In patients with ulcerative colitis, they have been shown to be very effective in inducing and maintaining remission of disease. Levels of 5-ASA in the lining of the bowels have been shown to predict efficacy and possibly act as a marker for clinical endpoints in patients with disease. A clinical trial was performed by Haines et al, to try and determine a simple, yet sensitive and reproducible method for detection of 5-ASA in the lining of the bowel. Specific concentrations of 5-ASA were added to biopsies (tissue samples) of the lining of the colon. From the study, clear, reproducible peaks were achieved at certain wavelengths. These peaks were significantly sensitive for 5-ASA. What we need to do now is to apply these results in a clinical context. Genes Implicated in IBD – IL23R is an IBD Susceptibility Gene (confirmation in an Australian cohort) and GLI1 gene a Risk Factor for Ulcerative Colitis With advances in research and from results of clinical studies, additional insight into the causes and genetics behind ulcerative colitis has been obtained. For example, variations in particular receptors such as the IL 23 receptor has recently been shown to be associated with both Crohn’s and ulcerative colitis. Another gene called the GLI1 gene plays a significant role in the formation and maintenance of a healthy lining for our gut. Defects in the GLI1 gene have been implicated in patients with ulcerative colitis. Patterns of Medication use in Inflammatory Bowel Disease PatientsThere is a wide range of therapies for ulcerative colitis – depending on the location of disease, different combinations of treatments are employed. In disease limited to the rectum, the mainstay of therapy includes topical aminosalicyclate (5-ASA) suppositories (small masses of medication that are designed to melt when inserted into a body cavity). Topical therapy refers to local application of treatment directly onto the surface of a body part. In more extensive cases where disease affects larger parts of the bowels, combination therapy involving 5-ASA agents (both oral and topical), steroids and other immunosuppressive agents is recommended. In a recent study conducted by Barclay et al, an increased use of medications which act to alter the immune response (immunomodulators) was demonstrated.
Australian GPs told to shake up colorectal cancer referral system
David Goldsbury (Cancer Council New South Wales, Sydney, Australia) and colleagues found that patients who consulted their GP between colonoscopy and surgery waited a median of 12 additional days for surgery over those who did not. They suggest that improved guidance could promote important GP engagement in early diagnosis without leading to delays in treatment. “A more systematic approach might be needed for GP involvement in the treatment pathway, perhaps including official guidelines from primary care/GP organisations,” the authors write in BMJ Open. In a sample of 407 colorectal cancer patients in New South Wales who underwent colonoscopy and surgery between 2004 and 2007, 43% had at least one GP consultation between diagnosis and surgery. Having a GP consultation between diagnosis and treatment was more common in patients who had self-reported poor health such as those with diabetes, chronic obstructive pulmonary disease, and previous smokers, and these patients were also more likely to consult the GP after their surgery. This indicates that GP consultations were primarily for patients in high-risk groups, say the authors. However, the association between delay to surgery and GP consultation remained after adjustment for cancer site, comorbidities, disadvantage, and health status. The authors say that it is not possible to determine cause from effect in their study. It could be that an increased time between diagnosis and surgery allowed for more GP consultations, they suggest. Alternatively, GP consultations could reflect the GP’s engagement and time to consider the optimal referral pathway. However, the finding that rectal cancer patients (n=142) who consulted their GP before surgery were no more likely to undergo treatment at a center with radiotherapy access than those who did not (21 vs 25%), indicated that continuity of care may not be a consequence of greater GP involvement.
An australian audit of vaccination status in children and adolescents with inflammatory bowel disease
September figures show priority-one gastroenterology patients waited an average 47 days to be seen at the outpatient clinic – 50 per cent longer than the recommended 30-day maximum – and category-two patients waited an average 16 weeks. But waiting times have improved since a year ago, when some children waited up to a year to be assessed because of an acute shortage of gastroenterologists. It prompted the State Government to launch an urgent recruitment drive for specialists. The hospital says progress has been made after finding a gastroenterologist to fill a vacant position but it will have to take on more staff. A spokeswoman said PMH expected waiting times to improve further with a new part-time gastroenterologist due to start this month. Another 0.5 full-time equivalent position was in the appointment process and PMH was optimistic about appointing someone early next year. The Australian Medical Association welcomed the recent addition of a specialist but said it was clear more were needed to keep up with demand in the highly specialised area. WA president Richard Choong said gastroenterology was historically a difficult specialty to staff, which led to long delays for patients to be assessed and treated. “The fact PMH has managed to find someone recently and is close to more appointments is good news and very encouraging,” he said. “This is an area of medicine that is very specific and there are many conditions that need to access its services, but it’s a classic example of where there just aren’t enough people to do the jobs required.” Dr Choong said as a result many children were waiting too long, often in pain and discomfort, to be diagnosed and treated. “What I really hope is that the hospital will be able to recruit the extra staff it needs so children can be seen even more quickly,” he said.
Specialist to help ease wait times
An Australian survey of adult gastroenterologists found hepatitis B, influenza and pneumococcal vaccines were recommended infrequently and the window before significant immunosuppressive therapies commenced not always being utilised [ 45 ]. Strategies to optimise protection from VPD include education of both patients and their parents/carers, as highlighted by the reasons given for influenza vaccination not being received. Education itself needs to be supported by system changes and this may include immunization reminders, which in the form of cards, telephone and electronic, have all been shown to be effective [ 46 , 47 ]. Protecting IBD patients through “cocooning”, by ensuring parents and siblings are protected against VPD (e.g. influenza, pertussis and varicella), is also recommended. Conclusion This study highlights a high level of vaccination coverage with routine scheduled vaccinations, but poor compliance with current guidelines for influenza and pneumococcal vaccination in adolescents and children with IBD. Improving serological assessment prior to commencing immunosuppressive therapies can help minimise the risk of reactivation of VPD such as hepatitis B. An approach using both direct and indirect protective immunization strategies is required to maximise protection from vaccine preventable diseases in this vulnerable population. Conflict of interests disclosure NWC has investigator-led study support for a study of Guillain-Barre Syndrome Surveillance post H1N1 influenza vaccination [CSL] and been on a Pfizer [Wyeth] advisory board for pneumococcal vaccines and presented at conferences, for which his MCRI research fund has received honoraria. AGC has chaired an advisory board for GSK – rotavirus vaccine and chaired an advisory board for MSD – Infliximab in Crohn’s disease. JPB sits on a data safety monitoring board for influenza vaccines [CSL] and MCRI has received conference travel reimbursement from GSK for Rotavirus vaccine conference presentation. MRO and DJSC have no conflicts of interests to declare. Authors’ contributions NWC and JPB conceived the study concept. All authors contributed to the study design and audit questionnaire. TCS provided the Victorian IBD database information. NWC undertook the statistical analysis and wrote the initial draft.
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