227 UNSCHEDULED ACUTE HOSPITAL ADMISSIONS FROM A COMMUNITY REHABILITATION TEAM – GERIATRIC GIANTS OR “ACOPIA”?

Background

The Integrated Care Team (founded 2018) provides community rehabilitation in the home for frail older adults. Frail older adults are at increased risk of hospitalisation, and frailty is associated with increased length of stay and mortality. This retrospective cohort study aims to explore the acute hospital admissions of this frail cohort from July 2019 to December 2021.

Methods

Patients were identified from the integrated care team database who had a discharge destination of “Acute Hospital”. Hospital IT system data and discharge summaries were used to analyse inpatient Length of Stay (LOS), presenting complaints and discharge diagnosis. The study period was from July 2019 to December 2021.

Results

67 patients were admitted to hospital during the study period from the care of the integrated care team, accounting for 98 individual hospital admissions. This accounted for 19.8% of discharges from the team during the study period, with 77% of patients discharged to community support. 23.8% of patients (n=16) had multiple admissions, with the majority of these(n=14) admitted twice. The average age of patients was 82.6 years. 58% of admitted patients were female. The longest LOS was 99 days, and shortest less than one day. The average LOS was 12.9 days for the total population. Excluding two outlier stays of 99 and 82 days, the average LOS was 11.27 days.

32% of patients presented with functional decline, 28% with falls, 18% with shortness of breath and 19% with delirium. Infections were diagnosed in 28% of patients, neurological events in 12% and bleeding diagnoses in 11% of patients. 1 patient died during admission. Only 12.2% of stays (n=12) were less than 72 hours in duration.

Conclusion

This frail patient cohort presented with a range of frailty syndromes and complications of medical comorbidities. The low prevalence of short hospital stays may reflect the ongoing role of the community team supporting patients in the community.

232 WORKING-UP DEMENTIA, A RETROSPECTIVE COHORT STUDY OF REFERRALS TO A SPECIALIST DEMENTIA SERVICE

Background

Rates of dementia in Ireland are rapidly increasing in line with our ageing population. Cases are predicted to more than double in the next 30 years from a prevalence of 55,000 in 2018, to 141,000 in 2050. Dementia services will be placed under significant pressure. It is essential that patients referred to specialist memory services are appropriately worked-up prior to referral, to ensure efficiency and optimise the running of these services, and also to improve patient experience.

Methods

We carried out a retrospective review of patients referred to the Psychiatry of Later Life Team for specialist dementia care by General Practitioners. We obtained date of referral to the service, and carried out an electronic chart review to evaluate the work-up performed prior to referral. Our standard work-up criteria consisted of neuroimaging (CT brain or MRI brain), and blood tests including B12, folate, and thyroid function tests within 12-months. Results were analysed descriptively.

Results

104 patients were included in the study, from referrals dated Nov 2014-June 2019. Neuroimaging had been performed in 79.8% (n=83) prior to referral- 89.1% CT, 9.6% MRI, 1.2% both CT and MRI. Of those who had neuroimaging, n=37 had been performed in the previous 12-months, representing 35.6% of overall cohort. In terms of blood work-up, 23.1% (n=24) had bloods performed in the 12 months prior to referral- 70.8% B12, folate and thyroid function tests; 20.8% TFTS only; 8.3% B12 and folate levels only).

Conclusion

Referrals to specialist memory services by General Practice often lack the appropriate first line investigations, which introduces delay in review and the need for further assessment once baseline investigations have been done. There is a need for a standardised work-up prior to referral for optimum running of such services.

329 ANTICHOLINERGIC BURDEN IN PEOPLE LIVING WITH DEMENTIA ATTENDING GERIATRIC MEDICINE AND PSYCHIATRY FOR OLDER PERSONS SERVICES

Background

Anticholinergic burden is associated with an increase in cognitive decline, delirium and confusion. We aimed to examine the Anticholinergic Cognitive Burden (ACB) of patients referred to local dementia services, and the prescribing of acetylcholinesterase inhibitors in patients with a significant anticholinergic burden. We also looked at frequency of prescribing of classes of some medications known to increase anticholinergic burden.

Methods

A retrospective chart review was carried out of new referrals attending local Geriatric Medicine and/or Psychiatry For Older Persons outpatient services with a diagnosis of dementia between 2017 and 2018. Medications in use at the time of patient review were obtained. ACB was calculated using ACB score. Results were analysed descriptively.

Results

163 patients over 65 years old were included in this study, 94 (57.6%) were female. 30% (N = 49) had a significant anticholinergic burden (ACB >3). The mean ACB was 1.69 (Range 0 – 8). 38% of all patients (N = 63) were prescribed an acetylcholinesterase inhibitor, and of those, 20% (N = 13) had a significant anticholinergic burden. Polypharmacy (use of 5 medications or more) was evident with 76% (N = 124) patients. Regarding groups of medications known to increase ACB, 35.5% (N = 58) were prescribed antipsychotics and 18.4% (30) were prescribed benzodiazepines.

Conclusion

There is a significant anticholinergic burden among people living with dementia attending the geriatric medicine and psychiatry of later life services. Some patients with a significant anticholinergic burden were being prescribed acetylcholinesterase inhibitors. This suggests acetylcholinesterase inhibitors may be prescribed without also discontinuing inappropriate medications that are contributing to the anticholinergic burden. We should look to further reduce the anticholinergic burden of patients attending the dementia services by avoiding these medications or using alternatives where available.

338 APPLYING STOPP/START CRITERIA TO A COHORT OF FALL PATIENTS IN THE COMMUNITY

Background

Integrated Care Teams for Older Persons (ICTOP) aim to transform care away from hospitals towards multidisciplinary community team care. Seventy percent of injuries requiring acute admission are caused by falls, costing €59 million annually, in addition to the overall morbidity and mortality burden. The Screening Tool of Older Person’s Prescriptions / Screening Tool to Alert Doctors to Right Treatment (STOPP/START) identifies inappropriate prescribing and prescribing omissions, which should reduce falls risk and optimise patient outcomes.

Methods

This prospective study randomly included 20 active ICTOP patients all of whom had fallen in the last 6 months. The STOPP/START Criteria were used to screen patient’s prescriptions at time of referral.

Results

The average age was 83 years old, 60% were male. Overall 45% had 1 fall, 15% had 2 falls, 20% had 3 falls and 20% had more than 5 falls. The most common comorbidities were hypertension (55%), heart disease (45%), and cognitive decline (40%). Regarding polypharmacy, 95% were prescribed more than 5 drugs, 55% were prescribed more than 10 drugs. Overall, 30% had a diagnosis of osteoporosis, 40% were on a bisphosphonate, while 65% were taking vitamin D and Calcium supplements. Of the 35% (7 patients) who had a previous fragility fracture, 1 had a DEXA scan and a further 3 were on the waiting list. Four of these patients were taking bisphosphonates and 6 were taking vitamin D and Calcium. Regarding STOPP criteria, 30% were taking opioids, 45% Proton Pump Inhibitors, 30% Calcium Channel Blockers, 30% Beta-blockers and 15% were taking Alpha-blockers.

Conclusion

The study identifies a need for community teams to consider medications that increase falls risk and medications that should be initiated to optimise bone health. Community teams should have access to professional medical and pharmacy support, in addition to timely access to DEXA scans.

112 A STUDY OF REFERRALS TO THE EMERGENCY DEPARTMENT FROM NURSING HOMES PRIOR TO AND IN THE CONTEXT OF COVID-19

Background

As of July 2020 there were 32,000 residential places in Ireland. In the context of Covid-19,there was a rise in attendance at Emergency Departments( ED) of those aged above seventy. The objectives were to collect data on the profile of Nursing Home (NH) residents referred to ED, establish if meeting target Patient Experience Times (PET) in ED with NH residents and to compare attendances of NH residents prior to and in the context of Covid-19.

Methods

The study was performed in two phases, the first a retrospective study in June 2017 and the second an observational study in December 2021. A proforma was drawn up to collect data of interest inclusive of reason for referral, mode of referral and clinical frailty scale. The data was analyzed using SPSS.

Results

The initial study included ninety charts, the second phase included twenty-six charts. In the recent study the majority were male 62% (16/26), aged 81-90 years 38% (10/26) and severely frail (Clinical Frailty Scale=7 50% 12/26). The percentage of weekend referrals remained similar with 26% and 27% of referrals on Saturday and Sunday in the initial and subsequent study respectively. Regarding medical review prior to transfer, 58% (15/26) had medical review (previously 62 %), 42% (11/26) had not (previously 38%). Of those who had a medical review 46% (7/15) were via telephone by out of hours service compared to 25%(14/56) in the initial study. PETs were greater than six hours in 73% (19/26) of cases, previously 68%.

Conclusion

Overall this timely study illustrates a majority of NH residents are brought to the ED without being seen face-to-face by a General Practitioner and an increase in virtual assessments since the advent of Covid-19. It highlights how a regional hospital and the NHs it serves could benefit from a community geriatric team and will help inform service provision.

70 THE RESPONSIVE NATURE OF AN INTEGRATED CARE COMMUNITY REHABILITATION TEAM THROUGHOUT THE COVID PANDEMIC

Background

The Integrated Care Team (founded 2018) provides community rehabilitation in the home. The Covid 19 pandemic, a new Reablement Service (June 2020) and Community Falls Service (September 2020) led to changes in the service, providing access to comprehensive geriatric assessment in the community when hospital outpatient services were limited. The effect of these changes on patient cohorts are explored.

Methods

Anonymised patient data from the team database was extracted for each episode of care under the service from July 2019 to February (Pre-covid), March 2020 to December 2020 (initial lockdown period), and January 2021 to December 2021 and analysed for length of stay (LOS), discharge destination, and reason for referral. A further analysis of discharge summaries for patients with the longest LOS in each period was conducted to assess for factors influencing LOS with the team.

Results

500 episodes of care were captured during the study period, 137 pre-covid, 179 March to December 2020 and 184 in 2021.From Pre-covid to 2021, the average LOS increased from 45.9 days to 57 days. The annual number of new referrals seen by the team was similar across this period (194 in 2019, 204 in 2020 and 190 in 2021). 40 patients with the longest LOS were analysed. No long-stay patients benefited from respite or day-centre care during the studied period (compared to 46% of all patients in 2018). 70% lived alone, 65% had cognitive decline or dementia and only 41% required mobility aids while indoor. Clinical frailty scores were unavailable.

Conclusion

A changing patient cohort may account for the increased length of stay, with less frail patients benefiting from reablement and falls services on hospital discharge, while high levels of cognitive impairment and low mobility aid usage may indicate limited rehabilitation potential. Ongoing access to social prescribing outlets such as respite and daycare are essential to sustain patients in their own homes.

Characteristics and outcomes of older persons attending the emergency department: a retrospective cohort study

BACKGROUND

The analysis of routinely collected hospital data informs the design of specialist services for at-risk older people.

AIM

Describe the outcomes of a cohort of older emergency department (ED) attendees and identify predictors of these outcomes.

DESIGN

retrospective cohort study.

METHODS

All patients aged 65 years or older attending an urban university hospital ED in January 2012 were included (N = 550). Outcomes were retrospectively followed for 12 months. Statistical analyses were based on multivariate binary logistic regression models and classification trees.

RESULTS

Of N = 550, 40.5% spent ≤6 h in the ED, but the proportion was 22.4% among those older than 81 years and not presenting with musculoskeletal problems/fractures. N = 349 (63.5%) were admitted from the ED. A significant multivariate predictor of in-hospital mortality was Charlson comorbidity index [CCI; odds ratio = 1.19, 95% confidence interval: 1.07, 1.34, P = 0.002]. Among patients who were discharged from ED without admission or after their first in-patient admission (N = 499), 232 (46.5%) re-attended ED within 1 year, with CCI being the best predictor of re-attendance (CCI ≤ 4: 25.8%, CCI > 5: 60.4%). Among N = 499, 34 (6.8%) had died after 1 year of initial ED presentation. The subgroup (N = 114) with the highest mortality (17.5%) was composed by those aged >77 years and brought in by ambulance on initial presentation.

CONCLUSIONS

Advanced age and comorbidity are important drivers of outcomes among older ED attendees. There is a need to embed specialist geriatric services within frontline services to make them more gerontologically attuned. Our results predate the opening of an acute medical unit with specialist geriatric input.

Outcome for children with cyclical vomiting syndrome

OBJECTIVE

Cyclical vomiting syndrome (CVS) is a disorder that carries a significant burden of disease for children and their families. The aim of this study was to examine the outcome of a group of children diagnosed with CVS from 1993 to 2003.

METHODS

Children diagnosed with CVS over a 10-year period were identified and a review of the clinical records was carried out to define demographic features and the spectrum of disease at presentation. The patient's parent was contacted to establish the child's current well-being. Ethical approval for the study was obtained.

RESULTS

Fifty one children were diagnosed with CVS and 41 agreed to participate in follow-up. Mean age was 5.8 (SD 3.3) years at onset of CVS, 8.2 (SD 3.5) years at diagnosis, and 12.8 (SD 4.8) years at follow-up. Vomiting had resolved at the time of follow-up in 25/41 (61%) children. Sixteen of 41 (39%) children reported resolution of symptoms either immediately or within weeks of diagnosis. However, a large number of children from the group whose vomiting resolved and the group that were still vomiting continued to have somatic symptoms, with 42% of children suffering regular headaches and 37% having abdominal pain. 32 (78%) parents felt that the provision of a positive diagnosis and information made a significant impact on the severity of vomiting.

CONCLUSIONS

While 60% of children with CVS have resolution of symptoms, a significant proportion of both those in whom symptoms have resolved and those in whom vomiting persists continue to suffer from other somatic symptoms.

Focally enhanced gastritis in children with Crohn's disease and ulcerative colitis

OBJECTIVES

Focally enhanced gastritis (FEG) has been suggested as a specific diagnostic marker for patients with Crohn's disease. However, the utility of FEG for distinguishing Crohn's disease from ulcerative colitis is uncertain in adults, and the occurrence of this lesion in children has not been defined. The aim of this study was to evaluate the occurrence of FEG and other gastric histological abnormalities in children with inflammatory bowel disease (IBD) and to examine the utility of FEG in discriminating between ulcerative colitis and Crohn's disease.

METHODS

This is a retrospective, case-controlled study of upper GI histopathological findings in children with IBD. Gastric histopathology was defined and graded according to the Updated Sydney System.

RESULTS

FEG was present in 28 of 43 (65.1%) children with Crohn's disease and five of 24 (20.8%) children with ulcerative colitis, compared to three of 132 (2.3%) children without IBD or one of 39 (2.6%) children with Helicobacter pylori infection. There were no differences between those with and without FEG with regard to upper GI symptoms or previous anti-inflammatory drug ingestion (5-aminosalicylic acid compounds or steroids). All patients with H. pylori infection had chronic antral gastritis, but only one child with H. pylori had FEG. In addition, mild to moderate chronic gastritis was present in 15 of 43 (34.9%) children with Crohn's disease and in 12 of 24 (50%) patients with ulcerative colitis.

CONCLUSIONS

The presence of FEG suggests underlying IBD. Although FEG is particularly common in children with Crohn's disease, it does not reliably differentiate between Crohn's disease and ulcerative colitis.

Limitations to carbon 13-labeled urea breath testing for Helicobacter pylori in infants

We determined the validity of the carbon 13-labeled urea breath test in young children. We found that although the 13C-labeled urea breath test had a specificity greater than 90%, borderline or false positive results occurred more frequently in children younger than 2 years compared with older children. False positive results may be caused by oral-urease-producing organisms because direct intragastric administration of 13C urea reduced the excess delta 13CO2. Care is urged in interpreting one positive 13C-labeled urea breath test in children younger than 2 years.

The oral cavity in Crohn's disease

We assessed the utility of expert oral examination as a part of the diagnostic evaluation of patients with suspected Crohn's disease. Of 45 patients with newly diagnosed CD, 25 had been examined by a dentist. Twelve (48%) of these had oral CD lesions. Mucosal tags constituted the most frequent form of oral lesion (8/12). Of 8 oral biopsy specimens, 6 (75%) contained non-caseating granulomas. Patients with oral CD had more oral symptoms, presented for diagnosis sooner, and were more likely to have other upper gastrointestinal inflammation than those without oral lesions. Oral manifestations of CD are common in children; therefore, expert oral examination may be useful during diagnostic evaluation of children with suspected inflammatory bowel disease.

Antigastric autoantibodies in ferrets naturally infected with Helicobacter mustelae

Infection with Helicobacter pylori has been associated with induction of autoantibodies that cross-react with the gastric mucosa. There have been discordant reports as to whether or not these autoantibodies arise due to molecular mimicry between H. pylori and host cell antigens on parietal cells. In this study, we investigated whether molecular mimicry by H. mustelae causes autoantibodies in infected ferrets. Serum from H. mustelae-infected ferrets reacted with parietal cells in the ferret gastric mucosa but not with duodenal or colonic mucosa. These sera did not react with the blood group A epitope on erythrocytes or H. mustelae lipopolysaccharide, and absorption with H. mustelae whole cells or red blood cells did not remove autoantibodies. In conclusion, ferrets naturally infected with H. mustelae generate antibodies that react with parietal cells, but these autoantibodies are not due to molecular mimicry.

Is Helicobacter pylori infection in childhood a risk factor for gastric cancer?

Helicobacter pylori infection is associated with chronic gastritis and peptic ulcer disease. Furthermore, the World Health Organization has classified this organism as a carcinogen for gastric cancer. H pylori infection is mainly acquired in childhood. Children with H pylori infection are asymptomatic except for a very small number that develop peptic ulcer disease. However, if H pylori gastritis is associated with gastric cancer, do pediatricians need to screen children for this infection and treat those who are infected? In an attempt to determine the significance of the association between H pylori and gastric cancer, we have reviewed all of the English language literature on this topic. H pylori infection seems to be associated with an increased risk of developing gastric cancer. However, only a small number of infected individuals (~1%) will develop gastric cancer. Furthermore, there are potential cofactors other than H pylori that could be equally important. The effect of the eradication of H pylori alone on the development of gastric cancer is unknown. Based on our knowledge to date, we suggest that it is not indicated to treat all children with H pylori infection because of the risk of developing gastric cancer or to institute a screening and treatment program.

A new polymorphism for the RI22H mutation in hereditary pancreatitis

BACKGROUND AND AIMS

Hereditary pancreatitis (HP) is a rare form of recurrent acute and chronic pancreatitis. Mutations in the cationic trypsinogen (protease serine 1, PRSS1) gene have been identified as causing HP. The R122H (previously known as R117H) mutation is the commonest and can be detected by a single and rapid polymerase chain reaction/restriction fragment length polymorphism (PCR/RFLP) based technique using the AflIII enzyme. This test however may give a false negative result in the presence of a neutral polymorphism within the enzyme recognition site. The frequency of this event was examined by sequencing studies in patients with HP and in healthy controls.

METHODS

Of 60 families identified by the UK and Ireland consortium of EUROPAC (European Registry for Hereditary Pancreatitis and Familial Pancreatic Cancer), 51 were screened for R122H, N29I, and A16V mutations using standard techniques, and by sequencing of all five exons of cationic trypsinogen.

RESULTS

Twelve families had the N29I mutation, one family had A16V and, on standard testing, 15 families had the R122H mutation. An additional family with the R122H mutation was found on direct sequencing. The false negative result was due to a neutral polymorphism C-->T at the third base of the codon, not affecting the amino acid coded for, destroying the AflIII restriction site. This polymorphism was not observed in 50 DNA specimens (100 chromosomes) from controls nor from 50 individuals from PRSS1 mutation negative HP families. A novel mutation specific PCR was developed to avoid this pitfall.

CONCLUSIONS

One of the 16 families with HP and an R122H mutation contained a polymorphism affecting the AflIII restriction site. Adoption of an alternative R122H assay is important for genetic studies in individuals with apparent HP.

Adherence of isogenic flagellum-negative mutants of Helicobacter pylori and Helicobacter mustelae to human and ferret gastric epithelial cells

Isogenic flagellum-negative mutants of Helicobacter pylori and Helicobacter mustelae were screened for their ability to adhere to primary human and ferret gastric epithelial cells, respectively. We also evaluated the adherence of an H. pylori strain with a mutation in the flbA gene, a homologue of the flbF/lcrD family of genes known to be involved in the regulation of H. pylori flagellar biosynthesis. H. pylori and H. mustelae mutants deficient in production of FlaA or FlaB and mutants deficient in the production of both FlaA and FlaB showed no reduction in adherence to primary human or ferret gastric epithelial cells compared with the wild-type parental strains. However, adherence of the H. pylori flbA mutant to human gastric cells was significantly reduced compared to the adherence of the wild-type strain. These results show that flagella do not play a direct role in promoting adherence of H. pylori or H. mustelae to gastric epithelial cells. However, genes involved in the regulation of H. pylori flagellar biosynthesis may also regulate the production of an adhesin.

Bullous mastocytosis: a fatal outcome

A 6-week-old boy was referred with a generalized bullous rash since birth. Examination revealed bullous mastocytosis with initially no evidence of systemic involvement. Hepatosplenomegaly was noted at 6 months, and at 12 months he was found to have generalized lymphadenopathy. He developed bouts of vomiting associated with increased blistering. At 17 months he had sudden collapse following a brief bout of vomiting and was apneic and asystolic on arrival at the emergency department. The cause of death was attributed to massive hypotension secondary to mast cell degranulation. Although childhood mastocytosis has a favorable course in general, the subset of children with congenital bullous mastocytosis is at higher risk of sudden death and a more guarded prognosis should be given.

Pancreatic duct stenting as a treatment for hereditary pancreatitis

Hereditary pancreatitis is a genetically transmitted condition usually presenting in childhood or adolescence. The natural history of the condition is that recurrent episodes of pancreatitis may be followed by the development of pancreatic exocrine and endocrine failure. Treatment options are limited, usually consisting of surgical drainage procedures whose efficacy is uncertain and whose effect on disease progression is unknown. We report a child with hereditary pancreatitis treated by means of a pancreatic duct stent placed via endoscopic retrograde cholangiopanctreatography resulting in long-term control of symptoms and speculate that earlier intervention may alter the disease course.

Low rates of Helicobacter pylori reinfection in children

BACKGROUND & AIMS

Reinfection after treatment for Helicobacter pylori is uncommon in adults. It is more likely to occur in children because they acquire primary infection. The aim of this study was to determine whether children are likely to become reinfected with H. pylori and if there are any risk factors for reinfection.

METHODS

A prospective study of children who had documented evidence of successful treatment for H. pylori infection was performed. Sixty children were eligible for inclusion; results for 52 are presented. Children, parents, and siblings underwent [(13)C]urea breath tests. Details of family size and socioeconomic status were documented. Cox logistic regression analysis was used to determine the risk factors for reinfection.

RESULTS

The duration of follow-up was 103.8 patient-years (mean +/- SD, 24 +/-14.0 months). Forty-six (88.5%) of the index children remained clear of infection, and 6 (11.5%) children were reinfected. The mean age of those who became reinfected was 5.8 +/- 5.6 years compared with 12.3 +/- 3.0 years for those who remained clear of infection (P = 0.00001). Only 2 of 46 (4.3%) children older than 5 years of age were reinfected, although 80.8% had 1 infected parent and 65% of siblings were infected. Reinfection rate was 2.0% per person per year in children older than 5 years. Living with infected parents and siblings and low socioeconomic status were not risk factors for reinfection. In logistic regression analysis, age was the only risk factor for reinfection.

CONCLUSIONS

Reinfection with H. pylori occurs rarely in children older than 5 years of age regardless of socioeconomic group or number of infected family members. These findings also indicate that it is not necessary to treat all family members to achieve long-term eradication of H. pylori.

How should Helicobacter pylori infected children be managed?

It is now recognised that Helicobacter pylori, like most enteric infections, is mainly acquired in childhood. Adults rarely become infected, with seroconversion rates varying between 0.33and 0.5% per person year. The age at which children are most likely to become infected is still unclear, but findings in a number of cross-sectional studies suggest that infection is acquired before the age of five. The prevalence of infection is highest in children in the developing world where up to 75% of children may be infected by the age of 10. In the developed world the prevalence of infection is noticeably increased among socially deprived children. The diagnosis of H pylori infection in childhood is most often made at endoscopy, for which there are many indications. Symptoms such as abdominal pain, vomiting, and haematemesis may be associated with duodenal ulcer and H pylori infection. However, in the case of children undergoing endoscopy for assessment of oesophagitis, failure to thrive, coeliac disease, Crohn's disease, or portal hypertension, the finding of H pylori infection is likely to be incidental. How should we manage these children with a diagnosis of H pylori infection? Currently, there are no consensus guidelines for the management of H pylori infected children. In 1994 the National Institutes of Health consensus statement recommended that adults with gastric or duodenal ulcer disease, who are infected with H pylori, should receive antimicrobial treatment. The European Maastricht Consensus Report suggested broader indications for treatment of infected adults. It states that treatment is advisable for all H pylori infected dyspeptic patients diagnosed non-invasively under 45 years of age at a primary care level. Patients older than 45 years with dyspeptic symptoms should be treated for H pylori infection but only after endoscopy to rule out any other underlying pathology. The European guidelines also recommend treatment for infected patients with mucosa associated lymphoid tissue lymphoma and patients who are found to have intestinal metaplasia and gastric atrophy.

Fine-resolution mapping by haplotype evaluation: the examples of PFIC1 and BRIC

Loci for two inherited liver diseases, benign recurrent intrahepatic cholestasis (BRIC) and progressive familial intrahepatic cholestasis type 1 (PFIC1), have previously been mapped to 18q21 by a search for shared haplotypes in patients in two isolated populations. This paper describes the use of further haplotype evaluation with a larger sample of patients for both disorders, drawn from several different populations. Our assessment places both loci in the same interval of less than 1 cM and has led to the discovery of the PFIC1/BRIC gene, FIC1; this discovery permits retrospective examination of the general utility of haplotype evaluation and highlights possible caveats regarding this method of genetic mapping.

Effect of Helicobacter pylori eradication on the natural history of duodenal ulcer disease

BACKGROUND

Duodenal ulcer disease is strongly associated with Helicobacter pylori infection of the gastric mucosa. Eradication of H pylori from the gastric mucosa in adults is associated with long term healing of ulcers.

AIMS

To follow a cohort of children with duodenal ulcer disease for a minimum of two years after the eradication of H pylori.

PATIENTS AND METHODS

Over a three year period, all children diagnosed with duodenal ulcer disease had their symptoms documented and their H pylori status evaluated. The histories of these children were carefully screened to determine previous symptoms and to document previous treatment regimens.

RESULTS

Sixteen children were diagnosed with ulcers and 15 were available for treatment and long term follow up. The median age at which symptoms first occurred was 10.5 years (range, 6-14) and the median duration of symptoms was 24 months (range, 2-60). Ten of the children had been treated with H2 receptor antagonists for a median of 3.5 months (range, 1-60). Duodenal ulcers healed in all children after eradication of H pylori and all children have remained asymptomatic for a median of 37 months (range, 26-62). No child has required subsequent admission to hospital.

CONCLUSION

Eradication of H pylori is very effective in the long term healing of duodenal ulcer disease. H pylori eradication should be the standard treatment for all infected children who present with duodenal ulcer disease.

Colonoscopy under general anesthesia in children

OBJECTIVE

In children, colonoscopy is usually performed using deep sedation that may be associated with significant risks. The purpose of this study was to evaluate the safety of colonoscopy performed under general anesthesia.

METHODS

All patients undergoing colonoscopy during a 3-year period were reviewed for the study. One hundred and thirty-six procedures were performed. Colonoscopies were performed by a pediatric gastroenterologist. Anesthesia was administered by a pediatric anesthetist in a gastroenterology procedure room, adjacent to the operating recovery area.

RESULTS

Three patients had significant abdominal pain and tenderness after the procedure, 1 of whom suffered a perforation of the sigmoid colon. This patient had severe ulcerative colitis. The gastrointestinal complication rate was no higher than reported in adult patients undergoing colonoscopy under sedation. No significant complications relating to the administration of anesthesia were encountered.

CONCLUSION

We conclude that colonoscopy performed under general anesthesia in children is a very safe procedure. It is superior to the use of sedation because the child is not placed at risk of respiratory compromise. Furthermore, the procedure is less worrisome for children when performed under a general anesthetic.

Molecular mimicry of ferret gastric epithelial blood group antigen A by Helicobacter mustelae

BACKGROUND & AIMS

Molecular mimicry of Lewis blood group antigens by Helicobacter pylori may be involved in immune evasion by the bacteria and in the pathogenesis of chronic atrophic gastritis. Helicobacter mustelae infects ferrets naturally, causing gastritis, and may be involved in ulcerogenesis. The aim of this study was to determine if H. mustelae shows a similar form of molecular mimicry.

METHODS

Antibodies raised against H. mustelae were used to stain ferret gastric tissue by immunoblotting, immunohistochemistry, and flow cytometry. Epitopes recognized by cross-reactivity were characterized by proteinase K and sodium metaperiodate treatment.

RESULTS

H. mustelae antiserum reacted with H. mustelae and with ferret gastric tissue. Absorption of the antiserum with H. mustelae or ferret and rabbit gastric tissue removed the cross-reactive antibodies. Antibodies reacted with a blood group antigen A-like structure on ferret gastric epithelial cells and H. mustelae lipopolysaccharide.

CONCLUSIONS

H. mustelae expresses a blood group-like antigen as part of its lipopolysaccharide that may be used as a method of immune evasion by mimicry of gastric epithelial cells. The cross-reactivity shown by H. mustelae-specific antibodies with gastric mucosa may suggest a role for autoantibodies in the pathogenesis of H. mustelae-induced gastritis in ferrets.

Clinical significance of Helicobacter infection in children

Helicobacter pylori infection of the gastric mucosa causes chronic gastritis and is associated with peptic ulcer disease and gastric carcinoma. These are conditions which usually occur in adult life. However, H. pylori is an infection which is mainly acquired in childhood. The overall prevalence of H. pylori in children is 10% in developed countries but can be as high as 30-40% in children from lower socio-economic groups. In developing countries, the prevalence of H. pylori in children ranges from 80-100%. H. pylori gastritis does not appear to be associated with symptoms in children in the absence of duodenal ulcer disease. H. pylori infection is present in the vast majority of children with duodenal ulcer disease and, as in adults, eradication of the organism results in long-term healing of duodenal ulceration. H. pylori infection acquired in childhood is now considered to be a significant risk factor for the development of gastric carcinoma. The World Health Organization has classified H. pylori as a Group 1 carcinogen. Specific epidemiological questions which need to be answered in children include the age at which infection is acquired, specific risk factors for infection, the mode of transmission and the risk of reinfection following treatment. Recently, a one week treatment regimen using colloidal bismuth subcitrate, metronidazole and clarithromycin has been shown to be effective in treating children, but compliance is important. Currently there are no guidelines on the need to treat children and a consensus is urgently required on this issue.

Carbon 13-labeled urea breath test for the diagnosis of Helicobacter pylori infection in children

Helicobacter pylori infection is mainly acquired in childhood, and studies on the epidemiology of this infection depend on the availability of a noninvasive diagnostic test for use in children. The aim of this study was to determine whether the carbon 13-labeled urea breath test (UBT) can be used in children by evaluating: (1) its sensitivity and specificity compared with either culture or both rapid urease test and histologic examination, (2) whether a test meal or a prolonged fast is required, (3) the usefulness after treatment for H. pylori. Eighty-eight children (mean age, 10.6 +/- 4.19 years) who were undergoing upper endoscopy were studied while fasting, not fasting, and after treatment. Children were given 50 mg of 13C-urea if they weighed less than 50 kg or 75 mg of 13C-urea if they weighed more than 50 kg with 50 mg of a glucose polymer solution in 7.5 ml of water. Breath samples were collected at baseline and at 15, 30, 45, and 60 minutes. In 63 fasting children the UBT was 100% sensitive and 97.6% specific at 30 minutes with a cutoff value of 3.5 delta 13CO2 per mil. Nonfasting tests in 23 children, performed between 1 and 2 hours after their usual meal, were 100% sensitive and 91.6% specific. In 13 children fed directly before the UBT, the sensitivity of the test was reduced to 50%. Thirty minutes was the optimal sampling time. There was a significant decrease in specificity when samples were obtained at 15 minutes, possibly caused by the interference of oral urease-producing organisms. The test was 100% sensitive and specific in 20 children after treatment for H. pylori infection. The UBT is a highly sensitive and specific test for the diagnosis of H. pylori infection in children. Neither a prolonged fast nor a test meal is required.

Helicobacter pylori: challenges for the paediatrician

During the last 15 years, a great body of knowledge about Helicobacter pylori has been accumulated. Much, however, remains to be studied, particularly in relation to children. The vast majority of infections occur in childhood. It is towards children that any widespread screening, prevention or treatment strategies would need to be aimed. In this annotation, we discuss the epidemiology, symptomatology, diagnosis and treatment of H. pylori in children.

Absence of effect of Lewis A and Lewis B expression on adherence of Helicobacter pylori to human gastric cells

BACKGROUND & AIMS

Lewis b blood group antigen and antibodies to Lewis b inhibit the binding of stationary-phase Helicobacter pylori organisms to fixed sections of gastric tissue. The aim of this study was to determine the effect of expression of Lewis a and Lewis b on binding of H. pylori to primary gastric cells.

METHODS

ABO and Lewis blood types were determined for 13 individuals. Cells were isolated from gastric biopsy specimens by collagenase digestion. Lewis antigen expression and adherence of H. pylori to the cells were quantitated using flow cytometry.

RESULTS

Two of the three nonsecretors were found to express Lewis b on their cells. Nineteen of 19 individuals expressed Lewis a on their cells and 18 of 19 expressed Lewis b. The percentage of cells expressing Lewis antigens varied from individual to individual. H. pylori binding was independent of expression of Lewis antigens. Preincubation of cells with antibodies to Lewis antigens did not inhibit the adherence.

CONCLUSIONS

H. pylori adheres to isolated human gastric cells in a manner that is not dependent on Lewis antigen expression on these cells, and expression of Lewis antigens on the surface of gastric cells is not dependent on Lewis antigen expression on erythrocytes.

In vitro evaluation of the role of antibodies against Helicobacter pylori in inhibiting adherence of the organism to gastric cells

BACKGROUND

Once Helicobacter pylori infection is established, it is difficult to eradicate despite a persistent systemic and local immune response. It is not known whether immunisation can be used to prevent H pylori infection in humans.

AIMS

To evaluate the effect of the human immune response on adherence of H pylori to gastric cells.

METHODS

Human milk from a woman infected with H pylori and milk from a non-infected woman were each fractionated by chromatography on DEAE cellulose. Bacteria were incubated with either serum, human milk, human milk fractions, or secretory IgA before incubation with Kato III cells (cells from a gastric adenocarcinoma cell line). Bacterial adherence to the cells was assessed using flow cytometry.

RESULTS

Serum from both the H pylori infected and non-infected women killed H pylori. This resulted from the action of complement as heating the serum to 56 degrees C for 30 minutes abolished the bactericidal activity. Immunoglobulin fractions from serum of both infected and non-infected women did not inhibit H pylori adherence to Kato III cells. Human milk from the woman infected with H pylori and from the non-infected woman inhibited binding of H pylori to Kato III cells by 50 to 70%. Secretory IgA isolated from human milk had minimal inhibitory effect on adherence and this was notably less than the inhibitory effect of whole human milk.

CONCLUSIONS

Human milk inhibits adherence of H pylori to Kato III cells and this inhibition is independent of whether or not the donor is infected with H pylori. Secretory IgA has minimal inhibitory effect on H pylori adherence.

Adherence of Helicobacter pylori to the gastric mucosa

Bacterial adhesion to the intestinal epithelium is a critical initial step in the pathogenesis of many enteric diseases. Helicobacter pylori is a duodenal pathogen that adheres to the gastric epithelium and causes gastritis and peptic ulceration. The mechanism by which H pylori causes disease has not been elucidated but adherence to the gastric mucosa is thought to be an important virulence determinant of the organism. What is known about adherence of H pylori to the gastric mucosa is summarized. Topics discussed are the mechanism of H pylori adherence; in vitro and in vivo models of H pylori infection; and adherence and potential adhesins and receptors for H pylori.

One week treatment for Helicobacter pylori infection

Helicobacter pylori is associated with primary antral gastritis, duodenal ulceration, and gastric cancer. Current regimens for treating infection in children using bismuth and antibiotics for two to six weeks are cumbersome. The aim of this study was to evaluate a one week course of treatment. All children undergoing endoscopy were assessed for the presence of H pylori by culture, histology, rapid urease test, and 13C urea breath test. Infected children received a one week course of colloidal bismuth subcitrate 480 mg/1.73 m2/day (maximum 120 mg four times a day), combined with metronidazole 20 mg/kg/day (maximum 200 mg three times a day), and clarithromycin 15 mg/kg/day (maximum 250 mg twice a day). To optimise compliance, drugs were dispensed in a 'Redidose' box containing a compartment for each day, and subcompartments marked 'breakfast', 'lunch', 'dinner', and 'bedtime'. Compliance and side effects were assessed immediately after treatment. A urea breath test was performed at least one month after treatment. Twenty two children infected with H pylori were entered into the study; 20 of these took all doses; two children suffered significant side effects (diarrhoea and vomiting). H pylori was eradicated in 21 of the 22 children (95.45%; 95% confidence interval 77% to 100%). This study shows that H pylori infection in children can be cleared by a one week course of treatment.

Cell envelope characteristics of Helicobacter pylori: their role in adherence to mucosal surfaces and virulence

Helicobacter pylori colonises the gastric mucosa of humans and causes both antral gastritis and duodenal ulcer disease. Exactly how H. pylori causes disease is not known but several pathogenic determinants have been proposed for the organism. These include adhesins, cytotoxins and a range of different enzymes including urease, catalase and superoxide dismutase. Surface molecules of H. pylori such as flagella, lipopolysaccharide, the urease enzyme and outer membrane proteins are putative adhesin molecules. While phosphatidylethanolamine and the Lewis(b) blood group antigen have been proposed as receptor molecules for the organism the exact mechanism by which H. pylori adheres to the gastric mucosa has still to be identified. Characterisation of the adhesins of H. pylori could lead to the development of adhesin analogues for use in the inhibition of colonisation and improved therapy for ulcer disease. In vivo studies with isogenic mutants which are incapable of adhering to the gastric mucosa would greatly clarify the significance of adherence. Such mutants could possibly be useful as a vaccine against infection with wild-type organisms.

Guidelines for the management of Helicobacter pylori-related upper gastrointestinal diseases. Irish Helicobacter Pylori Study Group

The discovery of H. pylori is the most important development in gastroduodenal disease this century. It has completely changed our understanding of conditions that occur in the upper gastrointestinal tract. Eradication of the bacterium will cure peptic ulcer disease, decrease the symptoms of non-ulcer dyspepsia and may prevent gastric cancer. There has been an exponential increase in the amount of research in this area in recent years and, consequently, there is considerable confusion as to how H. pylori-related conditions should be managed. It is hoped that these guidelines will clarify some of these issues.

Byler-like familial cholestasis in an extended kindred

Progressive familial intrahepatic cholestasis (PFIC) occurs in many communities and races. A form of PFIC in five children from two consanguineous marriages in an Irish kindred is described. In addition, a review of clinical information from the records of three deceased members of the kindred strongly implies that they also suffered from PFIC. The children had a history of neonatal diarrhoea, sepsis, and intermittent jaundice that ultimately became permanent. They suffered intractable pruritus and growth retardation. Despite evidence of severe cholestasis, serum gamma-glutamyl transferase and cholesterol were normal in these children. Sweat sodium concentration were raised in three children. Liver histology showed severe intrahepatic cholestasis and hepatocellular injury. Urinary bile acid analysis revealed a non-specific pattern consistent with chronic cholestasis. These children suffer from a form of PFIC remarkably similar to that occurring in members of the Byler kindred.

The urease enzyme of Helicobacter pylori does not function as an adhesin

Helicobacter pylori urease is essential for colonization of the gastric mucosa irrespective of whether the stomach is acidic or hypochlorhydric. It has therefore been speculated that the enzyme functions as an adhesin. The aim of this study was to compare the adherence of H. pylori N6 with the adherence of an isogenic urease-negative mutant, strain N6(ureB::TnKm), to gastric cells. Strain N6 originated from a patient with gastritis. Strain N6(ureB::TnKm) is specifically modified in the gene which encodes the large subunit of urease, UreB, and hence does not form a UreA-UreB enzyme complex. We have used flow cytometry to assess the adherence of H. pylori to the cells. We have also used phase-contrast microscopy to assess the adherence of the organism to Kato III cells. In the absence of urea both strains bound to Kato III cells and to primary gastric cells. Binding of both strains to the cells occurred rapidly. The presence of urea in the incubation medium decreased the binding of strain N6 to the cells. This was due to a rise in the pH of the incubation medium, which caused loss of viability of the organism. Urea had no effect on the adherence of strain N6(ureB::TnKm). We conclude that the urease of H. pylori does not play a role in the adherence of the organism to gastric cells.

Gastric metaplasia and duodenal ulcer disease in children infected by Helicobacter pylori

BACKGROUND

Helicobacter pylori infection of the gastric mucosa is vital in the pathogenesis of duodenal ulcer disease. H pylori will only colonise gastric epithelium and its association with duodenal disease is therefore not easily explained.

AIMS

To determine if gastric metaplasia in the duodenum increases the risk of duodenal ulcer disease in children infected with H pylori.

PATIENTS

All children undergoing upper endoscopy over a 20 month period in a children's hospital in Ireland.

METHODS

Two biopsy specimens were obtained from the antral mucosa and two from the first part of the duodenum. One antral biopsy specimen was used in a rapid urease test (Clo Test). Biopsy sections were stained with haematoxylin and eosin and also with cresyl violet for identification of H pylori. Periodic acid Schiff (PAS) stain was performed to identify areas of gastric metaplasia.

RESULTS

Gastric and duodenal biopsy specimens were obtained from 148 patients (M:F 1:2:1). Twenty five children (17%) had H pylori positive gastritis. Thirty four children (23%) had gastric metaplasia in the duodenum. Nine per cent of children under the age of 8 years had gastric metaplasia compared with 38% in those 12 years of age or over (p < 0.005). Seven children had duodenal ulcer disease. Gastric metaplasia was present in six of seven (86%) children with duodenal ulcer disease compared with 28 of 141 (20%) without ulceration (p < 0.001). While both H pylori and gastric metaplasia were each significant risk factors for duodenal ulcer disease, the combined presence of both factors was associated with a pronounced increase in duodenal ulcer disease. Duodenal ulcer disease occurred in over 50% of children with both H pylori infection and gastric metaplasia. In contrast duodenal disease did not occur in children (0 of 100) when both were absent.

CONCLUSION

The presence of gastric metaplasia in the duodenum is the major risk factor for duodenal ulcer disease in patients colonised by H pylori.