A plastic scintillator and HPGe β-γ coincidence detection system

A network of specialist laboratories support the International Monitoring System (IMS) of the Comprehensive Nuclear-Test-Ban Treaty (CTBT) with re-measurements of radionuclide samples, including xenon gas. The measurement of four xenon fission product radionuclides (133Xe, 135Xe, 131mXe and 133mXe) can be used to detect an underground nuclear explosion. Laboratories use a range of techniques to measure the radionuclides, including beta-gamma (β-γ) coincidence spectrometry. These highly-sensitive measurements are capable of detecting concentrations of down to 500 atoms of 133Xe in a few cm3 of xenon. In some detector systems, detection of the metastable isomers (131mXe and 133mXe) can be more challenging due to interferences between the signatures of different radionuclides. Recent work has shown that using high-purity Germanium (HPGe) high-resolution gamma detectors, these interferences can be reduced, lowering the dependence of the detection limits on radionuclide sample isotopic composition. One downside of these detectors is the reduction in detection efficiency, which impacts the overall detection sensitivity; so assessing different detector systems is a priority for radionuclide laboratories. This work presents a coincidence detector system comprising of a plastic scintillator gas cell and a large-crystal high-purity germanium detector. The energy resolution, coincidence detection efficiency, MDA and interference factors are determined from measurements of synthetic radioxenon gas samples.

Definitions of Remission in Psoriasis: A Systematic Literature Review from the National Psoriasis Foundation

Psoriasis studies increasingly employ outcomes that indicate complete disease resolution, yet remission and cure are poorly defined for psoriasis. We conducted a systematic literature review to identify definitions of psoriasis remission and cure reported in the literature. Medline, EMBASE, and The Cochrane Central Register of Controlled Trials databases were searched on July 22, 2020 for full-text studies providing definitions for psoriasis remission/cure. Definitions were analyzed descriptively for endpoint, time-frame, on/off treatment, patient-reported outcomes, and disease domains. We identified 106 studies that provided 41 unique remission definitions. Most definitions included endpoints based on Psoriasis Area and Severity Index (PASI), such as PASI75 (n=16 studies), PASI90 (n=10), PASI100 (n=10), and PASI of 0 (n=3), and descriptive endpoints related to 'skin clearance' (n=18). Few definitions specified time-frame, on/off treatment or other psoriasis-related disease domains. One small consensus-initiative defined drug-free remission for plaque psoriasis by BSA of 0 without any therapy for at least 12 months. While there is no cure for psoriasis, seven studies defined psoriasis cure using similar endpoints to those used to define remission. We identified a variety of definitions of psoriasis remission. These results will inform the development of consensus-based definitions for psoriasis remission to support efforts to improve research and clinical outcomes.

Efficacy of thiopurines and adalimumab in preventing Crohn's disease recurrence in high-risk patients - a POCER study analysis

BACKGROUND

Crohn's disease recurs in the majority of patients after intestinal resection.

AIM

To compare the relative efficacy of thiopurines and anti-TNF therapy in patients at high risk of disease recurrence.

METHODS

As part of a larger study comparing post-operative management strategies, patients at high risk of recurrence (smoker, perforating disease, ≥2nd operation) were treated after resection of all macroscopic disease with 3 months metronidazole together with either azathioprine 2 mg/kg/day or mercaptopurine 1.5 mg/kg/day. Thiopurine-intolerant patients received adalimumab induction then 40 mg fortnightly. Patients underwent colonoscopy at 6 months with endoscopic recurrence assessed blind to treatment.

RESULTS

A total of 101 patients [50% male; median (IQR) age 36 (25-46) years] were included. There were no differences in disease history between thiopurine- and adalimumab-treated patients. Fifteen patients withdrew prior to 6 months, five due to symptom recurrence (of whom four were colonoscoped). Endoscopic recurrence (Rutgeerts score i2-i4) occurred in 33 of 73 (45%) thiopurine vs. 6 of 28 (21%) adalimumab-treated patients [intention-to-treat (ITT); P = 0.028] or 24 of 62 (39%) vs. 3 of 24 (13%) respectively [per-protocol analysis (PPA); P = 0.020]. Complete mucosal endoscopic normality (Rutgeerts i0) occurred in 17/73 (23%) vs. 15/28 (54%) (ITT; P = 0.003) and in 27% vs. 63% (PPA; P = 0.002). The most advanced disease (Rutgeerts i3 and i4) occurred in 8% vs. 4% (thiopurine vs. adalimumab).

CONCLUSIONS

In Crohn's disease patients at high risk of post-operative recurrence adalimumab is superior to thiopurines in preventing early disease recurrence.

The relationships between IFNL4 genotype, intrahepatic interferon-stimulated gene expression and interferon treatment response differs in HCV-1 compared with HCV-3

BACKGROUND

The biological mechanism underlying the association between IFNL4/IFNL3 polymorphism and peginterferon/ribavirin (PR) response in HCV-1 is thought to involve differential intrahepatic interferon-stimulated gene expression. HCV-3 is more sensitive to PR, but there are no studies of the association between IFNL4 polymorphism, PR treatment response and liver interferon-stimulated gene expression in HCV-3.

AIM

We evaluated the association between IFNL4/IFNL3 genotypes, PR treatment outcomes and intrahepatic interferon-stimulated gene expression, according to HCV genotype.

METHODS

HCV-1 and HCV-3 patients who received PR therapy were identified. IFNL3 (rs12979860) and IFNL4 genotype (rs368234815) were determined. A second cohort with stored liver specimens was identified. Expression of ISGs was measured by rt-PCR.

RESULTS

Two hundred and fifty-nine patients were identified: 55% HCV-1, 45% HCV-3. IFNL4 genotype frequency was TT/TT 44%, TT/ΔG 42% andΔG/ΔG 14%. Linkage disequilibrium with IFNL3 genotype was high (r(2) = 0.98). The association between IFNL4 genotype and PR response was attenuated in HCV-3 vs. HCV-1 (HCV-3: SVR 89% vs. 76% vs. 72% for TT/TT vs. TT/ΔG vs. ΔG/ΔG, P = 0.09; HCV-1: SVR: 82% vs. 29% vs. 24%, P < 0.001). Intrahepatic ISG expression was evaluated in 92 patients; 61% HCV-1. The association between IFNL4 genotype and liver ISG expression was significantly different for HCV-3 vs. HCV-1 (P-value for interaction = 0.046), with levels of interferon-stimulated gene expression being highest in HCV-1 patients who carried a poor-response IFNL4 genotype.

CONCLUSIONS

The relationship between IFNL4 genotype and PR treatment response as well as intrahepatic interferon-stimulated gene expression differs between HCV-1 and HCV-3. These data suggest fundamental differences in host-virus interactions according to HCV genotype.

Perspectives of paediatric and adult gastroenterologists on transfer and transition care of adolescents with inflammatory bowel disease

BACKGROUND

Programmes specific to inflammatory bowel disease (IBD) that facilitate transition from paediatric to adult care are currently lacking.

AIM

We aimed to explore the perceived needs of adolescents with IBD among paediatric and adult gastroenterologists and to identify barriers to effective transition.

METHODS

A web-based survey of paediatric and adult gastroenterologists in Australia and New Zealand employed both ranked items (Likert scale; from 1 not important to 5 very important) and forced choice items regarding the importance of various factors in facilitating effective transition of adolescents from paediatric to adult care.

RESULTS

Response rate among 178 clinicians was 41%. Only 23% of respondents felt that adolescents with IBD were adequately prepared for transition to adult care. Psychological maturity (Mean = 4.3, standard deviation (SD) = 0.70) and readiness as assessed by adult caregiver (Mean = 4, SD = 0.72) were prioritised as the most important factors in determining timing of transfer. Self-efficacy and readiness as assessed by adult caregiver were considered the two most important factors to determine timing of transition by both groups of gastroenterologists. Poor medical and surgical handover (Mean = 4.10, SD = 0.8) and patients' lack of responsibility for their own care (Mean= 4.10, SD = 0.82) were perceived as major barriers to successful transition by both paediatric and adult gastroenterologists.

CONCLUSIONS

Deficiencies exist in current transition care of adolescents with IBD in Australia and New Zealand. Standardising transition care practices with strategies aimed at optimising communication, patient education, self-efficacy and adherence may improve outcomes.

Development and validation of a patient-reported disability measurement tool for patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease can impact on a patient's ability to maintain normal physical and mental function, and fulfil their social, family and work roles. Aspects of disability in IBD have received little attention.

AIM

To develop, validate and apply a questionnaire directed towards evaluating these disease aspects.

METHODS

A literature review on disability in IBD was undertaken, and opinion about aspects of disability to measure was sought from six IBD-specialised gastroenterologists. A questionnaire was developed, and IBD patients completed the new disability questionnaire, the SF-36 and the short-IBD (SIBDQ - 10 point). A subgroup of patients completed the questionnaire again 4 weeks later. Healthy volunteers were studied as a control group.

RESULTS

A total of 116 IBD out-patients were approached, of whom 81 (52 Crohn's disease and 28 ulcerative colitis) participated. Nineteen patients were re-evaluated at 4 weeks. Twenty-five controls were studied. All subscales demonstrated good Cronbach's alpha reliability and reproducibility. There was a significant inverse correlation between the disability score and the SIBDQ and between the disability score and the SF36 and a positive correlation with the Crohn's Disease Activity Index (CDAI) (all P < 0.001). Disability differed between ulcerative colitis and controls, but not between active and inactive disease.

CONCLUSIONS

The new disability questionnaire is sensitive for detecting disability, is reliable and reproducible, and correlates with disease activity in Crohn's disease, but not ulcerative colitis. Further prospective testing is now needed in the longer term, larger patient populations and in different countries and ethnicities.

Postoperative recurrence of Crohn's disease: impact of endoscopic monitoring and treatment step-up

AIM

Eighty per cent of patients with Crohn's disease require surgery, of whom 70% will require a further operation. Recurrence occurs at the anastomosis. Although often recommended, the impact of postoperative colonoscopy and treatment adjustment is unknown.

METHOD

Patients with a bowel resection over a 10-year period were reviewed and comparison made between those who did and did not have a postoperative colonoscopy within 1 year of surgery, and those who did or did not have a step-up in drug therapy.

RESULTS

Of 222 patients operated on, 136 (65 men, mean age 33 years, mean disease duration 8 years, median follow-up 4 years) were studied. Of 70 patients with and 66 without postoperative colonoscopy, clinical recurrence occurred in 49% and 48% (NS) and further surgery in 9% and 5% (NS). Eighty-nine per cent of colonoscoped patients had a decision based on the colonoscopic findings: of these, 24% had a step-up of drug therapy [antibiotics (n =10), aminosalicylates (n=2), thiopurine (n=5), methotrexate (n=1)] and 76% had no step-up in drug therapy. In colonoscoped patients clinical recurrence occurred in 9 (60%) of 15 patients with, and 23 (49%) of 47 without step-up and surgical recurrence in 2 (13%) of 15 and 4 (9%) of 47 (NS).

CONCLUSION

Clinical recurrence occurs in a majority of patients soon after surgery. In this cohort, there was no clinical benefit from colonoscopy or increased drug therapy within 1 year after operation. However, the response to the endoscopic findings was not standardized and immunosuppressive therapy was uncommon. Standardizing timing of colonoscopy and drug therapy, including more intense therapy, may improve outcome, although this remains to be proven.

Gastroenterology training in Australia: a perspective from the coal face

BACKGROUND

The Royal Australasian College of Physicians is developing curricula for training.

AIMS

We surveyed gastroenterology trainees on their training experience to establish whether training needs were being met.

METHODS

An online anonymous survey of all gastroenterology trainees in 2009.

RESULTS

Ninety-one per cent of trainees responded (105/115). Of these, 92% were adult, and 8% were paediatric trainees. Seventy four were core, and 31 were noncore trainees. Of those who had completed core training, the majority (86%) felt that their training had prepared them adequately for independent practice as a gastroenterologist. However, most respondents felt that core advanced training should be 3 years instead of 2 years. The majority (86%) saw a benefit in moving between hospitals during core training. Of the trainees managing inpatients, 57% were managing 10 or more per day, and 63% had three or more consultant ward rounds per week. The top three noncore fellowships were advanced endoscopy (44%), hepatology (28%) and inflammatory bowel disease (17%). Sixty-one per cent and 39% were undertaking a clinical and research fellowship respectively. Seventy-two per cent of core trainees attended up to three endoscopy lists per week, and 76% were on the on-call urgent endoscopy roster. For on-call endoscopy, 27% of third-year noncore trainees and 5% of core trainees were unsupervised.

CONCLUSIONS

The majority of trainees felt that their core training would prepare them adequately for independent practice as gastroenterologists. Overall, trainees valued movement between hospitals during training and felt that core training should be 3 years. Some trainees had inadequate consultant support for out-of-hours emergency endoscopy.

Gastroenterology training in Australia: how much is enough?

BACKGROUND

Advanced training in gastroenterology currently consists of 2 years of core training and 1 elective (non-core) year. We surveyed gastroenterologists 2-7 years following completion of training to determine the strengths and weaknesses of their training.

METHODS

All gastroenterologists were invited to participate in an anonymous online survey.

RESULTS

There was a 46% response rate (49/110). Eighty-one per cent were male with most aged 36-45. Respondents felt that the current training programme prepared them well for public practice and endoscopy but less well for private practice, ambulatory care, surgical aspects of gastroenterology and functional gastrointestinal disorders. Most had faced challenges transitioning to consultant practice. The majority (53%) spent more than the standard 3 years to complete training in gastroenterology. The top three subspecialty Fellowships were in endoscopy (45%), inflammatory bowel disease (29%) and hepatology (23%). In their elective year, 42% undertook a predominantly clinical year (registrar-type position in general or subspecialty gastroenterology), 28% engaged in research while 24% trained in another specialty. Seventy-eight per cent were in full-time work, and 36% were supervising trainees. Ninety-eight per cent felt that it was beneficial for trainees to move between hospitals during the core years of their advanced training.

CONCLUSIONS

The current Australian gastroenterology training programme is generally adequate in preparing trainees for consultant practice but could be improved by increased emphasis on areas such as private practice, ambulatory gastroenterology and functional gastrointestinal diseases. Exposure to a variety of experiences by training in several different hospitals during core training was universally viewed as being important.

Sarcina-like bacteria associated with bloat in young lambs and calves

Sarcina species are fastidious Gram-positive anaerobic bacteria that occur in cubical packets of eight or more cells. In 2006 to 2007, they were associated with cases of acute abomasal bloat in young lambs and calves. Two incidents were in lambs aged three to six weeks that were found dead, with one or two cases in each of a group of 15 and 100 lambs. Three incidents were recorded in small groups of calves up to 10 days of age, two cases in each incident, with the calves found dead or dying after a short illness characterised by bloat. Their gross lesions included emphysema and oedema of the abomasal wall, mucosal hyperaemia and haemorrhage, and rupture of the abomasum. Histological lesions included abomasitis with congestion, haemorrhage, emphysema and oedema. Bacteria characteristic of Sarcina species were observed in sections associated with the superficial mucosa of these cases, but the bacteria were not detected in cultures.

Chronic hepatitis B: recommendations for therapy based on the natural history of disease in Australian patients

BACKGROUND

Chronic hepatitis B infection (CHB) is a major health problem in Australia and worldwide. CHB is associated with significant long-term morbidity and mortality. Well tolerated treatment is now available, however the development of resistance is common and the optimal timing of treatment is yet to be determined. Identifying the factors that influence the natural history of CHB may help determine which patients need treatment and when to start it.

OBJECTIVE

To determine the demographics, clinical features and virological profile of Australian patients infected with CHB and the influence of these factors on disease activity and severity.

STUDY DESIGN

Review of prospectively collected demographic, clinical and virological features of all patients positive for hepatitis B surface antigen (HBsAg) for more than 6 months who were referred to St. Vincent's Hospital liver clinics. Age, sex and ethnicity were correlated with hepatitis B e antigen status (HBeAg), HBV replication status (ALT and HBV DNA), genotype and liver histology.

RESULTS

703 chronic hepatitis B surface antigen positive patients were identified. The patients were predominantly male with an average age of 44. Eighty two percent of patients were born overseas, primarily from Asian (65%) and Mediterranean countries (14%). Two thirds (426) had an elevated ALT (median 79) at presentation. HBeAg was positive in 37%. Active viral replication, defined as abnormal ALT or positive HBVDNA, was present in 74%, 48% of whom were HBeAg negative. In a subset of 103 patients genotyped, 8% had genotype A, 29% B, 41% C and 22% D. Genotype correlated with ethnicity; patients infected with genotypes A were predominantly Caucasian, B and C were Asian, and D were Mediterranean. Of 296 (42%) patients who underwent liver biopsy, 76 (27%) had advanced fibrosis. Advanced fibrosis was associated with increasing age and Mediterranean ethnicity.

CONCLUSION AND RECOMMENDATIONS

Perinatal or early childhood transmission is predominant mode of infection in Australia. Two thirds of this cohort had active replication and were at increased risk of developing cirrhosis and/or hepatoma. Advanced disease was associated with age and ethnicity. HBeAg negative CHB accounts for almost half of all those with active viral replication. This parallels the rise in this form of CHB in Asia and the Mediterranean basin. Screening should be offered to people born in, or with parents born in areas of high endemnicity. To detect the development of active disease, patients with positive HBsAg but normal ALT should have liver function tests done 6 monthly and those with elevated ALT should be referred for consideration of therapy, irrespective of HBeAg status.

Survivin interacts with Smac/DIABLO in ovarian carcinoma cells but is redundant in Smac-mediated apoptosis

Abnormalities in the control and execution of apoptosis are seen in many malignancies, including ovarian carcinoma. Many of these abnormalities involve the mitochondrial pathway of apoptosis, including overexpression of BIR-containing inhibitor of apoptosis protein (IAP) family proteins as well as dysregulated apoptosome function. We sought to stimulate the mitochondrial pathway of apoptosis by constructing a recombinant adenovirus encoding mature, processed Smac/DIABLO (Ad CMV tSmac), the second mitochondrial activator of caspases. Transfection of ovarian carcinoma cells with Ad CMV tSmac leads to increasing apoptosis in a dose-dependent manner. By contrast, transfection of IOSE397 immortalized normal ovarian surface epithelial cells does not cause apoptosis. We also show that the processed form of Smac is primarily expressed in the cytosol of ovarian carcinoma cells. Smac co-immunoprecipitates with both survivin and XIAP and stimulates survivin, but not XIAP, down-regulation. This down-regulation does not result from transcriptional changes, as determined by quantitative real-time PCR, but cycloheximide treatment indicates that survivin half-life is reduced from 6 to 2 h, which is secondary to ubiquitination and proteasomal degradation. RNA interference, however, suggests that survivin does not act to inhibit Smac-mediated apoptosis, which is confirmed by cotransfection with the phosphorylation mutant, survivin T34A. Finally, intraperitoneal delivery of Ad CMV tSmac increases median survival of mice bearing human ovarian carcinoma xenografts. We believe that expression of Smac/DIABLO can stimulate the intrinsic pathway of apoptosis in ovarian carcinoma without damaging normal ovarian tissue and therefore has therapeutic potential.

Gene therapy progress and prospects: cancer gene therapy using tumour suppressor genes

Targeting tumour suppressor gene pathways is an attractive therapeutic strategy in cancer. Since the first clinical trial took place in 1996, at least 20 other trials have investigated the possibility of restoring p53 function, either alone or in combination with chemotherapy, but with limited success. Other recent clinical trials have sought to harness abnormalities in the p53 pathway to permit tumour-selective replication of adenoviral vectors such as dl1520 (Onyx-015). Other tumour suppressor genes, such as retinoblastoma (Rb) and PTEN (phosphatase, tensin homologue, deleted on chromosome 10), are the targets for imminent clinical trials, while microarray technologies are revealing multiple new genes that are potential targets for future gene therapy.

Evaluation of Helicobacter species in inflammatory bowel disease

BACKGROUND

Bacteria have been implicated in the pathogenesis of inflammatory bowel disease. Helicobacter species have been shown to cause colitis in animal models and have been identified in human diarrhoeal illness and Crohn's disease.

AIM

To determine whether Helicobacter species are present in human inflammatory bowel disease tissue.

METHODS

Thirty patients undergoing colonoscopy for clinical reasons were studied. Nine had Crohn's disease, 11 had ulcerative colitis and 10 had histologically normal colons. Tissue was snap-frozen at -70 degrees C. DNA was extracted and examined by five different polymerase chain reaction (PCR) assays that were either genus or species specific for Helicobacter.

RESULTS

Analyses of colonic biopsies by two Helicobacter genus-specific PCR assays, two H. pylori-specific assays and a PCR assay designed to amplify fragments of 'H. heilmannii'-like organisms demonstrated that product was not generated by any test. Internal control PCR demonstrated that PCR results for the five assays were not negative due to the presence of residual substances inhibitory to PCR.

CONCLUSIONS

Helicobacter species were not identified in this study, using multiple PCRs to eliminate the problems of non-specific cross-reaction. This suggests that Helicobacter species do not play a role in the pathogenesis of inflammatory bowel disease.

The clinical course of fistulating Crohn's disease

AIM

To determine the clinical characteristics, management and outcome of Crohn's fistulas from the time of first presentation.

METHODS

Patients treated for fistulas 6 years previously were assessed for disease demographics, fistula characteristics and treatment from first presentation to final follow-up.

RESULTS

Eighty-seven patients with active Crohn's fistulas were evaluated. The median age was 35 years and the median duration of Crohn's disease was 8 years at study entry. Disease was ileo-colonic or colonic in 85%, and 65% had rectal involvement. A single fistula was present in one-third and multiple fistulas in two-thirds; 65% of fistulas were perianal; 80% of fistulas were complex. After a median follow-up from the last treatment of 5.9 years, 68% of patients showed healing of all fistulas, 18% showed healing of some fistulas and 14% showed no healing of fistulas. The fistula site did not influence healing. Perianal and recto-vaginal fistulas took a median of 2.6 years to heal. Half of the complex fistulas required a stoma, resection or proctectomy.

CONCLUSIONS

Healing is usually achieved. However, morbidity is great and healing is slow. Proctectomy is required in one-fifth of patients, and perineal healing is often slow. Defining the perianal fistula anatomy as complex or simple determines the likelihood of healing and the type of surgical approach required.

The clinical course of fistulating Crohn's disease

AIM

To determine the clinical characteristics, management and outcome of Crohn's fistulas from the time of first presentation.

METHODS

Patients treated for fistulas 6 years previously were assessed for disease demographics, fistula characteristics and treatment from first presentation to final follow-up.

RESULTS

Eighty-seven patients with active Crohn's fistulas were evaluated. The median age was 35 years and the median duration of Crohn's disease was 8 years at study entry. Disease was ileo-colonic or colonic in 85%, and 65% had rectal involvement. A single fistula was present in one-third and multiple fistulas in two-thirds; 65% of fistulas were perianal; 80% of fistulas were complex. After a median follow-up from the last treatment of 5.9 years, 68% of patients showed healing of all fistulas, 18% showed healing of some fistulas and 14% showed no healing of fistulas. The fistula site did not influence healing. Perianal and recto-vaginal fistulas took a median of 2.6 years to heal. Half of the complex fistulas required a stoma, resection or proctectomy.

CONCLUSIONS

Healing is usually achieved. However, morbidity is great and healing is slow. Proctectomy is required in one-fifth of patients, and perineal healing is often slow. Defining the perianal fistula anatomy as complex or simple determines the likelihood of healing and the type of surgical approach required.

Response of fistulating Crohn's disease to infliximab treatment assessed by magnetic resonance imaging

AIMS

To assess fistula track healing after infliximab treatment using magnetic resonance imaging.

METHODS

Magnetic resonance imaging and clinical evaluation were performed before and after three infliximab infusions given over a 6-week period. Magnetic resonance images were evaluated for abscesses and fistula tracks. Paired magnetic resonance image examinations were rated 'better', 'unchanged' or 'worse'. Magnetic resonance imaging and clinical outcomes were then compared.

RESULTS

Of the 12 referred patients, pre-treatment magnetic resonance imaging detected abscesses in three (two not treated). Of the 10 treated patients, seven had peri-anal fistulas, two of whom also had recto-vaginal fistulas, and three had abdominal wall entero-cutaneous fistulas. After infliximab, four were in remission, one had a response and five were non-responders. One developed a peri-anal abscess. Magnetic resonance imaging improved in six, was unchanged in two and was worse in two. In four of the six with improvement in magnetic resonance imaging, the fistula track resolved, but two of these had clinically persistent entero-cutaneous fistulas. The clinical outcome and magnetic resonance imaging correlated in seven of the 10 patients; in three (two entero-cutaneous and one peri-anal), there was discordance.

CONCLUSIONS

Magnetic resonance imaging identifies clinically silent sepsis. Fistulas may persist despite clinical remission. Clinical response to infliximab and clinical correlation with magnetic resonance imaging were poor in patients with abdominal entero-cutaneous fistulas.

Randomized, placebo-controlled clinical trial of oral azithromycin prophylaxis against respiratory infections in a high-risk, young adult population

Military Special Forces trainees undergo intense psychological and physical stressors that often lead to respiratory infection. During 1998-2000, 477 Navy Special Forces trainees were enrolled in a double-blind trial of oral azithromycin (1 g given weekly) plus a placebo injection, compared with benzathine penicillin G (1.2 million U) plus azithromycin placebo tablets. Among the 464 subjects with complete data, 44 developed acute respiratory infection (20 with pneumonia) during the 2 weeks of most intense training; of these subjects, 12 (27.3%) had evidence of Chlamydia pneumoniae infection and 7 (15.9%) had evidence of Mycoplasma pneumoniae infection. Trainees who received azithromycin were less likely than were trainees who received benzathine penicillin G to develop acute respiratory infection (risk ratio, 0.50; 95% confidence interval [CI], 0.28-0.92) and less likely at the end of training to report episodes of breathing difficulty (odds ratio [OR], 0.59; 95% CI, 0.34-1.01) or sore throat (OR, 0.66; 95% CI, 0.41-1.05). Compared with benzathine penicillin G prophylaxis, weekly oral azithromycin was superior in preventing respiratory infection in this population at transient high risk.

Model process for removal of caseins from milk of transgenic animals

We describe a method for selective removal of caseins from milk. The method was developed as a model for transgenic milk processing. Raw cow milk spiked with nonmilk proteins was chosen as the model to resemble transgenic animal milk containing recombinant proteins. The most important elements of the process are (1) "deconstruction" of casein micelles in milk by destroying their Ca(2+) core using a chelating agent (EDTA), thus freeing any protein that might be entrapped in casein aggregates, and (2) "reconstruction" of micelles by providing them with a new Ca(2+) core, thus precipitating them away from the whey proteins, and the protein of interest. Calcium phosphate particles (CAP) were used to reform the disrupted casein micelles. The crystal clear supernatant fraction generated by this method provided >90% recovery and 6- to 13-fold concentration of the desired protein. Product-rich supernatant contained no detectable casein residues, as silver-stained SDS-PAGE and Western blot analyses demonstrated.

Comparison of an automated thrombolytic predictive instrument to both diagnostic software and an expert cardiologist for diagnosis of an ST elevation acute myocardial infarction

Because the electrocardiograms (ECGs) of patients with symptoms suggesting an acute thrombotic coronary occlusion are typically read by physicians relatively inexperienced in this skill, it is important to develop automated decision support. A Thrombolytic Predictive Instrument (TPI) is now available along with the standard diagnostic software in a commercially available electrocardiograph. This study evaluates the performance of the predictive software in comparison to both an expert cardiologist and standard diagnostic software. True sensitivity and specificity cannot be determined because acute coronary angiography was not performed. The specificities determined by this study were excellent (98% and 99%), and the sensitivities were very good (72% and 78%). These results that the TPI will be only rarely applied to patients who do not indeed have an acute coronary thrombosis. However, the reasons for even this small number of presumably falsely TPI positive patients should be determined and analyzed. It is unlikely that alterations of the thresholds for TPI activation will significantly improve on this very good level of sensitivity, without prohibitively decreasing specificity.

Migration and maturation of human colonic dendritic cells

Dendritic cells (DC) in the colon may regulate intestinal immunity but remain poorly characterized. In this study a CD11c(+)HLA-DR(+)lin(-) (CD3(-)CD14(-)CD16(-)CD19(-)CD34(-)) population has been identified by flow cytometry in cells obtained by rapid collagenase digestion of human colonic and rectal biopsies. These day 0 (d0) CD11c(+)HLA-DR(+)lin(-) cells comprised approximately 0.6% of the mononuclear cells obtained from the lamina propria, were endocytically active, and had the phenotype of immature DC; they were CD40(+) and expressed low levels of CD83 and CD86, but little or no CD80 or CD25. Similar d0 DC populations were isolated from the colonic mucosa of healthy controls and from both inflamed and noninflamed tissue from patients with Crohn's disease. The lamina propria also contained a population of cells capable of migrating out of biopsies during an overnight culture and differentiating into mature DC with lower levels of endocytic activity and high cell surface expression of CD40, CD80, CD86, CD83, and CD25. This mature DC population was a potent stimulator of an allogeneic mixed leukocyte (MLR). Overnight culture of cells isolated by enzymatic digestion on d0 yielded DC with a phenotype intermediate between that of the d0 cells and that of the cells migrating out overnight. Overnight culture of colonic cells in which DC and HLA-DR(+)lin(+) cells were differentially labeled with FITC-dextran suggested that some of the maturing DC might differentiate from HLA-DR(+)lin(+) progenitors. This study presents the first analysis of the phenotype, maturational status, and migratory activity of human gut DC.

The evaluation of a precordial ECG BELT: technologist satisfaction and accuracy of recording

The standard method for performing electrocardiogram (ECG) recordings presents a challenge to technicians because of the need to correctly position the individual precordial electrodes according to 6 bony thoracic landmarks. A proposed new method using a 6-lead ECG BELT for precordial application was compared to the standard method to determine the level of agreement among automated interpretations. A comparison of automated interpretations from repeat standard recordings served as the control. Results indicate that BELT and standard automated interpretations disagreed significantly more frequently than repeat standard recording automated interpretations of the cardiac rhythm. The BELT's most obvious weakness was the inability to obtain a recording with a stable ECG baseline, triggering automated detection of "baseline artifact or wander," and requiring a repeat recording. These findings suggest that the ECG BELT is not adequate for clinical application in its current form.

Changes in hepatitis C-related liver disease in a large clinic population

BACKGROUND

Hepatitis C virus (HCV) infection is a significant problem in the Australian community. Over the past few years, the number of patients with diagnosed hepatitis C has increased greatly. The aims of the present study were to define the clinical features of a large group of patients with chronic HCV infection and to examine changes occurring in the referral base and epidemiological characteristics of this group since analysis of the first 342 patients in 1994.

METHODS

The study included 1,546 consecutive anti-HCV-positive patients who had been referred to St Vincent's Hospital from January 1990 to June 1998. Clinical and laboratory data were collected on all patients.

RESULTS

Referrals from general practitioners increased from 31% to 70% of all patients between 1990-1993 and 1994-1998. A history of injecting drug use (IDU) was present in 64% of the patients. While 89% of the IDU group was Australasian born, 49% of those in the sporadic group were born overseas. Cirrhosis was found in 18% of biopsied patients. Age, infection duration, age at infection, Mediterranean or Asian origin and a history of transfusion or lack of HCV risk factors were associated with cirrhosis on univariate analysis. Patient age was the only independent predictor of cirrhosis.

CONCLUSION

The majority of patients with HCV are diagnosed in general practice. A risk factor for infection is identified in 82% of patients. While our reported prevalence of cirrhosis may be an overestimate of that in the overall HCV community, the ultimate disease burden is likely to be significant.

Calcium phosphate nanoparticle adjuvant

Vaccination to protect against human infectious diseases may be enhanced by using adjuvants that can selectively stimulate immunoregulatory responses. In a murine model, a novel nanoparticulate adjuvant composed of calcium phosphate (CAP) was compared with the commonly used aluminum (alum) adjuvants for its ability to induce immunity to herpes simplex virus type 2 (HSV-2) and Epstein-Barr virus (EBV) infections. Results indicated that CAP was more potent as an adjuvant than alum, elicited little or no inflammation at the site of administration, induced high titers of immunoglobulin G2a (IgG2a) antibody and neutralizing antibody, and facilitated a high percentage of protection against HSV-2 infection. Additional benefits of CAP include (i) an insignificant IgE response, which is an important advantage over injection of alum compounds, and (ii) the fact that CAP is a natural constituent of the human body. Thus, CAP is very well tolerated and absorbed. These studies were performed with animal models. By virtue of the potency of this CAP adjuvant and the relative absence of side effects, we believe that this new CAP formulation has great potential for use as an adjuvant in humans.

Validation of cardiologists' decisions to initiate reperfusion therapy for acute myocardial infarction with electrocardiograms viewed on liquid crystal displays of cellular telephones

BACKGROUND

The transmission of 12-lead electrocardiograms from remote locations to hand-held computers of cardiologists is now possible with the development of wireless technology and computer software. This investigation determined whether the cardiologist's decisions regarding reperfusion therapy for patients with symptoms suggestive of an acute myocardial infarction are the same when given electrocardiograms displayed on a cellular telephone as on a standard paper recording.

METHODS

Cardiologists were given 20 electrocardiograms of patients with acute chest pain suggestive of acute myocardial infarction to test the diagnostic reliability of the Nokia 9000i cellular telephone liquid crystal display (LCD) screen. The cardiologists made their decision to initiate or not initiate reperfusion therapy for the patients after viewing their electrocardiograms displayed on both 5-mm and 1-mm formatted grids and twice on traditional printout electrocardiograms. The control level of intraobserver agreement between the responses from the 2 sets of paper display electrocardiograms was compared with the experimental level of intraobserver agreement between the 1-mm LCD electrocardiograms and both sets of paper display electrocardiograms to determine whether the viewing medium affected the cardiologist's decisions. The 1-mm and 5-mm LCD screen electrocardiograms were compared to determine if the grid size affected the cardiologist's decisions.

RESULTS

Ninety-three percent of the 2 sets of paper-guided decisions were in agreement. When comparing the 1-mm LCD-guided decisions with both sets of paper-guided decisions, 94% and 89% of the decisions, respectively, were in agreement. The differences between the control and experimental degrees of intraobserver agreement of 1% and 4% were not statistically significant (P1 =.81, P2 =.29). Ninety-one percent of the 1-mm LCD-guided decisions were in agreement with the 5-mm LCD-guided decisions.

CONCLUSIONS

Cardiologists' decisions did not vary significantly when viewing either traditional paper electrocardiograms or LCD screen electrocardiograms. Even though there was not a significant difference in the cardiologists' decisions when they viewed electrocardiograms displayed on both the 1-mm and 5-mm grid, it is recommended that the 1-mm grid be used for clinical implementation of the LCD screen.

Review article: the clinical role of anti-TNFalpha antibody treatment in Crohn's disease

The recent licensing of anti-TNFalpha antibody treatment offers the potential to radically alter the course of severe Crohn's disease using genetically-engineered drugs directed against a specific inflammatory mediator. Controlled randomized trials have demonstrated clinical benefit associated with tissue healing in patients with active intestinal disease and fistulae, often when conventional therapies were unsuccessful. This therapy is expensive, however, and long-term efficacy and safety data are still awaited. This review considers the nature of this therapy and the current evidence for its clinical benefit and adverse effects. The treatment is also considered in the context of available immunosuppressive agents, with suggestions about its practical application.

Severity of liver disease in hepatitis C infection contracted through injecting drug use

BACKGROUND

Injecting drug use (IDU) is currently the most common route of hepatitis C virus (HCV) transmission in Australia and many other Western countries. Most reports on the natural history of HCV have examined populations that included patients from all risk groups, but it is possible that this increasingly important subgroup is different.

AIMS

To assess the severity of liver disease in individuals who acquired HCV through IDU.

METHODS

Three hundred and forty-six patients with confirmed HCV infection and a history of IDU, who had had a liver biopsy performed were recruited from a liver clinic. Demographic data, liver function tests and hepatitis B serology were obtained on all patients. A detailed drug use history and HCV viral studies were also available in a subgroup of 142 patients.

RESULTS

Mean age of the group was 34 years and 73% were male. Mean duration of HCV infection was 14.6 years. Forty one per cent were infected with genotype 3a, 19% - 1a, 17% - 1 (nonsubtypable), 14% - 1b and 4% - 2b. Cirrhosis was present in 12% of patients. Patients with cirrhosis (38 years) were older than those with chronic hepatitis (34 years; p=0.0003) and had a longer duration of infection (17.2 vs 14.3 years; p=0.003). On multivariate analysis, however, patient age was the only factor independently associated with cirrhosis (odds ratio 4.2; 95% confidence interval 1.4-12.6).

CONCLUSION

While cirrhosis is less common in this group than in other HCV infected populations, its prevalence may increase as these patients are followed over a longer period of time.

Bioelectrical impedance methods in clinical research: a follow-up to the NIH Technology Assessment Conference

In 1994, the National Institutes of Health (NIH) convened a Technology Assessment Conference "to provide physicians with a responsible assessment of bioelectrical impedance analysis (BIA) technology for body composition measurement." In 1997, Serono Symposia USA, Inc., organized an invited panel of scientists and clinicians, with extensive research and clinical experience with BIA, to provide an update. Panel members presented reviews based on their own work and published studies for the intervening years. Updates were provided on the single and multifrequency BIA methods and models; continued clinical research experiences; efforts toward establishing population reference norms; and the feasibility of establishing guidelines for potential diagnostic use of BIA in a clinical setting. This report provides a summary of the panel's findings including a consensus on several technical and clinical issues related to the research use of BIA, and those areas that are still in need of additional study.

Plasma lipid changes after supplementation with beta-glucan fiber from yeast

BACKGROUND

Dietary fiber has been shown to improve blood lipids.

OBJECTIVE

The purpose of this study was to evaluate the effect on serum lipids of a yeast-derived beta-glucan fiber in 15 free-living, obese, hypercholesterolemic men.

DESIGN

After a 3-wk period in which subjects ate their usual diet, 15 g fiber/d was added to the diet for 8 wk and then stopped for 4 wk. Plasma lipids were measured weekly during baseline and at week 7 and 8 of fiber consumption, and again at week 12.

RESULTS

Compared with baseline, fiber consumption significantly reduced plasma total cholesterol (by 8% at week 7 and 6% at week 8; P < 0.05 using Bonferroni correction); week 12 values did not differ from baseline. No significant differences were noted between baseline LDL cholesterol and values at weeks 7, 8, or 12 when comparing individual groups by using Bonferroni correction, even though the overall one-way analysis of variance with repeated measures was highly significant (P < 0.001). LDL-cholesterol concentrations did decline by 8% at week 8 compared with baseline. There was a significant effect of diet on plasma HDL-cholesterol concentrations (P < 0.005 by one-way ANOVA with repeated measures). However, a group difference was observed only between baseline and week 12 (16% increase; P < 0.05 by Bonferroni correction). Triacylglycerol concentrations did not change.

CONCLUSIONS

The yeast-derived beta-glucan fiber significantly lowered total cholesterol concentrations and was well tolerated; HDL-cholesterol concentrations rose, but only 4 wk after the fiber was stopped.

Accounting units in DNA

Chargaff's first parity rule (%A=%T and %G=%C) is explained by the Watson-Crick model for duplex DNA in which complementary base pairs form individual accounting units. Chargaff's second parity rule is that the first rule also applies to single strands of DNA. The limits of accounting units in single strands were examined by moving windows of various sizes along sequences and counting the relative proportions of A and T (the W bases), and of C and G (the S bases). Shuffled sequences account, on average, over shorter regions than the corresponding natural sequence. For an E. coli segment, S base accounting is, on average, contained within a region of 10 kb, whereas W base accounting requires regions in excess of 100 kb. Accounting requires the entire genome (190 kb) in the case of Vaccinia virus, which has an overall "Chargaff difference" of only 0.086% (i.e. only one in 1162 bases does not have a potential pairing partner in the same strand). Among the chromosomes of Saccharomyces cerevisiae, the total Chargaff differences for the W bases and for the S bases are usually correlated. In general, Chargaff differences for a natural sequence and its shuffled counterpart diverge maximally when 1 kb sequence windows are employed. This should be the optimum window size for examining correlations between Chargaff differences and sequence features which have arisen through natural selection. We propose that Chargaff's second parity rule reflects the evolution of genome-wide stem-loop potential as part of short- and long-range accounting processes which work together to sustain the integrity of various levels of information in DNA.

Deviations from Chargaff's second parity rule correlate with direction of transcription

The distribution of deviations from Chargaff's second parity rule was examined for overlapping sequence windows of a length (1 kb) predicted to be suitable for detecting correlations with functional features of DNA. For long genomic segments from E. coli, Saccharomyces cerevisiae, and Vaccinia virus, Chargaff differences for the W bases and/or for the S bases correlate with transcription direction and gene location. For W-rich genomes, the mRNA-synonymous strand contains regions which, if extruded from negatively supercoiled DNA, would fold to generate stem-loop structures with A-rich loops. Similarly, for S-rich genomes the loops would be G-rich. We suggest that the disposition of genes in nucleic acid sequences arises from their having to adapt to a preexisting mosaic of genomic regions, each distinguished by its potential to extrude single-strand loops enriched for a particular base (or two non-Watson-Crick pairing bases). The mosaic would have facilitated the intrastrand and interstrand accounting required for correction of mutations, and would have evolved in the early RNA world before the emergence of protein-encoding capacity. The preexisting mosaic would have determined transcription direction since there is pressure for all mRNAs of a cell to have purine-rich loops, thus decreasing loop-loop interactions which might lead to formation of "self" sense-antisense RNA duplexes.

Nutritional management of hypoglycemia

PURPOSE

People with type 1 diabetes who follow an intensive management program have an increased risk of hypoglycemia, particularly overnight. New strategies for the nutritional management of hypoglycemia are essential.

METHODS

The unique properties of foods that affect blood glucose are reviewed, with special attention to a new medical food bar designed to reduce the incidence of nocturnal hypoglycemia.

RESULTS

All carbohydrate-containing foods affect blood glucose, but each causes a different rise in concentration. Consuming a variety of conventional foods with different glycemic indices can help control hypoglycemia. A new medical food bar that provides a sequential triphasic release of glucose from sucrose, protein, and uncooked cornstarch can help control blood glucose levels.

CONCLUSIONS

Hypoglycemia can be avoided by consuming foods with varying glycemic indices. A new medical food bar that provides sequential release of glucose into the bloodstream may also help control blood glucose levels.

Correlation of chi orientation with transcription indicates a fundamental relationship between recombination and transcription

Cross-over hot-spot instigator (Chi) sequences (5'-GCTGGTGG-3') are abundant, strand-specific, sequences, which locally increase recombination in Escherichia coli. Located within G-rich 'recombination islands', Chi orientations correlate with the orientations both of DNA replication and of transcription. Consistent with evidence from eukaryotic systems for a fundamental relationship between recombination and transcription, we find for E. coli Chi sequences, and for Haemophilus influenzae Chi-like sequences, that orientations correlate better with transcription than with replication. Complying with Szybalski's transcription direction rule, open reading frames in these prokaryotes have purine-rich mRNA-synonymous DNA strands. Hence, the G-richness of 'recombination islands' may reflect their correspondence with 'transcriptional islands' (genes). Comparison of a natural with the corresponding shuffled sequence, indicates a base order-dependent island unit of approx. 1kb. 1998 Elsevier Science B.V.

Oral nutrition for the patient with HIV infection

In the era of highly active antiretroviral therapy, it is unclear what percentage of patients with HIV infection will develop nutritional issues, including weight loss, diarrheal illness and anorexia. The purpose of this article is to discuss nutritional concerns that can occur with HIV infection and potential treatment strategies. We have included 3 case studies identifying these issues and a nutritional assessment guideline. Nutrition interventions, exercise recommendations, and other alternative strategies to combat HIV associated weight loss is discussed.

Body composition changes in patients with human immunodeficiency virus infection

Malnutrition characterized by weight loss and often extreme wasting generally develops when patients progress from infection with human immunodeficiency virus (HIV) to AIDS. There is evidence that before the development of AIDS, HIV-infected patients without weight loss show early signs of malnutrition, defined as an increase in the ratio of extracellular mass (ECM) to body cell mass (BCM). As part of a dietary intervention study, body composition measurement were obtained at baseline and after 6 wk in 18 patients with HIV infection and CD4 counts between 140 and 740 cells/mm3. Only one patient had a prior weight loss (3.7 kg); patients gained 2 pounds after 3 wk of dietary supplementation of 500 kcal daily. Bioelectrical impedance was used to measured body compartments. The average ECM/BCM ratio (0.77 +/- 0.13) was within the normal range (0.83 +/- 0.16) indicating the absence of malnutrition by this criterion. Most measurements of BCM (kg) approximated normal values, while several for BCM (kg) exceeded normal. BCM (kg) correlated poorly with the ECM/BCM ratio (r2 = 0.08; P = 0.11) in contrast to ECM (kg), which was well correlated (r2 = 0.82; P = 0.00). In addition, there was a significant correlation of body mass index (BMI) with the ECM/BCM ratio (r2 = 0.38; P = 0.00) and with ECM (r2 = 0.244; P = 0.003) indicating that overweight patients may be more likely to be considered malnourished than normal weight patients using this ratio. Without use of bioelectrical impedance, these subtle changes might be missed. Once significant weight loss has occurred coupled with decreases in BCM (kg), the ECM/BCM ratio may be more reflective of malnutrition. These conjectures will require prospective evaluation, but for now it seems reasonable to include bioelectrical impedance as a potentially useful tool in the evaluation of malnutrition in this population.

The new dietary fats in health and disease

Lipids are an integral part of the routine diet of patients and the general public. In this article, the physiologic properties of various dietary lipids are reviewed, beginning with those most commonly consumed-the long-chain triglycerides (LCTs) and extending to those with special purposes: the short- and medium-chain triglycerides. The nutritional dietary management of patients typically includes physical mixtures of lipids. Recently, structured triglycerides (STs), which combine advantages from conventional fats with those of special purposes, have become available. STs are currently developed by interesterifying a mixture of conventional fats and oils, usually with medium-chain triglycerides, to achieve a specific fatty acid profile. This results in a triglyceride containing combinations of short-, medium-, and long-chain fatty acids on a single glycerol backbone. They have unique chemical, physical, or physiologic properties that are not observed by simply blending mixtures of the starting fats and oils. A number of STs are under intense laboratory and clinical investigation in models of cancer, burns, and immune dysfunction. Much interest in the fatty acids resides in the sn-2 position on the glycerol molecule. This is because the fatty acid in the sn-2 position of triglycerides is preferentially absorbed as the 2-monoglyceride and serves as the template for reesterification by intestinal cells to re-form triglycerides. The sn-2 fatty acids are also preferentially preserved as components of chylomicrons and very-low-density lipoprotein particles for ultimate incorporation in tissue membranes. Technology is evolving to create STs with a selected fatty acid in this sn-2 position. For instance, incorporating linoleic, arachidonic, or eicosapentaenoic acid at the sn-2 position is being evaluated for the specific objective of modulating serum cholesterol concentrations and essential fatty acid absorption (a review of this work is included).

A role for Th2 T-memory cells in early airway obstruction

The role of T-cell memory in late-phase allergic lung inflammation is not well defined. To evaluate the role of systemic T-cell memory in allergic late-phase lung inflammation, BALB/c mice were injected intraperitoneally with ovalbumin (OVA) or ragweed (RW) allergens (Test I and Test II groups) or saline (control groups C I and C IV) and then challenged intratracheally with the allergen. Late-phase allergic lung inflammation was defined by: (i) recruitment of eosinophils to airways, (ii) IL-5 mRNA upregulation in BAL fluid cells, and (iii) detection of a Th2 cell cytokine profile in BAL fluids. The number of eosinophils recruited in allergic mice following intratracheal challenge with allergen was at least 300-fold higher P < or = 0.01) in mice with allergen-specific T-memory cells in BAL fluid (Test I and Test II) than in control mice without allergen-specific T-memory cells (C I and C IV). Further, the number of eosinophils recruited in Test I and II correlated with the magnitude of in vitro T-cell memory responses (r = 0.93, P < or = 0.04). Moreover, IL-5 mRNA upregulation in BAL cells and Th2 cytokine production in BAL fluids were observed only in Test I and Test II, and not in any of the control groups. Further, results from pulmonary function tests performed on the same allergic animals indicated that only animals from Test I and Test II groups had impaired lung function after allergen challenge. Taken together, these data strongly suggest that allergen-specific Th2-type T-cell memory is required for the development of allergic asthma. That is, without T-cell memory responses, no eosinophil recruitment and release of EPO (which is known to induce bronchoconstriction) occurred in the airways, and no Th2 cytokine profile was detected in the BAL fluid. Furthermore, if the Th2 cytokine profile was absent, then pulmonary functions remained normal.

Classical Kaposi's: a rare cause of gastrointestinal haemorrhage

Classical Kaposi's sarcoma (KS) is an indolent neoplasm involving mucocutaneous sites predominantly in elderly Mediterranean or Jewish persons. Whilst gastrointestinal involvement is common, it is usually asymptomatic. This case report presents a case of massive gastrointestinal haemorrhage in a patient with stable cutaneous disease and outlines options for the investigation and management of this rare complication.

High-energy, high-protein, oral, liquid, nutrition supplementation in patients with HIV infection: effect on weight status in relation to incidence of secondary infection

OBJECTIVE

to evaluate the use of high-energy, high-protein, oral, liquid, nutrition supplementation and nutrition counseling on the weight status of patients infected with the human immunodeficiency virus (HIV) with and without secondary infections.

DESIGN

Prospective, descriptive, intervention trial. Follow-up clinic visits were scheduled every 1 to 3 weeks for at least 6 weeks to monitor weight, gastrointestinal symptoms, number of supplements consumed, and incidence of secondary infections.

SUBJECTS/SETTING

Community-based, HIV-infected patients, with and without an acquired immunodeficiency syndrome (AIDS) defining illness, who were receiving outpatient medical care at Deaconess Hospital. Twenty-two patients enrolled; however, 4 dropped out and 1 died, so 17 were eligible for evaluation.

INTERVENTION

Dietary counseling consisted of recommendations to consume a high-protein diet (1.5 g/kg ideal body weight); select foods that minimize gastrointestinal complications; and take at least one high-energy, high-protein, oral, liquid, nutrition supplement daily.

MAIN OUTCOME MEASURES

Energy intake from the supplements and weight change over time in relation to whether a secondary infection occurred.

STATISTICAL ANALYSIS

Means, standard deviations, and frequency.

RESULTS

At the time of entry to the study, the patients with preexisting weight loss (16 of 17) were 14+/-8% below their usual body weight. On average, patients consumed 11+/-4 supplements per week for 6+/-3 weeks. The majority (12 of 17) were able to gain or maintain weight. Overall weight change was 1.1+/-2.2 kg. Only 5 of 17 patients lost weight, 4 of whom developed a secondary infection during the study (ie, after enrollment in the study). All of those who developed a secondary infection were classified as having AIDS and had lower mean CD4 counts at baseline than those who did not develop a secondary infection. Although those who developed a secondary infection had a higher incidence of weight loss, their consumption of oral supplements per week was greater than that of those without a secondary infection.

APPLICATIONS/CONCLUSIONS

In patients with HIV infection and in the early stages of AIDS without a secondary infection, weight gain and/or maintenance was achievable with a high-energy, high-protein, oral, liquid, nutrition supplement in conjunction with nutrition counseling. The majority of the patients who developed a secondary infection, however, lost weight despite the use of supplements and counseling. Use of a high-energy, high-protein, oral, liquid, nutrition supplement, with intact nutrients, should be the first-line nutrition treatment for malnourished, HIV-infected patients without secondary infections.

Dietary fish oil and cytokine and eicosanoid production during human immunodeficiency virus infection

BACKGROUND

Dietary fish oil (FO) has been shown to modulate the immune system. The purpose of this study was to explore the effects of FO supplementation on the production of dienoic eicosanoids and cytokines in patients with human immunodeficiency virus (HIV) infection.

METHODS

This was a randomized, prospective, double-blind study that included homosexual males with HIV infection. Patients were asked to consume voluntarily five food bars daily containing FO (n = 10) or safflower oil (SO) (n = 9) for 6 weeks. At baseline and week 6, plasma was obtained to measure incorporation of omega-3 fatty acids. At baseline, week 3, and week 6, measurements were made of changes in dienoic eicosanoids and cytokines from lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMC) or spontaneously releasing cells.

RESULTS

In the FO group but not the SO group, there was increased incorporation of the omega-3 fatty acid docosahexaenoic acid (DHA) into the phospholipids of the fatty acids of the plasma. In the FO group, there was a significant decrease (p = .01) in 6-keto prostaglandin (PG) F1 alpha released from PBMC. There was a significant increase (p = .01) in interleukin (IL)-6 released from the PBMC in the FO group between baseline and week 3 and between week 3 and week 6. At week 6, there was significantly more IL-6 (p = .01) released from the PBMC in the FO group compared with the SO group. There was no change in CD4 cell counts by analysis of variance.

CONCLUSIONS

The FO-containing food bars were well tolerated and allowed incorporation of omega-3 fatty acids to occur. Despite evidence of significant metabolic effects on eicosanoid and cytokine production, widespread clinical use of FO for HIV-infected patients is not warranted without further study, particularly given the trend toward a decline in CD4 cell numbers at this dose and with this type of fish oil.