Restrictive pericarditis

BACKGROUND—Pericardial thickening is an uncommon complication of cardiac surgery.
OBJECTIVES—To study pericardial thickening as the cause of severe postoperative venous congestion.
SUBJECTS—Two men, one with severe aortic stenosis and single coronary artery disease, and one with coronary artery disease after an old inferior infarction. Both had coronary artery bypass grafting surgery.
METHODS—Magnetic resonance imaging (MRI), Doppler echocardiography, and cardiac catheterisation.
RESULTS—Venous pressure was raised in both patients. MRI showed mildly thickened pericardium, and cardiac catheterisation indicated diastolic equalisation of pressures in the four chambers. Jugular venous pulse showed a dominant "Y" descent coinciding with early diastolic flow in the superior vena cava, and mitral and tricuspid Doppler forward flow proved restrictive physiology. The clinical background suggested pericardial disease so both patients had pericardiectomy. This proved the pericardium to be thickened; the extent of fibrosis also involved the epicardium.
CONCLUSIONS—Although rare, restrictive pericarditis (restrictive ventricular physiology resulting from pericardial disease) should be considered to be a separate diagnostic entity because its pathological basis and treatment are different from intrinsic myocardial disease. This diagnosis may be confirmed by standard investigational techniques or may require diagnostic thoracotomy.


Keywords: restrictive pericarditis; pericardial disease     

Pericardial involvement in systemic sclerosis

OBJECTIVE—To determine the frequency and histological characteristics of pericardial involvement in systemic sclerosis.
METHOD—Necropsy sections of pericardium from 44 patients with systemic sclerosis were studied, together with sections from 19 age/sex matched controls. Sections were stained with haematoxylin and eosin, acid toluidine blue, and elastic van Gieson. Mast cells were counted in 10 random high power fields and the degree of fibrosis was quantified using a Chalkley count.
RESULTS—Chronic pericarditis was seen in 31 (77.5%) of the systemic sclerosis cases, but in only one of the controls. The characteristic changes of uraemic pericarditis were not seen. The degree of fibrosis was greater in those with systemic sclerosis, though numbers of mast cells, thought to be important in fibrogenesis, were similar in both groups. Myocardial fibrosis was seen in 15 (37.5%) of systemic sclerosis cases but in none of the controls.
CONCLUSION—The incidence of pericarditis and myocardial fibrosis is much greater than in controls. The results indicate that pericarditis is a primary disease (rather than secondary to uraemia).

     

Efficacy and safety of the peripheral kappa agonist fedotozine versus placebo in the treatment of functional dyspepsia

Background—Peripheral kappa receptor agonists mayprovide a new therapeutic approach for the treatment of functional dyspepsia.
Aims—To evaluate, in a large multicentre trial,the use of the kappa receptor agonist fedotozine to improve symptomsassociated with functional dyspepsia.
Methods—Two or more of the followingpersistent symptoms were required for inclusion: epigastric pain, earlysatiety, epigastric fullness or distension, nausea, vomiting, and afeeling of slow digestion. On completing a two week placebo washout,271 patients were randomised into two groups to receive 30 mgfedotozine three times daily or placebo for six weeks under doubleblind conditions.
Results—The improvement in the overall intensityof dyspeptic symptoms (main efficacy criterion) was significantly morepronounced in the fedotozine group (p=0.002) compared with placebo, aswas epigastric pain (p=0.004) and nausea (p=0.01); the improvement inpostprandial fullness was nearly significant (p=0.052). Inability tofinish a meal and slow digestion were unaffected. The patient globalscore, the average of the five individual symptoms, was notablyameliorated with fedotozine (p=0.021). The safety of fedotozine was excellent.
Conclusions—Fedotozine at 30 mg three times dailyis safe and more effective than placebo for the relief of key symptomsassociated with functional dyspepsia.

Keywords:fedotozine; functional dyspepsia; kappa receptoragonist

     

Oral budesonide is as effective as oral prednisolone in active Crohn's disease

Background—The use of corticosteroids in activeCrohn's disease often becomes limited by side effects. Budesonide is apotent corticosteroid with low systemic bioavailability due to anextensive first pass liver metabolism.
Aims—To compare the efficacy and safety of twodosage regimens of budesonide and prednisolone in patients with activeCrohn's disease affecting the ileum and/or the ascending colon.
Patients and methods—One hundred and seventy eightpatients were randomised to receive budesonide controlled ileal release (CIR) capsules 9 mg once daily or 4.5 mg twice daily, or prednisolone tablets 40 mg once daily. The treatment period was 12 weeks. The primary efficacy variable was clinical remission, defined as a Crohn'sDisease Activity Index (CDAI) of 150 or less.
Results—After eight weeks of treatment, remissionoccurred in 60% of patients receiving budesonide once daily orprednisolone and in 42% of those receiving budesonide twice daily(p=0.062). The presence of glucocorticoid associated side effects wassimilar in all groups; however, moon face was more common in theprednisolone group (p=0.0005). The highest frequency of impairedadrenal function, as measured by a short ACTH test, was found in theprednisolone group (p=0.0023).
Conclusions—Budesonide CIR, administered at 9 mgonce daily or 4.5 mg twice daily, is comparable to prednisolone ininducing remission in active Crohn's disease. The single doseadministration is as promptly effective as prednisolone and representsa simpler and safer therapeutic approach, with a considerable reduction in side effects.

Keywords:adrenal function; CDAI; glucocorticoid; glucocorticoid associated side effects

     

Placebo controlled trial of enteric coated pancreatin microsphere treatment in patients with unresectable cancer of the pancreatic head region

Background—Impeded flow of pancreatic juice dueto mechanical obstruction of the pancreatic duct in patients withcancer of the pancreatic head region causes exocrine pancreaticinsufficiency with steatorrhoea and creatorrhoea. This may contributeto the profound weight loss that often occurs in these patients.
Aims—To investigate whether pancreatic enzymereplacement therapy prevents this weight loss.
Patients—Twenty one patients with unresectablecancer of the pancreatic head region with suspected pancreatic ductobstruction, a biliary endoprosthesis in situ, and a Karnofskyperformance status greater than 60.
Methods—Randomised double blind trial of eightweeks with either placebo or high dose enteric coated pancreatin enzymesupplementation. All patients received dietary counselling.
Results—The mean difference in the percentagechange of body weight was 4.9% (p=0.02, 95% confidence interval forthe difference: 0.9 to 8.9). Patients on pancreatic enzymes gained1.2% (0.7 kg) body weight whereas patients on placebo lost 3.7% (2.2 kg). The fat absorption coefficient in patients on pancreatic enzymesimproved by 12% whereas in placebo patients it dropped by 8% (p=0.13,95% confidence interval for the difference: -6 to 45). The dailytotal energy intake was 8.42 MJ in patients on pancreatic enzymes and 6.66 MJ in placebo patients (p=0.04, 95% confidence interval for thedifference: 0.08 to 3.44).
Conclusions—Weight loss in patients withunresectable cancer of the pancreatic head region and occlusion of thepancreatic duct can be prevented, at least for the period immediatelyafter insertion of a biliary endoprosthesis, by high dose entericcoated pancreatin enzyme supplementation in combination with dietary counselling.

Keywords:pancreatic cancer; weight loss; pancreatic enzyme therapy; enteric coated enzyme therapy; palliation; dietarycounselling

     

Beneficial haemodynamic effects of insulin in chronic heart failure

OBJECTIVE—To characterise the central and regional haemodynamic effects of insulin in patients with chronic heart failure.
DESIGN—Single blind, placebo controlled study.
SETTING—University teaching hospital.
PATIENTS—Ten patients with stable chronic heart failure.
INTERVENTIONS—Hyperinsulinaemic euglycaemic clamp and non-invasive haemodynamic measurements.
MAIN OUTCOME MEASURES—Change in resting heart rate, blood pressure, cardiac output, and regional splanchnic and skeletal muscle blood flow.
RESULTS—Insulin infusion led to a dose dependent increase in skeletal muscle blood flow of 0.36 (0.13) and 0.73 (0.14) ml/dl/min during low and high dose insulin infusions (p < 0.05 and p < 0.005 v placebo, respectively). Low and high dose insulin infusions led to a fall in heart rate of 4.6 (1.4) and 5.1 (1.3) beats/min (p < 0.05 and p < 0.005 v placebo, respectively) and a modest increase in cardiac output. There was no significant change in superior mesenteric artery blood flow.
CONCLUSION—In patients with chronic heart failure insulin is a selective skeletal muscle vasodilator that leads to increased muscle perfusion primarily through redistribution of regional blood flow rather than by increased cardiac output. These results provide a rational haemodynamic explanation for the apparent beneficial effects of insulin infusion in the setting of heart failure.


Keywords: blood flow; heart failure; insulin; muscle     

Use of mesalazine slow release suppositories 1 g three times per week to maintain remission of ulcerative proctitis: a randomised double blind placebo controlled multicentre study

Background—Daily administration of rectalformulations of mesalazine is effective in preventing relapse ofulcerative proctitis. Maintenance of remission with lower doses wouldbe an advantage.
Aim—The efficacy of mesalazine suppositories(Pentasa) 1 g three times a week v placebo to maintainremission in patients with cryptogenetic proctitis was studied.
Methods—Ninety five patients with cryptogeneticproctitis were randomised within two weeks of remission to receive forone year or until relapse three suppositories per week of eitherPentasa (n=48) or placebo (n=47). In the case of a relapse, thepatients received one suppository/day.
Results—It was found that 25 of 48 subjectsv 18 of 47 remained in remission in the mesalazine andplacebo groups respectively. The relapse rate was lower in themesalazine group for the following time intervals: 0-90 days (19%v 38%, p=0.035), 0-180 days (29% v 54%,p=0.017), 0-270 days (38% v 60%, p=0.031), and 0-365days (48% v 62%, p=0.18). Treatment of relapse with onesuppository/day induced remission in 11 of 18 and 2 of 26 patients inthe mesalazine and placebo groups respectively (p=0.001). Overall, 61%v 28% patients remained in the protocol and were inremission at one year (p=0.001). Tolerance was good.
Conclusion—Mesalazine suppositories 1 g threetimes a week are effective for preventing relapses of cryptogeneticproctitis. Increasing the dose to 1 g/day is effective in a highproportion of subjects who relapsed.

     

Anti-Ro/SS-A and anti-La/SS-B antibodies associated with cardiac involvement in childhood systemic lupus erythematosus

OBJECTIVES—To determine the frequency and type of cardiac manifestations in children with systemic lupus erythematosus (SLE) and investigate whether cardiac involvement of SLE in children was associated with any autoantibody pattern.
METHODS—Retrospective analysis of the medical records of all children with SLE (31 patients) seen between January 1984 and January 1994 by the paediatric rheumatology service at Children's Hospital in New Orleans. All patients satisfied the American College of Rheumatology criteria for the diagnosis of SLE. Paediatric SLE patients with cardiac manifestations based on echocardiogram were identified. Autoantibody tests at diagnosis were identified retrospectively by chart review, and the correlation between autoantibodies and cardiac involvement was analysed using the two tailed Fisher's exact test.
RESULTS—Thirteen (42%) of 31 SLE patients had cardiac manifestations of SLE. Seven (22%) had pericarditis without myocarditis, five (16%) had pericarditis and myocarditis, and one (3%) had myocarditis without pericarditis. Two patients (6%) with pericarditis had cardiac tamponade. Cardiac manifestations of SLE usually occurred at the time of diagnosis or within six months. Anti-Ro/SS-A antibodies were present in serum samples of nine of 11 (82%) patients with cardiac involvement and in five of 15 (33%) without cardiac involvement (p=0.02). Anti-La/SS-B antibodies were present in serum samples of six of 10 (60%) patients with cardiac involvement and two of 15 (13%) without cardiac involvement (p=0.03). Anti-Sm and anti-RNP antibodies showed no correlation with the presence of cardiac disease.
CONCLUSIONS—Cardiac involvement in our paediatric SLE population was frequently found and correlated significantly with the presence of anti-Ro/SS-A and anti-La/SS-B antibodies.

     

Macronutrient intake and malabsorption in HIV infection: a comparison with other malabsorptive states

Background—Wasting is a major complication of HIVinfection. The role of malabsorption in wasting is controversial.
Aims—To assess oral intake and malabsorption in acohort of weight losing HIV infected patients, with or without chronic diarrhoea.
Methods—A prospective study using a predefinedprotocol for HIV infected patients was performed in a gastroenterologyand nutrition unit in a university hospital. A retrospective comparison was made with HIV negative patients with malabsorption due either tosmall bowel disease or resection. Body weight and height, serum albumin, oral intake of macronutrients, faecal weight, and faecal fatwere measured.
Results—Seventy nine weight losing HIV infectedpatients were studied. Among the 66 patients with more than 5% lipidmalabsorption, wasting was significantly greater in patients withcryptosporidiosis (n=22) than in patients with microsporidiosis (n=18)who exhibited significantly more wasting than patients with noidentified enteropathogen (n=26) (body mass index 16.8 (14.0-20.7),18.9 (16.5-21.3), 19.7(15.9-23), respectively). When controlling forthe level of lipid malabsorption, HIV infected patients had asignificantly lower energy intake than HIV negative patients withchronic malabsorption. In HIV infected patients, but not in othercategories of malabsorbers, body mass index correlated significantlywith energy intake (r=0.33, 95% confidence intervals 0.12 to 0.51).
Conclusion—In weight losing HIV infectedpatients, reduced energy intake is superimposed on malabsorption andsignificantly contributes to wasting.

     

Assessment of ventricular diastolic function in AIDS patients from Congo: a Doppler echocardiographic study

Objective—To investigate the prevalence of left ventricular dysfunction in African patients infected with the human immunodeficiency virus (HIV). The hypothesis was that HIV infected patients with left ventricular dysfunction are asymptomatic.
Methods—M mode, cross sectional, and Doppler echocardiography were performed in 49 consecutive patients (30 HIV positive (HIV+) carriers and 19 AIDS patients). None of the patients or 58 controls had a medical history of cardiovascular abnormalities.
Results—Cardiac abnormalities were not suspected on physical, electrocardiographic, and radiological examination. Forty two of the HIV infected patients had left ventricular diastolic dysfunction; this was more pronounced in AIDS patients than in HIV+ carriers. Systolic function was normal in both stages of HIV infection. Left ventricular isovolumic relaxation time (mean (SD)) increased from 87.2 (12.4) ms in the carrier state to 103.9 (19.3) ms in AIDS (p < 0.05, Bonferoni correction), peak early filling velocity declined from 0.54 (0.1) to 0.44 (0.1) m/s (p < 0.05), and late velocity increased from 0.64 (0.1) to 0.69 (0.2) m/s. A restrictive filling pattern was explained by concentric hypertrophy in 23 HIV infected patients, and by systemic amyloidosis with left ventricular dilatation in 12 of 49 HIV infected patients.
Conclusions—Echocardiography is a useful technique for detecting left ventricular diastolic dysfunction in HIV infected patients with clinically unsuspected cardiac lesions. Systolic function was normal despite the presence of such cardiac abnormalities.

Keywords: HIV infection; AIDS; diastolic dysfunction; black Africans; echocardiography     

Low dose oral pH modified release budesonide for maintenance of steroid induced remission in Crohn's disease

Background—The relapse rate after steroid inducedremission in Crohn's disease is high.
Aims—To test whether oral pH modified releasebudesonide (3 × 1 mg/day) reduces the relapse rate and to identifypatient subgroups with an increased risk of relapse.
Methods—In a multicentre, randomised, doubleblind study, 179 patients with steroid induced remission of Crohn'sdisease received either 3 × 1 mg budesonide (n=84) or placebo (n=95)for one year. The primary study aim was the maintenance of remission ofCrohn's disease for one year.
Results—Patient characteristics at study entrywere similar for both groups. The relapse rate was 67% (56/84) in thebudesonide group and 65% (62/95) in the placebo group. The relapsecurves in both groups were similar. The mean time to relapse was 93.5days in the budesonide group and 67.0 days in the placebo group. Noprognostic factors allowing prediction of an increased risk for relapseor definition of patient subgroups who derived benefit from low dosebudesonide were found. Drug related side effects were mild and nodifferent between the budesonide and the placebo group.
Conclusion—Oral pH modified release budesonide ata dose of 3 × 1 mg/day is not effective for maintaining steroidinduced remission in Crohn's disease.

Keywords:budesonide; Crohn's disease; maintenance ofremission

     

Ventricular mass and diastolic function in patients infected by the human immunodeficiency virus

OBJECTIVE—Echocardiographic and Doppler analysis of myocardial mass and diastolic function in patients infected with HIV.
DESIGN—Case-control study.
SETTING—Tertiary referral centre, Huelva, Spain.
PATIENTS—61 asymptomatic patients with HIV infection and 32 healthy controls.
MAIN OUTCOME MEASURES—Time motion, cross sectional, and Doppler echocardiographic studies were performed, and left ventricular mass and diastolic function variables determined (peak velocity of early and late mitral outflow and isovolumic relaxation time).
RESULTS—Left ventricular mass index (LVMI) was decreased in patients compared with healthy controls (mean (SD): 76.7 (23.6) v 118.8 (23.5) g/m², p < 0.001). Linear regression analysis showed a correlation between LVMI and brachial fat and muscle areas. The ratio of peak velocities of early and late mitral outflow was decreased in HIV infected patients compared with controls (1.19 (0.44) v 1.58 (0.38), p < 0.001). This ratio was exclusively related to haemodynamic variables (heart rate, systolic and diastolic blood pressures). HIV infected patients had a prolonged isovolumic relaxation time (103.0 (10.5) v 72.9 (12.9) ms, p < 0.001). Isovolumic relaxation time was correlated only with brachial muscle area on multivariate analysis.
CONCLUSIONS—HIV infected patients had a reduced left ventricular mass index and diastolic functional abnormalities. These cardiac abnormalities are predominantly related to nutritional status.


Keywords: HIV infection; cardiac function; nutrition     

Increased immunoglobulin G production by short term cultured duodenal biopsy samples from HIV infected patients

Background—Secretory immunity is a major defencemechanism against infections at mucosal surfaces which are common inHIV infected patients.
Aims—To analyse intestinal immunoglobulinproduction in HIV infection in comparison with that in saliva and serum.
Patients and methods—Immunoglobulin G (IgG), A(IgA), and M (IgM) concentrations were determined in supernatants ofshort term cultured duodenal biopsy samples, serum, and saliva from HIVinfected patients (n = 28) and controls (n = 14) by radial immunodiffusion.
Results—IgG was increased in the supernatants ofshort term cultured biopsy samples and saliva from HIV infectedpatients compared with controls (p<0.01), but IgA and IgM levels werenormal. In contrast, both IgG and IgA concentrations in serum werehigher in HIV infected patients than in controls (p<0.002). Nocorrelation was found between IgA produced by duodenal biopsy specimensand serum IgA.
Conclusion—Abnormalities in mucosal immunoglobulinproduction in HIV infection were suprisingly small, indicating thatspecific secretory immunity rather than quantitative immunoglobulinproduction may be impaired. However, increased production of IgG couldcontribute to mucosal inflammation by complement activation. Ourfindings of normal mucosal IgA production and the lack of correlationbetween serum and mucosal IgA argues against an intestinal origin for the increased serum IgA levels in HIV infected patients.

Keywords:mucosal immunity; HIV infection; intestinalantibodies

     

HIV enteropathy: comparative morphometry of the jejunal mucosa of HIV infected patients resident in the United Kingdom and Uganda

Aims—To compare jejunal mucosalmorphometry in HIV infected patients resident in London and Uganda.
Patients—Twenty HIV positivepatients from London and 16 from Uganda were studied, and compared withHIV negative control subjects from both sites.
Methods—Stools and biopsy specimenswere examined for enteropathogens. Surface area to volume (S:V) ratiowas estimated morphometrically, mean crypt length of jejunal biopsyspecimens was measured, and HIV infected cells detectedimmunohistochemically were quantified.
Results—Enteric pathogens weredetected in none of the London patients, and in three Ugandan patients.S:V ratio was lower, and mean crypt length higher, in the specimens ofLondon patients than in normal subjects, but there was no difference inS:V ratio or mean crypt length between Ugandan patients and controls. A negative correlation was present between S:V ratio and mean crypt length in all biopsy specimens analysed. HIV infected cells were detected only in lamina propria.
Conclusion—Infection of cells inthe lamina propria of the jejunum with HIV stimulates crypt cellproliferation, and a fall in villous surface area. The mucosal responseto HIV is masked by other pathogens in the African environment.

Keywords:HIV; jejunum; AIDS; enteropathy

     

Effect of the nitric oxide donor, glyceryl trinitrate, on human gall bladder motility

Background—Nitric oxide is a majorneurotransmitter in non-adrenergic, non-cholinergic (NANC) pathways.NANC inhibitory innervation has been shown in human gall bladder musclein vitro; the role of nitric oxide in human gall bladder emptyinghowever is undefined.
Aims—To study the effect of glyceryltrinitrate, a nitric oxide donor, on gall bladder emptying in healthysubjects using a randomised, double blind, crossover, placebocontrolled design.
Methods—Ultrasonographic gall bladdervolume was measured in the fasting state in eight healthy volunteersafter randomised administration of either glyceryl trinitrate 1200 µgbuccal spray or placebo spray. On two further occasions, afterrandomised administration of either glyceryl trinitrate 1200 µgbuccal spray or placebo spray, gall bladder volumes were also measuredafter a liquid test meal.
Results—Glyceryl trinitrate significantlyincreased fasting gall bladder volume to a mean of 114% (SEM 5%) ofpretreatment volume (p=0.039). Glyceryl trinitrate also significantlyimpaired gall bladder emptying between five and 40 minutespostprandially. Gall bladder ejection fraction was also reduced afterglyceryl trinitrate compared with placebo (43 (6.9)% versus 68.4 (6.5)%, p=0.016).
Conclusions—This study shows that glyceryltrinitrate produces gall bladder dilatation in the fasting state andreduces postprandial gall bladder emptying, suggesting that nitricoxide mechanisms may be operative in the human gall bladder in vivo.

Keywords:gall bladder motility; nitric oxide; glyceryltrinitrate

     

Outcome of orthotopic liver transplantation in patients with haemophilia

Background—Many patients with haemophilia havedeveloped cirrhosis or hepatocellular carcinoma due to transfusionacquired chronic viral hepatitis.
Aims—To assess the long term outcome of allhaemophilic patients reported to have undergone orthotopic liver transplantation.
Methods—Transplant centres of patients identifiedby medical database search were contacted and survival data assessed by Kaplan-Meier analysis.
Results—Twenty six haemophilic men (median age 46 years, range 5-63 years) underwent orthotopic liver transplantation in16centres between 1982 and 1996. Indications for transplantation werehepatitis C cirrhosis (69%), hepatitis B with or without C cirrhosis(15%), viral hepatitis related hepatocellular carcinoma (12%), andbiliary atresia (4%). Six patients (23%) were infected with humanimmunodeficiency virus (HIV). Postoperatively, the median time tonormal clotting factor levels was 24 hours (range 0-48 hours) andexogenous clotting factors were stopped at a median of 24 hours (range0-480 hours). Four patients (15%) had bleeding complications. The oneand three year survival of HIV positive recipients (67% and 23%) wassignificantly poorer (p=0.0003) than that of HIV negative recipients(90% and 83%). Coagulopathy was cured in all patients surviving morethan 12 days post-transplant. Six of the 20 patients (30%) withhepatitis C cirrhosis pretransplant had evidence of disease recurrenceat a mean of nine months post-transplant.
Conclusions—Hepatitis C cirrhosis is the mostcommon indication for orthotopic liver transplantation in patients withhaemophilia. Transplantation results in long term cure of haemophiliabut may be complicated by the effects of HIV infection or recurrentviral hepatitis.

Keywords:liver transplantation; haemophilia; hepatitis C; cirrhosis; HIV

     

Energy expenditure and body composition in children with Crohn's disease: effect of enteral nutrition and treatment with prednisolone

Background—Malnutrition and growth retardation arecommon complications of Crohn's disease in children. The contributionof resting energy expenditure (REE) to malnutrition is unclear.
Aims—To characterise the REE and body compositionin children with Crohn's disease and compare them with normal controlsand patients with anorexia nervosa; to compare the effects ofprednisolone and enteral nutrition on energy expenditure and body composition.
Subjects—Twenty four children with Crohn'sdisease, 19 malnourished females with anorexia nervosa, and 22 healthycontrol subjects were studied.
Methods—In children with Crohn's diseasemeasurements were done when the disease was acute and repeated at oneand three months after treatment with either prednisolone or enteralnutrition. Resting energy expenditure was measured by indirectcalorimetry and body composition by anthropometry, bioelectricalimpedance analysis, total body potassium,H₂¹⁸O, and bromide space studies.
Results—Body weight and ideal body weight weresignificantly lower in patients with Crohn's disease than in healthycontrols. Lean tissue was depleted and there was an increase inextracellular water. Per unit of lean body mass, there was nodifference between REE in patients with Crohn's disease and controls,whereas patients with anorexia nervosa had significantly reduced REE.With enteral nutrition all body compartments and REE increasedsignificantly (p<0.001). In a subgroup of age-matched men there was asignificant increase in height after three months of enteral nutritioncompared with prednisolone (p<0.01). Those treated with steroids didnot show a significant change in height but did show an increase in allbody compartments. However, intracellular water as well as lean bodymass accretion were significantly higher in the enteral nutrition groupthan in the prednisolone group.
Conclusions—Despite being malnourished, childrenwith Crohn's disease fail to adapt their REE per unit of lean bodymass. This might be a factor contributing to their malnutrition. Lean tissue accretion is higher in patients treated with enteral nutrition than in those treated with prednisolone.

Keywords:Crohn's disease; resting energy expenditure; bodycomposition; anorexia nervosa; prednisolone; enteral nutrition

     

Low dose amiodarone and sotalol in the treatment of recurrent, symptomatic atrial fibrillation: a comparative, placebo controlled study

OBJECTIVE—To assess and compare the safety and efficacy of amiodarone and sotalol in the treatment of patients with recurrent symptomatic atrial fibrillation.
DESIGN—Prospective, randomised, single blind, placebo controlled study.
SETTING—Tertiary cardiac referral centre.
PATIENTS—186 consecutive patients (97 men, 89 women; mean (SD) age, 63 (10) years) with recurrent, symptomatic atrial fibrillation.
INTERVENTIONS—65 patients were randomised to amiodarone, 61 to sotalol, and 60 to placebo. Patients receiving amiodarone were maintained at a dose of 200 mg/day after a 30 day loading phase. The sotalol dose was 160-480 mg daily, as tolerated.
MAIN OUTCOME MEASURES—Recurrence of atrial fibrillation or side effects.
RESULTS—In the amiodarone group, 31 of the 65 patients developed atrial fibrillation after an average of six months, while 15 (11 in sinus rhythm and four in atrial fibrillation) experienced significant side effects after an average of 16 months. In the sotalol group, relapse to atrial fibrillation occurred in 47 of the 61 patients after an average of eight months; three experienced side effects during the titration phase. In the placebo group, 53 of the 60 patients developed atrial fibrillation after an average of four months (p < 0.001 for amiodarone and sotalol v placebo; p < 0.001 for amiodarone v sotalol).
CONCLUSIONS—Both amiodarone and sotalol can be used for the maintenance of normal sinus rhythm in patients with symptomatic atrial fibrillation. Amiodarone is more effective but causes more side effects.


Keywords: amiodarone; sotalol; atrial fibrillation     

Clinical significance of subcutaneous calcinosis in patients with systemic sclerosis. Does diltiazem induce its regression?

OBJECTIVE—To establish whether diltiazem reduces subcutaneous calcinosis (SCC) in patients with systemic sclerosis (SSc), and whether this calcinosis is related to other signs or symptoms.
METHODS—47 patients with SSc were evaluated and divided into two groups according to the presence or absence of SCC.
RESULTS—Among the 12 patients with SCC who were treated with diltiazem and had sequential hand radiographs (differential time between the two radiographs: 7.8±4 years), there was a slight radiological improvement in three patients only. More patients with SCC had anticentromere antibodies than patients without (p=0.003), fewer had anti-Scl 70 antibodies (p=0.01), more had telangiectasia and giant capillaries (p=0.04 and 0.048 respectively), and SCC patients had significantly fewer capillaries at the nailfold (p=0.03).
CONCLUSION—These results do not clearly indicate that diltiazem is effective in calcinosis associated with SSc. Among the patients with SSc, those who also had SCC exhibited a distinctive autoimmune profile and more severe cutaneous capillary injury than those without SCC.

Keywords: systemic sclerosis; scleroderma; calcinosis; diltiazem     

A randomised, double blind, multicentre trial of octreotide in moderate to severe acute pancreatitis

BACKGROUND—The pharmacological inhibition of exocrine pancreatic secretion with the somatostatin analogue octreotide has been advocated as a specific treatment of acute pancreatitis.
AIM—To investigate the efficacy of octreotide in acute pancreatitis in a randomised, placebo controlled trial.
METHODS—302 patients from 32 hospitals, fulfilling the criteria for moderate to severe acute pancreatitis within 96 hours of the onset of symptoms, were randomly assigned to one of three treatment groups: group P (n=103) received placebo, while groups O1 (n=98) and O2 (n=101) received 100 and 200 µg of octreotide, respectively, by subcutaneous injection three times daily for seven days. The primary outcome variable was a score composed of mortality and 15 typical complications of acute pancreatitis.
RESULTS—The three groups were well matched with respect to pretreatment characteristics. An intent to treat analysis of all 302 patients revealed no significant differences among treatment groups with respect to mortality (P: 16%; O1: 15%; O2: 12%), the rate of newly developed complications, the duration of pain, surgical interventions, or the length of the hospital stay. A valid for efficacy analysis (251 patients) also revealed no significant differences.
CONCLUSIONS—This trial shows no benefit of octreotide in the treatment of acute pancreatitis.


Keywords: acute pancreatitis; somatostatin; octreotide; randomised controlled multicentre trial