Characteristics and outcomes of acute colitis diagnosed on cross-sectional imaging presenting via the emergency department in an Irish academic medical centre

BACKGROUND AND AIMS

A significant proportion of patients presenting to the Emergency Department with gastrointestinal symptoms that result in cross-sectional imaging receive a radiological diagnosis of colitis. We aimed to review the characteristics, outcomes, and final diagnoses of new emergency department presentations with colitis diagnosed on cross-sectional imaging.

METHODS

A radiology database was interrogated to identify patients admitted from the Emergency Department of St James's Hospital whose cross-sectional imaging demonstrated colitis. Baseline demographic data, information on inpatient investigations, final diagnoses, and outcomes were recorded. Adverse outcomes were defined as a requirement for surgery, intensive care unit (ICU) stay, or mortality RESULTS: A total of 118 patients, 67% female, were identified with a median age of 64 years (range 16.9-101.2). Median (range) admission duration was 10 days (1-241). Final colitis diagnoses were infectious (28%), undefined (27%), reactive (18%), inflammatory bowel disease (11%), ischaemic (9%), chemotherapy-associated (3%), diverticular (3%), and medication-associated (1%). Colonic perforation, colectomy, and mortality occurred in 1%, 5%, and 13% of the cohort respectively. On univariate analysis, low haemoglobin, low albumin, high lactate, and male gender were associated with adverse outcomes with the following odds ratios (OR) and 95% confidence intervals (95%CI) were low haemoglobin 1.49 [1.15-1.92] P = 0.002, low albumin 1.16 [1.07-1.25] P = 0.0002, lactate 1.65 [1.13-2.42] P = 0.009, and male gender 3.09 [1.23-7.77] P = 0.019. On multivariate analysis, male gender was associated with adverse outcomes.

CONCLUSION

Patients presenting to the Emergency Department with a colitis, requiring an abdominal CT are a heterogenous group with a proportion having concomitant intra-abdominal pathology resulting in critical illness. Hence their is a significant morbidity and mortality observed in this cohort which should not be extrapolated to a general population of patients presenting with colitis. In this cohort of patients, anaemia, hypoalbuminaemia, and elevated lactate in patients presenting to the ED with acute colitis are significantly associated with adverse outcomes. Early recognition of these prognostic factors may identify the cohort of patients who are best managed in a high-dependency setting.

Utilities for advanced basal cell carcinoma

OBJECTIVE

Most incidences of basal cell carcinoma are cured by a number of surgical or non-surgical treatments. However, a few patients have lesions which have metastasized or progressed to an extent that surgery or other treatment options are not possible. The lesions associated with advanced basal cell carcinoma (aBCC) can be disfiguring, affecting patients' psychological state, general quality-of-life (QoL), and potentially life expectancy. The objective of this study was to capture societal utility values for health states related to aBCC, using the time trade-off (TTO) methodology.

METHODS

Nine health states were developed with input from expert clinicians and literature. States included: complete response (CR), post-surgical, partial response (PR) (with differing sized lesions [2 or 6 cm]), stable disease (SD) (with differing size and number of lesions [2 or 6 cm, or multiple 2 cm]) and progressive disease (PD) (with differing sized lesions [2 or 6 cm]). A representative sample of 100 members of the UK general public participated in the valuation exercise. The TTO method was used to derive utility values based upon subjects' responses to decision scenarios; between living in the health state for 10 years or living in a state of full health for 10-x years.

RESULTS

Mean utility scores were calculated for each state. The least burdensome state as valued by subjects was CR (mean = 0.94; SD = 0.08), suggesting only a minimal impact on QoL. The state valued as having a greatest impact on QoL was PD, with a 6 cm lesion (mean = 0.67, SD = 0.25).

LIMITATIONS AND CONCLUSIONS

Not all possible presentations of aBCC were included; the disease is a challenging condition to characterise given its rarity, the nature of the patients affected, and its variable progression. Findings suggest that aBCC is associated with significant burden for individuals, even when their disease is stable or where surgical treatment has been successful.

Intraindividual, right-left comparison of topical methyl aminolaevulinate-photodynamic therapy and cryotherapy in subjects with actinic keratoses: a multicentre, randomized controlled study

BACKGROUND

Actinic keratosis (AK), the most common premalignant skin condition, can represent a management challenge. Treatment should not only be effective, but also well tolerated and allow for good cosmesis on typical sun-exposed highly visible body sites.

OBJECTIVES

The primary objective was to compare the lesion response and subject preference for topical methyl aminolaevulinate (MAL)-photodynamic therapy (PDT) vs. cryotherapy for the treatment of AK.

METHODS

In this 24-week, multicentre, randomized, intraindividual (right-left) study, subjects received both one treatment session of MAL-PDT and a double freeze-thaw cryotherapy; the treatments were randomly allocated to either side of the face/scalp. Lesions with a noncomplete response were retreated after 12 weeks. The primary assessments were the subject's overall preference and lesion response at week 24. Secondary assessments included lesion response at week 12, cosmetic outcome, subject and investigator cosmetic outcome preference at week 24, and investigator overall preference at week 24. Skin discomfort and adverse events were also evaluated.

RESULTS

In total, 119 subjects with 1,501 lesions were included in the study. At week 12, treatment with MAL-PDT resulted in a significantly larger rate of cured lesions relative to cryotherapy (percentage lesion reduction from baseline: 86.9% vs. 76.2%; P < 0.001). At week 24, both treatment groups showed a high rate of cured lesions (89.1% for MAL-PDT vs. 86.1% for cryotherapy; P = 0.20; 95% confidence interval: -1.62 to 7.67). Results for subject and investigator preferences as well as cosmetic outcome favoured MAL-PDT. Both treatment regimens were safe and well tolerated.

CONCLUSIONS

The present study shows that, when treated with both MAL-PDT and cryotherapy, subjects significantly prefer MAL-PDT treatment for AK. MAL-PDT is an attractive treatment option for AK, with comparable efficacy and superior cosmetic outcomes compared with double freeze-thaw cryotherapy.

Social anxiety and disfigurement: the moderating effects of fear of negative evaluation and past experience

OBJECTIVES

To examine the relevance of social anxiety and past experience to the social and psychological consequences of disfigurement.

METHOD

One hundred and forty-one patients on the psoriasis register at a dermatology clinic responded to a postal survey which was designed to examine the effects of psoriasis on quality of life as it was related to clinical severity, level of social anxiety and patients' previous experiences of acceptance or rejection.

RESULTS

Psoriasis was most relevant for quality of life for those patients whose condition was visible on their face and hands and who reported a high fear of negative evaluation. Current quality of life, fear of negative evaluation and HAD anxiety scores were only tentatively related to the nature of previous experiences.

CONCLUSIONS

Although direction of causality cannot be ascertained from these results, they suggest that interventions designed to reduce social anxiety could be used to help people who are having difficulty in adjusting to disfiguring medical conditions.

Sweet's syndrome and malignancy in the U.K

Acute febrile neutrophilic dermatosis (Sweet's syndrome) is reported to be a marker for underlying malignancy. Much of the evidence for this is based on case reports, small series of cases and reviews of the literature. In order to clarify the association with malignancy and determine the common clinical features of Sweet's syndrome, we reviewed the case notes of patients presenting to six dermatology units in the U.K. Eighty-seven cases of histologically proven Sweet's syndrome were reviewed. Fourteen patients (16%) developed associated malignancy, predominantly haematological, two patients (2%) had a history of previous malignancy and four patients (5%) had premalignant conditions (monoclonal gammopathy, two: myelodysplasia, two). Malignancy developed up to a year after presentation with Sweet's syndrome. Patients with associated malignancy were more likely to be anaemic (P < 0.01) at presentation, had a lower mean platelet count (207 x 10(9)/L vs. 332 x 10(9)/L; P < 0.003) and were, on average, older (59 years vs. 49 years; P = 0.002). Contrary to previous reports, a greater percentage of females developed malignancy than males.