Pediatric to Adult Transition in Inflammatory Bowel Disease: Consensus Guidelines for Australia and New Zealand

BACKGROUND

The incidence of pediatric inflammatory bowel disease (IBD) is rising, and there is an increasing need to support adolescents when they transition to adult care. Evidence supports the use of a structured transition process but there is great variation across Australasia. The study aim was to develop evidence and expert opinion-based consensus statements to guide transitional care services in IBD.

METHODS

A modified UCLA-RAND methodology was employed to develop consensus statements. An IBD expert steering committee was formed and a systematic literature review was conducted to guide the drafting of consensus statements. A multidisciplinary group was formed comprising 16 participants (clinicians, nurses, surgeons, psychologists), who anonymously voted on the appropriateness and necessity of the consensus statements using Likert scales (1 = lowest, 9 = highest) with a median ≥7 required for inclusion. Patient support groups, including direct input from young people with IBD, informed the final recommendations.

RESULTS

Fourteen consensus statements were devised with key recommendations including use of a structured transition program and transition coordinator, mental health and transition readiness assessment, key adolescent discussion topics, allied health involvement, age for transition, and recommendations for clinical communication and handover, with individualized patient considerations. Each statement reached median ≥8 for appropriateness, and ≥7 for necessity, in the first voting round, and the results were discussed in an online meeting to refine statements.

CONCLUSIONS

A multidisciplinary group devised consensus statements to optimize pediatric to adult transitional care for adolescents with IBD. These guidelines should support improved and standardized delivery of IBD transitional care within Australasia.

Transitional care of adolescents with inflammatory bowel disease to adult services varies widely across Australia and New Zealand

Background and Aim

Children and adolescents account for approximately 14% of inflammatory bowel disease (IBD) diagnoses. At an appropriate age and level of development adolescents with IBD have their care transferred from the pediatric to adult clinical team during a process termed "transition". The study aim was to survey pediatric gastroenterologists throughout Australasia to identify commonality in the transition process to contribute to standardized guideline development.

Methods

A descriptive survey captured key variables: transition clinic format, process and infrastructure, transition assessments, and guidelines. The survey was distributed electronically to 59 Pediatric Gastroenterologists throughout Australasia in January 2023.

Results

Seventeen (29%) clinicians completed the survey: Australia 13 (76%). New Zealand 4 (24%). Thirteen (76%) respondents had access to a dedicated IBD transition clinic. Adolescents attended transition clinics 1-7 times, and the main processes transferred were: prescription provision, biologic appointments, and adult team contacts. Transition was first discussed age 13-15 years (53%), or 16-18 years (47%), with the main discussion topics including: continuing adherence (88%), smoking (59%), alcohol use (59%), recreational drug use (59%). Transition readiness assessments were done infrequently (24%). The minority (24%) used formal guidelines to inform the transition process, but 15 (88%) considered the development of a standardized Australasian guideline as beneficial/extremely beneficial.

Conclusions

This survey highlighted that transition care for adolescents with IBD is variable across Australasia. Australasian guideline development may optimize the transition process for adolescents with IBD and improve their longitudinal outcomes.

Co-design and Consultation Ensure Consumer Needs Are Met: Building an eHealth Platform for Children with Inflammatory Bowel Disease

BACKGROUND

Crohn's Colitis Care is an adult inflammatory bowel disease eHealth system. Crohn's Colitis Care required additional pediatric functionality to enable life-long records and mitigate transition inadequacies.

AIM

This study describes and evaluates a consensus method developed to ensure consumer needs were met.

METHODS

Pediatric-specific functionality and associated resources considered important for inclusion were developed by a clinician consensus group. This group was divided into thematic subgroups and underwent two voting rounds. The content validity index was used to determine items reaching consensus. Children with inflammatory bowel disease and their parents were later shown a descriptive list of non-clinical inclusion topics proposed by the consensus group, and asked to vote on whether topic-related functionality and resources should be included.

RESULTS

The consensus process consulted 189 people in total (38 clinicians, 32 children with inflammatory bowel disease and 119 parents). There was agreement across all groups to incorporate functionality and resources pertaining to quality of life, mental health, self-management, and transition readiness; however, divergence was seen for general inflammatory bowel disease facts, your inflammatory bowel disease history, and satisfaction. Cost saw the greatest disparity, being less supported by consumers compared to clinicians. Over 75% of consumers agreed it would be okay for appointments to take longer for survey completion, and > 90% thought Crohn's Colitis Care should allow consumers to ask their treating team questions.

CONCLUSIONS

Widespread consumer co-design and consultation were important in unveiling differing perspectives to ensure Crohn's Colitis Care was built to support both consumer and clinician perspectives. Consumers collaborate to create a list of functionality and resources to be included in software (left), influencing the final product build (right).

Isolated positive deamidated gliadin peptide-IgG has limited diagnostic utility in coeliac disease

AIM

Deamidated gliadin peptide-IgG (DGP-IgG) antibody serology testing is widely utilised in screening for coeliac disease in Australia; however, it is used sparingly in Europe. The aim of this study was to assess the diagnostic value of a positive DGP-IgG in the setting of a negative tissue transglutaminase-IgA (tTG-IgA) for gastrointestinal pathology among paediatric patients.

METHODS

We conducted a retrospective cohort study of all children with an elevated DGP-IgG in the setting of a negative tTG-IgA who underwent gastroscopy over a 48-month period (January 2015-December 2018) at a tertiary paediatric centre. They were identified utilising the electronic pathology database and demographic and clinical data were collected from electronic medical records. Patients who had previously been diagnosed with coeliac disease were on a gluten-free diet or over the age of 18 were excluded from the study.

RESULTS

Twenty-six patients with an elevated DGP-IgG in the setting of a negative tTG-IgA underwent gastroscopy. Our study yielded a positive predictive value of 1/26 (3.9% CI 95% 0.7%, 18.9%) for the diagnosis of coeliac disease. Overall, there were 25 histopathological diagnoses including 1 diagnosis of coeliac disease among the total 26 patients who were positive DGP-IgG and negative tTG-IgA and underwent gastroscopy.

CONCLUSIONS

Our findings suggest that an isolated positive DGP-IgG has a very low diagnostic yield for coeliac disease in children and may be indicative of other gastrointestinal pathology.

Impact of a new young adult inflammatory bowel disease transition clinic on patient satisfaction and clinical outcomes

AIM

The transition from paediatric to adult care for patients with inflammatory bowel disease (IBD) is associated with an increased risk of treatment non-adherence, hospitalizations and emergency department (ED) use. We established a new young adult IBD clinic (YAC) in Melbourne to capture this at-risk population. We aimed to assess patient satisfaction as well as clinical outcomes.

METHODS

All patients who attended the YAC between its inception in November 2016 and November 2018 were recruited to our YAC group, 61 patients in total. A control group was selected from the pre-existing adult clinic (AC) at our service, 34 patients in total. IBD-related ED (IBD-ED) visits were collected for all patients. We compared IBD-ED visits in the 2 years before and after attending the clinic for the first time. Patient satisfaction was assessed using the IBD-Patient Satisfaction Questionnaire.

RESULTS

There was an overall decrease in IBD-ED visits between the pre-clinic and post-clinic periods in both the YAC (42.9% reduction) and AC (69.2% reduction) (P < 0.001). Patient satisfaction was high amongst both services with YAC patients indicating higher satisfaction with communication (P = 0.015).

CONCLUSION

There was a reduction in IBD-ED visits in both the YAC and the AC, high patient satisfaction, and statistically higher satisfaction with communication in the YAC. We speculate the importance of a YAC is to capture those patients in the peri-transitional period at risk of being lost to follow-up or not previously referred for specialist care.

Decade of the dangers of multiple magnet ingestion in children: A retrospective review

AIM

Magnet ingestion has become more frequent in children as magnetic toys and jewellery have been popularised, with the potential to cause significant morbidity. Our aim was to describe our experience at a tertiary paediatric surgical centre.

METHODS

Retrospective review of patients admitted with multiple magnet ingestion (January 2011-December 2020). Division into an intervention group and conservative group. Comparisons included demographics, number of magnets and clinical outcomes. Data analysis with a Student's t-test and ROC Curve, P value of <0.05 was significant.

RESULTS

A total of 23 patients were identified with a total of 150 magnets ingested. The majority required an intervention for magnets retrieval (15/23, 65.2%), 11/15 (73.3%) surgical and 4/15 (26.7%) endoscopic. In the surgery group, 6/11 (54%) presented with an initial perforation and 1/11 (9.1%) an entero-enteric fistula. One patient (9.1%) had a multi-site anastomotic leak post-operatively. The conservative group had a significantly lower median number of ingested magnets (2 (2-6) vs. 7 (2-40), P = 0.03) and median length of stay (1 (1-4) vs. 7 (1-24), P = 0.03). ROC curve analysis revealed ingestion of >3 magnets had a sensitivity of 86.7% (95% CI: 62.1-97.6%) and specificity of 87.5% (95% CI: 53.0-99.4%) for requiring an intervention.

CONCLUSION

This series highlights a significant morbidity in children with a higher incidence of intervention following ingestion of more than three magnets. There is a strong requirement for the creation and adherence to new legislature involving industry standards.

Early Infliximab in Crohn's is associated with decreased intestinal surgery and similar health care costs

BACKGROUND

Using Infliximab early in Crohn's disease can provide a window of opportunity in children for restoration of growth and achievement of puberty. We aimed to compare clinical outcomes and costs of a retrospective pediatric Crohn's disease (pCD) cohort treated with early use Infliximab (EUI) within 12 months compared with later use Infliximab (LUI).

METHODS

Retrospective review of all children with pCD commenced on Infliximab was undertaken in a tertiary Australian pediatric center.

RESULTS

pCD progressing to Infliximab was identified in 70 children: 38 (54%) in the EUI cohort versus 32 (46%) in the LUI cohort. Intestinal surgery had a higher risk of occurring in EUI when compared with LUI (2 (5%) versus 9 (28%), HR 5.67 (95% CI 1.21-26.38); p = .027). No patients in EUI underwent intestinal surgery post Infliximab commencement compared with 3 (9%) in LUI (p = .09). Escalation of Infliximab in luminal Crohn's disease was not significantly different in EUI when compared with LUI (3 (10.3%) versus 9 (39.1%) (p = .1)). EUI was more frequently used than LUI in 2015-2018 (27 (71%) versus 14 (44%)) p = .029, with the inverse occurring in 2010-2014 (11 (29%) versus 18 (56%)). Hospital admissions per person per year in EUI and LUI were 43 (0.23 visits/person/year) versus 84 (0.67 visits/person/year); IRR 2.51 (95% CI 0.9-7.01); p = .078). Health costs were not significantly different between cohorts.

CONCLUSION

EUI in pCD is associated with an increased likelihood of being diagnosed in more recent years, less intestinal surgery and a trend toward decreased hospital admissions than LUI.

Histology at diagnostic gastroscopy predicts outcome after intestinal resection in pediatric Crohn's disease

BACKGROUND AND AIM

Pediatric Crohn's disease (CD) has been shown to have a high recurrence rate following surgical resection. Risk factors for postoperative CD recurrence in children are not well known. The aim of this study was to identify factors influencing postoperative recurrence in pediatric CD.

METHODS

Pediatric CD patients who underwent surgical resection with primary anastomosis with a minimum follow up of 2 years were identified from databases at the Royal London Hospital and Massachusetts General Hospital. Patients were subdivided into a recurrence group defined by clinical, endoscopic, histological, radiological and/or surgical outcomes, and a nonrecurrence group. Patient demographics, initial gastroscopy and colonoscopy findings, Paris classification, and preoperative and postoperative pharmacotherapy were analyzed.

RESULTS

Ninety-six children who underwent an ileal or ileocolonic resection with primary anastomosis were identified. Fifty-seven children had postoperative recurrence. Recurrence was associated with abnormal initial gastroscopy findings (P = 0.0077), ileocolonic disease location (P = 0.03), and perianal disease involvement (P = 0.04). Patients with abnormal initial gastroscopy had higher rates of relapse (hazard ratio 3.42, 95% confidence interval [CI] [1.86-6.30], P = 0.001). Multivariate analysis demonstrated that abnormal diagnostic gastroscopy histology was a significant independent predictor of postoperative recurrence in this cohort (odds ratio 1.33, 95% CI [1.04-1.70], P = 0.024). The most common histological abnormality was non-Helicobacter gastritis, found in 29/46 (63%).

CONCLUSION

This dual-center study has shown that the presence of upper gastrointestinal tract inflammation, especially non-Helicobacter gastritis, at the time of diagnosis, is associated with an increased risk of postoperative recurrence in pediatric CD.

Deep sequencing shows low-level oncogenic hepatitis B virus variants persists post-liver transplant despite potent anti-HBV prophylaxis

Recent studies suggest that withdrawal of hepatitis B immune globulin (HBIG) and nucleos(t)ide analogues (NA) prophylaxis may be considered in HBV surface antigen (HBsAg)-negative liver transplant (LT) recipients with a low risk of disease recurrence. However, the frequency of occult HBV infection (OBI) and HBV variants after LT in the current era of potent NA therapy is unknown. Twelve LT recipients on prophylaxis were tested in matched plasma and peripheral blood mononuclear cells (PBMCs) for HBV quasispecies by in-house nested PCR and next-generation sequencing of amplicons. HBV covalently closed circular DNA (cccDNA) was detected in Hirt DNA isolated from PBMCs with cccDNA-specific primers and confirmed by nucleic acid hybridization and Sanger sequencing. HBV mRNA in PBMC was detected with reverse-transcriptase nested PCR. In LT recipients on immunosuppressive therapy (10/12 male; median age 57.5 [IQR: 39.8-66.5]; median follow-up post-LT 60 months; 6 pre-LT hepatocellular carcinoma [HCC]), 9 were HBsAg-. HBV DNA was detected in all plasma and PBMC tested; cccDNA and/or mRNA was detected in the PBMC of 10/12 patients. Significant HBV quasispecies diversity (ie 143-2212 nonredundant HBV species) was noted in both sites, and single nucleotide polymorphisms associated with cirrhosis and HCC were detected at varying frequencies. In conclusion, OBI and HBV variants associated with severe liver disease persist in LT recipients on prophylaxis. Although HBV control and cccDNA transcriptional silencing may occur despite immunosuppression, complete virological eradication does not occur in LT recipients with a history of HBV-related end-stage liver disease.

Staphylococcus aureus spa type t437: identification of the most dominant community-associated clone from Asia across Europe

Methicillin-resistant Staphylococcus aureus (MRSA) belonging to the multilocus sequence type clonal complex 59 (MLST CC59) is the predominant community-associated MRSA clone in Asia. This clone, which is primarily linked with the spa type t437, has so far only been reported in low numbers among large epidemiological studies in Europe. Nevertheless, the overall numbers identified in some Northern European reference laboratories have increased during the past decade. To determine whether the S. aureus t437 clone is present in other European countries, and to assess its genetic diversity across Europe, we analysed 147 S. aureus t437 isolates from 11 European countries collected over a period of 11 years using multiple locus variable number tandem repeat fingerprinting/analysis (MLVF/MLVA) and MLST. Additionally 16 S. aureus t437 isolates from healthy carriers and patients from China were included. Most isolates were shown to be monophyletic with 98% of the isolates belonging to the single MLVA complex 621, to which nearly all included isolates from China also belonged. More importantly, all MLST-typed isolates belonged to CC59. Our study implies that the European S. aureus t437 population represents a genetically tight cluster, irrespective of the year, country and site of isolation. This underpins the view that S. aureus CC59 has been introduced into several European countries, not being restricted to particular geographical regions or specific host environments. The European S. aureus t437 isolates thus bear the general hallmarks of a high-risk clone.

Systematic review: MRI enterography for assessment of small bowel involvement in paediatric Crohn's disease

BACKGROUND

Barium meal enteroclysis (BM) is the recommended imaging technique for small bowel inaccessible by ileo-colonoscopy when diagnosing paediatric-onset inflammatory bowel disease, but it has poor sensitivity and involves ionising radiation. MRI enterography (MRE) is an alternative methodology.

AIMS

To critically appraise the published evidence on MRE in the assessment of Paediatric inflammatory bowel disease by systematic review.

METHODS

Review of all English language data reporting MRE for the investigation of patients <18 years with known or suspected IBD. Primary searches of Medline (Jan 1950-April 2012), Cinahl (1966-April 2012) and Pubmed (Jan 1950-April 2012) were performed using keyword and MeSH terms; IBD; Magnetic resonance imaging; small bowel imaging; EMBASE was then searched. Two authors independently assessed the quality of studies using the quality assessment of diagnostic accuracy studies tool.

RESULTS

Searches yielded 930 035 hits, combination word searches limited to 1983 titles. Fifty-two studies were fully reviewed, 41 were excluded due to lack of paediatric data. Eleven studies of 496 children were included. All studies used endoscopy as the reference test. 10/496 patients required jejunal intubation for bowel preparation. Meta-analysis of six comparable studies gave a pooled sensitivity and specificity for MRE detection of active terminal ileal Crohn's disease of 84% and 97% respectively. Studies displayed heterogeneity in bowel preparation, scanning technique, reporting methodology and timing of ileo-colonoscopy in relation to MRE. In three studies comparing BM, MRE had greater sensitivity and specificity.

CONCLUSIONS

MRE is a sensitive and specific tool for diagnosis in paediatric inflammatory bowel disease. Technical considerations require refinement and standardisation; however, MRE has no radiation. Current data suggest that MRE should supersede BM as the SB imaging technique in centres with appropriate expertise.

Distinct geographical and demographic distribution of hepatitis B virus genotypes in the Canadian Arctic as revealed through an extensive molecular epidemiological survey

Very little is known of hepatitis B virus (HBV) in Canadian Arctic indigenous populations, where HBV was considered endemic prior to the introduction of HBV vaccine. This study expands upon an HBV seroepidemiological survey conducted between 1983 and 1985 throughout the Canadian Arctic, to characterize HBV in this population. Archived hepatitis B surface antigen (HBsAg)-positive sera (n = 401) were processed for HBV DNA, followed by sequencing and phylogenetic analysis of the HBsAg- and HBcAg-coding regions. Sixty-nine per cent of samples (277/401) were DNA positive, with most having low viral load (median 3.4 log 10 IU/mL). The predominant HBV genotype observed was genotype B (HBV/B, 75%), followed by HBV/D (24%) and HBV/A (1%). All HBV/B strains clustered within subgenotype B6, a newly recognized HBV genotype among western circumpolar Inuit and Alaska Native people. HBV/D strains included both D3 (88%) and D4 (12%) subgenotypes, while all HBV/A strains were subgenotype A2. An association of HBV genotype B with Inuit living in the eastern Arctic and an association of genotype D with First Nation (Dene) living in the western Arctic was observed. This study establishes the high prevalence of HBV/B6 and HBV/D genotypes in Arctic populations and reveals their marked distribution within the Canadian Arctic based on geographical and demographic attributes.

Health-related quality-of-life outcomes from adult cochlear implantation: a cross-sectional survey

PURPOSE

The purpose of this study was to examine the extent to which cochlear implants and related rehabilitation improve health-related quality-of-life (HRQoL) and social participation for deafened adults and their partners.

METHOD

A cross-sectional survey was used to examine HRQoL and social participation experiences of 202 deafened adults (148 with implants and 54 without) and 136 partners associated with cochlear implant clinics in Australia and New Zealand. Respondents completed a mailed survey consisting of the Assessment of Quality of Life instrument (a utility instrument), the Participation Scale and questions concerning their socioeconomic status. Both univariate and multivariate analyses were performed.

RESULTS

Controlling for socioeconomic factors, people with cochlear implants reported improved HRQoL and social participation when compared with non-implantees. Implantees reported a relative gain in health utility of 50%, and a relative improvement in social participation of 31%. Such differences were not reported by partners, although patient and partner HRQoL were weakly correlated.

CONCLUSION

The results of this cross-sectional study suggest that cochlear implantation contributes significantly to improvements for deafened adults in everyday communication settings and makes a major contribution to their HRQoL. Nonetheless, when compared with population-based studies, this population continues to report considerably reduced quality of life. Partners also report significantly reduced quality of life when compared to population norms.

Genotype D amongst injection drug users with acute hepatitis B virus infection in British Columbia

The eight genotypes of hepatitis B virus (HBV) exhibit distinct geographical distributions. This study identified HBV genotypes and transmission modes associated with acute infection in British Columbia (BC), Canada, from 2001 to 2005. Seventy cases of acute HBV in BC were identified from laboratory reports using a standardized case definition. Interviews for risk factors and hepatitis history were conducted for each case. HBV genotypes were determined by BLAST comparison analysis of the surface (S) or preS gene sequence. To illustrate the distribution of genotypes identified amongst acute cases in BC, an annotated map was produced showing the global occurrence of HBV genotypes. The majority of acute HBV cases occurred in Caucasian, Canadian-born males, with 30% of cases reporting injection drug use (IDU) and 21% reporting incarceration. The most common genotype observed was genotype D (62.9%), followed by genotypes A (18.6%), C (11.4%), B (4.3%), and E (1.4%). A significant association was observed between Genotype D and IDU (P = 0.0025) and previous incarceration (P = 0.0067). Phylogenetic analysis of the S gene sequence demonstrated identical or high genetic relatedness amongst genotype D viral strains (86% sub-genotype D3), thus verifying transmission clustering amongst BC injection drug users. The association between acute HBV genotype and reported transmission modes has not been previously described in North America. Tracking of genotypes can help identify disease transmission patterns and target at-risk populations for preventive immunization.

Routine coagulation screening in children undergoing gastrointestinal endoscopy does not predict those at risk of bleeding

BACKGROUND AND STUDY AIMS

Routine coagulation screening prior to gastrointestinal endoscopy is performed in many centres in the UK, despite the lack of any evidence to support the practice. The aim of this study was to assess the benefits of routine pre-endoscopy coagulation screening in children and to assess how widespread this practice is in the UK.

PATIENTS AND METHODS

We performed a retrospective analysis of the case notes of 250 consecutive patients who had undergone routine coagulation screening prior to endoscopy and biopsy, in accordance with our unit's protocol, looking for evidence of abnormal results or episodes of bleeding. We also performed a telephone survey of the protocols for coagulation screening at other paediatric units in the UK which are known to perform gastrointestinal endoscopy on a routine basis.

RESULTS

According to our hospital's laboratory reference ranges, 16.8 % of the children who underwent endoscopy and biopsy had abnormal clotting. This was neither clinically significant nor associated with an increased bleeding risk in any patient. Of the 23 UK paediatric gastroenterology centres surveyed, including our own, five (21.7 %) perform routine coagulation screening before endoscopy.

CONCLUSIONS

This study suggests that, although it is a relatively common practice, routine coagulation screening is not indicated in children who are undergoing gastrointestinal endoscopy and biopsy, and that it does not predict those at risk of significant bleeding. We would therefore suggest that if pre-endoscopy screening is to be performed, it should be reserved for those who are potentially at high risk of bleeding.

Response to long-term lamivudine treatment (up to 5 years) in patients with severe chronic hepatitis B, role of genotype and drug resistance

Lamivudine is effective in suppressing viral replication, normalizing alanine aminotransferase (ALT), and improving histological appearance in HBe positive and negative hepatitis. It is unclear whether hepatitis B virus (HBV) genotype influences the response to lamivudine. We report the long-term response of patients with chronic hepatitis B with and without cirrhosis at baseline treated with lamivudine according to HBV genotype. Retrospective review of charts of all patients treated with lamivudine monotherapy between 1993 and 2002. Response to therapy defined as ALT in the normal range, undetectable HBV DNA, and in the HBeAg positive group loss of HBeAg and/or the development of anti-HBe. HBV DNA measured by the Digene Hybrid capture assay (sensitivity 1.4 x 10(6) copies/mL). YMDD mutation at rtL180M and rtM204V/I measured by restriction digest of amplified products. Genotyping performed by sequencing and phylogenetic tree analysis of the preS region of the virus genome. Seventy-one patients treated with lamivudine for 6 months or more, 53 (75%) were male, average age 47 years, 38 (54%) were HBeAg+ and 33 (46%) HBeAg-. Mean baseline HBV DNA viral titre was 1280.2 copies/mL and 518 copies/mL respectively. Cirrhosis was present in 30 (42%). Sera were examined for YMDD mutations at last patient visit in 61 (86%), and were detected in 45 (74%), there being no association with a particular genotype. Data from up to 5 years on lamivudine indicated no difference in biochemical or virological response between genotypes. Cirrhosis was more prevalent with specific genotypes. We found no influence of HBV genotype on the development of resistance to lamivudine, however liver disease severity was influenced by genotype.

The utility of Tc-99m dextran in the diagnosis and identification of melanoma metastases responsible for protein-losing enteropathy

Protein-losing enteropathy is an uncommon syndrome of excessive loss of protein via the gastrointestinal mucosa. Tc-99m dextran is a tracer ideally suited for diagnosis and localization. The authors report a case of melanoma mestastases to the small bowel that were causing protein-losing enteropathy. These were diagnosed and localized using Tc-99m dextran, leading to a curative resection.

[Risperidone in the treatment of psychotic, affective and behavioral symptoms associated to Alzheimer's disease]

INTRODUCTION

A total of 235 patients with diagnoses of Alzheimer's dementia together with psychotic and/or affective symptomatology, as well as behavioral disturbances was included in an open label postmarketing surveillance study. The study objectives were to asses: 1) risperidone efficiency in psychotic and affective symptomatology and behavioral disturbances; 2) risperidone influence in the patient's performance, 3) dosage range at which efficiency is observed; and 4) safety in this group of patients. Patients were observed during a six month period. Risperidone was used at a mean dosage of 1.23 +/- 0.86 mg daily (range: 0.5-4.5 mg daily).

MATERIAL AND METHODS

Risperidone was assessed by the Clinical Global Impression (CGI), Geriatric Depression Scale (GDS), Neuropsychiatric Inventory (NPI), Clinical Deterioration Rating (CDR), UKU subscale for neurological side effects and spontaneous reports. Patients were evaluated at baseline, 15 days and months 1, 2, 4 and 6. Sixteen patients (6.8%) were excluded from the statistical analysis due to protocol violation. Fifty four patients (24.7%) dropped out.

RESULTS

Risperidone produced a significant improvement in the mean total scores of CGI, NPI, GDS (patient's satisfaction, hope.) and CDR (judgment and problem solving, community affairs, hobbies.) scales. Extrapyramidal symptoms improved from day 15 onwards in patients who had received antipsychotic treatment previously; in naive treated patients these symptoms did not change during the study period.

CONCLUSIONS

Risperidone was well tolerated. Only 6 (2. 7%) discontinued treatment due to adverse events. Ninety seven percent of the patients did not suffer any adverse event; the resting 2.7% suffered one or more side effects: sedation (1.4%), constipation (0.5%) and vomiting (0.5%) among others.

Vestibular stimulation by multichannel cochlear implants

The recipient of a Nucleus 22 multichannel cochlear implant began to experience severe vestibular stimulation related to the implant. This patient's experience initiated a study with the objective of determining the frequency of implant-related vestibulo-ocular stimulation. Subjects consisted of 17 randomly selected patients who use cochlear implants. Included in the study were 14 Nucleus 22 and three Med-El Combi 40-devices. Stimulation of the implants was performed both by individual channel and with sound field broad-band 80-dB noise using the users' normal device settings. Eye movements were monitored with infrared videonystagmography. Only one subject, who used a Med-El Combi 40, showed a consistent and strong ocular response to cochlear stimulation but had no subjective symptoms. The authors conclude that vestibulo-ocular activation is possible with multichannel cochlear implants but is infrequent and may not be clinically significant.

Cochlear implantation in otosclerosis: a unique positioning and programming problem

A case is reported in which a Nucleus 22 channel cochlear implant was inserted into the basal turn of the cochlea of a patient with advanced otosclerosis. It then passed out of the anterior end of the basal turn into an otospongiotic cavity related to the cochlea. Seven electrodes were located in the basal turn and it was possible to map them sufficiently well for the patient to derive considerable benefit from the implant. The problem of implant induced facial nerve stimulation in otospongiosis is also discussed.

Neuropsychological performance, disease severity, and depression in progressive supranuclear palsy

To investigate the relationship between disease severity, cognitive impairment and depression in progressive supranuclear palsy (PSP) we studied a group of 25 patients who fulfilled strict research criteria and 25 matched controls. Disease severity was judged from the duration of symptoms, level of physical disability using the Columbia Rating Scale (CRS), and the degree of eye movement abnormality. The neuropsychological battery was designed to assess attention and executive function, visual and auditory perception, semantic memory and language production. Although the PSP group were significantly impaired on almost all of these measures, the most profound deficits were on tests of sustained and divided attention. There was no correlation between cognitive impairment and either disease duration or scores on the CRS, but performance on tests of attention correlated significantly with the degree of ocular motor impairment. Depression was found to be common in PSP but did not correlate with any other parameters. It is concluded that the cognitive deficit in PSP is widespread and independent of depression. The association between the severity of eye movement disorder and deficits in sustained and divided attention leads us to postulate that pathology involving the midbrain periaqueductal region may be critical for breakdown in these fundamental processes.

Progressive supranuclear palsy presenting with dynamic aphasia

BACKGROUND

Progressive supranuclear palsy (PSP) is an akinetic-rigid syndrome of unknown aetiology which usually presents with a combination of unsteadiness, bradykinesia, and disordered eye movement. Speech often becomes dysarthric but language disorders are not well recognised.

METHODS

Three patients with PSP (pathologically confirmed in two) are reported in which the presenting symptoms were those of difficulty with language output.

RESULTS

Neuropsychological testing showed considerable impairment on a range of single word tasks which require active initiation and search strategies (letter and category fluency, sentence completion), and on tests of narrative language production. By contrast, naming from pictures and from verbal descriptions, and word and sentence comprehension were largely intact. The degree of semantic memory impairment was also slight.

CONCLUSIONS

Relatively selective involvement of cognitive processes critical for planning and initiating language output may occur in some patients with PSP. This presentation resembles the phenomenon of "verbal adynamia" or "dynamic aphasia" seen in patients with frontal lobe damage. Although definite cortical changes were present at postmortem examination, it is likely that the neuropsychological deficits reflect functional frontal deafferentation secondary to interruption of frontostriatal feedback loops.

A review of patients attending a preliminary cochlear implant assessment clinic

The Cochlear Implant Programme at Manchester Royal Infirmary was established in 1988 and so far (January, 1992) 38 patients have been implanted with the Nucleus 22 channel intracochlear device and one with the Ineraid device. All patients who are referred for consideration for an implant are initially seen at a preliminary cochlear implant assessment clinic conducted by an ENT surgeon. One hundred and seventy three patients attended the initial outpatient screening clinic between 1987 and January 1992. Of these 112 patients (67.6 per cent) went on for further investigation regarding suitability for implantation. This paper details the aetiology and severity of deafness in these patients and explains how suitability for admission to the next stage of assessment was decided.

Height estimation from foot and shoeprint length

Foot length displays a biological correlation with height that suggests the latter might be estimated from foot- or shoeprints when such evidence provides an investigator the best or only opportunity to gauge that aspect of a suspect's physical description. Previous utilization of percentages and linear regressions of foot length to make height estimates is reviewed and appraised, as is such use of shoeprints. Newly determined percentages and linear regressions for determining height from foot length for young adult males and females based upon very large U.S. Army anthropometric databases are presented and evaluated. Suggestions are made for the practical employment of shoeprint length, preferably as a direct measurement but also indirectly as a shoe size indicator, for height assessment.

Corrections for age in estimating older adults' stature from long bones

Stature estimates based on long bone measurements require a correction factor to compensate for stature decrease in older people. Such a correction should exclude the effect of any secular trend in stature and reflect the age at which stature begins to decrease, sex differences, and the increasing rate of change with age. Stature correction which meet these requirements for ages 46 through 85, based upon two recent large-scale longitudinal anthropometric studies, are provided in tabular form.

Stature- and age-related bias in self-reported stature

The use of reported stature, especially self-reported stature such as on a driver's license, as a proxy for measured stature is necessary when measured stature is unavailable, for example, in matching data calculated from skeletal remains with data for missing persons. The accuracy of self-reported stature for older persons and especially for tall and short people is not well ascertained. Examination of published reports provides evidence that beginning at age 45, people compound their stature overestimation by an additional amount related to age (women by twice the amount of men). Analysis of anthropometric data from 8000 U.S. Army personnel indicates that the amount of general overestimation of stature by men is 2 1/2 times greater than that by women. Neither tall men nor tall women underestimate their stature, but men in the upper third of the stature range, and women in the upper 10%, self-report their stature with greater accuracy. No trends in accuracy are apparent in the remainder of the stature spectrum for men or women.

Confidence intervals for estimates based on linear regression in forensic anthropology

Forensic anthropologists commonly use simple linear regression to estimate the value of a dependent variable, such as stature, for a single specimen where the value of the independent variable, such as humerus length, is known. Published studies providing regression equations for such use almost invariably include the standard error of estimate. Unfortunately, it is exceptional for forensic anthropologists to use the standard error to calculate correctly the confidence limits for their single predicted value. We attempt to show why this may be and provide explicit guidelines for the proper construction of confidence interval in such circumstances.

Genetic studies in the Markham Valley, northeastern Papua New Guinea: gamma globulin (Gm and Inv), group specific component (Gc) and ceruloplasmin (Cp) typing

Genetic studies in the Markham Valley, northeastern Papua New Guinea; Gamma globulin (Gm and Inv), group specific component (Gc) and ceruloplasmin (Cp) typing. M. S. Schanfield, Eugene Giles and H. Gershowitz, Department of Human Genetics, University of Michigan, Ann Arbor, Michigan 48104. Immunoglobulin allotyping was carried out on 680 serum samples from inhabitants of the Markham Valley, Papua New Guinea (seven villages speaking the same Melanesian [PAP] speaking village). Family and population data verified the presence of Gm-ag, G-ab and Gm-afb among the MN speakers and Gm-ag, Gm-axg, Gm-ab and Gm-afb among the PAP speakers. The frequency of Gm-ag was between 0.048 and 0.235, while the frequency of Gm-ab was between 0.427 and 0.627 and the frequency of Gm-afb ranged between 0.261 and 0.424 among the seven MN villages; the single PAP village had frequencies of 0.568, 0.160, 0.213 and 0.059 for Gm-ag, Gm-axg, Gm-ab and Gm-afb respectively. The frequency of Inv1 ranged between 0.034 and 0.095 in the MN villages and 0.014 in the PAP village. The rare occurrence of Gm(x) without Gm(g) was explained by the presence of a Gm-axfb haplotype, while in two PAP families the presence of Gm(x) without Gm(g) was explained by the abnormally weak expression of Gm(g) in a Gm-axg haplotype. A total of 654 sera were typed for Gc, with the seven MN villages ranging between 0.350 and 0.650 for Gc-1, 0.312 and 0.575 for Gc-2 and between 0.017 and 0.112 for Gc-Ab; the single PAP village had a value of 0.627 for Gc-1, 0.165 for Gc-2 and 0.208 for Gc-Ab. A total of 693 sera were tested for ceruloplasmin type. All showed the common Cp(b) phenotype.