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Background Inflammatory bowel disease (IBD) has been associated with an increased risk of obstructive sleep apnea (OSA). We aimed to examine the associations of obstructive sleep apnea, sleepiness, and IBD-related data and comorbidities, with the aim of developing a screening tool for sleep apnea in this population. Methods An online survey of adults with IBD was administered which included measures of assessment of the risk of OSA, and measures of IBD activity, IBD-related disability, anxiety, and depression. Logistic regression was performed to investigate the associations between the risk of OSA and IBD data, medications, demographics, and mental health conditions. Further models were built for an outcome of severe daytime sleepiness and a combined outcome of risk of OSA and at least mild daytime sleepiness. A simple score was constructed for the purpose of screening for OSA. Results There were 670 responses to the online questionnaire. The median age was 41 years, the majority had Crohn’s disease (57%), the median disease duration was 11.9 years, and approximately half were on biologics (50.5%). Moderate–high risk of OSA was demonstrated in 22.6% of the cohort. A multivariate regression model for moderate–high risk of OSA included increasing age, obesity, smoking, and abdominal pain subscore. For a combined outcome of moderate–high risk of OSA and at least mild daytime sleepiness, a multivariate model included abdominal pain, age, smoking, obesity, and clinically significant depression. A simple score was constructed for screening for OSA utilizing age, obesity, IBD activity, and smoking status with an area under the receiver-operating curve of 0.77. A score >2 had a sensitivity of 89% and a specificity of 56% for moderate–high risk of OSA and could be utilized for screening for OSA in the IBD clinic. Conclusions Over one-fifth of an IBD cohort met significantly high-risk criteria for OSA to warrant referral for a diagnostic sleep study. The risk of OSA was associated with abdominal pain, along with more traditional risk factors such as smoking, increasing age, and obesity. Consideration should be given for screening for OSA in IBD patients utilizing a novel screening tool that utilizes parameters typically available in IBD clinic.

Background and Aim: Colonoscopic surveillance is undertaken at regular intervals (typically 3 or 5 years) to reduce the incidence of colorectal cancer (CRC) in people with an elevated risk (personal or family history of neoplasia). Pathology findings at index and each surveillance colonoscopy determine recall intervals. Due to coronavirus disease 2019, hospital services around the world have been limited, resulting in some surveillance colonoscopies being delayed beyond the recommended time frames. Previous studies suggest that delays to colonoscopy might increase the incidence of advanced neoplasia (advanced adenoma/CRC). However, it is possible that this risk could be reduced by ensuring that individuals are maintained in a CRC screening program with an immunochemical fecal occult blood test (FIT) in the interval between surveillance colonoscopies. Our aim was to determine whether risk of advanced neoplasia increases if surveillance colonoscopy is delayed in people with elevated CRC risk who perform and have a negative FIT result in the interval between colonoscopies. Methods: We performed a retrospective cohort study using data from the Southern Cooperative Program for the Prevention of Colorectal Cancer on people at elevated risk because of family history or personal history of adenoma or CRC. People with at least two consecutive colonoscopies of a 3- or 5-year surveillance interval and who had at least one negative interval FIT result were included in the study. They were stratified based on a previous colonoscopy finding of advanced adenoma, non-advanced adenoma, or no neoplasia. People with early colonoscopies (3 months before the recommended due date), poor bowel preparation, previous CRC, or hereditary CRC syndromes were excluded from the study. Colonoscopy was defined as 'delayed' if it did not occur within 6 months after the recommended recall interval and was further subdivided into delays of 6-12, 12-24, and >24 months. The incidence of advanced neoplasia was calculated for all groups. The relative risk (RR) and 95% confidence intervals estimated from a robust multivariable modified Poisson regression were used to assess the association between surveillance colonoscopy delay and risk of advanced neoplasia. Results: A total of 1748 public hospital surveillance colonoscopies (in 1516 participants) were included in the analysis. More than half of the colonoscopies (56.86%, 994/1748) were delayed by at least 6 months because of system and/or patient factors. In people with delayed colonoscopies, the incidence of advanced neoplasia was higher in those with previous advanced adenoma (16.72%, 48/287) and previous non-advanced adenoma (15.23%, 37/243) compared with those with no neoplasia (6.25%, 29/464) (P < 0.001). However, relative to on-time colonoscopy, delay of surveillance colonoscopy was not associated with an increased risk of advanced neoplasia for people who had at least one negative interval FIT result, regardless of previous colonoscopy finding (previous advanced adenoma: RR, 1.01;95% CI, 0.70-1.46;non-advanced adenoma: RR, 1.41;95% CI, 0.85-2.33;and no neoplasia: RR, 0.96;95% CI, 0.55-1.66) (Table 1). Conclusion: In an elevated-risk cohort undergoing FIT screening between surveillance colonoscopies, delays to colonoscopy did not increase risk of advanced neoplasia. These results suggest that surveillance colonoscopy could be safely extended in people at elevated CRC risk by participating in FIT testing between colonoscopies within a surveillance program.

To evaluate the effect of the braced arm-to-thigh technique (BATT) (versus self-selected techniques) on three-dimensional trunk kinematics and spinal loads for three common activities of daily living (ADLs) simulated in the laboratory: weeding (gardening), reaching for an object in a low cupboard, and car egress using the two-legs out technique. Ten young healthy males performed each task using a self-selected technique, and then using the BATT. The pulling action of weeding was simulated using a magnet placed on a steel plate. Cupboard and car egress tasks were simulated using custom apparatus representing the dimensions of a kitchen cabinet and a medium-sized Australian car, respectively. Three-dimensional trunk kinematics and L4/L5 spinal loads were estimated using the Lifting Full-Body OpenSim model and compared between techniques. Paired t-tests were used to compare peak values between methods (self-selected vs BATT). The BATT significantly reduced peak extension moments (13–51%), and both compression (27–45%) and shear forces (31–62%) at L4/L5, compared to self-selected techniques for all three tasks (p

Surveillance colonoscopies may be delayed because of pressure on resources, such as the COVID-19 pandemic. This study aimed to determine whether delayed surveillance colonoscopy increases the risk for advanced neoplasia and whether interval screening with faecal immunochemical tests (FITs) and other known risk factors can mitigate this risk.A retrospective cohort study of individuals undergoing surveillance colonoscopy for personal or family history of colorectal neoplasia was being provided with FIT between colonoscopies. Colonoscopy ≥ 6 months after the guideline-recommended interval was considered "delayed." Individuals were stratified based on prime colonoscopy findings to nonneoplastic findings, non-advanced adenoma, and advanced adenoma. The relative risk (RR) for developing advanced neoplasia was determined using a robust multivariable modified Poisson regression.Of 2548 surveillance colonoscopies, 1457 (57.18%) were delayed. Prior advanced adenoma, older age ( 60 years) and nonparticipation in interval FIT were associated with increased risk for advanced neoplasia (P 0.05). There was a trend to increased risk in those with prior advanced adenoma with an increasing colonoscopy delay (P trend = 0.01). In participants who did not complete interval FIT and having advanced adenoma in the prime colonoscopy, risk of advanced neoplasia was 2.48 times higher (RR = 2.48, 95% confidence interval: 1.20-5.13) in participants who had beyond 2 years of delayed colonoscopy compared with those with on-time colonoscopy. Colonoscopy delay did not increase the risk of advanced neoplasia in participants with negative interval FIT results.Surveillance colonoscopy can be safely extended beyond 6 months in elevated colorectal cancer risk patients who do not have prior advanced adenoma diagnosis, particularly if interval FIT is negative.

Study Objectives Poor sleep-in people with inflammatory bowel disease (IBD) has been associated with worse quality of life, along with anxiety, depression, and fatigue. This meta-analysis aimed to determine the pooled prevalence of poor sleep-in IBD. Methods Electronic databases were searched for publications from inception to November 1st 2021. Poor sleep was defined according to subjective sleep measures. A random effects model was used to determine the pooled prevalence of poor sleep-in people with IBD. Heterogeneity was investigated through subgroup analysis and meta-regression. Publication bias was assessed by funnel plot and Egger’s test. Results 519 Studies were screened with 36 studies included in the meta-analysis incorporating a total of 24 209 people with IBD. Pooled prevalence of poor sleep-in IBD was 56%, 95% CI (51–61%) with significant heterogeneity. The prevalence did not differ based on the definition of poor sleep. Meta-regression was significant for increased prevalence of poor sleep with increase in age and increased of prevalence of poor sleep with objective IBD activity but not subjective IBD activity, depression, or disease duration. Conclusions Poor sleep is common in people with IBD. Further research is warranted to investigate if improving sleep quality in people with IBD will improve IBD activity and quality of life.

BACKGROUND The international guidelines for surveillance following the finding of a small tubular adenoma vary between no surveillance or colonoscopy at 5 or 10 years, whereas surveillance after an advanced adenoma is 3 years. Optimization of surveillance reduces the risk of colorectal cancer (CRC) with efficient use of colonoscopy resources. We assessed the risks of advanced colorectal neoplasia following a baseline finding of a small adenoma compared with advanced adenoma. PATIENTS AND METHODS A retrospective audit was undertaken of patients enrolled in a CRC surveillance program, wherein regular colonoscopies and screening with faecal immunochemical test (FIT) were provided. Patients diagnosed with either small or advanced adenoma followed by at least one surveillance colonoscopy were included. Advanced adenoma included adenomas with features of villous change, size of at least 10 mm, high-grade dysplasia, three or more small tubular adenomas and traditional and sessile serrated adenomas. Subdistribution hazard ratios were calculated for advanced neoplasia (CRC or advanced adenoma). RESULTS Overall, 378 patients (62.6±11.2 years, 57.9% male) were included, with 44.2% diagnosed with small adenoma and 55.5% with advanced adenoma at baseline. The crude cumulative incidence of advanced neoplasia at first surveillance was 13.2 and 18.5% after small and advanced adenoma (P=0.16) (at 45.9 and 35.6 months, respectively), which became significant for advanced adenoma after adjustment (subdistribution hazard ratio=2.55, 95% confidence interval=1.49-4.35, P

Early detection and removal of precursor lesions reduce colorectal cancer morbidity and mortality. Sessile serrated adenomas/polyps (SSP) are a recognized precursor of cancer, but there are limited studies on whether current screening techniques detect this pathology.To investigate the sensitivity of fecal immunochemical tests (FIT) and epigenetic biomarkers in blood for detection of SSP.A prospective study offered FIT and a blood test (Colvera for methylated BCAT1 and IKZF1) to adults referred for colonoscopy. Sensitivity of FIT and the blood test were determined for four types of pathology: low-risk conventional adenoma, high-risk adenoma, SSP, and absence of neoplasia. Comparisons were made for FIT positivity at 10 and 20 μg hemoglobin (Hb)/g feces.One thousand eight hundred and eighty-two subjects completed FIT and underwent colonoscopy. One thousand four hundred and three were also tested for methylated BCAT1/IKZF1. The sensitivity of FIT (20 μg Hb/g feces) for SSP was 16.3%. This was lower than the sensitivity for high-risk adenomas (28.7%, p 0.05), but no different to that for low-risk adenomas (13.1%) or no neoplasia (8.4%). A positive FIT result for SSP was not associated with demographics, morphology, concurrent pathology or intake of medications that increase bleeding risk. FIT sensitivity for SSP did not significantly increase through lowering the positivity threshold to 10 μg Hb/g feces (20.4%, p 0.05). Sensitivity of the blood test for SSP was 8.8%, and 26.5% when combined with FIT.Both FIT and blood-based markers of DNA hypermethylation have low sensitivity for detection of SSP. Further development of sensitive screening tests is warranted.

There is currently no validated full-body lifting model publicly available on the OpenSim modelling platform to estimate spinal loads during lifting. In this study, the existing full-body-lumbar-spine model was adapted and validated for lifting motions to produce the lifting full-body model. Back muscle activations predicted by the model closely matched the measured erector spinae activation patterns. Model estimates of intradiscal pressures and in vivo measurements were strongly correlated. The same spine loading trends were observed for model estimates and reported vertebral body implant measurements. These results demonstrate the suitability of this model to evaluate changes in lumbar loading during lifting.

Surveillance colonoscopy guidelines following adenomas or sessile serrated adenomas/polyps (SSPs) are based on pathology features known to be associated with risk of future colorectal cancer. A synchronous conventional adenoma may increase the malignant potential of SSP, but current guidelines do not address this combination of pathologies. The aim was to assess the risk of advanced neoplasia after SSP with or without synchronous adenoma compared to that following a conventional adenoma. An audit was conducted on colonoscopies performed between 2000 and 2014 as part of a surveillance program. Index colonoscopy findings were classified as: low-risk SSP and high-risk SSP (size ≥ 10 mm or with cytological dysplasia) with and without synchronous adenoma; high-risk adenoma and low-risk adenoma. Risk of advanced neoplasia was determined at subsequent surveillance colonoscopies. In total, 2157 patients had adenoma or SSP found at index colonoscopy—low-risk adenoma (40%), high-risk adenoma (54%) and SSP (4%). Synchronous adenomas were seen with 47% of SSP. The median follow-up was 50.3 months (interquartile range 28.1–79.3). Compared to an index finding of low-risk adenoma, index findings of high-risk adenoma, as well as SSP with synchronous adenoma, were independent predictors of future advanced neoplasia (high-risk adenoma: hazard ratio (HR) = 2.04 (95% CI 1.70–2.45); high-risk SSP + adenoma HR = 3.20 (95% CI 1.31–7.82); low-risk SSP + adenoma: HR = 2.20 (95% CI 1.03–4.68)). Synchronous adenoma increases the risk of advanced neoplasia for SSP equivalent to that seen following high-risk adenoma. Guidelines for surveillance should take into account concurrent pathologies with SSP.

Purpose: Endoscopic surveillance for Barrett’s oesophagus is undertaken to detect dysplasia and early cancer, and to facilitate early intervention. Evidence supporting current practice is of low quality and often influenced by opinion. This study investigated the preferences of patients for surveillance of Barrett’s oesophagus in an Australian cohort. Methods: Four Barrett’s oesophagus surveillance characteristics/attributes were evaluated within a discrete choice experiment based on literature and expert opinion: (1) surveillance method (endoscopy vs a blood test vs a novel breath test), (2) risk of missing a cancer over a 10-year period, (3) screening interval, and (4) out-of-pocket cost. The data from the discrete choice experiment was analysed within the framework of random utility theory using a mixed logit regression model. Results: The study sample comprised patients (n = 71) undergoing endoscopic surveillance for Barrett’s oesophagus of whom n = 65 completed the discrete choice experiment. The sample was predominantly male (77%) with average age of 65 years. All attributes except surveillance method significantly influenced respondents’ preference for Barrett’s oesophagus surveillance. Policy analyses suggested that compared to the reference case (i.e. endoscopy provided annually at no upfront cost and with a 4% risk of missing cancer), increasing test sensitivity to 0.5% risk of missing cancer would increase participation by up to 50%; surveillance every 5 years would lead to 26% reduction, while every 3 to 3.5 years would result in 7% increase in participation. Respondents were highly averse to paying A$500 for the test, resulting in 48% reduction in participation. None of the other surveillance methods was preferred to endoscopy, both resulting in 11% reduction in participation. Conclusion: Test sensitivity, test frequency and out-of-pocket cost were the key factors influencing surveillance uptake. Patients prefer a test with the highest sensitivity, offered frequently, that incurs no upfront costs. Refereed/Peer-reviewed

OBJECTIVES To investigate the incidence of advanced neoplasia (colorectal cancer or advanced adenoma) at surveillance colonoscopy following removal of non-advanced adenoma; to determine whether the time interval before surveillance colonoscopy influences the likelihood of advanced neoplasia. DESIGN Retrospective cohort study. SETTING, PARTICIPANTS Patients enrolled in a South Australian surveillance colonoscopy program with findings of non-advanced adenoma during 1999-2016 who subsequently underwent surveillance colonoscopy. MAIN OUTCOME MEASURES Incidence of advanced neoplasia at follow-up surveillance colonoscopy. RESULTS Advanced neoplasia was detected in 169 of 965 eligible surveillance colonoscopies (18%) for 904 unique patients (median age, 62.0 years; interquartile range [IQR], 54.0-69.0 years), of whom 570 were men (59.1%). The median interval between the initial and surveillance procedures was 5.2 years (IQR, 4.4-6.0 years; range, 2.0-14 years). Factors associated with increased risk of advanced neoplasia at follow-up included age (per year: odds ratio [OR], 1.03; 95% CI, 1.01-1.05), prior history of adenoma (OR, 1.48; 95% CI, 1.01-2.15), two non-advanced adenomas identified at baseline procedure (v one: OR, 1.74; 95% CI, 1.18-2.57), and time to surveillance colonoscopy (OR, 1.21; 95% CI, 1.08-1.37). The estimated incidence of advanced neoplasia was 19% five years after non-advanced adenoma removal, and 30% at ten years. CONCLUSIONS Increasing the surveillance colonoscopy interval beyond five years after removal of non-advanced adenoma increases the risk of detection of advanced neoplasia at follow-up colonoscopy.

Background: Poor sleep quality has been associated with active inflammatory bowel disease (IBD) in several studies. This review examines sleep quality in people with active IBD and in those in remission, with a meta-analysis performed, considering subjective and objective sleep quality and IBD activity. Methods: Electronic databases were searched for publications from inception to December 1st 2020. Effect sizes were estimated to determine the association between sleep quality and IBD activity using a random effects model. Separate meta-analyses were performed for objective and subjective sleep and IBD activity, considering sleep quality in active and inactive IBD. Results: 19 studies were included in the qualitative review representing 4972 IBD patients. Subjective IBD activity was associated with subjective poor sleep quality with pooled odds ratio (OR) of 3.04 (95% CI 2.41-3.83). Sleep efficiency was lower in those self-reporting active IBD and, time awake post sleep onset was higher in those with active disease with acceptably heterogeneity. Objective IBD activity was associated with subjective poor sleep, with pooled OR of 6.64 95% CI (3.02 – 14.59). Insufficient data was available to consider objective IBD activity and objective sleep quality. Conclusion: IBD activity is associated with poor sleep using subjective and objective measures of sleep quality. This manifests as decreased sleep efficiency and increased number of waking episodes post sleep onset. This may be due to IBD symptoms, however emerging data suggests sleep quality remains poor in those with subclinical inflammation. The relationship between objective IBD activity and sleep requires further investigation. Funding: No funding sources were obtained for this study. Declaration of Interest: Conflicts of interest include speakers fees, and Ad Boards from : Abbott, AbbVie, Allergan, Anatara, AstraZeneca, Bayer, BMS 2020, Celegene, Celltrion, Falk, Ferring, Gilead, Hospira, Immuninc, ImmunsanT, Janssen, MSD, Nestle, Novartis, Progenity, Pfizer, Sandoz, Shire, Takeda, Vifor, RAH research Fund, The Hospital Research Fund 2020-2022, The Helmsley Trust 2020-2023

Clinically significant serrated polyps are precursors of colorectal cancers, with features considered high risk including size ≥10 mm, dysplasia, and presence of synchronous conventional adenoma. While these features have been described in cohorts undergoing screening colonoscopy, there is little information regarding the prevalence and patient characteristics associated with high-risk sessile serrated polyps (SSPs) in those undergoing surveillance colonoscopy.Polyp pathology at the index and first follow-up colonoscopy performed between 2004 and 2019 were examined in patients enrolled in a surveillance program because of an index finding of adenoma and/or SSP. Demographics and pathology features for SSP were compared between the colonoscopies.Of 6297 patients undergoing index colonoscopy, 2035 underwent follow-up colonoscopy after 3.3 years (interquartile range 2.1-4.8 years). The proportion with SSP decreased from 7.6% at index to 5.0% at follow-up (P 0.001); however, the proportion of SSPs that were considered high risk was not different between the colonoscopies (62.8% vs 62.4%). Female gender was associated with the presence of high-risk SSP at index colonoscopy (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.28-2.06), while age ≥75 years (OR 3.38, 95% CI 1.67-6.81) and previous high-risk SSP (OR 9.40, 95% CI 4.23-20.88) were independently associated with high-risk SSP at follow-up.The prevalence of SSP falls by one-third at first follow-up colonoscopy although the proportion of SSP with high-risk features remains the same. While females were more likely to have a high-risk SSP at the index colonoscopy, those at greatest risk for high-risk SSP at follow-up colonoscopy were age75 years and an index high-risk SSP.

Background The timing and dose of exclusive nutrition support (ENS) have not been investigated in previous studies aimed at validating the modified Nutrition Risk in Critically Ill (mNUTRIC) score. We therefore evaluated the mNUTRIC score by determining the association between dose of nutrition support and 28-day mortality in high-risk patients who received short- and longer-term ENS (≤ 6 days vs. ≥ 7 days). Methods A prospective cohort study included data from 252 adult patients with > 48 h of mechanical ventilation in a tertiary care institution in Singapore. The dose of nutrition support (amount received ÷ goal: expressed in percentage) was calculated for a maximum of 14 days. Associations between the dose of energy (and protein) intake and 28-day mortality were evaluated with multivariable Cox regressions. Since patients have different durations of ENS, only the first 6 days of ENS in patients with short- and longer-term ENS were assessed in the Cox regressions to ensure a valid comparison of the associations between energy (and protein) intake and 28-day mortality. Results In high-risk patients with short-term ENS (n = 106), each 10% increase in goal energy intake was associated with an increased hazard of 28-day mortality [adj-HR 1.37 (95% CI 1.17, 1.61)], and this was also observed for protein intake [adj-HR 1.31 (95% CI 1.10, 1.56)]. In contrast, each 10% increase in goal protein intake in high-risk patients with longer-term ENS (n = 146) was associated with a lower hazard of 28-day mortality [adj-HR 0.78 (95% CI 0.66, 0.93)]. The mean mNUTRIC scores in these two groups of patients were similar. Conclusion When timing and dose of nutrition support were examined, the mNUTRIC did not differentiate high-risk patients who would derive the most benefit from nutrition support. Electronic supplementary material The online version of this article (10.1186/s13613-018-0443-1) contains supplementary material, which is available to authorized users.

Participation rates in colorectal cancer (CRC) screening programmes using faecal occult blood tests (FOBTs) are low. Nonparticipation is commonly attributed to psychosocial factors, but some medical conditions also prevent screening. These barriers might be partially overcome if a blood test for CRC screening was available. This study determined whether people who had always declined screening by FOBT would participate if offered a blood test. An audit of registrants within a personalized CRC screening programme was undertaken to determine the reasons for regular nonparticipation in FOBT. Consistent nonparticipants (n=240) were randomly selected and invited for CRC screening with a blood test. Demographic characteristics and the reasons for prior FOBT nonparticipation were collected by means of a questionnaire. Nonparticipation in the screening programme could be classified as either behavioural (8.6%), with consistent noncompliance, or due to medical contraindications (8.5%), which included chronic rectal bleeding, being deemed unsuitable by a health professional, and needing personal assistance. Blood test uptake was 25%, with participation in the medical contraindications group greater than that in the behavioural group (43 vs. 12%, P0.001). Reported behavioural reasons for nonparticipation in faecal immunochemical test included procrastination and dislike of the test, but these were not associated with blood test uptake (P0.05). There is a subgroup of the community who have medical reasons for nonparticipation in CRC screening with FOBT but will participate if offered a blood test. The option of a blood test does not, however, improve uptake in those who admit to behavioural reasons for noncompliance with screening.

Background Poor sleep quality has been associated with active inflammatory bowel disease (IBD) in several studies. This review examines sleep quality in people with active IBD and in those in remission, with meta-analyses performed, considering subjective and objective sleep quality and IBD activity. Methods Electronic databases were searched from inception to December 1st 2020. A random effects model was used with separate meta-analyses performed for objective and subjective sleep and IBD activity, considering sleep quality in active and inactive IBD. Results 19 studies were included in the qualitative review representing 4972 IBD patients. Subjective IBD activity (11 studies) was associated with subjective sleep quality with pooled odds ratio (OR) for subjective poor sleep in active IBD compared to remission of 3.04 (95% CI 2.41–3.83). Including only studies with objective sleep measures (5 studies), sleep efficiency was lower in those self-reporting active IBD and time awake post sleep onset was higher in those with active IBD. Objective IBD activity was associated with subjective poor sleep (4 studies), with pooled OR of 6.64 95% CI (3.02 – 14.59). Insufficient data was available to consider objective IBD activity and objective sleep quality. Conclusion IBD activity is associated with poor sleep using subjective and objective measures of sleep quality. This poor sleep manifests as decreased sleep efficiency and increased number of waking episodes post sleep onset. The relationship between objective IBD activity and sleep requires further investigation.

Treatment uptake in chronic hepatitis B virus (HBV) infection is low in South Australia, and the cost-effectiveness of increasing treatment uptake rates in this population has not been assessed. AIMS AND METHODS Using a cohort Markov model, cost-effectiveness was assessed for three different treatment uptake scenarios: 2.9% (current level-scenario 1), 10% (scenario 2), and 15% (scenario 3). The initial HBV population included 2550 treatment eligible patients who transitioned between six different health states over a 10-year period. Treatment transition probabilities were based on tenofovir therapy, while those not assigned to treatment followed the natural history transition probabilities. We estimated the incremental cost per quality adjusted life year gained using the prevented number of deaths, hepatocellular carcinoma, and liver transplants. RESULTS Scenario 3 was associated with the lowest mean cost/person over 10 years (AU$60 133), compared with scenario 2 (AU$61 964) and scenario 1 (AU$64 597). Scenario 3 was also associated with the highest quality adjusted life year gained (8.196) compared with scenario 2 (7.985) and scenario 1 (7.684). Scenario 3 would result in 50% reduction in hepatocellular carcinoma and 30% reduction in HBV-related mortality compared with scenario 1, over a 10-year period. Higher treatment uptake was found to be cost-effective with at least 2 years of treatment at either 10% or 15% of the target population. CONCLUSION Maximizing the treatment uptake in the existing HBV population from 2.9% to 15% was cost-effective for periods of 2 years or more. This was due to a reduction in the number of expected clinical events.

Endoscopic surveillance of Barrett’s esophagus (BE) is probably not cost-effective. A sub-population with BE at increased risk of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) who could be targeted for cost-effective surveillance was sought. The outcome for BE surveillance from 2003 to 2012 in a structured program was reviewed. Incidence rates and incidence rate ratios for developing HGD or EAC were calculated. Risk stratification identified individuals who could be considered for exclusion from surveillance. A health-state transition Markov cohort model evaluated the cost-effectiveness of focusing on higher-risk individuals. During 2067 person-years of follow-up of 640 patients, 17 individuals progressed to HGD or EAC (annual IR 0.8%). Individuals with columnar-lined esophagus (CLE) ≥2 cm had an annual IR of 1.2% and >8-fold increased relative risk of HGD or EAC, compared to CLE

Background The promotility agents currently available to treat gastroparesis and feed intolerance in the critically ill are limited by adverse effects. The aim of this study was to assess the pharmacodynamic effects and pharmacokinetics of single doses of the novel gastric promotility agent motilin agonist camicinal (GSK962040) in critically ill feed-intolerant patients. Methods A prospective, randomized, double-blind, parallel-group, placebo-controlled, study was performed in mechanically ventilated feed-intolerant patients [median age 55 (19–84), 73% male, APACHE II score 18 (5–37) with a gastric residual volume ≥200mL]. Gastric emptying and glucose absorption were measured both pre- and post-treatment after intragastric administration of 50mg (n = 15) camicinal and placebo (n = 8) using the13C-octanoic acid breath test (BTt1/2), acetaminophen concentrations, and 3-O-methylglucose concentrations respectively. Results Following 50mg enteral camicinal, there was a trend to accelerated gastric emptying [adjusted geometric means: pre-treatment BTt1/2117minutes vs. post- treatment 76minutes; 95% confidence intervals (CI; 0.39, 1.08) and increased glucose absorption (AUC240minpre-treatment: 28.63mmol.min/L vs. post-treatment: 71.63mmol.min/L; 95% CI (1.68, 3.72)]. When two patients who did not have detectable plasma concentrations of camicinal were excluded from analysis, camicinal accelerated gastric emptying (adjusted geometric means: pre-treatment BTt1/2121minutes vs. post-treatment 65minutes 95 % CI (0.32, 0.91) and increased glucose absorption (AUC240minpre-treatment: 33.04mmol.min/L vs. post-treatment: 74.59mmol.min/L; 95 % CI (1.478, 3.449). In those patients receiving placebo gastric emptying was similar pre- and post-treatment. Conclusions When absorbed, a single enteral dose of camicinal (50mg) accelerates gastric emptying and increases glucose absorption in feed-intolerant critically ill patients. Trial registration The study protocol was registered with the US NIH clinicaltrials.gov on 23 December 2009 (IdentifierNCT01039805).

Background During the initial phase of critical illness, the association between the dose of nutrition support and mortality risk may vary among patients in the intensive care unit (ICU) because the prevalence of malnutrition varies widely (28 to 78%), and not all ICU patients are severely ill. Therefore, we hypothesized that a prognostic model that integrates nutritional status and disease severity could accurately predict mortality risk and classify critically ill patients into low- and high-risk groups. Additionally, in critically ill patients placed on exclusive nutritional support (ENS), we hypothesized that their risk categories could modify the association between dose of nutrition support and mortality risk. Methods A prognostic model that predicts 28-day mortality was built from a prospective cohort study of 440 patients. The association between dose of nutrition support and mortality risk was evaluated in a subgroup of 252 mechanically ventilated patients via logistic regressions, stratified by low- and high-risk groups, and days of exclusive nutritional support (ENS) [short-term (≤ 6 days) vs. longer-term (≥ 7 days)]. Only the first 6 days of ENS was evaluated for a fair comparison. Results The prognostic model demonstrated good discrimination [AUC 0.78 (95% CI 0.73–0.82), and a bias-corrected calibration curve suggested fair accuracy. In high-risk patients with short-term ENS (≤ 6 days), each 10% increase in goal energy and protein intake was associated with an increased adjusted odds (95% CI) of 28-day mortality [1.60 (1.19–2.15) and 1.47 (1.12–1.86), respectively]. In contrast, each 10% increase in goal protein intake during the first 6 days of ENS in high-risk patients with longer-term ENS (≥ 7 days) was associated with a lower adjusted odds of 28-day mortality [0.75 (0.57–0.99)]. Despite the opposing associations, the mean predicted mortality risks and prevalence of malnutrition between short- and longer-term ENS patients were similar. Conclusions Combining baseline nutritional status and disease severity in a prognostic model could accurately predict 28-day mortality. However, the association between the dose of nutrition support during the first 6 days of ENS and 28-day mortality was independent of baseline disease severity and nutritional status. Electronic supplementary material The online version of this article (10.1186/s13054-019-2500-z) contains supplementary material, which is available to authorized users.

James Ian Summers Robertson was born in Welbeck, Nottinghamshire, and educated at Queen Elizabeth’s Grammar School in Mansfield, Nottinghamshire, and then St Mary’s Hospital Medical School, University of London, Ian graduated bachelor of science with 1st class honours in human and comparative anatomy in 1949 and bachelor of medicine, bachelor of surgery with honours, and distinctions in medicine and pathology, in 1952. At St Mary’s he also found time to be captain of both cricket and soccer. He was admitted as a member of the Royal College of Physicians of London in 1954 and was subsequently elected as a fellow. Ian did national service with the Royal Army Medical Corps from 1954 to 1956, during which time he represented the army at cricket and rugby union football. He later said that one of his most demanding military duties was batting at first wicket down against Yorkshire. He also played club cricket for Worksop in the Bassetlaw League in the north of England, and later for West of Scotland in the Western Union. He then joined St Mary’s Hospital medical unit, initially as a lecturer in medicine from 1956 to 1964, and, thereafter, as a senior lecturer in therapeutics and honorary consultant physician from 1964 to 1967. From 1956 Stanley Peart led the unit. Peart had purified and sequenced angiotensin II, the product of the action of the renal enzyme renin and the most potent vasopressor …

BACKGROUND Upper gastrointestinal bleeding (UGIB) is a common cause of hospital admission and red cell transfusion is frequently required. A large single-centre randomised study from 2013 showed that a restrictive transfusion strategy in UGIB management was associated with better outcomes compared to a liberal strategy. Subsequently multiple international guidelines favour a restrictive transfusion strategy. However, given the multiple exclusion criteria in the study, generalisation to everyday practice was unclear. AIMS To assess applicability of the data to a non-trial UGIB population and determine how often restrictive thresholds are used in clinical practice. METHODS A retrospective case note review of patients with an UGIB admission during 2014 in three tertiary hospitals was undertaken. Information collected included demographics, comorbidities and factors associated with transfusion, such as apparent haemoglobin triggers and units transfused. The proportion of patients who would have met inclusion criteria of the study was calculated. RESULTS Of 89 UGIB admissions reviewed, up to 70% would be suitable for a restrictive approach. Use of this approach was evident in only 26% of transfusion episodes in patients meeting inclusion criteria. However, assessment was, limited by rapidly changing clinical status and potential for overestimation of true haemoglobin level with fluid resuscitation and equilibration. CONCLUSION A restrictive transfusion strategy may be suitable for many patients presenting with UGIB; however, important exclusions were not uncommon. Opportunities for increased uptake of restrictive thresholds were identified. Ongoing improvement initiatives should address the risks of both over and under-transfusion.

Suboptimal participation is commonly observed in colorectal cancer screening programs utilizing fecal tests. This randomized controlled trial tested whether the offer of a blood test as either a “rescue” strategy for fecal test nonparticipants or an upfront choice, could improve participation. A total of 1,800 people (50–74 years) were randomized to control, rescue, or choice groups (n = 600/group). All were mailed a fecal immunochemical test (FIT, OC-Sensor, Eiken Chemical Company) and a survey assessing awareness of the screening tests. The rescue group was offered a blood test 12 weeks after FIT nonparticipation. The choice group was given the opportunity to choose to do a blood test (Colvera, Clinical Genomics) instead of FIT at baseline. Participation with any test after 24 weeks was not significantly different between groups (control, 37.8%; rescue, 36.9%; choice, 33.8%; P > 0.05). When the rescue strategy was offered after 12 weeks, an additional 6.5% participated with the blood test, which was greater than the blood test participation when offered as an upfront choice (1.5%; P < 0.001). Awareness of the tests was greater for FIT than for blood (96.2% vs. 23.1%; P < 0.0001). In a population familiar with FIT screening, provision of a blood test either as a rescue of FIT nonparticipants or as an upfront choice did not increase overall participation. This might reflect a lack of awareness of the blood test for screening compared with FIT.

Despite the common use of one-handed lifting techniques for activities of daily living, these techniques have received little attention in the biomechanics literature. The braced arm-to-thigh technique (BATT) is a one-handed lifting method in which the dominant hand picks up objects, while the free hand braces the trunk on the ipsilateral thigh. The aim of this study was to compare the BATT to two-handed or unsupported one-handed lifting techniques with loads of 2 and 10 kg, by evaluating trunk motion and spine loading at L4/L5. Twenty healthy participants (30–70 years old) matched in age and sex to 18 participants with low back pain were recruited to the study. A three-axis load cell secured to the distal anterior thigh measured the bracing forces applied by the hand. The OpenSim Lifting Full-Body model was used to estimate trunk kinematics and spinal loading at L4/L5. Linear mixed-effects models were developed to compare trunk angles and L4/L5 moments and forces between lifting techniques. Trunk flexion angles were significantly reduced for the BATT lift compared to one-handed and two-handed stoop lifts (9–20%). However, the BATT also increased asymmetric trunk kinematics and moments at L4/L5. The BATT produced significantly lower moments (28–38%), and compressive (25–32%) and antero-posterior shear (25–45%) forces at L4/L5, compared to unsupported lifting techniques. Bracing the hand on the thigh to support the trunk can substantially reduce low back loading during lifting tasks of 2 to 10 kg.

Dysphagia becomes more common in old age. We performed high-resolution impedance manometry (HRIM) in asymptomatic healthy adults (including an older cohort80 years) to assess HRIM findings in relation to bolus clearance.Esophageal HRIM was performed in a sitting posture in 45 healthy volunteers (n = 30 young control, mean age 37 ± 11 years and n = 15 older subjects aged 85 ± 4 years) using a 3.2-mm solid-state catheter (Solar GI system; MMS, Enschede, The Netherlands) with 25 pressure (1-cm spacing) and 12 impedance segments (2-cm intervals). Five swallows each of 5- and 10-mL liquid and viscous bolus were performed and analyzed using esophageal pressure topography metrics and Chicago classification criteria as well as pressure-flow parameters. Bolus transit was determined using standard impedance criteria. A p-value0.05 was considered significant.Impaired bolus clearance occurred more frequently in asymptomatic older subjects compared with young controls (YC) during liquid (40 vs 18%, χImpaired liquid and viscous bolus clearance, esophageal pressure topography, and pressure-flow changes were seen in asymptomatic older subjects.

Malnutrition is associated with poor clinical outcomes among hospitalized patients. However, studies linking malnutrition with poor clinical outcomes in the intensive care unit (ICU) often have conflicting findings due in part to the inappropriate diagnosis of malnutrition. We primarily aimed to determine whether malnutrition diagnosed by validated nutrition assessment tools such as the Subjective Global Assessment (SGA) or Mini Nutritional Assessment (MNA) is independently associated with poorer clinical outcomes in the ICU and if the use of nutrition screening tools demonstrate a similar association. PubMed, CINAHL, Scopus, and Cochrane Library were systematically searched for eligible studies. Search terms included were synonyms of malnutrition, nutritional status, screening, assessment, and intensive care unit. Eligible studies were case-control or cohort studies that recruited adults in the ICU; conducted the SGA, MNA, or used nutrition screening tools before or within 48 hours of ICU admission; and ...

Background and Aim: Percutaneous thermal ablation using radiofrequency ablation (RFA) and microwave ablation (MWA) are both widely available curative treatments for hepatocellular carcinoma. Despite significant advances, it remains unclear which modality results in better outcomes. This meta-analysis of randomized controlled trials (RCT) and observational studies was undertaken to compare the techniques in terms of effectiveness and safety. Methods: Electronic reference databases (Medline, EMBASE and Cochrane Central) were searched between January 1980 and May 2014 for human studies comparing RFA and MWA. The primary outcome was the risk of local tumor progression (LTP). Secondary outcomes were complete ablation (CA), overall survival, and major adverse events (AE). The ORs were combined across studies using the random-effects model. Results: Ten studies (two prospective and eight retrospective) were included, and the overall LTP rate was 13.6% (176/1298). There was no difference in LTP rates between RFA and MWA [OR (95% CI): 1.01(0.67–1.50), P = 0.9]. The CA rate, 1- and 3-year overall survival and major AE were similar between the two modalities (P > 0.05 for all). In subgroup analysis, there was no difference in LTP rates according to study quality, but LTP rates were lower with MWA for treatment of larger tumors [1.88(1.10–3.23), P = 0.02]. There was no significant publication bias or inter-study heterogeneity (I2 0.1) observed in any of the measured outcomes. Conclusion: Overall, both RFA and MWA are equally effective and safe, but MWA may be more effective compared to RFA in preventing LTP when treating larger tumors. Well-designed, larger, multicentre RCTs are required to confirm these findings.

Background Assessment of upper esophageal sphincter (UES) motility is challenging, as functionally, UES relaxation and opening are distinct. We studied novel parameters, UES admittance (inverse of nadir impedance), and 0.2-s integrated relaxation pressure (IRP), in patients with cricopharyngeal bar (CPB) and motor neuron disease (MND), as predictors of UES dysfunction. Methods Sixty-six healthy subjects (n = 50 controls 20–80 years; n = 16 elderly >80 years), 11 patients with CPB (51–83 years) and 16 with MND (58–91 years) were studied using pharyngeal high-resolution impedance manometry. Subjects received 5 × 5 mL liquid (L) and viscous (V) boluses. Admittance and IRP were compared by age and between groups. A p < 0.05 was considered significant. Key Results In healthy subjects, admittance was reduced (L: p = 0.005 and V: p = 0.04) and the IRP higher with liquids (p = 0.02) in older age. Admittance was reduced in MND compared to both healthy groups (Young: p < 0.0001 for both, Elderly L: p < 0.0001 and V: p = 0.009) and CPB with liquid (p = 0.001). Only liquid showed a higher IRP in MND patients compared to controls (p = 0.03), but was similar to healthy elderly and CPB patients. Only admittance differentiated younger controls from CPB (L: p = 0.0002 and V: p < 0.0001), with no differences in either parameter between CPB and elderly subjects. Conclusions & Inferences The effects of aging and pathology were better discriminated by UES maximum admittance, demonstrating greater statistical confidence across bolus consistencies as compared to 0.2-s IRP. Maximum admittance may be a clinically useful determinate of UES dysfunction.

Objective The English Bowel Cancer Screening Programme (BCSP) recommends 3 yearly colonoscopy surveillance for patients at intermediate risk of colorectal cancer (CRC) postpolypectomy (those with three to four small adenomas or one ≥10 mm). We investigated whether faecal immunochemical tests (FITs) could reduce surveillance burden on patients and endoscopy services. Design Intermediate-risk patients (60–72 years) recommended 3 yearly surveillance were recruited within the BCSP (January 2012–December 2013). FITs were offered at 1, 2 and 3 years postpolypectomy. Invitees consenting and returning a year 1 FIT were included. Participants testing positive (haemoglobin ≥40 µg/g) at years one or two were offered colonoscopy early; all others were offered colonoscopy at 3 years. Diagnostic accuracy for CRC and advanced adenomas (AAs) was estimated considering multiple tests and thresholds. We calculated incremental costs per additional AA and CRC detected by colonoscopy versus FIT surveillance. Results 74% (5938/8009) of invitees were included in our study having participated at year 1. Of these, 97% returned FITs at years 2 and 3. Three-year cumulative positivity was 13% at the 40 µg/g haemoglobin threshold and 29% at 10 µg/g. 29 participants were diagnosed with CRC and 446 with AAs. Three-year programme sensitivities for CRC and AAs were, respectively, 59% and 33% at 40 µg/g, and 72% and 57% at 10 µg/g. Incremental costs per additional AA and CRC detected by colonoscopy versus FIT (40 µg/g) surveillance were £7354 and £180 778, respectively. Conclusions Replacing 3 yearly colonoscopy surveillance in intermediate-risk patients with annual FIT could reduce colonoscopies by 71%, significantly cut costs but could miss 30%–40% of CRCs and 40%–70% of AAs. Trial registration number ISRCTN18040196; Results.

To compare GI symptoms, measures of generic and disease specific health related quality of life (HRQoL), anorectal and pudendal nerve function and anal sphincter morphology between (i) patients ≥2 years after 3D conformal radiotherapy (3D-CRT)±high dose rate (HDR) brachytherapy for carcinoma of the prostate and aged matched patients before radiotherapy and (ii) symptomatic and asymptomatic patients ≥2 years after 3D-CRT ± HDR brachytherapy.Methodology included: (i) modified LENT-SOMA scales for GI symptoms, (ii) EORTC QLQ-C30 and EORTC QLQ-PR25 questionnaires for generic and disease specific HRQoL, (iii) anorectal manometry and terminal motor latency for anorectal and pudendal nerve function and (iv) endorectal ultrasound for anal sphincter morphology. GI symptoms, parameters of HRQoL, anorectal and pudendal nerve function and anal sphincter morphology were compared using Mann-Whitney's U, unpaired t and χImpairment of HRQoL bowel symptoms in the patients ≥2 years after 3D-CRT ± HDR brachytherapy was associated with worse anorectal motor and sensory function, internal and external anal sphincter morphology and 5× greater prevalence of pudendal nerve dysfunction compared with age matched patients before radiotherapy. Symptomatic patients had worse (i) HRQoL measures including global quality of life and bowel and urinary symptom scores, (ii) rectal bleeding, fecal urgency and incontinence scores and (iii) a 2× higher prevalence of pudendal nerve dysfunction compared with asymptomatic patients. Rectal and anal (i) V 40 Gy65%, (ii) Dmax60 Gy, (iii) pudendal nerve Dmax60 Gy and (iv) Anal V 60 Gy40% were associated with a greater prevalence of pudendal nerve dysfunction.3D-CRT ± HDR brachytherapy for prostate carcinoma, impairs late functional measures including HRQoL, anorectal and pudendal nerve function. Rectal, anal and pudendal nerve radiation dose constraints are proposed for reducing the prevalence of pudendal nerve dysfunction.

Background and study aims: Colonoscopy with inhaled methoxyflurane (Penthrox) is well tolerated in unselected subjects and is not associated with respiratory depression. The aim of this prospective study was to compare the feasibility, safety, and post-procedural outcomes of portable methoxyflurane used as an analgesic agent during colonoscopy with those of anesthesia-assisted deep sedation (AADS) in subjects with morbid obesity and/or obstructive sleep apnea (OSA). Patients and methods: The outcomes of 140 patients with morbid obesity/OSA who underwent colonoscopy with either Penthrox inhalation (n = 85; 46 men, 39 women; mean age 57.2 ± 1.1 years) or AADS (n = 55; 27 men, 28 women; mean age, 54.9 ± 1.1 years) were prospectively assessed. Results: All Penthrox-assisted colonoscopies were successful, without any requirement for additional intravenous sedation. Compared with AADS, Penthrox was associated with a shorter total procedural time (24 ± 1 vs. 52 ± 1 minutes, P

The precise etiology of fecal incontinence (FI), which occurs frequently following external beam radiotherapy (EBRT) for prostate carcinoma is unknown. It is possibly related to pelvic nerve injury. The aim of this study was to assess the incidence of pudendal nerve dysfunction in men with FI after EBRT for prostate cancer compared to men with FI but no history of EBRT.Data were evaluated from 74 men with intact anal sphincters on endo-anal ultrasound (17 post-EBRT) who had been investigated for FI at a tertiary center. Wexner incontinence scores, pudendal nerve function, anorectal manometry, and rectal sensitivity were compared between the two patient groups.Post-radiotherapy patients were older (77±6 vs. 62±17 years, p0.005) and had worse incontinence than those with no history of radiotherapy (Wexner score; 13±3 vs. 8±4; p0.005). Bilateral pudendal nerve terminal motor latency (PNTML) was abnormal in 87% of radiotherapy versus 22% of non-radiotherapy patients (p0.001) and the significant difference persisted even after correction for age differences. Anal sphincter pressures and rectal sensitivity for both groups were similar.There is a markedly higher incidence of pudendal nerve dysfunction in men with FI after EBRT for prostate cancer compared with men with FI from other etiologies. The increased severity of incontinence in radiotherapy patients is not matched by alterations in either anal sphincter pressures or rectal sensitivity compared to FI in non-ERBT patients.

OBJECTIVE To examine the compliance of colorectal cancer surveillance decisions for individuals at greater risk with current evidence-based guidelines and to determine whether compliance differs between surveillance models. DESIGN Prospective auditing of compliance of surveillance decisions with evidence-based guidelines (NHMRC) in two decision-making models: nurse coordinator-led decision making in public academic hospitals and physician-led decision making in private non-academic hospitals. SETTING Selected South Australian hospitals participating in the Southern Co-operative Program for the Prevention of Colorectal Cancer (SCOOP). MAIN OUTCOME MEASURES Proportions of recall recommendations that matched NHMRC guideline recommendations (March-May 2015); numbers of surveillance colonoscopies undertaken more than 6 months ahead of schedule (January-December 2015); proportions of significant neoplasia findings during the 15 years of SCOOP operation (2000-2015). RESULTS For the nurse-led/public academic hospital model, the recall interval recommendation following 398 of 410 colonoscopies (97%) with findings covered by NHMRC guidelines corresponded to the guideline recommendations; for the physician-led/private non-academic hospital model, this applied to 257 of 310 colonoscopies (83%) (P < 0.001). During 2015, 27% of colonoscopies in public academic hospitals (mean, 27 months; SD, 13 months) and 20% of those in private non-academic hospitals (mean, 23 months; SD, 12 months) were performed more than 6 months earlier than scheduled, in most cases because of patient-related factors (symptoms, faecal occult blood test results). The ratio of the numbers of high risk adenomas to cancers increased from 6.6:1 during 2001-2005 to 16:1 during 2011-2015. CONCLUSION The nurse-led/public academic hospital model for decisions about colorectal cancer surveillance intervals achieves a high degree of compliance with guideline recommendations, which should relieve burdening of colonoscopy resources.

Background & Aims: Swallowing diculties become increasingly prevalent in older age. Dierences exist in lower esophageal sphincter (LES) function between older and younger patients with dysphagia, but the contribution of aging per se to these is unclear. Methods: Esophageal motor function was measured using high resolution manometry in older (aged 81±1.7 yrs) and younger (23±1.7 yrs) asymptomatic healthy adults. Aer baseline recording, motility was assessed by swallowing boluses of liquid (right lateral and upright postures) and solids. Basal LES pressure, integrated relaxation pressure, distal esophageal peristaltic amplitude, distal contractile integral and velocity were measured. Data are presented as mean ± SEM. Results: Despite a trend for lower basal LES pressure (15.8±2.9 mmHg vs. 21.0±0.2 mmHg; P=0.08), completeness of LES relaxation was reduced in older subjects (liquid RL: P=0.003; UR: P=0.007; solid: P=0.03), with higher integrated relaxation pressure when upright (liquid: 6.9±1.1 vs. 3.1±0.4 mmHg; P=0.01; solids: 8.1±1.1 vs. 3.6±0.3 mmHg; P=0.001) and a longer time to recovery aer liquid boluses (right lateral: P=0.01; upright: P=0.04). In young, but not older adults, esophageal peristaltic velocity was increased when upright (3.6±0.2 cm/sec; P=0.04) and reduced with solids (3.0±0.1 cm-s; P=0.03). Distal contraction amplitude was higher with solid cf. liquid in the younger individuals (51.8±7.9 mmHg vs. 41.4±6.2 mmHg; P=0.03). In elderly subjects, the distal contractile integral was higher with liquid swallows in the upright posture (P=0.006). Conclusion: �ere are subtle changes in LES function even in asymptomatic older individuals. �ese age- related changes may contribute to the development of dysphagia.

Inflammatory bowel disease (IBD) management is increasingly concentrated in units with expertise in the condition leading to substantial improvement in outcomes. Such units often employ nurses with a specialised interest in IBD with enhancements in care reflecting in part the promotion of more efficient use of medical and hospital services by this role. However, the relative contributions of nurse specialist input, and the effect of medical staff with a sub-speciality interest in IBD are unclear although this has major implications for funding. Determining the value of IBD nurses by assessing the direct impact of an IBD nurse on reducing admissions and outpatient attendances has immediate cost benefits, but the long-term sustainability of these savings has not been previously investigated. We therefore assessed the effect of an IBD nurse on patient outcomes in a tertiary hospital IBD Unit where the position has been established for 8years by measuring the number of occasions of service (OOS) and outcomes of all interactions between the nurse and patients in a tertiary hospital IBD Unit over a 12-month period. There were 4920 OOS recorded involving 566 patients. IBD nurse intervention led to avoidance of 27 hospital admissions (representing a saving of 171 occupied bed days), 32 Emergency Department presentations and 163 outpatient reviews. After deducting salary and on-costs related to the IBD nurse there was a net direct saving to the hospital of AUD $136,535. IBD nurse positions provide sustained direct cost reductions to health services via reducing hospital attendances. This is additional to benefits that accrue through better patient knowledge, earlier presentation and increased compliance.

Age-related loss of swallowing efficiency may occur for multiple reasons. Objective assessment of individual dysfunctions is difficult and may not clearly differentiate these from normal. Pharyngeal pressure-flow analysis is a novel technique that allows quantification of swallow dysfunction predisposing to aspiration risk based on a swallow risk index (SRI). In this study, we examined the effect of ageing on swallow function.Studies were performed in 68 healthy subjects aged 20-91 years (mean 59 years; 29 male), asymptomatic for oropharyngeal disease. Swallowing of liquid and viscous boluses was recorded with a pressure-impedance catheter. Indices of swallow function including the SRI, postswallow residues, upper esophageal sphincter opening and bolus transit time were derived using purpose designed software.Swallow function worsened with increasing age with a significant decline after 80 years. Higher SRI correlated with increasing age (r = 0.257, p 0.05 for liquids and r = 0.361, p 0.005 viscous bolus). Subjects over 80 years were overrepresented amongst those with an SRI considered diagnostically relevant (SRI 15). In addition, upper esophageal sphincter opening was reduced and postswallow residues increased in older subjects.Pharyngeal pressure-flow analysis reveals multiple functional abnormalities in older individuals. The higher SRI levels seen in asymptomatic elders possibly reflect a loss of functional reserve with ageing. Automated impedance manometry analysis of swallow function may allow the risk of developing disordered swallowing to be quantified numerically.