Chronic intestinal failure: an overview and future perspectives.

Intestinal failure (IF) is the inability of the gut to absorb necessary water, macronutrients, micronutrients, and electrolytes sufficient to sustain life and requiring intravenous supplementation or replacement. IF Types 1 and 2 are the initial phase of this condition and usually last for weeks to a few months. Type 3 IF (also known as chronic IF [CIF]) is a chronic and stable condition, usually irreversible, whose main treatment is home parenteral nutrition. CIF is a relatively rare condition, and its prevalence and different causes vary throughout the world. Due to its complexity, CIF requires a multidisciplinary team with experience in this field to achieve successful outcomes. This editorial aims to provide an overview of CIF in adults, emphasizing the challenges faced by clinicians when managing this rare entity, as well as outlining the role of the gastroenterologist.

Mixed Oil-Based Lipid Emulsions vs Soybean Oil-Based Lipid Emulsions on Incidence and Severity of Intestinal Failure-Associated Liver Disease in a Neonatal Intensive Care Unit.

BACKGROUND: Neonates requiring long-term parenteral nutrition (PN) are at risk for developing intestinal failure-associated liver disease (IFALD). The purpose of this study was to compare the incidence and severity of IFALD in a highly surgical neonatal population receiving mixed oil-based lipid emulsions (MOLEs) vs soybean oil-based lipid emulsions (SOLEs) for long-term PN. METHODS: This retrospective cohort study evaluated patients admitted to a neonatal intensive care nursery that received PN for ≥14 days. Patients were separated into 2 cohorts; those who received SOLE and those who received MOLE. The primary outcome of this study was the occurrence of IFALD. Secondary outcomes included time to IFALD, peak bilirubin level during therapy, incidence of hypertriglyceridemia, bronchopulmonary dysplasia, and retinopathy of prematurity. RESULTS: A total of 107 patients were included in the study, IFALD occurred in 44.8% of patients receiving SOLE compared with 30% of patients receiving MOLE (relative risk, 0.67; 95% CI, 0.39-1.15). In the multivariable analysis, adjusting for the known confounders (prematurity, necrotizing enterocolitis, presence of ostomy, and duration of PN and lipids), the type of lipids was not a significant predictor for development of IFALD. Duration of PN and duration of lipids were determined to be significant risk factors for IFALD, regardless of type of lipid emulsion (odds ratio, 1.03; 95% CI, 1.01-1.05). CONCLUSIONS: Use of MOLE resulted in no significant difference in the outcomes studied when compared with SOLE. Duration of PN and duration of lipids were significant risk factors for development of IFALD.

Polyethylene glycol versus split high-dose senna for bowel preparation: A comparative prospective randomized study.

BACKGROUND AND AIM: The aim of this study was to compare the quality and tolerability of bowel preparation using split high-doses of sennosides versus split-dose polyethylene glycol (PEG). METHODS: In this prospective, randomized, and endoscopist-blinded study, 474 outpatients were included and randomly assigned to two groups: Group 1 was comprised of 237 patients receiving split high-dose (1000 mg) sennoside solutions, and group 2 included 237 patients receiving 4 L of PEG. The efficacy of the preparations was evaluated on the Boston Bowel Preparation Scale (BBPS), and compliance and adverse effects were recorded. RESULTS: The quality of colon cleansing and the ease of bowel preparation were significantly better in the senna group; the mean of total BBPS scores was 7.35 in the senna group and 6.57 in the PEG group, cleansing was adequate (BBPS score ≥ 6) in 89.9% of patients taking senna, and 73.8% in the PEG group (P = 0.001). The rates of vomiting in the senna and PEG groups were 12.7% and 29.5%, nausea rates were 28.7% and 43.9%, and abdominal pain rates were 70.9% and 43%, respectively (P < 0.001). Cecal intubation rates in the senna and PEG groups were 95.4% and 86.1% (P = 0.001), and the cecal intubation times were 6.73 ± 2.84 and 5.34 ± 5.98 min, respectively (P = 0.001). CONCLUSIONS: Split high-dose senna is more effective than split-dose PEG in terms of bowel preparation quality and patient compliance. The patients who received senna had significantly less vomiting and nausea but significantly more abdominal pain. Thus, senna may be used as an alternative to PEG for bowel preparation.

Transcriptomic analysis of enteropathy in Zambian children with severe acute malnutrition.

BACKGROUND: Children with severe acute malnutrition (SAM), with or without diarrhoea, often have enteropathy, but there are few molecular data to guide development of new therapies. We set out to determine whether SAM enteropathy is characterised by specific transcriptional changes which might improve understanding or help identify new treatments. METHODS: We collected intestinal biopsies from children with SAM and persistent diarrhoea. mRNA was extracted from biopsies, sequenced, and subjected to a progressive set of complementary analytical approaches: NOIseq, Gene Set Enrichment Analysis (GSEA), and correlation analysis of phenotypic data with gene expression. FINDINGS: Transcriptomic profiles were generated for biopsy sets from 27 children of both sexes, under 2 years of age, of whom one-third were HIV-infected. NOIseq analysis, constructed from phenotypic group extremes, revealed 66 differentially expressed genes (DEGs) out of 21,386 mapped to the reference genome. These DEGs include genes for mucins and mucus integrity, antimicrobial defence, nutrient absorption, C-X-C chemokines, proteases and anti-proteases. Phenotype - expression correlation analysis identified 1221 genes related to villus height, including increased cell cycling gene expression in more severe enteropathy. Amino acid transporters and ZIP zinc transporters were specifically increased in severe enteropathy, but transcripts for xenobiotic metabolising enzymes were reduced. INTERPRETATION: Transcriptomic analysis of this rare collection of intestinal biopsies identified multiple novel elements of pathology, including specific alterations in nutrient transporters. Changes in xenobiotic metabolism in the gut may alter drug disposition. Both NOIseq and GSEA identified gene clusters similar to those differentially expressed in pediatric Crohn's disease but to a much lesser degree than those identified in coeliac disease. FUND: Bill & Melinda Gates Foundation OPP1066118. The funding agency had no role in study design, data collection, data analysis, interpretation, or writing of the report.

[Analysis of the epidemiological profile of the indigenous community of Hueyapan, Morelos]. / Análisis del perfil epidemiológico de la comunidad indígena de Hueyapan, Morelos.

BACKGROUND: The epidemiological transition is a phenomenon that has had a different impact between urban and rural settings. The WHO points out that the population with the lowest socioeconomic status is the most adversely affected for the unequal distribution of resources, indigenous people are a part of this population. OBJECTIVE: To analyze the epidemiological profile of the indigenous people of Hueyapan, Morelos during the months of March to June 2017. METHODS: A cross-sectional epidemiological study was carried out in the indigenous community of Hueyapan, belonging to the municipality of Morelos, in 2017. A sample of 338 households was calculated; as inclusion criteria, those dwellings where the age of residence in Hueyapan was equal to or greater than four years were taken; a systematic sampling was carried out every three households, in addition, Mexico's INEGI and Health Department databases were analyzed from 2011 to 2015. RESULTS: In relation to morbidity, an upward trend was found in the crude rate, from 119.7 per 1,000 in 2011 to 270.7 per 1000 in 2015, among the most prevalent diseases in those years, infectious diseases were identified as major and the appearance of noncommunicable diseases began to be observed. In relation to mortality, a linear trend was observed in the crude rate of 5.7 per 1000 in 2011 to 6.6 per 1000 in 2015. CONCLUSIONS: The epidemiological profile of Hueyapan coincides with a process of epidemiological transition where there is a double burden of disease. This suggests a challenge for the public health area that should be addressed from the creation of health strategies, programs and policies aimed at this population from an intercultural approach.

INTRODUCCIÓN: la transición epidemiológica es un fenómeno que se ha presentado de forma distinta entre sectores urbanizados y rurales. OBJETIVO: analizar el perfil epidemiológico de la comunidad indígena de Hueyapan, Morelos, durante el periodo de marzo a junio de 2017. MÉTODOS: se realizó un estudio epidemiológico transversal en la comunidad indígena de Hueyapan, perteneciente al municipio de Morelos, en 2017. Se calculó un tamaño de muestra de 338 viviendas; como criterios de inclusión se tomaron aquellas viviendas dónde la edad de residencia en Hueyapan fuera igual o mayor a cuatro años; se realizó un muestreo sistemático cada tres viviendas, además se analizaron bases de datos de INEGI y Secretaría de Salud de 2011 a 2015. RESULTADOS: en relación con la morbilidad, se encontró una tendencia ascendente en la tasa bruta. Dentro de las enfermedades más prevalentes se identificaron las enfermedades infecciosas como principales y se empezó a observar la aparición de enfermedades no transmisibles. En relación con la mortalidad, se observó una tendencia lineal en su tasa bruta. CONCLUSIONES: el perfil epidemiológico de Hueyapan coincide con un proceso de transición epidemiológica, donde existe una doble carga de enfermedad. Esto sugiere un reto para el área de la salud pública que debiera enfrentarse desde la creación de estrategias, programas y políticas de salud dirigidas a esta población desde un enfoque intercultural.

Insulin-like growth factor-1 as a nutritional monitoring factor in patients with chronic intestinal failure.

BACKGROUND & AIMS: Nutritional monitoring plays an important role in optimizing nutritional support in patients with chronic intestinal failure (CIF) receiving long-term supplementation. Unlike initial nutritional assessment, however, there are no recommended guidelines for establishing a nutritional monitoring index. This study is to evaluate the suitability of insulin-like growth factor-1 (IGF-1) as a nutritional monitoring factor in CIF patients. METHODS: We retrospectively analyzed the correlation between serum nutritional indicators, including IGF-1 levels, and nutritional assessment, nutritional monitoring, and lean body mass in 197 patients with CIF. RESULTS: The mean age of the 197 enrolled patients was 47.22 ± 18.87 years old and; the mean BMI was 16.83 ± 3.31. The mean NRS-2002 score was 3.49 ± 0.83; and moreover, 76.3% of the patients were malnourished. The median length of hospital stay in hospital (LOS) was 18.5 days. IGF-1 was positively correlated with body mass index, hemoglobin, albumin, pre-albumin, retinol-binding protein (RBP), transferrin, serum creatinine (Scr) and cholesterol (p < 0.05 for all). Testing performed over 3 weeks post-admission showed that significantly different weekly changes were observed only in IGF-1, RBP, and Scr during the period of nutritional support (p < 0.05 for each). Multivariate linear regression analysis showed that IGF-1 and body mass index were independent factors influencing fat-free mass, skeletal muscle mass, and body protein mass (p < 0.05 for each). CONCLUSIONS: IGF-1 is suitable for monitoring short-term changes in the nutritional status in CIF patients. This may be attributed to its shorter half-life, greater sensitivity, and better correlation with lean body mass. ClinicalTrials.gov number, NCT03277014.

Nutrient intake and environmental enteric dysfunction among Nepalese children 9-24 months old-the MAL-ED birth cohort study.

BACKGROUND: Nutrient deficiencies limit the growth and turnover of intestinal mucosa, but studies assessing whether specific nutrients protect against or improve environmental enteric dysfunction (EED) are scarce. We aimed to investigate associations between nutrient intake and EED assessed by lactulose:mannitol (L:M) ratio, anti-1-antitrypsin, myeloperoxidase (MPO), and neopterin (NEO) among children 9-24 months in Bhaktapur, Nepal. METHODS: Among 231 included children, nutrient intake was assessed monthly by 24 h recalls, and 3-month usual intake was estimated using Multiple Source Method. Associations between nutrient intake and L:M ratio (measured at 15 months) were assessed using multiple linear regression, while associations between nutrient intake and fecal markers (measured quarterly) were assessed using Generalized Estimating Equations (GEE) models. RESULTS: We found that associations between nutrient intake from complementary food and L:M ratio, alpha-1-antitrypsin (AAT), MPO and NEO were generally negative but weak. The only significant associations between nutrient intake (potassium, magnesium, phosphorous, folate, and vitamin C) and markers for intestinal inflammation were found for MPO. CONCLUSION: Negative but weak associations between nutrient intake and markers of intestinal inflammation were found. Significant associations between several nutrients and MPO might merit further investigation.

Nutrition Deficiencies in Children With Intestinal Failure Receiving Chronic Parenteral Nutrition.

BACKGROUND: Home parenteral nutrition (PN) is a lifesaving therapy for children with intestinal failure (IF). Our aims were to describe the prevalence of micronutrient deficiencies (vitamin D, zinc, copper, iron, selenium) in a diverse population of children with IF receiving PN and to identify and characterize risk factors associated with micronutrient deficiencies, including hematologic abnormalities. METHODS: Data were collected on 60 eligible patients through retrospective chart review between May 2012 and February 2015. Descriptive statistics included frequencies, medians, interquartile ranges (IQRs), and odds ratios (ORs). Statistical analyses included χ2 , Fisher's exact, t tests, and logistic, univariate, and multivariate regressions. RESULTS: Patients were primarily young (median age, 3.3 years; IQR, 0.7-8.4), Latino (62%), and male (56%), with short bowel syndrome (70%). Of 60 study patients, 88% had ≥1 deficiency and 90% were anemic for age. Of 51 patients who had all 5 markers checked, 59% had multiple deficiencies (defined as ≥3). Multivariate analysis shows multiple deficiencies were associated with nonwhite race (OR, 9.4; P = .012) and higher body mass index z score (OR, 2.2; P = .016). Children with severe anemia (hemoglobin <8.5 g/dL) made up 50% of the cohort. Nonwhite race (OR, 6.6; P = .037) and zinc deficiency (OR, 11; P = .003) were multivariate predictors of severe anemia. CONCLUSIONS: Micronutrient deficiency and anemia are overwhelmingly prevalent in children with IF using chronic PN. This emphasizes the importance of universal surveillance and supplementation to potentially improve quality of life and developmental outcomes. Future research should investigate how racial disparities might contribute to nutrition outcomes for children using chronic PN.

Environmental Enteric Dysfunction and Growth Failure/Stunting in Global Child Health.

Approximately 25% of the world's children aged <5 years have stunted growth, which is associated with increased mortality, cognitive dysfunction, and loss of productivity. Reducing by 40% the number of stunted children is a global target for 2030. The pathogenesis of stunting is poorly understood. Prenatal and postnatal nutritional deficits and enteric and systemic infections clearly contribute, but recent findings implicate a central role for environmental enteric dysfunction (EED), a generalized disturbance of small intestinal structure and function found at a high prevalence in children living under unsanitary conditions. Mechanisms contributing to growth failure in EED include intestinal leakiness and heightened permeability, gut inflammation, dysbiosis and bacterial translocation, systemic inflammation, and nutrient malabsorption. Because EED has multiple causal pathways, approaches to manage it need to be multifaceted. Potential interventions to tackle EED include: (1) reduction of exposure to feces and contact with animals through programs such as improved water, sanitation, and hygiene; (2) breastfeeding and enhanced dietary diversity; (3) probiotics and prebiotics; (4) nutrient supplements, including zinc, polyunsaturated fatty acids, and amino acids; (5) antiinflammatory agents such as 5-aminosalicyclic acid; and (6) antibiotics in the context of acute malnutrition and infection. Better understanding of the underlying causes of EED and development of noninvasive, practical, simple, and affordable point-of-care diagnostic tools remain key gaps. "Omics" technologies (genomics, epigenomics, transcriptomics, proteomics, and metabolomics) and stable isotope techniques (eg, 13C breath tests) targeted at children and their intestinal microbiota will enhance our ability to successfully identify, manage, and prevent this disorder.

Predictors of failure of fish-oil therapy for intestinal failure-associated liver disease in children.

BACKGROUND: Parenteral fish-oil (FO) therapy is a safe and effective treatment for intestinal failure-associated liver disease (IFALD). Patients whose cholestasis does not resolve with FO may progress to end-stage liver disease. OBJECTIVE: We sought to identify factors associated with the failure of FO therapy in treating IFALD to guide prognostication and referral guidelines. DESIGN: Prospectively collected data for patients treated with FO at Boston Children's Hospital from 2004 to 2014 were retrospectively reviewed. Resolution of cholestasis was defined as sustained direct bilirubin (DB) <2 mg/dL, and treatment failure as liver transplantation or death while DB was >2 mg/dL as of July 2015. Demographics, laboratory values, and medical history at FO therapy initiation were compared between patients who achieved resolution of cholestasis and those who failed therapy. RESULTS: Among 182 patients treated with FO, 86% achieved resolution of cholestasis and 14% failed therapy. Patients who failed therapy had median (IQR) lower birth weight [1020 g (737, 1776 g) compared with 1608 g (815, 2438 g); P = 0.03] and were older at FO initiation [20.4 wk (9.9, 38.6 wk) compared with 11.7 wk (7.3, 21.4 wk); P = 0.02] than patients whose cholestasis resolved. Patients who failed therapy had more advanced liver disease at therapy initiation than patients whose cholestasis resolved, as evidenced by lower median (IQR) γ-glutamyltransferase [54 U/L (41, 103 U/L) compared with 112 U/L (76, 168 U/L); P < 0.001], higher DB [10.4 mg/dL (7.5, 14.1 mg/dL) compared with 4.4 mg/dL (3.1, 6.6 mg/dL); P < 0.001], and a higher pediatric end-stage liver disease (PELD) score [22 (14, 25) compared with 12 (7, 15); P < 0.001]. A PELD score of ≥15, history of gastrointestinal bleeding, age at FO initiation ≥16 wk, presence of nongastrointestinal comorbidities, and mechanical ventilation at FO initiation were independent predictors of treatment failure. CONCLUSIONS: Most infants with IFALD responded to FO therapy with resolution of cholestasis, and liver transplantation was rarely required. Early FO initiation once biochemical cholestasis is detected in parenteral nutrition-dependent patients is recommended. This trial was registered at clinicaltrials.gov as NCT00910104.

Environmental enteric dysfunction: an overview.

BACKGROUND: Environmental enteric dysfunction (EED) refers to an incompletely defined syndrome of inflammation, reduced absorptive capacity, and reduced barrier function in the small intestine. It is widespread among children and adults in low- and middle-income countries. Understanding of EED and its possible consequences for health is currently limited. OBJECTIVE: A narrative review of the current understanding of EED: epidemiology, pathogenesis, therapies, and relevance to child health. METHODS: Searches for key papers and ongoing trials were conducted using PUBMED 1966-June 2014; ClinicalTrials.gov; the WHO Clinical Trials Registry; the Cochrane Library; hand searches of the references of retrieved literature; discussions with experts; and personal experience from the field. RESULTS: EED is established during infancy and is associated with poor sanitation, certain gut infections, and micronutrient deficiencies. Helicobacter pylori infection, small intestinal bacterial overgrowth (SIBO), abnormal gut microbiota, undernutrition, and toxins may all play a role. EED is usually asymptomatic, but it is important due to its association with stunting. Diagnosis is frequently by the dual sugar absorption test, although other biomarkers are emerging. EED may partly explain the reduced efficacy of oral vaccines in low- and middle-income countries and the increased risk of serious infection seen in children with undernutrition. CONCLUSIONS: Despite its potentially significant impacts, it is currently unclear exactly what causes EED and how it can be treated or prevented. Ongoing trials involve nutritional supplements, water and sanitation interventions, and immunomodulators. Further research is needed to better understand this condition, which is of likely crucial importance for child health and development in low- and middle-income settings.

Nutrición e inversión en salud: microbioma y probióticos (los probióticos en la prevención y el tratamiento de enfermedades pediátricas; evidencias científicas) / Nutrition and investment: microbiome and probiotics (probiotics in prevention and treatment of pediatric conditions; scientific evidence)

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Methods used to eliminate colic in infants in the eastern parts of Turkey.

OBJECTIVE: Infant colic is a common problem characterized by excessive crying and fussing. There is not a consistent treatment method used to eliminate colic. Mothers make use of various models together to eliminate colic in their infants. This study was carried out to delineate the methods used by mothers to eliminate colic in their infants and to determine the efficacy of the various methods. DESIGN: Descriptive study. METHODS: The study was performed by visiting the homes of 186 babies (1-3 months of age) whose mothers had previously registered at a health center in Eastern Turkey between January 1 and February 28, 2005. Questionnaires and Wessel's criteria were used to obtain the data. The methods used by mothers to eliminate colic were classified as behavioral, natural, and drug treatments and were examined accordingly. RESULTS: According to mothers' statements, 75.8% of the babies had colic, while according to the Wessel criteria, 51.1% had colic symptoms. One hundred percent of the mothers used behavioral treatments, 66% used drug therapies, and 64.5% used natural treatment methods to eliminate colic. CONCLUSIONS: Mothers indicated that they achieved the most benefit from behavioral interventions, followed by natural therapies, and the least from drug treatments.

Allergic proctitis and abdominal distention mimicking Hirschsprung's disease in infants.

AIM: To determine the incidence and clinical aspects of allergic proctitis (AP) in infants with symptoms that mimic Hirschsprung's disease (HD). METHODS: One hundred and five patients less than 6 months of age, who underwent barium enema, anorectal manometry and rectal suction biopsy due to suspicion of HD, were enrolled. Comparison of the patient characteristics associated with each disease was based on the results of the triple testing. The sensitivity and specificity of the three tests, for the diagnosis of HD, were evaluated. RESULTS: The mean age of enrolled patients was 2.1+/-0.9 months. Based on the three tests, 39 patients (37.1%) were diagnosed with HD, seven patients (6.7%) with AP, and 53 (50.5%) had normal results. Of the 54 patients with transitional zone and a reversed rectosigmoid index on the barium enema, four (7.4%) were patients with AP. The mean age of the AP patients (3.1+/-1.5 months old) was older than the HD children (1.4+/-0.9 months old). The sensitivity of the three tests for HD was 97.4%, 87.2% and 92.3% and the specificity was: 74.2%, 78.8% and 100%, respectively. CONCLUSIONS: In the infants with severe abdominal distention, the incidence of AP mimicking HD was relatively high. Therefore, consideration of AP should be part of the differential diagnosis in infants with severe abdominal distention or findings that mimic HD. For differentiation of these disorders, a rectal suction biopsy is very useful.

Acaroid mite, intestinal and urinary acariasis.

AIM: To investigate epidemiology and pathogenic mite species of intestinal and urinary acariasis in individuals with different occupations. METHODS: A total of 1994 individuals were tested in this study. History collection, skin prick test and pathogen identification were conducted. The mites were isolated from stool and urine samples by saturated saline flotation methods and sieving following centrifugation, respectively. RESULTS: Among the 1994 individuals examined, responses to the skin prick test of "+++", "++", "+","+/-" and "-" were observed at frequencies of 3.96 % (79), 3.21 % (64), 2.31 % (46), 1.25 % (25) and 89.27 % (1780), respectively. A total number of 161 (8.07 %) individuals were shown to carry mites, with 92 (4.61 %) positive only for stool samples, 37 (1.86 %) positive only for urine samples and 32 (1.60 %) for both. The positive rate of mites in stool samples was 6.22 % (124/1994), being 6.84 % (78/1140) for males and 5.39 % (46/854) for females. No gender difference was observed in this study (chi(2)=1.77, P>0.05). The mites from stool samples included Acarus siro, TyroPhagus putrescentiae, Dermatophagoides farinae, D. pteronyssinus, Glycyphagus domesticus, G. ornatus, Carpoglyphus lactis and Tarsonemus granaries. The positive rate of mites in urine samples was 3.46 % (69/1994). The positive rates for male and female subjects were found to be 3.95 % (45/1140) and 2.81 % (24/854) respectively, with no gender difference observed (chi(2)=1.89, P>0.05). Mites species in urine samples included Acarus siro, Tyrophagus putrescentiae, T. longior, Aleuroglyphus ovatus, Caloglyphus berlesei, C. mycophagus, Suidasia nesbitti, Lardoglyphus konoi, Glycyphagus domesticus, Carpoglyphus lactis, Lepidoglyphus destructor, Dermatophagoides farinae, D. pteronyssinus, Euroglyphus magnei, Caloglyphus hughesi, Tarsonemus granarus and T. hominis. The species of mites in stool and urine samples were consistent with those separated from working environment. A significant difference was found among the frequencies of mite infection in individuals with different occupations (chi(2)=82.55, P<0.001), with its frequencies in those working in medicinal herb storehouses, those in rice storehouse or mills, miners, railway workers, pupils and teachers being 15.89 % (68/428), 12.96 % (53/409), 3.28 % (18/549), 2.54 % (6/236), 5.10 % (13/255) and 2.56 % (3/117), respectively. CONCLUSION: The prevalence of human intestinal and urinary acariasis was not associated with gender, and these diseases are more frequently found in individuals working in medicinal herb, rice storehouses or mills and other sites with high density of mites. More attention should be paid to the mite prevention and labor protection for these high-risk groups.

Fungal colonization and invasive fungal infections following allogeneic BMT using metronidazole, ciprofloxacin and fluconazole or ciprofloxacin and fluconazole as intestinal decontamination.

Invasive fungal infections (IFI) are increasingly diagnosed in patients undergoing allogeneic BMT. We have previously shown that the addition of metronidazole to ciprofloxacin for gastrointestinal bacterial decontamination significantly reduces the incidence of grades II-IV aGVHD by reduction of the anaerobic intestinal bacterial flora. Here, we found that the combined use of ciprofloxacin, metronidazole and fluconazole as antifungal prophylaxis increased intestinal yeast colonization when compared to ciprofloxacin and fluconazole alone (P < 0.01). Based on the EORTC criteria, a total of 18 out of 134 study patients developed IFI: seven of 68 (10%) patients who received metronidazole compared to 11 of the 66 (17%) patients decontaminated without metronidazole developed IFI (log-rank P = 0.36). Lethal IFI occurred in two of seven patients receiving metronidazole and in four of 11 patients without anaerobic decontamination. In conclusion, bacterial intestinal decontamination using metronidazole as an antibiotic with activity against most anaerobic intestinal bacteria significantly increases the intestinal yeast burden without influencing the incidence of IFI in patients undergoing allogeneic BMT.

Anaemia in pregnancy: possible causes and risk factors in Nepali women.

OBJECTIVE: The aim of this study was to investigate the importance of nutritional deficiencies and infections in the development of anaemia in pregnant Nepali women. DESIGN: Case-control study. SETTING: Patan Hospital, Kathmandu, Nepal. SUBJECTS: A sub-sample (n=479) of all pregnant women (n=2856) coming for their first antenatal visit in a 12 month period, 1994-1995. Women who had already received any micronutrient supplementation (n=82), and those whose serum samples showed macroscopic haemolysis (n=7) were excluded. The remaining women (n=390) were included in the statistical analysis. They were divided into three groups; a non-anaemic control group, haematocrit (Hct)>33% (n=82), and two case-groups: moderately anaemic, Hct 25-33% (n=254), and severely anaemic, Hct<25% (n=54). RESULTS: We found high prevalences of nutritional deficiencies and intestinal infections, both among cases and controls. The prevalence of low s-ferritin was high, especially among the severely anaemic women (55.6%). In a multiple logistic regression model, the presence of low s-vitamin A, elevated s-C-reactive protein or hookworm infection was associated with a significantly increased risk of severe anaemia. The adjusted odds ratios (95% CI) were 8.38 (1.99, 35.30), 4.91 (1.22, 19.67) and 5.43 (1.20, 24.61), respectively. CONCLUSIONS: In addition to the present routine iron and folate supplementation to pregnant Nepali women, vitamin A supplementation needs to be considered. Prevention and treatment of infections should, together with dietary advice, be emphasized more strongly in the antenatal care. SPONSORSHIP: The Norwegian Research Council and the Norwegian Universities Committee for Development, Research and Education. European Journal of Clinical Nutrition (2000) 54, 3-8

Infantile colic and small intestinal function: a nutritional problem?

Approximately 25% of infants with moderate or severe colic (crying > 3 h d(-1)) have a cow's milk-dependent colic. The author recommends a strict cow's milk-free diet for the mother (with an extra supplement of calcium) in breastfed infants and a casein-hydrolysate formula for formula-fed infants. With this dietary regimen, there will be no nutritional problems. Later in infancy a relatively high proportion of the infants will continue to show an adverse reaction to cow's milk and will also develop allergies to other foods. Several signs (e.g. increased macromolecular absorption, increased motilin levels in serum, increased breath hydrogen excretion, decreased gallbladder contractility) indicate an abnormal intestinal function in colicky infants. The nature of this abnormality is still unknown.

The moderate intestinal side effects of auranofin do not require prophylactic therapy with a bulkforming agent. Dutch Ridaura Study Group.

Incidences of diarrhoea and loose stools are reported up to 50% in patients starting treatment with auranofin. Moreover, +/-4% of patients discontinue treatment because of severe diarrhoea. We investigated whether a water binding agent would diminish the incidence of loose stools and diarrhoea. Endpoints were the patient's general impression of the quality of stools and a daily assessment of stool's frequency/consistency and adverse events. Secondly, some disease activity parameters were used to evaluate whether the bulkforming agent influences the efficacy of auranofin. In this study 269 patients suffering from Rheumatoid Arthritis (RA) were treated with auranofin 6 mgr daily for a period of six months. Simultaneously the patients were randomly treated with either a bulkforming agent (Volcolon: psyllium fibres) or placebo. Results show a 15% incidence of loose stools and diarrhoea during treatment with auranofin. During the treatment period the patients' general impression of defecation consistency showed a shift to softer types. The changes in defecation consistency was not significantly different between groups (Intention-to-treat analysis: C2=4.01; p=0.13). Also, the percentage of patients experiencing episodes of diarrhoea (reported as an adverse experience) was not different (14% of the patients treated with bulkformer versus 15% with placebo). During the first month 7% (n=5) of placebo treated patients reported short episodes of watery stools versus none in the bulkformer treated group. The percentage of days with loose or watery stools, reported on the diary cards, was consistently lower in bulkformer treated patients. Both groups improved equally with respect to disease activity parameters. Sixty-eight percent of patients continued auranofin treatment after the study period. In conclusion, these data do not support adjuvant therapy with a bulkforming agent on initiation of auranofin therapy. The overall low incidence of loose stools and diarrhoea suggests that a dose increase to 9 mgr daily is an option to enhance the efficacy of auranofin treatment.

Postoperative recurrence in patients with intestinal Behçet's disease.

PURPOSE: The postoperative course of intestinal Behçet's disease was studied in nine patients who had undergone a total of 15 operations due to intestinal ulcers. METHODS: These patients were followed up for an average of 6.0 years (range, 1 year, 3 months to 13 years, 10 months) after each operation and they were repeatedly examined by double-contrast radiography and/or colonofiberscopy. RESULTS: Recurrence of intestinal ulcers was observed in 12 (80 percent) of the 15 surgical cases. The incidence (50 percent) of postoperative recurrence in six cases in which intraoperative endoscopy revealed no abnormality in the retained intestine was lower than that (100 percent) in nine cases without this examination. Recurrent intestinal lesions in most cases were demonstrated as multiple aphthoid ulcers in the ileum near the ileocolectomy, or as one or two deep ulcers at the ileocolectomy site. The recurrent ulcers were successfully treated by various medical therapies, but the effectiveness of these therapies was only temporary. CONCLUSION: In the case of this disease, intraoperative endoscopy may be useful for preventing postoperative recurrence and periodic follow-up examination with radiography and endoscopy should be performed, even after surgery.