Appropriateness of therapy for active Crohn's disease: results of a multidisciplinary International Expert Panel (EPACT II)

Introduction: The development of novel therapies and the increasing number of trials testing management strategies for luminal Crohn's disease (CD) have not filled all the gaps in our knowledge. Thus, in clinical practice, many decisions for CD patients need to be taken without high quality evidence. For this reason, a multidisciplinary European expert panel followed the RAND method to develop explicit criteria for the management of individual patients with active, steroid-dependent (ST-D) and steroid-refractory (ST-R) CD. Methods: Twelve international experts convened in Geneva, Switzerland in December 2007, to rate explicit clinical scenarios, corresponding to real daily practice, on a 9-point scale according to the literature evidence and their own expertise. Median ratings were stratified into three categories: appropriate (7-9), uncertain (4-6) and inappropriate (1-3). Results: Overall, panelists rated 296 indications pertaining to mild-to-moderate, severe, ST-D, and ST-R CD. In anti-TNF naïve patients, budesonide and prednisone were found appropriate for mildmoderate CD, and infliximab (IFX) when those had previously failed or had not been tolerated. In patients with prior success with IFX, this drug with or without co-administration of a thiopurine analog was favored. Other anti-TNFs were appropriate in case of intolerance or resistance to IFX. High doses steroids, IFX or adalimumab were appropriate in severe active CD. Among 105 indications for ST-D or ST-R disease, the panel considered appropriate the thiopurine analogs, methotrexate, IFX, adalimumab and surgery for limited resection, depending on the outcome of prior therapies. Anti-TNFs were generally considered appropriate in ST-R. Conclusion: Steroids, including budesonide for mild-to-moderate CD, remain first-line therapies in active luminal CD. Anti-TNFs, in particular IFX with respect to the amount of available evidence, remain second-line for most indications. Thiopurine analogs are preferred to anti-TNFs when steroids are not appropriate, except when anti-TNFs were previously successful. These recommendations are available online (www.epact.ch). A prospective evaluation of these criteria in a large database in Switzerland in underway to validate these criteria.

Daily intake of lactating crossbred cows grazing elephant grass rotationally

The goal of this trial was to estimate the total dry matter (TDMI) and daily pasture dry matter intakes (PDMI) by lactating crossbred Holstein - Zebu cows grazing elephant grass (Pennisetum purpureum Schum.) paddocks submitted to different rest periods. Three groups of 24 cows were used during two years. The paddocks were grazed during three days at the stocking rate of 4.5 cows/ha. Treatments consisted of resting periods of 30 days without concentrate and resting periods of 30, 37.5 and 45 days with 2 kg/cow/day of 20.6% crude protein concentrate. From July to October, pasture was supplemented with chopped sugarcane plus 1% urea. Total daily dry matter intake was estimated using the extrusa in vitro dry matter digestibility and the fecal output with chromium oxide. Regardless of the treatment the estimated average TDMI was 2.7, 2.9 and 2.9±0.03% and the mean PDMI was 1.9, 2.1 and 2.1±0.03% of body weight in the first, second and third grazing day, respectively (P<0.05). Only during the summer pasture quality was the same whichever the grazing day. Sugarcane effectively replaced grazing pasture, mainly in the first day when pasture dry matter intake was lowest.

Bacterial lipopolysaccharide induces apoptosis in the trout ovary

BACKGROUND: In mammals it is well known that infections can lead to alterations in reproductive function. As part of the innate immune response, a number of cytokines and other immune factors is produced during bacterial infection or after treatment with lipopolysaccharide (LPS) and acts on the reproductive system. In fish, LPS can also induce an innate immune response but little is known about the activation of the immune system by LPS on reproduction in fish. Therefore, we conducted studies to examine the in vivo and in vitro effects of lipopolysaccharide (LPS) on the reproductive function of sexually mature female trout. METHODS: In saline- and LPS -injected brook trout, we measured the concentration of plasma steroids as well as the in vitro steroidogenic response (testosterone and 17alpha-hydroxyprogesterone) of ovarian follicles to luteinizing hormone (LH), the ability of 17alpha,20beta-dihydroxy-4-pregnen-3-one to induce germinal vesicle breakdown (GVBD) in vitro, and that of epinephrine to stimulate follicular contraction in vitro. We also examined the direct effects of LPS in vitro on steroid production, GVBD and contraction in brook trout ovarian follicles. The incidence of apoptosis was evaluated by TUNEL analysis. Furthermore, we examined the gene expression pattern in the ovary of saline- and LPS-injected rainbow trout by microarray analysis. RESULTS: LPS treatment in vivo did not affect plasma testosterone concentration or the basal in vitro production of steroids, although a small but significant potentiation of the effects of LH on testosterone production in vitro was observed in ovarian follicles from LPS-treated fish. In addition, LPS increased the plasma concentration of cortisol. LPS treatment in vitro did not affect the basal or LH-stimulated steroid production in brook trout ovarian follicles. In addition, we did not observe any effects of LPS in vivo or in vitro on GVBD or follicular contraction. Therefore, LPS did not appear to impair ovarian steroid production, oocyte final maturation or follicular contraction under the present experimental conditions. Interestingly, LPS administration in vivo induced apoptosis in follicular cells, an observation that correlated with changes in the expression of genes involved in apoptosis, as evidenced by microarray analysis. CONCLUSION: These results indicate that female trout are particularly resistant to an acute administration of LPS in terms of ovarian hormone responsiveness. However, LPS caused a marked increase in apoptosis in follicular cells, suggesting that the trout ovary could be sensitive to the pro-apoptotic effects of LPS-induced inflammatory cytokines.

Adjustable Suture Removal: Increasing Aqueous Flow in "Safe" Trabeculectomy.

Purpose: Aqueous flow through trabeculectomy blebs has been suggested to influence filtration bleb survival. We investigated the relationship between the requirement to increase aqueous flow via adjustable suture removal and surgical outcomes following "safe trabeculectomy" with mitomycin C (MMC). Methods: 62 consecutive eyes of 53 patients underwent fornix based trabeculectomy with adjustable sutures, intraoperative MMC and intensive postoperative steroids. Subconjunctival antimetabolite injections and bleb needlings were administered according to bleb vascularity and IOP trends. Main outcome measures were: success rates (definition: IOP≤21mmHg and 20% IOP reduction); number of antimetabolite injections; bleb needlings; number of of eyes recommencing glaucoma medications and complications. Results: Mean age was 70.4±16.0 years (mean± SD); mean preoperative IOP was 24.5±9.1 mmHg and decreased to 12.3±8.9mmHg postoperatively. Mean number of sutures was 2.6 ± 0.7. Eyes were divided into 2 groups in relation to the number of sutures removed. The number of subconjunctival MMC injections required for those requiring 2 suture removals was significantly greater than those requiring 1 suture removal (p<0.05) The number of needlings and 5FU injections also increased but did not reach significance (p=0.09 and p=0.34 respectively). Least-squared linear regression analysis showed the number of needlings required had a statistically significant (p=0.05) trend with respect to time elapsed between surgery and first suture removal. No other interventions had significant trends. Mean time between surgery and suture removal was: 4.2±9.2 weeks (suture #1) and 5.7±9.7 weeks (suture#2). Antiglaucoma medication was restarted in only 5 eyes. Postoperative complications were infrequent: Seidel (3.2%), peripheral choroidal effusions at any time (3.2%), and shallow anterior chamber (1.6%). Conclusion: Eyes requiring a greater number of suture removals required a significantly greater number of antifibrosis interventions. The time elapsed before suture removal was inversely related to the number of postoperative needlings, suggesting these eyes may have decreased aqueous production and therefore require aggressive post-operative management to prevent bleb failure.

Avaliação de biossólido de águas servidas domiciliares como adubo em couve

O objetivo deste trabalho foi avaliar o biossólido e proveniente da estação de tratamento de águas servidas domiciliares, como adubo no cultivo da couve (Brassica oleraceae var. acephala, grupo Georgia). O trabalho foi em delineamento de blocos ao acaso, com três tratamentos de adubação, esterco bovino, biossólido e uréia, com quatro repetições. Amostras de solo de cada tratamento foram analisadas quanto a parâmetros químicos, microbiológicos e parasitológicos. Os níveis de metais pesados encontravam-se abaixo dos permitidos pela legislação internacional. Após 54 dias da incorporação do biossólido ao solo, os coliformes fecais eram praticamente nulos e, a partir dos 60 dias, não foram mais encontradas amostras positivas com ovos de helmintos, apesar do alto grau de contaminação inicial. As plantas adubadas com biossólido, na maior dose, comparadas ao esterco, apresentaram maior produtividade e menores teores de N total nas folhas. O biossólido foi classificado como B, pela concentração de coliformes fecais apresentada, tornando-o impróprio para aplicação em culturas de contato primário como as hortaliças. Os resultados indicam a importância de selecionar indicadores de sanidade que permitam o uso seguro deste adubo.

Disponibilidade, composição bromatológica e consumo de matéria seca em pastagem consorciada de Brachiaria decumbens com Stylosanthes guianensis

O objetivo deste trabalho foi avaliar a disponibilidade de forragem, a composição bromatológica, o consumo de matéria seca e a proporção de gramínea e leguminosa na dieta de vacas mestiças Holandês x Zebu, em pastagem consorciada de Brachiaria decumbens cv. Basilisk, Stylosanthes guianensis var. vulgaris cv. Mineirão e leguminosas arbóreas. Para estimativa da produção fecal, foram usados 10 g vaca-1 dia-1 de óxido crômico, durante dez dias. Amostras de extrusa foram usadas para determinação da composição bromatológica e digestibilidade in vitro da matéria seca. A disponibilidade de matéria seca de forragem de B. decumbens variou com as condições climáticas, enquanto a de S. guianensis decresceu linearmente ao longo do período experimental. O consumo de matéria seca foi maior em maio de 2001 (1,9% do peso do animal vivo) e não diferiu entre os demais meses (1,5% do peso do animal vivo). Os baixos índices de consumo de matéria seca refletiram altos teores de fibra em detergente neutro (70,2% a 79,4%) e baixos coeficientes de digestibilidade in vitro de matéria seca (42,1% a 48,0%) da forragem. O consumo de leguminosa variou entre 8,7% e 24,1% do total ingerido. O consumo de matéria seca esteve diretamente relacionado à porcentagem de leguminosa na pastagem, o que evidencia o potencial de uso de pastagens consorciadas para vacas leiteiras.

Lésions traumatiques rachidiennes et indications au traitement chirurgical [Surgical indications in spinal trauma]

Surgical indications in spinal trauma remain a controversial topic. In general, unstable cervical injuries such as displaced odontoid fractures, burst fractures or tear drop fractures require surgical intervention. Thoracolumbar compression injuries without posterior wall involvement or significant kyphosis can be treated conservatively. Surgery is indicated in fractures-dislocations and burst fractures with significant canal narrowing and/or major kyphosis. The role of emergency decompression as well as that of steroids remain uncertain since no study to date has convincingly proven their efficacy.

Ophtalmologie orbitopathie dysthyroïdienne: du diagnostic au traitement

Mild to moderate forms of orbitopathy are common in auto-immune thyroid diseases, whereas severe forms are rare. Euthyroidism restoration, no smoking, and ocular local lubricants are necessary for all the patients. In case of mild orbitopathy, treatment by selenium is now indicated. Active forms of thyroid orbitopathy are better treated by IV steroids. Surgery is indicated in optic neuropathy resistant to steroids and in sequellar forms of the disease.

Clinical Prognostic Factors Predicting Outcomes Of Patients With Recurrent Gbm And Nomograms

BACKGROUND: Prognostic models and nomograms were recently developed to predict survival of patients with newly diagnosed glioblastoma multiforme (GBM).1 To improve predictions, models should be updated with the most recent patient and disease information. Nomograms predicting patient outcome at the time of disease progression are required. METHODS: Baseline information from 299 patients with recurrent GBM recruited in 8 phase I or II trials of the EORTC Brain Tumor Group was used to evaluate clinical parameters as prognosticators of patient outcome. Univariate (log rank) and multivariate (Cox models) analyses were made to assess the ability of patients' characteristics (age, sex, performance status [WHO PS], and MRC neurological deficit scale), disease history (prior treatments, time since last treatment or initial diagnosis, and administration of steroids or antiepileptics) and disease characteristics (tumor size and number of lesions) to predict progression free survival (PFS) and overall survival (OS). Bootstrap technique was used for models internal validation. Nomograms were computed to provide individual patients predictions. RESULTS: Poor PS and more than 1 lesion had a significant prognostic impact for both PFS and OS. Antiepileptic drug use was significantly associated with worse PFS. Larger tumors (split by the median of the largest tumor diameter >42.5 mm) and steroid use had shorter OS. Age, sex, neurologic deficit, prior therapies, and time since last therapy or initial diagnosis did not show independent prognostic value for PFS or OS. CONCLUSIONS: This analysis confirms that PS but not age is a major prognostic factor for PFS and OS. Multiple or large tumors and the need to administer steroids significantly increase the risk of progression and death. Nomograms at the recurrence could be used to obtain accurate predictions for the design of new targeted therapy trials or retrospective analyses. (1. T. Gorlia et al., Nomograms for predicting survival of patients with newly diagnosed glioblastoma. Lancet Oncol 9 (1): 29-38, 2008.)

Therapy of steroid-resistant inflammatory bowel disease.

Background and Aims: Although systemic corticosteroids are successfully administered for the induction of clinical response and remission in the majority of patients with inflammatory bowel disease (IBD) presenting with a flare, a proportion of these patients demonstrate a primary nonresponse to steroids or in the case of an initial response, they develop a resistance or a steroid dependence. Long-term therapy with corticosteroids for treatment of IBD should be avoided, given the high frequency of adverse treatment effects. Knowledge about treatment strategies in case of steroid nonresponse is therefore highly relevant. Methods: A systematic literature research was performed using Medline and Embase to summarize the currently recommended treatment strategies for steroid-resistant IBD. Results: Treatment of steroid-resistant Crohn's disease is based on the introduction of immunomodulators such as azathioprine, 6-mercaptopurine or methotrexate, the anti-TNF drugs infliximab, adalimumab and certolizumab pegol. In the case of steroid resistance in ulcerative colitis, aminosalicylates, the above-mentioned immunomodulators, infliximab, adalimumab or calcineurin inhibitors such as ciclosporin or tacrolimus may be administered. Conclusion: This review summarizes the current evidence for treating steroid-resistant IBD.

Consumo e digestibilidade de feno de baixa qualidade suplementado com nitrogênio não protéico em bovinos

O objetivo deste trabalho foi avaliar o efeito de níveis de inclusão de nitrogênio não protéico, em suplementos fornecidos a tourinhos Hereford, com 17 meses e peso médio de 220 kg, alimentados com feno de tifton (Cynodon dactylon) ad libitum. Os tratamentos avaliados foram: feno + suplemento sem uréia; feno + suplemento com 0,28 g de uréia kg-1 PV0,75; feno + suplemento com 0,55 g de uréia kg-1 PV0,75; feno + suplemento com 0,83 g de uréia kg-1 PV0,75 e feno + suplemento com 1,11 g de uréia kg-1 PV0,75. O feno apresentou, na média, 3,86% de proteína bruta e 84,66% de fibra em detergente neutro. Não se constatou efeito da suplementação sobre a digestibilidade da matéria orgânica, matéria orgânica do feno, fibra em detergente neutro, celulose e hemicelulose; o consumo total desses itens respondeu quadraticamente à suplementação com níveis crescentes de nitrogênio não protéico. A suplementação não afetou a excreção fecal metabólica de matéria orgânica, o que sugere aumento na taxa de passagem (variação no consumo) e na taxa de digestão (digestibilidade constante). O consumo de matéria orgânica digestível apresentou comportamento quadrático com aumento dos níveis de uréia na dieta. Quando o nível de proteína degradável no rúmen foi equivalente a 8,1% da matéria orgânica digestível, a relação de consumo entre esses componentes foi otimizada.

Mineralocorticoid effects in the kidney: correlation between alphaENaC, GILZ, and Sgk-1 mRNA expression and urinary excretion of Na+ and K+.

Aldosterone exerts its effects through interactions with two types of binding sites, the mineralocorticoid (MR) and the glucocorticoid (GR) receptors. Although both receptors are known to be involved in the anti-natriuretic response to aldosterone, the mechanisms of signal transduction leading to modulation of electrolyte transport are not yet fully understood. This study measured the Na(+) and K(+) urinary excretion and the mRNA levels of three known aldosterone-induced transcripts, the serum and glucocorticoid-induced kinase (Sgk-1), the alpha subunit of the epithelial Na(+) channel (alphaENaC), and the glucocorticoid-induced-leucine-zipper protein (GILZ) in the whole kidney and in isolated cortical collecting tubules of adrenalectomized rats treated with low doses of aldosterone and/or dexamethasone. The resulting plasma concentrations of both steroids were close to 1 nmol/L. Aldosterone, given with or without dexamethasone, induced anti-natriuresis and kaliuresis, whereas dexamethasone alone did not. GILZ and alphaENaC transcripts were higher after treatment with either or both hormones, whereas the mRNA abundance of Sgk-1 was increased in the cortical collecting tubule by aldosterone but not by dexamethasone. We conclude the increased expression of Sgk-1 in the cortical collecting tubules is a primary event in the early antinatriuretic and kaliuretic responses to physiologic concentrations of aldosterone. Induction of alphaENaC and/or GILZ mRNAs may play a permissive role in the enhancement of the early and/or late responses; these effects may be necessary for a full response but do not by themselves promote early changes in urinary Na(+) and K(+) excretion.

How do Swiss Gastroenterologists assess Activity of Inflammatory Bowel Disease in Daily Practice: by Clinical Indices, Endoscopic Activity, or Biomarkers?

Background a nd A ims: There is a n ongoing d ebate which i sthe most appropriate w ay t o measure inflammatory boweldisease (IBD) activity (be it b y clinical i ndices, e ndoscopy, orbiomarkers). Accumulating evidence associates m ucosalhealing with a reduction in I BD-related s urgery andhospitalizations. We a imed to i nvestigate which outcomeparameters are used in daily practice for IBD monitoring.Methods: A q uestionnaire was sent in J uly 2010 t o all boardcertified gastroenterologists in S witzerland to evaluate t heassessment strategy of IBD activity, t he items on whichtherapeutic decisions w ere based upon, and the kind ofbiomarkers used for monitoring IBD activity.Results: Response rate was 57% (153/270). Mean physician'sage was 5 0±9years, mean duration o f gastroenterologicpractice 1 4±8years, 52% of them were working in p rivatepractice a nd 48% in h ospitals. S eventy-eight percent usedclinical activity i ndices as g old standard for IBD activityassessment, followed by 15% choosing endoscopic activity, and7% favouring biomarkers. Gastroenterologists based theirtherapeutic decisions in 70% on clinical activity indices, 24% onendoscopic activity, a nd 6% o n biomarkers. Most frequentlyused biomarkers were C-reactive protein (94%), complete bloodcount (78%) and fecal calprotectin (74%).Conclusions: I n daily p ractice, most IBD patients a remonitored based u pon t heir clinical a ctivity. B iomarkers a reperceived as l ess important compared to clinical andendoscopic activity. S imilar to activity a ssessment, alsotherapeutic decisions a re mostly made on the basis of clinicalactivity indices. The upcoming scientific evidence on the impactof mucosal h ealing does n ot yet seem to influence the dailypractice of gastroenterologists.

Subject-based steroid profiling and the determination of novel biomarkers for DHT and DHEA misuse in sports.

Doping with natural steroids can be detected by evaluating the urinary concentrations and ratios of several endogenous steroids. Since these biomarkers of steroid doping are known to present large inter-individual variations, monitoring of individual steroid profiles over time allows switching from population-based towards subject-based reference ranges for improved detection. In an Athlete Biological Passport (ABP), biomarkers data are collated throughout the athlete's sporting career and individual thresholds defined adaptively. For now, this approach has been validated on a limited number of markers of steroid doping, such as the testosterone (T) over epitestosterone (E) ratio to detect T misuse in athletes. Additional markers are required for other endogenous steroids like dihydrotestosterone (DHT) and dehydroepiandrosterone (DHEA). By combining comprehensive steroid profiles composed of 24 steroid concentrations with Bayesian inference techniques for longitudinal profiling, a selection was made for the detection of DHT and DHEA misuse. The biomarkers found were rated according to relative response, parameter stability, discriminative power, and maximal detection time. This analysis revealed DHT/E, DHT/5β-androstane-3α,17β-diol and 5α-androstane-3α,17β-diol/5β-androstane-3α,17β-diol as best biomarkers for DHT administration and DHEA/E, 16α-hydroxydehydroepiandrosterone/E, 7β-hydroxydehydroepiandrosterone/E and 5β-androstane-3α,17β-diol/5α-androstane-3α,17β-diol for DHEA. The selected biomarkers were found suitable for individual referencing. A drastic overall increase in sensitivity was obtained.The use of multiple markers as formalized in an Athlete Steroidal Passport (ASP) can provide firm evidence of doping with endogenous steroids. Copyright © 2010 John Wiley & Sons, Ltd.

Digestibilidade e metabolismo de dietas de suínos contendo zearalenona com adição de organoaluminossilicato

Um experimento foi realizado para avaliar a digestibilidade de dietas e balanços metabólicos de suínos alimentados com dietas contendo zearalenona (ZEA) com e sem adição de organoaluminossilicato (OA). Foram utilizadas 12 leitoas com peso inicial de 12 kg, alojadas em gaiolas metabólicas. O delineamento foi inteiramente casualizado, com três tratamentos (controle, controle + 2 ppm de ZEA e controle + 2 ppm de ZEA com adição de 0,3% de OA na dieta) e quatro repetições, com o animal como unidade experimental. A ZEA e o OA não influenciaram (p>0,05) o consumo de matéria seca, a digestibilidade da matéria seca e energia bruta, metabolização da energia, proteína digestível e energias digestível e metabolizável das dietas. A ZEA e OA não alteraram o balanço do N (p>0,05), mas modificaram (p<0,05) a excreção fecal de P. Nas dietas contendo ZEA e ZEA+OA, a excreção fecal de P foi 15 e 10% menor do que no grupo controle. A ZEA e o OA não alteraram (p>0,05) a absorção de P em função da ingestão. O consumo de 2 ppm de ZEA com ou sem adição de 0,3% de OA não interfere na digestibilidade das dietas e no metabolismo dos suínos.