Rapidly increasing prevalence of eosinophilic oesophagitis in Western Australia

AIM

To assess the prevalence of eosinophilic oesophagitis in a tertiary paediatric gastroenterology clinic population.

METHODS

A retrospective audit of Western Australian children investigated for oesophageal disease by paediatric gastroenterologists in the years 1995, 1999 and 2004. Macroscopic appearance of the oesophagus at endoscopy, original histological findings and diagnosis were recorded for each child. Biopsy specimens were blindly re-evaluated, with re-coded histological diagnoses compared with original reports. Age, sex and socioeconomic status were identified for each child.

RESULTS

The prevalence of eosinophilic oesophagitis in Western Australia increased over the decade 1995-2004, rising from 0.05 to 0.89 per 10 000 children, with a concomitant increase in the severity of oesophagitis as determined by inflammatory cell numbers and associated features of inflammation. Children diagnosed with eosinophilic oesophagitis had a median age of 78.9 months (6.58 years), with no associated predisposition by sex or socioeconomic status trend. Almost one third of cases were macroscopically normal at endoscopy. All children with an original diagnosis of eosinophilic oesophagitis had > or =40 eosinophils per high-power field.

CONCLUSION

Over the decade 1995-2004, a true increase was seen in the prevalence of eosinophilic oesophagitis, not accounted for by diagnostic shift. Histological samples should be taken at endoscopy to confirm or exclude the diagnosis of eosinophilic oesophagitis.

Feed thickener for newborn infants with gastro-oesophageal reflux

BACKGROUND

Gastro-oesophageal reflux (GOR) is common in newborn infants. A common first line management is the use of feed thickeners.

OBJECTIVES

In newborn infants with GOR, to evaluate the use of feed thickeners in reducing signs and symptoms of GOR, acid episodes on pH monitoring and histological evidence of oesophagitis.

SEARCH STRATEGY

We searched MEDLINE from 1966 to December 2001, the Cochrane Controlled Trials Register, The Cochrane Library, Issue 1, 2002. CINAHL from 1982 to December 2001, and conference and symposia proceedings published in Pediatric Research 1990 to 1994. We also searched conference proceedings for the European Society for Paediatric Gastroenterology and Nutrition (ESPGAN) and the North American Society for Pediatric Gastroenterology and Nutrition (NASPGAN) from 1994 to December 2001. We did not restrict the searches to the English language.

SELECTION CRITERIA

All randomised controlled trials that examine the effects of thickening formulas on treating gastro-oesophageal reflux in neonates. The eligible studies were to compare thickened feeds to no intervention (unthickened feeds).

DATA COLLECTION AND ANALYSIS

Two independent reviewers identified potential studies from the literature search. Quality was independently assessed by two independent reviewers.

MAIN RESULTS

No studies fulfilled the requirements for inclusion in the systematic review.

REVIEWER'S CONCLUSIONS

There is no evidence from randomised controlled trials to support or refute the efficacy of feed thickeners in newborn infants with GOR. Given the absence of evidence, we cannot recommend using thickening agents for management of GOR in newborn infants.

Predictors of low bone density in young adolescent females with anorexia nervosa and other dieting disorders

OBJECTIVE

To compare the bone density of adolescent patients with anorexia nervosa with adolescent patients with other dieting disorders and to evaluate risk factors for low bone density in these patients.

METHOD

Sixty-nine consecutive female patients referred to an adolescent eating disorders clinic were studied by interview, blood sampling, body composition, and lumbar spine bone density measurement using dual energy X-ray absorptiometry.

RESULTS

Although patients with anorexia nervosa were more malnourished, their bone density was similar to other dieting patients. Patients were divided into a low and normal bone density group irrespective of psychiatric diagnosis. Patients with low bone density had dieted for longer, had lower lean body mass, more often had not achieved menarche, and had longer duration of secondary amenorrhea and lower estrogen levels.

DISCUSSION

Irrespective of clinical diagnosis, adolescents with dieting disorders have increased risk of low bone density when malnutrition commences early in puberty and is associated with reduced lean body mass and impaired ovarian function.

Enhancing mastery and sense of coherence: important determinants of health in older adults

The purpose of the study was to expand existing knowledge of the determinants of health for community-dwelling young-old and old-old people. A subsample (n = 2413) from the Health Canada Supplement to the 1994 National Population Health Survey was analyzed. The factors examined were biographic attributes, sociodemographic indicators, sense of coherence (SOC), mastery, self-esteem, informal social support, and use of health care services. Hierarchical regression analyses revealed that mastery and SOC were strongly related to health status and perceived health. Strategies discussed herein will help practitioners ensure that older adults' mastery and SOC are supported and enhanced.

Prevalence and pattern of childhood abdominal pain in an Australian general practice

OBJECTIVE

Abdominal pain is a common problem in childhood and accounts for a significant workload in general practice. The aim of this study was assess the nature of abdominal pain in a sample of Australian children attending a Western Australian general practice for any reason, and to determine factors associated with the reporting of such pain.

METHODOLOGY

A prospective study of children and their families attending a rural general practice was undertaken using a parental survey to assess the frequency and nature of abdominal pain, demographic features, physical and behavioural characteristics.

RESULTS

Abdominal pain was common in this population; 44% (70 of 164) of parents reported that the index child had experienced abdominal pain in the past 12 months. The average age of children who experienced recent abdominal pain was 9 years and 9 months. Multivariate analysis suggested that children experiencing abdominal pain in the preceding 12 months were more likely to be anxious (odds ratio (OR) = 3.74, P = 0.01), to have a family history of similar problems in siblings (OR = 4.26, P = 0.01) and to experience sleep disturbance (OR = 3.90, P = 0.02) than children without abdominal pain. Consumption of three or more serves of wholemeal bread or cereals per day had a significant protective effect on reported abdominal pain in children (OR = 0.12, P = 0.03). The majority of families (66%) dealt with the pain without resorting to medical care.

CONCLUSIONS

Abdominal pain remains a common problem of children attending an Australian general practice, and was associated with features suggesting that it is related to anxiety and coping ability. Abdominal pain is not usually associated with disease; most families recognize this and cope with abdominal pain without medical consultation.

Warrantable evidence in nursing science

Consensus among nurse scholars has not been reached regarding suitable qualities for accepting or rejecting the evidence arising from various world views. The authors' purpose in writing the paper is to describe the qualities or warrants for evaluating scientific findings (the 'evidence') of different research perspectives. The warrantable evidence pertinent to post-positivist, interpretivist, critical social theorist, and feminist perspectives are described and common warrants are suggested. Three warrants common to these scientific perspectives are proposed: (a) scrutiny and critique of methodological rigor and findings by the scientific community; (b) corroboration and intersubjectivity; and (c) scope of the evidence. The identification of common warrantable evidence will assist nurses in developing some core values regarding the constituents of good science or good scholarship even in the face of pluralism in nursing science approaches.

Sequence and PCR-RFLP analysis of the internal transcribed spacers of the rDNA repeat unit in isolates of Cryptosporidium from different hosts

The Cryptosporidium ITS1, 5.8S and ITS2 rDNA regions from a number of Cryptosporidium isolates from different hosts and geographical areas were cloned and sequenced in order to investigate the extent of sequence heterogeneity between human and cattle-derived isolates from different geographical locations and also between isolates of Cryptosporidium from different hosts such as cats, pigs, mice and a koala. Calf-derived isolates from different continents were virtually identical as were human-derived isolates from the UK and Australia. Genetic differences between Cryptosporidium isolates were extensive and were in fact greater than the level of nucleotide divergence between Toxoplasma gondii and Neospora caninum rDNA sequences. Based on the sequence information derived from this study, PCR-RFLP of the ITS1 region was undertaken in order to directly amplify and genotype Cryptosporidium isolates from different hosts. This PCR-RFLP approach can now be used for molecular epidemiology studies, circumventing the need for costly sequencing and allowing a wider range of genetically different isolates to be examined.

Goal Attainment Scaling. A responsive measure of client outcomes

Goal Attainment Scaling (GAS) was developed by Kiresuk and Sherman in 1968. Although highly criticized in the early years of its conception, GAS is beginning to be recognized as a reliable, valid, and responsive outcome measurement approach. This article describes the application of GAS, using elderly home health care clients as an example. Reliability and validity issues are examined. Criticism of GAS is often based on traditional psychometric assumptions associated with normative assessment and does not reflect the evaluative nature of the GAS methodology. The advantages and limitations of GAS are discussed. Goal Attainment Scaling has the potential to demonstrate the important contribution home health care programs make to clients by measuring the change that has occurred during their admission to the program. This kind of information is required by policy makers, case managers, and home health care providers to develop policy, allocate limited resources, and offer appropriate and effective services.

Strategies for managing behavioural symptomatology associated with dementia of the Alzheimer type: a systematic overview

The purpose of this systematic overview was to summarize research findings on strategies for managing the behavioural symptomatology associated with dementia of the Alzheimer type. A search of the published and unpublished literature resulted in 265 articles, 45 of which were judged to be relevant. Using validity criteria, 1 article was judged to be strong, 6 moderate, 20 weak, and 18 poor. Strategies such as planned walking, pet therapy, an attention-focusing program, functional skills training, music, and visual barriers demonstrated promising results in improving: (a) aggressive, agitated, and disruptive behaviours, (b) social interaction, (c) self-care ability, (d) day-night disturbances, or (e) wandering. The findings indicate that there is existing research, although in its infancy, to support the use of strategies for managing the behavioural symptomatology associated with dementia of the Alzheimer type.

Molecular characterization of Cryptosporidium from various hosts

A 298 bp region of the Cryptosporidium parvum 18S rDNA and a 390 bp region of the acetyl-CoA synthetase gene were sequenced for a range of human and animal isolates of Cryptosporidium from different geographical areas. A distinct genotype is common to isolates from cattle, sheep and goats and also an alpaca from Peru and is referred to here as the 'calf'-derived Cryptosporidium genotype. Another genotype of 'human'-derived isolates also appears to be conserved amongst human isolates although humans are also susceptible to infection with the 'calf' Cryptosporidium genotype. Mice and pigs carry genetically distinct genotypes of Cryptosporidium. Three snake isolates were also analysed, 2 of which exhibited C. muris genotypes and the third snake isolate carried a distinct 'mouse' genotype.

Precipitants and aetiology of cyclic vomiting syndrome

Thirty-two patients aged 2-22 y with cyclic vomiting syndrome (CVS), and 64 age- and gender-matched controls were assessed to determine the nature, severity, precipitants and associated features of attacks and the incidence of potential aetiological factors. The mean age of onset was 3.5 y. Patients experienced a mean of nine attacks per year, of average duration 2.4 d, and two-thirds missed more than 10 d of school per year. Patients were more likely to have migraine and co-ordination difficulties, a past history of forceps delivery and gastroesophageal reflux than controls. Compared with controls, subjects had a higher incidence of psychological symptoms (38% compared with 19%) and migraine (37% compared with 9%). CVS is a chronic, disabling condition and is a migraine variant, with attacks usually precipitated by stress and intercurrent infections.

Comparison of PCR and microscopy for detection of Cryptosporidium parvum in human fecal specimens: clinical trial

PCR technology offers alternatives to conventional diagnosis of Cryptosporidium for both clinical and environmental samples. We compared microscopic examination by a conventional acid-fast staining procedure with a recently developed PCR test that can not only detect Cryptosporidium but is also able to differentiate between what appear to be host-adapted genotypes of the parasite. Examinations were performed on 511 stool specimens referred for screening on the basis of diarrhea. PCR detected a total of 36 positives out of the 511 samples, while routine microscopy detected 29 positives. Additional positives detected by PCR were eventually confirmed to be positive by microscopy. A total of five samples that were positive by routine microscopy at Western Diagnostic Pathology but negative by PCR and by microscopy in our laboratory were treated as false positives. Microscopy therefore exhibited 83.7% sensitivity and 98.9% specificity compared to PCR. PCR was more sensitive and easier to interpret but required more hands-on time to perform and was more expensive than microscopy. PCR, however, was very adaptable to batch analysis, reducing the costs considerably. Bulk buying of reagents and modifications to the procedure would decrease the cost of the PCR test even more. An important advantage of the PCR test, its ability to directly differentiate between different Cryptosporidium genotypes, will assist in determining the source of cryptosporidial outbreaks. Sensitivity, specificity, ability to genotype, ease of use, and adaptability to batch testing make PCR a useful tool for future diagnosis and studies on the molecular epidemiology of Cryptosporidium infections.

Precipitants and aetiology of cyclic vomiting syndrome

Thirty-two patients aged 2-22 y with cyclic vomiting syndrome (CVS), and 64 age- and gender-matched controls were assessed to determine the nature, severity, precipitants and associated features of attacks and the incidence of potential aetiological factors. The mean age of onset was 3.5 y. Patients experienced a mean of nine attacks per year, of average duration 2.4 d, and two-thirds missed more than 10 d of school per year. Patients were more likely to have migraine and co-ordination difficulties, a past history of forceps delivery and gastroesophageal reflux than controls. Compared with controls, subjects had a higher incidence of psychological symptoms (38% compared with 19%) and migraine (37% compared with 9%). CVS is a chronic, disabling condition and is a migraine variant, with attacks usually precipitated by stress and intercurrent infections.

Strategies to address the methodological challenges of client-satisfaction research in home care

While there is an abundance of recent client satisfaction research, methodological difficulties continue. This paper addresses common methodological challenges in securing useful feedback from elderly clients receiving home-care services. The methodological challenges include socially desirable response sets (SDRS), fear of reprisal, acquiescent response sets (ARS), and negative or positive wording of items. These contribute to an inability to capture salient dimensions of satisfaction and dissatisfaction important to home-care clients. Several data-collection strategies are proposed: guided interactive interviews, story-telling, scenarios, and rating of the importance of the dimensions of satisfaction and dissatisfaction identified from interview data. Each strategy is discussed using illustrations from a study on elderly clients' satisfaction with home-care services. Nurses and other health-care providers require credible feedback about client satisfaction in order to develop policy and to provide more appropriate and effective services to home-care clients.

Differentiation between human and animal isolates of Cryptosporidium parvum using rDNA sequencing and direct PCR analysis

Sequence analysis of a polymerase chain reaction (PCR)-amplified 298-bp region of the Cryptosporidium parvum 18S rRNA gene was carried out on 10 human and 9 animal isolates. Eight of the 9 animal isolates and 3 human isolates displayed the recognition sequence TATATTT, whereas 7/10 human isolates exhibited the recognition sequence TTTTTTTTTTT. Sequence analysis of the ninth animal isolate, which was recovered from a Koala, revealed this isolate to be different from both human and animal isolates. The AT richness of the rDNA recognition sequences rendered them unsuitable for primer design and therefore a diagnostic randomly amplified polymorphic DNA fragment previously developed in our laboratory was also sequenced. Analysis of 2 human and 2 animal isolates again revealed distinct differences between animal and human isolates. On the basis of this sequence information, diagnostic primers were designed that could directly differentiate between animal and human isolates on the basis of the size of the PCR product. The ability to differentiate directly between human and animal isolates has important implications for studies of the transmission and zoonotic potential of this organism. These results also raise further doubts about the uniformity of the species C. parvum.

Patients' perceptions of outcomes of a Canadian hospitalization

Notes that with health care reform moving at tremendous speed throughout Canada, a great deal of interest in outcomes research has been generated. States that the research team consisted of 17 professional practice leaders from eight disciplines. Proposes, through the research, to identify from the perspective of former patients what results they hoped to achieve prior to discharge from hospital and what facilitated and hindered them in achieving these results. Reports that a representative sample was selected for the study. Forty-one former patients each participated in up to two focus groups, with a total of 16 focus groups conducted. Hierarchical analysis revealed themes that fell within the framework of structure, process and outcomes. The findings will assist in ensuring that more appropriate and effective care is offered to patients by a variety of disciplines.

Clarification of the constructs of satisfaction and dissatisfaction with home care

This study examined what elderly clients perceived as being important in contributing to their satisfaction and dissatisfaction with home care. Nineteen guided interactive interviews were conducted with 10 home care clients using storytelling, scenarios, and a rating of the importance of the dimensions of client satisfaction and dissatisfaction. A hierarchical thematic analysis revealed that satisfaction with home care was influenced by client characteristics and was composed of clients' expectations, program characteristics, home care workers' attributes, relationships with the workers, and clients' involvement with planning their care. Dissatisfaction was reported if positive aspects of these dimensions were lacking. This suggests that satisfaction and dissatisfaction are at opposite ends of multiple continua of dimensions.

Failure of liver transplantation in Wilson's disease with pulmonary arteriovenous shunting

A 12-year-old boy with Wilson's disease developed exertional dyspnea, cyanosis, and finger clubbing 10 months after diagnosis. The hypoxemia was caused by arteriovenous shunting, demonstrated by radionuclide scanning and pulmonary arteriography. Orthotopic liver transplantation was performed after the development of severe hypoxemia. There was no apparent reversal of the intrapulmonary arteriovenous shunting and he died 10 days posttransplantation of multiple organ failure secondary to hypoxemia. Monitoring arterial oxygen saturation in children with cirrhosis is warranted since the presence of significant arteriovenous shunting may influence prognosis and decisions regarding liver transplantation.

Primary anastomosis for necrotising enterocolitis: a 12-year experience

Between January 1975 and October 1987, 50 cases of necrotising enterocolitis (NEC) have required surgery. The principle that the best management is resection and exteriorisation of the ends, which was developed in the early 1970s, has been superseded by the realisation that resection and primary anastomosis can be safe in a well-resuscitated infant in whom the bowel ends appear viable. Eight babies had widespread NEC and no procedure was performed. Thirteen babies had resection and exteriorisation with five long-term survivors (39%). Twenty-nine babies had a primary anastomosis irrespective of birth weight, gestational age, length of resection, or the presence of peritonitis--with 22 (76%) long-term survivors. The pre-operative risk factors and length of bowel resected were similar in the two groups. The length of hospital stay, the period of total parenteral nutrition, the time to full feeds, and the time on a ventilator were all shorter in the primary anastomosis group, with no increase in short- or long-term morbidity or mortality. Provided that the bowel ends are viable, primary anastomosis is the procedure of choice for babies with NEC requiring laparotomy.

Metoclopramide in gastroesophageal reflux of infancy

This study examined the effect of metoclopramide on lower esophageal sphincter (LES) pressure, and frequency and duration of reflux episodes in 28 children (mean age (+/- SD) 9 +/- 11 months) referred for evaluation of gastroesophageal reflux (GER). Esophageal manometry was performed before and after one intravenous dose of metoclopramide (0.125 mg/kg), and esophageal pH was monitored over a 24-hour baseline period, followed by oral metoclopramide therapy (0.125 mg/kg four times a day, for 24 hours.) During pH monitoring, patients received diet for age and were kept in the prone position with the head elevated 45 degrees while sleeping. Eight patients entered a 6-month double-blind, placebo-controlled trial of metoclopramide. Metoclopramide significantly (P = 0.04) increased end-expiratory LES pressure, from 14.9 +/- 7.5 mm Hg to 18.6 +/- 6.8 mm Hg. However, there was a significant (P less than 0.05) increase in the number of reflux episodes/24 hours, and no significant change in percentage of time pH was less than 4, number of episodes lasting greater than 5 minutes, or the longest episode of reflux between the 24-hour baseline and M periods. LES pressure did not correlate well with any of these measurements (r = 0.2). In the controlled trial, the three patients receiving metoclopramide, but none of those receiving placebo, were withdrawn by their parents because of exacerbation of GER symptoms and marked irritability (P = 0.01). In the placebo group, symptoms improved in four infants, but did not change in one. The use of metoclopramide in the treatment of GER of infancy needs to be reconsidered.

Laxative abuse and secretory diarrhoea

Three children with chronic diarrhoea secondary to laxative abuse are reported. Growth disturbance, a previously unrecognised feature of this form of abuse, is recorded.