Look away now! Defensive processing and unrealistic optimism by level of alcohol consumption.

OBJECTIVE: Health risk information is insufficient as a means of reducing alcohol use, particularly when it evokes negative emotional states amongst those for whom it is most personally relevant. Appraisal biases, or 'defensive processing', may be employed to mitigate the psychological discomfort posed by such information. Few studies have evaluated the role of defensive processing in people with different levels of alcohol consumption. DESIGN: Online participants (n = 597) completed measures of defensive processing of a health risk infographic, perceived susceptibility and severity of alcohol use, efficacy for resisting alcohol use, unrealistic optimism, the Alcohol Use Disorder Identification Test - Consumption (AUDIT-C) and demographics. RESULTS: AUDIT-C scores were positively and linearly associated with all defensive processing measures (Pearson's correlation r from.16 to .36), threat and susceptibility (r = .16) and unrealistic optimism (r = .50). AUDIT-C scores were also negatively associated with efficacy for controlling alcohol use (r = -0.48). CONCLUSION: People with alcohol use disorder (AUD) engaged in much more defensive processing of alcohol-related messages, offering an explanation for why such messages are limited at eliciting behaviour change. High levels of unrealistic optimism in people with alcohol use disorder may reflect low problem recognition in order to maintain a problem-free drinking identity.

The "alcoholic other": Harmful drinkers resist problem recognition to manage identity threat.

OBJECTIVE: Harmful drinkers represent an important Alcohol Use Disorder (AUD) group in public health terms, accounting for significant health and social costs. However, harmful drinkers are characterized by low problem recognition; they tend to construct their drinking identity as positive and problem-free, actively setting themselves apart from the stigmatised 'alcoholic other'. As such, harmful drinkers rarely engage in treatment and represent an important opportunity for lower threshold interventions and self-change. The present study sought to explore AUD problem framing and stigma effects on problem recognition. METHODS: Harmful drinkers without perceived addiction experience recruited online (n = 244, 54% male, 46% female, 96% British) were randomised to one of six conditions comprising beliefs about alcohol problems (control, continuum, binary disease model) and stigma (stigma, non-stigma), and completed measures relating to problem recognition. RESULTS: As predicted, results found that harmful drinkers exposed to binary disease model beliefs and stigmatising language had significantly lower problem recognition than those in other conditions. However, no support was found for the prediction that continuum beliefs would be associated with higher problem recognition. Results suggest that the interaction of binary disease model beliefs and stigma prompted alcoholic label avoidance. CONCLUSION: These findings suggest that problem framing has important consequences for harmful drinkers. Implications for behaviour change amongst harmful drinkers through mechanisms of problem framing and identity are discussed.

Continuum beliefs are associated with higher problem recognition than binary beliefs among harmful drinkers without addiction experience.

Low problem recognition may be an important barrier to opportunities for self-change or help-seeking in harmful drinkers. Little is known about how the beliefs harmful drinkers hold about the nature and causes of alcohol problems affect problem recognition and subsequent behaviour change processes. Participants (n = 597) recruited online were randomised to one of two conditions designed to promote beliefs according to (a) a continuum model of alcohol problems or (b) a binary disease model, or (c) a control condition. Participants completed measures of alcohol problem beliefs, problem recognition and other indices including the Alcohol Use Disorder Identification Test (AUDIT), addiction beliefs, addiction experience and demographics. Results showed that harmful drinkers without addiction experience exposed to the continuum condition had significantly higher problem recognition than those in binary disease model or control conditions. Continuum beliefs appear to offer self-evaluative benefits for harmful drinkers with low alcohol problem recognition, thus potentially facilitating help-seeking or self-change regarding alcohol use. Further research to understand the mechanisms by which continuum beliefs may promote more accurate drinking self-evaluation and its potential for behaviour change is warranted. The role of continuum beliefs may have important consequences for alcohol-related messaging and interventions seeking to promote self-change or help-seeking.

Emergency department utilisation for inflammatory bowel disease in the United States from 2006 to 2014.

BACKGROUND: Despite advances in treatment, patients with inflammatory bowel disease (IBD) frequently require emergency department (ED) visits and hospitalisations. AIMS: To analyse trends in ED visits and subsequent hospitalisations for IBD in the United States (US). METHODS: Data were analysed from the Nationwide Emergency Department Sample (NEDS) years 2006-2014. The NEDS is the largest all-payer ED database in the US, weighted to represent 135 million visits/year. IBD was identified using ICD-9 codes for Crohn's disease (CD) or ulcerative colitis (UC). Surgeries were identified using procedure codes. RESULTS: The frequency of IBD-ED visits increased 51.8%, from 90 846 visits in 2006 to 137 946 in 2014, which was statistically significant in linear regression. For comparison, all-case ED use between 2006 and 2014 increased 14.8%. In-patient hospitalisations from the ED decreased 12.1% for IBD (from 64.7% rate of hospitalisation from the ED in 2006 to 52.6% in 2014), with a UC:CD ratio of 1.2:1 in 2006 and 1.3:1 in 2014. Chi-square analysis revealed that this was a significant decrease. Surgery rates also showed a statistically significant decrease. The mean ED charge per patient rose 102.5% and the aggregate national cost of IBD-ED visits increased 207.5%. CD accounted for over twice as many visits as UC in both years. UC, age, male gender, highest income quartile, private insurance, Medicaid/Medicare, and tobacco use were associated with in-patient admissions. CONCLUSIONS: The number of ED visits due to IBD and associated charges have continued to rise, while the rates of in-patient hospitalisations referred from the ED and surgeries have decreased.

Medical and psychological factors related to pain in adults with pediatric-onset spinal cord injury: a biopsychosocial model.

STUDY DESIGN: A cross-sectional study. OBJECTIVES: The aim of this study is to determine medical and psychological correlates of pain in individuals with pediatric-onset spinal cord injury (SCI). SETTING: Shriners Hospitals for Children-Chicago, Philadelphia and Northern California (USA). METHODS: A total of 187 adults who had sustained an injury before 19 years of age completed interviews that included medical information, standardized measures of psychological functioning (Beck Anxiety Inventory and Patient Health Questionnaire) and a comprehensive pain questionnaire to assess the location, frequency, intensity and duration of pain and distress and disability related to pain. RESULTS: The findings identified the medical and psychological correlates of pain. Greater symptoms of depression and anxiety were strong and consistent predictors of several aspects of pain, above and beyond the impact of gender, injury-related characteristics and secondary medical complications. DISCUSSION: The findings support a biopsychosocial model of the development and persistence of pain in individuals with pediatric-onset SCI. Interdisciplinary rehabilitation may incorporate psychological treatment such as cognitive-behavioral therapy to reduce the pain and improve functioning. The assessment and treatment of pain in pediatric-onset SCI is a clinical and research priority. SPONSORSHIP: This study is supported by funding from Shriners Hospitals for Children and the Craig H. Neilsen Foundation, grant #324671.

The use of pharmacological prophylaxis against venous thromboembolism in hospitalised patients with severe active ulcerative colitis.

BACKGROUND: Hospitalised patients with inflammatory bowel disease are 1.5- to 3.5-fold more likely to develop venous thromboembolism compared to controls. Clinical guidelines recommend pharmacological prophylaxis. AIM: To determine the rate of pharmacological venous thromboembolism prophylaxis prescription and administration in a cohort of hospitalised patients with severe active ulcerative colitis and to assess predictors of failure to order pharmacological prophylaxis at 24 h. METHODS: This is a retrospective review of hospitalised patients with severe active ulcerative colitis, identified by ICD-9-CM discharge code 556.x, admitted to a single tertiary care hospital from 1 January 2005 to 31 August 2012. Adequate thromboembolism prophylaxis was defined as an order for low-dose unfractionated heparin two to three times daily, low-molecular weight heparin 40 mg daily or fondaparinux 2.5 mg daily ordered and administered for >80% of the admission. Patient related factors associated with failure to order prophylaxis at 24 h were accessed as secondary outcomes. RESULTS: Three hundred and thirty-six patients were hospitalised with severe active ulcerative colitis. Hospitalists had prescribed appropriate pharmacological prophylaxis by 48 h in only 37% of cases. Of these, nurses administered all prescribed doses in 18% of cases. Only 7% of patients (22/304, 95% CI: 5-11%) received adequate pharmacological prophylaxis for >80% of their hospitalisation. Hematochezia (P = 0.002), elevated platelets (P = 0.008), male gender coupled with younger age (P = 0.005) and admission on a biologic (P = 0.03) were associated with failure to order prophylaxis. CONCLUSION: Hospitalised patients admitted with severe active ulcerative colitis are not receiving appropriate pharmacological venous thromboembolism prophylaxis.

Review article: immunogenicity of anti-TNF biologics in IBD - the role of patient, product and prescriber factors.

BACKGROUND: Anti-drug antibodies (ADAs) to biologic therapies contribute to the loss of response and infusion reactions to anti-TNF drugs in patients with inflammatory bowel disease (IBD). The reasons behind this immunogenicity are complex, and have not been the focus of a dedicated review for prescribers. AIM: To provide an overview of the patient, product and prescriber factors, which have been associated with the immunogenicity of anti-TNF therapy, and draw conclusions for clinical practice. METHODS: Review of representative observational studies and clinical trials from the IBD and other literature, which report associations with ADA development, with a focus on infliximab and adalimumab. RESULTS: ADAs develop in 10-20% of patients receiving anti-TNF maintenance therapy, and these patients are three times more likely to lose response as ADA-negative patients. Patient genotype plays a role in ADA risk in a minority of patients, but age or disease type is not a major factor. Drug mishandling, such as agitation or freeze-thaw cycles, can induce protein aggregates, which are known to be immunogenic. Prescription of maintenance therapy with concomitant immunomodulators, and achieving suitable trough drug levels, reduces the risk of ADAs in patients with IBD. CONCLUSIONS: Patients and prescribers can take several steps to reduce the risk of development of anti-drug antibodies to anti-TNF antibodies. Further research is required to determine if immunogenic factors identified in other situations apply to use of anti-TNFs in IBD.

Meta-analysis: the impact of disease activity at conception on disease activity during pregnancy in patients with inflammatory bowel disease.

BACKGROUND: The rate of exacerbation of inflammatory bowel disease (IBD) during pregnancy varies in the published literature. AIM: We sought to perform a systematic review and meta-analysis of the effects of disease activity at conception on disease course during pregnancy in women with IBD. METHODS: Published studies and abstracts from standard sources were screened for appropriate studies. Data were pooled and analysed using funnel and forest plots. Quality assessment scores were given using GRADE criteria. RESULTS: Fourteen studies were eligible for inclusion; ten studies contained patients with UC (N = 1130), and six studies contained patients with CD (N = 590). In patients with UC there was a significantly higher risk ratio of active disease during pregnancy in patients who commenced pregnancy with active disease (55%), when compared with those in remission at conception (36%) (RR 2.0, 95% CI: 1.5-3, P < 0.001). This risk was also higher in patients with CD (RR 2.0, 95% CI: 1.2-3.4, P = 0.006). Thirteen of the studies rated 'low' in all domains of a quality assessment, and there was significant statistical heterogeneity. CONCLUSIONS: Patients with IBD who conceive when their disease is active are more likely to have active disease during pregnancy than those who conceive when in remission. All studies used in this analysis had a high risk of bias therefore further studies are required.

Attentional bias for alcohol-related stimuli among belief based and non-belief based non-drinkers.

BACKGROUND/AIMS: Research has provided evidence for an association between attentional biases for substance-related stimuli and the development and maintenance of a variety of addictive behaviours. Attempts at reducing attentional bias amongst harmful and dependent drinkers have provided evidence to suggest that reduced attentional bias in heavy drinkers would lead to necessary reductions in alcohol intake. We tested one aspect of this assumption by measuring attentional bias amongst non-drinkers who, if the link between attentional bias and actual drug use is causal, should demonstrate no attentional bias for alcohol-related stimuli. METHODS: An alcohol Stroop task was administered to belief-based abstainers, non-belief based abstainers and light social drinkers to measure attentional biases for alcohol-related words compared to neutral words. RESULTS: Belief-based abstainers demonstrated significant attentional bias for alcohol-related stimuli, whilst non-belief based abstainers and light social drinkers did not. CONCLUSION: Attentional biases towards alcohol-related stimuli are not specific to harmful and problem drinkers, which has implications for interventions based on attentional bias change.

The Crohn's disease activity index (CDAI) is similarly elevated in patients with Crohn's disease and in patients with irritable bowel syndrome.

BACKGROUND: While the Crohn's disease activity index (CDAI) is the gold standard for defining clinical endpoints in Crohn's disease (Crohn's) clinical trials, its ability to distinguish symptoms due to inflammation from those that are non-inflammatory has been questioned. AIM: To compare CDAI scores in patients with Crohn's and those with Irritable Bowel Syndrome (IBS). METHODS: This was a prospective, cross-sectional cohort study of 91 patients with either Crohn's (n = 44) or IBS (n = 47). Total CDAI and individual component scores were recorded and comparisons were made between Crohn's and IBS patients. RESULTS: Mean CDAI scores were higher in the IBS patients (183 vs. 157, P = 0.1). Sixty-two per cent (n = 29) of IBS patients had CDAI scores greater than 150. Mean CDAI haematocrit score (35.9 vs. 23.0, P = 0.02) and CRP level (6.8 vs. 2.0, P = 0.002) were higher in the Crohn's group. Analysis of CDAI sub-scores demonstrated that IBS patients had significantly higher pain (mean 1.7 vs. 0.8, P = 0.0007) and well-being scores (mean 1.2 vs. 0.8, P = 0.04) relative to patients with Crohn's. Specifically evaluating patients with CDAI greater than 150 (n = 51), IBS patients had higher pain sub-scores (mean 2.4 vs. 1.4, P = 0.002), whereas patients with Crohn's had higher CRP (mean 8.4 vs. 1.8, P = 0.001). CONCLUSIONS: Our study demonstrates that the CDAI does not discriminate patients with symptoms due to active Crohn's from patients with IBS. Patients with IBS can have CDAI scores in the clinically meaningful range. Objective measures, such as CDAI haematocrit score and CRP, are more specific markers of inflammation.

Outcomes after escalation of infliximab therapy in ambulatory patients with moderately active ulcerative colitis.

BACKGROUND: Infliximab (IFX) therapy escalation during maintenance treatment occurs frequently in clinical practice in patients with ulcerative colitis (UC). Outcomes for these patients have not been described. AIM: To describe the prevalence of, and outcomes after, IFX escalation during maintenance therapy in patients with moderate-severe UC. METHODS: Retrospective observational study of clinical outcomes in ambulatory patients with moderate-severe UC treated with maintenance IFX. RESULTS: Fifty-six ambulatory patients received IFX for moderate-severe UC; fifty (89%) responded and proceeded to maintenance therapy. Mean duration of maintenance therapy was 14 months, with mean follow-up of 38 months. Twenty-seven patients (54%) required IFX therapy escalation after a mean of six maintenance infusions. Clinical remission was noted in 36% of the entire cohort (18/50) at 12 months; 19% in the escalation group and 56% in the non-escalation group. Patients who required IFX escalation were less likely to be in clinical remission at 12 months (OR 0.2, 95% CI 0.1-0.6, P = 0.01) when compared with those who did not. During the follow-up period, 27% of patients required a colectomy, and the mean time to colectomy was 17 months. Patients in the escalation group required a colectomy in 33% of cases, compared with 21% of non-escalation patients. CONCLUSIONS: A significant proportion of ambulatory patients with UC treated with maintenance infliximab required therapy escalation over time. This was associated with lower remission, and higher colectomy, rates.

Meta-analysis: targeting the intestinal microbiota in prophylaxis for post-operative Crohn's disease.

BACKGROUND: Enteric bacteria play an important early role in the pathogenesis of Crohn's disease. AIM: To perform a meta-analysis of trials testing antibiotics or probiotics for prevention of post-operative recurrence of Crohn's disease. METHODS: Review of all randomized controlled trials comparing antibiotics or probiotics with placebo in prevention of endoscopic or clinical recurrence of Crohn's disease after surgical resection. Fixed-effect meta-analysis was performed with dichotomous data summarized using relative risk with 95% confidence intervals, where appropriate. RESULTS: Seven studies were identified as suitable for inclusion (two comparing antibiotics with placebo, five comparing probiotics with placebo). The use of nitroimidazole antibiotics (metronidazole, ornidazole) reduced the risk of clinical (RR 0.23; 95% CI 0.09-0.57, NNT = 4) and endoscopic (RR 0.44; 95% CI 0.26-0.74, NNT = 4) recurrence relative to placebo. However, these agents were associated with higher risk of adverse events (RR 2.39, 95% CI 1.5-3.7) and patient withdrawal. Probiotic administration was not associated with any significant difference in risk of recurrence compared with placebo. CONCLUSIONS: Nitroimidazole antibiotics are effective in the prevention of post-operative Crohn's disease recurrence, but their side-effects limit acceptability. Probiotics have failed to show efficacy for post-operative prophylaxis, but may merit further study.

The impact of infliximab infusion reactions on long-term outcomes in patients with Crohn's disease.

BACKGROUND: Little is known about long-term outcomes in patients who experience infusion reactions while receiving infliximab. AIM: To investigate long-term outcomes in patients who experience infusion reactions while receiving infliximab. METHODS: Retrospective electronic chart review of long-term clinical outcomes. RESULTS: Clinical data on 287 patients who received infliximab infusions for Crohn's disease were reviewed, of whom 51 developed at least one infusion reaction (18%). Ileo-colonic disease (OR 2.2, 95% CI 1.1-4.4) and episodic infliximab (OR 2.4, 95% CI 1.2-4.7) were associated with a higher risk of infusion reactions in univariate analysis, but concomitant azathioprine/mercaptopurine therapy at the initiation of infliximab was associated with a reduced risk (OR 0.4, 95% CI 0.2-0.8). Only the effect of concomitant immunomodulators persisted on multivariate analysis. Patients who experienced infusion reactions were less likely to be in remission at 1 year (OR 0.6, 95% CI 0.3-1.2), 2 years (OR 0.4, 95% CI 0.2-0.8, P = 0.01), or 5 years (OR 0.4, 95% CI 0.1-1.3) and more likely to require surgery (OR 2.2, 95% CI 1.1-4.1, P = 0.01) than those who did not experience such reactions. CONCLUSIONS: Patients who experienced infusion reactions to infliximab had a high rate of discontinuation of therapy in this cohort. Concomitant immunomodulators and maintenance therapy reduced the risk of infusion reactions.

Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia.

BACKGROUND: Achalasia is an oesophageal motility disorder, of unknown cause, which results in increased lower oesophageal sphincter (LOS) tone and symptoms of difficulty swallowing. Treatments are aimed at reducing the LOS tone. Current endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection (BTX). OBJECTIVES: The objective of this review was to compare the efficacy and safety of two endoscopic treatments, pneumatic dilatation and intrasphincteric botulinum toxin injection, in the treatment of oesophageal achalasia. SEARCH STRATEGY: We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group trials register, the Cochrane Central Register of Controlled Trials, MEDLINE (1966 to Oct 2005), EMBASE (1980 to Oct 2005), BIOSIS (1969 to Oct 2005) and Web of Science (1955 to October 2005). We also searched abstracts from significant Gastroenterology meetings (DDW, UEGW) and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials comparing PD to BTX injection in patients with primary achalasia. DATA COLLECTION AND ANALYSIS: Two review authors independently performed quality assessment and data extraction. MAIN RESULTS: Six studies involving 178 participants were included. Two studies were excluded from the meta-analysis of remission rates on the basis of clinical heterogeneity of the initial endoscopic protocols. There was no significant difference in remission between PD or BTX treatment within four weeks of the initial intervention, with a relative risk of remission of 1.15 (95% CI 0.95 to 1.38, P = 0.39) for PD compared to BTX. There was also no significant difference in the mean oesophageal pressures between the treatment groups; weighted mean difference for PD of -0.77 (95% CI -2.44 to 0.91, P = 0.37). Data on remission rates following the initial endoscopic treatment was available for two studies at six months and three studies at 12 months. At six months 22 of 29 PD participants were in remission compared to 7 of 27 in the BTX group, giving a relative risk of 2.90 (95% CI 1.48 to 5.67, P = 0.002); whilst at 12 months 33 of 47 PD participants were in remission compared to 11 of 43 BTX participants, relative risk of 2.67 (95% CI 1.58 to 4.52, P = 0.0002). No serious adverse outcomes occurred in participants receiving BTX, whilst PD was complicated by perforation in three cases. AUTHORS' CONCLUSIONS: The results of this meta-analysis would suggest that PD is the more effective endoscopic treatment in the long term (greater than six months) for patients with achalasia.

Palliative biliary stents for obstructing pancreatic carcinoma.

BACKGROUND: Palliative endoscopic stents or surgical by-pass are often required for inoperable pancreatic carcinoma to relieve symptomatic obstruction of the distal biliary tree. The optimal method of intervention remains unknown. OBJECTIVES: To compare surgery, metal endoscopic stents and plastic endoscopic stents in the relief of distal biliary obstruction in patients with inoperable pancreatic carcinoma. SEARCH STRATEGY: We searched the databases of the Cochrane Upper Gastrointestinal and Pancreatic Group specialised register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CancerLit, Current Concepts Database and BIDS (September 2002 to September 2004). The searches were re-run in December 2005 and we are awaiting further details on two trials. Reference lists of articles and published abstracts from UEGW and DDW were hand-searched. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing surgery to endoscopic stenting, endoscopic metal stents to plastic stents, and different types of endoscopic plastic and metal stents, used to relieve obstruction of the distal bile duct in patients with inoperable pancreatic carcinoma. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Adverse effects information was collected from the trials. MAIN RESULTS: Twenty-one trials involving 1,454 people were included. Based on meta-analysis, endoscopic stenting with plastic stents appears to be associated with a reduced risk of complications (RR 0.60, 95% CI 0.45 - 0.81), but with higher risk of recurrent biliary obstruction prior to death (RR 18.59, 95% CI 5.33 - 64.86) when compared with surgery. There was a trend towards higher 30-day mortality in the surgical group (p=0.07, RR 0.58, 95% CI 0.32, 1.04). There was no evidence of a difference in technical or therapeutic success. Other outcomes were not suitable for meta-analysis. No trials comparing endoscopic metal stents to surgery were identified. In endoscopic stent comparisons, metal biliary stents appear to have a lower risk of recurrent biliary obstruction than plastic stents (RR 0.52, 95% CI 0.39 - 0.69). There was no significant statistical difference in technical success, therapeutic success, complications or 30-day mortality using meta-analysis. A narrative review of studies of the cost-effectiveness of metal stents drew conflicting conclusions, but results may be dependent on the patients' length of survival.Neither Teflon, hydrourethane, or hydrophilic coating appear to improve the patency of plastic stents above polyethylene in the trials reviewed. Only perflouro alkoxy plastic stents had superior outcome to polyethylene stents in one trial. The single eligible trial comparing types of metal stents reported higher patency with covered stents, but also a higher risk of complications. These results are based on review of the trials individual results only. AUTHORS' CONCLUSIONS: Endoscopic metal stents are the intervention of choice at present in patients with malignant distal obstructive jaundice due to pancreatic carcinoma. In patients with short predicted survival, their patency benefits over plastic stents may not be realised. Further RCTs are needed to determine the optimal stent type for these patients.

Palliative biliary stents for obstructing pancreatic carcinoma.

BACKGROUND: Palliative endoscopic stents or surgical by-pass are often required for inoperable pancreatic carcinoma to relieve symptomatic obstruction of the distal biliary tree. The optimal method of intervention remains unknown. OBJECTIVES: To compare surgery, metal endoscopic stents and plastic endoscopic stents in the relief of distal biliary obstruction in patients with inoperable pancreatic carcinoma. SEARCH STRATEGY: We searched the databases of the Cochrane Upper Gastrointestinal and Pancreatic Group specialised register, Cochrane Central Register of Controlled Trials , MEDLINE, EMBASE, CancerLit, Current Concepts Database and BIDS (September 2002 to September 2004). Reference lists of articles and published abstracts from UEGW and DDW were hand-searched. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing surgery to endoscopic stenting, endoscopic metal stents to plastic stents, and different types of endoscopic plastic and metal stents, used to relieve obstruction of the distal bile duct in patients with inoperable pancreatic carcinoma. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Adverse effects information was collected from the trials. MAIN RESULTS: Twenty-one trials involving 1,454 people were included. Based on meta-analysis, endoscopic stenting with plastic stents appears to be associated with a reduced risk of complications (RR 0.60, 95% CI 0.45 - 0.81), but with higher risk of recurrent biliary obstruction prior to death (RR 18.59, 95% CI 5.33 - 64.86) when compared with surgery. There was a trend towards higher 30-day mortality in the surgical group (p=0.07, RR 0.58, 95% CI 0.32, 1.04). There was no evidence of a difference in technical or therapeutic success. Other outcomes were not suitable for meta-analysis. No trials comparing endoscopic metal stents to surgery were identified. In endoscopic stent comparisons, metal biliary stents appear to have a lower risk of recurrent biliary obstruction than plastic stents (RR 0.52, 95% CI 0.39 - 0.69). There was no significant statistical difference in technical success, therapeutic success, complications or 30-day mortality using meta-analysis. A narrative review of studies of the cost-effectiveness of metal stents drew conflicting conclusions, but results may be dependent on the patients' length of survival. Neither Teflon, hydrourethane, or hydrophilic coating appear to improve the patency of plastic stents above polyethylene in the trials reviewed. Only perflouro alkoxy plastic stents had superior outcome to polyethylene stents in one trial. The single eligible trial comparing types of metal stents reported higher patency with covered stents, but also a higher risk of complications. These results are based on review of the trials individual results only. AUTHORS' CONCLUSIONS: Endoscopic metal stents are the intervention of choice at present in patients with malignant distal obstructive jaundice due to pancreatic carcinoma. In patients with short predicted survival, their patency benefits over plastic stents may not be realised. Further RCTs are needed to determine the optimal stent type for these patients.

Attitudes to peer review as a competence assurance structure--results of a survey of Irish physicians.

BACKGROUND: The Medical Council in Ireland is currently implementing Competence Assurance Structures (CAS). Peer review has been proposed as a tool to measure physician competence. AIMS: To assess the attitudes of physicians working in the Irish healthcare system to a peer review programme of competence assurance prior to its implementation. METHODS: A postal survey was sent to all physicians in the Irish Medical Directory in November 2003. Nine questions were asked to gauge attitudes to peer review as a CA tool. The returned questionnaires were collated and data extracted based on responses. RESULTS: The response rate was 67%. The majority of respondents (92%) felt peer review would inform competence assurance in Ireland. Most physicians who were surveyed felt an on-site assessment (88%) every 5 years (87%) was the preferred method. Over 30% responded that there should be a financial incentive for completing a review, and 70% would pay to be assessed. The UK model of competence assurance was the model most physicians preferred for the Irish setting (42%). CONCLUSION: The majority of physicians practising in Ireland would favour a peer review system of competence assurance. The financial implications, and structure, of such a system would need to be explored prior to implementation.