Sonia Ratib

Nature of Auditory Processing Disorder in Children

OBJECTIVE: We tested the specific hypothesis that the presentation of auditory processing disorder (APD) is related to a sensory processing deficit. METHODS: Randomly chosen, 6- to 11-year-old children with normal hearing (N = 1469) were tested in schools in 4 regional centers across the United Kingdom. Caregivers completed questionnaires regarding their participating childrens listening and communication skills. Children completed a battery of audiometric, auditory processing (AP), speech-in-noise, cognitive (IQ, memory, language, and literacy), and attention (auditory and visual) tests. AP measures separated the sensory and nonsensory contributions to spectral and temporal perception. RESULTS: AP improved with age. Poor-for-age AP was significantly related to poor cognitive, communication, and speech-in-noise performance (P < .001). However, sensory elements of perception were only weakly related to those performance measures (r < 0.1), and correlations between auditory perception and cognitive scores were generally low (r = 0.1–0.3). Multivariate regression analysis showed that response variability in the AP tests, reflecting attention, and cognitive scores were the best predictors of listening, communication, and speech-in-noise skills. CONCLUSIONS: Presenting symptoms of APD were largely unrelated to auditory sensory processing. Response variability and cognitive performance were the best predictors of poor communication and listening. We suggest that APD is primarily an attention problem and that clinical diagnosis and management, as well as further research, should be based on that premise.

Change of refractive state and eye size in children of birth weight less than 1701 g

Aims: To determine the refractive status and ocular dimensions of a cohort of children at age 10–12 years with birth weight below 1701 g, and also the relation between the neonatal ophthalmic findings and subsequent refractive state. Methods: 293 low birthweight children who had been examined in the neonatal period were assessed at 10–12 years of age. The examination consisted of autorefraction, keratometry, and A-scan. Results of right eyes were compared with published normative data. Results: 293 of the birth cohort of 572 children consented to participate. The average mean spherical equivalent (MSE) in the low birthweight cohort was +0.691 dioptre, significantly higher than the control data (+0.30D, p = 0.02). The average change in MSE over the 10–12 year period was −1.00 dioptre (n = 256), but only 62.1% of cases showed a shift in refractive error of the appropriate magnitude and direction. The presence of any retinopathy of prematurity (ROP) increases the risk of developing anisometropia sixfold. Conclusions: Low birth weight and ROP both significantly impact the refractive state in the long term. At age 10–12 years children born preterm have an increased prevalence of all refractive errors. In low birthweight children refractive state is relatively stable over the first decade of life with a shift towards myopia of 1 dioptre.

Visual function in low birthweight children

Aim: To determine the visual functions, at age 10–12 years, of a geographically based cohort of children of birth weight less than 1701 g. The results were compared to a group of children born at full term. Methods: 572 low birthweight (LBW) “low birthweight cohort” children who had been examined in the neonatal period were invited for review at 10–12 years of age. 169 11 year old schoolchildren born at full term were also recruited, “school cohort.” Visual acuity (at distance and near), contrast sensitivity, colour vision, and visual fields were measured. Results: 293 of the original 572 participants consented to a further examination. Compared to the school cohort of children born at term the low birthweight cohort showed significantly lower near and distance acuities and contrast sensitivity (p<0.001 for all uniocular and binocular measures). Retinopathy of prematurity (ROP) was a very poor predictor of outcome and multivariate analysis did not identify any key neonatal factors as predictors of long term visual outcome. Conclusions: Low birthweight children have a small but statistically significant deficit in both visual acuity and contrast sensitivity. Low birth weight and ROP both impact on long term visual functions.

Children born weighing less than 1701 g: visual and cognitive outcomes at 11-14 years.

Background and objective: Few studies of low birthweight children have explored the relationship between later visual morbidity and neuropsychological function. This study evaluated these outcomes using a geographically defined cohort. Methods: Prospective study of retinopathy of prematurity (ROP) in infants born weighing <1701 g, undertaken in 1985–7. 254 of the survivors consented to ophthalmic examination at 10–13 years. Four children were severely disabled and could not complete the tests. 198 of the remaining agreed to neuropsychological assessment at 11–14 years (British Ability Scales II (BAS), Movement Assessment Battery (ABC), Neale Analysis of Reading Ability). Results: At 10–13 years, 99/198 children had an adverse ophthalmic outcome (AOO) (reduced acuity n = 48, myopia n = 40, strabismus n = 36, colour defect n = 2, field defect n = 1). There were no significant differences between children with AOO and those with a normal ophthalmic outcome with regard to sex, gestation, birth weight, neonatal cranial scan appearances and social class. 106/198 had ROP; 98 had mild ROP with no increased risk of AOO in later childhood. All eight children with severe ROP had an AOO in later childhood. Children with an AOO performed worse on the BAS, ABC and reading ability tests. Conclusions: At age 10–13, 50% of children born <1701 g have an AOO. These children are not simply those with earlier gestations, lower birth weight or ROP. Children with AOO have a worse neuropsychological outcome. The next step is to determine whether there are visual interventions which can improve ophthalmic outcome and whether a better neuropsychological outcome follows.

1 and 5 year survival estimates for people with cirrhosis of the liver in England, 1998–2009: A large population study

BACKGROUND & AIMS Large, population-based studies that have included the full spectrum of cirrhosis estimating survival, taking into account time-at-risk are lacking. We aimed to report 1- and 5-year average survival rates for people with cirrhosis to be used in a clinical and healthcare policy setting. METHODS We used the Clinical Practice Research Datalink and linked English Hospital Episode Statistics to identify adult cases of cirrhosis from January 1998 to December 2009. We estimated 1- and 5-year survival according to whether time-at-risk was ambulatory or followed an emergency hospital admission related to liver disease, stratified by age, sex, and aetiology to be used in a clinical setting. We used a multivariate Cox-proportional hazards model with a time-varying variable, adjusted for Baveno IV stage of cirrhosis at diagnosis, age, aetiology, and sex. RESULTS We identified 5118 incident cases. Average survival probabilities at 1- and 5-years were 0.84 (95% CI 0.83-0.86) and 0.66 (95% CI 0.63-0.68) for the ambulatory group and 0.55 (95% CI 0.53-0.57) and 0.31 (95% CI 0.29-0.33) following hospitalisation, respectively. A hospital admission at diagnosis or subsequently for liver disease substantially impaired prognosis independent of stage of cirrhosis (HR=2.78, 95% CI 2.53, 3.06). CONCLUSIONS Emergency hospitalisation for liver disease heralds a downturn in a patients outlook independent of their stage of cirrhosis. Our results provide population-based clinically translatable estimates of prognosis for the purposes of healthcare delivery and planning and communication to patients.

Response rates to combination therapy for chronic HCV infection in a clinical setting and derivation of probability tables for individual patient management

Summary.  Evidence for efficacy of established treatment guidelines for chronic hepatitis C virus (HCV) disease is based on multinational randomized controlled trials (RCTs). Strategies for managing HCV, however, require an assessment of the effectiveness of intervention in routine clinical practice. We report the outcomes of combination therapy in a large cohort of HCV‐infected individuals in the UK. A total of 347 (113 genotype 1, 234 genotype non‐1) patients were treated with pegylated interferon and ribavirin according to current guidelines. Forty‐two (37.2%) of those with genotype 1 infection and 164 (70.1%) with genotype non‐1 infection achieved sustained viral response (SVR). Thirty‐nine (11%) patients withdrew from treatment. In addition to viral genotype, factors predictive of a response to therapy were age at start of treatment and disease stage on pretreatment liver biopsy. Multivariate regression analysis demonstrated that the effects of age [odds ratio 0.5; 95% confidence interval (0.31–0.82) per 10‐year increment (P = 0.006)] were confined to genotype 1 disease. In order to further inform the management of the individual patient, a multivariate logistic model was used to predict the probability of SVR for subgroups defined by disease stage, genotype and age at commencement of therapy. This model revealed striking differences in predicted response rates between subgroups and provided a strong rationale for early treatment, particularly for those with genotype 1 disease. Our study demonstrates that results comparable with those of RCTs can be achieved in clinical practice, and suggests that prediction of response rates based on probability modelling will provide a valuable adjunct to individual patient management.

Diagnosis of liver cirrhosis in England, a cohort study, 1998-2009: a comparison with cancer.

OBJECTIVES:There is no routine registration of the occurrence of newly diagnosed cases of cirrhosis in the United Kingdom. This study seeks to determine precise estimates and trends of the incidence of cirrhosis in England, and directly compare these figures with those for the 20 most commonly diagnosed cancers in the United Kingdom.METHODS:We used the Clinical Practice Research Datalink and linked English Hospital Episode Statistics to perform a population-based cohort study. Adult incident cases with a diagnosis of cirrhosis between January 1998 and December 2009 were identified. We described trends in incidence by sex and etiology. We performed a direct standardization to estimate the number of people being newly diagnosed with cirrhosis in 2009, and calculated the change in incidence between 1998 and 2009.RESULTS:A total of 5,118 incident cases of cirrhosis were identified, 57.9% were male. Over the 12-year period, crude incidence increased by 50.6%. Incidence increased for both men and women and all etiology types. We estimated approximately 17,000 people were newly diagnosed with cirrhosis in 2009 in the United Kingdom, greater than that of the fifth most common cancer non-Hodgkins lymphoma. The percentage change in incidence of cirrhosis between 1998 and 2009 for both men (52.4%) and women (38.3%) was greater than that seen for the top four most commonly diagnosed cancers in the United Kingdom (breast, lung, bowel, and prostate).CONCLUSIONS:The occurrence of cirrhosis increased more than that of the top four cancers during 1998 to 2009 in England. Strategies to monitor and reduce the incidence of this disease are urgently needed.

Causes of Death in People with Liver Cirrhosis in England Compared with the General Population: A Population-Based Cohort Study

OBJECTIVES:There is a need for unbiased estimates of cause-specific mortality by etiology in patients with liver cirrhosis. The aim of this study is to use nationwide linked electronic routine healthcare data from primary and secondary care alongside the national death registry data to report such estimates.METHODS:We identified from the linked Clinical Practice Research Datalink (CPRD) and English Hospital Episode Statistics adults with an incident diagnosis of liver cirrhosis linked to the Office for National Statistics between 1998 and 2009. Age-matched controls from the CPRD general population were selected. We calculated the cumulative incidence (adjusting for competing risks) and excess risk of death by 5 years from diagnosis for different causes of death, stratified by etiology and stage of disease.RESULTS:Five thousand one hundred and eighteen patients with cirrhosis were matched to 152,903 controls. Among compensated patients, the 5-year excess risk of liver-related death was higher than that of any other cause of death for all patients, except those of unspecified etiology. For example, those of alcohol etiology had 30.8% excess risk of liver-related death (95% confidence interval (CI): 27.9%, 33.1%) compared with 9.9% excess risk of non-liver-related death. However, patients of unspecified etiology had a higher excess risk of non-liver-related compared with liver-related death (10.7% vs. 6.7%). This was due to a high excess risk of non-liver neoplasm death (7.7%, 95% CI: 5.9%, 9.5%). All decompensated patients had a higher excess of liver-related mortality than any other cause.CONCLUSIONS:In order to reduce associated mortality among people with liver cirrhosis, patients’ care pathways need to be tailored depending on the etiology and stage of the disease.

Education for people with progressive neurological conditions can have negative effects: Evidence from a randomized controlled trial

Objectives: To test the effects of a home-based educational intervention in reducing the incidence and the risk of falls and pressure sores in adults with progressive neurological conditions. Design: Randomized controlled trial with 12 months follow-up. Setting: Participants’ homes in the City of Nottingham. Participants: One hundred and fourteen people with progressive neurological conditions recruited from general practices in Nottingham, including 53 with Parkinsons disease and 45 with multiple sclerosis. Interventions: In the education group (EG), baseline data were reviewed by an expert panel which advised on actions most likely to promote each individuals physical, social and psychological well-being. An occupational therapist (OT) then visited EG participants to provide education and information and to discuss a personalized 12-month health action plan. The comparison group (CoG) received standardized printed information delivered to their home. Main measures: Numbers of participants reporting falls and skin sores at two-monthly phone calls during the follow-up period of 12 months. Results: The EG reported significantly more falls during the follow-up period and at 12 months (adjusted odds ratio 2.83 (95% CI 1.07-7.47), p=0.036) and significantly more skin sores (adjusted odds ratio 12.74 (95% CI 1.14-142.6), p=0.039) than the CoG. There was no difference between CoG and EG in the Nottingham Extended Activities of Daily Living score, but EG patients showed a significant rise in this score over the study period of 1.62 (95% CI 0.69-2.55, p=0.002). Conclusions: Our findings provide evidence that education for people with progressive neurological conditions can have negative effects.

The epidemiology of childhood psoriasis: a scoping review

Psoriasis is an inflammatory noncommunicable skin disease that affects both adults and children. At present, the epidemiology and natural history of psoriasis are not widely understood. This scoping review aimed to map the existing literature on the epidemiology of childhood psoriasis, identify research gaps for future studies and provide a comprehensive, clinically useful review. Search strategies were developed for Ovid Medline, Ovid Embase, Google Scholar and hand searching. In total, 131 articles met the inclusion criteria and were mapped; 107 articles were included for data extraction. Over the last 25 years there has been a dramatic increase in the volume of published observational epidemiological studies on childhood psoriasis. The majority were case series or cross‐sectional studies, concentrated in Europe, Asia and North America. The prevalence of childhood psoriasis was found to be higher in European countries, older children and girls. Up to 48·8% of children had a family history of psoriasis in a first‐degree relative. The most frequent subtype was plaque psoriasis and the most common initial sites of presentation were the scalp, limbs and trunk. Specific genetic differences have been found between child‐onset and adult‐onset populations. Case–control and cohort studies investigating risk factors for psoriasis onset, comorbidities and long‐term health outcomes were extremely limited. The choice of study design and heterogeneity in methodology limit the validity and generalizability of the information, consistency of the results, and comparability of the studies. Well‐designed epidemiological studies are needed to provide precise and consistent information about the frequency and clinical presentation, risk factors, associated diseases and long‐term outcomes in childhood psoriasis.