Patient preferences and current practice for adults with steroid-resistant ulcerative colitis: POPSTER mixed-methods study

Background

Corticosteroids are a mainstay of the treatment of moderately severe relapses of ulcerative colitis, yet almost 50% of patients do not respond fully to these and risk prolonged steroid use and side effects. There is a lack of clarity about the definitions of steroid resistance, the optimum choice of treatment, and patient and health-care professional treatment preferences.

Objectives

The overall aim of this research was to understand how steroid-resistant ulcerative colitis is managed in adult secondary care and how current practice compares with patient and health-care professional preferences.

Design

A mixed-methods study, including an online survey, qualitative interviews and discrete choice experiments.

Setting

NHS inflammatory bowel disease services in the UK.

Participants

Adults with ulcerative colitis and health-care professionals treating inflammatory bowel disease.

Results

We carried out a survey of health-care professionals (n = 168), qualitative interviews with health-care professionals (n = 20) and patients (n = 33), discrete choice experiments with health-care professionals (n = 116) and patients (n = 115), and a multistakeholder workshop (n = 9). The interviews with and survey of health-care professionals showed that most health-care professionals define steroid resistance as an incomplete response to 40 mg per day of prednisolone after 2 weeks. The survey also found that anti-tumour necrosis factor drugs (particularly infliximab) are the most frequently offered drugs across most steroid-resistant (and steroid-dependent) patient scenarios, but they are less frequently offered to thiopurine-naive patients. Patient interviews identified several factors influencing their treatment choices, including effectiveness of treatment, recommendations from health-care professionals, route of administration and side effects. Over time, depending on the severity and duration of symptoms and, crucially, as medical treatment options become exhausted, patients are willing to try alternative treatments and, eventually, to undergo surgery. The discrete choice experiments found that the probability of remission and of side effects strongly influences the treatment choices of both patients and health-care professionals. Patients are less likely to choose a treatment that takes longer to improve symptoms. Health-care professionals are willing to make difficult compromises by tolerating greater safety risks in exchange for therapeutic benefits. The treatments ranked most positively by patients were infliximab and tofacitinib (each preferred by 38% of patients), and the predicted probability of uptake by health-care professionals was greatest for infliximab (62%).

Limitations

The survey and the discrete choice experiments with patients and health-care professionals are limited by their relatively small sample sizes. The qualitative studies are subject to selection bias. The timing of the different substudies, both before and during the COVID-19 pandemic, is a potential limitation.

Conclusions

We have identified factors influencing treatment decisions for steroid-resistant ulcerative colitis and the characteristics to consider when choosing treatments to evaluate in future randomised controlled trials. The findings may be used to improve discussions between patients and health-care professionals when they review treatment options for steroid-resistant ulcerative colitis.

Future work

This research highlights the need for consensus work to establish an agreed definition of steroid resistance in ulcerative colitis and a greater understanding of the optimal use of tofacitinib and surgery for this patient group. A randomised controlled trial comparing infliximab with tofacitinib is also recommended.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 41. See the NIHR Journals Library website for further project information.

The impact of almonds and almond processing on gastrointestinal physiology, luminal microbiology, and gastrointestinal symptoms: a randomized controlled trial and mastication study

BACKGROUND

Almonds contain lipid, fiber, and polyphenols and possess physicochemical properties that affect nutrient bioaccessibility, which are hypothesized to affect gut physiology and microbiota.

OBJECTIVES

To investigate the impact of whole almonds and ground almonds (almond flour) on fecal bifidobacteria (primary outcome), gut microbiota composition, and gut transit time.

METHODS

Healthy adults (n = 87) participated in a parallel, 3-arm randomized controlled trial. Participants received whole almonds (56 g/d), ground almonds (56 g/d), or an isocaloric control in place of habitual snacks for 4 wk. Gut microbiota composition and diversity (16S rRNA gene sequencing), SCFAs (GC), volatile organic compounds (GC-MS), gut transit time (wireless motility capsule), stool output and gut symptoms (7-d diary) were measured at baseline and endpoint. The impact of almond form on particle size distribution (PSD) and predicted lipid release was measured (n = 31).

RESULTS

Modified intention-to-treat analysis was performed on 79 participants. There were no significant differences in mean ± SD abundance of fecal bifidobacteria after consumption of whole almonds (8.7% ± 7.7%), ground almonds (7.8% ± 6.9%), or control (13.0% ± 10.2%; q = 0.613). Consumption of almonds (whole and ground pooled) resulted in higher mean ± SD butyrate (24.1 ± 15.0 μmol/g) than control (18.2 ± 9.1 μmol/g; P = 0.046). There was no effect of almonds on gut microbiota at the phylum level or diversity, gut transit time, stool consistency, or gut symptoms. Almond form (whole compared with ground) had no effect on study outcomes. Ground almonds resulted in significantly smaller PSD and higher mean ± SD predicted lipid release (10.4% ± 1.8%) than whole almonds (9.3% ± 2.0%; P = 0.017).

CONCLUSIONS

Almond consumption has limited impact on microbiota composition but increases butyrate in adults, suggesting positive alterations to microbiota functionality. Almonds can be incorporated into the diet to increase fiber consumption without gut symptoms.This trial was registered at clinicaltrials.gov as NCT03581812.

Patient preferences for treatment in steroid resistant ulcerative colitis - a discrete-choice experiment

BACKGROUND AND AIM

Understanding treatment preferences in those patients who are not responding to corticosteroids for ulcerative colitis is important in informing treatment choices. This study aimed to assess the relative importance of treatment characteristics to patients by conducting a discrete-choice experiment.

METHODS

Patients completed the questionnaire online. All data were collected between September and December 2020. Participants were shown 13 discrete-choice experiment tasks - a series of side-by-side comparisons of competing, hypothetical treatment characteristics and asked to select a preferred treatment. Survey responses were analysed using descriptive statistics and regression analyses.

RESULTS

115 patients completed the study. Patient preferences were strongest for treatments with a lower chance of side effects, this attribute had the most influence on the choice of treatment patients preferred. The second most important attribute was an improvement in maintaining remission. Conversely, route and frequency of administration were least important on the choice of treatment patients preferred. Respondents were willing to make trade offs and accept treatment benefits to compensate them for receiving a treatment with a less desirable attribute level. Participants were willing to accept a larger benefit of 45% improvement in maintenance of remission to accept a treatment with a higher probability of side effects. The benefit required was smaller with a 10% improvement in remission required to accept a treatment with a lower probability of side effects.

CONCLUSION

Quantifying preferences helps to identify and prioritise treatment characteristics that are important to patients. The results highlight the importance of careful discussion of side effects, including the magnitude of risk, using visualisation tools during a patient consultation to support decisions.

Almonds and Their Impact on Gastrointestinal Physiology, Luminal Microbiology and Gastrointestinal Function: A Randomized Controlled Trial

Objectives

The objective of this study was to investigate the impact of almonds, and almond form (whole, ground) on fecal Bifidobacteria (primary outcome) and gut microbiology, physiology, and symptoms in healthy adults.

Methods

Eighty-seven healthy adults with moderate fiber intake (<22g/d) were randomized to receive whole almonds (56 g/d), ground almonds (56 g/d) or a control muffin (2/d) in place of their habitual snacks for 4 weeks. Fecal Bifidobacteria, gut microbiota composition and diversity (16S rRNA sequencing), short-chain fatty acids (SCFA; gas-chromatography), volatile organic compounds (gas-chromatography mass-spectrometry), gut transit time (wireless motility capsule), and stool output and symptoms (7-day diary) were measured at baseline and at end of intervention. Differences between groups were assessed by analysis of covariance (ANCOVA) or a non-parametric equivalent and corrected for multiple testing (Bonferroni (p) or Benjamini-Hochberg FDR (q)) where appropriate.

Results

There were no differences in relative abundance of fecal bifidobacteria following 4-weeks consumption of whole almonds (8.7%, SD 7.7), ground almonds (7.8%, SD 6.9) or control (13.0%, SD 10.2; q = 0.613). There was no effect of almonds on gut microbiota at the phylum level or on diversity. At the genus level, almonds (whole and ground pooled) increased relative abundance of Lachnospiraceae_NK4A136_group, Phascolarctobacterium and decreased Tyzerella (all p < 0.05), however these were no longer significant following FDR adjustment. Pre-specified analysis comparing almonds (whole and ground pooled) demonstrated higher concentrations of butyrate (24.1 μmol/g, SD 15.0) versus control (18.2, SD 9.1; p = 0.046). There was no effect of almonds on gut transit time, stool consistency or gut symptoms. Almond form as either whole (low nutrient bioaccessibility) or ground (higher nutrient bioaccessibility) did not affect any outcome.

Conclusions

Almonds are a high fibre snack that can be incorporated into the diet of moderate fibre consumers with no adverse gastrointestinal symptoms. Almonds do not have major impact on global microbiota composition but may exert a prebiotic effect on microbial metabolism in healthy adults.

Funding Sources

The Almond Board of California.

Efficacy and Safety of Elective Switching from Intravenous to Subcutaneous Infliximab [CT-P13]: A Multicentre Cohort Study

BACKGROUND

Intravenous [IV] infliximab is a well-established therapy for inflammatory bowel diseases [IBD] patients. A subcutaneous [SC] formulation of infliximab [CT-P13] has recently been shown to be as effective as IV infliximab after two doses of IV induction in a randomised trial, but there are no data to support elective switching of patients on maintenance IV infliximab therapy. We aimed to assess the effectiveness of an elective switching programme to SC CT-P13 in patients treated with IV infliximab.

METHODS

Patients on established maintenance IV infliximab, who switched to SC CT-P13, were included in this retrospective multicentre cohort study. Disease activity was monitored serially with the Harvey-Bradshaw Index [HBI] for Crohn's disease [CD] and the Simple Clinical Colitis Activity Index [SCCAI] for ulcerative colitis (UC) for up to 12 months at months 3, 6, and 12. Faecal calprotectin [FC] and C-reactive protein [CRP] were recorded at baseline and follow-up, if available. Infliximab trough levels were measured prior to switch and at months 3, 6, and 12 following switch. The primary outcome measure was treatment persistence at latest follow-up. Secondary outcome measures included infliximab pharmacokinetics [PK], safety, need for corticosteroid rescue therapy, and need for surgery.

RESULTS

We included 181 patients, of whom 115 [63.5%] had CD. The majority [72.4%] were on 8-weekly dosing of intravenous infliximab prior to switching, and more than half [59.1%] were on concomitant immunomodulatory therapy. The majority of patients (CD: 106, 92.2%; UC: 46, 76.7%; and IBD unclassified [IBD-U]: 5, 83.3%) were in clinical remission. Treatment persistence rate was high [n = 167, 92.3%] and only 14 patients [7.7%] stopped treatment during the follow-up period. There was no significant difference between baseline and repeat measurements at 3, 6, or 12 months for HBI, SCCAI, CRP, or FC. Of the total cohort, 25 patients (13.8%) had perianal CD. Of these, only two patients [8%] had worsening of perianal CD and required antibiotic therapy and further examination under anaesthesia [EUA]. Both these patients also switched back to intravenous infliximab. Median infliximab level increased from a baseline of 8.9 µg/dl [range 0.4-16] to 16.0 µg/dl [range 2.3-16, p <0.001] at 3 months. Serum levels stayed stable at 6 months [median 16 µg/dl, range 0.3-17.2] and 12 months [median 16 µg/dl, range 0.3-19.1, both p <0.001 compared with baseline]. Among the variables examined, only antibodies to infliximab [ATI] was associated with infliximab levels (odds ratio [OR] -13.369, 95% CI -15.405, -11.333, p <0.001]. A total of 14 patients [7.7%] developed ATI; of these, nine [64.3%] were on concomitant immunomodulatory therapy. Immunomodulatory therapy was not significantly associated with development of ATI [p = 0.15]. In a subset of patients receiving escalated IV infliximab dosing frequency prior to switching, no difference in treatment persistence was observed in patients receiving weekly versus alternate weekly SC CT-P13. Patient acceptance and satisfaction rates with SC CT-P13 were very high.

CONCLUSIONS

Among patients on IV infliximab maintenance therapy switched to SC CT-P13, we observed high treatment persistence rates and low rates of immunogenicity, with no change in clinical disease activity indices or biomarkers. Infliximab levels increased after switch to SC CT-P13, and only ATI was associated with serum infliximab levels. Patient acceptance and satisfaction rates were high with SC CT-P13.

Trial summary and protocol for a phase II randomised placebo-controlled double-blinded trial of Interleukin 1 blockade in Acute Severe Colitis: the IASO trial

INTRODUCTION

Acute severe ulcerative colitis (ASUC) is a severe manifestation of ulcerative colitis (UC) that warrants hospitalisation. Despite significant advances in therapeutic options for UC and in the medical management of steroid-refractory ASUC, the initial treatment paradigm has not changed since 1955 and is based on the use of intravenous corticosteroids. This treatment is successful in approximately 50% of patients but failure of this and subsequent medical therapy still occurs, with colectomy rates of up to 40% reported. The Interleukin 1 (IL-1) blockade in Acute Severe Colitis (IASO) trial aims to investigate whether antagonism of IL-1 signalling using anakinra in addition to intravenous corticosteroid treatment can improve outcomes in patients with ASUC.

METHODS AND ANALYSIS

IASO is a phase II, multicentre, two-arm (parallel group), randomised (1:1), placebo-controlled, double-blinded trial of short-duration anakinra in ASUC. Its primary outcome will be the incidence of medical (eg, infliximab/ciclosporin) or surgical rescue therapy (colectomy) within 10 days following the commencement of intravenous corticosteroid therapy. Secondary outcomes will include disease activity, time to clinical response, time to rescue therapy, colectomy incidence by day 98 post intravenous corticosteroids and safety. The trial aims to recruit 214 patients across 20 sites in the UK.

ETHICS AND DISSEMINATION

The trial has received approval from the Cambridge Central Research Ethics Committee (Ref: 17/EE/0347), the Health Research Authority (Ref: 201505) and Clinical Trials Authorisation from the Medicines and Healthcare products Regulatory Agency. We plan to present trial findings at scientific conferences and publish in high-impact peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN43717130; EudraCT 2017-001389-10.

A comparison of sample preparation methods for extracting volatile organic compounds (VOCs) from equine faeces using HS-SPME

INTRODUCTION

Disturbance to the hindgut microbiota can be detrimental to equine health. Metabolomics provides a robust approach to studying the functional aspect of hindgut microorganisms. Sample preparation is an important step towards achieving optimal results in the later stages of analysis. The preparation of samples is unique depending on the technique employed and the sample matrix to be analysed. Gas chromatography mass spectrometry (GCMS) is one of the most widely used platforms for the study of metabolomics and until now an optimised method has not been developed for equine faeces.

OBJECTIVES

To compare a sample preparation method for extracting volatile organic compounds (VOCs) from equine faeces.

METHODS

Volatile organic compounds were determined by headspace solid phase microextraction gas chromatography mass spectrometry (HS-SPME-GCMS). Factors investigated were the mass of equine faeces, type of SPME fibre coating, vial volume and storage conditions.

RESULTS

The resultant method was unique to those developed for other species. Aliquots of 1000 or 2000 mg in 10 ml or 20 ml SPME headspace were optimal. From those tested, the extraction of VOCs should ideally be performed using a divinylbenzene-carboxen-polydimethysiloxane (DVB-CAR-PDMS) SPME fibre. Storage of faeces for up to 12 months at - 80 °C shared a greater percentage of VOCs with a fresh sample than the equivalent stored at - 20 °C.

CONCLUSIONS

An optimised method for extracting VOCs from equine faeces using HS-SPME-GCMS has been developed and will act as a standard to enable comparisons between studies. This work has also highlighted storage conditions as an important factor to consider in experimental design for faecal metabolomics studies.

Women with diarrhoea-predominant irritable bowel syndrome show an increased pressure response to 35% carbon dioxide stress challenge

The responses to inhalation of 35% carbon dioxide (CO(2)) as a stressor were compared in female irritable bowel syndrome (IBS) patients and healthy controls to assess potential differences in cardiovascular, neuroendocrine and behavioural responses to stress. A total of 22 women (12 patients with ROME II defined diarrhoea-predominant IBS and 10 aged-matched controls) were challenged with a single vital capacity breath of 35% CO(2) (with 65% oxygen). Beat-to-beat blood pressure and heart rate were recorded prior to, during and after the inhalation. Serum cortisol concentration and behavioural ratings were measured pre- and post-inhalation. A typical pattern of responses to CO(2) was observed, characterised by a reduction in heart rate and increases in serum cortisol and anxiogenic symptoms; however, these responses did not differ between groups. Both groups also demonstrated an increase in systolic blood pressure; however, this response was significantly enhanced in IBS patients compared to healthy controls (P < 0.05). These findings demonstrate that females with diarrhoea-predominant IBS have an exaggerated pressor response to 35% CO(2) stress challenge, suggesting a more stress-responsive sympathetic nervous system.

Infliximab use in Crohn's disease: impact on health care resources in the UK

OBJECTIVE

To quantify the impact of infliximab therapy on health care resource utilization in the UK.

METHODS

A retrospective audit was undertaken at seven centres in the UK, which reviewed patient notes for a period of 6 months before and 6 months after an initial infliximab infusion. Details of hospital admissions, outpatient visits, operations, diagnostic procedures, drug usage, and overall efficacy were collected. Results were compared for the two 6 month study periods.

RESULTS

A total of 205 patients (62% female, median age 33 years) with moderate/severe Crohn's disease were audited. The majority of patients had chronic active disease (62%) and most received one infusion initially (72%). Clinicians rated 74% of responses as good to excellent and patients 72%. Most patients had concomitant immunosuppression (pre: 75%, post: 75%). Approximately half of the patients (45%) stopped taking steroids, with a further 34% having a dosage reduction. A fall of 1093 inpatient days was seen (1435 vs. 342) in the 6 months following infliximab administration. There were seven fewer operations, 33 fewer examinations under anaesthetic, and 99 fewer diagnostic procedures. Outpatient visits were similar pre- versus post- (555 vs. 534). The total reduction in direct costs amounted to an estimated pounds 591,006. Three hundred and fifty-three infliximab infusions were administered at an estimated cost of pounds 562,719. Thus, there was a net reduction of pounds 28,287 or pounds 137.98 per patient.

CONCLUSIONS

Infliximab appears to be a potentially cost effective treatment for selected patients based on the reduced number of inpatient stays, examinations under anaesthetic, and diagnostic procedures over a 6 month period.

Should we monitor vitamin B12 levels in patients who have had end-ileostomy for inflammatory bowel disease?

BACKGROUND AND AIMS

We examined whether vitamin B12 levels are low following surgery in those patients who have had end-ileostomy for inflammatory bowel disease.

PATIENTS AND METHODS

This prospective observational study used the database of a university teaching hospital to identify patients with inflammatory bowel disease with an end-ileostomy constructed more than 30 months previously. Precise diagnosis, disease distribution and details of their surgery were collected from case notes of the 39 eligible patients (18 Crohn's disease, 17 ulcerative colitis, 4 indeterminate colitis). Mean duration since ileostomy formation was 12.53 years. Patients found to be vitamin B12 deficient underwent further investigations to ascertain the cause of their vitamin B12 deficiency (<150 ng/l).

RESULTS

There was no significant difference between serum vitamin B12 levels in patients with Crohn's disease and those in patients with ulcerative colitis following end ileostomy formation. Two patients (5.1%) were identified as having vitamin B12 deficiency. One of these had had a panproctocolectomy for Crohn's disease, followed by subsequent resection for ileal obstruction and ongoing small intestinal disease. The other had had colectomy for ulcerative colitis, in whom no cause other than the ileostomy was found for the vitamin B12 deficiency. There was no significant correlation between serum vitamin B12 levels and duration of ileostomy overall or in the disease subgroups.

CONCLUSION

We do not recommend routine screening for vitamin B12 deficiency in this group of patients unless they have undergone additional small bowel resection or have ongoing small bowel inflammation.

Upper gastrointestinal haemorrhage following cardiac surgery: a comparative study with vascular surgery patients from a single centre

OBJECTIVE

To compare the frequency and outcome of upper gastrointestinal haemorrhage (UGH) patients who had undergone cardiac surgery with a control group of vascular surgery patients.

PATIENTS

Patients who had undergone cardiac or vascular surgery from January 1999 to December 2000 were identified from departmental records. The inclusion criteria used were haematemesis and/or melaena in the post-operative period.

RESULTS

Only 20 of the 2274 (0.9%) cardiac operations were complicated by UGH compared to eight of 708 (1.1%) vascular operations. Among those with UGH, 90% of the cardiac and 43% of the vascular patients were taking aspirin, warfarin or both. The mean interval between surgery and the UGH was 9.6 days (range 1-30) for the cardiac and 6 days (range 0-15) for the vascular patients. Duodenal and gastric ulcers were the most common cause of UGH (60%) in the cardiac group. Despite endoscopic intervention, more than one third of ulcer associated haemorrhages required surgical over-sewing, but none of the patients who had surgery died. The overall mortality on the cardiac surgery patients who experienced UGH was 15%, significantly higher than the 2.3% for the whole cardiac surgery group during the study period (P = 0.00075, OR = 8, 95% confidence interval 2.3-28). However, even this mortality is less than that of general inpatients who suffer UGH (33%).

CONCLUSIONS

Cardiac and vascular surgical patients have similar low post-operative rate of UGH. Post-operative UGH is associated with increased mortality after primary surgery. Early surgical intervention appears to be life saving in those patients who are too ill to compensate for the haemodynamic disturbance of untreated UGH.

The manifestation and nursing management of agitation in institutionalised residents with dementia

This participatory action research study is the first formal research study undertaken by nurses in a nursing development unit. The study emerged as the result of nurses brainstorming issues that they perceived to be problematic in their nursing practice and their unit environment. The nurses of the psycho-geriatric nursing development unit, Wallsend Aged Care Facility, New South Wales, Australia identified that the management of agitated behaviour manifested by their severely demented clients was a major challenge in their practice. As a result, a pilot participatory action research study was designed to measure how agitation manifested, to measure the severity of agitation and to identify current nursing practices used to manage it and their outcome. Results of the study demonstrated that nurse actions triggered the majority of most highly rated episodes of agitated behaviour in this group of elderly residents, and that the majority of these nurse actions related to those involved in carrying out activities of daily living for the residents.

Sweet's syndrome without granulocytosis

BACKGROUND

Sweet's syndrome (SS), acute febrile neutrophilic dermatosis, has been linked to hematologic malignancies and presents with characteristic edematous dermal plaques. Peripheral blood neutrophilia is frequently seen in association with SS and is one of the diagnostic criteria.

OBJECTIVE

To report the clinical, laboratory, and hematologic data of four patients with myeloid leukemia who developed SS after chemotherapy. Three of these patients were neutropenic.

METHODS

A retrospective study of four patients with SS and hematologic malignancies was undertaken. Three patients had de novo acute myelogenous leukemia and one was in the acute blast crisis of chronic myelogenous leukemia.

RESULTS

Sweet's syndrome was not originally suspected in these patients because of the low peripheral white blood cell counts caused by chemotherapy. All of the patients presented with fevers, arthralgias, and an eruption. They had been treated with antibiotics because of a presumed infection. Once the correct diagnosis was made and oral prednisolone was started, a rapid response followed.

CONCLUSIONS

Sweet's syndrome should be considered in the differential diagnosis when acute myeloid leukemic patients develop skin lesions and unexplained fevers regardless of the peripheral blood counts.

The effects of chronic ill health and treatment with sulphasalazine on fertility amongst men and women with inflammatory bowel disease in Leicestershire

The aims of the study were to ascertain whether patients have similar a fertility rate to the background population in Leicestershire and whether they have a similar rate of congenital malformations compared to the background population in Leicestershire. Over 1400 patients were invided to participate with an overall response rate of 81% after three successive mailings. The response rate was similar for both sexes and between the disease groups. The crude infertility rate for the group was 21%. The mean number of children for the whole group was 1.7 +/- 1.3 but both men and women with Crohn's disease had significantly less children than would be expected, (men with Crohn's disease 1.5, women with Crohn's disease 1.2). There were 39 children (2% of overall births) with congenital abnormalities reported by patients with inflammatory bowel disease and in 29 cases the parents reported taking sulphasalazine (Table 3). Although this figure compares well with the 1.8% reported congenital abnormality rate for Leicestershire within the patient group in this study congenital malformations were significantly related to sulphasalazine use, z = 4.3, P < 0.0001. In conclusion sulphasalazine not only as causes morphological abnormalities in spermatozoa but may increase the chances of having congenitally abnormal offspring amongst men with IBD. The effects of other 5-aminosalacylic acids have yet to be studied in detail.

Composition of TCR-CD3 complex in human intestinal intraepithelial lymphocytes: lack of Fc epsilon RI gamma chain

Human intestinal intraepithelial lymphocytes (iIEL) are a unique population of predominantly CD8 alpha beta+, TCR alpha beta+ lymphocytes and, to a lesser extent, TCP gamma delta+ lymphocytes that proliferate poorly to anti-CD3 mitogenic signals but display significant cytolytic activity. Studies in mouse model systems have shown that the gamma chain of the high-affinity receptor for IgE (Fc epsilon RI gamma) may substitute for the zeta chain in the TCR-CD3 complex of iIEL. This has suggested that the functional properties of these cells may be associated with an altered composition of the TCR-CD3 complex. We therefore analyzed the TCR-CD3 complex of normal human iIEL. One- and two-dimensional non-reducing/reducing SDS-PAGE analysis of CD3 gamma, CD3 delta, CD3 epsilon, zeta and Fc epsilon RI gamma chain immunoprecipitates of cell surface radiolabeled proteins with subunit-specific antibodies revealed a TCR-CD3 complex without associated Fc epsilon RI gamma chains. Thus, normal human iIEL contain a TCR-CD3 complex that consists predominantly of zeta homodimers in association with the alpha beta TCR and CD3 gamma, delta and epsilon, similar to the majority of peripheral lymphocytes. This indicates that the distinct properties of human iIEL are not associated with substitutions of the Fc epsilon RI gamma chain in the TCR-CD3 complex.

Patients' satisfaction survey: a review of in-patient attitudes towards care during a 12 month period

In order to assess the value of medical and nurse team meetings in a programme designed to improve the quality of care given on a general medical ward, a 33% sample of recent in-patients was asked to complete a questionnaire about the quality of care that they received from doctors and nurses. Regular meetings were convened to respond to criticisms and improve overall care. During the year of the programme there was no significant change in the quality of care as perceived by patients and it is clear that this approach to improving care is ineffective.

Perceived discrimination in education and employment by people with Crohn's disease: a case control study of educational achievement and employment

Eighty three patients in whom the diagnosis of Crohn's disease had been made before the age of 40 years and who had been resident in the city of Cardiff were asked to complete a detailed questionnaire about their educational and employment experiences. Responses were obtained from 58 patients (response rate = 70%), 23 buddy controls, and 27 community controls. The mean (SD) age of patients at the time of the survey was 31 (5) years. Twenty four of the patients were diagnosed before leaving secondary education, at a mean age of 17 years. They had lost significantly more days' schooling than controls (chi 2 = 14.3 p less than 0.001) but had achieved similar academic success as measured by examination passes and attendance at tertiary institutes of education. Similar numbers of patients and controls were employed at the time of the survey, although significantly more patients had experienced long term unemployment (z = 2.6 p less than 0.01). As a result of their experiences up to 30% actively concealed their illness from employers.

Colo-pericardial and colo-caval fistula. Late complication of colon interposition

We report the first recorded case of a colo-pericardial fistula and of a colo-caval fistula following interposition of colon after resection of the oesophagus.

Analysis of fetal activity and maternal and fetal heart rate using a laboratory minicomputer

Using a PDP-11 minicomputer, a system was developed for real-time acquisition of fetal breathing, body movement, and heart rate data. Analogue event pulses were input electronically to a DR-11 16 channel A/D, D/A interface and the event times were measured using an AR-11 real-time clock. Event times were stored for comprehensive off-line analysis and useful data summaries were also provided on-line. The on-line printouts enabled investigators to examine the quality of the data at the time of the study. The system has resulted in faster data acquisition and analysis and greater accuracy of measurement.

The distribution of accelerations of the human fetal heart rate at 38 to 40 weeks' gestational age

In order to further understand the use of antepartum fetal heart rate monitoring we measured the distribution, in time, of two, three, or five fetal heart rate accelerations of greater than or equal to 15 bpm for greater than or equal to 15 seconds and of greater than or equal to 10 bpm for greater than or equal to 6 seconds in 12 healthy pregnant women at 38 to 40 weeks' gestation. The length of time necessary to measure 50% or 95% of intervals containing five accelerations would be substantially reduced by changing to a definition of two or three accelerations. However, an observation interval of at least 80 minutes is required to include the longest time interval of two, three, or five accelerations. These data may suggest new strategies for decreasing time and expense of fetal heart rate testing.

The effects of maternal hyperoxia on fetal breathing movements in third-trimester pregnancies

Fetal breathing movements and gross fetal body movements were observed before, during, and after maternal hyperoxia induced by inhalation of 50% oxygen in 14 women with normal term pregnancies. Studies were performed with real-time B-scan linear-array ultrasound and were standardized for time of day, maternal nutritional status, postprandial interval, and length of observation. Each study included a 30-minute baseline, followed by 15 minutes of hyperoxia, and 45 minutes of continued monitoring. No significant changes occurred in the mean incidences of fetal breathing movements, gross fetal body movements, the mean breathing rate, or breath interval variability, as analyzed in 5-minute epochs. Maternal PO2, as measured by transcutaneous electrodes, increased to the maximum level after 5 minutes of hyperoxia (155% over control levels). The breathing activity of normal third-trimester fetuses appears to be stimulated maximally in the second and third postprandial hours and cannot be further increased by maternal hyperoxia. This protocol represents a possible clinical strategy for investigating fetuses at risk for intrauterine hypoxia, provided that similar experimental conditions are maintained.

Absence or impaired response of fetal breathing to intravenous glucose is associated with pulmonary hypoplasia in congenital myotonic dystrophy

Two fetuses of a patient affected with myotonic dystrophy were studied ultrasonically from 28 to 34 weeks' gestation. After a 1-hour observation period, an intravenous injection of 25 gm of 50% glucose solution was given to the mother. Fetal breathing movements were 0% during the control period and increased to only 10% at 90 minutes after the injection of glucose; the episode lasted approximately 30 minutes. The infants, who were delivered at 33 and 35 weeks, had generalized hypotonia, normal arterial cord blood gases, and died shortly after birth from pulmonary insufficiency, in spite of maximum ventilatory support. Postmortem pulmonary hypoplasia was confirmed by a lung weight/body weight ratio of less than 0.019. We postulate that fetal breathing activity and its response to the injection of glucose may be a potential clinical test by which normal fetuses can be differentiated from fetuses affected by neuromuscular disorders, including myotonic dystrophy.

Maternal glucose injections do not alter the suppression of fetal breathing following maternal ethanol ingestion

In order to determine whether intravenous injections of glucose could reverse the effects of maternal ingestion of ethanol (0.25 gm/kg), glucose (25 gm intravenously) or an equal volume of saline solution was administered to eight pregnant women at 37 to 40 weeks' gestation after ingestion of ethanol. Fetal breathing movements were abolished within 30 minutes after ingestion of ethanol and were not increased by maternal intravenous injections of glucose. Maternal heart rate was increased by ethanol. The disposition of ethanol in maternal blood was not altered by injection of glucose, and fetal gross body movements were not influenced by maternal ingestion of ethanol or by injections of glucose after ethanol.

Effect of intravenous glucose injection on human maternal and fetal heart rate at term

The effects of maternal intravenous glucose administration (25 gm) on maternal heart rate, fetal heart rate, gross fetal body movements, and fetal heart rate accelerations was measured in 11 healthy pregnant women at 38 to 40 weeks' gestational age. Mean maternal heart rate increased from 78.3 +/- 0.8 bpm during the control period to 82.7 +/- 0.5 bpm at 30 to 85 minutes following glucose injections (p less than 0.01). Mean fetal heart rate rose from 137.8 +/- 0.4 bpm to 142.4 +/- 0.3 bpm at 50 to 95 minutes following injections (p less than 0.001). The incidence of gross fetal body movements and the number, duration, and amplitude of fetal heart rate accelerations did not change following glucose injection. We conclude that maternal glucose administration near term results in a small but significant increase in the mean maternal heart rate and fetal heart rate and no change in the incidence of gross fetal body movements or in fetal heart rate accelerations.

Effect of maternal ethanol ingestion on fetal breathing movements, gross body movements, and heart rate at 37 to 40 weeks' gestational age

The effect of maternal ingestion of ethanol (0.25 gm/kg) on fetal breathing movements, gross fetal body movements, and fetal heart rate was studied in 11 healthy pregnant women at 37 to 40 weeks' gestation. Fetal breathing movements were almost abolished within 30 minutes of the alcoholic drink and remained significantly decreased for 3 hours. The incidence of gross fetal body movements before or after ethanol was not different from that on the control day, and the fetal heart rate was not changed after maternal ingestion of ethanol.

Influence of maternal heart rate and gross fetal body movements on the daily pattern of fetal heart rate near term

Continuous measurements of fetal heart rate (FHR), gross fetal body movements, fetal breathing movements, and maternal heart rate (MHR) were made for 24-hour observation intervals in 11 pregnant women at 38 to 40 weeks. There was a significant positive correlation between each mother's daily mean MHR and her fetus' daily mean FHR. There was a trough in mean hourly FHR between 0200 and 0600 hours and a trough in mean hourly MHR between 2400 and 0700 hours. Mean hourly FHR both during and between times of gross fetal body movements was significantly correlated to mean hourly MHR. At term, the mean FHR is strongly influenced by the mean MHR and the presence or absence of gross fetal body movements.