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Despite advances in medical therapy, surgery continues to play a vital role in the management of Crohn's disease and its complications. Continuing from Part I of this series (small intestine/ileal disease), we focus next on colonic Crohn's disease and associated neoplasms. We will first review the surgical management of medical-refractory Crohn's colitis and its complications and then examine cancer risk, surveillance, and surgical management of Crohn's-associated colorectal dysplasia and malignancy. We conclude with a discussion of restoration of gastrointestinal continuity following colonic surgery for Crohn's disease.

Contains fulltext : 291657.pdf (Publisher’s version ) (Open Access) BACKGROUND: Anti-TNF drugs, such as infliximab, are associated with attenuated antibody responses after SARS-CoV-2 vaccination. We aimed to determine how the anti-TNF drug infliximab and the anti-integrin drug vedolizumab affect vaccine-induced neutralising antibodies against highly transmissible omicron (B.1.1.529) BA.1, and BA.4 and BA.5 (hereafter BA.4/5) SARS-CoV-2 variants, which possess the ability to evade host immunity and, together with emerging sublineages, are now the dominating variants causing current waves of infection. METHODS: CLARITY IBD is a prospective, multicentre, observational cohort study investigating the effect of infliximab and vedolizumab on SARS-CoV-2 infection and vaccination in patients with inflammatory bowel disease (IBD). Patients aged 5 years and older with a diagnosis of IBD and being treated with infliximab or vedolizumab for 6 weeks or longer were recruited from infusion units at 92 hospitals in the UK. In this analysis, we included participants who had received uninterrupted biological therapy since recruitment and without a previous SARS-CoV-2 infection. The primary outcome was neutralising antibody responses against SARS-CoV-2 wild-type and omicron subvariants BA.1 and BA.4/5 after three doses of SARS-CoV-2 vaccine. We constructed Cox proportional hazards models to investigate the risk of breakthrough infection in relation to neutralising antibody titres. The study is registered with the ISRCTN registry, ISRCTN45176516, and is closed to accrual. FINDINGS: Between Sept 22 and Dec 23, 2020, 7224 patients with IBD were recruited to the CLARITY IBD study, of whom 1288 had no previous SARS-CoV-2 infection after three doses of SARS-CoV-2 vaccine and were established on either infliximab (n=871) or vedolizumab (n=417) and included in this study (median age was 46·1 years [IQR 33·6-58·2], 610 [47·4%] were female, 671 [52·1%] were male, 1209 [93·9%] were White, and 46 [3·6%] were Asian). After three doses of SARS-CoV-2 vaccine, 50% neutralising titres (NT50s) were significantly lower in patients treated with infliximab than in those treated with vedolizumab, against wild-type (geometric mean 2062 [95% CI 1720-2473] vs 3440 [2939-4026]; p

This Major Research Paper explores the value of face-to-face communication in a digital age by examining the effect of face-to-face communication on media coverage. The author outlines the theoretical components of agenda-setting theory, presentation theory, and invitational rhetoric to illustrate the process by which individuals or groups compete to gain attention and power, and the role that face-to-face communication can play to persuade. This theory is examined with a political case study of the Liberal Party of Canada’s cross-Canada bus tour in July and August of 2010. The author provides a discourse analysis of newspaper editorials published in Ontario, Canada before and after then-Party Leader Michael Ignatieff visited. The author observes that the tone of media coverage is more favourable after face-to-face communication with citizens and journalists took place, suggesting that face-to-face communication is an effective tool for politicians in a digital age.

It is estimated that a third of people in the United Kingdom with signs of dementia are living without a formal diagnosis. In Wales, the proportion is nearly half. Some explanations for the gap between prevalence of dementia and number of diagnoses include living with a long-term partner/spouse and systemic barriers to diagnosis. This study recruited participants from the Cognitive Function and Ageing Studies-Wales (CFAS-Wales) cohort, randomly selected from people aged over 65 living in two areas of Wales, who met study criteria for a diagnosis of dementia and did not have a record of a formal diagnosis in general practice records. We aimed to understand more about the contexts and circumstances of people who live with and cope with cognitive difficulties without having a formal diagnosis of dementia. We conducted qualitative interviews with six participants and their spouses, and additionally with four family members of three invited people who were unable to take part. Themes were generated using thematic analysis. We present the argument that there is an adaptive response to low service levels and a complex interaction between the expectations of levels of service, perceptions of the legitimacy of cognitive problems and the right to make demands on services. This paper concludes that more could be done to address barriers to diagnosis and treatment services for those living with symptoms of dementia, but that the value placed on diagnosis by some individuals might be lower than anticipated by government policy.

The management of cholecysto-choledocholithiasis is controversial with the risks and benefits of one versus two-stage approaches debated. This study aims to perform decision analysis of minimally invasive laparo-endoscopic approaches. An advanced decision tree was constructed to compare pre, intra and post-operative ERCP and laparoscopic common bile duct exploration in terms of primary ductal clearance and significant complications for patients intended to undergo laparoscopic cholecystectomy. Transition probabilities were calculated from randomised controlled trials following a comprehensive literature search. Model uncertainties were extensively tested through deterministic and probabilistic Monte Carlo sensitivity analysis. Utility outcomes were 1 and 0.5 for successful primary clearance without and with complications, respectively, and 0 for failure of primary clearance of the duct. Twenty-one studies (n = 2697) were included in the analysis. At base case analysis, a laparo-endoscopic rendezvous approach had the highest utility output (0.90; no complication probability: 0.87/complication probability 0.06). Laparoscopic common bile duct exploration was ranked second with a utility output 0.87 (no complication probability: 0.82/complication probability 0.10). Pre-operative ERCP utility score was 0.84 (no complication probability: 0.78/ complication probability 0.11) and post-operative ERCP utility score was 0.78 (no complication probability: 0.71/complication probability 0.13). Monte Carlo analysis showed that laparo-endoscopic rendezvous and laparoscopic common bile duct exploration had an equal mean utility output of 0.57 (standard deviation 0.36; variance 0.13; 95% confidence interval 0.00–0.99 versus standard deviation 0.34; variance 0.12; 95% confidence interval 0.01–0.98). Laparo-endoscopic rendezvous had a superior treatment selection frequency of 39.93% followed by laparoscopic bile duct exploration (36.11%), pre-operative ERCP (20.67%) and post-operative ERCP (2.99%). One-stage approach to the management of cholecysto-choledocholithiasis is superior to two-stage, in terms of primary clearance of the duct and risk of operative morbidity. Laparo-endoscopic rendezvous approach could offer marginal additional benefit but more high-quality randomised controlled trials are needed.

BackgroundBarrett's esophagus is strongly associated with esophageal adenocarcinoma. Considering costs and risks associated with invasive surveillance endoscopies better methods of risk stratification are required to assist decision-making and move toward more personalised tailoring of Barrett's surveillance.MethodsA Bayesian network was created by synthesizing data from published studies analysing risk factors for developing adenocarcinoma in Barrett's oesophagus through a two-stage weighting process.ResultsData was synthesized from 114 studies (n = 394,827) to create the Bayesian network, which was validated against a prospectively maintained institutional database (n = 571). Version 1 contained 10 variables (dysplasia, gender, age, Barrett's segment length, statin use, proton pump inhibitor use, BMI, smoking, aspirin and NSAID use) and achieved AUC of 0.61. Version 2 contained 4 variables with the strongest evidence of association with the development of adenocarcinoma in Barrett's (dysplasia, gender, age, Barrett's segment length) and achieved an AUC 0.90.ConclusionThis Bayesian network is unique in the way it utilizes published data to translate the existing empirical evidence surrounding the risk of developing adenocarcinoma in Barrett's esophagus to make personalized risk predictions. Further work is required but this tool marks a vital step towards delivering a more personalized approach to Barrett's surveillance.

Background Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up. Methods A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment. Results A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery. Conclusion This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions., Adult appendicitis is the most common emergency general surgery condition worldwide, and is normally treated with laparoscopic appendicectomy despite evidence that it can be treated safely with antibiotics. The authors followed up patients who received operative treatment and non-operative treatment with antibiotics during the first wave of the COVID-19 pandemic. Non-operative management was associated with a shorter length of hospital stay, fewer complications and a significant health cost reduction compared with operative management.

AimsTo monitor the quality of physical health monitoring of patients prescribed depot antipsychotic medication in the North West Edinburgh Community Mental Health Team (CMHT). We also evaluated the completeness of prescriptions and Mental Health Act (Scotland) (Act) 2003 paperwork where relevant.BackgroundAntipsychotic medications are medicines for treating conditions such as Schizophrenia, but some may be associated with an increased risk of Metabolic Syndrome. Moreover, evidence indicates that patients with major mental disorder have a reduced life expectancy in comparison to those without such diagnoses. These two factors illustrate the importance of the physical health of this patient cohort being monitored on a regular basis. This project will evaluate how a local CMHT is performing, with the possibility of enacting service improvements if required.MethodThe records of the 60 patients prescribed depot antipsychotic medication administered by this CMHT were reviewed. A check-list was created consisting of 14 categories analysing the quality of physical health monitoring, as well as compliance with prescription standards and, where relevant, Mental Health Act (Scotland) (Act) 2003 paperwork. We compared patient records against our checklist for the calendar year of 2019. The Scottish Intercollegiate Guidelines Network (SIGN) 131 (Management of Schizophrenia) section 5.2 was used as the gold standard for physical health monitoring against which the data we collected was compared.ResultWe identified a wide range of flaws with the current system and implementation of monitoring, and difficulty in locating the required information. There was no consistent monitoring of physical observations on electronic record, nor an accepted alternative way in which this was documented. Furthermore, blood tests were not consistently obtained either by the service or GP practices in a reproducible manner. This led to discussions within the CMHT regarding creation of a new pathway for the monitoring of this patient cohort using a Quality Improvement model, with the ultimate goal to establish a regular physical health clinic.ConclusionThere is significant evidence that patients with major mental disorder do not access healthcare as consistently as those without, leading to a disparity in life expectancy. In light of the fact that antipsychotic medications can be associated with Metabolic Syndrome, we have an even greater responsibility to tackle this marked health inequality by appropriately monitoring our patients. This was not done well in this particular CMHT, but this project will lead to improvements in the service and ultimately patient care.

Gaelic women’s poetry and song track the reception of Reformed theology in Gaelic communities both geographically and diachronically. They also allow insights into the spiritual, ethical, and societal concerns of those whose voices are otherwise unheard. Whether ostensibly secular or explicitly spiritual, Gaelic women’s songs carry a record of the religious, cultural, and domestic life of Highland Scotland in many individual voices. The earliest Gaelic evangelical songs belonged to the oral tradition, and were specifically directed towards making biblical teaching and Reformed doctrine accessible within non-literate Gaelic-speaking communities. Women’s spiritual songs quickly became a forum for personal and communal religious expression, public exhortation, and discussions on faith and doctrine. They show women, both literate and non-literate, acting as spiritual mentors, actively engaging in biblical exegesis, relating scriptural teaching to contemporary issues, and demanding that Christian ethics be applied in both personal and public life.

In this article, we trace the ideological and social policy roots of asset-based community development (ABCD) in the United States and the United Kingdom, and explore how this approach has been legitimized in Scotland. We argue that ABCD is a capitulation to neoliberal values of individualization and privatization. Drawing on findings from our empirical work, we discuss how ABCD generates dilemmas for community development. Although some practitioners are able to adapt ABCD to focus on renewing Scottish democracy, several practitioners are using ABCD to privatize public issues such as inequality and justify dramatic cuts to the Scottish welfare state.

Background: The aim of the study was to review our post-colonoscopy colorectal cancer (PCCRC) diagnoses rate and compare it to national standards, to identify any common factors in our missed cancer cases and create a policy for capturing missed cancers data.Methods: We analyzed retrospectively collected data on patients with colorectal cancer from January 2015 to July 2017. Patients who had a previous colonoscopy within 3 years of diagnosis were then identified. We excluded colonoscopies done within 6 weeks of diagnosis or repeat colonoscopies due to poor bowel preparation.Results: 503 colorectal cancer patients were identified. 135 (26.8%) were initially diagnosed without a lower GI endoscopy. 30 had a negative colonoscopy 6 weeks to 3 years prior to diagnosis. Only 10 patients (2.7%) were true missed lesions (false negative colonoscopy). Male/female: 5/5. Mean age was 68.4 (49-80). 9 patients had good or satisfactory bowel preparation. 50% of lesions were found during follow-up or treatment of a different lesion. Average time from false negative scope to diagnosis was 20.3 months (4-31). Sites of missed lesions are left colon- 4, low rectum- 3, caecum- 2 and transverse colon- 1.Conclusions: Our PCCRC rate is below the GUT recommended target of

Glucocorticoids stimulate the prostaglandin E2 production of confluent amnion cell cultures, but have no stimulatory effect on the PGE2 output of freshly isolated human amnion cells. Since protein phosphorylation may modify the responsiveness of target cells to steroids, and activators of protein kinase C (PKC), as well as corticosteroids, promote amnion cell PGE2 output by stimulating the synthesis of prostaglandin endoperoxide H synthase (PGHS), we investigated the possibility that PKC is involved in the glucocorticoid-induction of PGE2 synthesis in cultured amnion cells. The dexamethasone-induced PGE2 output of arachidonate-stimulated cells was blocked by the protein kinase inhibitors staurosporine, K-252a, H7, HA1004, and sphinganine, in a manner consistent with their effect on PKC. However, dexamethasone increased the PGE2 production of cultures treated with maximally effective concentrations of the PKC-activator compound TPA. Moreover, dexamethasone stimulated PGE2 synthesis in cultures which were desensitized to TPA-stimulation by prolonged phorbol ester treatment. Concentration-dependence studies showed that staurosporine completely (greater than 95%) blocked glucocorticoid-provoked PGE2 synthesis at concentrations which did not inhibit TPA-stimulated prostaglandin output, and that K-252a inhibited the effect of TPA by more than 95% at concentrations which decreased the effect of dexamethasone only moderately (approximately 40%). Dibutyryl cyclic AMP had no influence on the basal- or dexamethasone-stimulated PGE2 production, and on the staurosporine inhibition of the steroid effect. These results show that glucocorticoids and phorbol esters control amnion PGE2 production by separate regulatory mechanisms. It is suggested that the response of human amnion cells to glucocorticoids is modulated by protein kinase(s) other than phorbol ester-sensitive PKC and cyclic AMP-dependent protein kinase.

An intervention study was conducted in a Vancouver, British Columbia High School in the Spring of 1977. The objective of the study was to measure changes in knowledge, attitude and behaviour in regard to the cardiovascular risk-factors, smoking, physical inactivity and high-fat diet, following a short-term educational program. The principal hypotheses were that students exposed to an educational program directed towards reducing cardiovascular risk-behaviours will: (I) have more knowledge about cardiovascular risk-behaviours than students who are not exposed to the program. (2) have a more positive attitude towards reducing cardiovascular risk-behaviours than students who are not exposed to the program. (3) will change their behaviour in such a way as to practice fewer risk-behaviours than students who are not exposed to the program. The majority of the students in the study school were from middle-class backgrounds and were in the university entrance program. The study population consisted of all of the students in grade 9 and one-half of the students in grade 10 and 11 for a total of 510 students. The students were randomly assigned to two groups. One group was exposed to a health educational program directed towards reducing risk of cardiovascular disease. The program consisted of a presentation by a health educator, a film and written materials provided by the British Columbia Heart Foundation. The control group took part in the regular school guidance classes. A pretest, post-test research design was used. The measuring instrument used was a written questionnaire developed from the content of the educational program. The students completed the same questionnaire before and after their exposure to the educational program. The students also took part in pretest, post-test fitness testing using the Canada Home Fitness Test. The 287 students exposed to the educational program were compared with 187 from the same grade and school who were not exposed to the educational program. In regard to the hypotheses stated above, significantly more students in the intervention group answered 11 of the 34 of the knowledge questions correctly. There were no differences between the intervention and nonintervention groups indicated by replies to the questions about attitude towards reducing cardiovascular risk. There were no differences between the intervention and nonintervention group in self-reported, cardiovascular risk-behaviour. Fitness levels as measured by the Canada Home Fitness Test showed a puzzling increase in fitness among the nonintervention group. In summary, the study indicated that students exposed to a health educational program in school had a significant increase in health knowledge but not in health, attitude nor behaviour. The evidence in this study that students made significant knowledge gains following an educational program, together with the theory that knowledge of factual information is often the first step in the decision making process (Bloom, 1956), justifies continued health educational programs in schools. Although, this study did not provide evidence of attitude or behaviour change in the short-term, further long-term evaluative studies of health educational programs in the schools are indicated.