Psychological problems in gastroenterology outpatients: A South Australian experience. Psychological co-morbidity in IBD,IBS and hepatitis C

Background

In independent studies, IBD, IBS and HCV have each been associated with a substantially increased risk of psychological problems such as depression and anxiety and impairment of quality of life compared to the general healthy population. However, the relative psychological burden for each of these diagnoses is unknown as it has never been compared contemporaneously at one institution. Current local data are therefore needed to enable an evidence-based allocation of limited clinical psychological resources.

Methods

Overall, 139 outpatients (64 IBD, 41 HCV, and 34 IBS) were enrolled in this cross-sectional study. The HADS, SCL90, SF-12 and appropriate disease-specific activity measures were administered. Differences between groups were assesed with ANOVA, the Chi-Square test and the independent samples t-test (two-tailed).

Results

Each of the three groups had significantly lower quality of life than the general population (p < 0.05). Overall, a total of 58 (42%) participants met HADS screening criteria for anxiety and 26 (19%) participants for depression. The HCV group had a significantly higher prevalence of depression than either of the other groups (HCV = 34%, IBS = 15% and IBD = 11%, p = 0.009). In the SCL90, the three disease groups differed on 7 out of 12 subscales. On each of these subscales, the HCV group were most severely affected and differed most from the general population.

Conclusion

Patients with these common chronic gastrointestinal diseases have significant impairment of quality of life. Anxiety is a greater problem than depression, although patients with HCV in particular, should be regularly monitored and treated for co-morbid depression. Evaluation of specific psychological interventions targeting anxiety is warranted.

     

Mid-trimester loss--appraisal of a screening protocol

The main causes for mid-trimester loss are known. There is likely to be overlap with those of first trimester loss, but the proportions may be different. We wished to perform an aetiological survey in a large population of patients with a history of recurrent miscarriage, for possible explanations for their second trimester miscarriages. Database analysis of 636 patients attending a UK University Teaching Hospital dedicated miscarriage clinic between 1991 and 1996 revealed a 25% prevalence (n = 158) for second trimester miscarriage. Results from an investigative screening protocol were positive in 50% of cases: 33% (n = 52) tested positive for antiphospholipid syndrome (APS); 8% (n = 13) fulfilled strict criteria for cervical incompetence; there was a 4% prevalence of uterine anomaly; 3% for infection (n = 5) and 2% of patients (n = 3) proved to be hypothyroid. Importantly, dual pathology was found in 5% of patients with a history of second trimester miscarriage. As idiopathic mid-trimester loss is a diagnosis by exclusion, a high index of suspicion is required, as are modern diagnostic techniques.      

IRON DEFICIENCY ANAEMIA IN GENERAL PRACTICE: PRESENTATIONS AND INVESTIGATIONS

Twenty-six patients over the age of 50 years with proven iron deficiency anaemia were identified, investigated and followed up in general practice over a five-year period. The anaemia was symptomatic in 50% of patients but only 20% had symptoms related to the gut. Faecal occult blood testing was positive in five patients only and negative tests occurred in three patients with significant disease, including one caecal carcinoma. All patients agreed to oesophagogastroduodenoscopy (OGD) and fibreoptic sigmoidoscopy carried out on the same occasion. In eight patients, significant abnormalities were found on OGD and in two patients on sigmoidoscopy. Four patients declined barium enema examinations, two of whom had significant OGD abnormalities. Barium enema examination of the other 22 patients showed polyposis of the colon and a caecal carcinoma and initially missed one carcinoma of the caecum which was found subsequently. The likelihood of finding significant disease in iron-deficient patients over 50 years of age is high and should be assumed to be due to blood loss into the gut. Investigation by OGD, sigmoidoscopy and barium enema in the first instance seems warranted and is a condition that can be safely managed by the GP. (Br J Clin Pract 1997; 51(2) : 78-80)     

Enprostil, a prostaglandin E2 analogue, in the treatment of gastric ulcer--a multicentre comparison with pirenzepine

In a double-blind, multicentre study 77 patients with benign gastric ulcer were randomly allocated to treatment with either enprostil 35 micrograms bd or pirenzepine 50 mg bd. After four weeks of treatment 13/26 (50 per cent) of evaluable enprostil-treated patients and 9/30 (30 per cent) of evaluable pirenzepine-treated patients were healed. Corresponding healing figures after eight weeks were 20/25 (80 per cent) and 25/31 (81 per cent). Both drugs rapidly reduced the severity of ulcer pain and the need for antacid use. No statistically significant differences were detected between the treatments with respect to healing rate or symptom control. Adverse events were reported by eight patients taking enprostil and by 17 patients taking pirenzepine. Two patients withdrew from each treatment group because of adverse events. None of these was serious. In conclusion, enprostil and pirenzepine were equally effective in healing gastric ulcers and no statistically significant differences in safety and efficacy were detected. There was a tendency for earlier healing and fewer side effects in the enprostil-treated patients.     

A randomized double-blind placebo-controlled crossover study of subcutaneous sumatriptan in general practice

Objective. To evaluate the therapeutic response to sumatriptan in the acute migraine attack. Material and methods. Two hundred and thirty migraineurs diagnosed by their general practitioners in accordance with their usual practice were included in the study. The patients treated two migraine attacks at home by subcutaneous injection of sumatriptan or placebo for the first attack and the alternative medication, i.e. placebo or sumatriptan, for the second attack (crossover). Following treatment, a neurology resident interviewed and examined the patients, Results. When sumatriptan was compared to placebo, significantly more of the 209 evaluable patients reported headache relief at I h (56% vs 8%, p < 0.001) and 2 h (62% vs 15%, p < 0.001) after the first injection. Resolution of nausea, photophobia, and phonophobia was significantly more common in patients on sumatriptan than in those on placebo ( p < 0.001 for all comparisons). The adverse events were usually transient and of mild or moderate severity; however, three patients withdrew due to adverse events. Ninety-five percent of patients evaluated by a neurology resident met the IHS criteria for migraine. Conclusion. In general practice, sumatriptan taken subcutaneously using an autoinjector at home was an effective and well tolerated acute treatment for migraine.     

Unresolved questions regarding human hereditary deafness

Human hearing loss is a common neurosensory disorder about which many basic research and clinically relevant questions are unresolved. This review on hereditary deafness focuses on three examples considered at first glance to be uncomplicated, however, upon inspection, are enigmatic and ripe for future research efforts. The three examples of clinical and genetic complexities are drawn from studies of (i) Pendred syndrome/DFNB4 (PDS, OMIM 274600), (ii) Perrault syndrome (deafness and infertility) due to mutations of CLPP (PRTLS3, OMIM 614129), and (iii) the unexplained extensive clinical variability associated with TBC1D24 mutations. At present, it is unknown how different mutations of TBC1D24 cause non‐syndromic deafness (DFNB86, OMIM 614617), epilepsy (OMIM 605021), epilepsy with deafness, or DOORS syndrome (OMIM 220500) that is characterized by d eafness, o nychodystrophy (alteration of toenail or fingernail morphology), o steodystrophy (defective development of bone), mental r etardation, and s eizures. A comprehensive understanding of the multifaceted roles of each gene associated with human deafness is expected to provide future opportunities for restoration as well as preservation of normal hearing.     

Acute kidney injury survivors should have long-term follow-up

Acute kidney injury (AKI) is a frequently occurring complication in ICU patients and is associated with decreased short- and long-term survival. Gammelager and colleagues showed that AKI patients are at increased risk for developing heart failure and myocardial infarction at long-term follow-up. Their study provides strong epidemiological data on cardiorenal syndrome type 3, and their findings help explain the worse long-term survival of AKI patients. Finally, it also highlights the need for specific follow-up programs for ICU survivors.In a recent article, Gammelager and colleagues [1] investigated the association between acute kidney injury (AKI) and long-term cardiac morbidity and stroke in a representative ICU cohort. AKI occurs in one- to two-thirds of ICU patients and is associated with worse outcome [2,3]. Short-term worse outcomes can be explained by the effects of decreased kidney function, such as volume overload and retention of uremic toxins [4]. Long-term outcomes are probably affected by development of chronic kidney disease [5]. Recently, there has been increased interest in the complex interaction between the kidney and heart. AKI leading to acute cardiac events has been termed cardiorenal syndrome type 3 (CRS-3) [6]. At present this concept is only sparsely supported by human data [7]. The study by Gammelager and colleagues is one of the first providing high-quality data on CRS-3 in ICU patients.Several groups, including the group of Gammelager and colleagues, have demonstrated worse long-term outcomes for AKI patients [3,8-11]. The present study by Gammelager and colleagues demonstrates that cardiovascular disease may contribute to these worse outcomes. Over a 3-year period, AKI stage 1 and greater was associated with heart failure (hazard ratio 1.33), and AKI stages 2 and 3 were associated with myocardial infarction (hazard ratio 1.51). Similar findings were reported before by James and colleagues [12] in a cohort of non-ICU patients after coronary angiography. The paper by Gammelager and colleagues is one of the first providing long-term epidemiologic data on CRS-3 in ICU patients. Importantly, it shows that CRS-3 is also relevant for patients discharged from the ICU, a less well-recognized aspect of CRS-3.These findings are strengthened by the methodological quality of the study. Selection bias was limited by including a large multicenter ICU cohort, and a population-based medical registry guaranteed virtually complete patient follow-up. Studies using different AKI definitions cannot be compared. Therefore, it is crucial that the universally accepted KDIGO (Kidney Disease: Improving Global Outcomes) definition for AKI was used [13].A limitation is that administrative data were used for recoding of the endpoints. Administrative databases may be limited by both over- and under-reporting, and also miss detailed information on, for example, severity of heart failure. Also, an epidemiologic study can only demonstrate an association, rather than prove a causal effect, in this case between AKI and cardiac events. These data on CRS-3 are therefore hypothesis generating and should prompt further research on the pathophysiologic mechanisms explaining the worse cardiovascular outcomes.How can we explain this increased risk for cardiovascular events? This may be mediated, especially in the long-term, by chronic kidney disease developing after AKI, but other factors may also play a role [5]. In the acute phase, AKI may exert a negative impact on the heart, leading to cellular response with apoptosis, remodeling and fibrosis, which may ultimately lead to arrhythmias, conduction abnormalities, heart failure, and ischemia [7,14].The study by Gammelager and colleagues is also one of the few that reports on the association between AKI and stroke, but showed no association during the 3-year follow-up. These findings are in contrast to those found in Taiwan by Wu and colleagues [15], where in a matched case-controlled study AKI patients had a higher risk and higher severity of stroke than non-AKI patients. An important difference with the cohort of Gammelager and colleagues was that the study cohort included only severe AKI treated with renal replacement therapy and was not limited to ICU patients. Severity of AKI may therefore play a role in risk for stroke.Another important lesson that can be learned from these long-term outcome data is that AKI survivors should have long-term follow-up. We were already aware that follow-up of kidney function is important, but these data also highlight the importance of cardiovascular follow-up. As other types of ICU survivors also have specific long-term morbidity issues, this highlights the need for specific and multidisciplinary follow-up programs for ICU survivors.