Child with protein losing enteropathy as presentation of collagenous duodenitis and eosinophilic gastroenteritis

Background

Collagenous duodenitis and gastritis are rare histopathological findings in children.

Patients and methods

: We describe a four-year old girl, who presented with non-bloody diarrhea for two months and progressive edema with an albumin of 16g/dl.

Results

The diagnosis of a protein losing enteropathy was made. Extensive investigations withheld only an infectious cause of the protein losing enteropathy (cytomegalovirus and adenovirus). However, the patients still required repetitive albumin infusions 3.5 months after onset of symptoms without spontaneous recovery. Therefore, a new endoscopic work-up was performed. Duodenal biopsies revealed collagen deposition, in association with a high number of eosinophils and mast cells throughout different parts of the gastrointestinal tract.

Conclusions

The collagen deposition seems to be triggered by an eosinophilic gastrointestinal disorder. Treatment was started with amino acid-based formula, oral iron therapy, an antihistamine, and a proton pomp inhibitor that resulted in persistent normalization of serum albumin already after 1.5 weeks.

Tapering of Etanercept is feasible in patients with Rheumatoid Arthritis in sustained remission: a pragmatic randomized controlled trial

Objective: In patients with rheumatoid arthritis (RA) in sustained remission, tapering of biological disease-modifying anti-rheumatic drugs can be considered. Tapering has already been investigated, but its feasibility remains to be determined. Therefore, we explored the feasibility of tapering etanercept in RA in a setting close to practice.Method: Patients with RA in 28-joint Disease Activity Score (DAS28) remission (≥ 6 months) and treated with etanercept 50 mg weekly (≥ 1 year) were included in the pragmatic 1 year open-label multicentre randomized controlled TapERA (Tapering Etanercept in Rheumatoid Arthritis) trial. Patients were assigned to continue etanercept weekly or to taper to every other week (EOW). Patients who lost remission [DAS28-C-reactive protein (CRP) ≥ 2.6] were re-escalated to etanercept weekly. The primary outcome was the proportion of patients maintaining DAS28-CRP remission for 6 months.Results: Sixty-six patients were randomized to etanercept weekly (n = 34) or EOW (n = 32). After 6 months, 26/34 patients (76%) in the weekly and 19/32 (59%) in the EOW group maintained disease control (p = 0.136). In the EOW group, 20/32 patients (63%) remained on their tapered treatment during the trial. Two patients reintroduced weekly etanercept themselves. Ten patients were re-escalated to etanercept weekly by the rheumatologist, after a median (interquartile range) interval of 3.0 (2.0-6.0) months. Among these patients, 7/10 regained remission after re-escalation, four of them at the next study visit.Conclusions: Although non-inferiority could not be demonstrated, tapering of etanercept to EOW appeared feasible in patients in sustained remission.

Barriers and facilitators to smoking cessation among HIV-infected people who inject drugs (PWID) in Hanoi, Vietnam: a qualitative study

INTRODUCTION

In Vietnam, 60% of men living with HIV smoke tobacco, and 92% of HIV-infected people who inject drugs (PWID) smoke tobacco. Tobacco use increases mortality through increased health risks including tuberculosis and malignancy in HIV-infected smokers. However, tobacco use treatment is not widely available in Vietnam. The objective was to examine current barriers and facilitators of smoking cessation and tobacco use treatment for HIV-infected PWID in Hanoi, Vietnam.

METHODS

Native speaking ethnographers conducted semi-structured qualitative interviews about tobacco use and tobacco use treatment with sixteen HIV-infected PWID and eight healthcare providers, recruited from four HIV-Methadone Maintenance Treatment (MMT) clinics in Hanoi, Vietnam. Interviews were recorded, transcribed, and translated for thematic analysis in Dedoose.

RESULTS

Clients and providers had learned the general health risks of smoking from public awareness campaigns. Half had tried to quit previously, often motivated by advice from family members but not by HIV providers' advice. Almost all clients did not want to quit, citing the low price of tobacco, prevalence of smoking in Vietnam, and physical cravings. HIV provider's counseling was brief, inconsistent, and limited by low provider knowledge and competing burdens of HIV and injection drug use. Providers recently trained by NGO-led seminars on tobacco prioritized tobacco use treatment.

CONCLUSIONS

Smoking cessation efforts for people living with HIV/AIDS (PLHA) and PWID smokers in Hanoi, Vietnam could benefit from further community public awareness campaigns, and exploring increased tobacco taxation. Tobacco use treatment at HIV clinics could benefit from involving family and friends in cessation, and training providers in treatment methods.

A practical method to account for random phase approximation effects on the dynamic scattering of multi-component polymer systems

Investigations of polymer systems that rely on the interpretation of dynamical scattering results as, e.g., the structure factor S(Q, t) of single chains or chain sections may require the inclusion of effects, as described within the framework of the random phase approximation (RPA) for polymers. To do this in practice for the dynamic part of S(Q, t) beyond the initial slope is a challenge. Here, we present a method (and software) that allows a straightforward assessment of dynamical RPA effects and inclusion of these in the process/procedures of model fitting. Examples of applications to the interpretation of neutron spin-echo data multi-component polymer melts are shown.

Precise Fluor ometric Micro determination of Selenium in Agricultural Materials

A precise, accurate, and comparatively rapid fluorometric method for the determination of selenium in the nanogram range is described and results are presented for Youden's uniformity and ruggedness tests. The sample is digested in a nitric-sulfuricperchloric acid mixture, potential interferences are masked with disodium EDTA, and selenium is complexed with freshly-prepared 2,3-diaminonaphthalene solution and estimated fluorometrically after extraction into cyclohexane. On the basis of its performance, collaborative study of the method is recommended

The implementation of environmental health policies in health care facilities: The case of Malawi

Establishing and maintaining safe and sufficient environmental health (EH) conditions in health care facilities (HCFs) is important to prevent and control infections. In 2018, the Government of Malawi finalized an environmental health policy that defines specific targets and programs for EH in healthcare settings. This and other related policies have been used since 2010 as a guide for EH practice in HCFs, but the implementation of these policies has been incomplete to-date. This study qualitatively examines the successes and shortcomings of implementing these policies in Malawi's public HCFs. Thematic analysis of interviews with 53 respondents from all levels of government was used to identify the successes of the policies and the barriers to effective implementation using Contextual Interaction Theory. The greatest identified strength lies in the design of the EH department and its ability to connect individual HCFs and EH actors directly to the policy-making level of government. Identified barriers to implementation include: insufficient financial support; lack of human resources; incomplete reporting; poor stakeholder coordination; and insufficient training of EH actors. We recommend refresher trainings for all EH actors, the establishment of a directorate level EH position, and strengthened coordination to improve the collection, analysis, and reporting of monitoring data to enable EH actors to advocate for the additional funding needed to develop programs for EH personnel and to apply effective EH interventions.

Circulation of cosmogenic 22Na using the global monitoring network of the Comprehensive Nuclear-Test-Ban Treaty Organization (CTBTO)

Using a recently published global data set of ²²Na and ⁷Be from the global monitoring network of the Comprehensive Nuclear-Test-Ban Treaty Organization (CTBTO), atmospheric circulation and stratosphere-troposphere interactions are examined. Cosmogenic ²²Na has a half-life well-suited to environmental processes with durations from several months to a decade. Combined with corresponding ⁷Be observations, these two cosmogenic isotopes form a useful environmental tracer and new radiochronometer to study physical interactions of air masses in the stratosphere and troposphere.

History and Diagnostic Value of Antibodies to Citrullinated Proteins in Rheumatoid Arthritis

Rheumatoid arthritis is a chronic inflammatory joint disease characterized by the presence of autoantibodies. The best known autoantibody is the rheumatoid factor. Another group of antibodies directed against citrullinated epitopes is proven to be more specific for rheumatoid arthritis. This review gives an overview of the history of the different anti-citrullinated protein antibody detection methods and their diagnostic and prognostic properties in RA.

Analysis of 22Na using a spectral summation technique on high-volume aerosol samples

Measurement of cosmogenic ²²Na in daily aerosol samples is often difficult due to low atmospheric production rates. A new technique based upon spectral summation of sequential high-volume aerosol samples to measure ²²Na is described and validated. This summation technique has broad applications to any detection system that produces sequential representative sample measurements in which radioisotopes are just below the detection limit, provided the energy calibration is stable. It is anticipated that a global dataset of this radionuclide will have many important environmental science applications.

Patients with large-duct primary sclerosing cholangitis and Crohn's disease have a better outcome than those with ulcerative colitis, or without IBD

BACKGROUND

Approximately 20% of primary sclerosing cholangitis (PSC) patients with concomitant inflammatory bowel disease (IBD) have Crohn's disease (CD).

AIM

To compare PSC/CD with other PSC patients.

METHODS

Retrospective study of 240 PSC patients diagnosed between 1975 and 2012 (median follow-up 12 years). Activity of PSC at diagnosis was assessed by liver biopsy, Mayo risk and ERC scores. Survival without liver transplantation, number of transplantations and liver-related death were endpoints.

RESULTS

Sixty-three per cent of patients had IBD: 105 UC, 32 CD and 14 IBD unclassified (IBDu). IBD was diagnosed before PSC in 50%. The yearly development of PSC after diagnosing IBD was similar in UC, CD or IBDu. Small-duct PSC was present in 28% of PSC/CD compared to 3% of PSC/UC. Small-duct PSC had a markedly better survival than large-duct PSC: no patient developed cholangiocarcinoma or liver-related death, but colorectal cancer occurred in three patients. In large-duct PSC, a more favourable outcome was evident in patients with CD. The liver disease was less progressive: one patient underwent liver transplantation compared to 28% and liver-related deaths were absent compared to 7% in the other PSC groups.

CONCLUSIONS

The prevalence of PSC with concomitant Crohn's disease is relatively rare, but the outcome is more benign than PSC with UC or without IBD. Approximately one-fourth has small-duct PSC. In large-duct PSC/CD, liver disease is less aggressive and the outcome is much better. The outcome of PSC patients with UC resembled that of PSC without IBD.

Genetic Diversity and Protective Efficacy of the RTS,S/AS01 Malaria Vaccine

BACKGROUND

The RTS,S/AS01 vaccine targets the circumsporozoite protein of Plasmodium falciparum and has partial protective efficacy against clinical and severe malaria disease in infants and children. We investigated whether the vaccine efficacy was specific to certain parasite genotypes at the circumsporozoite protein locus.

METHODS

We used polymerase chain reaction-based next-generation sequencing of DNA extracted from samples from 4985 participants to survey circumsporozoite protein polymorphisms. We evaluated the effect that polymorphic positions and haplotypic regions within the circumsporozoite protein had on vaccine efficacy against first episodes of clinical malaria within 1 year after vaccination.

RESULTS

In the per-protocol group of 4577 RTS,S/AS01-vaccinated participants and 2335 control-vaccinated participants who were 5 to 17 months of age, the 1-year cumulative vaccine efficacy was 50.3% (95% confidence interval [CI], 34.6 to 62.3) against clinical malaria in which parasites matched the vaccine in the entire circumsporozoite protein C-terminal (139 infections), as compared with 33.4% (95% CI, 29.3 to 37.2) against mismatched malaria (1951 infections) (P=0.04 for differential vaccine efficacy). The vaccine efficacy based on the hazard ratio was 62.7% (95% CI, 51.6 to 71.3) against matched infections versus 54.2% (95% CI, 49.9 to 58.1) against mismatched infections (P=0.06). In the group of infants 6 to 12 weeks of age, there was no evidence of differential allele-specific vaccine efficacy.

CONCLUSIONS

These results suggest that among children 5 to 17 months of age, the RTS,S vaccine has greater activity against malaria parasites with the matched circumsporozoite protein allele than against mismatched malaria. The overall vaccine efficacy in this age category will depend on the proportion of matched alleles in the local parasite population; in this trial, less than 10% of parasites had matched alleles. (Funded by the National Institutes of Health and others.).

Algorithms for managing infant constipation, colic, regurgitation and cow's milk allergy in formula-fed infants

Gastrointestinal symptoms, such as constipation, regurgitation and infant colic, occur in about half of infants. These symptoms are often functional, but they may also be caused by cow's milk protein allergy. We developed three algorithms for formula-fed infants, which are consensus rather than evidence-based due to the limited research available in the existing literature.

CONCLUSION

We believe that these algorithms will help primary healthcare practitioners to recognise and manage these frequent gastrointestinal manifestations in infants.

Interest in multipurpose prevention of HIV and pregnancy: perspectives of women, men, health professionals and community stakeholders in two vaginal gel studies in southern Africa

OBJECTIVE

The pipeline of vaginal microbicides for HIV prevention has expanded to include products for multipurpose prevention, but the interests of potential users and those advising on use have not been sufficiently investigated. Rather, assumptions about interest in multipurpose prevention technologies (MPTs) are inferred from what is known about acceptability and use of microbicides or contraceptives.

DESIGN AND SETTING

This paper presents data on concerns and preferences for multipurpose prevention of HIV and pregnancy. Data were collected in two microbicide gel studies in Malawi and Zimbabwe. Participants were women using candidate vaginal products, their male partners, health professionals and community stakeholders.

METHODS

An individual interview was conducted with participants. Interviews were audio-recorded, transcribed, coded for content and analysed for key themes.

RESULTS

Participants indicated strong interest in a vaginal HIV prevention product that could also prevent pregnancy. Reasons for this interest were convenience, problems with adverse effects with current contraceptive methods, concerns about long-term effects of contraceptives, and concerns about the health burdens of HIV infection during pregnancy. The main disadvantage of an MPT was recognition that while interest in preventing HIV is constant, contraceptive needs change over time.

CONCLUSION

The study population indicated support for an MPT to prevent HIV and pregnancy. This support may be further strengthened if the product is also available for prevention of only HIV. Women and men will be more willing to use an MPT if they can be reassured that its use will have no long-term effect on fertility.

Radioxenon detections in the CTBT international monitoring system likely related to the announced nuclear test in North Korea on February 12, 2013

Observations made in April 2013 of the radioxenon isotopes (133)Xe and (131m)Xe at measurement stations in Japan and Russia, belonging to the International Monitoring System for verification of the Comprehensive Nuclear-Test-Ban Treaty, are unique with respect to the measurement history of these stations. Comparison of measured data with calculated isotopic ratios as well as analysis using atmospheric transport modeling indicate that it is likely that the xenon measured was created in the underground nuclear test conducted by North Korea on February 12, 2013, and released 7-8 weeks later. More than one release is required to explain all observations. The (131m)Xe source terms for each release were calculated to 0.7 TBq, corresponding to about 1-10% of the total xenon inventory for a 10 kt explosion, depending on fractionation and release scenario. The observed ratios could not be used to obtain any information regarding the fissile material that was used in the test.

Source term estimation of radioxenon released from the Fukushima Dai-ichi nuclear reactors using measured air concentrations and atmospheric transport modeling

Systems designed to monitor airborne radionuclides released from underground nuclear explosions detected radioactive fallout across the northern hemisphere resulting from the Fukushima Dai-ichi Nuclear Power Plant accident in March 2011. Sampling data from multiple International Modeling System locations are combined with atmospheric transport modeling to estimate the magnitude and time sequence of releases of (133)Xe. Modeled dilution factors at five different detection locations were combined with 57 atmospheric concentration measurements of (133)Xe taken from March 18 to March 23 to estimate the source term. This analysis suggests that 92% of the 1.24 × 10(19) Bq of (133)Xe present in the three operating reactors at the time of the earthquake was released to the atmosphere over a 3 d period. An uncertainty analysis bounds the release estimates to 54-129% of available (133)Xe inventory.

Profile of pediatric Crohn's disease in Belgium

AIM

A Belgian registry for pediatric Crohn's disease, BELCRO, was created. This first report aims at describing disease presentation and phenotype and determining associations between variables at diagnosis and registration in the database.

METHODS

Through a collaborative network, children with previously established Crohn's disease and newly diagnosed children and adolescents (under 18 y of age) were recruited over a 2 year period. Data were collected by 23 centers and entered in a database. Statistical association tests analyzed relationships between variables of interest at diagnosis.

RESULTS

Two hundred fifty-five patients were included. Median age at diagnosis was 12.5 y (range: 1.6-18 y); median duration of symptoms prior to diagnosis was 3 m (range: 1-12 m). Neonatal history and previous medical history did not influence disease onset nor disease behavior. Fifty three % of these patients presented with a BMI z-score < -1. CRP was an independent predictor of disease severity. Steroids were widely used as initial treatment in moderate to severe and extensive disease. Over time, immunomodulators and biological were prescribed more frequently, reflecting a lower prescription rate for steroids and 5-ASA. A positive family history was the sole significant determinant for earlier use of immunosuppression.

CONCLUSION

In Belgium, the median age of children presenting with Crohn's disease is 12.5 y. Faltering growth, extensive disease and upper GI involvement are frequent. CRP is an independent predictive factor of disease activity. A positive family history appears to be the main determinant for initial treatment choice.

Womens experiences of HIV testing and counselling in the labour ward: a case of Bwaila hospital

INTRODUCTION

HIV counseling and testing during labour can be emotional, but is important because it allows mothers and babies to receive PMTCT prophylaxis if previous identification of HIV infection has not occurred. The study explores how HIV testing and counseling during early labour affects women.

METHODOLOGY

This was a qualitative exploratory study to understand women's experiences during early labor. From September to October 2009, we conducted 10 indepth interviews with women who tested for HIV during early labour. We recruited women who tested > 3 months previously and those who had never tested for HIV from the postpartum ward of Bwaila Hospital. Data were analyzed manually using the life story approach in order to examine and analyse subjective experiences of women and their constructions of the social world. Transcripts were read multiple times to understand meanings which participants attached to their experiences. We coded data according to emerging themes and subthemes.

RESULTS

Ten women 20-35 years were interviewed. Eight women had unknown HIV status while two had known HIV results but re-tested to update their status. Four women were found HIV-positive while 6 were HIV-negative. The primary theme was that women appreciated and accepted HIV testing and counseling. Testing was accepted as a necessary step to protect the infant from HIV infection. Counseling was viewed as helpful for acceptance of HIV status. One key subtheme was that HIV positive women experienced disappointment about their HIV diagnosis, though this was outweighed by the knowledge that one could protect her infant. All women viewed the short time to complete the counseling and testing procedures as favourable.

CONCLUSION

Labour testing is acceptable and should be promoted to enhance PMTCT services by identifying HIV positive women with unknown status. Counseling helps women to accept being found with HIV and seek appropriate services.

Utilization of family members to provide hospital care in Malawi: the role of Hospital Guardians

AIM

Like most of sub-Saharan Africa, Malawi suffers from a paucity of human resources in the health sector. With an average of one physician for every 50,000 persons, and a health care professional to in-patient population ratio of 1:277, patient care suffers. At Kamuzu Central Hospital (KCH) of Lilongwe, Malawi, family members, termed Hospital Guardians, are utilized to provide basic care for patients. The aim of our study is to characterize this population and explore their role in the health care system of KCH.

METHODS

Seventy three semi-qualitative surveys and nineteen in-depth interviews were conducted with hospital administrators, Guardians, nurses, and physicians from these wards. The results were analyzed using descriptive analysis and emergent coding.

RESULTS

It was found that Hospital Guardians were primarily female family members of patients and have a low literacy rate. They performed a wide range of daily tasks in patient care from wound care to advocacy. Despite their essential role in the health care system, the Guardians were provided with little support from the hospital. There was often conflict between the Guardians and hospital personnel due to overcrowding with more than one Guardian per patient; a lack of understanding of hospital rules and regulations; and a lack of respect for the Guardian role by hospital staff.

CONCLUSIONS

Until their role can be reduced by additional trained health care professionals, patient care could be improved by institutional support including a clarification of the role of the Hospital Guardians. Recommendations include a one-patient one-guardian policy; Guardian education; and enhancing Guardian resources.

Analysis of data from sensitive U.S. monitoring stations for the Fukushima Dai-ichi nuclear reactor accident

The March 11, 2011 9.0 magnitude undersea megathrust earthquake off the coast of Japan and subsequent tsunami waves triggered a major nuclear event at the Fukushima Dai-ichi nuclear power station. At the time of the event, units 1, 2, and 3 were operating and units 4, 5, and 6 were in a shutdown condition for maintenance. Loss of cooling capacity to the plants along with structural damage caused by the earthquake and tsunami resulted in a breach of the nuclear fuel integrity and release of radioactive fission products to the environment. Fission products started to arrive in the United States via atmospheric transport on March 15, 2011 and peaked by March 23, 2011. Atmospheric activity concentrations of (131)I reached levels of 3.0×10(-2) Bqm(-3) in Melbourne, FL. The noble gas (133)Xe reached atmospheric activity concentrations in Ashland, KS of 17 Bqm(-3). While these levels are not health concerns, they were well above the detection capability of the radionuclide monitoring systems within the International Monitoring System of the Comprehensive Nuclear-Test-Ban Treaty.

Safety and cost of infliximab for the treatment of Belgian pediatric patients with Crohn's disease

Biologicals have become an important component in the treatment of Crohn's disease in children. Their increased and long term use raises safety concerns. We describe safety and cost of infliximab in Belgian pediatric Crohn's disease patients. All patients on infliximab as part of the present or past treatment for Crohn's Disease until January 1st 2011 were selected from an existing database. Information on disease phenotype, medication and adverse events were extracted. Adverse events occurred in 25.9% of patients exposed to infliximab of which 29.6% were severe. In total 31.7% of patients stopped infliximab therapy. The main reasons for discontinuation were adverse events in 45.4% and loss of response in 30.3%. No malignancies or lethal complications occurred over this 241 patient year observation period. Immunomodulators were concomitant medication in 75% of patients and were discontinued subsequently in 38.4% of them. The cost of infliximab infusions per treated patient per year in the Belgian health care setting is approximately 9 474 euro, including only medication and hospital related costs. Even though infliximab is relatively safe in pediatric CD on the short term, close follow-up and an increased awareness of the possible adverse reactions is highly recommended. Adverse reactions appeared in 25.9% of all patients and were the main reason for discontinuation. Treatment cost has to be balanced against efficacy and modifications in disease course. In the Belgian health care system, the medication is available to all patients with moderate to severe CD.

Review article: non-malignant haematological complications of anti-tumour necrosis factor alpha therapy

BACKGROUND

Tumour necrosis factor-alpha (TNF-α) is an important mediator of the molecular cascade leading to chronic inflammation. TNF-α inhibitors have proven their safety and efficacy in the treatment of inflammatory diseases.

AIM

To review the non-malignant haematological adverse events, such as thrombocytopaenia, neutropaenia, hypercoagulability, pancytopaenia and aplastic anaemia in patients receiving TNF-α inhibitors.

METHODS

We reviewed the literature by searching MEDLINE and EMBASE databases as well as references of all retrieved articles for the following terms: anti-tumour necrosis factor, anti-TNF, infliximab, adalimumab, certolizumab, etanercept, haematological complications, thrombocytopaenia, neutropaenia, anaemia, bone marrow and thrombosis.

RESULTS

Thombocytopaenia is a very rare phenomenon and was associated with no serious adverse events. However, transient neutropaenia developed in up to 16% of cases. Patients with a previous history of neutropaenia on other therapies or baseline neutrophil count <4 × 10(9) /L are at a particularly higher risk. The association between anti-TNF-α therapy and thrombosis is very nebulous due to the multitude of potential confounders. Only one case of primary eosinophilia has been reported with anti-TNF-α therapy.

CONCLUSION

Regular monitoring of the white blood cell count at baseline and with each infusion is recommended for patients on anti-TNF-α. Further studies to elucidate their interaction with the immune system are warranted.

Sexually Transmitted Infection (STI) screening, case and contact treatment, and condom promotion resulting in STI reduction two years later in rural Malawi

As part of a longitudinal cohort study in rural Malawi in 2000, 469 men and 758 women were asked to respond to a series of surveys, were tested for gonorrhea and chlamydia, and received their results and treatment, if applicable, for themselves and up to 2 partners if positive for either sexually transmitted infection (STI). Two years later, in 2002, 328 men and 525 women were again asked to respond to survey questions, tested again for gonorrhea and chlamydia, and were also tested for HIV--of these, 247 men and 453 women had also given urine samples in 2000. In 2000, the gonorrhea and chlamydia prevalence was 6.2% and 5.8% among men, and 3.6% and 4.9% among women. Two years later, prevalence of gonorrhea and chlamydia was 0.7% and 1.4% among men, and 1.3% and 1.1% among women. Although we did not test for HIV in the first round, the HIV prevalence in 2002 was 19.2%. The implications of the findings are discussed in the context of interventions for STI prevention and to reduce HIV transmission in sub-Saharan Africa.

Assessment of gastric motor function in childhood functional dyspepsia and obesity

BACKGROUND

The aim was to compare gastric emptying rate and nutrient tolerance during a satiety drinking test in children with functional dyspepsia (FD) and obesity and to study the relationship between daily caloric intake and the satiety drinking test.

METHODS

A total of 28 dyspeptic children (22 girls, mean age 12.5 ± 3.1 years) and 15 obese children (five girls, 13.3 ± 1.8 years) were studied. The patients underwent an octanoic acid gastric emptying breath test and a satiety drinking test. Prior to both tests, a dyspepsia questionnaire was filled out to calculate the mean calorie intake.

KEY RESULTS

The most prevalent dyspeptic symptoms were early satiety (96.4%), postprandial fullness (89.2%), and epigastric pain (78.6%), followed by nausea (50%). All dyspeptic and obese children (n = 43) started the satiety drinking test and 41 children completed the test until a score of 5 was reached. The maximum ingested volume in FD was significantly lower than in obesity or in age-matched healthy controls (252 ± 85 vs 479 ± 199 and 359 ± 29 mL respectively, both P < 0.05). As a group, dyspeptic children had significantly slower gastric emptying than obese children (89.7 ± 54.8 min vs 72.5 ± 26.0 min, P = 0.05). Daily calorie intake was significantly higher in obese children than that in dyspeptic children (2325 ± 469 vs 1503 ± 272 cal, P < 0.0001). The endpoint of the satiety drinking test was significantly correlated with body weight or BMI (both R = 0.41, P = 0.04), but not with daily calorie intake, gastric emptying rate or age.

CONCLUSIONS & INFERENCES

The satiety drinking test is a potentially useful non-invasive tool in the investigation of children with FD and obesity.

Hypertension in pregnancy among HIV-infected women in sub-Saharan Africa: prevalence and infant outcomes

This analysis was performed to determine the prevalence of hypertension and association of MAP (mean arterial pressure) with birth outcomes among HIV-infected pregnant women not taking antiretrovirals. HIV-infected pregnant women, enrolled into the HPTN024 trial in Tanzania, Malawi and Zambia were followed up at 26-30, 36 weeks, and delivery. The prevalence of hypertension was <1% at both 20-24 weeks and 26-30 weeks and 1.7% by 36 weeks. A 5 mm Hg elevation in MAP increased the risk of stillbirth at 20-24 weeks by 29% (p = 0.001), 32% (p = 0.001) at 26-30 weeks and of low birth weight (LBW) at 36 weeks by 26% (p = 0.001). MAP was not associated with stillbirth at 36 weeks, LBW prior to 36 weeks, preterm birth, neonatal mortality or the risk of maternal to child transmission (MTCT) of HIV.

Sensitivity and specificity of criteria for spondyloarthritis in children with late onset pauciarticular juvenile chronic arthritis as well as their characteristics

OBJECTIVE

To evaluate the sensitivity and specificity of criteria designed for spondyloarthritis in a university hospital treated population of children with late onset pauciarticular juvenile chronic arthritis and a control population.

METHODS

Four sets of criteria especially designed for juvenile patients: Garmisch-Partenkirchen juvenile spondylitis criteria (= Garmisch), SEA (=seronegative enthesopathy and arthritis) syndrome, Enthesitis Related Arthritis (ERA), Atypical spondyloarthritis for children and two sets of criteria for patients without age specification (European spondyloarthropathy Study Group - ESSG and Amor) were evaluated in a cross-sectional way in a group of 43 consecutive patients with late onset pauciarticular juvenile chronic arthritis (LOPA) seen over a six-month period in the outpatient clinic. These criteria were analysed in 69 patients with other forms of juvenile chronic arthritis as well. The sensitivity and specificity were calculated for each set, as well as positive predictive value and likelihood ratio. The characteristics described in the different sets of criteria were separately evaluated in the LOPA patients and the other patients.

RESULTS

For sensitivity, the Garmisch criteria scored the highest value (97.7%). However, sensitivity was significantly lower in two of the juvenile sets (SEA syndrome and Atypical spondyloarthritis), respectively 44.2% and 51.2%, as opposed to the other criteria (>85%; p<0.01 by Mc Nemar test). Specificity and positive predictive value (PPV) was the highest for the SEA syndrome criteria (98.5%, vs. 95.0%) followed by the ERA (95.6 % vs. 92.1 %) and the Garmisch criteria (94.2% vs. 91.3%). The positive likelihood ratio (LR+) was >10 in SEA (30.5), ERA (18.7) and Garmisch (16.8). The negative likelihood ratio (LR-) was <0.1 only in the Garmisch criteria (0.02).

CONCLUSION

Sensitivity, specificity, PPV, LR+ and LR- for the Garmisch-Partenkirchen criteria suggest that they classify almost the same population as defined by LOPA. The SEA syndrome criteria, which were not designed to be classification criteria, being very specific, cannot be used in this patient population to classify a sufficient number of patients. The sensitivity and specificity for the ESSG criteria being similar in these children as in adults suggest they have similar characteristics. The Garmisch-Partenkirchen criteria and/or LOPA definition are major candidates for future research in identifying spondyloarthritis in juvenile patients.

Increased environmental gamma-ray dose rate during precipitation: a strong correlation with contributing air mass

It has long been observed that the environmental gamma-ray dose rate increases noticeably during precipitation intervals. This increase, due to the presence of radon progeny in the rain droplets (or snow flakes), can affect the reliability of the monitoring of artificial radioactivity and long term estimates of exposure to ambient natural radionuclides in surveillance network. Predicting the amplitude of the dose increase has been shown to be surprisingly challenging. In this work, standard air mass back trajectory analysis is used to show that the amplitude of the increase can be quantitatively linked to the history of the air mass where the precipitation is occurring. Furthermore, we show how back trajectory analysis, environmental gamma and rain data can be used to obtain estimations of relative radon emanation rates for locations far from the actual point of detection.

Corticosteroids but not infliximab increase short-term postoperative infectious complications in patients with ulcerative colitis

BACKGROUND

Recent reports suggest that the preoperative use of infliximab (IFX) increases postoperative infectious complications in patients with ulcerative colitis (UC). Therefore, we determined the impact of IFX on postoperative infectious complications.

METHODS

A consecutive group of 141 UC patients (41% female, median age 39.8 years) undergoing (procto)colectomy was studied. Postoperative infectious complications were compared between 22 patients who received IFX within 12 weeks prior to (procto)colectomy (IFX group) and 119 patients who did not (control group). Short-term infectious complications, consisting of anastomotic leaks, pelvic abscesses, wound infections, and nonsurgical site infections, were recorded within 30 days after primary surgery.

RESULTS

At primary surgery there was no significant difference in gender, disease extent, smoking behavior, body mass index, and concomitant medication (including corticosteroids) between the groups. Patients in the IFX group less often underwent restorative proctocolectomy without defunctioning ileostomy (9% versus 34%, P = 0.022), had a significantly shorter median (interquartile range, IQR) disease duration (2.7 [1.2-8.6] versus 5.9 [2.6-13.0] years, P < 0.036) and a significantly higher C-reactive protein level at primary surgery (51.7 [9.9-103.6] versus 19.1 [7.5-42.6] mg/L, P = 0.023). There was no short-term mortality. A moderate-to-high dose of corticosteroids (>or=20 mg methylprednisolone for >or=2 months, odds ratio 5.19 [95% confidence interval [CI]: 1.72-15.66], P = 0.003) and a restorative proctocolectomy without defunctioning ileostomy (odds ratio 6.45 [95% CI: 2.12-19.64], P = 0.001) were independent predictors of short-term postoperative infectious complications.

CONCLUSION

Corticosteroids and a restorative proctocolectomy without defunctioning ileostomy, but not IFX, are associated with an increased risk of short-term postoperative infectious complications in UC.

Normal values for the satiety drinking test in healthy children between 5 and 15 years

In adults, a slow caloric drinking test has been proposed as a non-invasive tool to estimate gastric accommodation and to quantify meal-induced symptoms in functional dyspepsia (FD). The same test has been proposed for paediatric FD, but normal values are only available for adolescents and adults. The aim of the study was (i) to establish normal values for the satiety drinking test in young children and (ii) to study the influence of demographic factors. In all, 59 healthy children [27 girls; age range 5-16 years, body mass index (BMI) 17.4 +/- 2.5 kg m(-2)] were studied in the morning after an overnight fast. They drank a liquid nutrient meal (1.5 kcal mL(-1)) from beakers that were filled by a peristaltic pump filled at a rate of 15 mL min(-1) with. For every 5 min, satiety was scored on a graphic rating scale grade 0-5 (1 = threshold, 5 = maximum), until a score of 5 was reached. Values are given as mean +/- SEM and compared by t-test; correlation analysis was performed using Spearman rank test. All children performed the test as indicated except for one 5 years old who stopped prematurely for dislike of the taste. The endpoint was reached at 360 +/- 23 mL (540 +/- 34 kcal), and was age-dependent (Spearman r = 0.28, P = 0.03). No correlation was found between the maximum volume ingested and gender, weight, height or BMI. Age-dependent normal ranges were determined for ages 5-16 at 3-year intervals, and were found to increase with age. We established feasibility of and normal values for a non-invasive satiety drinking test in children with an age range of 5-15 years. This tool can now be used in the assessment of paediatric FD and eating disorders.

Long-term outcome of treatment with infliximab in 614 patients with Crohn's disease: results from a single-centre cohort

BACKGROUND AND AIMS

This observational study assessed the long-term clinical benefit of infliximab (IFX) in 614 consecutive patients with Crohn's disease (CD) from a single centre during a median follow-up of 55 months (interquartile range (IQR) 27-83).

METHODS

The primary analysis looked at the proportion of patients with initial response to IFX who had sustained clinical benefit at the end of follow-up. The long-term effects of IFX on the course of CD as reflected by the rate of surgery and hospitalisations and need for corticosteroids were also analysed.

RESULTS

10.9% of patients were primary non-responders to IFX. Sustained benefit was observed in 347 of the 547 patients (63.4%) receiving long-term treatment. In 68.3% of these, treatment with IFX was ongoing and in 31.7% IFX was stopped, with the patient being in remission. Seventy patients (12.8%) had to stop IFX due to side effects and 118 (21.6%) due to loss of response. Although the yearly drop-out rates of IFX in patients with episodic (10.7%) and scheduled treatment (7.1%) were similar, the need for hospitalisations and surgery decreased less in the episodic than in the scheduled group. Steroid discontinuation also occurred in a higher proportion of patients in the scheduled group than in the episodic group.

CONCLUSIONS

In this large real-life cohort of patients with CD, long-term treatment with IFX was very efficacious to maintain improvement during a median follow-up of almost 5 years and changed disease outcome by decreasing the rate of hospitalisations and surgery.

Measurement and modelling of radioxenon plumes in the Ottawa Valley

Since 2001 a real-time radiation monitoring network of Canadian nuclear facilities and major population centres has been implemented for response to nuclear incidents including a possible terrorist attack. Unshielded NaI(Tl) spectroscopic detectors are employed to measure gamma radiation from airborne radioactivity and radioactivity deposited on the ground. These detectors are composed of a standard 3''x3'' cylindrical NaI(Tl) spectrometers with data storage and integrated telemetry. Some of the detectors have been deployed in the Ottawa Valley near Chalk River Laboratories and Ottawa, which has a complex radioxenon environment due to the proximity of nuclear power reactors, and medical isotope facilities. Although not a health threat, these releases have provided an opportunity for the Canadian Meteorological Centre and the Commissariat à l'Energie Atomique to validate their meteorological models. The meteorological models of the two organizations are in good agreement on the origin and the source terms of these releases.

Infliximab for pediatric Crohn's disease

The natural history of Crohn's disease (CD) is characterized by recurrent flares combined with periods of inactive disease. The goal of therapy should be to induce and maintain clinical remission, to strive for endoscopic healing of the intestinal mucosa and to improve the quality of life. The nineties have been characterized by the introduction of biological therapies designed to block or neutralize pro-inflammatory cytokines which play a role in the pathogenesis of the disease. Biologic treatment with the anti-human tumor necrosis factor alpha antibody infliximab has dramatically changed the therapeutic approach even in pediatric patients. Numerous studies are available and report the beneficial effect of infliximab in pediatric CD patients with moderate to severe disease, refractory and steroid-dependent patients. The safety profile of infliximab is overall favorable although continued vigilance, especially for the occurrence of infrequent but serious events, including opportunistic infection and lymphomas, remains necessary.

Statistical analysis of uncertainties of gamma-peak identification and area calculation in particulate air-filter environment radionuclide measurements using the results of a Comprehensive Nuclear-Test-Ban Treaty Organization (CTBTO) organized intercomparison, Part I: assessment of reliability and uncertainties of isotope detection and energy precision using artificial spiked test spectra, Part II: assessment of the true type I error rate and the quality of peak area estimators in relation to type II errors using large numbers of natural spectra

In this paper, the uncertainties of gamma-ray small peak analysis have been examined. As the intensity of a gamma-ray peak approaches its detection decision limit, derived parameters such as centroid channel energy, peak area, peak area uncertainty, baseline determination, and peak significance are statistically sensitive. The intercomparison exercise organized by the CTBTO provided an excellent opportunity for this to be studied. Near background levels, the false-positive and false-negative peak identification frequencies in artificial test spectra have been compared to statistically predictable limiting values. In addition, naturally occurring radon progeny were used to compare observed variance against nominal uncertainties. The results infer that the applied fit algorithms do not always represent the best estimator. Understanding the statistically predicted peak-finding limit is important for data evaluation and analysis assessment. Furthermore, these results are useful to optimize analytical procedures to achieve the best results.

Identification of a novel PEX14 mutation in Zellweger syndrome

BACKGROUND

Peroxisome biogenesis disorders are a clinically and genetically heterogeneous group of very severe autosomal recessive disorders caused by impaired peroxisome biogenesis. The prototype of this group of disorders is the cerebro-hepato-renal syndrome of Zellweger.

METHODS AND RESULTS

Here we report a patient with Zellweger syndrome, who presented at the age of 3 months with icterus, dystrophy, axial hypotonia, facial dysmorphy, posterior embryotoxon, and hepatomegaly. Abnormal findings of metabolic screening tests included hyperbilirubinaemia, hypoketotic dicarboxylic aciduria, increased C(26:0) and decreased C(22:0) plasma levels, and strongly reduced plasmalogen concentrations. In fibroblasts, both peroxisomal alpha- and beta-oxidation were impaired. Liver histology revealed bile duct paucity, cholestasis, arterial hyperplasia, very small branches of the vena portae, and parenchymatic destruction. Immunocytochemical analysis of cultured fibroblasts demonstrated that the cells contain peroxisomal remnants lacking apparent matrix protein content and PEX14, a central membrane component of the peroxisomal matrix protein import machinery. Transfection of fibroblasts with a plasmid coding for wild-type PEX14 restored peroxisomal matrix protein import, indicating that the primary genetic defect affecting the patient is indeed linked to PEX14. Mutational analysis of this gene revealed a genomic deletion leading to the deletion of exon 3 from the coding DNA (c.85-?_170+?del) and a concomitant change of the reading frame (p.[Ile29_Lys56del;Gly57GlyfsX2]).

CONCLUSIONS

This report represents the second PEX14-deficiency associated with Zellweger syndrome and the first documentation of a PEX14-deficient patient with detailed clinical follow-up and biochemical, morphological, and radiological data.

Assessment of gastric sensorimotor function in paediatric patients with unexplained dyspeptic symptoms and poor weight gain

Recent studies indicate that impaired meal accommodation or hypersensitivity to distention are highly prevalent in adult functional dyspepsia (FD). Our aim was to investigate whether similar abnormalities also occur in paediatric FD. Sixteen FD patients (15 girls, 10-16 years) were studied. The severity (0-3; 0, absent; 3, severe) of eight dyspeptic symptoms (epigastric pain, fullness, bloating, early satiety, nausea, vomiting, belching and epigastric burning) and the amount of weight loss were determined by questionnaire. All children underwent a gastric barostat study after an overnight fast to determine sensitivity to distention and meal-induced accommodation, which were compared with normal values in young adults (18-22 years). On a separate day, all patients underwent a gastric emptying breath test. A mean weight loss of 4.8 +/- 0.9 kg was present in 14 children. Compared with controls, patients had lower discomfort thresholds to gastric distention (8.8 +/- 1.0 mmHg vs 13.9 +/- 1.9 mmHg, P < 0.02) and gastric accommodation (87 +/- 25 mL vs 154 +/- 20 mL P < 0.04). Hypersensitivity to distention and impaired accommodation were present in respectively nine (56%) and 11 (69%) patients. No relationship was found between barostat and gastric emptying, which was delayed in only three patients. The majority of children with unexplained epigastric symptoms have abnormalities of gastric sensorimotor function.