Advice to remain active with arm pain reduces disability.

BACKGROUND: Arm pain is common amongst working-aged adults and causes substantial work disability. The results of a population-based randomized controlled trial (the ARM trial) suggested that advice to remain active reduced disability after 6 months. AIMS: To verify ARM trial results amongst people in paid employment. METHODS: The ARM trial recruited adults with distal arm pain referred for physiotherapy and randomized equally to three groups: wait-listed for physiotherapy (advised to rest); wait-listed for physiotherapy (advised to remain active) or early physiotherapy. The primary outcome was absence of disability at 26 weeks. Secondary analyses were undertaken amongst participants in paid employment. RESULTS: Amongst 538 trial participants, 347 (64%) were in paid employment, mean age 46.1 years and 47% in manual work. Employed participants were randomized equally to the three arms. Amongst the 271 (78% workers with 26-week data), 43% of those advised to remain active were free from disability, as compared with 37% of those advised to rest. Forty per cent of those who waited for physiotherapy were disability-free as compared with 35% of those treated rapidly. Advice to rest was associated with lower chances of recovery amongst workers who lift/carry weights and those who believed work had caused their symptoms (P = 0.023). CONCLUSIONS: Although not powered as a trial for workers only, our findings suggest that advising activity was as beneficial for people currently in paid work and may be superior to advice to rest in reducing disability. Addressing harmful beliefs about causation of symptoms has the potential to reduce disability.

Cross-validation of good versus poor self-reported outcome trajectory types following knee arthroplasty.

OBJECTIVE: To determine whether good versus poor outcome trajectories and predictors of poor outcome obtained in a derivation study could be replicated in an independent sample of persons undergoing knee arthroplasty (KA). METHODS: We used data from TRIO-POPULAR, a prospective cohort study of 926 participants who underwent KA in the United Kingdom. The participants were assessed preoperatively and 6-weeks, 6- and 12-months postoperatively. The Oxford Knee Score was the primary outcome and a variety of pre-operative predictors of outcome were selected. The outcome measure and the predictors were selected to most closely align with a previously published derivation study of good versus poor outcome. Confirmatory two-piece latent class growth curve analyses were used to model outcome and regression was used to identify predictors of outcome class. RESULTS: Trajectories for the Oxford Knee Scores from TRIO-POPULAR replicated trajectories for WOMAC Pain and Function scores from the previously published derivation study. Multivariable predictors of poor outcome were pain catastrophizing (odds ratio = 1.125, 95% CI = 1.048, .206, p = 0.001) and comorbidity (odds ratio = 1.134, 95%CI = 1.049, 1.227, p = 0.002. Pain catastrophizing also predicted poor outcome in the derivation study. CONCLUSIONS: Good and poor outcome trajectories replicated those found in the previously published derivation study. Our model-based method produces stable outcome trajectories despite using data from different countries and participants with substantively different characteristics. Predictors of poor outcome were somewhat inconsistent between the cross-validation and derivation studies. Pain catastrophizing was the only consistent poor outcome predictor.

Beliefs about back pain and pain management behaviours, and their associations in the general population: A systematic review.

Previous mass media campaigns have aimed to influence how people manage back pain, with mixed success. Campaigns should target beliefs which are related to the behaviours they aim to change. This systematic review brings together research that has measured the prevalence of beliefs about back pain in the general population and factors associated with these beliefs, including future pain-related outcomes. Five databases were searched up until April 2017. Quantitative studies which reported a measure of agreement with a belief about back pain, cross-sectional associations, or associations between beliefs and future outcomes were eligible. Eligibility was assessed and data extracted independently by two authors. Results were tabulated and narratively synthesized. Nineteen studies from 10 countries were eligible (median study n [IQR] = 990.5 [524.75-2387.5]). Beliefs were measured using eight questionnaires and 57 stand-alone items. Beliefs about back pain's negative consequences were common across countries and populations, whereas most samples did not hold fear-avoidance beliefs. Beliefs about back pain's consequences were associated with pain and disability, but only one study investigated this specific relationship prospectively. No studies investigated whether beliefs are associated with future pain management behaviours. Agreement with certain beliefs (e.g. about negative consequences) was associated with sociodemographic characteristics (e.g. older age) and poorer self-rated health. Interventions may benefit from targeting beliefs about the perceived negative consequences of back pain in these populations. However, future research should explore how beliefs prospectively influence the management of back pain. SIGNIFICANCE: This review brings together studies which have assessed the prevalence of beliefs about back pain, and factors associated with holding them. It highlights that whether or not these beliefs represent important determinants of how people manage pain remains unknown.

Association of opioid prescribing practices with chronic pain and benzodiazepine co-prescription: a primary care data linkage study.

BACKGROUND: Opioid prescribing is increasing worldwide with associated increases in misuse and other harms. We studied variations in national opioid prescription rates, indicators of prescribing quality, co-prescribing of benzodiazepines and relationship with pain severity in Scotland. METHODS: Electronic linkages of opioid prescribing in Scotland were determined from: (i) national data from Information Services Division, NHS Scotland (2003-2012); and (ii) individual data from Generation Scotland: Scottish Family Health Study. Descriptive analyses were conducted on national data, multilevel modelling to examine factors associated with variations in prescribing rates. χ2 tests examined associations between individual pain severity and opioid prescriptions. RESULTS: The number of strong opioid prescriptions more than doubled from 474 385 in 2003 to 1 036 446 in 2012, and weak opioid prescribing increased from 3 261 547 to 4 852 583. In Scotland, 938 674 individuals were prescribed an opioid in 2012 (18% of the population). Patients in the most deprived areas were 3.5 times more likely to receive a strong opioid than patients in the least deprived. There was significant variation in prescribing rates between geographical areas, with much of this explained by deprivation. Of women aged 25-40 yr prescribed a strong opioid, 40% were also prescribed a benzodiazepine. There was significant association between pain severity and receipt of opioid prescription. Over 50% of people reporting severe pain were not prescribed an opioid analgesic. CONCLUSIONS: We found opioid prescribing in primary care to be common and increasing in Scotland, particularly for severe pain. Co-prescribing of opioids and benzodiazepines was common.

EULAR revised recommendations for the management of fibromyalgia.

OBJECTIVE: The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were 'expert opinion'. METHODS: A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations. RESULTS: 2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible. Based on meta-analyses, the only 'strong for' therapy-based recommendation in the guidelines was exercise. Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as 'weak for' based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability). CONCLUSIONS: These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.

Chronic pelvic pain in women of reproductive and post-reproductive age: a population-based study.

BACKGROUND: Epidemiological studies on chronic pelvic pain (CPP) have focused on women of reproductive age. We aimed to determine the prevalence of chronic pelvic pain (CPP) in adult women and the differences in associated factors among women of reproductive age and older women. In addition, to determine whether distinct subgroups existed among CPP cases. METHODS: A cross-sectional postal survey was conducted among 5300 randomly selected women aged ≥25 years resident in the Grampian region, UK. Multivariable logistic regression was used to determine pregnancy-related and psychosocial factors associated with CPP. To identify subgroups of CPP cases, we performed cluster analysis using variables of pain severity, psychosocial factors and pain coping strategies. RESULTS: Of 2088 participants, 309 (14.8%) reported CPP. CPP was significantly associated with being of reproductive age (odds ratios (OR) 2.43, 95% CI 1.69-3.48), multiple non-pain somatic symptoms (OR 3.58 95% CI 2.23-5.75), having fatigue (OR mild 1.74 95% CI 1.24-2.44, moderate/severe 1.82, 95% CI 1.25-2.63) and having depression (OR 1.61, 95% CI 1.09-2.38). CPP was less associated with multiple non-pain somatic symptoms in women of reproductive age compared to older women (interaction OR 0.51, 95% CI 0.28-0.92). We identified two clusters of CPP cases; those having little/no psychosocial distress and those having high psychosocial distress. CONCLUSION: CPP is common in both age groups, though women of reproductive age are more likely to report it. Heightened somatic awareness may be more strongly associated with CPP in older women. There are distinct groups of CPP cases characterized by the absence/presence of psychosocial distress. SIGNIFICANCE: Heightened somatic awareness may be more strongly associated with CPP in women of post-reproductive years compared to women of reproductive years. Two subgroups of CPP cases can be differentiated by the absence/presence of psychosocial distress suggesting that stratified management approach may be more efficient.

Common and unique associated factors for medically unexplained chronic widespread pain and chronic fatigue.

OBJECTIVE: Chronic widespread pain and chronic fatigue share common associated factors but these associations may be explained by the presence of concurrent depression and anxiety. METHODS: We mailed questionnaires to a randomly selected sample of people in the UK to identify participants with chronic widespread pain (ACR 1990 definition) and those with chronic fatigue. The questionnaire assessed sociodemographic factors, health status, healthcare use, childhood factors, adult attachment, and psychological stress including anxiety and depression. To identify persons with unexplained chronic widespread pain or unexplained chronic fatigue; we examined participant's medical records to exclude medical illness that might cause these symptoms. RESULTS: Of 1443 participants (58.0% response rate) medical records of 990 were examined. 9.4% (N=93) had unexplained chronic widespread pain and 12.6% (N=125) had unexplained chronic fatigue. Marital status, childhood psychological abuse, recent threatening experiences and other somatic symptoms were commonly associated with both widespread pain and fatigue. No common effect was found for few years of education and current medical illnesses (more strongly associated with chronic widespread pain) or recent illness in a close relative, neuroticism, depression and anxiety scores (more strongly associated with chronic fatigue). Putative associated factors with a common effect were associated with unexplained chronic widespread pain or unexplained chronic fatigue only when there was concurrent anxiety and/or depression. DISCUSSION: This study suggests that the associated factors for chronic widespread pain and chronic fatigue need to be studied in conjunction with concurrent depression/anxiety. Clinicians should be aware of the importance of concurrent anxiety or depression.

Production of immune response mediators by HT-29 intestinal cell-lines in the presence of Bifidobacterium-treated infant microbiota.

The colonisation and establishment of the intestinal microbiota starts immediately at birth and is essential for the development of the intestine and the immune system. This microbial community gradually increases in number and diversity until the age of two or three years when it becomes a stable ecosystem resembling that of adults. This period constitutes a unique window of opportunity to modulate it through probiotic action, with a potential impact in later health. In the present work we have investigated how putative bifidobacterial probiotics modify the metabolic profiles and immune-modulatory properties of faecal microbiotas. An in vitro pH-controlled single-stage continuous-culture system (CCS) inoculated with infant faeces was employed to characterise the effects of two Bifidobacterium species on the intestinal microbiotas in three children, together with the effects of these modified microbiotas on cytokine production by HT-29 cells. Intestinal bacterial communities, production of short-chain fatty acids and lactate were determined by quantitative PCR and gas chromatography, respectively. Cytokines production by HT-29 cells was measured by ELISA. The combination of CCS with infant faeces and human intestinal cells provided a suitable model to evaluate the specific modulation of the intestinal microbiota and immune system by probiotics. In the CCS, infant faecal microbiotas were influenced by the addition of bifidobacteria, resulting in changes in their ability to induce the production of immune mediators by HT-29 cells. The different metabolic and immunological responses induced by the bifidobacterial species tested indicate the need to assess potential probiotics in model systems including complex intestinal microbiotas. Potential probiotic bifidobacteria can modulate the infant microbiota and its ability to induce the production of mediators of the immune response by intestinal cells.

The relationship between back pain and mortality in older adults varies with disability and gender: results from the Cambridge City over-75s Cohort (CC75C) study.

BACKGROUND: This study aims to determine whether older adults reporting back pain (BP) are at increased risk of premature mortality, specifically, to examine the association with disabling/non-disabling pain separately. METHODS: Participants aged ≥75 years were recruited to the Cambridge City over-75s Cohort (CC75C) study. Participants answered interviewer-administered questions on BP and were followed up until death. The relationship between BP and mortality was examined using Cox regression, adjusted for potential confounding factors. Separate models were computed for men and women. RESULTS: From 1174 individuals with BP data, the date of death was known for 1158 (99%). A significant association was found between disabling BP and mortality (hazard ratio: 1.4; 95% confidence interval: 1.1-1.8) and this remained, albeit of borderline significance, following adjustment for socio-demographic variables and potential disease markers (1.3; 0.99-1.7). Further, this association was found to vary with sex: women experienced a 40% increase in the risk of mortality associated with disabling BP (1.4; 1.1-1.9), whereas no such increase was observed for men (1.0; 0.5-1.9). Participants with non-disabling BP were not at increased risk of mortality. CONCLUSIONS: This study confirmed previous findings regarding the relationship between pain and excess mortality. Further, we have shown that, among older adults, this association is specific to disabling pain and to women. Clinicians should be aware not only of the short-term implications of disabling BP but also the longer-term effects. Future research should attempt to understand the mechanisms underpinning this relationship to avoid excess mortality and should aim to determine why the relationship differs in men and women.

Self-reported pain severity is associated with a history of coronary heart disease.

BACKGROUND: Previous studies have found an association between chronic pain and cardiovascular (CV) mortality. OBJECTIVE: To explore the relationship between the severity of pain and non-fatal CV disease. METHODS: A total of 45,994 adults randomly selected from general practice registers in Manchester and Aberdeen were posted a survey, which included a Chronic Pain Grade questionnaire, pain manikin and questions about lifestyle and medical history. A single component measuring pain severity was extracted using factor analysis. Logistic regression was used to test for an association between quintiles of pain severity and a history of CV disease, adjusting for confounders. RESULTS: Of the 15,288 responders, 61% (n = 9357) reported pain for ≥ 1 day in the past month. Compared with the first (lowest) pain severity quintile, the fully adjusted odds ratio for heart attack in the second severity quintile was 1.25 (95% confidence interval 0.68, 2.30); third quintile: 1.65 (0.93, 2.94); fourth quintile: 1.76 (1.00, 3.11) and fifth (highest) quintile 2.47 (1.43, 4.28). Corresponding figures for angina (excluding heart attack) were: 1.79 (0.93, 3.45), 1.91 (1.00, 3.62), 1.03 (0.50, 2.11) and 3.17 (1.71, 5.85). CONCLUSION: A history of CV disease is reported more often in those with severe pain than would be expected by chance, even when adjusting for shared risk factors.

Functioning of the hypothalamic-pituitary-adrenal and growth hormone axes in frequently unexplained disorders: results of a population study.

BACKGROUND: The aim of the study was to test the hypothesis that associations with specific stress systems [hypothalamic-pituitary-adrenal (HPA) and growth hormone (GH) axes] would increase as the number of unexplained disorders increased while accounting for the possible confounding effects of psychosocial factors. METHODS: A cross-sectional study identified those reporting chronic widespread pain, irritable bowel syndrome, chronic orofacial pain and chronic fatigue. Of the 1315 subjects, disorder status was available for 1180 (89.7%), of whom 766 (64.9%) reported no disorders, 277 (23.5%) reported one and 137 (11.6%) reported two or more. Eighty subjects were sought from each group for assessment of HPA (morning 8:00 a.m. and evening 10:00 p.m. saliva, and post-dexamethasone serum cortisol levels) and GH [serum insulin-like growth factor 1 (IGF-1) level] axis function. Validated questionnaires informed current psychological state. RESULTS: Two hundred twenty-seven subjects participated [79 (35%) with no disorders, 78 (34%) with one disorder and 70 (31%) with two or more disorders]. There were no significant associations (p < 0.05) between individual disorders or an increasing disorder load with any of the neuroendocrine levels measured: saliva/serum cortisol, IGF-1 and dehydroepiandrosterone. Psychosocial factors were independently associated with disorders and with an increasing disorder load: health anxiety p < 0.01, anxiety p < 0.01, depression p < 0.01, life events p = 0.03. CONCLUSION: Although previous studies have shown that stress axis function acts to moderate the risk of onset of some of these disorders, the present study shows that the degree of dysfunction is not correlated with a corresponding increasing load of disorders. The uncertainty surrounding the role of these biomarkers in the aetiology of unexplained disorders needs further investigation.

Synbiotic consumption changes the metabolism and composition of the gut microbiota in older people and modifies inflammatory processes: a randomised, double-blind, placebo-controlled crossover study.

BACKGROUND: Ageing can result in major changes in the composition and metabolic activities of bacterial populations in the large gut and an impaired immune system. AIM: To investigate the effects of synbiotic consumption on the colonic microbiota, immune function and health status in older people. METHODS: A randomised, double-blind placebo-controlled, 4-week crossover study was carried out, involving 43 older volunteers, using a synbiotic comprising the probiotic Bifidobacterium longum and an inulin-based prebiotic Synergy 1 (SudZucker, Mannheim, Germany). Faecal and blood samples were collected, and clinical status scored at the start, and at 2- and 4-week intervals, with a 4-week washout between each feeding period. Faecal bacteria were determined by fluorescent in situ hybridisation. Short-chain fatty acid concentrations, cytokine production, bowel habit and a range of clinical parameters were measured. RESULTS: The synbiotic increased bifidobacterial numbers by 1.4 log units (P < 0.0001) and also increased members of the phyla Actinobacteria and Firmicutes (P = 0.0004, P < 0.0001). Proteobacteria were reduced by 1.0 log units (P < 0.0001). Synbiotic feeding was associated with increased butyrate production (P = 0.0399). The pro-inflammatory response was modified by the synbiotic, with significantly reduced pro-inflammatory cytokine TNF-α in peripheral blood after 2 and 4 weeks of synbiotic consumption (P = 0.02, P = 0.0406). The synbiotic had no effect on bowel habit or any clinical parameters. CONCLUSION: Short-term synbiotic use can be effective in improving the composition and metabolic activities of colonic bacterial communities and immune parameters in older people. This study was registered at clinicaltrials.gov as NCT01226212.

Oesophageal bacterial biofilm changes in gastro-oesophageal reflux disease, Barrett's and oesophageal carcinoma: association or causality?

SUMMARY: Barrett's oesophagus (BO) and gastro-oesophageal reflux disease (GERD) are precursors of oesophageal adenocarcinoma (OAC). There is an oesophageal biofilm, which changes in disease, but its role in aetiopathogenesis remains unclear. AIM: To define the oesophageal microbiota of patients with GERD, BO and OAC compared with controls and to investigate mucosal responses related to the microbiota. METHODS: Cultural analysis identified the dominant bacterial species from a subset of each disease group. Based on this, molecular techniques were used to define the cohort. Host responses were analysed in tissues and co-culture experiments. RESULTS: A total of 111 species belonging to 26 genera were isolated. There was a significant decrease in bacterial counts in the GERD and BO groups for all genera except Campylobacter, which colonised GERD and Barrett's patients in increasing numbers. Campylobacter concisus was the dominant species. This relationship was not seen in the cancer group. Significant increases in IL-18 were seen in GERD and BO colonised by Campylobacter. CONCLUSIONS: This study defines differences in the oesophageal biofilm in disease states, revealing the emergence of C. concisus as the dominant new colonist in the refluxed oesophagus. We also associate the presence of these bacteria with increased expression of cytokines related to carcinogenesis.

Low back pain among textile workers: a cross-sectional study.

BACKGROUND: Low back pain (LBP) is one of the most prevalent occupational health problems in industrialized countries. Little is known about the epidemiology of LBP in developing countries. AIMS: To determine the prevalence of LBP among Nepalese textile workers and to investigate the influence of exposure to mechanical and other factors on LBP reporting. METHODS: Interviewers completed questionnaires with study subjects, and work-related mechanical exposures were measured by self-completed questionnaires. Associations of LBP with mechanical factors and somatic symptoms were determined by logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CI). RESULTS: Nine hundred and thirty-eight workers took part, a participation rate of 92%. The 1 month period prevalence of LBP was 35% (n = 324), being higher in females than males (45% versus 28%; P < 0.001). Several work-related mechanical factors were associated with increased odds of reporting LBP: lifting heavy weights with one hand (OR 1.7; 95% CI 1.1-2.8), pushing weights (OR 1.6; 95% CI 1.2-2.3 and pulling weights (OR 1.6; 95% CI 1.1-2.1). No association was found with working posture. Strong associations were found for reporting one (OR 2.4; 95% CI 1.7-3.4) or two somatic symptoms (OR 2.7; 95% CI 1.4-5.1). On multivariable analysis, reporting of somatic symptoms (OR 2.8; 95% CI 1.5-5.4), female gender (OR 2.2; 95% CI 1.5-3.1) and increasing age were significantly associated with increased risk of reporting LBP (OR 1.7; 95% CI 1.2-2.5), but no associations were found with mechanical factors. CONCLUSIONS: This study suggests that mechanical load may not be the leading cause of LBP and adds to evidence that psychological factors play an important role in LBP in non-industrialized countries.

Multiple somatic symptoms predict impaired health status in functional somatic syndromes.

BACKGROUND: The relationship between functional somatic syndromes and multiple somatic symptoms is unclear. PURPOSE: We assessed whether the number of somatic symptoms is a predictor of health status in three functional somatic syndromes (FSS). METHODS: In a population-based study of 990 UK adults we assessed chronic widespread pain (CWP), chronic fatigue (CF) and irritable bowel syndrome (IBS) by questionnaire and medical record data. We assessed health status (Short Form 12 and EQ-5D), number of somatic symptoms (Somatic Symptom Inventory) and anxiety/depression (Hospital Anxiety and Depression Scale) both at baseline and at follow-up 1 year later. RESULTS: The proportion of people with an FSS who also have multiple somatic symptoms (52-55 %) was similar in the three functional syndromes. The presence of multiple somatic symptoms was associated with more impaired health status both at baseline and at follow-up. This finding was not explained by severity of FSS. In the absence of multiple somatic symptoms, the health status of the FSS was fair or good. In multiple regression analysis, the number of somatic symptoms, the presence of a functional syndrome (CWP or CF) and anxiety/depression were predictors of EQ-5D thermometer at follow-up after adjustment for confounders. CONCLUSIONS: Multiple somatic symptoms in people with an FSS are associated with impaired health status and this cannot be explained by more severe functional syndrome or the presence of anxiety and depression.

Investigating the role of pain-modulating pathway genes in musculoskeletal pain.

AIMS: The aim of this study was to determine if genetic variation in the pain-modulating gene DREAM and its pathway genes influence susceptibility to reporting musculoskeletal pain in the population. METHODS: Pairwise tag single nucleotide polymorphisms (SNPs) in DREAM, PDYN and OPRK1 were genotyped in a UK population-based discovery cohort in whom pain was assessed using blank body manikins at three time points. Depression and anxiety symptoms were assessed at the first time point. Zero-inflated negative binomial regression was used to test for association between SNPs and the maximum number of pain sites reported (0-29) across the three time points. Significantly associated SNPs (p < 0.05) were subsequently genotyped for validation in a cohort of European men with pain assessed at two time points. RESULTS: Thirty-five SNPs were genotyped in 1055 subjects, of whom 83% reported pain, in the discovery cohort. SNPs in each gene were associated with the maximum number of pain sites reported, were independent of symptoms of anxiety and depression and had a significant cumulative effect (p = 7.0 × 10(-5) ). Significantly associated SNPs were successfully genotyped in 1733 men, 76% of whom reported pain, in the validation cohort, but did not show significant association with the number of pain sites. CONCLUSIONS: Genetic variation in the DREAM pathway genes was associated with the extent of pain reporting in a population-based cohort. These findings were not replicated in a single independent cohort; however, given the potential of this pathway as a therapeutic target, further investigation in additional cohorts is warranted.

Systematic review and meta-analysis of the evidence for flexible sigmoidoscopy as a screening method for the prevention of colorectal cancer.

BACKGROUND: Colorectal cancer is a significant cause of death. Removal of precancerous adenomas, and early detection and treatment of cancer, has been shown to reduce the risk of death. The aim of this review and meta-analysis was to determine whether flexible sigmoidoscopy (FS) is an effective population screening method for reducing mortality from colorectal cancer. METHODS: MEDLINE (1946 to December 2012) and Embase (1980-2012, week 15) were searched for randomized clinical trials in which FS was used to screen non-symptomatic adults from a general population, and FS was compared with either no screening or any other alternative screening methods. Meta-analysis was carried out using a random-effects Mantel-Haenzsel model. RESULTS: Twenty-four papers met the inclusion criteria, reporting results from 14 trials. Uptake of FS was usually lower than that for stool-based tests, although FS was more effective at detecting advanced adenoma and carcinoma. FS reduced the incidence of colorectal cancer after screening, and long-term mortality from colorectal cancer, compared with no screening in a selected population. Compared with stool-based tests in a general population, FS was associated with fewer interval cancers. CONCLUSION: FS is efficacious at reducing colorectal cancer mortality compared with no screening. It is more effective at detecting advanced adenoma and carcinoma than stool-based tests. FS may be compromised by poorer uptake. Introduction of FS as a screening method should be done on a pilot basis in populations in which it is not currently used, and close attention should be paid to maximizing uptake. The relative risk of adverse events with FS compared with stool-based tests should be quantified, and its real-world effectiveness evaluated against the most effective stool-based tests.

Estrogen mediated effects in the Sydney rock oyster, Saccostrea glomerata, following field exposures to sewage effluent containing estrogenic compounds and activity.

The Sydney rock oyster, Saccostrea glomerata, has been demonstrated as a useful biomonitor of estrogenic compounds following laboratory exposures, yet its utility in the assessment of estrogenic exposure and effects under field conditions requires investigation. To achieve this aim, S. glomerata were deployed in Newcastle, Australia in the effluent receiving marine waters of Burwood Beach WWTP (Burwood Beach "near", <50 m from outfall and Burwood Beach "far", 100-150 m from outfall) and reference locations (Redhead, Fingal Island 1 and Fingal Island 2) at depths of 4, 8 and 12 m for six weeks. Effluent receiving waters of Burwood Beach WWTP were found to be a suitable impact location, demonstrated via measurement of estrogenic compounds and activity throughout the deployment. Estrogenic compounds were detected (average of combined solids and liquid fractions) at average concentrations of: 1.42 ng/L for estrone, 0.69 ng/L for 17ß estradiol, 3.83 ng/L for estriol (E3), 0.56 ng/L for 17α-ethynylestradiol, 64.2 ng/L for bisphenol A, 7.51 ng/L for 4-nonylphenol and 5.93 ng/L for 4-tert-octylphenol. Total estrogenic activity was estimated at 4.48 ng/L EEQ via the Yeast Estrogen Screen (YES(®)) assay (average of combined solid and liquid fractions). Female vitellogenin gene expression was highest at Burwood Beach locations, yet no significant differences were detected among locations for either sex. Vitellogenin protein was significantly higher (p<0.05) in S. glomerata at Burwood Beach Near compared to reference locations for the 4 and 12 m depths. Increased proportions of females were found at Burwood Beach Near, at 4m depth (p<0.05). Both Burwood Beach locations had higher proportions of mature female gonadal development stages compared to reference locations (p<0.05). Oocyte area was highest at both Burwood Beach locations, but no significant differences were detected among locations. Findings provided further evidence that female S. glomerata may be a suitable candidate species for assessment of effects of estrogenic compounds in Australian waters.

Organising a World Congress of Epidemiology (WCE): reflections and lessons from the XIX WCE, Scotland.

The 3-yearly World Congress of Epidemiology is the premier, international, scientific conference organised under the auspices of the International Epidemiological Association (in open competition). This paper explores the justification for seeking to host the Congress and reflects on the structures and processes adopted in making the XIXth Congress in Scotland happen. Preparing the bid was invaluable for forming collaborations, generating scientific ideas, and garnering opinion. After the bid was accepted, we formed a local organising committee, named the Management Executive Committee to signal its decision making authority; and scientific, fundraising, marketing, international and social subcommittees. There was uncertainty about critical matters such as delegate numbers, costs and the total budget. Early decisions had to be made on, for example, the fee and fundraising target (£250,000), despite financial risks. Development of the scientific programme was a critical step that underpinned fundraising and marketing and permitted involvement of the international committee. Overall the 2011 WCE succeeded. The key ingredients to success were: a large collaboration of institutions and individuals; early pledges of financial support mostly from the UK; the valuable and relevant experience of the professional conference organisers; unstinting support and advice from IEA; and the effectiveness of the committee structure. The educational and professional development benefits of this WCE will reach a worldwide community and not just delegates, because of video, PowerPoint and textual accounts being open access on the Internet. This reach is unprecedented for IEA's World Congresses. We anticipate that the Congress will translate into better public health practice, better future Congresses, advances in epidemiology and improved population health.

A high tender point count is associated with the presence of multiple idiopathic pain disorders: results from a population study.

BACKGROUND/AIMS: To test whether mechanical hyperalgesia is associated with multiple idiopathic pain disorders (IPDs) and whether this relationship is independent of the confounding effects of psychosocial factors. METHODS: One hundred eighteen subjects with chronic orofacial pain (COFP) were identified from their questionnaire responses to a population study in North West England. All subjects had a tender point examination according to the American College of Rheumatology classification. Validated tools on the questionnaire were used to identify presence of other IPDs (irritable bowel syndrome and chronic widespread pain) and psychosocial factors (anxiety, depression, health anxiety, sleep disturbance and reporting of somatic symptoms and adverse life events). RESULTS: Of the 118 subjects, 47.6% (n = 56) had COFP, 34.7% (n = 41) had COFP plus one IPD and 17.8% (n = 21) had all three IPDs. Univariate analysis revealed a dose-response relationship between number of tender points (TPs) and number of IPDs [2-6 TPs (OR 2.6, 95% CI 1.0-7.3), ≥ 7 TPs (OR 10.5, 95% CI 3.8-29.3)] and number of IPDs and psychological distress [anxiety (OR 2.8, 95% CI 1.2-6.4), depression (OR 4.3, 95% CI 1.7-10.6), sleep disturbance (OR 4.8, 95% CI 1.6-14.6)]. The relationship between IPDs and TPs persisted after adjusting for psychosocial factors in multivariate analyses [2-6 TPs (OR 2.5, 95% CI 0.8-7.8) ≥ 7 TPs (OR 10.7, 95% CI 3.4-33.7)]. CONCLUSION: The dose-response relationship between TPs and IPDs needs further investigation to determine the temporal nature of these relationships and to disentangle the complex gene-environment relationships that may influence the occurrence of multiple IPDs.