Frontal Fibrosing Alopecia survey of severity assessment methods in routine clinical practice and validation of the IFFACG measurement guidance

BACKGROUND

Lack of validated and responsive outcome measures in the management of Frontal Fibrosing Alopecia (FFA) significantly limits our ability to assess disease progression and treatment response over time.

OBJECTIVES

The aim of this study was to understand how FFA extent and progression is currently assessed in UK specialist centres, validate components of the International FFA Cooperative Group (IFFACG) statement on FFA assessment, and identify pragmatic advice to improve FFA management in clinic.

METHODS

Consultant Dermatologists with a specialist interest in hair loss (n=17) were invited to take part. Preferred FFA assessment methods were explored using questionnaires and clinical scenarios. Participants were asked to identify and mark the current hairline in 10 frontal and 10 temporal hairline images, with assessment repeated 3 months later (to assess intra-individual variability) and 12 months later (to test whether inter-individual accuracy could be improved with simple instruction).

RESULTS

All 17 clinicians (100%) completed the questionnaire at each time interval. We identified a wide variation in assessment techniques between our experts. Measurements were perceived as the most accurate method of assessing frontal recession whereas photography was preferred for temporal recession. Inter-rater reliability between clinicians measuring the frontal hairline scenarios indicated a moderate strength of agreement (ICC 0.613; 95% CI: 0.398 to 0.848), yet intra-rater reliability was found to be poor with wide limits of agreement (-8.71mm to 9.92mm) on follow-up. Importantly, when clear guidance was provided on how the hairline should be identified (questionnaire 3), inter-rater reliability improved significantly, with an ICC 0.702 suggesting moderate agreement (95% CI: 0.508 to 0.890; p<0.001). A similar pattern was seen with temporal hairline measurements, which again improved in accuracy with instruction.

CONCLUSION

We show that accuracy of measurements in FFA can be improved with simple instruction and validate components of the IFFACG measurement recommendations.

A granulomatous response to tribal medicine as a feature of the immune reconstitution syndrome

Summary Immune reconstitution is a well recognized phenomenon associated with the use of highly active antiretroviral therapy (HAART) for HIV infection. After the administration of HAART there is a rise in CD4 T-cell count in the circulation brought about by cessation of HIV replication. This allows the body to respond to antigens that it previously ignored. This manifests itself most commonly as an overt illness to previously ignored pre-existing infections such as Mycobacterium tuberculosis, herpes simplex virus, varicella zoster virus, hepatitis B and C viruses, cytomegalovirus, cryptococcal infection, human papilloma virus and molluscum contagiosum. There are further reports of reactions to sarcoid and tattoo pigment and one previous case reported of a granulomatous reaction to a foreign body. We report another case of a foreign body granuloma reaction, to tribal medicine implanted in tribal marks made in childhood in a Zimbabwean woman. This reaction is part of the immune reconstitution syndrome.

The outcome of the older (> or =100 days) infant with biliary atresia

BACKGROUND

There is a detrimental effect of increasing age on the results of the Kasai portoenterostomy for biliary atresia (BA), and some centers routinely advocate primary liver transplantation for the older infant, irrespective of other criteria. This perception that such infants are indeed irretrievable was tested by retrospective analysis.

METHODS

All infants who had undergone surgery for BA during the period 1980 through 2000 aged > or =100 days were reviewed. Actuarial survival was calculated using 2 end-points (death and transplantation). A retrospective review of their ultrasonography (n = 12) and preoperative liver histology (n = 22) was also undertaken to ascertain possible predictive criteria.

RESULTS

A total of 422 infants had BA diagnosed during this period, of which 35 (8.2%) were > or =100 days at surgery (median [interquartile range], 133 [range, 108 to 180] days). Surgery included portoenterostomy (n = 26), hepaticojejunostomy (n = 7), and a resection and end-to-end anastomosis (n = 1). A laparotomy only was performed in 1. Five- and 10-year actuarial survival rate with native liver was 45% and 40%, respectively. Currently, 12 (35%) patients are alive with their native liver (8 are anicteric), 9 (28%) have undergone transplantation, and 13 have died. Although there were some survival advantages for types 1 or 2 BA and "noncirrhosis" at time of surgery, neither reached statistical significance. Individual histologic features (eg, degrees of fibrosis, giant cell transformation, bile duct destruction) in the retrospective review of available material were not discriminatory. The finding of a "heterogeneous" parenchyma on ultrasonography was predictive of poor outcome but lacked sensitivity.

CONCLUSIONS

The potential for reasonable medium-term survival is present in about one third of infants 100 days or older coming to primary corrective surgery. In the absence of accurate discrimination, the authors continue to favor this option rather than subject all to transplant simply on the basis of age.

Improved diagnosis of extraheptic biliary atresia by high frequency ultrasound of the gall bladder

Ultrasound scanning using a 13 MHz probe was performed on 158 infants, aged 12 weeks or less, presenting with conjugated hyperbilirubinaemia. The gall bladder was identified in 156 infants, 35 of whom had biliary atresia. The two patients in whom no gall bladder was seen both had biliary atresia. The gall bladder shape was normal in 128 patients (9 with biliary atresia) and irregular in 28 patients (26 with biliary atresia). The gall bladder wall was regular in 121 patients (4 with biliary atresia) and irregular in 35 patients (31 with biliary atresia). Combining these findings gave a sensitivity of 91.9%, a specificity of 96.7%, a positive predictive value of 89.5%, a negative predictive value of 97.5% and an accuracy rate of 95.6% for ultrasound of the gall bladder in the identification of biliary atresia. This compares with 90%, 92.4%, 75.3%, 97.3% and 91.9%, respectively, in our previous report using a 7 MHz probe.

Ultrasound features of the gall bladder in infants presenting with conjugated hyperbilirubinaemia

An initial investigation of 313 patients suggested that the ultrasound appearances of gall bladder shape and wall structure might be abnormal in infants with biliary atresia. These observations were then tested in a prospective study. In this study, 346 infants, aged 12 weeks or less, presenting with conjugated hyperbilirubinaemia underwent ultrasound scanning. The gall bladder was identified in 331, 60 of whom had biliary atresia. 11 of the 15 patients in whom the gall bladder was not seen had biliary atresia. Gall bladder shape was normal in 272 patients, 16 of whom had biliary atresia, and irregular in 59, 44 of whom had biliary atresia. The gall bladder wall was regular in 262 patients, 8 of whom had biliary atresia, and irregular in 69, 52 of whom had biliary atresia. Combining these findings gave a sensitivity of 90%, a specificity of 92.4%, a positive predictive value of 75.3%, a negative predictive value of 97.3% and an accuracy rate of 91.9% for ultrasound of the gall bladder in identification of biliary atresia.

Developmental intrahepatic shunts of childhood: radiological features and management

The purpose of this study was to evaluate the role of radiological techniques in the diagnosis and management of developmental intrahepatic shunts. Hepatic vascular fistulae are recognised sequelae of liver trauma and intrahepatic tumours. However, there are rare developmental malformations which may present in childhood or later life and which may carry life-threatening complications. Retrospective analysis of clinical and radiological data was carried out in 24 patients. Anomalies evaluated were: (a) direct communication between hepatic artery and hepatic veins; (b) congenital hepatoportal arteriovenous malformations; and (c) congenital portocaval anastomosis with persistent flow through the ductus venosus. Although rare, the prompt recognition of these vascular anomalies allows early surgical or radiological intervention and reversal of the haemodynamic complications.

Hepatic artery resistance index can predict early death in children with biliary atresia

Hepatic artery resistance index has been measured by ultrasonography Doppler and has been found to predict rapid deterioration and death in children with biliary atresia. Clinical, biochemical, ultrasonographic, and outcome data were collected prospectively and retrieved on 32 patients with resistance index of > or = 1.0 (group A). These were compared with the same data for 32 age- and sex-matched patients with biliary atresia and a resistance index of < 1.0 (group B). Group A was found to have significantly worse liver function tests than group B. In group A, all patients died (n = 11) or underwent transplantation (n = 21; of whom 4 died) compared with only 2 patients who died in group B and 4 patients who underwent transplantation without fatality. Survival at 2 years was 52% in group A v 94% in group B. It is suggested that regular ultrasonography Doppler examination in patients with biliary atresia can detect a group with a resistance index of > 1.0 who have a very high risk of early mortality. Such patients require early evaluation and listing for transplantation. Those listed for liver transplantation on other grounds require ultrasonography examinations every 2 to 3 months with immediate upgrading of the priority of those patients found to have a resistance index of > or = 1.0.

Hepatic vein pulsatility assessment on spectral Doppler ultrasound

Hepatic vein pulsatility correlates with the severity of disease in a range of different liver disorders. We describe a simple visual grading system for scoring hepatic vein pulsatility which does not require any on-screen measurements and which has proved reproducible in clinical practice. The system gives a six point score for the waveform pulsatility, 6 being a normal value and 1 indicating a complete lack of modulation.

Ultrasound diagnosis of portocaval anastomosis in infants--a report of eight cases

We report eight cases of portocaval anastomosis in infants diagnosed by ultrasound. Anatomically we believe this represents continuing patency of the ductus venosus, either as a primary developmental abnormality or secondary to established liver cell failure.

Liver volume measurement by ultrasonography in normal subjects and alcoholic patients

Computer-assisted ultrasonic planimetry was used to determine hepatic volumes in normal subjects and patients with alcoholic liver disease. Normal subjects showed a diurnal variation in liver volume with a minimum between 12.00 and 14.00 h. Studies indicated that this was related to hydration and liver glycogen content. Using data obtained from nonfasted ambulant subjects correlations were found between liver volume and body weight, height and surface area, with body weight showing the closest correlation. The normal range for adults was 18.1 +/- 0.5 (SE) ml/kg body weight. Patients with alcoholic fatty liver showed increased hepatic volumes correlating with degree of fatty change as judged histologically. Patients who continued to abuse alcohol showed a persistent increase in hepatic volume. Those who moderated, and particularly those who abstained, showed a significant decrease in hepatic volume. Serial measurements of liver volume are useful in assessing hepatic changes in alcohol abusers.

Ultrasound demonstration of an unusual fetal growth pattern in indians

An ultrasound study of fetal growth patterns in women of Indian origin showed that the mean abdominal circumference measurements throughout pregnancy were significantly smaller than measurements obtained in white European patients. The mean birth weight of the Indian babies was 340 g less than that of the controls and Indian patients also exhibited a significantly shorter duration of gestation. There was no significant difference between the biparietal diameter measurements of European and Indian women throughout pregnancy.

Pancreatic ultrasound--a systematic approach to scanning technique

The pancreas remains one of the more difficult organs to visualize but ultrasound can be successful in nearly 90% of patients. A systematic technique for identifying and delineating the pancreas is described and has been verified on over 500 patients to date. The success of the technique depends on an accurate knowledge of the vascular relations of the pancreas and on correct adjustment of the ultrasound equipment. This paper is intended to help ultrasound practitioners achieve both these ends.

Distinction of benign from malignant ovarian cysts by ultrasound

The ultrasonic characteristics of benign and malignant cystic ovarian tumours have been reviewed. The value of each of eight different ultrasonic features has been assessed and the specificity of each for confirmation or exclusion of malignancy is indicated. In combination they permit correct differentiation in 91 percent of cases.

A comparison of grey-scale image recording systems

There is currently a rapid rise in the variety of image recording systems and recording media available for use with ultrasound and CT scanners. We have evaluated nine different systems and ten recording media and have compared their cost, convenience and performance. The choice of system in a particular department depends upon many factors, especially the number of images recorded and the reasons for recording them. We suggest that a busy department will probably require one of the more expensive automatic devices since these are the most convenient to use and have the lowest cost per image.

Preparation of the patient for abdominal ultrasound scanning

The value of dietary restriction and laxatives both separately and in combination for the reduction of bowel gas has been investigated and compared with unprepared patients. No significant difference was found between the results from prepared and un-prepared patients.

Place of ultrasound and radiography in obstetrics

In the two years after an ultrasound service was introduced at this hospital obstetric referrals for abdominal radiography decreased by over 55%. Most of these were for estimation of fetal maturity. Out of 349 such patients subjected to radiography in 1976, 176 had already been examined by ultrasound; in only four did radiography appear to influence management. We believe that if a satisfactory ultrasound scan is obtained before 30 weeks of gestation subsequent radiological estimation of fetal maturity is unjustified. Radiography may still be necessary, however, for diagnosing fetal abnormalities.