Radiopaque marker colonic transit study in the pediatric population BSPGHAN Motility Working Group consensus statement

Functional constipation (FC) is a common condition in childhood in the United Kingdom and worldwide. Various radiological approaches have been established for diagnostic purposes. The radiopaque marker study (ROMS) is universally accepted and used to assess colonic transit time (CTT) in children with FC. Despite being widely used, there is a lack of standardization with various technical protocols, reproducibility of different populations, the purpose for using investigation, variance in the number of markers used, the amount of study days and calculations, the need to empty the colon before performing the test, and whether to perform on medication or off, or the use of specific diets. As part of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) motility working group (MWG), we decided to explore further into the evidence, in order to provide guidance regarding the use of ROMS in dealing with FC in the pediatric population.

Chronic rheumatologic disorders and cardiovascular disease risk in women

Cardiovascular disease (CVD) is a major health threat to women worldwide. In addition to traditional CVD risk factors, autoimmune conditions are increasingly being recognized as contributors to adverse CVD consequences in women. Chronic systemic autoimmune and inflammatory disorders can trigger premature and accelerated atherosclerosis, microvascular dysfunction, and thrombosis. The presence of comorbid conditions, duration of the autoimmune condition, disease severity, and treatment of underlying inflammation are all factors that impact CVD risk and progression. Early identification and screening of CVD risk factors in those with underlying autoimmune conditions may attenuate CVD in this population. Treatment with non-steroidal anti-inflammatory drugs, corticosteroids, disease modifying agents and biologics may influence CVD risk factors and overall risk. Multi-disciplinary and team-based care, clinical trials, and collaborative team-science studies focusing on systemic autoimmune conditions will be beneficial to advance care for women.

Balance testing: does it make a difference?

OBJECTIVE

This study aimed to analyse whether referral for specialist balance testing influences diagnosis and management of patients with dizziness.

METHOD

This was a retrospective study examining patients referred for vestibular function testing between 1 January 2018 and 30 June 2018.

RESULTS

A total of 101 patients were referred, with 69 patients (68.3 per cent) receiving a preliminary 'pre-vestibular function testing balance diagnosis', which included benign paroxysmal positional vertigo (32.7 per cent), Ménière's disease (13.8 per cent) and migraine (14.9 per cent). Following vestibular function testing, revised diagnoses were achieved for 54 patients (53.5 per cent), including benign paroxysmal positional vertigo (14.9 per cent), Ménière's disease (3.0 per cent) and migraine (10.9 per cent). Pre-vestibular function testing balance diagnoses were confirmed for 32.4 per cent of patients. If no pre-vestibular function testing suspected diagnosis was provided, vestibular function testing was significantly more likely to be inconclusive. Following vestibular function testing, 38.6 per cent were discharged, 21.7 per cent were referred to another specialty and treatment was commenced for 17.8 per cent of patients.

CONCLUSION

Referral for vestibular function testing has a role when attempting to answer a clear clinical question. Diagnosing the underlying aetiology of complex imbalance is challenging, but diagnosis can be assisted by judicious use of vestibular function testing.

295 Ear Conditions in Adult Patients with Learning Disabilities and Autism: A New Approach to Outpatient Management

Introduction

Patients with learning disability and autism (PwLDA) are a priority group for care quality and outcomes improvement in the NHS Long Term Plan. The aim of this project was to establish a new standard of care for PwLDA in our otology department.

Method

We first conducted a retrospective analysis of PwLDA who accessed routine adult otology clinics (RCs) between August-October 2020. We assessed achievement in four broad outcome domains: i) documentation of patient-specific special needs; ii) examination of ears; iii) assessment of hearing; iv) completion of hospital passport. We then formed a multidisciplinary team (MDT), which introduced specialised MDT-clinics (SCs) for PwLDA with otology conditions. These SCs were continuously improved by incorporating reasonable adjustments. We subsequently performed a retrospective analysis of PwLDA reviewed in the initial four months of SCs. This enabled a comparison between the type of clinic, RCs or SCs, and the achievement of specific outcomes. This interaction was statistically analysed using Chi-squared test.

Results

A mean of 7.7 and 5.0 PwLDA per month were booked into RCs and SCs respectively. Type of clinic had a significant effect on achievement of outcomes in domains i. and iv. (χ2 (1)>10.3; p<0.005) favouring attendance at SCs. There was no significant interaction for these variables in domains ii. and iii.

Conclusions

This is the first dedicated otology MDT service for PwLDA in the UK. Overall, these results demonstrate an improvement following implementation of the SCs. This innovative work establishes a new MDT-clinic outpatient model for PwLDA who suffer with ear- and hearing-related conditions.

A new method to estimate catheter length for esophageal multichannel intraluminal impedance monitoring in children

BACKGROUND

Multichannel intraluminal impedance combined with pH (MII-pH) is the gold standard test for diagnosing gastro-esophageal reflux disease (GERD). It provides an opportunity to study acid and non-acid GOR and temporal association between symptoms and reflux. Accurate catheter placement is essential to prevent erroneous recording of reflux events. The aims of our study were to assess the accuracy of our devised method in predicting the catheter length for MII-pH in children (Great Ormond Street Hospital (GOSH) Table) and to compare the results with Strobel and Monreau methods.

METHODS

Retrospective review of all records of infants and children who underwent MII-pH studies between January to October 2014. Desired catheter position was calculated using Strobel, Monreau and GOSH formulas and compared to X ray position.

KEY RESULTS

One hundred and forty-four children were included; mean age was 5.1 (±4.5) years, 73 males and 71 females. In the whole group, the correlation between desired catheter position and GOSH Table was 0.95, for Strobel was 0.84, and Monreau was 0.85. In the first group (age <3 years), the correlation was: GOSH Table 0.91, Strobel 0.56, and Monreau 0.6; in the second group (3-10 years): GOSH Table 0.78, Strobel 0.82, and Monreau 0.82; the third group (>10 years): GOSH 0.81, Strobel 0.43, and Monreau 0.43.

CONCLUSIONS & INFERENCES

GOSH Table is an accurate method to estimate the insertion length of MII-pH catheters from nares to a point of approximately two vertebral bodies above the diaphragm in children. Although radiography is required to confirm final catheter position, using GOSH Table will reduce the need for repeated catheter manipulation after initial insertion and will reduce the use of a mathematically complicated formulae.

The E1 helicase of human papillomavirus type 11 binds to the origin of replication with low sequence specificity

Expression of the human papillomavirus type 11 E1 and E2 genes is necessary and sufficient to support viral DNA replication. The full-length E2 protein is a transcriptional modulator that also interacts with the E1 helicase to form an E1/E2 complex at the viral origin of replication. Previous studies indicated that efficient binding of this complex to the replication origin is site-specific and that the E2 homodimer was required for efficient E1 binding. Human papillomavirus type 11 E2 and E1 proteins have been purified and their cooperative binding to the HPV type 11 viral replication origin has been characterized. Low-affinity E1 binding to the HPV type 11 replication origin was demonstrated and found to be largely nonspecific. DNA binding by E1 does not require complex formation with E2 and appears to be independent of ATP binding or hydrolysis. E1 binding quantitatively increased with the addition of increasing amounts of E2 and mutations in the E2 binding site demonstrated that the E2BS site is required for E1 and E2 to specifically bind as a high-affinity complex at the replication origin. Analysis of the A/T-rich E1 binding site via mutation showed that it was nonessential for high-affinity E1/E2 complex formation. Thus, although the replication functions between the animal and the human papillomaviruses are well conserved, there are subtle differences in the DNA binding requirements for E1, which may portend mechanistic differences among the DNA replication systems of various papillomavirus types.

Feeding difficulties and foregut dysmotility in Noonan's syndrome

PURPOSE

Noonan's syndrome is a common dysmorphic syndrome in which failure to thrive and gastrointestinal symptoms are frequent but poorly understood.

DESIGN

Twenty five children with Noonan's syndrome were investigated by contrast radiology, pH monitoring, surface electrogastrography (EGG), and antroduodenal manometry (ADM).

RESULTS

Sixteen had poor feeding and symptoms of gastrointestinal dysfunction. All 16 required tube feeding. Seven of 25 had symptoms of foregut dysmotility and gastro-oesophageal reflux. In the most symptomatic children (four of seven) EGG showed fasting frequency gradient loss along the stomach fundus and pylorus with antral postprandial frequency loss. ADM showed shortened fasting cycle length, with abnormal phase III and shortened postprandial activity containing phasic contractions.

IMPLICATIONS

Gastroduodenal motor activity was reminiscent of 32-35 week preterm patterns. The feeding difficulties appear to resolve as gut motility matures. In Noonan's syndrome, feeding problems appear to be the result of delayed gastrointestinal motor development.

Neonatal insulin secretion: implications for the programming of metabolic homeostasis

Patterns of metabolic adaptation are described in the neonate, which generate two fundamental concepts. First, that early nutritional experiences may have long-term effects on the control of metabolic homeostasis, and second, that insulin has a fundamental role in this process. The endocrine pancreas in the neonate is unable to regulate insulin secretion in relation to blood glucose concentration with the same level of tight control seen in the older child and adult. Moreover, the pattern of metabolic adaptation in the fullterm infant in the first postnatal week is different to that of the preterm baby and the infant born small-for-gestational-age (SGA), with both preterm and SGA infants being unable to generate counter-regulatory ketogenesis as blood glucose concentrations fall. The inability to initiate ketogenesis and switch off insulin secretion after birth persists for several weeks in preterm infants. Methods of feeding term and preterm infants have profound effects on the neonatal endocrine milieu and it is suggested that patterns of insulin secretion provoked in the newborn period may 'programme' the subsequent development of metabolic control. The recently described molecular mechanisms that underlie the pathogenesis of abnormal insulin secretion in the syndrome of persistent hyperinsulinaemic hypoglycemia of infancy (or pancreatic nesidioblastosis) may offer insights into how such programming may occur.

Medical image interpretation: a generic approach using deformable templates

We describe a generic approach to image interpretation, based on combining a general method of building flexible template models with genetic algorithm (GA) search. The method can be applied to a given image interpretation problem simply by training a statistical shape model, using a set of examples of the image structure to be located. A local optimization technique has been incorporated into the GA search and shown to improve the speed of convergence and optimality of solution. We present results from three medical applications, demonstrating that the new method offers significant improvements when compared with previously reported approaches to flexible template matching, particularly the ability to deal with different domains of application using a standard method and the possibility of employing complex multipart models. We also describe how the method can be simply extended to track structures in image sequences and segment three dimensional objects in volume images.