Child psychosis due to hypothyroidism

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Responsiveness of IGF-I and IGFBP-3 to therapeutic intervention in children and adolescents with Crohn's disease

OBJECTIVE

Abnormal linear growth is common in childhood and adolescent Crohn's disease. We have studied the concentrations of the inflammatory marker CRP and of serum IGF-I and IGFBP-3 in patients with active Crohn's disease and have assessed the changes in these parameters during therapeutic intervention with enteral nutrition or intestinal resection.

DESIGN

Children and adolescents attending the inflammatory bowel disease clinic at our hospital underwent treatment either with enteral nutrition (Study A) or intestinal resection (Study B). These are two separate studies and the results cannot be compared. Serum concentrations of CRP, IGF-I and IGFBP-3 were determined at 0, 2, 8 and 16 weeks after start of enteral nutrition and in addition to height velocity, at 0 and 6 months after intestinal resection.

SUBJECTS

Study A: 14 patients, 9 male, 5 female, median age 12.5 years (range 7.0-17.2), puberty stage 1 (n = 13), stage 3 (n = 1). All had active Crohn's disease. Study B: 9 patients, 7 male, 2 female, median age 13.5 years (range 7.8-16.5), puberty stage 1 (n = 5), stages 2-4 (n = 4). All had Crohn's disease resistant to medical therapy.

METHODS

Crohn's disease was confirmed radiologically, endoscopically and histologically. Disease activity was scored using the Lloyd Still index (LSI). Study A: nutritional support was with a polymeric, casein-based formula feed AL 110. Study B: surgical procedures were small bowel resection (n = 2), right hemicolectomy (n = 5), subtotal colectomy (n = 2).

MEASUREMENTS

Study A: weight SDS, CRP, IGF-1 and IGFBP-3 were measured at 0, 2, 8, 16 weeks after start of enteral feeding. Study B: height velocity, CRP, IGF-I and IGFBP-3 were measured 0, 6 months after intestinal resection.

STATISTICAL ANALYSIS

Medians and ranges were used. Significance of changes was calculated using the Wilcoxon rank test for the analysis of paired data.

RESULTS

Study A: median LSI before treatment was 39 and increased after 8 weeks of enteral nutrition to 60 (P < 0.05). Weight SDS increased at 8 and 16 weeks (P < 0.05) compared to pretreatment. CRP was elevated at 0 weeks, falling during treatment. Median (range) values (normal < 5 mg/l) at 0 at 2, 8, 16 weeks were 53 mg/l (15-150), 8 mg/l (5-25), 7 mg/l (5-83) and 14 mg/l (5-39), all P < 0.001 compared with pretreatment. Median IGF-I-values increased during treatment. Median (range) values at 0, 2, 8, 16 weeks (all P < 0.005) compared to pretreatment, median (range) values at 0, 2, 8, 16 weeks were 78 micrograms/l (50-204), 131 micrograms/l (73-251), 119 micrograms/l (77-291) and 133 micrograms/l (67-497), all P < 0.005 compared to pre-treatment. IGFBP-3 levels increased during treatment. Median (range) values at 0, 2, 8, 16 weeks were 2.4 mg/l (1.4-3.1), 2.9 mg/l (1.8-4.6), 3.0 mg/l, 3.2 mg/l (1.8-4.5), all P < 0.01 compared to pretreatment. Study B: height velocity increased during 6 months after surgery. Median (range) values; 3.3 cm/year (0-8.3) before surgery, 8.4 cm/year (2-12.6) 6 months post-surgery, P < 0.01. Median (range) CRP values fell from 45 mg/l (5-150) to 8 mg/l (5-31) and IGF-I-values increased from 163 micrograms/l (64-286) to 226 micrograms/l (71-391). These changes were not statistically significant. IGFBP-3 values did not change.

CONCLUSION

The IGF system, as shown by serum IGF-I and IGFBP-3, is responsive to therapeutic intervention in active Crohn's disease. It is likely that a combination of decreased inflammatory activity and improved nutrition contributes to these changes.

Childhood Crohn's disease and the efficacy of enteral diets

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

Randomised controlled trial of eutectic mixture of local anaesthetics cream for venepuncture in healthy preterm infants

AIM

To assess the safety and efficacy of EMLA cream (eutectic mixture of local anaesthetics) used to induce surface anaesthesia for venepuncture in healthy preterm infants.

METHODS

Nineteen infants, median gestational age 31 weeks (range 26-33 weeks) were assessed in a randomised, double blind, placebo controlled, cross-over trial. Changes in physiological variables (heart rate, blood pressure, oxygen saturation) and behavioural responses (neonatal facial coding system score, crying time) before and after venepuncture with EMLA cream were compared with those obtained with a placebo cream to assess efficacy. Toxicity was assessed by comparing methaemoglobin concentrations at 1 hour and 8 hours after application.

RESULTS

There was no significant difference in efficacy between EMLA and placebo creams in physiological and behavioural responses. There was no significant difference in methaemoglobin concentrations one hour after the cream had been applied. At eight hours, however, concentrations were significantly higher after EMLA than placebo (p = 0.016). There was no evidence of clinical toxicity.

CONCLUSION

This study does not support the routine use of EMLA for venepuncture in healthy preterm infants.

T-type Ca2+ current properties are not modified by Ca2+ channel beta subunit depletion in nodosus ganglion neurons

At the molecular level, our knowledge of the low voltage-activated Ca2+ channel (T-type) has made little progress. Using an antisense strategy, we investigated the possibility that the T-type channels have a structure similar to high voltage-activated Ca2+ channels. It is assumed that high voltage-activated channels are made of at least three components: a pore forming alpha1 subunit combined with a cytoplasmic modulatory beta subunit and a primarily extracellular alpha2delta subunit. We have examined the effect of transfecting cranial primary sensory neurons with generic anti-beta antisense oligonucleotides. We show that in this cell type, blocking expression of all known beta gene products does not affect T-type current, although it greatly decreases the current amplitude of high voltage-activated channels and modifies their voltage dependence. This suggests that beta subunits are likely not constitutive of T-type Ca2+ channels in this cell type.

Computed tomography in chronic inflammatory bowel disease

In children with complicated inflammatory bowel disease, conventional ultrasound imaging may not define the extent of extraluminal disease and the involvement of other viscera. Three children with chronic inflammatory bowel disease are presented, where computed tomography was well tolerated and provided valuable information on extraluminal disease, involvement of other organs, and the state of the bowel wall and mesentery. In children in whom ultrasound examination is inconclusive or limited by gas or tenderness, computed tomography can provide important information that may determine clinical management.

Endoscopic assessment of the colonic response to corticosteroids in children with ulcerative colitis

Twenty children with active ulcerative colitis were assessed before and after 8 weeks of medical therapy with 5-aminosalicylic acid (5-ASA) derivatives and corticosteroids. Local therapy was given for distal disease (seven cases); other disease was treated with oral prednisolone (1-2 mg/kg/day, maximum 40 mg). Eighteen of the children showed a clinical improvement on therapy, and complete remission of clinical disease activity by 8 weeks was seen in 17 (85%). C-reactive protein was elevated initially in 10 of 20 children and returned to normal posttreatment in all but one. Reassessment of the colon after treatment showed an improved endoscopic appearance in 15 and complete remission in eight (40%). Histological improvement was seen in 13, with full remission in only three (15%). In conclusion, remission of clinical disease activity by corticosteroid therapy in ulcerative colitis may not be accompanied by endoscopic remission and uncommonly by mucosal healing. This finding may be important prognostically because of the risk of dysplasia in long-standing persistent mucosal inflammation.

Distribution of alpha 1A, alpha 1B and alpha 1E voltage-dependent calcium channel subunits in the human hippocampus and parahippocampal gyrus

The distribution of voltage-dependent calcium channel subunits in the central nervous system may provide information about the function of these channels. The present study examined the distribution of three alpha-1 subunits, alpha 1A, alpha 1B and alpha 1E, in the normal human hippocampal formation and parahippocampal gyrus using the techniques of in situ hybridization and immunocytochemistry. All three subunit mRNAs appeared to be similarly localized, with high levels of expression in the dentate granule and CA pyramidal layer. At the protein level, alpha 1A, alpha 1B and alpha 1E subunits were differentially localized. In general, alpha 1A-immunoreactivity was most intense in cell bodies and dendritic processes, including dentate granule cells, CA3 pyramidal cells and entorhinal cortex pre-alpha and pri-alpha cells. The alpha 1B antibody exhibited relatively weak staining of cell bodies but stronger staining of neuropil, especially in certain regions of high synaptic density such as the polymorphic layer of the dentate gyrus and the stratum lucidum and radiatum of the CA regions. The alpha 1E staining pattern shared features in common with both alpha 1A and alpha 1B, with strong immunoreactivity in dentate granule, CA3 pyramidal and entorhinal cortex pri-alpha cells, as well as staining of the CA3 stratum lucidum. These findings suggest regions in which particular subunits may be involved in synaptic communication. For example, comparison of alpha 1B and alpha 1E staining in the CA3 stratum lucidum with calbindin-immuno-reactivity suggested that these two calcium channels subunits may be localized presynaptically in mossy fibre terminals and therefore may be involved in neurotransmitter release from these terminals.

The expression of neuronal voltage-dependent calcium channels in human cerebellum

Little is known about the comparative distribution of voltage-dependent calcium channel subtypes in normal human brain. Previous studies in experimental animals have predominantly focused on the regional expression of single alpha 1 genes. We describe the preparation of riboprobes and antisera specific for human alpha 1A, alpha 1B and alpha 1E subunits and their application in comprehensive mapping studies of the human cerebellum. Within the cerebellar cortex, these pore forming proteins were found to have differential localisations when examined in adjacent sections. The alpha 1A and alpha 1B subunits broadly colocalised and were both present, though at apparently different levels, in the molecular, Purkinje and granule cell layers whilst alpha 1E was predominantly expressed in Purkinje cells. In the dentate nucleus, an area which has received little attention in previous studies, alpha 1A was highly expressed in regions in which Purkinje cell nerve terminals form synapses with deep cerebellar neurones.

The role of small bowel radiology in the diagnosis and management of Crohn's disease

A total of 50 children with Crohn's disease were examined by barium follow-through and colonoscopy with ileoscopy, to determine the value of small bowel radiology. Of these children, 40 (80%) had evidence of small bowel Crohn's disease on ileoscopy and/or barium follow-through. Twenty-two (44%) had disease confined to the terminal ileum. Radiology diagnosed disease proximal to the terminal ileum in 18 cases (36%), including 5 children in whom the terminal ileum was normal. Ileoscopy was not possible in nine patients (18%), six of whom had small bowel disease on barium follow-through. Colonic involvement, demonstrated in 34 (68%), was the sole site of disease in 6 (12%). Fifteen (30%) children had surgery, which in six (12%) was determined by the radiological findings of complicated small bowel disease. As the terminal ileum may be uninvolved in the presence of proximal ileal disease, normal ileoscopy does not exclude small bowel Crohn's disease. Small bowel radiology remains necessary to assess the full extent of Crohn's disease in children.

Lipocortin-1 autoantibody concentration in children with inflammatory bowel disease

BACKGROUND

Corticosteroids are widely used to treat children with inflammatory bowel disease although the response is variable, side-effects are common, and many patients develop a partial or complete steroid resistance. The mechanism underlying these phenomena are unclear. Corticosteroids mediate some of their actions through lipocortin-1, and the induction of autoantibodies to lipocortin has been proposed as a possible mechanism by which steroid efficacy is suboptimal in vivo.

PATIENTS AND METHODS

We have measured serum lipocortin-1 antibody concentration by ELISA in 38 children with Crohn's disease, 12 with ulcerative colitis and in 15 controls.

RESULTS

IgG and IgA anti-lipocortin-1 antibody levels were higher in the Crohn's group than in the ulcerative colitis or control groups. Elevated concentrations did not relate to disease activity, history of steroid therapy or steroid-responsiveness. Lipocortin IgM antibody status was similar in all three groups.

CONCLUSION

It is therefore unlikely that serum antibodies to lipocortin-1 have a role in the development of steroid-resistance in children with inflammatory bowel disease.

Indications for investigation of chronic gastrointestinal symptoms

Simple routine blood tests (full blood count, platelet count, erythrocyte sedimentation rate, C reactive protein, and serum albumin) may select children with chronic gastrointestinal symptoms who require endoscopic assessment and are thus an important aid in the prediction of endoscopic status. When all of the results are normal then chronic inflammatory bowel disease is an unlikely diagnosis.

Polymeric nutrition as the primary therapy in children with small bowel Crohn's disease

BACKGROUND

Recent studies in adults have shown that polymeric (whole protein) diets are as effective as semi-elemental and elemental formulae for the induction of remission in small bowel Crohn's disease. Whole protein diets are more palatable and cheaper. There have been no studies confirming efficacy in children.

PATIENTS AND METHODS

We report our experience with seven children with active small bowel Crohn's disease given a casein-based, polymeric feed rich in TGF-beta 2 (Specific Polymeric Diet; Nestle-Clintec; Vevey, Switzerland) as complete nutrition for 8 weeks.

RESULTS

Initial and follow-up assessments were performed. All children showed a significant improvement in disease activity, with C-reactive protein returning to normal, an increase in serum albumin and a good weight gain. Initial and follow-up ileal biopsies were assessed and showed reduced mucosal inflammation in six of seven children, with complete healing in two.

CONCLUSION

In an uncontrolled descriptive study we have shown that a polymeric (whole protein) diet is a therapeutic option for small bowel Crohn's disease in children. By comprehensive follow-up we have demonstrated clinical and biochemical remission, with an improved endoscopic appearance and a reduction of mucosal inflammation in the terminal ileum.

Heparin-induced thrombocytopenia in children

Two children aged 3 months and 14 years developed heparin-induced thrombocytopenia whilst receiving heparin. The clinical course was complicated by renal vein thrombosis in the 3-month-old infant and subcutaneous haemorrhage requiring resuscitation in the 14-year-old child. Anticoagulant therapy was discontinued immediately in the 3-month-old child. In the 14-year-old child, because of the need for continued anticoagulation therapy, low molecular weight heparin was used until warfarin could be substituted.

Early thrombocytopenia in HIV infection

Three children aged between 7 months and 2 years developed thrombocytopenia as an early feature of HIV infection. The prevalence of this condition, possible pathogenesis, and options for treatment are discussed. HIV testing should be considered in the investigation of a child with thrombocytopenia.

Recovery of antibody production after HIV infection in 'common' variable hypogammaglobulinaemia

A patient with a history of at least 10 years 'common' variable hypogammaglobulinaemia seroconverted to HIV-1 and became hypergammaglobulinaemic. The HIV isolated from his blood did not polyclonally activate B cells from normal donors. The mechanism of the hypergammaglobulinaemia is discussed.

Assessment of responses of normal human B lymphocytes to different isolates of human immunodeficiency virus: role of normal donor and of cell line used to prepare viral isolate

The effect of different HIV-1 isolates on normal human B lymphocyte function has been studied in vitro. Production of IgM and IgG was measured by ELISA using a "standard" non-T preparation of B cells depleted of macrophages and T cells (but not of low-density accessory cells, LDC). Only one (H9/CBL-4) of five different isolates induced polyclonal production of immunoglobulin. Apart from intrinsic differences between isolates, important inherent variables were shown to affect the response. One was the mix of cell types in the responding preparation of B cells. This was tested by examining the effects of HIV-1 isolates independently on the accessory function of LDC and on B cell function when the LDC were removed. Isolate H9/HTLV-IIIRf was nonstimulatory on a B cell preparation containing LDC and suppressive on LDC accessory function yet could enhance function of B cells when the LDC were depleted. Another variable was the donor of the normal B cells. The B cell response was consistent with each donor but varied greatly with different donors. Thus, no single explanation emerges for the hypergammaglobulinemia in some adult AIDS patients and for the hypogammaglobulinemia in some pediatric cases. Additionally, the cell lines used to propagate the virus particularly affected the assay of B cells depleted of LDC. Uninfected supernatants had different effects on the B cell function, and these host cell effects (perhaps by release of cytokines or other mediators) may be exacerbated in infected cell lines. Our data show the complexity of the abnormal B cell function in AIDS.

Role of retroviruses in acquired hypogammaglobulinaemia

Mononuclear cells were obtained from 42 patients with 'common variable' hypogammaglobulinaemia (CVH) and co-cultured with various cell lines in an attempt to isolate retroviruses. Cultures from only two patients showed evidence of a viral infection, although the virus could not be isolated and characterized in either. Despite the previous isolation of HIV's from two other CVH patients, this data suggests that similar viruses are not etiologically involved in the majority of patients.

Type A behavior as a function of reversed computer activity

Four consecutive trials involving a computer activity were presented to 110 students categorized as Type A+, A-, B+, or B- personalities. A fifth trial presented the same computer activity with controls in reversed position, and Type A groups had more difficulty than Type B groups.

Isolation of retroviruses from two patients with "common variable" hypogammaglobulinaemia

Retroviruses related to human T-lymphotropic virus III/lymphadenopathy-associated virus (HTLV-III/LAV) have been isolated from peripheral-blood mononuclear cells of two patients with "common variable" hypogammaglobulinaemia who were being treated with intravenous gammaglobulin. One has had three different opportunistic infections. In both patients hypogammaglobulinaemia developed within 6 years of a longlasting undiagnosed viral-like illness in adolescence, and it is suggested that the virus causing that illness also gave rise to the hypogammaglobulinaemia. However, iatrogenic infection from intravenous gammaglobulin cannot be ruled out.