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Introduction: Perianal manifestations occur in almost half of patients with Crohn's disease and often respond poorly to conventional therapies. The introduction of anti-tumour necrosis factor alpha agents (e.g. infliximab) has altered the management of patients who fail first and second line medical and surgical therapies.Methods: We performed a literature search of the PubMed database using the Medical Search Headings infliximab, perianal Crohn's disease, fistulae, cost and safety. We also performed a manual search using references from these articles, review articles and proceedings from major gastroenterology meetings.Results: Use of infliximab, at a dose of 5mg/kg at intervals of 0, 2 and 6 weeks, results in significant improvement in disease in approximately 70% of patients with fistulae. Prior examination under anaesthesia with placement of non-cutting seton sutures in fistula tracks is a useful adjunct in many patients. Preliminary results show a benefit from maintenance infliximab therapy and from concomitant use of immunosuppressants such as azathioprine. No clinical or biochemical markers have been identified which predict non-response to infliximab, although its use is contraindicated in patients with strictures. Acute infusion reactions are the most common side-effect of infliximab therapy and they are usually mild. Despite initial fears, the incidence of opportunistic infection is low. There is inadequate information, at present, regarding a possible increase in incidence of lymphoma with infliximab therapy. Infliximab is expensive compared with established therapies and its use will increase the lifetime cost of treating Crohn's disease.Conclusion: While infliximab is a useful adjunct in selected patients, the cornerstones of management of perianal Crohn's are essentially unchanged. [ABSTRACT FROM AUTHOR]

Aims To examine the understanding and beliefs of people with diabetes from the Bangladeshi community living in the UK. Methods Structured interviews were carried out with 14 people invited to a peer educational programme. All interviews were on a one-to-one basis and were in Sylheti or in English. Interviews were transcribed and analysed by two independent researchers. Results The majority of participants did not know what caused diabetes. Knowledge of the management of diabetes was linked to controlling sugar intake and a number of participants reported eating bitter foods such as bitter gourd to control their diabetes. There was little access to information as many participants did not speak English and did not have a Bengali-speaking doctor. The majority of participants felt that education classes should teach them what the doctor thought was important and that these classes would best be advertised by word of mouth. Therefore, participants were quite passive about their own self management and relied very strongly on the doctor’s views and recommendations. Conclusions Findings from this study can be used to help health professionals working with Bangladeshi people. There is a need for improved information for Bangladeshi people and much of this information might need to come from health professionals. In addition, there is a need for increased awareness by health professionals of practices used by Bangladeshi people, such as eating bitter gourd (which may enhance the effects of rosiglitazone), and the influence these practices could have on the individual’s diabetes management. [ABSTRACT FROM AUTHOR]

Aims The aim of this study was to assess an adapted version of the X-PERT® Programme for Type 2 diabetes within a Bangladeshi population. Methods Bangladeshi adults, living in the UK, with Type 2 diabetes participated in a diabetes educational session based on an adapted version of the X-PERT® Programme. Participants attended a session, led by a trained peer educator and carried out in Sylheti. All participants who registered on the course were telephoned or visited in person the day before the course as a reminder. Results Registration to attend the course was excellent. However, actual attendance rates were 58% (42/72) out of those registered. Once participants attended, overall they enjoyed attending the sessions and felt they benefited as they understood more about how to better self-manage their condition. Those aspects of the sessions that were most enjoyed were group discussions and interactive posters to explain diabetes. Participants requested a home-based exercise guide, which was developed by the research team. The study was underpowered to show behaviour change, but did demonstrate a trend to improvement in self-care activities. All participants reported recommending the course to others. Conclusions There was an excellent response in terms of registration for the course. However, the time to attend the course appeared to be a barrier to participants. Nevertheless, for those attending the course, responses were very positive. The amended X-PERT® Programme could be used as a component of a package to improve outcome and self-management for people with diabetes in the Bangladeshi community. [ABSTRACT FROM AUTHOR]

Aim To define the incidence and characteristics of latent autoimmune diabetes in adults (LADA). Methods We estimated the incidence of LADA by examining the incidence of Type 2 diabetes and calculating the proportion that were antibody positive. The incidence of Type 2 diabetes was calculated by analysis of computer records of 35 out of 36 general practices in Swansea. In addition, thirty-two practices participated in recruiting people with Type 2 diabetes to have glutamic acid decarboxylase (GAD) antibody testing. Results The crude proportion of Type 2 patients testing positive for GAD antibodies (GADA) was 4.0% (28/683). This figure did not change when we analysed only the practices that tested more than 60% of all eligible patients. In these practices, 79% (387/487) of all eligible patients were GADA tested and 14/387 [3.6% (95% confidence interval: 2.1–6.1%)] were classified as having LADA. This gives an incidence of LADA of 9 per 100 000 (95% confidence interval: 4.4–17.8 per 100 000) people per year registered with a general practitioner. Patients testing positive for GADA were more likely to have a lower body mass index, other antibodies, to present with acute symptoms and to have higher glycated haemoglobin. Conclusions This is the first study of the incidence of LADA in primary care. People with LADA make up a significant proportion of people with apparent Type 2 diabetes. Patients with LADA are likely to be symptomatic, have poorer glycaemic control and have other autoimmune antibodies. [ABSTRACT FROM AUTHOR]

Introduction: Perianal manifestations occur in almost half of patients with Crohn's disease and often respond poorly to conventional therapies. The introduction of anti-tumour necrosis factor alpha agents (e.g. infliximab) has altered the management of patients who fail first and second line medical and surgical therapies. Methods: We performed a literature search of the PubMed database using the Medical Search Headings infliximab, perianal Crohn's disease, fistulae, cost and safety. We also performed a manual search using references from these articles, review articles and proceedings from major gastroenterology meetings. Results: Use of infliximab, at a dose of 5 mg/kg at intervals of 0, 2 and 6 weeks, results in significant improvement in disease in approximately 70% of patients with fistulae. Prior examination under anaesthesia with placement of nonacutting seton sutures in fistula tracks is a useful adjunct in many patients. Preliminary results show a benefit from maintenance infliximab therapy and from concomitant use of immunosuppressants such as azathioprine. No clinical or biochemical markers have been identified which predict non- response to infliximab, although its use is contraindicated in patients with strictures. Acute infusion reactions are the most common side-effect of infliximab therapy and they are usually mild. Despite initial fears, the incidence of opportunistic infection is low. There is inadequate information, at present, regarding a possible increase in incidence of lymphoma with infliximab therapy. Infliximab is expensive compared with established therapies and its use will increase the lifetime cost of treating Crohn's disease. Conclusion: While infliximab is a useful adjunct in selected patients, the cornerstones of management of perianal Crohn's are essentially unchanged [ABSTRACT FROM AUTHOR]

Background: Latent autoimmune diabetes in adults (LADA) is a form of type 1 diabetes which in the UK is often diagnosed and treated as type 2 diabetes (T2D). People with LADA show slow progression to insulin dependence and can be distinguished from T2D by blood tests for glutamic acid decarboxylase autoantibodies (GADA). Aims. This study explores the views and experiences of patients who are newly diagnosed with LADA, with particular reference to (i) routine GADA testing; (ii) whether this diagnosis has any influence on the self-management of their diabetes; and (iii) the information needs of patients newly diagnosed with LADA. Methods: Ten consecutive patients newly diagnosed with LADA (GADA positive) were invited to participate in individual qualitative semi-structured interviews. Their views and experiences were analysed into codes and categories, using a constant comparative method. Findings: Participants supported routine GADA testing in all patients with diabetes because the provision of a correct diagnosis has an empowering effect on patients, as it encourages the consideration of treatment options early on in the condition. Participants preferred to rely on future Hba(1c) levels and their doctor's opinion to determine a change in treatment to insulin. Some participants had difficulty distinguishing between the different types of diabetes, including LADA. Others needed to ask questions about LADA in addition to written information. Conclusions: Participants were supportive of routine GADA testing, would prefer not to start insulin immediately following a diagnosis of LADA and needed to discuss treatment options with health professionals who were knowledgeable on LADA. [ABSTRACT FROM AUTHOR]

Background: To determine the extent and nature of changes associated with COVID-19 infection in terms of healthcare utilisation, this study observed healthcare contact 1 to 4 and 5 to 24 weeks following a COVID-19 diagnosis compared to propensity-matched controls. Methods: Two hundred forty nine thousand three hundred ninety Welsh individuals with a positive reverse transcription–polymerase chain reaction (RT-PCR) test were identified from data from national PCR test results. After elimination criteria, 98,600 positive individuals were matched to test negative and never tested controls using propensity matching. Cohorts were split on test location. Tests could be taken in either the hospital or community. Controls were those who had tested negative in their respective environments. Survival analysis was utilised for first clinical outcomes which are grouped into primary and secondary. Primary outcomes include post-viral-illness and fatigue as an indication of long-COVID. Secondary outcomes include clinical terminology concepts for embolism, respiratory conditions, mental health conditions, fit notes, or hospital attendance. Increased instantaneous risk for positive individuals was quantified using hazard ratios (HR) from Cox regression, while absolute risk (AR) and relative risk were quantified using life table analysis. Results: Analysis was conducted using all individuals and stratified by test location. Cases are compared to controls from the same test location. Fatigue (HR: 1.77, 95% CI: 1.34–2.25, p = < 0.001) and embolism (HR: 1.50, 95% CI: 1.15–1.97, p = 0.003) were more likely to occur in all positive individuals in the first 4 weeks; however, anxiety and depression (HR: 0.83, 95% CI: 0.73–0.95, p = 0.007) were less likely. Positive individuals continued to be more at risk of fatigue (HR: 1.47, 95% CI: 1.24–1.75, p = < 0.001) and embolism (HR: 1.51, 95% CI: 1.13–2.02, p = 0.005) after 4 weeks. All positive individuals are also at greater risk of post-viral illness (HR: 4.57, 95% CI: 1.77–11.80, p = 0.002). Despite statistical association between testing positive and several conditions, life table analysis shows that only a small minority of the study population were affected. Conclusions: Community COVID-19 disease is associated with increased risks of post-viral-illness, fatigue, embolism, and respiratory conditions. Despite elevated risks, the absolute healthcare burden is low. Subsequently, either very small proportions of people experience adverse outcomes following COVID-19 or they are not presenting to healthcare. [ABSTRACT FROM AUTHOR]

This brief report discusses the introduction of routine Glutamic Acid Decarboxylase Antibody (GADA) testing in primary care for newly diagnosed diabetes. GADA testing is well used and the majority of people found to be positive are initiated on insulin rapidly and progress to require a basal bolus regime. [ABSTRACT FROM AUTHOR]

Abstract: This brief report discusses the introduction of routine Glutamic Acid Decarboxylase Antibody (GADA) testing in primary care for newly diagnosed diabetes. GADA testing is well used and the majority of people found to be positive are initiated on insulin rapidly and progress to require a basal bolus regime. [Copyright &y& Elsevier]

The incidence of Type 2 diabetes is increasing worldwide and diabetes is four times more common among ethnic minority groups than among the general Caucasian population. This study reflects on the specific issues of engaging people and evaluating interventions through written questionnaires within older ethnic minority groups.~Background~Background~The original protocol set out to evaluate an adapted version of the X-PERT patient program http://www.xpert-diabetes.org.uk/ using questionnaires and interviews.~Methods~Methods~Questionnaires, even verbally completed, were unsuccessful and difficult to administer as participants found the questionnaire structure and design difficult to follow and did not perceive any benefit to completing the questionnaires. The benefits of attending the course were also poorly understood by participants and in many cases people participated in coming to the course as a favour to the researcher. Engaging participants required word of mouth and the involvement of active members of the community.~Results~Results~Peer led courses and their evaluation in older ethnic minority communities needs a very different approach for that in younger Caucasian patients. A structured approached to evaluation (favoured by western educational system) is inappropriate. Engaging participants is difficult and the employment of local well known people is essential.~Conclusion~Conclusions [ABSTRACT FROM AUTHOR]

Background: The clinical effectiveness of complementary and alternative medicines (CAMs) is widely debated because of a lack of clinical trials. The internet may provide an effective and economical approach for undertaking randomised controlled trials (RCTs) of low-risk interventions. We investigated whether the internet could be used to perform an internet-based RCT of a CAM fulfilling the revised CONSORT (Consolidated Standards of Reporting Trials) statement quality checklist for reporting of RCTs. A secondary aim was to examine the effect of probiotics compared to placebo in terms of well-being over 12 weeks. Methods: People aged ≥18 years with confirmed spondyloarthropathy living in the United Kingdom with internet access were invited to participate in an internet-based RCT of probiotic compared to placebo for improving well-being and bowel symptoms. The intervention was a probiotic containing 4 strains of live bacteria or identical placebo taken by mouth daily for 3 months. The primary outcome measure was the performance of the trial according to the revised CONSORT statement. Results: 147 people were randomised into the trial. The internet-based trial of the CAM fulfilled the revised CONSORT statement such as efficient blinding, allocation concealment, intention to treat analysis and flow of participants through the trial. Recruitment of the required number of participants was completed in 19 months. Sixty-five percent (96/147) completed the entire 3 months of the trial. The trial was low cost and demonstrated that in an intention to treat analysis, probiotics did not improve well-being or bowel symptoms. Conclusion: The internet-based RCT proved to be a successful and economical method for examining this CAM intervention. Recruitment, adherence and completion rate were all similar to those reported with conventional RCTs but at a fraction of the cost. Internet-based RCTs can fulfil all the criteria of the revised CONSORT statement and are an appropriate method for studying low-risk interventions. Trial registration: ISRCTN36133252 [ABSTRACT FROM AUTHOR]

Osteoporotic fractures in older people are a major and increasing public health problem. We examined the effect of vitamin D supplementation on fracture rate in people living in sheltered accommodation. In a pragmatic double blind randomised controlled trial of 3 years duration, we examined 3,440 people (2,624 women and 816 men) living in residential or care home. We used four-monthly oral supplementation using 100,000 IU vitamin D2 (ergocalciferol). As a main outcome measure, we used the incidence of first fracture using an intention to treat analysis. This was a multicentre study in 314 care homes or sheltered accommodation complexes in South Wales, UK. The vitamin D and placebo groups had similar baseline characteristics. In intention-to-treat analysis, 205 first fractures occurred in the intervention group during a total of 2,846 person years of follow-up (7 fractures per 100 people per year of follow-up), with 218 first fractures in the control group over 2,860 person years of follow-up. The hazard ratio of 0.95 (95% confidence interval 0.79–1.15) for intervention compared to control was not statistically significant. Supplementation with four-monthly 100,000 IU of oral vitamin D2 is not sufficient to affect fracture incidence among older people living in institutional care. [ABSTRACT FROM AUTHOR]

Cross-sectoral cancer care is complex and involves collaboration from health care professionals ( HCPs) across multiple sectors. However, when health information exchange ( HIE) is not adequate, it results in impeded coordination and continuity of care. A web-based personal electronic health record ( PEPA) under patients′ control, providing access to personal health data across sectors, is being developed. Aim of this study was to explore perceived benefits and concerns. Using a qualitative approach, 10 focus groups were performed collecting views of three prospective user groups: patients with colorectal cancer ( n = 12), physicians ( n = 17) and other HCPs ( n = 16). Representatives from different health sectors across the Rhine-Neckar region (Germany) participated. Data were audio- and videotaped, transcribed verbatim and thematically analysed. Our study shows that patients and HCPs expected a PEPA to enhance cross-sectoral availability of information, cross-sectoral cooperation and facilitate data management. Quality of cancer care was expected to be improved. Concerns were expressed in terms of data protection and data security. Concepts like a PEPA offer the chance to support HIE and avoid gaps of information in cross-sectoral cancer care. This may lead to improvements in coordination and continuity of care. Issues concerning data security and protection have to be addressed. [ABSTRACT FROM AUTHOR]

Endometriosis affects up to 10% of women of reproductive age and 176 million women worldwide. The prevalence in women with infertility is between 30% and 50% but may be higher in women with pelvic pain, interstitial cystitis, or irritable bowel syndrome. Cytokeratin 19 has been suggested as a potential biomarker in urine for the diagnosis of this condition. The objective of this study was to prospectively determine the accuracy and the performance of a urinary cytokeratin 19 (uCYFRA 21-1) test for diagnosing endometriosis. Ninety-eight consecutive women who underwent laparoscopy had a urinary sample obtained before surgery and were included in the study. Endometriosis was diagnosed by laparoscopy and pathology in 64.3% (63 of 98 women). The estimates and 95% confidence intervals for sensitivity, specificity, positive and negative predictive values, and likelihood ratios were 11.1% (4.5%-21.5%), 94.3% (80.8%-99.3%), 77.7% (39.9-97.1), 37% (27-47.9), 1.94 (0.43-8.86), and 0.94 (0.84-1.06), respectively. Despite the high specificity, the uCYFRA 21-1 test has limited value for clinical practice to discriminate between women with and without endometriosis. [ABSTRACT FROM AUTHOR]

Background Variations in reported prevalence of challenging behaviour indicate the need for further epidemiological research to support accurate planning of future service provision. Methods All services providing for people with learning disabilities across seven unitary authorities, with a total population of 1.2 million, were screened to identify people with challenging behaviour. Interviews were conducted with primary carers to gain data on identified individuals' characteristics and support. Measures designed for a similar study conducted in Manchester University were incorporated to allow direct comparison with earlier findings, together with standardized tools to assess adaptive behaviour and social impairment. Results In total, 4.5 (2.5–7.5) people per 10 000 population were rated as seriously challenging, representing 10% (5.5–16.8%) of the learning disability population; the most prevalent general form was other difficult/disruptive behaviour, with non-compliance being the most prevalent topography. The majority showed multiple behaviours and multiple topographies within each general behaviour category. Also identified were substantial numbers of additional people reported as presenting challenging behaviours at lower degrees of severity. Conclusions Prevalence rates for seriously challenging behaviours were comparable to those reported in the earlier studies, thus confirming previous findings. The prevalence of less serious challenging behaviour also has major clinical significance and emphasizes the need for enhanced understanding and skills among personnel within primary- and secondary-tier health, education and social care services, and for strengthening the capacity of community teams to provide behavioural expertise. [ABSTRACT FROM AUTHOR]

Background Out of area placements for people with challenging behaviour represent an expensive and often ineffective strategy for meeting the needs of this service user group. Methods More than 800 agencies and service settings in a large area of South Wales were screened to identify children and adults with challenging behaviour against a number of defined operational criteria. Detailed data on identified individuals and the services they received were collected by interviewing key informants. Univariate and multivariate statistics were employed to identify predictors of out of area placement. Results In total, 1458 people were identified. Full data were available for 901 participants, 97 of whom were placed out of area. Predictors of out of area placement included behaviours resulting in physical injury and exclusion from service settings, a history of formal detention under the mental health act, the presence of mental health problems, a diagnosis of autism and higher total score on the Adaptive Behaviour Scale. Out of area placements were typically of high cost, and associated with only limited evidence of improved service quality. Conclusions Identifying predictors for out of area placement can be used to highlight deficiencies in local services and individuals at increased risk of exclusion from local services. [ABSTRACT FROM AUTHOR]

Thrombomodulin (TM) is an endothelial receptor that exhibits anticoagulant, antifibrinolytic and anti-inflammatory activity by inhibiting thrombin and cellular adhesion. In this study, the expression and significance of TM was examined in primary colorectal cancer and its prognostic implications explored. TM immunostaining was performed on formalin-fixed, paraffin-embedded tissue sections, from primary lesions of 200 patients with colorectal carcinoma. Institutional Ethical approval was granted and clinical data retrieved from patients' records. All normal colonic tissue expressed TM on endothelial cells. TM tumour cell expression was demonstrated in 53 (26.5%) cases and 147 (73.5%) showed no neoplastic cell staining. On univariate and multivariate analysis TM expression on tumour cells correlated significantly with tumour stage, differentiation, Jass score and 5 year survival. TM expression decreases as overall stage and tumour size increase (P=0.03). In all, 91% TM positive tumours were well differentiated and 85% of TM negative tumours were poorly differentiated (P<0.01). Five year survival rates of patients with positive and negative TM expression were 71 and 41%, respectively. Survival rate was poorer in those patients who were TM negative compared with those who were positive (P<0.01). A total of 101 (50.5%) of the cases were node negative. In this group, 5 year survival rates of patients with positive and negative TM expression were 87.5 and 37.8%, respectively, demonstrating a poorer survival rate for those who are node negative and TM negative at the time of surgery (P<0.001). This study demonstrates that loss of TM is a key indicator in tumour biology and prognosis. [ABSTRACT FROM AUTHOR]

Presents information on a study which provided evidence supporting the existence of non-major histocompatibility complex genes involved in ankylosing spondylitis. Summaries of families included in genome screening; Regions showing stronger linkage with the disease; Details on the analysis performed.

Objectives The UKBOI study was designed to quantify important components of the population burden of injury in the UK. Methods A mixed methods study incorporating a multi-centred prospective cohort of injured individuals; extrapolation of patient reported outcomes to population metrics using routine data from emergency departments (ED), hospital discharge registers and mortality data; calculation of Disability Adjusted Life Years (DALYs) using Global Burden of Diseases methodology and estimated indirect costs; and the calculation of direct medical costs. Results The study recruited 1517 injured individuals. Estimated numbers (and rates per 100 000) for UK population extrapolations were 750 999 (1240) for hospital admissions, 7 982 947 (13 339) for emergency department attendances, and 22 185 (36.8) for injury related deaths, in the financial year 2005/6. An estimated 1 574 000 DALYs were lost from injuries occurring in that year, with 80% due to Years Lived with Disability (YLDs) and 20% from Years of Life Lost (YLLs). Some 10% of DALYs lost were due to YLDs occurring within 12 months post injury and 70% due to lifelong injuries. Direct medical costs were estimated at 482 million for ED visits and 2.15 billion for inpatient stays, with indirect costs of up to 31.5 billion. The qualitative study with 90 participants revealed many additional negative consequences for individuals, family and society. Implications The high population burden and costs associated with injuries in the UK demonstrates the need for sustained policies and interventions in support of prevention. [ABSTRACT FROM PUBLISHER]

Aim To compare different models of excess health service utilisation (HSU) to produce enhanced estimates of the short and medium term direct medical costs of injuries. Method A retrospective and prospective anonymised electronic population cohort, encompassing all residents of Swansea, Wales, UK (n = 227 100). The Secure Anonymised Information Linkage (SAIL) system is being used to anonymously track injured and uninjured individuals through multiple healthcare databases over a 3 year period. Excess HSU within emergency department, inpatient and outpatient sectors will be determined using two different models. In one the HSU postinjury will be counted and subsequently adjusted for potential confounders, including age, gender, deprivation status, preinjury healthcare utilisation, co-morbidities and access to/distance from hospital, using negative binomial regressions. In the other model the number of healthcare contacts observed during the follow-up period will be compared with the number expected to have occurred, based on pre injury healthcare contacts, to calculate standardised utilisation ratios. In both models general practice and inpatient data will be used to identify co-morbidities. Results Analysis is ongoing and results will be presented at the conference. Conclusion This study presents an enhanced approach to determining the extent of excess HSU and medical costs following injury, and will contribute to improved measurement of the burden of injury. [ABSTRACT FROM PUBLISHER]

Objectives The UKBOI study was designed to quantify important components of the population burden of injury in the UK. Methods A mixed methods study, incorporating a multi-centred prospective cohort of injured individuals; extrapolation of patient reported outcomes to population metrics using routine data from emergency departments (ED), hospital discharge registers and mortality data; calculation of Disability Adjusted Life Years (DALYs) using Global Burden of Diseases methodology and estimated indirect costs; and the calculation of direct medical costs. Results The study recruited 1517 injured individuals. Estimated numbers (and rates per 100 000) for UK population extrapolations were 750 999 (1240) for hospital admissions, 7 982 947 (13 339) for emergency department attendances and 22,185 (36.8) for injury related deaths, in the financial year 2005/6. An estimated 1 771 486 DALYs were lost from injuries occurring in that year, with 82% due to Years Lived with Disability (YLDs) and 18% from Years of Life Lost (YLLs). Some 20% of DALYs lost were due to YLDs occurring within 12 months post injury and 62% due to lifelong injuries. Direct medical costs were estimated at 482 million for ED visits and 2.15 billion for inpatient stays, with indirect costs of up to 35.5 billion. The qualitative study with 90 participants revealed many additional negative consequences for individuals, family and society. Implications The high population burden and costs associated with injuries in the UK demonstrates the need for sustained policies and interventions in support of prevention. [ABSTRACT FROM PUBLISHER]