Plasma and rectal mucosal oxylipin levels during aspirin and eicosapentaenoic acid treatment in the seAFOod polyp prevention trial

BACKGROUND

Aspirin and eicosapentaenoic acid (EPA) have colorectal polyp prevention activity, alone and in combination. This study measured levels of plasma and rectal mucosal oxylipins in participants of the seAFOod 2 × 2 factorial, randomised, placebo-controlled trial, who received aspirin 300 mg daily and EPA 2000 mg free fatty acid, alone and in combination, for 12 months.

METHODS

Resolvin (Rv) E1, 15-epi-lipoxin (LX) A₄ and respective precursors 18-HEPE and 15-HETE (with chiral separation) were measured by ultra-high performance liquid chromatography-tandem mass spectrometry in plasma taken at baseline, 6 months and 12 months, as well as rectal mucosa obtained at trial exit colonoscopy at 12 months, in 401 trial participants.

RESULTS

Despite detection of S- and R- enantiomers of 18-HEPE and 15-HETE in ng/ml concentrations, RvE1 or 15‑epi-LXA₄ were not detected above a limit of detection of 20 pg/ml in plasma or rectal mucosa, even in individuals randomised to both aspirin and EPA. We have confirmed in a large clinical trial cohort that prolonged (12 months) treatment with EPA is associated with increased plasma 18-HEPE concentrations (median [inter-quartile range] total 18-HEPE 0.51 [0.21-1.95] ng/ml at baseline versus 0.95 [0.46-4.06] ng/ml at 6 months [P<0.0001] in those randomised to EPA alone), which correlate strongly with respective rectal mucosal 18-HEPE levels (r = 0.82; P<0.001), but which do not predict polyp prevention efficacy by EPA or aspirin.

CONCLUSION

Analysis of seAFOod trial plasma and rectal mucosal samples has not provided evidence of synthesis of the EPA-derived specialised pro-resolving mediator RvE1 or aspirin-trigged lipoxin 15‑epi-LXA₄. We cannot rule out degradation of individual oxylipins during sample collection and storage but readily measurable precursor oxylipins argues against widespread degradation.

Early-Life Factors Are Associated with Vitamin D Status in Early and Mid-Childhood and May Differ between White and Black Children

BACKGROUND

Suboptimal vitamin D (VitD) status has been associated with poor bone health and other adverse health outcomes and is common among children. Various early-life factors are associated with child VitD, yet few studies have examined multiple factors simultaneously in a single study population.

OBJECTIVES

We aimed to characterize relations of early-life factors with plasma 25-hydroxyvitamin D [25(OH)D] concentrations in early and mid-childhood, and to explore potential differences in these associations between white and black children.

METHODS

We identified associations of various early-life factors with 25(OH)D concentrations in early and mid-childhood among 961 children in Project Viva using linear regression models. All variables associated with 25(OH)D were included together in final multivariable models at each outcome time point: 1 in the overall sample and additional models for children whose mothers identified them as being white or black.

RESULTS

Overall mean ± SD 25(OH)D concentrations were 86 ± 29 nmol/L in early childhood and 68 ± 21 nmol/L in mid-childhood. After accounting for other predictors, children who took VitD supplements (compared with those who did not) had 25(OH)D concentrations 5.6 nmol/L (95% CI: 2.0, 9.2 nmol/L) higher in early childhood and 8.2 nmol/L (95% CI: 4.8, 11.6 nmol/L) higher in mid-childhood. Other factors consistently associated with higher 25(OH)D were blood collection in summer or fall, white race, nonfall birth season, prenatal exposure to higher 25(OH)D, and higher dietary intake of VitD. Greater waist circumference was associated with lower 25(OH)D in early childhood (β: -3.8; 95% CI: -7.4, -0.2 per 1-SD increase) among black children only.

CONCLUSIONS

Our findings may help clinicians better target children at risk of lower 25(OH)D for screening and/or intervention and may inform research focused on associations of 25(OH)D with different exposures and outcomes or causal effects of early-life factors on later VitD status.This trial was registered at clinicaltrials.gov as NCT02820402.

Age-related reference curves of volumetric bone density, structure, and biomechanical parameters adjusted for weight and height in a population of healthy women: an HR-pQCT study

In a cross-sectional cohort of 450 healthy women aged 20 to 85 years, data on the density, structure, and strength of the distal radius and tibia were obtained using high-resolution peripheral quantitative computed tomography (HR-pQCT) and were adjusted for age, weight, and height. Age-dependent patterns of change differed between the sites and between the trabecular and cortical compartments. In postmenopausal women, the trabecular bone remained relatively stable at the distal tibia, but the cortical compartment changed significantly. Cortical porosity exhibited a very weak correlation with stiffness.

INTRODUCTION

The aim of this study is to provide information on age-related, weight-related, and height-related changes in the volumetric bone mineral density (vBMD), structure, and biomechanical parameters of the cortical and trabecular compartments in a healthy female population using HR-pQCT.

METHODS

For a cross-sectional Brazilian cohort of 450 women aged 20 to 85 years, age-related reference curves of the vBMD, structure, and biomechanical parameters of the distal radius (DR) and distal tibia (DT) were constructed and adjusted for weight and height, and comparisons between premenopausal and postmenopausal women were performed.

RESULTS

Reference curves were obtained for all parameters. At the DR, age-related changes varied from -8.68% (cortical thickness [Ct.Th]) to 26.7% (trabecular separation [Tb.Sp]). At the DT, the changes varied from -12.4% (Ct.Th) to 26.3% (Tb.Sp). Cortical porosity (Ct.Po) exhibited the largest percent changes: 342.2% at the DR and 381.5% at the DT. In premenopausal women, Ct.Th remained constant; in postmenopausal women, structural trabecular parameters (trabecular number (Tb.N), trabecular thickness (Tb.Th), Tb.Sp) did not change, whereas cortical parameters and stiffness were significantly altered. Cortical vBMD showed the greatest absolute decrease at both sites, and the slopes were highly negative after menopause. Pearson correlations between stiffness (S) and HR-pCT parameters revealed a significant correlation between the densities and structures of the trabecular and cortical compartments. A weak correlation was observed between S and Ct.Po (DR r = -0.162, DT r = -0.273; p < 0.05).

CONCLUSIONS

These data provide reference curves from healthy women and demonstrate that density and structural and biomechanical parameters differ between the radius and tibia and between the trabecular and cortical compartments. In postmenopausal women, the trabecular bone remained relatively stable at the tibia site, whereas the cortical compartment changed significantly.

Immunoglobulin treatment for respiratory syncytial virus infection

BACKGROUND

Respiratory syncytial virus (RSV) bronchiolitis and pneumonia hospitalize hundreds of thousands of infants every year. Treatment is largely supportive therapy, (for example, oxygen, fluids and occasionally mechanical ventilation). Ribavirin, an antiviral agent, is licensed for severe RSV infection, although systematic reviews find it of no benefit. Passive protection against RSV can be achieved through monthly intramuscular injection of the humanized monoclonal anti-RSV antibody palivizumab (Synagis), and yields a 55% reduction in RSV hospitalisation in susceptible infants. This review assesses immunoglobulin treatment of RSV infection rather than its role as a prophylactic measure.

OBJECTIVES

To assess the efficacy of adding human or humanized immunoglobulin therapy to supportive therapy in infants hospitalized with laboratory-determined RSV infection.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2006), MEDLINE (1966 to Week 4, January 2006) and EMBASE (1980 to September 2005). We also ran searches of reference lists of relevant trials and review articles and searches of personal files. We did not impose any language restrictions.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) that compared immunoglobulin treatment with a placebo control in children hospitalized for RSV infection with bronchiolitis or pneumonia or other lower respiratory tract infection (LRTI) with laboratory-documented RSV infection. The primary outcomes of interest were mortality, length of hospitalisation, length of ventilation and oxygen dependence. Secondary outcome measures were pulmonary function and re-hospitalisations for recurrent breathing difficulties in subsequent years. Any adverse effects of the treatments were also noted, for example, hypersensitivity reactions.

DATA COLLECTION AND ANALYSIS

Data were extracted but cross-comparison was not possible due to the shortage of studies and lack comparative measurements.

MAIN RESULTS

Four papers fitted the search criteria. None demonstrated statistically significant benefit of intravenous immunoglobulin (IVIG) treatment added to supportive care compared with supportive care alone. The evidence does not support a role for RSVIG in such a setting, with the doses used in the studies.

AUTHORS' CONCLUSIONS

The evidence on the role of respiratory syncytial virus immunoglobulin (RSVIG) in treating RSV severe infections is limited. Future research might consider using stronger titres of neutralising antibodies; and further analyse severely ill children (who might respond differentially compared to those less ill, but yet hospitalised).

IPSE/alpha-1: a major immunogenic component secreted from Schistosoma mansoni eggs

During infection with Schistosoma mansoni the egg stage of this parasite modulates the initial T helper (Th1) response into a Th2 response. This suggests that schistosome eggs contain factors responsible for that effect. We have recently described a glycoprotein (IPSE) from S. mansoni eggs that has a potent IL-4-inducing effect on human basophils. Here we demonstrate that IPSE is identical to a previously described molecule, the S. mansoni egg antigen alpha-1. We furthermore show that the expression of IPSE/alpha-1 at the level of both mRNA and protein is restricted to the egg stage. IPSE/alpha-1 is produced in and released from the subshell area of the egg and comes into close contact with inflammatory cells recruited to the vicinity of the egg surface. In line with this IPSE/alpha-1 is one of three major S. mansoni egg glycoproteins that induce pronounced antibody responses. Its IL-4-inducing capacity, moreover, suggests that IPSE/alpha-1 plays a role in initiating the Th2 response induced by patent S. mansoni infections.

Comparison of two sampling techniques for the detection of Malassezia pachydermatis on the skin of dogs with chronic dermatitis

Adhesive tape strip and dry swab sampling techniques were compared for the detection of Malassezia pachydermatis on the skin of dogs with chronic dermatitis. One hundred and four dogs were sampled by each of the techniques. Two methods, a culture method and a stain method, were used to assess the sampling techniques. By the adhesive tape strip sampling technique, M. pachydermatis was detected on 83 (80%) dogs using the culture method and on 45 (43%) dogs using the stain method. By the dry swab sampling technique, M. pachydermatis was detected on 55 (53%) dogs using the culture method and on 33 (32%) dogs using the stain method. The study showed that the adhesive tape strip sampling technique, using the culture method, detected Malassezia on the skin of significantly more dogs (P<0.001) than the same technique using the stain method and also significantly more than the dry swab sampling technique, using either the culture or stain methods. It was also shown that an adhesive tape sample could be used to transfer cells to a slide for staining and microscopy prior to being used for culturing Malassezia.

Adjudicating ventilator-associated pneumonia in a randomized trial of critically ill patients

PURPOSE

The purpose of this study was to evaluate an adjudication strategy for diagnosing ventilator-associated pneumonia (VAP) in a randomized trial.

MATERIALS AND METHODS

In a double-blind trial of sucralfate versus ranitidine, one of four pairs of adjudicators examined each case of clinically suspected VAP. Nurse and physician notes and all relevant laboratory data were allocated to each adjudication pair in groups of five patients. Each reader in the pair decided whether the patient had VAP; differences were resolved by consensus discussion.

RESULTS

The overall unadjusted study odds ratio for VAP was 0.82 (P = .21) representing a trend toward less pneumonia with sucralfate compared with ranitidine. The odds ratio adjusted for adjudication pair was 0.85 (P = .27). The proportion of charts adjudicated as VAP positive among pairs ranged from 50% to 92%; crude agreement between readers in each pair varied from 50% to 82%. When adjudicators disagreed, the final consensus was split evenly between the two adjudicators' initial opinions in two pairs; in the other two pairs, the final decision reflected one dominant initial opinion. Personnel time to adjudicate all patients with a suspicion of VAP was 74 days.

CONCLUSIONS

Though adjudication of outcomes such as VAP is time-consuming, consistent decision-making requires strict criteria, training, and calibration. Patients should be assigned to adjudication teams through random allocation.

A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group

BACKGROUND

Critically ill patients who require mechanical ventilation are at increased risk for gastrointestinal bleeding from stress ulcers. There are conflicting data on the effect of histamine H2-receptor antagonists and the cytoprotective agent sucralfate on rates of gastrointestinal bleeding, ventilator-associated pneumonia, and mortality.

METHODS

In a multicenter, randomized, blinded, placebo-controlled trial, we compared sucralfate with the H2-receptor antagonist ranitidine for the prevention of upper gastrointestinal bleeding in 1200 patients who required mechanical ventilation. Patients received either nasogastric sucralfate suspension (1 g every six hours) and an intravenous placebo or intravenous ranitidine (50 mg every eight hours) and a nasogastric placebo.

RESULTS

The patients in the two groups had similar base-line characteristics. Clinically important gastrointestinal bleeding developed in 10 of 596 (1.7 percent) of the patients receiving ranitidine, as compared with 23 of 604 (3.8 percent) of those receiving sucralfate (relative risk, 0.44; 95 percent confidence interval, 0.21 to 0.92; P=0.02). In the ranitidine group, 114 of 596 patients (19.1 percent) had ventilator-associated pneumonia, as compared with 98 of 604 (16.2 percent) in the sucralfate group (relative risk, 1.18; 95 percent confidence interval, 0.92 to 1.51; P=0.19). There was no significant difference between the groups in mortality in the intensive care unit (ICU) (23.5 percent in the ranitidine group and 22.9 percent in the sucralfate group) or the duration of the stay in the ICU (median, nine days in both groups).

CONCLUSIONS

Among critically ill patients requiring mechanical ventilation, those receiving ranitidine had a significantly lower rate of clinically important gastrointestinal bleeding than those treated with sucralfate. There were no significant differences in the rates of ventilator-associated pneumonia, the duration of the stay in the ICU, or mortality.

Effect of magnesium on the intestinal absorption of calcium in man

OBJECTIVE

In view of the widespread use of magnesium (Mg) as a nutritional supplement, we investigated whether Mg would affect the absorption of calcium (Ca) as the intestinal absorption sites for Mg and Ca differ.

METHODS

The intestinal absorption of Ca, using 47CaCl2 as the tracer, and metabolic balances of Ca, phosphorus (P) and Mg were determined in five adult males under strictly controlled dietary conditions in control studies and during Mg supplementation. Mg was given as magnesium oxide (MgO) in 10 studies during two Ca intakes: five studies during a low Ca intake of 241 mg/day and five studies during a normal Ca intake of 812 mg/day. Dietary Mg intake ranged from 241 to 264 mg/day in control studies. During Mg supplementation, the total Mg intake ranged from 789 to 826 mg/day.

RESULTS

There was no change of the intestinal Ca absorption during Mg supplementation during the two Ca intakes. The only change was the higher 1-hour 47Ca plasma level in the 47Ca absorption studies during the high Mg intake. Urinary Ca increased during Mg supplementation only during the low Ca intake, the Ca balance became more negative but this difference was not significant. There was also no change in Ca excretion or Ca balance during the high Mg intake at the normal Ca intake of 800 mg/day. P balance studies showed a slight decrease in urinary P and an increase in fecal P, but the P balances did not change. Mg balances were negative in control studies during the two Ca intakes. Supplemental Mg increased both urinary and fecal Mg excretion and the Mg balance became positive, but these differences were not significant.

CONCLUSION

The increased Mg intake of 826 mg did not affect intestinal Ca absorption determined with tracer doses of 47Ca during Ca intakes of 241 and 812 mg/day.

Prevalence of hypertension among diabetic patients and its relation to vascular risk. Diabetes Hypertension Study Group

In order to determine the factors related to the occurrence of hypertension in diabetic patients, blood pressure distributions were determined, using standardised methods, in a sample of 5,842 patients attending ten diabetic clinics in the London area. After allowing for the influence of age and obesity, BPs tended to be higher in patients with non-insulin-dependent diabetes compared with those with insulin-dependent diabetes, and were in general higher in males compared with females. Average BPs were lower in South Indian patients when contrasted with Caucasians and Afro-Caribbeans. The frequency of WHO-defined hypertension was highest in the non-insulin-dependent patients older than 55 years, being 43% for males and 52% for females. A substantial proportion of subjects already taking anti-hypertensive treatment had BPs above 160/95 mmHg. Centile distributions of BP in this population have been used to assess the implications of treatment strategies in diabetic patients.

An observation of the dental department and the treatment needs of patients presenting at Dohnavur Hospital, southern India

A hope and a prayer, and a healthy measure of innovative inspiration, makes Dohnavur a surprisingly archaic, but reassuringly effective hospital, despite the appalling shortage of funds and equipment. Rebekah Anderson and Helen Fuller spent the month of their student elective in southern India and here reveal some of the dental anachronisms they encountered.

X-linked megalocornea: close linkage to DXS87 and DXS94

In a family in which X-linked megalocornea is segregating, the disease locus was found to be closely linked to DXS87 (zeta max = 3.91, theta max = 0.00) and DXS94 (zeta max = 3.34, theta max = 0.00) in Xq21.3-q22.

The current status and future directions of impedance cardiography in ICU

Impedance cardiography has not achieved popularity in the Intensive Care Unit (ICU) to date probably because of the limitations in technique and interpretation associated with the altered physiology of critically ill patients, and also because of interference from other machinery in the ICU. The current climate of questioning the existing technology for bedside cardiovascular assessment however spurs the need to evaluate impedance cardiography as a noninvasive alternative. Validation in noncritically ill patients is good when compared to other technologies (e.g., thermodilution, Fick, dye dilution (r greater than 0.9)). Reliability is good with a coefficient of variation in an ICU population of 8.9%, (compared to 18.6% for thermodilution). It has also shown promise in detecting the clinically significant changes of central intravascular volume. Impedance cardiography appears to be useful for measurement of stroke volume (SV) and ejection fraction (EF). From these, left ventricular end-diastolic volume (VED) can be calculated, probably a more reliable estimate of left ventricular filling than pulmonary capillary wedge pressure (PW), measured by pulmonary artery (PA) catheter. In addition, VES can be calculated and with the knowledge of left ventricular end-systolic pressure (PES) (from invasive arterial monitoring), an end-systolic pressure-volume (ES-PV) relationship can be derived. This is thought to be a measure of contractility that is independent of preload and afterload. The ultimate test in the ICU for impedance cardiography is whether clinical outcome of critically ill patients is altered by the use of this technology. Such outcome testing is essential before the true value of impedance cardiography in the management of critically ill patients can be determined.

Acute non-dilating obstructive renal failure in a patient with AIDS

A 30-year-old male who presented with acute renal failure was found to have acquired immunodeficiency syndrome (AIDS). Although sonography and computerized tomography did not show urinary tract dilatation, obstructive renal failure was demonstrated by retrograde pyelography. Relief of obstruction(s) due to encasement of the renal pelves and ureters with histiocytic lymphoma led to immediate return of normal renal function. Although the etiology of renal failure in this patient is highly unusual, the high incidence of lymphoma in patients with AIDS should make tumor-related renal disease a consideration in all such patients with renal dysfunction.