Practices and perspectives on advanced diagnostic and interventional bronchoscopy among pediatric pulmonologists in the United States

INTRODUCTION

Advanced diagnostic bronchoscopy includes endobronchial ultrasound (EBUS) guided transbronchial lung and lymph node biopsies, CT navigation and robotic bronchoscopy. Interventional bronchoscopy refers to procedures performed for therapeutic purposes such as balloon dilation of the airway, tissue debulking, cryotherapy, removal of foreign bodies and insertion of endobronchial valves [1]. For adult patients, these procedures are standard of care [2, 3]. Despite a lack of formalized training, there are numerous case reports and case series describing the use of advanced diagnostic and interventional bronchoscopy techniques in children. The safety and feasibility of EBUS-TBNA, cryotherapy techniques, endobronchial valves among other techniques have been demonstrated in these publications [1, 4-9].

METHODS

We sought to better understand the current practices and perspectives on interventional and advanced bronchoscopy among pediatric pulmonologists through surveys sent to pediatric teaching hospitals across the United States.

RESULTS

We received 43 responses representing 28 programs from 25 states. The highest bronchoscopy procedure volume occurred in the 0-5 years age group. Among our respondents, 31% self-identified as a pediatric interventional/advanced bronchoscopist. 79% believe that advanced and interventional training is feasible in pediatric pulmonology and 77% believe it should be offered to pediatric pulmonary fellows.

DISCUSSION

This is the first study to characterize current practices and perspectives regarding advanced diagnostic and interventional bronchoscopy procedures among pediatric pulmonologists in the United States. Pediatric interventional pulmonology (IP) is in its infancy and its beginnings echo those of the adult IP where only certain centers were performing these procedures.

An unusual cause of stridor

A 12-month-old infant was referred with a 6-week history of recurrent admissions with worsening stridor. On each previous admission, the stridor responded well, but transiently, to oral dexamethasone. At this presentation, he required high-dependency unit care with high flow oxygen due to marked increased work of breathing.He was born at term, previously well, and up to date with immunisations. There was no significant family history. There were no smokers and two cats at home.He was afebrile with moderate subcostal recession and tracheal tug. On auscultation, breath sounds were normal with transmitted sounds of inspiratory and expiratory stridor. The rest of his examination was normal.He commenced dexamethasone 0.15 μg/kg three times a day, which was weaned as his clinical status improved.Blood tests showed total white cell count 9 x 10ˆ9/L, CRP <1 mg/L, lactate dehydrogenase level and blood film normal. Chest radiograph showed left lung hyperexpansion and apparent right-sided bronchial narrowing (figure 1). Flexible nasendoscopy was unremarkable. Microlaryngoscopy and bronchoscopy showed external airway compression at the level of the carina (figure 2). CT thorax demonstrated a non-enhancing mediastinal mass extrinsic to the airway, approximately 3cmx2.5cmx1.5cm, compressing the carina and main-stem bronchi (figure 3).

Clinical impact of primary tumour 123ImIBG response to induction chemotherapy in children with high-risk neuroblastoma

BACKGROUND

More than 50% children with high-risk neuroblastoma (HR-NBL) experience disease progression, which we hypothesise is due to non-response of primary tumour to treatment. Current imaging techniques are unable to characterise response in primary tumour (necrotic versus viable tissue) at diagnosis or follow-up.

OBJECTIVES

Compare clinico-histological characteristics between primary ¹²³ImIBG-avid tumours that became entirely ¹²³ImIBG-non-avid (responders) after induction chemotherapy (IC) versus primary ¹²³ImIBG-avid tumour that remained ¹²³ImIBG-avid (non-responders).

METHODS

Retrospective review of clinico-radiological data of children diagnosed with ¹²³ImIBG-avid HR-NBL at our centre (2005-2016). Patients received Rapid COJEC IC and two additional courses of TVD if metastatic response was inadequate. Primary tumour ¹²³ImIBG response was assessed qualitatively as positive, negative or intermediate at diagnosis and after IC. Post-surgical histopathology slices were marked considering percentage of viable tissue.

RESULTS

Sixteen of 61 patients showed complete primary tumour ¹²³ImIBG response, 20 partial response, while 25 no response. There was no statistically significant difference between clinical demographics of complete responders and group of non- or partial responders. Mean percentage of viable tumour cells was higher in non-responders than in complete responders (44.6% vs 20.6%; p = 0.05). Five-year EFS was significantly higher in complete responders than non-responders (43 ± 15% vs 7 ± 6%; p < 0.005).

CONCLUSIONS

¹²³ImIBG response in primary HR-NBL correlates with amount of necrotic tissue, skeletal metastatic ¹²³ImIBG response and outcome. An entirely ¹²³ImIBG non-avid tumour can still harbour viable tumour cells. Therefore, our findings do not support utility of primary tumour ¹²³ImIBG response in decision making regarding residual tumour surgery. Combining both, primary and metastatic ¹²³ImIBG response will improve interpretability of clinical trial results.

Artificial intelligence for interpretation of segments of whole body MRI in CNO: pilot study comparing radiologists versus machine learning algorithm

BACKGROUND

To initiate the development of a machine learning algorithm capable of comparing segments of pre and post pamidronate whole body MRI scans to assess treatment response and to compare the results of this algorithm with the analysis of a panel of paediatric radiologists.

METHODS

Whole body MRI of patients under the age of 16 diagnosed with CNO and treated with pamidronate at a tertiary referral paediatric hospital in United Kingdom between 2005 and 2017 were reviewed. Pre and post pamidronate images of the commonest sites of involvement (distal femur and proximal tibia) were manually selected (n = 45). A machine learning algorithm was developed and tested to assess treatment effectiveness by comparing pre and post pamidronate scans. The results of this algorithm were compared with the results of a panel of radiologists (ground truth).

RESULTS

When tested initially the machine algorithm predicted 4/7 (57.1%) examples correctly in the multi class model, and 5/7 (71.4%) correctly in the binary group. However when compared to the ground truth, the machine model was able to classify only 33.3% of the samples correctly but had a sensitivity of 100% in detecting improvement or worsening of disease.

CONCLUSION

The machine learning could detect new lesions or resolution of a lesion with good sensitivity but failed to classify stable disease accurately. However, further validation on larger datasets are required to improve the specificity and accuracy of the machine model.

Technique, pitfalls, quality, radiation dose and findings of dynamic 4-dimensional computed tomography for airway imaging in infants and children

This retrospective review of 33 children's dynamic 4-dimensional (4-D) computed tomography (CT) images of the airways, performed using volume scanning on a 320-detector array without anaesthesia (free-breathing) and 1.4-s continuous scanning, was undertaken to report technique, pitfalls, quality, radiation doses and findings. Tracheobronchomalacia (airway diameter collapse >28%) was recorded. Age-matched routine chest CT scans and bronchograms acted as benchmarks for comparing effective dose. Pitfalls included failure to administer intravenous contrast, pull back endotracheal tubes and/or remove nasogastric tubes. Twenty-two studies (67%) were diagnostic. Motion artefact was present in 16 (48%). Mean effective dose: dynamic 4-D CT 1.0 mSv; routine CT chest, 1.0 mSv, and bronchograms, 1.4 mSv. Dynamic 4-D CT showed tracheobronchomalacia in 20 patients (61%) and cardiovascular abnormalities in 12 (36%). Fourteen children (70%) with tracheobronchomalacia were managed successfully by optimising conservative management, 5 (25%) underwent surgical interventions and 1 (5%) died from the presenting disorder.

Selective duodenography for controlled first-pass bolus distention of the duodenum in neonates and young children with bile-stained vomiting

AIM

To compare "selective duodenograms" performed through nasogastric tubes advanced into the proximal duodenum against traditional contrast studies regarding visualisation of a first-pass bolus distention of the duodenum and frequency of inconclusive results.

MATERIALS AND METHODS

Retrospective comparison of "selective duodenograms" and traditional upper gastrointestinal contrast studies in neonates with bile-stained vomiting, regarding demonstration of the duodenal C-loop, first-pass bolus capture, degree of distention of the duodenum, and number of inconclusive studies. Statistical comparison was performed using the two-tailed Fishers exact and chi-squared tests.

RESULTS

There were 31 "selective duodenograms" and 70 traditional studies. The C-loop was demonstrated in 93% of traditional studies versus 100% in "selective duodenograms" and was demonstrated significantly more often during the first-pass (94% versus 73%; p=0.018) and more often with distention of the duodenum for "selective duodenography" (94% versus 56%, p<0.001). There were more inconclusive traditional studies (7% versus 3%; non-significant).

CONCLUSION

Emergency upper gastrointestinal tract studies performed in neonates using the "selective duodenogram" technique demonstrated the duodenum with 100% success, with significantly more frequent first-pass bolus visualisation and duodenal distention than traditional studies. The five (7%) inconclusive traditional studies, present a significant diagnostic conundrum in the emergency setting because emergency surgery must be contemplated without proof.

Paediatric magnetic resonance enteroclysis under general anaesthesia - initial experience

MR enterography is the accepted imaging reference standard for small bowel assessment in inflammatory bowel disease. There is an increasing cohort of children with inflammatory bowel disease presenting at an early age (<5 years) with severe disease. Younger children present a technical challenge for enterography because of the need for sedation/general anaesthesia to allow image optimisation and the need for oral contrast to allow adequate luminal assessment. Through our experiences, MR enteroclysis under general anaesthesia has proven to be a successful imaging technique for the work-up of these patients. In this paper, we present our institutional practice for performing MR enteroclysis under general anaesthesia.

Exon skipping creates novel splice variants of DMC1 gene in ruminants

Disrupted meiotic cDNA1 (DMC1) recombinase plays a pivotal role in homology search and strand exchange reactions during meiotic homologous recombination. In the present study, full length coding sequence of DMC1 gene was sequence characterized for the first time from four ruminant species (cattle, buffalo, sheep and goat) and phylogenetic relationship of ruminant DMC1 with other eukaryotes was analyzed. DMC1 gene encodes a putative protein of 340 amino acids in cattle, sheep and buffalo and 341 amino acids in goat. A high degree of evolutionary conservation at both nucleotide and amino acid level was observed for the four ruminant orthologs. In cattle and sheep, novel alternatively spliced mRNAs with skipping of exons 7 and 8 (Transcript variant 1, TV1) were isolated in addition to the full length (FL) transcript. Novel transcript variants with partial skipping of exon 7 and complete skipping of exon 8 (Transcript variant 2, TV2) were found in sheep and goat. The presence of these variants was validated by amplifying cDNA isolated from testis tissue of ruminants using two oligonucleotides flanking the deleted region. To accurately estimate their relative proportions, real-time PCR was performed using primers specific for each variant. Expression level of DMC1-FL was significantly higher than that of TV1 in cattle and TV2 in goat (P < 0.05). Relative ratio for expression of DMC1-FL: TV1: TV2 in sheep was 6.78: 1.43: 1. In-silico analysis revealed presence of splice variants of DMC1 gene across other mammalian species underpinning the role of alternative splicing in functional innovation.

A Five-Year Study of Intrapleural Fibrinolytic Therapy in Loculated Pleural Collections

BACKGROUND

Pleural fluid loculations due to complicated parapneumonic effusion (CPE), empyema, tubercular effusion and traumatic hemothorax can be managed either by video-assisted thoracoscopic surgery (VATS) or intrapleural ibrinolytic therapy (IPFT). The former is more invasive, not easily available and is also more expensive. On the other hand, IPFT is less invasive, cheaper, easily accessible and if used early, in loculated pleural collections, break loculations and early pleural peel, thereby facilitating pleural space drainage.

OBJECTIVE

To study the efficacy of IPFT in facilitating pleural space drainage in loculated pleural collections of diverse aetiologies.

METHODS

A five-year retrospective, observational study of 200 patients, with loculated pleural collections and failed tube drainage and managed with IPFT was carried out. Responders were defined as those with significant volume of fluid drained and significant radiological resolution.

RESULTS

There were 106 (53%) cases of CPE, 59 (29.5%) cases of tubercular effusion, 23 (11.5%) cases of empyema and 12 (6%) cases of hemothorax. Responders were 148 (74%) in number. The distribution of responders as per type of loculated pleural collection was as follows: CPE 88 (83%), tubercular 37 (62.7%), empyema 14 (60.8%) and traumatic hemothorax 11 (91.6%). The adverse effects were mild and included chest pain in six patients and low-grade transient fewer in three cases.

CONCLUSIONS

Intrapleural fibrinolytic therapy is a safe and cost-effective option in the management of selected patients with loculated pleural effusions.

The target cell of transformation is distinct from the leukemia stem cell in murine CALM/AF10 leukemia models

The CALM/AF10 fusion gene is found in various hematological malignancies including acute myeloid leukemia (AML), T-cell acute lymphoblastic leukemia and malignant lymphoma. We have previously identified the leukemia stem cell (LSC) in a CALM/AF10-driven murine bone marrow transplant AML model as B220+ lymphoid cells with B-cell characteristics. To identify the target cell for leukemic transformation or 'cell of origin of leukemia' (COL) in non-disturbed steady-state hematopoiesis, we inserted the CALM/AF10 fusion gene preceded by a loxP-flanked transcriptional stop cassette into the Rosa26 locus. Vav-Cre-induced panhematopoietic expression of the CALM/AF10 fusion gene led to acute leukemia with a median latency of 12 months. Mice expressing CALM/AF10 in the B-lymphoid compartment using Mb1-Cre or CD19-Cre inducer lines did not develop leukemia. Leukemias had a predominantly myeloid phenotype but showed coexpression of the B-cell marker B220, and had clonal B-cell receptor rearrangements. Using whole-exome sequencing, we identified an average of two to three additional mutations per leukemia, including activating mutations in known oncogenes such as FLT3 and PTPN11. Our results show that the COL for CALM/AF10 leukemia is a stem or early progenitor cell and not a cell of B-cell lineage with a phenotype similar to that of the LSC in CALM/AF10+ leukemia.

Declining trends of Syphilis seroprevalance among antenatal clinic cases and STD clinic cases in a tertiary care centre: from January 2002 to December 2012

Syphilis affects nearly 1.36 million pregnant women, majority of these cases being concentrated in the developing countries. We aimed at analysing the 11 years' trends in syphilis seroprevalence in antenatal clinics (ANC) and STD clinic cases. Laboratory data of syphilis cases from 2002-2012 were retrospectively analysed. Out of the total 73,642 cases, 393 (0.53%) tested positive for Syphilis. A statistically significant decline in syphilis prevalence was found in both ANC and STD clinic cases. The efforts of various interventional programs should continue to make the screening and treatment facilities readily accessible to continue the decline in syphilis seropositivity.

Congenital generalized lipodystrophy: identification of novel variants and expansion of clinical spectrum

Congenital generalized lipodystrophy (CGL) is an autosomal recessive disorder with two major subtypes. Variants in AGPAT2 result in CGL type 1 with milder manifestations, whereas BSCL2 variants cause CGL type 2 with more severe features. Muscle hypertrophy caused by lack of adipose tissue is present early in life in CGL patients. Our aim was to investigate 10 CGL patients from 7 different countries and report genotype-phenotype relationships. Genetic analysis identified disease-causing variants in AGPAT2 (five patients) and in BSCL2 (five patients), including three novel variants; c.134C>A (p.Ser45*), c.216C>G (p.Tyr72*) in AGPAT2 and c.458C>A (p.Ser153*) in BSCL2. We also report possible novel clinical features such as anemia, breast enlargement, steatorrhea, intraventricular hemorrhage and nephrolithiasis in CGL patients. Generalized lipodystrophy and muscular hypertrophy were the only features in all of our patients. Hepatomegaly was the second common feature. Some manifestations were exclusively noticed in our CGL2 patients; hypertrichosis, high-pitched voice and umbilical hernia. Bone cysts and history of seizures were noticed only in CGL1 patients. The findings of this study expand our knowledge of genotype-phenotype correlations in CGL patients. These results have important clinical applications in diagnosis and management of the CGL patients as well as in genetic counseling in families at-risk.

Survival of infants in the context of prevention of mother to child HIV transmission in South Africa

AIM

We sought to study the survival of newborn children according to HIV status of the mother, that of the child and the timing of infection.

METHODS

This is a prospective cohort study of 883 mothers (665 HIV-positive and 218 HIV-negative) and their infants. Data were collected using semi-structured questionnaires during home visits between the antenatal period and 36 weeks post-delivery. Infant HIV status was determined at 3, 24 and 36 weeks by HIV DNA PCR.

RESULTS

The majority (81.3%) of infected infants who died were infected by 3 weeks of age. Of the HIV-exposed infants who died, 19 (28.4%) died before 6 weeks and 38 (56.7%) died by 12 weeks. The hazard ratio (HR) of mortality at 36 weeks of age in HIV-infected infants compared with exposed but negative infants was 8.9 (95% CI: 6.7-11.8). There was no significant difference in 36 week survival rates between HIV-non-exposed and HIV-exposed but negative infants (HR: 0.7; 95% CI: 0.3-1.5). The infant being HIV-positive at age 3 weeks (HR: 32 95% CI: 14.0-73.1) and rural site (HR: 4.4 95% CI: 1.2-23.4) were the two independent risk factors for infant death amongst HIV-exposed infants.

CONCLUSION

The prognosis for infants with early HIV infection was very poor in this cohort. A greater focus on prevention of early infection, earlier screening for HIV infection and access to antiretrovirals for eligible infants is recommended.

Russell-Silver syndrome due to paternal H19/IGF2 hypomethylation in a patient conceived using intracytoplasmic sperm injection

Epigenetic alterations at several maternal loci have been associated with imprinting disorders in children conceived using assisted reproductive technologies. To date, epimutations at paternal loci have been observed in the spermatozoa of infertile men, but there is little evidence of paternal epimutations in babies conceived using assisted reproductive treatment. This is a report of a female infant with classic Russell-Silver Syndrome (RSS) who was conceived using intracytoplasmic injection of spermatozoa obtained from testicular aspiration. Methylation studies revealed hypomethylation of the paternally derived H19/IGF2 locus. As far as is known, this is the second assisted reproduction treatment-conceived patient with classic RSS and this epigenotype. This case provides further evidence that epimutations affecting paternal alleles might be associated with assisted reproductive treatment.

A health systems assessment of the KwaZulu-Natal tuberculosis programme in the context of increasing drug resistance

SETTING

High mortality and high transmission rates of extensively drug-resistant tuberculosis (XDR-TB) in KwaZulu-Natal Province of South Africa have highlighted the role of hospitals in the spread of TB and drug-resistant TB.

OBJECTIVES

To determine the operational effectiveness of the National TB Programme (NTP) at a regional/district hospital and its referral clinics.

DESIGN

In this multi-faceted retrospective case study, a framework was developed to evaluate the different components of the TB services, their performance in relation to each other and the system as a whole. Different methods used included structured and semi-structured interviews, retrospective medical record reviews and retrospective register reviews.

RESULTS

Only 18% of those diagnosed with smear-positive pulmonary TB (PTB) in the hospital laboratory completed their treatment and 11% were cured. Clinicians did not adhere to the diagnostic guidelines of the NTP. In the TB register, 85% of PTB cases were diagnosed in the absence of sputum microscopy. Chest X-rays alone were used to diagnose PTB in 45% of the records reviewed. In addition, clinicians failed to document a clinical history suggestive of TB. Only 66 (29%) of the hospital's 225 smear-positive PTB patients reached the clinics for completion of their treatment.

CONCLUSION

System failures, together with inadequate knowledge and understanding of clinicians, undermined the effectiveness of the NTP. A reduction in TB and drug-resistant forms of TB is dependent on effective diagnosis, treatment and improved communication systems between the hospital, laboratory and its down-referral clinics.

Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes

OBJECTIVE

To assess the infant feeding components of prevention of mother to child HIV transmission (PMTCT) programmes.

METHODS

Assessments were performed across Botswana, Kenya, Malawi and Uganda. 29 districts offering PMTCT were selected by stratified random sampling with rural and urban strata. All health facilities in the selected PMTCT district were assessed. The facility level manager and the senior nurse in charge of maternal care were interviewed. 334 randomly selected health workers involved in the PMTCT programme completed self-administered questionnaires. 640 PMTCT counselling observations were carried out and 34 focus groups were conducted amongst men and women.

RESULTS

Most health workers (234/334, 70%) were unable to correctly estimate the transmission risks of breastfeeding irrespective of exposure to PMTCT training. Infant feeding options were mentioned in 307 of 640 (48%) observations of PMTCT counselling sessions, and in only 35 (5.5%) were infant feeding issues discussed in any depth; of these 19 (54.3%) were rated as poor. Several health workers also reported receiving free samples of infant formula in contravention of the International Code on Breastmilk Substitutes. National HIV managers stated they were unsure about infant feeding policy in the context of HIV. Finally, there was an almost universal belief that an HIV positive mother who breastfeeds her child will always infect the child and intentional avoidance of breastfeeding by the mother indicates that she is HIV positive.

CONCLUSION

These findings underline the need to implement and support systematic infant feeding policies and programme responses in the context of HIV programmes.

A European carotenoid database to assess carotenoid intakes and its use in a five-country comparative study

A food frequency questionnaire (FFQ) and carotenoid database with information onα- and β-carotene, lutein, lycopene and β-cryptoxanthin was prepared and used to compare the carotenoid intakes in five European countries: UK, Republic of Ireland, Spain, France and The Netherlands. Eighty, age- (25–45 years) and sex-matched volunteers were recruited in each of the five countries. A FFQ and carotenoid database was prepared of the most commonly consumed carotenoid rich foods in the participating countries and the information was used to calculate frequency and intake of carotenoid-rich foods. The median total carotenoid intake based on the sum of the five carotenoids, was significantly higher (P<0.05) in France (16.1 mg/day) and lower in Spain (9.5 mg/day,) than the other countries, where the average intake was approximately 14 mg/day. Comparison of dietary source of carotenoids showed that carrots were the major source of β-carotene in all countries except Spain where spinach was most important. Likewise, carrots were also the main source ofα-carotene. Tomato or tomato products, were the major source of lycopene. Lutein was mainly obtained from peas in Republic of Ireland and the UK, however, spinach was found to be the major source in other countries. In all countries, β-cryptoxanthin was primarily obtained from citrus fruit. Comparing the data with that from specific European country studies suggests that the FFQ and carotenoid database described in the present paper can be used for comparative dietary intake studies within Europe. The results show that within Europe there are differences in the specific intake of some carotenoids which are related to different foods consumed by people in different countries.

Can lycopene be delivered into semen via prostasomes? In vitro incorporation and retention studies

Lycopene (C(40) H(56)) is a highly lipophilic antioxidant found in human semen in nanomolar concentrations. It has been shown to be one of the most potent carotenoid antioxidant in various human studies. Prostasomes are organelles secreted by glandular prostatic epithelial cells and are known to play an important role in fertility and prostate cancer. They are also known to possess antioxidant activity and aid the functioning of sperm. We studied the ability of these vesicles to adsorb and retain lycopene into their rich lipid environment in vitro. High-performance liquid chromatography analysis confirmed micrograms of lycopene per milligram of prostasomal protein. In view of the prostasomes' lipid-rich nature it is highly likely that these organelles act as delivery vehicles for this highly lipophilic antioxidant substance into human semen.

Confronting Africa's health crisis: more of the same will not be enough

The international community needs to rethink its approach to Africa if it wants to produce sustained improvements in health

Effect of an IMCI intervention on quality of care across four districts in Cape Town, South Africa

AIMS

To measure the change in quality of care provided to sick children as a result of the routine implementation of the IMCI intervention.

METHODS

Structured observations of consultations with sick children, exit interviews with caregivers, and facility reviews were conducted both before and after IMCI intervention in four health districts in Cape Town. Interventions were case management training, orientation courses for supervisors and medical officers, and some reorganisation of management systems.

RESULTS

Twenty one nurses in 21 clinics were observed before and after the IMCI intervention; 90 and 70 child observations were conducted before and after IMCI intervention respectively. There was a marked improvement in assessment of danger signs in sick children (7% before versus 72% after), assessment of co-morbidity (integrated score 5.2 versus 8.2), rational prescribing (62% versus 84%), and starting treatment in the clinic (40% versus 70%). However there was no change in the treatment of anaemia or the prescribing of vitamin A or counselling of caregivers. There was no change in the knowledge of caregivers regarding medication or when to return to the health facility. Facilities were well stocked and supervision regular both before and after IMCI.

CONCLUSION

This study has shown that under normal operating conditions and in a context of good facility infrastructure and management support, IMCI is associated with improvements in some important aspects of care.

Dietary supplementation with the anti-tumour promoter quercetin: its effects on matrix metalloproteinase gene regulation

Dietary modification, especially the consumption of larger amounts of fruits and vegetables can act to decrease the risk of a variety of human cancers. Quercetin, a bioflavonoid widely distributed in fruits and vegetables has been shown to have a chemoprotective role in cancer, through complex effects on signal transduction involved in cell proliferation and angiogenesis. In this study we examined the effects of dietary supplementation of quercetin (30 mg per day) incorporated into a black currant drink. Healthy male subjects aged between 33 and 64 years (mean=47.1 years) received either quercetin or placebo for 14 days. Blood samples were taken at baseline and upon completion of the study and analysed for full blood count, matrix metalloproteinase-2 (MMP-2), tissue inhibitor of matrix metalloproteinse-1 and -2 (TIMP-1 and -2) plasma levels using ELISA techniques. RNA was extracted from the peripheral blood lymphocytes and reverse transcriptase-polymerase chain reaction (RT-PCR) carried out for MMP-2 and TIMP-1, TIMP-2 gene expression determination. Supplementation of the diet with quercetin did not alter the MMP-2 or TIMP-2 gene transcription or plasma protein levels of the healthy subjects in this study. The TIMP-1 gene transcription and plasma protein levels (311+/-70 ng/ml at baseline to 183+/-35 ng/ml post-supplementation, P<0.05) of the subjects in this study were, however, significantly decreased following quercetin supplementation. This is an interesting result, as there is some controversy over the functions of TIMP-1 in tumour progression. In certain model systems, artificially increased TIMP-1 levels prevent or decrease tumour growth. However, in other studies high levels of TIMP-1 have been correlated with aggressive disease and poor prognosis in patients with certain malignancies. This study has outlined a potential role for the anti-tumour promoter quercetin as a dietary mediator of the carcinogenic cascade.

No significant effects of lutein, lycopene or beta-carotene supplementation on biological markers of oxidative stress and LDL oxidizability in healthy adult subjects

OBJECTIVE

The objective of this study was to determine the effect of individual carotenoid supplementation on biochemical indices of oxidative status in apparently healthy adult males.

METHODS

The study was a placebo controlled single blind study. Healthy male volunteers (n= 175) were assigned to four groups. They received daily supplements of beta-carotene (15 mg), lutein (15 mg), lycopene (15 mg) and placebo for three months. The effects of the supplementation on antioxidant status were monitored by plasma carotenoid, vitamin C and A levels, glutathione (GSH and GSSG) concentrations, protein SH groups. erythrocyte antioxidant enzyme activities (Cu-Zn SOD, Se-GSH-Px) and susceptibility of LDL to copper-induced oxidation.

RESULTS

beta-carotene, lycopene and lutein supplementation led to significant plasma and LDL increases in each of these carotenoids, without modifications of other carotenoid levels in plasma or in LDL. The supplementation failed to enhance the resistance of LDL to oxidation or to modify the LDL polyunsaturated/ saturated fatty acid ratio. Vitamin C, GSH, protein SH groups and antioxidant metalloenzyme activities were also unchanged.

CONCLUSION

We did not observe beneficial or adverse effects of lutein, lycopene or beta-carotene supplementation on biomarkers of oxidative stress. In apparently healthy subjects, carotenoid supplementation does not lead to significantly measurable improvement in antioxidant defenses.

Serum concentrations of carotenoids and vitamins A, E, and C in control subjects from five European countries

High intakes of fruits and vegetables, or high circulating levels of their biomarkers (carotenoids, vitamins C and E), have been associated with a relatively low incidence of cardiovascular disease, cataract and cancer. Exposure to a high fruit and vegetable diet increases antioxidant concentrations in blood and body tissues, and potentially protects against oxidative damage to cells and tissues. This paper describes blood concentrations of carotenoids, tocopherols, ascorbic acid and retinol in well-defined groups of healthy, non-smokers, aged 25-45 years, 175 men and 174 women from five European countries (France, UK (Northern Ireland), Republic of Ireland, The Netherlands and Spain). Analysis was centralised and performed within 18 months. Within-gender, vitamin C showed no significant differences between centres. Females in France, Republic of Ireland and Spain had significantly higher plasma vitamin C concentrations than their male counterparts. Serum retinol and alpha-tocopherol levels were similar between centres, but gamma-tocopherol showed a great variability being the lowest in Spain and France, and the highest in The Netherlands. The provitamin A: non-provitamin A carotenoid ratio was similar among countries, whereas the xanthophylls (lutein, zeaxanthin, beta-cryptoxanthin) to carotenes (alpha-carotene, beta-carotene, lycopene) ratio was double in southern (Spain) compared to the northern areas (Northern Ireland and Republic of Ireland). Serum concentrations of lutein and zeaxanthin were highest in France and Spain; beta-cryptoxanthin was highest in Spain and The Netherlands; trans-lycopene tended to be highest in Irish males and lowest in Spanish males; alpha-carotene and beta-carotene were higher in the French volunteers. Due to the study design, the concentrations of carotenoids and vitamins A, C and E represent physiological ranges achievable by dietary means and may be considered as 'reference values' in serum of healthy, non-smoking middle-aged subjects from five European countries. The results suggest that lutein (and zeaxanthin), beta-cryptoxanthin, total xanthophylls and gamma-tocopherol (and alpha- : gamma-tocopherol) may be important markers related to the healthy or protective effects of the Mediterranean-like diet.

Evaluating the clinical management of severely malnourished children--a study of two rural district hospitals

BACKGROUND

Severe malnutrition is an important cause of preventable mortality in most South African hospitals. Work recently done in two rural Eastern Cape hospitals supports the literature which shows that many deaths occur as a result of outdated clinical practices and that improving these practices reduces case fatality rates. Rapid assessment of clinical management in paediatric wards is necessary to highlight areas for improvement.

OBJECTIVE

To assess the management of severely malnourished children in two rural district hospitals and to recommend improvements for their care.

METHODS

Based on draft World Health Organisation (WHO) guidelines for inpatient care of children with severe malnutrition, data collection instruments were developed in conjunction with the district nutrition team to assess the quality of care given to malnourished children in two Mount Frere hospitals, Eastern Cape. Data were collected through retrospective review of case records, with detailed studies of selected cases, structured observations of the paediatric wards, and interviews with ward sisters and doctors.

RESULTS

The combined case fatality rate for severe malnutrition was 32%. Inadequate feeding, poor management of rehydration and infection, lack of resources, and a lack of knowledge and motivation among staff were identified as areas that need attention.

CONCLUSION

The clinical management of severely malnourished children can be rapidly assessed to highlight areas for improvement. Involving staff in the assessment process has led to their active involvement in improving the management of malnourished children in their hospitals.

Dialysis and gel filtration of isolated low density lipoproteins do not cause a significant loss of low density lipoprotein tocopherol and carotenoid concentration

The resistance of isolated low density lipoprotein (LDL) to copper-initiated oxidation is often used as a measure of effectiveness of an antioxidant intervention. Prior to oxidation, excess salt and EDTA are removed via dialysis or gel filtration of the LDL sample. However, there is concern over whether the antioxidant content of dialyzed or gel-filtered LDL is truly representative of native LDL extracted from a blood sample. Previously, the experiments done after the storage of native and dialyzed LDL at -80 degrees C showed that the dialysis step can cause a loss of up to 60% in the tocopherol and carotenoid content of LDL. In the present study, a comparison of the micronutrient concentration in freshly prepared dialyzed and native LDL from 35 subjects showed that after the correction for cholesterol, only lycopene (13%, P < 0.001) and to a lesser extent alpha-carotene (8%, P < 0.02) were significantly decreased, and the absolute fall in concentration was far smaller than previously reported. Other experiments done with smaller numbers of samples suggested that there were minimal micronutrient losses following gel filtration and that it was important to include 10 micromol/L EDTA in the dialysis and elution buffer; otherwise micronutrient losses did occur. In summary, immediate dialysis of freshly isolated LDL in the presence of 10 micromol/L EDTA does not cause any major loss in the concentration of tocopherol and most carotenoids.

Copper supplementation in humans does not affect the susceptibility of low density lipoprotein to in vitro induced oxidation (FOODCUE project)

The oxidative modification of low-density lipoprotein cholesterol (LDL) has been implicated in the pathogenesis of atherosclerosis. Copper (Cu) is essential for antioxidant enzymes in vivo and animal studies show that Cu deficiency is accompanied by increased atherogenesis and LDL susceptibility to oxidation. Nevertheless, Cu has been proposed as a pro-oxidant in vivo and is routinely used to induce lipid peroxidation in vitro. Given the dual role of Cu as an in vivo antioxidant and an in vitro pro-oxidant, a multicenter European study (FOODCUE) was instigated to provide data on the biological effects of increased dietary Cu. Four centers, Northern Ireland (coordinator), England, Denmark, and France, using different experimental protocols, examined the effect of Cu supplementation (3 or 6 mg/d) on top of normal Cu dietary intakes or Cu-controlled diets (0.7/1.6/6.0 mg/d), on Cu-mediated and peroxynitrite-initiated LDL oxidation in apparently healthy volunteers. Each center coordinated its own supplementation regimen and all samples were subsequently transported to Northern Ireland where lipid peroxidation analysis was completed. The results from all centers showed that dietary Cu supplementation had no effect on Cu- or peroxynitrite-induced LDL susceptibility to oxidation. These data show that high intakes (up to 6 mg Cu) for extended periods do not promote LDL susceptibility to in vitro-induced oxidation.

Consumption of tomato products with olive oil but not sunflower oil increases the antioxidant activity of plasma

Health benefits of lycopene from tomato products have been suggested to be related to its antioxidant activity. Dietary fat may influence the absorption and hence the plasma levels and antioxidant activity of lycopene. In the present study, we have compared the effect of consumption of tomato products with extra-virgin olive oil vs. tomato products plus sunflower oil on plasma lycopene and antioxidant levels. Results show that the oil composition does not affect the absorption of lycopene from tomato products because similar levels of plasma lycopene (mean +/- SD) were obtained on feeding tomatoes (providing approximately 46 mg lycopene/d) for 7 d with either olive oil (0.66 +/- 0.26 vs 1.20 +/- 0.20 micromol/l, p <.002) or sunflower oil (0.67 +/- 0.27 vs. 1.14 micromol/l, p <.001). However, consumption of tomato products with olive oil significantly raised the plasma antioxidant activity (FRAP) from 930 +/- 150 to 1118 +/- 184 micromol/l, p <.01) but no effect was observed when the sunflower oil was used. The change (supplementation minus start values) in FRAP following the consumption of tomato products with oil was significantly higher for olive oil (190 +/- 101) than for sunflower oil (-9.6 +/- 99, p <. 005). In conclusion, the results of the study show that consumption of tomato products with olive oil but not with sunflower oil improves the antioxidant activity of the plasma.

Influence of increased fruit and vegetable intake on plasma and lipoprotein carotenoids and LDL oxidation in smokers and nonsmokers

BACKGROUND

Epidemiological studies suggest a cardioprotective role for carotenoid-rich foods. Smokers have a high risk of cardiovascular disease and low dietary intake and plasma concentrations of carotenoids. The aim of this study was to determine the carotenoid response of smokers and nonsmokers to increased intake of 300-400 g of vegetables and its effect on LDL oxidation.

METHODS

After a depletion period of 8 days, 34 healthy females (18 nonsmokers, 16 smokers) were supplemented with beta-carotene- and lutein-rich (green) and lycopene-rich (red) vegetable foods, each for 7 days.

RESULTS

Baseline concentrations (mean +/- SD) of plasma beta-carotene (0.203+/-0.28 micromol/L vs. 0.412+/-0.34 micromol/L; P <0.005) and lutein (0.180 +/-0.10 vs. 0.242+/-0.11 micromol/L; P<0.05) but not lycopene (0.296+/-0.10 vs. 0.319+/-0.33 micromol/L) were significantly lower in smokers compared with nonsmokers. After supplementation, the change (supplementation minus depletion) in plasma beta-carotene (0.152+/- 0.43 vs. 0.363+/-0.29 micromol/L in smokers vs. nonsmokers; P = 0.002) and LDL lutein (0.015+/-0.03 vs. 0.029+/-0.03 micromol/mmol cholesterol; P = 0.01) was significantly lower in smokers than nonsmokers. Green-vegetable supplementation had no effect on the resistance of LDL to oxidation (lag-phase) in either group. After red-vegetable supplementation, plasma and LDL lycopene concentrations were increased in both groups, but only nonsmokers showed a significant increase in the lag-phase (44.9+/-9.5 min at baseline, 41.4+/-6.5 min after depletion, and 49.0+/-8.9 min after supplementation; P<0.01) compared with depletion.

CONCLUSIONS

In this short-term intervention study, a dietary intake of >40 mg/day of lycopene by a group of nonsmoking individuals significantly reduced the susceptibility of LDL to oxidation, whereas an equivalent increase in lycopene by a group of smokers showed no such effect.