Cost effectiveness of mass screening for coeliac disease is determined by time-delay to diagnosis and quality of life on a gluten-free diet.

BACKGROUND: Coeliac disease is frequently diagnosed after a long delay resulting in increased morbidity and mortality. AIMS: To define the parameters which have the highest impact on the cost-effectiveness of mass screening for coeliac disease. METHODS: A Markov model examined a coeliac disease screening programme of the healthy young-adult general population compared with a no-screening strategy. The main outcome measures were quality adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER). Effects of variables were examined using sensitivity analyses. RESULTS: The screening strategy resulted in a gain of 0.0027 QALYs. The ICER of screening vs. no-screening strategy was US$48,960/QALYs. The variables with the largest impact on cost effectiveness were: the time delay from symptom onset to diagnosis, the utility of adherence to a gluten-free diet (GFD) and the prevalence of coeliac disease. Screening would be cost-effective if the time delay to diagnosis is longer than 6 years and utility of GFD adherence is greater than 0.978. CONCLUSIONS: Our model suggests that mass screening for coeliac disease of the young-adult general population is associated with improved QALYs and is a cost effectiveness strategy. Shortening of the time-delay to diagnosis by heightened awareness of health-care professionals may be a valid alternative to screening.

Topical capsaicin--a novel and effective treatment for idiopathic intractable pruritus ani: a randomised, placebo controlled, crossover study.

PURPOSE: Pruritus ani is a common and embarrassing proctological condition which can be very difficult to treat. We report the results of a double blind placebo controlled study of treatment with capsaicin. METHODS: Firstly, a pilot open study was carried out on five patients to establish which of two doses was the most acceptable by comparing effectiveness and side effects. Secondly, a double blind, placebo controlled, crossover study of topical capsaicin was performed. This study involved two four week treatment phases separated by a one week washout phase. Forty four patients were randomised to receive locally either active capsaicin (0.006%) or placebo (menthol 1%) ointment over a four week period (22 patients per group). After four weeks of treatment and a one week washout period, the placebo group began to receive capsaicin while the treated group received placebo (menthol 1%) for another four weeks. At the end of the controlled study, responders from both groups continued with capsaicin treatment in an open labelled manner. RESULTS: Thirty one of 44 patients experienced relief during capsaicin treatment periods and did not respond to menthol; all patients not responding to capsaicin also failed on menthol (p<0.0001). In 13 patients, treatment with capsaicin was unsuccessful: eight patients did not respond to capsaicin treatment, one responded equally to capsaicin and placebo, and four others dropped out because of side effects. During the follow up period (mean 10.9 (SD 5.8) months), 29 "responders" needed a mean application of capsaicin every day (1.6 (SD 1.2); range 0.5-7 days) to remain symptom free (or nearly symptom free). CONCLUSION: Capsaicin is a new, safe, and highly effective treatment for severe intractable idiopathic pruritus ani.

Wheat grass juice in the treatment of active distal ulcerative colitis: a randomized double-blind placebo-controlled trial.

BACKGROUND: The use of wheat grass (Triticum aestivum) juice for treatment of various gastrointestinal and other conditions had been suggested by its proponents for more than 30 years, but was never clinically assessed in a controlled trial. A preliminary unpublished pilot study suggested efficacy of wheat grass juice in the treatment of ulcerative colitis (UC). METHODS: A randomized, double-blind, placebo-controlled study. One gastroenterology unit in a tertiary hospital and three study coordinating centers in three major cities in Israel. Twenty-three patients diagnosed clinically and sigmoidoscopically with active distal UC were randomly allocated to receive either 100 cc of wheat grass juice, or a matching placebo, daily for 1 month. Efficacy of treatment was assessed by a 4-fold disease activity index that included rectal bleeding and number of bowel movements as determined from patient diary records, a sigmoidoscopic evaluation, and global assessment by a physician. RESULTS: Twenty-one patients completed the study, and full information was available on 19 of them. Treatment with wheat grass juice was associated with significant reductions in the overall disease activity index (P=0.031) and in the severity of rectal bleeding (P = 0.025). No serious side effects were found. Fresh extract of wheat grass demonstrated a prominent tracing in cyclic voltammetry methodology, presumably corresponding to four groups of compounds that exhibit anti-oxidative properties. CONCLUSION: Wheat grass juice appeared effective and safe as a single or adjuvant treatment of active distal UC.

Time course of nitric oxide synthase generation after gluten exposure in the rectal mucosa of gluten-sensitive patients.

BACKGROUND: Nitric oxide is thought to play an important role in modulating chronic inflammatory responses as well as in immune-mediated inflammation. We reproduced a gluten-mediated mucosal response in the rectum of celiac and control subjects in order to determine the role of inducible and constitutive nitric oxide synthases in the pathogenesis of this process. MATERIAL: Nine patients with confirmed celiac disease and five healthy controls underwent a long-term rectal gluten challenge (48 h) after an enema of 6 g of crude gluten, and constitutive and inducible nitric oxide synthase activity were determined in rectal biopsies. The histological localization of inducible nitric oxide synthase was determined by immunohistochemistry. RESULTS: Activity of both isoforms of nitric oxide synthase in control subjects did not change significantly after gluten instillation. In celiac patients, constitutive nitric oxide synthase on rectal mucosa also showed no significant changes after challenge with gluten. Inducible nitric oxide synthase isoform exhibited a modest increase 4 h after gluten instillation in celiac patients (mean increase 35% compared with baseline levels) but, 8 h after challenge, generation of iNO synthase was significantly higher: 54% more than pre-challenge production (P < 0.05) and higher than control values (P < 0.05). Inducible nitric oxide synthase staining was mostly localized in mononuclear cells of the epithelium and the lamina propria. After gluten instillation, the enhanced staining was mainly localized in subepithelial areas of the lamina propria. CONCLUSION: Our data suggest a role for nitric oxide, generated by inducible nitric oxide synthase, in the process of rectal mucosa injury by local gluten instillation in sensitized patients. We could not, however, determine if the role of nitric oxide in the ensuing injury of this gluten-induced immune inflammation model is a protective one, or merely a by-product generated by the activation of the inflammatory cells.

New endoscopic palliative treatments in gastrointestinal malignancies.

Many gastrointestinal cancers are diagnosed when no curative approach is possible. Patients with these malignancies frequently have dysphagia, jaundice, intestinal obstruction and other severe symptoms which significantly impair their quality of life. We present our experience with two new endoscopic techniques for palliative treatment in these patients: placement of biliary endoprostheses to alleviate malignant obstructive jaundice and destruction of neoplastic tissue by phototherapy with laser rays.

Comparison of misoprostol and cimetidine in the treatment of duodenal ulcer.

The efficacy of misoprostol (a synthetic analogue of prostaglandin E1) and cimetidine in the treatment of duodenal ulcer was evaluated. Seventy-one patients with endoscopically proven duodenal ulcer were randomized in a double-blind manner in one of three groups that received four daily doses of either misoprostol, 50 or 200 micrograms, or cimetidine, 300 mg. Ulcer healing was assessed endoscopically after 4 weeks of treatment. The mean age, sex distribution, and tobacco, alcohol and caffeine consumption were similar in all treatment groups. Only one patient was lost to follow-up. On the misoprostol low dose, healing of the ulcer was observed in 60.9% of the patients. In contrast, healing on the higher dose of misoprostol was not significantly different to that with cimetidine. No significant clinical or laboratory side effects were observed in any of the patients. We found that the daily dose of 800 micrograms misoprostol is safe and effective in the treatment of duodenal ulcer.

Ileoscopic diagnosis of terminal ileitis.

Crohn's disease of the bowel is usually diagnosed by complete barium contrast studies of the gastrointestinal tract. However, at times, in spite of a high index of clinical suspicion, the radiologic diagnosis is not conclusive. In the present report, we describe five patients with Crohn's ileitis in whom the diagnosis was established only at ileoscopy.