Clinical characteristics of people with intellectual disability admitted to hospital with constipation: identifying possible specific high-risk factors

BACKGROUND

People with intellectual disabilities (ID) die on an average 20 years earlier to the general population. They have higher rates of multimorbidity and polypharmacy. Around 25% of people with ID report chronic constipation. The England Learning Disabilities Mortality Review found that nearly 25% of deaths identified constipation as a long-term health problem. However, the likely risk factors for constipation related harm are poorly enumerated. We sought to identify possible specific high-risk factors by examining the clinical characteristics of people with ID admitted to hospital with constipation.

METHODS

Data of people with ID admitted with constipation in two general hospitals covering a population of 1.3 million from 2017 to 2022 were reported using the STROBE guideline for cohort studies. Collected data included age, gender, intellectual disability severity, recorded medication, presenting complaint and co-morbidities. The medication anticholinergic burden was calculated using the anticholinergic burden scale. Continuous variables were summarised by mean and standard deviation if normally distributed, with categorical variables summarised by the number and percentage in each category.

RESULTS

Of 46 admissions (males 52%), 57% had moderate to profound ID, 37% had epilepsy, 41% prescribed antiseizure medication (ASM) and 45% were on laxatives. Average age was 46 years. The anticholinergic burden score mean was 2.3 and median, one.

CONCLUSIONS

We can hypothesise that people with more severe ID, suffering from epilepsy and on ASM may be more at risk of developing severe constipation. Some admissions may be avoided with earlier use of laxatives in the community.

Subcutaneous immunoglobulin replacement therapy in patients with immunodeficiencies - impact of drug packaging and administration method on patient reported outcomes

BACKGROUND

Here, the perspective of patients with primary and secondary immunodeficiency receiving subcutaneous immunoglobulin (SCIg) via introductory smaller size pre-filled syringes (PFS) or vials were compared.

METHODS

An online survey was conducted in Canada by the Association des Patients Immunodéficients du Québec (APIQ) (10/2020-03/2021). Survey questions included: reasons for choosing SCIg packaging and administration methods, training experiences, infusion characteristics, and switching methods. The survey captured structured patient-reported outcomes: treatment satisfaction and its sub-domains, symptom state, general health perception, and physical and mental function. Respondents using PFS were compared with vial users, overall and stratified by their administration method (pump or manual push).

RESULTS

Of the 132 total respondents, 66 respondents used vials, with 38 using a pump and 28 using manual push. PFS (5 and 10 mL sizes) were being used by 120 respondents, with 38 using a pump and 82 using manual push. PFS users were associated with a 17% lower median (interquartile range) SCIg dose (10 [8, 12] vs. 12 [9, 16] g/week, respectively), a significantly shorter infusion preparation time (15 [10, 20] vs. 15 [10, 30] mins, respectively), and a trend for shorter length of infusion (60 [35, 90] vs. 70 [48, 90] mins, respectively) compared with those on vials. Patient-reported treatment satisfaction scores were overall similar between vial and PFS users (including on the domains of effectiveness and convenience), except for a higher score for vials over PFS on the domain of global satisfaction (p=0.02).

CONCLUSIONS

Consistent with prescribing that reflects a recognition of less wastage, PFS users were associated with a significantly lower SCIg dose compared with vial users. PFS users were also associated with shorter pre-infusion times, reflecting simpler administration mechanics compared with vial users. Higher global satisfaction with treatment among vial users compared with PFS users was consistent with users being limited to smaller PFS size options in Canada during the study period. Patient experience on PFS is expected to improve with the introduction of larger PFS sizes. Overall, treatment satisfaction for SCIg remains consistently high with the introduction of PFS packaging compared with vials.

Awareness of social care needs in people with epilepsy and intellectual disability

BACKGROUND

Nearly a quarter of people with intellectual disability (ID) have epilepsy with large numbers experiencing drug-resistant epilepsy, and premature mortality. To mitigate epilepsy risks the environment and social care needs, particularly in professional care settings, need to be met.

PURPOSE

To compare professional care groups as regards their subjective confidence and perceived responsibility when managing the need of people with ID and epilepsy.

METHOD

A multi-agency expert panel developed a questionnaire with embedded case vignettes with quantitative and qualitative elements to understand training and confidence in the health and social determinants of people with ID and epilepsy. The cross-sectional survey was disseminated amongst health and social care professionals working with people with ID in the UK using an exponential non-discriminative snow-balling methodology. Group comparisons were undertaken using suitable statistical tests including Fisher's exact, Kruskal-Wallis, and Mann-Whitney. Bonferroni correction was applied to significant (p < 0.05) results. Content analysis was conducted and relevant categories and themes were identified.

RESULTS

Social and health professionals (n = 54) rated their confidence to manage the needs of people with ID and epilepsy equally. Health professionals showed better awareness (p < 0.001) of the findings/recommendations of the latest evidence on premature deaths and identifying and managing epilepsy-related risks, including the relevance of nocturnal monitoring. The content analysis highlighted the need for clearer roles, improved care pathways, better epilepsy-specific knowledge, increased resources, and better multi-disciplinary work.

CONCLUSIONS

A gap exists between health and social care professionals in awareness of epilepsy needs for people with ID, requiring essential training and national pathways.

The ability of post-chemoradiotherapy DWI ADCmean and 18F-FDG SUVmax to predict treatment outcomes in head and neck cancer: impact of human papilloma virus oropharyngeal cancer status

OBJECTIVES

To evaluate the ability of post-chemo-radiotherapy (CRT) diffusion-weighted-MRI apparent diffusion coefficient (ADCmean) and 18F-FDG PET maximum standardized uptake value (SUVmax) to predict disease-free survival (DFS) in head and neck squamous cell carcinoma (HNSCC), and to determine whether this ability is influenced by human papillomavirus oropharyngeal cancer (HPV-OPC) status.

METHODS

This prospective cohort observational study included 65 participants (53 male, mean ± SD age 59.9 ± 7.9 years, 46 HPV-OPC) with stage III or IV HNSCC. Primary tumour and nodal ADCmean (pre-treatment, 6- and 12-weeks post-CRT) and SUVmax (12-weeks post-CRT) were measured. Variables were compared with 2-year DFS (independent t-test/Mann-Whitney test) and overall DFS (Cox regression), before and after accounting for HPV-OPC status. Variables were also compared between HPV-OPC and other HNSCC subgroups after stratifying for DFS.

RESULTS

Absolute post-CRT ADCmean values predicted 2-year DFS and overall DFS for all participants (p = 0.03/0.03, 6-week node; p = 0.02/0.03 12-week primary tumour) but not in the HPV-OPC subgroup. In participants with DFS, percentage interval changes in primary tumour ADCmean at 6- and 12-weeks were higher in HPV-OPC than other HNSCC (p = 0.01, 6 weeks; p = 0.005, 12 weeks). The 12-week post-CRT SUVmax did not predict DFS.

CONCLUSION

Absolute post-CRT ADCmean values predicted DFS in HNSCC but not in the HPV-OPC subgroup. Amongst participants with DFS, post-CRT percentage interval changes in primary tumour ADCmean were significantly higher in HPV-OPC than in other HNSCC. Knowledge of HPV-OPC status is crucial to the clinical utilisation of post-CRT DWI-MRI for the prediction of outcomes.

Home viewing of educational video improves patient understanding of Mohs Surgery

BACKGROUND

Educational videos improve patient knowledge of wound care and skin cancer. However, the effect of viewing an educational video at home prior to Mohs surgery has not been demonstrated.

OBJECTIVE

To evaluate the use of an educational video to improve patient understanding of MMS MATERIALS AND METHODS: Patients scheduled to undergo MMS were randomized to receive standard patient education, or standard patient education with an additional video developed by the authors. The educational material was mailed to patients along with the details of their MMS appointment. Both groups answered questionnaires to assess their knowledge of MMS, as well as their anxiety and satisfaction.

RESULTS

Patients that watched the educational video scored higher on the knowledge questionnaire than patients in the control group (0.8, 95% CI 0.3 to 1.4, p = 0.003), but were not statistically less anxious (-0.7, 95% CI -2.6 to 1.3, p = 0.50). Overall, patients undergoing MMS were satisfied.

CONCLUSION

Home viewing of an educational video prior to MMS can improve patient understanding.

Impact of severe acute respiratory syndrome coronavirus 2 on ectopic pregnancy management in the United Kingdom: a multicentre observational study

Objective

To describe the impact of coronavirus disease 2019 (COVID‐19) on the management of women with ectopic pregnancy.

Design

A multicentre observational study comparing outcomes from a prospective cohort during the pandemic [COVID‐19‐ectopic pregnancy registry (CEPR)] compared with a historical pre‐pandemic cohort [non‐COVID‐19‐ectopic pregnancy registry (NCEPR)].

Setting

Five London university hospitals.

Population and methods

Consecutive patients diagnosed clinically and/or radiologically with ectopic pregnancy (March 2020–August 2020) were entered into the CEPR and results were compared with the NCEPR cohort (January 2019–June 2019). An adjusted analysis was performed for potentially confounding variables.

Main outcome measures

Patient demographics, management (expectant, medical and surgical), length of treatment, number of hospital visits (non‐surgical management), length of stay (surgical management) and 30‐day complications.

Results

Three hundred and forty‐one women met the inclusion criteria: 162 CEPR and 179 NCEPR. A significantly lower percentage of women underwent surgical management versus non‐surgical management in the CEPR versus NCEPR (58.6%; 95/162 versus 72.6%; 130/179; P = 0.007). Among patients managed with expectant management, the CEPR had a significantly lower mean number of hospital visits compared with NCEPR (3.0, interquartile range [IQR] [3, 5] versus 9.0, [5, 14]; P = <0.001). Among patients managed with medical management, the CEPR had a significantly lower median number of hospital visits versus NCEPR (6.0, [5, 8] versus 9, [6, 10]; P = 0.003). There was no observed difference in complication rates between cohorts.

Conclusion

Women were found to undergo significantly higher rates of non‐surgical management during the COVID‐19 first wave compared with a pre‐pandemic cohort. Women managed non‐surgically in the CPER cohort were also managed with fewer hospital attendances. This did not lead to an increase in observed complication rates.

Tweetable abstract

A higher rate of non‐surgical management of ectopic pregnancy during the COVID‐19 pandemic did not increase complication rates.

A higher rate of non‐surgical management of ectopic pregnancy during the COVID‐19 pandemic did not increase complication rates.

Comparison between high-resolution water-perfused anorectal manometry and THD® Anopress anal manometry: a prospective observational study

AIM

Anorectal physiology tests provide a functional assessment of the anal canal. The aim of this study was to compare the results generated by standard high-resolution water-perfused manometry (WPM) with the newer THD^® Anopress manometry system.

METHOD

This was a prospective observational study. Conventional manometry was carried out using a water-perfused catheter with high-resolution manometry and compared with the Anopress system with air-filled catheters. All patients underwent the two procedures successively in a randomized order. Time to arrive at the resting pressure plateau, resting, squeeze, straining pressure and visual analogue scale (VAS) scores for pain were recorded. A qualitative analysis of the two devices was performed.

RESULTS

Between 2016 and 2017, 60 patients were recruited. The time from insertion of the catheter to arriving at the resting pressure plateau was significantly lower with the Anopress compared with WPM: 12 s [interquartile range (IQR) 10-17 s] versus 100 s (IQR 67-121 s) (P < 0.001). A strong correlation between the manometric values of WPM and the Anopress was observed. Both procedures were well tolerated, although the VAS score for insertion of the WPM catheter was significantly higher. The Anopress was easier to use and more time-efficient than the WPM.

CONCLUSION

The pressure values obtained with Anopress correlated well with those of conventional manometry. The Anopress has the advantage of being less time-consuming, user-friendly and better tolerated by patients.

Endoscopic Resections in Inflammatory Bowel Disease: A Multicentre European Outcomes Study

BACKGROUND AND AIMS

Inflammatory bowel disease is associated with an increased risk of colorectal cancer, with estimates ranging 2-18%, depending on the duration of colitis. The management of neoplasia in colitis remains controversial. Current guidelines recommend endoscopic resection if the lesion is clearly visible with distinct margins. Colectomy is recommended if complete endoscopic resection is not guaranteed. We aimed to assess the outcomes of all neoplastic endoscopic resections in inflammatory bowel disease.

METHODS

This was a multicentre retrospective cohort study of 119 lesions of visible dysplasia in 93 patients, resected endoscopically in inflammatory bowel disease.

RESULTS

A total of 6/65 [9.2%] lesions <20 mm in size were treated by ESD [endoscopic submucosal dissection] compared with 59/65 [90.8%] lesions <20 mm treated by EMR [endoscopic mucosal resection]; 16/51 [31.4%] lesions >20 mm in size were treated by EMR vs 35/51 [68.6%] by ESD. Almost all patients [97%] without fibrosis were treated by EMR, and patients with fibrosis were treated by ESD [87%], p < 0.001. In all, 49/78 [63%] lesions treated by EMR were resected en-bloc and 27/41 [65.9%] of the ESD/KAR [knife-assisted resection] cases were resected en-bloc, compared with 15/41 [36.6%] resected piecemeal. Seven recurrences occurred in the cohort. Seven complications occurred in the cohort; six were managed endoscopically and one patient with a delayed perforation underwent surgery.

CONCLUSIONS

Larger lesions with fibrosis are best treated by ESD, whereas smaller lesions without fibrosis are best managed by EMR. Both EMR and ESD are feasible in the management of endoscopic resections in colitis.

The effect of a novel Bayesian penalised likelihood PET reconstruction algorithm on the assessment of malignancy risk in solitary pulmonary nodules according to the British Thoracic Society guidelines

PURPOSE

British Thoracic Society (BTS) guidelines advocate using FDG PET-CT with the Herder model to estimate malignancy risk in solitary pulmonary nodules (SPNs). Qualitative and semi-quantitative assessment of SPN uptake is based upon analysis of Ordered Subset Expected Maximisation (OSEM) PET images. Our aim was to assess the effect of a Bayesian Penalised Likelihood (BPL) PET reconstruction on the assessment of SPN FDG uptake and estimation of malignancy risk (Herder score).

METHODS

Subjects with SPNs who underwent FDG PET-CT between 2014-2017, with histological confirmation of malignancy or histological/imaging follow-up confirmation of benignity were included. Two blinded readers independently classified SPN uptake on both OSEM and BPL (BTS score; 1 = none; 2 = ≤ mediastinal blood pool (MBP); 3 = >MBP but ≤ 2x liver; 4 = >2x liver), with resultant calculation of the Herder score (%) for both reconstructions.

RESULTS

97 subjects with 75 (77%) malignant SPNs were included. BPL increased the BTS score in 25 (26%) SPNs; 9 SPNs (7 malignant) increased from BTS score 2 to 3, 16 (13 malignant) from BTS score 3 to 4, with a mean Herder score increase of 18 ± 22%. The mean Herder score for all SPNs with BPL was higher than OSEM (73 ± 29 vs 68 ± 32%, p = 0.001). There was no difference in Herder model diagnostic performance between BPL and OSEM, with similar areas under the curve (0.84 vs 0.83, p = 0.39).

CONCLUSION

BPL increases the Herder score in 26% of SPNs compared to OSEM but does not alter the diagnostic performance of the Herder model.

Nidotherapy compared with enhanced care programme approach training for adults with aggressive challenging behaviour and intellectual disability (NIDABID): cluster-randomised controlled trial

BACKGROUND

Aggressive challenging behaviour is very common in care homes for people with intellectual disability, and better psychological treatments are needed. Nidotherapy aims to change the environment of people with mental illness and is an appropriate treatment for this group of disorders.

METHOD

The design was a cluster randomised trial of 20 care homes in which the staff either received training in nidotherapy or the enhanced care programme approach (ECPA), with equivalent duration of treatment in each arm. Cluster randomisation of care homes was carried out at the beginning of the study by an independent statistician. Primary and secondary outcomes were not specified exactly in view of absence of previous study data, but changes over time in scores on two scales, the Modified Overt Aggression Scale and the Problem Behaviour Check List were the main outcome measures. Serious violent incidents were recorded using the Quantification of Violence Scale. All these measures were recorded monthly by research assistants who were carefully kept blind to the allocation of treatment.

RESULTS

A total of 200 residents entered the trial, 115 allocated to the ECPA arm and 85 to the nidotherapy one. Seven residents left the care homes in the course of the study, and six were replaced; these were included 79 in the analysis as the trial was a pragmatic one. There were no material reductions in challenging behaviour in the first 8 months of the trial in either group, but in the last 7 months, those allocated to nidotherapy had a 33% reduction in Modified Overt Aggression Scale (MOAS) scores and a 43% reduction in Problem Behaviour Check List scores compared with 5% and 13%, respectively, for the ECPA group, differences which for the MOAS were close to statistical significance.

DISCUSSION

Nidotherapy shows promise in the management of aggressive challenging behaviour in care homes, but a delay in its benefit might be expected if given to staff only. The treatment is worthy of further evaluation and development.

Outcome of a screening programme for the prevention of neonatal invasive early-onset group B Streptococcus infection in a UK maternity unit: an observational study

BACKGROUND

Against a background of failure to prevent neonatal invasive early-onset group B Streptococcus infections (GBS) in our maternity unit using risk-based approach for intrapartum antibiotic prophylaxis, we introduced an antenatal GBS carriage screening programme to identify additional women to target for prophylaxis.

OBJECTIVES

To describe the implementation and outcome of an antepartum screening programme for prevention of invasive early-onset GBS infection in a UK maternity unit.

DESIGN

Observational study of outcome of screening programme (intervention) with comparison to historical controls (preintervention).

SETTING

Hospital and community-based maternity services provided by Northwick Park and Central Middlesex Hospitals in North West London.

PARTICIPANTS

Women who gave birth between March 2014 and December 2015 at Northwick Park Hospital.

METHODS

Women were screened for GBS at 35-37 weeks and carriers offered intrapartum antibiotic prophylaxis. Screening programme was first introduced in hospital (March 2014) and then in community (August 2014). Compliance was audited by review of randomly selected case records. Invasive early-onset GBS infections were defined through GBS being cultured from neonatal blood, cerebrospinal fluid or sterile fluids within 0-6 days of birth.

MAIN OUTCOME

Incidence of early-onset GBS infections.

RESULTS

6309 (69%) of the 9098 eligible women were tested. Screening rate improved progressively from 42% in 2014 to 75% in 2015. Audit showed that 98% of women accepted the offer of screening. Recto-vaginal GBS carriage rate was 29.4% (1822/6193). All strains were susceptible to penicillin but 11.3% (206/1822) were resistant to clindamycin. Early onset GBS rate fell from 0.99/1000 live births (25/25276) in the prescreening period to 0.33/1000 in the screening period (Rate Ratio=0.33; p=0.08). In the subset of mothers actually screened, the rate was 0.16/1000 live births (1/6309), (Rate Ratio=0.16; p<0.05).

CONCLUSIONS

Our findings confirm that an antenatal screening programme for prevention of early-onset GBS infection can be implemented in a UK maternity setting and is associated with a fall in infection rates.

Outcomes of an integrated community-based nurse-led cardiovascular disease prevention programme

Background

National guidance for England recommends that cardiovascular disease (CVD) should be managed as a family of diseases in the community. Here, we describe the results of such an approach.

Methods

Patients with established CVD or who were at high multifactorial risk (HRI) underwent a 12-week community-based nurse-led prevention programme (MyAction) that included lifestyle and risk factor management, prescription of medication and weekly exercise and education sessions.

Results

Over a 6-year period, 3232 patients attended an initial assessment; 63% were male, and 48% belonged to black and minority ethnic groups. 56% attended an end-of-programme assessment, and 33% attended a one year assessment. By the end of the programme, there was a significant reduction in smoking prevalence but only in HRI (−3.7%, p<0.001). Mediterranean diet score increased in both CVD (+1.2, p<0.001) and HRI (+1.5; p<0.001), as did fitness levels (CVD +0.8 estimated Mets maximum, p<0.001, HRI +0.9 estimated Mets maximum, p<0.001) and the proportions achieving their physical activity targets (CVD +40%, p<0.001, HRI +37%, p<0.001). There were significant increases in proportions achieving their blood pressure (CVD +15.4%, p<0.001, HRI +25%, p<0.001 and low-density lipoprotein cholesterol targets (CVD +6%, p=0.004, HRI +23%, p<0.001). Statins and antihypertensive medications significantly increased in HRI. Significant improvements in depression scores and quality-of-life measures were also seen. The majority of improvements were maintained at 1 year.

Conclusion

These results demonstrate that an integrated vascular prevention programme is feasible in practice and reduces cardiovascular risk in patients with established CVD and in those at high multifactorial risk.

Assessing fatigue in inflammatory bowel disease: comparison of three fatigue scales

BACKGROUND

Fatigue is commonly reported by patients with inflammatory bowel disease (IBD), both in quiescent and active disease. Few fatigue scales have been tested in IBD.

AIM

To assess three fatigue assessment scales in IBD and to determine correlates of fatigue.

METHODS

Potential participants (n = 2131) were randomly selected from an IBD organisation's members' database; 605 volunteered and were posted three fatigue scales: Inflammatory Bowel Disease Fatigue scale, Multidimensional Fatigue Inventory and Multidimensional Assessment Fatigue scale and questionnaires assessing anxiety, depression, quality of life (QoL) and IBD activity. The questionnaires were tested for stability over time with another group (n = 70) of invited participants. Internal consistency was measured by Cronbach's alpha and test-retest reliability by the intraclass correlation coefficient (ICC).

RESULTS

Four hundred and sixty-five of 605 (77%) questionnaires were returned; of 70 invited, 48/70 returned test (68.6%) and 41/70 (58.6%) returned retest. The three scales are highly correlated (P < 0.001). Test-retest suggests reasonable agreement with ICC values between 0.65 and 0.84. Lower age, female gender, IBD diagnosis, anxiety, depression and QoL were associated with fatigue (P < 0.001) on univariable analysis. However, on multivariable analysis only depression and low QoL were consistently associated with fatigue, while female gender was associated on most scales. IBD diagnosis, age and other factors were not consistently associated with severity or impact of fatigue once other variables were controlled for.

CONCLUSIONS

All three fatigue scales are likely to measure IBD fatigue adequately. Responsiveness to change has not been tested. Depression, poorer QoL and probably female gender are the major associations of fatigue in IBD.

Direct comparison of the effects of intravenous kisspeptin-10, kisspeptin-54 and GnRH on gonadotrophin secretion in healthy men

STUDY QUESTION

How potently does the novel hypothalamic stimulator of reproduction, kisspeptin, increase gonadotrophin secretion when compared with GnRH in healthy men?

SUMMARY ANSWER

At the doses tested, intravenous administration of either of two major kisspeptin isoforms, kisspeptin-10 and -54, was associated with similar levels of gonadotrophin secretion in healthy men; however, GnRH was more potent when compared with either kisspeptin isoform.

WHAT IS KNOWN ALREADY

Kisspeptin-10 and -54 are naturally occurring hormones in the kisspeptin peptide family which potently stimulates endogenous GnRH secretion from the hypothalamus, so have the potential to treat patients with reproductive disorders. Rodent studies suggest that kisspeptin-54 is more potent when compared with kisspepitn-10; however, their effects have not previously been directly compared in humans, or compared with direct pituitary stimulation of gonadotrophin secretion using GnRH.

STUDY DESIGN, SIZE AND DURATION

A single-blinded placebo controlled physiological study was performed from January to December 2013. Local ethical approval was granted, and five participants were recruited to each dosing group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Healthy men were administered vehicle, kisspeptin-10, kisspeptin-54 and GnRH intravenously for 3 h on different study days. Each hormone was administered at 0.1, 0.3 and 1.0 nmol/kg/h doses (n = 5 subjects per group). Regular blood sampling was conducted throughout the study to measure LH and FSH. Study visits were conducted at least a week apart.

MAIN RESULTS AND THE ROLE OF CHANCE

Serum LH and FSH levels were ∼3-fold higher during GnRH infusion when compared with kisspeptin-10 and ∼2-fold higher when compared with kisspeptin-54 [mean area under the curve serum LH during infusion (in hours times international units per litre, h.IU/l): 10.81 ± 1.73, 1.0 nmol/kg/h kisspeptin-10; 14.43 ± 1.27, 1.0 nmol/kg/h kisspeptin-54; 34.06 ± 5.18, 1.0 nmol/kg/h GnRH, P < 0.001 versus kisspeptin-10, P < 0.01 versus kisspeptin-54].

LIMITATIONS, REASONS FOR CAUTION

This study had a small sample size.

WIDER IMPLICATIONS OF THE FINDINGS

Kisspeptin offers a novel means of stimulating the reproductive axis. Our data suggest that kisspeptin stimulates gonadotrophin secretion less potently when compared with GnRH; however, kisspeptin may stimulate gonadotrophins in a more physiological manner when compared with current therapies. Kisspeptin is emerging as a future therapeutic agent, so it is important to establish which kisspeptin hormones could be used to treat patients with infertility. Results of this study suggest that either isoform has similar effects on reproductive hormone secretion in healthy men when administered intravenously.

STUDY FUNDING/COMPETING INTERESTS

This work is funded by grants from the MRC and NIHR and is supported by the NIHR Imperial Biomedical Research Centre Funding Scheme. C.N.J. is supported by an NIHR Clinical Lectureship. A.A. is supported by Wellcome Trust Research Training Fellowships. A.N.C. is supported by Wellcome Trust Translational Medicine Training Fellowship. W.S.D. is supported by an NIHR Career Development Fellowship.

A prospective case controlled study of the short-term outcome following hemicolectomy for benign compared with malignant colonic polyps

AIM

The number of patients diagnosed with advanced colonic polyps has increased due to screening. The outcome of hemicolectomy for benign lesions is poorly documented. We present a case-matched study comparing the results of hemicolectomy for benign and malignant polyps performed in two institutions.

METHODS

Data for consecutive patients undergoing surgery for benign colonic polyps (BCPs) were prospectively collected in two hospitals. Each patient was matched for age, sex, ASA grade, site and type of resection (laparoscopic, open and converted) with two controls who underwent surgery for colon cancer (CC). The length of stay (LOS) and 30-day outcome were analysed adjusting for potential confounders. Multilevel linear and logistic regression analyses were performed.

RESULTS

Forty-six patients having hemicolectomy for BCP were matched with 81 patients with CC. The median size of BCP was 4 cm [interquartile range (IQR) 2.5-5.4 cm]. Patients with a BCP had a marginally longer LOS [median 5.5 (IQR 4-8) days and 5 (IQR 3-7) days (P = 0.04)]. Twenty-one (46%) of 46 patients with BCP had a postoperative complication compared with 25 (31%) of 81 CC patients (P = 0.12, OR = 2.11, 95% CI 0.82-5.41). Four (9%) of 46 patients with BCP underwent re-operation and a further three (7%) were readmitted compared with one (1%) and two (2%) of 81 patients with CC (P = 0.07 and 0.28). There was no mortality in either group.

CONCLUSION

Complications following hemicolectomy for BCP or CC are not significantly different. The results of the study provide further impetus to develop local full thickness colonic excision for benign colonic lesions as an alternative to major surgery.

Factors affecting the healing of the perineum following surgery

INTRODUCTION

The aim of this study was to establish patient and procedural factors associated with the development of an unhealed perineum in patients undergoing a proctectomy or excision of an ileoanal pouch.

METHODS

A review of 194 case notes for procedures performed between 1997 and 2009 was carried out. All patients had at least 12 months' follow-up. Univariate and multivariate analyses were performed in 16 parameters. For those patients who developed an unhealed perineum, Cox regression analysis was performed to establish healing over a 12-month period.

RESULTS

Two hundred patients were included in the study, of which six had unknown wound status and were subsequently excluded. This left 194 study patients. Of these, 86 (44%) achieved primary wound healing with a fully healed perineum and 108 (56%) experienced primary wound failure. With reference to the latter, 63 (58%) healed by 12 months. Comparing patients with an initially intact perineum with those with initial wound failure showed pre-existing sepsis was highly relevant (odds ratio: 4.32, 95% confidence interval [CI]: 2.16-8.62, p<0.001). In patients who had an unhealed perineum initially, perineal sepsis and surgical treatment were both significantly associated with time to healing (hazard ratio [HR]: 0.54, 95% CI: 0.31-0.93, p=0.03; and HR: 0.42, 95% CI: 0.21-0.84, p=0.01).

CONCLUSIONS

The presence of pre-existing perineal sepsis is associated with an unhealed perineum following proctectomy in inflammatory bowel disease (IBD) and non-IBD surgery. Further studies are indicated to establish perineal sepsis as a causative factor.

Rescreening for abnormal vaginal flora in pregnancy and re-treating with clindamycin vaginal cream significantly increases cure and improvement rates

We investigated 199 pregnant women with bacterial vaginosis (BV) who received clindamycin vaginal cream (CVC) for three days and compared with 205 women treated with placebo. The vaginal flora was assessed at each visit. At the second visit, 71% in the CVC group were cured/improved, compared with 12% in the placebo group (P < 0.001). At visit 3 about 90% who responded to initial CVC treatment were still cured/improved. Of women who initially failed to respond to CVC and were given an additional seven-day course, 33% were cured/improved by the third visit, compared with 15% who failed to respond to placebo initially and were given a further seven-day course (P = 0.02). By visit 4, half the women in the CVC group who received additional treatment remained cured/improved, compared with 26% who had additional placebo (P = 0.004). In the CVC group, a change from abnormal to normal rose from 71% (visit 2) to 76% (visit 3) and 79% (visit 4). A similar trend was seen in women who received placebo but the proportions were significantly lower (12%, 24% and 33%, respectively). There is value in rescreening and re-treating women who remain BV-positive after initial clindamycin treatment.

A randomized, controlled trial of narrow-band imaging vs high-definition white light for adenoma detection in patients at high risk of adenomas

AIM

The study aimed to investigate whether narrow-band imaging (NBI) can enhance adenoma detection in patients at high risk for adenomas compared with high-definition white-light endoscopy (WLE). High risk was defined as three or more adenomas at last colonoscopy, history of colorectal cancer and positive faecal occult blood test.

METHOD

Two hundred and fourteen patients were randomized 1:1 to examination with NBI or WLE. The primary outcome measure was the proportion of patients with at least one adenoma detected. Secondary outcomes included total adenomas and polyps, flat adenomas, nonadenomatous polyps, advanced adenomas and patients with three or five or more adenomas. A post hoc analysis to examine the effect of endoscopist and bowel preparation was performed.

RESULTS

There was no significant difference in the proportion of patients with at least one adenoma: NBI 73%vs WLE 66%, odds ratio 1.40 (95% CI 0.78-2.52), P = 0.26. There was no significant difference for any secondary outcome measure except for the number of flat adenomas which was significantly greater with NBI [comparison ratio 2.66 (95% CI 1.52-4.63), P = 0.001]. Post hoc analysis indicated that one of three endoscopists performed significantly better for adenoma detection with NBI than WLE [comparison ratio 1.92 (95% CI 1.07-3.44), P = 0.03]. Good bowel preparation was associated with significantly improved adenoma detection with NBI [comparison ratio 1.55 (95% CI 1.01-2.22), P = 0.04] but not with fair preparation.

CONCLUSION

Overall NBI did not improve detection compared with WLE in a group of patients at high risk for colorectal adenomas, but specific subgroups might benefit.

The implications of a raised maternal BMI: a DGH experience

This retrospective analysis evaluated the association between maternal body mass index (BMI) and the incidence of maternal and neonatal complications in those women delivering at a North West London hospital between January 2002 and December 2007. Of the women examined, obese mothers (BMI ≥ 30) were shown to be at significantly higher risk from multiple morbidities (p < 0.05), including gestational diabetes; antepartum haemorrhages; pre-term delivery before 37 and 33 weeks' gestation; induction of labour; analgesia use (beyond inhalational methods and local infiltration); caesarean sections; massive postpartum haemorrhages; higher birth weights; Apgar scores < 8 at 1 min and 5 min; cord base deficits less than-12 and a greater need for neonatal care (SCBU, HDU, NICU) compared with mothers with a BMI < 30. These findings add to the growing consensus that obesity increases the risks involved with pregnancy. While information is filtering through to the general public about the overall risks of obesity, more focused pre-pregnancy and inter-pregnancy counselling on the implications of a raised BMI specifically on pregnancy is required at both primary and secondary care sector levels.

School lunch and learning behaviour in primary schools: an intervention study

BACKGROUND/OBJECTIVES

In addition to the nutritional benefits of healthier school food, anecdotes describe improvements in children's behaviour and educational outcomes when school food or the school dining room environment is improved. This study hypothesized that a school food and dining room intervention would improve pupils' learning-related classroom behaviour.

SUBJECTS/METHODS

A controlled intervention trial involving six primary schools matched in triplets and randomly assigned to a 12-week intervention (promotion of healthier school food at lunchtime and changes in the school dining environment) or 12-week wait-listed control group. Study outcome was learning-related behaviours measured in a random sample of 146 pupils in years 3-5.

RESULTS

On-task and off-task behaviours were observed and used as proxy measures for concentration and disengagement (disruption), respectively. Teacher-pupil on-task engagement was 3.4 times more likely in the intervention schools compared with the control schools (adjusted model odds ratio (OR)=3.40 (95% confidence interval (CI)=1.56, 7.36), P=0.009). However, on-task pupil-pupil behaviour was less likely in the intervention group (adjusted model OR=0.45 (95% CI=0.28, 0.70), P<0.001). Similarly, off-task pupil-pupil behaviour was more likely in the intervention group than in the control group in both the unadjusted model (OR=2.18 (95% CI=1.52, 3.13), P<0.001) and the adjusted model (OR=2.28 (95% CI=1.25, 4.17), P=0.007).

CONCLUSIONS

This study offers some support for the hypothesis that a school food and dining room intervention can have a positive impact on pupils' alertness. However, if raised alertness is not channelled and supervised, it may result in increased off-task behaviour when pupils are working together.

Validation of the second-generation Olympus colonoscopy simulator for skills assessment

BACKGROUND AND STUDY AIMS

Simulators have potential value in providing objective evidence of technical skill for procedures within medicine. The aim of this study was to determine face and construct validity for the Olympus colonoscopy simulator and to establish which assessment measures map to clinical benchmarks of expertise.

PATIENTS AND METHODS

Thirty-four participants were recruited: 10 novices with no prior colonoscopy experience, 13 intermediate (trainee) endoscopists with fewer than 1000 previous colonoscopies, and 11 experienced endoscopists with more than 1000 previous colonoscopies. All participants completed three standardized cases on the simulator and experts gave feedback regarding the realism of the simulator. Forty metrics recorded automatically by the simulator were analyzed for their ability to distinguish between the groups.

RESULTS

The simulator discriminated participants by experience level for 22 different parameters. Completion rates were lower for novices than for trainees and experts (37 % vs. 79 % and 88 % respectively, P < 0.001) and both novices and trainees took significantly longer to reach all major landmarks than the experts. Several technical aspects of competency were discriminatory; pushing with an embedded tip ( P = 0.03), correct use of the variable stiffness function ( P = 0.004), number of sigmoid N-loops ( P = 0.02); size of sigmoid N-loops ( P = 0.01), and time to remove alpha loops ( P = 0.004). Out of 10, experts rated the realism of movement at 6.4, force feedback at 6.6, looping at 6.6, and loop resolution at 6.8.

CONCLUSIONS

The Olympus colonoscopy simulator has good face validity and excellent construct validity. It provides an objective assessment of colonoscopic skill on multiple measures and benchmarks have been set to allow its use as both a formative and a summative assessment tool.

An analysis of predictive factors for healing and mortality in patients with enterocutaneous fistulas

BACKGROUND

Most studies of enterocutaneous fistula report management and outcome. Few studies examine factors predicting healing and mortality.

AIM

To identify factors predicting healing and mortality in patients with ECF managed either with a definitive attempt at surgical closure or conservatively.

METHODS

The case notes of 277 patients with enterocutaneous fistula, treated at our institution over a 10 year period, were retrospectively reviewed. Patients were divided into those managed operatively or conservatively. Eleven factors were examined for their relationship to fistula healing and fistula-related mortality.

RESULTS

For patients treated operatively, successful enterocutaneous fistula closure related only to the complexity of the fistula (multiple fistula or presence of an internal abscess cavity) (P = 0.03), whereas fistula-related mortality related only to the presence of comorbidity (P = 0.02). In patients managed conservatively, a decreased likelihood of enterocutaneous fistula closure was associated with a high fistula output (P = 0.01), comorbidity (P = 0.03) and being referred from an external institution (P < 0.001). Fistula related-mortality in this group was related to a high output (P = 0.003) and an increased age (P = 0.001).

CONCLUSION

In patients managed operatively, fistula healing and fistula-related mortality are each associated with only one factor, whereas in patients managed conservatively healing and mortality are predicted by three and two factors, respectively.

Narrow band imaging with magnification for the characterization of small and diminutive colonic polyps: pit pattern and vascular pattern intensity

BACKGROUND AND STUDY AIMS

Narrow band imaging (NBI) can accurately characterize colonic polyps using microvascular appearances. We aimed to assess whether the Kudo pit pattern classification is accurate when used with NBI (without dye-spray), and if microvascular appearances or NBI pit patterns maintain accuracy for polyp characterization at sizes < 10 mm.

PATIENTS AND METHODS

116 polyps < 10 mm in size were detected in 62 patients undergoing surveillance colonoscopy. The polyps were prospectively assessed using NBI and magnification for Kudo pit pattern (III-V neoplastic, I-II non-neoplastic) and vascular pattern intensity (VPI), a measure of microvascular density (strong VPI, neoplastic; normal or weak VPI, non-neoplastic). Sensitivity, specificity, and accuracy were calculated and compared with results from histopathology.

RESULTS

The mean polyp size was 3.4 mm (range 1 - 9 mm). Overall, NBI pit pattern sensitivity, specificity, and accuracy were 0.88, 0.91, and 89.6 %, respectively. Equivalent values for VPI were 0.94, 0.89, and 91.4 %. Results were similar when polyps were subdivided into diminutive polyps (size <or= 5 mm) and flat polyps. Combining both pit pattern and VPI improved the sensitivity (0.98, P = 0.06 versus NBI pit pattern alone). There was very good agreement between NBI pit pattern and VPI for prediction of dysplasia (kappa = 0.83). No evidence of a learning curve for VPI was found. The NBI pit pattern was better than the VPI at subclassifying hyperplastic from other non-neoplastic polyps (sensitivity 0.79 versus 0.56, respectively, P = 0.02), but accuracy was poor.

CONCLUSION

The NBI pit pattern and VPI are both highly accurate in characterizing neoplastic colonic polyps of < 10 mm, with VPI appearing to be simple to learn. NBI has the potential to replace conventional histology for small polyps.

The impact of experience on polyp detection and sizing accuracy at capsule endoscopy: implications for training from an animal model study

BACKGROUND AND STUDY AIMS

Indications for capsule endoscopy include polyp surveillance in Peutz-Jeghers syndrome and potentially colorectal examination and bowel cancer screening. The ability to detect and accurately size polyps associated with these conditions is critical when deciding which patients require further investigation or therapy. Inexperience may affect the ability of capsule endoscopists to perform these skills resulting in sub-optimal patient care. We assessed the performance of volunteers with different levels of endoscopy and capsule endoscopy experience using an animal-based polyp model.

PATIENTS AND METHODS

Thirty-six artificial polyps were sewn onto the luminal surface of porcine small bowel through which a capsule was propelled. Video images generated by the capsule were then shown to five expert capsule endoscopists, seven consultant gastroenterologists, seven trainee gastroenterologists, six endoscopy nurses, six gastrointestinal radiologists, and six nonmedical participants. Polyp detection rates and sizing accuracy were calculated according to each group and compared.

RESULTS

Expert capsule endoscopists had the highest polyp detection rate (91%) but only noncapsule endoscopy experience was independently correlated with improved polyp detection and sizing accuracy (OR missing polyp--endoscopy experience 1.0, no experience 1.96 [95% CI 1.29 - 2.97], P = 0.002; ratio of estimated to actual size--endoscopy experience 1.0, no experience 1.43 [95% CI 1.22 - 1.66], P < 0.001). Both expert capsule endoscopists and experienced endoscopists tended to underestimate polyp size more than novices, particularly for large polyps (OR capsule expert to non-expert: 2.39 vs. 1.0 [95% CI 1.73 - 3.29], P < 0.001).

CONCLUSIONS

Polyp detection rates and sizing accuracy during capsule endoscopy improve with endoscopic experience. However large polyps, which are the most clinically relevant, are least-accurately sized, and capsule endoscopy experts and experienced endoscopists are the most likely to underestimate the size of these polyps. Training to improve performance in these measures for capsule endoscopy novices as well as experts is required.

Computer-aided detection for CT colonography: incremental benefit of observer training

The purpose of this study was to investigate the incremental effect of focused training on observer performance when using computer-assisted detection (CAD) software to interpret CT colonography (CTC). Six radiologists who were relatively inexperienced with CTC interpretation underwent 1 day of focused training before reading 20 patient datasets with the assistance of CAD software (ColonCAR 1.3, Medicsight PLC). Sensitivity, specificity and interpretation times were determined and compared with previous performance when reading the same datasets but without the benefit of focused training, using the binomial exact test and Wilcoxon's signed rank test. Per-polyp sensitivity improved after training by 18% overall (95% confidence interval (CI): 14-24%, p<0.001) and was greatest for polyps of 6-9 mm (26%, 95% CI: 18-34%, p<0.001). Absolute sensitivity was 23% (9-36%), 51% (33-71%) and 74% (44-100%) for polyps of <or=5 mm, 6-9 mm and >or=10 mm, respectively. Specificity fell significantly after focused training (median of 5.5 false positives per 20 datasets (interquartile range (IQR): 4-6) post-training vs median of 2.5 (IQR: 1-5) pre-training, p = 0.03). Interpretation time also increased significantly after training (from a median of 9.3 min (IQR: 9.3-14.5 min) to a median of 17.1 min (IQR: 15.4-19.4 min), p = 0.03). In conclusion, one day of training increases observer polyp sensitivity when using CAD for CTC at the expense of increased reporting time and reduction in specificity.

Intensive training over 5 days improves colonoscopy skills long-term

BACKGROUND AND AIMS

Poor standards in colonoscopy services and the introduction of a colorectal cancer screening program in the United Kingdom have highlighted the need to establish high-quality training and competency assessments in colonoscopy. The aims of this study were to evaluate the effectiveness of a 1-week hands-on colonoscopy course utilizing novel assessment tools.

METHODS

Twenty-one doctors with varying colonoscopy experience who attended an accelerated colonoscopy training week (ACTW) were prospectively studied. They were trained and assessed in key aspects of colonoscopy. Knowledge was assessed with a multiple choice question (MCQ) paper. Practical hand skills were taught and evaluated using a computer simulator and live case teaching. Actual colonoscopy performance was assessed using Direct Observation of Procedural Skills scores (DOPS) and an objective tri-split video score of insertion technique. Two independent trainers taught and assessed the trainees at the start and end of the ACTW and at a median of 9 months' follow-up.

RESULTS

Following training there were significant improvements in the MCQ score (P < 0.001), the simulator test case times (P = 0.02, P = 0.003), and the global DOPS score (P < or = 0.02). All improvements following the accelerated training were sustained at a median follow-up of 9 months.

CONCLUSIONS

This study is the first in the literature to describe the positive, sustained impact of an intensive hands-on colonoscopy training course. Measurements of performance in key areas of skill acquisition improved following training.

CT colonography: interpretative performance in a non-academic environment

AIM

To investigate interpretative accuracy and reporting time for radiologists performing computed tomography (CT) colonography in day-to-day non-academic clinical practice.

MATERIALS AND METHODS

Thirteen radiologists from seven centres, who were reporting CT colonography in non-academic daily clinical practice, interpreted a dataset of 15 colonoscopically validated cases in a controlled environment. Ten cases had either a cancer or polyp >10mm; one case had a medium polyp and four were normal. Correct case categorization and interpretation times were compared using analysis of variance to aggregated results obtained from both experienced observers and observers recently trained using 50 cases, working in an academic environment. The effect of experience was determined using Spearman's rank correlation.

RESULTS

Individual accuracy was highly variable, range 53% (95% CI 27-79%) to 93% (95% CI 68-100%). Mean accuracy overall was significantly inferior to experienced radiologists (mean 75 versus 88%, p=0.04) but not significantly different from recently trained radiologists (p=0.48). Interpretation time was not significantly different to experienced readers (mean 12.4 min versus 11.7, p=0.74), but shorter than recently trained radiologists (p=0.05). There was a significant, positive, linear correlation between prior experience and accuracy (p<0.001) with no plateau.

CONCLUSION

Accuracy for sub-specialist radiologists working in a non-academic environment is, on average, equivalent to radiologists trained using 50 cases. However, there is wide variability in individual performance, which generally falls short of the average performance suggested by meta-analysis of published data. Experience improves accuracy, but alone is insufficient to determine competence.

A comparison of hypnotic and analgesic based sedation in a general intensive care unit †

BACKGROUND

Sedation of the critically ill patient has several components including hypnosis and analgesia. Hypnotic-based sedation (HBS), where midazolam and/or propofol are used, with morphine or another analgesic added as needed has been common. The advent of remifentanil has allowed greater use of analgesia-based sedation (ABS) where relief of discomfort from the tracheal tube or pain are the important objectives, and hypnosis is given as necessary. Method. We compared HBS and ABS (remifentanil-based sedation) within a general intensive care unit (ICU). During the first study period of 12 weeks, 111 patients received HBS. After the development of new guidelines for the use of remifentanil in the ICU, a second 12 week study period used an analgesia-based regimen, with hypnotics added only if needed.

RESULTS

Ninety-six patients received ABS, and 79 received remifentanil. It was possible to manage 29 (37%) of the patients receiving remifentanil without the use of supplementary hypnotic agents. In the remaining 63% the use of remifentanil was associated with a reduction in the amount and duration of propofol used. Significantly more patients receiving ABS had satisfactory levels of sedation during synchronized intermittent mandatory ventilation (19 [2,55] vs 50 [14,83], P<0.001).

CONCLUSIONS

The use of ABS allowed patients to be managed more comfortably, either without a hypnotic drug or with less hypnotic drug, than using conventional HBS.

Analgesia with sevoflurane during labour: II. Sevoflurane compared with Entonox for labour analgesia † ‡

BACKGROUND

We determined the optimal inspired sevoflurane concentration for use during labour as 0.8% in our previous study. This study compared sevoflurane at a concentration of 0.8% and Entonox((R)) (nitrous oxide 50%: oxygen 50%) for analgesia during labour in 32 healthy parturients.

METHODS

Each mother underwent two open-label, three-part sequences in random order, Entonox-sevoflurane-Entonox or sevoflurane-Entonox-sevoflurane. In each part the agent was self-administered during 10 contractions. A 100 mm visual analogue scores for pain relief and sedation was completed immediately after each contraction.

RESULTS

Two patients withdrew during administration of sevoflurane (because of its odour) and five during Entonox (requesting epidural analgesia). Of the remaining women, data were available for analysis from 29 participants: median (IQR [range]) pain relief scores were significantly higher for sevoflurane 67 (55-74 [33-100]) mm than for Entonox 51 (40-69.5 [13-100]) mm (P<0.037). Nausea and vomiting were more common in the Entonox group [relative risk 2.7 (95% CI 1.3-5.7); P=0.004]. No other adverse effects were observed in the mothers or babies. There was significantly more sedation with sevoflurane than with Entonox {74 (66.5-81 [32.5-100]) and 51 (41-69.5 [13-100]) mm, respectively; P<0.001}. Twenty-nine patients preferred sevoflurane to Entonox and found its sedative effects helpful.

CONCLUSIONS

We conclude that self-administered sevoflurane at subanaesthetic concentration (0.8%) can provide useful pain relief during the first stage of labour, and to a greater extent than Entonox. Although greater sedative effects were experienced with sevoflurane, it was preferred to Entonox.

Survival and dependence on home parenteral nutrition: experience over a 25-year period in a UK referral centre

BACKGROUND

Home parenteral nutrition (HPN) is the standard treatment for severe intestinal failure in the United Kingdom.

AIM

To review long-term survival and ongoing HPN dependence of patients receiving HPN treated at a specialist UK referral centre.

METHODS

Medical records of patients commenced on HPN between 1979 and 2003 were reviewed retrospectively. Regression analysis was employed to identify factors associated with poor prognosis.

RESULTS

Case notes of 188 patients were reviewed. Overall probability of survival was 86%, 77%, 73% and 71% at 1, 3, 5 and 10 years after starting treatment. In multivariate analysis, association was seen between mechanism of intestinal failure and survival: short bowel syndrome associated with a favourable prognosis, and intestinal dysfunction, dysmotility and obstruction with poorer prognoses. There was an association between increasing age and poor prognosis, but increased mortality was also seen in the youngest age groups. Only 9% of deaths were due to complications of HPN. Continued HPN dependence was 89%, 87%, 84% and 84% at 1, 3, 5 and 10 years in survivors.

CONCLUSIONS

Long-term survival of patients receiving HPN remains better than that reported after intestinal transplantation. Mortality predominantly relates to underlying disease rather than complications of HPN.

Quantitative colorectal cancer perfusion measurement by multidetector-row CT: does greater tumour coverage improve measurement reproducibility?

The purpose of this study was to determine if greater z-axis tumour coverage improves the reproducibility of quantitative colorectal cancer perfusion measurements using CT. A 65 s perfusion study was acquired following intravenous contrast administration in 10 patients with proven colorectal cancer using a four-detector row scanner. This was repeated within 48 h using identical technical parameters to allow reproducibility assessment. Quantitative tumour blood volume, blood flow, mean transit time and permeability measurements were determined using commercially available software (Perfusion 3.0; GE Healthcare, Waukesha, WI) for data obtained from a 5 mm z-axis tumour coverage, and from a 20 mm z-axis tumour coverage. Measurement reproducibility was assessed using Bland-Altman statistics, for a 5 mm z-axis tumour coverage, and 20 mm z-axis tumour coverage, respectively. The mean difference (95% limits of agreement) for blood volume, blood flow, mean transit time and permeability were 0.04 (-2.50 to +2.43) ml/100 g tissue; +8.80 (-50.5 to +68.0) ml/100 g tissue/min; -0.99 (-8.19 to +6.20) seconds; and +1.20 (-5.42 to +7.83) ml/100 g tissue/min, respectively, for a 5 mm coverage, and -0.04 (-2.61 to +2.53) ml/100 g tissue; +7.40 (-50.3 to +65.0) ml/100 g tissue/min; -2.46 (-12.61 to +7.69) seconds; and -0.23 (-8.31 to +7.85) ml/100 g tissue/min, respectively, for a 20 mm coverage, indicating similar levels of agreement. In conclusion, increasing z-axis coverage does not improve reproducibility of quantitative colorectal cancer perfusion measurements.

Intra-individual comparison of patient acceptability of multidetector-row CT colonography and double-contrast barium enema

AIMS

To compare the subjective acceptability of CT colonography in comparison with barium enema in older symptomatic patients, and to ascertain preferences for future colonic investigation.

MATERIALS AND METHODS

The study population comprised 78 persons aged 60 years or over with symptoms suggestive of colorectal neoplasia, who underwent CT colonography followed the same day by barium enema. A 25-point questionnaire was administered after each procedure and an additional follow-up questionnaire a week later. Responses were compared using Wilcoxon matched pairs testing, Mann-Whitney test statistics and binomial exact testing.

RESULTS

Participants suffered less physical discomfort during CT colonography (p = 0.03) and overall satisfaction was greater compared with barium enema (p = 0.03). On follow-up, respondents reported significantly better tolerance of CT colonography (p = 0.002), and were less prepared to undergo barium enema again (p < 0.001). Of 52 subjects expressing an opinion, all preferred CT to barium enema.

CONCLUSION

Patient satisfaction was higher with CT colonography than barium enema. CT colonography caused significantly less physical discomfort and was overwhelmingly preferred by patients.

Evidence for genetic predisposition to desmoid tumours in familial adenomatous polyposis independent of the germline APC mutation

BACKGROUND

Many patients with familial adenomatous polyposis (FAP) die from desmoid tumours which can arise spontaneously but often appear to be surgically induced by prophylactic colectomy. FAP results from germline adenomatous polyposis coli (APC) gene mutations and desmoids arise following biallelic APC mutation, with one change usually occurring distal to the second beta-catenin binding/degradation repeat of the gene (3' to codon 1399). We have suggested that because families with germline mutations in this region already have the requisite change, they are more likely to develop desmoids. However, there are families with 5' germline mutations where desmoids are common.

PATIENTS AND METHODS

We examined desmoid risk dependent on germline APC mutation, sex, history of abdominal surgery, and family history in FAP patients from the St Mark's Hospital Polyposis Registry.

RESULTS

Overall desmoid prevalence was 15%. Desmoids tended to cluster in susceptible individuals, irrespective of the germline APC mutation. Independent predictors of increased desmoid risk were: germline mutation distal to codon 1399; any family history of disease; and a strong family history of desmoids. A family history of multiple desmoids (>1) increased an individual's own risk of multiplicity. Females had twice the odds of developing desmoids compared with males. There was no significant interaction between any of the three explanatory variables.

CONCLUSIONS

Our results indicate the influence of unknown genetic factors independent of APC in susceptibility to desmoid tumours in FAP. The data have implications in terms of clinical management of FAP patients and assessing the balance between chemoprevention and prophylactic colectomy.

Observer Variation in the Detection of Colorectal Neoplasia on Double-contrast Barium Enema: Implications for Colorectal Cancer Screening and Training

AIM

To assess inter-observer error for the diagnosis of neoplasia on double contrast barium enema (DCBE) in the light of claims that no additional interpretative training would be needed for implementation in a national screening programme.

MATERIALS AND METHODS

10 experts, 10 consultants, and 10 experienced trainees each reported 20 DCBE studies, of which two showed cancer, three showed large polyps, four showed small polyps, and 12 were normal. Inter-observer variation was compared using odds ratios with the trainee group as reference (baseline group).

RESULTS

Experts were significantly more likely to correctly identify neoplasia on DCBE than trainees. The odds of a correct diagnosis for experts were 2.79 (95% CI 2.04, 3.81) for cancer, 2.36 (1.88, 2.97) for large polyps, and 3.50 (1.98, 6.18) for small polyps. While consultants were more likely to correctly diagnose a large polyp than trainees, 1.45 (1.15, 1.84), there was no significant difference between these two groups for the correct diagnosis of either cancer, 1.24 (0.52, 2.96), or small polyps, 1.26 (0.83, 1.90). A cancer was missed by 6 (60%) experts, 9 (90%) consultants, and 8 (80%) trainees. Large polyps were missed by 4 (40%) experts, 5 (50%) consultants, and 6 (60%) trainees. There was no significant difference between any group when false positive diagnoses were considered.

CONCLUSIONS

There is considerable inter-observer perceptive error for the diagnosis of neoplasia on DCBE. Experts performed significantly better than other observers but the overall standard of performance was poor, even amongst experts.

C-reactive protein, insulin resistance, central obesity, and coronary heart disease risk in Indian Asians from the United Kingdom compared with European whites

BACKGROUND

Indian Asians in the United Kingdom have increased coronary heart disease (CHD) mortality compared with European whites, but the causes are not well understood. Increased circulating concentrations of C-reactive protein (CRP) are an independent risk factor for CHD. Therefore, we investigated this marker of inflammation in healthy UK Indian Asian and European white men. Methods and Results-- We measured serum CRP concentrations and conventional CHD risk factors in 1025 healthy male subjects (518 Indian Asians and 507 European whites) aged 35 to 60 years who were recruited at random from general practitioner lists. The geometric mean CRP concentration was 17% higher (95% confidence interval, 3% to 33%) in Indian Asians compared with European whites. CRP values were strongly associated with conventional CHD risk factors, measures of obesity, and metabolic disturbances associated with insulin resistance in both racial groups. The difference in CRP concentrations between Indian Asians and European whites remained after adjustment for conventional CHD risk factors but was eliminated by an adjustment for central obesity and insulin resistance score in Asians. On the basis of these results, we estimate that the processes underlying elevated CRP and/or increased CRP production itself are associated with an approximately 14% increase in population CHD risk among Indian Asians compared with European whites.

CONCLUSIONS

CRP concentrations are higher in healthy Indian Asians than in European whites and are accounted for by greater central obesity and insulin resistance in Indian Asians. Our results suggest that inflammation or other mechanisms underlying elevated CRP values may contribute to the increased CHD risk among Indian Asians.