Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) technique and analgesic efficacy in patients with pancreatic cancer: A systematic review and meta-analysis.

BACKGROUND: Endoscopic Ultrasound-guided Celiac Plexus Neurolysis (EUS-CPN) for the treatment of abdominal pain in pancreatic cancer can be administered in three different ways, depending on the site of needle insertion: central injection (CI), bilateral injection (BI) and celiac ganglia neurolysis (CGN). This meta-analysis aimed to (1) estimate the overall efficacy of the EUS-CPN; (2) compare the efficacy of each of the three techniques; and (3) investigate demographic and disease characteristics as potential predictors of treatment response. METHODS: We searched MEDLINE and EMBASE for studies that reported the proportion of treatment responders to EUS-CPN overall, and according to the technique used. We performed a random effects meta-analysis of proportions, and meta-regression was used to estimate the association between technique and clinical characteristics on treatment response. The safety profile was reviewed through narrative synthesis. RESULTS: Overall response rate to EUS-CPN was 68% (95% CI 61%-74%) at week two and 53% (95% CI 45%-62%) at week four. There was no evidence of a significant difference in the response rates between the three techniques. Demographics and disease characteristics were not associated with treatment response. Serious complications have been reported for BI and CGN but not for CI. Moderate to high risk of bias was observed. DISCUSSION: EUS-CPN is a useful adjunct to opioids in the management of pain. There is no evidence of a difference in the efficacy among the three techniques, however, CI is the only one for which serious complications have not been reported. Future research should focus on the appropriate timing of EUS-CPN (early versus on demand) and randomised comparison to establish the comparative efficacy of each technique.

Does physical activity protect against the development of gastroesophageal reflux disease, Barrett's esophagus, and esophageal adenocarcinoma? A review of the literature with a meta-analysis.

Physical activity affects the functioning of the gastrointestinal system through both local and systemic effects and may play an important role in reducing the risk of esophageal adenocarcinoma. This review assesses the biological mechanisms and epidemiological evidence for the relationship between physical activity and the development of esophageal adenocarcinoma and its precursor diseases: gastroesophageal reflux disease (GORD) and Barrett's esophagus. A search of PubMed, Medline, Embase, and CINAHL was conducted from their inceptions to 25th March 2017 for analytical studies that examined associations between recreational and/or occupational levels of physical activity and the risk of GORD, Barrett's esophagus, and esophageal adenocarcinoma. Where appropriate, a meta-analysis of effects was undertaken. Seven studies were included (2 cohort, 5 case control). For GORD, there were three case-control studies with 10 200 cases among 78 034 participants, with a pooled estimated OR of 0.67 (95% CI 0.57-0.78) for high versus low levels of recreational physical activity. In Barrett's esophagus, there was a single case-control study, which reported no association, OR 1.19 (95% CI 0.82-1.73). For esophageal adenocarcinoma, there were three studies (two prospective cohort, one case control) with 666 cases among 910 376 participants. The largest cohort study reported an inverse association for high versus low levels of recreational physical activity, RR 0.68, 95% CI 0.48-0.96. The remaining two studies reported no associations with either occupational or combined recreational and occupational activity. Heterogeneity in the measurement of exposure (recreational, occupational, and both) made a pooled estimate for esophageal adenocarcinoma inappropriate. Although limited, there is some evidence that higher levels of recreational physical activity may reduce the risk of both GORD and esophageal adenocarcinoma, but further large cohort studies examining the type, intensity and duration of activities that may be beneficial are needed.

Aspirin may prevent cholangiocarcinoma: a case-control study from the United kingdom.

BACKGROUND: The proliferation of cholangiocarcinoma cells is suppressed in cell culture by nonsteroidal antiinflammatory drugs (NSAIDs) through the inhibition of cyclo-oxygenase-2 enzyme and also by statins which decrease the production of mediators of the cell cycle. AIMS: To investigate whether there is an inverse association between NSAIDs, including aspirin, and the development of cholangiocarcinoma and, for the first time in a Western population, between statin use and the development of cholangiocarcinoma. METHODS: This epidemiological study had a case-control design in which cases of cholangiocarcinoma diagnosed in Norwich between 2004 and 2010 and in Leicester in 2007 were identified from clinical databases. Controls were patients with basal cell carcinomas treated in the respective dermatology departments. The case notes of all subjects were reviewed to confirm diagnoses and obtain information on medication use. The data were analyzed using unconditional logistic regression to calculate odds ratios (OR) with 95 % confidence intervals (CI). RESULTS: In total, 81 cases of cholangiocarcinoma and 275 controls were identified. For all cases there was radiological evidence of cancer and 86 % of the cases involved the extrahepatic biliary system. Aspirin use was inversely associated with the development of cholangiocarcinoma (OR 0.45, 95 % CI 0.22-0.92), but there were no significant associations between the development of cholangiocarcinoma and NSAIDs (OR 0.39; 95 % CI 0.11-1.42) or statins (OR 0.58; 95 % CI 0.28-1.19). CONCLUSIONS: The epidemiological data from this study support the biological evidence for aspirin having a protective effect against the development of cholangiocarcinoma. Aspirin use should be measured in future etiological studies and assessed as a chemoprevention agent in those at high risk of developing this type of cancer.

Diffusion-weighted imaging and magnetic resonance proton spectroscopy following preterm birth.

AIM: To study the associations between magnetic resonance proton spectroscopy (MRS) data and apparent diffusion coefficients (ADC) from the preterm brain with developmental outcome at 18 months corrected age and clinical variables. MATERIALS AND METHODS: A prospective observational cohort study of 67 infants born before 35 weeks gestational age who received both magnetic resonance imaging of the brain between 37 and 44 weeks corrected gestational age and developmental assessment around 18 months corrected age. RESULTS: No relationships were found between ADC values and MRS results or outcome. MRS ratios involving N-acetyl aspartate (NAA) from the posterior white matter were associated with "severe" and "moderate to severe" difficulties, and fine motor scores were significantly lower in participants with a visible lactate doublet in the posterior white matter. The presence of a patent ductus arteriosus (PDA) was the only clinical factor related to NAA ratios. CONCLUSION: Altered NAA levels in the posterior white matter may reflect subtle white matter injury associated with neuro-developmental difficulties, which may be related to a PDA. Further work is needed to assess the longer-term neuro-developmental implications of these findings, and to study the effect of PDAs on developmental outcome in later childhood/adolescence.

Diverticular disease in younger patients--is it clinically more complicated and related to obesity?

AIM: The aims of this systematic review were to determine the presentations of diverticular disease in patients under 40 years of age and to assess whether obesity is an important factor. METHOD: The PubMed and EMBASE databases and the Cochrane Library were searched to identify all original articles published between 1990 and 2011 on diverticular disease severity in obese patients (body mass index of ≥ 30 kg/m(2) ) under 40 years of age. RESULTS: Twenty-three clinical case series (two of which were prospective) were identified plus two large aetiological population-based studies. These reported that young patients with diverticular disease were presenting more frequently, that diverticular disease in this age group was less likely to be complicated but that emergency operation rates were higher. The majority (63.1-96.5%) of patients under 40 years of age with diverticular disease were obese. CONCLUSION: The studies suggest that in the young, obese patient with lower abdominal pain, diverticulitis and appendicitis are included in the differential diagnosis. CT and/or laparoscopy should be considered where the diagnosis is in doubt.

The differential effects of statins on the risk of developing pancreatic cancer: a case-control study in two centres in the United Kingdom.

INTRODUCTION: There are plausible biological mechanisms for how statins may prevent pancreatic cancer, although the evidence from epidemiological studies in the general population is conflicting. This study aims to clarify whether statins exert their effects in specific sub-groups, namely, gender, smoking status and diabetes. METHODS: A matched case-control study was conducted in patients diagnosed with pancreatic cancer, and a group of dermatology patients of similar ages and gender, diagnosed with basal cell carcinoma. Participants' medical records were reviewed for information on statin use prior to diagnosis. Odds ratios and 95 % CIs for the development of pancreatic cancer were estimated using conditional logistic regression. Subgroup analysis was performed in men, women, smokers and those with type 2 diabetes. RESULTS: Two hundred fifty-two cases (median age 71 years, range 48-73 years, 51 % women) and 504 controls were identified, of which 23 % of cases were regular statin users versus 21 % of controls. In the general study population there was no association between pancreatic cancer and regular statin use (OR 0.82, 95 % CI 0.53-1.23, p = 0.33). However, in male smokers, regular statin use was associated with significantly reduced odds of pancreatic cancer compared to male smokers not prescribed a statin (OR 0.11, 95 % CI 0.01-0.96, p = 0.05). In patients with type 2 diabetes statins use was not associated with reduced odds (OR 0.92, 95 % CI 0.35-2.45, p = 0.80), with no gender effects. CONCLUSIONS: In male smokers, statins may reduce the odds of pancreatic cancer. Statin use should be measured in aetiological studies of pancreatic cancer but analysed in specific sub-groups. Future work should investigate statins as chemopreventative agents in this high risk sub-group.

CT of the neonatal head.

Computed tomography (CT) is used less often than other techniques on neonatal units. However, in the acute setting, CT can be invaluable in diagnosing or excluding potentially life-threatening conditions and guiding initial management in neonates. Common indications for scanning include trauma, suspected non-accidental injury, infection, or an acute hypoxic or metabolic event. The aim of this review is to provide an overview of the normal neonatal head at CT and compare this to the common pathological abnormalities. Several key features of each condition will be highlighted. It is important to note that some pathological conditions can have overlapping features at CT and, therefore, the clinical history and additional investigations are also of key importance in determining the diagnosis.

Evaluation of a computer program ('disect') to consolidate anatomy knowledge: a randomised-controlled trial.

BACKGROUND: The teaching of anatomy to medical undergraduates continues to develop. Medical imaging can accurately demonstrate anatomy. 'disect' is a computer program which manipulates and reconstructs real CT images in 3-D. AIM: To implement and assess a novel computer-based imaging resource. METHODS: Third-year undergraduate medical students at the University of East Anglia were randomised to different methods of delivering the program - either self-directed use or guided use with worksheets. Knowledge of gastro-intestinal anatomy was assessed using a 20-item test. Attitudes to using 'disect' were evaluated using Likert scales. RESULTS: Most students reported the program was easy to use and a valuable resource for learning anatomy. There was no difference in scores between guided use and self-directed use (10.7 marks versus 10.6 marks, p = 0.52). Students who undertook the anatomy special study module, which involved dissection of the digestive system, performed best (12.8 marks versus 9.9 marks, p = 0.005). CONCLUSION: Students can adequately use a computer program to see major anatomical structures derived from CT scans. Students reported that learning anatomy can be aided by the imaging-based resource. Learning anatomy is a multi-modal activity and packages like 'disect' can enhance learning by supplementing current teaching methods.

Adjuvant statin therapy for oesophageal adenocarcinoma: the STAT-ROC feasibility study.

BACKGROUND: Statins inhibit proliferative signalling in oesophageal adenocarcinoma (OAC) and their use is associated with better survival in observational studies. The present study was undertaken to examine the feasibility of assessing adjuvant statin therapy in patients with operable OAC in a phase III RCT. METHODS: For this multicentre, double-blind, parallel-group, randomized, placebo-controlled feasibility trial, adults with OAC (including Siewert I-II lesions) who had undergone oesophagectomy were centrally allocated (1 : 1) to simvastatin 40 mg or matching placebo by block randomization, stratified by centre. Participants, clinicians and investigators were blinded to treatment allocation. Patients received treatment for up to 1 year. Feasibility outcomes were recruitment, retention, drug absorption, adherence, safety, quality of life, generalizability and survival. RESULTS: A total of 120 patients were assessed for eligibility at four centres, of whom 32 (26·7 per cent) were randomized, 16 in each group. Seven patients withdrew. Participants allocated to simvastatin had lower low-density lipoprotein cholesterol levels by 3 months (adjusted mean difference -0·83 (95 per cent c.i. -1·4 to -0·22) mmol/l; P = 0·009). Median adherence to medication was greater than 90 per cent between 3 and 12 months' follow-up. Adverse events were similar between the groups. Quality-of-life data were complete for 98·3 per cent of questionnaire items. Cardiovascular disease, diabetes and aspirin use were more prevalent in the non-randomized group, whereas tumour site, stage and grade were similar between groups. Survival estimates were imprecise. CONCLUSION: This RCT supports the conduct and informs the design considerations for a future phase III trial of adjuvant statin therapy in patients with OAC. Registration number: ISRCTN98060456 (www.isrctn/com).

ANTECEDENTES: Las estatinas inhiben las señalizaciones proliferativas en el adenocarcinoma de esófago (oesophageal adenocarcinoma, OAC) y su uso se asocia con mejor supervivencia en estudios observacionales. El presente estudio se llevó a cabo para examinar la viabilidad de evaluar el tratamiento adyuvante con estatinas en pacientes con OAC operable en un ensayo aleatorizado y controlado de fase III. MÉTODOS: En este ensayo de viabilidad controlado por placebo, aleatorizado, de grupos paralelos, doble ciego y multicéntrico, los pacientes adultos con OAC (incluyendo lesiones Siewert I/II) que fueron sometidos a esofaguectomía se asignaron de forma centralizada (1:1) a tratamiento con simvastatina 40 mg o placebo equivalente mediante aleatorización en bloques, estratificados por centro. Los participantes, los clínicos y los investigadores desconocían la asignación del tratamiento. Los pacientes recibieron el tratamiento hasta un año. Los resultados de viabilidad fueron reclutamiento, retención, absorción del fármaco, adherencia, seguridad, calidad de vida, generalización, y supervivencia. RESULTADOS: Un total de 120 pacientes fueron evaluados para elegibilidad en 4 centros, de los cuales 32 (26,7%) fueron aleatorizados, 16 en cada grupo. Siete pacientes abandonaron el ensayo. Los pacientes asignados a tratamiento con simvastatina tenían niveles de colesterol LDL más bajos a los 3 meses (diferencia media ajustada, −0,83 mmol/L, i.c. del 95% −1,4 a −0,22, P = 0,009). La mediana de la adherencia a la medicación fue mayor del 90% entre los 3-12 meses de seguimiento. Los eventos adversos fueron similares entre los grupos. Los datos de calidad de vida estaban completos en el 98,3% de las preguntas del cuestionario. Enfermedad cardiovascular, diabetes y uso de aspirina eran más prevalentes en el grupo no aleatorizado, mientras que la localización del tumor, el estadio y el grado fueron similares entre los grupos. Las estimaciones de supervivencia fueron imprecisas. CONCLUSIÓN: Este RCT apoya la realización e informa de las consideraciones de diseño para un futuro ensayo de fase III de tratamiento adyuvante con estatinas en pacientes con OAC.

Is learning anatomy facilitated by computer-aided learning? A review of the literature.

BACKGROUND: There is ongoing debate concerning the best way to teach anatomy. Computer-assisted learning (CAL) is one option for teaching anatomy and these resources are increasingly available. AIMS: To assess the use of such resources in undergraduate medical student anatomy tuition. METHOD: Literature review. RESULTS: Eight quantitative studies were found and these tended to report favourably. Though these educational packages can show improvement in knowledge, the studies tended to cover small areas of anatomy or were assessed in short courses. There were also several assessments of learner's attitudes to CAL which tended to report favourably in terms of educational satisfaction and enjoyment. CONCLUSIONS: There is insufficient evidence to show that these resources have a true place for replacing traditional methods in teaching anatomy. Further research should be conducted to determine how to use these resources in conjunction with current teaching methods or how their use can be integrated into the current anatomy curriculum.

Incidence of perforated diverticulitis and risk factors for death in a UK population.

BACKGROUND: Perforated diverticulitis (PD) remains a serious acute abdominal condition. The aims of this study were to measure its incidence in a large UK population and to identify factors affecting outcomes. METHODS: Computerized searches of hospital coding databases for PD were performed in five hospitals in East Anglia, UK. Data were collected from hospital records over 5 years (1995-2000). Incidence was calculated using population data, and factors associated with mortality and morbidity were identified using univariable and multivariable testing. RESULTS: Some 202 patients with PD were identified, of whom 93.1 per cent underwent surgery and 24.3 per cent died. The age-adjusted adult incidence of perforation was 3.5 per 100 000 per annum, with a standardized female to male ratio of 1.3 (95 per cent confidence interval (c.i.) 1.1 to 1.5) to 1. Risk factors for death were increased age (odds ratio (OR) 3.5 (95 per cent c.i. 1.9 to 6.1)), pre-existing renal disease (OR 18.7 (1.6 to 211.4)) and pre-existing use of non-steroidal anti-inflammatory drugs (NSAIDs) (OR 3.1 (1.3 to 7.3)). CONCLUSION: PD is uncommon, with the highest incidence in women over 65 years old. Mortality rates are high, particularly in those taking NSAIDs or with pre-existing renal impairment.

Development of a food frequency questionnaire for the assessment of quercetin and naringenin intake.

OBJECTIVES: To measure the relationship between quercetin and naringenin intakes as estimated by food frequency questionnaire (FFQ), and the urinary excretion of quercetin and naringenin aglycones after their enzymatic hydrolysis in human volunteers. SUBJECTS AND METHODS: Volunteers were recruited via the Human Nutrition Unit volunteer databank at the Institute of Food Research, Norwich. Sixty-three volunteers were recruited into the study, of which 14 were excluded and 49 completed the study. A modified FFQ was developed and used to estimate daily intake of quercetin and naringenin in 49 healthy volunteers who also provided five 24-h urine samples over a 2-week period. Urinary excretion of quercetin and naringenin metabolites was determined by solid-phase extraction and high-pressure liquid chromatography. RESULTS: The estimated mean intakes of quercetin and naringenin were 29.4 mg (s.d. 15.0) and 58.1 mg (s.d. 62.7) per day, respectively. Mean urinary excretion of quercetin was 60.1 microg (s.d. 33.1) and that of naringenin was 0.56 mg (s.d. 0.4). The correlation between FFQ estimated intake of quercetin and naringenin and levels excreted in the urine were r=0.82 (P<0.0001) and r=0.25 (P=0.05), respectively. CONCLUSIONS: We observed a statistically significant correlation between the urinary excretion of quercetin and naringenin metabolites and their dietary intake as estimated by FFQ. Use of FFQs in epidemiological studies requiring an estimate of flavonoid intake seems justified.

No association of alcohol use and the risk of ulcerative colitis or Crohn's disease: data from a European Prospective cohort study (EPIC).

BACKGROUND/OBJECTIVES: The role of long-term alcohol consumption for the risk of developing ulcerative colitis (UC) and Crohn's disease (CD) is unclear. For the first time, to prospectively assess the role of pre-disease alcohol consumption on the risk of developing UC or CD. SUBJECTS/METHODS: Nested within the European Prospective Investigation into Cancer and Nutrition (EPIC-IBD), incident UC and CD cases and matched controls where included. At recruitment, participants completed validated food frequency and lifestyle questionnaires. Alcohol consumption was classified as either: non-use, former, light (⩽0.5 and 1 drink per week), below the recommended limits (BRL) (⩽1 and 2 drinks per day), moderate (⩽2.5 and 5 drinks per day), or heavy use (>2.5 and >5 drinks per day) for women and men, respectively; and was expressed as consumption at enrolment and during lifetime. Conditional logistic regression was applied adjusting for smoking and education, taking light users as the reference. RESULTS: Out of 262 451 participants in six countries, 198 UC incident cases/792 controls and 84 CD cases/336 controls were included. At enrolment, 8%/27%/32%/23%/11% UC cases and 7%/29%/40%/19%/5% CD cases were: non-users, light, BRL, moderate and heavy users, respectively. The corresponding figures for lifetime non-use, former, light, BRL, moderate and heavy use were: 3%/5%/23%/44%/19%/6% and 5%/2%/25%/44%/23%/1% for UC and CD cases, respectively. There were no associations between any categories of alcohol consumption and risk of UC or CD in the unadjusted and adjusted odds ratios. CONCLUSION: There was no evidence of associations between alcohol use and the odds of developing either UC or CD.

Clinical perception of disease probability associated with Bethesda System diagnoses.

The degree to which clinical perceptions of Papanicolaou smear sensitivity contribute to patient mismanagement is uncertain. A voluntary, anonymous questionnaire was mailed to 350 obstetricians/gynecologists (OGYNs) and 350 other primary care providers (PCPs) located in Pennsylvania or Ohio. The clinicians estimated the probability of no disease, dysplasia, and invasive carcinoma for 1 of 7 Bethesda System diagnoses. Differences in probability estimates between provider types and between the clinicians and medical literature data were measured. The response rate was 22.7%. Compared with published values, clinicians estimated similar disease probabilities for many diagnoses. However, for some diagnoses, the probability estimates differed considerably from published values (e.g., overestimation of dysplasia and invasive carcinoma for benign diagnoses and underestimation of dysplasia for some dysplasia diagnoses), and such errors could contribute to patient mismanagement. OGYNs generally were more accurate in probability estimates than PCPs. Methods to convey more accurately these diagnostic disease probabilities should be examined.

Colorectal cancer prevention. An approach to increasing compliance in a faecal occult blood test screening programme.

STUDY OBJECTIVE: The assessment of the uptake of colorectal cancer screening offered in a workplace setting. DESIGN: Employees were offered a free faecal occult blood test (Haemoccult). A repeat letter was sent two months later to non-responders. Those with positive tests were invited for colonoscopy. Compliance was measured according to age, sex, and occupational group and the effects of reinviting non-compliers investigated. SETTING: Leicester General Hospital, a large university teaching hospital. PARTICIPANTS: 990 employees aged 41 to 65 years. MAIN RESULTS: Total compliance was 46% with women participating more than men (49% v 34%, chi 2 = 12.2, p < 0.001). The difference was mostly because of women aged 41 to 50 years complying more than their male counterparts (48% v 24%, chi 2 = 15.5, p < 0.0001). Participation was highest in clinical support staff (56%), nurses (52%), and clerical workers (46%). Uptake by doctors (26%) and managers (26%) was significantly lower than by clinical support staff and nurses (chi 2 > 5.5, p < 0.02). Remailing raised compliance slightly from 43.6% to 46.3%. Four employees (1%) had positive faecal occult blood tests but three were negative on repeat testing with dietary restrictions. CONCLUSIONS: The government favours the development of health promotion programmes as stated in its document "Health at work in the NHS". The response in this study, showed methods to increase compliance must be developed if such programmes are to be successful. As uptake was similar to that in several community based programmes in general practice, workplace based programmes could offer a complementary method of delivering screening.

The effect on compliance of a health education leaflet in colorectal cancer screening in general practice in central England.

OBJECTIVE: To raise compliance in a general practice based colorectal cancer screening programme by the use of a simple health educational leaflet. DESIGN: A randomised controlled trial of the leaflet's effect on completion of faecal occult blood tests. The leaflet explained the high frequency of colorectal cancer, the principles of screening, and addressed reasons for non-compliance. SETTING: The British town of Market Harborough where most of the population are registered with a single practice. PARTICIPANTS: These comprised 1571 residents aged 61 to 70 years registered with the practice. Residents were invited to receive a free faecal occult blood test in a colorectal cancer screening programme. Half the population were randomly assigned to receive the educational leaflet about screening. RESULTS: Compliance in test and control groups, positive rate of stool testing, and pathology detected were measured. Compliance was higher in men who received the leaflet in those aged 61 to 65 years (36% v 27%, chi2 = 4.0, p < 0.05) and in men aged 66 to 70 years (39% v 23%, chi2 = 9.7, p < 0.01). In women, use of the leaflet did not affect compliance in those aged either 61 to 65 years (38% v 36%, chi2 = 0.1, NS) or 66 to 70 years (31% v 31%, chi2 = 0.0, NS). The positive rate of stool testing in patients observing the required dietary restrictions was 1.6%. A significant lesion was detected in 1.4% of people tested (2 carcinomas and 5 patients with adenomatous polyps). CONCLUSIONS: Health education leaflets addressing reasons for non-compliance significantly increased compliance in men and should be used in screening programmes. Reasons for the lack of success of the leaflet in women should be investigated and other interventions for raising compliance should be developed.

Screening for colorectal cancer: reasons for refusal of faecal occult blood testing in a general practice in England.

STUDY OBJECTIVE: To ascertain reasons for non-compliance with faecal occult blood tests in colorectal cancer screening programmes. DESIGN: A standard interview by a trained nurse of a random sample of those who declined screening. SETTING: The Leicestershire town of Market Harborough, where most of the 25,000 population are served by a single general practice of 10 partners. PARTICIPANTS: Altogether 4185 residents aged 51 to 70 years were invited to receive a free faecal occult blood test (Haemoccult). Eighty one subjects from a sample of 351 who wrote declining the offer were interviewed. MAIN RESULTS: Non-compliers were divided into those who did not request a test kit and those who returned an unused kit. In the former group the commonest reasons given were intercurrent illness (39%), fear of further tests and surgery (24%), and feeling well (22%). For those who returned unused kits the commonest reasons were the unpleasantness of the stool collection procedure (65%), feeling well (30%), intercurrent illness (23%), and fear of further tests and surgery (20%). In both groups the main concern of those who did not comply were fear of further diagnostic tests and surgery rather than concern at the lack of effective treatment for cancer. CONCLUSIONS: To increase compliance, education and publicity must explain the concept of asymptomatic illness and allay people's fear of hospital investigation and treatment. The benefits of screening should be particularly emphasised to those who return kits so they may overcome their reservations.

How frequently do large bowel diverticula perforate? An incidence and cross-sectional study.

The aetiology of perforation of large bowel diverticula is poorly understood and a case-control study is required to identify the causes. Before such a study can be attempted, the incidence must be determined and groups at particular risk identified. Cases of perforated large bowel diverticula living in the Norwich postal code region treated between 1995 and 1997 were identified. Fifty-eight cases presented in a population of 531 241. The incidence was 4.0 cases per 100,000 per year, increased with age and was higher in men than women (5.8 vs 3.1). The most frequently used drugs were non-steroidal anti-inflammatory drugs (NSAIDs) (29%) and opiate analgesics (26% of cases). This is the first report of the incidence of perforated diverticular disease and allows a calculation of the population size needed to recruit sufficient cases for an aetiological investigation. The differences in incidence between genders should prompt a search for factors which differ between the sexes such as diet. NSAIDs are a known risk factor, although the data show that opiate analgesics should be investigated.

Epidemiology of duodenal ulcer perforation: a study on hospital admissions in Norfolk, United Kingdom.

BACKGROUND: Studies on the incidence of perforated duodenal ulcer are limited and in the United Kingdom, data are largely based on findings observed over two decades ago. To provide updated epidemiological data on duodenal ulcer perforation, the incidence of the disease in Norfolk, United Kingdom was determined. METHODOLOGY: Medical records of patients with duodenal ulcer perforation were reviewed to confirm the diagnosis and obtain information on possible risk factors, namely, Helicobacter pylori infection, smoking and intake of non-steroidal anti-inflammatory drugs. The patients were admitted between 1 January 1996 and 31 December 1998, and were residents of Norfolk, United Kingdom. RESULTS: Sixty-eight cases of duodenal ulcer perforation were identified, 36 (52.9%) were males and 32 (47.1%) were females. The age-standardised incidence rate was 3.77 per 100,000 population per year (95% confidence interval 3.72-3.83). The mean age upon admission for all cases was 72.3 years (standard deviation: 17.8). The mean age for males was 67.7 years (standard deviation: 19.4) and for females 77.6 years (standard deviation: 15.7), which differed significantly (difference in means: 9.9, 95% confidence interval 1.5-18.3). There were 29 deaths (42.7%), of which 19 were females. After adjustment for covariates, the odds ratio of mortality in women was 4.57 (95% confidence interval 1.28-16.29). There were 25 (36.8%) smokers and 22 (32.4%) patients were non-steroidal anti-inflammatory drug users. Helicobacter pylori infection was assessed in only 14 (20.6%) patients; 2 were positive, 3 were negative, and in the rest the results were unrecorded. CONCLUSIONS: The incidence rates were lower compared to previous studies in the United Kingdom conducted in the 1960's and 1980's, which could reflect either improved health care or decreasing exposure to known risk factors. Furthermore, the difference in age distribution of incident cases between males and females may explain the higher mortality in females.

Design of a multicentre randomised trial to evaluate flexible sigmoidoscopy in colorectal cancer screening.

A randomised, controlled trial in progress in 14 United Kingdom and six Italian centres is evaluating screening for colorectal cancer using a single flexible sigmoidoscopy (FS) at around the age of 60 with removal during FS of all small adenomas, and colonoscopy for "high risk" polyps. The regimen aims to ensure that 95% of people (with either no polyps or only low risk polyps) complete the entire screening process in a single visit. This paper describes the rationale and design of the trial. Participants were patients aged between 55 and 64 on the lists of designated general practitioners (GPs) who were not excluded by their GP. A two stage recruitment procedure was employed to raise compliance rates in the intervention group. Potentially eligible persons were sent an "interest in screening" questionnaire; those who responded positively were randomised to the intervention or control groups. The trial is sufficiently large to estimate within narrow confidence intervals the magnitude of benefit and the duration of effect and optimum age for a single screen. It also examines the feasibility and acceptability of the screening regimen, and will identify training and quality assurance issues. Recruitment and screening are now complete and all baseline data have been collected. The first analysis of the effect on colorectal cancer incidence and mortality rates and suitability for a national screening programme can be expected in 2004.