near the crypt-villus junction, the amount of PepT1 mRNA increasing rapidly in the lower villus to a maximum approximately 100-200 microns from this point. Along the length of the small intestine PepT1 mRNA was most abundant in duodenal and jejunal enterocytes, with lower levels in the ileal epithelium. PepT1 expression is greatly depressed in the follicle-associated epithelium of the Peyer's patch relative to both interfollicular and adjacent "normal" villi. These data are discussed in the context of the known physiological role of PepT1 in the gastrointestinal tract.

[Better results with early surgical intervention in biliary atresia. Icterus in infants older than 14 days should be investigated!]. / Tidlig kirurgisk behandling bedrer resultatene ved gallegangsatresi. Icterus hos spedbarn etter 14 dagers alder skal utredes!

The average survival of patients with biliary atresia that remains untreated is 12 months. Early portoenterostomy, and subsequent liver transplantation if necessary, have improved survival dramatically. The success rate after portoenterostomy is inversely related to age at primary operation, and the results after liver transplantation are best in children who receive the transplant after the age of one year. Thus, early portoenterostomy will buy time and bring the patient into a group with a better prognosis if liver transplantation is performed later. Among infants older than two weeks of age with neonatal jaundice, patients with conjugated hyperbilirubinemia must be identified and referred for investigation. In this case ultrasonography is most important for discovering biliary atresia.