Anne E. Duggan

Gastrointestinal adverse effects of non-steroidal anti-inflammatory drugs

NSAIDs are used extensively worldwide at a cost of billions of dollars annu-ally. Adverse side effects, especially in the gastrointestinal (GI) tract, are uncommon but cause a substantial burden of illness because of the volume of use. Important upper GI complications include dyspepsia, gastric erosions and peptic ulcers and complications such as bleeding, perforation or gastric outlet obstruction. Dyspeptic symptoms may occur without correlation to endoscopic findings. Topical injury and COX-1 inhibition resulting in gastric prostaglandin suppression are two commonly postulated mechanisms of gastroduodenal damage. Advanced age, previous peptic ulcers or ulcer complications, concomitant use of glucocorticoids or anticoagulants, and high-dose or prolonged NSAID administration are known risk factors. Prevention of adverse GI events involves use of safer NSAIDs including COX-2 inhibitors, and co-prescription of gastroprotective agents. NSAID-induced ulcers heal with proton pump inhibitors or misoprostol. The role of Helicobacter pylori eradication in NSAID ulcer prophylaxis and management is controversial. Choice of NSAIDs and gastroprotective agents should be guided by risk/bene-fit and cost-effectiveness assessment.

Testing for Helicobacter pylori infection: validation and diagnostic yield of a near patient test in primary care

Abstract Objective: To evaluate the performance of a near patient test for Helicobacter pylori infection in primary care. Design: Validation study performed within a randomised trial of four management strategies for dyspepsia. Setting: 43 general practices around Nottingham. Subjects: 394 patients aged 18-70 years presenting with recent onset dyspepsia. Main outcome measures: Results of the Flex Sure test compared with an enzyme linked immunosorbent assay (ELISA; HM-CAP) with an identical antigen profile and with results of an earlier validation study in secondary care Diagnostic yield of patients undergoing endoscopy on the basis of their Flex Sure result compared with those of patients referred directly for endoscopy. Results: When used in primary care Flex Sure test had a sensitivity and specificity of 67% (95% confidence interval 59% to 75%) and 98% (95% to 99%) compared with a sensitivity and specificity of 92% (87% to 97%) and 90% (83% to 97%) when used previously in secondary care. Of the H pylori test and refer group 14% (28/199) were found to have conditions for which H pylori eradication was appropriate compared with 23% (39/170) of the group referred directly for endoscopy. Conclusions: When used in primary care the sensitivity of the Flex Sure test was significantly poorer than in secondary care About a third of patients who would have benefited from H pylori eradication were not detected. Near patient tests need to be validated in primary care before they are incorporated into management policies for dyspepsia. Key messages Near patient tests for H pylori infection have been recommended in the management of dyspepsia in primary care without proper evaluation Such tests should have a high sensitivity to avoid missing treatable illness related to infection The Flex Sure near patient test had a lower sensitivity than previously reported in validation studies performed in secondary care Fewer than expected numbers of patients with H pylori related pathology were identified with the Flex Sure in primary care

Prescriptions for antiulcer drugs in Australia: volume, trends, and costs

H2 receptor antagonists and proton pump inhibitors have markedly changed the management of peptic ulcer and gastro-oesophageal reflux disease; they have also changed the profile of national drug budgets. Antiulcer drugs have retained the leading position in drug sales worldwide: sales of antiulcer drugs were valued at

Clinical variation: why it matters

US12.9 billion (£8.6bn) in 1998 and were increasing at 3% a year.1 Since 1992 the Australian governments pharmaceutical benefits scheme has required prescribers of proton pump inhibitors to certify the presence of peptic ulcer disease or ulcerating oesophagitis (confirmed by endoscopy, radiography, or surgery) and refractory to treatment with other drugs, scleroderma oesophagus, or Zollinger-Ellison syndrome. The aim of this study was to assess how these restrictions have affected prescribing of antiulcer drugs. We analysed data from the pharmaceutical benefits scheme on the number of prescriptions for H2 receptor antagonists, …

Helicobacter pylori: when is treatment now indicated?

j 2 1 N o ve m b e r 2 0 16 Vmedications, interventions and procedures may be very different and lead to variation in outcomes. The following articles discusswhy exploring unwarranted variation is a priority for health care systems; how atlases of health care variation act as catalysts of change andwhat health care systems can do to increase appropriate care. In this context, the Australian health care systems’ response to the problem of unwarranted health care variation is considered.

Short- and long-term outcomes for patients with variceal haemorrhage in a tertiary hospital

Abstract

Bleeding peptic ulcer: characteristics and outcomes in Newcastle, NSW

To determine short‐ and long‐term outcomes among a cohort of patients with variceal haemorrhage at a tertiary referral centre, and to determine the predictive value of the model for end‐stage liver disease (MELD) score for mortality in these patients.

Management of dyspepsia at the beginning of the twenty-first century.

Background:  Peptic ulcer disease risk factors have changed, as has the impact of treatment on morbidity and mortality. Recent data on clinical presentation and outcome are sparse in Australia.

All colonoscopies are not created equal: why Australia now has a clinical care standard for colonoscopy

Abstract

Health care variation: the next challenge for clinical colleges

427 Iand removal of polyps, it reduces colorectal cancer incidence and mortality. Evidence for population screening using a faecal occult blood test and follow-up colonoscopy was based on randomised controlled studies that found a reduction in colorectal cancer mortality of 28e32% with flexible sigmoidoscopy. It is estimated that by 2040, the National Bowel Cancer Screening Programwill prevent 92 200 cases of colorectal cancer and 59 000 deaths, using conservative modelling based on current participation of just 40%. These benefits are substantial, given that bowel cancer is the second highest cause of cancer death in Australia and participation in the National Bowel Cancer Screening Program is increasing. However, without high quality and appropriate use of colonoscopy, patients may be exposed to avoidable adverse outcomes without significant benefit. These include procedural and sedation-related complications, missed cancers, missed adenomas (hence increased risk of bowel cancer), and adverse patient experience. Further, overuse of the procedure in patients who are unlikely to benefit from it results in low value care and reduces access for patients in greater need. In order to ensure the maximum benefit to the Australian population, the Australian Commission on Safety and Quality in Health Care has developed a Colonoscopy Clinical Care Standard (www.safetyandquality.gov.au/our-work/clinicalcare-standards/colonoscopy-clinical-care-standard).