Regulation of APD and force by Na+/Ca2+ exchanger in hiPSC-cardiomyocytes

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): BMBF

Introduction

Human induced pluripotent stem cell-derived cardiomyocytes (HiPSC-CM) are an emerging, powerful tool to study human cardiac physiology, pharmacology and toxicology, to model cardiovascular diseases or even to use for cardiac repair. Understanding the similarities and differences between hiPSC-CM and adult human cardiomyocytes is critical for their use. Here we focus on sodium calcium exchanger (NCX) who plays a crucial role in the Ca2+-homeostasis in the mammalian heart. Importantly, alterations in NCX expression in human heart are associated with various cardiac pathologies such as heart failure or arrhythmias. In order to investigate whether hiPSC-CM could serve as model for adult human heart NCX we measured the properties of NCX in hiPSC-CM and human ventricular tissue. Rat ventricular tissue was used for comparison.

Methods

HiPSC-CM were differentiated from a healthy iPSC line and dissociated from engineered heart tissue (EHT). Adult human and rat cardiomyocytes were digested from ventricular samples. We measured NCX current by the whole-cell patch clamp technique at 37 °C. Standard sharp microelectrodes were used to record action potentials (AP). Contractile force in human and rat ventricular samples was measured isometrically. A video-optical contractility test system was used to measure force in EHT. SEA0400 (10 µM) was used to block NCX.

Results

NCX currents could be measured in every hiPSC-CM. The NCX current densities in hiPSC-CM were larger than in human ventricular cardiomyocytes (3.2±0.2 pA/pF n=28 vs. 1.3±0.2 pA/pF n=15, p<0.05), but lower than reported for rat left ventricular cardiomyocytes using the same protocol. SEA0400 shortened APD90 markedly in EHT (264.1±24.9 ms to 191±31.6 ms, n=4) and to a lesser extent in rat ventricular tissue (54.4±3.9 ms to 48.9±4.2 ms, n=7). Shortening in human left ventricular preparations was tiny (320±22.1 ms to 305.5±20.3 ms, n=6) and not different from time-matched controls (TMC). Resting membrane potential, action potential amplitude and upstroke velocity were not affected neither in EHT nor in left ventricular preparations (rat and human). Force was significantly increased by NCX block in rat ventricle (by 31±5.4%, n=18) and EHT (by 20.8±3.9%, n=4), but in human left ventricular preparations there was only a tendency to attenuate spontaneous run-down (-3.7±4.3% n=8 with SEA vs. -6.2±3.7% n=12 in TMC).

Conclusion

HiPSC-CM possess NCX in the physiological range. HiPSC-CM show NCX-effects on APD and force as predicted from rat ventricle and in full accordance with cardiac physiology. Lack of NCX effect in human adult ventricles that had been already reported previously needs further investigations.

When is it considered reasonable to start a risky and uncomfortable treatment in critically ill patients? A random sample online questionnaire study

Background

Health care professionals have to judge the appropriateness of treatment in critical care on a daily basis. There is general consensus that critical care interventions should not be performed when they are inappropriate. It is not yet clear which chances of survival are considered necessary or which risk for serious disabilities is acceptable in quantitative terms for different stakeholders to start intensive care treatment.

Methods

We performed an anonymous online survey in a random sample of 1,052 participants recruited via email invitation and social media. Age, sex, nationality, education, professional involvement in health care, critical care medicine and treatment decisions in critical care medicine as well as personal experience with critical illness were assessed as potential influencing variables. Participants provided their opinion on the necessary chances of survival and the acceptable risk for serious disabilities to start a high-risk or uncomfortable therapy for themselves, relatives or for their patients on a scale of 0–100%.

Results

Answers ranged from 0 to 100% for all questions. A three-peak pattern with different distributions of the peaks was observed. Sex, education, being a health care professional, being involved in treatment decisions and religiosity influence these opinions. Male respondents and those with a university education would agree that a risky and uncomfortable treatment should be started even with a low chance of survival for themselves, relatives and patients. More respondents would choose a lower necessary chance of survival (0–33% survival) when deciding for patients compared to themselves or relatives to start a risky and uncomfortable treatment. On the other hand, the majority of respondents would accept only a low risk of severe disability for both themselves and their patients.

Conclusion

No cut-off can be identified for the necessary chances of survival or the acceptable risk of disability to help quantify the “inappropriateness” of critical care treatment. Sex and education are the strongest influencing factors on this opinion. The large variation in personal opinions, depending on demographic and personality variables and education needs to be considered in the communication between health care professionals and patients or surrogates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00705-4.

Culture conditions effect properties of the Na+/K+-ATPase pump current in hiPSC cardiomyocytes

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): BMBF

Background

Cardiomyocytes derived from human induced pluripotent stem cells (hiPSC) provide an opportunity to study human cardiac physiology and pathophysiology or to use for cardiac repair as well as for cardiovascular drug testing. Suitability for these purposes requires generating hiPSC cardiomyocytes that share typical electrophysiological properties of adult human cardiomyocytes. In the human heart the Na+/K+-ATPase pump current plays a major role in the regulation of contractile force and electrical stability. So far there are no data about Na+/K+-ATPase pump current function in hiPSC cardiomyocytes available.

Purpose

We compared the properties of Na+/K+-ATPase pump current in hiPSC cardiomyocytes from conventional monolayers (ML) culture to three-dimensional engineered heart tissue (EHT).

Methods

HiPSC cardiomyocytes differentiated from in-house control hiPSC cell line C25 were dissociated from ML and EHT culture. Na+/K+-ATPase pump current was recorded by whole-cell patch clamp technique at 37°C. The holding potential was -40 mV to inactivate sodium current. Current was measured in the absence of K+ and after adding 5.4 mM potassium chloride (KCL). Na+/K+-ATPase pump current was defined as the ouabain (10 µM) sensitive current. Voltage-dependency of Na+/K+-ATPase pump was determined using rectangular voltage pulses (increasing from -120 mV to +60 mV).

Results

Outwardly directed Na+/K+-ATPase pump could be recorded at -40 mV when KCL was added to the bath solution (5.4 mM). Currents were larger in EHT than in ML (0.8 ± 0.08 pA/pF n = 16 ML vs. 1.29 ± 0.13 pA/pF n = 28 EHT; p < 0.05). The K+-induced outward current was abolished by ouabain. The K+- and ouabain-sensitive current densities were similar in size (0.84 ± 0.11 pA/pF n = 16 ML vs. 1.12 ± 0.11 pA/pF n = 28 EHT for ouabain), indicating the measured K+-induced current was Na+/K+-ATPase pump current. Increasing extracellular K+-concentration in a stepwise manner (0,25 mM, 0,5 mM, 1 mM, 2 mM, 5,4 mM and 10 mM) showed a concentration-dependent relationship to Na+/K+-ATPase pump current with throughout higher current densities in EHT compared to ML (sensitivity to K+ not different). Na+/K+-ATPase pump current showed expected voltage-dependency with +0.23 ± 0.13 pA/pF at -120 mV and +0.89 ± 0.16 pA/pF at +60 mV (n= 18) in ML and with +0.71 ± 0.17 pA/pF at -120 mV and +1.2 ± 0.2 pA/pF at +60 mV (n= 24) in EHT.

Conclusion

HiPSC cardiomyocytes possess Na+/K+-ATPase pump current. Current density is in the range of human cardiomyocytes in EHT but substantially smaller in ML. 3D culturing may be needed to develop the physiological properties of Na+/K+-ATPase pump current.

Distinguishing Extravascular from Intravascular Ferumoxytol Pools within the Brain: Proof of Concept in Patients with Treated Glioblastoma

BACKGROUND AND PURPOSE

Glioblastoma-associated macrophages are a major constituent of the immune response to therapy and are known to engulf the iron-based MR imaging contrast agent, ferumoxytol. Current ferumoxytol MR imaging techniques for localizing macrophages are confounded by contaminating intravascular signal. The aim of this study was to assess the utility of a newly developed MR imaging technique, segregation and extravascular localization of ferumoxytol imaging, for differentiating extravascular-from-intravascular ferumoxytol contrast signal at a delayed 24-hour imaging time point.

MATERIALS AND METHODS

Twenty-three patients with suspected post-chemoradiotherapy glioblastoma progression underwent ferumoxytol-enhanced SWI. Segregation and extravascular localization of ferumoxytol imaging maps were generated as the voxelwise difference of the delayed (24 hours) from the early (immediately after administration) time point SWI maps. Continuous segregation and extravascular localization of ferumoxytol imaging map values were separated into positive and negative components. Image-guided biologic correlation was performed.

RESULTS

Negative segregation and extravascular localization of ferumoxytol imaging values correlated with early and delayed time point SWI values, demonstrating that intravascular signal detected in the early time point persists into the delayed time point. Positive segregation and extravascular localization of ferumoxytol imaging values correlated only with delayed time point SWI values, suggesting successful detection of the newly developed extravascular signal.

CONCLUSIONS

Segregation and extravascular localization of ferumoxytol MR imaging improves on current techniques by eliminating intrinsic tissue and intravascular ferumoxytol signal and may inform glioblastoma outcomes by serving as a more specific metric of macrophage content compared with uncorrected T1 and SWI techniques.

Automatic Spinal Cord Gray Matter Quantification: A Novel Approach

BACKGROUND AND PURPOSE

Currently, accurate and reproducible spinal cord GM segmentation remains challenging and a noninvasive broadly accepted reference standard for spinal cord GM measurements is still a matter of ongoing discussion. Our aim was to assess the reproducibility and accuracy of cervical spinal cord GM and WM cross-sectional area measurements using averaged magnetization inversion recovery acquisitions images and a fully-automatic postprocessing segmentation algorithm.

MATERIALS AND METHODS

The cervical spinal cord of 24 healthy subjects (14 women; mean age, 40 ± 11 years) was scanned in a test-retest fashion on a 3T MR imaging system. Twelve axial averaged magnetization inversion recovery acquisitions slices were acquired over a 48-mm cord segment. GM and WM were both manually segmented by 2 experienced readers and compared with an automatic variational segmentation algorithm with a shape prior modified for 3D data with a slice similarity prior. Precision and accuracy of the automatic method were evaluated using coefficients of variation and Dice similarity coefficients.

RESULTS

The mean GM area was 17.20 ± 2.28 mm² and the mean WM area was 72.71 ± 7.55 mm² using the automatic method. Reproducibility was high for both methods, while being better for the automatic approach (all mean automatic coefficients of variation, ≤4.77%; all differences, P < .001). The accuracy of the automatic method compared with the manual reference standard was excellent (mean Dice similarity coefficients: 0.86 ± 0.04 for GM and 0.90 ± 0.03 for WM). The automatic approach demonstrated similar coefficients of variation between intra- and intersession reproducibility as well as among all acquired spinal cord slices.

CONCLUSIONS

Our novel approach including the averaged magnetization inversion recovery acquisitions sequence and a fully-automated postprocessing segmentation algorithm demonstrated an accurate and reproducible spinal cord GM and WM segmentation. This pipeline is promising for both the exploration of longitudinal structural GM changes and application in clinical settings in disorders affecting the spinal cord.

Dysbiosis in early sepsis can be modulated by a multispecies probiotic: a randomised controlled pilot trial

The gut is hypothesised to play an important role in the development and progression of sepsis. It is however unknown whether the gut microbiome and the gut barrier function is already altered early in sepsis development and whether it is possible to modulate the microbiome in early sepsis. Therefore, a randomised, double blind, placebo-controlled pilot study to examine the alterations of the microbiome and the gut barrier in early sepsis and the influence of a concomitant probiotic intervention on dysbiosis at this early stage of the disease was conducted. Patients with early sepsis, defined as fulfilling the sepsis definition from the 2012 Surviving Sepsis Campaign guidelines but without signs of organ failure, received multispecies probiotic (Winclove 607 based on Omnibiotic® 10 AAD) for 28 days. Gut microbiome composition, function, gut barrier and bacterial translocation were studied. Patients with early sepsis had a significantly lower structural and functional alpha diversity, clustered differently and showed structural alterations on all taxonomic levels. Gut permeability was unaltered but endotoxin, endotoxin binding proteins and peptidoglycans were elevated in early sepsis patients compared to controls. Probiotic intervention successfully increased probiotic strains in stool and led to an improvement of functional diversity. Microbiome composition and function are altered in early sepsis. Probiotic intervention successfully modulates the microbiome and is therefore a promising tool for early intervention in sepsis.

Soluble CD163 and soluble mannose receptor predict survival and decompensation in patients with liver cirrhosis, and correlate with gut permeability and bacterial translocation

BACKGROUND

Activated hepatic macrophages play a key role in inflammation and fibrosis progression in chronic liver disease.

AIM

To assess the prognostic value of soluble (s)CD163 and mannose receptor (sMR) in cirrhotic patients and explore associations with markers of intestinal permeability (lactulose-mannitol ratio, diamine oxidase), bacterial translocation (endotoxin, lipopolysaccharide-binding protein) and markers of systemic immune activation (interleukin-6, interleukin-8, sCD14).

METHODS

We prospectively investigated 101 cirrhotic patients (Child-Pugh class A: n = 72, Child-Pugh classes B and C: n = 29) and 31 healthy controls. Patients were observed for a median follow-up of 37 months.

RESULTS

Median plasma levels of sCD163 and soluble mannose receptor were significantly elevated in cirrhotic patients (P < .001) and increased with disease severity (sCD163 in healthy controls = 1.3, Child-Pugh class A = 4.2, Child-Pugh classes B and C = 8.4 mg/L; sMR in healthy controls = 15.8, Child-Pugh class A = 36.5, Child-Pugh classes B and C = 66.3 μg/dL). A total of 21 patients died during the observation period. Patients with sCD163 levels above 5.9 mg/L showed significantly reduced survival (survival rate after 36 months: 71% versus 98%, P < .001). Patients with soluble mannose receptor levels above 45.5 μg/dL developed significantly more complications of cirrhosis within 12 months (73% versus 9%, P < .001). Furthermore, both variables correlated with the lactulose-mannitol ratio, diamine oxidase, lipopolysaccharide and interleukin-8.

CONCLUSION

Our data demonstrate the prognostic value of sCD163 in predicting long-term survival in patients with liver cirrhosis and identify soluble mannose receptor as a prognostic marker for occurrence of cirrhosis-associated complications. The correlation between gut barrier dysfunction and activation of macrophages points towards a link between them.

Lactobacillus reuteri DSM 17938 and a placebo both significantly reduced symptoms in children with functional abdominal pain

AIM

Lactobacillus reuteri is a Gram-positive bacterium that naturally inhabits the human intestinal tract. This study assessed how effectively the probiotic L. reuteri DSM 17938 managed childhood functional abdominal pain (FAP).

METHODS

We recruited 54 children with a mean age 9.1 ± 3.8 years, who were diagnosed with FAP in the outpatient clinics of three university hospitals in Greece, Slovenia and Poland, according to the Rome III criteria, from January 2013 to December 2015. They were randomly assigned to receive either 2 × 10⁸ colony-forming units of L. reuteri (n = 27) or a placebo (n = 27) for four weeks.

RESULTS

Both L. reuteri and the placebo significantly reduced the frequency and intensity of abdominal pain episodes at four and eight weeks compared to baseline (all p < 0.001). L. reuteri decreased the use of pain relieving drugs at four weeks and the number of child school and adult work absences at four and eight weeks, unlike the placebo, which achieved nonsignificant results. However, the difference between the groups did not reach significance. No side effects were recorded.

CONCLUSION

Both L. reuteri and the placebo were effective in alleviating pain in children with FAP, but only L. reuteri improved the child's and family's normal activities.

Randomised clinical trial: the effects of a multispecies probiotic vs. placebo on innate immune function, bacterial translocation and gut permeability in patients with cirrhosis

BACKGROUND

Probiotics may correct intestinal dysbiosis and proinflammatory conditions in patients with liver cirrhosis.

AIM

To test the effects of a multispecies probiotic on innate immune function, bacterial translocation and gut permeability.

METHODS

In a randomised, double blind, placebo-controlled study, stable cirrhotic out-patients either received a daily dose of a probiotic powder containing eight different bacterial strains (Ecologic Barrier, Winclove, Amsterdam, The Netherlands) (n = 44) or a placebo (n = 36) for 6 months and were followed up for another 6 months.

RESULTS

We found a significant but subclinical increase in neutrophil resting burst (2.6-3.2%, P = 0.0134) and neopterin levels (7.7-8.4 nmol/L, P = 0.001) with probiotics but not with placebo. Probiotic supplementation did not have a significant influence on neutrophil phagocytosis, endotoxin load, gut permeability or inflammatory markers. Ten severe infections occurred in total; one during intervention in the placebo group, and five and four after the intervention has ended in the probiotic and placebo group, respectively. Liver function showed some improvement with probiotics but not with placebo.

CONCLUSIONS

Probiotic supplementation significantly increased serum neopterin levels and the production of reactive oxygen species by neutrophils. These findings might explain the beneficial effects of probiotics on immune function. Furthermore, probiotic supplementation may be a well-tolerated method to maintain or even improve liver function in stable cirrhosis. However, its influence on gut barrier function and bacterial translocation in cirrhotic patients is minimal.

Quantitative evaluation of orofacial motor function in mice: The pasta gnawing test, a voluntary and stress-free behavior test

BACKGROUND

Evaluation of motor deficits in rodents is mostly restricted to limb motor tests that are often high stressors for the animals.

NEW METHOD

To test rodents for orofacial motor impairments in a stress-free environment, we established the pasta gnawing test by measuring the biting noise of mice that eat a piece of spaghetti. Two parameters were evaluated, the biting speed and the biting peaks per biting episode. To evaluate the power of this test compared to commonly used limb motor and muscle strength tests, three mouse models of Parkinson's disease, amyotrophic lateral sclerosis and Niemann-Pick disease were tested in the pasta gnawing test, RotaRod and wire suspension test.

RESULTS

Our results show that the pasta gnawing test reliably displays orofacial motor deficits.

COMPARISON WITH EXISTING METHODS

The test is especially useful as additional motor test in early onset disease models, since it shows first deficits later than the RotaRod or wire suspension test. The test depends on a voluntary eating behavior of the animal with only a short-time food deprivation and should thus be stress-free.

CONCLUSIONS

The pasta gnawing test represents a valuable tool to analyze orofacial motor deficits in different early onset disease models.

Diversity Arrays Technology (DArT) Marker Platforms for Diversity Analysis and Linkage Mapping in a Complex Crop, the Octoploid Cultivated Strawberry (Fragaria × ananassa)

Cultivated strawberry (Fragaria × ananassa) is a genetically complex allo-octoploid crop with 28 pairs of chromosomes (2n = 8x = 56) for which a genome sequence is not yet available. The diploid Fragaria vesca is considered the donor species of one of the octoploid sub-genomes and its available genome sequence can be used as a reference for genomic studies. A wide number of strawberry cultivars are stored in ex situ germplasm collections world-wide but a number of previous studies have addressed the genetic diversity present within a limited number of these collections. Here, we report the development and application of two platforms based on the implementation of Diversity Array Technology (DArT) markers for high-throughput genotyping in strawberry. The first DArT microarray was used to evaluate the genetic diversity of 62 strawberry cultivars that represent a wide range of variation based on phenotype, geographical and temporal origin and pedigrees. A total of 603 DArT markers were used to evaluate the diversity and structure of the population and their cluster analyses revealed that these markers were highly efficient in classifying the accessions in groups based on historical, geographical and pedigree-based cues. The second DArTseq platform took benefit of the complexity reduction method optimized for strawberry and the development of next generation sequencing technologies. The strawberry DArTseq was used to generate a total of 9,386 SNP markers in the previously developed ‘232’ × ‘1392’ mapping population, of which, 4,242 high quality markers were further selected to saturate this map after several filtering steps. The high-throughput platforms here developed for genotyping strawberry will facilitate genome-wide characterizations of large accessions sets and complement other available options.

Risks, risk assessment and risk competence in toxicology

Understanding the toxic effects of xenobiotics requires sound knowledge of physiology and biochemistry. The often described lack of understanding pharmacology/toxicology is therefore primarily caused by the general absence of the necessary fundamental knowledge. Since toxic effects depend on exposure (or dosage) assessing the risks arising from toxic substances also requires quantitative reasoning. Typically public discussions nearly always neglect quantitative aspects and laypersons tend to disregard dose-effect-relationships. One of the main reasons for such disregard is the fact that exposures often occur at extremely low concentrations that can only be perceived intellectually but not by the human senses. However, thresholds in the low exposure range are often scientifically disputed. At the same time, ignorance towards known dangers is wide-spread. Thus, enhancing the risk competence of laypersons will have to be initially restricted to increasing the awareness of existing problems.

Vitamin D status in men with psoriatic arthritis: a case-control study

We determined hypovitaminosis D prevalence in men with psoriatic arthritis. This is a cross-sectional, analyst blinded, age- and sex-matched, case-control study. Men with psoriatic arthritis have significantly lower 25-hydroxyvitamin D levels. Men with psoriatic arthritis are at increased odds of suffering from hypovitaminosis D.

INTRODUCTION

Skeletal manifestations as a result of abrupted bone metabolism may be predominant in psoriatic arthritis (PsA). Vitamin D plays a vital role in maintenance of skeletal health and is known to modulate the immune system in various autoimmune diseases including PsA. The aim of the present study was to determine the prevalence of hypovitaminosis D in a treatment naïve, de novo psoriatic arthritis male cohort in a cross-sectional, analyst blinded, age- and sex-matched, case-control study.

METHODS

25 hydroxyvitamin D (25OHD), parathyroid (PTH), osteocalcin (OC) and C-terminal telopeptides of type-I collagen (CTx) levels, and lumbar spine and femoral neck bone mineral density were compared between 53 PsA and controls.

RESULTS

The prevalence of hypovitaminosis D (25 hydroxyvitamin D (25OHD) levels <75 nmol/L) was 81 and 57 % in the PsA and control groups, respectively. Compared to the healthy controls, 25OHD (67.2 (12-137) nmol/L vs. 51.9 (15-95) nmol/L; p = 0.001) was significantly lower, and osteocalcin (13.6 (5-33) μg/L vs. 18.2 (6-35) μg/L; p = 0.003) and C-terminal telopeptides of type-I collagen (0.20 (0.01-0.71) μg/L vs. 0.28 (0.06-0.69) μg/L; p = 0.008) were significantly higher in the PsA group. A significant association was found between hypovitaminosis D and PsA; the odds for patients with PsA of having hypovitaminosis D was 3.297 (95 % confidence interval 1.372 to 7.922).

CONCLUSION

The results of this study suggest that men with PsA have significantly lower 25-hydroxyvitamin D levels, and furthermore, men with PsA are at statistically significant increased odds of suffering from hypovitaminosis D.

Systematic review with meta-analysis: Saccharomyces boulardii supplementation and eradication of Helicobacter pylori infection

BACKGROUND

Unsatisfactory Helicobacter pylori eradication rates and therapy-associated side effects remain a problem.

AIM

To update our 2010 meta-analysis on the effects of Saccharomyces boulardii as supplementation to a standard eradication regimen on H. pylori eradication rates and therapy-associated side effects.

METHODS

The Cochrane Library, MEDLINE and EMBASE databases were searched from July 2010 (end date of last search) to February 2015, with no language restrictions, for randomised controlled trials (RCTs); additional references were obtained from reviewed articles. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

Eleven RCTs (2200 participants, among them 330 children) met the inclusion criteria. Of the 853 patients in the S. boulardii group, 679 (80%, 95% CI 77-82) experienced eradication compared with 608 of the 855 patients (71%, 95% CI 68-74) in the control group [relative risk (RR) 1.11, 95% confidence interval (CI) 1.06-1.17; moderate quality evidence]. S. boulardii compared with control reduced the risk of overall H. pylori therapy-related adverse effects (RR 0.44, 95% CI 0.31-0.64; moderate quality evidence), particularly of diarrhoea (RR 0.51, 95% CI 0.42-0.62; high quality evidence) and nausea [RR 0.6, 95% CI 0.44-0.83 (moderate quality of evidence)].

CONCLUSIONS

In the populations studied, the effectiveness of standard triple therapy was unsatisfactory. The addition of S. boulardii significantly increased the eradication rate, but it was still below the desired level of success. Saccharomyces boulardii significantly decreased some therapy-related side effects.

Immunolocalization of AQP5 in resting and stimulated normal labial glands and in Sjögren's syndrome

OBJECTIVE

In our current work, in vivo examination of AQP5 distribution in labial salivary glands following stimulation of secretion has been carried out in normal individuals and in patients with Sjögren's syndrome.

SUBJECTS AND METHODS

For this study, we selected five patients with primary Sjögren's syndrome (mean age 62.4 ± 10.6 s.d. years) diagnosed in accordance with the European Cooperative Community classification criteria. There were five patients (mean age 27 ± 2.5 s.d. years) in the control group. The subcellular distribution of AQP5 in human labial gland biopsies was determined with light and immunoelectron microscopy before and 30 min after administration of oral pilocarpine.

RESULTS

In unstimulated control and Sjögren's labial glands, AQP5 is about 90% localized in the apical plasma membrane, with only rarely associated gold particles with intracellular membrane structures. We have found no evidence of pilocarpine-induced changes in localization of AQP5 in either healthy individuals or patients with Sjögren's syndrome.

CONCLUSIONS

Our studies indicate that neither Sjögren's syndrome itself, nor muscarinic cholinergic stimulation in vivo caused any significant changes in the distribution of AQP5 in the labial salivary gland cells.

Systematic screening for PRKAR1A gene rearrangement in Carney complex: identification and functional characterization of a new in-frame deletion

BACKGROUND

Point mutations of the PRKAR1A gene are a genetic cause of Carney complex (CNC) and primary pigmented nodular adrenocortical disease (PPNAD), but in 30% of the patients no mutation is detected.

OBJECTIVE

Set up a routine-based technique for systematic detection of large deletions or duplications of this gene and functionally characterize these mutations.

METHODS

Multiplex ligation-dependent probe amplification (MLPA) of the 12 exons of the PRKAR1A gene was validated and used to detect large rearrangements in 13 typical CNC and 39 confirmed or putative PPNAD without any mutations of the gene. An in-frame deletion was characterized by western blot and bioluminescence resonant energy transfer technique for its interaction with the catalytic subunit.

RESULTS

MLPA allowed identification of exons 3-6 deletion in three patients of a family with typical CNC. The truncated protein is expressed, but rapidly degraded, and does not interact with the protein kinase A catalytic subunit.

CONCLUSIONS

MLPA is a powerful technique that may be used following the lack of mutations detected by direct sequencing in patients with bona fide CNC or PPNAD. We report here one such new deletion, as an example. However, these gene defects are not a frequent cause of CNC or PPNAD.

Meta-analysis: sequential therapy for Helicobacter pylori eradication in children

BACKGROUND

Problems with the standard triple treatment recommended for Helicobacter pylori eradication therapy include unsatisfactory (less than 80%) eradication rates among children.

AIM

To assess the evidence for sequential therapy compared with triple therapy on H. pylori eradication rates in children.

METHODS

The Cochrane Library, MEDLINE and EMBASE databases were searched in May 2012, with no language restrictions, as were abstracts from major gastroenterology conferences, for randomised controlled trials (RCTs) comparing sequential therapy with standard triple therapy for H. pylori eradication. Additional references were obtained from reviewed articles. Authors were contacted for extra information. Dichotomous data were pooled to obtain the relative risk (RR) of the eradication rate, with a 95% CI.

RESULTS

Ten RCTs involving a total of 857 children aged 3-18 years met the inclusion criteria. Of the 409 patients in the sequential therapy group, 318 (78%, 95% CI 73-82) experienced eradication compared with 314 of the 444 patients (71%, 95% CI 66-75) in the standard triple therapy group (RR 1.14, 95% CI 1.06-1.23, number needed to treat 15; fixed-effects model). Sequential therapy was superior to 7-day standard triple therapy, but was not significantly better than 10-day or 14-day triple therapy. There were no significant differences between groups in the risk of adverse effects.

CONCLUSIONS

The pooled evidence suggests that 10-day sequential therapy compared with standard triple therapy may be considered as an option for increasing the eradication rates in children; however, it is still less than desired.

PRKAR1A gene analysis and protein kinase A activity in endometrial tumors

PRKAR1A codes for the type 1a regulatory subunit (RIα) of the cAMP-dependent protein kinase A (PKA), an enzyme with an important role in cell cycle regulation and proliferation. PKA dysregulation has been found in various tumors, and PRKAR1A-inactivating mutations have been reported in mostly endocrine neoplasias. In this study, we investigated PKA activity and the PRKAR1A gene in normal and tumor endometrium. Specimens were collected from 31 patients with endometrial cancer. We used as controls 41 samples of endometrium that were collected from surrounding normal tissues or from women undergoing gynecological operations for other reasons. In all samples, we sequenced the PRKAR1A-coding sequence and studied PKA subunit expression; we also determined PKA activity and cAMP binding. PRKAR1A mutations were not found. However, PKA regulatory subunit protein levels, both RIα and those of regulatory subunit type 2b (RIIβ), were lower in tumor samples; cAMP binding was also lower in tumors compared with normal endometrium (P<0.01). Free PKA activity was higher in tumor samples compared with that of control tissue (P<0.01). There are significant PKA enzymatic abnormalities in tumors of the endometrium compared with surrounding normal tissue; as these were not due to PRKAR1A mutations, other mechanisms affecting PKA function ought to be explored.

Vitrification of bovine blastocysts pretreated with sublethal hydrostatic pressure stress: evaluation of post-thaw in vitro development and gene expression

Sublethal stress treatment has been reported to enhance gametes' performance in subsequent procedures, such as cryopreservation. The aim of the present study was to evaluate the effect of different equilibration times between the termination of a sublethal hydrostatic pressure (HP) stress treatment and the initiation of vitrification on the post-thaw survival, continued in vitro development, hatching rate and gene expression of selected candidate genes of in vitro-produced (IVP) expanded bovine blastocysts. Day 7 IVP blastocysts were subjected to 600 bar pressure for 60 min at 32°C. Immediately after pressure treatment (HP0h) or after 1 or 2h incubation (HP1h and HP2h groups, respectively), embryos were either vitrified and warmed using the open pulled straw method, followed by 72 h in vitro culture or were stored at -80°C until gene expression analysis. Re-expansion and hatching rates after vitrification-warming were significantly (P<0.05) higher in the HP0h (88 and 76%, respectively) and HP1h (90 and 75%, respectively) groups than in the untreated (82 and 63%, respectively) and HP2h groups (79 and 70%, respectively). Moreover, the HP1h group showed further improvement in the speed of re-expansion and resumption of normal in vitro development. Cumulative analysis of all genes (SC4MOL, HSP1A1A, SOD2 and GPX4) revealed a similar pattern of expression, with a tendency for peak transcript abundance 1h after HP treatment. Application of HP stress treatment was found to be efficient in increasing the in vitro developmental competence of vitrified bovine embryos.

N-Methylated sst2 Selective Somatostatin Cyclic Peptide Analogue as a Potent Candidate for Treating Neurogenic Inflammation

A focused multiply N-methylated library of a cyclic hexapeptidic somatostatin analogue: MK678 cyclo(-MeAYwKVF-) was generated, which resulted in the unexpected observation of an efficacious tetra-N-methylated analogue, cyclo(-MeAYMewMeKVMeF-) with a potent inhibitory action on sensory neuropeptide release in vitro and on acute neurogenic inflammatory response in vivo. The analogue shows selectivity toward somatostatin receptor subtype 2 (sst2). Extensive 2D NMR spectroscopy and molecular dynamics simulation revealed the solution conformation of the analogue, which can be adopted as a lead for the further structure-activity relationship studies targeting neurogenic inflammation.

Meta-analysis: Lactobacillus rhamnosus GG for abdominal pain-related functional gastrointestinal disorders in childhood

BACKGROUND

A lack of reliable treatments for abdominal pain-related functional gastrointestinal disorders prompts interest in new therapies.

AIM

To evaluate systematically the effect of Lactobacillus rhamnosus GG (LGG) for treating abdominal pain-related functional gastrointestinal disorders in children.

METHODS

MEDLINE, EMBASE, CINAHL, the Cochrane Library, trial registries and proceedings of major meetings were searched for randomised controlled trials (RCTs) evaluating LGG supplementation in children with abdominal pain-related functional gastrointestinal disorders based on the Rome II or Rome III criteria. Risk of bias was assessed for generation of the allocation sequence, allocation concealment, blinding and follow-up.

RESULTS

Compared with placebo, LGG supplementation was associated with a significantly higher rate of treatment responders (defined as no pain or a decrease in pain intensity) in the overall population with abdominal pain-related functional gastrointestinal disorders (three RCTs, n = 290; risk ratio, RR 1.31, 95% CI 1.08-1.59, number needed to treat, NNT 7, 95% CI 4-22) and in the irritable bowel syndrome (IBS) subgroup (three RCTs, n = 167; RR 1.70, 95% CI 1.27-2.27, NNT 4, 95% CI 3-8). However, no difference was found in the rate of treatment responders between children with functional abdominal pain or functional dyspepsia who received placebo or LGG. The intensity of pain was significantly reduced in the overall study population and in the IBS subgroup. The frequency of pain was significantly reduced in the IBS subgroup only.

CONCLUSION

The use of Lactobacillus rhamnosus GG moderately increases treatment success in children with abdominal pain-related functional gastrointestinal disorders, particularly among children with IBS.

The role of germline AIP, MEN1, PRKAR1A, CDKN1B and CDKN2C mutations in causing pituitary adenomas in a large cohort of children, adolescents, and patients with genetic syndromes

The prevalence of germline mutations in MEN1, AIP, PRKAR1A, CDKN1B and CDKN2CI is unknown among pediatric patients with pituitary adenomas (PA). In this study, we screened children with PA for mutations in these genes; somatic GNAS mutations were also studied in a limited number of growth hormone (GH) or prolactin (PRL)-secreting PA. We studied 74 and 6 patients with either isolated Cushing disease (CD) or GH- or PRL-secreting PA, respectively. We also screened four pediatric patients with CD, and four with GH/PRL-secreting tumors who had some syndromic features. There was one AIP mutation (p.Lys103Arg) among 74 CD patients. Two MEN1 mutations that occurred in patients with recurrent or difficult-to-treat disease were found among patients with CD. There was one MEN1 and three AIP mutations (p.Gln307ProfsX104, p.Pro114fsX, p.Lys241X) among pediatric patients with isolated GH- or PRL-secreting PA and one additional MEN1 mutation in a patient with positive family history. There were no mutations in the PRKAR1A, CDKN1B, CDKN2C or GNAS genes. Thus, germline AIP or MEN1 gene mutations are frequent among pediatric patients with GH- or PRL-secreting PA but are significantly rarer in pediatric CD; PRKAR1A mutations are not present in PA outside of Carney complex.

Meta-analysis: the effects of Saccharomyces boulardii supplementation on Helicobacter pylori eradication rates and side effects during treatment

BACKGROUND

Problems with currently recommended Helicobacter pylori eradication therapies include unsatisfactory eradication rates and/or therapy-associated side effects.

AIM

To investigate the effects of Saccharomyces boulardii as supplementation to standard triple therapy on H. pylori eradication rates and therapy-associated side effects.

METHODS

The Cochrane Library, MEDLINE and EMBASE databases were searched in July 2010, with no language restrictions, for randomized controlled trials (RCTs); additional references were obtained from reviewed articles.

RESULTS

Five RCTs involving a total of 1307 participants (among them only 90 children) met the inclusion criteria. Compared with placebo or no intervention, S. boulardii given along with triple therapy significantly increased the eradication rate [four RCTs, n = 915, relative risk (RR) 1.13, 95% confidence interval (CI) 1.05-1.21] and reduced the risk of overall H. pylori therapy-related adverse effects (five RCTs, n = 1305, RR 0.46, 95% CI 0.3-0.7), particularly of diarrhoea (four RCTs, n = 1215, RR 0.47, 95% CI 0.32-0.69). There were no significant differences between groups in the risk of other adverse effects.

CONCLUSION

In patients with H. pylori infection, there is evidence to recommend the use of S. boulardii along with standard triple therapy as an option for increasing the eradication rates and decreasing overall therapy-related side effects, particularly diarrhoea.

Meta-analysis: the effects of Saccharomyces boulardii supplementation on Helicobacter pylori eradication rates and side effects during treatment

BACKGROUND

Problems with currently recommended Helicobacter pylori eradication therapies include unsatisfactory eradication rates and/or therapy-associated side effects.

AIM

To investigate the effects of Saccharomyces boulardii as supplementation to standard triple therapy on H. pylori eradication rates and therapy-associated side effects.

METHODS

The Cochrane Library, MEDLINE and EMBASE databases were searched in July 2010, with no language restrictions, for randomized controlled trials (RCTs); additional references were obtained from reviewed articles.

RESULTS

Five RCTs involving a total of 1307 participants (among them only 90 children) met the inclusion criteria. Compared with placebo or no intervention, S. boulardii given along with triple therapy significantly increased the eradication rate [four RCTs, n = 915, relative risk (RR) 1.13, 95% confidence interval (CI) 1.05-1.21] and reduced the risk of overall H. pylori therapy-related adverse effects (five RCTs, n = 1305, RR 0.46, 95% CI 0.3-0.7), particularly of diarrhoea (four RCTs, n = 1215, RR 0.47, 95% CI 0.32-0.69). There were no significant differences between groups in the risk of other adverse effects.

CONCLUSION

In patients with H. pylori infection, there is evidence to recommend the use of S. boulardii along with standard triple therapy as an option for increasing the eradication rates and decreasing overall therapy-related side effects, particularly diarrhoea.

Are treatment targets for hypercholesterolemia evidence based? Systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

Search for evidence supporting target age, level of intervention and target values for low-density lipoprotein (LDL) cholesterol levels in children with familial hypercholesterolemia.

DESIGN

Systematic review and meta-analysis. PubMed, Medline, CINAHL and Cochrane Reviews databases from 1966 to 2007 were searched for articles reporting statin therapy in children and adolescents aged 8-18 years. Retrieved articles were screened for double-blind randomised controlled trials (RCTs).

RESULTS

Seven trials involving 884 patients met inclusion criteria. Meta-analysis findings showed significantly reduced total cholesterol, LDL cholesterol and apolipoprotein B, whereas high-density lipoprotein cholesterol and apolipoprotein A1 were significantly increased by statin therapy. Evidence on target level in children was limited to one study attainment of LDL cholesterol treatment target in 60% of the subjects in the treatment group and none in the placebo group reached their target LDL cholesterol. Evidence on the effect of statins on surrogate markers of atherosclerosis was limited to two studies (one RCT on the effect upon the carotid intima-media thickness (n=211; mean difference (MD) -0.01; 95% CI -0.03 to -0.00), and one showing that the mean absolute change in flow-mediated dilation after 28 weeks of statin treatment was significantly higher in the simvastatin group compared to placebo group (MD 2.7%; 95% CI 0.42 to 4.98).

CONCLUSIONS

There is no firm evidence regarding when to start statin treatment or what target LDL cholesterol level should be attained. Recent recommendations that favour statins as the first-line drug treatment for hypercholesterolemia are evidence based. Studying high-risk groups (obese or diabetic patients) and incorporating composite end points may help define treatment guidelines.

Quantitative differences in antibiotic resistance between methicillin-resistant and methicillin-susceptible Staphylococcus aureus strains isolated in Hungary, Austria and Macedonia

The aim of this study was to compare the quantitative susceptibility of methicillin-resistant and -susceptible Staphylococcus aureus (MRSA and MSSA) strains from three European countries to nine antistaphylococcal agents. The antibiotic susceptibility of 274 MRSA and 284 MSSA strains from Hungary, Austria and macedonia was tested by the broth microdilution method. The clonal relationship of strains was determined by pulsed-field gel electrophoresis. Intermediate susceptibility to vancomycin appeared in Macedonian MRSA strains. Macedonian MRSA strains had high-level amikacin and gentamicin resistance. MSSA strains generally were susceptible to all drugs at minimum inhibitory concentrations (MIC(50)) except for gentamicin resistance in Macedonian strains. In Hungary and Austria a common antibiotic resistance phenotype of MRSA predominated, while in macedonia three other phenotypes were also prevalent. Geographical differences in the resistance of S. aureus are still high. Since resistance levels of MRSA and MSSA strains differ extensively, they should be considered separately for antibiotic resistance analysis.

Analysis of diversity and linkage disequilibrium along chromosome 3B of bread wheat (Triticum aestivum L.)

A highly polymorphic core collection of bread wheat and a more narrow-based breeding material, gathered from pedigrees of seven modern cultivars, was analysed in order to compare genetic diversity indices and linkage disequilibrium (LD) patterns along the chromosome 3B with microsatellite (SSR) and Diversity Arrays Technology markers. Five ancestral gene pools could be identified within the core collection, indicating a strong geographical structure (Northwest Europe, Southeast Europe, CIMMYT-ICARDA group, Asia, Nepal). The breeding material showed a temporal structure, corresponding to different periods of breeding programmes [old varieties (from old landraces to 1919), semi-modern varieties (1920-1959), modern varieties (1960-2006)]. Basic statistics showed a higher genetic diversity in the core collection than in the breeding material, indicating a stronger selection pressure in this latter material. More generally, the chromosome 3B had a lower diversity than the whole B-genome. LD was weak in all studied materials. Amongst geographical groups, the CIMMYT-ICARDA pool presented the longest ranged LD in contrast to Asian accessions. In the breeding material, LD increased from old cultivars to modern varieties. Genitors of seven modern cultivars were found to be different; most marker pairs in significant LD were observed amongst genitors of Alexandre and Koreli varieties, indicating an important inbreeding effect. At low genetic distances (0-5 cM), the breeding material had higher LD than the core collection, but globally the two materials had similar values in all classes. Marker pairs in significant LD are generally observed around the centromere in both arms and at distal position on the short arm of the chromosome 3B.

An Intronic mutation is associated with prolactinoma in a young boy, decreased penetrance in his large family, and variable effects on MEN1 mRNA and protein

Prolactinomas are rare tumors in prepubertal children. A prolactinoma in a young child may be due to sequence variants in genes that are known to cause these tumors ( MEN1, PRKAR1A, AIP). An 11-year-old boy with a macroprolactinoma was treated with cabergoline and the tumor receded. We studied the patient and his family for genetic causes of this tumor. No mutations were present in the coding sequence of PRKAR1A and AIP. A novel heterozygous substitution (IVS3-7 c>a) was identified in intron 3 of MEN1. We also found an additional PCR amplicon that incorporated the entire intron 3 of the gene (210 bp) in the patient's cDNA. The same amplicon was present with lower intensity in some of the control individuals who were not mutation carriers. Intron 3 harbors an in-frame stop codon and its incorporation is predicted to result in a prematurely terminated protein. We conclude that a novel MEN1 variation was identified in a young boy with prolactinoma and six of his relatives who did not present with prolactinoma or other MEN1 related symptoms. This novel MEN1 variation may be associated with low penetrance of the disease. The IVS3-7 c>a defect is suggested to be pathogenic because it is associated with lower menin levels in the cells of these patients, but its consequences may be mitigated by a variety of factors including changes in transcription and translation of the MEN1 gene.

Protein kinase A subunit expression is altered in Bloom syndrome fibroblasts and the BLM protein is increased in adrenocortical hyperplasias: inverse findings for BLM and PRKAR1A

Bloom syndrome is a genetic disorder associated with chromosomal instability and a predisposition to tumors that is caused by germline mutations of the BLM gene, a RecQ helicase. Benign adrenocortical tumors display a degree of chromosomal instability that is more significant than benign tumors of other tissues. Cortisol-producing hyperplasias, such as primary pigmented nodular adrenocortical disease (PPNAD), which has been associated with protein kinase A (PKA) abnormalities and/or PRKAR1A mutations, also show genomic instability. Another RecQ helicase, WRN, directly interacts with the PRKAR1B subunit of PKA. In this study, we have investigated the PRKAR1A expression in primary human Bloom syndrome cell lines with known BLM mutations and examined the BLM gene expression in PPNAD and other adrenal tumor tissues. PRKAR1A and other protein kinase A (PKA) subunits were expressed in Bloom syndrome cells and their level of expression differed by subunit and cell type. Overall, fibroblasts exhibited a significant decrease in protein expression of all PKA subunits except for PRKAR1A, a pattern that has been associated with neoplastic transformation in several cell types. The BLM protein was upregulated in PPNAD and other hyperplasias, compared to samples from normal adrenals and normal cortex, as well as samples from cortisol- and aldosterone-producing adenomas (in which BLM was largely absent). These data reveal an inverse relationship between BLM and PRKAR1A: BLM deficiency is associated with a relative excess of PRKAR1A in fibroblasts compared to other PKA subunits; and PRKAR1A deficiency is associated with increased BLM protein in adrenal hyperplasias.

Phosphodiesterase 11A expression in the adrenal cortex, primary pigmented nodular adrenocortical disease, and other corticotropin-independent lesions

A variety of adrenal tumors and bilateral adrenocortical hyperplasias (BAH) leading to Cushing syndrome (CS) may be caused by aberrant cAMP signaling. We recently identified patients with a micronodular form of BAH that we have called "isolated micronodular adrenocortical disease" (iMAD) in whom CS was associated with inactivating mutations in phosphodiesterase (PDE) 11A ( PDE11A). In the present study, we examined PDE11A expression in normal adrenocortical tissue, sporadic tumors, and hyperplasias without PDE11A mutations, and primary pigmented nodular adrenocortical disease (PPNAD) and adenomas from patients with PRKAR1A and a single tumor with a GNAS mutation. The total number of the tumor samples that we studied was 22. Normal human tissues showed consistent PDE11A expression. There was variable expression of PDE11A in sporadic adrenocortical hyperplasia or adenomas; PPNAD tissues from patients with PRKAR1A mutations expressed consistently high levels of PDE11A in contrast to adenomas caused by GNAS mutations. Phosphorylated CREB was the highest in tissues from patients with iMAD compared to all other forms of BAH and normal adrenal tissue. We conclude that PDE11A is expressed widely in adrenal cortex. Its expression appears to be increased in PPNAD but varies widely among other adrenocortical tumors. PRKAR1A expression appears to be higher in tissues with PDE11A defects. Finally, sequencing defects in PDE11A are associated with a high state of CREB phosphorylation, just like PRKAR1A mutations. These preliminary data suggest that these two molecules are perhaps regulated in a reverse manner in their control of cAMP signaling in adrenocortical tissues.

How the new tools to analyze the human genome are opening new perspectives: the use of gene expression in investigations of the adrenal cortex

With the promise of state-of-the-art molecular technologies and the tools provided by the human genome project, a number of investigators are trying to identify molecular targets of adrenocortical tumorigenesis. One path in this endeavor was the identification by positional cloning of genes that are mutated in rare adrenocortical tumors. The subject of this article is an update of the results of experiments in the second path that was followed by us and others: that of using genome-wide expression analysis of adrenocortical cells in normal and various disease states. Transcriptomic analysis is a rapidly evolving technology; this article summarizes some data on the adrenal cortex and points out how these new technologies can be used in the identification of important genes and molecular pathways in both normal and diseased adrenal cortex.

Male infertility as a component of Carney complex

Carney complex (CNC) is a multiple neoplasia syndrome characterised by endocrine tumours, spotty skin pigmentation, cardiac and other myxomas, psamommatous and pigmented schwannomas, large cell calcifying Sertoli cell tumours, and mammary ductal adenomas and other more rare lesions. CNC is inherited in an autosomal-dominant manner and has been mapped to at least two chromosomal loci. Patients who map to the CNC1 locus located on chromosome 17 carry inactivating mutations of the PRKAR1A gene that encodes the cAMP-dependent protein kinase regulatory subunit type 1-alpha (Kirschner et al., 2000). One gene responsible for type 2 (CNC2) is located on chromosome 2p16. Infertility in CNC can be caused by a number of factors; there is evidence that prkar1a deficiency in mice leads directly to infertility (Burton et al., 2006), but patients with CNC also have Sertoli cell tumours and a number of other reasons to affect fertility. We report on an infertile male with CNC and present evidence that male infertility should be considered as part of the phenotype of CNC.

Meta-analysis: enteral nutrition in active Crohn's disease in children

BACKGROUND

Controversy exists surrounding the optimal treatment for inducing remission in active Crohn's disease.

AIM

To review and update evidence on the effectiveness of enteral nutrition (EN) in treating active Crohn's disease in children.

METHODS

MEDLINE, EMBASE and The Cochrane Library (up to February 2007) were searched for randomized controlled trials (RCTs) relevant to Crohn's disease and EN in children.

RESULTS

We included 11 RCTs (n = 394). Seven RCTs (n = 204) compared EN with corticosteroid therapy. On the basis of pooled results of four RCTs (n = 144), we found no significant difference in the remission rates between groups (relative risk, RR 0.97, 95% CI 0.7-1.4, random effect model). Four RCTs (n = 190) compared two EN regimens. One of the four RCTs (n = 50) revealed a significant increase in the percentage of patients achieving remission in the total EN group compared with the partial EN group (RR 2.7, 95% CI 1-7.4). Because of lack of data, formal pooling of results was not possible for many outcomes (e.g., time until remission, duration of remission, growth data).

CONCLUSIONS

Limited data suggest similar efficacy for EN and corticosteroids. As the number of patients needed to provide a definite answer is too large, future studies should focus on detailed outcome measurements including growth and quality of life.