Physician global assessment at 3 months is strongly predictive of remission at 12 months in early rheumatoid arthritis: results from the CATCH cohort.

OBJECTIVE: The objective of this study was to determine predictors of 1-year remission in early RA (ERA) using baseline and 3-month data. METHODS: The Canadian Early Arthritis Cohort (CATCH) patients were included if baseline, 3- and 12-month data were available. Regression analyses for four different definitions of remission at 12 months were done to determine baseline and 3-month predictors of remission. RESULTS: Five hundred and sixty-two patients had complete data at 12 months (mean age 53.4 years, disease duration 6.2 years, 73% female). The factors at baseline associated with all four remission outcomes at 12 months were age, gender, income, education, tender joint count (TJC), patient global assessment (PtGA), HAQ and pain. Baseline ESR was associated with the 28-joint DAS (DAS28) remission only. At 3 months, all four remission definitions were associated with TJC, swollen joint count, physician global assessment (PGA), PtGA, HAQ, pain, ESR and CRP in univariate analyses. In the regression model, variables associated with Simple Disease Activity Index remission were PGA [odds ratio (OR) 0.77, P < 0.001), pain (OR 0.85, P = 0.004), age (OR 0.98, P = 0.006) and HAQ (OR 0.49, P = 0.011); Clinical Disease Activity Index remission was associated with PGA (OR 0.77, P < 0.001), pain (OR 0.85, P = 0.003), age (OR 0.98, P = 0.015) and CRP (OR 0.80, P = 0.031). DAS28 remission was predicted by ESR (OR 0.95, P < 0.001), PGA (OR 0.76, P < 0.001), age (OR 0.98, P = 0.001), HAQ (OR 0.57, P = 0.006) and male gender (OR 2.01, P = 0.005), whereas Boolean remission was associated with pain (OR 0.79, P = 0.009), age (OR 0.98, P = 0.016), PtGA (OR 0.83, P = 0.025) and PGA (OR 0.86, P = 0.038). CONCLUSION: A low PGA at 3 months was consistently associated with 1-year remission in ERA.

Are there differences between young- and older-onset early inflammatory arthritis and do these impact outcomes? An analysis from the CATCH cohort.

OBJECTIVE: The aim of this study was to determine the impact of age on disease and remission in suspected early RA (ERA). METHODS: Data from the Canadian Early Arthritis Cohort (CATCH) were examined at baseline, 6 and 12 months. Patients were divided into three groups based on age. Analysis of variance (ANOVA) and regression models were performed to determine the impact of age on the 28-joint DAS (DAS28) and remission at 12 months. RESULTS: A total of 1809 patients were initially assessed: 442 (24.4%) young (<42 years), 899 (49.7%) middleaged (542<64 years) and 468 (25.9%) old (564 years); 72.9% female; 63.8% met 2010 ACR/European League Against Rheumatism (EULAR) classification criteria for RA; symptom duration at first visit 186.0 days; DAS28 4.9; HAQ 1.0; 25.3% had baseline erosions. A significant correlation existed between older age and a lower percentage of females, less positive RF and CCP, fewer meeting RA criteria, shorter symptom duration, more erosions at first visit, higher DAS28 and HAQ at baseline and 12 months and fewer DAS28 remission at 12 months (all P<0.003). The age group did not affect the change in DAS28 and HAQ from 0 to 12 months. Co-morbidities increased with age; more DMARDs, including MTX and steroids, and fewer biologics were used in older age. Age and female had a lesser chance of remission in the regression model. CONCLUSION: In suspected ERA, older-onset patients start and end their first year worse in terms of DAS28 and HAQ, with fewer meeting RA criteria, less remission, more DMARDs and steroids use but less biologics use. However, there were no differences between age groups in the change in DAS28.

Effect of rectal distension on voluntary external anal sphincter function in healthy subjects.

AIM: Quantification of the anorectal reflex function is critical for explaining the physiological control of continence. Reflex external anal sphincter activity increases with rectal distension in a dynamic response. We hypothesized that rectal distension would similarly augment voluntary external anal sphincter function, quantified by measuring the anal maximum squeeze pressure. METHOD: Fifty-seven subjects (32 men, 25 women; median age 62 years), with normal anal canal manometry and endoanal ultrasound results, underwent a rectal barostat study with simultaneous anal manometry. Stepwise isovolumetric 50-ml distensions (n=35) or isobaric 4-mmHg distensions (n=22) above the minimum distending pressure were performed (up to 200 ml or 16 mmHg respectively), whilst anal resting pressure and maximum squeeze pressure were recorded and compared with the baseline pressure. RESULTS: The distension-induced squeeze increment was calculated as the maximum percentage increase in maximum squeeze pressure with progressive rectal distension. This was observed in 53 of the 57 subjects as a mean ± standard deviation (range) increase of 32.8 ± 24.1 (-5.5 to 97.7)%. The mean ± standard deviation (range) distension-induced squeeze increment in male subjects was 36.1 ± 25.7 (-5.5 to 97.7)% and in female subjects was 28.1 ± 20.1 (-3.8 to 70.2)%. There was no significant difference between the sexes (P=0.194). CONCLUSION: Rectal distension augments external anal sphincter function, confirming the existence of a dynamic rectoanal response. This may represent a quantifiable and important part of the continence mechanism.

The role of ¹8fluoro-deoxy glucose combined position emission and computed tomography in the clinical management of anal squamous cell carcinoma.

AIM: Anal squamous cell carcinoma (SCC) is uncommon in the western world but continues to increase in incidence. Optimal treatment and outcome are dependent upon pretreatment staging strategies. We evaluate the role of ¹8fluoro-deoxyglucose (¹8FDG) combined position emission and computed tomography (PETCT) in the management of anal SCC. METHOD: Patients with a histologically confirmed anal SCC underwent standard staging investigations, including computed tomography, Magnetic resonance imaging and examination under anaesthetic. A tumour, node, metastasis (TNM) system was used. All patients subsequently underwent additional whole-body ¹8FDG PETCT scanning. Management was planned accordingly, blinded to ¹8FDG PETCT findings, at a multidisciplinary meeting, and reviewed again following disclosure of PETCT results. RESULTS: Forty patients (24 men), with a median age of 57 years (range 38-87 years), were prospectively recruited. All primary tumours were ¹8FDG avid. PETCT did not alter the T stage but did result in disease upstaging (N and M stages). Management was altered in five (12.5%) patients: one patient was identified to have an isolated distant metastasis, and four patients had ¹8FDG-avid lymph nodes not otherwise detected, all of which were tumour-positive on fine needle aspiration cytology/biopsy. CONCLUSION: PETCT upstages anal SCC and influences subsequent management. PETCT should be considered in the staging of anal SCC, although the definitive benefit of such a strategy requires further evaluation.

Diagnostic and therapeutic impact of MR enterography in Crohn's disease.

AIM: To assess the impact of magnetic resonance enterography (MRE) on clinician diagnostic confidence and therapeutic strategy in patients under investigation for small bowel Crohn's disease. MATERIAL AND METHODS: Gastroenterologists completed a proforma before and following MRE in 51 patients (mean age 35 years, 26 female) under investigation for small bowel Crohn's disease, indicating percentage confidence for presence/absence of small bowel involvement. In suspected disease, diagnostic confidence (using a scoring system from 1=no to 6=yes) was scored for subcategories: extent >30 cm (DE), terminal ileum (lTI), jejunal (JD), colonic disease (CoD), strictures (ST), activity (AD), extraluminal complications (EL), and surgical need (NS). Therapeutic strategy was recorded. Patients were divided into three groups: 1=suspected disease, MRE normal (n=15); 2=suspected disease, MRE abnormal (n=30); 3=no suspected disease, MRE normal (n=6). Binomial exact and paired t-tests were use to compare confidence pre and post-MRE. RESULTS: Mean percentage confidence for the presence/absence of small bowel disease increased from 62 to 84% (p=0.003), 87 to 98% (p=0.0001), and 83 to 98% (p=0.005) after MRE for groups 1, 2, and 3, respectively. In suspected disease, confidence changed significantly for all of the subcategories (p<0.001) except EL in group 1. The percentage of patients with a confidence change ranged from 40% (CoD) to 87% (lTI; group 1) and from 7% (EL) to 93% (DE; group 2). Therapeutic strategy changed in 31/51 (61%, 95% CI 47-74%), 14 with a reduction in planned therapy and 17 with an increase. CONCLUSION: MRE had a positive diagnostic impact in patients under investigation for small bowel Crohn's disease and this influenced therapeutic strategy in 61% of the patients.

Is MSI-H of value in predicting the development of metachronous colorectal cancer?

Nearly 10% of patients with colorectal cancer (CRC) develop a metachronous cancer after curative resection of their primary malignancy, however identifying these patients is problematic. Although microsatellite instability (MSI) is associated with the development of multiple CRC, this is predominantly seen in those with hereditary non-polyposis colon cancer (HNPCC). This study has examined the value of MSI analysis in identifying patients at risk of developing metachronous cancer from the general population. MSI analysis was performed at the Bat25, Bat26, Bat40, D2S123, D5S346 and D17S250 loci using polymerase chain reaction and single-stranded conformational polymorphism on DNA extracted from 62 specimens taken from 49 patients with metachronous CRC, and from 71 primary single CRCs. MSI status was classified into MSI-H, MSI-L and MSS. MSI-H was more prevalent in metachronous cancers, 34/62 compared to 8/71 single cancers (P < 0.0001). The incidence of MSI-H from proximal colon cancers in index metachronous group, 4/22 was similar to single cancer group, 7/71 (P = 0.28), however MSI-H was more commonly identified in index metachronous cancers located distal to the splenic flexure 9/22 than single cancers 1/71 (P < 0.0001). Patients presenting with MSI-H colorectal cancers distal to the splenic flexure are more likely to develop a metachronous cancer and will benefit from surveillance.

Complicated diverticulosis.

"Uncomplicated" diverticulitis can be prevented from progressing into "complicated" diverticulitis by early diagnosis and active medical treatment. Complicated diverticulitis develops from a peridiverticular abscess, to a perforation with peritonitis, to fistulation into adjacent viscera, to luminal narrowing by inflammation or stricture formation causing obstruction. Computer tomography (CT) scanning is the diagnostic imaging modality when diverticulitis is suspected and allows percutaneous drainage of peridiverticular abscesses that will enhance the effect of antibiotic therapy with resolution of the acute episode in 75% of patients. Thus, an emergent or urgent operation is converted to an elective operation and a two-stage operative procedure, namely a temporary stoma and a second operation, is avoided. Interventional surgery is urgent for perforation and obstruction. While a Hartmann's resection and temporary colostomy has been the favoured operative procedure, under favourable conditions resection with primary anastomosis is preferable. Although a temporary stoma may be required with primary anastomosis, and hence the procedure is a two-stage one similar to a Hartmann's, the closure of the stoma is less demanding and has a lower morbidity. A single-stage resection and anastomosis is the standard elective treatment for symptomatic fistulas and strictures.

Possible absence of Helicobacter pylori in the early stages of duodenal ulceration.

BACKGROUND: Helicobacter pylori is thought to be a cause of duodenal ulceration, but there is some evidence that it is found less often in early than in later disease. AIM: To assess the presence of H. pylori in patients undergoing endoscopy for dyspepsia, with respect to their duration of symptoms. DESIGN: Retrospective case note review. METHODS: Patients were categorized as having a history greater or less than 6 months, and as H. pylori-positive or -negative, using biopsy rapid urease, culture and PCR tests. RESULTS: Thirty-two duodenal ulcer patients with a history >6 months were all H. pylori-positive according to the PCR test; the five with a shorter history were H. pylori-negative. No patient H. pylori-negative by PCR was positive by the other tests. DISCUSSION: H. pylori was (at least) less commonly present before 6 months. It is possible that H. pylori, although nearly always present after 6 months, is not present at the onset of the disease. Confirmation of this finding would imply that infection with the organism is not the cause of duodenal ulceration, but a factor producing recurrence and chronicity.

The distribution of matrix metalloproteinases and tissue inhibitor of metalloproteinases in colorectal cancer.

Studies suggest that the interplay between matrix metalloproteinases (MMPs) and their inhibitors, tissue inhibitor of metalloproteinases (TIMPs), is an important mediator of tumour invasion and metastasis. Using immunohistochemistry, 40 specimens of colorectal cancer were examined for the presence of TIMP-1 and the MMPs, stromelysin, gelatinases A and B and interstitial collagenase. Neither enzyme nor TIMP-1 was detected in histologically normal mucosa. Within malignant tissue, stromelysin and gelatinase A were conspicuously absent in tumour cells but were immunolocalized to the extracellular matrix and for gelatinase A also to peritumoural fibroblast-like cells. Gelatinase B was confined to polymorphonuclear leucocytes. Interstitial collagenase was not identified. TIMP-1 was present in only three of the 40 tumours within the malignant stroma. These observations suggest that the mesenchymal elements of colorectal carcinomas, by acting as a source of MMPs and TIMPs, may modulate tumour invasion.

The distribution of matrix metalloproteinases and tissue inhibitor of metalloproteinases in colorectal cancer.

Studies suggest that the interplay between matrix metalloproteinases (MMPs) and their inhibitors, tissue inhibitor of metalloproteinases (TIMPs) is an important mediator of tumour invasion and metastasis. Using immunohistochemistry, 40 specimens of colorectal cancer were examined for the presence of TIMP-1 and the MMPs, stromelysin, gelatinases A and B and interstitial collagenase. Neither enzyme nor TIMP-1 was detected in histologically normal mucosa. Within malignant tissue, stromelysin and gelatinase A were conspicuously absent in tumor cells but were immunolocalized to the extracellular matrix and for gelatinase A also to peritumoural fibroblast-like cells. Gelatinase B was confined to polymorphonuclear leucocytes. Interstitial collagenase was not identified. TIMP-1 was present in only three of the 40 tumours within the malignant stroma. These observations suggest that the mesenchymal elements of colorectal carcinomas, by acting as a source of MMPs and TIMPs, may modulate tumour invasion.

Comparison of distribution and photodynamic effects of di- and tetra-sulphonated aluminium phthalocyanines in normal rat colon.

We have previously reported photodynamic therapy of normal rat colon using aluminium sulphonated phthalocyanine (AISPc). In that study, the AISPc used was a mixture of phthalocyanines of different degrees of sulphonation. Phthalocyanines of defined degrees of sulphonation have recently become available and we compared the distribution of the di- and tetra-sulphonates (AIS2Pc and AIS4Pc) in rat colon and colon wall structures employing both chemical extraction and fluorescence photometry using a charge coupled device imaging system. Also, the photodynamic effects produced by these components in rat colon were compared at various times after photosensitization. After intravenous photosensitizer administration using equimolar doses, the concentration of AIS2Pc in colon fell off more rapidly with time than AIS4Pc. Differences were noted in the microscopic distribution of these compounds, with the di-sulphonate exhibiting peak fluorescence in colon wall structures by 1 h after photosensitization, while mucosal fluorescence with the tetra-sulphonate peaked at 5 h. Fluorescence was also lost from the colon wall much more slowly with the tetra-sulphonate, which tended to be retained in the submucosa. Maximum photosensitizing capability was seen at 1 h with AIS2Pc and no lesions could be produced with photodynamic therapy at 1 week, with up to 5.65 mumol/kg. With AIS4Pc (5.65 mumol/kg), while no lesions could be produced with light treatment at 1 h, photodynamic therapy at 1 week produced lesions only slightly smaller than those produced with treatment at 48 h (the time of maximum effect), and significant photosensitization was present at 2 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical importance and prognostic implications of microsatellite instability in sporadic cancer.

AIMS: The genetic abnormality known as microsatellite instability (MSI), first identified in colorectal cancer in 1993, has subsequently been recognised in other malignancies. These cancers are caused by a defect in the nuclear mismatch repair system, allowing mutations to accumulate with every cellular division. Hereditary Non Polyposis Colon Cancers (HNPCC) and associated malignancies demonstrating MSI have a unique histological appearance, improved prognosis and altered response to chemotherapy and radiotherapy. This review examines the incidence of MSI and its clinical significance in commonly occurring solid malignancies. METHOD: A medline based literature search was performed using the key words 'Microsatellite Instability' and the name of the specific malignancy being investigated. Additional original papers were obtained from citations in those articles identified in the original medline search. RESULTS: MSI has been detected in many solid malignancies although the definition of instability applied has been variable. It is most commonly found in sporadic malignancies that also occur in the HNPCC syndrome such as colorectal, stomach, endometrial and ovarian cancer. MSI may impart a favorable prognosis in colorectal, gastric, pancreatic and probably oesophageal cancers but a poor prognosis in non small cell lung cancer. In clinical studies colorectal cancers demonstrating MSI respond better to chemotherapy while in vitro studies using MSI positive cell lines show resistance to radiotherapy and chemotherapy. CONCLUSION: MSI may be a useful genetic marker in prognosis and could be an influential factor in deciding treatment options. However, in many cancers its significance remains unclear and more evaluation is required.

Crypt cell carcinoma of the appendix.

A case of crypt cell carcinoma of the appendix is reported detailing its characteristic histological and immunohistochemical features and outlining current view on management.

Progressive loss of perivascular nerves adjacent to colorectal cancer.

AIMS: The perivascular innervation of arterioles in colorectal cancer and adjacent submucosa was investigated. METHODS: Neurotransmitter markers, neuropeptide Y (NPY), vasoactive intestinal peptide (VIP), substance P (SP), calcitonin gene-related peptide (CGRP) and tyrosine hydroxylase (TH), were studied and immunoreactivity was compared with that of control normal tissue. RESULTS: There was absence of perivascular nerves within tumours and loss of perivascular innervation in the submucosa adjacent to the tumour. The pattern of loss varied for different transmitters. The loss was progressively greater with advancing tumour stage for NPY (controls 95%, Dukes' A 68%, Dukes>> B 13%, Dukes' C 6%) and VIP (50%, 23%, 20%, 17%). For TH there was extensive loss of innervation around tumours of all stages (69%, 5%, 7%, 0%). SP immunoreactive peri-arteriolar nerves were similar in control tissue (39%) and tissue adjacent to Dukes' A tumours (40%) but diminished to 19% and 0% in tissue adjacent to Dukes' B and C tumours, respectively. In none of the tissues was CGRP immunoreactivity above 4%. The mean distance over which there was reduced NPY immunoreactivity from the tumour edge was 2.43 mm for Dukes' A/B tumours compared with 7.20 mm for Dukes' C tumours; for VIP immunoreactivity this distance was 5.22 mm for Dukes' A/B tumours and 5.52 mm for Dukes' C tumours. CONCLUSIONS: The progressive loss, both in terms of vascular nerve immunoreactivity and distance from the tumour edge with tumour grade, suggests that the tumour itself may influence neural integrity in perivascular plexuses, perhaps via the secretion of an inhibitory factor.

Immunoscintigraphy of colorectal cancer using a monoclonal antibody 77-1.

The monoclonal antibody (mAb) 77-1 recognizes epithelial membrane antigen (EMA) expressed by the majority of colorectal cancers. Following administration of indium-111 labelled 77-1, gamma camera imaging was carried out on 16 patients with known or suspected colorectal cancer prior to surgery or endoscopic laser therapy. Fourteen of the patients were found to have cancer, with one patient having two primary lesions. Two patients suspected of tumour recurrence were not found to have a lesion at laparotomy. Imaging before operation or laser therapy detected 10 out of 15 lesions (67%). Tumours which produced positive images were found to express the target antigen on immunocytochemical staining of the excised tumours. A mean tumour to normal colon ratio of 1.63 +/- S.D. 0.46 and a mean tumour to blood ratio of 3.60 +/- 1.48 were found at day 6 after antibody administration. A high uptake of radiolabel by the liver prevented the detection of hepatic metastases, present in three patients. Of the two patients with suspected recurrence a false positive scan was found in one owing to the presence of inflammatory tissue. Indium-111 labelled 77-1 may have a role in the imaging or targeting of colorectal cancer.

The relationship of plasminogen activators and oncogenes to tumour invasion.

Accruing evidence suggests an association between increased activity of plasminogen activators and transformed cells, and urokinase activity with tumour aggressiveness. The PIP2 pathway seems to provide a link between oncogene-associated transformation, cellular proliferation, plasminogen-activator expression and tumour invasion and metastasis.

Immunolocalisation of an anti-EMA monoclonal antibody to a renal carcinoma xenograft.

The monoclonal antibody 77-1 originally raised to a membrane extract of human bladder cancer reacted with a human renal carcinoma xenograft XK1 on immunoperoxidase staining. This suggested a potential role for its immunolocalisation to renal carcinoma, and prompted a localisation study of the I-125 and In-111 labelled 77-1 to the xenograft. The uptake of the radiolabelled antibody by the xenograft was measured as a tumour to blood ratio taken at 24 hour intervals for up to 72 hours. Four animals were used for each time point and the mean tumour to blood ratio obtained. A monoclonal antibody 48-1, non reactive with XK1, was similarly radiolabelled and administered to another group of animals bearing the xenografts to act as a control. Statistical analysis using the unpaired Student't' test showed that the uptake of the 1-125 and In-111 labelled 77-1 by the xenografts was significantly higher than the non-specific antibody 48-1 at all time points (p less than 0.002-0.018), demonstrating that a specific localisation to the xenograft XK1 by the radiolabelled 77-1 had occurred.

Acute spinal cord injury, part I: pathophysiologic mechanisms.

Spinal cord injury (SCI) is a devastating and common neurologic disorder that has profound influences on modern society from physical, psychosocial, and socioeconomic perspectives. Accordingly, the present decade has been labeled the Decade of the Spine to emphasize the importance of SCI and other spinal disorders. Spinal cord injury may be divided into both primary and secondary mechanisms of injury. The primary injury, in large part, determines a given patient's neurologic grade on admission and thereby is the strongest prognostic indicator. However, secondary mechanisms of injury can exacerbate damage and limit restorative processes, and hence, contribute to overall morbidity and mortality. A burgeoning body of evidence has facilitated our understanding of these secondary mechanisms of injury that are amenable to pharmacological interventions, unlike the primary injury itself. Secondary mechanisms of injury encompass an array of perturbances and include neurogenic shock, vascular insults such as hemorrhage and ischemia-reperfusion, excitotoxicity, calcium-mediated secondary injury and fluid-electrolyte disturbances, immunologic injury, apoptosis, disturbances in mitochondrion function, and other miscellaneous processes. Comprehension of secondary mechanisms of injury serves as a basis for the development and application of targeted pharmacological strategies to confer neuroprotection and restoration while mitigating ongoing neural injury. The first article in this series will comprehensively review the pathophysiology of SCI while emphasizing those mechanisms for which pharmacologic therapy has been developed, and the second article reviews the pharmacologic interventions for SCI.

Acute spinal cord injury, part II: contemporary pharmacotherapy.

Spinal cord injury (SCI) remains a common and devastating problem of modern society. Through an understanding of underlying pathophysiologic mechanisms involved in the evolution of SCI, treatments aimed at ameliorating neural damage may be developed. The possible pharmacologic treatments for acute spinal cord injury are herein reviewed. Myriad treatment modalities, including corticosteroids, 21-aminosteroids, opioid receptor antagonists, gangliosides, thyrotropin-releasing hormone (TRH) and TRH analogs, antioxidants and free radical scavengers, calcium channel blockers, magnesium replacement therapy, sodium channel blockers, N -methyl-D-aspartate receptor antagonists, alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid-kainate receptor antagonists, modulators of arachadonic acid metabolism, neurotrophic growth factors, serotonin antagonists, antibodies against inhibitors of axonal regeneration, potassium channel blockers (4-aminopyridine), paclitaxel, clenbuterol, progesterone, gabexate mesylate, activated protein C, caspase inhibitors, tacrolimus, antibodies against adhesion molecules, and other immunomodulatory therapy have been studied to date. Although most of these agents have shown promise, only one agent, methylprednisolone, has been shown to provide benefit in large clinical trials. Given these data, many individuals consider methylprednisolone to be the standard of care for the treatment of acute SCI. However, this has not been established definitively, and questions pertaining to methodology have emerged regarding the National Acute Spinal Cord Injury Study trials that provided these conclusions. Additionally, the clinical significance (in contrast to statistical significance) of recovery after methylprednisolone treatment is unclear and must be considered in light of the potential adverse effects of such treatment. This first decade of the new millennium, now touted as the Decade of the Spine, will hopefully witness the emergence of universal and efficacious pharmacologic therapy and ultimately a cure for SCI.

Preliminary evaluation of United Kingdom National Referral Guidelines for lower gastrointestinal tract cancer.

OBJECTIVE: To evaluate the efficiency of the criteria proposed by the National Referral Guidelines at selecting patients with lower gastrointestinal tract cancer for urgent outpatient assessment when compared with the standard method for prioritization. PATIENTS AND METHODS: Consecutive patients aged 50 and over referred to a colorectal unit were offered urgent or non-urgent outpatient appointments on the basis of the contents of the referral letter. Clinical information obtained during the outpatient consultation was used to identify those patients that satisfied the guideline criteria for urgent referral. Patients were investigated and the findings recorded. RESULTS: Of 247 patients who completed their investigations 18 were found to have lower gastrointestinal tract cancer. Urgent outpatient appointments were offered to 115 patients of whom 14 had cancer (P = 0.0067, sensitivity=78%). A total of 119 patients satisfied the guideline criteria for urgent referral, including 17 of the patients who were found to have cancer (P < 0.0001, sensitivity=94%). CONCLUSION: The criteria used in the guidelines provide an effective method for selecting patients with cancer for urgent assessment. Application of the guidelines by general practitioners can be recommended.