thedigest Primary Care
Society for GastroenterologySample Article
Cancer focus: Screening acceptability: more than the public can swallow?Pancreatic cancer: tracking a silent killer
Beyond our scope:Endoscopy special
Functional illness training -
Patients deserve more
In my early years in practice I looked after a young woman with primary liver
cancer. Her family were Irish and in her last weeks of life, a seemingly endless stream of relatives moved in and shared the nursing care. She died late
one night and the family called me. When I got to the house the priest was already there. I suspected that they called him first.
FOBt: what's not to like?
The next day I returned to complete the death certificate. There was a
Quite a lot, argues Richard Stevens
stream of visitors at the front door where murmured condolences were said. They then went upstairs to see the body. She was still in her bed and her
Cancer and screening:
eight-year-old sister was brushing her hair. A moment's silence with heads
Identify IBD clearly
Primary care makes the difference 8-9
bowed; then down to the kitchen where a party, led by the priest, seemed in full swing.
Oesophageal cancer: less invasive and
Death rituals can be deeply ingrained. And if behaviour around death
costly screening is on the way
Inflammatory bowel disease (IBD) or irritable bowel syndrome (IBS)? Differentiate between
can be culturally specific, perhaps other behaviour can be, too; something demonstrated in this issue of The Digest, which focuses on gastrointestinal
IBD/IBS quickly and clearly with EliA Calprotectin – the first fully automated calprotectin stool
cancer and screening.
silent killer or hiding behind the white
Though perhaps less ritualistic, there may nevertheless be deep-rooted
test. High sensitivity, high specificity, and excellent predictive values deliver reliable results
attitudes around accepting advice and health messages especially: taking up screening, presenting a worrying symptom to a doctor, complying with
and provide early diagnostic guidance. Go one step beyond in autoimmune diagnostics:
treatment and approaching the last stages of life. All the stages that can affect cancer outcomes, in fact.
How a budding GP endoscopist
Culture can be defined as ‘the way we do things around here' and can be
fought for her training
at a family and social grouping level, as well as a racial and national one. As
doctors, we need to be aware of the unwritten, and usually unconscious, rules
that our patients live their lives by, and tailor our messages accordingly.
creating a high quality,
In this issue we have major articles on gastrointestinal cancer topics
by leading figures. The national bowel cancer screening programme has the opportunity to significantly reduce mortality from colorectal cancer.
Community endoscopy in Bristol
However, it is not without contentious areas: consent, especially for those with limited capacity, being one of them. How can the benefits and risks
Do all heartburn patients need an OGD? 21
(physical and psychological) of entering a screening programme be ethically
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Hepatitis C in context
communicated? And is the fact that the take-up of screening is only a
• Tel : +49 761 47805-0 • www.thermoscientific.com/phadia
little over 50 per cent down to people voting with their feet, or a lack of
knowledge and awareness? These and other issues are discussed.
Other topics covered touch on the role and provision of endoscopy,
Functional disease education:
especially in community settings. Sophie Summers' account of training as a
too important to be ignored
GP endoscopist (almost an endangered species) relates the story of how hard it is to swim against the tide in the current training set-up.
Fast facts: Obesity
Attitudes to functional disorders may be ingrained early, and this is
examined in medical student Lydia Yarlott's challenging account. It is worth
Bowel screening and learning disabilities:
remembering that, taken literally, functional means ‘working and in order, i.e. it
Good practice isn't yet the norm
Profile: Professor John Ashton
As always, comments, criticism, compliments and contributions are most
welcome. The Digest editorial team is always happy to receive, discuss and
Why it's well worth signing up to CPRD 33
help with ideas for articles and contributions. Whether you have a special interest in the area or not, a major part of your work will be dealing with
gastrointestinal problems. Our aim is therefore to produce a lively and
readable journal that is stimulating to all GPs.
Taking the tedium out of constipation
2012 Thermo Fisher Scientific Inc. All rights reserved. All trademarks are the property of
Thermo Fisher Scientific Inc. and its subsidiaries. Legal Manufacturer: Phadia AB, Uppsala, Sweden
Hepatitis C in context:
A rapid guide for GPs
The global problem
useful for patients who have injected intravenously in the
With 3 per cent of the world's population living with
past and in whom venepuncture is difficult or impossible.
the disease, Hep C – a major cause of cirrhosis and liver
Confirmatory PCR testing of the serum for HCV RNA
cancer – is a significant global problem. Infection rates vary
may be followed by a liver biopsy.
significantly from country to country. Hep C affects 2 per
Selecting patients for treatment
cent of the USA population, 3 per cent in China and 5 per
Fewer than 3 per cent of known Hep C patients are treated.
cent in Pakistan. In Egypt, the figure rises to 22 per cent
Practical difficulties arise as they need to be stable enough
of the population (probably as a result of a schistosomiasis
to attend for testing, discussion of the results, OPD, further
vaccination programme with contaminated instruments).
investigations such as ultrasound and liver biopsy. They
In the UK, the numbers of those infected is believed to
must also commit to treatment which can last for between
be 200,000–400,000. London accounts for 26 per cent of
6 and 12 months, with side effects.
all hepatitis C diagnoses, according to a report published
by Public Health England, while Scotland has an estimated
There are 11 major genotypes, numerous sub-types
37,500 carriers (about 0.8 per cent of the population).
(designated by numbers and letters respectively) and an
The vast majority of those with hepatitis C, however, are
estimated 100 or so strains, and considerable geographic
unaware that they are infected.
Types 1 to 3 have a worldwide distribution, with the
The natural history is slowly progressive, with a median
most common, 1a (predominant in northern Europe
time to cirrhosis of 28–32 years. Risk factors for acquiring
and America) and 1b (south and east Europe and Japan),
the disease include blood-to-blood, IVDU, transfusion responsible for around 60 per cent of all infections. (pre-1992) haemodialysis, tattooing and body piercing, and
The identification of the genotype will guide the
medical (and dental) equipment as well as ‘not known'. It
treatment regime as it provides a prediction of a patient's
is estimated that 50 per cent of prisoners are exposed to
likely response to antiviral treatment1.
IVDU or tattooing.
Vaginal sexual contact in the absence of ulcers, broken
Treatment consists of mono or combination therapy with
skin or bleeding probably does not result in transmission.
one or more interferon and/or ribavirin, lasting, usually,
In the case of vertical transmission, the mother to child
for between 24 and 48 weeks. Combining pegylated
transmission rate is low (<10 per cent), although a long
interferon-a with ribavirin results in a significant
labour does increase the risk. Breast feeding is usually
improvement for all genotypes.
not contraindicated (in the absence of cracked nipples or
Success rates can be high – over 75 per cent for
similar problems) and there are high rates of up to 50 per
patients with genotypes 2 and 3, and 40–50 per cent for
cent of spontaneous clearing of the virus in babies.
those with for genotype 1. Against this, however, other
Acute infection is asymptomatic (85 per cent), or may
patients, including those who have not responded with
present as a mild illnesses characterised by nausea, myalgia,
prior treatment, have severe liver fibrosis or cirrhosis, or
fatigue and occasionally jaundice (which is associated with
comorbidities – such as alcohol consumption, fatty liver or
a better outcome).
insulin resistance, can be far harder to treat2.
Between 15 and 20 per cent of adults and up to 50 per
Side effects are common, most commonly fatigue,
cent of children clear the virus. The remainder go on to
together with flu-like symptoms and mild psychological
be chronically infected. Of these, around half will go on
reactions, while florid neuropsychiatric reactions can
to develop fatty liver disease, a risk factor for progressing
occasionally occur. Pre-treatment screening of mental
to cirrhosis. Liver function tests are normal in about half
illness risk is important.
Two recently published studies3 focusing on the difficult-
Many of these will go on to develop fibrosis of the liver
to-treat hepatitis C genotype 1 (the most common in
with a median time of 30 years from infection. Concurrent
Europe as well as in the USA, north Asia, Australia and
Hep B, HIV and alcohol use are risk factors for progressive
South America) suggest that two new oral antiviral drug
treatments are shorter, more effective and have fewer side
Cirrhosis can lead to portal hypertension and varices,
liver failure, hepatic encephalopathy, and is a risk factor
In the first study, 645 patients from 18 countries received
for primary liver cancer (an annual ultrasound may a 6-month course of treatment with two oral DAAs, be recommended.) Liver transplantation is sometimes asunaprevir and daclatasvir, with a placebo control group performed. The re-infection rate after surgery, however, is
consisting of 102 treatment-naïve patients.
high (80 per cent).
Ninety per cent of patients who not previously been
People who experience a needle stick injury from treated, and just over 80 per cent of patients where either
someone with HCV have a 1.8 per cent chance of previous treatment had failed or were intolerant, were subsequently contracting the disease, greater if the needle
is hollow and the puncture wound deep, though there is
In the second study, 167 patients with HCV genotype
only a small risk from mucosal exposure to blood and no risk from blood exposure to intact skin.
"People who experience a needle
stick injury from someone with
Detection of HCV antibodies by enzyme-linked HCV have a 1.8 per cent chance
immunosorbent assay (ELISA) is used for screening. There are some false positives, especially in low prevalence
of subsequently contracting the
populations. Dried blood testing is possible and is especially
The Digest The Journal of the Primary Care Society for Gastroenterology
1a and 1b received either a 12 or 24-week course of once-daily sofosbuvir plus simeprevir with or without ribavirin. The cure rate, after just 12 weeks of treatment without ribavirin, was 93 per cent. Fewer than two per cent of patients reported any adverse effects. The GP's role GPs have five roles in Hepatitis C:
• Screening and counselling. Hep C is a significant disease
and informed consent and counselling are neededbefore testing.
• Case finding in at-risk groups. Members of at-risk
populations should be sought out and counselled.
• Re-testing at intervals if indicated by ongoing high-risk
behaviour (such as continued injecting of drugs)
• Harm minimisation in those not ready for treatment.
• Preparing and counselling patients, family and carers for
treatment and supporting them throughout.
Conclusion With HCV-related disease and morbidity rates predicted to rise and no vaccine as yet available, the short-term goal is to develop new treatments with fewer side effects, while GP education and knowledge of this complex disease also need to be improved.
BRAY1411 RES(UK) Digest (143.5x210) AW.indd 1
Alimentary Pharmacology and Therapeutics Randomised clinical trial: comparison of two everolimus dosingschedules in patients with advanced hepatocellular carcinoma H.-S. Shiah*,†,‡, C.-Y. Chen†, C.-Y. Dai§, C.-F. Hsiao¶, Y.-J. Lin**, W.-C. Su†, J.-Y. Chang*,†, J. Whang-Peng*,††,P.-W. Lin**, J.-D. Huang‡‡,1 & L.-T. Chen*,†,§,‡‡,1 *National Institute of Cancer
2013 Health Insurance Trust Fund Annual Report Arizona Department of Administration Human Resources Division – Benefit Services Janice K. Brewer Brian C. McNeil Governor Director FOREWORD Benefit Options is the program name for the benefits offered to State of Arizona ("State") employees and retirees by the Arizona Department of Administration ("ADOA"). This report provides a broad overview of the Benefit Options program, and meets the requirements of A.R.S. §38-652 (G) and A.R.S. §38-658 (B). The data shown is presented for the period January 1, 2013 through December 31, 2013. The active and retiree plans were concurrent for this period. For this report, ADOA internally developed a consistent statistical model based on generally accepted actuarial principles and standards, including Milliman Health Cost Guidelines Commercial Rating Structures, July 1, 2012.