Anti-CD20 monoclonal antibodies inhibit seropositive response to Covid-19 vaccination in Non-Hodgkin lymphoma patients within six months after treatment

The Covid-19 pandemic has caused millions of deaths worldwide. Although vaccines have been developed, patients on immunosuppressive therapy are less likely to respond. This study was aimed at investigating the efficacy of a Covid-19 vaccine (Pfizer-BioNTech) in patients with non-Hodgkin lymphoma treated with anti-CD20 monoclonal antibodies. Only 1 of 28 lymphoma patients (3.6%) developed a seropositive response, compared with 100% (28/28) of the healthy volunteers. The low levels of CD19⁺ lymphocytes among the lymphoma patients suggest that anti-CD20 treatment prevents the seropositive response to the vaccine. An additional vaccination might be indicated in these patients once B cells are repopulated.

Safety, tolerability and efficacy of a novel self-use biodegradable device for management of obesity

OBJECTIVE

Obesity is a major public health issue with significant impact on quality of life, morbidity and mortality rates. It is estimated that if the current trends continue, 18% of men and 21% of women worldwide will be obese by 2025. All the current therapies are not optimal due to limited efficacy or safety; thus, there is a need for additional devices for the treatment of obesity. This study aimed to examine the safety, tolerability, and efficacy of a biodegradable encapsulated Epitomee device for weight loss. The technology is based on absorbent pharmaceuticals polymers and bonding materials that self-expand in the stomach to create a pH-sensitive super absorbent gel structure for weight loss.

METHODS

A prospective, 12-week twice daily use of the encapsulated device in patients with body mass index of 27-40 kg m-2. Efficacy endpoints were the percent total body weight loss (%TBWL), proportion of participants with 5% TBWL and changes in cardio-metabolic markers. Safety analysis included evaluation of adverse events, laboratory and endoscopic findings.

RESULTS

Overall, 52 patients completed the study. TBWL per intension-to-treat analysis was 3.68 ± 3.07% (3.23 ± 2.69 kg) and 4.52 ± 2.97% (3.95 ± 2.57 kg) per protocol. No device serious adverse effects reported. The most common adverse events were headache (18.1%), viral infection (11.5%), abdominal discomfort (10.1%), bloating (7.9%), nausea and constipation (5% each) and flatulence (4.3%). Endoscopy in 26 patients revealed mild, asymptomatic gastric/duodenal erythema without erosions in five patients.

CONCLUSIONS

Twelve weeks of Epitomee capsules treatment combined with lifestyle counselling resulted in 3.68-4.52% of TBWL. With continued research, the Epitomee capsules have considerable potential to become a non-invasive, safe and effective treatment option for weight loss.

Acquisition of Multidrug-Resistant Organisms Among Hospital Patients Hospitalized in Beds Adjacent to Critically Ill Patients

Objective.

To assess whether patients hospitalized in beds physically adjacent to critically ill patients are at increased risk to acquire multidrug-resistant pathogens.

Design.

Cohort study.

Setting.

Shaare Zedek Medical Center, a 550-bed medical referral center.

Patients.

From April to September 2004, we enrolled consecutive newly admitted patients who were hospitalized in beds adjacent to either mechanically ventilated patients or patients designated as “do not resuscitate” (DNR). For each of these patients, we also enrolled a control patient who was not hospitalized in a bed adjacent to a critically ill patient. We collected specimens from the anterior nares, the oral cavity, and the perianal zone at the time of admission and subsequently at 3-day intervals until discharge or death. Specimens were cultured on selective media to detect growth of antibiotic-resistant pathogens, includingAcinetobacter baumannii, methicillin-resistantStaphylococcus aureus(MRSA), extended-spectrum β lactamase (ESBL)–producing Enterobacteriaceae, and vancomycin-resistant enterococci (VRE).

Results.

We enrolled 46 neighbor-control pairs. Among neighbors and controls, respectively, the incidence rates for isolation ofA. baumanniiwas 8.3 and 4 isolations per 100 patient-days (relative risk [RR], 2.1 [95% confidence interval {CI}, 0.8-5.2];P= .12), the incidence rates for MRSA were 1.4 and 2.6 isolations per 100 patient-days (RR, 0.6 [95% CI, 0.1-2.3];P= .45), the incidence rates for ESBL-producing Enterobacteriaceae were 10.5 and 9 isolations per 100 patient-days (RR, 1.2 [95% CI, 0.6-2.4];P= .84), the incidence rates for VRE were 4.3 and 4.8 isolations per 100 patient-days (RR, 0.9 [95% CI, 0.3-2.4];P= 1), and the composite incidence rate was 21.7 and 16.2 isolations per 100 patient-days (RR, 1.3 [95% CI, 0.8-2.3];P= 0.3).

Conclusions.

In this pilot study, we did not detect an increased incidence rate of isolation of multidrug-resistant pathogens among patients hospitalized in beds adjacent to critically ill patients. Further studies with larger samples should be conducted in order to generate valid data and provide patients, physicians, and policy makers with a sufficient knowledge base from which decisions can be made.

Portal hypertension is associated with modulation of regulatory T cells

Background:

Portal hypertension is a complication of liver cirrhosis. The portal vein drains the spleen and the intestines, which are both rich in inflammatory mediators. Portal hypertension- induced stress within these organs that may result in pro-inflammatory changes. The association of these changes with regulatory T cells was not addressed before.

Aim:

Our aim is to investigate the involvement of some subsets of regulatory T cells in portal hypertension.

Methods:

In the current study we used the partial portal vein ligation model to demonstrate differences in the distribution of regulatory T cells within the portal vein and the inferior vena cava associated with portal hypertension.

Results:

We show that CD4+CD25+FoxP3+ regulatory T cells are significantly ( P <0.05) increased only in the inferior vena cava of partial portal vein ligation-rats. The development of portal hypertension was associated with the reversal of the distribution patterns in the portal vein and inferior vena cava for both CD4+ and CD8+ cells. We further show that in naïve rats CD4+IL17+ cells were significantly ( P <0.05) and specifically enriched in inferior vena cava compared to the portal vein.

Conclusions:

These novel findings support the involvement of regulatory T cells in the inflammatory signals accompanied with acute portal hypertension.

Prospective Evaluation of Colonization with Extended-Spectrum β-Lactamase (ESBL)–Producing Enterobacteriaceae Among Patients at Hospital Admission and of Subsequent Colonization with ESBL-Producing Enterobacteriaceae Among Patients During Hospitalization

Objective.

To determine the rates of and risk factors for carriage and acquisition of extended-spectrum (β-lactamase (ESBL)-producing Enterobacteriaceae during hospitalization.

Design.

Cohort study.

Setting.

Shaare Zedek Medical Center, a 550-bed teaching hospital.

Methods.

During a 5-month period (February 1-June 30, 2004), 167 (8%) of 1,985 newly admitted general medical patients were enrolled in our study. Nasal, oropharyngeal, and rectal swab specimens were obtained at admission and every 2-3 days until hospital discharge or death. Enterobacteriaceae isolates were tested for ESBL, andStaphylococcus aureusisolates were tested for methicillin resistance.

Results.

Of the 167 patients enrolled in our study, 15 (9%) were identified as nasal carriers of methicillin-resistantS. aureus(MRSA) at admission, and 13 (8%) were rectal carriers of ESBL-producing Enterobacteriaceae at admission. Univariate risk factors for rectal carriage of ESBL-producing Enterobacteriaceae included female sex (odds ratio [OR], 11 [95% confidence interval {CI}, 1.4—238];P< .05), nursing home residence (OR, 6.9 [95% CI, 1.8-27];P< .01), recent antibiotic treatment (OR, 9.8 [95% CI, 1.7-74];P< .05), and concomitant nasal carriage of MRSA and/or ESBL-producing Enterobacteriaceae (OR, 5.8 [95% CI, 1.2-26];P< .01). Multivariate risk factors were female sex and recent antibiotic treatment. During hospitalization, 35 (21%) of 167 patients had acquired rectal carriage of ESBL-producing Enterobacteriaceae (P= .002, for trend analysis). Of the 12 patients who were still in the hospital 2 weeks after admission, 4 (33%) were carriers of ESBL-producing Enterobacteriaceae. Univariate risk factors for acquisition included an age of older than 65 years (P< .005), nursing home residence (OR 2.6, [95% CI, 0.98-2.6]), impaired cognition (OR, 4.8 [95% CI, 1.9-12]), recent antibiotic treatment (OR, 2.7 [95% CI, 0.9-8.3]), respiratory assistance (OR, 4.2 [95% CI, 1.2-14]), and prolonged hospitalization. Multivariate risk factors were an age of older than 65 years and broad-spectrum antibiotic therapy.

Conclusions.

Rectal carriage of ESBL-producing Enterobacteriaceae occurred in 13 (8%) of 167 patients at admission to the medical departments of our hospital and in 4 (33%) of 12 patients still remaining in our hospital after 2 weeks.

Reduced GLP-1R expression in gastric glands of patients with type 2 diabetes mellitus

BACKGROUND

The incretin effect is reduced in type 2 diabetes mellitus (T2DM) patients. Whether the impaired function of the enteropancreatic axis in these patients is due to defective GLP-1 receptor (GLP-1R) expression in extrapancreatic target organs is not known.

AIMS AND METHODS

To compare the GLP-1R expression and distribution in gastric mucosa biopsies of patients with (n =22) and without (n =22) T2DM referred for routine esophagogastroduodenoscopies. GLP-1R mRNA levels were estimated by real-time PCR. The intensity of GLP-1R immunostaining, frequency, and types of glandular cells bearing GLP-1R and their glandular distribution in different stomach mucosa regions were evaluated by immunohistochemical morphological semiquantitative and quantitative analysis.

RESULTS

Mean mRNA GLP-1R levels were significantly reduced in patients with T2DM compared with nondiabetic patients (P < .02). Immunohistochemical analysis revealed that the reduced GLP-1R expression in T2DM patients was due to a decreased intensity of immunostaining (P < .01). The number of glandular GLP-1R-bearing cells in both body and antrum mucosa was decreased in T2DM patients. Most notably, the frequency of GLP-1R immunoreactive acid-secreting parietal cells was reduced in the neck area of the gastric principal glands of T2DM patients (P < .01). No correlation was found between the reduced GLP-1R expression and clinical parameters including body mass index, age, glycosylated hemoglobin, and disease duration.

CONCLUSION

This is the first evidence of reduced GLP-1R expression in gastric glands of T2DM patients. These data demonstrate that the defective function of the incretin axis in T2DM may also result from decreased GLP-1R expression in its extrapancreatic target organs.

Comparison of central and intraesophageal factors between gastroesophageal reflux disease (GERD) patients and those with GERD-related noncardiac chest pain

Gastroesophageal reflux disease (GERD) causes a wide range of symptoms. Some patients present with typical symptoms such as heartburn and regurgitation and others with atypical symptoms such as chest pain. The mechanism responsible for the varying clinical presentation of GERD is still not fully elucidated. The aim of this study was to prospectively evaluate differences in central and local intraesophageal factors between patients with typical GERD symptoms and those with noncardiac chest pain (NCCP). Patients presenting with typical and atypical symptoms suspicious of GERD underwent upper endoscopy and 24-hour pH monitoring with four sensors, each positioned at a different esophageal level. All patients completed GERD symptom, Hospital Anxiety and Depression Scale, and Symptom Stress Rating questionnaires. From January 2006 to December 2009, 50 patients were recruited, 29 with typical symptoms, and 21 with NCCP. Patients with proven GERD and NCCP had higher proximal extension of acid during reflux episodes than patients with typical symptoms. They were found to be older, had a shorter history of symptom onset, worse anxiety scores, and more endoscopic findings compatible with gastritis. Proximal extension of acid during the reflux episodes in patients with GERD presenting with NCCP may play a role in symptom generation.

Comparison of central and intraesophageal factors between gastroesophageal reflux disease (GERD) patients and those with GERD-related noncardiac chest pain

Gastroesophageal reflux disease (GERD) causes a wide range of symptoms. Some patients present with typical symptoms such as heartburn and regurgitation and others with atypical symptoms such as chest pain. The mechanism responsible for the varying clinical presentation of GERD is still not fully elucidated. The aim of this study was to prospectively evaluate differences in central and local intraesophageal factors between patients with typical GERD symptoms and those with noncardiac chest pain (NCCP). Patients presenting with typical and atypical symptoms suspicious of GERD underwent upper endoscopy and 24-hour pH monitoring with four sensors, each positioned at a different esophageal level. All patients completed GERD symptom, Hospital Anxiety and Depression Scale, and Symptom Stress Rating questionnaires. From January 2006 to December 2009, 50 patients were recruited, 29 with typical symptoms, and 21 with NCCP. Patients with proven GERD and NCCP had higher proximal extension of acid during reflux episodes than patients with typical symptoms. They were found to be older, had a shorter history of symptom onset, worse anxiety scores, and more endoscopic findings compatible with gastritis. Proximal extension of acid during the reflux episodes in patients with GERD presenting with NCCP may play a role in symptom generation.

Evidence for aberrant regulation of MAP kinase signal transduction pathway in peripheral blood mononuclear cells in patients with active celiac disease

BACKGROUND

Aberrant signaling via the p21/mitogen-activated proteins (MAP) kinase pathway has been described in lymphocytes of patients with various autoimmune diseases. There is little published data about the intracellular mediators and signals that regulate expression and activity of transcription factors and their effect on celiac disease induction and progression.

AIM

To investigate the possible involvement of MAP kinase pathway in peripheral blood mononuclear cells (PBMC) in celiac disease and its correlation with disease activity.

METHODS

Expression of the total and activated forms of two MAP kinases [extracellular response kinase (ERK) and c-Jun amino terminal kinase (JNK)] were studied by Western blots in PBMC of 17 untreated and 19 treated celiac patients, and 17 controls. Seven of these untreated celiac patients were studies before and after 6 months of gluten-free diet.

RESULTS

Phosphorylated ERK of active celiac disease patients was significantly lower compared with controls (P < 0.01) and was increased towards normal after 6 month of gluten-free diet (P < 0.01). Phosphorylated JNK was increased significantly in the untreated celiac group (P < 0.01) and normalized towards the control level after 6 months of gluten-free diet (P < 0.04).

CONCLUSIONS

Aberrant MAP-kinase pathway activity is associated with active celiac disease (CD). Further studies should examine the potential role of this aberration in pathogenesis of CD.

Direct fluconazole susceptibility testing of positive Candida blood cultures by flow cytometry

The standard methods for yeast susceptibility testing require 24-48 h of incubation. As there has been an increase in incidence of non-albicans Candida species, the clinician is very often wary of initiating therapy with fluconazole until a final susceptibility report is generated, especially when treating very sick patients. A rapid reliable susceptibility testing method would enable the clinician to prescribe fluconazole, thus avoiding more toxic or expensive therapy. To determine the feasibility of direct susceptibility testing of Candida species to fluconazole by a rapid flow cytometric method, 50 Candida strains were seeded into blood culture bottles and were tested for susceptibility to fluconazole directly from the bottles after their being flagged as positive by the blood culture instrument. Minimal inhibitory concentration (MIC) determined by fluorescent flow cytometry (FACS) showed excellent agreement to that determined by macrodilution. Following the seeding experiments, 30 true patient specimens were tested directly from positive blood cultures, and MIC determined by both methods showed excellent agreement. Antifungal susceptibility testing by FACS directly from positive blood culture bottles is a reliable, rapid method for susceptibility testing of Candida to fluconazole. The method allows same-day results, does not require subculture to agar media, and can greatly assist in the selection of appropriate antifungal therapy.

Antiplatelet therapy and the risk of bleeding induced by gastrointestinal endoscopic procedures. A systematic review of the literature and recommendations

Antiplatelet drugs may increase the risk of bleeding induced by gastrointestinal endoscopic procedures. The antiplatelet effect of cyclooxygenase-1 inhibitors lasts less than 4 h. Skin and colonic bleeding times are prolonged for 3 and 5 days after aspirin and ticlopidine withdrawal respectively. Major bleeding from endoscopic biopsies is extremely rare. In the four recent largest series, the general incidence of polypectomy-induced major bleeding was 0.11-0.42%. In more than half of the cases the bleeding was delayed, usually up to 2 weeks after the endoscopy. Although three retrospective studies suggested that aspirin does not increase the risk of polypectomy-induced bleeding, the power of these studies is limited. Similarly, it is difficult to draw conclusions from the two studies that assessed the risk of aspirin use during sphincterotomy. Aspirin withdrawal may be harmful in susceptible patients, mainly if it is for more than 7 days. There is no indication to stop aspirin before esophagogastroduodenoscopy, which may reveal aspirin-induced lesions. We recommend discontinuation of aspirin 4-7 days (according to the cardiovascular risk) before other endoscopic procedures. When aspirin is indicated for primary prevention, it can be resumed 14 and 10 days after polypectomy and sphincterotomy respectively. In cases of secondary prevention, it should be resumed after 1 week.

Susceptibilities of ESBL-Producing Enterobacteriaceae to Ertapenem, Meropenem and Piperacillin-Tazobactam with and without Clavulanic Acid

BACKGROUND

Faced with the extended-spectrum beta-lactamase (ESBL) pandemic, we compared the susceptibilities of ESBL-producing Enterobacteriaceae to ertapenem, meropenem and piperacillin-tazobactam with and without clavulanate.

METHODS

121 strains of Escherichia coli and Klebsiella were studied. 70 strains were originally reported as resistant to ceftazidime based upon disk diffusion; 51 strains were originally reported as sensitive to ceftazidime based upon previous guidelines of the National Committee for Clinical Laboratory Standards, but subsequently shown to be ESBL producers. Minimal inhibitory concentrations (MICs) of the strains towards ertapenem, meropenem and piperacillin-tazobactam were determined by Etest. The effect of adding clavulanate on the MICs was determined by performing the Etest, using plates containing 2 microg/ml of clavulanate.

RESULTS

The MIC90 of all isolates was 0.094 and 0.25 microg/ml for ertapenem, 0.032 and 0.064 microg/ml for meropenem, and 16 and 256 microg/ml for piperacillin-tazobactam with and without clavulanate, respectively.

CONCLUSIONS

ESBL-producing organisms were more susceptible to meropenem than to ertapenem, although the MICs to ertapenem were well within clinically achievable levels. Piperacillin-tazobactam was ineffective in a large percentage of isolates. The presence of clavulanate resulted in a 5-fold decrease in the MIC of ertapenem and in a drastic reduction in the MIC of piperacillin-tazobactam. The decrease observed with ertapenem is unlikely to be of clinical significance. Thus, in our hospital, ertapenem could be a good meropenem-sparing agent for infections due to ESBL-producing organisms. Piperacillin-tazobactam appeared to be a poor choice, as our isolates produce ESBLs which are not successfully inhibited by tazobactam.

Chronic hepatitis C infection in children

Hepatitis C virus infection may differ in the pediatric age group with respect to transmission, natural history and response to treatment. Most infected children develop chronic hepatitis but with a relatively mild course of the disease. The most efficient transmission of hepatitis C virus is through direct percutaneous exposure to infected blood or blood products. However, the major risk factor for acquisition of hepatitis C virus in children at present is maternal-infant transmission. The rate of progression to advanced liver disease seems to be more rapid in post transfusional and vertically acquired hepatitis C virus infection than in sporadic hepatitis C virus infection acquired postnatally, or in those without known risk factors. There is a wide variety of histopathological expression, depending on the geographical distribution of the different countries. Treatment for hepatitis C virus in children has not yet been approved. However, combination treatment with peginterferon-alpha-2b with ribavirin shows encouraging results and is generally well tolerated. More randomized controlled trials are needed in the future to optimize the approach to hepatitis C virus infection in children.

Laparoscopically monitored percutaneous endoscopic gastrostomy (PEG) in children: a safer procedure

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has now become the preferred technique for facilitating enteral nutrition in children with inadequate caloric intake. Because many problems related to PEG insertion have recently been reported, we were motivated to reassess this established technique. We have therefore added a new step--laparoscopic monitoring--to the classic PEG procedure.

METHODS

Fifteen children who required PEG during the previous year were studied. Their ages ranged from 2 months to 18 years. Six children were < 1 year old at the time of operation. In 11 patients, the PEG was performed at the end of a laparoscopic Nissen fundoplication. In the others, it was done as a single procedure.

RESULTS

In all 15 children, the PEG was performed safely and quickly, without complications.

CONCLUSION

The addition of 'laparoscopic monitoring' to the classic PEG procedure introduced by Gauderer et al. changes the first and last parts of the procedure from an almost 'blind' undertaking to a well-controlled and safer procedure.

Diagnosing small bowel Crohn's disease with wireless capsule endoscopy

BACKGROUND

The small bowel is the most commonly affected site of Crohn's disease (CD) although it may involve any part of the gastrointestinal tract. The current methodologies for examining the small bowel are x ray and endoscopy.

AIMS

To evaluate, for the first time, the effectiveness of wireless capsule endoscopy in patients with suspected CD of the small bowel undetected by conventional modalities, and to determine the diagnostic yield of the M2A Given Capsule.

PATIENTS

Seventeen patients (eight males, mean age 40 (15) years) with suspected CD fulfilled study entry criteria: nine had iron deficiency anaemia (mean haemoglobin 10.5 (SD 1.8) g%), eight had abdominal pain, seven had diarrhoea, and three had weight loss. Small bowel x ray and upper and lower gastrointestinal endoscopic findings were normal. Mean duration of symptoms before diagnosis was 6.3 (SD 2.2) years.

METHODS

Each subject swallowed an M2A Given Capsule containing a miniature video camera, batteries, a transmitter, and an antenna. Recording time was approximately eight hours. The capsule was excreted naturally in the patient's bowel movement, and the data it contained were retrieved and interpreted the next day.

RESULTS

Of the 17 study participants, 12 (70.6%, six males, mean age 34.5 (12) years) were diagnosed as having CD of the small bowel according to the findings of the M2A Given Capsule.

CONCLUSIONS

Wireless capsule endoscopy diagnosed CD of the small bowel (diagnostic yield of 71%). It was demonstrated as being an effective modality for diagnosing patients with suspected CD undetected by conventional diagnostic methodologies.

Lack of correlation between disease activity and decreased stimulated secretion of IL-10 in lymphocytes from patients with celiac disease

BACKGROUND

Celiac disease (CD) is commonly believed to be a predominantly Th1 disease. However, the exact balance between the Th1 and Th2 arms, as well as the correlation to clinical parameters, remains unclear. The aim was to assess the Th1/Th2 cytokine profile and its correlation to clinical parameters in active and non-active CD patients.

METHODS

Peak, total secretion and secretory pattern of the Th1 cytokines (IFN-gamma and IL-2) and Th2 cytokines (IL-4 and IL-10) were determined in resting and stimulated peripheral blood mononuclear cells (PBMC) from 19 CD patients with active and non-active disease and 20 normal controls.

RESULTS

Peak and total secretion of IL-10 were significantly reduced in CD patients compared with normal controls. This was due to a persistently flat secretory pattern of IL-10 over time in CD patients. In addition, IFN-gamma/IL-10 and the IL-2/IL-10 ratios of peak and total secretion were higher in patients than in controls. In contrast, peak, total secretion and secretory pattern of IL-2, IFN-gamma and IL-4 were comparable in patients and controls as well as the IL-2/IL-4 and IFN-gamma/IL-4 ratios. No difference in the cytokine secretion or Th1/Th2 ratio was found between active and non-active patients or between pediatric and adult patients.

CONCLUSIONS

These data indicate that the Thl/Th2 balance in CD is shifted towards Th1 cytokines because of a down-regulated IL-10 secretion. The aberrant profile of cytokine secretion of these patients is not associated with clinical parameters and suggests an inherent defect in IL-10 secretion in CD.

Measles is more prevalent in Crohn's disease patients. A multicentre Israeli study

The question whether there is a transmissible pathogenetic agent as a cause for Crohn's disease, remains unanswered. Measles virus has been the subject of many intensive studies, in the attempt to find a role for it in the pathogenesis of inflammatory bowel disease. Whether an early infection with measles virus may predispose to Crohn's disease in later life is still not clear. We conducted a large scale multicentre study, in order to obtain sufficient data to answer this question. To do so, we compared inflammatory bowel disease patients, with Crohn's disease or ulcerative colitis, with two matched control groups: clinical controls, and community controls. A total of 531 patients, 271 with ulcerative colitis and 260 with Crohn's disease were interviewed, as well as 903 matched controls. Blood from 104 inflammatory bowel disease patients and 50 controls was tested for antibodies to measles virus. We did not find any differences related to measles vaccination, either in Crohn's disease or in ulcerative colitis. Exposure to measles in childhood was more frequent in Crohn's disease patients than in their controls, the difference being statistically significant (p < 0.05) in relation to community controls. The presence of IgG antibodies to measles virus was higher in patients with Crohn's disease than in patients with ulcerative colitis or controls (p = 0.084). Another observation of interest was the finding that Crohn's disease patients who had measles in childhood, more frequently had large bowel disease than those who had not had measles. These data lead us to postulate that there may be a role for measles infection in Crohn's disease, even if, at present, this role remains unclear.

Effects of current cigarette smoking on clinical course of Crohn's disease and ulcerative colitis

Cigarette smoking worsens Crohn's disease (CD) but ameliorates ulcerative colitis (UC). In Israel, where there is no epidemiological association of smoking with CD, we examined the effects of current smoking on the course of CD and UC. Patients at nine public hospitals completed a questionnaire detailing their smoking history, disease course and treatments; subjects altering their smoking habit after the onset of disease were excluded. Sixty-four smokers and 144 nonsmokers had CD, and 34 smokers and 158 nonsmokers had UC. No differences were found between CD smokers and nonsmokers for hospitalizations, operations, and requirement for corticosteroid and immunosuppressive treatment. By contrast, UC smokers had less extensive disease than nonsmokers (P < 0.02) and fewer hospitalizations (P = 0.01) and operations (P = 0.025). Our results agree with a minority of studies showing no adverse effect of smoking on the course of CD, and confirm the protective effect of smoking in UC.

Effectiveness of acupuncture for treatment of childhood constipation

The aim of the present study was to examine the influence of acupuncture on chronic constipation in children and to investigate their basal plasma panopioid level and the changes of this treatment. Seventeen children constipated for at least six months were treated by five weekly placebo acupuncture sessions, followed by 10 weekly true acupuncture sessions. Their parents filled a bowel habit questionnaire. Panopioid activity was measured at time 0 and after 5, 10, and 15 acupuncture sessions. The frequency of bowel movements in males increased more gradually compared to females and reached a maximal improvement only after 10 true acupuncture sessions, from 1.4 +/- 0.6/week to 4.4 +/- 0.6/week and females from 1.4 +/- 0.3/week up to 5.6 +/- 1.2/week. The basal panopioid activity was lower in constipated children as compared to the control population and increased gradually up to control level after 10 true acupuncture sessions. This study is the first to describe a successful treatment by acupuncture of constipated children.

Appendectomy is more frequent but not a risk factor in Crohn's disease while being protective in ulcerative colitis: a comparison of surgical procedures in inflammatory bowel disease

OBJECTIVE

Appendectomy was shown to be protective in patients with ulcerative colitis (UC). There are fewer data in Crohn's disease (CD). Other operations were less studied. The aim of this study was to investigate the prevalence of appendectomy, cholecystectomy, and tonsillectomy, including their timing, in patients with inflammatory bowel disease in comparison to controls.

METHODS

Two hundred seventy-one patients with UC and 260 with CD, 475 clinic controls, and 428 community controls were interviewed.

RESULTS

Appendectomy was found in 5.5% patients with UC, in 11% of clinic controls (p < 0.05), and 7.7% of community controls (p = not significant). The differences were more significant for appendectomy before onset of disease. Appendectomy was performed in 19.2% of patients with CD, in 10.9% of clinic controls, and in 10.1% of community controls (p < 0.01). However, there were no significant differences when only appendectomy before onset of disease was considered. Cholecystectomy was found in 1.5% of patients with UC, in 6.1% of clinic controls (p < 0.01), and in 4.5% of community controls (p = not significant). The difference remained significant when confined to operations performed before disease onset. No such difference was found in patients with CD. No significant difference was found in the prevalence of tonsillectomy between patients and controls.

CONCLUSIONS

Appendectomy is protective in UC; it is more frequent, but not a risk factor in CD. The role of cholecystectomy should be investigated further.

Passive smoking in patients with inflammatory bowel disease: an Israeli multicentre case-control study

BACKGROUND

The association between smoking and inflammatory bowel disease (IBD) is well established. There are, however, no large scale studies of passive smoking in inflammatory bowel disease and this has never been surveyed in the Jewish population of Israel.

AIM

To study the passive smoking exposure of Jewish IBD patients in Israel in a large scale multicentre study.

METHODS

Patients with established IBD, aged 18-70 years, were interviewed regarding smoking and other habits. Two controls, one clinic and one neighbourhood, matched by age, sex, community group, and education, were sought for each subject.

RESULTS

Five hundred and thirty-four patients (273 ulcerative colitis (UC) and 261 Crohn's disease (CD)), 478 clinic controls and 430 community controls were interviewed. There were no significant differences in the passive smoking habits between IBD patients and their controls. Fifty-one percent of UC patients, 50% of the clinic controls and 58% of the community controls were exposed to passive smoking at home (NS); similar results were found among CD patients (50%, 55% and 56%, respectively). When a quantitative exposure index was used UC patients were significantly less exposed to passive smoking than were their community controls (7.46 +/- 8.40 vs 9.36 +/- 9.46, n = 229, P< 0.031). There was no difference in the exposure to passive smoking among CD patients and their controls. No differences in exposure to passive smoking were found when UC patients who had never smoked were compared with their controls. When the quantitative index was used 'never-smoked' CD patients tended to be less exposed to passive smoking at home than their community controls (5.40 +/- 7.60 vs 8.04 +/- 8.72, P < 0.05).

CONCLUSION

There is a lack of association between passive smoking and IBD in Jewish patients in Israel. When a quantitative exposure index was used UC patients were found to be less exposed to passive smoking than their community controls.

Serum transferrin receptor in children and adolescents with inflammatory bowel disease

Iron studies are difficult to interpret in patients with chronic inflammatory states such as inflammatory bowel disease (IBD). Serum transferrin receptor (TfR) has been reported to be a reliable tool for the diagnosis of iron deficiency in adults. Our aim was to evaluate the role of serum TfR in diagnosing iron deficiency in children and adolescents with IBD. A total of 63 consecutive patients with IBD, aged 9 to 22 years (median 15 years), were tested for serum haemoglobin level, mean corpuscular volume (MCV), and serum iron, transferrin, ferritin and serum TfR levels. Those found to be anaemic were compared with seven age-matched subjects with iron deficiency anaemia (IDA) and 24 age-matched children without signs of anaemia or inflammation. Of the 63 patients with IBD, 26 had anaemia. Based on ferritin levels and MCV indices, anaemia was classified as IDA in 11 patients and as anaemia of chronic disease (ACD) in 15 patients. Mean serum TfR level in normal controls was 3.5 mg/l (range 1.2-8.2 mg/l). Mean (+/-SD) serum TfR levels were significantly lower in the IBD patients with ACD (5.3 +/- 2.3 mg/l) than in the IBD patients with IDA (8.2 +/- 3.1 mg/l) (P < 0.05). Serum TfR levels above 5 mg/l identified 10/11 IBD patients with IDA. The calculated TfR/ferritin ratio was 84 (range 17-367) for controls and 133 (range 6.4-1840) for IBD patients. A cut-off level of 350 (91% sensitivity, 100% specificity, 100% positive predictive value, 98% negative predictive value) was established for the diagnosis of IDA in IBD.

CONCLUSION

The results suggest that serum transferrin receptor is a useful parameter for the diagnosis of iron deficiency in inflammatory bowel disease, in particular, the transferrin receptor/ferritin ratio with a cut-off level > or = 350.

Prevalence of celiac antibodies in children with neurologic disorders

Neurologic complications are a recognized but unusual manifestation of celiac disease (CD) in adults and children. The use of antigliadin and antiendomysial antibodies in screening has revealed the frequency of CD among symptom-free individuals to be high. Recently, a high frequency (57%) of antigliadin antibodies was demonstrated in adult patients with neurologic dysfunctions of unknown cause. We investigated the yield of screening for CD in children with common neurologic disorders. One hundred sixty-seven children, 1-16 years of age, were included in the study: 41 with migraine headaches, 39 with attention-deficit disorder with or without hyperactivity, 36 with epileptic disorders, and 51 with hypotonia and motor abnormalities. Positive IgG antigliadin antibodies were evident in 22 children (13%) in the study group compared with three children (9%) in the control group. However, in all children, negative IgA and endomysial antibodies were observed; thus duodenal biopsies were not performed. Contrary to studies performed in adults, these results did not demonstrate any relationship between common neurologic disorders without a specific diagnosis during childhood and CD. Thus screening for CD does not need to be routinely included in the diagnostic evaluation of children with these disorders.

Chronic hepatitis B virus in children in Israel: clinical and epidemiological characteristics and response to interferon therapy

OBJECTIVE

To describe the clinical and epidemiological features of hepatitis B virus infection in Israeli children, and to evaluate their response and compliance to therapy.

METHODS

We retrospectively studied 51 patients (34 males, 17 females), aged 2-18 years, from several medical centers in Israel.

RESULTS

Of the 51 patients, 38 with elevated transaminase, positive hepatitis B e antigen and/or HBV DNA, and histologic evidence of liver inflammation were treated. Interferon was administered by subcutaneous injections three times a week for 3-12 months (dosage range 3-6 MU/m2). Only 16% were native Israelis, while 78% of the children were of USSR origin. A family history of HBV infection was recorded in 25 of the 51 patients (9 mothers, 16 fathers or siblings). Five children had a history of blood transfusion. The histological findings were normal in 3 patients, 24 had chronic persistent hepatitis, 14 had chronic active hepatitis and 2 had chronic lobular hepatitis. Five children also had anti-hepatitis D virus antibodies. Twelve of the 38 treated patients (31.5%) responded to IFN completely, with normalization of the transaminase levels and disappearance of HBeAg and HBV DNA. In no patient was there a loss of hepatitis B surface antigen. The main side effects of IFN were fever in 20 children, weakness in 10, headaches in 9, and anorexia in 6; nausea, abdominal pain, and leukopenia were present in 3 cases each. The response rate was not affected by age, country of origin, alanine/aspartate aminotransferase levels, or histological findings. However, a history of blood transfusion was a predictor of good response, 60% vs 27% (P < 0.05).

CONCLUSIONS

We found IFN to be a safe and adequate mode of treatment in children with chronic HBV infection, regardless of their liver histology and transaminase levels. Therefore, in view of the transient side effects associated with this drug, we recommend considering its use in all children with chronic hepatitis B.

Lack of association between smoking and Crohn's disease but the usual association with ulcerative colitis in Jewish patients in Israel: a multicenter study

OBJECTIVE

The association between smoking and inflammatory bowel disease (IBD) is well established, but data in Jewish patients in Israel were discrepant. The aim of this study was to examine the smoking habits of Jewish IBD patients in Israel in a large scale, multicenter study.

METHODS

Patients with established IBD aged 18-70 yr were interviewed in relation to smoking and other habits. Two controls (one clinic and one neighborhood control matched by age, sex, community group, and education) were sought for each subject.

RESULTS

A total of 534 patients (273 ulcerative colitis [UC], and 261 Crohn's disease [CD]), along with 478 clinic controls and 430 neighborhood controls, were interviewed. There was no significant difference in the smoking habits between CD patients and their controls. Of patients with CD, 24.5% were current smokers, as compared to 19.9% of clinic controls and 25.2% of neighborhood controls (NS). The odds ratio for CD in current smokers was 1.30 (95% confidence interval 0.85-1.99) versus clinic controls, and 0.96 (0.63-1.46) versus neighborhood controls. There were also no significant differences in the proportion of ex-smokers between the groups. Only 12.9% of UC patients were current smokers versus 21.9. % Clinic controls, and 26.4% community controls (p<0.005). The proportions of ex-smokers were higher in UC patients 29.7% versus 25.9%, and 19.5% in their respective controls (p<0.001 vs. community controls). No significant differences were found in the proportions of never-smokers between IBD patients and controls. All the above trends were similar in four different parts of the country. The proportion of current smokers in UC decreased with the extent of disease (19.7% in proctitis, 13.6% in left-sided, and 4.5% in total colitis) (p<0.05). Patients with UC were more likely to be light smokers(1-10 cigarettes/day), whereas patients with CD were more likely to be moderate smokers (11-20 cigarettes/day) in comparison to their controls.

CONCLUSIONS

The lack of association between smoking and CD has now been established in Jewish patients in Israel. The association was found in UC. The stronger genetic tendency in CD may contribute to this discrepancy.

Superoxide dismutase activity in children with chronic liver diseases

BACKGROUND/AIMS

Liver disease in infancy has multiple etiologies. As reactive oxygen intermediates are involved in several types of tissue damage, we have investigated whether different forms of liver disease in infancy are associated with increased free radical generation, using an indirect approach in which superoxide dismutase (a free radical scavenger) activity is determined in the liver tissue.

METHODS

A total of 48 liver biopsies performed at diagnosis were evaluated retrospectively. Nine infants had biliary atresia, eight Alagille syndrome, seven alantitrypsin deficiency and 12 cryptogenic hepatitis. As controls we studied 12 biopsies with normal histology obtained from seven children with portal vein thrombosis and five children who underwent biopsy for management reason but had no liver disease. Superoxide dismutase activity in liver biopsy specimens was measured using the cytochrome C method by spectrophotometry and expressed as U SOD/mg protein.

RESULTS

Superoxide dismutase activity was significantly increased in biliary atresia (1.25 +/- 0.56 U SOD/mg protein, p<0.0001) and Alagille syndrome (1.31 +/- 0.56 U SOD/mg protein, p<0.0001) as compared with al-antitrypsin deficiency (0.75 +/- 0.3 U SOD/mg protein), neonatal hepatitis (0.72 +/- 0.37 U. SOD/mg protein) and normal controls (0.4 +/- 0.7 U. SOD/mg protein). The highest level of SOD activity was found, however, in control children with portal vein thrombosis (2.09 +/- 0.96 U SOD/mg protein; p<0.0001 as compared to the other groups).

CONCLUSION

Superoxide dismutase, a key enzyme in free radical protection, is increased significantly in the liver tissue of infants with cholestatic liver disease due to bile duct damage and in children with portal vein thrombosis, suggesting that products of free radical reactions are involved in the pathogenesis of these disorders.

Gallbladder contraction in familial dysautonomia

The impaired function of the autonomic nervous system in patients with familial dysautonomia (FD) is frequently associated with gastrointestinal dysfunction. This study sought to determine whether gallbladder contraction is also affected in these patients. Nine consecutive patients with FD were assessed by real-time ultrasonography for gallbladder volume and calculated percentage of gallbladder contraction before and 45-60 min after a 50 g fatty meal, and compared with nine healthy control patients, matched for age and gender. Gallbladder volume before the fatty meal was found to be larger in healthy controls than in FD patients (25.4+/-9.5 and 15.4+/-7.4 ml3, respectively; p = 0.024). No significant difference was demonstrated between the groups after the fatty meal (controls: 12.1+/-6.0; FD: 9.0+/-6.6 ml, respectively) and the calculated percentage of gallbladder contraction was similar in both groups (controls: 53.4+/-16.6; FD: 44.8+/-18.8%). These results indicate that gallbladder function in FD patients does not differ from the general population and preventive measures for gallstone formation are not required.

The contribution of endoscopy and biopsy to the diagnosis of periampullary tumors

BACKGROUND AND STUDY AIMS

Endoscopy and biopsy from a suspicious Vater's papilla may establish an early preoperative diagnosis of a periampullary tumor. However, information regarding the diagnostic accuracy of this procedure is limited and variable. The aim of the present study was to evaluate retrospectively the accuracy of this procedure compared to that of other diagnostic methods.

PATIENTS AND METHODS

Among 928 patients referred to our institute for endoscopic retrograde cholangiopancreatography (ERCP), a suspicious Vater's papilla was seen in 28. In each case comparison was made between the pre-ERCP clinical diagnosis, endoscopic appearance, histologic interpretation of endoscopic biopsies, and the final diagnosis. Two patients in whom a final diagnosis was not available were excluded from the study.

RESULTS

A final diagnosis of an ampullary or periampullary carcinoma was established in 17 patients (65%), a carcinoma within an adenoma of the papilla in three patients (12%), and adenoma and a metastatic gallbladder carcinoma in one patient each. The remaining four patients (15%) were finally diagnosed as having "pseudotumors" (due to choledocholithiasis). Eight (38%) of the 21 patients with ampullary or periampullary neoplasm also had gallstones. A pre-ERCP diagnosis (by clinical evaluation and non-invasive imaging) of tumor versus choledocholithiasis was accurate in only 65% of all 26 patients. In these, the diagnostic accuracy of endoscopic appearance and endoscopic biopsy was 77% and 85%, respectively. Regarding the 21 patients with carcinomas, the diagnosis by endoscopic appearance was more accurate than that by endoscopic biopsy (90% vs 81%). Unlike the positive predictive values, the negative predictive values for malignancy were weak: 33% for the endoscopic appearance and 50% for the endoscopic biopsy.

CONCLUSIONS

Because of a high incidence of concurrent cholelithiasis, many patients with a periampullary tumor seen during ERCP are misdiagnosed earlier (by clinical evaluation and non-invasive imaging) as having choledocholithiasis only. However, the accuracy of endoscopy and biopsy is also limited. This limitation must be considered when evaluating the optimal management of patients with suspected periampullary tumor.

The effect of colonoscopy on tumor markers

As preoperative elevated serum levels of carcinoembryonic antigen (CEA) and CA19.9 are markers for bad prognosis in colorectal cancer patients, it is important to decide whether preoperative total colonoscopy would make a significant change in their serum levels. CEA and CA 19.9 were evaluated in three groups of patients before and after colonoscopy. The groups comprised the following: Group A, 20 patients with colorectal cancer; Group B, 17 patients with colorectal polyp of > or = 1-cm diameter; Group C, 16 patients with no colorectal pathology. CEA serum levels were found to be significantly lower after colonoscopy in all groups. CA19.9 was found to be significantly lower after colonoscopy only in Group B; it did not reach significance in Group A and was found not to be significantly higher in Group C.

Methotrexate in chronic active Crohn's disease: a double-blind, randomized, Israeli multicenter trial

BACKGROUND

At present only one large controlled study has indicated that parenteral methotrexate may be effective in chronic active Crohn's disease (CD).

AIM

To evaluate the effectiveness of oral methotrexate in chronic steroid-dependent CD.

PATIENTS

Patients with active CD, who have received steroids and/or immunosuppressives for at least 4 months during the preceding 12 months and with a current Harvey-Bradshaw index of > or = 7 were studied.

METHODS

Methotrexate (12.5 mg weekly) or 6-mercaptopurine (50 mg daily), or placebo were given during the 9 months of the trial in addition to steroids and 5-aminosalicylic acid as clinically indicated.

RESULTS

Eighty-four patients were included (methotrexate, 26 patients; 6-mercaptopurine, 32 patients; placebo, 26 patients). The proportion of patients entering first remission as well as the proportions of patients relapsing after first remission were not significantly different between the groups. The mean Harvey-Bradshaw index and the mean monthly steroid dose were also similar. However, when each patient was evaluated as his or her own control, the reduction in steroid dose, the general well being, and the reduction in abdominal pain were significantly better in the methotrexate treated patients.

CONCLUSIONS

Methotrexate at a weekly oral dose of 12.5 mg was found to be moderately better than 6-mercaptopurine and placebo in patients with chronic active CD.

Hepatic artery resistance index can predict early death in children with biliary atresia

Hepatic artery resistance index has been measured by ultrasonography Doppler and has been found to predict rapid deterioration and death in children with biliary atresia. Clinical, biochemical, ultrasonographic, and outcome data were collected prospectively and retrieved on 32 patients with resistance index of > or = 1.0 (group A). These were compared with the same data for 32 age- and sex-matched patients with biliary atresia and a resistance index of < 1.0 (group B). Group A was found to have significantly worse liver function tests than group B. In group A, all patients died (n = 11) or underwent transplantation (n = 21; of whom 4 died) compared with only 2 patients who died in group B and 4 patients who underwent transplantation without fatality. Survival at 2 years was 52% in group A v 94% in group B. It is suggested that regular ultrasonography Doppler examination in patients with biliary atresia can detect a group with a resistance index of > 1.0 who have a very high risk of early mortality. Such patients require early evaluation and listing for transplantation. Those listed for liver transplantation on other grounds require ultrasonography examinations every 2 to 3 months with immediate upgrading of the priority of those patients found to have a resistance index of > or = 1.0.

Type IV 3-methylglutaconic (3-MGC) aciduria: a new case presenting with hepatic dysfunction

We describe a new patient with type IV 3-methylglutaconic aciduria who presented with a clinical picture simulating a primary hepatic disorder subsequently followed with progressive neurologic impairment and an magnetic resonance imaging picture of Leigh syndrome.

Incidence of recurrent intussusception following barium versus air enema

The aim of this study was to determine whether using air enema for acute intussusception is related to a higher rate of recurrence than other methods of treatment. A 10-y (1986-95) retrospective study was performed in a university-affiliated paediatric division. The overall recurrence rate for 97 patients with acute intussusception was 7.8% (10% of whom were treated non-surgically). There were no recurrences following the surgical treatment. In matched groups of patients, no risk factors were found for recurrence following air vs barium enema.

Esophagogastric mucosal junction (EGMJ): its location as measured by endoscopy

The "esophageal" length, i.e., incisors-esophagogastric mucosal junction distance, was measured endoscopically in 758 patients, retrospectively. Two hundred twenty-five additional patients were evaluated prospectively and their height and weight were measured. All patients were analyzed according to their age and sex, indication for the procedure, and its endoscopic diagnosis. "Esophageal" length was found to be significantly longer in male patients. Fifty-three percent of the examined population had "esophageal" length shorter than 38 cm, whereas 99% of patients with normal endoscopy had "esophageal" length of 38-40 cm. Linear correlation was found between "esophageal" length and height, but not with weight. Patients with dyspepsia and esophagitis had a "shorter" esophagus, whereas those with tumors of the upper gastrointestinal tract and those with duodenal ulcer had a "longer" esophagus.

Orthotopic liver transplantation reverses the adverse nutritional changes of end-stage liver disease in children

The changes in growth and body composition after orthotopic liver transplantation (OLT) were studied in 61 children [median age at OLT 3.49 y (range: 0.04-14.5 y), 26 boys and 35 girls] who had survived > or = 1 y post-OLT. Height, weight, midarm circumference (MAC), triceps skinfold thickness (TSF), and subscapular skinfold thickness (SSF) were measured at OLT, 3 and 6 mo later, then annually up to 5 y. SD scores (SDS) were derived from population standards. Results are reported as mean SDS +/- SEM. At OLT the children were short and malnourished (height: -0.98 +/- 0.22; weight -0.82 +/- 0.18; MAC: -1.77 +/- 0.21; TSF: -1.27 +/- 0.17; SSF: -1.49 +/- 0.17). By 3 mo post-OLT, there was a sustained improvement in MAC (-0.73 +/- 0.22), TSF (-0.48 +/- 0.18), and SSF (-0.50 +/- 0.18). Weight SDS (-0.48 +/- 0.20) improved by 6 mo without significant change in height SDS. The three children with Alagille syndrome were smaller (height, weight, and MAC) than children with other diagnoses but did show catch-up growth. Fulminant hepatic failure was not associated with growth failure before or after OLT. Infants (n = 14) were smaller and more malnourished at OLT (smaller skinfold thicknesses and lower weight SDS) than those who received transplants at an older age. By 1 y post-OLT, the only persisting difference was in TSF. Abnormal liver function at 1 y post-OLT (n = 8) and repeated episodes of steroid-treated rejection (n = 13) were associated with worsening height and weight SDS. The use of tacrolimus for graft salvage from rejection (n = 6) was not associated with growth failure. In conclusion, end-stage liver disease has a more adverse effect on MAC, TSF, and SSF than on height and weight, but a marked and rapid improvement occurred post-OLT. Children who were most severely malnourished and growth restricted at the time of OLT showed the greatest catch-up growth after OLT.

Superoxide dismutase activity in Helicobacter pylori-positive antral gastritis in children

Reactive oxygen metabolites have been implicated in gastric mucosal injuries. Superoxide dismutase, a scavenger of superoxide radical, is a key enzyme in gastric mucosal protection against several damaging factors. This study was aimed at investigating the relationship of superoxide dismutase activity to Helicobacter pylori-induced antral gastritis in children. Two groups of 11 children each, one positive and the other negative for Helicobacter pylori, were studied. Biopsies from the antrum and corpus were obtained for evaluation of Helicobacter pylori by CLOtest and histology as well as for superoxide dismutase activity (cytochrome c method). Erythrocytic and serum superoxide dismutase levels were determined as well. Superoxide dismutase activity was significantly higher only in the antrum of children with Helicobacter pylori-induced antral gastritis. There was no significant difference in superoxide dismutase activity in the corpus, erythrocytes, or serum of both groups. These findings may suggest a pathogenic relationship between the presence of Helicobacter pylori and oxygen radicals in inducing antral mucosal injury.

Increased prevalence of diabetes-related autoantibodies in celiac disease

Forty-four nondiabetic patients with celiac disease (CD) were examined for the presence of insulin-dependent diabetes mellitus (IDDM)-related autoantibodies. Islet cell antibodies (ICA) were detected in 2 of 44 (4.5%). None of the 200 age- and sex-matched healthy controls was ICA positive (p < 0.05). Competitive anti-insulin antibodies (CIAA) were detected in 1 of 44 (2.5%) patients. First-phase insulin reserve (FPIR), stimulated insulin reserve (SIR), and glycosylated hemoglobin (GHB) levels were normal in the autoantibody-positive patients. Our data suggest that, like first-degree relatives of IDDM patients, CD patients are characterized by an increased prevalence of diabetes-related autoantibodies. Further follow-up is needed to determine whether the presence of these autoantibodies in nondiabetic CD patients predicts future IDDM.

Superoxide dismutase activity in duodenal ulcer patients

OBJECTIVE

To investigate whether duodenal ulcer (DU) is associated with increased free radical generation at the site of ulceration and to attempt, indirectly, to confirm the hypothesis by determining activity of free radical scavengers such as superoxide dismutase (SOD).

STUDY DESIGN

Prospective study comparing SOD activity in biopsies taken from the ulcer edge, and antrum in DU patients before and after one month of treatment to SOD activity in biopsies from the duodenal bulb and antrum in a control population.

SETTING

Institute of Gastroenterology of a university hospital.

STUDY POPULATION

Twenty-five patients with DU. The diagnosis was confirmed by endoscopy.

MEASUREMENTS

SOD activity in biopsy specimen, red blood cells (RBC) and serum was measured using the cytochrome c method by spectrophotometry and expressed as U SOD/mg protein. Helicobacter pylori was diagnosed by the rapid urease test (CLO test) from antral biopsies.

RESULTS

SOD activity was markedly depleted in the ulcer edge (2.78 +/- 0.9 U SOD/mg protein) as compared to the same patients after one month of treatment (4.59 +/- 2.2 U SOD/mg protein) (P = 0.05) and to biopsies from the duodenal bulb in control population (6.7 +/- 2.4 U.SOD/mg protein) (P = 0.05). SOD activity in the antrum of both groups was similar. There was no difference in SOD activity in RBC and serum of both groups.

CONCLUSION

Products of free radical reactions are implicated in the pathogenesis of DU disease. SOD, which is a key enzyme in gastric mucosal protection, is depleted significantly in the ulcer edge compared with controls and increases after healing. However, it is not clear whether this abnormality in oxygen free radical metabolism reflects, rather than causes, the condition which characterizes DU.

Methotrexate in chronic active ulcerative colitis: a double-blind, randomized, Israeli multicenter trial

BACKGROUND & AIMS

Uncontrolled studies have suggested that methotrexate may be effective in patients with active ulcerative colitis. The aim of this study was to evaluate the effectiveness of oral methotrexate in chronic steroid-dependent ulcerative colitis in a randomized, double-blind multicenter trial.

METHODS

Patients with active ulcerative colitis who have received steroids and/or immunosuppressives for at least 4 months during the preceding 12 months with a current Mayo Clinic score of > or = 7 were included in the study. Methotrexate (12.5 mg) or placebo was added to their treatment once weekly for 9 months.

RESULTS

Sixty-seven patients were included (methotrexate, 30 patients, placebo, 37 patients). The proportion of patients entering first remission (methotrexate, 46.7%; placebo, 48.6%), the time to reach first remission (methotrexate, 4.1 +/- 1.9 months; placebo, 3.4 +/- 1.7 months), as well as the proportions of patients having a relapse after first remission (methotrexate, 64.3%; placebo, 44.4%) were not significantly different between the two groups. The mean Mayo Clinic score, the mean monthly steroid dose, and the proportion of abnormal laboratory results during the study were also similar.

CONCLUSIONS

Methotrexate at a weekly oral dose of 12.5 mg was not found to be better than placebo in the induction or maintenance of remission in patients with chronic active ulcerative colitis.

A controlled double blind multicenter study of the effectiveness of 5-aminosalicylic acid in patients with Crohn's disease in remission

We evaluated the efficacy of an oral formulation of 5-amino-salicylic acid in lowering the relapse rate after remission of Crohn's disease. Included were 59 patients who had proven Crohn's disease of at least 1 year's duration, and who had been in continuous remission for at least 6 months, while taking only 5-aminosalicylic acid or no therapy at all. Remission was defined as a Harvey Bradshaw index score (Softley-Clamp modification) of < 4. Patients were given coded mesalzaine 250 mg or placebo tablets (2 x 2 day). They were seen at 0, 1, and 2 months, and then every 2 months until the end of the study. Trial endpoints were 1 year of follow-up, or clinical relapse results. After randomization, 31 patients were included in the placebo arm, and 28 in the treatment arm. There were no significant differences between the two groups at entry. Ten patients were withdrawn from the trial because of noncompliance, loss of follow-up, or headache. There were more clinical relapses in the placebo arm (15 patients, 55%) than in the treatment arm (6 patients, 27%) (p < 0.05). Mesalazine had a significant advantage over placebo (p < 0.05) only in the subgroups of patients with ileal Crohn's disease and in those older than 30 years. We conclude that mesalazine has a moderate but significant benefit in preventing relapse in Crohn's disease in remission; this occurred only in patients with small-bowel involvement or in those older than 30 years.

[Groove pancreatitis and adenocarcinoma of the pancreatic head]

A mass within the head of the pancreas causing obstructive jaundice is frequently adenocarcinoma, or infrequently focal pancreatitis. Groove pancreatitis is an inflammation of the head of the pancreas which fills the anatomic space between the head of the pancreas on 1 side and the second part of the duodenum on the other. Obstruction from either cause may cause vomiting, abdominal pain, and loss of weight. It is sometimes impossible to differentiate between the 2 conditions clinically. We present 2 women, aged 41 and 42 years, respectively, with recent onset of diabetes mellitus, obstructive jaundice, abdominal pain and severe loss of weight in whom diagnosis was difficult. In 1 repeated fine needle biopsy directly from the mass did not show adenocarcinoma, but she died of the disease a few months later. The other, in whom malignancy was also suspected, recovered from what was retrospectively diagnosed as groove pancreatitis.

Colocutaneous fistula--a rare complication of percutaneous endoscopic gastrostomy

Although the percutaneous endoscopic gastrostomy technique for feeding is a fairly common procedure now, we have not come across a complication such as described below, a probable migration of the tube from the stomach to the colon, without any objective proof for this.