Understanding community provider practices in diagnosing and treating atypical anorexia nervosa: A mixed methods study

OBJECTIVE

There is a lack of consensus in defining "significant weight loss" when diagnosing atypical anorexia nervosa (atypical AN) and no guidelines exist for setting target weight (TW). The current study aimed to identify community providers' practices related to the diagnosis of atypical AN and the determination of TW. A secondary aim was to evaluate whether professional discipline impacted "significant weight loss" definitions.

METHOD

A variety of providers (N = 141; 96.4% female) completed an online survey pertaining to diagnostic and treatment practices with atypical AN. Descriptive statistics were computed to characterize provider-based practices and Fisher's exact tests were used to test for differences in diagnostic practices by professional discipline. Thematic analysis was used to examine open-ended questions.

RESULTS

Most (63.97%) providers diagnosed atypical AN in the absence of any weight loss if other AN criteria were met, but doctoral-level psychologists and medical professionals were less likely to do so compared to nutritional or other mental health professionals. Most providers found weight gain was only sometimes necessary for atypical AN recovery. Qualitative responses revealed providers found atypical AN to be a stigmatizing label that was not taken seriously. Providers preferred to use an individualized approach focused on behaviors, rather than weight when diagnosing and treating atypical AN.

DISCUSSION

Lack of diagnostic clarity and concrete treatment guidelines for atypical AN may result in substantial deviations from the DSM-5-TR criteria in real-world practice. Clinically useful diagnostic definitions for restrictive eating disorders and evidence-based treatment guidelines for TW and/or other relevant recovery metrics are needed.

PUBLIC SIGNIFICANCE

The current study found variability in how community providers diagnose and determine target recovery weight for atypical anorexia nervosa (atypical AN). Many providers viewed the diagnosis of atypical AN as stigmatizing and preferred to focus on behaviors, rather than weight. This study underscores the importance of creating a clinically useful diagnostic definition and guidelines for recovery for atypical AN backed by empirical evidence that providers may implement in practice.

A pilot multiple-baseline study of a mobile cognitive behavioral therapy for the treatment of eating disorders in university students

OBJECTIVE

Eating disorders (EDs) are serious psychiatric disorders associated with substantial morbidity and mortality that are prevalent among university students. Because many students do not receive treatment due to lack of access on university campuses, mobile-health (mHealth) adaptations of evidence-based treatments represent an opportunity to increase treatment accessibility and engagement. The purpose of this study was to test the initial efficacy of Building Healthy Eating and Self-Esteem Together for University Students (BEST-U), which is a 10-week mHealth self-guided cognitive-behavioral therapy (CBT-gsh) app that is paired with a brief 25-30-min weekly telehealth coaching, for reducing ED psychopathology in university students.

METHOD

A non-concurrent multiple-baseline design (N = 8) was used to test the efficacy of BEST-U for reducing total ED psychopathology (primary outcome), ED-related behaviors and cognitions (secondary outcomes), and ED-related clinical impairment (secondary outcome). Data were examined using visual analysis and Tau-BC effect-size calculations.

RESULTS

BEST-U significantly reduced total ED psychopathology and binge eating, excessive exercise, and restriction (effect sizes ranged from -0.39 to -0.92). Although body dissatisfaction decreased, it was not significant. There were insufficient numbers of participants engaging in purging to evaluate purging outcomes. Clinical impairment significantly reduced from pre-to-post-treatment.

DISCUSSION

The current study provided initial evidence that BEST-U is a potentially efficacious treatment for reducing ED symptoms and ED-related clinical impairment. Although larger-scale randomized controlled trials are needed, BEST-U may represent an innovative, scalable tool that could reach greater numbers of underserved university students than traditional intervention-delivery models.

PUBLIC SIGNIFICANCE

Using a single-case experimental design, we found evidence for the initial efficacy of a mobile guided-self-help cognitive-behavioral therapy program for university students with non-low weight binge-spectrum eating disorders. Participants reported significant reductions in ED symptoms and impairment after completion of the 10-week program. Guided self-help programs show promise for filling an important need for treatment among university students with an ED.

The Building Healthy Eating and Self-Esteem Together for University Students Mobile App to Treat Eating Disorders: User-Centered Research Design and Feasibility Study

BACKGROUND

University students are an at-risk group for the development of eating disorders (EDs); however, many college campuses lack sufficient resources to provide ED specialty care. Students report unique reasons for not seeking ED treatment, including the desire to solve the problem on their own (eg, seeking help from friends, self-medicating, or waiting to see if their problems improve), inability to afford treatment, lack of time to participate in the treatment, fear of seeing their primary care physician, and lack of recognition of their issues as an ED. Mobile health (mHealth) apps may be a cost-effective, helpful adjunctive tool to overcome personal and systemic barriers and encourage help seeking.

OBJECTIVE

This paper describes the development, usability, and acceptability of the Building Healthy Eating and Self-Esteem Together for University Students (BEST-U) mHealth smartphone app, which is designed to fill critical gaps in access to ED treatment on college campuses.

METHODS

We undertook a 4-phase iterative development process that focused on user-centered design. The 4 phases included needs assessment based on literature reviews, prototype development and initial evaluation in a pilot trial, redesign, and further pilot-testing to assess the usability and acceptability of the final version of the mHealth app. Acceptability and user satisfaction were assessed using an ad hoc survey that ranged from 1 (strongly disagree) to 7 (strongly agree).

RESULTS

Our needs assessment identified a lack of accessible and affordable treatments for university students. To help meet this need, the BEST-U prototype was designed as an 11-week program that provided interactive, weekly modules that focused on second- and third-wave cognitive behavioral skills. The modules focused on topics such as psychoeducation, reducing thought distortions and body checking, improving body image, interpersonal effectiveness, and behavior chain analysis. The content included interactive quizzes, short answer questions, daily and weekly logs, and surveys completed in the app. BEST-U was paired with brief 25-30 minutes of weekly telehealth coaching sessions provided by a licensed provider or supervised trainee. Pilot-testing revealed minor issues with one module of the app content, which some participants viewed as having low relevance to their experience and therapist concerns about the organization of the app content. These issues were addressed through the removal, addition, and reorganization of BEST-U modules, with the help of therapists-in-training across 2 workshops. The revised version of the BEST-U app had a grand mean acceptability rating of 5.73 out of 7. The participants completed 90.1% (694/770) of the BEST-U modules, indicating high compliance.

CONCLUSIONS

BEST-U is a new, acceptable, and user-friendly mHealth app to help therapists deliver brief, evidence-based cognitive behavioral interventions. Owing to its acceptability and user-friendly nature, BEST-U has high user compliance and holds promise for future implementation and dissemination in university mental health settings.

Screening for eating disorders across genders in college students: Initial validation of the brief assessment of stress and eating

Given that eating disorders (EDs) are relatively common in college populations, it is important to have reliable and valid tools to identify students so that they can be referred to evidence-based care. Although research supports the psychometric properties of existing ED screens for identifying cases of EDs, most studies have been conducted in samples of young white-majority women or have not reported the psychometric properties of the screening tool in men.

OBJECTIVE

The purpose of the current study was to validate a brief, 10-item screening tool for the identification of EDs-the brief assessment of stress and eating (BASE).

METHOD

Participants were college students (N = 596; 68.2% cisgender women) from a large Midwestern university who completed the BASE and SCOFF. The Eating Disorders Diagnostic Survey was used to generate DSM-5 ED diagnoses. We evaluated area under the curve (AUC) for both receiver operating curves (ROC) and precision-recall curves (PRC).

RESULTS

Both the BASE and SCOFF performed significantly better than chance at identifying probable EDs in cisgender women (BASE AUC: ROC = .787, PRC = .633, sensitivity = .733, specificity = .697; SCOFF AUC: ROC = .810, PRC = .684, sensitivity = .793, specificity = .701). However, the BASE (AUC: ROC = .821, PRC = .605, sensitivity = .966, specificity = .495) significantly outperformed the SCOFF (AUC: ROC = .710, PRC = .354, sensitivity = .828, specificity = .514) for identifying probable EDs in cisgender college men.

DISCUSSION

The BASE is appropriate for student healthcare and college research settings. Because the BASE outperforms the SCOFF in college men, results from the current study are expected to contribute to improved identification of EDs on college campuses.

PUBLIC SIGNIFICANCE

The BASE is a new screening tool to identify eating disorders. The BASE performed as well as, if not better than, the SCOFF (particularly in men). Given the need for brief, psychometrically strong, and unbiased ED screening tools in college students, the current study helps address an unmet student healthcare need that we expect will contribute to improved identification of EDs on college campuses.

Measurement invariance of the Eating Pathology Symptoms Inventory (EPSI) in adolescents and adults

Adolescence is a common period for eating disorder (ED) onset. The availability of psychometrically sound measures of ED psychopathology enables clinicians to accurately assess symptoms and monitor treatment outcomes continuously from adolescence and adulthood. The purpose of this study was to assess if the Eating Pathology Symptoms Inventory (EPSI) is invariant across adolescents and adults. Participants (N = 29,821) were adolescent (n = 5250) and adult (n = 24,571) users of the Recovery Record (RR) mobile phone application who provided EPSI responses through the application. Measurement invariance testing was conducted to assess invariance of the EPSI Body Dissatisfaction, Restricting, Excessive Exercise, Purging, Cognitive Restraint, and Binge Eating scales across adolescents (age 13 through 17) and adults (age 18 and older). Findings indicated that all EPSI factors administered in the RR app replicated in both adolescent and adult users. The EPSI factor structure was largely equivalent in adolescents and adults, demonstrating evidence for configural and metric invariance, as well as some evidence for scalar invariance. Our results indicated that EPSI scales measured the same constructs across development. Clinicians and researchers may benefit from utilizing the EPSI to measure ED psychopathology in adolescents and for continued progress monitoring into adulthood.

HiTOP Assessment of the Somatoform Spectrum and Eating Disorders

We report on Phase 1 efforts of the Hierarchical Taxonomy of Psychopathology (HiTOP) measurement subgroup tasked with developing provisional scales for the somatoform spectrum and eating disorders. In Study 1, items were written to assess five somatoform spectrum constructs (bodily distress symptoms, conversion symptoms, health anxiety, disease conviction, and somatic preoccupation). Scale development analyses were conducted on 550 university students. The conversion symptom items were too infrequently endorsed and were set aside for Phase 2. Analyses of the other items yielded four scales corresponding closely to their hypothesized structure. In Study 2, we delineated 15 specific feeding and eating disorder constructs. A sample of 400 university students were administered candidate items and several eating disorder questionnaires for criterion validity. Analyses yielded six scales capturing previously described constructs, tapping content related to body image and weight concerns, restricting and purging, cognitive restraint, binging, excessive exercise, and muscle building. Two scales representing additional constructs deemed to be of high clinical import-negative attitude towards obesity and avoidant/restrictive food intake disorder-were retained for Phase 2, for a total of eight scales. Overall, we concluded that Phase 1 had been successful at generating a comprehensive set of provisional scales for inclusion in Phase 2.

Do differences between individuals who are healthy weight or overweight on self-report measures of disinhibited eating and restrained eating reflect reality or item "bias"?

In light of increasing rates of overweight and obesity worldwide, there is a critical need for accurate self-report measures of disinhibited and restrained eating behaviors across the weight spectrum. Item response theory was used to determine whether differences in disinhibited and restrained eating between healthy weight and overweight or obese individuals were due to item bias (i.e., differential item functioning). Study 1 participants were healthy weight (n = 510) or overweight or obese (n = 304) adults recruited from the community. Study 2 participants were healthy weight (n = 778) or overweight or obese (n = 320) college students. Study 1 participants completed the Eating Disorder Examination-Questionnaire (EDE-Q), Eating Disorder Inventory-3, Dutch Eating Behaviors Questionnaire, Restraint Scale, and Three-Factor Eating Questionnaire. Study 2 participants completed the Eating Pathology Symptoms Inventory (EPSI). Items on the Restraint Scale demonstrated the most evidence for bias (60% of items), whereas the majority of other scales demonstrated low to moderate levels of item bias (17-38% of items). However, EDE-Q Restraint and EPSI Binge Eating, Cognitive Restraint, Excessive Exercise, Muscle Building, and Negative Attitudes Toward Obesity scales did not show any evidence of differential item functioning among weight groups. Participants with the same level of disordered eating responded differently to certain eating disorder self-report items due to weight-bias, rather than true between-groups differences. Nevertheless, EDE-Q Restraint, EPSI Cognitive Restraint, and EPSI Binge Eating did not exhibit any evidence of bias and are ideal for assessing restrained and disinhibited eating across the weight spectrum in both research and clinical settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A new approach to eating-disorder classification: Using empirical methods to delineate diagnostic dimensions and inform care

OBJECTIVE

Despite changes to the diagnostic criteria for eating disorders (EDs) in the DSM-5, the current diagnostic system for EDs has limited ability to inform treatment planning and predict outcomes. Our objective was to test the clinical utility of a novel dimensional approach to understanding the structure of ED psychopathology.

METHOD

Participants (N = 243; 82.2% women) were community-recruited adults with a DSM-5 ED assessed at baseline, 6-month, and 1-year follow-up. Hierarchical factor analysis was used to identify a joint hierarchical-dimensional structure of eating, mood, and anxiety symptoms. Exploratory structural equation modeling was used to test the ability of the dimensional model to predict outcomes.

RESULTS

At the top of the hierarchy, we identified a broad Internalizing factor that reflected diffuse symptoms of eating, mood, and anxiety disorders. Internalizing branched into three subfactors: distress, fear-avoidance (fears of certain stimuli and behaviors to neutralize fears, including ED behaviors designed to reduce fear of weight gain), and body dissatisfaction, which was nested within distress. The lowest level of the hierarchy was characterized by 15 factors. The hierarchical model predicted 60.1% of the variance in outcomes at 6-month follow-up, whereas all DSM eating, mood, and anxiety disorders combined predicted 35.8% of the variance in outcomes.

DISCUSSION

A dimensional approach to understanding and diagnosing EDs improved the ability to prospectively predict clinical course above-and-beyond the traditional categorical (DSM-based) approach. Our findings have implications for endeavors to improve the prediction of ED prognosis and course, and to develop more effective trans-diagnostic treatments.

Understanding eating disorders within internalizing psychopathology: A novel transdiagnostic, hierarchical-dimensional model

BACKGROUND

Several problems with the classification and diagnosis of eating disorders (EDs) have been identified, including proliferation of 'other specified' diagnoses, within-disorder heterogeneity, and frequent diagnostic migration over time. Beyond problems within EDs, past research suggested that EDs fit better in a spectrum of internalizing psychopathology (characterized by mood and anxiety disorders) than in a separate diagnostic class.

PURPOSE

To develop a transdiagnostic, hierarchical-dimensional model relevant to ED psychopathology that: 1) reduces diagnostic heterogeneity, 2) includes important dimensions of internalizing psychopathology that are often excluded from ED diagnostic models, and 3) predicts clinical impairment.

PROCEDURES

Goldberg's (2006) method and exploratory structural equation modeling were used to identify a hierarchical model of internalizing in community-recruited adults with EDs (N=207).

FINDINGS

The lowest level of the hierarchy was characterized by 15 factors that defined specific aspects of eating, mood, and anxiety disorders. At the two-factor level, Internalizing bifurcated into Distress (low well-being, body dissatisfaction, suicidality, dysphoria, ill temper, traumatic intrusions) and Fear-Avoidance (claustrophobia, social avoidance, panic symptoms, dietary restricting, excessive exercise, and compulsions). Results showed that the lowest level of the hierarchy predicted 67.7% of the variance in clinical impairment. In contrast, DSM eating, mood, and anxiety disorders combined predicted 10.6% of the variance in impairment secondary to an ED.

CONCLUSIONS

The current classification model represents an improvement over traditional nosologies for predicting clinically relevant outcomes for EDs.

New Horizons in Measurement: a Review of Novel and Innovative Approaches to Eating-Disorder Assessment

PURPOSE OF REVIEW

Eating disorders are serious mental-health concerns that will affect over 30 million individuals in the USA at some point in their lives. Eating disorders occur across the lifespan, in a variety of ethnicities and races, in both men and women, and across the socioeconomic spectrum. Given the prevalence and severity of eating disorders, it is important that clinicians and researchers have access to appropriate assessment tools to aid in the early identification and treatment referral, differential diagnosis, treatment planning, and progress monitoring, and to ensure valid research findings. In this review, we describe novel and innovative assessment tools that were developed within the past 5 years for utilization in research and/or clinical practice with individuals with eating disorders.

RECENT FINDINGS

We identified six multidimensional assessments for eating disorders, all of which can be administered online (with some also offering paper-and-pencil versions). Strengths of the measures included good internal consistency, test-retest reliability, and convergent validity. However, in part, due to problematic scale construction methods, certain scales had poor discriminant validity and most were developed and validated in mostly female samples. There are promising new eating disorder measures from which to choose; however, many measures continue to be limited by poor discriminant validity and need additional validation prior to incorporation into routine research and clinical practice.

It could only happen to a doctor--Haemophilus aphrophilus septicaemia complicated by a prevertebral infection after dental work

A 53 year old man presented with severe neck pain and a flu-like illness; he had recently returned from Sri Lanka and had had dental treatment six days before illness onset. Blood culture showed infection by Haemophilus aphrophilus. Magnetic resonance imaging was performed and exploratory surgery undertaken. The prevertebral cervical fascia was inflamed but no abscess identified. He was treated with antibiotics and made an uneventful recovery.

Laboratory findings associated with thrombophilia are not more common in inflammatory bowel disease

Thromboembolic disease (TED) has been recognized as a complication of inflammatory bowel disease (IBD) since the 1930s (Bargen & Barker 1936). The relative contributions of inherited or acquired thrombophilia and the inflammatory response to the mechanism of this tendency is unclear. Thrombotic events are more common in active disease although significant numbers also occur spontaneously, when the disease is in clinical remission (Talbot et al. 1986; Jackson et al. 1997). Studies looking at the prevalence of specific thrombophilic states such as Antithrombin III deficiency (Jackson et al. 1997; Lake, Stauffer & Stuart 1978; Cianco et al. 1996; Ghosh et al. 1983), Factor V Leiden mutation (APC Resistance) (Jackson et al. 1997; Probert et al. 1997; Ardizzone et al. 1998; Liebman et al. 1998), anticardiolipin antibodies (Ciancio et al. 1996), Protein C (Wyshock, Caldwell & Crowley 1988; Korsten & Reis 1992) and Protein S deficiencies (Jorens et al. 1990; Aadland et al. 1992) in IBD have been contradictory or equivocal. We had previously found that IBD patients with a history of TED are not more likely to have a laboratory thrombophilic abnormality than those with uncomplicated disease. We also demonstrated that the prevalence of heterogenous laboratory thrombophilic abnormalities (usually minor) in all IBD patients may be as high as 60%, much higher than the recognized prevalence of TED (Lim, Jones & Gould 1996). We wondered how this would compare with the healthy non-IBD population. We have therefore explored the prevalence of such thrombophilic abnormalities in a group of IBD patients who had no history of TED and compared them with healthy age and sex matched controls.

Thrombophilia in a man with long-standing hypogonadism

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Helicobacter pylori eradication using a 7-day regimen of low-dose clarithromycin, lansoprazole and amoxycillin

AIM

To evaluate the efficacy of a 7-day regimen of clarithromycin 250 mg b.d., amoxycillin 1 g b.d., and lansoprazole 30 mg b.d. as a treatment for Helicobacter pylori infection.

METHODS

H. pylori status of dyspeptic patients was assessed by 13C-urea breath test and at endoscopy by histology, culture and rapid urease testing of gastric biopsies. Fifty-one H. pylori-positive patients were treated with the above regimen. H. pylori status was reassessed by 13C-urea breath test not less than 28 days after completing treatment. Adverse events and compliance were evaluated.

RESULTS

On an intention-to-treat basis. H. pylori infection was cured in 77% (95% CI: 65-88%) of patients. Minor side-effects including diarrhoea, nausea and taste disturbance were reported by 64% of patients. Ninety-five per cent of patients consumed > 95% of tablets. Metronidazole resistance was 29% but all cultures were sensitive to amoxycillin and clarithromycin.

CONCLUSION

This 7-day treatment with low-dose clarithromycin was moderately effective in curing H. pylori infection. Although compliance was excellent, there was a high frequency of minor adverse events.

Helicobacter pylori serology and the management of young dyspeptics: a UK survey of gastroenterologists and general practitioners with an interest in gastroenterology

AIM

To survey the current use of Helicobacter pylori serology for pre-endoscopy screening and management of young dyspeptics amongst gastroenterologists and general practitioners with an interest in gastroenterology in the United Kingdom.

METHODS

A postal questionnaire was sent to 536 members of the British Society of Gastroenterology and 164 members of the Primary Care Society in Gastroenterology.

RESULTS

Of those who responded (66%), 25% of general practitioners and 17% of gastroenterologists were using H. pylori serology as a screening test for young dyspeptics. General practitioners and gastroenterologists differed in their use of serology to guide management strategies (P < 0.0003): general practitioners eradicate infection from sero-positive patients prior to endoscopy (92%), whilst the majority of gastroenterologists endoscope sero-positive patients before treatment (55%). More gastroenterologists (89%) would re-test all or selected patients to assess eradication compared to general practitioners (45%). 106 different drug regimes were being used as first line treatment.

CONCLUSIONS

H. pylori serology as a pre-endoscopy screening test for young dyspeptic patients was used by only a fifth of respondents. There were wide variations in attitudes and practice in the way H. pylori serology was used in the management of young dyspeptics. Trials comparing clinical outcome and cost-effectiveness of different serology-based strategies are needed.

A seven-day Helicobacter pylori treatment regimen using clarithromycin, omeprazole and tripotassium dicitrato bismuthate

AIM

To evaluate clarithromycin 500 mg t.d.s., tripotassium dicitrato bismuthate 240 mg b.d. and omeprazole 20 mg b.d. for 7 days as a Helicobacter pylori treatment regimen.

METHODS

The H. pylori status of dyspeptic patients undergoing endoscopy was assessed by histology, culture and rapid urease testing of biopsies and by 13C-urea breath test. Fifty patients who were H. pylori-positive were treated with the above treatment regimen for 7 days. Those patients with active duodenal ulcers present at endoscopy were given omeprazole 20 mg nocte for a further 21 days. Not less than 28 days after completing treatment, all tests were repeated to reassess H. pylori status. Bacterial sensitivity of H. pylori cultures was determined and patients recorded any side-effects.

RESULTS

On an intention-to-treat basis, H. pylori infection was cured in 90% (95% CI: 78-96%) of patients. Taste disturbance was experienced by 35% patients. Compliance was excellent, with 96% patients taking more than 95% of tablets. Metronidazole resistance was 41% but all cultures were sensitive to clarithromycin.

CONCLUSIONS

This 7-day treatment achieved a high level of cure of H. pylori infection with relatively minor side-effects. It may have a role to play, particularly where there is a high level of metronidazole resistance.

Seroprevalence of Helicobacter pylori in residents of a hospital for people with severe learning difficulties

OBJECTIVE

To assess the seroprevalence of Helicobacter pylori among the residents of a hospital for people with severe learning difficulties.

DESIGN

Retrospective analysis of stored sera from the hospital residents and control sera from the local, non-residential population.

METHODS

H. pylori immunoglobulin G antibody was measured in 424 hospital residents using an enzyme-linked immunosorbent assay, taking an antibody level of > 10 units/ml as evidence of H. pylori infection. The results were compared with 267 age- and sex-matched controls.

RESULTS

Seropositivity rates were significantly higher in the hospital residents than in controls for all ages. This was most marked among those under 40 years of age (87 versus 24% H. pylori-positive for residents and controls, respectively; P < 0.001). The overall seropositivity rates were 87 and 43% for residents and controls, respectively (P < 0.001).

CONCLUSIONS

This English study of H. pylori seroprevalence in an institutionalized population is the largest to date and confirms the very high seropositivity rates found by previous studies in Australia. Our findings may have significance for the future health of these patients and for the possible modes of transmission of H. pylori.

Hamartomatous rectal polyps are common in tuberous sclerosis

The earlier finding of microhamartomatous rectal polyps in tuberous sclerosis (TSC)2 is detailed. These polyps are common, occurring in 14 of 18 (78%) patients with TSC in the present series, and they do not cause symptoms. Their distinctive appearance and distribution readily distinguish them from other types of rectal polyp and emphasize their importance as a potentially useful clinical marker of TSC.

Detailed study of oxidative esterification and elimination reactions undergone by a steroidal 17 alpha-benzoyloxy-20-oxo-21-aldehyde

The reaction of 17 alpha-benzoyloxy-11 beta-hydroxy-3,20-dioxo-1, 4-pregnadien-21-al as the hemiacetal (1) with methanol:acetic acid:potassium cyanide:manganese dioxide followed by acetylation and preparative HPLC of the reaction mixture afforded 11 crystalline products. These products can be conveniently divided into three categories representing side-chain cleavage and oxidative esterification with or without elimination of the benzoyloxy group. Of special interest was the stereospecific formation of the C-17 cyanohydrin acetate 4a and the cis delta 17(20) enol acetate methyl ester 5. On the other hand, nonstereospecific addition of HCN to the side chain gave the C-20 epimeric cyanohydrin acetates 7a and 7b. The use of activated versus nonactivated MnO2 plays a major role in determining the quantitative distribution of the products. It was also discovered that even in the absence of MnO2, the reaction goes to completion. A proposed mechanism which explains the formation of all products is presented.

Evaluation of a tubeless pancreatic function test in patients with steatorrhoea in a district general hospital

The Pancreolauryl Test (PLT), a tubeless pancreatic function test, has been evaluated in an unselected series of outpatients with steatorrhoea presenting to a district general hospital (DGH). This is the first study of the PLT in a DGH, involving an unselected series of patients and not those from secondary or tertiary referral hospitals. Health controls (n = 15) and patients with self-limiting diarrhoea (n = 8) had normal urinary excretion indices (greater than or equal to 30). Coeliac disease (n = 13) and small bowel bacterial overgrowth (n = 12) were the commonest causes of steatorrhoea and there were no false-positive results in these patients. The mean urinary excretion index in patients with untreated coeliac disease (mean index = 38%) was lower than in healthy controls (n = 15, mean index = 53%; P less than 0.05 greater than 0.02). No patient with proven pancreatic steatorrhoea had a normal PLT result, confirming the high negative predictive value found by others. Low results in patients with steatorrhoea following gastric surgery indicate poor mixing of food with pancreatic juices. The PLT proved to be a simple, inexpensive and noninvasive outpatient screening test suitable for use in a DGH to exclude a pancreatic origin of steatorrhoea.

An improved method of vancomycin administration to dialysis patients

Vancomycin is a nondialyzable antibiotic frequently used by patients on hemodialysis. Traditionally, a 1-gram dose is administered at the conclusion of dialysis. Recent rate-related side effects have prompted the manufacturer to revise the package insert suggesting a maximum infusion rate of 500 mg/h; necessitating a two-hour infusion post-dialysis. We evaluated the safety and efficacy of vancomycin administered during dialysis in nine chronic hemodialysis patients in an open crossover study. All patients received vancomycin during and post-dialysis in consecutive weeks. Therapeutic peak and trough serum concentrations were achieved in all patients. No adverse reactions occurred.

Double-blind comparison of olsalazine and sulphasalazine in active ulcerative colitis

Fifty-six patients with ulcerative colitis of mild to moderate severity were entered into a randomized, double-dummy comparison of sulphasalazine, 3 g/day, with olsalazine, 3 g/day. Patients were assessed clinically, and by sigmoidoscopy and biopsy, on entry and at 5 weeks. Both agents produced a similar reduction in stool frequency and in the passage of blood and mucus. Improvements in sigmoidoscopic and histological appearances of the rectal mucosa were observed to a similar extent in both groups of patients. Two patients treated with olsalazine were withdrawn because of increased diarrhoea attributable to the medication. Two patients given sulphasalazine for the first time developed a skin rash. Other side-effects seen during the trial were mild. In this small short-term study, oral olsalazine appeared to be as effective as sulphasalazine in the treatment of mild to moderate ulcerative colitis.

Subacute hepatic necrosis induced by piroxicam

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Coexistent ulcerative colitis and Crohn's disease

This case report describes a patient with chronic ulcerative colitis and epithelial dysplasia of 17 y duration ultimately complicated by colonic carcinoma. At laparotomy, clinically unsuspected but typical Crohn's disease of the terminal ileum was also found. The macroscopic and histological features of the resected terminal ileum were characteristic of Crohn's disease.

Castor oil or senna preparation before colonoscopy for inactive chronic ulcerative colitis

Few clinically apparent clinical relapses of colitis occurred in 340 patients with previously extensive ulcerative colitis in an inactive phase submitted to total colonoscopy for dysplasia screening after bowel preparation with castor oil or senna. A prospective trial in 46 such patients showed both preparations to be equally safe and effective. Minor untreated disturbances of bowel habit occurred in 14 patients (30%), and three patients (7%) required a short period of oral corticosteroids. No patient with inactive colitis in either the retrospective series or the trial group had a serious exacerbation of colitis as a result of the bowel preparation, which was considered necessary and clinically justified for the purposes of cancer screening.

Studies of prostaglandins and sulphasalazine in ulcerative colitis

Specific evidence is presented of the release of prostaglandins from the colon in active ulcerative colitis. An increase in the levels of bioassayed prostaglandin-like activity in the stools and colo-rectal venous plasma from patients with active ulcerative colitis is described. Radioimmunoassay confirms the presence of prostaglandin E and prostaglandin F in the stools in colitis. Increased urinary levels of prostaglandin F metabolite occur in patients with active colitis and return to normal as the disease becomes quiescent. Sulphasalazine and its faecal metabolite, 5-aminosalicylic acid, were shown by an indirect method (reduction of the tone of the isolated rat fundus strip) to inhibit prostaglandin biosynthesis in vitro. In contrast, sulphasalazine was without effect on the urinary excretion of prostaglandin F metabolite in 7 healthy subjects. In 2 patients with colitis withdrawal of sulphasalazine was associated with increasing levels of stool prostaglandin-like activity and urinary prostaglandin F metabolite excretion. Indomethacin, given to 3 patients with chronically active ulcerative colitis, unresponsive to standard medical treatment, was associated with a decreased urinary excretion of prostaglandin F metabolite but was without clinical benefit. The possible mode of action of sulphasalazine as a prostaglandin inhibitor in colitis is discussed along with the potential use of other prostaglandin inhibitors.

Controlled trial of disodium cromoglycate in chronic persistent ulcerative colitis

Oral disodium cromoglycate (200 mg qds) has been tested in 26 patients with ulcerative colitis that was resistant to medical treatment. In a double-blind crossover trial disodium cromoglycate and placebo were added to conventional treatment in random order, each for four weeks. There was no significant difference in therapeutic effect between disodium cromoglycate and placebo.

Barium meal appearance simulating superficial ulceration

Five cases of diffuse gastric spiculation seen on single contrast barium meal examination are reported. This appearance may spuriously suggest superficial mucosal ulceration in cases in which no evidence of this is found endoscopically or histologically. This radiological appearance may be due to filling of the grooves between the areae gastricae and may thus represent a normal anatomical variant.

Incidence of deep vein thrombosis and leg oedema in patients with strokes

In a series of 26 patients with strokes 13 had deep vein thrombosis (DVT) in the leg, demonstrated by fibrinogen scanning. In 10 patients the thrombosis was in the paralysed leg but the degree of paralysis was unrelated to the tendency to develop DVT, which usually occurred about the third day. Leg oedema in 10 patients was unrelated to the DVT.

Assay of prostaglandin-like substances in faeces and their measurement in ulcerative colitis

A method is described for extracting and measuring prostaglandin-like substances from faeces. Bioassay has shown virtual absence of activity in stools from normal people (8 subjects) but raised levels in stools from patients with active ulcerative colitis (16 observations on 6 patients). The relevance of these observations to the mode of action of sulphasalazine is discussed and suggestions for possible applications of this method to other problems made.

Influence of previous oral contraception and maternal oxytocin infusion on neonatal jaundice

A prospective study of serum bilirubin levels on the first and sixth days of life in a series of 181 infants has failed to provide evidence to suggest that previous maternal oral contraception, maternal oxytocin infusion, epidural anaesthesia, or breast-feeding are factors influencing neonatal jaundice.

Rectal and gastric involvement in a case of sarcoidosis

A case of sarcoidosis with involvement of the rectum is described. This is believed to be the first unequivocal case of large bowel sarcoidosis.