Recurrent autumnal psychosis.

Acute confusional states in the older patient often have a remediable cause. Every effort should be made to ascertain the cause so that appropriate treatment can be given and future episodes prevented. A patient is described who presented with recurrent episodes of acute psychosis after ingestion of Atropa belladonna (deadly nightshade).

Current practice in surveillance strategy for patients with Barrett's oesophagus in the UK.

BACKGROUND: Many guidelines exist regarding the surveillance of patients with Barrett's oesophagus. There are limited data, however, with regard to whether practitioners follow these guidelines. METHODS: We assessed current surveillance practice amongst members of the British Society of Gastroenterology using a simple 11-question anonymous survey, mailed to 300 randomly selected members from the British Society of Gastroenterology Handbook. RESULTS: Two hundred and three of the 300 (68%) responded, 76% considering that surveillance was worthwhile. In those who considered surveillance to be worthwhile, 83% used sub-selection based on age, the length of Barrett's oesophagus or the presence of ulcer or stricture. Patients with Barrett's oesophagus of < 3 cm (short-segment) were considered to be inappropriate for surveillance by 62%. Forty-one per cent reported following the 'advised' recommendations of four-quadrant biopsies every 2 cm, whereas 44% followed a 'random and suspicious areas only' protocol. Marked variation was reported in the re-endoscope interval for both low- and high-grade dysplasia. Only 55% reported that two experienced pathologists reviewed all biopsies showing high-grade dysplasia. CONCLUSIONS: Despite the existence of multiple guidelines for Barrett's surveillance, clinical practice varies widely in the UK. This may be due to a lack of knowledge or because gastroenterologists remain unconvinced by the quality of the current evidence of its value. These results have implications for studies attempting to collate data from multiple centres.

Use of the 'nutriceutical', bovine colostrum, for the treatment of distal colitis: results from an initial study.

BACKGROUND: Bovine colostrum is a rich source of nutrients, antibodies and growth factors. AIM: To examine the efficacy of colostrum enemas in the treatment of distal colitis using a randomized, double-blind, controlled protocol. METHODS: Fourteen patients (eight female), with a mean age of 45 years (range, 16-75 years) and mild to moderately severe distal colitis (Powell-Tuck scoring system), received colostrum enema (100 mL of 10% solution) or placebo (albumin solution) b.d. for 4 weeks. Both groups also received mesalazine (1.6 g/day) or, if already taking it, had a dose increment of 1.6 g/day. Disease activity was documented at 0, 2 and 4 weeks. RESULTS: After 4 weeks, the colostrum group showed a mean reduction in symptom score of - 2.9 (95% confidence interval (CI), - 5.4 to - 0.3), whereas the placebo group showed a mean response of + 0.5 (95% CI, - 2.4 to +3.4). The histological score improved in five of the eight patients in the colostrum group (mean response, - 0.9; 95% CI, - 1.69 to - 0.03), whereas the histological scores only improved in two of the six patients in the placebo group (mean response, 0.2; 95% CI, - 2.4 to +2.6). CONCLUSIONS: Bovine colostrum enema shows potential as a novel therapy for left-sided colitis with additional benefits over using mesalazine alone. Further studies appear to be warranted.

Cost analysis of breath test versus endoscopy for dyspepsia.

BACKGROUND: There is currently much debate on the best way to manage dyspepsia in the community and cost effectiveness is often discussed. We aim to perform a cost analysis of a test and treat strategy for Helicobacter pylori versus endoscopy using data based on the breath test service in Leicester. METHODS: Retrospective analysis of data acquired over the 1-year period from March 1, 1999, to February 29, 2000, in a university teaching hospital. The main outcome measure was the cost of each management strategy. RESULTS: Referral to the breath test service cost pound 84.67 per person with dyspepsia (including treatment of positive patients and endoscopy cost of patients endoscoped). If the breath test service had not existed, referral for endoscopy would have cost pound 98.35 per person. This equates to a cost saving of pound 8,276 over the year studied for the 605 patients referred. It also resulted in 353 fewer endoscopies being performed. CONCLUSION: Direct referral to a H. pylori breath test service saves money, avoids an unpleasant test for many people and reduces the endoscopy waiting list.

Does Helicobacter pylori eradication reduce the long-term requirements for acid suppressants in patients with a history of peptic ulcer disease in general practice? Results from a four-year longitudinal study.

BACKGROUND: Acid suppressants, especially proton-pump inhibitors, are major contributors to the drug costs in primary care. Although Helicobacter pylori eradication reduces peptic ulcer relapse, some studies suggest that patients may remain symptomatic and continue to require acid-suppressant therapy. METHODS: We identified all patients taking long-term acid suppressants in a large primary health care clinic to determine the proportion who had peptic ulcer disease and to examine the effect of H. pylori eradication on their long-term requirement for acid suppressants. RESULTS: 126/394 patients taking long-term acid suppressants had a definite diagnosis of peptic ulcer. Of these 126 patients, 60 were considered appropriate for the study. At Stage 1 (May 1994), all patients were tested for H. pylori infection and positive patients (60/66) received eradication therapy with omeprazole 20 mg bd and amoxycillin (1 gm bd) or clarithromycin (500 mg tds) for 2 weeks. Six weeks later (Stage 2) patients, requirements for continued acid-suppressant treatment were determined and previously positive subjects retested using the 13C urea breath rest. This showed that 70% (42/60) had been successfully eradicated. One year later (Stage 3), 44% (18/41) of the patients successfully eradicated still required acid suppressants. The majority of these patients (11/18; 61%) continued to remain on acid-suppressant treatment at 4 years (Stage 4) (95% CI 38%, 83%). CONCLUSIONS: We found that about 1/3 of all patients on long-term acid-suppressant therapy in General Practice had a confirmed diagnosis of peptic ulcer disease. Despite successful eradication treatment for H. pylori at the start of the study, about half of these patients still used acid suppressants after 1 year and 1/4 patients (11/41) in this group continued to remain on acid-suppressant treatment for another 3 years.

Co-administration of the health food supplement, bovine colostrum, reduces the acute non-steroidal anti-inflammatory drug-induced increase in intestinal permeability.

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective analgesics but cause gastrointestinal injury. Present prophylactic measures are suboptimal and novel therapies are required. Bovine colostrum is a cheap, readily available source of growth factors, which reduces gastrointestinal injury in rats and mice. We therefore examined whether spray-dried, defatted colostrum could reduce the rise in gut permeability (a non-invasive marker of intestinal injury) caused by NSAIDs in volunteers and patients taking NSAIDs for clinical reasons. Healthy male volunteers (n=7) participated in a randomized crossover trial comparing changes in gut permeability (lactulose/rhamnose ratios) before and after 5 days of 50 mg of indomethacin three times daily (tds) per oral with colostrum (125 ml, tds) or whey protein (control) co-administration. A second study examined the effect of colostral and control solutions (125 ml, tds for 7 days) on gut permeability in patients (n=15) taking a substantial, regular dose of an NSAID for clinical reasons. For both studies, there was a 2 week washout period between treatment arms. In volunteers, indomethacin caused a 3-fold increase in gut permeability in the control arm (lactulose/rhamnose ratio 0.36+/-0.07 prior to indomethacin and 1.17+/-0.25 on day 5, P<0.01), whereas no significant increase in permeability was seen when colostrum was co-administered. In patients taking long-term NSAID treatment, initial permeability ratios were low (0.13+/-0.02), despite continuing on the drug, and permeability was not influenced by co-administration of test solutions. These studies provide preliminary evidence that bovine colostrum, which is already currently available as an over-the-counter preparation, may provide a novel approach to the prevention of NSAID-induced gastrointestinal damage in humans.

Retrospective case series analysis of patients with inflammatory bowel disease on azathioprine. A district general hospital experience.

OBJECTIVES: The aim of this study was to look at our practice of using azathioprine and to compare our results with those in published trials both from the point of view of response and also the side-effect profile. DESIGN: A retrospective case series analysis was done on patients with inflammatory bowel disease (IBD) who were on azathioprine at Leicester General Hospital. METHODS: 111 patients (47 males, 64 females, mean age 35.3 years) were included from gastroenterology outpatients records between November 1997 and August 1998. Clinical and demographic details were collected. Response in Crohn's disease was determined using the Harvey-Bradshaw index. In case of ulcerative colitis the following parameters were used: stool frequency; rectal bleeding, weight gain, and general well-being. Logistic regression was performed to look at the influence of age, sex and diagnosis in relation to the response/relapse rate. RESULTS: The average duration of treatment with azathioprine was 28.6 months. The starting dose of 1.53 mg/kg was similar to the maintenance dose (1.51 mg/kg). 58 patients had Crohn's disease and 53 patients were diagnosed with ulcerative colitis. 85 patients were steroid-dependent, 9 steroid-resistant, and 17 patients were started on azathioprine on the basis of extensive disease either seen at the time of endoscopy or radiologically. Improvement in clinical features at 3, 6 and 12 months was 69.5, 77 and 84.1%, respectively. 74% patients showed an improvement in relapse rates during the first year on azathioprine compared to 1 year prior to treatment. 68% patients who had shown improvement at 1 year were no longer taking steroids (p = 0.002). Logistic regression did not show any statistically significant influence of age, sex or diagnosis on response. 4.5% patients had leukopenia requiring dose reductions. Severe leukopenia (leukocyte count <2.5 x 10(9)/l) occurred in 3.6% patients. CONCLUSIONS: Response rates in our IBD patients on azathioprine are comparable with those of the published data despite using a relatively smaller dose.

Final results from 10 year cohort of patients undergoing surveillance for Barrett's oesophagus: observational study.

OBJECTIVES: To review the benefit of an endoscopic surveillance programme for patients with Barrett's oesophagus. DESIGN: Observational study. SETTING: University teaching hospital. PARTICIPANTS: 409 patients in whom Barrett's oesophagus was identified during 1984-94; 143 were entered into the annual surveillance programme. MAIN OUTCOME MEASURES: Development of dysplasia and cancer and mortality. RESULTS: The average period of surveillance was 4.4 years; 55 patients were reassessed in 1994 but only eight remained in the programme in 1999, withdrawal being due to death (not from carcinoma of the oesophagus), illness, or frailty. Five of the patients who entered surveillance developed carcinoma of the oesophagus. Only one cancer was identified as a result of a surveillance endoscopy, the others being detected during endoscopy to investigate altered symptoms. Of the 266 patients who were not suitable for surveillance, one died from oesophageal cancer and 103 from other causes. Surveillance has resulted in 745 endoscopies and about 3000 biopsy specimens. CONCLUSION: The current surveillance strategy has limited value, and it may be appropriate to restrict surveillance to patients with additional risk factors such as stricture, ulcer, or long segment (>80 mm) Barrett's oesophagus.

An unusual case of pyrexia of unknown origin with cervical lymphadenopathy.

Kikuchi's disease is usually a self limiting illness characterised by pyrexia, neutropenia, and cervical lymphadenopathy particularly in young women of Asian descent. This often leads to an initial misdiagnosis of lymphoma. A case of a young Asian woman who presented with pyrexia of unknown origin is described.

Production and evaluation of guidelines for the management of inflammatory bowel disease: the Leicester experience.

Consensus guidelines for the management of patients with inflammatory bowel disease were produced by gastroenterologists, gastrointestinal surgeons and a cross-section of general practitioners (GPs) from Leicestershire in order to develop a seamless pattern of care with a common approach to diagnosis and treatment. It was hoped that the guidelines would encourage a movement towards care in the community for many patients with stable disease and so speed up new consultation rates. The study then assessed the impact of these guidelines on the referral letters of GPs to hospital consultants, the prediction of disease and adherence to them on re-referring patients after discharge. The guidelines were distributed to all 487 GPs in the Leicester Health Authority area and the gastroenterology teams within the hospitals. The value of the guidelines was assessed by an audit of referral letters, the length of time from referral letter to out-patient appointment, both before and after the launch of the guidelines, adherence to the guidelines on re-referral, and monitoring the outcome of the discharged patients. Whilst the guidelines may have helped GPs to manage stable patients in the community, the content of referral letters and the diagnostic abilities of GPs were not seen to improve since the launch of the guidelines. However, only 5% of stable patients who were discharged from one clinic were re-referred for inflammatory bowel disease.

Cholecystostomy: an unusual approach to stenting of a distal common bile duct stricture.

Strictures, both benign and malignant, of the distal common bile duct (CBD) are reasonably common, and if stented are usually approached endoscopically via the duodenum, or transhepatically via an intrahepatic and then common hepatic duct. We describe a case of endoscopic stenting of a distal CBD stricture over a wire passed percutaneously through the gallbladder, cystic duct and into the duodenum. To our knowledge, this has not been previously described.

Screening workers for genetic hypersusceptibility: potential ethical, legal, and social implications from the Human Genome Project.

One of the potential outcomes of the Human Genome Project will be the ability to identify individuals who are at increased risk of adverse health effects following exposure to hazardous substances in the workplace because of genetic hypersusceptibility. The ability to identify such individuals is likely to lead to the inclusion of genetic screening in worker protection programs. This technology and its applications will have a number of potential ethical, legal, and social implications. In this commentary, the authors examine five broad topics relating to the use of screening for genetic hypersusceptibility in the workplace: (1) issues of risk; (2) the rationale and legal basis for screening; (3) the privacy concerns of workers; (4) the confidentiality of test results; and (5) potential discrimination. The authors close by suggesting some guidelines for developing policies regarding genetic screening.

Expression of the mucosal gamma delta T cell receptor V region repertoire in patients with IgA nephropathy.

IgA nephropathy (IgAN) is characterized by the deposition of IgA in the glomerular mesangium and often leads to progressive renal dysfunction and kidney failure. We have previously shown that the mesangial IgA is likely to derive from the bone marrow plasma cells, and suggested that a primary abnormality within the mucosal immune system may underly the pathogenesis of IgAN. This study has analyzed the T cell receptor (TCR) variable (V) region expression by gamma delta T cells in the intestinal mucosa of patients with IgAN. The V gamma and V delta usage of TCR transcripts was determined using a semiquantitative reverse transcriptase-PCR protocol. Primers specific for the four human V gamma and six V delta subfamilies were used each with a constant (C) gamma or C delta specific primer, and the PCR-amplified TCR transcripts were detected by Southern blotting and oligonucleotide hybridization. gamma delta TCR V region expression was determined in gut biopsies and peripheral blood of 11 patients with IgAN, and the TCR V gamma and V delta repertoires were compared to those in gut and peripheral blood of 11 control individuals. gamma delta T cells in normal blood predominantly expressed V gamma 2 (V gamma 9 gene) and V delta 2 gene segments whereas those in normal gut mainly expressed V gamma 3 and V delta 3. In IgAN patients, V delta 2 was also the predominant V delta gene utilized by peripheral blood gamma delta T cells, however, we observed a predominance of V gamma 3 and reduced V gamma 2 usage by these cells. gamma delta T cells in the gut of IgAN patients mainly used V gamma 3 and V delta 1. While the gamma and delta TCR V region repertoires did not differ significantly between the peripheral blood of patients and controls, there were significant differences in V gamma and V delta repertoire expression between IgAN and control gut biopsies. V gamma 3 gene expression was significantly decreased in IgAN gut compared to control gut (P = 0.023). In addition, there was a significant decrease in V delta 3 gene expression in IgAN gut compared to control gut (P = 0.043). These findings indicate that a subpopulation of gamma delta T cells, which represent the majority of gamma delta T cells in normal gut mucosa, are significantly diminished in the gut of patients with IgAN. This suggests that a "hole" in the mucosal gamma delta T cell repertoire may play a fundamental role in contributing to the pathogenesis of IgAN.

Near patient testing for Helicobacter pylori: a detailed evaluation of the Cortecs Helisal Rapid Blood test.

OBJECTIVE: To evaluate the Cortecs Helisal Rapid Blood test for accuracy overall and in specific subgroups by age and ethnic origin. Additionally, to assess readability of results, including inter-observer error, with consideration also given to usability and acceptability. DESIGN: A prospective evaluation using four reference tests. SETTING: A hospital endoscopy unit. METHODS: Two hundred patients attending for endoscopy were recruited for H. pylori testing with the Helisal test, plus antral biopsies for CLO test, culture and histology and serology using a commercial enzyme-linked immunosorbent assay (ELISA). The Helisal test was carried out and results read strictly according to the manufacturer's instructions. Two or more reference tests positive were taken as a gold standard positive; all results negative as negative and any remaining cases were regarded as equivocal. Performance figures were calculated twice, treating patients with equivocal status as either positive or negative. Results were in most cases double-read, blinded, by two observers and readings subsequently compared. RESULTS: The test was considered convenient, easy to use and acceptable to symptomatic patients, but a notable proportion (10%) of results were very difficult to read. Sensitivity was acceptable (91-92% overall, 95% confidence interval (CI) 82-97%), but specificity was poor overall (56-62%, 95% CI 45-72%), and particularly in patients aged 45 years or over (44-51%) and those of South Asian origin (42-50%). CONCLUSION: The test could be appropriate for testing younger symptomatic patients. Its usefulness was, however, found to be limited by poor readability of some results and poor specificity. Reading of some results as equivocal would be appropriate.

Ten years' experience of screening patients with Barrett's oesophagus in a university teaching hospital.

BACKGROUND: Barrett's metaplasia is a premalignant condition for which screening is recommended. AIMS/METHODS: Annual screening endoscopies have been performed on all subjects suitable for surgery for many years. To examine the benefits to patients of continuing this policy 10 years' experience of screening for Barrett's oesophagus was reviewed. RESULTS: Of the 29,374 endoscopies performed over this period, Barrett's metaplasia was present in 1.4%. There was an approximate equal sex distribution with the majority of cases being identified in patients over 50 years old. Thirty five per cent of these patients were suitable to enter a yearly screening programme. During screening, the length of oesophagus involved did not vary over time. As a result of 379 endoscopies performed for screening purposes, only one patient was identified as developing carcinoma solely as a result of the screening programme. Two further patients had carcinoma identified as a result of progressive dysphagia requiring additional endoscopies. All three patients who developed carcinoma while in the screening programme had "long segment" (> 8 cm) regions of Barrett's metaplasia with a stricture present at the initial endoscopy. CONCLUSIONS: The poor yield from this screening programme suggests that the policy should be reconsidered. Resources may be better spent on focusing on patients who present with ulceration or stricture in addition to Barrett's metaplasia.