Gastrostomy feeding versus oral feeding alone for children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) can be significantly disabled in terms of their ability to suck, chew and swallow. This can lead to significant impairment in feeding ability and, eventually, to under-nutrition. It can also result in aspiration of food into the lungs. Feeding time may be considerably increased and, instead of being an enjoyable experience, mealtimes may be distressing for both the child and carer. Increasingly for children unable to maintain a normal nutritional state feeding by mouth, gastrostomy or jejunostomy tubes are being used to provide the digestive system with nutrients. A gastrostomy tube is a feeding tube inserted surgically through the abdominal wall directly into the stomach. A jejunostomy feeding tube is inserted into the jejunum, part of the small intestine, either directly or via a previous gastrostomy. Although gastrostomy or jejunostomy placement may greatly facilitate feeding of children with CP, many carers find it very difficult to accept this intervention emotionally. The treatment is also relatively costly. For all of these reasons, its effectiveness requires assessment.

OBJECTIVES

To assess the effects of nutritional supplementation given via gastrostomy or jejunostomy in children with feeding difficulties due to cerebral palsy.

SEARCH STRATEGY

We searched the Cochrane Library's register of controlled trials (CENTRAL) up to Issue 4, 2003, MEDLINE 1977 - December 2003, EMBASE 1980 - December 2003, CINAHL 1982 - December 2003, LILACS 1980 - end 2003, ASLIB 1983 - 2003 and Dissertation Abstracts 1980 - 2003.

SELECTION CRITERIA

Only randomised controlled trials which compared delivery of nutrition via a gastrostomy or jejunostomy tube compared with oral feeding alone for children up to the age of 16 were considered for this review.

DATA COLLECTION AND ANALYSIS

Selection of trials, data extraction and assessment of trial quality were undertaken independently by two reviewers.

MAIN RESULTS

No trials were identified that met the inclusion criteria for this review.

REVIEWERS' CONCLUSIONS

On the basis of this systematic review, considerable uncertainty about the effects of gastrostomy for children with cerebral palsy remains. A well designed and conducted randomised controlled trial should be undertaken to resolve the current uncertainties about medical management for children with cerebral palsy and physical difficulties in eating.

Low serum concentrations of insulin-like growth factor-I in children with active Crohn disease: effect of enteral nutritional support and glutamine supplementation

Dept. of Paediatric Gastroenterology, Central Manchester Hospital, Manchester, UK.

Contributions of Time Dependent and Cyclic Crack Growth to the Crack Growth Behavior of Non Strain-Crystallizing Elastomers

Engineering components are observed to fail more rapidly under cyclic loading than under static loading. This reflects features of the underlying crack growth behavior. This behavior is characterized by the relation between the tearing energy, T, and the crack growth per cycle, dc/dn. The increment of crack growth during each cycle is shown here to result from the sum of time dependent and cyclic crack growth components. The time dependent component represents the crack growth behavior that would be present in a conventional constant T crack growth test. Under repeated stressing additional crack growth, termed the cyclic crack growth component, occurs. For a non-crystallizing elastomer, significant effects of frequency have been found on the cyclic crack growth behavior, reflecting the presence of this cyclic element of crack growth. The cyclic crack growth behavior over a wide range of frequencies was investigated for unfilled and swollen SBR materials. The time dependent crack growth component was calculated from constant T crack growth tests and the cyclic contribution derived from comparison with the observed cyclic growth. It is shown that decreasing the frequency or increasing the maximum tearing energy during a cycle results in the cyclic crack growth behavior being dominated by time dependent crack growth. Conversely at high frequency and at low tearing energy, cyclic crack growth is dominated by the cyclic crack growth component. A large effect of frequency on cyclic crack growth behavior was observed for highly swollen SBR. The cyclic crack growth behavior was dominated by the time dependent crack growth component over the entire range of tearing energy and/or crack growth rate. The origin of the cyclic component may be the formation/melting of quasi crystals at the crack tip, which is absent at fast crack growth rates in the unswollen SBR and is absent at all rates in the swollen SBR.

Chlamydial infection and unplanned pregnancy in women with ready access to health care

OBJECTIVE

To apply urine-based ligase chain reaction for Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae) detection and standard urine-based pregnancy testing for Navy-enlisted women, and to compare the prevalence and epidemiologic correlates of these adverse reproductive outcomes.

METHODS

Participants were surveyed and urine was collected for pregnancy testing using standard laboratory methods and detection of C. trachomatis and N. gonorrhoeae infection by ligase chain reaction. Self-administered surveys facilitated collection of demographics, sexual behavior, including contraceptive use, sexual partners, sexually transmitted disease, and pregnancy history.

RESULTS

Among 299 of 314 participants, the prevalence of chlamydial infection was 4.7% and of pregnancy was 9.7%, with 48.3% of the pregnancies unplanned. Chlamydia trachomatis infection was univariately associated with having a new sex partner within the last 6 months, more sexual partners, single marital status, condom use, drinking until passing out or vomiting in the past 30 days (alcohol misuse), and current pregnancy. Unplanned pregnancy was univariately associated with young age, single marital status, inconsistent condom use, having a new sex partner within the last 6 months, and more recent sexual partners. Among the pregnant women, four (13.8%) were infected with C. trachomatis.

CONCLUSION

The high rates of chlamydial infection and unplanned pregnancy found in this population of employed young women with ready access to health care and health education underscore the challenge of enhancing reproductive health via compliance with effective contraceptive and sexually transmitted disease prevention methods. This is a challenge that remains unmet.

Neuroprotection mediated by glutamate carboxypeptidase II (NAALADase) inhibition requires TGF-beta

Inhibition of glutamate carboxypeptidase (GCP) II (EC 3.4.17.21), also termed N-acetylated alpha-linked acidic dipeptidase (NAALADase), has been shown to protect against ischemic injury presumably via decreasing glutamate and increasing N-acetyl-aspartyl-glutamate (NAAG). NAAG is a potent and selective mGlu3 receptor agonist. Activation of glial mGlu3 receptors has been shown to protect against NMDA toxicity by releasing transforming growth factors, TGF-betas. We hypothesized that GCP II inhibition could be neuroprotective also via TGF-betas, due to increased NAAG. To verify this, Enzyme-Linked Immunosorbent Assays (ELISAs) were performed on media from both control and ischemic cultures treated with the GCP II inhibitor, 2-(phosphonomethyl)-pentanedioic acid (2-PMPA). We found that 2-PMPA attenuated ischemia-induced declines in TGF-beta. To further assess the role of TGF-betas in 2-PMPA-mediated neuroprotection, a neutralizing antibody to TGF-beta (TGF-beta Ab) was used. In both in vitro and in vivo models of cerebral ischemia, TGF-beta Ab reversed the neuroprotection by 2-PMPA. Antibodies to other growth factors had no effect. Data suggests that neuroprotection by GCP II inhibition may be partially mediated by promoting TGF-beta release.

Neuroprotection afforded by NAAG and NAALADase inhibition requires glial cells and metabotropic glutamate receptor activation

N-acetylated-alpha-linked-acidic-dipeptidase (NAALADase or glutamate carboxypeptidase II) cleaves the neuropeptide N-acetyl-aspartyl-glutamate (NAAG) to glutamate and N-acetyl-aspartate (NAA). Previously, NAAG and 2-(phosphonomethyl)-pentanedioic acid (2-PMPA), a potent and selective NAALADase inhibitor, were found to be neuroprotective in neuronal/glial co-cultures and in animals following transient middle cerebral artery occlusion. In this report, we examined the involvement of glial cells and metabotropic glutamate (mGlu) receptors in neuroprotection mediated by NAAG and 2-PMPA in an in vitro model of metabolic inhibition. Neuroprotection of neuronal/glial co-cultures by both NAAG and 2-PMPA, against metabolic inhibition, was significantly higher than neuroprotection in the absence of glia. Similarly, (2S,2'R,3'R)-2-(2',3'-dicarboxycyclopropyl)glycine (DCG IV), a selective group II mGlu receptor agonist, was less neuroprotective in the absence of glia. Selective group II mGlu receptor antagonists and (S)-alpha-methyl-4-carboxyphenylglycine (MCPG), a non-selective mGlu receptor antagonist, reduced the protection afforded by both NAAG and 2-PMPA when using neuronal/glial co-cultures. In contrast, groups I and III mGlu receptor antagonists did not affect NAAG or 2-PMPA neuroprotection. These results underscore the critical involvement of glia and group II mGlu receptors in NAAG and 2-PMPA-mediated neuroprotection.

Quality of life in inflammatory bowel disease: a cross-cultural comparison of English and Canadian children

BACKGROUND

Any disease and its treatment has an important impact on health-related quality of life for affected individuals. There have been few previous studies on the quality of life for children with inflammatory bowel disease (IBD).

METHODS

A cross-cultural comparison was performed to determine whether the concerns of children with IBD in the United Kingdom are ranked similarly to those of children with IBD in Canada. An item reduction questionnaire, developed from interviews with Canadian children with IBD, was scored by 53 British children with IBD for importance and frequency, as a questionnaire had been scored previously by 117 Canadian children.

RESULTS

There was a significant correlation between the mean scores (r = 0.831, P < 0.001) and ranks (r = 0.801, P < 0.001) for the 96 questions, and 43 of the 50 highest-ranking concerns corresponded for both populations. Confidence interval analysis showed a significant difference between the mean values for 21 of the 96 items; 20 of these 21 were ranked higher in the United Kingdom than they had been in Canada, suggesting that the frequency and/or degree of concern was greater for the British children with IBD.

CONCLUSIONS

Health-related concerns of British children with Crohn disease and ulcerative colitis correlate closely with those of Canadian children with those diseases. Further studies are needed to determine the sensitivity of individual questions, the most appropriate wording of these questions, and the optimal length for a proposed instrument to assess quality of life in children with IBD.

High-Speed Fracture of Elastomers: Part I

The fracture behavior of elastomers has been studied in the high speed region immediately above a transition region where a change in the nature of the fracture surface occurs. A video camera operating at up to 6000 frames/s was used to follow the progress of failure. The test pieces employed were of the pure shear or tensile strip (with edge crack) varieties employed in earlier tear studies; in order to attain the high energy release rates required they were usually pre-strained and then cut to initiate the crack growth. The materials studied included various strain crystallizing and non-crystallizing elastomers, with different glass-transition temperatures, including natural rubber in normal, cis—trans isomerized or partially-epoxidized forms, a butadiene—acrylonitrile copolymer, a styrene—butadiene copolymer and ethylene—propylene co- and ter-polymers. The use of a fracture mechanics approach based on the strain energy release rate enables results for different test piece geometries to be brought into agreement in the region above the transition. Fracture energies in this region correlate well with viscoelastic properties, but the potential for strain crystallization to strengthen is not exhibited. This is presumably because at the high failure rates involved, the loading time at the crack tip is insufficient to allow significant crystallization to occur. The correlation with viscoelastic behavior suggests that the material around the propagating tip is still essentially rubbery in its behavior, although the fracture surfaces in the high speed region have a smooth, “glassy” appearance. Further evidence of this is provided by effects of crosslink type and density and filler type and loading, where again the effects seen in the high speed failure region parallel those observed below the transition. An effect of thickness on fracture properties appears to be absent in the high speed region, by contrast with behavior at lower energies and at the transition itself. This supports the view that the fracture surface roughness that develops in the lower energy region is due to the initiation of a process akin to cavitation by through-the-thickness stresses near the crack tip. The transition is found to vary with pressure and temperature, as well as thickness, in a way that does not correlate with viscoelastic changes but may reflect changes in the through-the-thickness stresses. The existence of a limiting crack speed is illustrated and discussed. Fracture under large biaxial deformations, where higher crack speeds are observed, will be discussed in Part II.

N-Acetylated alpha-linked acidic dipeptidase converts N-acetylaspartylglutamate from a neuroprotectant to a neurotoxin

We previously reported that inhibition of the brain enzyme N-acetylated alpha-linked acidic dipeptidase (NAALADase; glutamate carboxypeptidase II) robustly protects cortical neurons from ischemic injury. Since NAALADase hydrolyzes N-acetylaspartylglutamate (NAAG) to glutamate we hypothesized that inhibiting NAALADase would both decrease glutamate and increase NAAG. Increasing NAAG is potentially important because NAAG is a metabotropic glutamate receptor agonist and an N-methyl-D-aspartate (NMDA) partial antagonist, both of which have previously been shown to be neuroprotective. To understand the likely effects of endogenous NAAG in the central nervous system, we have now investigated the activity of NAAG in primary cortical cultures while manipulating NAALADase activity. Under hydrolyzing conditions, when NAALADase was active, NAAG had toxic effects that were blocked by NMDA and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)/kainate receptor antagonists and by NAALADase inhibition. NAAG's toxic effects were presumably due to the liberation of glutamate. Under nonhydrolyzing conditions, when NAALADase was inhibited, NAAG demonstrated neuroprotective effects against both NMDA toxicity and metabolic inhibition. In the case of NMDA-induced toxicity, NAAG provided neuroprotection through its partial antagonist activity at the NMDA receptor. In the case of metabolic inhibition, NAAG had an additional neuroprotective effect mediated through its agonist properties at the type II metabotropic glutamate receptor. These results indicate that NAAG might play an important role in the central nervous system, under certain pathological conditions, as a neurotoxin or as a neuroprotectant, depending on the activity of NAALADase.

Technical aspects of feeding the disabled child

Children with neurological impairment frequently have difficulties in consuming sufficient energy and other nutrients to maintain adequate nutritional status. Under-nutrition is a significant contributory factor to growth failure. Eating may be distressing and time-consuming for the child and carer. Aspiration of feeds is common and may predispose to chronic chest infections. Gastro-oesophageal reflux is also common and may contribute to significant morbidity. This paper discusses some of the issues involved in the nutritional management of neurologically impaired children.

Breast cancer education program based in Asian grocery stores

Culturally and linguistically compatible university students were trained as community health educators to provide breast cancer education and screening information to shoppers at Asian grocery stores. Information about early detection of breast cancer was shared with 8,877 women, who reported speaking 40 different languages. Baseline surveys were completed by 1,202 women; 779 took part in the follow-up survey. The survey questions assessed baseline knowledge, attitudes, and screening behaviors regarding breast cancer, tested the efficacy of the intervention, and sought barriers to accessing screening services. Screening adherence at baseline was low, but reported screening compliance had increased by follow-up. This study confirms the cost-effectiveness of student health educators and Asian grocery store sites as venues to reach the diverse age, ethnic, and socioeconomic segments of the Asian community, while demonstrating the community's receptiveness to the dissemination of health information and introducing bilingual students to health education and research careers.

Black cosmetologists promoting health program: pilot study outcomes

BACKGROUND

African Americans suffer a disproportionate burden of illness and premature mortality.

METHODS

A health education program delivered via cosmetologists was pilot tested as a supplement to other programs seeking to reach this community with information designed to remedy this inequality. Eight cosmetologists were randomized to either an active or a passive educational intervention arm, with the active arm (experimental arm) focused on breast cancer early detection.

RESULTS

Both cosmetologists and clients found this an acceptable intervention. Nearly all women in the study demonstrated that they had heard the mainstream messages about the value of breast cancer early detection, but a considerable proportion appeared not to realize breast cancer's high level of morbidity and mortality within their own community.

CONCLUSION

The results suggest this approach is worthy of further evaluation.

Double-blind randomized controlled trial of glutamine-enriched polymeric diet in the treatment of active Crohn's disease

BACKGROUND

Glutamine is traditionally considered a nonessential amino acid but may be conditionally essential in patients with catabolic conditions. Glutamine-supplemented foods in these patients have been shown to prevent deterioration of gut permeability, protect against the development of intestinal mucosal atrophy, and improve nitrogen balance. Animal models of inflammatory bowel disease suggest that glutamine-enriched enteral diets may lead to less severe intestinal damage, less weight loss, improved nitrogen balance, and reduced disease activity. The purpose of the current study was to compare the efficacy of a glutamine-enriched polymeric diet with a standard low-glutamine polymeric diet in the treatment of active Crohn's disease.

METHODS

Eighteen children with active Crohn's disease were randomly assigned to receive a 4-week course of either a standard polymeric diet with a low glutamine content (4% of amino acid composition; group S) or a glutamine-enriched polymeric diet (42% of amino acid composition; Group G). The two diets were isocaloric and isonitrogenous with an identical essential amino acid profile. Remission rates were analysed on an intent-to-treat basis. Changes in clinical and laboratory parameters of disease activity were also compared after 4 weeks of nutritional treatment.

RESULTS

Two of the children, both in group G, were withdrawn from the trial because of nontolerance of the diet. There was no difference between the two groups in proportion of patients achieving remission (intent-to-treat basis): 5 (55.5%) of 9 in group S versus 4 (44.4%) of 9 in group G (p = 0.5). Improvement in mean paediatric Crohn's disease activity index (PCDAI) was significantly more in group S (p = 0.002) but changes in orosomucoid level, platelet count, and weight were not different between the groups.

CONCLUSIONS

The findings suggest that a glutamine-enriched polymeric diet offers no advantage over a standard low-glutamine polymeric diet in the treatment of active Crohn's disease. Rather, it appears to be less effective in improving PCDAI. The reported beneficial effects of glutamine seen in many catabolic states must be viewed with caution when extrapolating to the management of Crohn's disease.

Selective inhibition of NAALADase, which converts NAAG to glutamate, reduces ischemic brain injury

We describe here a new strategy for the treatment of stroke, through the inhibition of NAALADase (N-acetylated-alpha-linked-acidic dipeptidase), an enzyme responsible for the hydrolysis of the neuropeptide NAAG (N-acetyl-aspartyl-glutamate) to N-acetyl-aspartate and glutamate. We demonstrate that the newly described NAALADase inhibitor 2-PMPA (2-(phosphonomethyl)pentanedioic acid) robustly protects against ischemic injury in a neuronal culture model of stroke and in rats after transient middle cerebral artery occlusion. Consistent with inhibition of NAALADase, we show that 2-PMPA increases NAAG and attenuates the ischemia-induced rise in glutamate. Both effects could contribute to neuroprotection. These data indicate that NAALADase inhibition may have use in neurological disorders in which excessive excitatory amino acid transmission is pathogenic.

Indentation Tests on Elastomer Blocks

The problem of indentation hardness for elastomer blocks has been examined at two levels. Initially an examination of the geometric non-linearity was undertaken. It was observed that the empirical equations adopted by the various standards organizations to predict the stiffness relationships were not always applicable. It appears that the classical Hertz solution to the problem gives a better representation of the general behavior. A finite element approach was also adopted here to tackle the large displacement problem and the limitations of this approach have been discussed. This geometric problem is further complicated in practice by the effect of the finite thickness of the elastomer sheet. This problem has also been analyzed and a suitable general relationship proposed to account for the finite thickness effects. The second problem examined is how the effects of the non-linear elasticity of the material can be tackled. It is shown that the form of the elastic stored energy function at small strains influences the indentation behavior.

Toxicity induced by a polyglutamated folate analog is attenuated by NAALADase inhibition

Folates have been shown to be neurotoxic and convulsive. Endogenously, folates exist in the brain in a polyglutamated form with 1-7 terminal glutamates (approx. 1 microM). The brain enzyme N-acetylated alpha-linked acidic dipeptidase (NAALADase) has been shown to remove sequentially the gamma-linked glutamates from folic acid polyglutamates. We report that, at high concentrations (300 microM-30 mM), a folic acid hexaglutamate analog is dose-dependently toxic to dissociated rat cortical cultures and that this toxicity is reversed by 2-PMPA, a potent and selective NAALADase inhibitor. These data suggest a new mechanism for folic acid toxicity.