The legal and medical consequences of child marriage.

The Marriage and Civil Partnership (Minimum Age) Act 2022 came into force in England on 27 February 2023 and made both registered and unregistered marriages involving people under 18 illegal in England and Wales. This means that such marriages which take place outside England and Wales will not be recognised and those who organised them, including parents, will have committed a criminal offence.This review considers issues related to families where such marriages have happened, including their impact on the health of the victim and any resulting children. It touches on religious and societal issues and the need for targeted and appropriate education.

Surveillance for colorectal cancer and chemoprevention in ulcerative and Crohn's colitis: The need for clinical strategies to increase effectiveness.

This review considers why current strategies for surveillance and the prevention of colorectal cancer as a long-term complication are ineffective. The role of endoscopists, pathologists, and patients are investigated. Colorectal cancer is linked to poor compliance with therapy, and attention may be better directed at improving adherence to treatment than strengthening current surveillance programs. Clearly, 5-ASA compounds, particularly mesalazine, are the most appropriate agents to choose, but there may also be a place for the daily intake of folic acid. Currently, the evidence in support of ursodeoxycholic acid is mixed, and it cannot be recommended, in general, to patients for the prophylaxis of colorectal cancer risk. An alternative approach through better concordance with medications is considered. The situation in Crohn's colitis is less clear. Although the risk of colorectal cancer mirrors that in ulcerative colitis, there are no published community-based studies that exclusively assess the effects of surveillance on the early detection of cancer, and the benefits of 5-ASA compounds in treatment seem less certain than in ulcerative colitis. In addition, there have been no assessments of the effects of any medications on cancer risk in Crohn's disease.

Medical negligence and likely developments in Oman.

Medical mistakes can never be eliminated but they can be minimised. From the world of aviation, it is clear that simulation training can have dramatic beneficial effects. Such training, however, is compulsory. In contrast, in the world of medicine there are few countries which have adopted a comparable approach. Unless continued medical registration is directly linked to satisfactory performance in simulated exercises and real events, it is unlikely that significant reductions will be achieved. This review will concentrate on the situation where mistakes and their mismanagement have direct and adverse consequences for patients. It will not be concerned with the recognised complications of procedures and treatments, with the exceptions of poor communication where patients have entered into treatments unaware of the associated risks.

Risk of esophageal cancer in achalasia cardia: A meta-analysis.

INTRODUCTION: The association between cancer of the esophagus and achalasia has long been recognized. However, it has also been recognized that cancers themselves can give rise to achalasia-like syndromes. The risk of developing cancer is also a factor in assessing whether there is a potential role for surveillance in this disease. This paper uses published work to form the basis for a meta-analysis of the risk of developing esophageal cancer among patients with pre-existing achalasia. METHODS: This paper considered cancer risk reported in a range of studies of achalasia published over a 50-year period. Twenty-seven potential studies were identified. In 16 reports, it was possible to extract information on both length of follow-up and duration of achalasia so that person-years duration (PYD) could be calculated. The analysis was stratified between cancers identified in the first year after diagnosis of achalasia and cancers identified in subsequent years. RESULTS: From pooling the results of 16 studies, the incidence rate of esophageal cancer in achalasia patients was estimated to be 1.36 (95% CI: 0.56, 2.51) per 1000 person years. This is over 10 times higher than the general population incidence rates as reported by the lARC. CONCLUSIONS: Therefore, our meta-analysis shows that achalasia is a major risk factor for the development of esophageal cancer. This is supported by the results from the time-stratified analysis. Incidence of esophageal cancer per 1000 person years was lower in the first year after diagnosis of achalasia than in subsequent years. This is strong evidence against the idea that achalasia may be induced by esophageal cancer instead of vice versa.

Review: Statutory regulation of invasive complementary therapies, such as hijama and acupuncture, is the only effective way of ensuring both patient safety and good practice.

The development of statutory regulation of healthcare professionals first emerged in the 15th century in the UK. However, it was not until the 20th century that statutory regulation of complementary therapies emerged with the Osteopath and Chiropractors Acts. However, during that period, acupuncture failed to gain statutory regulation but was rather subject to the equivalent of trading standards. This review explores the background to this failure and the present need for statutory regulation. It draws comparisons with the need for regulation of hijama, another invasive therapy, for which there is at present no regulation. The benefits of the negative licensing model developed in Australia are considered.

The Need to Develop a Regulatory Body for the Practice of Al-Hijama.

Al-Hijama is a traditional therapy which has been extensively used in the Middle East. It has an Islamic basis but is used in many cultures in the form of wet cupping. There has been a significant growth in its availability in most Western countries during the last decade. In none is it subject to statutory regulation and the training and quality of practitioners is variable. It has both a preventive and therapeutic element and so there are appropriate concerns about the potential for incorrect diagnoses and delays in other effective treatments. In the past, the apprenticeship model in which a trainee worked for some years with an experienced ijazah ensured such problems did not arise. However, there is now an urgent need to recognise the widespread practice of this therapy and ensure that it has the benefits of statutory regulation, be this through specific regulatory bodies or a negative licensing model.

Epidemiology and risk factors for Barrett's oesophagus.

The highest incidence and prevalence of Barrett's oesophagus is in western countries. Risk factors include smoking, obesity, gastro-oesophageal reflux disease and hiatus hernia, increasing age and use of oral bisphosphonates. This article discusses the significance of these findings.

Ethnic variations in the provision of biologic therapy for Crohn's disease: a Freedom of Information study.

In this study, we investigate whether the provision of biologic therapy for Crohn's disease is equitable across South Asian and English groups in NHS Trusts, which serve areas with significant ethnic variation. Data were requested from 10 NHS Trusts using a Freedom of Information (FOI) approach. Details of numbers of patients by ethnicity treated with infliximab or adalumimab for Crohn's disease between 2010 and 2012 were requested. Using population-based estimates of disease prevalence and Census data on population structure, observed and expected numbers who should have received treatment were calculated. In three Trusts, the number of South Asian patients who received such treatment was significantly less than British/White patients. These were: Pennine Acute Hospitals NHS Trust covering Oldham and North Manchester, Barking, Havering & Redbridge University Hospitals NHS Trust and University Hospitals of Leicester NHS Trust. The study is limited by several factors: 1. The only data available on prevalence in both English and South Asian communities comes from Leicester and was published in 1993. More recent data suggests that the prevalence of Crohn's disease now approaches 150/10(5) compared to the 76/10(5) for English patients which was recorded in Leicester. However, the two subsequent studies on prevalence which were published in 2000 from the North of England and 2010 from Scotland do not provide a breakdown by ethnicity. 2. The data were collected by administrative staff using a variety of approaches to their Trust's data bases and so the techniques used in each Trust are not comparable. In addition, studies from elsewhere suggest that the quality of FOI data is affected by the motivation of staff who collect the data. 3. With the exception of Leicester, there was no quality check on the accuracy of the data. In Leicester, 139 patients were on a register of biologic therapy and this compared with 343 patients reported by the FOI request. However, the proportions of patients by type of treatment and by ethnicity were comparable in the two data sets. This suggests that the data on ethnic differences reported by the FOI study reflects real differences. Clearly, there are South Asian communities where patients with Crohn's disease appear not to receive appropriate treatment in the form of biologics, and the reasons behind this need further consideration and investigation. We need to develop robust methods of monitoring the provision of biologic therapy across ethnic groups and communities. It is unacceptable for there to be a difference based on such grounds.

Medico-legal significance of service difficulties and clinical errors in the management of patients with inflammatory bowel diseases.

There is a significant growth in medical litigation, and cases involving the care and management of patients with inflammatory bowel disease are becoming common. There is no central register of such cases, and the majority are settled before court proceedings. As a result, there is no specific case law related to such conditions, and secrecy usually surrounds the outcome with "no admission of guilt" by the defendant and a clause about non-disclosure and discussion linked to the financial compensation received by the claimant. This review discusses common areas of potential litigation.

Patient knowledge in inflammatory bowel disease: the Crohn's and Colitis Knowledge Score.

In the UK, key professional organizations have joined to provide inflammatory bowel disease (IBD) standards to be delivered by the NHS, highlighting the importance of patient education and support. The Crohn's and Colitis Knowledge Score (CCKNOW) is a validated multiple-choice questionnaire on the subject of IBD that is able to objectively quantify the level of patient knowledge. The aim of this study was to summarize the findings of the CCKNOW, in particular, the current level of patient knowledge and the implications clinically. Literature search was conducted using Medline, Google Scholar and the Cochrane Library, compiling results of studies using the CCKNOW to date. In the UK, a median score of 10 was achieved by participants with IBD in Leicestershire in 1999. Recent surveys in the Northwest and Pennine Trust achieved median scores of 9 and 7, respectively. Knowledge deficits regarding fertility and pregnancy were found, as seen in 1999. Studies in Canada and Iran achieved median scores of 13 and 4, respectively. Sri Lanka achieved a mean score of 6.86 (range 1-16). Higher CCKNOW scores were associated with the use of adaptive coping strategies. A significant positive link was found between patient knowledge and anxiety levels. There was no significant difference in CCKNOW scores between patients with the complication of colorectal cancer versus control populations. In the UK, patient knowledge of IBD may be no better than in 1999. The subjects of fertility and implications for pregnancy are particular areas of deficit. Further knowledge shortfalls may exist in the developing countries. Evidence suggests that improving knowledge may empower patients to use more adaptive coping strategies but may not be effective in reducing anxiety or the risk complications such as colorectal cancer.

An analysis of blogs from medical students on "English Parallel" courses in Central and Eastern Europe.

During the last 20 years, there has been a significant growth in the training of overseas students especially within the European Union. Informal discussions with past and present students revealed a marked reluctance to take part in interviews about the nature of "English Parallel" courses. Alternative sources of information include blogs and commentaries written on the internet by present and former students at these schools. Such blogs are relatively limited in number and of variable length. They have been written for a variety of reasons and range in content from commentaries on training to wider discussion of life in Central and Eastern Europe. Six blogs were identified from an internet search, and a qualitative approach was adopted for the analysis of text content. Their experience is assessed, and potential approaches to greater integration of training across Europe are considered.

The registration of medical graduates from Eastern European Union countries with the General Medical Council (GMC) and the Medical Council, Ireland.

The purpose of this study was to identify the number of medical graduates registered with the General Medical Council (GMC) between 1990 and 2005, whose initial training was in Eastern Europe and who came from universities which have subsequently developed an "English Parallel" course and are now within the European Union (EU). A similar exercise was undertaken with graduates registered with the Medical Council, Ireland. Between 1990 and 2005 one thousand six hundred and fourteen (1614) doctors, who had trained in the selected universities from Eastern Europe, registered with the General Medical Council (GMC) in the United Kingdom (Table 1). The Register of Medical Practitioners for Ireland as at 1st July 2005 was also scanned manually to identify graduates from these countries who were registered in Ireland. Sixty four such graduates were identified of whom 6 qualified before 1990 and 5 were in their internship year. The study suggests that since 2000 younger graduates who sought training in Central and Eastern Europe are returning to the UK shortly after graduation to register and start clinical training.

Impact of a tailored patient preference intervention in adherence to 5-aminosalicylic acid medication in ulcerative colitis: results from an exploratory randomized controlled trial.

BACKGROUND: Up to 40% of patients with ulcerative colitis (UC) fail to comply with 5-aminosalicylic acid (5-ASA) therapy. This study aimed to evaluate multifaceted adherence-enhancing interventions for oral 5-ASA therapy in UC and consider changes in health beliefs and satisfaction with information. METHODS: Adults attending a UK gastroenterology outpatient clinic were recruited to an exploratory randomized controlled trial. The tailored intervention included educational and motivational components, plus options including simplified dosing regimes and practical reminders such as pill dispensers. Adherence was assessed objectively at baseline and after 1 year based on levels of urinary 5-ASA and N-acetly-5-ASA concentration. Changes in relevant beliefs and satisfaction with information were measured using validated questionnaires. RESULTS: Seventy-one people completed the study. Adherence levels in the study population were relatively high at baseline (76%) but a decline in adherence levels over the study period was noted. However, at follow-up adherence in the intervention group was 44% greater than in the control group. Intervention group status had a significant positive impact on maintaining adherence levels after adjusting for potential confounders including baseline adherence (P = 0.001). This finding was supported by the results of a sensitivity analysis including patients who withdrew from the study. Changes in questionnaire scores suggested a positive effect of the intervention on satisfaction with information (P < 0.001). CONCLUSIONS: The multifaceted approach studied has potential for implementation in routine care for enhancing persistence with 5-ASA and thus improving patient outcomes.

Islet auto transplantation following total pancreatectomy: a long-term assessment of graft function.

UNLABELLED: Total pancreatectomy is considered the final resort in the treatment of chronic pancreatitis; however, here we show that simultaneous islet autotransplantation can abrogate the onset of diabetes. METHODS: : In Leicester, 46 patients have now undergone total pancreatectomy with immediate islet auto transplant, and they have received a median of 2246 islet equivalent (IEQ)/kg body weight (range, 405-20,385 IEQ/kg body weight). RESULTS: : Twelve patients have shown periods of insulin independence, for a median of 16.5 months (range, 2-63 months), and 5 remain insulin independent. Over the 10 years of follow-up, there has been a notable increase in insulin requirement per kilogram per day, and percentage of glycosylated hemoglobin levels have increased significantly (r = 0.66, P = 0.01). However, 100% of patients tested were C-peptide positive at their most recent assessment, and high fasting and stimulated C-peptide values recorded at 10 years after transplantation, 1.44 (range, 1.09-1.8 ng/mL) and 2.86 ng/mL (range, 1.19-4.53 ng/mL), respectively, suggest significant graft function in the long term. In addition, median serum creatinine has increased very little after the operation (71 nmol/L [range, 49-125 nmol/L] atpreoperation vs 76.5 nmol/L [range 72-81 nmol/L] at year 10), suggesting no diabetic nephropathy. CONCLUSIONS: : Although there is a notable decline in islet function after islet auto transplant, there is still evidence of significant long-term insulin secretion and possible protection against diabetic complications.

An epidemiological study of achalasia among the South Asian population of Leicester, 1986-2005.

Achalasia is an uncommon esophageal motility disorder of unknown etiology that predominantly affects people over the age of 50. The overall incidence in this study was 0.89 cases/10(5)/year. There was no significant difference in the proportion of South Asian women with achalasia compared to the proportion of men affected in the whole population nor between the male-to-female ratio in the patient group compared to the healthy population. Throughout the twentieth century there have been sporadic attempts to find any etiological link but to date none have been confirmed. However, there is evidence that environmental factors may be important and these are reflected in geographical differences in the distribution of the disease. In this study we were also unable to identify any triggering factor responsible for the development of achalasia.

The design and application of effective written instructional material: a review of published work.

This review will consider the evidence base for the format of educational material drawing on academic papers and the practice of the design industry. The core issues identified from the review are drawn together in guidelines for educational posters, text and web based material. The review deals with the design of written material both for use in leaflets and books as well as the impact of factors such as font type and size as well as colour on poster design. It sets these aspects of educational material within a research framework, which looks at impact on learning and subsequent change in practice. These issues are examined through a practical example of a poster designed for a regional gastroenterology meeting.