Antenatal and delivery practices and neonatal mortality amongst women with institutional and non-institutional deliveries in rural Zimbabwe: observational data from a cluster randomized trial

BACKGROUND

Despite achieving relatively high rates of antenatal care, institutional delivery, and HIV antiretroviral therapy for women during pregnancy, neonatal mortality has remained stubbornly high in Zimbabwe. Clearer understanding of causal pathways is required to inform effective interventions.

METHODS

This study was a secondary analysis of data from the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial, a cluster-randomized community-based trial among pregnant women and their infants, to examine care during institutional and non-institutional deliveries in rural Zimbabwe and associated birth outcomes.

RESULTS

Among 4423 pregnant women, 529 (11.9%) delivered outside a health institution; hygiene practices were poorer and interventions to minimise neonatal hypothermia less commonly utilised for these deliveries compared to institutional deliveries. Among 3441 infants born in institutions, 592 (17.2%) were preterm (< 37 weeks gestation), while 175/462 (37.9%) infants born outside health institutions were preterm (RR: 2.20 (1.92, 2.53). Similarly, rates of stillbirth [1.2% compared to 3.0% (RR:2.38, 1.36, 4.15)] and neonatal mortality [2.4% compared to 4.8% (RR: 2.01 1.31, 3.10)] were higher among infants born outside institutions. Among mothers delivering at home who reported their reason for having a home delivery, 221/293 (75%) reported that precipitous labor was the primary reason for not having an institutional delivery while 32 (11%), 34 (12%), and 9 (3%), respectively, reported distance to the clinic, financial constraints, and religious/personal preference.

CONCLUSIONS

Preterm birth is common among all infants in rural Zimbabwe, and extremely high among infants born outside health institutions. Our findings indicate that premature onset of labor, rather than maternal choice, may be the reason for many non-institutional deliveries in low-resource settings, initiating a cascade of events resulting in a two-fold higher risk of stillbirth and neonatal mortality amongst children born outside health institutions. Interventions for primary prevention of preterm delivery will be crucial in reducing neonatal mortality in Zimbabwe.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov, number NCT01824940.

A Quality Improvement Initiative to Reduce the Frequency of Delays in Initiation and Restarts of Continuous Renal Replacement Therapy

BACKGROUND

Continuous renal replacement therapy (CRRT) is a lifesaving intervention for critically ill patients. Delays in initiation, or an inability to resume CRRT following a temporary suspension in therapy (CRRT restart), can result in suboptimal CRRT delivery.

LOCAL PROBLEM

Intensive care units across the health care system were experiencing significant delays in CRRT initiation and restarts.

APPROACH

A multimodal quality improvement initiative was implemented across 7 adult intensive care units, which allowed unit-based staff nurses to initiate and restart CRRT, a task that had previously been delegated to non-unit-based dialysis nurses.

OUTCOMES

A 75% reduction in CRRT initiation delays and a 90% reduction in CRRT restart delays were observed in the 12 months following the initiative. There were no adverse events or increased disposable CRRT circuit usage following the initiative.

CONCLUSIONS

Implementation of CRRT initiation and restarts by unit-based nurses were achievable and resulted in substantial improvements in timeliness of CRRT delivery.

Athletic groin pain (part 2): a prospective cohort study on the biomechanical evaluation of change of direction identifies three clusters of movement patterns

Background

Athletic groin pain (AGP) is prevalent in sports involving repeated accelerations, decelerations, kicking and change-of-direction movements. Clinical and radiological examinations lack the ability to assess pathomechanics of AGP, but three-dimensional biomechanical movement analysis may be an important innovation.

Aim

The primary aim was to describe and analyse movements used by patients with AGP during a maximum effort change-of-direction task. The secondary aim was to determine if specific anatomical diagnoses were related to a distinct movement strategy.

Methods

322 athletes with a current symptom of chronic AGP participated. Structured and standardised clinical assessments and radiological examinations were performed on all participants. Additionally, each participant performed multiple repetitions of a planned maximum effort change-of-direction task during which whole body kinematics were recorded. Kinematic and kinetic data were examined using continuous waveform analysis techniques in combination with a subgroup design that used gap statistic and hierarchical clustering.

Results

Three subgroups (clusters) were identified. Kinematic and kinetic measures of the clusters differed strongly in patterns observed in thorax, pelvis, hip, knee and ankle. Cluster 1 (40%) was characterised by increased ankle eversion, external rotation and knee internal rotation and greater knee work. Cluster 2 (15%) was characterised by increased hip flexion, pelvis contralateral drop, thorax tilt and increased hip work. Cluster 3 (45%) was characterised by high ankle dorsiflexion, thorax contralateral drop, ankle work and prolonged ground contact time. No correlation was observed between movement clusters and clinically palpated location of the participant's pain.

Conclusions

We identified three distinct movement strategies among athletes with long-standing groin pain during a maximum effort change-of-direction task These movement strategies were not related to clinical assessment findings but highlighted targets for rehabilitation in response to possible propagative mechanisms.

Trial registration number

NCT02437942, pre results.

Evaluating equipment for people with disabilities: user and technical perspectives on basic commodes

Disabled people often do not use the equipment supplied to them. Past work indicates that there are many reasons for this, including the low priority given to user views by the designers and manufacturers of such equipment. A number of different methodologies have been used to evaluate equipment. This paper describes an evaluation of basic commodes, a project funded by the Medical Devices Agency, Department of Health, in which both a user survey and technical tests were employed.

A sample of 18 basic commodes, divided into four categories, was evaluated by 40 users, a questionnaire being administered to determine user views. A series of 13 technical tests was also carried out.

The results showed that the preferred commodes as indicated by the users did not necessarily perform well in the technical tests, with at least one of the products having potentially serious design faults. It is suggested that users, therapists and engineers each have an essential contribution to make in the evaluation of equipment for disabled people.

Long-term impacts of nitrogen deposition on coastal plant communities

Nitrogen deposition has been shown to have significant impacts on a range of vegetation types resulting in eutrophication and species compositional change. Data from a re-survey of 89 coastal sites in Scotland, UK, c. 34 years after the initial survey were examined to assess the degree of change in species composition that could be accounted for by nitrogen deposition. There was an overall increase in the Ellenberg Indicator Value for nitrogen (EIV-N) of 0.15 between the surveys, with a clear shift to species characteristic of more eutrophic situations. This was most evident for Acid grassland, Fixed dune, Heath, Slack and Tall grass mire communities and despite falls in EIV-N for Improved grass, Strand and Wet grassland. The increase in EIV-N was highly correlated to the cumulative deposition between the surveys, and for sites in south-east Scotland, eutrophication impacts appear severe. Unlike other studies, there appears to have been no decline in species richness associated with nitrogen deposition, though losses of species were observed on sites with the very highest levels of SOx deposition. It appears that dune vegetation (specifically Fixed dune) shows evidence of eutrophication above 4.1 kg N ha(-1) yr(-1), or 5.92 kg N ha(-1) yr(-1) if the lower 95% confidence interval is used. Coastal vegetation appears highly sensitive to nitrogen deposition, and it is suggested that major changes could have occurred prior to the first survey in 1976.

Species composition of coastal dune vegetation in Scotland has proved resistant to climate change over a third of a century

Climate change is expected to have an impact on plant communities as increased temperatures are expected to drive individual species' distributions polewards. The results of a revisitation study after c. 34 years of 89 coastal sites in Scotland, UK, were examined to assess the degree of shifts in species composition that could be accounted for by climate change. There was little evidence for either species retreat northwards or for plots to become more dominated by species with a more southern distribution. At a few sites where significant change occurred, the changes were accounted for by the invasion, or in one instance the removal, of woody species. Also, the vegetation types that showed the most sensitivity to change were all early successional types and changes were primarily the result of succession rather than climate-driven changes. Dune vegetation appears resistant to climate change impacts on the vegetation, either as the vegetation is inherently resistant to change, management prevents increased dominance of more southerly species or because of dispersal limitation to geographically isolated sites.

The pharmacokinetics of azacitidine following subcutaneous treatment in patients with myelodysplastic syndromes (MDS) or acute myelogenous leukemia (AML)

7087

Background: 5-azacitidine (AZA), through its effects on DNA metabolism, gene expression, and cell differentiation, has proven beneficial in treatment of MDS and AML and AZA therapy significantly increases survival in higher-risk MDS and AML compared to conventional care. Few studies have evaluated the pharmacokinetics (PK) of AZA and the renal elimination of AZA has not been previously published to our knowledge. Plasma PK of AZA are herein reported in patients receiving SC doses of 75 mg/m2. This study was designed to also assess the contribution of renal elimination to the overall clearance of AZA. Methods: Adult patients with MDS or AML and ECOG status 0–2 were treated with 7 consecutive daily SC doses of 75 mg/m2 AZA during their first treatment cycle. PK parameters of AZA were derived from drug concentrations in plasma and urine collected after the first and last dose (day 7) of AZA. Safety was evaluated by adverse event reporting (NCI-CTC). Results: Currently, 18 patients have been treated with SC AZA. AZA was rapidly absorbed and reached peak plasma concentrations (concs) within 0.5 hr post dosing. The AUCinf after SC doses was 1170 hr*ng/mL. The AZA concs declined in a pseudo bi-phasic manner with an elimination half-life of 1.25 hours. The plasma PK profiles after the first and last dose were superimposable. The apparent total clearance (CL/F) and volume of distribution (Vd/F) were 143 L/hr and 318 L, respectively. AZA recovery in urine was very small relative to dose (<2%). AZA was well tolerated and no unexpected toxicities were observed. Conclusions: The AZA AUCinf after SC doses is similar to the published AUC value (1044 hr*ng/mL) after 75 mg/m2 IV doses indicating approximating 100% systemic bioavailability. After SC dosing, CL/F exceeded hepatic blood flow indicating extra-hepatic metabolism. Vd/F was 4–5 fold greater than total body water suggesting extensive AZA tissue distribution. Renal elimination appears to play a minor role in the overall clearance of AZA.

[Table: see text]

Analysis on sliding helices and strands in protein structural comparisons: a case study with protein kinases

Protein structural alignments are generally considered as 'golden standard' for the alignment at the level of amino acid residues. In this study we have compared the quality of pairwise and multiple structural alignments of about 5900 homologous proteins from 718 families of known 3-D structures. We observe shifts in the alignment of regular secondary structural elements (helices and strands) between pairwise and multiple structural alignments. The differences between pairwise and multiple structural alignments within helical and beta-strand regions often correspond to 4 and 2 residue positions respectively. Such shifts correspond approximately to "one turn" of these regular secondary structures. We have performed manual analysis explicitly on the family of protein kinases. We note shifts of one or two turns in helix-helix alignments obtained using pairwise and multiple structural alignments. Investigations on the quality of the equivalent helix-helix, strand-strand pairs in terms of their residue side-chain accessibilities have been made. Our results indicate that the quality of the pairwise alignments is comparable to that of the multiple structural alignments and, in fact, is often better. We propose that pairwise alignment of protein structures should also be used in formulation of methods for structure prediction and evolutionary analysis.

PRODOC: a resource for the comparison of tethered protein domain architectures with in-built information on remotely related domain families

PROtein Domain Organization and Comparison (PRODOC) comprises several programs that enable convenient comparison of proteins as a sequence of domains. The in-built dataset currently consists of ∼698 000 proteins from 192 organisms with complete genomic data, and all the SWISSPROT proteins obtained from the Pfam database. All the entries in PRODOC are represented as a sequence of functional domains, assigned using hidden Markov models, instead of as a sequence of amino acids. On average 69% of the proteins in the proteomes and 49% of the residues are covered by functional domain assignments. Software tools allow the user to query the dataset with a sequence of domains and identify proteins with the same or a jumbled or circularly permuted arrangement of domains. As it is proposed that proteins with jumbled or the same domain sequences have similar functions, this search tool is useful in assigning the overall function of a multi-domain protein. Unique features of PRODOC include the generation of alignments between multi-domain proteins on the basis of the sequence of domains and in-built information on distantly related domain families forming superfamilies. It is also possible using PRODOC to identify domain sharing and gene fusion events across organisms. An exhaustive genome–genome comparison tool in PRODOC also enables the detection of successive domain sharing and domain fusion events across two organisms. The tool permits the identification of gene clusters involved in similar biological processes in two closely related organisms. The URL for PRODOC is .

A phase II trial of three sequential doublets for the treatment of advanced müllerian malignancies☆☆Funding provided by Eli Lilly Pharmaceutical Company and Amgen

OBJECTIVES

In an effort to improve the results of primary chemotherapy for müllerian malignancies a novel chemotherapy program was piloted that delivered three sequential chemotherapy doublets. The primary endpoints were surgically defined response rates and evaluation of toxicity.

METHODS

After primary cytoreductive surgery patients were treated with three sequential doublets including three initial cycles of carboplatin and paclitaxel (doublet 1) and then two cycles of cisplatin (day 1) and gemcitabine (days 1 and 8; doublet 2), and finally two cycles of doxorubicin (day 1) and topotecan (days 3,4, and 5; doublet 3). Cycles 4 through 7 were given with G-CSF (Neupogen) support at a dose of 5 mcg/kg/day. After therapy, all women were clinically staged and evaluated by second-look laparoscopy/laparotomy (SLO) if clinical staging was negative for residual disease.

RESULTS

A total of 49 eligible patients were enrolled with a median age of 52 (SD 9). Forty-four women had either ovarian cancer or primary peritoneal carcinoma with 3 women diagnosed with fallopian tube carcinoma and 2 with papillary serous carcinoma of the uterus. Eighty-four percent of patients had stage IIIc/IV tumors, with 29% having >1 cm residual disease after primary cytoreductive surgery. Thirty-nine of 49 (80%) patients completed therapy. A total of 283 cycles of chemotherapy were delivered with acceptable toxicities. There were no toxic deaths. Five women were withdrawn from trial (3 for Taxol hypersensitivity, 1 for gemcitabine pulmonary hypersensitivity, and 1 for serious line infection). Neutropenia, typically without fever, was relatively frequent in the first doublet. Nausea and thrombocytopenia were the predominant toxicities in doublet 2. Thirty-nine women completed all cycles of treatment. Thirty-six women had restaging results consistent with a clinical complete response (CR) and underwent SLO. The pathologic CR rate of the patients undergoing SLO was 38%.

CONCLUSIONS

Treatment with this sequential doublet regimen is feasible with a 38% pathologic CR rate.

Human AML cells in NOD/SCID mice: engraftment potential and gene expression

Most cases of human acute myeloid leukemia (AML) engraft in irradiated non-obese diabetic/severe combined immunodeficient (NOD/SCID) mice. Intravenous transfer of as few as 10(5) human AML cells resulted in engraftment. Cases with poor prognosis clinical features, including FLT3 mutations, tended to engraft efficiently. Nevertheless, AML cells obtained from patients at relapse did not engraft more efficiently than cells obtained from the same patients at initial diagnosis. One passage of human AML cells in NOD/SCID mice did not appear to select for increased virulence, as measured by serial transplantation efficiency. Finally, cDNA microarray analyses indicated that approximately 95% of genes were expressed at similar levels in human AML cells immunopurified after growth in mice, as compared to cells assessed directly from patients. Thus, the growth of human AML cells in NOD/SCID mice could yield large numbers of human AML cells for direct experimental use and could also function as a renewable, potentially unlimited source of leukemia cells, via serial transplantation.

Transferring people safely with manual handling equipment

OBJECTIVE

To determine whether transferring equipment designed to assist a carer when moving someone who is able to take some weight through their legs is likely to affect the risk of back problems in the carer.

DESIGN

Twelve pieces of equipment were tested by nurses transferring patients from commode to wheelchair and vice versa, and from wheelchair to bed and vice versa. Video recordings were taken of each transfer and freeze-frame pictures at the moment of greatest load were analysed. Compressive disc force was deduced, using a biomechanical model, from the weights of the patient and nurse and measurements of anatomical distances and angles.

SETTING

The Sir Walter Puckey Gait Laboratory, in the Rehabilitation Research Unit, University of Southampton.

SUBJECTS

Six female trained nurses with no recent history of hernia, back pain or pregnancy during the previous six months were recruited to use the equipment. Two female patients were chosen from those volunteering and screened for stroke, confusion and unusual footwear. The patients were able to partially weight-bear and were used to being transferred.

RESULTS

The results indicate that the critical value of 3.4 kN at the L5/S1 disc (specified by the US National Institute for Occupational Safety and Health) was not exceeded when using transferring equipment.

CONCLUSION

In this study, loading on the spine during transferring tasks with or without equipment was not considered harmful when good technique was employed.

The co-occurrence of depression and substance abuse in late adolescence

This article examines the role of adolescent social relationships in fostering the occurrence and co-occurrence of depression and substance abuse, using two waves of data from a community sample of adolescents (N = 900). Multinomial logistic response models were estimated to identify the extent to which risk and protective features of youths' family and peer relations were differentially linked with depressive symptoms, substance abuse, and their co-occurrence. Taking a within-person, configurational approach to adolescent adaptation, contrasts involved four subgroups of adolescents: those high on both depressed mood and substance abuse, those who experience neither problem, those evidencing high levels of depressive symptoms only, and those high on substance abuse only. Risk for depressive symptoms was differentiated by its association with conflict and lack of support in the friendship domain. Substance abuse was associated with negative peer pressure, but these youth were otherwise little different from youths with no problems. Whereas co-occurrence of depression and substance use was associated with more difficulties in both the family and peer environments, the most distinctive risk was that of low family support. Discussion centers on the developmental antecedents of co-occurring problems and family relations during adolescence.

Report of an international working group to standardize response criteria for myelodysplastic syndromes

Standardized criteria for assessing response are essential to ensure comparability among clinical trials for patients with myelodysplastic syndromes (MDS). An international working group of experienced clinicians involved in the management of patients with MDS reviewed currently used response definitions and developed a uniform set of guidelines for future clinical trials in MDS. The MDS differ from many other hematologic malignancies in their chronicity and the morbidity and mortality caused by chronic cytopenias, often without disease progression to acute myeloid leukemia. Whereas response rates may be an important endpoint for phase 2 studies of new agents and may assist regulatory agencies in their evaluation and approval processes, an important goal of clinical trials in MDS should be to prolong patient survival. Therefore, these response criteria reflected 2 sets of goals in MDS: altering the natural history of the disease and alleviating disease-related complications with improved quality of life. It is anticipated that the recommendations presented will require modification as more is learned about the molecular biology and genetics of these disorders. Until then, it is hoped these guidelines will serve to improve communication among investigators and to ensure comparability among clinical trials. (Blood. 2000;96:3671-3674)

Life stress, anger and anxiety, and delinquency: an empirical test of general strain theory

General strain theory (Agnew 1992) departs from traditional strain theories by emphasizing the role of the individual's affective responses to negative life experiences in fostering deviant behavior. In this analysis, we examine the central hypotheses of general strain theory using data from a three-wave panel study of high school youths in the Boston metropolitan area (N = 939). Covariance structure models reveal that anger and hostility in response to negative life events do play a causal role in fostering more aggressive forms of delinquency, but are not significantly related to either nonaggressive delinquency or marijuana use. Furthermore, the conditional effects predicted by general strain theory, in which the impact of strain on delinquency varies by youths' personal and social resources, are inconsistent. Discussion centers on the prospect of increasing the utility of general strain theory by further imbuing it with concepts and perspectives from the sociology of mental illness.

The use of leg lifting equipment

This article discusses the manual handling risks associated with lifting patients' legs and describes equipment designed to minimise these risks. The findings of an evaluation of leg lifters are summarised and the potential benefits and limitations of this equipment for nursing practice are highlighted.

A dose-finding study of liposomal daunorubicin with CVP (COP-X) in advanced NHL

BACKGROUND

Standard therapy for lymphoma consists of a cyclophosphamide (C), doxorubicin, vincristine (V), and prednisone (P) (CHOP) combination regimen. Liposomal daunorubicin (DaunoXome) is an alternative to doxorubicin for patients with lymphoma because of its more favorable safety profile and potentially more selective uptake in lymphoma. The objectives of this study were to determine the maximum tolerated dose (MTD) of liposomal daunorubucin with CVP (COP-X) and the tolerability of the regimen in patients with indolent lymphoma.

PATIENTS AND METHODS

Patients with low-grade and intermediate-grade lymphoma having adequate cardiac, hepatic, and renal function were enrolled. Patients received C 750 mg/m2, V 1.4 mg/m2 (maximum 2.0 mg), and liposomal daunorubicin 50-100 mg/m2 i.v. on day 1 and P 100 mg p.o. on days 1-5. MTD was the liposomal daunorubicin dose associated with 20% dose-limiting toxicity (ANC < 500/mm3 for > 5 days or febrile neutropenia).

RESULTS

Twenty patients, median age 59 years, were treated. The liposomal daunorubicin MTD combined with CVP was 70-80 mg/m2, depending on patient population. No significant non-hematologic toxicity occurred. Response rate was 44% (2 complete and 5 partial responses).

CONCLUSIONS

A liposomal daunorubicin dose of 80 mg/m2 in the COP-X regimen was well tolerated with little nonhematologic toxicity.

Parents' and therapists' opinion on features that make a chair useful for a young disabled child

Children who fail to develop postural skills within a normal time scale are prescribed special seating to position them appropriately. For children to derive benefit from such seating, they must use it at home as well as in therapy sessions. A study was undertaken to explore the opinions of therapists and parents concerning the effectiveness and acceptability of a sample of special seating available on the UK market for young children. Each of the ten chairs selected to represent the range of possible styles and features was tested by 12 or 16 children in their homes (total sample of 40) for a week each, and four therapy centres for a fortnight each. Results obtained from these two populations were compared to determine whether chair features considered useful differed when used in a therapy centre or family home. Parents' rating for overall usefulness was affected by their perception of the child's comfort, as well as the child's posture, the level of support the chair offered, and other factors. Therapists' response, in contrast, seemed to be mainly influenced by the quality of posture children achieved in the chair.

Prevention of diarrhea and pneumonia by zinc supplementation in children in developing countries: pooled analysis of randomized controlled trials. Zinc Investigators' Collaborative Group

OBJECTIVES

This study assessed the effects of zinc supplementation in the prevention of diarrhea and pneumonia with the use of a pooled analysis of randomized controlled trials in children in developing countries.

STUDY DESIGN

Trials included were those that provided oral supplements containing at least one half of the United States Recommended Daily Allowance (RDA) of zinc in children <5 years old and evaluated the prevention of serious infectious morbidity through household visits. Analysis included 7 "continuous" trials providing 1 to 2 RDA of elemental zinc 5 to 7 times per week throughout the period of morbidity surveillance and 3 "short-course" trials providing 2 to 4 RDA daily for 2 weeks followed by 2 to 3 months of morbidity surveillance. The effects on diarrhea and pneumonia were analyzed overall and in subgroups defined by age, baseline plasma zinc concentration, nutritional status, and sex. The analysis used random effects hierarchical models to calculate odds ratios (OR) and 95% CIs.

RESULTS

For the zinc-supplemented children compared with the control group in the continuous trials, the pooled ORs for diarrheal incidence and prevalence were 0.82 (95% CI 0.72 to 0.93) and 0.75 (95% CI 0.63 to 0.88), respectively. Zinc-supplemented children had an OR of 0.59 (95% CI 0.41 to 0.83) for pneumonia. No significant differences were seen in the effects of the zinc supplement between the subgroups examined for either diarrhea or pneumonia. In the short-course trials the OR for the effects of zinc on diarrheal incidence (OR 0.89, 95% CI 0.62 to 1.28) and prevalence (OR 0.66, 95% CI 0.52 to 0.83) and pneumonia incidence (OR 0.74, 95% CI 0.40 to 1.37) were similar to those in the continuous trials.

CONCLUSIONS

Zinc supplementation in children in developing countries is associated with substantial reductions in the rates of diarrhea and pneumonia, the 2 leading causes of death in these settings.

Regression of columnar-lined (Barrett's) oesophagus with omeprazole 40 mg daily: results of 5 years of continuous therapy

BACKGROUND

We have previously reported the effect of 2 years of omeprazole 40 mg daily on columnar-lined (Barrett's) oesophagus (CLO).

AIMS

In the present study, follow-up has been extended to 5 years to assess the macroscopic and microscopic effects of continuing therapy.

PATIENTS AND METHODS

The 23 patients have been followed for up to a further 3 years. Endoscopy with multiple biopsies was performed at the end of years 3, 4 and 5.

RESULTS

Although there had been a statistically significant regression in the length of CLO after 2 years, there was no overall further measurable change after 5 years. However, one patient showed complete macroscopic and microscopic regression. The number and size of macroscopic squamous islands within the CLO continued to increase, and there was a further increase in microscopic squamous re-epithelialization of surface mucosa, gland ducts and Barrett's gland tissue. Low-grade dysplasia was found consistently in one patient in biopsies taken up to the end of year 3 but it could not be detected thereafter.

CONCLUSIONS

Omeprazole 40 mg daily appears to have beneficial effects on CLO, although it rarely induces a complete regression. Whether the benefits will reduce the risk of malignant transformation is unknown.

Toward improved management of NIDDM: A randomized, controlled, pilot intervention using a lowfat, vegetarian diet

OBJECTIVE

To investigate whether glycemic and lipid control in patients with non-insulin-dependent diabetes (NIDDM) can be significantly improved using a low-fat, vegetarian (vegan) diet in the absence of recommendations regarding exercise or other lifestyle changes.

METHODS

Eleven subjects with NIDDM recruited from the Georgetown University Medical Center or the local community were randomly assigned to a low-fat vegan diet (seven subjects) or a conventional low-fat diet (four subjects). Two additional subjects assigned to the control group failed to complete the study. The diets were not designed to be isocaloric. Fasting serum glucose, body weight, medication use, and blood pressure were assessed at baseline and biweekly thereafter for 12 weeks. Serum lipids, glycosylated hemoglobin, urinary albumin, and dietary macronutrients were assessed at baseline and 12 weeks.

RESULTS

Although the sample was intentionally small in accordance with the pilot study design, the 28% mean reduction in fasting serum glucose of the experimental group, from 10.7 to 7.75 mmol/L (195 to 141 mg/dl), was significantly greater than the 12% decrease, from 9.86 to 8.64 mmol/L (179 to 157 mg/dl), for the control group (P < 0.05). The mean weight loss was 7.2 kg in the experimental group, compared to 3. 8 kg for the control group (P < 0.005). Of six experimental group subjects on oral hypoglycemic agents, medication use was discontinued in one and reduced in three. Insulin was reduced in both experimental group patients on insulin. No patient in the control group reduced medication use. Differences between the diet groups in the reductions of serum cholesterol and 24-h microalbuminuria did not reach statistical significance; however, high-density lipoprotein concentration fell more sharply (0.20 mmol/L) in the experimental group than in the control group (0.02 mmol/L) (P < 0.05).

CONCLUSION

The use of a low-fat, vegetarian diet in patients with NIDDM was associated with significant reductions in fasting serum glucose concentration and body weight in the absence of recommendations for exercise. A larger study is needed for confirmation.