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Objectives To determine the age-standardised prevalence of inflammatory bowel disease (IBD) in a metropolitan area of Sydney, with a focus on its prevalence among older people. Design, setting Population-based epidemiological study of people with IBD in the City of Canada Bay, a local government area in the inner west of Sydney, during 1 March 2016 - 10 November 2016. Participants Patients diagnosed with confirmed IBD according to the Copenhagen or revised Porto criteria. Main outcome measures Crude prevalence of IBD, including Crohn disease and ulcerative colitis; age-standardised prevalence of IBD, based on the World Health Organization standard population; prevalence rates among people aged 65 years or more. Results The median age of 364 people with IBD was 47 years (IQR, 34-62 years); 185 were women (50.8%). The crude IBD prevalence rate was 414 cases (95% CI, 371-456 cases) per 100 000 population; the age-standardised rate was 348 cases (95% CI, 312-385 cases) per 100 000 population. The age-standardised rate for Crohn disease was 166 cases (95% CI, 141-192 cases) per 100 000 population; for ulcerative colitis, 148 cases (95% CI, 124-171 cases) per 100 000 population. The IBD prevalence rate in people aged 65 years or more was 612 cases (95% CI, 564-660 cases) per 100 000, and for those aged 85 years or more, 891 cases (95% CI, 833-949 cases) per 100 000; for people under 65, the rate was 380 cases (95% CI, 342-418 cases) per 100 000. Conclusions We found that the prevalence of confirmed IBD in a metropolitan sample was highest among older people. Challenges for managing older patients with IBD include higher rates of comorbid conditions, polypharmacy, and cognitive decline, and the immunosuppressive nature of standard therapies for IBD. more...

Thiopurines effectively maintain remission in ulcerative colitis patients. Whether early initiation of thiopurines after ulcerative colitis diagnosis decreases proximal disease progression and colectomy rates is not known.We conducted a cohort study of ulcerative colitis subjects recruited from 1970 to 2009. Early thiopurine maintenance was defined as commencement of azathioprine or mercaptopurine within 5 years of diagnosis and maintenance for at least 6 months. Propensity score matching was conducted to correct for confounders influencing early thiopurine introduction. Outcomes of interest were colectomy rate and endoscopic proximal disease extension.982 consecutive ulcerative colitis subjects (12 879 patient-years) were recruited with 116 requiring colectomy. Thiopurines initiation and maintenance increased over time with median time to thiopurine commencement decreasing from 23 years in the first decade to 2 years in the last decade (P 0.0001). Multivariate analysis showed that early thiopurine maintenance significantly decreased the need for colectomy [hazard ratio, 0.13; 95% confidence interval (CI):0.03-0.55; P = 0.006]. The number of subjects needed to be treated to reduce one colectomy at 5 and 10 years was 18 (95% CI, 16- 36) and 12 (95% CI, 11-25). After propensity score matching, early thiopurine maintenance was significantly associated with decreased colectomy (hazard ratio, 0.10; 95% CI, 0.03-0.43; P = 0.002) and proximal progression of disease extent (hazard ratio, 0.26; 95% CI, 0.10-0.78; P = 0.015).Early thiopurine maintenance for6 months is significantly associated with reduced colectomy and proximal progression of disease extent in ulcerative colitis. more...

Strongyloides stercoralis is a soil-transmitted helminth, but it has a unique life cycle that can be completed in the human host, in a process known as autoinfection. Worldwide, the burden of disease is substantial (300 to 400 million infections). Strongyloidiasis is mainly prevalent in the tropics and subtropics, but there is as yet no global public health strategy for controlling the parasite. more...

PROBIOTICS—THE CONCEPTHistory and DefinitionsA century ago, Elie Metchnikoff (a Russian scientist, Nobel laureate, and professor at the Pasteur Institute in Paris) postulated that lactic acid bacteria (LAB) offered health benefits capable of promoting longevity. He suggested that “intestinal autoint more...

Helicobacter pylori infection is a major cause of morbidity and mortality worldwide. More than 50% of the global population is estimated to be infected. Differences in prevalence exist within and between countries, with higher prevalence seen among people with lower socio-economic status. Most transmission of infection occurs early in life, predominantly from person to person in the family setting. H. pylori is the cause of most peptic ulcer disease, gastric cancer and gastric mucosa-associated lymphoid tissue (MALT) lymphoma and causes symptoms in a subset of patients with functional dyspepsia. Choice of diagnostic test depends on the clinical context; urea breath tests and endoscopy with biopsy are the major diagnostic tools. Evidence-based indications for eradication of H. pylori infection are well documented. The most widely used and recommended eradication therapy in Australia is triple therapy comprising a proton pump inhibitor, amoxycillin and clarithromycin, usually for 1 week. Effective alternative regimens are available for patients with proven allergy to penicillin. Antimicrobial resistance is the major determinant of the outcome of eradication therapy. Trends in antibiotic resistance need to be monitored locally, but individual patient susceptibility testing is not usually necessary as it rarely guides the choice of therapy. The outcome of treatment should be assessed not less than 4 weeks after therapy. This is usually done with a urea breath test if follow-up endoscopy is not required. When first-line therapy fails, several proven second-line therapies may be used. Repeat first-line therapy and ad hoc regimens should be avoided. Overall cumulative eradication rates should approach 99%. more...

Background and Aim The use of immunomodulators (IMs) is often avoided in elderly patients with inflammatory bowel disease (IBD) due to concerns about complications. Our aim is to compare the use of IMs in elderly and younger patients with Crohn’s disease (CD) or ulcerative colitis (UC) and identify markers that predict their use. Methods In this retrospective cohort study, patients diagnosed with IBD from 1970 to 2009 were recruited from the “Sydney IBD Cohort.” Patients diagnosed at age 60 years old or older and between 16 and old 40 years were classified as “elderly-onset” and “young-onset” respectively. Results A total of 255 elderly-onset patients (115 CD, 140 UC) and 1244 young-onset patients (657 CD, 587 UC) were recruited. Most elderly-onset patients had colonic CD (61.4%), whereas young-onset patients had predominantly ileocolonic CD (42.8%, P < 0.0001). Left-sided UC was the most common disease localization for both elderly-onset (52.1%) and young-onset patients (42.2%, P = 0.013). The cumulative probability of IM exposure at 5 years post-diagnosis was significantly less in elderly-onset patients compared with young-onset patients for CD (20.0% vs 33.4%, P = 0.0002) and UC (7.8% vs 13.4%, P = 0.0007). Age at diagnosis was not associated with the time to IMs introduction. Charlson Comorbidity Index was shown to delay IM introduction in CD (hazard ratio [HR] 0.863; 95% CI, 0.787–0.946; P = 0.002) and UC (HR 0.807; 95% CI, 0.711–0.917; P = 0.001). Early IM use was associated with reduced need for abdominal and perianal surgery in CD (HR 0.177; 95% CI, 0.089–0.351; P < 0.0001). Conclusions Comorbidity and not age at diagnosis is associated with IM introduction. Early IM is associated with reduced surgery in both young- and elderly-onset CD but not UC. more...

Background Knowledge of Inflammatory Bowel Disease (IBD) prevalence allows health care administrators to understand disease burden and appropriately plan for research and medical care. Young IBD subjects often migrate from rural to urban areas for education and work opportunities, necessitating metropolitan prevalence studies to reduce under-representation. Also, the impact of urbanisation on IBD prevalence requires further exploration. Unlike IBD incidence, where young age-groups dominate, we hypothesised that the elderly age-groups would have the highest IBD prevalence given mortality rates being equivalent to the general population. We aimed to determine the first IBD prevalence rates for New South Wales, Australia. Methods This was an observational, population-based epidemiological study which captured disease information of people living with IBD within the metropolitan City of Canada Bay Local Government Area on the 1st of January 2016. The diagnosis was according to the Copenhagen Criteria. Age-standardisation was according to the WHO Standard Population. Results We identified 330 cases of IBD (49.1% male, median age 47, IQR=27, crude point prevalence rate of 371.5 per 100,000). Full diagnostic confirmation was achieved in 100%. The age-standardised point prevalence rate was 359.2 per 1 00 000. The crude point prevalence rates were 167.8, 158.8 and 45.0 per 1 00 000 for Crohn’s disease (CD), ulcerative colitis (UC) and IBD Unspecified (IBDU), respectively. The age-standardised rates were 171.6, 148.1 and 39.5 per 1 00 000 for CD, UC, and IBDU respectively. IBD prevalence steadily increased with age, peaking at 1061 per 1 00 000 in patients older than 85 years. A trend was observed between prevalence and socioeconomic status between suburbs. Conclusions Sydney exhibited the highest prevalence of IBD in Australasia. The extrapolated estimate for Australia was 89 000 people with IBD. Higher socioeconomic status and urbanisation may be contributing factors. The ageing IBD population accounts for the highest prevalence, peaking at greater than 1000 per 1 00 000. Safer therapies, cancer screening strategies and greater attention towards comorbidities are therefore of increasing importance in managing IBD patients. more...

Background: Polyethylene glycol laxatives are the cornerstone of the management of constipation in children. They are available with and without electrolytes.Aims: The aims of this network meta-analysis (NMA) were to assess the relative efficacy, safety and tolerability of polyethylene glycol with (PEG+E) or without electrolytes (PEG) in the management of constipation in children.Methods: A systematic review and NMA was undertaken to identify and analyse all published randomised controlled clinical trials of polyethylene glycol in children with constipation. Text word searches were carried out using MEDLINE, MEDLINE in Progress, EMBASE, Cochrane Database and Systematic Reviews databases covering inception to April 2015. The primary efficacy analysis was the mean number of bowel movements per week. Secondary endpoints assessed safety, tolerability and compliance.Results: 15 studies (involving 1,384 patients) were included in the NMA. PEG and PEG+E are both more effective than placebo, increasing the mean number of bowel movements per week by 2.3 (95% Crl 0.3, 4.4) and 2.2 (95% Crl 0.1, 4.7) respectively. Direct comparison of PEG+E with PEG identified no differences in efficacy, safety, or tolerability, with the exception of one study demonstrating better tolerability with PEG. Compared to PEG+E, PEG was easier to take, with a trend towards improved compliance.Conclusion: This NMA provides no evidence to support the clinical utility of added electrolytes to polyethylene glycol in the management of constipation in children. PEG alone is as effective as PEG+E and both therapies are well tolerated. This analysis supports the ongoing use of polyethylene glycol as a first-line treatment of constipation in children. Formulations without electrolytes should be considered first to optimize patient acceptability and adherence. more...

It is common in clinical practice to perform a colonoscopy in patients with symptoms, often with the aim of detecting or ruling out colorectal cancer. We present results from a systematic review and large primary clinical study that show that most bowel symptoms are not predictive of colorectal cancer. Considered individually, bowel symptoms that predicted colorectal cancer were rectal bleeding, change in bowel habit, rectal mucus and weight loss of more than 6 kg. Prediction was the strongest in those people who had symptoms weekly and of less than 12 months duration. When all bowel and general symptoms are considered together, only bleeding and rectal mucus remain predictive, and abdominal pain and anaemia become predictive. more...

Background Medication nonadherence is common in inflammatory bowel disease and is associated with poor outcomes. There has been no study on pediatric-to-adult transition as a risk factor for nonadherence in inflammatory bowel disease, which has been demonstrated in other diseases. We aimed to assess whether transitioned (TR) patients have higher nonadherence rates than young adults (YAs) diagnosed in adulthood. Methods Consecutive ambulatory subjects were prospectively recruited and completed the validated Medication Adherence Reporting Scale (MARS), with the primary outcome being adherence differences between group age-matched TR and YA groups. Pediatric subjects were taken as the control group. Perceptions of medication-related necessity and concerns were assessed with the Beliefs about Medicines Questionnaire (BMQ). Nonadherers (defined as MARS ≤16) received the Inflammatory Bowel Diseases Pharmacist Adherence Counselling (IPAC) intervention and adherence change was reassessed after 6 months as a secondary outcome. Results Adherence in TR patients (n = 38, mean age 20.4, 13.2% nonadherent) was noninferior to and numerically better than YAs diagnosed in adulthood (n = 41, mean age 21.2, 24.4%). Nonadherence in the pediatric control group (n = 50, mean age 14.7) was 8.0%. YAs had significantly higher medication-related concerns (14.6 versus 11.9, P = 0.02) than the pediatric group. The IPAC intervention reduced nonadherence rates by 60% (P = 0.004). Conclusions TR patients did not have worse adherence than YAs diagnosed in adulthood. Protective factors may include previous treatment in pediatric centers and the salient symptomatology of inflammatory bowel disease, whereas increasing concerns over medications contribute to nonadherence in YAs. Pharmacist-led counselling improves adherence in these patients. more...

BACKGROUND Poor adherence frequently impaired the efficacy of therapy to maintain remission from inflammatory bowel diseases (IBD). There is a lack of practical and effective interventions to improve adherence. This study aimed to identify modifiable risk factors, which may yield targets for new interventions. METHODS Participants with IBD were recruited from hospital outpatient clinics and office-based gastroenterologists. Demographic and disease-related data were recorded by means of self-administered questionnaires. Modifiable risk factors were assessed with the validated Belief about Medicine Questionnaire, Hospital Anxiety and Depression Score, and short inflammatory bowel disease questionnaire. Adherence was assessed separately for 5-aminosalicylates, thiopurines, and biological agents using the validated Medicine Adherence Report Scale (good adherence defined as >16). RESULTS Nonadherence occurred in 102 of 356 participants (28.7%). Adherence increased significantly with more aggressive therapies (median Medicine Adherence Report Scale: 5-aminosalicylates 18, thiopurines 19, biological 20; P < 0.0001). Nonadherence was not associated with anxiety and depression or disease-related patient knowledge. Adherent patients had significantly higher belief of necessity for medication (P < 0.0001) and a trend toward lower concerns about medication (P = 0.08). Membership of an IBD patient organization was associated with better adherence (P < 0.0001). Concerns about medication rose significantly with more aggressive therapies (P = 0.009), but belief of necessity was similar for all medications. CONCLUSIONS Nonadherence occurs most frequently with 5-aminosalicylates. Belief of necessity may prove the key target for future interventions, although general IBD education is unlikely to yield an adherence benefit. Patient organization membership should be encouraged. more...

Enabling women with inflammatory bowel diseases (IBD) to have successful pregnancies requires complex decisions. The study aimed to assess patients' views on IBD and pregnancy and to evaluate any association with subject knowledge.General attitudes of females with IBD were assessed on fertility, medication use, delivery mode and pregnancy outcomes. Attitudes regarding personal situation were assessed in participants nulliparous since IBD diagnosis. Knowledge of pregnancy-related issues in IBD was assessed by the Crohn's and Colitis Pregnancy Knowledge Score 'CCPKnow'.Of 145 participants 68% of participants agreed with need for medical therapy for flares during pregnancy, but 24% felt it more important to tolerate symptoms. 36% believed that all IBD medication is harmful to unborn children. Of 96 women nulliparous after IBD diagnosis, 46% were worried about infertility, 75% expressed concern about passing IBD to offspring and 30% considered not having children. Nearly all participants worried about the effects of IBD on pregnancy and the effects of pregnancy on IBD. General attitudes that 'medication should be stopped prior to conception' (P0.001), 'pregnant women should avoid all IBD drugs' (P0.001), and 'put up with symptoms' (P0.001) were associated with significantly lower CCPKnow scores.Over a third of patients considered IBD medication harmful to unborn children. Fear of infertility and concerns about inheritance may explain high rates of voluntary childlessness. Attitudes contrary to medical evidence were associated with significantly lower knowledge. Young women with IBD, particularly those with poor knowledge, should be offered education and counselling about pregnancy-related issues. more...

Background: Inflammatory bowel disease (IBD)-related knowledge not only empowers patients, but may also engender anxiety. The study aimed to identify predictors of anxiety in IBD and examine the interplay between anxiety and disease-related patient knowledge. The effect of anxiety on quality of life was also explored. Methods: Ambulatory IBD patients provided data on demographics, their IBD and Crohn's Colitis Association (CCA) membership status. Disease-related knowledge was assessed using the validated Crohn's and Colitis Knowledge score (CCKnow) and disease related QOL using the short IBD questionnaire (SIBDQ). Anxiety and depression were assessed with the Hospital Anxiety and Depression Scores. Results: Of the 258 patients 19.4% had a potential anxiety and a further 22.4% had a probable anxiety disorder. Females ( P = 0.003), tertiary care patients ( P = 0.014) and non-Caucasian patients ( P = 0.037) had significantly higher anxiety levels. CCA members had marginally higher levels of anxiety ( P = 0.07). Anxiety was associated with significantly better patient knowledge ( P = 0.016) and increased depression ( P < 0.001). Disease related quality of life was significantly lower in patients with anxiety ( P < 0.001). Conclusions: This is the first study to demonstrate that better patient knowledge is associated with higher anxiety levels. The reason for this is unclear: educating patients about their disease might trigger anxiety, but, equally, anxious patients might seek out information and hence have better knowledge. It is thus noteworthy that an educational intervention may not necessarily reduce anxiety. Further work is needed to evaluate the association between anxiety and knowledge and to develop targeted interventions that will improve knowledge and simultaneously reduce anxiety. more...

The availability of over-the-counter (OTC) proton pump inhibitors (PPIs) for the short-term (2 weeks) management of frequent heartburn (≥2 days/week) has increased markedly, yet evidence-based recommendations have not been developed. A panel of nine international experts in gastroesophageal reflux disease developed consensus statements regarding the risks and benefits of OTC PPIs using a modified Delphi process. Consensus (based on ≥80% approval) was reached through multiple rounds of remote voting and a final round of live voting. To identify relevant data, the available literature was searched and summarized. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system terminology was used to rate the quality of evidence and strength of recommendations; consensus was based on ≥2/3 agreement. After 4 rounds of review, consensus was achieved for 18 statements. Notably, the available data did not directly reflect OTC use, but instead, prescription use; therefore, extrapolations to the OTC setting were often necessary. This limitation is regrettable, but it justifies performing this exercise to provide evidence-based expert opinion on a widely used class of drugs. The panel determined that using OTC PPIs according to label instructions is unlikely to mask the symptoms of esophageal or gastric cancer or adversely impact the natural history of related precursor conditions. OTC PPIs are not expected to substantially affect micronutrient absorption or bone mineral density or cause community-acquired pneumonia, Clostridium difficile infection, or cardiovascular adverse events. However, OTC PPI use may be associated with slightly increased risks for infectious diarrhea, certain idiosyncratic reactions, and cirrhosis-related spontaneous bacterial peritonitis. The available evidence does not suggest that OTC PPI use consistent with label instructions is associated with substantial health risks. To minimize potential risks, healthcare professionals and consumers must actively participate in decision making when managing reflux-related symptoms in the self-care setting. Electronic supplementary material The online version of this article (doi:10.1007/s40265-017-0712-6) contains supplementary material, which is available to authorized users. more...

Inflammatory bowel diseases (IBDs) increase the risk of colorectal cancer. Surveillance colonoscopy with chromoendoscopy is recommended, but conventional forward-viewing colonoscopy (FVC) detects dysplasia with low levels of sensitivity. Full-spectrum endoscopy (FUSE) incorporates 2 additional lateral cameras to the forward camera of the colonoscope, allowing endoscopists to view behind folds and in blind spots, which might increase dysplasia detection. We compared FUSE vs FVC in the detection of dysplasia in patients with IBDs.We performed a prospective, randomized, cross-over, tandem colonoscopy study comparing FVC vs FUSE in 52 subjects with IBD undergoing surveillance for neoplasia in Australia (23 with Crohn's colitis, 29 with ulcerative colitis; median age, 45.0 y; 60% male; mean IBD duration, 16.4 y). All subjects met national IBD surveillance inclusion criteria; 27 were assigned randomly to groups that underwent FVC followed by FUSE, and 25 were assigned to groups that underwent FUSE followed by FVC. All procedures were performed from February 2014 through December 2015. Random biopsy specimens were collected and visible lesions were collected; all were analyzed histologically. The primary end point was dysplasia missed by the first colonoscopy detected by the second colonoscopy. Dysplasia was diagnosed by an expert gastrointestinal pathologist blinded to the colonoscope allocation in consensus with a second expert pathologist.FVC missed 71.4% of dysplastic lesions per lesion whereas FUSE missed 25.0% per lesion (P = .0001); FVC missed 75.0% of dysplastic lesions per subject and FUSE missed 25.0% per subject (P = .046). FUSE identified a mean of 0.37 dysplastic lesions and FVC identified a mean of 0.13 dysplastic lesions (P = .044). The total colonoscopy times were similar (21.2 min for FUSE vs 19.1 min for FVC; P = .32), but withdrawal time was significantly longer for FUSE (15.8 min) than for FVC (12.0 min) (P = .03). Correcting for per-unit withdrawal time, the mean dysplasia miss rate per subject was significantly lower for FUSE (0.19) than for FVC (0.83; P .0001). Targeted tissue acquisition identified significantly more dysplastic lesions than random biopsies (P.0001).In a prospective cross-over study of IBD patients undergoing surveillance colonoscopy, we found panoramic views obtained by full-spectrum endoscopy increased the number of dysplastic lesions detected, compared with conventional forward-viewing colonoscopy. Trial no: ACTRN12616000047493. more...

Inflammatory bowel diseases (IBD) require complex therapeutic decisions and life choices concerning pregnancy, but little is known about patient's knowledge of IBD and its treatment before and during pregnancy.To develop a novel tool (Crohn's and Colitis Pregnancy Knowledge Score 'CCPKnow') to assess knowledge of pregnancy-related issues in IBD. The validated tool was then applied to determine knowledge in patients.Discriminate ability of 'CCPKnow' was validated in four groups with different levels of IBD knowledge. Reliability and readability were tested by Cronbach-α and Flesch-Kencaid. Construct validity was subsequently assessed against general IBD knowledge (CCKnow) in 145 women with IBD. Associations between patient factors and knowledge were studied.Median CCPKnow scores differed significantly between the validation groups (P0.001). CCPKnow displayed excellent internal consistency, reliability (Cronbach-α 0.94), readability (reading age 9 years) and close correlation with CCKnow (Spearman's ρ 0.64; P0.001). Of 145 patients, 44.8% had poor, 27.6% adequate, 17.3% good and only 10.3% very good knowledge. Better knowledge was associated with Caucasian ethnicity, higher income, having a partner, having children, Crohn's and Colitis Association membership, longer disease duration and Crohn's disease.Crohn's and Colitis Pregnancy Knowledge Score, a novel knowledge assessment tool of pregnancy and IBD, demonstrated excellent test characteristics. We found that nearly half of the women with IBD had poor knowledge, identifying a pressing need for better education. more...

There are no objective ambulatory studies on the temporal relationship between reflux and cough in children. Commercial pHmetry loggers have slow capture rates (0.25 Hz) that limit objective quantification of reflux and cough. The authors aimed to evaluate if there is a temporal association between cough and acid pH in ambulatory children with chronic cough.The authors studied children (aged14 years) with chronic cough, suspected of acid reflux and considered for pHmetry using a specifically built ambulatory pHmetry-cough logger that enabled the simultaneous ambulatory recording of cough and pH with a fast (10 Hz) capture rate.Coughs within (before and after) 10, 30, 60 and 120 s of a reflux episode (pH4 for0.5 s).Analysis of 5628 coughs in 20 children. Most coughs (83.9%) were independent of a reflux event. Cough-reflux (median 19, IQR 3-45) and reflux-cough (24.5, 13-51) sequences were equally likely to occur within 120 s. Within the 10 and 30 s time frame, reflux-cough (10 s=median 2.5, IQR 0-7.25; 30 s=6.5, 1.25-22.25) sequences were significantly less frequent than reflux-no cough (10 s=27, IQR 15-65; 30 s=24.5, 14.5-55.5) sequences, (p=0.0001 and p=0.001, respectively). No differences were found for 60 and 120 s time frame. Cough-reflux sequence (median 1.0, IQR 0-8) within 10 s was significantly less (p=0.0001) than no cough-reflux sequences (median 29.5, 15-67), within 30 s (p=0.006) and 60 s (p=0.048) but not within 120 s (p=0.47).In children with chronic cough and suspected of having gastro-oesophageal reflux disease, the temporal relationship between acid reflux and cough is unlikely causal. more...

Aliment Pharmacol Ther 2010; 32: 270–281 Summary Background Many bodies advise that people with bowel symptoms undergo colonoscopy to detect colorectal cancer. Aim To determine which bowel symptoms predict cancer on colonoscopy. Methods Information was collected on symptoms, demographics and medical history from patients subsequently undergoing colonoscopy. Multiple logistic regression modelling was used to identify predictors of colorectal cancer. An ROC curve was estimated for each model, and the area under the curve (AUC) was computed. Results Cancer was found in 159 patients and no cancer or adenoma in 7577 patients. Bowel symptoms that predicted cancer were rectal bleeding, change in bowel habit and rectal mucus. Prediction was the strongest in patients who had symptoms at least weekly and commencing within the previous 12 months; abdominal pain was predictive only in such patients. The odds ratios never exceeded 4.27. A model based on age, gender, and medical history was highly predictive (AUC = 0.79). Adding symptoms to this model increased the AUC to 0.85. Conclusions This model predicts patients in whom colonoscopy will have the highest yield. Conversely, colonoscopy can be avoided in people at low risk: in our study, 95% of cancers could have been detected by doing only 60% of the colonoscopies. more...

Cough is a common and distressing symptom that results in significant health care costs from medical consultations and medication use. Cough is a reflex activity with elements of voluntary control that forms part of the somatosensory system involving visceral sensation, a reflex motor response and associated behavioural responses. At the initial assessment for chronic cough, the clinician should elicit any alarm symptoms that might indicate a serious underlying disease and identify whether there is a specific disease present that is associated with chronic cough. If the examination, chest x-ray and spirometry are normal, the most common diagnoses in ADULTS are asthma, rhinitis or gastro-oesophageal reflux disease (GORD). The most common diagnoses in CHILDREN are asthma and protracted bronchitis. Management of chronic cough involves addressing the common issues of environmental exposures and patient or parental concerns, then instituting specific therapy. In ADULTS, conditions that are associated with removable causes or respond well to specific treatment include protracted bacterial bronchitis, angiotensin-converting enzyme inhibitor use, asthma, GORD, obstructive sleep apnoea and eosinophilic bronchitis. In CHILDREN, diagnoses that are associated with removable causes or respond well to treatment are exposure to environmental tobacco smoke, protracted bronchitis, asthma, motor tic, habit and psychogenic cough. In ADULTS, refractory cough that persists after therapy is managed by empirical inhaled corticosteroid therapy and speech pathology techniques. more...

Helicobacter pylori infects up to half of the world's population. It remains the major cause of peptic ulcer disease and is recognised as a carcinogen for its role in gastric carcinogenesis. Successful eradication of the bacteria is associated with improved health outcomes including fewer dyspeptic symptoms, reduced peptic ulcer recurrence and rebleeding, reduced peptic ulcer risk with NSAIDs and as a cure for low-grade gastric MALT lymphoma. The risk of gastric cancer is reduced in those without premalignant mucosal abnormalities at the time of eradication.This review outlines the current indications and options for therapy of H. pylori with particular reference to drug-induced adverse events associated with treatment.The indications for H. pylori eradication are evidence-based and in accordance with recent consensus statements and recommendations. The eradication treatment is based on numerous clinical trials and meta-analyses.Eradication therapy, in general, is safe and well tolerated. Antibiotic therapy may be associated with significant drug adverse reactions, especially gastrointestinal symptoms. more...

Objective: Constipation is the most common and often most debilitating adverse effect associated with opioid use. Opioid-induced constipation persists for the duration of therapy. The aims of this clinical audit were to investigate the GP management of opioid-induced constipation, gain insights on how to improve its management and determine if the audit could improve the management of opioid-induced constipation. Methods: Using quantitative questionnaires, GPs prospectively evaluated their management of constipation in patients prescribed strong opioid analgesic for chronic non-cancer pain, across two audit cycles. The audited patients completed a quantitative survey after the initial GP visit and returned the completed survey to the GP in a sealed envelope. The patient questionnaire was used to assess consistency between patients’ and GPs’ evaluation and management of constipation. Following each cycle GPs received feedback and a decision support tool. Results: Opioid-induced constipation was reported by 50.5% of patients, but its presence was underestimated by GPs, with GPs failing to recognise opioid-induced constipation in a third of patients. GP management of opioidinduced constipation improved during the audit with improvements in the frequency of assessment and the proactive management of constipation. Conclusion: GPs need to regularly ask all patients taking opioid analgesics about the presence of constipation. Questioning should include both objective and subjective measures to assist the detection and assessment of opioidinduced constipation. The high prevalence of opioid-induced constipation necessitates proactive management at the time of opioid initiation and for the duration of opioid therapy more...

Background and Aims: Since the publication of the Asia-Pacific GERD consensus in 2004, more data concerning the epidemiology and management of gastroesophageal reflux disease (GERD) have emerged. An evidence based review and update was needed. Methods: A multidisciplinary group developed consensus statements using the Delphi approach. Relevant data were presented, and the quality of evidence, strength of recom- mendation, and level of consensus were graded. Results: GERD is increasing in frequency in Asia. Risk factors include older age, male sex, race, family history, higher socioeconomic status, increased body mass index, and smoking. Symptomatic response to a proton pump inhibitor (PPI) test is diagnostic in patients with typical symptoms if alarm symptoms are absent. A negative pH study off therapy excludes GERD if a PPI test fails. The role for narrow band imaging, capsule endoscopy, and wireless pH monitoring has not yet been undefined. Diagnostic strategies in Asia must consider coexistent gastric cancer and peptic ulcer. Weight loss and elevation of head of bed improve reflux symptoms. PPIs are the most effective medical treatment. On-demand therapy is appropriate for nonerosive reflux disease (NERD) patients. Patients with chronic cough, laryngitis, and typical GERD symptoms should be offered twice daily PPI therapy after excluding non-GERD etiologies. Fundoplication could be offered to GERD patients when an experienced surgeon is available. Endoscopic treatment of GERD should not be offered outside clinical trials. Conclusions: Further studies are needed to clarify the role of newer diagnostic modalities and endoscopic therapy. Diagnostic strategies for GERD in Asia must consider coexistent gastric cancer and peptic ulcer. PPIs remain the cornerstone of therapy. more...

Aim A world-wide recognised and accepted definition and classification of gastroesophageal reflux disease (GERD) would be highly desirable for research and clinical practice. The purpose of this project was to develop such a generally accepted definition and classification that could be used equally by patients, physicians, and supervisory bodies. Methods In order to ensure a consensus among the participating experts a modified delphi process with a step-wise selection modality was employed. For this the working group of five persons formulated a series of statements on the basis of a systematic search of the literature using three databases (Embase, Cochrane-Study register, Medline). Then these statements were developed further for two years, revised and finally passed as consensus. The consensus group consisted of 44 experts from 18 countries. Each key vote was held on the basis of a six-point scale. A "consensus" was considered to have been reached when two-thirds of the participants voted in favour of the respective statement. Results The level of agreement between the experts increased in the course of the multistep decision process, in the individual voting steps requiring at least two-thirds of the participants, the results were at first 86%, then 88% through to 94% and finally 100% in favour of the chosen statement. In the final voting, 94% of the final 51 statements were accepted by 90% of the consensus group. 90% of all statements were accepted unanimously or with only minor reservations. GERD was defined as a disease that is associated with troublesome symptoms and/or complications on account of reflux of stomach contents into the esophagus. The complaints are divided into esophageal and extra-esophageal syndromes. Among the novel aspects of this definition are the patient-orientated approach that is independent of endoscopic findings, the classification of the ailment into independent syndromes as well as the consideration of laryngitis, cough, asthma and dental problems as possible GERD syndromes. Furthermore, a new definition of suspected or demonstrated Barrett's esophagus is proposed. Conclusion Irrespective of country-specific differences in terminology, language, prevalence and manifestations of this disease, evidence-based, world-wide valid consensus definitions are possible. A global consensus definition of GERD will simplify disease management, make mutual research possible and help in the design of generally valid studies. This will not only help the patient but also the physician and supervisory bodies. more...

Summary Background Failure of first line and subsequent Helicobacter pylori eradication therapy is a significant problem and alternative treatments are few. Aims To evaluate the efficacy of a rifabutin-based triple therapy in clinical practice and determine the optimal strategy for its use. Methods Patients referred after first or subsequent treatment failure were prescribed rifabutin triple therapy consisting of standard dose proton pump inhibitor, amoxicillin 1 g and rifabutin 150 mg each b.d. for 10 days. Results In 67 patients, the main indications for treatment were dyspepsia (55%), peptic ulcer disease (24%) and increased gastric cancer risk (18%). The median number of previous treatments was 2 (range: 1–9). Eradication of Helicobacter pylori was achieved in 76% (48/63) per protocol and 72% (48/67) on an intention-to-treat basis. When used as second line therapy, 95% (18/19) achieved eradication compared with 68% (30/44) when two or more previous treatments had been used (P = 0.03). Outcome was independent of age, ethnicity, gender or indication for treatment. Adverse events were reported in 10%. Conclusion Rifabutin triple therapy is a well tolerated and effective second line therapy in the treatment of persistent Helicobacter pylori; however, its efficacy decreases with increasing number of failed previous therapies. more...

SummaryBackground Acute severe ulcerative colitis (ASUC) is a potentially life-threatening complication of ulcerative colitis. Aim To develop consensus statements based on a systematic review of the literature of the management of ASUC to improve patient outcome. Methods Following a literature review, the Delphi method was used to develop the consensus statements. A steering committee, based in Australia, generated the statements of interest. Three rounds of anonymous voting were carried out to achieve the final results. Acceptance of statements was pre-determined by ≥80% votes in ‘complete agreement’ or ‘agreement with minor reservation’. Results Key recommendations include that patients with ASUC should be: hospitalised, undergo unprepared flexible sigmoidoscopy to assess severity and to exclude cytomegalovirus colitis, and be provided with venous thromboembolism prophylaxis and intravenous hydrocortisone 100 mg three or four times daily with close monitoring by a multidisciplinary team. Rescue therapy such as infliximab or ciclosporin should be started if insufficient response by day 3, and colectomy considered if no response to 7 days of rescue therapy or earlier if deterioration. With such an approach, it is expected that colectomy rate during admission will be below 30% and mortality less than 1% in specialist centres. Conclusion These evidenced-based consensus statements on acute severe ulcerative colitis, developed by a multidisciplinary group, provide up-to-date best practice recommendations that improve and harmonise management as well as provide auditable quality assessments. more...

Summary Background : Following initial healing of erosive oesophagitis, most patients require maintenance therapy to prevent relapse. Aim : To compare endoscopic and symptomatic remission rates over 6 months’ maintenance therapy with esomeprazole or pantoprazole (both 20 mg once daily) in patients with healed erosive oesophagitis. Methods : Patients with symptoms of gastro-oesophageal reflux disease and endoscopically confirmed erosive oesophagitis at baseline were randomized to receive esomeprazole 40 mg or pantoprazole 40 mg for up to 8 weeks. Patients with healed erosive oesophagitis and free of moderate/severe heartburn and acid regurgitation at 4 weeks or, if necessary, 8 weeks entered the 6-month maintenance therapy phase of the study. Results : A total of 2766 patients (63% men; mean age 50 years) received esomeprazole 20 mg (n = 1377) or pantoprazole 20 mg (n = 1389) and comprised the intention-to-treat population. Following 6 months of treatment, the proportion of patients in endoscopic and symptomatic remission was significantly greater for those receiving esomeprazole 20 mg (87.0%) than pantoprazole 20 mg (74.9%, log-rank test P more...

Summary Background : The 13C-caffeine breath test is a non-invasive, quantitative test of liver function. Aim : To determine the utility of the 13C-caffeine breath test in chronic hepatitis B virus and its ability to monitor response to lamivudine. Methods : Forty-eight chronic hepatitis B virus patients and 24 controls underwent the 13C-caffeine breath test. In 28 patients commenced on lamivudine, 13C-caffeine breath tests were performed at 1 week (n = 12) and after 1 year of therapy. Results : Patients with Metavir F0–1 fibrosis (2.30 ± 1.02 Δ‰ per 100 mg caffeine) had a 13C-caffeine breath test similar to controls (2.31 ± 0.85, P = 0.96). However, patients with F2–3 fibrosis (1.59 ± 0.78, P = 0.047) and cirrhotic patients (0.99 ± 0.33, P = 0.001) had a decreased 13C-caffeine breath test. Fibrosis correlated best with the 13C-caffeine breath test (rs = −0.62, P more...

Summary Aim: To assess the efficacy of the 8-week therapy with esomeprazole 40 mg vs. pantoprazole 40 mg for healing erosive oesophagitis (EE) as part of a management study. Methods: Patients had a history of gastro-oesophageal reflux disease symptoms (≥6 months) and had suffered heartburn on at least 4 of the 7 days preceding enrolment. Endoscopies were performed to grade EE severity using the Los Angeles (LA) classification system at baseline, 4 and 8 weeks (if unhealed at 4 weeks). Heartburn severity was recorded by patients on diary cards. The primary end point was healing of EE by week 8 of treatment. Results: Of 3170 patients randomized, the intent-to-treat population consisted of 3151 patients (63% male, mean age: 50.6 years, 27%Helicobacter pylori-positive). Esomeprazole 40 mg healed a significantly greater proportion of EE patients than pantoprazole 40 mg at both 4 weeks (life table estimates: esomeprazole 81%, pantoprazole 75%, P more...

The major oesophageal complications associated with persistent gastro-oesophageal reflux disease (GERD) include erosive oesophagitis, ulceration, strictures and gastrointestinal (GI) bleeding. Although the causes of these complications are uncertain, studies indicate that erosive oesophagitis may progress to the development of ulcers, strictures and GI bleeding. Pharmacological treatment with proton pump inhibitors is favoured over that with H(2)-receptor antagonists for the treatment of strictures. The treatment of strictures is accomplished with dilation and many favour the concomitant use of proton pump inhibitors. Most gastroenterologists are seeing far fewer oesophageal strictures these days since the introduction of proton pump inhibitors. In addition, research has shown that oesophageal complications have a greater impact on patients suffering from night-time GERD than on those suffering from daytime GERD. Barrett's oesophagus is a significant complication associated with persistent GERD and those at risk generally experience a longer duration of symptoms, especially those with a high degree of severity. In addition, there is a strong relationship between Barrett's oesophagus and oesophageal adenocarcinoma. This is in part due to the association of obesity and the development of hiatal hernias. Furthermore, endoscopic screening is being used to detect Barrett's oesophagus and oesophageal adenocarcinoma in persons suffering from chronic GERD, even though screening may not have an impact on outcomes (Sharma P, McQuaid K, Dent J, et al. A critical review of the diagnosis and management of Barrett's esophagus: The AGA Chicago Workshop. Gastroenterology 2004; 127: 310-30.). more...

Gastroesophageal reflux disease (GERD) is among the commonest of gastro-intestinal disorders and the costs of management worldwide are considerable. GERD symptoms impair quality of life and in a minority of subjects, there is a risk of significant morbidity due to complications including strictures and extra-esophageal manifestations. There is also a significant mortality related to the risk of esophageal adenocarcinoma. Although the absolute risk is low in any individual, the incidence of this cancer is rising in Western populations, particularly among Caucasian males over 50 years of age. Therefore, the goals of GERD therapy are to relieve symptoms, restore quality of life, heal esophagitis if present and reduce complications in the most cost-effective manner. Medical therapy is the mainstay of treatment for most patients with surgery appropriate for a well selected minority. Newer endoscopic techniques are currently under evaluation. A direct comparison of the benefits and drawbacks of all modalities of treatment is limited by the lack of quality comparative data, the different interests of the providers of therapy and also by the complementary rather than competing nature of these alternatives. more...

Background and Aims: Helicobacter pylori infection has been associated with lower ferritin levels in some adult populations, but subsets of potentially higher risk subjects, such as the elderly have not been examined. The aim of the present study was to determine the impact of H. pylori infection and low-dose aspirin use on iron stores in a well elderly population. Methods: Consecutive subjects aged 65 years or older attending day care facilities were studied. Each subject was assisted in completing a medical questionnaire. Serum ferritin, hemoglobin, mean corpuscular volumes (MCV) and IgG antibodies (ELISA) against H. pylori were measured. Results: In 220 subjects (age 75 ± 8 years), 42% were H. pylori seropositive (male 41%, female 44%). The median (IQR) ferritin level (ug/L) was higher in men 149 (89–280) than women 94 (54–161), p more...

SummaryBackground Smoking demonstrates divergent effects in Crohn's disease (CD) and ulcerative colitis (UC). Smoking frequency is greater in CD and deleterious to its disease course. Conversely, UC is primarily a disease of nonsmokers and ex-smokers, with reports of disease amelioration in active smoking. Aim To determine the prevalence of smoking and its effects on disease progression and surgery in a well-characterised cohort of inflammatory bowel diseases (IBD) patients. Methods Patients with smoking data of the Sydney IBD Cohort were included. Demographic, phenotypic, medical, surgical and hospitalisation data were analysed and reported on the basis of patient smoking status. Results 1203 IBD patients were identified comprising 626 CD and 557 UC with 6725 and 6672 patient-years of follow-up, respectively. CD patients were more likely to smoke than UC patients (19.2% vs. 10.2%, P more...

OBJECTIVES To investigate whether pantoprazole (20 mg/d) produces significantly greater symptom control than ranitidine (300 mg/d) in patients with gastro-oesophageal reflux disease (GORD). DESIGN Multicentre, randomised, double-blind, parallel-group comparison. SETTING 76 general practices in north-west Sydney and Newcastle, New South Wales (Australia), from 19 January 1999 to 22 September 2000. PATIENTS 307 patients aged 18 years or over presenting with symptomatic GORD. INTERVENTIONS Pantoprazole (20 mg once daily) or ranitidine (150 mg twice daily). MAIN OUTCOME MEASURES Patient-assessed frequency and severity of heartburn using the Gastrointestinal Symptom Rating Scale (GSRS) and a patient heartburn diary. RESULTS Pantoprazole was associated with significantly higher rates of complete control of GORD symptoms than ranitidine at four weeks (40% v 19%; P < 0.001), eight weeks (55% v 33%; P < 0.001), six months (71% v 56%; P = 0.007) and 12 months (77% v 59%; P = 0.001). CONCLUSIONS Low-dose pantoprazole is an effective alternative to standard-dose ranitidine for initial and maintenance treatment of patients with symptomatic GORD. more...

BACKGROUND Earlier introduction of immunomodulators (IM) thiopurine or methotrexate is advocated to improve Crohn's disease (CD) outcomes, but whether abdominal surgery can be prevented remains controversial. METHODS A specialist-referred cohort of CD was recruited from 1970 to 2009. Early IM use was defined as commencement of azathioprine or methotrexate within 3 years of CD diagnosis and adherence of at least 6 months. Propensity score matching was conducted to correct for confounders influencing early IM introduction. Outcomes of interest were rates of initial and recurrent major abdominal surgery for CD and their predictive factors. RESULTS A total of 1035 consecutive patients with CD (13,061 patient-years) were recruited. The risk of first and recurrent major abdominal surgery at 1, 5, and 10 years were 17.5%, 28.4%, and 39.5% and 5.9%, 19.0%, and 33.3%, respectively. Early IM use increased over time from 1.3% to 55.3% (P < 0.0001) and was a significant independent predictor of lower rates of initial abdominal surgery (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.35-0.69), recurrent abdominal surgery (HR, 0.44; 95% CI, 0.25-0.79) and perianal surgery (HR, 0.30; 95% CI, 0.16-0.56). Using propensity score matching, early IM significantly reduced surgical rates (HR, 0.54; 95% CI, 0.37-0.79). Number needed to treat to prevent a surgical event at 5 years from diagnosis and after initial surgery was 6.99 (95% CI, 5.34-11.95) and 8.59 (95% CI, 6.26-23.93), respectively. CONCLUSIONS Early IM use with thiopurines or methotrexate was significantly associated with the reduced need for abdominal and perianal surgery in CD. more...

Background:The clinical usefulness of the ratio of serum aspartate aminotransferase (AST) to alanine aminotransferase (ALT) has been explored in several liver disorders. It has been suggested that in patients with chronic hepatitis C virus (HCV) infection an AST : ALT ≥ 1 has 100% specificity and positive predictive value in distinguishing cirrhotic from non-cirrhotic patients. Such statistical certainty attached to a simple biochemical test merits further evaluation. The present study, therefore, assessed the AST : ALT in patients with chronic HCV infection to determine the validity of the ratio in predicting cirrhosis and to correlate the ratio with the histological grade of necroinflammatory activity and fibrosis. Methods: A retrospective analysis of 153 patients with chronic HCV infection was conducted. Serum biochemistry had been obtained within a mean of 4 weeks of liver biopsy. The histology was scored in terms of activity and fibrosis as described by Scheuer and correlated with AST : ALT. Results: In 30 patients with cirrhosis, the mean AST : ALT (0.99 ± 0.06) was higher than in 123 patients without cirrhosis (0.60 ± 0.02; P < 0.001). A ratio ≥ 1 had 95.9% specificity and 73.7% positive predictive value in distinguishing cirrhotic from non-cirrhotic patients, with a 46.7% sensitivity and 88.1% negative predictive value. The ratio also parallelled the Scheuer score with respect to fibrosis but not with respect to inflammation. Conclusion: Although relatively insensitive, an AST : ALT ≥ 1 is highly specific but not diagnostic for the presence of cirrhosis in patients with chronic HCV infection. The ratio reflects the grade of fibrosis in these patients. © 2000 Blackwell Science Asia Pty Ltd more...

Background : The 13C-urea breath test (13C-UBT) is an accurate means of Helicobacter pylori diagnosis. However, proton pump inhibitors may suppress H. pylori and cause false negative results. Aim : To study the kinetics of H. pylori suppression by omeprazole during and after short-term use. Methods : Volunteers underwent a baseline 13C-UBT (13C-urea 100 mg). H. pylori-positive subjects took omeprazole 20 mg daily for 14 days. Those who remained 13C-UBT positive (δ13CO2 ≥ 5) continued omeprazole for a further 14 days. 13C-UBTs were performed weekly on omeprazole and then every second day after it was stopped. False negatives occurred when δ13CO2 fell to more...

Undernutrition is considered to have a central role in the pathogenesis of growth retardation in Crohn's disease. This may occur as a consequence of inadequate food intake, increased energy expenditure, or both. Ten growing adolescents with inactive Crohn's disease were assessed with respect to anthropometric parameters and resting energy expenditure, measured by indirect calorimetry during remission, repeated in relapse (N = 5), and compared to that predicted from the Harris-Benedict formula. Mean energy intake was assessed with seven-day diaries in five patients and compared to recommended intake for age, sex, weight, and physical activity. Ten healthy, growing, age- and sex-matched adolescents served as controls. Nine patients with inactive Crohn's disease, who had ceased growing, were matched for disease site and duration and acted as disease controls. Patients and disease controls had lower body mass index (19.2 +/- 0.6; 20.9 +/- 0.7) than healthy controls (23.7 +/- 0.6; P0.001). Percent body fat was lower in patients (13.2 +/- 1.9%) compared to healthy controls (20.5 +/- 2.4%; P0.05) but not to disease controls (17.0 +/- 2.6%). Patients had higher resting energy expenditure per kilogram of fat-free mass than disease or healthy controls (36.9 +/- 5.1; 32.9 +/- 2.6; 30.9 +/- 2.1 kcal; P0.02). Measured resting energy expenditure in patients, but not in disease or healthy controls, was higher than the predicted (measured: predicted 1.15, 1.03, 0.9, respectively; P0.03). Energy intake in patients was 97% of recommended intake but the measured ratio of energy intake/resting energy expenditure was lower than the predicted ratio (1.49 vs 1.71; P0.05). During subsequent relapse in five patients resting energy expenditure was unchanged. In growing adolescents with inactive Crohn's disease, there is increased energy expenditure that is not accompanied by an increase in energy intake. Relapse of disease does not appear to increase resting energy expenditure further but may "divert" energy from growth to disease activity. This suggests that nutritional therapy should be directed towards increasing caloric intake to maximize growth potential. more...

Traveler's diarrhea is usually a short, self-limiting illness lasting on average 3-5 days. The illness may present either as (1) acute watery diarrhea, (2) diarrhea with blood (dysentery) or (3) chronic diarrhea, often with clinical evidence of fat or carbohydrate malabsorption. The majority of cases of traveler's diarrhea are due to intestinal infection and resolve without specific treatment. Antibiotics can reduce the severity and duration of the illness and are always indicated for dysenteric shigellosis and amoebiasis. Oral rehydration therapy is the mainstay for managing water and electrolyte depletion. more...

Adherence to medication that maintains remission by patients with ulcerative colitis (UC) is poor but little is known regarding patients' perception of medication benefit that may enhance adherence rates. The aims were to study patients' understanding and preference on methods of conveying statistical information and to study indicated thresholds for adherence to medication for UC.Four methods of displaying information on benefits of maintenance therapy were explained to patients with UC in remission: relative risk reduction [RR], absolute risk reduction [AR], number needed to treat [NNT] and optical representation via Cates plot [CP]. Patients' understanding and preference for each method were evaluated. Participants were asked to state minimum thresholds relating to relapse prevention and colorectal cancer risk reduction that they would require in order for them to adhere to medication for UC.Of 50 participants, 48% preferred data presentation by RR over CP (28%), AR (20%) and NNT (4%). 94% found RR easy to understand, better than AR (88%), CP (74%), or NNT (48%). For bowel cancer prevention, 94% indicated adherence for benefit levels of 61% RR but only 57% for the corresponding CP (P0.001). For relapse prevention, 78% of patients indicated adherence for benefit levels of 40% RR but only 43% for the corresponding CP (P0.001).Patients with UC prefer data presented by RR, and apply significantly higher thresholds for adherence when presented with CP compared to RR. Reduction of cancer risk may be a stronger motivator than maintenance of remission. more...

Background Colonoscopy is an invasive and costly procedure with a risk of serious complications. It would therefore be useful to prioritise colonoscopies by identifying people at higher risk of either cancer or premalignant adenomas. The aim of this study is to assess a model that identifies people with colorectal cancer, advanced, large and small adenomas. Methods Patients seen by gastroenterologists and colorectal surgeons between April 2004 and December 2006 completed a validated, structured self-administered questionnaire prior to colonoscopy. Information was collected on symptoms, demographics and medical history. Multinomial logistic regression was used to simultaneously assess factors associated with findings on colonoscopy of cancer, advanced adenomas and adenomas sized 6 -9 mm, and ≤ 5 mm. The area under the curve of ROC curve was used to assess the incremental gain of adding demographic variables, medical history and symptoms (in that order) to a base model that included only age. Results Sociodemographic variables, medical history and symptoms (from 8,204 patients) jointly provide good discrimination between colorectal cancer and no abnormality (AUC 0.83), but discriminate less well between adenomas and no abnormality (AUC advanced adenoma 0.70; other adenomas 0.67). Age is the dominant risk factor for cancer and adenomas of all sizes. Having a colonoscopy within the last 10 years confers protection for cancers and advanced adenomas. Conclusions Our models provide guidance about which factors can assist in identifying people at higher risk of disease using easily elicited information. This would allow colonoscopy to be prioritised for those for whom it would be of most benefit. more...