Inflammatory bowel disease cancer surveillance in a tertiary referral hospital: attitudes and practice.

BACKGROUND: Physician adherence to guidelines for colorectal cancer (CRC) surveillance in inflammatory bowel disease (IBD) is often poor. This may lead to adverse patient outcomes and excess endoscopic workload. AIMS: To assess the attitudes and practice of IBD specialists in a tertiary centre towards colonoscopic surveillance. METHODS: First, a questionnaire evaluating attitudes and approach to CRC surveillance was issued to 36 clinicians at one tertiary referral hospital. Second, a retrospective audit of IBD surveillance colonoscopy practice over a 2-year period was performed. RESULTS: Questionnaire response rate was 97%. Sixty-nine per cent of respondents were aware of, and used, Australian guidelines. Surveillance was undertaken by all clinicians in patients with extensive colitis, 83% in patients with left-sided colitis and 51% in patients with proctitis. Seventy-six per cent used chromoendoscopy, and 47% took 10 to 20 random biopsies. Colectomy was considered appropriate in 0% for unifocal low-grade dysplasia, 35% for multifocal low-grade dysplasia and 83% for high-grade dysplasia. Sixty-six per cent would remove elevated dysplastic lesions endoscopically. The audit identified 103 surveillance colonoscopies in 81 patients. Chromoendoscopy was used in 21% of cases, and the median number of random biopsies was 13. Sixty-two per cent of colonoscopies were performed outside the guidelines in relation to colonoscopic frequency. Following colonoscopy, an appropriate recommendation for subsequent surveillance was documented in 40% of cases. CONCLUSIONS: Knowledge and practice of CRC surveillance in IBD vary among specialist clinicians and often deviate from guidelines. Many clinicians perform surveillance earlier and more frequently than recommended. These findings have implications for patient outcomes and workload.

Determination of dose rate from Chernobyl-derived radiocaesium in Estonian soil.

The deposition and vertical depth distribution of 134Cs and 137Cs in the natural undisturbed soil profiles down to 20-25 cm were studied at locations in the North Eastern Estonia, which were most strongly affected by the Chernobyl fallout in 1986. The total depositions were estimated based on summing the sampled and measured activities of 134Cs and 137Cs in all sections of soil profiles. The Chernobyl 137Cs deposition values varied considerably from site to site and the range was from 3.9 kBq m(-2) to 50.2 kBq m(-2), with the average of 22.8 kBq m(-2) for the region (reference data May 1, 1986). The ratio of total activities, A(134Cs)/A(137Cs), varied in the range from 0.47 to 0.55. Using a compartment model and the observed data on the 134Cs and 137Cs activity concentrations (Bq m(-2)) in four compartments, 0-1 cm, 1-5 cm, 5-15 cm and 15-30 cm, of soil collected in 1991-2003, the approximate residence half-times of radiocaesium in soil were determined. The latter increased from 3.7 y in the top-most compartment to 8.6 y and 36.4 y in the deeper compartments, respectively. The time dependence of the external gamma-dose rate at the height of 1 m above a flat ground area arising from the deposited and migrating radiocaesium was calculated using the modeled data on the 134Cs and 137Cs activity in soil compartments. Considering the total depositions of radiocaesium in soil from the Chernobyl 1986 accident, the 50 year effective doses caused by external gamma exposure varied in the range from 0.13 mSv to 1.74 mSv, with the mean of 0.79 mSv in the region.

A mechanistic model for fate and removal of estrogens in biological nutrient removal activated sludge systems.

Two estrogen fate and transformation models were integrated with a comprehensive activated sludge model (ASM) to predict estrogen removal based on biomass and solids production. Model predictions were evaluated against published full-scale plant data as well as results from a laboratory-scale sequencing batch reactor (SBR) fed synthetic wastewater. The estrogen fate model relating the rate of total estrogen degradation to soluble estrogen concentrations successfully predicted estrogen removals when compared with measured concentrations. Model fit 17α-ethinylestradiol (EE2) biodegradation rate constant was 19 to 43% of the estrone (E1) value and 31 to 72% of the 17ß-estradiol (E2) value.

A unique clinical phenotype of primary sclerosing cholangitis associated with Crohn's disease.

BACKGROUND AND AIMS: A distinct clinical phenotype has been demonstrated for ulcerative colitis with concomitant primary sclerosing cholangitis (PSC). The course and behaviour of Crohn's disease (CD) with PSC has, in contrast, never been defined. We aimed to define the characteristics of patients with concomitant PSC and CD. METHODS: The Oxford PSC and IBD databases were abstracted for: PSC subtype, date of diagnosis, symptom onset, smoking history, Mayo Clinic PSC score and outcomes (hepatic failure, liver transplantation, Montréal CD classification, treatment, cancer and death). Patients with PSC/CD were matched 1:2 to two control groups: one with PSC/UC and one with isolated CD. RESULTS: 240 patients with PSC were identified; 32 (13%) with CD, 129 (54%) with co-existing UC, and 79 had PSC without IBD. For PSC/CD vs. CD controls, isolated ileal CD was less common (6% vs. 31%, p=0.03). Smoking was less common in PSC/CD (13% vs. 34%, p=0.045). No difference in the distribution of CD, or treatment required was observed. For PSC/CD vs. PSC/UC controls, more patients with PSC/CD were female (50% vs. 28%, p=0.021). 22% of PSC/CD patients had small duct PSC compared with 6% with PSC/UC, (p=0.038). Major event-free survival was prolonged in the PSC/CD group compared with PSC/UC, (Cox regression p=0.04). CONCLUSION: Unlike PSC/UC, patients with PSC/CD were as likely to be female as male, more commonly had small duct PSC and less commonly progressed to cancer, liver transplantation, or death. Compared to patients with isolated CD, patients with PSC/CD were less likely to smoke or have ileal disease.

Cerebral venous thrombosis associated with ulcerative colitis.

Thromboembolic complications, such as deep venous thrombosis and pulmonary embolism, are well recognized in patients with inflammatory bowel disease (IBD). We describe three cases of cerebral venous thrombosis complicating ulcerative colitis. Cerebral venous thrombosis is a rare but potentially devastating complication of IBD, and the diagnosis needs to be considered in any patient with IBD presenting with neurological symptoms.

Measurement of faecal fat excretion: an evaluation of attitudes and practices of Australian gastroenterologists.

BACKGROUND: Although faecal fat excretion over 72 h is the gold standard for quantifying fat malabsorption, there has been a push from chemical pathology laboratories to discontinue this test, arguing that it is unreliable and of limited clinical value. AIMS: To assess attitudes, knowledge and practices of Australian gastroenterologists in relation to the test and to gauge opinion as to whether it should remain available. METHODS: A self-administered questionnaire was developed to assess attitudes towards, patterns of use and understanding of 72-h faecal fat collections. This was posted to all members of the Gastroenterological Society of Australia. RESULTS: Of 429 eligible gastroenterologists, 124 (29%) responded. Eighty-two per cent utilized the test; 62% at least once per year. Main indications were suspected steatorrhoea (55%), unexplained chronic diarrhoea (39%) or weight loss (29%). Thirty-eight per cent ordered the test to determine stool volume. Only 26% attempted to appropriately fat load patients and approximately half did not recognize the potential influence of medications and stool volume. This was also reflected in poor interpretation of results in specific clinical scenarios. Of those who use the test at least once per year, 97% wanted its continued availability and 51% felt their practice would be significantly affected if the test was discontinued. CONCLUSIONS: Although continued availability of 72-h faecal fat estimation is supported by many Australian gastroenterologists, the test appears to be often performed and interpreted suboptimally. Rather than discard the test, efforts should more appropriately be directed to improving baseline knowledge to ensure its optimal performance and interpretation.

Beta-amyloid levels predict cholinesterase activity in human cerebrospinal fluid.

There is increasing evidence suggesting that beta-amyloid (Abeta) has a direct influence on cholinergic activity. In particular, Abeta has been shown to induce the expression of acetylcholinesterase in the brains of CT-100-expressing transgenic mice and in cell culture experiments. These data indicate a link exists between Abeta production and acetylcholinesterase expression in the human CNS. To test this hypothesis, Abeta levels and cholinesterase activity were measured in 110 human CSF samples. Abeta levels were found to have a significant and positive correlation with cholinesterase activity. This correlation was particularly strong in individuals > 50 years of age. These data support the hypothesis that Abeta can effect cholinergic activity and that this effect may be enhanced in the elderly.

An age-related correlation between levels of beta-amyloid precursor protein and beta-amyloid in human cerebrospinal fluid.

We investigated the levels of amyloid precursor protein (APP) and beta-amyloid peptide (A beta) in the cerebrospinal fluid (CSF) from 110 individuals ranging in age from newborn to 82-years old to analyze their regulation with age. These samples were segregated into two groups; one group contained CSF samples from patients with diagnosed CNS abnormalities and the second group contained CSF samples from patients with no known CNS disorders. The presence of APP and A beta was detected in all ages and from both CSF groups. No significant difference in the average level of A beta or APP was noted from either group with a change in age. However, a positive correlation was found to exist between levels of APP and A beta in individuals 25 years and older, suggesting that APP and A beta processing in the CSF is developmentally regulated. This observation was observed for both CSF groups.