The Lourdes Pilgrimage and the Impact on Pilgrim Quality of Life.

Lourdes, France, is a major site of pilgrimage, particularly for Roman Catholics with illness. The direct impact of pilgrimage on pilgrim quality of life (QOL) has not previously been measured. The present study aimed to measure the impact of pilgrimage to Lourdes on QOL in self-defined "sick pilgrims". The standardised EuroQol EQ-5D-5L questionnaire measured two aspects of QOL, namely a Visual Analogue Scale (VAS) score of self-rated health and an Index Value Score (IVS) of the five dimensions of QOL, in a group of pilgrims, before (Q1), immediately after (Q2) and two months after (Q3) return from pilgrimage to Lourdes. A total of 93 pilgrims responded at time Q1, 71 at Q2 and 64 at Q3. The VAS scores of self-rated health showed statistically significant improvement at Q2 (p = 0.04), although this was not sustained at Q3. The IVS Scores showed no significant differences at Q2 or Q3. However, at Q2, 67.6% of pilgrims reported their self-rated QOL as "much better" or "better", and this was maintained in 54.7% at Q3. Pilgrims identified "spiritual and religious aspects of pilgrimage", "a sense of togetherness" and "spiritual healing" as having the most significant impact on their QOL. The Lourdes pilgrimage had a statistically significant positive impact on the immediate post-pilgrimage VAS scores of QOL of "sick pilgrims", but this was not sustained two months following pilgrimage. The IVS scores were unchanged. Pilgrims identified beneficial holistic, spiritual and communal aspects of the pilgrimage experience.

The impact on hospital resource utilisation of treatment of hepatic encephalopathy with rifaximin-α.

BACKGROUND & AIMS: Rifaximin-α reduces the risk of recurrence of overt hepatic encephalopathy. However, there remain concerns regarding the financial cost of the drug. We aimed to study the impact of treatment with rifaximin-α on healthcare resource utilisation using data from seven UK liver treatment centres. METHODS: All seven centres agreed a standardised data set and data characterising clinical, demographic and emergency hospital admissions were collected retrospectively for the time periods 3, 6 and 12 months before and following initiation of rifaximin-α. Admission rates and hospital length of stay before and during therapy were compared. Costs of admissions and drug acquisition were estimated using published sources. Multivariate analyses were carried out to assess the relative impact of various factors on hospital length of stay. RESULTS: Data were available from 326 patients. Following the commencement of rifaximin, the total hospital length of stay reduced by an estimated 31-53%, equating to a reduction in inpatient costs of between £4858 and £6607 per year. Taking into account drug costs of £3379 for 1-year treatment with rifaximin-α, there was an estimated annual mean saving of £1480-£3228 per patient. CONCLUSIONS: Initiation of treatment with rifaximin-α was associated with a marked reduction in the number of hospital admissions and hospital length of stay. These data suggest that treatment of patients with rifaximin-α for hepatic encephalopathy was generally cost saving.

Alcohol-Specific Mortality in People With Epilepsy: Cohort Studies in Two Independent Population-Based Datasets.

Objectives: The risk of dying by alcohol-specific causes in people with epilepsy has seldom been reported from population-based studies. We aimed to estimate the relative risk of alcohol-specific mortality in people with epilepsy, and the extent to which problematic alcohol use was previously identified in the patients' medical records. Method: We delineated cohort studies in two population-based datasets, the Clinical Practice Research Datalink (CPRD GOLD) in England (January 01, 2001-December 31, 2014) and the Secure Anonymised Information Linkage (SAIL) Databank in Wales (January 01, 2001-December 31, 2014), linked to hospitalization and mortality records. People with epilepsy were matched to up to 20 persons without epilepsy on gender, age (±2 years) and registered general practice. We identified alcohol-specific death from Office for National Statistics (ONS) records using specified ICD-10 codes. We further identified prescriptions, interventions and hospitalisations related to alcohol use. Results: In the CPRD GOLD, we identified 9,871 individuals in the incident epilepsy cohort and 185,800 in the comparison cohort and, in the SAIL Databank, these numbers were 5,569 and 110,021, respectively. We identified a five-fold increased risk of alcohol-specific mortality in people with epilepsy vs. those without the condition in our pooled estimate across the two datasets (deprivation-adjusted HR 4.85, 95%CI 3.46-6.79). Conclusions: People with epilepsy are at increased risk of dying by an alcohol-specific cause than those without the disorder. It is plausible that serious alcohol misuse could either contribute to the development of epilepsy or it could commence subsequent to epilepsy being diagnosed. Regardless of the direction of the association, it is important that the risk of dying as a consequence of alcohol misuse is accurately quantified in people affected by epilepsy. Systematically-applied, sensitive assessment of alcohol consumption by healthcare professionals, at opportunistic, clinical contacts, with rapid access to quality treatment services, should be mandatory and play a key role in reduction of health harms and mortality.

Exploring possible mechanisms for primary bile acid malabsorption: evidence for different regulation of ileal bile acid transporter transcripts in chronic diarrhoea.

OBJECTIVES: Chronic diarrhoea resulting from primary idiopathic bile acid malabsorption (IBAM) is common, but its aetiology is largely unknown. We investigated possible mechanisms, first looking for common sequence variations in the cytoplasmic ileal bile acid-binding protein (IBABP, gene symbol FABP6), and secondly, determining the expression of ileal mucosal transcripts for the apical sodium-linked bile acid transporter (ASBT), IBABP, the putative basolateral transporters, OSTalpha and OSTbeta, and regulatory factors. METHODS: Genomic DNA was prepared from two cohorts of patients and two control groups; the promoter and exonic regions of FABP6 were sequenced. In intestinal biopsies, transcript expression was measured by quantitative real time-PCR, using ileum from 17 patients and 21 controls. RESULTS: Sequence variations were identified in FABP6, but overall frequencies were similar in patients and controls. Transcripts of ASBT and IBABP, but not OSTalpha and OSTbeta, were expressed at higher levels in ileum than duodenum. The transcription factors farnesoid-X-receptor (FXR) and liver-receptor-homologue (LRH-1) were also more abundant in ileum, as was fibroblast growth factor 19 (FGF19), unlike short heterodimer partner (SHP), c-Fos, or CDX2. No significant differences in mean or median values were found between the groups for any of these transcripts. However, findings on regression analysis suggested that these transporters differ in their regulation, particularly in the relationships of CDX2, LRH-1 and FXR with OSTalpha. CONCLUSION: Most cases of IBAM are unlikely to be caused by genetic variation in FABP6 or by major differences in transporter transcript expression. Our evidence indicates that other factors, such as regulation of expression of the basolateral bile acid transporter, should be considered as possible causes.

Collaborative care for alcohol-related liver disease.

By implementing collaborative care for patients with alcohol misuse and alcohol-related liver disease, the Royal Bolton Hospital aimed to improve and coordinate their care by recruiting a multidisciplinary team and placing the patient at the centre of all efforts. There has been a marked improvement in the accuracy of the drinking histories taken, detoxification, dietary documentation, and patient and staff attitudes and confidence, with enhanced satisfaction in patients, their families and staff and improved accessibility and communication. We observed a considerable increase in the number of inpatient and outpatient referrals and believe that it is more effective to work together in a joint gastroenterology/psychiatry team. There is a critical national need to establish steering groups of key clinical, managerial and commissioning personnel to address the growing problem of alcohol misuse. The appointment of dedicated alcohol health workers is central to this strategy.

Alcohol-Related Mortality in Patients With Psoriasis: A Population-Based Cohort Study.

Importance: People diagnosed with psoriasis have an increased risk of premature mortality, but the underlying reasons for this mortality gap are unclear. Objective: To investigate whether patients with psoriasis have an elevated risk of alcohol-related mortality. Design, Setting, and Participants: An incident cohort of patients with psoriasis aged 18 years and older was delineated for 1998 through 2014 using the Clinical Practice Research Datalink (CPRD) and linked to Hospital Episode Statistics (HES) and Office for National Statistics (ONS) mortality records. Patients with psoriasis were matched with up to 20 comparison patients without psoriasis on age, sex, and general practice. Main Outcomes and Measures: Alcohol-related deaths were ascertained via the Office for National Statistics mortality records. A stratified Cox proportional hazard model was used to estimate the cause-specific hazard ratio for alcohol-related death, with adjustment for socioeconomic status. Results: The cohort included 55 537 with psoriasis and 854 314 patients without psoriasis. Median (interquartile) age at index date was 47 (27) years; 408 230 of total patients (44.9%) were men. During a median (IQR) of 4.4 (6.2) years of follow-up, the alcohol-related mortality rate was 4.8 per 10 000 person-years (95% CI, 4.1-5.6; n = 152) for the psoriasis cohort, vs 2.5 per 10 000 (95% CI, 2.4- 2.7; n = 1118) for the comparison cohort. The hazard ratio for alcohol-related death in patients with psoriasis was 1.58 (95% CI, 1.31-1.91), and the predominant causes of alcohol-related deaths were alcoholic liver disease (65.1%), fibrosis and cirrhosis of the liver (23.7%), and mental and behavioral disorders due to alcohol (7.9%). Conclusions and Relevance: People with psoriasis have approximately a 60% greater risk of dying due to alcohol-related causes compared with peers of the same age and sex in the general population. This appears to be a key contributor to the premature mortality gap. These findings call for routine screening, identification and treatment, using the Alcohol Use Disorders Identification Test (AUDIT-C) in both primary and secondary care to detect alcohol consumption and misuse among people diagnosed with psoriasis.

Alcohol misuse in older people: heavy consumption and protean presentations.

BACKGROUND: Alcohol misuse, especially binge drinking in young people, and alcoholic liver disease are major public health concerns. However, alcohol misuse in older people is underestimated and often goes undetected. OBJECTIVE: To document alcohol consumption and clinical presentation of alcohol misuse in hospital inpatients aged >or=60 years. METHODS: 208 inpatients aged >or=60 years, referred to the alcohol liaison nurse between 1998 and 2003 at the Royal Bolton Hospital, Bolton, UK, were assessed for sex, alcohol intake, primary and secondary reasons for admission, and other concurrent health problems and death. RESULTS: 90% of men drank >21 units weekly and 93% of women drank >14 units weekly. Median weekly alcohol intake was 78.5 units for men and 47 units for women. Acute intoxication, falls, circulatory problems and alcoholic liver disease were the main primary reasons for admission. Neglect or malnutrition, alcoholic liver disease and hypertension were the main secondary reasons and concurrent health problems. 30% of patients died between 1998 and 2003. CONCLUSION: In inpatients aged >or=60 years who were referred to the alcohol liaison nurse in a district general hospital, heavy alcohol consumption, often to very high levels, was characteristic in both men and women and was associated with a wide variety of primary and secondary clinical presentations, including death.

Collaborative liver and psychiatry care in the Royal Bolton Hospital for people with alcohol-related disease.

Since 1990, the Royal Bolton Hospital has been evolving a patient-centred, collaborative, seamless, holistic, gastroenterology, psychiatry, community model of alcohol care, team working, governance, research, training, education and health promotion. The aim is to deliver an accessible, responsive, cost-effective, rolled-out service. Consultant gastroenterologists, a specialist liaison psychiatrist, psychiatric alcohol liaison nurse, gastroenterology-based liver nurse practitioner and ward nurses provide joint inpatient and outpatient care for people with alcohol misuse, especially alcohol-related liver disease. A ward based, consultant-led, multidisciplinary team, with a dedicated social worker, meets daily to discuss all inpatients, unify treatment and facilitate discharges. On Monday-Friday, the two alcohol specialist nurses assess, triage and give brief advice to all alcohol-related medical admissions, liaise with consultants about admission or arrange outpatient appointments with the community alcohol team. This has reduced the average length of stay from 8.0 days to 5.7 days, saving the Trust more than 1000 bed days annually. This highlights the need for a 7 day alcohol specialist nurse service, one of 11 key recommendations in a recent position paper by the British Society of Gastroenterology, Alcohol Health Alliance UK and British Association for Study of the Liver on future alcohol care required in British district general hospitals. Other key recommendations include a hospital 'alcohol care team', with a lead clinician, coordinated policies in accident and emergency, with an outreach service, psychiatry input, adequate consultant numbers and integrated alcohol treatment pathways between primary and secondary care.

Functional dyspepsia: motor abnormalities, sensory dysfunction, and therapeutic options.

Functional dyspepsia is a common condition, but as yet, the underlying etiology is unclear. In this article, upper gastrointestinal motor and sensory physiology are reviewed and the current evidence for motor and/or sensory functional abnormalities causing dyspeptic symptoms is presented. The complex interrelationship between abnormal motor activity and sensation is explored, as well as the potential roles for autonomic dysfunction and psychological state in modulating gastrointestinal sensation and motor function. Finally, based on clinical trial evidence, a treatment pathway for functional dyspepsia is suggested.