Supplementary Respiratory Therapy Improves Pulmonary Function in Pediatric Patients with Cerebral Palsy: A Systematic Review and Meta-Analysis

BACKGROUND

Despite medical advances, individuals with cerebral palsy (CP) face significant respiratory challenges, leading to heightened hospitalization rates and early mortality among this population. We hypothesize that integrating supplementary respiratory therapy into standard rehabilitation will result in significant improvements in pulmonary function, enhanced respiratory muscle strength, and an overall increase in the quality of life among pediatric patients with CP.

METHODS

A systematic search of literature across five databases was conducted, and random-effects meta-analyses were performed to assess the impact of supplementary respiratory therapy on (a) pulmonary function: forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FVC/FEV1 ratio, peak expiratory flow (PEF), and (b) respiratory muscle strength: maximal inspiratory and expiratory pressure (MIP, MEP), and (c) quality of life. Certainty of evidence was determined by the GRADE assessment.

RESULTS

Analysis of data from 11 eligible randomized controlled trials revealed clinically meaningful changes in pulmonary function. We found a relevant mean difference (MD) in absolute PEF of 0.50 L/s (95% confidence interval (CI): 0.19; 0.82 p = 0.0107). The certainty of the evidence ranged from moderate to high.

CONCLUSIONS

This study presents current evidence on the impact of various supplementary respiratory therapies for CP patients classified under gross motor function classification level I-IV, demonstrating clinically meaningful improvements in pulmonary function and respiratory muscle strength. These improvements suggest the potential for an enhanced quality of life. Our findings hold the promise of serving as a foundational reference for potential revisions to conventional rehabilitation care, incorporating supplementary respiratory therapy.

Beyond the Gut: A Systematic Review and Meta-analysis of Advanced Therapies for Inflammatory Bowel Disease-associated Extraintestinal Manifestations

BACKGROUND AND AIMS

Extraintestinal manifestations are frequent in patients with inflammatory bowel disease and have a negative impact on quality of life. Currently, however, there is no evidence available to determine which drug should be recommended for these patients beyond anti-TNF treatment. We aimed to analyse the frequency of new extraintestinal manifestations and the behaviour of pre-existing extraintestinal manifestations during advanced therapy.

METHODS

We conducted a systematic search on November 15th, 2022, and enrolled randomised controlled trials, cohorts and case series reporting the occurrence and behaviour of extraintestinal manifestations in patients with inflammatory bowel disease receiving advanced therapy (non-TNF inhibitor biologicals and JAK inhibitors). Proportions of new, recurring, worsening, and improving extraintestinal manifestations were calculated with 95% confidence intervals (CIs). The risk of bias was assessed with QUIPS tool.

RESULTS

Altogether, 61 studies comprising 13,806 patients reported eligible data on extraintestinal manifestations. The overall proportion of new extraintestinal manifestations was 8% (95%CI, 6% to 12%) during advanced therapy. There was no significant difference between the frequency of new extraintestinal manifestations during vedolizumab and ustekinumab therapy (11%, 95%CI, 8% to 15% versus 6%, 95%CI, 3% to 11%, p=0.166). The improvement of pre-existing manifestations was comparable between vedolizumab and ustekinumab-treated patients, except for joint involvement (42%, 95%CI, 32% to53% versus 54%, 95%CI, 42% to65%, p=0.029).

CONCLUSION

The proportion of new extraintestinal manifestations was low during advanced therapy. Furthermore, the improvement of pre-existing manifestations was comparable between advanced therapies, except for pre-existing joint manifestations.

Safety Analysis of Preoperative Anti-TNF-α Therapy in Pediatric IBD After Intestinal Resection: A Systematic Review and Meta-analysis

BACKGROUND

Biological agents have transformed the management of inflammatory bowel disease (IBD). However, intestinal resection is still unavoidable in complicated IBD. It is still under debate whether antitumor necrosis factor (TNF)-α is related to higher postoperative complications in children with IBD. Therefore, we aimed to analyze data on preoperative anti-TNF-α and postoperative complications in pediatric IBD.

METHODS

We conducted a systematic literature search in 4 databases for studies that compared the incidence of postoperative complications between children with IBD who received anti-TNF-α treatment within 12 weeks prior to intestinal resection and who did not receive anti-TNF-α before the operation. To analyze this question, pooled odds ratios (ORs) were calculated with 95% confidence intervals (CIs). Odds ratios higher than 1 mean higher complication rate among children treated with preoperative anti-TNF-α, whereas an OR lower than 1 means lower complication rate. The I² value was calculated to measure the strength of the between-study heterogeneity, where a smaller percentage means the lower heterogeneity.

RESULTS

We found 8 eligible articles with 526 pediatric patients with IBD. The primary outcome was the overall complication. The pooled OR of overall complications was 1.38 (95% CI, 0.10-18.76; P = .65; I2 = 34%) in contrast, the OR of infectious and noninfectious complications were 0.59 (95% CI, 0.21-1.69; P = .16; I2 = 0%) and 0.48 (95% CI, 0.18-1.25; p = .09; I2 = 0%), although both showed a nonsignificant result.

CONCLUSION

There is no significant association between preoperative anti-TNF-α therapy and postoperative complications in children with IBD after intestinal resection. However, the evidence is low due to the low number of studies investigating this question.

Hungarian Linguistic, Cross-Cultural and Age Adaptation of Transition Specific Questionnaires in Patients with Inflammatory Bowel Disease

Objective: In the TRANS-IBD clinical trial, the outcomes are measured with selected validated questionnaires. Cross-cultural and age adaptations of the Self-Efficacy Scale for adolescents and young adults (IBD-SES), the Transition Readiness Assessment Questionnaire (TRAQ), and the Self-Management and Transition Readiness Questionnaire (STARx) were performed. Methods: Linguistic and cultural adaptation was carried out with the usage of reliability coefficients (Cronbach's α coefficients, Spearman's rank correlation), and with confirmatory factor analysis (CFA; root Mean Square Error of Approximation [RMSEA], Comparative Fit Index [CFI], and Tucker-Lewis Index [TLI]). Results: 112 adolescents participated in the study (45.5% male, mean age 17 ± 1.98 years). CFA was acceptable in the IBD-SES and the TRAQ. Internal consistency was acceptable in IBD-SES and good in TRAQ (0.729; 0.865, respectively). Test-retest reliability was good in IBD-SES, but below the acceptable threshold in TRAQ (ρ = 0.819; ρ = 0.034). In STARx tools, RMSEA showed poor fit values, CFI and TLI were below acceptable fit values, and internal consistency was not satisfied (0.415; 0.693, respectively), while test-retest reliabilities were acceptable (ρ = 0.787; ρ = 0.788, respectively). Conclusions: Cross-cultural, age-specific adaptation was successfully completed with IBD-SES and TRAQ. Those are comparable to the original validated versions. The adaption of the STARx tools was not successful.

Body composition, physical activity, and quality of life in pediatric patients with inflammatory bowel disease on anti-TNF therapy-an observational follow-up study

BACKGROUND

Poor outcome of inflammatory bowel disease (IBD) is associated with malnutrition. Our aim was to compare body composition (BC) and physical activity (PA) between patients with IBD and healthy controls, and to assess the changes in BC, PA and health related quality of life (HRQoL) in children with IBD during anti-TNF therapy.

METHODS

32 children with IBD (21 with Crohn's disease (CD), (age: 15.2 ± 2.6 years, 9 male) and 11 with ulcerative colitis (UC), (age: 16.4 ± 2.2 years, 5 male) participated in this prospective, observational follow up study conducted at Semmelweis University, Hungary. As control population, 307 children (age: 14.3 ± 2.1) (mean ± SD) were included. We assessed BC via bioelectric impedance, PA and HRQoL by questionnaires at initiation of anti-TNF therapy, and at two and six months later. The general linear model and Friedman test were applied to track changes in each variable.

RESULTS

During follow-up, the fat-free mass Z score of children with CD increased significantly (-0.3 vs 0.1, p = 0.04), while the BC of patients with UC did not change. PA of CD patients was lower at baseline compared to healthy controls (1.1 vs. 2.4), but by the end of the follow up the difference disappeared.

CONCLUSIONS

The fat-free mass as well as PA of CD patients increased during the first six months of anti-TNF treatment. As malnutrition and inactivity affects children with IBD during an important physical and mental developmental period, encouraging them to engage in more physical activity, and monitoring nutritional status should be an important goal in patient care.

Disease Activity Is Associated with Obesity in Newly Diagnosed Pediatric Patients with Ulcerative Colitis

Malnutrition and inflammatory bowel disease (IBD) are interrelated conditions. Our aim was to assess the prevalence of malnutrition, to compare anthropometric parameters in the evaluation of nutritional status in pediatric IBD, and to investigate the association between anthropometric parameters and disease activity indices (AI). Pediatric patients with newly diagnosed IBD recorded between 2010 and 2016 in the Hungarian Pediatric IBD Registry were included in this cross-sectional study. Body weight, body mass index (BMI), weight-for-height, and ideal body weight percent (IBW%) were analyzed. Pearson linear and non-linear correlations and polynomial regression analyses were performed to assess correlation between nutritional status and AI. p-values < 0.05 were considered significant. Anthropometric data of 1027 children with IBD (Crohn’s disease (CD): 699; ulcerative colitis (UC): 328; mean age 13.7 years) were analyzed. IBW% identified more obese patients than BMI both in CD (7.02% vs. 2.28%) and UC (12.17% vs. 5.48%). Significant negative correlation was found among anthropometric parameters and AI in CD. In contrast, polynomial regression analysis revealed a U-shaped correlation curve between IBW% and AI in UC. Our findings show that obesity has a bimodal association with disease activity in pediatric UC. Furthermore, IBW% was more useful to identify obese pediatric patients with IBD.

Selective intraoperative cholangiography should be considered over routine intraoperative cholangiography during cholecystectomy: a systematic review and meta-analysis

Background

Decades of debate surround the use of intraoperative cholangiography (IOC) during cholecystectomy. To the present day, the role of IOC is controversial as regards decreasing the rate of bile duct injury (BDI). We aimed to review and analyse the available literature on the benefits of IOC during cholecystectomy.

Methods

A systematic literature search was performed until 19 October 2020 in five databases using the following search keys: cholangiogra* and cholecystectomy. The primary outcomes were BDI and retained stone rate. To investigate the differences between the groups (routine IOC vs selective IOC and IOC vs no IOC), we calculated weighted mean differences (WMD) for continuous outcomes and relative risks (RR) for dichotomous outcomes, with 95% confidence intervals (CI).

Results

Of the 19,863 articles, 38 were selected and 32 were included in the quantitative synthesis. Routine IOC showed no superiority compared to selective IOC in decreasing BDI (RR = 0.91, 95% CI 0.66; 1.24). Comparing IOC and no IOC, no statistically significant differences were found in the case of BDI, retained stone rate, readmission rate, and length of hospital stay. We found an increased risk of conversion rate to open surgery in the no IOC group (RR = 0.64, CI 0.51; 0.78). The operation time was significantly longer in the IOC group compared to the no IOC group (WMD = 11.25 min, 95% CI 6.57; 15.93).

Conclusion

Our findings suggest that IOC may not be indicated in every case, however, the evidence is very uncertain. Further good quality research is required to address this question.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09267-x.

Prevalence of disorders in preweaned dairy calves from 731 dairies in Germany: A cross-sectional study

The objective of this cross-sectional study was to determine the prevalence of disorders in preweaned calves in 3 regions in Germany, exemplary for structural diversity in dairy farming. A farm visit was performed on a single occasion on 731 dairy farms in the northern, eastern, and southern regions of Germany between December 2016 and July 2019. Farms differed in herd size, geographical location, and management. In the northern region, the farms had a median of 90 milking cows and were often run as full-time family businesses, partly with external workers. The eastern region tended to have larger farms (a median of 251 milking cows), which were often large-scale agricultural enterprises with employees. In the southern region, the farms had a median of 39 milking cows and were often traditional family businesses, some of these being part-time businesses. Clinical examinations were performed on 14,164 preweaned dairy calves (median 12 calves per farm) by trained veterinarians. A complete data set was available for 13,656 calves. Almost half (42.0%) of the evaluated calves were classified as being affected by at least 1 of the common calf disorders. Omphalitis (O, 20.9%; n = 2,876) and diarrhea (D, 18.5%; n = 2,670) were the most frequently recorded diagnoses, whereas respiratory diseases (RD) were observed to a lesser extent (8.7%; n = 1,100). A striking feature was the fact that 7.1% (n = 987) of the calves were affected by more than 1 disorder at the same time (multimorbidity, M). The following combinations of disorders were frequently observed: O and D (n = 596), O and RD (n = 164), and D and RD (n = 140). Disorders such as O and D, as well as M, were predominantly observed in calves aged 2 wk. A gradual increase in the frequency of RD was observed with age. For all disorders except RD, male calves were more often affected than females. Omphalitis was predominantly diagnosed in the summer months, whereas RD, D, and M were more common in the fall. We detected several statistically significant differences in the prevalence of clinical signs and disorders in preweaned dairy calves between the 3 exemplary regions. The prevalence of RD was higher in the south (10.8%) than in the north (8.2%) and east (7.4%). In the north (33.2%), O was observed more frequently than in the other regions (east: 18.9%; south: 10.5%), whereas D was found less frequently in the north (13.8%) than in the east (21.6%) and south (20.0%).

Pathogenesis, clinical characteristics, diagnostics and treatment of bacterial foodborne diseases

Összefoglaló. Az élelmiszer-eredetű megbetegedések igen gyakoriak, bár pontos adatok nem állnak rendelkezésre, mivel az enyhe, gyorsan múló gastrointestinalis tünetekkel a betegek nem fordulnak orvoshoz, vagy nem történik diagnosztikus vizsgálat. Az amerikai Járványügyi és Betegségmegelőzési Központ (CDC) adatai szerint az USA-ban évente 6 lakosból 1 esik át élelmiszer okozta tüneteken. Az ételintoxikációk során a baktérium által termelt toxinok okozzák a tüneteket, közülük a leggyakoribb a Clostridium perfringens, a Staphylococcus aureus és a Bacillus cereus okozta, élelmiszer-eredetű intoxikáció. A nem megfelelően tárolt vagy hőkezelt élelmiszerekben - beleértve a S. aureus által szennyezett anyatejet - ezen baktériumok életképesek maradnak, elszaporodnak, és toxint termelhetnek, illetve toxinjaik megőrzik megbetegítőképességüket. Az étel elfogyasztása után 3-12 órával hányást, hasmenést okoznak. A tünetek többnyire 24 órán belül megszűnnek. A Clostridium botulinum súlyos neurológiai tünetei miatt emelkedik ki a többi toxikoinfekció sorából. C. botulinum okozta tünetekre felnőtteknél házi készítésű konzervek és húskészítmények elfogyasztása után jelentkező gastrointestinalis vagy neurológiai tünetek esetén kell gondolnunk. A Clostridioides difficile szintén a toxinjai révén okoz súlyos, életveszélyes megbetegedést, továbbá az esetek 20-30%-ában számolnunk kell az infekció relapsusával. Növekvő gyakorisága miatt ismernünk érdemes a laboratóriumi és klinikai diagnosztika részleteit és a legmodernebb kezelési lehetőségeket, úgymint megfelelő mintavétel, mintatárolás és -szállítás, tenyésztés, toxinkimutatás, helyes tüneti kezelés, antibiotikumkombinációk, széklettranszplantáció és monoklonálisantitest-kezelés. Orv Hetil. 2020; 161(48): 2019-2028. Summary. Foodborne diseases are quite common, however, accurate data are not available because patients do not visit doctors with mild, rapidly resolving symptoms and diagnostic tests are not performed. The Centers of Disease Control and Prevention (CDC) estimates that, in the USA, 1 in 6 citizens gets food poisoning yearly. Symptoms of intoxication are due to the toxins produced by bacteria, mostly by Clostridium perfringens, Staphylococcus aureus and Bacillus cereus. These bacteria can survive in not properly stored or heated food, including S. aureus contaminated breastmilk. They can multiply and produce toxins causing intoxications. The gastrointestinal symptoms start 3-12 hours after consumption of the contaminated food and resolve in 24 hours. Clostridium botulinum causes severe neurological symptoms that should be suspected after consumption of home-made cans, smoked hams and sausages. The disease caused by Clostridioides difficile is not a foodborne one, but C. difficile causes severe infection via its toxins. Another problem is that C. difficile infection recurs in 20-30% of cases. Due to the increasing incidence of foodborne diseases, it is worth to learn the precise clinical and laboratory diagnostic algorithms including sampling, storage and transportation of samples, cultivation of bacteria and differential diagnosis of these diseases, furthermore the most up-to-date symptomatic and causative treatment options like antibiotic combinations, stool transplantation and monoclonal antibodies. Orv Hetil. 2020; 161(48): 2019-2028.

Factors associated with calf mortality and poor growth of dairy heifer calves in northeast Germany

A cross-sectional study was conducted on fifty German dairy farms to identify risk factors for high mortality and poor growth in calves. Between 2012 and 2014, farm visits took place and a questionnaire on farm management practices was completed by in-person interview. In addition, heart girth measurements of calves around weaning were performed to estimate average daily weight gain. Furthermore, blood and faecel samples of calves were collected and a score addressing calf welfare was determined. The epidemiological associations between risk factors and high mortality and poor growth were estimated using two regression models. The factors significantly associated with high calf mortality (> 5%) were a high rate of calves with failure of passive transfer (> 25%) and the metaphylactic use of halofuginone lactate. A small amount of concentrates consumed around weaning, relocating calves more than twice until weaning and a low incidence risk of milk fever (< 5%) were found to be significantly associated with poor growth (median: 675 grams). Although the fifty farms cannot be considered as a representative sample for North-East Germany, the results indicate that the farm management has a big impact on growth and survival of dairy calves and needs to be addressed more thoroughly when raising the future dairy cow.

Altered mucosal expression of microRNAs in pediatric patients with inflammatory bowel disease

INTRODUCTION

MicroRNAs (miRs) came recently into focus as promising novel research targets offering new insights into the pathogenesis of inflammatory bowel diseases (IBD).

AIMS

The aim of our study was to identify a pediatric IBD (pIBD) characteristic miR profile serving as potential Crohn's disease (CD) and ulcerative colitis (UC) specific diagnostic pattern and to further analyze the related target genes.

METHODS

Small RNA sequencing was performed on inflamed and intact colonic biopsies of CD, and control patients. Selected miRs were further investigated by RT-PCR, complemented with an UC group, in order to address the differential diagnostic potential of miRs in the two IBD subtypes. To analyze network connection of differentially expressed miRs and their target genes MiRTarBase database and previous transcriptome sequencing data from pediatric patient groups were used.

RESULTS

Sequencing analysis identified 170 miRs with altered expression. RT-PCR analysis revealed altered expression of miR-31, -125a, -142-3p, and -146a discriminating between the inflamed mucosa of CD and UC. In the intact mucosa of CD patients the expression of miR-18a, -20a, -21, -31, -99a, -99b, -100, -125a, -126, -142-5p, -146a, -185, -204, -221, and -223 was elevated compared to the controls. The expression of miR-20a, -204 and -221 was elevated exclusively in the intact region of CD patients compared to the controls. Enrichment analysis identified main IBD-related functional groups.

CONCLUSIONS

We demonstrated a characteristic colonic miR pattern in pIBD that could facilitate deeper understanding of the pathomechanism of IBD and may serve as a diagnostic tool.

Seasonal variability of vitamin D and bone metabolism in infliximab-treated paediatric Crohn's disease

BACKGROUND

Paediatric Crohn's disease patients suffer from several complications, including low bone mineral density and inadequate serum levels of 25-hydroxy vitamin D.

AIMS

The aim of this prospective study was to address the effect of infliximab therapy on bone metabolism, bone mineral density and vitamin D homeostasis. The seasonal variability of serum vitamin D levels in relation to infliximab treatment was also analysed.

METHODS

Serum osteocalcin and beta-crosslaps (markers of bone metabolism), seasonal variability of vitamin D, and bone mineral density were assessed and followed throughout the yearlong treatment regimen of infliximab in 50 consecutive paediatric patients with moderate to severe Crohn's disease.

RESULTS

Bone forming osteocalcin levels were significantly (p<0.001) increased during infliximab therapy. In contrast, no significant changes in beta-crosslaps and vitamin D levels were observed. Vitamin D levels were significantly different when the summer and winter periods were compared at week 0 (p=0.039); however, this difference was not detected after one year of infliximab therapy. Despite the beneficial clinical effect of infliximab, there was no significant change in bone mineral density Z-scores after one year of treatment.

CONCLUSION

Infliximab may beneficially affect bone homeostasis. Moreover, seasonal variability in vitamin D levels observed prior to initiation of infliximab treatment was diminished after one year of treatment.

Autoregressive cross-lagged models of IMPACT-III and Pediatric Crohn's Disease Activity Indexes during one year infliximab therapy in pediatric patients with Crohn's disease

BACKGROUND

Quality of life (QoL) is an important outcome measure in the evaluation of therapies for inflammatory bowel disease. The primary aim of this study was to determine the effect of one year infliximab treatment on QoL and clinical parameters in pediatric patients with Crohn's diseases (CD).

METHODS

Our prospective study involved 51 children with conventional therapy resistant, severe CD (mean age: 15.25years, range: 11-18years). Infliximab was given according to the protocol (5mg/kg, at weeks 0, 2, 6 and every 8weeks). During the infliximab courses QoL of patients was evaluated by IMPACT-III questionnaire at weeks 0, 6, 30 and 53. At the same time, the Pediatric Crohn's Disease Activity Index (PCDAI) score was calculated. Moreover, serum C-reactive protein (CRP), serum platelets and serum albumin were followed up. Auto-regressive, cross-lagged models were used to assess relation between QoL and the clinical parameters.

RESULTS

The initial IMPACT-III scores [median, percentile 25-75 (pc 25-75) at week 0: 115, 102.5-130.25] increased significantly (p<0.001) following infliximab therapy at week 54 (median: 141.5, 124.5-153.75). Clinical and laboratory parameters also improved significantly (p<0.001). Auto-regressive regression coefficients (β value) were significant between each variable over time. The strongest cross-lagged relations were observed between IMPACT-III and serum albumin, IMPACT-III and platelets. Reliability test of IMPACT-III revealed an excellent level of internal consistency (Cronbach's alpha=0.931).

CONCLUSION

Infliximab treatment has beneficial clinical effect which is confirmed by decrease of PCDAI and increase of IMPACT-III. Autoregressive regression analysis showed regression relation between IMPACT-III and PCDAI and laboratory parameters.

Incidence and paris classification of pediatric inflammatory bowel disease

New epidemiological data suggest that the incidence of inflammatory bowel disease (IBD) is increasing. As a result the burden of disease accounts for more strains to the health care system. The clinical variability queries whether disease characteristics are related to clinical outcome. Our aim was to delineate the latest results of incidence trends in pediatric IBD and to compare the first experiences with Paris Classification. Incidence of pediatric IBD has been increasing in Western Europe and in Eastern Europe. To better characterize IBD, Paris Classification was introduced and validated recently. Ileocolonic involvement is the most characteristic disease location in Crohn's disease (CD) based on applying Paris Classification. The rate of perianal disease and complicated behaviour in CD was similar. It is of interest that CD patients with colonic involvement were less likely to have stricturing disease compared with patients with ileal involvement. In addition, pancolitis dominated in ulcerative colitis (UC). However, most countries lack prospective, nationwide epidemiological studies to estimate incidence trends. This review emphasizes the importance of nationwide registries that enroll all pediatric IBD cases serving reliable data for "everyday practice." These first reports have shown that Paris Classification is a useful tool to determine the pediatric IBD phenotype.

[Genetic and epigenetic aspects of celiac disease]

Genetic background of coeliac disease has been subjects to intensive research since decades. However, only results of HLA phenotyping have been taken over to routine clinical practice. Meanwhile, data on the role of epigenetical factors in the manifestation of diseases have been emerging. In coeliac disease, there are several questions both in the fields of genetics and epigenetics yet to be answered. In this review, a cross section of current knowledge on these issues is presented with special interest regarding the future clinical applications.

Frequency and characteristics of granulomas in 368 pediatric patients with Crohn’s disease

Introduction: Epitheloid granulomas are one of the best histological criteria for distinguishing Crohn’s disease from other inflammatory bowel diseases. However, the role of granuloma in the pathogenesis and clinical characteristics of Crohn’s disease is unclear. Aim: The aim of the present study was to evaluate the frequency of granulomas and their association with clinical characteristics using the database of the Hungarian Pediatric Inflammatory Bowel Disease Registry. Method: Three hundred and sixty-eight children with Crohn’s disease were registered between January 1st, 2007 and December 31st, 2010. Results: The frequency of granulomas was 31.4% (111/353) at diagnosis. Isolated granuloma in the upper gastrointestinal tract was detected in 2.5% of patients, while those in the terminal ileum was found in 5% of patients. There was no difference in location, behavior and disease activity indexes between patients with and without granulomas. Need for immunomodulators and biological therapy was similar in the two groups in the first year of diagnosis. Conclusions: The frequency of granulomas in this cohort was comparable to the frequency reported in other studies. Interestingly, granulomas in the terminal ileum or upper gastrointestinal tract contributed to the diagnosis of Crohn’s disease in one of 13 children. These data indicate that multiple biopsies from multiple sites are essential for the diagnosis of pediatric Crohn’s disease. Orv. Hetil., 154 (43), 1702–1708.

Flow cytometry technique for analysing Leishmania promastigote phagocytosis by human polymorphonuclear leucocytes and monocytes

In this study, we developed a flow cytometry technique for studying Leishmania (L.) mexicana phagocytosis by human polymorphonuclear leucocytes (PMNs) and monocytes. Leishmania promastigotes are elongated in shape and flagellated. This influences the light scatter when phagocytosis is measured by flow cytometry. Accordingly, we developed an oxidative burst method for measuring the phagocytic process. As this is an indirect marker of phagocytosis, we used confocal, light and electron microscopy to verify that promastigotes were, indeed, internalized by the phagocytes. For both PMNs and monocytes, the optimal conditions for achieving high sensitivity in flow cytometry detection were 5% pooled human serum and 15 min. incubation time. Incubations at 35, 37 and 39°C were also equally efficient for both PMNs and monocytes. Optimal parasite ratios were 10 parasites per PMN and 20 parasites per monocyte. Under these conditions, Leishmania were readily phagocytosed by human PMNs and monocytes and the effects of other influences, such as treatment, would be readily detectable. This indicated that these cells may play a role in the immune response against Leishmania.

Analysis of infliximab treated pediatric patients with Crohn disease in Hungary

A terápiarezisztens, súlyos Crohn-beteg gyermekek kezelésére új lehetőséget nyújt az antitumornekrózis-faktor-α-terápia (infliximab). Jelen vizsgálat célja az infliximabterápia hatékonyságának, mellékhatásainak felmérése hazánkban, a gyógyszer gyermekgyógyászati alkalmazásának engedélyezésétől a 2008. december 31-ig terjedő időszakban. A vizsgált periódusban országosan 23 gyermek részesült infliximabkezelésben. Az indukciós terápia során a betegek 5 mg/ttkg infliximabot kaptak a 0., a 2. és a 6. héten, ahol meghatároztuk a betegség aktivitását jelző mutatót (pediatric Crohn disease activity index). Az infliximabkezelés során kedvező terápiás választ 18 betegnél (81,8%) tapasztaltunk, teljes remisszióba 13 gyermek került (59,1%). A számításokat 22 beteg adatai alapján végeztük. A kezelés 6. hetére a fistulák 70%-a bezárult. A gyógyszerrel összefüggésbe hozható akut infúziós reakció 2 betegnél jelentkezett, egy másik esetben anaphylaxiás reakció alakult ki. Késői mellékhatás három gyermeknél jelentkezett. A vizsgálatunkban részt vett, hagyományos terápiára rezisztens, súlyos Crohn-betegek döntő többségénél az indukciós infliximabterápia hatásosnak bizonyult.

[Vena portae obstruction as a cause of portal hypertension in a child with Turner syndrome]

Cardiovascular and renal malformations are well-known in Turner syndrome. However, gastrointestinal bleeding is less frequent. The possible etiologies of gastrointestinal bleeding in Turner syndrome are intestinal teleangiectasia, inflammatory bowel disease and portal hypertension. The authors report a 3-year-old girl with Turner syndrome who presented with severe gastrointestinal bleeding requiring transfusion. The radiological examination indicated prehepatic portal hypertension as a reason for haematochezia. The liver biopsy demonstrated the anomaly of intrahepatic arteries and veins. In this report we describe a case of congenital portal vein obstruction and we reviewed liver abnormalities associated with Turner syndrome and causes of obstruction of vena portae in childhood.

Effects of polyunsaturated fatty acids on the proliferation of mitogen stimulated bovine peripheral blood mononuclear cells

The present study aimed at analysis of the effects of polyunsaturated fatty acid (PUFA), linoleic acid (LA, C18:2n - 6) and linolenic acid (LNA, C18:3n - 3) on bovine peripheral blood mononuclear cells (PBMC) in vitro. Both mitogen (ConA)-induced proliferative lymphocyte responsiveness during 4 days of culture and eicosanoid (prostaglandin E(2) (PGE(2)) and leukotriene B(4) (LTB(4))) production during 36 h were determined in relation to the absence or presence of various concentrations of LA and LNA (0, 1, 5, 25, 125 and 250 microM). Mitogen-driven proliferative responses of lymphocytes tended to be uninfluenced in the presence of lower concentrations of LA, whereas significant inhibition was observed at the higher concentrations of LA (125 and 250 microM). However, increasing amounts of LNA did not affect the proliferation. ConA stimulation induced a clear PGE(2) response, which significantly decreased in the presence of 250 microM of LA. In addition, increasing amounts of LNA, but not LA, led to a significant decrease in LTB(4) levels. However, The production of LTB(4) did not alter due to mitogenic stimulation. In conclusion, the present study shows that bovine mononuclear cells may functionally be influenced by the presence of PUFA in their environment. Further studies need to be conducted to clarify in vivo consequences of these findings in a situation of PUFA enriched rations in ruminants.

Bovine respiratory syncytial virus infection influences the impact of alpha- and beta-integrin-mediated adhesion of peripheral blood neutrophils

Neutrophil migration into the airways and pulmonary tissue is a common finding in bovine respiratory syncytial virus (BRSV) infections. Although neutrophil trans-endothelial migration in general depends on beta2-integrins, alternative integrins such as the alpha4-integrins have been implicated. In this study, rolling and firm adhesion of peripheral blood neutrophils isolated from healthy and BRSV-infected calves to tumour necrosis factor (TNF)-alpha activated pulmonary endothelium was investigated under flow conditions in vitro. For neutrophils obtained from healthy animals, inhibition of the beta2-integrin reduced firm adhesion to 63% and inhibition of alpha4-integrin to 73% compared with untreated controls. Inhibition of both integrins reduced firm adhesion to 25%. Rolling velocity, which is used as a parameter for integrin involvement in neutrophil rolling, increased 1.7-fold by blocking beta2-integrin and was significantly augmented to 2.5-fold by blocking both alpha4- and beta2-integrins. For neutrophils obtained from BRSV-infected animals, however, rolling velocities at 10 days after infection (p.i.) were not influenced by blocking adhesion of alpha4- and beta2-integrins, indicating that these integrins did not support neutrophil rolling. In addition, the inhibition of firm adhesion by blocking both alpha4- and beta2-integrins was reduced significantly 9 days post-infection, resulting in a residual 68% neutrophil binding at 9 days p.i. Non-blocked firm adherence was not reduced, indicating that binding was achieved by other mechanisms than through alpha4- and beta2-integrins. These results demonstrate an important function for alpha4- and beta2-integrins in rolling and firm adherence of bovine neutrophils, to TNF-alpha-activated endothelium and show the dynamic use of these integrins for adhesion and migration by neutrophils in the course of BRSV infection.

Identification and phenotyping of leukocytes in bovine bronchoalveolar lavage fluid

A method is proposed to identify leukocyte subpopulations in bovine bronchoalveolar lavage fluid by dual-laser flow cytometry. The technique uses several parameters, i.e., exclusion of highly autofluorescent alveolar macrophages and inclusion of leukocytes on the basis of labeling by specific antibodies and light scatter characteristics.

Effects of a single dose of dexamethasone-21 - isonicotinate on the metabolism of heifers in early lactation

Eight Swedish crossbred heifers, about two-and-a-half years old, were given a single intramuscular dose of dexamethasone-21-isonicotinate between nine and 15 days after they had calved and eight similar heifers were left untreated. The treatment had no significant effects on the lipolytic activity of the heifers' fat tissues, and no effect on the concentrations of non-esterified fatty acids and beta-hydroxybutyrate in blood or the triacylglycerol content of the liver. However, there were significant increases in plasma glucose concentrations two days after the injection and in plasma insulin concentrations two and four days after the injection.

Changes in the feed intake, pH and osmolality of rumen fluid, and the position of the abomasum of eight dairy cows during a diet-induced left displacement of the abomasum

During the last six weeks of the dry period, eight Holstein-Friesian cows were fed a restricted amount of grass silage; after calving, a mixture of maize silage and concentrates was offered in a feeding regimen designed to induce a displacement of the abomasum. In the first month after calving, the cows were monitored for the following variables: feed intake and composition, milk production, the position of the abomasum, and the pH and osmolality of the rumen contents. In five of the eight cows, a left displacement of the abomasum occurred between four and 21 days after calving in the absence of other diseases. The displacement was temporary, lasting between five and 36 consecutive hours and one or two days in two of the cows (floaters), and for three or more days in the other three. Before these three cows developed the displacement, their abomasum was 4.3 to 7.9 cm higher, its contents had a higher mean osmolality (+19.2 mosmol/kg), and the ratio of roughage to concentrates in their feed was lower (-0.87) than in the three cows that did not develop clinical signs of a displaced abomasum. There were no significant differences in these variables between the floaters and the healthy cows.

Effect of a Dietary n-6 Polyunsaturated Fatty Acid Supplement on Distinct Immune Functions of Goats

The aim of this study was to investigate whether dietary n-6 polyunsaturated fatty acids (PUFA) alter immune functions as lymphocyte blastogenesis, expression of lymphocyte and monocyte markers, and cell adhesion molecules of the integrin family in goats. Dutch White castrated male goats received a diet either rich in olive oil (control group, n = 4) or rich in corn oil (test group, n = 4) over a period of 3 weeks. The animals in the test group had significantly higher linoleic acid (LA, 18:2n-6) levels in plasma on days 7, 14 and 21 of the diet than control animals. This was also true for washed erythrocyte membranes at day 21. A significant reduction in the percentage of alpha-4 integrin (CD49d) expressing lymphocytes was observed in goats fed LA rich corn oil at day 21. However, no changes were observed in either lymphocyte proliferative responses to ConA and PHA or the expression of other lymphocyte/monocyte markers. In conclusion, feeding corn oil rich in LA caused significant increases in the proportion of LA in the fatty acid composition of plasma and erythrocyte membranes and was accompanied by a significant decrease of the adhesion molecule alpha-4 integrin (CD49d) on lymphocytes but not on monocytes.

[Case report: lymphosarcoma in a cow]

A case of sporadic lymphosarcoma in a cow is described. The animal showed a tumorous mass in the area of the right orbita accompanied by conjunctival oedema. Clinical investigation showed an enlargement of a number of internal and external lymph nodes. Haematological and clinicochemical investigations revealed no alterations besides a slight shift to the right in the white blood picture. Blood serum was negative for antibodies directed against bovine leucosis virus. Necropsy showed leucotic and tumorous alterations in a number of organs.

Feed intake, milk yield, and metabolic parameters prior to left displaced abomasum in dairy cows

As left-displaced abomasum (LDA) often occurs in cows with high contents of fat in the liver (fatty liver), a postpartum fatty liver-inducing regimen was applied to 16 cows. The main interest of the study was whether there were productive or metabolic changes in cows prior to LDA. Therefore, feed intake and milk production were monitored and blood samples were collected from the cows. The LDA occurred in 4 out of 16 dairy cows that were included in the feeding regimen. Compared to cows not developing LDA, LDA-cows had a significantly lower feed intake, 6.5 kg/d less, and milk production, 8 kg/d less, prior to clinical diagnosis of LDA. In the 10-d period preceding clinical diagnosis of LDA, blood concentrations of calcium, glucose, and insulin were significantly lower, whereas blood concentrations of nonesterified fatty acids and beta-hydroxybutyrate, as well as aspartate aminotransferase activities were significantly elevated compared to cows not developing LDA. These preclinical changes may play an important role in the pathogenesis of LDA. It is not certain, however, whether there is a causal association between these parameters and LDA.

Position of the abomasum in dairy cows during the first six weeks after calving

The position of the abomasum in six cows was examined by ultrasonography at regular intervals for six weeks after they had calved. Its position was established by determining the distance between the margin of the left side of the abomasum and the ventral midline at two sites. During the last weeks of pregnancy, the abomasum was positioned in a small region of the left ventral side of the abdominal cavity. At parturition it was positioned high on the left side and then descended. The abomasum was furthest from the midline immediately after parturition. Its position was related to the interval after calving, the cow's feed intake, and the pH and osmotic pressure of the rumen fluid. There was considerable variation between the cows in the position of the abomasum, which was in part due to analytical variation, and in individual cows it had a circadian rhythm.

A direct StyI polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) test for the myophosphorylase mutation in cattle

Myophosphorylase deficiency in cattle is a muscle disease induced by a C-->T point mutation in codon 489 of the myophosphorylase gene, which until now has only been diagnosed in the Charolais breed. The disease seems to be inherited in an autosomal monogenic recessive manner. A calf of double muscled phenotype was suspected of suffering from myophosphorylase deficiency based on typical symptoms, i.e. brown-coloured, transparent urine, occurring after exercise; exercise intolerance; symptoms of pain; and an elevated level of plasma creatine kinase. The presence of the previously described mutation was excluded using a newly developed, improved polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) procedure to identify easily heterozygous carriers and homozygous affected animals.

Studies on the pH value of abomasal contents in dairy cows during the first 3 weeks after calving

The pH value of the abomasal contents in adult cattle is normally constant and has a value of 2. Abomasal contents with pH values of 5.5 and higher could give rise to bacterial fermentation with subsequent gas production. The accumulation of gas is thought to form a key event in the pathogenesis of abomasal displacement. The aim of the present study was to determine the pH values of abomasal contents of dairy cows in the first 3 weeks after calving. The pH of the abomasal contents was, over several days. higher than the pH value of the abomasal juice in mid-lactation cows. The highest pH values were measured on day 14 after calving, thereafter the pH declined. Possible explanations for the rise in the pH value of the abomasal contents are discussed.

[Clinical findings of cows who originated from dairy herds with chronic wasting disease]

Since Spring 1999, a number of dairy farms have reported problems with wasting in cattle. After calving, the physical condition of the cows deteriorated for reasons unknown. Chronic wasting is also associated with disorders such as lameness, abortion, endometritis, mastitis, and respiratory problems. Between April 1999 and March 2000, 19 cows were sent to the Faculty of Veterinary Medicine for further investigation of the chronic wasting. Clinical and pathological investigations resulted in a broad range of diagnoses such as mastitis, abomasal displacement, and claw disorders. The latter, characterised severe laminitis, were predominant and could explain a number of secondary symptoms (inflammation of the bursa, metastatic processes). There were no clear consistent changes compatible with a certain agent, with the exception of one case in which a virus was shown to be the causative agent. The results indicate that wasting disease is not a distinct entity but is characterized by a broad range of diseases in which acute laminitis may be the original problem. The disease profile of chronic wasting disease is very similar to that of 'concrete disease' described by Rebhun in 1995.

Heat-shock protein-specific T-cell responses in various stages of bovine paratuberculosis

Bovine paratuberculosis is characterized by a chronic inflammation of the small intestine, caused by infection with Mycobacterium avium ssp. paratuberculosis. Research regarding diagnostic as well as immunopathogenic aspects of paratuberculosis are hampered by the lack of specific antigens. The aim of the present study was to evaluate the potential of mycobacterial heat-shock proteins, as specific antigens, to measure cell-mediated immune responses during various stages of the disease. In a cross-sectional study, peripheral blood mononuclear cells of 179 cows in different stages of M. avium ssp. paratuberculosis infection, vaccinated against paratuberculosis or noninfected, were used to evaluate lymphoproliferative responses to mycobacterial heat-shock protein of 70 kD (HSP70) and 65 kD (HSP65). In addition, lymphoproliferative responses were measured using purified protein derivate (PPD) preparations from M. avium ssp. paratuberculosis, M. avium and M. bovis as antigens. Responses to HSP70 were higher in the vaccinated animals and in asymptomatic animals that shed the organism in their faeces. Compared with these animals, responses were lower in cows with clinical signs of paratuberculosis. Mycobacterial HSP65 induced less prominent responses compared with HSP70, but showed a similar pattern with regard to the stages of disease. Vaccinated and shedding animals also showed the highest responses to PPD derived from M. avium ssp. paratuberculosis (PPD-P). Observations with short-term cell lines raised to PPD-P and to HSP70 indicated that the similarity between those two antigens was not due to the presence of HSP70 in PPD-P. In conclusion, our study indicated that, as for PPD antigens the mycobacterial heat-shock protein-specific cell-mediated immune responses decrease when comparing the asymptomatic stage to the clinical stage in bovine paratuberculosis. Furthermore, this study shows that HSP70, being a well-defined antigen in comparison with PPD antigens, can be used to monitor cell-mediated immune responses in studies regarding the immunopathogenesis of bovine paratuberculosis.

Reduced lymphoid response to skin allotransplants in cows with hepatic lipidosis

The immune responsiveness of cows with hepatic lipidosis (fatty liver) in comparison to control cows with a normal liver fat content was tested by applying skin allotransplants to the skin of the back of cows on day 3 after parturition. Immunoreactivity was determined by semiquantitative counting of the number of infiltrating lymphocytes in the recipient skin adjacent to the allotransplants during a period of 21 days. There were more invading lymphocytes in samples from control cows than there were in samples from cows with hepatic lipidosis. It was concluded that cows with hepatic lipidosis have a reduced lymphoid response to skin allotransplants.

Antigen-specific immune responses in cattle with inherited beta2-integrin deficiency

The significance of beta2-integrins for the generation of antigen-specific immune responses in vivo was studied employing the bovine model of beta2-integrin deficiency. To that end four cattle with bovine leukocyte adhesion deficiency (BLAD) and healthy age-matched controls were immunized with tetanus toxoid (TT) and rabies virus (RV) vaccines three times in monthly intervals. In addition, two animals with BLAD and three controls received a fourth vaccination 8 months after the start of the study. Proliferative responses of peripheral blood mononuclear cells (PBMC) to the antigens TT and RV as well as specific serum immunoglobulin G (IgG) titers were determined in intervals for up to 10 months after primary vaccination. Proliferative responses of PBMC to TT and RV were substantially lower in cattle with BLAD than in controls, although PBMC from cattle with BLAD were shown to have the capacity to proliferate in the response to the mitogen concanavalin A. Occurrence of antigen-specific IgG titers was delayed and they were considerably lower in cattle with BLAD compared to controls. Finally, treatment of TT- and RV-stimulated PBMC from an immunized control with different concentrations of the anti-CD18 monoclonal antibody R15.7 resulted in a dose-dependent inhibition of lymphocyte proliferation to almost 100%. The results of the present study show that beta2-integrin deficiency leads to delayedand severely impaired immune responsiveness in vivo. The observations that antibody production, although considerably delayed and impaired, does occur and that apparently class-switching takes place in BLAD indicate T-cell reactivity in vivo.

Impaired specific immunoreactivity in cows with hepatic lipidosis

In this study, hepatic lipidosis in cows was experimentally induced by offering an energy surplus during the dry period. Liver triacylglycerol (TAG) was 16% in the experimental group. In the control group fed the same diet in restricted quantities, liver TAG was about 7%. The animals of both groups were vaccinated with tetanus vaccine at Day 3 after parturition. It was demonstrated that the cows with high liver TAG percentages had lower humoral and cellular (P < 0.05) immunological responses compared with the animals with low liver TAG levels at Day 14 after vaccination. The results obtained in the high TAG group support the notion that the frequent occurrence of aspecific infections in cows with hepatic lipidosis may be due to impaired immunoreactivity.

Identification of monoclonal antibodies with specificity to alpha- or beta-chains of beta 2-integrins using peripheral blood leucocytes of normal and bovine leucocyte adhesion deficient (BLAD) cattle

The reactivity of monoclonal antibodies entered in the panels of the Third Workshop on Ruminant Leucocyte Antigens with lymphocytes and monocytes of normal and beta 2-integrin deficient (Bovine Leucocyte Adhesion Deficiency: BLAD) animals was determined by flow cytometry to investigate potential specificities to alpha- or beta-chains of beta 2-integrins. From the 13 monoclonal antibodies that were entered as having specificity for CD11/CD18 antigens, ten were confirmed correct, but three had reactivity with cells from BLAD animals. We conclude that our approach provides an easy way to reliably identify the majority of beta 2-integrin specific monoclonal antibodies.

Allograft rejection in cattle with bovine leukocyte adhesion deficiency

In the present investigation cell-mediated immunity in animals with bovine leukocyte adhesion deficiency (BLAD) was studied by means of skin transplantation experiments. Autograft and allograft behaviour in animals with BLAD was compared with the behaviour of simultaneously transplanted autografts and allografts in healthy controls. Allograft survival time was prolonged in three BLAD cattle (28, 30, and 72 days) compared to six healthy controls (12-14 days). When transplantations were repeated on one animal with BLAD using skin grafts from the same donor, accelerated rejection was observed (allograft survival time decreased from 72 days at primary to 35 days at secondary and to 21 days at tertiary transplantation), suggesting the development of immunological memory. Graft-infiltrating lymphocytes that were obtained from allograft biopsies during the period of rejection, were shown to be from recipient origin (beta 2-integrin negative). Our findings demonstrate that, although prolonged allograft survival is observed in cattle with BLAD, skin allografts are ultimately rejected.

Bovine leukocyte adhesion deficiency--clinical course and laboratory findings in eight affected animals

The clinical course of Bovine Leukocyte Adhesion Deficiency (BLAD) in eight Holstein Friesian cattle is described. Affected animals were presented with a history of poor thriving and recurrent bacterial infections. Five of these animals had to be killed because of severe respiratory disease shortly after admittance. Three affected animals survived calfhood only as a result of frequent antibacterial treatments. At one year of age, failure to thrive and stunted growth were still evident, but infections requiring antibiotic treatments occurred only sporadically. Clinical manifestations of BLAD were found in the digestive system (gingivitis, periodontitis, alveolar periostitis, diarrhoea), the respiratory system and the skin (impaired wound healing, chronic dermatitis). A leukocytosis based on a mature neutrophilia, which persisted during infection-free periods, was observed in all animals. Granulocytes were substantially deficient of beta 2-integrin expression on their membranes. Anaemia, which was noted in four animals, may be related to the Anaemia of Inflammatory Disease Complex (AID). The serum total protein content increased with time and was associated with elevated gamma-globulin levels. We suggest that, at a certain age, animals affected with BLAD are able to cope with environmental agents due to compensatory mechanisms of the immune system.

Bovine leukocyte adhesion deficiency--clinical course and laboratory findings in eight affected animals

The clinical course of Bovine Leukocyte Adhesion Deficiency (BLAD) in eight Holstein Friesian cattle is described. Affected animals were presented with a history of poor thriving and recurrent bacterial infections. Five of these animals had to be killed because of severe respiratory disease shortly after admittance. Three affected animals survived calfhood only as a result of frequent antibacterial treatments. At one year of age, failure to thrive and stunted growth were still evident, but infections requiring antibiotic treatments occurred only sporadically. Clinical manifestations of BLAD were found in the digestive system (gingivitis, periodontitis, alveolar periostitis, diarrhoea), the respiratory system and the skin (impaired wound healing, chronic dermatitis). A leukocytosis based on a mature neutrophilia, which persisted during infection-free periods, was observed in all animals. Granulocytes were substantially deficient of beta 2-integrin expression on their membranes. Anaemia, which was noted in four animals, may be related to the Anaemia of Inflammatory Disease Complex (AID). The serum total protein content increased with time and was associated with elevated gamma-globulin levels. We suggest that, at a certain age, animals affected with BLAD are able to cope with environmental agents due to compensatory mechanisms of the immune system.

Post-mortem findings in calves suffering from bovine leukocyte adhesion deficiency (BLAD)

Five female Holstein-Friesian calves were clinically suspected of suffering from Bovine Leukocyte Adhesion Deficiency (BLAD), because of multiple recurrent infections and persistent leucocytosis. The diagnosis was established by a Polymerase Chain Reaction (PCR) technique, by which a point mutation in the DNA encoding for the CD18 allele was detected. The animals either died spontaneously or were killed because of incurable life threatening infections. Gross post-mortem examination revealed severe and extensive necrotizing processes mainly located in the respiratory and digestive tract. Microscopic examination of these necrotizing lesions demonstrated a lack of extravascularly located polymorphonuclear granulocytes (PMN) although vascular leucocytosis was obvious. However, extensive catarrhal bronchopneumonia was noticed with marked infiltration of the alveoli and bronchioli by PMN. These findings are discussed in relation to the pathogenesis of BLAD.