Thick malignant melanoma is a long-term problem.

AIMS: To investigate changes in incidence of in-situ, 'thin' (< 0.76 mm) and 'thick' (> 0.76 mm) melanoma. To explore the relationship of melanoma depth with the patient's age at diagnosis. METHODS: A retrospective case series of melanoma was taken from pathology records in Palmerston North between 1983 and 1994. The denominator population was estimated, for each year, from published 1986 and 1991 census figures. RESULTS: Over the 12 years, the diagnostic rate of in-situ and invasive melanomas increased annually by 16% and 5%, respectively (Poisson regression, p < 0.0001). This analysis did not show a difference between the overall rate of increase in 'thin' and 'thick' invasive melanomas. After excluding Hutchinson's melanoma, the mean age at diagnosis for 'thin' and 'thick' melanomas was 49.0 and 55.4 years, respectively (p < 0.0001); the peak number of 'thin' and 'thick' melanomas were in the 30-39 and 60-69 age groups, respectively. CONCLUSIONS: There is evidence for progression from 'thin' to 'thick' melanoma over a 6-to 30-year period. Poor prognosis 'thick' melanomas are currently increasing. Providing removal of 'thin' melanomas is sustained, a decline in 'thick' melanomas is expected but may take decades.

Laboratory markers of colonoscopic activity in ulcerative colitis and Crohn's colitis.

BACKGROUND: Previous studies have not identified a convenient laboratory marker of colonoscopic activity in Crohn's colitis or ulcerative colitis. METHODS: Twenty-eight patients with either ulcerative colitis or Crohn's colitis undergoing colonoscopy by the same observed had laboratory measurements of serum albumin, orosomucoid, C-reactive protein, plasma viscosity, haemoglobin, leucocyte and platelet counts, and faecal alpha-1-antitrypsin from single non-lyophilized samples. Multiple linear regression was performed using each laboratory variable as the dependent variable and the lengths of each grade of endoscopic activity as the explanatory variables. RESULTS: Multiple regression analysis using all the endoscopic grades of acute activity showed significant correlations with faecal alpha-1-antitrypsin (p < 0.001), serum albumin (p < 0.001), C-reactive protein (p = 0.02), and plasma viscosity (p = 0.03). CONCLUSIONS: The highest multiple correlation coefficients were obtained with faecal alpha-1-antitrypsin (r = 0.82) and serum albumin (r = 0.80), and these measurements can be recommended as convenient markers of endoscopic activity in these diseases.

Diagnostic value of a guaiac occult blood test and faecal alpha 1-antitrypsin.

This study evaluates the diagnostic accuracy of a faecal occult blood test and faecal alpha 1-antitrypsin in the investigation of patients with gastrointestinal symptoms or iron deficiency anaemia. One hundred and seventy nine patients with either iron deficiency anaemia (n = 67), changed bowel habit and aged > 39 years (n = 107), or a history suggestive of melaena (n = 5) provided faecal samples. After investigation, 32 patients had a diagnosis of possible gastrointestinal bleeding and 139 patients had no evidence of gastrointestinal bleeding. Eight patients had a cause of enteric protein loss in the absence of gastrointestinal bleeding and were excluded from subsequent analysis. The faecal alpha 1-antitrypsin test was diagnostically more accurate than the guaiac test in identifying probable gastrointestinal bleeding (82% and 72% respectively, p < 0.05). This faecal alpha 1-antitrypsin test was also more specific (83% and 72% respectively, p < 0.05), but was not significantly more sensitive (78% and 72% respectively). The sensitivity of these tests was insufficient to recommend their use for most patients in this study.

Adolescents' and parents' conceptions of parental authority and personal autonomy.

Conceptions of parental authority and ratings of adolescent-parent conflict were assessed in 68 sixth, eighth, and tenth graders and their parents. Boundaries of adolescent personal jurisdiction and conflict over these boundaries were examined. Participants judged the legitimacy of parental authority and rated the frequency and intensity of conflict regarding 24 hypothetical moral, conventional, personal, multifaceted (e.g., containing conventional and personal components), prudential, and friendship issues. Adolescents and parents agreed that parents should retain authority regarding moral and conventional issues. Parents treated multifaceted, friendship, prudential, and personal issues as more contingent on parental authority than did adolescents, based on conventional, prudential, and psychological reasons, whereas adolescents treated these issues as under personal jurisdiction, based on personal concerns. Personal reasoning and judgments increased with age. Multifaceted issues were discussed more than all other issues, but moral and conventional conflicts were more intense than all other conflicts. The findings are discussed in terms of previous research on parental authority and adolescent-parent conflict during adolescence.

Toxic megacolon: the knee-elbow position relieves bowel distension.

Toxic megacolon complicating inflammatory or infective colitis carries a high morbidity and mortality and surgical intervention is necessary in up to 80% of cases. Perforation complicates toxic megacolon in about 35% of cases. After perforation, the death rate nears 50%. Gaseous distension of the bowel causes considerable discomfort to the patient and increases transmural pressure. The latter is thought to cause a reduction in blood flow and may predispose to perforation. The use of instruments for colonic aspiration is discouraged, because of the high risk of perforation. The successful use of the knee-elbow position to relieve bowel distension in two patients with toxic megacolon is described.

Value of faecal alpha-1-antitrypsin, haemoglobin and a chemical occult blood test in the detection of gastrointestinal disease.

Specimens from hospital out-patients and in-patients sent for faecal occult blood tests were also analysed for faecal alpha-1-antitrypsin and faecal haemoglobin. 453 stool specimens from 222 patients were analysed. The clinicians were only aware of the faecal occult blood test results, and diagnoses were made using conventional clinical and investigative criteria. Gastrointestinal bleeding or putative sites of bleeding were diagnosed in 98 patients, whereas in 81 patients putative sites of bleeding were not found or other cause of anaemia diagnosed. In 41 patients there was insufficient information to reach a definitive diagnosis. Comparison of the 3 faecal tests using these grouping methods showed that faecal alpha-1-antitrypsin performed best, with an accuracy of 89%, specificity of 90% and sensitivity of 88%, all significantly better (P < 0.001) than the faecal occult blood test (68%, 60% and 73%, respectively). There was no significant difference between the performance of the faecal occult blood and faecal haemoglobin tests. Faecal alpha-1-antitrypsin measurement may be a useful investigation in situations where a faecal occult blood test would normally be requested.

The use of proprietary medicines by patients presenting with peptic ulcer haemorrhage.

1. Medication, social and symptom histories were compared in patients with severe haemorrhage from a peptic ulcer (n = 71) and matched control subjects. Self-medication with proprietary agents was catalogued in addition to therapy prescribed by general medical practitioners. 2. Prior to the bleed, only 4% of ulcer patients had been free of symptoms normally associated with peptic ulceration, whereas 76% of the control group had been asymptomatic. 3. Gastro-irritant proprietary medicines were used regularly by 23% of ulcer patients compared with only 4% of controls. However, proprietary antacids were used chronically by 46% of ulcer patients compared with only 7% of controls. Bicarbonate was the antacid of choice used by 13% of ulcer patients. The odds ratio for the association between development of bleeding peptic ulcer and the use of indigestion remedies was 11.5% (95% CI 1.1, 121). 4. Fifty-one percent of ulcer patients were prescribed agents known to cause gastro-intestinal damage, whereas only 25% of the control group were prescribed similar agents. Only 7% of the control group were prescribed anti-ulcer therapy compared with 37% of those with bleeding ulcer. 5. A large proportion of patients with haemorrhage from a peptic ulcer had had symptoms sufficient to warrant recourse to self-medication with antacids without medical knowledge. Exacerbation of peptic ulcer by self-medication with proprietary products is likely to be of lesser significance.

Detection of colorectal cancer by faecal alpha 1-antitrypsin.

Alpha 1-antitrypsin was measured in 5-day faecal collections from patients with colorectal cancer or adenomatous polyps and a symptomatic control group. Collections were homogenized and lyophilized prior to measurement of alpha 1-antitrypsin by radial immuno-diffusion. Colorectal cancer dry weight concentrations were significantly higher than the symptomatic control results, with 57% having results greater than 95% normal values of this control group. There was no significant difference between adenomatous polyp dry weight concentrations and symptomatic control results. Wet weight concentrations were calculated from wet/dry ratios. Colorectal cancer wet weight concentrations were significantly higher than symptomatic control results with 48% having results greater than 95% normal values of this control group. Alpha 1-antitrypsin was also measured in non-lyophilized samples from an asymptomatic control group (n = 39). Colorectal cancer wet weight concentrations were significantly higher than asymptomatic control results, with 62% having results greater than 95% normal values of this control group. Faecal alpha 1-antitrypsin measurement deserves further assessment for use in detecting colorectal cancer.

Granulomatous enteropathy in common variable immunodeficiency: a cause of chronic diarrhoea.

Gastrointestinal disease is a well recognized feature in patients with common variable immunodeficiency, and is often due to infection with a variety of organisms. Symptoms usually improve with appropriate antibiotic therapy and replacement gammaglobulin. We describe three middle-aged female patients with common variable immunodeficiency who had protracted diarrhoea and weight loss. Despite extensive investigation no infectious cause was found. All patients had granulomas distributed throughout the gastrointestinal tract, but no features of inflammatory bowel disease. There was a poor response to gammaglobulin replacement therapy, antibiotics or symptomatic treatment. We suggest that granulomatous enteropathy is another gastrointestinal manifestation of common variable immunodeficiency.

Small bowel enema in non-responsive coeliac disease.

A small bowel enema was performed in patients with non-responsive coeliac disease, in coeliac patients on a normal diet (untreated) and those who had shown a good response to a gluten free diet, and in control subjects to determine whether there were any specific radiological features of the non-responsive state. A significant reduction in the average number of jejunal folds and an increase in the number of ileal folds (reversal of the jejunoileal fold pattern) was found in eight of nine non-responsive coeliac patients, one of seven untreated coeliac patients, and in none of the good responders or control subjects. This pattern identifies coeliac patients with a poor response to a gluten free diet who are likely to suffer major complications.

The usefulness of faecal haemoglobin, albumin and alpha-1-antitrypsin in the detection of gastrointestinal bleeding.

A pilot study was undertaken to find out whether faecal haemoglobin, albumin and alpha-1-antitrypsin from patients with gastrointestinal disorders could distinguish active bleeders from non-active bleeders and healthy volunteers. Alpha-1-antitrypsin is not as readily degraded by endogenous and bacterial breakdown as haemoglobin and albumin and consequently could be a better marker for occult bleeding.

A new manifestation of seminal fluid hypersensitivity.

An immediate hypersensitivity reaction to seminal fluid is an uncommon but well recognized condition. We describe a young woman who developed haemorrhagic proctitis, arthralgia and urticaria on honeymoon. Investigations suggested an immune complex (type III) hypersensitivity. It subsequently became clear that her symptoms were temporally related to sexual intercourse. After 8 hours she developed nasal congestion and urticaria followed by migratory arthralgia and periorbital oedema. Over the ensuing 24 hours she had diarrhoea, occasionally with blood. She became breathless and had evidence of a restrictive ventilatory defect. These symptoms improved over 4-5 days. Further in vitro investigations were inconclusive but intradermal skin testing with seminal plasma led to recurrence of all her symptoms. Symptoms ceased with condom usage, and the condition abated over 2 years. This patient is unique in that seminal fluid hypersensitivity appears to have produced a type III immune response.

Small intestinal bacterial overgrowth in patients with chronic lymphocytic leukaemia.

As part of a study to assess the possible contribution of lymphoid infiltration of the gastrointestinal mucosa to occult blood loss or malabsorption 20 patients with chronic lymphocytic leukaemia (CLL) had a lactulose hydrogen breath test. In 10 cases (50%) a small intestinal peak was detected, suggesting small bowel bacterial overgrowth, and this was confirmed in seven patients by the positive culture of jejunal aspirate. Of the patients with a positive hydrogen breath test, radiological examination showed a duodenal diverticulum in two but no anatomical abnormalities in the other cases. There was no evidence of achlorhydria and transit times were normal. There was no difference in the incidence of hypogammaglobulinaemia among those patients with evidence of small intestinal bacterial overgrowth and those without. Seven patients with a positive hydrogen breath test, however, had undetectable secretory piece in their jejunal aspirates whereas this was present in all patients with a normal breath test who had local immunoglobulin concentrations measured (p less than 0.05), indicating that the small intestinal bacterial overgrowth may be due to impaired local immunity.

Susceptibility to tuberculosis in patients with coeliac disease.

An increased prevalence of past tuberculosis is reported in an adult coeliac population. Of 76 adult coeliac disease patients, 6 had had a history of tuberculosis. This compared with the finding of no cases in a population of 81 patients with non-inflammatory bowel diseases, (p = 0.023), which was matched for age, sex, smoking, ethnic origin and social class. The 'expected' number of cases of tuberculosis amongst ACD patients has also been calculated based on local annual notification rates; this was 2.9. Radiological evidence of past tuberculosis was found in 13 (17%) ACD patients, compared with 4 (5%) control patients (p less than 0.05). It is postulated that the increased prevalence of past tuberculosis in ACD patients is the result of depressed cell mediated immunity and/or malnutrition.

Ulcerative colitis in Asian immigrants.

Forty-four Asian immigrants in Birmingham and 44 age- and sex-matched white Caucasians with ulcerative colitis were compared to investigate the existence of any ethnic differences in the pattern of disease. Asian immigrants demonstrated a male preponderance of 2:1, and compared to the matched Caucasians there was a higher incidence of presenting eosinophilia and a milder course of disease, with more patients experiencing only a single initial attack. In spite of this clinical difference, total or subtotal colitis was the commonest pathological type in both white Caucasians and Indians, whereas in Pakistanis localized distal disease predominated. All ethnic groups suffered the same overall complication rate (55%) which is at variance with the experience of low complication rates in India. The age of onset of ulcerative colitis was related to age at immigration with a mean interval of 11 years. Although in some respects Asian immigrants share the disease pattern of the indigenous population, the observed significant differences could be of importance with regard to pathogenesis.