CAP Profiles

Bio

Clinical Focus

  • Gastroenterology/Nutrition/Hepatology, Pediatric
  • Pediatric Gastroenterology

Academic Appointments

Professional Education

  • Fellowship: Stanford University School of Medicine Registrar (1979) CA
  • Residency: Stanford University School of Medicine Registrar (1976) CA
  • Medical Education: University of California at San Francisco School of Medicine (1973) CA
  • Board Certification: Pediatric Gastroenterology, American Board of Pediatrics (1990)
  • Board Certification: Pediatrics, American Board of Pediatrics (1979)
  • Internship: Stanford University School of Medicine (1974) CA

Contact

    • Tel: (650) 723-5070
  • Pediatric Gastroenterology 750 Welch Rd Ste 116 Palo Alto, CA 94304
    • Tel: (650) 721-2250
    Fax: (650) 721-3822

Research & Scholarship

Current Research and Scholarly Interests

I am interested in pediatric nutritional support and have experience evaluating new enteral and parenteral products especially for the neonate (I studied a "new" I.V. fat product for Abbott; I participated in a multicenter trial of a formula with fish oil in it for neonates with Mead Johnson and a multicenter trial of a new human milk fortifier for Wyeth). I am the medical director of our nutrition support team and home pharmacy and am interested in short- and long-term "outcome studies" re: use of TPN-impact on development of patient and family functioning in short bowel patients on long-term parenteral/enteral support.

Teaching

2019-20 Courses

Stanford Advisees

Publications

All Publications

  • Risk Factors of Ambulatory Central Line-Associated Bloodstream Infection in Pediatric Short Bowel Syndrome. JPEN. Journal of parenteral and enteral nutrition Seddik, T. B., Tian, L., Nespor, C., Kerner, J., Maldonado, Y., Gans, H. 2019

    Abstract

    BACKGROUND: Children with short bowel syndrome (SBS) receiving home parenteral nutrition (HPN) are predisposed to ambulatory central line-associated bloodstream infection (A-CLABSI). Data describing risk factors of this infection in children are limited.METHODS: Retrospective cohort, single-center, case-crossover study of children ≤18 years old with SBS receiving HPN from January 2012 to December 2016. Univariate and multivariate mixed effect Poisson regression identified the relative risk (RR) of A-CLABSI with proposed risk factors.RESULTS: Thirty-five children were identified; median follow-up was 30 months. A-CLABSI rate was 4.2 per 1000 central line (CL) days. Univariate analysis identified younger age (RR: 0.92 per 12-month increase [95% confidence interval {CI}: 0.85-0.99; P = 0.036]), shorter small intestine length (RR: 0.96 per 10-cm increase [95% CI: 0.92-0.99; P = 0.008]), lower citrulline level (RR: 0.86 per 5-nmol/mL increase [95% CI: 0.75-0.99; P = 0.036]), and recent CL break (RR: 1.55 [95% CI: 1.06-2.28; P = 0.024]) as risk factors for A-CLABSI. Multivariate analysis showed increased A-CLABSI with clinical diagnosis of small intestine bacterial overgrowth (SIBO) (RR: 1.87 [95% CI: 1.1-3.17; P = 0.021]) and CL breaks (RR: 1.49 [95% CI: 1-2.22; P = 0.024]).CONCLUSIONS: Factors influencing gut integrity increase A-CLABSI rate, supporting translocation as an important mechanism and target for prevention. Clinical diagnosis of SIBO increases A-CLABSI rate, but whether dysbiosis or diarrhea is responsible is an area for future research. CL maintenance is crucial, and prevention of breaks would likely decrease A-CLABSI rate.

    View details for DOI 10.1002/jpen.1667

    View details for PubMedID 31179578

  • Delayed appearance of mature ganglia in an infant with an atypical presentation of total colonic and small bowel aganglionosis: a case report. BMC pediatrics Salimi Jazi, F., Chandler, J. M., Thorson, C. M., Sinclair, T. J., Hazard, F. K., Kerner, J. A., Dutta, S., Dunn, J. C., Chao, S. D. 2019; 19 (1): 93

    Abstract

    BACKGROUND: Total colonic and small bowel aganglionosis (TCSA) occurs in less than 1% of all Hirschsprung's disease patients. Currently, the mainstay of treatment is surgery. However, in patients with TCSA, functional outcomes are often poor. A characteristic transition zone in TCSA can be difficult to identify which may complicate surgery and may often require multiple operations.CASE PRESENTATION: We present the case of a male infant who was diagnosed with biopsy-proven total colonic aganglionosis with extensive small bowel involvement as a neonate. The patient was diverted at one month of age based on leveling biopsies at 10cm from the Ligament of Treitz. At 7months of age, during stoma revision for a prolapsed stoma, intra-operative peristalsis was observed in nearly the entire length of the previously aganglionic bowel, and subsequent biopsies demonstrated the appearance of mature ganglion cells in a previously aganglionic segment.CONCLUSIONS: TCSA remains a major challenge for pediatric surgeons. Our case introduces new controversy to our understanding of aganglionosis. Our observations warrant further research into the possibility of post-natal ganglion maturation and encourage surgeons to consider a more conservative surgical approach.

    View details for PubMedID 30953480

  • Procalcitonin as a Predictive Marker for Bacteremia in Children With a Central Line and Fever. Hospital pediatrics Damman, J., Arias, P., Kerner, J., Zhang, K. Y., Dehghan, M., Krishnan, G., Nespor, C., Bensen, R., Park, K. T. 2019

    Abstract

    Unnecessary use of antibiotics is an increasing problem. In this study, we sought to determine the diagnostic accuracy of procalcitonin in predicting bacteremia in children with a central line and fever, and we sought to determine optimal cutoff values to maximize sensitivity and specificity. This is the largest study to date in which procalcitonin is examined as a predictive marker of bacteremia in pediatric patients with a central line and fever.We conducted a retrospective cohort study of children aged 0 to 23 years with a central line and fever of 38°C who had procalcitonin and blood cultures drawn before initiation of antibiotics and had no other identified bacterial infection. Patients were also prospectively monitored via a custom-built electronic medical record dashboard for eligibility.There were 523 patients and >2500 procalcitonin values reviewed for eligibility. Of these, 169 (47%) patients and 335 blood cultures with procalcitonin were included. There were 94 (28%) positive bacterial blood cultures and 241 (72%) negative bacterial blood cultures. In bacteremic cultures, the mean procalcitonin level was 9.96 ± 15.96 ng/mL, and the median procalcitonin level was 4.85 ng/mL (interquartile range 18.5). In nonbacteremic cultures, the mean procalcitonin level was 1.23 ± 10.37 ng/mL, and the median procalcitonin level was 0.3 ng/mL (interquartile range 0.7). A receiver operating characteristic analysis indicated a procalcitonin level of ≥0.6 ng/mL as the best cutoff point that produced a sensitivity of 85.6% and a specificity of 65.7% (area under the curve 0.85).Procalcitonin is a sensitive biomarker in predicting bacteremia in children with a central line and fever.

    View details for PubMedID 31097470

  • The Runs: Sudden Copious Ostomy Output in an Acolonic Hirschsprung Disease Patient with Short Gut Syndrome DIGESTIVE DISEASES AND SCIENCES Nakayuenyongsuk, W., Barnes, D., Martin, B., Christofferson, M., Kerner, J. 2019; 64 (1): 56–59

    View details for DOI 10.1007/s10620-018-5229-7

    View details for Web of Science ID 000454932700011

  • Nutritional Needs and Support for Children with Chronic Liver Disease. Nutrients Yang, C. H., Perumpail, B. J., Yoo, E. R., Ahmed, A., Kerner, J. A. 2017; 9 (10)

    Abstract

    Malnutrition has become a dangerously common problem in children with chronic liver disease, negatively impacting neurocognitive development and growth. Furthermore, many children with chronic liver disease will eventually require liver transplantation. Thus, this association between malnourishment and chronic liver disease in children becomes increasingly alarming as malnutrition is a predictor of poorer outcomes in liver transplantation and is often associated with increased morbidity and mortality. Malnutrition requires aggressive and appropriate management to correct nutritional deficiencies. A comprehensive review of the literature has found that infants with chronic liver disease (CLD) are particularly susceptible to malnutrition given their low reserves. Children with CLD would benefit from early intervention by a multi-disciplinary team, to try to achieve nutritional rehabilitation as well as to optimize outcomes for liver transplant. This review explains the multifactorial nature of malnutrition in children with chronic liver disease, defines the nutritional needs of these children, and discusses ways to optimize their nutritional.

    View details for PubMedID 29035331

  • Feeling the Impact of Long-Term Total Parenteral Nutrition. Digestive diseases and sciences Sellers, Z. M., Thorson, C., Co, S., Schaberg, K. B., Kerner, J. A. 2017

    View details for DOI 10.1007/s10620-017-4588-9

    View details for PubMedID 28455563

  • Management of short bowel syndrome in postoperative very low birth weight infants SEMINARS IN FETAL & NEONATAL MEDICINE Mayer, O., Kerner, J. A. 2017; 22 (1): 49–56

    Abstract

    Short bowel syndrome is a potentially devastating morbidity for the very low birth weight infant and family with a high risk for mortality. Prevention of injury to the intestine is the ideal, but, if and when the problem arises, it is important to have a systematic approach to manage nutrition, use pharmaceutical strategies and tools to maximize the outcome potential. Safely maximizing parenteral nutrition support by providing adequate macronutrients and micronutrients while minimizing its hepatotoxic effects is the initial postoperative strategy. As the infant stabilizes and starts to recover from that initial injury and/or surgery, a slow and closely monitored enteral nutrition approach should be initiated. Enteral feeds can be complemented with medications and supplements emerging as valuable clinical tools. Engaging a multidisciplinary team of neonatologists, gastroenterologists, pharmacists, skilled clinical nutrition support staff including registered dietitians and nutrition support nurses will facilitate optimizing each and every infant's long term result. Promoting intestinal rehabilitation and adaptation through evidence-based practice where it is found, and ongoing pursuit of research in this rare and devastating disease, is paramount in achieving optimal outcomes.

    View details for PubMedID 27576105

  • Severe Lactic Acidosis in a Parenteral Nutrition-Dependent Teenager with Ulcerative Colitis. Digestive diseases and sciences Barnes, D., Kerner, J. 2016; 61 (10): 2804-2806

    View details for DOI 10.1007/s10620-015-3961-9

    View details for PubMedID 26589816

  • Iodine Supplementation for Pediatric Patients Receiving Long-Term Parenteral Nutrition. Nutrition in clinical practice Santoro, J. D., Nespor, C., Poole, R. L., Kerner, J. A. 2016; 31 (2): 245-249

    Abstract

    Patients dependent on parenteral nutrition (PN) are among a group at risk of developing iodine deficiency. Supplementation with iodine in this population has been debated in a number of studies, resulting in variable clinical practices. The Committee on Clinical Practice Issues of the American Society for Clinical Nutrition recommends a dose of 1 mcg/kg/d of parenteral iodine for patients receiving PN. At our institution, PN trace elements do not include iodine, although this is not the case internationally. Our study sought to assess iodine levels and thyroid function in a cohort of PN-dependent pediatric patients.A retrospective analysis studied 32 pediatric patients with a variety of medical diagnoses who received PN as a primary means of nutrition for 6 months or longer. Patients received variable proportions of their total caloric intake as PN, which ranged from 14%-100%. Iodine and thyroid function levels were obtained by serum sampling.No patient in our cohort of 32 demonstrated thyroid dysfunction or developed iodine deficiency. The length of time on PN and the percentage of total nutrition intake as PN were not associated with iodine levels (P < .89 and P < .73, respectively). There were no significant associations between age (P < .342), clinical diagnosis (P < .46), or sex (P < .43) on iodine status. There were no incidences of abnormal iodine levels in our cohort. Our study suggests that pediatric patients older than 6 months receiving PN may not benefit from iodine supplementation, but further investigation is needed.

    View details for DOI 10.1177/0884533615611846

    View details for PubMedID 26507189

  • Intractable Diarrhea in Two Brothers: Late Diagnosis of Tufting Enteropathy in Adolescence. Digestive diseases and sciences Haas, K., Martin, B., Martín, M., Kerner, J. 2016; 61 (2): 381-383

    View details for DOI 10.1007/s10620-015-3766-x

    View details for PubMedID 26115750

  • ACTG2 variants impair actin polymerization in sporadic Megacystis Microcolon Intestinal Hypoperistalsis Syndrome HUMAN MOLECULAR GENETICS Halim, D., Hofstra, R. W., Signorile, L., Verdijk, R. M., van der Werf, C. S., Sribudiani, Y., Brouwer, R. W., van IJcken, W. J., Dahl, N., Verheij, J. M., Baumann, C., Kerner, J., van Bever, Y., Galjart, N., Wijnen, R. H., Tibboel, D., Burns, A. J., Muller, F., Brooks, A. S., Alves, M. M. 2016; 25 (3): 571–83

    Abstract

    Megacystis Microcolon Intestinal Hypoperistalsis Syndrome (MMIHS) is a rare congenital disorder, in which heterozygous missense variants in the Enteric Smooth Muscle actin γ-2 (ACTG2) gene have been recently identified. To investigate the mechanism by which ACTG2 variants lead to MMIHS, we screened a cohort of eleven MMIHS patients, eight sporadic and three familial cases, and performed immunohistochemistry, molecular modeling and molecular dynamics (MD) simulations, and in vitro assays. In all sporadic cases, a heterozygous missense variant in ACTG2 was identified. ACTG2 expression was detected in all intestinal layers where smooth muscle cells are present in different stages of human development. No histopathological abnormalities were found in the patients. Using molecular modeling and MD simulations, we predicted that ACTG2 variants lead to significant changes to the protein function. This was confirmed by in vitro studies, which showed that the identified variants not only impair ACTG2 polymerization, but also contribute to reduced cell contractility. Taken together, our results confirm the involvement of ACTG2 in sporadic MMIHS, and bring new insights to MMIHS pathogenesis.

    View details for PubMedID 26647307

  • Hodgkin Lymphoma Following Adalimumab for the Treatment of Crohn's Disease in an Adolescent DIGESTIVE DISEASES AND SCIENCES Rodriguez, A. A., Kerner, J., Luna-Fineman, S., Berry, G. J. 2014; 59 (10): 2403-2405

    View details for DOI 10.1007/s10620-014-3191-6

    View details for Web of Science ID 000342148900007

  • Case 3 Lactic Acidosis and Cardiovascular Collapse in a Teen With Ulcerative Colitis PEDIATRICS IN REVIEW Wallenstein, M. B., Burgener, E. B., Klotz, J., Kerner, J. A. 2014; 35 (10): 444–46

    View details for Web of Science ID 000421128400006

  • Index of suspicion. Pediatrics in review Todd, S., Arora, R., Kannikeswaran, N., Allarakhia, I., Sivaswamy, L., Wallenstein, M. B., Burgener, E. B., Klotz, J., Kerner, J. A. 2014; 35 (10): 439-446

    View details for DOI 10.1542/pir.35-10-439

    View details for PubMedID 25274971

  • Evaluation of Intestinal Biopsies for Pediatric Enteropathy A Proposed Immunohistochemical Panel Approach AMERICAN JOURNAL OF SURGICAL PATHOLOGY Martin, B. A., Kerner, J. A., Hazard, F. K., Longacre, T. A. 2014; 38 (10): 1387-1395

    Abstract

    Congenital enteropathies are rare disorders with significant clinical consequences; however, definitive diagnosis based on morphologic assessment of duodenal biopsies with routine stains alone is often impossible. To determine the role of immunohistochemistry (IHC) in the evaluation for microvillous inclusion disease, congenital tufting enteropathy (intestinal epithelial dysplasia), and enteroendocrine cell dysgenesis, a series of duodenal biopsies from 26 pediatric patients with chronic/intractable diarrhea was retrospectively reviewed. IHC stains for CD10, EpCAM, chromogranin, and villin were performed on all biopsies, and the results were correlated with hematoxylin and eosin and ultrastructural findings using electron microscopy, when available. Biopsies from 2 patients diagnosed with microvillous inclusion disease at the time of original biopsy demonstrated diffuse CD10-positive cytoplasmic inclusions within enterocytes and normal expression of EpCAM and chromogranin. Biopsies from 3 patients, including 2 siblings with confirmed EPCAM mutations, demonstrated complete loss of EpCAM expression and normal expression of CD10 and chromogranin; electron microscopic evaluation revealed characteristic ultrastructural findings of tufting enteropathy. Biopsies from 1 patient with a confirmed NEUROG3 mutation demonstrated an absence of intestinal enteroendocrine cells by chromogranin staining, consistent with enteroendocrine cell dysgenesis. Four patients' biopsies displayed nonspecific staining patterns for CD10 and/or EpCAM with normal expression of chromogranin, and 16 patients' biopsies exhibited normal expression for all 3 markers. Villin stains demonstrated heterogenous brush border labeling with nonspecific cytoplasmic reactivity, a pattern variably present throughout the biopsy series. In conclusion, the routine use of an IHC panel of CD10, EpCAM, and chromogranin is warranted in patients meeting specific age and/or clinical criteria, as the morphologic findings of congenital enteropathies may be subtle, focal, or inapparent on routine stains.

    View details for Web of Science ID 000342001800010

  • Hodgkin lymphoma following adalimumab for the treatment of Crohn's disease in an adolescent. Digestive diseases and sciences Rodriguez, A. A., Kerner, J., Luna-Fineman, S., Berry, G. J. 2014; 59 (10): 2403-2405

    View details for DOI 10.1007/s10620-014-3191-6

    View details for PubMedID 24817339

  • Misdiagnosis of Alpha-1 Antitrypsin Phenotype in an Infant with CMV Infection and Liver Failure DIGESTIVE DISEASES AND SCIENCES Arias, P., Kerner, J., Christofferson, M., Berquist, W., Park, K. T. 2014; 59 (8): 1710-1713

    View details for DOI 10.1007/s10620-014-3094-6

    View details for Web of Science ID 000340051200075

    View details for PubMedID 24633574

  • Infliximab for the treatment of granulomatous peritonitis. Digestive diseases and sciences Yeh, A. M., Kerner, J., Hillard, P., Bass, D. 2013; 58 (12): 3397-3399

    View details for DOI 10.1007/s10620-013-2726-6

    View details for PubMedID 23817923

  • Multiple hepatic adenomas in a child with microvillus inclusion disease. Digestive diseases and sciences Burgis, J. C., Pratt, C. A., Higgins, J. P., Kerner, J. A. 2013; 58 (10): 2784-2788

    View details for DOI 10.1007/s10620-013-2646-5

    View details for PubMedID 23525737

  • Evaluation of ethanol lock therapy in pediatric patients on long-term parenteral nutrition. Nutrition in clinical practice Pieroni, K. P., Nespor, C., Ng, M., Garcia, M., Hurwitz, M., Berquist, W. E., Kerner, J. A. 2013; 28 (2): 226-231

    Abstract

    Pediatric home parenteral nutrition (PN) patients present a unique challenge with risks of catheter-associated bloodstream infections (CABSIs), sometimes requiring subsequent catheter removal. Recurrent infections can lead to line removal and potential loss of venous access in the future.Demonstrate that weekly ethanol lock therapy decreases CABSIs in long-term home PN patients and decreases line removals due to infections.Beginning August 2007, patients receiving PN with a history of multiple previous CABSIs were started on ethanol lock therapy. Seventy percent ethanol solution was instilled into the central venous catheter (CVC) for 2 hours weekly. Episodes of CABSIs and catheter removal due to infection were documented in patients prior to and after ethanol lock therapy.Fourteen patients were followed for an average of 690 days after ethanol lock therapy was initiated. These patients were found to average 9.8 CABSIs per 1000 catheter days prior to starting ethanol lock therapy and only 2.7 CABSIs per 1000 catheter days after ethanol lock therapy (P < .001). Prior to ethanol lock therapy, the group averaged 4.3 catheter removals per 1000 catheter days but only 1.0 catheter removal per 1000 catheter days after ethanol lock therapy.Our group of patients showed a 73% reduction in CABSIs and a 77% reduction in catheter removal due to infection after ethanol lock therapy. In our patient population, weekly ethanol lock therapy for 2 hours is an effective technique to reduce CABSIs and catheter removal in long-term home PN patients.

    View details for DOI 10.1177/0884533612468009

    View details for PubMedID 23232749

  • ECHINOCANDIN AND ETHANOL LOCK THERAPY TREATMENT OF FUNGAL CATHETER INFECTIONS PEDIATRIC INFECTIOUS DISEASE JOURNAL Pieroni, K. P., Nespor, C., Poole, R. L., Kerner, J. A., Berquist, W. E. 2013; 32 (3): 289-291

    Abstract

    Ethanol lock therapy has been implemented to prevent infections of central venous catheters as well as to treat infections. Fungal catheter-associated blood stream infections are historically more difficult to treat and have required removal of central venous catheters. We report the largest case series to date, successfully treating 5 of 7 fungal catheter-associated blood stream infections with ethanol lock therapy and systemic echinocandin administration.

    View details for DOI 10.1097/INF.0b013e3182784867

    View details for Web of Science ID 000314932700027

    View details for PubMedID 23076381

  • Aluminum Exposure in Neonatal Patients Using the Least Contaminated Parenteral Nutrition Solution Products NUTRIENTS Poole, R. L., Pieroni, K. P., Gaskari, S., Dixon, T., Kerner, J. A. 2012; 4 (11): 1566-1574

    Abstract

    Aluminum (Al) is a contaminant in all parenteral nutrition (PN) solution component products. Manufacturers currently label these products with the maximum Al content at the time of expiry. We recently published data to establish the actual measured concentration of Al in PN solution products prior to being compounded in the clinical setting [1]. The investigation assessed quantitative Al content of all available products used in the formulation of PN solutions. The objective of this study was to assess the Al exposure in neonatal patients using the least contaminated PN solutions and determine if it is possible to meet the FDA “safe limit” of less than 5 μg/kg/day of Al. The measured concentrations from our previous study were analyzed and the least contaminated products were identified. These concentrations were entered into our PN software and the least possible Al exposure was determined. A significant decrease (41%–44%) in the Al exposure in neonatal patients can be achieved using the least contaminated products, but the FDA “safe limit” of less than 5 μg/kg/day of Al was not met. However, minimizing the Al exposure may decrease the likelihood of developing Al toxicity from PN.

    View details for DOI 10.3390/nu4111566

    View details for Web of Science ID 000311426800004

    View details for PubMedID 23201834

    View details for PubMedCentralID PMC3509507

  • An Evolving Case of Concurrent Eosinophilic Esophagitis and Eosinophilic Gastroenteritis DIGESTIVE DISEASES AND SCIENCES Le-Carlson, M., Triadafilopoulos, G., Pai, R. K., Kerner, J. A. 2012; 57 (4): 842-844

    View details for DOI 10.1007/s10620-012-2061-3

    View details for Web of Science ID 000301835600005

    View details for PubMedID 22307337

  • Chylous Ascites After Laparoscopic Nissen Fundoplication DIGESTIVE DISEASES AND SCIENCES Park, K. T., Adikibi, B., MacKinlay, G. A., Gillett, P. M., Sylvester, K. G., Kerner, J. A. 2012; 57 (1): 28-31

    View details for DOI 10.1007/s10620-011-1808-6

    View details for Web of Science ID 000298968500005

    View details for PubMedID 21735080

  • New Advances in the Management of Children With Intestinal Failure JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Peterson, J., Kerner, J. A. 2012; 36: 36S-42S

    View details for DOI 10.1177/0148607111422069

    View details for Web of Science ID 000328729700008

  • New advances in the management of children with intestinal failure. JPEN. Journal of parenteral and enteral nutrition Peterson, J., Kerner, J. A. 2012; 36 (1): 36S-42S

    View details for DOI 10.1177/0148607111422069

    View details for PubMedID 22190603

  • Immunophenotyping of Peripheral Eosinophils Demonstrates Activation in Eosinophilic Esophagitis JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Tammie Nguyen, T., Gernez, Y., Fuentebella, J., Patel, A., Tirouvanziam, R., Reshamwala, N., Bass, D., Berquist, W. E., Cox, K. L., Kerner, J. A., Nadeau, K. C. 2011; 53 (1): 40-47

    Abstract

    Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder characterized by upper gastrointestinal symptoms and the presence of high numbers of eosinophils in the esophagus. Although eosinophils in the esophagus have been found to be activated in subjects with EoE, detailed studies of intracellular signaling pathways involved in the mechanism of activation of eosinophils in EoE have heretofore been limited. The aim of the study was to assess whether any surface molecules or transcription factors are activated in peripheral eosinophils in subjects with EoE.Eosinophils and CD3+ lymphocytes were identified directly from 50 μL of whole blood of EoE and control subjects. Using Hi-FACS, levels of surface activation markers, including CD66b, and intracellular phosphoepitopes, including phosphorylated forms of signal transducer and activator of transcription (phospho-STAT) 1 and 6, were measured within each cell subset.Levels of surface CD66b as well as levels of intracellular phospho-STAT1 and phospho-STAT6 in peripheral blood eosinophils were significantly higher for untreated subjects with EoE vs healthy controls (P < 0.05). Levels of phospho-STAT1 and phospho-STAT6 in peripheral blood eosinophils were lower in subjects with EoE on therapy versus untreated subjects with EoE (P < 0.05).Levels of phospho-STAT1 and phospho-STAT6, transcription factors involved in inflammatory processes, were both significantly higher in peripheral eosinophils from untreated (ie, newly diagnosed) subjects with EoE versus subjects with EoE on therapy, healthy controls. Blood-based measurements of CD66b and phospho-STAT levels in peripheral eosinophils may be beneficial for identifying EoE.

    View details for DOI 10.1097/MPG.0b013e318212647a

    View details for Web of Science ID 000291925500006

    View details for PubMedID 21694534

  • Reversal of Hepatic and Renal Failure from Sickle Cell Intrahepatic Cholestasis DIGESTIVE DISEASES AND SCIENCES Khan, M. A., Kerner, J. A. 2011; 56 (6): 1634-1636

    View details for DOI 10.1007/s10620-011-1574-5

    View details for Web of Science ID 000290770900008

    View details for PubMedID 21267779

  • The use of Omegaven in treating parenteral nutrition-associated liver disease JOURNAL OF PERINATOLOGY Park, K. T., NESPOR, C., Kerner, J. 2011; 31: S57-S60

    Abstract

    Parenteral nutrition (PN), containing fat emulsions derived from soybean, has been implicated in the progression of PN-associated liver disease and cholestasis, particularly in infants with short bowel syndrome. Clinical use of Omegaven, a parenteral fish-oil emulsion, has been shown in recent studies to be a promising therapy to reverse liver disease and cholestasis. This review summarizes the rationale, relevant clinical investigations and future direction of Omegaven therapy for PN-dependent infants.

    View details for DOI 10.1038/jp.2010.182

    View details for Web of Science ID 000289236900009

    View details for PubMedID 21448206

  • Aluminum in pediatric parenteral nutrition products: measured versus labeled content. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG Poole, R. L., Pieroni, K. P., Gaskari, S., Dixon, T. K., Park, K., Kerner, J. A. 2011; 16 (2): 92-97

    Abstract

    Aluminum is a contaminant in all parenteral nutrition solutions. Manufacturers currently label these products with the maximum aluminum content at the time of expiry, but there are no published data to establish the actual measured concentration of aluminum in parenteral nutrition solution products prior to being compounded in the clinical setting. This investigation assessed quantitative aluminum content of products commonly used in the formulation of parenteral nutrition solutions. The objective of this study is to determine the best products to be used when compounding parenteral nutrition solutions (i.e., those with the least amount of aluminum contamination).All products available in the United States from all manufacturers used in the production of parenteral nutrition solutions were identified and collected. Three lots were collected for each identified product. Samples were quantitatively analyzed by Mayo Laboratories. These measured concentrations were then compared to the manufacturers' labeled concentration.Large lot-to-lot and manufacturer-to-manufacturer differences were noted for all products. Measured aluminum concentrations were less than manufacturer-labeled values for all products.The actual aluminum concentrations of all the parenteral nutrition solutions were significantly less than the aluminum content based on manufacturers' labels. These findings indicate that 1) the manufacturers should label their products with actual aluminum content at the time of product release rather than at the time of expiry, 2) that there are manufacturers whose products provide significantly less aluminum contamination than others, and 3) pharmacists can select products with the lowest amounts of aluminum contamination and reduce the aluminum exposure in their patients.

    View details for DOI 10.5863/1551-6776-16.2.92

    View details for PubMedID 22477831

  • Increased HLA-DR Expression on Tissue Eosinophils in Eosinophilic Esophagitis JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Patel, A. J., Fuentebella, J., Gernez, Y., Nguyen, T., Bass, D., Berquist, W., Cox, K., Sibley, E., Kerner, J., Nadeau, K. 2010; 51 (3): 290-294

    Abstract

    The aim of the study was to investigate whether eosinophils have increased human leukocyte antigen (HLA)-DR expression in subjects with eosinophilic esophagitis (EoE) compared with controls.Patients who were undergoing an upper endoscopy with biopsies for suspected gastroesophageal reflux disease (GERD) or EoE at Lucile Packard Children's Hospital were enrolled. In total, the blood and tissue samples of 10 healthy controls (HC), 11 subjects with GERD, and 10 with EoE were studied. Multiple tissue staining to identify eosinophils (via eosinophil cationic protein-clone EG2) and major histocompatibility complex class II cell surface receptors (via HLA-DR) was performed via immunohistochemistry. The peripheral blood was analyzed using flow cytometry to detect eosinophil HLA-DR expression among these subjects.In the tissue, a greater proportion of eosinophils expressed HLA-DR among the subjects with EoE (mean 0.83 +/- 0.14, n = 9) relative to those with GERD (mean 0.18 +/- 0.19, n = 8, P < 0.01) and HC (mean 0.18 +/- 0.13, n = 6, P < 0.01). In total, 6 participants (4 HC subjects and 2 subjects with GERD) did not have any eosinophils identified on tissue staining and were unable to be included in the present statistical analysis. In the blood, there was no statistically significant difference in eosinophil HLA-DR expression among HC subjects (mean 415 +/- 217, n = 6), subjects with GERD (mean 507 +/- 429, n = 2), and those with EoE (mean 334 +/- 181, n = 6).These data demonstrate that the eosinophils from the esophagus of subjects with EoE have increased HLA-DR expression within this tissue.

    View details for DOI 10.1097/MPG.0b013e3181e083e7

    View details for Web of Science ID 000281453500008

    View details for PubMedID 20639774

  • Increased Number of Regulatory T Cells in Children With Eosinophilic Esophagitis JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Fuentebella, J., Patel, A., Nguyen, T., Sanjanwala, B., Berquist, W., Kerner, J. A., Bass, D., Cox, K., Hurwitz, M., Huang, J., Nguyen, C., Quiros, J. a., Nadeau, K. 2010; 51 (3): 283-289

    Abstract

    There are limited data on the role of regulatory T cells (Treg) in the disease pathology of eosinophilic esophagitis (EoE). We tested the differences in Treg in subjects with EoE compared with those with gastroesophageal reflux disease (GERD) and healthy controls (HC).Pediatric patients evaluated by endoscopy were recruited for our study. Participants were categorized into 3 groups: EoE, GERD, and HC. RNA purified from esophageal biopsies were used for real-time quantitative polymerase chain reaction assays and tested for forkhead box P3 (FoxP3) mRNA expression. Treg were identified as CD4+CD25hiCD127lo cells in peripheral blood and as CD3+/FoxP3+cells in esophageal tissue.Forty-eight subjects were analyzed by real-time quantitative polymerase chain reaction: EoE (n = 33), GERD (n = 7), and HC (n = 8). FoxP3 expression was higher by up to 1.5-fold in the EoE group compared with the GERD and HC groups (P < 0.05). Protein levels of FoxP3 in blood and tissue were then investigated in 21 subjects: EoE (n = 10), GERD (n = 6), and HC (n = 5). The percentage of Treg and their subsets in peripheral blood were not significant between groups (P > 0.05). The amount of Treg in esophageal tissue was significantly greater in the EoE group (mean 10.7 CD3+/FoxP3+cells/high power field [HPF]) compared with the other groups (GERD, mean 1.7 CD3+/FoxP3+cells/HPF and HC, mean 1.6 CD3+/FoxP3+cells/HPF) (P < 0.05).We show that Treg are increased in esophageal tissue of EoE subjects compared with GERD and HC subjects. The present study illustrates another possible mechanism involved in EoE that implicates impairment of immune homeostasis.

    View details for DOI 10.1097/MPG.0b013e3181e0817b

    View details for PubMedID 20639775

  • Nickel Toxicity Presenting as Persistent Nausea and Abdominal Pain DIGESTIVE DISEASES AND SCIENCES Fuentebella, J., Kerner, J. A. 2010; 55 (8): 2162-2164

    View details for DOI 10.1007/s10620-010-1271-9

    View details for Web of Science ID 000279294200006

    View details for PubMedID 20458617

  • Aluminum Content of Parenteral Nutrition in Neonates: Measured Versus Calculated Levels JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Poole, R. L., Schiff, L., Hintz, S. R., Wong, A., Mackenzie, N., Kerner, J. A. 2010; 50 (2): 208-211

    Abstract

    Aluminum (Al) is associated with significant central nervous system toxicity and bone and liver damage. Because Al is a contaminant of parenteral nutrition (PN) components including calcium and phosphate additives, premature infants are at potentially high risk for toxicity. The US Food and Drug Administration (FDA) has mandated PN component product labeling and recommended maximum Al daily exposure limits. The objective of this article is to determine the actual Al content of neonatal PN solutions, compare these values to the calculated amounts from manufacturers' PN product labels, and ascertain whether the actual Al exposure exceeds the FDA recommended maximum of 5 microg . kg(-1) . day(-1).Samples from 40 neonatal patient PN solutions were selected for sampling and Al content determination. Samples were also taken from 16 manufacturer's component products used in PN formulation. All of the samples were sent to Mayo Laboratories for Al content measurement. The calculated Al concentrations in PN samples were determined from the manufacturer's labeled content.Both measured and calculated Al concentrations exceeded the FDA recommended safe limit of <5 microg . kg(-1) . day(-1). The actual measured Al content was significantly lower than the calculated Al content in both the patient PN solutions and the component product samples.Al exposure exceeded the FDA recommended maximum limit for all patient samples; however, the actual measured Al content of all the samples was significantly less than the calculated Al content based on manufacturer's labels. These findings suggest that manufacturers label their products with actual Al content at the time of product release rather than at time of expiration. Periodic monitoring of Al levels should be considered with prolonged PN therapy. Changes in manufacturing processes, including the use of better raw materials, are essential to reduce Al contamination to meet FDA mandates.

    View details for DOI 10.1097/MPG.0b013e3181aed70b

    View details for Web of Science ID 000273994000018

    View details for PubMedID 20038851

  • Eotaxin and FGF enhance signaling through an extracellular signal-related kinase (ERK)-dependent pathway in the pathogenesis of Eosinophilic esophagitis. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology Huang, J. J., Joh, J. W., Fuentebella, J., Patel, A., Nguyen, T., Seki, S., Hoyte, L., Reshamwala, N., Nguyen, C., Quiros, A., Bass, D., Sibley, E., Berquist, W., Cox, K., Kerner, J., Nadeau, K. C. 2010; 6 (1): 25-?

    Abstract

    Eosinophilic esophagitis (EoE) is characterized by the inflammation of the esophagus and the infiltration of eosinophils into the esophagus, leading to symptoms such as dysphagia and stricture formation. Systemic immune indicators like eotaxin and fibroblast growth factor were evaluated for possible synergistic pathological effects. Moreover, blood cells, local tissue, and plasma from EoE and control subjects were studied to determine if the localized disease was associated with a systemic effect that correlated with presence of EoE disease.Real-time polymerase chain reaction from peripheral blood mononuclear cells (PBMC), immunohistochemistry from local esophageal biopsies, fluid assays on plasma, and fluorescence-activated cell sorting on peripheral blood cells from subjects were used to study the systemic immune indicators in newly diagnosed EoE (n = 35), treated EoE (n = 9), Gastroesophageal reflux disease (GERD) (n = 8), ulcerative colitis (n = 5), Crohn's disease (n = 5), and healthy controls (n = 8).Of the transcripts tested for possible immune indicators, we found extracellular signal-regulated kinase (ERK), Bcl-2, bFGF (basic fibroblast growth factor), and eotaxin levels were highly upregulated in PBMC and associated with disease presence of EoE. Increased FGF detected by immunohistochemistry in esophageal tissues and in PBMC was correlated with low levels of pro-apoptotic factors (Fas, Caspase 8) in PBMC from EoE subjects. Plasma-derived bFGF was shown to be the most elevated and most specific in EoE subjects in comparison to healthy controls and disease control subjects.We describe for the first time a possible mechanism by which increased FGF is associated with inhibiting apoptosis in local esophageal tissues of EoE subjects as compared to controls. Eotaxin and FGF signaling pathways share activation through the ERK pathway; together, they could act to increase eosinophil activation and prolong the half-life of eosinophils in local tissues of the esophagus in EoE subjects.

    View details for DOI 10.1186/1710-1492-6-25

    View details for PubMedID 20815913

    View details for PubMedCentralID PMC2976489

  • Transcription Factors as Disease Indicators in Eosinophilic Esophagitis 10th Annual Meeting of the Federation-of-Clinical-Immunology-Societies Nguyen, T., Gernez, Y., Fuentella, J., Patel, A., Tirouvanziam, R., Reshamwala, N., Saper, V., Bass, D., Berquist, W., Kerner, J., Nadeau, K. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2010: S81–S82

    View details for DOI 10.1016/j.clim.2010.03.246

    View details for Web of Science ID 000277953700230

  • Liver Abscesses, Pylephlebitis, and Appendicitis in an Adolescent Male DIGESTIVE DISEASES AND SCIENCES Patel, A. J., Ong, P. V., Higgins, J. P., Kerner, J. A. 2009; 54 (12): 2546-2548

    View details for DOI 10.1007/s10620-009-0880-7

    View details for Web of Science ID 000271923300002

    View details for PubMedID 19575293

  • Diversion Colitis in a 19-Year-Old Female with Megacystis-Microcolon-Intestinal Hypoperistalsis Syndrome DIGESTIVE DISEASES AND SCIENCES Talisetti, A., Longacre, T., Pai, R. K., Kerner, J. 2009; 54 (11): 2338-2340

    View details for DOI 10.1007/s10620-009-0882-5

    View details for Web of Science ID 000270836900007

    View details for PubMedID 19582576

  • Refeeding Syndrome PEDIATRIC CLINICS OF NORTH AMERICA Fuentebella, J., Kerner, J. A. 2009; 56 (5): 1201-?

    Abstract

    Refeeding syndrome (RFS) is the result of aggressive enteral or parenteral feeding in a malnourished patient, with hypophosphatemia being the hallmark of this phenomenon. Other metabolic abnormalities, such as hypokalemia and hypomagnesemia, may also occur, along with sodium and fluid retention. The metabolic changes that occur in RFS can be severe enough to cause cardiorespiratory failure and death. This article reviews the pathophysiology, the clinical manifestations, and the management of RFS. The key to prevention is identifying patients at risk and being aware of the potential complications involved in rapidly reintroducing feeds to a malnourished patient.

    View details for DOI 10.1016/j.pcl.2009.06.006

    View details for Web of Science ID 000272846100011

    View details for PubMedID 19931071

  • Identifying Eosinophilic Esophagitis through Evaluation of Plasma Biomarkers 65th Annual Meeting of the American-Academy-of-Allergy-Asthma-and-Immunology Joh, J., Huang, J., Nguyen, T., Vishwaanath, N., Patel, A., Fuentebella, J., Saper, V., Kerner, J., Cox, K., Berquist, W., Nadeau, K. MOSBY-ELSEVIER. 2009: S169–S169

    View details for Web of Science ID 000263596301118

  • Aluminum exposure from pediatric parenteral nutrition: Meeting the new FDA regulation JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Poole, R. L., Hintz, S. R., Mackenzie, N. I., Kerner, J. A. 2008; 32 (3): 242-246

    Abstract

    Aluminum toxicity can cause serious central nervous system and bone toxicities. Aluminum is a contaminant of parenteral nutrition (PN) solution components. Premature neonates requiring high doses of calcium and phosphate to mineralize their bones, children with impaired renal function, and children on PN therapy for prolonged duration are at the highest risk. Effective in July 2004, the U.S. Food and Drug Administration (FDA) mandated labeling requirements for aluminum content in all PN solution components. To assess the aluminum exposure in neonatal and pediatric populations, this study aims to determine patients' daily aluminum load (mug/kg/d) delivered from PN solutions.The study included all inpatients who received PN during calendar year 2006 (13,384 PN patient days). The calculated parameters of mug/kg/d and mug/L of parentally administered aluminum were stratified according to patient age and weight. Aluminum content by product and manufacturer were tabulated.Forty-nine percent of the PN patient days were in patients weighing < 3 kg. These patients also received the largest amounts of aluminum (range, 30-60 mug/kg/d). Meeting the FDA regulation was possible only in patients weighing > 50 kg.Currently available parenteral products used to make PN solutions contain amounts of aluminum that make it impossible to meet the new FDA rule of <5 mug/kg/d of aluminum exposure. Manufacturers must identify, develop, and adopt new methods to reduce the aluminum contamination in their products. Health care professionals should calculate aluminum loads in patients and make informed decisions when choosing PN products.

    View details for DOI 10.1177/0148607108316187

    View details for Web of Science ID 000259016300003

    View details for PubMedID 18443135

  • Alteplase for the treatment of central venous catheter occlusion in children: Results of a prospective, open-label, single-arm study (The Cathflo Activase Pediatric Study) JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Blaney, M., Shen, V., Kerner, J. A., Jacobs, B. R., Gray, S., Armfield, J., Semba, C. P. 2006; 17 (11): 1745-1751

    Abstract

    Alteplase is approved for use in the restoration of function to occluded central venous access devices (CVADs); however, there are few prospective studies in children. This study was undertaken to evaluate the safety and efficacy of alteplase in the treatment of CVAD occlusions in a pediatric population.A prospective, multicenter, open-label, single-arm study evaluating a maximum of two doses (< or =2 mg per dose) of alteplase was performed in pediatric patients. Inclusion criteria included patient age less than 17 years with an occluded CVAD (single-, double-, and triple-lumen catheter or implanted port). Patients with hemodialysis catheters, those with known mechanical occlusion, or those considered at high risk for bleeding or embolization were excluded. Assessment of function was made 30 and 120 minutes (if required) after each dose. The primary objective of the study was to evaluate the safety of alteplase as measured by the incidence of intracranial hemorrhage (ICH); secondary objectives included the evaluation of specific targeted serious adverse events and efficacy of alteplase in the restoration of catheter function.A total of 310 patients (174 male patients, 136 female patients; mean age, 7.2 years; range, 0.04-18.3 y) were treated; 55 of the patients (17.7%) were younger than 2 years of age. No patients experienced ICH (95% CI, 0%-1.2%). Nine serious adverse events were noted in eight patients (2.6% incidence), two of which were attributed by the investigator to study drug administration (one case of sepsis and one case of a ruptured catheter lumen). The cumulative rate of restoration of CVAD function after serial administration of a maximum of two instillations of alteplase, each with a maximum dwell time of 120 minutes, was 82.9% (95% CI, 78.2%-86.9%). Similar rates of catheter function restoration were seen among all catheter types studied; there were no clinically meaningful differences among age or sex subgroups.The administration of alteplase is safe and effective for the restoration of function to CVADs in pediatric patients.

    View details for DOI 10.1097/01.RVI.0000241542.71063.83

    View details for Web of Science ID 000242482400003

    View details for PubMedID 17142704

  • The use of IV fat in neonates. Nutrition in clinical practice Kerner, J. A., Poole, R. L. 2006; 21 (4): 374-380

    Abstract

    IV fat emulsion (IVFE) is an integral part of the parenteral nutrition (PN) regimen in neonates. It provides a concentrated isotonic source of calories and prevents or reverses essential fatty acid deficiency. Continuous administration of IV fat with PN regimens prolongs the viability of peripheral IV lines in infants who might have limited venous access. IVFE must be administered separately from the PN solution in neonates. The acidic pH of a PN solution is necessary for maximum solubility of calcium and phosphorus. If fat emulsion is added to the PN solution, as is done in 3-in-1 (total nutrient admixture) solutions, the high amount of calcium and phosphorus needed by these infants may result in an unseen precipitate with serious consequences. Continuous fat infusion over 24 hours is the preferred method in neonates. The administration rate of 0.15 g/kg/hour for IVFE in the neonate should not be exceeded. Essential fatty acid deficiency can be prevented in neonates by providing IVFE in a dose of 0.5-1.0 g/kg/day. Carnitine is not routinely required to metabolize IVFE in the neonate. Infants should receive 20% lipid emulsion to improve clearance of triglycerides and cholesterol. Serum triglyceride levels should be maintained at <150-200 mg/dL in neonates. There are concerns about potential adverse effects of early administration of IV fat in very-low-birth-weight infants weighing <800 g. We hold the IV fat dose at 1.0-1.5 g/kg/day until the second week of life in infants <30 weeks gestation.

    View details for PubMedID 16870805

  • Parenteral nutrition-associated cholestasis related to parental care. Nutrition in clinical practice Wu, P. A., Kerner, J. A., Berquist, W. E. 2006; 21 (3): 291-295

    Abstract

    Parenteral nutrition-associated cholestasis (PNAC) is a complication not uncommon in the pediatric population. In severe cases, patients require a liver transplant. To our knowledge, we report the only case of PNAC with end-stage liver failure in a child with short bowel syndrome that resolved with a change in caretaker. Until his care was transferred from his abusive parents, he was frequently admitted for infection and sepsis. His liver function vastly improved from aspartate aminotransferase (AST) 3139 units/L, conjugated bilirubin 25.9 mg/dL to AST 47 units/L, direct bilirubin 0.3 mg/dL under the care of his attentive foster mother, and a liver transplant was no longer necessary. Bacterial infection and sepsis are risk factors correlated with patients with PNAC requiring liver transplant. Prevention of infection by a good caregiver may be a means to reduce the incidence of PNAC.

    View details for PubMedID 16772546

  • Hepatic infantile hemangioendothelioma with unusual manifestations 16th Annual Meeting of the North-American-Society-of-Pediatric-Gastroenterology-Hepatology-and-Nutrition Burtelow, M., Garcia, T., Lucile, S., Cox, K., Berquist, W., Kemer, J. LIPPINCOTT WILLIAMS & WILKINS. 2006: 109–13

    View details for PubMedID 16385264

  • Gastrointestinal manifestations of food allergies in pediatric patients. Nutrition in clinical practice Garcia-Careaga, M., Kerner, J. A. 2005; 20 (5): 526-535

    Abstract

    Foods that account for 90% of allergic reactions in children are cow's milk protein, eggs, peanut, soy, tree nuts, fish, and wheat. Food allergy can manifest as urticaria/angioedema, anaphylaxis, atopic dermatitis, respiratory symptoms, or a gastrointestinal (GI) disorder. GI allergic manifestations can be classified as immunoglobulin E (IgE) mediated (immediate GI hypersensitivity and oral allergy syndrome); "mixed" GI allergy syndromes (involving some IgE components and some non-IgE or T-cell-mediated components) include eosinophilic esophagitis and eosinophilic gastroenteritis. Non-IgE-mediated or T-cell-mediated allergic GI disorders include dietary protein enteropathy, protein-induced enterocolitis, and proctitis. All these conditions share a common denominator: the response of the immune system to a specific protein leading to pathologic inflammatory changes in the GI tract. This immunological response can elicit symptoms such as diarrhea, vomiting, dysphagia, constipation, or GI blood loss, symptoms consistent with a GI disorder. The detection of food allergies can be accomplished by the use of radioallergosorbent (RAST) testing and skin prick tests in helping to assess the IgE-mediated disorders. Patch tests may help evaluate delayed hypersensitivity reactions. Treatment of GI allergic disorders ranges from strict dietary elimination of offending food(s), use of protein hydrolysates, and use of L-amino acid-based formula when protein hydrolysates fail. Treatment with topical (for eosinophilic esophagitis) or systemic steroids is used if all dietary measures are unsuccessful. Maternal breast feeding or the use from birth of hydrolysate formulas (extensive or partial hydrolysates) may be efficacious in the prevention of atopic disease in "high-risk" families (with at least 1 parent or sibling with a history of atopic disease).

    View details for PubMedID 16207693

  • Copper deficiency during parenteral nutrition: a report of four pediatric cases. Nutrition in clinical practice Hurwitz, M., Garcia, M. G., Poole, R. L., Kerner, J. A. 2004; 19 (3): 305-308

    Abstract

    The standard of care for patients with cholestasis (direct bilirubin >or=2 mg/dL) while receiving parenteral nutrition (PN) solutions is to reduce or discontinue the copper and manganese. The repercussions of this action have not been studied. Two adult case reports document low serum copper levels associated with clinical symptoms of copper deficiency after the removal of copper from their PN solutions. We now describe the first known series of pediatric patients to develop copper deficiency after copper was removed from their PN solutions.

    View details for PubMedID 16215119

  • The use of alteplase for restoring patency to occluded central venous access devices in infants and children. Journal of infusion nursing : the official publication of the Infusion Nurses Society Fisher, A. A., Deffenbaugh, C., Poole, R. L., Garcia, M., Kerner, J. A. 2004; 27 (3): 171-174

    Abstract

    A 21-month retrospective review was completed at the Lucile Packard Children's Hospital to assess the experience of 22 infants and children who received alteplase for the clearance of occluded central venous access devices. After the first dose, 86% (n = 19) of the catheters cleared. Two additional catheters cleared with a second dose. With alteplase treatment, 95% (n = 21) of the catheters cleared. No adverse events were noted within 24 hours after the alteplase was received. Infusion of alteplase appeared to be safe and effective in restoring patency to occluded central venous access devices in infants and children.

    View details for PubMedID 15118455

  • A practical guideline for calculating parenteral nutrition cycles. Nutrition in clinical practice Longhurst, C., Naumovski, L., Garcia-Careaga, M., Kerner, J. 2003; 18 (6): 517-520

    Abstract

    Both physiologic and psychological reasons for cycling total parenteral nutrition (TPN) have been well established. Despite widespread acceptance of this practice, the only previously published method for calculating TPN cycle rates is inherently flawed.A mathematical formula was derived to facilitate reliable calculation of cyclic TPN flow rates as a function of total volume and cycle time. A publicly accessible website was subsequently developed to expedite rapid determination of TPN cycles.A fail-safe method of calculating TPN cycle flow rates can be expressed as F = V/(4T-10), where F is equal to the basal flow rate (mL/h), T is equal to the desired cycle time (hours), and V is equal to the total volume of TPN (mL) to be delivered in 24 hours. The basal flow rate and twice the basal flow rate are used for the first and last 2 hours of the TPN cycle, and the remainder of the cycle runs at 4 times the basal flow rate. TPN cycles may be easily calculated online using this formula at http://peds.stanford.edu/tpn.html.We have developed a fail-safe method of calculating TPN cycle flow rates that will consistently deliver the desired volume and have made an online implementation of this formula publicly available.

    View details for PubMedID 16215087

  • A gastroenterologist's approach to failure to thrive PEDIATRIC ANNALS Careaga, M. G., Kerner, J. A. 2000; 29 (9): 558-?

    View details for Web of Science ID 000089207500005

    View details for PubMedID 11016049

  • Clinical pathway for pediatric parenteral nutrition. Nutrition in clinical practice Fisher, A. A., Poole, R. L., Machie, R., Tsang, C., Baugh, N., Utley, K., Kerner, J. A. 1997; 12 (2): 76-80

    Abstract

    The nutrition support team at Lucile Salter Packard Children's Hospital at Stanford developed a clinical pathway for infants and children receiving parenteral nutrition (PN). Use of clinical pathways for health care delivery is one way in which clinicians and institutions are responding to pressure from managed care organizations to reduce costs and maintain or improve quality. This pathway was developed to standardize the process for ordering, implementing, and monitoring PN. Specific goals for the pathway are as follows: to decrease the number of patients receiving PN inappropriately, to decrease the duration of PN for those patients who require it, to determine complication rates, and to monitor outcomes of therapy. Such comprehensive monitoring will help identify areas for improvement. By developing and implementing action plans to address these issues, we expect to improve continuously the processes and outcomes associated with PN therapy.

    View details for PubMedID 9155406

  • INTRAVENOUS AMITRIPTYLINE IN PEDIATRICS JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Collins, J. J., Kerner, J., SENTIVANY, S., Berde, C. B. 1995; 10 (6): 471-475

    Abstract

    Oral amitriptyline has been used as an analgesic in a wide range of pain settings. Despite long-term availability of a parenteral form, the few reports about this formulation have been limited to pharmacokinetic studies in normal volunteers, trials in depressed patients, and analyses of electroencephalogram (EEG) activation. We retrospectively reviewed our experience using intravenous (IV) amitriptyline at Children's Hospital, Boston and at Children's Hospital at Stanford. Eight children (aged 5-16.6 years), who were unable to tolerate medications by the oral route, received IV amitriptyline for a variety of indications, including neuropathic pain, depression, sleep disturbance, and as an adjuvant agent for opioid analgesia. One patient experienced an extrapyramidal reaction temporally related to the administration of IV amitriptyline, which was successfully managed with diphenhydramine. Further prospective, controlled studies are needed to further assess the safety, efficacy and tolerability of this novel use of amitriptyline.

    View details for Web of Science ID A1995RP55500009

    View details for PubMedID 7561230

  • EVOLVING ASYMMETRIC HYPERTROPHIC PYLORIC-STENOSIS ASSOCIATED WITH HISTOLOGIC EVIDENCE OF EOSINOPHILIC GASTROENTERITIS PEDIATRIC RADIOLOGY Blankenberg, F. G., Parker, B. R., Sibley, E., Kerner, J. A. 1995; 25 (4): 310-311

    Abstract

    The most frequently occurring and important cause of gastric outlet obstruction in the neonate and young infant is infantile hypertrophic pyloric stenosis (IHPS). A reported association of IHPS and eosinophilic gastroenteritis [1] raises interesting questions about the possible etiologic relationship between the two entities. It is plausible that the observed sonographic pyloric muscular wall thickness in IHPS may in part be dependent on the degree and duration of an allergic gastroenteropathy. A recent report suggests that endoscopy may be a more reliable diagnostic method than sonography in the patient with evolving IHPS [2]. Our recent experience with a patient with evolving IHPS supports the findings described in these prior reports.

    View details for Web of Science ID A1995RF84300025

    View details for PubMedID 7567248

  • FORMULA ALLERGY AND INTOLERANCE GASTROENTEROLOGY CLINICS OF NORTH AMERICA Kerner, J. A. 1995; 24 (1): 1-25

    Abstract

    There are two major types of adverse reactions in infant formulas: (1) formula allergy/hypersensitivity, which is an immunologic response, and (2) formula intolerance, which is a nonimmunologic response. Formula intolerance can occur in infants with an underlying congenital or acquired enzyme deficiency (disaccharidase deficiency, galactosemia, hereditary fructose intolerance). The clinical presentation, diagnosis, and treatment of both reactions are reviewed in this article. The appropriateness of the use of a variety of infant formulas is discussed. Guidelines for the prevention of allergic disease are described as well.

    View details for Web of Science ID A1995QH18800002

    View details for PubMedID 7729855

  • THE EFFECT OF NUTRITIONAL ADDITIVES ON ANTIINFECTIVE FACTORS IN HUMAN-MILK CLINICAL PEDIATRICS Quan, R., Yang, C., Rubinstein, S., LEWISTON, N. J., Stevenson, D. K., Kerner, J. A. 1994; 33 (6): 325-328

    Abstract

    It has become a common practice to supplement human milk with a variety of additives to improve the nutritive content of the feeding for the premature infant. Twenty-two freshly frozen human milk samples were measured for lysozyme activity, total IgA, and specific IgA to Escherichia coli serotypes 01, 04, and 06. One mL aliquots were mixed with the following: 1 mL of Similac, Similac Special Care, Enfamil, Enfamil Premature Formula, and sterile water; 33 mL of Poly-Vi-Sol, 33 mg of Moducal, and 38 mg of breast-milk fortifier, and then reanalyzed. Significant decreases (41% to 74%) in lysozyme activity were seen with the addition of all formulas; breast-milk fortifier reduced activity by 19%, while no differences were seen with Moducal, sterile water, or Poly-Vi-Sol. No differences were seen in total IgA content, but some decreases were seen in specific IgA to E. coli serotypes 04 and 06. E. coli growth was determined after 3 1/2 hours of incubation at 37 degrees C after mixing. All cow-milk formulas enhanced E. coli growth; soy formulas and other additives preserved inhibition of bacterial growth. Nutritional additives can impair anti-infective properties of human milk, and such interplay should be considered in the decision on the feeding regimen of premature infants.

    View details for Web of Science ID A1994NR58100002

    View details for PubMedID 8200164

  • IMPROVED GROWTH AND DISEASE-ACTIVITY AFTER INTERMITTENT ADMINISTRATION OF A DEFINED FORMULA DIET IN CHILDREN WITH CROHNS-DISEASE JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Polk, D. B., HATTNER, J. A., Kerner, J. A. 1992; 16 (6): 499-504

    Abstract

    Growth failure is the most common extraintestinal manifestation of Crohn's disease in childhood, occurring in up to 50% to 88% of affected patients. Previous studies have shown malnutrition to be the most likely cause of the decrease in height and weight velocities in these children. The purpose of this study was to determine the effect of an intermittent defined formula diet on growth and disease activity in children with Crohn's disease and growth failure. Six Tanner stage I-II patients, mean age 13.6 years with height less than the 5th percentile or height velocity less than the 3rd percentile were enrolled in a 1-year prospective study. An isotonic, hydrolyzed whey, medium-chain triglyceride formula was given by nocturnal nasogastric infusion at a caloric equivalent of 50th percentile for age, as the exclusive nutrient source 1 out of 4 months during a 1-year period. A 2-week exclusion diet and a 2-week low-residue diet followed the defined formula diet before resuming the regular diet for 2 months. Patients served as their individual control based on observations of at least 1 year before the study. Height and weight velocity significantly increased. Prednisone intake significantly decreased, and significant improvement was seen in disease activity, albumin, and somatomedin C. The results indicate that an intermittent defined formula diet can improve growth failure and significantly decrease disease activity in children with Crohn's disease.

    View details for Web of Science ID A1992JY70000001

    View details for PubMedID 1494204

  • EFFECTS OF MICROWAVE-RADIATION ON ANTIINFECTIVE FACTORS IN HUMAN-MILK PEDIATRICS Quan, R., Yang, C., Rubinstein, S., LEWISTON, N. J., Sunshine, P., Stevenson, D. K., Kerner, J. A. 1992; 89 (4): 667-669

    Abstract

    In intensive care nurseries it has become common practice to use microwave thawing of frozen human milk for more rapid accessibility. Twenty-two freshly frozen human milk samples were tested for lysozyme activity, total IgA, and specific secretory IgA to Escherichia coli serotypes 01, 04, and 06. The samples were heated by microwave for 30 seconds at a low- or high-power setting and then reanalyzed. One-mL aliquots of 10 additional human milk samples were microwaved at low (20 degrees C to 25 degrees C), medium (60 degrees C to 70 degrees C), and high (greater than or equal to 98 degrees C) setting before the addition to each of 1 mL of diluted E coli suspension. E coli growth was determined after 3 1/2 hours of incubation at 37 degrees C. Microwaving at high temperatures (72 degrees C to 98 degrees C) caused a marked decrease in activity of all the tested antiinfective factors. E coli growth at greater than or equal to 98 degrees C was 18 times that of control human milk. Microwaving at low temperatures (20 degrees C to 53 degrees C) had no significant effect on total IgA, specific IgA to E coli serotypes 01 and 04, but did significantly decrease lysozyme and specific IgA to E coli serotype 06. Even at 20 degrees C to 25 degrees C, E coli growth was five times that of control human milk. Microwaving appears to be contraindicated at high temperatures, and questions regarding its safety exist even at low temperatures.

    View details for Web of Science ID A1992HM25100018

    View details for PubMedID 1557249

  • MICROVILLOUS INCLUSION DISEASE - THE IMPORTANCE OF ELECTRON-MICROSCOPY FOR DIAGNOSIS AMERICAN JOURNAL OF SURGICAL PATHOLOGY Bell, S. W., Kerner, J. A., Sibley, R. K. 1991; 15 (12): 1157-1164

    Abstract

    We report two cases of microvillous inclusion disease (MID) occurring in a set of siblings. Although it is a rare disorder, MID appears to be a common cause of familial intractable secretory diarrhea. Diagnosis rests on the ultrastructural finding of intracytoplasmic inclusions that are lined by intact microvilli. These inclusions are present in the absorptive surface epithelial cells of the small and large intestine and are associated with poorly developed surface brush border microvilli. The prognosis of MID is poor and curative therapy is not currently available. Because MID appears to be a hereditary disorder, genetic counseling of affected families is essential.

    View details for Web of Science ID A1991GV11600006

    View details for PubMedID 1660676

  • Anthropometry and bilirubin production. Journal of perinatology Stevenson, D. K., Ochikubo, C. G., Rodgers, P. A., Kerner, J. A. 1991; 11 (4): 340-342

    Abstract

    Anthropometric measurements and total bilirubin formation (TBF) estimates were performed on infants born to normal and diabetic mothers. Although we do not exclude the theoretical possibility of a low-frequency occurrence of increased TBF in macrosomic infants of normal mothers, we can conclude that infants of mothers whose diabetes is well managed may have normal TBF.

    View details for PubMedID 1770390

  • TESTING THE PSYCHOGENIC VOMITING DIAGNOSIS - 4 PEDIATRIC-PATIENTS AMERICAN JOURNAL OF DISEASES OF CHILDREN GONZALEZHEYDRICH, J., Kerner, J. A., Steiner, H. 1991; 145 (8): 913-916

    Abstract

    We treated four patients with chronic vomiting during childhood in whom a tentative diagnosis of psychogenic vomiting was made after an extensive evaluation. In each case, the diagnosis was reconsidered during the course of treatment, as observations about the patients and their response to interventions accumulated. In three instances, these observations did not fit those expected if the diagnosis of psychogenic vomiting was correct. This led to a reexamination of the organic evaluation and the discovery of an undiagnosed organic contribution to the vomiting. In the fourth patient, gastric emptying studies confirmed that there was a strong psychological contribution to the vomiting, and helped to more carefully define this contribution. Family and individual psychotherapy and treatment were aided by the greater clarity in diagnosis.

    View details for Web of Science ID A1991FZ98300026

    View details for PubMedID 1858729

  • CARBON-MONOXIDE PRODUCTION BY NONBACTERIAL SOURCES AFTER HEME FEEDING OF NEONATAL RATS BIOLOGY OF THE NEONATE Stevenson, D. K., HAMORI, C. J., Carlton, R. R., Castillo, R. O., Kerner, J. A., Vreman, H. J. 1990; 57 (3-4): 238-242

    Abstract

    We determined the relative potential for nonbacterial CO production after oral heme feeding of 12-hour-old rats. The intestinal flora was eliminated by treatment with kanamycin, ampicillin, and neomycin. CO excretion (VeCO) was measured after oral administration of heme (0.64 mumol/animal). Antibiotic treatment alone did not significantly affect the VeCO of rats gavaged with saline. Heme administration increased (p less than 0.05) the VeCO during t = 1-11 h with a peak at 3 h. Antibiotic treatment reduced this VeCO (p less than 0.05) during t = 2-8 h, but its level (peak at t = 2-3 h) was still significantly (p less than 0.05) above its nonheme control. The results confirm that bacterial degradation of heme is an important source of CO in suckling rats not pretreated with broad-spectrum antibiotics. However, oral heme feeding of gut-sterilized animals yielded transiently significantly increased VeCO. HO-mediated degradation of enteral heme is a likely nonbacterial source of CO and possibly bilirubin in the neonate.

    View details for Web of Science ID A1990CR41700015

    View details for PubMedID 2322605

  • REGULATION OF INTESTINAL ONTOGENY BY INTRALUMINAL NUTRIENTS JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Castillo, R. O., Feng, J. J., Stevenson, D. K., Kerner, J. A., Kwong, L. K. 1990; 10 (2): 199-205

    Abstract

    Major events in gastrointestinal ontogeny occur in the infant rat in association with weaning, resulting in striking alterations in small intestinal structure and function. Although the dietary changes attendant to weaning are not essential for the initiation of these events, dietary nutrients have been shown to participate in the maturation of some intestinal parameters. In order to define more precisely the role of intraluminal nutrients in the regulation of small intestinal ontogeny, a longitudinal study was conducted using a unique animal model in which intraluminal nutrients were excluded from the intact maturing intestine in vivo throughout the entire weaning period without major compromise in nutritional status. The absence of intraluminal nutrients over the weaning period resulted in diminished lengthening and accretion of mucosal mass, suggesting a slower rate of intestinal growth. Lower mucosal DNA, protein, and mitotic indices in intestines of animals receiving no intraluminal nutrients suggested that the lack of intraluminal nutrients resulted in the blunting of the striking increases in cellular proliferation normally exhibited by the developing intestinal mucosa at this time. Maturation of intestinal lactase-phlorizin hydrolase and maltase-glucoamylase was not affected by the absence of intraluminal nutrients. Although the appearance of sucrase-isomaltase was not altered by the absence of intraluminal nutrients, activity levels rose to only 50% of control levels. These data suggest that during this period of rapid intestinal maturation, intestinal growth is more dependent upon intraluminal nutrients than are the characteristic enzymic alterations normally expressed during this period.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1990CM93700010

    View details for PubMedID 2303970

  • EVALUATION OF A NEW FAT EMULSION (LIPOSYN-II) IN NEONATES Malkani, A., Abraham, S., HARTMAN, G., Shochat, S., Castillo, R. O., Inguillo, D., Martin, D., Kerner, J. SLACK INC. 1990: A190–A190

    View details for Web of Science ID A1990CF63601099

  • RELATIONSHIP BETWEEN BREATH AND TOTAL-BODY HYDROGEN EXCRETION RATES IN NEONATES JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Modler, S., Kerner, J. A., Castillo, R. O., Vreman, H. J., Stevenson, D. K. 1988; 7 (4): 554-558

    Abstract

    Our study examined the relationship of H2 excreted in breath to total body H2 excreted by neonates. We report simultaneously measured end-tidal H2 concentrations, plus breath H2 and total body H2 (breath H2 plus flatus H2) excretion rates in 10 neonates. End-tidal H2 concentrations varied from 2.4 to 192 ppm. Breath H2 excretion rates ranged from 0.20 to 6.5 and total body H2 excretion rates from 0.29 to 15.0 ml/h. The fractional breath H2 excretion in these infants was 48% (range 33-69%), compared with 21% reported in adults. The correlation coefficient for end-tidal derived H2 excretion and directly measured breath H2 excretion rates was 0.95 (p less than 0.001). We conclude that the proportion of total H2 excreted in the breath of neonates is increased compared with adults, suggesting that caution must be exercised when interpreting newborn breath H2 measurements and using adult norms.

    View details for Web of Science ID A1988N975500013

    View details for PubMedID 3397846

  • VITAMIN-A INTOXICATION PRESENTING WITH ASCITES AND A NORMAL VITAMIN-A LEVEL WESTERN JOURNAL OF MEDICINE Mendoza, F. S., Johnson, F., Kerner, J. A., Tune, B. M., Shochat, S. J. 1988; 148 (1): 88-90

    View details for Web of Science ID A1988L724600027

    View details for PubMedID 3341140

    View details for PubMedCentralID PMC1026032

  • Postnatal somatic growth in very low birth weight infants on supplemental peripheral parenteral nutrition. Journal of pediatric & perinatal nutrition Kerner, J. A., HATTNER, J. A., Trautman, M. S., Stevenson, D. K. 1988; 2 (1): 27-34

    View details for PubMedID 3145974

  • RELATIONSHIP BETWEEN BREATH AND TOTAL HYDROGEN EXCRETION RATES IN NEONATES Modler, S., Kerner, J. A., Castillo, R. O., Vreman, H. J., Stevenson, D. K. SLACK INC. 1988: A206–A206

    View details for Web of Science ID A1988L516801203

  • High serum vitamin E levels in premature infants receiving MVI-Pediatric. Journal of pediatric & perinatal nutrition Kerner, J. A., Poole, R. L., Sunshine, P., Stevenson, D. K. 1987; 1 (1): 75-82

    View details for PubMedID 3694523

  • HEPATIC-FAILURE FOLLOWING INGESTION OF MULTIPLE DOSES OF ACETAMINOPHEN IN A YOUNG-CHILD JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Smith, D. W., ISAKSON, G., Frankel, L. R., Kerner, J. A. 1986; 5 (5): 822-825

    Abstract

    A 7-month-old male developed hepatic failure following the mistaken administration of multiple excessive doses of acetaminophen. Hepatic toxicity following multiple dose ingestion has been reported infrequently. Risk factors for hepatic toxicity following multiple dose ingestion are discussed.

    View details for Web of Science ID A1986D717700028

    View details for PubMedID 3761116

  • INTESTINAL FLORA IN THE 2ND WEEK OF LIFE IN HOSPITALIZED PRETERM INFANTS FED STORED FROZEN BREAST-MILK OR A PROPRIETARY FORMULA CLINICAL PEDIATRICS Stevenson, D. K., Yang, C., Kerner, J. A., YEAGER, A. S. 1985; 24 (6): 338-341

    Abstract

    Twenty infants fed stored frozen breast milk or a proprietary formula only had both aerobic and anaerobic cultures performed at a chronologic age of 8 to 14 days. Nine out of 10 stools from the infants fed stored frozen breast milk contained Enterobacteriaceae and one stool was sterile. One contained a Pseudomonas species; one contained anaerobic gram-positive rods; one contained anaerobic gram-negative rods; and four contained anaerobic gram-positive cocci. No anaerobes were found in six stools. Six stools had aerobic gram-positive cocci, none of which was hemolytic. Nine out of 10 stools from infants fed a proprietary formula had Enterobacteriaceae. Six stools had anaerobic gram-positive rods, three had anaerobic gram-negative rods, and four had gram-positive cocci. Four stools had no anaerobic bacteria. All 10 stools had nonhemolytic aerobic gram-positive cocci. Enterobacteriaceae were predominant in the stools of the infants fed either stored frozen breast milk or a proprietary formula, and the colony counts of aerobic bacteria were similar in both groups. This pattern of intestinal flora in hospitalized preterm infants in the second week of life is very different from that of normal term infants and may contribute to their increased incidence of systemic and localized infections. The use of stored frozen breast milk for the purpose of suppressing coliform and other potentially pathogenic organisms may not be effective in hospitalized preterm infants who have been treated previously with broad-spectrum, parenteral antibiotics.

    View details for Web of Science ID A1985AHW9200008

    View details for PubMedID 3995864

  • THE NATURE OF MATURATIONAL DECLINE OF INTESTINAL LACTASE ACTIVITY BIOCHIMICA ET BIOPHYSICA ACTA TSUBOI, K. K., Kwong, L. K., DHARLINGUE, A. E., Stevenson, D. K., Kerner, J. A., Sunshine, P. 1985; 840 (1): 69-78

    Abstract

    We have examined the nature of the decline of lactase (EC 3.2.1.23) activity in the maturing rat intestine. It was established in an initial study that the activity decline reflected a proportional reduction in the concentration of the enzyme protein. Accumulation patterns of label into lactase, total intestinal proteins and sucrase (EC 3.2.1.48)-isomaltase (EC 3.2.1.10) were compared, 4 h following administration of a tracer dose of [3H]leucine to weanling rats exhibiting a wide range of lactase decline. Accumulation of increasing amounts of label in total intestinal proteins and sucrase-isomaltase pools was found to accompany the lactase decline, in contrast to accumulation of a constant amount of label in the declining lactase pools. The pattern of increased label accumulation in total intestinal proteins was shown in a corollary study to reflect a corresponding acceleration of total protein synthesis. On this basis, the finding of a constant amount of label in the declining lactase pools suggested a constant synthesis of lactase. We proposed earlier that associated reductions in enterocyte life-span (leading to correspondingly less lactase accumulation) rather than suppressed synthesis may provide the primary causal basis of lactase decline in the postweaned mammal.

    View details for Web of Science ID A1985AKH8600011

    View details for PubMedID 3922428

  • BILIRUBIN BINDING IN THE PLASMA OF NEWBORNS - CRITICAL-EVALUATION OF A FLUORESCENCE QUENCHING METHOD AND COMPARISON TO THE PEROXIDASE METHOD PEDIATRIC RESEARCH Berde, C. B., Benitz, W. E., RASMUSSEN, L. F., Kerner, J. A., Johnson, J. D., Wennberg, R. P. 1984; 18 (4): 349-354

    Abstract

    Bilirubin binding affinities and capacities and apparent unbound ("free") bilirubin levels were determined in serum samples from 47 high-risk newborns, in 22 samples of cord serum, and in serum samples from 15 Greek children with marked hyperbilirubinemia, by both fluorescence quenching and peroxidase methods. The free fatty acid:albumin molar ratio was also determined for serum samples from high-risk newborns. In vitro and in vivo measurements suggest that free fatty acids are rarely present at levels that produce significant displacement of bilirubin, which is in agreement with previous studies. The two bilirubin binding assays showed only fair correlation with sizable discrepancies for many specimens. Technical difficulties inherent in the fluorescence quenching method and possible sources of error are discussed. Our observations suggest that routine application of these two assays as the primary criterion for therapeutic intervention (e.g., exchange transfusion) is premature.

    View details for Web of Science ID A1984SJ47800009

    View details for PubMedID 6718091

  • CALCIUM AND PHOSPHORUS IN NEONATAL PARENTERAL-NUTRITION SOLUTIONS JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Poole, R. L., RUPP, C. A., Kerner, J. A. 1983; 7 (4): 358-360

    Abstract

    Due to calcium and phosphorus solubility problems in parenteral nutrition solutions, it is difficult to provide the premature infant with enough of these two minerals for adequate bone mineralization. In order to determine the maximum amounts of both Ca and P soluble in neonatal parenteral nutrition solutions, we employed the following procedure: (1) using concentrations of dextrose 10 to 25% and amino acid 0.5 to 4.0% with standard electrolyte and vitamin concentrations, Ca and P additions were sequentially made to determine the critical concentrations at which precipitates formed; (2) the pH of each test solution was determined; (3) all test solutions were incubated for 30 hr at room temperature; (4) following incubation, all tests were visually observed for calcium-phosphate crystals; (5) the solutions not obviously precipitated were filtered using black Millipore filters to determine the presence of any microprecipitates. Multiple graphs of Ca and P solubility in various dextrose/amino acid solutions were prepared from data generated by the study. The Ca and P interaction is primarily pH sensitive. Factors affecting the solution pH include both dextrose and amino acid concentrations. Our study showed that increases in amino acid concentrations enabled us to increase both Ca and P in the solutions.

    View details for Web of Science ID A1983QY84500005

    View details for PubMedID 6413711

  • ON THE MECHANISM OF NORMAL INTESTINAL LACTASE DECLINE IN THE POSTWEANED MAMMAL TSUBOI, K. K., DHARLINGUE, A., Kwong, L. K., Stevenson, D. K., Kerner, J. A., Sunshine, P. SLACK INC. 1983: A106–A106

    View details for Web of Science ID A1983PU88600631

  • BREATH HYDROGEN ANALYSIS - A REVIEW OF THE METHODOLOGIES AND CLINICAL-APPLICATIONS JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION OSTRANDER, C. R., Cohen, R. S., Hopper, A. O., SHAHIN, S. M., Kerner, J. A., Johnson, J. D., Stevenson, D. K. 1983; 2 (3): 525-533

    Abstract

    Hydrogen gas (H2) is a product of the fermentation of dietary carbohydrate (CHO) by bacteria in the lumen of the gastrointestinal tract in man. Thus, H2 is actually an exogenously produced gas, which either is passed as flatus, or diffuses into the body and is exhaled. In the adult, a fairly constant fraction is expired, providing a reliable indicator of total colonic H2 production. Breath H2 analysis currently represents a useful clinical means of testing adults and older children for the malabsorption of CHO. Noninvasive and easy procedures for the collection of expired air have encouraged their increasingly widespread use in pediatrics. Evidence to date suggests that breath H2 analysis may provide the best available method for estimating semiquantitatively the degree of CHO malabsorption. The association of the results of breath H2 analysis with other clinical measures of CHO digestion and absorption is expected, but discrepancies can also be anticipated based on the nature of this particular trace gas method. The interpretation of the results of breath H2 analysis in neonates and young infants remains especially problematic because of confounding variables which are difficult to control and are measured infrequently.

    View details for Web of Science ID A1983RC94400022

    View details for PubMedID 6620060

  • BREATH HYDROGEN IN PRETERM INFANTS - CORRELATION WITH CHANGES IN BACTERIAL-COLONIZATION OF THE GASTROINTESTINAL-TRACT JOURNAL OF PEDIATRICS Stevenson, D. K., SHAHIN, S. M., OSTRANDER, C. R., Kerner, J. A., Cohen, R. S., Hopper, A. O., YEAGER, A. S. 1982; 101 (4): 607-610

    View details for Web of Science ID A1982PK84200032

    View details for PubMedID 7119967

  • A SENSITIVE ANALYTICAL APPARATUS FOR MEASURING HYDROGEN PRODUCTION-RATES .1. APPLICATION TO STUDIES IN SMALL ANIMALS - EVIDENCE OF THE EFFECTS OF AN ALPHA-GLUCOSIDEHYDROLASE INHIBITOR IN THE RAT ANALYTICAL BIOCHEMISTRY OSTRANDER, C. R., Stevenson, D. K., Neu, J., Kerner, J. A., Moses, S. W. 1982; 119 (2): 378-386

    View details for Web of Science ID A1982NE96700025

    View details for PubMedID 7041699

  • EVIDENCE FOR THE POSSIBLE RELATIONSHIP OF NEONATAL SKINFOLD THICKNESS TO MATERNAL GLUCOSE-METABOLISM DURING THE 3RD TRIMESTER JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Kerner, J. A., Stevenson, D. K., HATTNER, J. A., Cohen, R. S., Schwartz, H. C., Sunshine, P. 1982; 1 (1): 59-62

    Abstract

    Forty-eight infants, including 14 premature infants who were appropriate size for gestational age (AGA), 10 full-term AGA infants, 18 full-term infants who were large for gestational age (LGA), and six premature LGA infants of diabetic mothers (IDMs), had measurements of skinfold thickness (SFT) in the first 72 h of life. For the 24 LGA infants, there was a significant positive correlation between maternal glycohemoglobin (Hb AIc) in the post-partum period and SFT (r = 0.42, p less than 0.05). Our observations in this study support those of others, demonstrating that SFT increases with increasing gestational age. In addition, they support the hypothesis that, in diabetic pregnancies, or pregnancies associated with an elevated Hb AIc, a reflection of the time-integrated blood glucose level over the weeks preceding parturition, fetal hyperglycemia and hyperinsulinemia stimulate increased triglyceride synthesis in adipose cells and lead to an increase in fetal subcutaneous fat.

    View details for Web of Science ID A1982PB96400012

    View details for PubMedID 6193261

  • MACROSOMIA - CAUSES AND CONSEQUENCES JOURNAL OF PEDIATRICS Stevenson, D. K., Cohen, R. S., Kerner, J. A. 1982; 100 (4): 515-520

    View details for Web of Science ID A1982NK67300001

    View details for PubMedID 7062199

  • A SENSITIVE ANALYTICAL APPARATUS FOR MEASURING HYDROGEN PRODUCTION-RATES .2. APPLICATION TO STUDIES IN HUMAN INFANTS JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Stevenson, D. K., Cohen, R. S., OSTRANDER, C. R., SHAHIN, S. M., Kerner, J. A., WETMORE, D. L., Werner, S. B., Tomczyk, M., Johnson, J. D. 1982; 1 (2): 233-237

    Abstract

    We estimated hydrogen (H2) production by determining simultaneously the end-tidal concentration (ETH2) and the direct pulmonary excretion rate (VeH2) in normal-sized, healthy, term and preterm neonates between 2 days and 7 weeks of life who were receiving all their calories enterally as breast milk or a proprietary formula. We found that there was no peak or pattern in H2 production during the first 3 postprandial hours (mean VeH2 = 1.00 +/- 0.97 SD ml/kg/h; mean ETH2 = 40.3 +/- 33.1 SD ppm). Frequently, there was marked short-term variability of the ETH2 in a given infant (coefficient of variation = 13.4% +/- 18.7%). H2 production was elevated in normal neonates without signs of malabsorption. We found that VeH2 correlated with ETH2 using both nasopharyngeal catheter (r = 0.63; p less than 0.001) and nasal prong (r = 0.71; p less than 0.001) collection techniques. We conclude that breath hydrogen determinations in neonates are not readily comparable to similar studies in older patients. Longitudinal studies of individual infants may reveal changes in breath H2 excretion of sufficient magnitude to be distinguishable from moment-to-moment variations, and correlatable with certain intercurrent clinical problems affecting intestinal H2 production or pulmonary H2 excretion. However, interpretation of breath H2 determinations in human infants will be difficult.

    View details for Web of Science ID A1982PB96500014

    View details for PubMedID 7186035

  • MONITORING INTRAVENOUS FAT EMULSIONS IN NEONATES WITH THE FATTY-ACID SERUM-ALBUMIN MOLAR RATIO JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Kerner, J. A., Cassani, C., Hurwitz, R., Berde, C. B. 1981; 5 (6): 517-518

    Abstract

    Weekly determinations of the fatty acid/albumin molar ratio (FA/SA) were obtained 136 times on 50 neonates (birthweight range, 675-4300 grams; median, 1360 grams) to determine if our use of intravenous fat (IVF) was putting these newborns at risk for kernicterus. The FA/SA was measured using a convenient spectrophotometric technique which we have previously described (Berde CB, Kerner JA, Johnson JD: Clin Chem 26:1173-1177, 1980). Twenty-nine infants received IVF with doses from 0.5 to 3.3 gram/kilogram/day (mean 1.5 gram/kilogram/day), given over 24 hours whenever possible, most commonly begun in the second week of life when the bilirubin level was less than one half of the potential exchange level. Twenty-one infants received no IVF. Previous studies show that fatty acids do not begin to displace bilirubin from albumin until the FA/SA is greater than 6 in vivo, and greater than 4 in vitro. All our infants had safe values with mean FA/SA values of approximately 1.0. Continuous IVF as we administer it does not place neonates at risk for kernicterus. Centers administering IVF in the first week of life or by bolus should consider close monitoring of their infants with the FA/SA.

    View details for Web of Science ID A1981MZ06200011

    View details for PubMedID 7199590

  • ORAL CORRECTION OF ESSENTIAL FATTY-ACID DEFICIENCY IN CYSTIC-FIBROSIS JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Landon, C., Kerner, J. A., Castillo, R., Adams, L., Whalen, R., LEWISTON, N. J. 1981; 5 (6): 501-504

    Abstract

    A combination of pancreatic insufficiency and inadequate caloric intake may produce essential fatty acids (EFA) deficiency in patients with cystic fibrosis. Seventy-five percent of the adolescents and young adults with poor weight gain in our clinic were EFA-deficient by total plasma linoleic acid criteria. Twenty of these patients were placed on an oral hyperalimentation regimen containing 230% of calories required for basal energy expenditure, 40% as fat. Forty percent of these (8/20) achieved normal EFA levels on this diet. Eight of the nonresponding patients were given an additional 5% of their caloric intake as linoleic acid monoglyceride. All who maintained caloric intake achieved normal EFA levels. Normalization of EFA levels was associated with a number of clinical benefits including increase in weight and activity and, in five teenage girls, regulation of menses. The 16 control patients who received standard pancrelipase therapy and nutritional supplements remained fatty acid deficient. We conclude that oral hyperalimentation can restore EFA levels in cystic fibrosis patients if adequate calories are available to provide energy needs.

    View details for Web of Science ID A1981MZ06200007

    View details for PubMedID 6801283

  • FAMILIAL INTRACTABLE SECRETORY DIARRHEA Kerner, J. A., Sunshine, P. SLACK INC. 1980: A96–A96

    View details for Web of Science ID A1980JB49200564

  • LATE MORBIDITY AMONG SURVIVORS OF NECROTIZING ENTEROCOLITIS PEDIATRICS Stevenson, D. K., Kerner, J. A., MALACHOWSKI, N., Sunshine, P. 1980; 66 (6): 925-927

    Abstract

    Of 40 survivors of necrotizing enterocolitis 19 were completely normal children at the time of follow-up, one to three years later. Among the other 21 children, only six had moderate to severe neurologic impairment, representing 15% of all survivors. Despite the fact that intestinal injury is the main feature of the neonatal disease, only four children were symptomatic from gastrointestinal sequelae, and none of these suffered failure to thrive. Thus, 81% (17) of the children with late morbidity had problems unrelated to the gastrointestinal tract. The nongastrointestinal morbidity was associated with prematurity and the degree of perinatal stress.

    View details for Web of Science ID A1980KU96100021

    View details for PubMedID 7454483

  • USE OF THE CONJUGATED POLYENE FATTY-ACID, PARINARIC ACID, IN ASSAYING FATTY-ACIDS IN SERUM OR PLASMA CLINICAL CHEMISTRY Berde, C. B., Kerner, J. A., Johnson, J. D. 1980; 26 (8): 1173-1177

    Abstract

    We describe a method for rapidly assaying fatty acid concentrations in plasma or serum. This method is particularly appropriate for monitoring increased concentrations of fatty acids that may be present during intravenous lipid infusion, especially in neonates. Binding cisparinaric acid (9, 11, 13, 15-cis-trans-trans-cis-octadecatetraenoic acid) to albumin shifts the absorption spectrum of the acid. If fatty acids are present in serum, they will compete with parinaric acid for binding, changing the extent of this absorption shift. The measurement requires a spectrophotometer, 30 microL of serum or plasma, and knowledge of the sample's albumin concentration.

    View details for Web of Science ID A1980KB48600011

    View details for PubMedID 7389088

  • USE OF SKINFOLD THICKNESS (SFT) AND MID UPPER-ARM CIRCUMFERENCE (MAC) IN THE NUTRITIONAL ASSESSMENT OF LOW-BIRTH-WEIGHT INFANTS Kerner, J. A., HATTNER, J. A., Sunshine, P. INT PEDIATRIC RESEARCH FOUNDATION, INC. 1979: 401–

    View details for Web of Science ID A1979GS68100453

  • PARENTERAL-ALIMENTATION SEMINARS IN PERINATOLOGY Kerner, J. A., Sunshine, P. 1979; 3 (4): 417-434

    View details for Web of Science ID A1979HR74500011

    View details for PubMedID 120008

  • IMPACT OF GRIEF - RETROSPECTIVE STUDY OF FAMILY FUNCTION FOLLOWING LOSS OF A CHILD WITH CYSTIC-FIBROSIS JOURNAL OF CHRONIC DISEASES Kerner, J., Harvey, B., LEWISTON, N. 1979; 32 (3): 221-225

    View details for Web of Science ID A1979GT31000004

    View details for PubMedID 429466

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