Drug treatment of eosinophilic oesophagitis

Eosinophilic oesophagitis is a clinicopathological disease characterized by oesophageal eosinophilia and gastrointestinal symptoms. Currently, the optimal treatment regimens remain unclear. The pathogenesis of eosinophilic oesophagitis appears to involve immune dysregulation, while acid reflux may have a secondary role; the mainstays in treatment are aimed principally at these dual processes. While a trial of a PPI is worthwhile it is likely that PPI therapy is treating concurrent acid reflux rather than true eosinophilic oesophagitis. Dietary elimination with elemental feed is safe but poorly tolerated. Swallowed topical steroids are the mainstay of commercially available therapies. Both fluticasone and budesonide have been proven to be beneficial both symptomatically and in reducing oesophageal eosinophil counts in the short and medium term. Basic studies have determined a role for IL-5 in oesophageal remodelling in eosinophilic esophagitis. Initial clinical studies have shown single or multiple infusions of monoclonal antibody to IL-5 to be well tolerated and to cause a long-term decrease in both peripheral and sputum eosinophil count in these eosinophil driven conditions. At present, swallowed corticosteroids are the mainstay of treatment for patients with eosinophilic oesophagitis in patients failing PPI therapy. Studies have been heterogenous in their diagnostic criteria for eosinophilic oesophagitis and in the definition of response to therapy, making comparison of results difficult.

Self-management strategies in overweight and obese Canadians with arthritis

OBJECTIVE

To estimate the prevalence of overweight and obese Canadians with arthritis and to describe their use of arthritis self-management strategies, as well as explore the factors associated with not engaging in any self-management strategies.

METHODS

Respondents to the 2009 Survey on Living with Chronic Diseases in Canada, a nationally representative sample of 4,565 Canadians age ≥20 years reporting health professional-diagnosed arthritis (including more than 100 rheumatic diseases and conditions), were asked about the impact of their arthritis and how it was managed. Among the overweight (body mass index [BMI] 25-29.9 kg/m(2)) and obese (BMI ≥30 kg/m(2)) individuals with arthritis (n = 2,869), the use of arthritis self-management strategies (i.e., exercise, weight control/loss, classes, and community-based programs) were analyzed. Log binomial regression analyses were used to examine factors associated with engaging in none versus any (≥1) of the 4 strategies.

RESULTS

More than one-quarter (27.4%) of Canadians with arthritis were obese and an additional 39.9% were overweight. The overweight and obese individuals with arthritis were mostly female (59.5%), age ≥45 years (89.7%), and reported postsecondary education (69.0%). While most reported engagement in at least 1 self-management strategy (84.9%), less than half (45.6%) engaged in both weight control/loss and exercise. Factors independently associated with not engaging in any self-management strategies included lower education, not taking medications for arthritis, and no clinical recommendations from a health professional.

CONCLUSION

Fewer than half of the overweight and obese Canadians with arthritis engaged in both weight control/loss and exercise. The provision of targeted clinical recommendations (particularly low in individuals that did not engage in any self-management strategies) may help to facilitate participation.

The development of national indicators for the surveillance of osteoporosis in Canada

INTRODUCTION

The Public Health Agency of Canada, in collaboration with bone health and osteoporosis experts from across Canada (n = 12), selected a core set of indicators for the public health surveillance of osteoporosis using a formal consensus process.

METHODS

A literature review identified candidate indicators that were subsequently categorized into an osteoporosis-specific indicator framework. A survey was then administered to obtain expert opinion on the indicators' public health importance. Indicators that scored less than 3 on a Likert scale of 1 (low) to 5 (high) were excluded from further consideration. Subsequently, a majority vote on the remaining indicators' level of public health importance was sought during a face-to-face meeting.

RESULTS

The literature yielded 111 indicators, and 88 were selected for further consideration via the survey. At the face-to-face meeting, more than half the experts considered 39 indicators to be important from the public health perspective.

CONCLUSION

This core set of indicators will serve to inform the development of new data sources and the integration, analysis and interpretation of existing data into surveillance products for the purpose of public health action.

Life with arthritis in Canada: a personal and public health challenge

"Arthritis" describes more than 100 conditions that affect the joints, the tissues that surround joints and other connective tissue. These conditions range from relatively mild forms of tendonitis and bursitis to systemic illnesses, such as rheumatoid arthritis. Life with arthritis in Canada: a personal and public health challenge presents the latest knowledge about arthritis in the Canadian population and its wide-ranging impact. It provides an overview of the impact of arthritis, and is designed to increase public awareness of the importance of prevention and timely management. Although progress has been made on interventions, arthritis remains common, disabling and costly. Increasing participation in physical activity and maintaining a healthy body weight may help to mitigate the effects of arthritis.

Population-based Canadian hip fracture rates with international comparisons

SUMMARY

We identified hospitalizations throughout Canada during 2000-2005 in which the most responsible diagnosis was a proximal femoral fracture. Use of the US fracture risk assessment tool (FRAX) would be inappropriate for Canada as it would overestimate fracture risk in Canadian women and older men.

INTRODUCTION

It is recommended that the WHO fracture risk assessment tool should be calibrated to the target population.

METHODS

We identified hospitalizations for women and men throughout Canada during the study period 2000-2005 in which the most responsible diagnosis was a proximal femoral fracture (147,982 hip fractures). Age-standardized hip fracture rates were compared between Canadian provinces, and national rates were compared with those reported for the USA and Germany.

RESULTS

There were relatively small differences in hip fracture rates between provinces, and most did not differ appreciably from the Canadian average. Hip fracture rates for women in Canada in 2001 were substantially lower than in the USA (population-weighted rate ratio 0.70) and were also lower than in Germany for 2004 (population-weighted rate ratio 0.74).

CONCLUSIONS

Overall hip fracture rates for Canadian women were found to be substantially lower than those for the USA and Germany. This study underscores the importance of assessing country-specific fracture patterns prior to adopting an existing FRAX tool.

Invasive filamentous fungal infections associated with renal transplant tourism

'Transplant tourism,' the practice of traveling abroad to acquire an organ, has emerged as an issue in kidney transplantation. We treated a patient who developed invasive aspergillosis of the allograft vascular anastomosis after receiving a kidney transplant in Pakistan, prompting us to review the literature of invasive mycoses among commercial organ transplant recipients. We reviewed all published cases of infections in solid organ transplant recipients who bought their organs abroad and analyzed these reports for invasive fungal infections. Including the new case reported here, 19 cases of invasive fungal infections post commercial kidney transplant occurring in 17 patients were analyzed. Infecting organisms were Aspergillus species (12/19; 63%), Zygomycetes (5/19; 26%), and other fungi (2/19; 5%). Invasive mold infections were present at the transplanted graft in 6/17 patients (35%) with graft loss or death in 13/17 (76%) of patients and overall mortality (10/17) 59%. Invasive fungal infections, frequently originating at the graft site, have emerged as a devastating complication of commercial renal transplant and are associated with high rates of graft loss and death.

The role of capsule endoscopy in small bowel Crohn's disease

Video capsule endoscopy is an invaluable tool for examining the small bowel. It is non-invasive and generally well tolerated, however its role in the assessment of the severity and extent of small bowel Crohn's disease has not, to date, been adequately evaluated.

METHODS

All capsule endoscopies performed over a two year period in a tertiary referral centre in subjects with known or suspected Crohn's disease were reviewed.

RESULTS

Twenty-six capsule endoscopy studies in total were included. These were performed in 15 cases of known Crohn's disease, 5 cases of suspected Crohn's disease, 3 cases of endoscopically diagnosed non-specific terminal ileal inflammation and finally 3 post colectomy cases of indeterminant being considered for IPAA formation. Ten patients known to have small bowel Crohn's disease were prospectively recruited; of 3 with normal small bowel follow through or CT exams, one had an abnormal capsule endoscopy. The other 7 patients had small bowel follow through or abdominal CT scans consistent with small bowel Crohn's disease; additional mucosal abnormalities were detected by capsule endoscopy in 6 cases with capsule retention in the stomach in one. Of 5 with colonic Crohn's disease normal small bowel imaging corresponded with normal capsule endoscopy in all but one. A diagnosis of Crohn's disease was made in 2 out of 5 cases of suspected Crohn's disease on the basis of the capsule endoscopy findings. Three patients with non-specific acute terminal ileal inflammation at ileocolonoscopy were confirmed to have ongoing inflammation. The capsule was retained in four subjects beyond 24 h.

CONCLUSION

Capsule endoscopy more accurately determines the severity and extent of the Crohn's disease in the small bowel than traditional imaging modalities.

Brain organization mirrors caste differences, colony founding and nest architecture in paper wasps (Hymenoptera: Vespidae)

The cognitive challenges that social animals face depend on species differences in social organization and may affect mosaic brain evolution. We asked whether the relative size of functionally distinct brain regions corresponds to species differences in social behaviour among paper wasps (Hymenoptera: Vespidae). We measured the volumes of targeted brain regions in eight species of paper wasps. We found species variation in functionally distinct brain regions, which was especially strong in queens. Queens from species with open-comb nests had larger central processing regions dedicated to vision (mushroom body (MB) calyx collars) than those with enclosed nests. Queens from advanced eusocial species (swarm founders), who rely on pheromones in several contexts, had larger antennal lobes than primitively eusocial independent founders. Queens from species with morphologically distinct castes had augmented central processing regions dedicated to antennal input (MB lips) relative to caste monomorphic species. Intraspecific caste differences also varied with mode of colony founding. Independent-founding queens had larger MB collars than their workers. Conversely, workers in swarm-founding species with decentralized colony regulation had larger MB calyx collars and optic lobes than their queens. Our results suggest that brain organization is affected by evolutionary transitions in social interactions and is related to the environmental stimuli group members face.

Review article: use of antitumour necrosis factor therapy in inflammatory bowel disease during pregnancy and conception

BACKGROUND

One of the most frequently asked questions during consultation with those affected by inflammatory bowel disease is what are its effects on pregnancy, and how the treatment will impact on conception and pregnancy outcomes.

AIM

To review available data regarding the safety of biological therapies during pregnancy, primarily in woman with inflammatory bowel disease.

METHODS

A Medline search was performed and available original research and review articles relating to the use of biological (antitumour necrosis factor-alpha) therapies in inflammatory bowel disease were reviewed. Where information regarding the use of a drug in inflammatory bowel disease during pregnancy was limited, articles referring to its use for other indications, such as rheumatoid arthritis, were reviewed.

CONCLUSIONS

Based on available data, biological therapies appear to be safe in pregnancy. Most studies looking at the effects of any one medication on pregnancy in inflammatory bowel disease are confounded by the fact that most patients are on multiple medications and have varying levels of disease activity. Stopping therapy in the third trimester should be considered. Large registries with longer follow-up periods will be necessary before firm conclusions about the safety of antitumour necrosis factor-alpha therapies during conception and pregnancy can be drawn.

Aryepiglottoplasty for laryngomalacia: results and recommendations following a case series of 84

OBJECTIVES

To examine one consultant's experience of aryepiglottoplasty at Leeds General Infirmary. To identify risk factors for post-operative complications. Comparing the outcomes of surgery with the published literature on aryepiglottoplasty.

DESIGN

A retrospective case series of consecutive patients undergoing aryepiglottoplasty identified from theatre records.

SETTING

The Otolaryngology Department, Leeds General Infirmary. This is part of Leeds Teaching Hospitals NHS Trust and is a tertiary referral centre with regional paediatric intensive care unit (PICU) and specialises in managing paediatric airway pathology.

PARTICIPANTS

Ninety-one consecutive cases of aryepiglottoplasties, between 1997 and 2005. The medical records for 84 cases were reviewed.

MAIN OUTCOME MEASURES

Unplanned admissions to PICU, complication rate, length of post-operative hospital stay, and successful resolution of symptoms amongst our patient group.

RESULTS

The primary indication for surgery was found to be severe stridor. There was a low rate (3.6%) of unplanned admissions to the PICU. 7.1% of patients suffered a post-operative aspiration pneumonia. The majority (66.7%) of patients were able to return home after just one night in hospital. 11.9% of patients continued to have some stridor at follow-up.

CONCLUSIONS

The majority of patients undergoing aryepiglottoplasty for isolated laryngomalacia can be monitored overnight on a paediatric surgical ward and return home the following day (85%). Furthermore, they should expect improvement of their stridor with a single procedure (90%). Aryepiglottoplasty at an experienced unit is a low-risk procedure with a high success rate.

Strontium ranelate for preventing and treating postmenopausal osteoporosis

BACKGROUND

Strontium ranelate is a new treatment for osteoporosis therefore, its benefits and harms need to be known.

OBJECTIVES

To determine the efficacy and safety of strontium ranelate for the treatment and prevention of postmenopausal osteoporosis.

SEARCH STRATEGY

We searched MEDLINE (1996 to March 2005), EMBASE (1996 to week 9 2005), the Cochrane Library (1996 to Issue 1 2005), reference lists of relevant articles and conference proceedings from the last two years. Additional data was sought from authors.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of at least one year duration comparing strontium ranelate versus placebo reporting fracture incidence, bone mineral density (BMD), health related quality of life or safety in postmenopausal women. Treatment (versus prevention) population was defined as women with prevalent vertebral fractures and/or lumbar spine BMD T score < -2.5 SD.

DATA COLLECTION AND ANALYSIS

Two reviewers independently determined study eligibility, assessed trial quality and extracted the relevant data. Disagreements were resolved by consensus. RCTs were grouped by dose of strontium ranelate and treatment duration. Where possible, meta-analysis was conducted using the random effects model.

MAIN RESULTS

Four trials met the inclusion criteria. Three included a treatment population (0.5 to 2 g of strontium ranelate daily) and one a prevention population (0.125 g, 0.5 g and 1 g daily). A 37% reduction in vertebral fractures (RR 0.63, 95% CI 0.56, 0.71) and a 14% reduction in non-vertebral fractures (RR 0.86, 95% CI 0.75, 0.98) were demonstrated over three years with 2 g of strontium ranelate daily in a treatment population. An increase in BMD was shown at all BMD sites after two to three years in both populations. Lower doses of strontium ranelate were superior to placebo and the highest dose demonstrated the greatest reduction in vertebral fractures and increase in BMD. An increased risk of diarrhea with 2 g of strontium ranelate was found; however, adverse events did not affect the risk of discontinuing treatment nor did it increase the risk of serious side effects, gastritis or death. Additional data suggests that the risk of vascular and nervous system side-effects is slightly increased with taking 2 g of strontium ranelate daily over three to four years.

AUTHORS' CONCLUSIONS

There is silver level evidence (www.cochranemsk.org) to support the efficacy of strontium ranelate for the reduction of fractures (vertebral and to a lesser extent non-vertebral) in postmenopausal osteoporotic women and an increase in BMD in postmenopausal women with/without osteoporosis. Diarrhea may occur however, adverse events leading to study withdrawal were not significantly increased with taking 2 g of strontium ranelate daily. Potential vascular and neurological side-effects need to be further explored.

Strontium ranelate for preventing and treating postmenopausal osteoporosis

BACKGROUND

Strontium ranelate is a new anti-osteoporosis therapy therefore, its benefits and harms need to be known.

OBJECTIVES

To determine the efficacy and safety of strontium ranelate for the treatment and prevention of postmenopausal osteoporosis.

SEARCH STRATEGY

We searched MEDLINE (1996 to March 2005), EMBASE (1996 to week 9 2005), the Cochrane Library (1996 to Issue 1 2005), reference lists of relevant articles and conference proceedings from the last two years. Additional data was sought from authors and industry sponsors.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of at least one year duration comparing strontium ranelate versus placebo reporting fracture incidence, bone mineral density (BMD), health related quality of life and/or safety outcomes in postmenopausal women. Treatment (versus prevention) population was defined as women with prevalent vertebral fractures and/or lumbar spine BMD T score < -2.5 SD.

DATA COLLECTION AND ANALYSIS

Two reviewers independently determined study eligibility, assessed trial quality and extracted the relevant data. Disagreements were resolved by consensus. RCTs were grouped by dose of strontium ranelate and treatment duration. Where possible, meta-analysis was conducted using the random effects model.

MAIN RESULTS

A total of four trials met our inclusion criteria, three of which investigated the effects of strontium ranelate compared to placebo in a treatment population (doses ranged from 0.5 to 2 g daily) and one, in a prevention population (doses 0.125, 0.5 and 1 g daily). In osteoporotic, postmenopausal women a 37% reduction in vertebral fractures (two trials, n = 5082, RR 0.63, 95% CI 0.56 to 0.71) and a 14% reduction in non-vertebral fractures (two trials, n = 6572, RR 0.86, 95% CI 0.75 to 0.98) was demonstrated over a three year period with 2 g of strontium ranelate daily. An increase in BMD at all sites was shown with the same dose: lumbar spine BMD (two trials, n = 1614, WMD adjusted for strontium content 5.44, 95% CI 3.41 to 7.46 and WMD not adjusted 11.29, 95% CI 10.22 to 12.37 over two years), femoral neck and total hip (two trials, n = 4230, WMD 8.25, 95% CI 7.84 to 8.66 and WMD 9.83, 95% CI 9.39 to 10.26 respectively over three years). One gram of strontium ranelate daily in postmenopausal women without osteoporosis increased BMD at all sites over a two year period: lumbar spine (one trial, n = 59, WMD adjusted for strontium content 2.39, 95% CI 0.15 to 4.63 and WMD not adjusted 6.68, 95% CI 5.16 to 8.20), femoral neck (one trial, n= 60, WMD 2.52, 95%CI 0.96 to 4.09) and total hip (one trial, n = 60, WMD 1.02, 95% CI 0.48 to 1.56). In both the treatment and prevention populations, lower doses of strontium ranelate were superior to placebo with the highest dose of strontium ranelate demonstrating the greatest reduction in vertebral fractures and increase in BMD. There is some evidence to suggest that 2 g of strontium ranelate daily compared to placebo may have a beneficial effect on health related quality of life in postmenopausal women after three years of treatment. Two grams of strontium ranelate daily increased the risk of diarrhea (RR 1.38%, 95% CI 1.02 to 1.87); however, adverse events did not affect the risk of discontinuing strontium ranelate nor did it increase the risk of serious side effects, gastritis or death. Additional data obtained suggests that the risk of vascular system disorders including venous thromboembolism (two trials, n = 6669, 2.2% versus 1.5%, OR 1.5, 95% CI 1.1 to 2.1) and pulmonary embolism (two trials, n = 6669, 0.8% versus 0.4%, OR 1.7, 95% CI 1.0 to 3.1) as well as nervous system disorders such as headaches (3.9% versus 2.9%), seizures (0.3% versus 0.1%), memory loss (2.4% versus 1.9%) and disturbance in consciousness (2.5% versus 2.0%) is slightly increased with taking 2 g of strontium ranelate daily over a 3 to 4 year period.

AUTHORS' CONCLUSIONS

There is silver level evidence to support the efficacy of strontium ranelate for the reduction of vertebral fractures (and to a lesser extent non-vertebral fractures) in postmenopausal osteoporotic women and an increase in BMD (all sites) in postmenopausal women with and without osteoporosis. Diarrhea may occur however, adverse events leading to study withdrawal were not significantly increased in the strontium ranelate group. Potential risks to the vascular and neurological system associated with taking 2 g of strontium ranelate daily need to be further explored and quantified.