Fatigue and Physical Activity Patterns in Children With Inflammatory Bowel Disease

OBJECTIVES

Fatigue is a common symptom in children with inflammatory bowel disease (IBD). Diagnostic tests to evaluate biological causes of fatigue commonly include markers of inflammation and hemoglobin (Hb), yet functional parameters have been inadequately studied in pediatric IBD. In this study, we compared fatigued and non-fatigued children with IBD from both a biological and functional point of view.

METHODS

A cross-sectional study of 104 pediatric IBD patients with mild to moderately active IBD was conducted. Fatigued children were defined as those with a Pediatric Quality of Life Inventory Multidimensional Fatigue Scale z score <-2.0. Non-fatigued children had a z score ≥-2.0. Disease-specific quality of life (measured with IMPACT-III score), C-reactive protein (CRP), fecal calprotectin (FC), hemoglobin z score (Hb z score), and physical activity tests including 6-minute walking distance z score (6MWD z score) and triaxial accelerometry (TA) were evaluated.

RESULTS

Fatigued children (n = 24) had a significant lower IMPACT-III score than non-fatigued children (n = 80). Hb z scores, CRP, FC, and 6MWD z scores were not significantly different between groups. TA was performed in 71 patients. Wear time validation requirements were met in only 31 patients. Fatigued patients spent significant shorter median time in moderate-to-vigorous activity than non-fatigued patients (18.3 vs 37.3 minutes per day, P = 0.008).

CONCLUSION

Biological parameters did not discriminate fatigued from non-fatigued patients. TA possibly distinguishes fatigued from non-fatigued patients; the potential association may provide a target for interventions to combat fatigue and improve quality of life.

ESPEN guideline on Clinical Nutrition in inflammatory bowel disease

The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.

Pediatric endoscopy training across Europe: a survey of the ESPGHAN National Societies Network 2016-2019

Background and study aims  The ability to perform endoscopy procedures safely and effectively is a key aspect of quality clinical care in Pediatric Gastroenterology, Hepatology and Nutrition (PGHN). The aim of this survey, which was part of a global survey on PGHN training in Europe, was to assess endoscopy training opportunities provided across Europe. Methods  Responses to standardized questions related to endoscopy training were collected from training centers across Europe through the presidents/representatives of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition National Societies from June 2016 to December 2019. Results  A total of 100 training centers from 19 countries participated in the survey. In 57 centers, the endoscopy suit was attached to the PGHN center, while in 23, pediatric endoscopies were performed in adult endoscopy facilities. Ninety percent of centers reported the availability of specialized endoscopy nurses and 96 % of pediatric anesthetists. Pediatric endoscopies were performed by PGHN specialists in 55 centers, while 31 centers reported the involvement of an adult endoscopist and 14 of a pediatric surgeon. Dividing the number of procedures performed at the training center by the number of trainees, ≤ 20 upper, lower, or therapeutic endoscopies per trainee per year were reported by 0 %, 23 %, and 56 % of centers, respectively, whereas ≤ 5 wireless capsule endoscopies per trainee per year by 75 %. Only one country (United Kingdom) required separate certification of competency in endoscopy. Conclusions  Differences and deficiencies in infrastructure, staffing, and procedural volume, as well as in endoscopy competency assessment and certification, were identified among European PGHN training centers limiting training opportunities in pediatric endoscopy.

Training in Paediatric Clinical Nutrition Across Europe: A Survey of the National Societies Network (2016-2019) of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition

OBJECTIVES/BACKGROUND

Disease-related malnutrition is common in patients with chronic diseases and has detrimental effects, therefore, skills in nutrition care are essential core competencies for paediatric digestive medicine. The aim of this survey, conducted as part of a global survey of paediatric gastroenterology, hepatology and nutrition (PGHN) training in Europe, was to assess nutrition care-related infrastructure, staff, and patient volumes in European PGHN training centres.

METHODS

Standardized questionnaires related to clinical nutrition (CN) care were completed by representatives of European PGHN training centres between June 2016 and December 2019.

RESULTS

One hundred training centres from 17 European countries, Turkey, and Israel participated in the survey. Dedicated CN clinics exist in 66% of the centres, with fulltime and part-time CN specialists in 66% and 42%, respectively. Home tube feeding (HTF) andhome parenteral nutrition (HPN) programmes are in place in 95% and 77% of centres, respectively. Twenty-four percent of centres do not have a dedicated dietitian and 55% do not have a dedicated pharmacist attached to the training centre. Even the largest centres with >5000 outpatients reported that 25% and 50%, respectively do not have a dedicated dietitian or pharmacist. Low patient numbers on HTF and HPN of <5 annually are reported by 13% and 43% of centres, respectively.

CONCLUSIONS

The survey shows clear differences and deficits in Clinical Nutrition training infrastructure, including staff and patient volumes, in European PGHN training centres, leading to large differences and limitations in training opportunities in Clinical Nutrition.

Training in pediatric hepatology across Europe: a survey of the National Societies Network (2016-2019) of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition

Background

The widely recognized burden of liver diseases makes training in pediatric hepatology (PH) imperative. The aim of this survey, which was part of a global survey on training in pediatric gastroenterology, hepatology and nutrition (PGHN) across Europe, was to assess the PH and liver transplantation (LT) infrastructure, staff and training programs in PGHN training centers.

Method

Standardized questionnaires were collected from training centers via the presidents/representatives of the National Societies Network of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) from June 2016 to December 2019.

Results

A total of 100 PGHN training centers participated in the survey (14/100 were national referral centers in PH and/or LT). Dedicated PH clinics were available in 75%, but LT clinics in only 11%. Dedicated beds for PGHN inpatients were available in 47/95 (49%) centers. Full-time or part-time specialists for PH care were available in 31/45 (69%) and 11/36 (31%) centers, respectively. Liver biopsies (LB) were performed in 93% of centers by: a PGHN specialist (35%); an interventional radiologist (26%); a pediatric surgeon (4%); or a combination of them (35%). Dividing the annual number of LBs in the centers performing LBs by the number of trainees gave a median (range) of 10 (1-125) per trainee. Transient elastography was available in 60/92 (65%) of centers.

Conclusions

The survey highlighted the differences and shortcomings in PH training across Europe. ESPGHAN should take initiatives together with National Societies to ensure the acquisition of PH knowledge and skills according to the ESPGHAN curriculum.

An infographic is available for this article at: http://www.annalsgastro.gr/files/journals/1/earlyview/2022/Infographic-Hepatology-training-paper.pdf

Association of training standards in pediatric gastroenterology, hepatology and nutrition in European training centers with formal national recognition of the subspecialty: a survey of the ESPGHAN National Societies Network 2016-2019

Background

This survey evaluated the effects of the recognition of pediatric gastroenterology, hepatology and nutrition (PGHN) on European PGHN training centers.

Method

Standardized questionnaires were collected from training centers via the presidents/representatives of the National Societies Network of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition, from June 2016 to December 2019.

Results

A total of 100 training centers from 19 countries participated in the survey: 55 from 12 countries where PGHN is formally recognized (Group 1) and 45 from 7 countries where it is not (Group 2). Training centers in Group 2 were less likely to have an integrated endoscopy suite, a written training curriculum and a training lead (P=0.059, P<0.001 and P=0.012, respectively). Trainees in Group 2 were less likely to be exposed to an adequate number of diagnostic endoscopies, while no differences were found in relation to liver biopsies. Half of the training centers in both Groups do not have dedicated beds for PGHN patients, while in 64% and 58%, respectively, trainees do not participate in on-call programs for PGHN emergencies. Research training is mandatory in 26% of the centers. The duration of training, as well as the assessment and accreditation policies, vary between countries.

Conclusions

This study has revealed significant discrepancies and gaps in infrastructure and training programs, training leadership, and assessment of training and certification across European training centers in PGHN. Strategies to support the recognition of PGHN and to standardize and improve training conditions should be developed and implemented.

An infographic is available for this article at: http://www.annalsgastro.gr/files/journals/1/earlyview/2022/Infographic_AG-6496.pdf

Training in pediatric neurogastroenterology and motility across Europe: a survey of the ESPGHAN National Societies Network 2016-2019

Background

Method

Results

Conclusions

Early diagnosis of coeliac disease in the Preventive Youth Health Care Centres in the Netherlands: study protocol of a case finding study (GLUTENSCREEN)

Introduction

Coeliac disease (CD) occurs in 1% of the population, develops early in life and is severely underdiagnosed. Undiagnosed and untreated disease is associated with short-term and long-term complications. The current healthcare approach is unable to solve the underdiagnosis of CD and timely diagnosis and treatment is only achieved by active case finding. Aim: to perform a case finding project to detect CD children who visit the Youth Health Care Centres (YHCCs) in a well-described region in the Netherlands to evaluate whether it is feasible, cost-effective and well accepted by the population.

Methods/analysis

Prospective intervention cohort study. Parents of all children aged 12 months and 4 years attending the YHCCs for a regular visit are asked whether their child has one or more CD-related symptoms from a standardised list. If so, they will be invited to participate in the case finding study. After informed consent, a point of care test (POCT) to assess CD-specific antibodies against tissue transglutaminase (TG2A) is performed onsite the YHCCs. If the POCT is positive, CD is highly suspected and the child will be referred to hospital for definitive diagnosis according to the Guideline Coeliac Disease of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition guideline.

Main outcomes

Incidence rate of new CD diagnoses in the study region in comparison to the one in the same age diagnosed by standard of care in the rest of the Netherlands.Feasibility and cost-effectiveness of active CD case finding at the YHCCs. All costs of active case finding, diagnostics and treatment of CD and the potential short-term and long-term consequences of the disease will be calculated for the setting with and without case finding.Ethical acceptability: by questionnaires on parental and healthcare professionals' satisfaction.A statistical analysis plan was prepared and is published on the GLUTENSCREEN website (Statistical-Analysis-Plan-11-5-2021_def.pdf (glutenscreen.nl) and added as annex 1).

Ethics and dissemination

The Medical Ethics Committee Leiden approved this study. If we prove that case finding at the YHCC is feasible, cost-effective and well accepted by the population, implementation is recommended.

Trial registration number

NL63291.058.17.

Pathogenic STX3 variants affecting the retinal and intestinal transcripts cause an early-onset severe retinal dystrophy in microvillus inclusion disease subjects

Biallelic STX3 variants were previously reported in five individuals with the severe congenital enteropathy, microvillus inclusion disease (MVID). Here, we provide a significant extension of the phenotypic spectrum caused by STX3 variants. We report ten individuals of diverse geographic origin with biallelic STX3 loss-of-function variants, identified through exome sequencing, single-nucleotide polymorphism array-based homozygosity mapping, and international collaboration. The evaluated individuals all presented with MVID. Eight individuals also displayed early-onset severe retinal dystrophy, i.e., syndromic-intestinal and retinal-disease. These individuals harbored STX3 variants that affected both the retinal and intestinal STX3 transcripts, whereas STX3 variants affected only the intestinal transcript in individuals with solitary MVID. That STX3 is essential for retinal photoreceptor survival was confirmed by the creation of a rod photoreceptor-specific STX3 knockout mouse model which revealed a time-dependent reduction in the number of rod photoreceptors, thinning of the outer nuclear layer, and the eventual loss of both rod and cone photoreceptors. Together, our results provide a link between STX3 loss-of-function variants and a human retinal dystrophy. Depending on the genomic site of a human loss-of-function STX3 variant, it can cause MVID, the novel intestinal-retinal syndrome reported here or, hypothetically, an isolated retinal dystrophy.

ESPEN practical guideline: Clinical Nutrition in inflammatory bowel disease

The present guideline is the first of a new series of "practical guidelines" based on more detailed scientific guidelines produced by ESPEN during the last few years. The guidelines have been shortened and now include flow charts that connect the individual recommendations to logical care pathways and allow rapid navigation through the guideline. The purpose of the present practical guideline is to provide an easy-to-use tool to guide nutritional support and primary nutritional therapy in inflammatory bowel disease (IBD). The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. In 40 recommendations, general aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.

Response to treatment is more important than disease severity at diagnosis for prediction of early relapse in new-onset paediatric Crohn's disease

BACKGROUND

Paediatric Crohn's disease is characteried by frequently relapsing disease which may lead to hospitalisations and complications.

AIM

To develop predictive models for early relapse following first remission.

METHODS

The GROWTH CD prospective inception cohort was designed to predict risk for early disease relapse and poor outcomes. Newly diagnosed children underwent endoscopies and imaging. They were phenotyped and followed at scheduled visits through 78 weeks for relapses. Twenty-eight dichotomous and continuous variables were assessed at baseline and week 12, including phenotype, inflammatory markers, disease activity (PCDAI) and other markers. Clinical relapses defined as PCDAI >10 after remission were recorded using a relapse form. Logistic regression & risk modelling was performed.

RESULTS

We enrolled 282 eligible patients of whom 178 (63.6%) patients achieved steroid free remission by week 12. Disease complications developed in 22/76(29%) of patients with relapse compared to 20/206 (9.7%) without relapse (P = 0.01). Multivariable analysis demonstrated that while variables from age/gender at diagnosis were not predictive, week 12 variables including PCDAI >5 (P = 0.02), CRP >20 mg/L (P = 0.02), and faecal calprotectin >400 µg/g (P = 0.03) as optimal cut-offs were associated with increased risk of relapse. A prediction model for patients in remission including gender, age, week 12 PCDAI, calprotectin and CRP had sensitivity 43%, specificity 92%, PPV 78%, NPV 71% for relapse.

CONCLUSIONS

Early relapses were associated with a higher risk for disease complications at followup. Relapse prediction based on week 12 disease activity or inflammation is superior to prediction using data from diagnosis.

Efficacy of Home Telemonitoring versus Conventional Follow-up: A Randomized Controlled Trial among Teenagers with Inflammatory Bowel Disease

BACKGROUND AND AIMS

Conventional follow-up of teenagers with inflammatory bowel diseases [IBD] is done during scheduled outpatient visits regardless of how well the patient feels. We designed a telemonitoring strategy for early recognition of flares and compared its efficacy with conventional follow-up.

METHODS

We used a multicentre randomized trial in patients aged 10-19 years with IBD in clinical remission at baseline. Participants assigned to telemonitoring received automated alerts to complete a symptom score and send a stool sample for measurement of calprotectin. This resulted in an individual prediction for flare with associated treatment advice and test interval. In conventional follow-up the health check interval was left to the physician's discretion. The primary endpoint was cumulative incidence of disease flares. Secondary endpoints were percentage of participants with a positive change in quality-of-life and cost-effectiveness of the intervention.

RESULTS

We included 170 participants [84 telemonitoring; 86 conventional follow-up]. At 52 weeks the mean number of face-to-face visits was significantly lower in the telemonitoring group compared to conventional follow-up [3.6 vs 4.3, p < 0.001]. The incidence of flares [33 vs 34%, p = 0.93] and the proportion of participants reporting positive change in quality-of-life [54 vs 44%, p = 0.27] were similar. Mean annual cost-saving was €89 and increased to €360 in those compliant to the protocol.

CONCLUSIONS

Telemonitoring is as safe as conventional follow-up, and reduces outpatient visits and societal costs. The positive impact on quality-of-life was similar in the two groups. This strategy is attractive for teenagers and families, and health professionals may be interested in using it to keep teenagers who are well out of hospital and ease pressure on overstretched outpatient services.

TRIAL REGISTRATION

NTR3759 [Netherlands Trial Registry].

Infliximab Is Not Associated With Increased Risk of Malignancy or Hemophagocytic Lymphohistiocytosis in Pediatric Patients With Inflammatory Bowel Disease

BACKGROUND AND AIMS

Immunosuppressive therapy for inflammatory bowel disease (IBD) in pediatric patients is thought to increase the risk of malignancy and lymphoproliferative disorders, including hemophagocytic lymphohistiocytosis (HLH). We compared unadjusted incidence rates of malignancy and HLH in pediatric patients with IBD exposed to infliximab (IFX) with patients not exposed to biologics and calculated standardized incidence ratios (SIRs).

METHODS

We collected and analyzed data from 5766 participants in a prospective study of long-term outcomes of pediatric patients with IBD (NCT00606346), from May 31, 2007 through June 30, 2016. Patients were 17 years old or younger and had Crohn's disease, ulcerative colitis, or IBD-unclassified with 24,543.0 patient-years of follow-up. We estimated incidence rates for malignancy and HLH as events/1000 patient-years of follow-up. We calculated age-, sex-, and race-adjusted SIRs, with 95% confidence intervals (CIs), using the Surveillance, Epidemiology, and End Results Program (SEER) database.

RESULTS

Thirteen of the 15 patients who developed a malignancy and all 5 of the patients who developed HLH had been exposed to thiopurines; 10 patients with malignancy had also been exposed to a biologic agent. Unadjusted incidence rates showed no increased risk of malignancy (0.46/1000 patient-years) or HLH (0.0/1000 patient-years) in patients exposed to IFX as the only biologic vs those unexposed to biologics (malignancy: 1.12/1000 patient-years; HLH: 0.56/1000 patient-years). SIRs did not demonstrate an increased risk of malignancy among patients exposed to IFX (SIR, 1.69; 95% CI, 0.46-4.32) vs patients not exposed to a biologic agent (SIR, 2.17; 95% CI, 0.59-5.56), even when patients were stratified by thiopurine exposure.

CONCLUSIONS

In determination of age-, sex-, and race-adjusted SIRs using data from a large clinical study and the SEER database, we found that IFX exposure did not associate with increased risk of malignancy or HLH in pediatric patients with IBD. Thiopurine exposure is an important precedent event for the development of malignancy or HLH in pediatric patients with IBD.

ESPEN guideline: Clinical nutrition in inflammatory bowel disease

INTRODUCTION

The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD).

METHODOLOGY

The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).

Self-efficacy in adolescents with inflammatory bowel disease: a pilot study of the "IBD-yourself", a disease-specific questionnaire

BACKGROUND AND AIMS

Successful transfer of adolescent IBD patients to an adult gastroenterologist requires anticipation of a changing role for patients and their parents. Self-efficacy has been demonstrated to be important for transfer readiness. We therefore developed an IBD-specific questionnaire (the "IBD-yourself") to assess self-efficacy in adolescent IBD patients visiting a transition clinic. Our aim was to evaluate the reliability of this questionnaire, and to describe the self-efficacy level of adolescent IBD patients, and the perceived self-efficacy level according to their parents.

METHODS

In a cross-sectional design, 50 IBD patients (aged 14-18 years) and 40 parents completed the "IBD-yourself" questionnaire. Internal reliability was assessed by standardised Cronbach's α. Median self-efficacy scores per domain were calculated.

RESULTS

The domains of the questionnaire for adolescents showed good to excellent internal consistency, with Cronbach's α ranging from 0.64 to 0.93. The domains of the parental questionnaire had Cronbach's α ranging from 0.47 to 0.93. Median self-efficacy scores of adolescents varied from 70 to 100%. In comparison with patient's self-assessment, parents thought that their child was more self-efficacious in knowledge of IBD and diagnostic tests, self-management of medication use, and transfer readiness. Length of time since first visit to the transition clinic was positively correlated with several domains of the questionnaire, such as independent behaviour at the outpatient clinic, and transfer readiness.

CONCLUSION

The "IBD-yourself" questionnaire is a first step toward evaluating quality and efficacy of IBD transition programmes. Paediatric gastroenterologists should be aware that parents do not always accurately assess the self-efficacy of their child.

Use of exclusive enteral nutrition in paediatric Crohn's disease in The Netherlands

BACKGROUND AND AIMS

A six-week course of exclusive enteral nutrition (EEN) is recommended as first treatment in active paediatric Crohn's disease (CD). We aimed to assess short-term and long-term outcome of EEN, and to identify predictive factors of treatment success.

METHODS

The medical records of newly diagnosed paediatric CD patients initiating EEN as remission induction therapy between January 2008 and October 2011 were retrospectively studied. Treatment outcome was assessed using a previously described pattern recognition model.

RESULTS

77 CD patients (median age 13.9 years, 57% male) initiated a six-week course of EEN, combined with azathioprine maintenance treatment in 92%. Patients received EEN as either hyperosmolar sip feeds or polymeric formula by nasogastric tube. In patients completing a six-week course of EEN (n=58), complete remission was achieved in 71%, partial remission in 26%, and no response in 3%. Complete remission rates were higher in children presenting with isolated ileal/ileocaecal disease and malnutrition. Nineteen patients discontinued EEN before the intended treatment period due to worsening of symptoms (n=9) or adherence issues (n=10). Non-adherence occurred more often in older children, females, children from non-Dutch parents, and patients taking hyperosmolar sip feeds compared with polymeric formula by nasogastric tube. The likelihood of relapsing disease within the first year after EEN treatment was 59%.

CONCLUSION

A six-week course of EEN is effective in newly diagnosed paediatric CD, with response rates that seem to be influenced by disease location and nutritional status, but not by type of formula. Non-adherence occurs frequently and limits the success of this treatment in everyday clinical practice.

Limitations of fecal calprotectin at diagnosis in untreated pediatric Crohn's disease

BACKGROUND

Fecal Calprotectin (FC) is a validated screening test for intestinal inflammation in Crohn's disease (CD). The objective of the study was to prospectively evaluate the limitations of FC for identifying CD in newly diagnosed untreated pediatric patients and to assess the association of FC levels with disease location and serum inflammatory markers.

METHODS

Consecutive children with new onset untreated CD participating in the ongoing ESPGHAN GROWTH CD study were evaluated at diagnosis for disease activity, extent, C-reactive protein (CRP), and FC.

RESULTS

In all, 60 children met the inclusion criteria (mean age 12.6 ± 4.6 years,), 25 (42%) with mild disease, 17 (28%) moderate disease, and 18 (30%) severe disease. Twenty-seven (45%) had small bowel disease only. Median FC levels did not differ between children with small bowel only (2198 μg/g interquartile range [IQR] 696-2400) and those with colonic involvement (with or without small bowel disease; 2400 μg/g (IQR 475-2400) (P = 0.76). FC was elevated in 95% of patients, in comparison to CRP (86%) and erythrocyte sedimentation rate (ESR) (83%). Three children (5%) who had normal calprotectin levels also had low or normal CRP and/or ESR. There was no correlation between calprotectin levels and either the pediatric CD activity index (r = -0.11; P = 0.94) or physicians global assessment.

CONCLUSIONS

FC levels in active disease confined to the small bowel were elevated in the vast majority of children and site of disease was not a confounding factor in this setting. Patients with low FC had a trend toward low levels of inflammatory markers as well. We did not find a significant correlation between FC and clinical indices of activity.

Partial dynamical symmetry in a fermion system

The relevance of the partial dynamical symmetry concept for an interacting fermion system is demonstrated. Hamiltonians with partial SU(3) symmetry are presented in the framework of the symplectic shell model of nuclei and shown to be closely related to the quadrupole-quadrupole interaction. Implications are discussed for the deformed light nucleus 20Ne.

[Music and heart rate variability. Study of the effect of music on heart rate variability in healthy adolescents]

The effect of trophotropic (relaxing) music on heart rate and heart rate variability has been investigated in 23 healthy young individuals by means of 24-hour Holter-ECG. Relaxing music (Bach, Vivaldi, Mozart) resulted in significant reduction of heart rate and also significant reduction of heart rate variability. The significance of these results for the use of music in coronary heart disease is discussed.

Prevalence of GB virus type C/hepatitis G virus RNA and anti-E2 among blood donors in Southeastern France

BACKGROUND

The purpose of the study was to analyze serologic and molecular markers of the GB virus type C/hepatitis G virus (GBV-C/HGV) infection in voluntary blood donors from Southeastern France.

STUDY DESIGN AND METHODS

Sera were tested for the presence of GBV-C/HGV RNA by reverse transcriptase-polymerase chain reaction and that of antibodies to the GBV-C/HGV E2 (anti-E2) antigen by an enzyme-linked immunosorbent assay. A first cohort (1660 blood donors) was tested prospectively and a second cohort (238 samples with hepatitis markers) was tested retrospectively. Donors in the prospective study were questioned for possible risk factors of virus transmission. Amplification products were sequenced and subjected to phylogenetic analysis.

RESULTS

Approximately 2.6 percent of individuals accepted for blood donation and 15.4 percent with positive hepatitis C virus serologic tests carried GBV-C/HGV RNA. Anti-E2 was detected in these two populations in approximately 12 percent and 48 percent of donors, respectively. Moderate relative risks were found only in tattooed or pierced individuals (1.82) and health care workers (2.45). Almost all strains were located in the same phylogenetic branch as HGV Group 2.

CONCLUSION

Though a large proportion of the donors tested have been in contact with GBV-C/HGV, no elevated relative risk of infection was identified. The phylogenetic distribution of viral strains suggests that the infection is endemic in this population.

[Hypersensitivity myocarditis. A case of myocarditis following drug administration]

Based upon the findings of eosinophilia and concomitant ECG changes, hypersensitivity myocarditis was diagnosed in a patient who had been given longstanding antibiotic therapy. With cessation of drug treatment the disease resolved spontaneously.

[Music therapy and internal medicine]

Since December 1988 the district hospital of the Oberwallis hosts the 4 year project "Music-Therapy in Internal Medicine" under the scientific guidance of Dr. H. H. Decker-Voigt, director of the Institute of music therapy of the musical academy Hamburg. This therapy can be described as a form of psychotherapy which uses the medium music with its particularities as an adjunct for treatment. The different levels of action of music, a functional and a regressive one and their respective importance for music therapy are described first. An introduction to the two forms of music therapy, the receptive and the active with their respective particularities follows. Indications for music therapy are by large not disease-specific but depend on the assessment of the importance of psychic components in somatic disease. Coping with disease, psychosocial integration and promotion of positive resources or self-healing potential are regarded as indications for music therapy. Music therapy is not indicated when the patient is not motivated or his stay at the hospital is shorter than 2 weeks. We offer a music therapy to all patients in whose illness, according to our evaluation, emotional and psychic factors play an important role and to those patients with functional disorders on whom we would like to learn more by the psychoanalytic possibilities of music therapy. According to our experience music therapy is well suited as an adjunct in many diseases in internal medicine and represents an enrichment of our therapeutic possibilities.

[Music during gastroscopy]

As part of a project "Music therapy in internal medicine" we investigated 32 consecutive patients undergoing gastroscopy for various reasons. Patients were randomly assigned to two groups, regardless of sex, age or underlying disease. One group listened to music during gastroscopy, while the other did not. The choice of the type of music within the corresponding group was made with the patient and a trained music therapist in a short discussion prior to gastroscopy. The hormones ACTH and cortisol, as well as the catecholamines adrenalin and noradrenaline, were measured in both groups with three blood samples taken before, directly after and one hour after gastroscopy. Parallel measurements included blood pressure and pulse rate as well as questions about the patients' feelings during gastroscopy. The study showed the rise in the plasma levels of the stress hormones ACTH and cortisol to be significantly lower under the influence of music. The subjective feelings of the patients concerning "fear in general" and "fear about gastroscopy" paralleled these findings. Conversely, the plasma adrenalin and noradrenaline levels before and after gastroscopy were virtually unchanged in both groups, as were pulse rate and blood pressure. This study shows the influence of music on human biochemical parameters when used in the setting of a diagnostic procedure.

Analysis of ELISA hepatitis C virus-positive blood donors population by polymerase chain reaction and recombinant immunoblot assay (RIBA). Comparison of second and third generation RIBA

A new RIBA-3 (Chiron-Ortho Diagnostic System) was performed for discriminating uninterpretable results of RIBA-2. Recognition of antibodies to hepatitis C virus by RIBA-2 and RIBA-3 was compared among 95 ELISA-2 (second generation ELISA) positive blood donors and correlated with alanine-aminotransferase (ALAT) levels and viremia, using polymerase chain reaction (PCR). These studies led to three important conclusions. First, all ELISA-2-positive, RIBA-2-positive and ALAT-positive samples were found viremic compared with 73% of ELISA-2-positive, RIBA-2-positive and ALAT-negative samples. Then, the comparison of the different RIBAs allowed to conclude that RIBA-3 was more sensitive but less specific than RIBA-2. RIBA-3 was interesting to discriminate undetermined RIBA-2, owing to an improved specificity of C100-3 antigen. In fact, most of the C100-3 positive, RIBA-2 undetermined samples became RIBA-3 negative whereas C22-3 positive, RIBA-2 undetermined samples became RIBA-3 positive or undetermined. Finally, a significant correlation was found between the presence of antibodies against C33-c antigen and viremia.

Cardiac manifestations of myotonic dystrophy

Twenty-four patients with Myotonic Dystrophy (MyD), age 19-66 years, underwent non-invasive cardiac evaluation which included physical examination, resting and 24 h ECG recording, echocardiography, and multigated radionuclide (Tc99) scanning (MUGA) to assess left ventricular ejection fraction (LVEF). Only 4 of the 24 patients studied did not display any cardiac pathology. Though most patients (20 out of 24) were free of cardiac symptomatology, 15 had abnormal resting ECG. In 12 of the patients mild rhythm disturbances were present in the 24 h ECG monitoring. Left ventricular contraction impairment was a most striking feature; it was noted in 8 patients, in whom the LVEF was below 50%. The apical region was the most affected. Seventeen patients showed abnormal echocardiographic findings: mitral valve prolapse was noted in 8, dilatation of left atrium in 5 and of the left ventricle in 2 of the 24 patients. No correlation between the severity of muscular impairment and the cardiac manifestation was seen. No correlation was found between disease duration or severity (as judged by the functional capacity of the patients) and its cardiac manifestations.

Implementing a "Do-Not-Resuscitate" (DNR) policy in a nursing home

During implementation of a new Do-Not-Resuscitate (DNR) policy in New York State, decisions by 233 nursing home patients of their surrogates were evaluated. Eighteen patients with capacity (mean age +/- SD = 76.4 +/- 12.1 years) chose DNR; 30 patients with capacity (mean age +/- SD = 76.2 +/- 10.7 years) chose to be resuscitated (CODE); 54 patients without capacity, (mean age +/- SD = 86.1 +/- 9.1 years) had surrogates who chose DNR; and 131 patients without capacity and with surrogates (mean age +/- SD = 81.9 +/- 9.8 years) remained CODE. Most patients with capacity who chose DNR had multiple sclerosis, while most choosing CODE had strokes. Most patients who lacked capacity had dementia. Forty-five percent of surrogates did not respond regarding CODE status during the three-month study interval, and 10% wanted additional time to decide. Patient age appeared to be a factor in surrogate choice for DNR but not in patients with capacity making their own decision. Reasons for patients with capacity choosing DNR are discussed; perceived quality of life and premorbid feelings by patients help in the decision-making process.

Efficacy and safety of midazolam and oxazepam in insomniacs

In a multicentre, double-blind, parallel study performed in 78 hospitalized patients who complained of mild, moderate or severe insomnia, the efficacy and safety of 15 mg midazolam were compared with those of 15 mg oxazepam, both orally administered. The results showed statistically significant better results in the onset of sleep in the patients treated with midazolam. Other sleep parameters, such as quality and duration of sleep as well as the condition of the patients on morning awakenings, were also improved in more patients treated with midazolam. Safety (clinical and biological) was very good in both groups of patients.