High diagnostic yield despite a lower completion rates for inpatient versus outpatient colon and pan-intestinal capsule endoscopy: a nested case-control study

BACKGROUND

Increased familiarity with capsule endoscopy (CE) has been associated with a growing demand for urgent inpatient procedures. Limited data exists comparing the effect of admission status on colon capsule (CCE) and pan-intestinal capsule (PIC) performance. We aimed to compare the quality of inpatient versus outpatient CCE and PIC studies.

METHODS

A retrospective nested case-control study. Patients were identified from a CE database. PillCam Colon 2 Capsules with standard bowel preparation and booster regimen were used in all studies. Basic demographics and key outcome measures were documented from procedure reports and hospital patient records, and compared between groups.

RESULTS

105 subjects were included, 35 cases and 70 controls. Cases were older, were more frequently referred with active bleeding and had more PICs. The diagnostic yield was high at 77% and was similar in both groups. Completion rates were significantly better for outpatients, 43% (n = 15) v's 71% (n = 50), OR 3, NN3. Neither gender nor age affected completion rates. Completion rates and preparation quality were similar for CCE and PIC inpatient procedures.

CONCLUSION

Inpatient CCE and PIC have a clinical role. There is an increased risk of incomplete transit in inpatients, and strategies to mitigate against this are needed.

Real-Time Electron Solvation Induced by Bursts of Laser-Accelerated Protons in Liquid Water

Understanding the mechanisms of proton energy deposition in matter and subsequent damage formation is fundamental to radiation science. Here we exploit the picosecond (10^{-12}  s) resolution of laser-driven accelerators to track ultrafast solvation dynamics for electrons due to proton radiolysis in liquid water (H_{2}O). Comparing these results with modeling that assumes initial conditions similar to those found in photolysis reveals that solvation time due to protons is extended by >20  ps. Supported by magnetohydrodynamic theory this indicates a highly dynamic phase in the immediate aftermath of the proton interaction that is not accounted for in current models.

A remote self-directed psychological intervention for the public: The PAUSE programme protocol

Background: This protocol outlines procedures for the development and evaluation of a remotely accessible intervention tool known as the ‘Psychology And yoU: Self-Enhancement programme’ (i.e., PAUSE programme). The PAUSE programme aims to support and promote psychological well-being using positive psychological concepts and principles. The programme has been developed in the context of the coronavirus disease 2019 pandemic, where effective and evidence-based remote interventions are needed. The PAUSE programme will provide users with valuable tools and skills that they may choose to implement in their daily lives, in order to foster and support positive mental well-being. The programme includes six modules: Well-being and Happiness; Healthy Body and Mind; Being Grateful and Savouring Life; Thought and Action; Strengthening Relationships; and Overcoming Challenges. Methods: Participants will be recruited using media outlets, social media, and professional networking websites in Ireland. Those who choose to participate in this study will be asked to complete a set of measures at baseline, immediate follow-up, and six weeks post-intervention. This will allow for changes in subjective well-being scores to be analysed and interpreted over time. This study adopts a Groups x Time design, with participants being randomly assigned to either an intervention or wait-list control group. Ethical approval is currently under review at the host institution. Dissemination: The dissemination strategy will follow the Evidence-based model for the Transfer and Exchange of Research Knowledge (EMTReK) and study findings will be prepared in line with various formats (e.g. study newsletters, conferences/meetings) in order to meet the needs of different audiences. Targeted and timely dissemination activities are anticipated, and the team intends to disseminate research in an ongoing manner, throughout the lifetime of the project. Registration: This RCT protocol is pre-results and has been registered with an international database resulting in an International Standard Randomised Controlled Trials Number (ISRCTN14772616)

Colon capsule endoscopy is a viable alternative to colonoscopy for the investigation of intermediate- and low-risk patients with gastrointestinal symptoms: results of a pilot study

Background and study aims  Colon capsule endoscopy (CCE) is a recommended viable alternative to colonoscopy for colonic visualisation in a variety of clinical settings with proven efficacy in polyp detection, surveillance, screening and Inflammatory Bowel Disease (IBD) assessment. CCE efficacy in an unselected average risk symptomatic cohort has yet to be established. The aim of this study was to determine the feasibility of CCE imaging assessment in average risk symptomatic patients as an alternative to colonoscopy with and without additional biomarker assessment. Patients and methods  This was a prospective, single-center comparison study of colonoscopy, CCE and biomarker assessment. Results  Of 77 invited subjects, 66 underwent both a CCE and colonoscopy. A fecal immunochemical test (FIT) and fecal calprotectin (FC) were available in 56 and 59 subjects. In all 64 % (n = 42) had any positive finding with 16 (24 %) found to have significant disease (high-risk adenomas, IBD) on colonoscopy. The CCE completion rate was 76 %, five (8 %) had an inadequate preparation, the CCE polyp detection rate was high at 35 %. The sensitivity, specificity, positive and negative predictive values of CCE for significant disease were 81 %, 98 %, 93 % and 94 % respectively. In addition, three (5 %) significant small bowel diagnoses were made on CCE. FC and FIT were frequently elevated in patients with both colitis (5/7, 71 %) and high-risk adenomas (4/7 57 %). While both had a low positive predictive value for clinically significant disease, FIT 32 % and FC 26 %. Conclusions  CCE is a safe and effective alternative to colonoscopy in symptomatic average risk patients with or without the addition of biomarker screening.

Lower gastrointestinal symptoms and symptoms-based triaging systems are poor predictors of clinical significant disease on colonoscopy

Introduction

Lower gastrointestinal symptoms (LGS) are a common cause of referral to the gastroenterology service. International guidelines are available to prioritise referrals. Some studies have reported that symptoms alone are a poor marker of clinically significant disease (CSD) but symptoms remain the main way to prioritise referrals in routine clinical practice.

Aims/background

To correlate LGS with colonoscopy findings in an unselected patient cohort and to investigate whether using National Institute for Health and Care Excellence (NICE) guidelines improve risk stratification.

Method

Colonoscopy data over a 2-year period were obtained from our endoscopy database. Only patients with assessment of symptoms as their primary indication for colonoscopy were included. Patient records were retrospectively reviewed. Exclusion criteria: known inflammatory bowel disease (IBD), familial cancer syndromes, polyp and colorectal cancer (CRC) surveillance, and prior colonoscopy within 5 years. Demographics, symptoms and colonoscopy findings were recorded and analysed.

Results

1116 cases were reviewed; 493 (44%) males, age 54.3 years (16–91). CSD occurred in only 162 (14.5%); CRC 19 (1.7%), high-risk adenoma 40 (3.6%), inflammation 97 (8.7%) (IBD 65 (5.8%), microscopic colitis 9 (0.8%) and indeterminate-inflammation 23 (2%)), angiodysplasia 6 (0.5%). Diarrhoea gave the highest diagnostic yield for CSD of 5.3% (OR 3.15, 95% CI 2.2 to 4.7, p<0.001), followed by PR bleeding, 2.9% (OR 1.9, 95% CI 1.24 to 2.9, p=0.003). Weight loss gave the lowest diagnostic yield of 0.4%; (OR 0.79, 95% CI 0.28 to 2.24, p=0.65). 592 (53%) and 517 (46%) fitted the NICE guidelines for CRC and IBD, respectively. Using NICE positivity improved detection but overall yield remained low 3% vs 0.4% (OR 7.71, 95% CI 1.77 to 33.56, p=0.0064) for CRC, and 9% vs 2.8% (OR 3.5, 95% CI 1.99 to 6.17, p<0.0001) for IBD.

Conclusions

The overall prevalence of CSD in our unselected symptomatic patients is low (14.5%). A holistic approach including combining symptoms and demographics with novel tools including stool biomarkers and minimally invasive colonoscopy alternatives should be applied to avoid unnecessary colonoscopy.

Predicting pathology on small bowel capsule endoscopy: a good FIT

Background and study aims  Small bowel capsule endoscopy [SBCE) has an established role in investigating suspected small bowel bleeding [SSBB). Identification of a biomarker to predict pathology would maximize utility of this valuable diagnostic modality. This study aimed to investigate if fecal immunochemical test [FIT) could predict likelihood of small bowel pathology on SBCE. Patients and methods  Patients referred for SBCE to investigate anaemia or suspected small bowel bleeding were prospectively recruited. All patients had negative upper and lower endoscopy prior to referral. A FIT ≥ 45 ug Hb/g was considered positive. SBCE was positive if a potential source of SSBB was identified. The primary endpoint was correlation between FIT and positive SBCE. Secondary endpoints were correlation between anemia and SBCE and a combination of anemia plus FIT and SBCE. Results  Fifty-one patients were included in the final study cohort. 29.4 % had a positive FIT, 33.3 % were anemic, and 25.5 % patients had significant SBCE findings. There was a statistically significant association between positive FIT and pathology on SBCE (OR 12, 95 % CI [2.8 - 51.9), P  = 0.001). Sensitivity and specificity of positive FIT in predicting SBCE findings were 69 % and 84 %, respectively. A normal Hb had an NPV of 83 % (OR 0.30, P  = 0.09). Combining Hb and FIT was statistically significant in predicting pathology on SBCE (OR 9.14, 67 % PPV, 82 % NPV, P  = 0.025). Conclusion  FIT ≥ 45 ug Hb/g is a useful tool in predicting small bowel pathology on SBCE. Use of this biomarker alone, or in combination with serum haemoglobin, has value as a screening tool and may help to better triage patients referred for SBCE.

Adherence to European Polypectomy Guidelines: Retrospective Experience from a Tertiary Irish Hospital

Background and Study Aim

The European guidelines for colorectal cancer screening state that snare resection should remove any polyps ≥5 mm. This study aimed to investigate if these new guidelines are adhered to in clinical practice.

Patients and Methods

This study consists of patients who underwent colonoscopies in Tallaght Hospital, Dublin (AMNCH), between 2012 and 2015. The size of the polyp, the method of removal, and the subspecialty and grade of the endoscopists were all recorded.

Results

6,000 colonoscopies were reviewed and 687 (12.5%) of these patients were found to have polyps. In 655 (95%) colonoscopies, the caecum was positively identified. In all, 371 (54%) of the polyps detected were < 5 mm; resection via forceps was carried out in n405 cases (59%). Overall, 16% (n = 45) of the polyps > 5 mm underwent resection with forceps, showing that the new European guidelines are not being tightly adhered to.

Conclusions

This study found an 84% compliance with polypectomy resection guidelines which is an improvement on previous studies. However, endoscopist grade significantly affected compliance and may reflect overall competency, highlighting the need for specific training in snare polypectomy techniques.

Impact of timing of delivery on maternal and neonatal outcomes for women after three previous caesarean deliveries; a secondary analysis of the caesarean section registry

BACKGROUND

As more women are presenting with three previous caesarean deliveries (CD), providers may suggest early term delivery as a means to avoid the risk of spontaneous labour and associated maternal morbidity.

OBJECTIVE

To determine whether early term delivery is associated with lower maternal and neonatal morbidity for women with three previous CD.

STUDY DESIGN

Secondary analysis of a prospective registry of CD at 19 US academic centres from 1999 to 2002.

POPULATION

Women with three previous CD undergoing scheduled or emergent delivery with live, singleton gestations 37-41+ weeks of gestation were included. Women with non-low transverse incisions, antepartum stillbirth, previous myomectomy, fetal anomalies, more or fewer than three previous CD or attempting trial of labour after caesarean section were excluded.

METHODS

Gestational age was categorised by week. We fitted logistic regression models to adjust for clinically relevant or statistically significant confounders.

MAIN OUTCOME MEASURES

The primary and secondary outcomes were composites, respectively, of maternal and neonatal morbidity.

RESULTS

In all, 821 women met the inclusion criteria; maternal morbidity composite occurred in 9.86% and neonatal morbidity occurred in 10.5%. After adjusting for confounding variables, maternal and neonatal morbidity occurred least frequently at 39 weeks.

CONCLUSIONS

In women with three previous CDs, adverse maternal outcomes do not increase with increasing gestational age beyond 37 weeks but early term elective repeat CDs are associated with higher neonatal morbidity. Elective delivery of women with three previous CD at 39 weeks of gestation is safe in the absence of maternal or fetal indications for early term delivery.

TWEETABLE ABSTRACT

Delivery of women with three previous caesarean deliveries at 39 weeks, in the absence of maternal or fetal indications for early term delivery, is associated with decreased maternal morbidity.

Positive relationship between infliximab and adalimumab trough levels at completion of induction therapy with clinical response rates, at a tertiary referral center

BACKGROUND AND AIM

Anti-tumor necrosis factor alpha (TNFα) therapies have improved outcomes for patients with inflammatory bowel disease. The aim of this study was to explore the relationship between infliximab (IFX) and adalimumab (ADL) trough and antibody levels with clinical response rates at the end of induction.

METHODS

This was a prospective, single-center study. Patients were recruited from July 2015 to August 2016. Inclusion criteria were all inflammatory bowel disease patients older than 17 years who started treatment with IFX or ADL. Baseline clinical disease activity indexes were performed. Clinical response was defined as HBI ≤3 or partial Mayo score ≤4% or <30% reduction from baseline. Anti-TNFα trough and antibody levels were measured using standard ELISA techniques.

RESULTS

Thirty-five patients were recruited, of whom 23 had Crohn's disease and 12 had ulcerative colitis. Eighteen were treated with ADL and 17 with IFX. The mean age of the cohort was 40.3 years, 62.9% were females, 34.3% were on concomitant thiopurines, and 25.7% had prior anti-TNFα exposure. Overall response rate was 51.4%, 33.3% for ADL and 70.6% for IFX.Mean trough levels were 12.5 μg/mL for IFX and 4.4 μg/mL for ADL. There was a clear link between higher anti-TNFα trough levels at the end of induction with clinical response rates. For IFX, mean trough level was 16.4 μg/mL for responders versus 5.3 μg/mL for non-responders (P = 0.026). Area under the curve for association of IFX level at induction with clinical response was 0.864 (P = 0.0001). Similar link was present between higher ADL levels with clinical response, although not statistically significant.

CONCLUSION

Higher trough levels at the end of induction are associated with improved response. Ongoing work will define optimal targets at this key timeframe.

The natural history of small bowel angiodysplasia

BACKGROUND

Small bowel angiodysplasias (SBA) account for 50% of obscure gastrointestinal bleeding. Lesions bleed recurrently and current treatments are relatively ineffective at reducing re-bleeding. Little is known about the natural history of SBA which is needed to guide treatment decisions and counsel patients on prognosis.

AIM

The aim of this study is to describe the natural history of a cohort of patients with SBA.

METHODS

Patients with SBA were identified retrospectively and clinical and outcome information were collected. Logistic regression analysis was performed to identify factors associated with re-bleeding.

RESULTS

SBAs were found in 86 patients of which 54% (n = 47) were female, and the average age was 71.6 years. The majority (69%) had multiple lesions, mean of 2.76/patient, and 65% were located in the jejunum. Follow-up was available in 65% (n = 56). There was a significant increase in haemoglobin level from 10.05g/dL to 11.94g/dL, p < 0.001 after mean follow up of 31.9 (6-62) months. Re-bleeding events occurred in 80% (n = 45), with an average of 2.91/person. The mean interval between diagnosis and the first re-bleeding event was 10.7 months. Of the group overall, 70% (n = 40) required transfusions during follow up, and 67% required hospitalisation due to re-bleeding. About 50% received a directed treatment, including argon plasma coagulation, somatostatin analogues, or surgical resection. A total of 3.5% (n = 2) died as a direct consequence of bleeding from SBAs. Multiple lesions (p = 0.048) and valvular heart disease (p = 0.034) were predictive of re-bleeding.

CONCLUSION

Our results show the significant impact of SBA on patients' morbidity, with high rates of re-bleeding, persistent anaemia and a mortality rate of 3.5%, despite the use of currently available medical and endoscopic therapies.

Long-acting somatostatin analogues provide significant beneficial effect in patients with refractory small bowel angiodysplasia: Results from a proof of concept open label mono-centre trial

INTRODUCTION

Small bowel angiodysplasias account for over 50% of causes of small bowel bleeding and carry a worse prognosis than lesions located elsewhere in the gastrointestinal tract. Re-bleeding rates are high even after first-line endoscopic therapy and are associated with high levels of morbidity for affected patients. Small trials of long-acting somatostatin analogues have shown promising results but have not yet been assessed in patients with refractory small bowel disease.

AIM

The purpose of this study was to assess the effect of long-acting somatostatin analogues in reducing re-bleeding rates and transfusion requirements, and improving haemoglobin levels in patients with refractory small bowel angiodysplasia.

METHODS

Patients with refractory small bowel angiodysplasia were treated with 20 mg of long-acting octreotide for a minimum of three months. Response was assessed according to: rates of re-bleeding, haemoglobin levels, transfusion requirements, and side effects.

RESULTS

A total of 24 patients were initially treated and 20 received at least three doses. Rates of complete, partial and non-response were 70%, 20% and 10% respectively. Average haemoglobin rates increased from 9.19 g/dl to 11.35 g/dl (p = 0.0027, 95% confidence interval (CI) -3.5 to -1.1) in the group overall and 70% remained transfusion-free after a mean treatment duration of 8.8 months. The rate of adverse events was higher than previously reported at 30%.

CONCLUSION

Long-acting somatostatin analogues offer a therapeutic advantage in a significant proportion of patients with small bowel angiodysplasia. With careful patient selection and close observation, a long-acting somatostatin analogue should be considered in all patients with persistent anaemia attributable to refractory disease in conjunction with other standard treatments.

Impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on medication appropriateness of older patients

Objectives

A high prevalence of potentially inappropriate prescribing (PIP) has been identified in older patients in Ireland. The impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on the medication appropriateness of acute hospitalised older patients during admission and at discharge is reported.

Methods

Uncontrolled before-after study. The study population for this study was medical patients aged ≥65 years, using ≥3 regular medicines at admission, taken from a previous before-after study. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT model involved clinical pharmacists being physician team-based, leading admission and discharge medication reconciliation and undertaking prescription review, with authority to change the prescription during admission or at discharge. The primary outcome was the Medication Appropriateness Index (MAI) score applied pre-admission, during admission and at discharge.

Results

Some 108 patients were included (48 PACT, 60 standard). PACT significantly improved the MAI score from pre-admission to admission (mean difference 2.4, 95% CI 1.0 to 3.9, p<0.005), and from pre-admission to discharge (mean difference 4.0, 95 CI 1.7 to 6.4, p<0.005). PACT resulted in significantly fewer drugs with one or more inappropriate rating at discharge (PACT 15.0%, standard 30.5%, p<0.001). The MAI criteria responsible for most inappropriate ratings were 'correct directions' (4.8% PACT, 17.3% standard), expense (5.3% PACT, 5.7% standard) and dosage (0.6% PACT, 4.0% standard). PACT suggestions to optimise medication use were accepted more frequently, and earlier in the hospital episode, than standard care (96.7% PACT, 69.3% standard, p<0.05).

Conclusions

Collaborative pharmaceutical care between physicians and pharmacists from admission to discharge, with authority for pharmacists to amend the prescription, improves medication appropriateness in older hospitalised Irish patients.

Collaborative pharmaceutical care in an Irish hospital: uncontrolled before-after study

BACKGROUND

We investigated the benefits of the Collaborative Pharmaceutical Care in Tallaght Hospital (PACT) service versus standard ward-based clinical pharmacy in adult inpatients receiving acute medical care, particularly on prevalence of medication error and quality of prescribing.

METHODS

Uncontrolled before-after study, undertaken in consecutive adult medical inpatients admitted and discharged alive, using at least three medications. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT intervention involved clinical pharmacists being team-based, leading admission and discharge medication reconciliation and undertaking prescription review. Primary outcome measures were prevalence per patient of medication error and potentially severe error. Secondary measures included quality of prescribing using the Medication Appropriateness Index (MAI) in patients aged ≥65 years.

FINDINGS

Some 233 patients (112 PACT, 121 standard) were included. PACT decreased the prevalence of any medication error at discharge (adjusted OR 0.07 (95% CI 0.03 to 0.15)); number needed to treat (NNT) 3 (95% CI 2 to 3) and no PACT patient experienced a potentially severe error (NNT 20, 95% CI 10 to 142). In patients aged ≥65 years (n=108), PACT improved the MAI score from preadmission to discharge (Mann-Whitney U p<0.05; PACT median -1, IQR -3.75 to 0; standard care median +1, IQR -1 to +6).

CONCLUSIONS

PACT, a collaborative model of pharmaceutical care involving medication reconciliation and review, delivered by clinical pharmacists and physicians, at admission, during inpatient care and at discharge was protective against potentially severe medication errors in acute medical patients and improved the quality of prescribing in older patients.

Helicobacter pylori resistance rates for levofloxacin, tetracycline and rifabutin among Irish isolates at a reference centre

INTRODUCTION

Helicobacter pylori eradication rates using conventional triple therapies are falling, making viable second-line and rescue regimens necessary. Levofloxacin, tetracycline and rifabutin are three efficacious antibiotics for rescue therapy.

AIM

We aimed to assess the resistance rates for H. pylori against these antibiotics in an Irish cohort.

METHODS

Gastric biopsies were collected from 85 patients infected with H. pylori (mean age 46 years) in the Adelaide and Meath Hospital, Dublin in 2008 and 2009. Susceptibility to antibiotics was tested using the Etest. Clinical information was obtained from endoscopy reports and chart review.

RESULTS

50.6 % of patients were females. Mean age was 47 years. Ten had prior attempts at eradication therapy with amoxicillin-clarithromycin-PPI, two had levofloxacin-based second-line therapy. 11.7 % [95 % CI (6.5-20.3 %)] (N = 10) had strains resistant to levofloxacin. There were no strains resistant to rifabutin or tetracycline. Levofloxacin resistance in the under 45 age group was 2.6 % (1/38) compared to 19.1 % (9/47) of above 45 age group (p = 0.02).

DISCUSSION

The levofloxacin rates illustrated in this study are relatively low by European standards and in line with other studies from the United Kingdom and Germany, with younger patients having very low levels of resistance. Levofloxacin, tetracycline and rifabutin are all valid options for H. pylori eradication in Irish patients but the importance of compliance cannot be underestimated.

Inappropriate colonoscopic surveillance of hyperplastic polyps

Colonoscopic surveillance of hyperplastic polyps alone is controversial and may be inappropriate. The colonoscopy surveillance register at a university teaching hospital was audited to determine the extent of such hyperplastic polyp surveillance. The surveillance endoscopy records were reviewed, those patients with hyperplastic polyps were identified, their clinical records were examined and contact was made with each patient. Of the 483 patients undergoing surveillance for colonic polyps 113 (23%) had hyperplastic polyps alone on last colonoscopy. 104 patients remained after exclusion of those under appropriate surveillance. 87 of the 104 patients (84%) were successfully contacted. 37 patients (8%) were under appropriate colonoscopic surveillance for a significant family history of colorectal carcinoma. 50 (10%) patients with hyperplastic polyps alone and no other clinical indication for colonoscopic surveillance were booked for follow up colonoscopy. This represents not only a budgetary but more importantly a clinical opportunity cost the removal of which could liberate valuable colonoscopy time for more appropriate indications.

Endoscopic ultrasound with fine needle aspiration and biopsy in lung cancer and isolated mediastinal lymphadenopathy

Endoscopic ultrasound with fine-needle aspiration and biopsy (EUS-FNAB) is well established in diagnosing and staging lung cancer in patients with mediastinal adenopathy. EUS-FNAB is highly sensitive, less invasive and has lower complication rates when compared to surgical staging of mediastinal nodes. In this study we describe our experience of EUS-FNAB in lung cancer and other causes of mediastinal lymphadenopathy. EUS-FNAB was performed for assessment of PET positive mediastinal lymph nodes between January 2007 and March 2009 in AMNCH. The endpoints of our study were sensitivity and specificity of EUS-FNAB, morbidity and length of hospital stay. Thirty four patients underwent EUS-FNAB during the study period for both diagnosis and staging. Thirty patients had positive lymph node invasion and 4 had no evidence of malignant invasion. In these 4 patients negative cytology was confirmed on mediastinoscopy giving EUS-FNAB a sensitivity and specificity of 100%. EUS-FNAB upstaged the disease in 12 patients. EUS-FNAB is a reliable tool for mediastinal staging in lung cancer, significantly reducing the need for surgical staging procedures in patients with suspected mediastinal involvement.

The role of capsule endoscopy in small bowel Crohn's disease

Video capsule endoscopy is an invaluable tool for examining the small bowel. It is non-invasive and generally well tolerated, however its role in the assessment of the severity and extent of small bowel Crohn's disease has not, to date, been adequately evaluated.

METHODS

All capsule endoscopies performed over a two year period in a tertiary referral centre in subjects with known or suspected Crohn's disease were reviewed.

RESULTS

Twenty-six capsule endoscopy studies in total were included. These were performed in 15 cases of known Crohn's disease, 5 cases of suspected Crohn's disease, 3 cases of endoscopically diagnosed non-specific terminal ileal inflammation and finally 3 post colectomy cases of indeterminant being considered for IPAA formation. Ten patients known to have small bowel Crohn's disease were prospectively recruited; of 3 with normal small bowel follow through or CT exams, one had an abnormal capsule endoscopy. The other 7 patients had small bowel follow through or abdominal CT scans consistent with small bowel Crohn's disease; additional mucosal abnormalities were detected by capsule endoscopy in 6 cases with capsule retention in the stomach in one. Of 5 with colonic Crohn's disease normal small bowel imaging corresponded with normal capsule endoscopy in all but one. A diagnosis of Crohn's disease was made in 2 out of 5 cases of suspected Crohn's disease on the basis of the capsule endoscopy findings. Three patients with non-specific acute terminal ileal inflammation at ileocolonoscopy were confirmed to have ongoing inflammation. The capsule was retained in four subjects beyond 24 h.

CONCLUSION

Capsule endoscopy more accurately determines the severity and extent of the Crohn's disease in the small bowel than traditional imaging modalities.

Diagnosis and fine needle aspiration of pancreatic pseudocysts: the role of endoscopic ultrasound

Pseudocysts are localized collections of pancreatic fluid surrounded by nonepithelialized granulation tissue that occur following an insult to the pancreas. High image resolution and the ability sample in real-time by fine needle aspiration permit accurate distinction between various cystic lesions in the pancreas by endoscopic ultrasound (EUS). Other cyst characteristics and background pancreatic changes detectable at EUS assist in the diagnostic process. The use of Doppler flow ultrasound allows diagnosis of important pseudocyst complications such as pseudoaneurysms and varices. Endoscopic approaches to the drainage of symptomatic lesions previously relied on the use of cross-sectional imaging studies such as computed tomography scanning in combination with stent placement using a duodenoscope in the presence of an endoscopically visible cyst bulge. EUS facilitates this process allowing accurate imaging of the lesion prior to stent placement via the echoendoscope and overcomes many of the drawbacks and pitfalls of other endoscopic techniques.

Serum antibody for somatostatin-14 and prodynorphin 209-240 in patients with obsessive-compulsive disorder, schizophrenia, Alzheimer's disease, multiple sclerosis, and advanced HIV infection

Patients with obsessive-compulsive disorder (OCD) demonstrated significant levels of antibody for somatostatin-28, its C-terminal fragment somatostatin-14, and prodynorphin. In contrast there were lower levels of reactivity for somatostatin-28(1-14) (the N-terminal fragment of somatostatin-28) and negligible reactivity for several other peptides including beta-endorphin and corticotropin. Healthy volunteers and disease controls [schizophrenia, Alzheimer's disease, multiple sclerosis, and subjects with advanced human immunodeficiency virus (HIV) infection] exhibited negligible reactivity. These data raise the consideration of an autoimmune mechanism for some OCD.

DNA repair and mutant frequency in schizophrenia

The in vivo frequency of mutants resulting from mutation at the hprt locus in human T-lymphocytes was determined with a cloning assay. T-lymphocytes were obtained from 14 individuals diagnosed with schizophrenia and 5 controls. No significant difference in mutant frequency was observed between the 2 groups. In addition, DNA-repair capacity was measured with the unscheduled DNA synthesis technique in lymphocytes from 7 individuals diagnosed with schizophrenia and 7 controls. Repair capacity was determined following treatment with MMS, MNNG, and 20 J/m2 ultraviolet light. No significant differences in DNA repair were observed between the patient and control groups in response to any of the 3 DNA-damaging agents. These results argue against differences between normal and schizophrenic individuals with respect to in vivo mutant frequency or their capacity to repair DNA lesions induced by MMS, MNNG, or ultraviolet radiation.

Prader-Willi syndrome in black females

Reports of Black females with Prader-Willi have been rare. This communication describes two Black females with Prader-Willi syndrome. Chromosome analysis revealed a small deletion of the proximal portion of a chromosome 15 in one case and apparently normal chromosomes in the other.