Systematic review: medical and nutritional interventions for the management of intestinal failure and its resultant complications in children.

BACKGROUND: Intestinal failure (IF) affects a growing number of children due to increasing numbers of preterm infants surviving intestinal resection for necrotising enterocolitis and improving surgical techniques for congenital gut anomalies. Parenteral nutrition (PN) is the mainstay of therapy; enteral nutrition may have trophic effects on the gut. AIM: To review systematically evidence for the effectiveness of medical and nutritional interventions in the treatment of IF in children. METHODS: Retrieval of data from studies of patients aged <18 years and receiving >28 days of PN. Outcome measures were improvement in intestinal function, intestinal adaptation, growth, prevention and treatment of IF-associated liver disease, and mortality. Cochrane Database (November 2009), MEDLINE (1950-November 2009) and CINAHL (1982-November 2009) electronic database searches were made using keyword and subject headings (MeSH): IF, Short Bowel Syndrome (SBS), PN and Child. The level of the evidence (EL) was assessed using SIGN (Scottish Intercollegiate Guidelines Network) methodology (http://www.sign.ac.uk). RESULTS: From 1 607 620 hits, 720 abstracts were reviewed. Thirty-three original articles were included. No studies were of high methodological quality. CONCLUSIONS: The evidence base for medical and nutritional interventions in paediatric IF is limited and of poor quality. In the absence of randomised-controlled trials, this evidence base can improve through case control and cohort research; and with better multiagency communication, the study of inter-centre differences is possible. Achievable short-term goals would include the study of: optimal ursodeoxycholic usage, novel intralipid formulations, cycled enteral antibiotics, enteral probiotics and new enteral feeding strategies.

Transgenic Leishmania and the immune response to infection.

Genetic manipulation of single-celled organisms such as the Leishmania parasite enables in depth analysis of the consequences of genotypic change on biological function. In probing the immune responses to infection, use of transgenic Leishmania has the potential to unravel both the contribution of the parasite to the infection process and the cellular interactions and mechanisms that characterize the innate and adaptive immune responses of the host. Here, we briefly review recent technical advances in parasite genetics and explore how these methods are being used to investigate parasite virulence factors, elucidate immune regulatory mechanisms and contribute to the development of novel therapeutics for the leishmaniases. Recent developments in imaging technology, such as bioluminescence and intravital imaging, combined with parasite transfection with fluorescent or enzyme-encoding marker genes, provides a rich opportunity for novel assessment of intimate, real-time host-parasite interactions at a previously unexplored level. Further advances in transgenic technology, such as the introduction of robust inducible gene cassettes for expression in intracellular parasite stages or the development of RNA interference methods for down-regulation of parasite gene expression in the host, will further advance our ability to probe host-parasite interactions and unravel disease-promoting mechanisms in the leishmaniases.

Pathways of neonatal stroke and subclavian steal syndrome.

Neonatal stroke may occur silently. Identification of potential embolic pathways unique to the neonate is important when investigating the aetiology of infarction and arterial occlusion, and preventing further episodes. This is a case report of an infant with venous thrombus embolising across the foramen ovale causing cerebral infarction and subclavian artery steal syndrome, without neurological signs.

Temporal changes in reproductive hormones and conceptus-endometrial interactions during embryonic diapause and reactivation of the blastocyst in European roe deer (Capreolus capreolus).

The roe deer blastocyst is in diapause between August and December, after which time it expands and elongates rapidly before implantation. Blood samples were taken from 30 animals to define temporal changes in reproductively important hormones to investigate the physiological cues present at embryo reactivation. In 15 of these animals, changes in uterine and conceptus protein synthesis and secretion, and luteal progesterone release during diapause and reactivation, were assessed after culture of these tissues in vitro. Oestradiol concentrations remained low during diapause (1.07 +/- 0.4 pg ml(-1)) and expansion (1.2 +/- 0.4 pg ml(-1)) but increased by 30 times at trophoblast elongation (49.17 +/- 0.37 pg ml(-1)). Prolactin remained at basal concentrations (4.69 +/- 0.86 ng ml(-1)) and increased after implantation (12.34 +/- 2.71 ng ml(-1)). Peripheral progesterone concentrations and luteal progesterone release remained constant throughout diapause, reactivation and implantation (peripheral progesterone: 3.82 +/- 1.97 ng ml(-1); luteal progesterone: 6.72 +/- 0.81 ng mg(-1) protein). Incorporation of a radiolabel into conceptus secretory proteins increased by four times at expansion compared with diapause, whereas incorporation into endometrial secretions remained constant. At elongation, incorporation into endometrial secretions increased two times and conceptus secretions increased 32 times. Two-dimensional electrophoresis and fluorography showed that the profile of endometrial secretory proteins was constant until implantation when qualitative changes were evident. Although a role for an endocrine maternal trigger of reactivation from diapause cannot be dismissed, these data provide no supporting evidence and indicate that the conceptus itself may drive reactivation.

Hospital consolidation. Applying stakeholder analysis to merger life-cycle.

Nearly three of every five hospitals in the United States have been involved in some form of consolidation during the past 5 years. Within this turbulent hospital merger environment, nurse executives are confronted with organizational, professional, and personal decisions. Stakeholder analysis is offered as one strategy to facilitate effectiveness throughout the hospitals' merger life-cycle.

Effects of pre- and post-mating feed intake on blastocyst size, secretory function and glucose metabolism in meishan gilts.

This experiment was designed to determine the effects of a nutritional regime, known to increase embryo survival, on blastocyst development and function. Day 12 blastocysts were recovered from Meishan gilts allocated in a 2x2 factorial design to receive either a high or a maintenance diet before or after mating (n = 4-6 gilts per group). The post-mating diet had no effect on individual blastocyst size, cell number, secretion of oestradiol-17beta or retinol binding protein, glucose metabolism or on the within-litter variability in these measures. Blastocysts recovered from gilts consuming the high pre-mating diet had more cells (13.501 v. 13.006 log cells; SED = 0.23; P = 0.05), greater production of CO2 from glucose (2.19 v. 1.23 log pmol(-1) blastocyst(-1) 3 h(-1), SED = 0.42; P = 0.05) and a lower within-litter standard deviation in blastocyst surface area (0.66 v. 1.18 log mm2, SED = 0.24; P = 0.04) compared with gilts fed the maintenance pre-mating diet. Collectively, these data suggest that a nutritional strategy that increases embryo survival is also associated with an increase in individual blastocyst cell number and reduced within-litter variability in blastocyst size.

Effects of pre- and post-mating nutritional status on hepatic function, progesterone concentration, uterine protein secretion and embryo survival in Meishan pigs.

This experiment examined whether the pre- or the post-mating diet had greater impact on embryo survival in Meishan gilts. Gilts received either a maintenance (1.15 kg day(-1); n = 12) or a high (3.5 kg day(-1); n = 12) diet during the oestrous cycle preceding mating. After mating, half the animals in each group received either the maintenance or the high diet until slaughter on Day 12. Gilts fed the high pre-mating diet had more corpora lutea (22.7 v. 19.0, SED = 0.98; P<0.001), increased embryo survival (95.5% v. 74.8%, SED = 7.58; P<0.01) and heavier corpora lutea (-0.71 log g v. -0.90 log g, SED = 0.09; P = 0.07) compared with gilts fed the maintenance diet prior to mating. The post-mating diet had no effect on embryo survival. There were no treatment effects on blastocyst developmental stage, luteal surface area or progesterone release. Gilts receiving the high post-mating diet had heavier livers than those fed the maintenance post-mating diet (1.45 v 1.08% of total bodyweight, SED = 0.07; P<0.001), suggesting that these gilts have a greater capacity to metabolize progesterone. Pre-mating nutritional status therefore appears to be a greater determinant of embryo numbers and survival than the post-mating diet.

The quality of psychiatric nurses' interactions with patients: an observational study.

The behaviour of nursing staff in each ward of a psychiatric hospital was observed at 5-min intervals for between 7 and 10 h per day for 10 days. The nurses' behaviour was equally divided between interacting with patients, interacting with staff, solitary task oriented behaviour and other behaviours. There was less staff-patient interaction in the acute ward than in the long-term and psychogeriatric wards and senior nurses interacted less with patients and engaged in more solitary task oriented behaviour. Of the interactions with patients, almost 25% were rated as positive and only 0.3% negative. In the long-term wards almost 47% of the interactions were positive.

Localization of HIV RNA in mitochondria of infected cells: potential role in cytopathogenicity.

The intracellular distribution of HIV-1 RNA transcripts in infected cells was studied using in situ hybridization detected by electron microscopy and cellular fractionation. Although viral RNA and core protein could be detected throughout the cytoplasm and nucleus, viral RNA was found in significantly increased amounts in mitochondria relative to the cytoplasm and nucleus. In contrast, cellular poly(A) RNA or viral gag proteins were not increased in the mitochondria. A cell line containing an integrated latent genome that could be induced to express viral RNA after phorbol ester stimulation showed an increase in viral RNA accumulation in mitochondria parallel with the increase in HIV expression levels. Concomitant with HIV expression, there was a decrease in mitochondrial viability. Using immunofluorescent markers to detect probes to HIV RNA transcripts and antibodies to mitochondrial proteins simultaneously in single cells, there was an inverse relationship between the amount of viral RNA and mitochondrial integrity. High levels of viral RNA in mitochondria were found in acutely (but not chronically) infected cells. We propose that HIV RNA import into mitochondria can compromise mitochondrial function.

Inherited platelet-storage pool deficiency associated with a high incidence of acute myeloid leukaemia.

A family with an inherited bleeding disorder extending over four generations, and multiple cases of myeloblastic and myelomonoblastic leukaemia was studied. Ten members of the family had, by history, a haemorrhagic diathesis. There were three documented cases of myeloblastic leukaemia, two documented cases of myelomonoblastic leukaemia and two more cases of leukaemia by history. In four of the cases the bleeding diathesis clearly antedated the leukaemia, in two by many years. The bleeding disorder is characterized by a long bleeding time, abnormal platelet aggregation, low platelet ADP and decreased numbers of platelet dense bodies consistent with a dense granule storage pool deficiency. The number of dense granules was decreased by immunofluorescence employing quinacrine or using an antibody to the dense granule membrane protein, granulophysin, confirming an absolute decrease in dense granule numbers rather than the presence of empty granule sacs. This congenital storage pool deficiency is associated with a high incidence of acute myeloid leukaemia in this family.

Inhibition of antigen-induced airway hyperresponsiveness, but not acute hypoxia nor airway eosinophilia, by an antagonist of platelet-activating factor.

The role of platelet-activating factor (PAF) in Ag-induced airway hyperresponsiveness was evaluated in a guinea pig model using the PAF antagonist SDZ 64-412. Repeated OVA challenge by aerosol (twice weekly x 4 wk) of previously sensitized guinea pigs produced striking airway hyperresponsiveness as determined by pulmonary resistance changes to increasing doses of inhaled acetylcholine given 3 days after the last OVA challenge. Each OVA challenge produced significant hypoxia that was unaffected by oral pretreatment with 20 mg/kg SDZ 64-412, 2 h before each challenge (pO2 = 35 +/- 2 mm Hg for OVA alone vs 40 +/- 6 mm Hg for SDZ and OVA groups, respectively). SDZ 64-412 pretreatment abolished the airway hyperresponsiveness resulting from repeated Ag challenge. Morphometric analysis revealed that SDZ 64-412 treatment had no effect on the increased numbers of eosinophils that infiltrated the airways of OVA-challenged guinea pigs. These results suggest that PAF may be a primary mediator of airway hyperresponsiveness, but not acute bronchoconstriction, induced by repeated Ag challenge. This activity of PAF appears independent of eosinophil recruitment to airways.

A role for protein kinase C in the membrane fusion necessary for platelet granule secretion.

The addition of 1-oleoyl-2-acetylglycerol (OAG), or phorbol-12-myristate-13-acetate (PMA) to platelets induced the phosphorylation of a 47,000 dalton protein (47 Kd), fusion of granule membranes with membranes of the surface connected canalicular system, the formation of large vesicles and the secretion of serotonin. 1-(5-isoquinolinesulfonyl)-2-methyl-piperazine (H7), and sphingosine, inhibitors of protein kinase C, significantly inhibited the ultrastructural changes and the phosphorylation of 47 Kd. N-(2-guanidinoethyl)-5-isoquinolinesulfonamide (HA1004), structurally similar to H7, but a weaker inhibitor of protein kinase C, did not attenuate these responses to OAG or to PMA. H7, but not HA1004, also markedly inhibited secretion induced by the synergistic combination of OAG and the calcium ionophore A23187. Amiloride and 5-(N,N dimethyl)-amiloride, inhibitors of the Na+/H+ transporter, did not inhibit the ultrastructural response and the protein phosphorylation induced by OAG, or the secretion induced by the combination of A23187 and OAG. The results link the activation of protein kinase C by diglycerides to the labilization and fusion of granule membranes important for secretion.

Repeated antigen challenge induces airway hyperresponsiveness with tissue eosinophilia in guinea pigs.

To test the hypothesis that the development of airway hyperresponsiveness (AHR) lasting greater than or equal to 3 days after the last antigenic exposure required repeated mediator release, we compared dose-response changes in lung resistance (RL) to acetylcholine (ACh) in animals sensitized with 1% ovalbumin (OA), 4% Bordatella pertussis aerosol and subsequently challenged with 0.5% OA aerosol twice weekly for 4-6 wk vs. animals receiving saline aerosol instead of OA. Despite antihistamine pretreatment, each OA challenge produced cyanosis and inspiratory indrawing. Blood gas analysis in six guinea pigs revealed an immediate fall in arterial PO2 (PaO2) from 104.3 +/- 4.9 to 35.4 +/- 2.2 Torr after a 1-min exposure to aerosolized OA. ACh dose-response measurements of RL 3 days after the last OA challenge demonstrated a leftward shift and an increased magnitude of response. These differences were less marked at 7 days, and by 14 days after the last OA challenge, ACh dose-response curves were not different from those of control guinea pigs. Sensitization without repeated antigen challenge did not cause hyperresponsiveness. Morphometric analysis showed significantly increased numbers of eosinophils in the epithelium of airways in hyperresponsive guinea pigs, without neutrophil infiltration or alterations in epithelium and airway wall areas. We conclude that repeated antigenic challenge, but not sensitization alone, causes prolonged AHR in guinea pigs, which is associated with tissue eosinophilia.

Probability of transition into cell cycle does not depend on growth factor concentration.

When quiescent cells in monolayer culture are stimulated to proliferate with growth factor, the entry into S-phase or mitosis appears to follow first-order kinetics, with a probability to enter the cell cycle that depends on growth factor concentration (Smith and Martin, 1973). Suboptimal growth factor concentrations also lead to a decreased fraction of the cell population that responds to the stimulation (Brooks et al., 1984). Using flow cytometry, we have re-investigated this dual effect of growth factor concentration on cultures of quiescent normal human skin fibroblasts, stimulated with submaximal concentrations of fetal calf serum, epidermal growth factor, and platelet-derived growth factor. The size of the responding population decreased with decreasing concentration of growth factor, but the time course of cell division within this responding population was identical for all growth factor concentrations. This is in conflict with previous concepts and indicates that the entry into the proliferative state is based on a decision mechanism that cannot be adequately described using transition probabilities determined by mitogen concentration.

The influence of lysophosphatidic acid on platelet protein phosphorylation.

Lysophosphatidic acid (LPA) is a lysophospholipid that is produced during thrombin stimulation of platelets, which can promote platelet aggregation. The mechanism of the effect of LPA was explored in normal platelets and in platelets from a patient with a storage pool deficiency (SPD). A comparison with other lysophospholipids showed that only LPA exerted significant effects to cause or potentiate platelet aggregation. Aspirin, an inhibitor of prostaglandin endoperoxide synthetase, had little effect on LPA-induced aggregation, but completely blocked LPA-induced serotonin secretion. LPA also promoted phosphorylation of myosin light chain (MLC), a 47 kilodalton (kDa) protein, and actin-binding protein. Aspirin significantly inhibited the phosphorylation of the 47-kDa and actin-binding proteins at 3-8 min after the addition of LPA, but had no effect on protein phosphorylation within the 1st min and had no significant effect on MLC phosphorylation. In SPD platelets, aspirin partially inhibited both aggregation and phosphorylation of the 47-kDa protein (less than 30% inhibition) and MLC (less than 40% inhibition) at time points of 1 min or less. The addition of ADP to SPD platelets enhanced the LPA response in platelets either pretreated or not pretreated with aspirin. Studies with SPD platelets indicate that thromboxane and secreted ADP contribute to, but are not necessary for, LPA-induced aggregation and phosphorylation. A23187 (a calcium ionophore) and LPA showed some selectivity to promote MLC as opposed to the 47-kDa protein phosphorylation, particularly at low concentrations of agonists and at earlier time points. The protein phosphorylation changes seen are consistent with a role for MLC phosphorylation in the granule centralization promoted with LPA.

Stimulation of the basal nucleus of Meynert in senile dementia of Alzheimer's type. A preliminary report.

The basal nuclei of Meynert are the principal sources of cholinergic innervation of the cerebral cortex. It has been hypothesized that the depressed cortical glucose metabolic activity in senile dementia of Alzheimer's type (SDAT) may result primarily from diminished activity and loss of these cells. The present study was designed to test the hypothesis that electrical stimulation of the basal nuclei would bring about clinical improvement and increase cortical glucose metabolic activity in SDAT. An electrode was implanted in September 1984 into the left basal nucleus of a 74-year-old man with SDAT. Repetitive cycles of stimulation for 9 months since have had no definite effect clinically but a follow-up positron emission tomography scan shows that cortical glucose metabolic activity was preserved in the ipsilateral temporal and parietal lobes while it declined elsewhere in the cortex.