Anti-tuberculous therapy for maintaining remission of Crohn's disease.

OBJECTIVES: To evaluate the effects of anti-tuberculous therapy for the maintenance of remission in patients with Crohn's disease. SEARCH STRATEGY: We searched the Inflammatory Bowel Disease Trials Register, the Cochrane Controlled Trials Register and MEDLINE from 1966 to 1998 (supplemented by a manual search of Index Medicus from 1966 to 1994). We also searched for abstracts in Gut, Gastroenterology, and The American Journal of Gastroenterology from 1990 to 1996. Date of most recent search: August 1998. SELECTION CRITERIA: Randomized trials of anti-tuberculous therapy in patients with Crohn's disease. DATA COLLECTION AND ANALYSIS: Data on the number of patients maintaining remission for each treatment group were abstracted. These data were pooled to yield Mantel-Haenszel odds ratios and numbers needed to treat for maintenance of remission in treated versus control groups. MAIN RESULTS: A total of seven randomized trials which included 355 patients were identified. Two trials used anti-tuberculous therapy (clofazimine or clofazimine, rafmpin, ethambutol, and dapsone) in combination with corticosteroids to induce remission. Maintenance therapy consisted of the anti-tuberculous agents without corticosteroids. Control patients received corticosteroids to induce remission but no anti-tuberculous therapy. The analysis of all seven trials yielded an odds ratio for maintenance of remission of 1.36 (95% CI 0.87-2. 13). Removing the two studies that were published as abstracts did not significantly affect this result: the pooled odds ratio was 1.14 (95% CI 0.71-1.83). The two trials reported as abstracts were excluded from subgroup analyses because they did not include any information on adjunct therapy. Subgroup analysis of the two trials which used steroids to induce remission yielded an odds ratio for maintenance of remission of 3.37 (95% CI 1.38-8.24). The number needed to treat was three. However, these two trials included only 89 patients, and the results should be interpreted with caution. The remaining three trials compared the combination of anti-tuberculous therapy and 'standard therapy' with 'standard therapy alone'. The pooled odds ratio was 0.70 (95% CI 0.39-1.25). REVIEWER'S CONCLUSIONS: Anti-tuberculous therapy may be effective in maintaining remission in patients with Crohn's disease when remission has been induced with corticosteroids combined with anti-tuberculous therapy. However, the results which support this conclusion come from a subgroup of only two trials with small numbers of patients and should be interpreted with caution. Use of this therapy cannot be recommended on the basis of this evidence.

A meta-analysis of antimycobacterial therapy for Crohn's disease.

OBJECTIVE: Various therapies have been studied for the treatment of Crohn's disease, including antimycobacterial therapy. Meta-analysis was used to evaluate the effect of antimycobacterial therapy in patients with Crohn's disease. METHODS: Randomized, controlled trials comparing antimycobacterial therapy with placebo were identified. Key outcome data were abstracted and the results were pooled to yield odds ratios for maintenance of remission in treated versus control groups. RESULTS: A total of eight randomized trials were identified. Six trials were fully published and were included in the primary analysis. Two trials used antimycobacterial therapy in combination with corticosteroids to induce remission in patients with active Crohn's disease, followed by maintenance therapy with antimycobacterial agents. In these trials, control patients received corticosteroids to induce remission but no antimycobacterial therapy. Pooling of these trials yielded an odds ratio of maintenance of remission in treatment versus control of 3.37 (95% confidence interval [CI], 1.38-8.24) in favor of antimycobacterial therapy. The remaining four trials used antimycobacterial therapy combined with standard therapy in patients with Crohn's disease. In these trials, control patients received standard therapy alone. Pooling of these trials yielded an odds ratio of maintenance of remission in treatment versus control of 0.69 (95% CI, 0.39-1.21) in favor of standard therapy. CONCLUSIONS: These results suggest that antimycobacterial therapy is effective in maintaining remission in patients with Crohn's disease after a course of corticosteroids combined with antimycobacterial therapy to induce remission. Treatment of Crohn's disease with antimycobacterial therapy does not seem to be effective without a course of corticosteroids to induce remission. Because of the small number of studies included in this meta-analysis, the results should be interpreted with caution.

The national asthma audit. Bridging the gap between guidelines and practice.

OBJECTIVE: This pilot study was undertaken to assess the need and acceptability of a theoretically based audit model to assist GPs improve their asthma care. METHOD: Seventeen GPs from two GP divisions conducted a chart audit and patient survey of asthma patients presenting during the 8 week audit period. Audit results were discussed at a workshop providing a forum for GP peer groups to review their asthma care against current guidelines. This workshop allowed the GPs to develop strategies to improve their asthma care in the context of the resources of their individual practice, GP division, local community and health services. RESULTS: Of the 243 asthma patients audited 177 (72.8%) had a review of their asthma recorded in the past 12 months, 138 (56.8%) were prescribed regular preventive therapy and 118 (48.2%) had been given an asthma action plan. Despite the time commitment required to participate in the activity, 16 respondents who answered the audit evaluation questionnaire reported that the audit was a useful process and 15 (93.8%) stated that it had motivated them to change their practice. CONCLUSION: The results confirmed the need for improved asthma care in general practice and demonstrated the feasibility of the GP-peer led, regionally coordinated, audit-workshop model.

Antibiotics.

Antibiotics may be a helpful addition to your therapy for IBD. Although it sounds as if there are a number of side effects, most patients do well, without any problems. If you develop new or worsening symptoms, or if you have other concerns, feel free to discuss them with your physician.

Clinical workload decreases the level of aerobic fitness in housestaff physicians.

PURPOSE: To examine the relationship between clinical workload and aerobic fitness. METHODS: Twenty healthy intern and resident volunteers were studied in a cross over manner to compare their aerobic fitness after a 1 month "easy" clinical rotation (ECR) to that after a 1 month "hard" clinical rotation (HCR). The ECR and HCR were prospectively estimated as requiring <60 (ECR) and >70 (HCR) total hours per week of hospital work respectively. Aerobic fitness was determined by directly measuring peak oxygen uptake (peakVO2) during peak cycle exercise testing after each rotation. Clinical workload for the month preceding the exercise test was estimated by documenting the amount of hospital work and sleep lost because of on-call duties. The average weekly amount of effective aerobic training for each rotation was also documented. RESULTS: Trainees had a 206.4 (P = 0.0019, 95% CI 94-318.8) mL/min or 3 mL/kg/min (P = 0.0019, 95% CI 1.5-4.4) improvement of peakVO2 after the ECR compared with the HCR. Trainees averaged 1 (95% CI 0.16-1.81) less hour per week of exercise training, 34.1 more hours per week of hospital work (95% CI 23.0-45.3, P < 0.0001) and lost 19.1 hours more sleep per month (95% CI 11.8-26.4, p < 0.0001) during the HCR compared with the ECR. There was no correlation between changes in peakVO2 and changes in exercise training between the two rotations. CONCLUSION: Clinical workload seems to adversely affect aerobic fitness independent of changes in exercise training. This supports previous less-objective survey data.

A meta-analysis of prophylactic endoscopic sclerotherapy for esophageal varices.

OBJECTIVES: A number of randomized clinical trials of prophylactic sclerotherapy have been carried out with different results. The main objective of this study was to determine if the literature provides evidence that prophylactic sclerotherapy increases the survival rate of patients with esophageal varices. METHODS: Meta-analysis was used to evaluate the effect of prophylactic sclerotherapy on the survival of patients with esophageal varices. Only randomized controlled trials that compared prophylactic sclerotherapy to placebo were included. RESULTS: Fourteen fully published randomized controlled trials, as well as six trials published as abstracts, were identified in the English literature. Pooling of the 14 fully published trials yielded an odds ratio of death in the treatment group compared with the control group of 0.74 (95% confidence interval, 0.60-0.93) in favor of prophylactic sclerotherapy. There was statistically significant heterogeneity that resolved when the trials were pooled in subgroups based on the sclerosant used. Pooling of trials using polidocanol showed a highly significant benefit for prophylactic sclerotherapy in terms of overall mortality, particularly when those trials that selected subjects at high risk of bleeding were pooled, yielding an odds ratio of 0.51 (95% confidence interval, 0.36-0.73). When trials using sodium tetradecyl sulfate were pooled, a detrimental effect for prophylactic sclerotherapy was seen, with an odds ratio of 1.86 (95% confidence interval, 1.15-3.00). Subgroup analysis by Child's class showed no benefit for patients in Child's class A. CONCLUSION: These results suggest that prophylactic sclerotherapy with polidocanol is effective, particularly in high-risk patients.

Magnetic susceptibility mapping of the human thorax using a SQUID biomagnetometer.

Biomagnetism is essentially the study of the weak magnetic fields generated by biological organisms, in particular the human body. The human thorax is composed of a variety of tissues and organs of slightly different magnetic susceptibility. In an applied magnetic field (of the order of milliTeslas) these small differences in susceptibility lead to measurable field variations (of the order of nanoTeslas) at the body surface which may be of diagnostic value. Physiological processes such as cardiac activity, cardiac output, blood flow and respiratory related lung volume changes also contribute to the observed signal. In this study susceptibility 'maps' were obtained by measuring the magnetic field at several hundred points over the thorax. Results indicate that magnetic susceptibility mapping produces low-resolution images of internal body structures from which is should be possible to detect pathologies that cause alterations in tissue susceptibility.

Toxic heavy metals and other trace elements in foodstuffs from 12 different countries. An IAEA coordinated research program.

A research program related to the assessment of toxic heavy metals and essential trace elements in foodstuffs has been carried out in 12 countries under the auspices of the IAEA. The main purpose of this program was to obtain data on the elemental concentrations of potentially toxic elements in foodstuffs in various countries, and to compare them with the maximum permissible levels specified in national legislation and international guidelines. High-priority elements for this study were As, Cd, Cr, Pb, Hg, and Se. Also of interest, but of lower priority, were Sb, Cu, and Zn. Emphasis was placed on the use of nuclear and nuclear-related analytical techniques, complemented by conventional methods, and on quality assurance.

Thorium metabolism and bioassay of mineral sands workers.

The concentration of thorium in the blood serum and urine of Western Australian mineral sands workers was studied to complement estimates of radiation dose derived from air sampling measurements. The concentration of thorium in urine samples from occupationally unexposed persons and pooled serum samples was also investigated. The concentration of thorium in the urine of the workers varied from 3-210 ng L-1 (geometric mean = 31 ng L-1, n = 34) while the concentration of thorium in the serum varied from 170-2,000 ng L-1 (geometric mean = 480 ng L-1, n = 25). No correlation was found between the bioassay results and cumulative airborne thorium exposure. The geometric mean ratio of daily excretion of thorium in urine to total thorium in the serum pool was 2.5%, considerably lower than the value of 10% proposed by the ICRP. These data indicate that more information is required to clarify the biokinetic models for thorium and that doses assessed from air sampling data must be interpreted with caution.

Selenium and human lactation in Australia: milk and blood selenium levels in lactating women, and selenium intakes of their breast-fed infants.

A series of 20 mother-infant pairs were studied in Brisbane, Australia, at 6-12 weeks postpartum. The mean selenium concentration in maternal blood was 101 (SD +/- 19) ng/g and in maternal serum 81(+/- 15) ng/g; serum values appeared low in comparison with those reported for lactating women from Japan and the USA, but similar to those from Finland and from a previous Australian study. Breast milk selenium concentrations (11.9 +/- 3.5 ng/g) were also low by international standards, but not as low as in New Zealand or Scandinavia. There was no correlation between selenium concentrations in milk and blood (or serum). The infants' 24-h breast-milk intakes were 856 +/- 172 g, and their 24-h selenium intakes 10.7 +/- 4.1 micrograms (compared to the Australian RDI of 10 micrograms).

Gastrointestinal gas.

Complaints related to gastrointestinal gas are commonly encountered in clinical practice. Various therapies have been proposed, yet none has appeared to be extremely effective. A review of the literature revealed little hard evidence to support the use of simethicone, pancreatic enzymes, anticholinergic agents or antibiotics. Evidence supporting the use of prokinetic agents has been the strongest, and there may be a pathophysiologic basis for the use of these agents if the complaints are related to abnormal intestinal motility. The use of activated charcoal for adsorbing intestinal gas has been effective in healthy subjects but has not been properly investigated in patients with gas complaints. Dietary modification may be beneficial in certain cases. Additional controlled trials are necessary to clarify the issues in the treatment of this common problem.

Adverse effects with oral 5-aminosalicyclic acid.

Two patients with ulcerative colitis and a past history of allergic reactions to sulfasalazine had similar reactions when treated with 5-aminosalicylic acid. This suggests that, at least in some patients, the adverse effects of sulfasalazine are due to 5-aminosalicylic acid rather than sulfapyridine. Desensitization to sulfasalazine was successfully carried out in one patient but was not attempted in a second.

Marlex mesh erosion: a complication of horizontal banded gastroplasty.

One-hundred and thirty-eight obese patients underwent horizontal banded gastroplasty. The stoma in each case was reinforced with Marlex mesh. Fifty of these patients developed upper gastrointestinal symptoms sufficiently severe to require endoscopy. At endoscopy 12 were found to have erosion of the Marlex mesh into the stoma. Mesh erosion was found at various intervals postoperatively ranging from 5 weeks to 55 months with a mean of 23 months. Nine of the 12 had associated stenosis of the stoma and three had dehiscence of the staple line. There were no symptoms peculiar to Marlex erosion. Seven patients required surgical revision of the stoma, four were treated medically, and one was treated with a combination of stomal dilation and medical therapy.

Trace elements in human milk.

Presented is a study, using multielement neutron activation analysis, of the elemental composition of blood plasma and milk in a group of lactating Australian women. Having established baseline values for nine elements, the authors studied factors affecting concentrations in milk and the partitioning of those elements between plasma and milk. Changes in this partitioning with the progression of lactation were demonstrated, and their nutritional implications for the exclusively breast-fed baby discussed. Progestogen-only oral contraceptives had no significant effect on levels of any of the trace elements in either blood or milk.