Gluten-free Casein-free Diet Research Articles

CLINICAL NUTRITION PROGRAM IMPROVES CORE FEATURES OF AUTISM IN 3 YEAR OLD GIRL

Event Abstract Back to Event CLINICAL NUTRITION PROGRAM IMPROVES CORE FEATURES OF AUTISM IN 3 YEAR OLD GIRL David J. Clark1* 1 Carrick Institute of Clinical Neuroscience and Rehabilitation, United States Background: A 3 year old Africa-American girl was presented by her mother with chief concerns of language delay characterized by using only one or two word communications, receptive language delay, stereotypies (e.g. hand flapping), toe walking, low attention span, inability to focus, repetitive behaviors (e.g. opening/closing doors, turning lights on and off), and tantrums lasting 15 to 20 minutes. She routinely awoke giggling from sleep at 1:00 a.m. Past interventions included chelation, removal of gluten and casein, as well as current consumption of many supplements. She was currently following a gluten-free and casein-free diet, although not strictly, at time of presentation. Methods: Neurological examination revealed an ability to visually fixate and hold gaze steady, pursue a target without moving her head, grossly intact optokinetic reflexes horizontally and vertically. She demonstrated no gross ataxia or incoordination. Blood chemistry revealed high platelet count (550,000), low neutrophil percentage (33%), high lymphocyte percentage high serum B12 (1,500), low methylmalonic acid (70). Clinically significant results were noted in the following: white blood cell count (10.6), vitamin D (36.6). Tissue antibody testing showed out of range antibody levels for ASCA+ANCA and borderline antibody levels for Intrinsic Factor and Synapsin. Urine organic acid testing showed high carboxycitric, high 4-Hydroxybenzoic, high 4-Cresol, high succinate, high aconitate, high 2-hydroxyhippuric. She was placed on an anti-inflammatory and anti-fungal supplement regimen including magnesium threonate, phenibut, saccaromyces boulardii, lauric acid, probiotics, vitamin D, omega fatty acids, turmeric and resveratrol. Her mother was directed to strictly follow a gluten-free and casein-free diet with her. Results: After 30 days, the patient began to sit still for minutes at a time, began doing independent art projects and using 4 to 6 word communications but without appropriate grammar. She began sleeping through the night undisturbed. After 60 days, she called her mother “Mommy” for the first time, as well as her sister and father by name. In addition, she spoke her first complete grammatically correct sentence. At school, she was noted to engage in appropriate imaginative play for the first time ever, as well as completing art projects in class independently. She had not had a tantrum in 6 weeks. Over the next 6 months, the patient began making friends and playing with other children on the playground, stereotypies and repetitive behaviors reduced, toilet training was mastered, expressive language continued to improved but she was not yet engaging in conversation. Conclusion: The author suggests further investigation into clinical nutrition and supplementation in the treatment of children with Autism Spectrum Disorders. Keywords: Autism spectrum disorders (ASD), gluten-free casein-free diet, small intestinal fungal overgrowth, Sleep Disorders, Stereotyped Behavior Conference: International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function, Orlando, United States, 7 Oct - 9 Oct, 2016. Presentation Type: Poster Presentation Topic: Abstracts ISCN 2016 Citation: Clark DJ (2016). CLINICAL NUTRITION PROGRAM IMPROVES CORE FEATURES OF AUTISM IN 3 YEAR OLD GIRL . Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function. doi: 10.3389/conf.fneur.2016.59.00076 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 02 Sep 2016; Published Online: 07 Sep 2016. * Correspondence: Dr. David J Clark, Carrick Institute of Clinical Neuroscience and Rehabilitation, Cape Canaveral, FL, United States, mail@doctordavidclark.com Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers David J Clark Google David J Clark Google Scholar David J Clark PubMed David J Clark Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Ernährungstherapie bei Autismus-Spektrum-Störungen im Kindes- und Jugendalter: wie ist die Evidenz?

Autism spectrum disorders (ASDs) are a group of developmental disabilities in childhood and adolescence. Beside genetic predisposition also environmental influences may contribute to the ASD pathogenesis. Family members of children and adolescents with ASD often ask for specific diets to alleviate ASD-associated symptoms. The aim of this review is to provide evidence-based data on nutritional interventions for children and adolescents with ASD, thus enabling practitioners to competently assess these diets. Applying defined inclusion and exclusion criteria, a systematic literature research in PubMed, Cinahl and The Cochrane Library was conducted. Studies published earlier than 1999 were excluded. Study quality was assessed by using the CONSORT, STROBE or PRISMA checklist, respectively. 12 randomised controlled studies and 2 non-controlled studies could be included in the evaluation (n=971). There is no proven efficacy of the widely used gluten-free casein-free diets (GFCF), and no respective predictive marker has been proven significant. Based on available data, no evidence based recommendations regarding nutritional interventions for children and adolescents with autism spectrum disorders can be made. Future studies need to clarify whether particular patients may yet benefit from certain diets.

Use and Perceived Effectiveness of Complementary and Alternative Medicine to Treat and Manage the Symptoms of Autism in Children: A Survey of Parents in a Community Population.

Parents of children with autism spectrum disorders (ASDs) often try a variety of treatments for their children, including complementary and alternative medicine (CAM). The objective of this study was to improve understanding of the frequency of CAM use by parents for their children with autism and to quantify the parents' perceived effectiveness of various CAM therapies in mitigating the health and functioning problems associated with autism. Parents in southeastern Virginia were recruited for study participation from local autism organizations and a clinical practice where a large proportion of the patients are children with autism. Parents completed an online survey and answered questions about CAM use for their children with autism, and they rated the perceived effectiveness of each therapy. Of 194 parents surveyed, 80.9% reported that they had tried some form of CAM for their child with autism. Among CAM users, the most frequently used therapies were multivitamins (58.6%), the gluten-free casein-free diet (54.8%), and methyl B-12 injections (54.1%). The CAM therapies that received the highest average rating of effectiveness were sensory integration therapy, melatonin, and off-label use of prescription antifungal medications. CAM therapies were frequently used in this population, and many were perceived to be effective in helping to ease some of the health challenges associated with autism. CAM therapies for the autism population should be further studied in well-controlled clinical research settings to provide safety and efficacy data on treatments, as well as validated treatment options for those with ASD.

A review of gluten- and casein-free diets for treatment of autism: 2005-2015.

The gluten free, casein free (GFCF) diet is heralded by strong anecdotal parental reports to greatly improve and even "cure" symptoms of Autism Spectrum Disorders (ASD). Yet to date, little conclusive empirical evidence exists supporting its use. The purpose of this paper is to provide an overview of the state of the recent evidence regarding use of GFCF diet for treatment of individuals with ASD. Five database providers (PubMed, Web of Knowledge, EBSCO, ProQuest, and WorldCat) were used to search 19 databases yielding a total of 491 articles that were published through February 2015. Peer reviewed articles published between 2005 and February 2015 were included for review if study participants were identified as having ASD and investigated the effects of the GFCF diet on ASD behaviors or the relationship between the diet and these behaviors. Evaluation of search results yielded 11 reviews, 7 group experimental studies including 5 randomized controlled trials, 5 case reports, and 4 group observational studies published during the last 10 years. These studies represent a marked increase in number of reported studies as well as increased scientific rigor in investigation of GFCF diets in ASD. While strong empirical support for the GFCF diet in ASD is currently lacking, studies point to the need for identifying subsets of individuals (e.g., those with documented gastrointestinal abnormalities) who may be the best responders to the GFCF diet. Identifying these subsets is critically needed to enhance rigor in this research area. Until rigorous research supporting use of GFCF diet is reported, clinicians should continue use caution and consider several factors when advising regarding implementation of the GFCF diet for individuals with ASD.

Dietary Supplementation in Children with Autism Spectrum Disorders: Common, Insufficient, and Excessive

BackgroundLittle is known about the effect on dietary adequacy of supplements given to children with autism spectrum disorder (ASD). ObjectiveThis cross-sectional study examines dietary supplement use and micronutrient intake in children with ASD. DesignThree-day diet/supplement records and use of a gluten/casein-free diet (GFCF) were documented. Estimates of usual intake of micronutrients from food and supplements were compared with the Dietary Reference Intakes. ParticipantsChildren aged 2 to 11 years (N=288) with ASD from five Autism Treatment Network sites from 2009-2011. Main outcome measuresPercentage of children meeting or exceeding upper limits of micronutrient intake with or without supplements and relative to GFCF diet status. Statistical analysisMicronutrient intake from food and supplements was compared by Spearman rank correlation. Usual intake was estimated by the National Cancer Institute method adjusted for age, sex, supplement use, and GFCF diet. Adequacy of intake was compared between supplement use status and between food and total intake in supplement users relative to Dietary Reference Intakes limits. ResultsDietary supplements, especially multivitamin/minerals, were used by 56% of children with ASD. The most common micronutrient deficits were not corrected (vitamin D, calcium, potassium, pantothenic acid, and choline) by supplements. Almost one-third of children remained deficient for vitamin D and up to 54% for calcium. Children receiving GFCF diets had similar micronutrient intake but were more likely to use supplements (78% vs 56%; P=0.01). Supplementation led to excess vitamin A, folate, and zinc intake across the sample, vitamin C, and copper among children aged 2 to 3 years, and manganese and copper for children aged 4 to 8 years. ConclusionsFew children with ASD need most of the micronutrients they are commonly given as supplements, which often leads to excess intake. Even when supplements are used, careful attention should be given to adequacy of vitamin D and calcium intake.

Review article: intestinal barrier dysfunction and central nervous system disorders--a controversial association.

Central nervous system (CNS) development and physiopathology are greatly affected by environmental stimuli. The intestinal barrier restricts the entrance of toxins, pathogens, and antigens while modulating the expression of various neuroactive compounds. The existence of a rich gut-to-brain communication raises the possibility that intestinal barrier alterations may take part in the pathophysiology of CNS disorders. To review evidence associating intestinal barrier dysfunction with the development of CNS disorders. Literature search was conducted on PubMed using the following terms: intestinal barrier, intestinal permeability, central nervous system, mental disorders, schizophrenia, autism, stress, anxiety, depression, and neurodegeneration. Clinical and animal model studies of the association between intestinal barrier and schizophrenia, autism spectrum disorders, neurodegenerative diseases or depression were reviewed. The majority of reports concentrated on schizophrenia and autism spectrum disorders. About half of these described increased intestinal permeability/mucosal damage in patients compared with healthy controls, with up to 43% of children with autism spectrum disorders and up to 35% of schizophrenia patients displaying abnormally high urinary excretion of the sugars used as permeability markers. However, another substantial group of studies did not find such differences. In autism spectrum disorders, some reports show that the use of diets such as the gluten-free casein-free diet may contribute to the normalisation of lactulose/mannitol ratio, but to date there is no adequately controlled study showing improvement in behavioural symptoms following these dietary interventions. Evidence of altered intestinal permeability in individuals suffering from CNS disorders is limited and cannot be regarded as proven. Moreover the efficacy of targeting gut barrier in the management of neurological and behavioural aspects of CNS disorders has not yet been established, and needs further investigation.

Parents’ and Child Health Professionals’ Attitudes Towards Dietary Interventions for Children with Autism Spectrum Disorders

Parents of children with autism spectrum disorders (ASD) use a wide range of interventions including poorly evidenced dietary interventions. To investigate parents' and professionals' experience of dietary interventions and attitudes towards a proposed trial to evaluate the gluten free casein free diet (GFCFD). Survey of U.K. parents of children with ASD, and professionals. 258 parents and 244 professionals participated. 83 of children had received a range of dietary manipulations; three quarters of professionals have been asked for advice about GFCFD. Respondents identified an inadequate evidence base for dietary interventions in ASD and suggested modifications to a proposed trial design. Both parents and professionals supported the need for further evaluation of dietary interventions in ASD.

The Gluten-Free, Casein-Free Diet and Autism

The gluten-free, casein-free (GFCF) diet is widely used by families of children with autism spectrum disorders (ASD). Despite its popularity, there is limited evidence in support of the diet. The purpose of this article was to identify and evaluate well-controlled studies of the GFCF diet that have been implemented with children with ASD. A review of the literature from 1999 to 2012 identified five studies meeting inclusion criteria. Research rigor was examined using an evaluative rubric and ranged from Adequate to Strong. In three of the studies, no positive effects of the diet were reported on behavior or development, even after double-blind gluten and casein trials. Two studies found positive effects after 1 year but had research quality concerns. Reasons why families continue to expend effort on GFCF diets despite limited empirical evidence are discussed. Recommendations are that families should invest time and resources in more robustly supported interventions and limit GFCF diets to children diagnosed with celiac disease or food allergies.

A review of traditional and novel treatments for seizures in autism spectrum disorder: findings from a systematic review and expert panel.

Despite the fact that seizures are commonly associated with autism spectrum disorder (ASD), the effectiveness of treatments for seizures has not been well studied in individuals with ASD. This manuscript reviews both traditional and novel treatments for seizures associated with ASD. Studies were selected by systematically searching major electronic databases and by a panel of experts that treat ASD individuals. Only a few anti-epileptic drugs (AEDs) have undergone carefully controlled trials in ASD, but these trials examined outcomes other than seizures. Several lines of evidence point to valproate, lamotrigine, and levetiracetam as the most effective and tolerable AEDs for individuals with ASD. Limited evidence supports the use of traditional non-AED treatments, such as the ketogenic and modified Atkins diet, multiple subpial transections, immunomodulation, and neurofeedback treatments. Although specific treatments may be more appropriate for specific genetic and metabolic syndromes associated with ASD and seizures, there are few studies which have documented the effectiveness of treatments for seizures for specific syndromes. Limited evidence supports l-carnitine, multivitamins, and N-acetyl-l-cysteine in mitochondrial disease and dysfunction, folinic acid in cerebral folate abnormalities and early treatment with vigabatrin in tuberous sclerosis complex. Finally, there is limited evidence for a number of novel treatments, particularly magnesium with pyridoxine, omega-3 fatty acids, the gluten-free casein-free diet, and low-frequency repetitive transcranial magnetic simulation. Zinc and l-carnosine are potential novel treatments supported by basic research but not clinical studies. This review demonstrates the wide variety of treatments used to treat seizures in individuals with ASD as well as the striking lack of clinical trials performed to support the use of these treatments. Additional studies concerning these treatments for controlling seizures in individuals with ASD are warranted.

A pilot study to evaluate nutritional influences on gastrointestinal symptoms and behavior patterns in children with Autism Spectrum Disorder

One in 110 children in the US have autism spectrum disorder (ASD), a debilitating and life-long disorder that affects the health, relationships, and learning of affected children. Existing research on the etiology, contributing factors, and treatment for ASD is limited and controversial. Studies suggest that GI symptoms are related to behavior issues in children with ASD, which may be improved by a gluten-free, casein-free (GFCF) diet. To evaluate the relationship between a GFCF diet and gastrointestinal symptoms and behavior patterns in children with ASD. Cross-sectional design in which parents completed an online survey regarding general health, diet (adapted food-frequency questionnaire (FFQ)), gastrointestinal symptoms, and behavior patterns of their children with ASD. Scores on the Gastrointestinal Symptoms Rating Scale (GSRS) and Childhood Autism Rating Scale (CARS). Seven of thirteen children (median age 9years) were on a GFCF diet, consuming significantly fewer gluten- and casein-containing foods than those not on a GFCF diet. GSRS and CARS scores did not differ significantly according to diet. Parents of all the children on a GFCF diet reported improved GI symptoms and behavior patterns. This study provides evidence that the adapted FFQ is an effective tool for evaluating adherence to a GFCF diet. Continued well-controlled research is necessary to elucidate the gut-brain relationship in ASD.

Mealtime feeding behaviors and gastrointestinal dysfunction in children with classic autism compared with normal sibling controls

Introduction: We compared the frequency and duration of specific mealtime behaviors and GI dysfunction in children with classic autism to typically-developing siblings. Survey Method: A 41-item on-line parent survey. Statistics: Chi square and binomial logistical regression. Results: 79 children with classic autism matched with a normally-developing sibling. Logistic Regression Analysis Revealed: Dislike of new foods and bizarre mealtime mannerisms, were more frequent in those with classic autism (p < 0.01). They also had higher odds ratio of constipation and fecal incontinence (p < 0.01). 40% of children with classic autism had been on GFCF diets (p < 0.01). Only 1% of those children on a gluten-free diet had a biopsy-proven diagnosis of celiac disease. Conclusion: Children with classic autism had more frequent dislike of new foods, bizarre mealtime behaviors, constipation, and fecal incontinence.

Effects of Gluten Free / Casein Free Diet in Young Children with Autism: A Pilot Study

With reports of the growing incidence of autism spectrum disorder ASD in the United States, a large number of families of affected children is seeking alternative or complementary forms of treatment. One of the more popular interventions has been use of elimination regimes, such as the gluten and casein free (GFCF) diet. This pilot study involved a three-month, prospective, open label, randomized, parallel groups design of a GFCF diet compared to a healthy, low sugar diet (attention control) for young children with ASD. Both treatment groups evidenced some gains across a range of variables, including measures of behavior, language, and ratings of the core features of ASD. No statistically significant differences were noted between treatment groups. While our results do not support use of a GFCF diet in ASD, it is possible that a greater period of time is required for treatment before gains can be observed. Moreover, no significant nutritional differences or side effects were observed on the GFCF diet compared to the control diet. However, adherence to the GFCF diet proved difficult based on our adherence data.

Parents' and child health professionals' attitudes to dietary interventions in autism spectrum disorder: findings from a UK survey

A recent Cochrane review highlighted the need for rigorous evaluation of the gluten free casein free (GFCF) diet in autism spectrum disorder (ASD). A multi-site randomised controlled trial (RCT) would require the cooperation of both parents and child health professionals. <h3>Aims</h3> To investigate parents9 and child health professionals9 attitudes towards dietary interventions including the GFCF diet. To assess the feasibility of an RCT of this diet in preschool children with autism, and identify potential barriers and facilitators for successful trial completion. <h3>Methods</h3> UK parents of children with ASD and child health professionals were invited to complete a short web-based questionnaire. <h3>Results (Findings to Date)</h3> 247 of 361 parents and 248 of 317 professionals (of these 42% were paediatricians, 35% child and adolescent psychiatrists; 23% dieticians and “other” professionals) who expressed an interest have completed the relevant versions of the questionnaire. Parents: Just under half (46%) were currently giving their child dietary supplements. 84% were aware of GFCF diet (51% of these had heard about it from other parents). A third were implementing special diets, mainly GFCF (81%), and all but 2 of these families were also using dietary supplements. Three quarters of parents said they would “definitely” take part, or would consider participating in an RCT of GFCF diet. Parents commented that they would be more likely to enrol their child knowing they would have access to a study dietician. Professionals: 50% of all respondents reported they did not know enough about the efficacy of the GFCF diet to advise families and 72% had been approached by parents for advice about this diet. The majority of professionals (94%) strongly supported the need for evaluation of the GFCF diet and 75% would be prepared to recruit children to a future trial. <h3>Conclusion</h3> These findings confirm the need to evaluate biomedical interventions such as the GFCF diet. Facilitators and barriers towards recruitment and retention of families for a future RCT have been identified. Professionals and parents have shown support through their preparedness to refer, and willingness to participate.

The Gluten‐Free, Casein‐Free Diet in Autism: An Overview With Clinical Implications

The prevalence of classic autism and autism spectrum disorder (ASD) appears to be on the rise, and to date, there remains no clear etiology or cure. Out of desperation, many families are turning to new therapies and interventions discovered through various media sources and anecdotal reports from other parents. Unfortunately, many of these newer, well-publicized interventions have little empirical support. One of the most popular yet currently scientifically unproven interventions for ASD is the gluten-free, casein-free (GFCF) diet. Clinicians working with families of individuals with ASD are often asked for advice and find themselves unable to offer the most up-to-date and scientifically credible information. This article provides an overview of ASD and the GFCF diet, a summary and critique of current research findings, recommendations for future research, and practical advice for families to use in deciding if a trial of the GFCF diet is in the best interest of their child and family.

Development of double blind gluten and casein free test foods for use in an autism dietary trial

Background: Autism is a severe long‐term neurodevelopmental disorder. Families are increasingly undertaking a gluten and casein free (GFCF) diet in response to largely anecdotal reports of autistic clinical improvement. Exclusion of staple foods can place these children, with self‐imposed limited diets, at nutritional risk (Keen, 2007). There is an urgent need to investigate the efficacy of GFCF diets in an adequately powered, medium term, randomised controlled trial (Millward et al., 2007). However, double blinding to the removal of gluten and/or casein is desirable but complex to accomplish. Therefore, this study was essential preparation for a large scale study and investigated the feasibility of producing test foods to achieve double‐blinding which are transportable, easy to prepare, palatable and suitable for daily consumption by young children with autism.Methods: Heron Foods Cork, developed a range of test foods including a muffin, porridge and batter mix, lemon and almond cookies and chocolate krispie bars. The estimated average habitual intake (Gregory et al., 1995) of gluten (10 g) and/or casein (10 g) was added as outlined below: Test Food with gluten and casein added; Test Food with added casein only; Test Food with added gluten only; Test Food with no gluten or casein added. Groups were randomly labelled A–D. The foods’ GFCF status or presence of additions was confirmed by independent assay. R&amp;D and ethical approval was given for health professionals to recruit 60 children with autism (3–6 years) in Newcastle, Edinburgh and London and to randomly allocate to the above groups. Following assessment of eligibility and informed consent, families received a supply of test foods, detailed cooking instructions and behaviour and food preference questionnaires for self‐completion. Parents offered test foods for 28 days and recorded daily consumption. As this study investigated the acceptability of the test foods and not the effect of GFCF diet on autism, gluten and casein containing foods were not withdrawn from the child's diet. Telephone dietetic support was available throughout. Outcomes were measured by food consumption diaries, a test foods acceptability questionnaire and telephone interviews with a sub‐set of parents. Parents and all researchers were blind to group allocation.Results: A total of 52 children were recruited with only three families withdrawing during the 28 days due to food refusal. Results are available for the first 43 children [A – 9, B – 10, C – 13, D – 11]. Of 38 parents responding 63% stated that their children were ‘usually willing to try new foods’ [A – 86%, B – 67%, C – 42%, D – 70%]. Ninety‐five percent of the children (n = 40) [A – 89%, B – 90%, C – 100%, D – 100%] tried at least some foods over the 28 days. Muffins and chocolate krispies were most readily accepted. Porridge and batter mix were least well liked. Children in groups A and D were most likely to consume more of the foods offered. The status of the groups is not yet known but these results suggest that porridge could be removed as an option. At interview parents confirmed these findings and suggested an alternative savoury food item such as bread should be available.Discussion: Families demonstrated a high level of motivation and commitment to this study indicating their desire for dietary research in autism. The research team encountering considerable challenges in both the planning and execution of this study, but despite this, a range of test foods have been produced suitable for young children with autism.Conclusion: This is the first study to develop and test a range of double‐blind test foods for regular consumption by young children with autism. This is essential preparation for a large scale multicentered RCT of gluten and casein free diets in the management of autism.Funded by Research Autism &amp; The Children's Foundation. This work was supported by the BDA General Education Trust.References Gregory, J.R., Collins, D.L., Davies, P.S.W., Hughes, J.M. &amp; Clarke, P.C. (1995) National Diet and Nutrition Survey: children aged 1 1/2 to 4 1/2 years, volume 1: Report of the Diet and Nutrition. London: HMSO.Keen, D.V. (2007) Childhood autism, feeding problems and failure to thrive in early infancy. Seven case studies. Eur. Child. Adolesc. Psychiatry. Published online Sept 14th 2007.Millward, C., Ferriter, M., Calver, S., &amp; Connell‐Jones, G. (2007) Gluten‐ and casein‐free diets for autistic spectrum disorder. Cochrane Database Syst. Rev.4, CD003498.