Decreased Urinary Sodium-to-urinary Creatinine Ratio Identifies Sodium Depletion in Pediatric Acute Gastroenteritis.

UNLABELLED: In acute gastroenteritis (AG) fecal losses may cause depletion of sodium (NaD) which may not be recognized because of normal plasma Na (pNa) concentrations. We studied the incidence of this state of normonatremic sodium depletion (NNaD) and the suitability of the urinary Na/urinary creatinine ratio (uNa/uCr) for diagnosing NNaD. PATIENTS: 16 AG- and 16 healthy control children aged 0.8-15.0 years. METHODS: Prospective cross sectional pilot study. Measurements of Na, K and creatinine in plasma (p) and urine (u). Calculation of uNa/uCr Ratio, fractional excretion of Na (FENa) and uNa/uK ratio as the hitherto best known parameters of prerenal Na depletion, respectively. RESULTS: pNa concentrations were normal in 15/16 AG patients (93.8%) with only one subnormal value of 133 mmol/L, and a mean value of 137.9±2.3 mmol/L not different from the normal control group (139.4±2.2 mmol/L). Also, mean uNa concentrations and uNa/uK ratios did not differ between both groups. However, uNa/uCr ratios were below normal in 13/16 AG children (81.3%) but normal in all healthy controls with a significantly lower mean value in the AG group (12.6±8.8 vs. 31.2±8.3 mmol/mmol; p<0.0001). Similarly, 14/16 AG patients (87.5%) had a decreased FENa<0.5% with a mean FENa value significantly lower than in controls (0.36±0.28% vs. 0.95±0.26%, p<0.0001). The good agreement between FENa and uNa/uCr results was also reflected by a high correlation coefficient of r=0.9333. CONCLUSIONS: The majority of AG patients was found to have NNaD as determined by uNa/uCr and FENa. Calculation of uNa/uCr may be useful for diagnosing NNaD in AG.

Severe anemia in 3 toddlers with gastric lactobezoar.

BACKGROUND: Anemia in toddlers may result from many disorders including excessive feeding with cow's milk. Another sequel of age-inadequate cow's milk nutrition may be gastric lactobezoar (GLB), a dense lump of coagulated milk and mucus in the stomach. PATIENTS: 3 toddlers presented with a history of excessive intake of full cream cow's milk, abdominal distension, vomiting, dehydration, fatigue, marked pallor and tachycardia. DIAGNOSTIC WORKUP: Diagnostic imaging revea-led large GLBs as the likely origin of the abdominal symptoms. Laboratory evaluation showed severe anemia with depleted iron stores and signs of protein catabolism. Non-cow's milk-induced causes of anemia including defects of erythropoiesis, hemoglobin structure, RBC-enzymes and blood coagulation, hemolysis, immune disorders, infection, inflammation, extraintestinal hemorrhage, nephropathy were - according to the available data - unlikely to cause the anemia in our patients. Thus their anemia is thought to be due to age-inadequate cow's milk nutrition leading to 1) low intake, decreased absorption/bioavailability and increased intestinal loss of iron, and 2) GLB which induced blood loss following mechanical irritation of the gastric mucosa and vomiting causing high gastric pH and decrease in duodenal iron absorption. CONCLUSION: The anemia in our patients is due to both exaggerated feeding with cow's milk and adverse effects of GLBs. This hypothesis is supported by the finding that, after erythrocyte transfusion, iron substitution, age-adapted nutrition and GLB-dissolution, the anemia did not recur. We propose to include GLB in the differential diagnosis of anemia in cow's milk fed small children.

Deficient vasoactive intestinal peptide innervation in the sweat glands of cystic fibrosis patients.

The innervation of acini and ducts of eccrine sweat glands by immunoreactive, vasoactive intestinal peptide-containing nerve fibers was sharply reduced in seven patients with cystic fibrosis compared to eight normal subjects. The decrease in innervation by this neuropeptide, which has been shown to promote blood flow and the movement of water and chloride across epithelial surfaces in other systems, may be a basic mechanism for the decreased water content and relative impermeability of the epithelium to chloride and other ions that characterize cystic fibrosis.

Preoperative stress and anxiety in day-care patients and inpatients undergoing fast-track surgery.

BACKGROUND: To investigate preoperative levels of stress and anxiety in day-care patients and inpatients undergoing surgical interventions. METHODS: Before induction of anaesthesia, the degree of stress and anxiety was assessed in 135 patients using stress and anxiety questionnaires, bio-feedback, physiological measures, and serum levels for stress variables. Questionnaire responses and physiological measures such as arterial pressure, heart rate, skin conductance, cortisol, and catecholamine levels were compared for day-care patients and inpatients. RESULTS: Significant preoperative anxiety was reported by 34 (45.3%) inpatients and 23 (38.3%) day-care patients. Personal responses in stress and anxiety questionnaires and mean values of arterial pressure and heart rate did not differ significantly in day-care patients when compared with inpatients. Correlation between deviations in plasma cortisol concentrations from normal diurnal distribution and anxiety scores and stress scores was also similar, and the relative increase in preoperative stress variables and measures observed in day-care patients and inpatients was also comparable. Bio-feedback measurements revealed significantly higher preoperative skin conductance (P<0.001) in day-care patients than in inpatients, indicating increased vegetative stress responses. CONCLUSIONS: Preoperative anxiety and stress are common in surgical patients. Questionnaires and bio-feedback measurements may help to assess the degree of patients' burdens. Surgeons should be aware of the personal anxiety of patients and consider patient preferences when deciding who should undergo fast-track surgery in day-care.

The relation of cerebrospinal fluid and plasma glycine levels in propionic acidaemia, a 'ketotic hyperglycinaemia'.

The characteristic elevation of plasma glycine concentrations observed in propionic acidaemia (PA) and other 'ketotic hyperglycinaemias' has been attributed to secondary inhibition of the hepatic glycine cleavage system (GCS) by accumulating CoA derivatives of branched-chain amino acid metabolites. In nonketotic hyperglycinaemia (NKH), cerebrospinal fluid (CSF) and plasma glycine levels and their ratio are increased due to primary deficiency of central nervous system (CNS) as well as hepatic GCS. Whether the GCS in the CNS is also inhibited in PA is unclear, as there are scant data available on CSF glycine levels in this disorder. We studied the relation of CSF and plasma glycine levels in 6 paired samples from 4 PA patients, including one PA patient with bacterial meningitis who underwent ventriculoperitoneal shunting and multiple CSF analyses (n = 26). In contrast to the CSF glycine levels which were generally elevated in all four PA patients, the CSF/plasma glycine concentration ratios in paired samples were normal (0.016-0.029), with the exception of a single sample (0.132) with extremely high CSF protein concentration (2010 mg/L) during the course of meningitis indicating a disturbed blood-brain barrier. This finding of normal CSF/plasma glycine ratio in PA suggests that the observed elevations of CSF glycine levels are a reflection of the concurrent hyperglycinaemia resulting from secondary inhibition of hepatic GCS, but that brain GCS is not affected, in contrast to the situation in NKH. The neurological sequelae in PA are therefore unlikely to be related to disturbed glycine metabolism.

Amino acids in CSF and plasma in hyperammonaemic coma due to arginase1 deficiency.

UNLABELLED: We report the CSF and plasma amino acid concentrations and their ratios in a male patient with arginase1 deficiency with an unusual early presentation at 34 days of age. He developed hyperammonaemic coma (ammonia >400 µmol/L; normal <90 µmol/L) on postnatal day 35. CSF and plasma concentrations were assayed by ion-exchange chromatography on day 36. Arginine was increased both in plasma (971 µmol/L; controls (mean ± 2SD) 50 ± 42) and in CSF (157 µmol/L; controls 19 ± 8.6), resulting in a normal CSF/plasma ratio of 0.16 (controls 0.41 ± 0.26). Interestingly, glutamine was disproportionately high in CSF (3114 µmol/L; controls 470 ± 236) but normal in plasma (420 µmol/L; controls 627 ± 246); the ratio exceeded unity (7.4; controls 0.76 ± 0.31). The CSF/plasma ratios of most neutral amino acids were elevated but not those of the imino- and of the dibasic amino acids lysine and ornithine. The mechanism leading to the increase of most neutral amino acids in brain is not known. CONCLUSION: A normal glutamine in plasma does not exclude an increased concentration in CSF; it could be useful to ascertain by MRS that a high CSF glutamine concentration truly reflects a high concentration in brain tissue for better understanding its pathogenesis.

High frequency of missense mutations in glycogen storage disease type VI.

Deficiency of liver glycogen phosphorylase in glycogen storage disease (GSD) type VI results in a reduced ability to mobilize glucose from glycogen. Six mutations of the PYGL gene, which encodes the liver isoform of the enzyme, have been identified in the literature. We have characterized eight patients from seven families with GSD type VI and identified 11 novel PYGL gene defects. The majority of the mutations were missense, resulting in the substitution of highly conserved residues. These could be grouped into those that were predicted to affect substrate binding (p.V456M, p.E673K, p.S675L, p.S675T), pyridoxal phosphate binding (p.R491C, p.K681T), or activation of glycogen phosphorylase (p.Q13P) or that had an unknown effect (p.N632I and p.D634H). Two mutations were predicted to result in null alleles, p.R399X and [c.1964_1969inv6;c.1969+1_+4delGTAC]. Only 7 of the 23 (30%) reported PYGL alleles carry nonsense, splice site or frameshift mutations compared to 68-80% of affected alleles of the highly homologous muscle glycogen phosphorylase gene, PYGM, that underlie McArdle disease. There was heterogeneity in the clinical symptoms observed in affected individuals. These varied from hepatomegaly and subclinical hypoglycaemia, to severe hepatomegaly with recurrent severe hypoglycaemia and postprandial lactic acidosis. We conclude that deficiency of liver glycogen phosphorylase is predominantly the result of missense mutations affecting enzyme activity. There are no common mutations and the severity of clinical symptoms varies significantly.

Identification and in situ localization of the insulin-like growth factor-II/mannose-6-phosphate (IGF-II/M6P) receptor in the rat gastrointestinal tract: comparison with the IGF-I receptor.

In the present study we investigated pharmacological, biochemical, and immunological characteristics as well as the tissue distribution of the insulin-like growth factor-II/mannose-6-phosphate (IGF-II/M6P) receptor in the rat gastrointestinal tract, and compared the data with those from corresponding experiments for the IGF-I receptor. Competitive binding and affinity cross-linking studies with [125I]IGF-II, and [125I]IGF-I respectively, in rat jejunum yielded results analogous to those previously obtained for IGF-II/M6P and IGF-I receptors in intestinal epithelial membranes and other tissues. Furthermore, the IGF-II/M6P receptor antibody no. 3637 completely inhibited the association of [125I]IGF-II with receptor protein but nonimmune antibody did not, providing additional evidence for the presence of the IGF-II/M6P receptor in the rat gut. Also, analysis of the IGF-II/M6P receptor by immunoblotting using antiserum no. 3637 identified a specific band of mol wt 220.000 throughout the gastrointestinal tract with the highest content of immunoreactivity being present in colon and ileum. Autoradiographic mapping of the distribution of IGF-receptors in the rat gut showed that the expression of IGF-II/M6P receptors was in general 2-3 times greater than that of IGF-I receptors. IGF-II/M6P receptors were found 1) in greatest densities in colon and ileum, 2) more abundantly in the mucosa than in the muscularis propria, and 3) predominantly in the luminal part of the mucosal epithelial cells. Radioimmunocytochemistry employing anti-IGF-II/M6P receptor antibody no. 3637 and [125I]protein A demonstrated an IGF-II/M6P receptor distribution analogous to that shown by autoradiography with [125I]IGF-II). IGF-I receptors were present 1) in greatest densities in ileum and colon, 2) more abundantly in the muscularis propria than in the mucosa, and 3) within the mucosa in greater densities in the lamina propria than in the surface epithelium. For both receptor types densities were greater in crypt than in villous epithelial cells. We conclude: 1) the presence of IGF-II/M6P receptors throughout the rat gastrointestinal tract points to an important role for IGF-II in this organ, 2) the finding of different patterns of distribution for IGF-II/M6P and IGF-I receptors supports the concept of their different principal functions, 3) a high degree of expression of both receptor types in crypt epithelium suggests an essential role for both IGF receptors in the regulation of cell mitogenesis and growth.

Human colon carcinoma cells (CaCo-2) synthesize IGF-II and express IGF-I receptors and IGF-II/M6P receptors.

The IGFs have been implicated in the development of the intestinal tract. We have studied the human colon carcinoma cell line CaCo-2 to gain more insight into the function of the IGFs in the gut. [125I]IGF-I and -II bound specifically to CaCo-2 cells as measured in competitive binding experiments. The existence of IGF-I receptors was further demonstrated by affinity crosslinking studies using DSS as the crosslinking agent. Western blotting of CaCo-2 cell extracts using an anti IGF-II/M6P receptor antiserum provided additional evidence for the expression of the IGF-II/M6P receptor. In addition, Northern blotting experiments showed specific IGF-I receptor and IGF-II/M6P receptor gene expression in CaCo-2 cells. An 11 kb band was visualized with a 614 bp PstI IGF-I receptor probe on autoradiographs. Hybridization with a 663 bp IGF-II/M6P receptor probe yielded a 9 kb RNA species. Analysis of CaCo-2 cell RNA using solution hybridization/RNase protection assays yielded two protected fragments, approximately 379 bases in length, with a 394 base IGF-I receptor riboprobe and a 250 base protected fragment with a 260 base IGF-II/M6P receptor riboprobe. In a subset of experiments a PstI 700 base fragment of the IGF-I cDNA and a 554 base SalI fragment of the IGF-II cDNA were used for hybridization: no hybridization was detected with the IGF-I probe. However, using the [32P]IGF-II probe bands at 6.0 and 5.0 kb were labeled in Northern blotting experiments. Analysis of CaCo-2 cell RNA using solution hybridization/RNase protection assays yielded a 289 base protected fragment and a faint 534 base species with a 556 base human IGF-II riboprobe. In addition, IGF-II immunoreactivity was measured in CaCo-2 cell-conditioned medium using an IGF-binding protein blocked radioimmunoassay. CaCo-2 cell-conditioned medium contained 5-15 ng/ml IGF-II immunoreactivity. In conclusion, (1) CaCo-2 cells express both IGF-I receptor mRNA and IGF-II/M6P receptor mRNA and contain functional IGF-I receptor and IGF-II/M6P receptor protein. (2) CaCo-2 cells express IGF-II mRNA and secrete IGF-II immunoreactivity. We hypothesize that in human colon carcinoma cells IGF-II could act as an autocrine growth factor or alternatively could serve as a regulatory factor during differentiation.

Receptors for vasoactive intestinal peptide on isolated human sweat glands.

Human sweat gland function is predominantly under cholinergic control. Sweat secretion may also be regulated by Vasoactive Intestinal Peptide (VIP), which coexists with acetylcholine in nerves to sweat gland acini and ducts. We have examined the expression of VIP receptors on isolated human eccrine sweat glands. Two classes of specific binding sites for VIP were demonstrated: one with high affinity (Kd = 0.58-2.4 nM), and another with low affinity (Kd = 175-288 nM). The data suggest a physiological regulatory role for VIP in sweat gland function.

Effect of substitutions in position 12 of bombesin on antagonist activity.

Recent studies show that substitutions for the His in position 12 of bombesin (Bn) are important in determining antagonist activity. The present study was designed to investigate the chemical properties of the substitution in position 12 of Bn that determined antagonist activity and affinity. Nine [Leu14]Bn analogues with a single amino acid substitution and two analogues with multiple substitutions in addition to position 12 were synthesized. Replacing His12 with Phe12 resulted in an agonist with 100-fold decrease in potency and as reported previously, replacement with D-Phe12 resulted in an antagonist, but with a 10,000-fold decrease in affinity. Substitution of D-beta-naphthylalanine (D-Nal12), a larger and more hydrophobic group than D-Phe, produced a complete loss of antagonist activity, whereas substitution of D-pyridylalanine (D-Pal12), a group more hydrophilic and similar in size to D-Phe, converted the analogue to a very weak agonist with 300-fold lower affinity than the D-Phe analogue. Antagonist activity depended on the nature of the aromatic moiety, with a D-Trp12 resulting in an inactive analogue, and with a D-Tyr12 resulting in a weak antagonist being 100-fold less potent than the D-Phe12 substitution. The addition of an electron withdrawing group to the D-Phe substitution (D-Cpa12) resulted in a minimal decrease in antagonist activity, whereas the addition of an electron donating group (p-hydroxy in D-Tyr12) resulted in a 30-fold decrease in antagonist activity. The addition of a basic group (D-Arg12 or D-Pal12) resulted in weak agonists.(ABSTRACT TRUNCATED AT 250 WORDS)

Autoradiographic localization and characterization of bradykinin receptors in human skin.

High affinity [3H]bradykinin binding sites have been identified in human skin cryosections by in vitro autoradiography. Equilibrium binding studies were performed with increasing concentrations of [3H]bradykinin for 120 min in the presence of protease inhibitors at 4 degrees C. In saturation experiments a single class of high affinity binding sites was identified with a dissociation constant Kd of 1.2 +/- 0.8 nM (mean +/- S.E.M., n = 3) and a maximal binding capacity Bmax of 33 +/- 8 fmol [3H]bradykinin specifically bound/mg protein (mean +/- S.E.M., n = 3). Competition experiments revealed a rank order of potency with bradykinin being most effective (bradykinin = [Lys]bradykinin > [Met- Lys]bradykinin > [Tyr]bradykinin > [des-Arg9]bradykinin), whereas [des-Arg9]bradykinin was ineffective. This indicates a B2 subtype of bradykinin receptors in normal human skin. Morphological data: autoradiography revealed that bradykinin receptors were localized in the stratum basale of the epidermis. The data are consistent with the hypothesis, that these mitotic active keratinocytes express bradykinin binding sites, that fulfil the pharmacological criteria for true receptors. Diverse stimuli, including bradykinin, play a role in the mediation of cutaneous inflammatory responses (e.g. fluid extravasation, reactive cell proliferation, hyperalgesia). Our data indicate that specific kinin receptors of the stratum basale are likely to contribute to these effects.

Copper-induced hepatotoxicosis with hepatic stellate cell activation and severe fibrosis in North Ronaldsay lambs: a model for non-Wilsonian hepatic copper toxicosis of infants.

Copper-sensitive North Ronaldsay sheep represent a possible model for certain hepatic-overload syndromes of infancy and childhood that are clinically, pathologically and genetically distinct from Wilson's disease. The purpose of this study was to simulate in artificially reared lambs the syndrome produced by copper exposure in susceptible human infants. Twenty four North Ronaldsay lambs were assigned to three groups of eight animals, namely, an unsupplemented control group and two trial groups given milk replacer to which copper (CuSO4) had been added at the rate of 5 mg/litre and 10 mg/litre. Four lambs from each group were killed at 40 or 69 days. Livers were fixed in 10% formalin and analysed for copper by mass spectrometry. Paraffin wax-embedded sections were stained with rhodanine for copper and labelled immunohistochemically for alpha smooth muscle actin (ASMA). At 40 days the maximum amounts of copper in the livers of both copper-supplemented groups was 1466-1605 microg/g dry weight (control group 172-201 microg/g Cu dry weight). Histochemically, copper was demonstrated within hepatocytes, together with marked apoptosis. At 69 days there was a florid pericellular fibrosis complemented by strong ASMA immunolabelling, confirming phenotypic modulation of hepatic stellate cells. Such primary copper-induced fibrogenesis confirms the unique status of this animal model in respect of childhood copper toxicosis.

Lack of seasonal variation in flow-mediated dilatation of the brachial artery in women with primary Raynaud's phenomenon and healthy controls.

BACKGROUND: The aim of this study was to examine endothelium function and seasonal variations of endothelium function in women with primary Raynaud's phenomenon (RP) and healthy controls. PATIENTS AND METHODS: After a fast of at least 8 hours we studied 21 patients with primary RP (mean age 31.1 years, mean duration of RP 9.1 years) and 22 controls (mean age 27.8 years) by use of high resolution brachial artery sonography in winter (December/January 2000) and summer (July/August 2001). To exclude circadian variations all examinations were performed in the late afternoon only. All subjects were non-smokers. Confounding factors like serum glucose, HbAlc, and lipid concentrations were analyzed immediately before the investigations. Nicotine contamination was randomly analyzed in hair samples in 8 subjects of each study group. Flow mediated dilatation (FMD%) and nitroglycerin induced dilatation (NID%) were calculated by putting the basal vessel diameter as 100%. RESULTS: Basal, flow-mediated, and nitroglycerin-induced absolute diameters of the brachial artery did not differ significantly between the study groups (p = 0.85). The test conditions (basal, postocclusive, nitroglycerin-induced) always let to the same vessel response in winter and summer (p = 0.61) and there was no significant influence between these test conditions and the study groups (p = 0.07). Compared to patients FMD% was slightly reduced in controls in summer (p = 0.09). Analysis of variance excluded a significant relation between study group and season (p = 0.43). For NID% too, no statistically significant differences were found. CONCLUSIONS: We were not able to show impaired or seasonally variant flow-mediated or nitroglycerin-induced dilatation of the brachial artery in patients with primary RP. Our results argue against the presence of a more generalized endothelium dysfunction detectable with high resolution ultrasound of the brachial artery in patients with primary RP.

[Vasoactive intestinal polypeptide (VIP)--possible importance in diseases of childhood]. / Vasoactive Intestinal Polypeptide (VIP)--mögliche Bedeutung bei Erkrankungen des Kindesalters.

Vasoactive intestinal peptide (VIP), first isolated from the gut, was originally considered a candidate gastrointestinal hormone. Since about 1975, however, it has become increasingly clear that it is primarily a neurotransmitter or neuromodulator and that it exerts its functions mainly by local release from nerve endings. VIP plays a hormonal role only when it is released in large amounts from a tumor, with a consequent overflow into the circulation and grossly elevated plasma concentrations of the peptide. Moderately increased VIP plasma and tissue concentrations that cause mainly local effects are found in intestinal ischemia. Crohn's disease and some other chronic inflammatory diseases of the bowel. VIP is also measured in increased amounts in the normal fetus and neonate, where it may play an important physiological role. Such an increase of VIP levels in the circulation could enhance perfusion and metabolic activity of tissues during their rapid-growth period. On the other hand, disorders with a disturbed VIP function such as achalasia and Hirschsprung's disease and possibly also asthma and cystic fibrosis seem to be characterized mainly by a derangement of smooth muscle activity and/or exocrine secretion. Considering this list of disorders where VIP has either a proven or suspected role, it is easy to imagine the significance of this peptide in pediatric pathophysiology.