Enteral Nutrition in Crohn’s Disease: An Underused Therapy

This paper reviews the literature on the history, efficacy, and putative mechanism of action of enteral nutrition for inflammatory bowel disease in both paediatric and adult patients. It also analyses the reasoning behind the low popularity of exclusive enteral nutrition in clinical practice despite the benefits and safety profile

Biologics in Paediatric Crohn's Disease

Crohn's disease affects increasing numbers of children worldwide. Generally, childhood-onset disease runs a more severe course than in adults and has a greater impact on quality of life. Therapy in children must take account of a different set of risks for toxicity compared to adults, but also to their longevity. Biologic drugs present remarkable advantages in terms of disease control for children, especially in those whose disease cannot be controlled with conventional therapies, but their long-term risks are still being assessed. Data regarding biologic use in children is limited and mostly amounts to case series, but results have been promising, both in terms of controlling disease activity and improving growth parameters. Adverse reactions are infrequent in the short term, but loss of response is a long-term problem, particularly in children. More information is needed about very long term risks. Infliximab and adalimumab are the most studied agents in children, while there is relatively limited data on certolizumab and natalizumab. Further collection of data on these agents is still needed, but this should not restrict access to these agents for children in whom no other agent is effective

Quality indicators for bladder cancer services : a collaborative review

Context There is a lack of accepted consensus on what should constitute appropriate quality-of-care indicators for bladder cancer. Objective To evaluate the optimal management of bladder cancer and propose quality indicators (QIs). Evidence acquisition A systematic review was performed to identify literature on current optimal management and potential quality indicators for both non–muscle-invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer. A panel of experts was convened to select a recommended list of QIs. Evidence synthesis For NMIBC, preoperative QIs include tobacco cessation counselling and appropriate imaging before initial transurethral resection of bladder tumour (TURBT). Intraoperative QIs include administration of antibiotics, proper safe conduct of TURBT using a checklist, and performing restaging TURBT with biopsy of the prostatic urethra in appropriate cases. Postoperative QIs include appropriate receipt of perioperative adjuvant therapy, risk-stratified surveillance, and appropriate decision to change therapy when indicated (eg, unresponsive to bacillus Calmette-Guerin). For MIBC, preoperative QIs include multidisciplinary care, selection for candidates for continent urinary diversion, receipt of neoadjuvant cisplatin-based chemotherapy, time to commencing radical treatment, consideration of trimodal therapy as a bladder-sparing alternative in select patients, preoperative counselling with stoma marking, surgical volume of radical cystectomy, and enhanced recovery after surgery protocols. Intraoperative QIs include adequacy of lymphadenectomy, blood loss, and operative time. Postoperative QIs include prospective standardised monitoring of morbidity and mortality, negative surgical margins for pT2 disease, appropriate surveillance after primary treatment, and adjuvant cisplatin-based chemotherapy in appropriate cases. Participation in clinical trials was highlighted as an important component indicating high quality of care. Conclusions We propose a set of QIs for both NMIBC and MIBC based on established clinical guidelines and the available literature. Measurement of these QIs could aid in improvement and benchmarking of optimal care of bladder cancer. Patient summary After a systematic review of existing guidelines and literature, a panel of experts has recommended a set of quality indicators that can help providers and patients measure and strive towards optimal outcomes for bladder cancer care

A Case of Cyclic Vomiting Syndrome Responding to Gonadotropin-Releasing Hormone Analogue

Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent episodes of incapacitating nausea and vomiting interspersed with symptom free periods. Common triggers of cyclic vomiting include noxious stress, excitement, fatigue and menstrual period. Here, we report a case of cyclic vomiting syndrome in adult patient characterized by stereotypical vomiting attack, occurring in every menstruation period. Recurrent vomiting episodes began 6 years ago and we treated this patient with subcutaneous injection of goserelin, a gonadotropin-releasing hormone analogue (GnRHa) and oral estrogen. After 4 months of therapy, she was symptom free for the following 5 years, even with the resumed normal menstruation. Recurrence of vomiting attack with same pattern occurred 1 month before readmission. Treatment with intravenous lorazepam aborted vomiting, but could not prevent recurrences of vomiting and epigastric pain. We treated the patient with GnRHa and oral estradiol again which effectively prevented recurrence of the symptoms

A Model of Turbulence in Magnetized Plasmas: Implications for the Dissipation Range in the Solar Wind

This paper studies the turbulent cascade of magnetic energy in weakly collisional magnetized plasmas. A cascade model is presented, based on the assumptions of local nonlinear energy transfer in wavenumber space, critical balance between linear propagation and nonlinear interaction times, and the applicability of linear dissipation rates for the nonlinearly turbulent plasma. The model follows the nonlinear cascade of energy from the driving scale in the MHD regime, through the transition at the ion Larmor radius into the kinetic Alfven wave regime, in which the turbulence is dissipated by kinetic processes. The turbulent fluctuations remain at frequencies below the ion cyclotron frequency due to the strong anisotropy of the turbulent fluctuations, k_parallel << k_perp (implied by critical balance). In this limit, the turbulence is optimally described by gyrokinetics; it is shown that the gyrokinetic approximation is well satisfied for typical slow solar wind parameters. Wave phase velocity measurements are consistent with a kinetic Alfven wave cascade and not the onset of ion cyclotron damping. The conditions under which the gyrokinetic cascade reaches the ion cyclotron frequency are established. Cascade model solutions imply that collisionless damping provides a natural explanation for the observed range of spectral indices in the dissipation range of the solar wind. The dissipation range spectrum is predicted to be an exponential fall off; the power-law behavior apparent in observations may be an artifact of limited instrumental sensitivity. The cascade model is motivated by a programme of gyrokinetic simulations of turbulence and particle heating in the solar wind.Comment: 29 pages, 14 figure

Bloch bundles, Marzari-Vanderbilt functional and maximally localized Wannier functions

We consider a periodic Schroedinger operator and the composite Wannier functions corresponding to a relevant family of its Bloch bands, separated by a gap from the rest of the spectrum. We study the associated localization functional introduced by Marzari and Vanderbilt, and we prove some results about the existence and exponential localization of its minimizers, in dimension d < 4. The proof exploits ideas and methods from the theory of harmonic maps between Riemannian manifolds.Comment: 37 pages, no figures. V2: the appendix has been completely rewritten. V3: final version, to appear in Commun. Math. Physic