Discharge planning from A & E: Part I

The discharge of patients from hospital has always been a vital part of the nurse's role. The government recognized the need for health personnel to plan effective discharge of patients from hospital and guidelines were produced by the Department of Health in 1989. While these were aimed more at the inpatient than the Accident and Emergency (A & E) attender, many of the recommendations can be applied to the emergency setting. Nowhere more than A & E does this create a management problem for patients, carers and colleagues alike. Those patients that belong to vulnerable groups, the elderly, the homeless, children and the mentally ill require a comprehensive discharge programme, utilizing the skills and knowledge of a number of community care personnel. Current practices are explored and recommendations made for future management. Part 2 of the study, covering appropriate discharge advice for patients who do not need to reattend the department, will be published in 1998.

Assessment and management of ulcerative colitis in children

The incidence of ulcerative colitis in school-age children in most parts of Europe has been steady at 1.5-2.0 per 100,000 children per year for the last 20-30 years. In comparison to adults, abdominal pain is a relatively frequent presenting symptom in children in addition to rectal bleeding, bloody diarrhoea or diarrhoea. Distribution of disease in children is generally more extensive (ratio rectal:left sided:extensive 25:30:45). There are remarkably few clinical trials of therapy in children and reasons for this are discussed. Subjective indices of disease severity and activity are unreliable in children. Objective measures such as endoscopy are of value to define the extent of ulceration and histopathological features; a test of gut protein loss using whole gut lavage gives an objective index of disease activity. Principles of medical management in children are generally the same as in adults with the additional need for scrupulous attention to nutrition and growth, and psychological factors. Reassuring results of a review of the health status of young adults who had developed ulcerative colitis in childhood are presented. Twenty-four of 27 considered themselves fully fit although nine of the patients had a permanent ileostomy.

Linkage analysis of candidate regions for coeliac disease genes

A strong HLA association is seen in coeliac disease [specifically to the DQ(alpha1*0501,beta1*0201 heterodimer], but this cannot entirely account for the increased risk seen in relatives of affected cases. One or more genes at HLA-unlinked loci also predispose to coeliac disease and are probably stronger determinants of disease susceptibility than HLA. A recent study has proposed a number of candidate regions on chromosomes 6p23 (distinct from HLA), 6p12, 3q27, 5q33.3, 7q31.3, 11p11, 15q26, 19p13.3, 19q13.1, 19q13.4 and 22cen for the location of a non-HLA linked susceptibility gene. We have examined these regions in 28 coeliac disease families by linkage analysis. There was excess sharing of chromosome 6p markers, but no support for a predisposition locus telomeric to HLA. No significant evidence in favour of linkage to coeliac disease was obtained for chromosomes 3q27, 5q33.3, 7q31.3, 11p11, 19p13.3, 19q13.1, 19q13.4 or 22cen. There was, however, excess sharing close to D15S642. The maximum non-parametric linkage score was 1.99 (P = 0.03). Although the evidence for linkage of coeliac disease to chromosome 15q26 is not strong, the well established association between coeliac disease and insulin dependent diabetes mellitus, together with the mapping of an IDDM susceptibility locus (IDDM3) to chromosome 15q26, provide indirect support for this as a candidate locus conferring susceptibility to coeliac disease in some families.

Oral budesonide is as effective as oral prednisolone in active Crohn's disease. The Global Budesonide Study Group

BACKGROUND

The use of corticosteroids in active Crohn's disease often becomes limited by side effects. Budesonide is a potent corticosteroid with low systemic bioavailability due to an extensive first pass liver metabolism.

AIMS

To compare the efficacy and safety of two dosage regimens of budesonide and prednisolone in patients with active Crohn's disease affecting the ileum and/or the ascending colon.

PATIENTS AND METHODS

One hundred and seventy eight patients 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's Disease Activity Index (CDAI) of 150 or less.

RESULTS

After eight weeks of treatment, remission occurred in 60% of patients receiving budesonide once daily or prednisolone and in 42% of those receiving budesonide twice daily (p = 0.062). The presence of glucocorticoid associated side effects was similar in all groups; however, moon face was more common in the prednisolone group (p = 0.0005). The highest frequency of impaired adrenal function, as measured by a short ACTH test, was found in the prednisolone group (p = 0.0023).

CONCLUSIONS

Budesonide CIR, administered at 9 mg once daily or 4.5 mg twice daily, is comparable to prednisolone in inducing remission in active Crohn's disease. The single dose administration is as promptly effective as prednisolone and represents a simpler and safer therapeutic approach, with a considerable reduction in side effects.

Body composition at the bedside

OBJECTIVE

To evaluate the use of an inexpensive hand-held bioelectric impedance analysis machine which measures lean body mass, by technical comparisons against standard instruments and techniques (an in-house bioelectric impedance machine and dual energy X-ray absorptiometry), and by performing body composition analyses in groups of potentially malnourished patients.

DESIGN

Prospective simultaneous comparison of measurements made by the hand-held and in-house bioelectric analysis machines and dual energy x-ray absorptiometry.

SETTING

Medical Physics Department and Gastrointestinal Unit in a university teaching hospital.

SUBJECTS/METHODS

One hundred and sixty subjects were recruited into the study. Data from 58 adolescent and 14 adult volunteers and from 42 adult patients were used for technical comparisons (n = 114). Body composition information was evaluated (n = 102) for 60 adult volunteers and 42 patients (17 with eating disorders, 7 with chronic alcoholic pancreatitis and 18 with inflammatory bowel disease).

OUTCOME MEASURES

Estimation of bias, limits of agreement and correlations on data from the three machines. Relationships between percentage body mass as lean, absolute weights and body mass index, in the adult subjects.

RESULTS

Both resistance and calculated impedance measured by the hand-held machine significantly correlated with the impedance measured by the in-house machine (r = 0.996; P < 0.0001). An estimation of the level of agreement in percentage lean measurement between dual energy x-ray absorptiometry and hand-held bioelectrical impedance analysis machine by the Bland and Altman method showed a bias of -0.07% and satisfactory limits of agreement from -7.97% to 7.76%. Body mass index was similar in the groups of healthy men and women, but proportion of weight as lean was significantly higher in men than women. In underweight patients with eating disorders, the ratio of lean to fat varied widely; in inflammatory bowel disease patients, proportions of lean and fat were similar to controls; however patients with alcoholic pancreatitis had values for body mass index similar to controls, but had significantly lower proportion of their body weight as lean (P < 0.05).

CONCLUSION

In non-obese and thin adults, an accurate two-compartment (lean, fat) measurement of body composition can be made in 10 min by using an inexpensive, hand-held, bioelectric impedance analysis machine.

Successful pregnancy in a patient with chronic intestinal pseudo-obstruction while on ambulatory percutaneous endoscopic gastrostomy feeding

We report a case of ambulatory endoscopic gastrostomy feeding via a low profile button device using a portable feeding pump. This provided successful nutritional support to a patient with chronic intestinal pseudo-obstruction who became pregnant while on gastrostomy feeding. She successfully completed her pregnancy with nutritional support through the gastrostomy. The portable feeding pump gave her excellent quality of life both indoors and outdoors, and she could continue feeding without interrupting her daily housework, shopping and babycare.

Detection of insulin-like growth factor-I and transforming growth factor-beta in whole gut lavage fluid: a novel method of studying intestinal fibrosis

BACKGROUND

Insulin-like growth factor-I (IGF-I) and/or transforming growth factor-beta (IGF-beta), may be involved in gut fibrous strictures.

METHODS

Concentrations of these two peptides have been measured by enzyme-linked immunosorbent assays (ELISAs) in whole gut lavage fluid from 57 patients, of whom 14 had strictures of the small intestine or colon associated with Crohn's disease, irradiation injury, ischaemia or diverticulitis.

RESULTS

IGF-I was detected in fluid from 11 of 14 patients with strictures, and 5 of 43 others (P < 0.01). TGF-beta was detectable in all 57 samples and concentrations were unrelated to the presence or absence of strictures.

CONCLUSION

Clinical studies of growth factors in intestinal fluid should facilitate research on intestinal fibrogenesis, and the diagnosis of fibrous stricturing in Crohn's disease.

Overexpression of ZBP-89, a zinc finger DNA binding protein, in gastric cancer

ZBP-89 is a Krüppel-type zinc finger protein that binds to the gastrin EGF response element (gERE). Sp1 binds to the same DNA element and transactivates gastrin promoter activity, whereas ZBP-89 competes for Sp1 binding and prevents EGF induction. Both transcription factors mediate growth factor signals originating from the EGF receptor and thus were studied in normal and neoplastic tissues or cell lines. When compared to normal tissue from the same patient, ZBP-89 protein expression was increased in neoplastic tissue from the stomach antrum and in malignant cell lines. RT-PCR analysis of ZBP-89 mRNA correlated with protein overexpression. Immunocytochemical studies confirmed that ZBP-89 expression is elevated in neoplastic tissue and chronic gastritis, whereas Sp1 expression was nearly unchanged. These results suggest that the transcription factor ZBP-89, like Sp1, may be a marker for neoplastic transformation in some gastric cancers.

Mucosa-associated bacterial flora of the human colon

Biopsy samples of mucosa were taken during colonoscopy from the proximal colon and rectum of 12 patients, six with ulcerative colitis (UC) and six with non-inflammatory conditions. After anaerobic transport to the laboratory, biopsy specimens were examined by quantitative bacteriological culture on selective and non-selective media for total aerobic count, total anaerobic count, Bacteroides spp., lactobacilli, bifidobacteria and asaccharolytic, lactic acid producers. Isolates of the genus Bacteroides were identified to species level. Counts from proximal colonic and rectal biopsy samples in the same patient were not significantly different. Viable aerobic counts (aerobes and facultative organisms) ranged from 2.4 x 10(3) to 1.3 x 10(6) cfu/sample biopsy (5.6 mg) and total anaerobic counts were 10-10(2) times higher at (1.4 x 10(5))-(3 x 10(7)) cfu/sample. Bacteroides spp. predominated at both sites (range 8.6 X 10(4) to 1.4 x 10(7) cfu/sample), comprising 66% of total counts from proximal colon (range in individual patients 31-80%) and 68.5% from rectum (range 38-91%). Lactobacilli were isolated from eight biopsy samples from five patients, counts ranging from 3.6 X 10(2) to 1 X 10(5) cfu/sample; bifidobacteria were isolated from both sites from 10 of the 12 patients, counts ranging from 50 to 1.8 x 10(6) cfu/sample. From the 24 biopsy samples, 235 isolates representing 11 species of Bacteroides were identified. For any individual patient, only a few species (2-7; mean 4.4) of Bacteroides were found, with just one or two species predominating. B. vulgatus was cultured from both samples of seven patients (where it was the major isolate in four) and from single samples of two others; B. fragilis was cultured from both sites in six patients, being the major isolate in one patient and second commonest in three, but was not detected in the other six; the majority of other isolates were B. merdae/distasonis, B. ovatus, B. thetaiotaomicron and B. uniformis. B. thetaiotaomicron was isolated from both biopsy samples in all three UC patients with active inflammation (16 of the 60 isolates from these patients) but from only four of the other 18 samples from non-inflamed colonic mucosa (nine of 175 isolates).

Gastric tonometry: evaluating tissue oxygenation

Critically ill patients require vigilant monitoring of tissue oxygenation, particularly oxygenation of the gut mucosa, because of the mucosa's fragile blood supply. With the advent of gastric tonometry, splanchnic tissue oxygenation can be measured in a minimally invasive and cost-effective manner. Requiring only a gastric tonometer (approximately $70) and facilities to measure arterial blood gases, this method allows early detection of covert compensated shock by determining pHi. Thus, early intervention and correction of deficits in tissue oxygenation are possible and may improve patients' outcome.

Gastric tonometry: evaluating tissue oxygenation

Critically ill patients require vigilant monitoring of tissue oxygenation, particularly oxygenation of the gut mucosa, because of the mucosa's fragile blood supply. With the advent of gastric tonometry, splanchnic tissue oxygenation can be measured in a minimally invasive and cost-effective manner. Requiring only a gastric tonometer (approximately $70) and facilities to measure arterial blood gases, this method allows early detection of covert compensated shock by determining pHi. Thus, early intervention and correction of deficits in tissue oxygenation are possible and may improve patients' outcome.

Mucosal immunology: from bench to the bedside and beyond

This paper, written by the President of the Society for Mucosal Immunology, marks the 9th International Congress of Mucosal Immunology, in Sydney: Mucosal Solutions. Current molecular, cellular and animal work in mucosal immunity has great potential when applied to issues of human and animal health. However, practical and technical problems in the transfer of theoretical concepts into clinically based research must not be underestimated. Ideally, studies in disease need to be designed and run jointly by clinicians and scientists, as illustrated by examples drawn from Crohn's disease. Ethical aspects of research in mucosal physiology and disease are challenging, but not insurmountable.

Transjugular intrahepatic portosystemic shunt as a treatment for protein-losing enteropathy caused by portal hypertension

A case of a 41-year-old man with diarrhea, hypoalbuminemia, and cryptogenic cirrhosis with features of portal hypertension is described. Protein-losing enteropathy was confirmed by analysis of whole-gut lavage fluid, and intestinal inflammation and infection were excluded. Distal duodenal biopsy specimens showed evidence of edematous villi with prominent submucosal vascular and lymphatic vessels. A transjugular intrahepatic portosystemic stent-shunt was inserted, resulting in resolution of both his diarrhea and elevated whole gut lavage fluid protein concentrations. His symptoms recurred and then again improved after shunt thrombosis and parallel shunt placement, respectively. Histological improvement of the villous edema was also noted. This is the first recorded case of protein-losing enteropathy caused by portal hypertension confirmed by successful treatment with transjugular intrahepatic portosystemic stent-shunt.

Changes in peak flow, symptom score, and the use of medications during acute exacerbations of asthma

Changes in symptom score and peak expiratory flow (PEF) and the use of medications during the first acute exacerbation of asthma were studied in 41 patients and matched controls who took part in a panel study. An acute exacerbation was defined as the presence of at least one of the following: any unscheduled physician visit, visit to an emergency room, or hospitalization for treatment of asthma; a decrease in PEF by 30% from the patient's best reading; an increase in asthma symptoms during the day and night for over 48 h and not responding to usual medications; and the commencement or doubling of the dose of oral or inhaled steroids for any of the foregoing reasons. Data from -9 to -7 d before the onset of an acute exacerbation were taken as the baseline data, with which the values of the subsequent 14 d were compared. Significant increases in symptoms occurred before a significant reduction in PEF. None of the patients had a decrease of more than 30% in PEF before the onset of symptoms. Daily variation in PEF was not significantly increased from the baseline. Our results suggest that PEF monitoring is not as sensitive as a symptom diary for revealing acute exacerbations of asthma, and that a 30% decrease in PEF is too stringent a criterion for defining an acute exacerbation.

Collaborating on the integration of cancer nursing services

This article outlines the proposals contained in the Calman-Hine report (DoH 1995), and then presents the work of a nursing task group set up in response to its recommendations. The authors describe how different agencies collaborated in a network approach to improving the provision of cancer services.

Effect of application of benzyl benzoate on house dust mite allergen levels

BACKGROUND

Several acaricides have become available for reducing house dust mite allergen levels.

OBJECTIVE

The purpose of this study was to assess whether the use of benzyl benzoate (Acarosan) provides additional benefit to the usual mite control measures including encasement of mattress and pillows with vinyl covers.

METHODS

A randomized controlled trial was carried out in 26 homes (14 control versus 12 treatment) of asthmatic patients in two cities (Vancouver and Winnipeg). The control group had the usual house dust mite control measures including the use of vinyl covers for mattresses and pillows while the treatment group had application of benzyl benzoate to mattresses and carpets in the bedroom and the most commonly used room, in addition to the above control measures. Mite allergen levels were measured 3 months and immediately before, 1 week, and 1 and 3 months after the application of house dust mite control measures. Patients kept diary cards on asthma symptoms and peak expiratory flow rates morning and evening one month before and three months after the onset of mite allergen control measures.

RESULTS

A reduction of mite allergen level was found in mattress samples in both groups, statistically significant at all times in the treatment group and at one and three months in the control group. Mite allergen levels on floor carpets also showed progressive reduction in both groups, but were significantly different in the treatment group (compared with controls) at 1 week, and were lower compared with baseline in the treatment group up to 3 months. No significant changes in asthma symptoms, peak expiratory flow rates, spirometric measurements, or bronchial hyperresponsiveness were observed among treatment or control group subjects.

CONCLUSION

The addition of benzyl benzoate to conventional house dust mite control measures resulted in a significant reduction in floor carpet dust mite levels that persisted for 3 months. The results of this study should be confirmed in a larger and longer study.

Investigation of neutrophils in the gut lumen by assay of granulocyte elastase in whole-gut lavage fluid

BACKGROUND

Intestinal neutrophils can be studied by radiolabelling techniques and by cytology of whole-gut lavage fluid. Our aim was to evaluate the use of a biochemical test for the presence of these cells in whole-gut lavage fluid.

METHOD

Whole-gut lavage was performed by having the patients drink a polyethylene-glycol-electrolyte solution; the clear fluid passed per rectum after complete bowel cleansing had been collected. In 203 patients granulocyte elastase was assayed in sonicated unfiltered lavage fluid, using the specific enzyme substrate L-pyroglutamyl-I-prolyl-L-valine-p-nitroanilide. Free granulocyte elastase was also assayed in filtered (that is, cell-free) lavage fluid in 39 of the 43 patients in whom the enzyme was present in unfiltered fluid. In 47 of the patients, cells were also separated by density gradient centrifugation, and counted.

RESULTS

Granulocyte elastase concentration correlated significantly with cell count (r = 0.80, p < 0.001). Granulocyte elastase concentration was high (> 100 nkat/l) in fluid from 25 of 68 inflammatory bowel disease patients and 6 of 135 others with radiation colitis, diverticulitis, pericolic abscess, and use of non-steroidal anti-inflammatory drugs. In patients with detectable total granulocyte elastase, cell-free granulocyte elastase was present in 11 of 29 with inflammatory bowel disease and 1 of 10 others.

CONCLUSION

Whole-gut lavage fluid samples can readily be used to investigate luminal inflammatory cells.