New means to monitor the effect of glucocorticoid therapy in children

AIM:To study the individual effects of glucocorticoid (GC) therapy on the state ofimmune activation in patient serum.METHODS:We developed a novel assay in which the effect of corticosteroid-treated patient serum on healthy donor peripheral blood mononuclear cells (target cells) was studied,with a panel of markers for effector [interferon (IFN)γ and interleukin (IL)-5] and regulatory T cells (FOXP3 and glucocorticoid-induced tumor necrosis factor receptor,GITR).The study group comprised 19 children with inflammatory bowel disease.The individual effect of patient serum on target cells was analyzed prior to GC therapy and 2 wk later.RESULTS:The effect of GC therapy mediated by patient serum was seen as a decrease in the target cells expression of regulatory T-cell-related markers GITR (median suppression 24%,range of suppression 1%-63%,in 2 cases increase of 6% and 77%,P < 0.01 for mitogen-activated target cells) and FOXP3 (median suppression 33%,range of suppression 0%-79%,in one case an increase of 173%,P < 0.05 for resting cells),and secretion of IFNγ [from a mean of 87 700 pg/mL (SD 33 900 pg/mL) to 60 900 pg/mL (SD 44 200 pg/mL) in mitogen-activated target cells,13 of the cases showed a decrease,P < 0.01].The total or weight-related prednisolone dose did not correlate with the patient-seruminduced changes in the target cell markers.CONCLUSION:GC response could be monitored at an individual level by studying the effect of patient serum on signaling pathways of target immune cells.

Molecularly defined adult-type hypolactasia in school-aged children with a previous history of cow's milk allergy

AIM： To assess the role of lactase non-persistence/per- sistence in school-aged children and their milk-related symptoms. METHODS： The genotypes for the C/T-13910 variant associated with lactase non-persistence/ persistence were determined using PCR-minisequencing in a group of 172 children with a mean age of 8.6 years （SE = 0.02, 93 boys） participating in a follow-up study for cow＇s milk allergy. The parents were asked to assess their children＇s milk consumption and abdominal symptoms. RESULTS： The presence of allergy to cow＇s milk was not associated with the C/C-13910 genotype related with a decline of lactase enzyme activity during childhood （lactase non-persistence）. The frequency of the C/C-13910 genotype （16%） was similar to published figures for the prevalence of adult-type hypolactasia in Finland. The majority of the children （90%） in this series consumed milk but 26% of their families suspected that their children had milk-related symptoms. Forty-eight percent of the children with the C/C-13910 genotype did not drink milk at all or consumed a low lactose containing diet prior to the genotyping （P〈 0.004 when compared to the other genotypes）. CONCLUSION： Analysis of the C/T-13910 polymorphism is an easy and reliable method for excluding adult-type hypolactasia in children with milk-related symptoms. Genotyping for this variant can be used to advise diets for children with a previous history of cow＇s milk allergy.

Correlation of intestinal disaccharidase activities with the C/T_(-13910) variant and age

AIM： To correlate the C/T-13910 variant, associated with lactase persistence/non-persistence （adulttype hypolactasia） trait, with intestinal disaccharidase activities in different age groups of the adult population.METHODS： Intestinal biopsies were obtained from 222 adults aged 18 to 83 years undergoing upper gastrointestinal endoscopy because of unspecified abdominal complaints. The biopsies were assayed for lactase, sucrase and maltase activities and genotyped for the C/T-13910 variant using PCR-minisequencing. RESULTS： There was a significant correlation between lactase activity and the C/T-13910 variant （P 〈 0.00001）. The mean level of lactase activity among subjects with C/C-1391o genotype was 6.86± 0.35 U/g, with C/T-13910 genotype 37.8 ± 1.4 U/g, and with T/T-13910 genotype 57.6± 2.4 U/g protein, showing a trimodal distribution of this enzyme activity. Significant differences were also observed in maltase activities among individuals with different C/T-13910 genotypes （P = 0.005）. In contrast, in sucrase activity, no significant differences emerged between the C/T-13910 genotypes （P = 0.14）. There were no statistical differences in lactase （P = 0.84）, sucrase （P = 0.18）, or maltase activity （P = 0.24） among different age groups. In the majority （〉 84%） of the patients with the C/C-13910 genotype associated with lactase non- persistence, the lactase activity was less than 10 U/g protein.CONCLUSION： Our study demonstrates a statistically significant correlation between the C/T-13910 genotype and lactase activity and this correlation is not affected by age in adults but the cut-off value of 20 U/g protein used for the diagnosis of lactase non-persistence might be too high.

Milk protein IgG and IgA:The association with milk-induced gastrointestinal symptoms in adults

AIM:To study the association between serum levels of milk protein IgG and IgA antibodies and milk-related gastrointestinal symptoms in adults.METHODS:Milk protein IgG and IgA antibodies were determined in serum samples of 400 subjects from five outpatient clinics in Southern Finland.Subjects were randomly selected from a total of 1900 adults undergoing laboratory investigations in primary care.All 400 participants had completed a questionnaire on abdominal symptoms and dairy consumption while waiting for the laboratory visit.The questionnaire covered the nature and frequency of gastrointestinal problems,the provoking food items,family history and allergies.Twelve serum samples were disqualifi ed due to insuff icient amount of sera.The levels of specif ic milk protein IgG and IgA were measured by using the ELISA technique.The association of the milk protein-specific antibody level was studied in relation to the milk-related gastrointestinal symptoms and dairy consumption.RESULTS:Subjects drinking milk(n=265) had higher levels of milk protein IgG in their sera than non-milk drinkers(n=123,P<0.001).Subjects with gastrointestinal problems related to milk drinking(n=119) consumed less milk but had higher milk protein IgG levels than those with no milk-related gastrointestinal symptoms(n=198,P=0.02).Among the symptomatic subjects,those reporting dyspeptic symptoms had lower milk protein IgG levels than non-dyspeptics(P<0.05).However,dyspepsia was not associated with milk drinking(P=0.5).The association of high milk protein IgG levels with constipation was close to the level of statistical signif icance.Diarrhea had no association with milk protein IgG level(P=0.5).With regard to minor symptoms,flatulence and bloating(P=0.8),were not associated with milk protein IgG level.Milk protein IgA levels did not show any association with milk drinking or abdominal symptoms.The levels of milk protein IgA and IgG declined as the age of the subjects increased(P<0.004).CONCLUSION:Milk protein IgG but not milk IgA seems to be associated with self-reported milk-induced gastrointestinal symptoms.

Molecularly defined adult-type hypolactasia among working age people with reference to milk consumption and gastrointestinal symptoms

AIM: To study milk consumption and subjective milk- related symptoms in adults genotyped for adult-type hypolactasia. METHODS: A total of 1900 Finnish adults were genotyped for the C/T-13910 variant of adult-type hypolactasia and filled in a structured questionnaire concerning milk consumption and gastrointestinal problems. RESULTS: The C/C-13910 genotype of adult-type hypolactasia was present in 18% of the study population. The prevalence of the C/C-13910 genotype was higher among subjects who were undergoing investigations because of abdominal symptoms (24%, P < 0.05). Those with the C/C-13910 genotype drank less milk than subjects with either the C/T-13910 or the T/T-13910 genotype of lactase persistence (18% vs 38%; 18% vs 36%, P < 0.01). Subjects with the C/C-13910 genotype had experienced more gastrointestinal symptoms (84%) during the preceding three-month period than those with the C/T-13910 (79%, P < 0.05) or the T/T-13910 genotype (78 %, P < 0.05). Only 9% (29/338) of the subjects with the C/C-13910 genotype consumed milk and reported no symptoms from it.CONCLUSION: Gastrointestinal symptoms are more common among adults with the C/C-13910 genotype of adult-type hypolactasia than in those with genotypes of lactase persistence.

Diagnostic Yield of Non-Invasive Testing in Patients with Anomalous Aortic Origin of Coronary Arteries:A Multicentric Experience

Background:Anomalous aortic origin of a coronary artery(AAOCA)is a congenital heart disease with a 0.3%−0.5%prevalence.Diagnosis is challenging due to nonspecific clinical presentation.Risk stratification and treatment are currently based on expert consensus and single-center case series.Methods:Demographical and clinical data of AAOCA patients from 17 tertiary-care centers were analyzed.Diagnostic imaging studies(Bidimensional echocardiography,coronary computed tomography angiography[CCTA]were collected.Clinical correlations with anomalous coronary course and origin were evaluated.Results:Data from 239 patients(42%males,mean age 15 y)affected by AAOCA were collected;154 had AAOCA involving the right coronary artery(AAORCA),62 the left(AAOLCA),23 other anomalies.211(88%)presented with an inter-arterial course.Basal electrocardiogram(ECG)was abnormal in 37(16%).AAOCA was detected by transthoracic echocardiography and CCTA in 53%and 92%of patients,respectively.Half of the patients reported cardiac symptoms(119/239;50%),mostly during exercise in 121/178(68%).An ischemic response was demonstrated in 37/106(35%)and 16/31(52%)of patients undergoing ECG stress test and stress-rest single positron emission cardiac tomography.Compared with AAORCA,patients with AAOLCA presented more frequently with syncope(18%vs.5%,P=0.002),in particular when associated with inter-arterial course(22%vs.5%,P<0.001).Conclusion:Diagnosis of AAOCA is a clinical challenge due to nonspecific clinical presentations and low sensitivity of first-line cardiac screening exams.Syncope seems to be strictly correlated to AAOLCA with inter-arterial course.

High-sensitivity C-reactive protein in paediatric inflammatory bowel disease

AIM:To study whether high-sensitivity C-reactive protein(hs-CRP) measurement can aid the assessment of disease activity and glucocorticoid treatment in paediatric inflammatory bowel disease(IBD).METHODS:CRP levels were measured in 39 children with IBD undergoing colonoscopy [median age 12.8 years,Crohn's disease(CD) n=20],in 22 other children with IBD followed for acute response to glucocorticoids,and in 33 paediatric non-IBD patients.When standard CRP level was below detection limit(<5mg/L),hs-CRP was analyzed.RESULTS:Sixty-four percent(25/39) of the children with IBD undergoing colonoscopy displayed undetectable(<5mg/L) standard CRP levels.Of these,the hs-CRP measurement could not differentiate between active(median,0.2 mg/L,range,0.007-1.37,n=17) or quiescent(0.1 mg/L,0.01-1.89,n=8,P=NS) disease.Patients with ileocolonic CD had higher CRP levels(14mg/L,0.06-45,n=13) than patients with no ileal involvement(0.18 mg/L,0.01-9,n=7,P<0.01) or ulcerative colitis(UC)(0.13 mg/L,0.007-23,P<0.05).In children with active IBD treated with systemic glucocorticoids,the standard CRP was undetectable in 59% of the patients.The hs-CRP levels did not differ between patients that responded to steroid therapy and in non-responders.CONCLUSION:The measurement of hs-CRP did not prove useful in the assessment of disease activity or glucocorticoid treatment in paediatric IBD patients that had undetectable standard CRP.

患有杂合性家族性高胆固醇血症并接受帕伐他汀治疗患儿的血清中非胆固醇类甾醇

Objective:To assess causes for insufficient cholesterol-lowering response to pravastatin and plant stanol esters in children with heterozygous familial hype rcholesterolemia(HeFH)-.Study design:Nine of 16 children with HeFH who had n ot reached normocholesterolemia(≤194 mg/dL [≤5 mmol/L])-by 1 year after trea tment(40 mg pravastatin and plant stanol ester)were called nonresponders.The 7 remaining children were responders.Serum noncholesterol sterol ratios(102 × mmol/mol of cholesterol),surrogate estimates of cholesterol absorption(cholest anol,campesterol,sitosterol)and synthesis(desmosterol and lathosterol),were studied at study baseline(on plant stanol esters)and during combination therap y with pravastatin and plant stanol esters.Results:Pravastatin decreased the s erum levels of cholesterol and cholesterol synthesis markers,and increased the ratios of cholesterol absorption markers.Compared with the responders,the nonr esponders had higher study baseline(on plant stanol esters)serum cholesterol c oncentrations(299±39 vs 251 ±35 mg/dL [7.7 ±1.0 vs 6.5 ±0.9 mmol/L];P <.0 01)and higher respective ratios of campesterol(371 ±99 vs 277 ±67 102 ×mmol /mol of cholesterol;P =.049)and sitosterol(176 ±37 vs 126 ±24 102 ×mmol/m ol of cholesterol;P =.008).The higher the ratio of cholestanol at study basel ine,the smaller the 1-year percent reduction in cholesterol(r =.556;P =.02 5).Conclusions:Pravastatin treatment increases the markers of cholesterol abso rption and decreases those of cholesterol synthesis in HeFH during simultaneous inhibition of cholesterol absorption.Combined inhibition of cholesterol absorpt ion and synthesis may not normalize serum lipids in those patients with the high est cholesterol levels,especially if signs of enhanced cholesterol absorption a re detectable.