Never underestimate inflammatory bowel disease: High prevalence rates and confirmation of high incidence rates in Australia.

BACKGROUND AND AIMS: Regional variations in inflammatory bowel disease (IBD) rates have been observed. Limited epidemiological data are available from Australasia. IBD prevalence rates have never been assessed in an Australian population-based setting. In addition, there are few historical IBD incidence data to allow assessment of rate changes. The aims were to calculate Australia's first population-based IBD prevalence rates, to reassess local IBD incidence rates, and to establish a population-based inception cohort. METHODS: An observational, prospective population-based epidemiological study was performed to assess IBD prevalence and incidence rates from July 2010 to June 2011 in a geographically defined Australian population (Barwon, Victoria). RESULTS: There were 1011 prevalent IBD cases identified, representing a crude point prevalence rate of 344.6 per 100,000 on June 30, 2011. Crohn's disease was the most common prevalent subtype. Seventy-one incident cases of IBD were identified, with a crude incidence rate of 24.2 per 100,000. Crohn's disease was again more common. Local incidence rates have not changed between 2007 and the present study. All incident cases were successfully incorporated into an inception cohort. CONCLUSION: The burden of IBD in our local region is high. Demographic similarities allow these results to be applied to the broader Australian community. We propose that the number of existing and new cases each year in Australia has been previously underestimated. These revised figures will be important when planning the provision of health resources for these patients in the future and when assessing need for research funding priorities.

Prospective population-based cohort of inflammatory bowel disease in the biologics era: Disease course and predictors of severity.

BACKGROUND AND AIM: We have previously found high incidence of inflammatory bowel disease (IBD) in Australia. A population-based registry was established to assess disease severity, frequency of complications, and prognostic factors. METHODS: Incident cases were prospectively identified over 4 years. Early disease severity was assessed according to need for hospitalization and resective surgery and medication use. RESULTS: We report on the early outcomes (median 18 months, range 12-60 months) for 252 patients comprising 146 with Crohn's disease (CD), 96 with ulcerative colitis (UC), and 10 IBD undifferentiated. Eighty-seven percent of CD patients had inflammatory disease at diagnosis, and this reduced to 73% at 5 years (n = 38). Immunomodulators were prescribed in 57% of CD patients and 19% with UC. A third of all CD patients were hospitalized, the majority (77%) in the first 12 months. Risk factors for hospitalization included penetrating, perianal, and ileocolonic disease (P < 0.05). Twenty-four percent of UC patients were hospitalized, most within the first 12 months. Intestinal resection rates were 13% at 1 year in CD and 26% at 5 years. Risk factors include penetrating and stricturing disease (P < 0.001) and ileal involvement (P < 0.05). Colectomy rates in UC were 2% and 13% at 1 and 5 years. High C-reactive protein (CRP) at diagnosis was associated with colectomy. CONCLUSIONS: A high rate of inflammatory disease, frequent immunomodulator use in CD, and a low rate of surgery in both CD and UC were identified. In CD, ileal involvement and complex disease behavior are associated with a more severe disease course, while in UC a high CRP predicted this outcome.

A novel serogenetic approach determines the community prevalence of celiac disease and informs improved diagnostic pathways.

BACKGROUND: Changing perspectives on the natural history of celiac disease (CD), new serology and genetic tests, and amended histological criteria for diagnosis cast doubt on past prevalence estimates for CD. We set out to establish a more accurate prevalence estimate for CD using a novel serogenetic approach. METHODS: The human leukocyte antigen (HLA)-DQ genotype was determined in 356 patients with 'biopsy-confirmed' CD, and in two age-stratified, randomly selected community cohorts of 1,390 women and 1,158 men. Sera were screened for CD-specific serology. RESULTS: Only five 'biopsy-confirmed' patients with CD did not possess the susceptibility alleles HLA-DQ2.5, DQ8, or DQ2.2, and four of these were misdiagnoses. HLA-DQ2.5, DQ8, or DQ2.2 was present in 56% of all women and men in the community cohorts. Transglutaminase (TG)-2 IgA and composite TG2/deamidated gliadin peptide (DGP) IgA/IgG were abnormal in 4.6% and 5.6%, respectively, of the community women and 6.9% and 6.9%, respectively, of the community men, but in the screen-positive group, only 71% and 75%, respectively, of women and 65% and 63%, respectively, of men possessed HLA-DQ2.5, DQ8, or DQ2.2. Medical review was possible for 41% of seropositive women and 50% of seropositive men, and led to biopsy-confirmed CD in 10 women (0.7%) and 6 men (0.5%), but based on relative risk for HLA-DQ2.5, DQ8, or DQ2.2 in all TG2 IgA or TG2/DGP IgA/IgG screen-positive subjects, CD affected 1.3% or 1.9%, respectively, of females and 1.3% or 1.2%, respectively, of men. Serogenetic data from these community cohorts indicated that testing screen positives for HLA-DQ, or carrying out HLA-DQ and further serology, could have reduced unnecessary gastroscopies due to false-positive serology by at least 40% and by over 70%, respectively. CONCLUSIONS: Screening with TG2 IgA serology and requiring biopsy confirmation caused the community prevalence of CD to be substantially underestimated. Testing for HLA-DQ genes and confirmatory serology could reduce the numbers of unnecessary gastroscopies.

A Rare Case of Hematuria; Primary Amyloidosis of the Bladder Neck.

Primary and localized amyloidosis of the urinary tract is considered to be a rare clinical entity with approximately 160 cases documented in the literature. Here we present a case of a 77 year old gentleman with painless visible hematuria. Flexible cystoscopy revealed abnormal and polypoidal bladder mucosa. Transurethral resection of these lesions revealed histology with congo-red staining and positive green-apple birefringence, these findings are consistent with amyloidosis. There has so far been no sign of recurrence in this gentleman, with routine cystoscopic surveillance. Here we present a literature review on the presentation, diagnosis and management of this rare condition.

Laparoscopic and cystoscopic-assisted suprapubic catheter insertion: A case study and technical note.

OBJECTIVE: To describe a new technique for suprapubic urinary catheterisation that can be used in selected patients with high anaesthetic risk, and previous lower abdominal surgery and bowel adhesions. PATIENT AND METHODS: In a 33-year-old woman, laparoscopic guidance with cystoscopic vision was used to ensure the safe passage of a suprapubic catheter. RESULTS: The suprapubic catheter was successfully inserted in this challenging patient; release of adhesions allowed for the passage of the catheter without bowel injury. CONCLUSION: Laparoscopic and cystoscopic-assisted suprapubic catheter insertion is a novel technique to avoid significant morbidity and mortality in selected patients with high anaesthetic risk, and previous lower abdominal surgery and bowel adhesions.

Health Care Cost Analysis in a Population-based Inception Cohort of Inflammatory Bowel Disease Patients in the First Year of Diagnosis.

BACKGROUND: There are limited prospective population-based data on the health care cost of IBD in the post-biologicals era. A prospective registry that included all incident cases of inflammatory bowel disease [IBD] was established to study disease progress and health cost. AIM: To prospectively assess health care costs in the first year of diagnosis among a well-characterised cohort of newly diagnosed IBD patients. METHOD: Incident cases of IBD were prospectively identified in 2007-2008 and 2010-2013 from multiple health care providers, and enrolled into the population-based registry. Health care resource utilisation for each patient was collected through active surveillance of case notes and investigations including specialist visits, diagnostic tests, medications, medical hospitalisation, and surgery. RESULTS: Off 276 incident cases of IBD, 252 [91%] were recruited to the registry, and health care cost was calculated for 242 (146 Crohn's disease [CD] and 96 ulcerative colitis [UC] patients). The median cost in CD was higher at A$5905 per patient (interquartile range [IQR]: A$1571-$91,324) than in UC at A$4752 [IQR: A$1488-A$58,072]. In CD, outpatient resources made up 55% of all cost, with medications accounting for 32% of total cost [15% aminosalicylates, 15% biological therapy], followed by surgery [31%], and diagnostic testing [21%]. In UC, medications accounted for 39% of total cost [of which 37% was due to 5-aminosalicylates, and diagnostics 29%; outpatient cost contributed 71% to total cost. CONCLUSION: In the first year of diagnosis, outpatient resources account for the majority of cost in both CD and UC. Medications are the main cost driver in IBD.

Electronic health risk assessment adoption in an integrated healthcare system.

OBJECTIVES: To examine uptake patterns of the electronic health risk assessment (eHRA) and compare characteristics of early adopters among adults in 1 healthcare system with those of the potentially eligible population. STUDY DESIGN: Retrospective cohort study (September 2006-March 2009). METHODS: We designed and implemented an integrated eHRA to improve individual health plan members' self-management of their health risks and chronic illness. We included individuals aged 21 to 85 years who had been enrolled at Group Health Cooperative for 12 or more months before September 2006, when the eHRA was first introduced. Study participants had to be registered users of the health plan's secure Web portal by March 2009 in order to complete the eHRA. RESULTS: A total of 332,381 adults were potentially eligible; of these 39.3% were eligible to complete the eHRA. One or more eHRAs were completed by 22.4% of registered Web portal users over the study period with slow but consistent uptake. Completers were more likely to be women, to be middle-aged (41-65 years), and to have had a recent well-care visit and fewer comorbid conditions. CONCLUSIONS: Significant additional outreach, engagement strategies, and incentives are likely required by health systems to increase adoption and ongoing use of an eHRA among target populations. Future research on eHRA uptake in primary care should focus on whether the use of these tools leads to patient action and provider engagement that improve health outcomes in moderate-risk and high-risk individuals, as well as on modalities to reach broader audiences for higher completion rates.

High incidence of inflammatory bowel disease in Australia: a prospective population-based Australian incidence study.

BACKGROUND: To date, there have been no population-based epidemiological studies published from Australia concerning the incidence of inflammatory bowel disease (IBD). Our hypothesis was that the incidence of IBD in Australia is at least as high as other industrialized countries, given similar genetic and environmental risk factors. METHODS: A prospective, population-based IBD incidence study was conducted between April 2007 and March 2008 in Greater Geelong, Victoria, Australia. According to 2006 Australian Census data, this comprises an at-risk population of 259,015. Cases were ascertained from multiple overlapping sources. All local general practitioners, gastroenterologists, surgeons, and pediatricians were contacted every 2 months to identify new IBD cases. The Royal Children's Hospital in Melbourne, local endoscopy and pathology centers were also searched to ensure completeness of case capture. Standard IBD case definitions were used with clinical, endoscopic, and histological criteria. RESULTS: In all, 76 new cases of IBD were identified during the 1-year period. There were 45 cases of Crohn's disease, 29 of ulcerative colitis, and 2 of indeterminate colitis. The crude annual incidence rates for IBD overall, Crohn's disease, ulcerative colitis, and indeterminate colitis were 29.3 per 100,000 (95% confidence interval [CI] 23.5-36.7 per 100,000), 17.4 per 100,000, 11.2 per 100,000, and 0.8 per 100,000, respectively. When directly age-standardized to the World Health Organization standard population the overall IBD incidence rate was 29.6 per 100,000. CONCLUSIONS: This is the first prospective, Australian population-based IBD incidence study. The incidence rates are among the highest reported in the literature of IBD.

Predictive ability of partin tables 2001 in a Welsh population.

OBJECTIVES: Partin tables are widely used to select and counsel patients prior to radical surgery for prostate cancer. However, Partin tables have been developed in the USA which has a different ethnic mixture from that of North Wales. We aimed to assess Partin tables' predictive ability in a Welsh population. MATERIALS AND METHODS: 193 patients underwent radical retropubic prostatectomy for clinically localized carcinoma of the prostate between April 1993 and July 2004 in a single institution in North Wales. Complete preoperative clinical staging information was available in 177 patients. Receiver operating characteristic curve analysis was used. RESULTS: The mean patient age was 64 (48-73) years. Preoperative clinical staging distribution was: T1c 46.6% and T2 53.4%. 75% had organ-confined disease (TNM 1992). Extracapsular extension without seminal vesicle or lymph node involvement was seen in 13.5%. Nine percent had seminal vesicle invasion without lymph node involvement. Lymph node metastasis was found in 2.2%. The predictive effectiveness of the Partin table was high with an area under ROC curve of 0.733 for organ confinement, 0.738 for seminal vesicle invasion and 0.780 for lymph node involvement (CI 95%). CONCLUSION: Our study demonstrated that the predictive ability of Partin tables for prostate cancer is also applicable to a Welsh population.