Treatment of active Crohn's disease in children using partial enteral nutrition with liquid formula: a randomised controlled trial

BACKGROUND AND AIMS

Total enteral nutrition (TEN) with a liquid formula can suppress gut inflammation and induce remission in active Crohn's disease. The mechanism is obscure. Studies have suggested that long term nutritional supplementation with a liquid formula (partial enteral nutrition (PEN)) may also suppress inflammation and prevent relapse. The aim of this study was to compare PEN with conventional TEN in active Crohn's disease.

PATIENTS AND METHODS

Fifty children with a paediatric Crohn's disease activity index (PCDAI)>20 were randomly assigned to receive 50% (PEN) or 100% (TEN) of their energy requirement as elemental formula for six weeks. The PEN group was encouraged to eat an unrestricted diet while those receiving TEN were not allowed to eat. The primary outcome was achievement of remission (PCDAI<10). Secondary analyses of changes in erythrocyte sedimentation rate (ESR), C reactive protein, albumin, and platelets were performed to look for evidence of anti-inflammatory effects.

RESULTS

Remission rate with PEN was lower than with TEN (15% v 42%; p=0.035). Although PCDAI fell in both groups (p=0.001 for both), the reduction was greater with TEN (p=0.005). Moreover, the fall in PCDAI with PEN was due to symptomatic and nutritional benefits. With both treatments there were significant improvements in relation to abdominal pain, "sense of wellbeing", and nutritional status. However, only TEN led to a reduction in diarrhoea (p=0.02), an increase in haemoglobin and albumin, and a fall in platelets and ESR.

CONCLUSIONS

TEN suppresses inflammation in active Crohn's disease but PEN does not. This suggests that long term nutritional supplementation, although beneficial to some patients, is unlikely to suppress inflammation and so prevent disease relapse.

An Opposed Piston Rapid Compression Machine for Preflame Reaction Studies

Mixtures of fuel and air ignite spontaneously if exposed to sufficiently high temperatures. Such ignition is not an instantaneous event, and there is always a delay of chemical origin between the establishment of the particular conditions of temperature and pressure and the rapid, exothermic chemical reactions that constitute ignition. This delay is of outstanding importance in any fuel application in which spontaneous ignition plays a part. It is determined by the progress of the near-isothermal chemical processes that precede ignition, and these processes therefore merit continued study.

This paper describes the development of an experimental technique which allows these studies to be extended to much higher pressures than those accessible in glass vessels, while retaining many of the advantages of laboratory vessel experiments. This technique is centred on a rapid compression machine of novel design which is used to heat and compress fuel/air mixtures to conditions near those in a knocking engine. After this compression process, which occupies a few milliseconds only, the hot, high pressure charge is held at constant volume while thermochemical, spectroscopic or analytical observations are made.

The principal new developments in the machine are the use of twin opposed pistons for compression with an associated hydraulic synchronizing system and a precisely triggered valve that enables rapid quenching and sampling of the reacting mixture to be made at an appropriate stage of reaction.

"De novo" design of peptides with specific lipid-binding properties

In this study, we describe an in silico method to design peptides that can be made of non-natural amino acids and elicit specific membrane-interacting properties. The originality of the method holds in the capacities developed to design peptides from any non-natural amino acids as easily as from natural ones, and to test the structure stability by an angular dynamics rather than the currently-used molecular dynamics. The goal of this study was to design a non-natural tilted peptide. Tilted peptides are short protein fragments able to destabilize lipid membranes and characterized by an asymmetric distribution of hydrophobic residues along their helix structure axis. The method is based on the random generation of peptides and their selection on three main criteria: mean hydrophobicity and the presence of at least one polar residue; tilted insertion at the level of the acyl chains of lipids of a membrane; and conformational stability in that hydrophobic phase. From 10,000,000 randomly-generated peptides, four met all the criteria. One was synthesized and tested for its lipid-destabilizing properties. Biophysical assays showed that the "de novo" peptide made of non-natural amino acids is helical either in solution or into lipids as tested by Fourier transform infrared spectroscopy and is able to induce liposome fusion. These results are in agreement with the calculations and validate the theoretical approach.

Low maternal vitamin B12 status is associated with intrauterine growth retardation in urban South Indians

OBJECTIVE

To assess the maternal sociodemographic, anthropometric, dietary and micronutrient status in apparently healthy pregnant women in order to determine their associations with intrauterine growth retardation (IUGR).

DESIGN

Prospective observational study.

SETTING

Bangalore City, India.

SUBJECTS

A total of 478 women were recruited at 12.9+/-3.3 weeks of gestation and followed up at the first, second and third trimesters of pregnancy and at delivery. The dropout rate was 8.5%.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Birth weight was measured at hospital delivery.

RESULTS

The mean birth weight was 2.85+/-0.45 kg. In all, 28.6% of newborns were IUGR. There was a strong inverse relationship between maternal educational level and risk of IUGR. A low body weight at baseline was also associated with a high risk of IUGR. Compared with women in the highest quartile for second trimester weight gain, those in the lowest quartile had a significantly higher adjusted odds ratio (AOR: 3.98; 95% CI: 1.83, 8.65) for IUGR. Women in the lowest tertile for serum vitamin B(12) concentration during each of the three trimesters of pregnancy had significantly higher risk of IUGR (AOR: 5.98, 9.28 and 2.81 for trimesters 1-3, respectively).

CONCLUSIONS

The present study demonstrates associations between educational status, maternal weight and gestational weight gain with IUGR. Importantly, in a subsample, there were strong associations of vitamin B(12) status with IUGR, suggesting that better socioeconomic conditions, improved nutritional status and early detection of vitamin B(12) deficiency in pregnancy combined with appropriate interventions are likely to play an important role in reducing IUGR.

The relationship of neonatal serum vitamin B12 status with birth weight

Earlier studies have shown a relationship between maternal vitamin B12 status and birth weight. This study extends those findings directly in terms of neonatal vitamin B12 status and birth weight. One hundred and twelve women were followed from the first trimester of pregnancy and maternal blood was obtained in all three trimesters along with cord blood at birth of their neonates. The maternal and cord serum vitamin B12 concentrations were examined in relation to birth weight. There was a significant correlation between vitamin B12 concentration in maternal antenatal serum during each of the trimesters of pregnancy and cord serum (all P< 0.01). Neonates that were born with lower birth weights (categories of <2500 g and 2500-2999g) had significantly lower mean cord serum vitamin B12 concentrations when compared to those who were > or = 3000g (P = 0.02 and P = 0.05 respectively). A similar, however, non significant trend was observed for antenatal vitamin B12 concentrations at first and third trimesters. Cord serum vitamin B12 concentrations were significantly correlated with birth weight, up to 40 weeks of pregnancy (r=0.28, P=0.01) but not beyond that (> or =40 weeks gestation). Vitamin B12 status in the mother was related to neonatal vitamin B12 status as measured by cord serum vitamin B12 concentration. In addition, low neonatal vitamin B12 concentrations were adversely associated with low birth weights.

Initial drug susceptibility profile of M. tuberculosis among patients under TB programme in South India

SETTING

Pulmonary tuberculosis (PTB) patients enrolled for treatment at government health facilities in a sub-district of Thiruvallur district, Tamil Nadu, India.

OBJECTIVES

To determine the drug susceptibility profile among PTB patients admitted to treatment according to the Revised National Tuberculosis Control Programme (RNTCP).

METHODOLOGY

From May 1999 to December 2003, two additional sputum samples were collected from all patients at the start of anti-tuberculosis treatment under DOTS and were transported to a central laboratory for Mycobacterium tuberculosis culture and drug susceptibility testing (DST).

RESULTS

DST results were available for 1603 new sputum smear-positive patients; 85% of patients had organisms fully susceptible to streptomycin (S), isoniazid (H) and rifampicin (R), 10.4% any resistance to H and 1.7% to HR. Of 443 patients with history of previous anti-tuberculosis treatment, 59% had organisms susceptible to S, H and R, 37% had any resistance to H and 11.7% to HR.

CONCLUSION

The DST profile showed that the vast majority of patients have drug-susceptible organisms, and that currently recommended regimens under the RNTCP would be effective in the treatment of TB.

Eine neue Methode zur standardisierten Diagnostik nach Nierentransplantation

Ultrasound (US) imaging is an important diagnostic tool following renal transplantation. Unfortunately, due to the heterogeneity of the recipients and their multimorbidity, imaging procedures in the early phase after kidney transplantation are difficult and of limited use. We performed a study to evaluate the use of a contrast enhancer for US examination as a standardized method in the follow-up of kidney transplant recipients.The study included 40 recipients: 32 were examined on the 5th to 7th day following transplantation and 8 patients at the time when clinically suspicious findings occurred (acute rejection, tumor, acute tubular necrosis). Following the intravenous application of the contrast medium, pictures were taken during the arterial and parenchymatous phase and compared with conventional B-mode and power Doppler pictures of the same visual plane. Three examiners assessed different parameters of the transplant organ (max. vascularized area, suspected hematomas, tumors, rejection, acute tubular necrosis). Findings were confirmed by histological results of a biopsy if rejection, tumor, or acute tubular necrosis were suspected. Application of ultrasound contrast medium significantly increased visualization of the vascularized kidney area. Also, US findings in the follow-up after acute rejection therapy corresponded with the clinical course; 19 hematomas could be detected with contrast medium compared to only 9 without. With contrast medium a perfusion deficit was detectable in three patients compared to one patient with power Doppler US. Also, US contrast medium helped to detect tumor vascularization in two patients in whom conventional sonography suspected no abnormality. Ultrasound contrast medium enhancement is a reproducible, reliable, and easy to apply method which is superior to conventional sonography in the follow-up after kidney transplantation. This method is also helpful to detect and control acute rejections and to better visualize hematomas, deficits of perfusion, and tumors.

Identification and study of Utah pseudo-isolate populations-prospects for gene identification

Isolate populations of varied types have proven powerful for gene identification for rare Mendelian disorders, and continue to show such promise for more complex phenotypes. Existing isolate populations are limited in the phenotypes available for study, and new population isolates are unlikely to arise. We utilize genealogical data available for the state of Utah, dating back to its European founders, to retrospectively define and examine pseudo-isolate subpopulations. These pseudo-isolate populations are defined by selection of a set of "founders" from the genealogical data, and then limitation of "immigration" by censoring of matings and offspring that do not match the isolate population design. A wide variety of pseudo isolate and other study designs are possible by varying the number and type of founders and the extent of immigration allowed. We present several different example Birth-Country pseudo-isolate populations defined within the Utah Population Database (UPDB). We utilize linked cancer phenotype data available for the Utah population to show the utility of this pseudo-isolate approach for identification of more genetically homogeneous prostate cancer pedigrees for predisposition gene identification. In conclusion, we present a unique approach to retrospective "creation" of isolate populations using existing genealogical data. We use the UPDB to exhibit the utility of this approach for the highly heterogeneous Utah population, and suggest the approach is feasible for any population for which high quality genealogy and phenotype data are available.

Inner calvarial erosion from traumatic subdural haematoma in infancy

CASE REPORT

This is a report of a case of a subdural haematoma in infancy of possible non-accidental aetiology with raised pericerebral pressure, which we postulate has eroded the inner table of the cranial bones and resulted in leakage of marrow precursor cells into the extradural space.

RESULT

Subdural tapping via the fontanelle has created a channel allowing subsequent ingress of nucleated red cell precursors into the subdural space. This addition to the subdural collection has prolonged its course necessitating subduro-peritoneal shunting.

[Clinical case of the month. Rendu-Osler-Weber disease: a rare case of stroke in the young]

Rendu-Osler disease or hereditary hemorragic telangiectasia is a group of autosomal dominant diseases characterized by angiodysplasic lesions in the skin, mucous membranes and viscera with risks of recurrent bleedings. Neurological complications have been described in 10-30% of these patients, most often hemorrhagic or septic. More exceptionally, ischemic strokes occur in these patients, particularly if they have pulmonary arteriovenous malformations. We report the observation of a 25 year old man who developed a latero-protuberantial stroke. The explorations revealed pulmonary AV malformations and nasal telangiectasias that led to the diagnostic of Rendu-Osler disease. This affection should be considered as a potential cause of cerebral ischemic attack, particularly in young patients without risk factors.