Absence of detectable measles virus genome sequence in inflammatory bowel disease tissues and peripheral blood lymphocytes

A highly sensitive measles-specific RT-PCR-nested PCR system was established, which consistently amplified measles virus genome sequence from control samples containing as little as 5.5 x 10(-3) pfu per reaction. This method failed to detect the presence of measles virus in 93 colonoscopic biopsies and 31 peripheral blood lymphocyte preparations, examined and obtained from patients with inflammatory bowel disease (IBD) and noninflammatory controls. All patients had detectable levels of serum neutralization antibody against measles virus. Each biopsy was estimated to have about one million cells, based on the amplification of the beta actin gene. The assay was calibrated by use of a known number of lymphocytes. The method applied was able to amplify measles virus RNA from a nucleic acid mixture equivalent to 18 cells derived from subacute sclerosing panencephalitis (SSPE) brain material. The level of measles RNA present, if any, in the biopsies is therefore at least 50,000-fold less than in SSPE.

Notification of tuberculosis in patients with AIDS

BACKGROUND

In the early 1990s cases of tuberculosis in people with HIV infection and AIDS were undernotified. A study to evaluate changes in notification rates in two inner London local authorities was undertaken for the period January 1993-June 1996 inclusive.

METHODS

For residents of the two local authorities, tuberculosis notifications were identified using a local database, and cases of AIDS with a recorded diagnosis of tuberculosis were identified from AIDS case reports.

RESULTS

During the study period, only 13 (32 per cent) of the 41 AIDS cases with a recorded diagnosis of tuberculosis were also notified as a case of tuberculosis. However, the proportion of notified cases rose from 0 per cent (0 of 11) in 1993 to 50 per cent (5 of 10) in 1995 and 63 per cent (5 of 8) in early 1996.

CONCLUSION

The increase in the tuberculosis notification rate for people with AIDS is encouraging, but scope for improvement remains.

Crohn's disease: nutrition and nutritional therapy

Disordered nutrition is common in Crohn's disease and is multifactorial. Regular and systematic monitoring of at least a minimum set of nutrition data is an essential component of care of children and adults with Crohn's disease. However, even in children, monitoring of growth and development may be deficient. Multiple macro- and micronutrient deficiencies are common in Crohn's disease, especially in those with extensive small bowel deficiencies or after multiple surgical resections. Body composition analysis may show differences from simple starvation, and metabolic effects of inflammation are increasingly being recognized. Nutritional support is part of the management of all patients with Crohn's disease, but nutritional intervention with defined formula liquid diet is an effective specific anti-inflammatory therapy. Although meta-analysis of published trials suggest that steroids are more effective than defined formula liquid diets, objective evidence from whole gut lavage fluid analysis and from faecal excretion of radiolabelled leukocytes shows unequivocal benefit of elemental diet based on measuring parameters of tissue damage. Enteral feeding with liquid diets should be considered in patients with incomplete small bowel obstruction, severe painful perianal disease, failure of corticosteroids in active Crohn's disease, borderline intestinal failure and in children with active Crohn's disease or with growth failure.

Oral budesonide as maintenance therapy in Crohn's disease--results of a 12-month study. Global Budesonide Study Group

BACKGROUND

Budesonide is a corticosteroid with high topical anti-inflammatory activity and low systemic activity due to rapid inactivation. We have assessed the efficacy and safety of an oral controlled ileal release (CIR) preparation of budesonide for maintenance of remission in patients with ileal or ileocaecal Crohn's disease.

METHODS

In a double-blind, multicentre trial, 75 patients in clinical remission (Crohn's Disease Activity Index, CDAI, < or = 150) were randomly assigned to receive placebo, budesonide 3 mg or budesonide 6 mg daily for 12 months. Trial drugs were given at a fixed dose and without concomitant medication. The primary outcome measure was relapse, defined as a CDAI > 150 together with an increase of at least 60 units from entry. A patient was also considered to have a relapse if withdrawn from the study due to clinical deterioration, whether or not a CDAI value could be calculated at that time.

RESULTS

There were no statistically significant differences in the relapse rate at any time-point throughout the study. By 12 months the proportion of patients having relapsed were 48, 46 and 60% in those patients treated with budesonide 6 mg, 3 mg and placebo, respectively (N.S.). Treatments were well tolerated, and the proportion of patients with suppressed adrenal function (according to predetermined criteria) were 50% (6 mg), 26% (3 mg) and 17% (placebo) (P = 0.096).

CONCLUSIONS

In the present study, relapse rate and time to relapse were similar in the patients treated with budesonide CIR, 6 mg daily or 3 mg daily or with placebo, throughout 12 months. This is in contrast to the two previous trials with identical design, where a significant effect of budesonide CIR in prolonging the median time to relapse was found. Possible reasons for the negative results of the present study include small sample size, and the fact that there was a high placebo response.

Discharge planning in A & E: part 2

Discharge of patients from A & E was considered by both the 1992 and 1996 Audit Commission reports. The 1992 Commission recommended that unnecessary return attendance for follow-up care should be reduced to a minimum, those requiring to make a return visit falling within the range of 10-15% of first attendances. Other hospital specialties, GP services and self care were identified as appropriate follow-up treatment. This places more emphasis on appropriate discharge advice for those who do not need to reattend, and this is an aspect of health promotion which largely goes unrecognized. The second part of this study explores how effectively A & E departments perform the role of giving appropriate discharge advice. Part I of the study, published in October 1997, covered the comprehensive discharge planning required for patients who belong to vulnerable groups and who commonly reattend.

General principles of epidemiology, as applied to studies of IgE-mediated food allergy

Epidemiology is the study of the distribution of disease and of the factors which contribute to or determine the development of a disease. Descriptive studies measure the frequency of a disease whereas analytic studies are predominantly concerned with identifying determinants or causes. In any epidemiological study it is essential that the exact objectives are clearly understood in terms of definitions and diagnostic criteria for the condition under scrutiny. Rather than address all food-induced reactions and diseases, the issues raised by epidemiological studies of one main group of conditions with a common mechanism, IgE-mediated food allergy, are considered. Problems with population-based and hospital-based surveys include case definition, case ascertainment, calculations and presentation of results and small numbers with wide confidence limits.

Symptoms and manifestations of food allergy, with particular relevance to the gut

Adverse reactions to ingested foods can cause a wide variety of symptoms, syndromes and diseases. Several different mechanisms may be implicated in organic (i.e. not psychologically based) reactions to foods, and these include IgE- and non-IgE-mediated immunological reactions-food allergies. Many specific conditions have now been recognised, and can be separated from the general body of food allergy/food intolerance disease; diagnostic criteria are recognised, and often a specific diagnostic test is available. For others, both to establish that reaction to food is involved, and to establish the foods implicated, diagnosis may require exclusion diet, open and/or double blind, placebo-controlled challenges, ideally monitored objectively. Manifestations of food allergy in the gut are described; and the relevance of digestive function, in relation to dose and distribution of allergens, is discussed.

Circumventricular organs and fever

We have examined the roles of three circumventricular organs, the area postrema, the subfornical organ, and the organum vasculosum of the lamina terminalis (OVLT), as possible access points for circulating pyrogens to cause fever. In conscious, unrestrained rats prepared with telemetry devices, intracerebroventricular cannulas, and intravenous catheters, body temperature was monitored after intravenously administered lipopolysaccharide and, on a different occasion, after intracerebroventricular prostaglandin E1. Lipopolysaccharide-induced fevers in sham control lesioned rats were indistinguishable from those observed in animals with lesions of the area postrema, the OVLT, or the tissue immediately adjacent to this structure (peri-OVLT). In contrast, rats with lesions of the subfornical organ displayed reduced fevers. In none of the groups of lesioned animals were prostaglandin E1 fevers reduced. Thus lesions did not interfere with central thermogenic pathways responsive to prostaglandin. Our results indicate that subfornical organ neurons respond to circulating pyrogens and through their efferent projections activate central pathways involved in fever.

Discharge planning from A & E: Part I

The discharge of patients from hospital has always been a vital part of the nurse's role. The government recognized the need for health personnel to plan effective discharge of patients from hospital and guidelines were produced by the Department of Health in 1989. While these were aimed more at the inpatient than the Accident and Emergency (A & E) attender, many of the recommendations can be applied to the emergency setting. Nowhere more than A & E does this create a management problem for patients, carers and colleagues alike. Those patients that belong to vulnerable groups, the elderly, the homeless, children and the mentally ill require a comprehensive discharge programme, utilizing the skills and knowledge of a number of community care personnel. Current practices are explored and recommendations made for future management. Part 2 of the study, covering appropriate discharge advice for patients who do not need to reattend the department, will be published in 1998.

Assessment and management of ulcerative colitis in children

The incidence of ulcerative colitis in school-age children in most parts of Europe has been steady at 1.5-2.0 per 100,000 children per year for the last 20-30 years. In comparison to adults, abdominal pain is a relatively frequent presenting symptom in children in addition to rectal bleeding, bloody diarrhoea or diarrhoea. Distribution of disease in children is generally more extensive (ratio rectal:left sided:extensive 25:30:45). There are remarkably few clinical trials of therapy in children and reasons for this are discussed. Subjective indices of disease severity and activity are unreliable in children. Objective measures such as endoscopy are of value to define the extent of ulceration and histopathological features; a test of gut protein loss using whole gut lavage gives an objective index of disease activity. Principles of medical management in children are generally the same as in adults with the additional need for scrupulous attention to nutrition and growth, and psychological factors. Reassuring results of a review of the health status of young adults who had developed ulcerative colitis in childhood are presented. Twenty-four of 27 considered themselves fully fit although nine of the patients had a permanent ileostomy.

Linkage analysis of candidate regions for coeliac disease genes

A strong HLA association is seen in coeliac disease [specifically to the DQ(alpha1*0501,beta1*0201 heterodimer], but this cannot entirely account for the increased risk seen in relatives of affected cases. One or more genes at HLA-unlinked loci also predispose to coeliac disease and are probably stronger determinants of disease susceptibility than HLA. A recent study has proposed a number of candidate regions on chromosomes 6p23 (distinct from HLA), 6p12, 3q27, 5q33.3, 7q31.3, 11p11, 15q26, 19p13.3, 19q13.1, 19q13.4 and 22cen for the location of a non-HLA linked susceptibility gene. We have examined these regions in 28 coeliac disease families by linkage analysis. There was excess sharing of chromosome 6p markers, but no support for a predisposition locus telomeric to HLA. No significant evidence in favour of linkage to coeliac disease was obtained for chromosomes 3q27, 5q33.3, 7q31.3, 11p11, 19p13.3, 19q13.1, 19q13.4 or 22cen. There was, however, excess sharing close to D15S642. The maximum non-parametric linkage score was 1.99 (P = 0.03). Although the evidence for linkage of coeliac disease to chromosome 15q26 is not strong, the well established association between coeliac disease and insulin dependent diabetes mellitus, together with the mapping of an IDDM susceptibility locus (IDDM3) to chromosome 15q26, provide indirect support for this as a candidate locus conferring susceptibility to coeliac disease in some families.

Oral budesonide is as effective as oral prednisolone in active Crohn's disease. The Global Budesonide Study Group

BACKGROUND

The use of corticosteroids in active Crohn's disease often becomes limited by side effects. Budesonide is a potent corticosteroid with low systemic bioavailability due to an extensive first pass liver metabolism.

AIMS

To compare the efficacy and safety of two dosage regimens of budesonide and prednisolone in patients with active Crohn's disease affecting the ileum and/or the ascending colon.

PATIENTS AND METHODS

One hundred and seventy eight patients were randomised to receive budesonide controlled ileal release (CIR) capsules 9 mg once daily or 4.5 mg twice daily, or prednisolone tablets 40 mg once daily. The treatment period was 12 weeks. The primary efficacy variable was clinical remission, defined as a Crohn's Disease Activity Index (CDAI) of 150 or less.

RESULTS

After eight weeks of treatment, remission occurred in 60% of patients receiving budesonide once daily or prednisolone and in 42% of those receiving budesonide twice daily (p = 0.062). The presence of glucocorticoid associated side effects was similar in all groups; however, moon face was more common in the prednisolone group (p = 0.0005). The highest frequency of impaired adrenal function, as measured by a short ACTH test, was found in the prednisolone group (p = 0.0023).

CONCLUSIONS

Budesonide CIR, administered at 9 mg once daily or 4.5 mg twice daily, is comparable to prednisolone in inducing remission in active Crohn's disease. The single dose administration is as promptly effective as prednisolone and represents a simpler and safer therapeutic approach, with a considerable reduction in side effects.

Body composition at the bedside

OBJECTIVE

To evaluate the use of an inexpensive hand-held bioelectric impedance analysis machine which measures lean body mass, by technical comparisons against standard instruments and techniques (an in-house bioelectric impedance machine and dual energy X-ray absorptiometry), and by performing body composition analyses in groups of potentially malnourished patients.

DESIGN

Prospective simultaneous comparison of measurements made by the hand-held and in-house bioelectric analysis machines and dual energy x-ray absorptiometry.

SETTING

Medical Physics Department and Gastrointestinal Unit in a university teaching hospital.

SUBJECTS/METHODS

One hundred and sixty subjects were recruited into the study. Data from 58 adolescent and 14 adult volunteers and from 42 adult patients were used for technical comparisons (n = 114). Body composition information was evaluated (n = 102) for 60 adult volunteers and 42 patients (17 with eating disorders, 7 with chronic alcoholic pancreatitis and 18 with inflammatory bowel disease).

OUTCOME MEASURES

Estimation of bias, limits of agreement and correlations on data from the three machines. Relationships between percentage body mass as lean, absolute weights and body mass index, in the adult subjects.

RESULTS

Both resistance and calculated impedance measured by the hand-held machine significantly correlated with the impedance measured by the in-house machine (r = 0.996; P < 0.0001). An estimation of the level of agreement in percentage lean measurement between dual energy x-ray absorptiometry and hand-held bioelectrical impedance analysis machine by the Bland and Altman method showed a bias of -0.07% and satisfactory limits of agreement from -7.97% to 7.76%. Body mass index was similar in the groups of healthy men and women, but proportion of weight as lean was significantly higher in men than women. In underweight patients with eating disorders, the ratio of lean to fat varied widely; in inflammatory bowel disease patients, proportions of lean and fat were similar to controls; however patients with alcoholic pancreatitis had values for body mass index similar to controls, but had significantly lower proportion of their body weight as lean (P < 0.05).

CONCLUSION

In non-obese and thin adults, an accurate two-compartment (lean, fat) measurement of body composition can be made in 10 min by using an inexpensive, hand-held, bioelectric impedance analysis machine.

Successful pregnancy in a patient with chronic intestinal pseudo-obstruction while on ambulatory percutaneous endoscopic gastrostomy feeding

We report a case of ambulatory endoscopic gastrostomy feeding via a low profile button device using a portable feeding pump. This provided successful nutritional support to a patient with chronic intestinal pseudo-obstruction who became pregnant while on gastrostomy feeding. She successfully completed her pregnancy with nutritional support through the gastrostomy. The portable feeding pump gave her excellent quality of life both indoors and outdoors, and she could continue feeding without interrupting her daily housework, shopping and babycare.

Detection of insulin-like growth factor-I and transforming growth factor-beta in whole gut lavage fluid: a novel method of studying intestinal fibrosis

BACKGROUND

Insulin-like growth factor-I (IGF-I) and/or transforming growth factor-beta (IGF-beta), may be involved in gut fibrous strictures.

METHODS

Concentrations of these two peptides have been measured by enzyme-linked immunosorbent assays (ELISAs) in whole gut lavage fluid from 57 patients, of whom 14 had strictures of the small intestine or colon associated with Crohn's disease, irradiation injury, ischaemia or diverticulitis.

RESULTS

IGF-I was detected in fluid from 11 of 14 patients with strictures, and 5 of 43 others (P < 0.01). TGF-beta was detectable in all 57 samples and concentrations were unrelated to the presence or absence of strictures.

CONCLUSION

Clinical studies of growth factors in intestinal fluid should facilitate research on intestinal fibrogenesis, and the diagnosis of fibrous stricturing in Crohn's disease.