Persistent mucosal damage and risk of epilepsy in people with celiac disease.

BACKGROUND AND PURPOSE: Celiac disease (CD) is associated with an increased risk of developing epilepsy, a risk that persists after CD diagnosis. A significant proportion of patients with CD have persistent villous atrophy (VA) on follow-up biopsy. The objective of this study was to determine whether persistent VA on follow-up biopsy affected long-term epilepsy risk and epilepsy-related hospital emergency admissions. METHODS: This was a nationwide cohort study. We identified all people in Sweden with histological evidence of CD who underwent a follow-up small intestinal biopsy (1969-2008). We compared those with persistent VA with those who showed histological improvement, assessing the development of epilepsy and related emergency hospital admissions (defined according to relevant International Classification of Diseases codes in the Swedish Patient Register). Cox regression analysis was used to assess outcome measures. RESULTS: Villous atrophy was present in 43% of 7590 people with CD who had a follow-up biopsy. The presence of persistent VA was significantly associated with a reduced risk of developing newly-diagnosed epilepsy (hazard ratio, 0.61; 95% confidence interval, 0.38-0.98). On stratified analysis, this effect was primarily amongst males (hazard ratio, 0.35; 95% confidence interval, 0.15-0.80). Among the 58 patients with CD with a prior diagnosis of epilepsy, those with persistent VA were less likely to visit an emergency department with epilepsy (hazard ratio, 0.37; 95% confidence interval, 0.09-1.09). CONCLUSIONS: In a population-based study of individuals with CD, persisting VA on follow-up biopsy was associated with reduced future risk of developing epilepsy but did not influence emergency epilepsy-related hospital admissions. The mechanism as to why persistent VA confers this benefit requires further exploration.

Long-term care for patients with coeliac disease in the UK: a review of the literature and future directions.

Coeliac disease is a common digestive disorder that affects 1% of adults. It is characterised by mucosal damage of the small intestine caused by dietary gluten. The main treatment for coeliac disease is a lifelong gluten-free diet, which can reduce morbidity and mortality and also improve quality of life. Despite the benefits, adhering to this diet is often challenging, with patients often struggling to sustain dietary restriction. Structured follow-up for coeliac disease is recommended in international guidelines for improving adherence and for detecting complications;however, uncertainty exists concerning exactly who should be administering this follow-up care. Here, we undertake a review of the current approaches described in the literature to follow-up patients with coeliac disease, and assess the efficacy of these differing models. We also explore future directions for the care of these patients in the context of the UK National Health Service (a publicly funded healthcare system). Although the focus of this review pertains to follow-up within the UK healthcare system, these problems are recognised to be international, and so the findings of our review are likely to be of interest to all healthcare professionals seeing and managing patients with coeliac disease.

Correlation of visual analogue scale foot and ankle (VAS-FA) to AOFAS score in malleolar fractures using Indian language questionnare.

BACKGROUND: Visual analogue scale foot and ankle (VAS-FA score) is a new score, validated in previous studies, but never compared to AOFAS score. OBJECTIVE: Analysis of the two scores using Indian language questionnaire. METHODS: Fifty patients with Malleolar fractures were assessed for functional outcome, time for calculation of scores, difficulty in correlation and comprehension of the questionnaire, in Malayalam language. The score parameters were compared by SSPSS. RESULTS: There was similarity in pattern of score values in both systems but also a difference between values in each category, with VAS-FA having lower values, reflecting its efficacy. There was significant correlation, similar sensitivity and agreement between the scoring systems. VAS-FA correlated better with patient's outcome and required less time for assessment. CONCLUSION: This study shows that Indian language VAS-FA has a similar pattern of extracting scores as AOFAS and can be an efficient tool in ankle outcome assessment in Indian patients.

Interventions for Managing Late Gastrointestinal Symptoms Following Pelvic Radiotherapy: a Systematic Review and Meta-analysis.

AIMS: Pelvic radiotherapy can induce gastrointestinal injury and symptoms, which can affect quality of life. We assessed interventions for managing these symptoms. MATERIALS AND METHODS: A review of randomised controlled trials published between January 1990 and June 2023 from databases including MEDLINE, EMBASE, CENTRAL, CINAHL, clinicaltrials.gov, ISRCTN and grey literature sources was conducted. Meta-analyses were carried out using the DerSimonian and Laird random effects model to produce overall treatment differences with 95% confidence intervals. RESULTS: Twenty-eight studies (2392 participants) of varying methodological quality were included. 4% formalin was superior to sucralfate for improving gastrointestinal symptom score (standardised mean difference [SMD] -1.07, 95% confidence interval -1.48 to -0.65). Argon plasma coagulation (APC) was inferior to sucralfate (SMD 1.22, 95% confidence interval 0.84 to 1.59). Counselling positively influenced symptom score (SMD -0.53, 95% confidence interval -0.76 to -0.29), whereas hyperbaric oxygen therapy showed conflicting results. Sucralfate combined with APC increased endoscopic markers of moderate-severe bleeding versus APC alone (risk ratio 2.26, 95% confidence interval 1.12 to 4.55). No definite conclusions on pain, incontinence, diarrhoea, tenesmus or quality of life interventions were confirmed. CONCLUSIONS: Small study sizes, methodological quality and heterogeneity limit support of any individual intervention. APC and 4% formalin seem to be promising interventions, with further larger randomised controlled trials now warranted.

Serological testing for coeliac disease in Type 1 diabetes mellitus: is immunoglobulin A level measurement necessary?

AIMS: Immunoglobulin A (IgA) measurement is advocated when case finding for coeliac disease in patients with Type 1 diabetes mellitus. Currently, there is a paucity of contemporary studies assessing IgA deficiency in Type 1 diabetes. This study evaluates the prevalence of IgA deficiency in individuals with Type 1 diabetes, compared with patients with coeliac disease and control subjects. In addition, we evaluate whether routine IgA measurement is justifiable when case finding for coeliac disease in patients with Type 1 diabetes. METHODS: All patients were assessed using IgA endomysial antibodies, IgA anti-tissue transglutaminase antibodies and total IgA levels. Altogether, 2434 individuals were tested: 1000 patients with Type 1 diabetes, 234 patients with coeliac disease and 1200 population control subjects. Definitive IgA deficiency was defined as total IgA levels < 0.07 g/l. RESULTS: The prevalence of IgA deficiency was significantly more common in patients with Type 1 diabetes (0.9%, n = 9/1000; P = 0.036) and coeliac disease (1.29%, n = 3/234; P = 0.041) when compared with population control subjects (prevalence of 0.17%, 2/1200). No statistical difference between Type 1 diabetes and coeliac disease for IgA deficiency was identified (P = 0.87). Of patients in the group with Type 1 diabetes, 3.3% (33/1000) had coeliac disease, and of those only one patient had IgA deficiency leading to an antibody-negative presentation. Both IgA-deficient individuals within the population control subjects had normal duodenal biopsies and no relevant symptoms. CONCLUSIONS: IgA deficiency is more common in Type 1 diabetes compared with population control subjects. Despite this, very few individuals with Type 1 diabetes and IgA deficiency appear to have villous atrophy on biopsy. These outcomes question the practice of routine IgA measurement when case finding for coeliac disease in patients with Type 1 diabetes.

Ultrasound Probe Positions for Internal Jugular Vein Cannulation: A Prospective Study of Different Techniques.

OBJECTIVE: We compared sonoanatomy of the internal jugular vein (IJV) the high (HA), conventional (CA) and the medial oblique approach (MA) to identify the best approach and head position for IJV cannulation. MATERIALS & METHODS: Total of 45 volunteers aged 18-65 years were included in this study. The degree of overlap in percentage, depth of IJV from skin, antero-posterior (AP) and transverse diameters (TD) of IJV were measured in real time with ultrasound (US). Measurements were taken in the HA, CA and MA in neutral and 30° head rotation on both the right and left side of the neck. RESULTS: The HA had lower percentage of overlap when compared to CA and MA in neutral and 30° head rotation (p= 0.002 to ≤0.001). The IJV was more shallow in the CA and MA. The AP and TD of the IJV were larger in the MA when compared to HA (p=<0.001) and CA (p =0.026 to < 0.001) and the right IJV has a larger AP and TD in all approaches. DISCUSSION: The HA had the least percentage of overlap compared to CA and MA, therefore the risk of accidental ICA puncture can be reduced. The apparent overlap seen in MA may not reflect the actual scenario because of the way the US beam cuts the vessel. The AP and TD of IJV were significantly increased in the MA, which would ease CVC. CONCLUSION: We conclude and recommend the medial oblique probe position with 30° head rotation provides optimal real time sonographic parameters for US guided IJV cannulation.

What is the role of small bowel capsule endoscopy in established coeliac disease?

INTRODUCTION: Patients with established coeliac disease (CD) can present with signs and symptoms requiring small bowel capsule endoscopy (SBCE) to assess for persistent disease beyond the duodenum and to rule out complications. There is paucity of data on extent of disease on SBCE in relation to histology, clinical and serological parameters. The aim of this study was to assess the relationship between symptoms, CD serology and Marsh classification of disease and extent of disease on SBCE in patients with established CD. METHODS: Hundred patients with established CD and 200 controls underwent a SBCE. SBCEs were reviewed by expert reviewers. Extent of disease on SBCE, CD findings and small bowel transit were recorded. RESULTS: Considering duodenal histology (D2; Marsh 3a or above) as the gold standard for diagnosing CD activity, the sensitivity of SBCE to delineate active disease was 87.2%. The specificity was 89.0%. Age at SBCE (P=0.006), albumin (P=0.004) and haemoglobin (P=0.0001), Marsh score of histology from the duodenal bulb (D1) (P=0.0001) and the second part of the duodenum (P=0.0001), refractory CD (P=0.007) on histology correlated with extent of affected small bowel (SB) mucosa on univariate analysis. On multiple regression analysis, albumin (P=0.036) and Marsh score of histology (D1) (P=0.019), vitamin B12 (P=0.001) and folate levels (P=0.008) were statistically significant. Extent of affected SB mucosa (11.0% vs 1.35%) was greater in patients with complications including those with refractory CD (P=0.008). CONCLUSIONS: This is the first study showing correlation between extent of disease and severity of duodenal histology, markers of malabsorption such as folate levels and vitamin B12 and complications of CD.

Screening for HIV infection by health professionals in India.

BACKGROUND: Stigma and discrimination, particularly in access to healthcare, remains a major problem for people Infected with HIV in most parts of India. METHODS: We did a multicentre study (n = 10) with a cross-sectional survey design using a standardized, interviewer-administered questionnaire. RESULTS: A total of 2200 healthcare providers participated. The knowledge, attitude and practice (KAP) related to HIV service delivery were very poor with a mean overall KAP score of only 49.7% (CI: 49.1-50.3). Only 5%, 5% and 1% of the participants scored more than 75% separately for the dimensions of knowledge, attitude and practice, respectively. Only 24.4% and 36.7% of responders knew that HIV screening was not recommended prior to surgery and pre-employment check-up. Many doctors (19.4%) had refused treatment to people living with HIV/AIDS (PLHA) at least some of the time and nearly half (47.2%) identified and labelled them; 23.9% isolated them in separate care areas and 13.3% postponed or changed treatment based on the patient's HIV status. Screening for HIV prior to elective surgery was done by 67% of providers. While 64.7% of responders were aware of the existence of national guidelines on and recommendations for HIV testing, only 38.4% had read the policy document. CONCLUSION: There is a growing need to provide care, support and treatment to a large number of PLHA. The capacity of healthcare providers must be urgently built up so as to improve their knowledge of and attitude to HIV to enable them to deliver evidence-based and compassionate care to PLHA in various healthcare settings.

Changing trends in the UK management of upper GI bleeding: is there evidence of reduced UK training experience?

OBJECTIVE: The aim of this study was to evaluate UK trainee experience in endoscopy for acute upper gastrointestinal bleeding (AUGIB). METHODS: Data was prospectively collected from all patients presenting to South Yorkshire Hospitals with AUGIB from September 2011 to December 2011 and compared with data from 1996. Concurrently, all gastroenterology trainees registered with the British Society of Gastroenterology were invited to respond to a web-based questionnaire regarding their experience in AUGIB management. RESULTS: 77% (589/766) of the patient cohort underwent endoscopy for AUGIB; 15% (90/589) were performed by trainees. 7.2% (9/125) of the out of hours endoscopy case load was performed by trainees; all were low-risk or medium-risk cases (pre-endoscopy Rockall score ≤4). During the study period, dual therapy was delivered by a trainee on only four occasions. Comparison with the 1996 cohort demonstrated a marked reduction in the number of trainee performed endoscopies (76% vs 15%; p<0.001). Questionnaires were returned by 51% (245/478) of British Society of Gastroenterology trainees. 81% (198/245) thought that <10% of the gastroscopies they had performed involved therapeutic intervention. 23% (57/245) felt they would not be competent in AUGIB endoscopy by completion of specialty training. CONCLUSIONS: This study demonstrates the decline over time in trainee experience in AUGIB endoscopy. It also highlights a lack of trainee exposure to more challenging cases, out of hours endoscopy and therapeutic procedures. Furthermore, trainees are concerned that a level of competency may not be attained during specialty training. We advocate reviewing UK endoscopic training provision for AUGIB to ensure that experienced endoscopists are produced to meet future service needs.

Complications of acute infective rhinosinusitis: experience from a developing country.

INTRODUCTION: Complications of acute infective sinusitis are a therapeutic emergency. The purpose of this study was to determine the clinical presentation, microbiological pattern, treatment modalities and outcome of patients diagnosed to have acute rhinogenic orbital, intra- and extra-cranial complications from a developing country in Asia. METHODS: A retrospective chart review from October 1999 to January 2004 was conducted. RESULTS: Among 247 ENT surgical emergencies documented, 13 patients (5.3 percent) were diagnosed to have acute sinusitis with various complications either as in solitary or multiple forms. Orbital complications were the most common (61.5 percent) followed by acute subdural empyema (23.1 percent) and meningitis (15.2 percent). Subdural empyema was the most common intracranial complication. Staphylococcus was reported to be the most common offending organism (45.5 percent). Majority of the patients (84.6 percent) had surgical drainage of the affected sinuses, 38.5 percent being endoscopic drainage while external approach was done for those with coexisting osteomyelitis (30.8 percent). Two patients had combined approach, and one patient had post-operative facial paresis. There was no mortality in our series. CONCLUSION: Early detection, aggressive medical and prompt surgical treatment by multidisciplinary approach involving ophthalmological, neurosurgical and rhinological procedures, can successfully treat the complications with a significant reduction in the morbidity and no mortality.

Otogenic intracranial abscess: concurrent craniotomy and mastoidectomy--changing trends in a developing country.

OBJECTIVES: To evaluate (1) the clinical profile, treatment, and outcome of adult and pediatric patients presenting with intracranial abscess of otogenic origin and (2) the advantages of concurrent craniotomy and mastoidectomy. DESIGN: A prospective case series. SETTING: An academic tertiary referral center in India. PATIENTS: Thirty-six patients clinically diagnosed as having intracranial abscess that was secondary to suppurative otitis media and confirmed by computed tomographic scanning. INTERVENTION: Concurrent craniotomy and mastoidectomy. RESULTS: Children were more commonly affected than adults, and there was a male preponderance. All patients had cholesteatoma at surgery, although one third of the children had only granulation tissue on otoscopy. More than two thirds of the patients in both the groups presented with more than one intracranial complication and definitive surgical intervention was done later than 24 hours. Meningitis was the most frequent intracranial complication, followed by cerebellar abscess. There was no significant intraoperative or postoperative morbidity, mortality, recurrence of intracranial complications, or residual neurological deficits. Three children (14%) showed evidence of recidivism cholesteatoma requiring revision surgery. CONCLUSIONS: In suppurative otitis media with intracranial complications, it is accepted practice to treat the neurosurgical complication first, followed by mastoidectomy at a later date after the patient has been stabilized. Craniotomy with concurrent mastoidectomy is not only safe, but it also removes the source of infection at the same time the complications are being treated, thus avoiding reinfection while the patient is awaiting the ear surgery. In addition, the treatment is completed with a single, shorter hospital stay, which is more economical for the patient.

Inherited nasal and laryngeal degenerative chondropathy.

Four rare cases of congenital saddle-nose deformity and slowly progressive degeneration of laryngeal cartilages with stenosis are described. The term inherited degenerative chondropathy is suggested for this disease entity. To our knowledge this is the first article on such a disease.

Bilateral simultaneous hearing preservation mastoidectomy in otogenic meningitis.

Bilateral simultaneous hearing conservation mastoidectomy has not been previously documented. We present our experience with this procedure. Three patients with pyogenic meningitis secondary to bilateral unsafe ears had hearing preservation surgeries of both ears in a single sitting. Although ear surgery carries risk of inner ear damage, in our series there was no deterioration of inner ear function in the 6 ears operated on. The air conduction threshold improved in 3 (50%) of the ears. When meningitis results from bilateral otogenic foci as in our series, simultaneous mastoidectomy in both ears may be the preferred method of treatment to eradicate the source of infection.

External laryngotracheal trauma in children.

External laryngotracheal trauma in the paediatric population, although rare, presents a diagnostic and therapeutic dilemma for the attending surgeon. The purpose of this study was to evaluate the clinical profile, treatment and outcome and to establish a simple, effective management protocol in this emergency. A retrospective case series was studied. There were 12 patients aged 2-14 years in this series, eight of them (67%) having closed injuries. Their clinical presentation was correlated to conservative management, tracheostomy and surgical intervention. In the open injury group all the patients (100%) underwent tracheostomy, upper endoscopy and neck exploration. One patient (25%) in this group developed subglottic stenosis. In the closed injury group, seven patients (88%) had tracheostomy with upper endoscopy, and two of them (25%) had neck exploration in addition. One patient (13%), however, developed glottic stenosis. The patients with stenosis underwent multiple surgical interventions prior to final decannulation. There was no mortality. Breathing difficulty/stridor were the commonest clinical presentations in children with acute external laryngotracheal trauma. Tracheostomy and early surgical intervention appeared to be the treatment of choice. A protocol with major and minor criteria of clinical presentation is suggested for effective management.

Ketotifen in prevention of indomethacin-induced gastropathy.

BACKGROUND: Therapeutic benefits of nonsteroidal anti-inflammatory drugs (NSAIDs) are offset by their gastrointestinal side effects. We evaluated whether oral ketotifen, which prevents experimental NSAID-induced gastric mucosal injury, is superior to placebo in preventing NSAID-induced gastropathy. DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING: Rheumatology clinic in a tertiary care hospital. PARTICIPANTS: A majority of the 53 subjects had rheumatoid arthritis (n = 36) or osteoarthritis (12). Those with comorbidity, gastrointestinal (GI) symptoms or abnormal endoscopic findings at entry were excluded. Persons on steroids or NSAIDs in the previous month were also excluded. The subjects were started on indomethacin 25 mg thrice daily. INTERVENTION: Subjects were randomly allocated to receive 2 mg ketotifen or placebo tablets. Compliance was measured by tablet count. OUTCOME MEASURE: At the end of every week a questionnaire was administered to elicit GI symptoms or adverse effects. Every patient underwent endoscopy after four weeks. RESULTS: Of 53 patients recruited (27 drug, 26 placebo), three (2 drug, 1 placebo) dropped out. The age, sex, NSAID use and clinical conditions were similar in the two groups. Eight in the drug group and 16 in the placebo group developed GI symptoms and/or endoscopic lesions (relative risk 0.51, 95% CI 0.27-0.95). The difference was significant on intention-to-treat analysis. CONCLUSIONS: Ketotifen significantly reduced the risk of GI side effects in patients on indomethacin.

Angiosarcoma of the nasal cavity and maxillary antrum.

Angiosarcoma (malignant haemangioendothelioma) of the nasal cavity and paranasal sinuses is extremely rare. Only a few cases have been reported in literature. A case of angiosarcoma of the nasal cavity and maxillary antrum in a 38-year-old male patient is reported. He was treated with pre-operative external radiotherapy followed by wide excision of the tumour. He currently remains free of the disease 10 months after diagnosis (and seven months after completing therapy).

Inherited degenerative chondropathy--an autosomal dominant new clinical entity: report two cases and follow-up of four cases.

Four cases of the rare disorder, inherited degenerative chondropathy have been previously reported (Kurien et al., 1989). A five-year follow-up of these patients and two additional cases are presented in this report. The progress of this disease appears to be arrested after regular dapsone therapy and there was no other organ involvement noted during the follow-up period.

Hearing threshold in patients with diabetes mellitus.

Hearing threshold of 30 diabetic patients and 30 healthy controls attending the medical outpatient department were determined using pure tone audiometry (Arphi Digital 900). All subjects were less than 50 years old. Subjects with otological and other metabolic diseases were excluded from the study. The patients were categorized into groups according to age, duration of disease, complications and control of diabetes. These observations were compared with those from the control subjects using appropriate statistical methods. It was found that diabetics had a poorer hearing threshold than the non-diabetics; all age groups with diabetes showed a significant high frequency hearing loss, as compared to the control population; poorly controlled and complicated diabetics have significant, high frequency hearing loss as compared to those who were well controlled and uncomplicated; there was no relationship between duration of the diabetes and the level of hearing loss.

Maxillary sinus fusariosis in immunocompetent hosts.

We report the first known cases of Fusariosis of maxillary sinus with granuloma and oro-antral fistula in two immunocompetent hosts. Fusarium solani was demonstrated in the direct microscopic examination and isolated in heavy growth from the biopsy materials. Both these patients were successfully treated with oral ketoconazole (200 mg daily) for three weeks followed by a Caldwell-Luc operation. Ketoconazole was continued for two months post-operatively.