Nitazoxanide for persistent diarrhoea in Zambian acquired immune deficiency syndrome patients: a randomized-controlled trial

BACKGROUND

Adults with acquired immune deficiency syndrome and persistent diarrhoea in Zambia have intestinal infection, predominantly protozoa.

AIM

To search for treatment which can be offered with minimal investigation, we carried out a double-blind, randomized-controlled trial of nitazoxanide (a drug with a range of activity against parasites and bacteria).

METHODS

Patients with diarrhoea of 1 month duration or longer were randomized to receive nitazoxanide (1000 mg twice daily) or placebo for 2 weeks. End-points were clinical response, parasitological clearance and mortality.

RESULTS

Two hundred and seven adults were randomized; 42 died during the study. The primary assessment of efficacy was made after 17 days. Clinical response was observed in 56 (75%) of 75 patients receiving nitazoxanide and 45 (58%) of 77 patients receiving placebo (P = 0.03). The rate of improvement was markedly higher in patients with CD4 counts under 50 cells/microL receiving nitazoxanide (P = 0.007). The benefit was largely restricted to the period when the drug was being administered. No difference was seen in parasitological clearance between the two groups. Mortality was 19% by 4 weeks of follow-up and did not differ with treatment allocation.

CONCLUSIONS

Nitazoxanide given orally for 14 days was associated with clinical improvement in Zambian acquired immune deficiency syndrome patients with diarrhoea, especially those with very low CD4 counts.

Up-regulated cytoplasmic expression, with reduced membranous distribution, of the src substrate p120(ctn) in gastric carcinoma

p120(ctn) is a substrate of the tyrosine kinase pp60 src. Tyrosine kinases such as src localize to the adherens junctions and phosphorylate junctional proteins in both normal and transformed cells.(1) p120(ctn) forms a complex with E-cadherin at the adherens junction and is phosphorylated by ligands such as epidermal growth factor receptor as well as pp60 src. Phosphorylation of p120(ctn) has been shown to correlate with cell transformation. The aim of this study was to investigate in vivo expression of p120(ctn) in gastric carcinoma and to examine any relationship to pathological characteristics and patient survival. Immunohistochemical staining for p120(ctn) was performed in 68 gastric carcinoma specimens (19 diffuse, 49 intestinal type), in 22 lymph node metastases, and in gastric mucosal biopsies from 16 patients with gastric dysplasia and ten healthy controls. Up-regulation of p120(ctn) cytoplasmic staining was seen in six (37 per cent) of the gastric dysplasia cases and in 45 (66 per cent) tumours (89 per cent of diffuse and 57 per cent of intestinal tumours). Loss of membranous distribution of staining for p120(ctn) was seen in 22 (32 per cent) tumours (52 per cent of diffuse and 24 per cent of intestinal tumours). The staining pattern in the primary tumour showed no correlation with tumour type, grade, or stage, or patient survival. Of 22 lymph node metastases examined, 13 (60 per cent) showed loss of membranous staining. In conclusion, staining for p120(ctn) in gastric carcinoma and dysplasia revealed marked up-regulation of cytoplasmic staining, sometimes associated with reduced membranous expression. Up-regulation of expression of p120(ctn) has not previously been described in human epithelial malignancy. The significance of these findings is uncertain, but they may reflect a change in tyrosine kinase signal transduction pathways, and a role for p120(ctn) in ligand-induced mitogenic signalling and cell transformation.

Up-regulated cytoplasmic expression, with reduced membranous distribution, of the src substrate p120(ctn) in gastric carcinoma

p120(ctn) is a substrate of the tyrosine kinase pp60 src. Tyrosine kinases such as src localize to the adherens junctions and phosphorylate junctional proteins in both normal and transformed cells.(1) p120(ctn) forms a complex with E-cadherin at the adherens junction and is phosphorylated by ligands such as epidermal growth factor receptor as well as pp60 src. Phosphorylation of p120(ctn) has been shown to correlate with cell transformation. The aim of this study was to investigate in vivo expression of p120(ctn) in gastric carcinoma and to examine any relationship to pathological characteristics and patient survival. Immunohistochemical staining for p120(ctn) was performed in 68 gastric carcinoma specimens (19 diffuse, 49 intestinal type), in 22 lymph node metastases, and in gastric mucosal biopsies from 16 patients with gastric dysplasia and ten healthy controls. Up-regulation of p120(ctn) cytoplasmic staining was seen in six (37 per cent) of the gastric dysplasia cases and in 45 (66 per cent) tumours (89 per cent of diffuse and 57 per cent of intestinal tumours). Loss of membranous distribution of staining for p120(ctn) was seen in 22 (32 per cent) tumours (52 per cent of diffuse and 24 per cent of intestinal tumours). The staining pattern in the primary tumour showed no correlation with tumour type, grade, or stage, or patient survival. Of 22 lymph node metastases examined, 13 (60 per cent) showed loss of membranous staining. In conclusion, staining for p120(ctn) in gastric carcinoma and dysplasia revealed marked up-regulation of cytoplasmic staining, sometimes associated with reduced membranous expression. Up-regulation of expression of p120(ctn) has not previously been described in human epithelial malignancy. The significance of these findings is uncertain, but they may reflect a change in tyrosine kinase signal transduction pathways, and a role for p120(ctn) in ligand-induced mitogenic signalling and cell transformation.

Micronutrient supplementation in the AIDS diarrhoea-wasting syndrome in Zambia: a randomized controlled trial

OBJECTIVE

As HIV has spread through sub-Saharan Africa, persistent diarrhoea has emerged as a major problem in hospitals and in the community in severely affected areas. We have previously demonstrated that antiprotozoal therapy with albendazole reduces diarrhoea in AIDS patients in urban Zambia. This trial was designed to test the hypothesis that the clinical response to albendazole might be improved by oral micronutrient supplementation.

DESIGN

Randomized, placebo-controlled trial.

SETTING

Home care service of Ndola Central Hospital, Zambia.

PATIENTS

HIV-seropositive patients with persistent diarrhoea.

INTERVENTION

Patients were randomized to albendazole plus vitamins A, C and E, selenium and zinc orally or albendazole plus placebo, for 2 weeks.

MAIN OUTCOME MEASURES

Time with diarrhoea following completion of treatment; mortality; adverse events.

RESULTS

Serum vitamin A and E concentrations before treatment were powerful predictors of early mortality, but supplementation did not reduce time with diarrhoea or mortality during the first month, even after taking into account initial vitamin A or E concentrations, CD4 cell count or clinical markers of illness severity. Serum concentrations of vitamins A and E did not increase significantly in supplemented patients compared with those given placebo, and there were no changes in CD4 cell count or haematological parameters. No adverse events were detected except those attributable to underlying disease.

CONCLUSIONS

Although micronutrient deficiency is predictive of early death in Zambian patients with the diarrhoea-wasting syndrome, short-term oral supplementation does not overcome it nor influence morbidity or mortality.

Cryptosporidiosis in urban Zambian children: an analysis of risk factors

In four crowded townships of Lusaka, Zambia, the prevalence of cryptosporidiosis in 222 children with diarrhea was 18%, with marked temporal and geographic variation over the course of one rainy season. Using data on the finding of oocysts of Cryptosporidium parvum in urban water supplies, the areas under study were categorized as high or low risk. Prevalence of cryptosporidiosis in children with diarrhea was higher in high risk areas after stratification by early/late stage of the rains (Mantel-Haenszel odds ratio [OR] = 2.9, 95% confidence interval [CI] = 1.3, 6.7; P = 0.008). Cryptosporidiosis was not associated with keeping animals, nutritional status, or parental education, but was apparently more common in breast fed children (OR = 2.7, 95% CI = 1.1, 6.9; P = 0.01), although the proportion of exclusively breast fed children was not measured. Since most of these infections were of short duration, we conclude that transmission of C. parvum can vary dynamically within one city and over short periods of time, and that water-borne contamination may be a substantial influence.

Plasma leptin in chronic inflammatory bowel disease and HIV: implications for the pathogenesis of anorexia and weight loss

1. Leptin inhibits food intake and is an important regulator of long-term energy balance. In rodents, plasma concentrations of leptin are increased by administration of interleukin-1 and tumour necrosis factor. Hyperleptinaemia may mediate the anorexia and weight loss which is observed in chronic infections and inflammatory conditions. 2. Plasma leptin and soluble tumour necrosis factor receptor (sTNF-r55) concentrations were measured in patients with inflammatory bowel disease and acquired immunodeficiency syndrome (AIDS), and healthy controls. 3. The patients with AIDS were severely wasted [% body fat 12 (9-16); median (interquartile range)] compared with those with inflammatory bowel disease [25.1 (19-31.5)] and control subjects [29.4 (23.6-37.8)]. Leptin concentrations were highly correlated with percentage body fat in controls (r = 0.74, P < 0.001) and patients with IBD (r = 0.73, P < 0.001) but not in the patients with AIDS (r = -0.024). Leptin concentrations were similar in the inflammatory bowel disease [4.8 (2.6-10.1) ng/ml] and control groups [8.0 (3.1-14.1) ng/ml] but were significantly lower (P < 0.05) in patients with AIDS [1.8 (1.5-2.3) ng/ml] after 23 patients were matched for sex and percentage body fat in patients with inflammatory bowel disease [2.4 (1.8-4.1) ng/ml]. Plasma concentrations of sTNF-r55 were higher in both the patients with inflammatory bowel disease [0.19 (0.16-0.23) ng/ml] and those with AIDS [4.8 (2.8-7.3) ng/ml] compared with controls [0.14 (0.09-0.16) ng/ml] but were not correlated with either percentage body fat or plasma leptin concentrations. 4. Hyperleptinaemia does not appear to mediate the anorexia and weight loss associated with inflammatory bowel disease and AIDS. In patients with AIDS with extreme wasting there was no relationship between body fat and leptin and this may be related to the rapid weight loss which occurs in these patients.

Sclerosing cholangitis, race and sex

BACKGROUND

Primary sclerosing cholangitis develops in 3-10% of patients with ulcerative colitis, and may be associated with an increased cancer risk. Ulcerative colitis is probably less common in people of African origin than in populations of European descent.

AIMS AND METHODS

To review the records of all patients under regular follow up for ulcerative colitis at St Bartholomew's Hospital (London, UK), a tertiary referral centre, prompted by discovering a cluster of cases with common features.

RESULTS AND CONCLUSIONS

Among 166 patients with ulcerative colitis under regular follow up, only four (all women) are of African or Caribbean genetic origin, and three of these have developed sclerosing cholangitis within three years of presentation with colitis, compared with four of 162 patients of European or Asian descent (odds ratio 119, 95% confidence interval 8-3837; p = 0.0002). This cluster, which is not explained by common HLA DR or DQ type, suggests that Africans and Afro-Caribbeans, especially women, may be at increased risk of sclerosing cholangitis. This may reflect genetic influences on the development of enteric and hepatobiliary inflammatory disease.

Enkephalins and enkephalinase inhibitors in intestinal fluid and electrolyte transport

Opioids have long been known to inhibit intestinal fluid and electrolyte secretion. They act locally on central and peripheral opiate receptors where they are rapidly degraded by neuropeptidases, the major one being enkephalinase (EC 3.4.24.11). A number of studies have shown that, when the problem of degradation can be overcome, enkephalins have potent antisecretory properties. In 1980, an enkephalinase inhibitor was described which increased the functional availability of enkephalins. More recently an orally active enkephalinase inhibitor, acetorphan, has been shown to inhibit infectious and chemically induced diarrhoea. Acetorphan does not appear to affect gastrointestinal motility and, although it also inhibits the breakdown of a range of other neuropeptides, such as substance P and neuropeptide Y, it is a promising agent with therapeutic potential.

The prevalence of symptoms of irritable bowel syndrome among acute psychiatric inpatients with an affective diagnosis

An interview study of 87 inpatients with affective diagnoses, according to the International Classification of Diseases (9th Edition), yielded a prevalence of irritable bowel syndrome (IBS) of 39.7%, approximately twice that found in the general population. The IBS symptoms almost invariably preceded the onset of the affective disorder, but were exacerbated by it. The consultation rate for bowel symptoms (41.9%) was greater than that in the general population. In this study, 69.2% of consulters and 55.5% of nonconsulters had experienced an exacerbation of their IBS symptoms since the onset of their emotional disorder. These findings suggest that such disorders may influence the subjective severity of IBS and also consultation behavior, but do not play a major part in the etiology of the gastrointestinal symptoms.

Albendazole chemotherapy for treatment of diarrhoea in patients with AIDS in Zambia: a randomised double blind controlled trial

OBJECTIVE

To determine the value of short course, high dose albendazole chemotherapy in the treatment of persistent diarrhoea related to HIV in unselected patients in urban Zambia.

DESIGN

A randomised double blind placebo controlled trial of albendazole 800 mg twice daily for two weeks. Patients were monitored intensively for one month and followed for up to six months.

SETTING

Home care. AIDS services in Lusaka and Ndola.

PATIENTS

174 HIV seropositive patients with persistent diarrhoea (defined as loose but not bloody stools three or more times a day for three weeks or longer). No investigations were undertaken except HIV testing after counselling.

MAIN OUTCOME MEASURES

Proportion of time periods during which diarrhoea was experienced after completion of treatment; proportion of patients with full remission after completion of treatment; mortality.

RESULTS

The patients taking albendazole had diarrhoea on 29% fewer days than those taking placebo (P < 0.0001) in the two weeks after treatment. The benefit of albendazole was maintained over six months. In patients with a Karnofsky score of 50 to 70 (needing help with activities of daily living and unable to work, but not needing admission to hospital) diarrhoea was reduced by 50%. Remission was obtained in 26% of all patients who received albendazole (P = 0.004 against 9% receiving placebo), and this difference was maintained over six months (log rank test, P = 0.003). Albendazole had no effect on mortality. Minimal adverse effects were noted.

CONCLUSIONS

For HIV infected Zambians with diarrhoea of more than three weeks' duration albendazole offers substantial relief from symptoms and may be used empirically, without prior investigation.

Abnormal illness attitudes in patients with irritable bowel syndrome

The Illness Attitudes Scales (IAS) and the Beck Depression Inventory (BDI) were administered to 40 patients with irritable bowel syndrome (IBS) and these were compared with 35 patients with organic gastrointestinal (GI) disease, 37 depressed patients, and 40 healthy volunteers. The BDI score was found to be greater in the IBS patients than in either the patients with organic disease or healthy subjects. All the patient groups had abnormal IAS scores compared with the healthy group, but these were most marked among the IBS patients with elevated scores on six out of the eight subscales. Three of these were specific to the IBS patients: bodily preoccupation, hypochondriacal beliefs and disease phobia. The results of this study indicate that clinical IBS is associated with abnormal illness attitudes which are not simply a reflection of either an associated depression or of experiencing physical symptoms.

An evaluation of factors affecting Helicobacter pylori prevalence in Tibetans exiled in India

Helicobacter pylori infection is found world-wide although the epidemiology of infection has not been well defined in many geographical areas. The aims of this study were to determine the prevalence of H. pylori infection and chronic gastritis and the demographic correlates of infection in a single racial group in southern India. The sample population was selected randomly from the male population register of a Tibetan refugee settlement. Demographic data and results of endoscopy with antral mucosal biopsy were evaluated in 197 subjects (median age 28, range 21-81 years). H. pylori was present in 77.2% of subjects by histology and/or urease test. Chronic gastritis and H. pylori were closely related and there was an association between the number of bacteria present and the severity of the gastritis (P < 0.04). Infection with H. pylori was inversely associated with socio-economic factors, specifically educational level (P < 0.02) and occupation (P < 0.02). Unlike other studies, the prevalence of H. pylori was not found to rise with age, being lower in those older than 40 years (P < 0.005). This difference was still apparent when adjusted for socio-economic status. The major demographic difference between younger and older subjects of low socio-economic status was the greater proportion of early life spent outside India (and in Tibet) by older subjects. Among younger subjects, residence in India for 20 years or more was associated with a greater risk of H. pylori infection (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The management of rectal bleeding

Rectal bleeding is a common symptom in the general population; it may signal the presence of serious gastrointestinal disease but more frequently is caused by minor and self-limiting local ano-rectal conditions. Appropriate and accurate evaluation of rectal bleeding requires an investigative approach which balances an appreciation of the need to provide an adequate explanation for the bleeding against over-investigation, excessive referral and wasted resources. As doctors of first contact, general practitioners (GPs) are frequently faced with difficult questions concerning the optimum management of rectal bleeding. This paper was prepared as a result of a series of interactive meetings with over 1,000 GPs from throughout the UK, which revealed wide variations in the possession and use of investigative equipment in the surgery, access to secondary care facilities, estimates of the prevalence and potential seriousness of rectal bleeding and the management strategies adopted in response to a series of case histories. We highlight a number of unresolved issues about the roles of GPs and hospital specialists in the management of rectal bleeding and the need for research directed at answering outstanding questions. In addition, a management strategy is proposed which might form the basis for a protocol for care, shared between general practice and the hospital.

Lornoxicam, indomethacin and placebo: comparison of effects on faecal blood loss and upper gastrointestinal endoscopic appearances in healthy men

Forty-five healthy men aged 21-34 years took part in a double-blind, parallel-group, placebo-controlled study of the effects of 28 days' treatment with lornoxicam 4 mg twice daily or indomethacin 50 mg twice daily on faecal blood loss and the endoscopic appearances of gastric and duodenal mucosa. After an initial endoscopic examination, subjects received, intravenously, on day 0, autologous erythrocytes labelled with 51Cr. Complete daily faecal collections were then made from days 6-12, 20-26 and 34-40. The drug treatments or placebo were given from days 13-41. Faecal blood loss was calculated from 51Cr-specific activity of blood and faeces. Endoscopy was repeated 4-8 hours after the last dose of medication; mucosal appearance was graded on a 5-point scale. Lornoxicam caused no more adverse events than placebo; indomethacin caused more indigestion and central nervous system effects, and one subject in this group was withdrawn from the study. Median total blood losses during the pre-treatment and the second and fourth weeks of treatment were respectively 3.33, 3.95 and 5.71 ml for lornoxicam, 2.87, 7.04 and 7.75 ml for indomethacin, and 4.55, 3.64 and 4.13 ml for placebo. Differences between treatments were not statistically significant (P = 0.081 for second week of treatment, P = 0.383 for fourth week of treatment; Kruskal-Wallis test). The effect of chlortenoxicam on faecal blood loss in this study was thus intermediate between placebo and indomethacin, but within- and between-subject variability was such that the differences were not statistically significant. Endoscopic findings were normal in most subjects before and after all treatments, but indomethacin was associated with a slightly greater deterioration in endoscopic score and was the only treatment associated with Grade 3 appearance (in a single patient) in post-treatment endoscopy.

4-Aminosalicylic acid retention enemas in treatment of distal colitis

Forty-five of 47 patients with distal ulcerative colitis completed a two-week double-blind, randomized, controlled trial to determine if 4-aminosalicylic acid (4-ASA) enemas, 1 g bid or 2 g bid, were therapeutically effective compared to placebo. Forty-one patients enrolled because they were refractory to or had side effects during conventional therapy with sulfasalazine or corticosteroids. Proctoscopic examination was done before and after two weeks of treatment. Patients kept daily diaries assessing: blood in stools, mucus in stools, tenesmus, abdominal pain, loss of appetite, fatigue, weight loss, and malaise. Severity of each symptom ranged from 0 (absent) to 3 (severe). A total severity score was calculated from the above for each patient. At the end of the two-week study, 35 patients elected to take 4-ASA in an open-label trial for one year. 4-ASA enemas in the 1-g bid but not the 2-g bid dosage were significantly more effective in improving symptoms than placebo: P less than or equal to 0.05. Neither dose of 4-ASA enema was better than placebo in improving the sigmoidoscopic appearance at the end of two-weeks. Forty-six percent of patients had complete resolution of all signs and symptoms in the open-label trial and 31% were better but still had sigmoidoscopic evidence of disease, a total response rate of 77%. Side effects were similar in the placebo and 4-ASA groups. We conclude that 4-ASA enemas in a dose of 1 g bid are safe and effective in the treatment of distal ulcerative colitis.