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Frontline Gastroenterol-2011-Valori-195-6

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UpFront
Roland Valori                                                                        10.1136/flgastro-2011-100040

This      issue     of      Frontline     A debate on the roles of                   Inflammatory bowel disease
Gastroenterology is more clinically       antireflux surgery and long-                in transition: challenges and
based than usual and is packed with       term acid suppression in                   solutions in adolescent care
practical information for frontline       the management of gastro-                  Few could argue with Sara
teams. There is a particular focus        oesophageal reflux disease                  McCartney’s view that we could do
on gastro-oesophageal reflux dis-         It is informative and reassuring to        a lot better managing adolescents
ease (GORD). GORD may seem                read this balanced review of the           with inflammatory bowel disease
like old hat but there are still many     role of surgery and medication for         (IBD). Caring for adolescents with
contentious issues and we have            GORD. The observation that there           IBD is difficult enough without clini-
three excellent articles that explore     are no absolutes, and the conclu-          cal teams being constrained by a lack
these in detail. GORD is so com-          sion that recommendations should           of clarity about what a good service
mon that even small changes in            be tailored to the individual, make        looks like and about the organisa-
our practice will have big effects so     a lot of sense. One key tip high-          tional challenges involved in achiev-
please take the time to review these      lighted in the paper, which we have        ing such a service. Dr McCartney’s
articles.                                 adopted locally, is to reconsider the      thorough review (based on much
                                          diagnosis of GORD before switch-           experience as well as the literature)
What you need to know                     ing to surgery when a patient is           outlines the problems coherently,
when you prescribe a proton               refractory to medical treatment:           offers solutions to how we might
pump inhibitor                            poor response to a PPI is a sound          think through the issues and pro-
We have waited a long while for           predictor of poor response to sur-         vides suggestions for patient-centred
Chris Hawkey’s thoughtful paper on        gery. I like the neat little section       solutions to fit local contexts.
prescribing proton pump inhibitor         entitled ‘issues where there is sim-       See page 237
(PPIs), but the wait has been worth       ply no evidence’. Maybe we should
it. I thought using PPIs was pretty                                                  A survey of patients’ attitudes
                                          encourage more reviews entitled            to upper gastrointestinal
straightforward but this paper has        ‘common practice for which there
proved me wrong. Hawkey argues                                                       endoscopy identifies the
                                          is simply no evidence’.                    value of endoscopist–patient-
that we can look at PPIs in a different   See page 206
way now that their cost is no longer                                                 interactive factors
a significant issue. He explains the      Mortality following blood                  The endoscopy service in the UK
key areas of difficulty very clearly,     transfusion for non-variceal               has become very patient-focused in
and makes balanced judgments on           upper gastrointestinal bleeding            recent years, but there is some way
current literature and careful rec-       Management of gastrointestinal             to go before we can truly claim we
ommendations for practice.                bleeding is often complicated by the       have got it right for our patients.
See page 199                              number of teams involved and the           Understanding what matters most
                                          variation in treatment this leads to.      to them, and appreciating that their
Respiratory and laryngeal                 Patients receiving blood they don’t        priorities might change with time,
symptoms secondary to                     need is not uncommon. While the            is critical to achieving this goal. It
gastro-oesophageal reflux                  jury is still out on the headline of       is very likely that as problems are
In recent years the literature on         this original paper, ‘transfusion          overcome (eg, long waits and poor
this important topic has been very        does harm’, surely it makes sense          environments) patient concerns
confusing – so much so that I have        for us to review our transfusion           switch to new issues. This is why
been saying different things to my        practice and ensure we use no              this study, and ones that will fol-
patients and to my respiratory and        more blood than is necessary. Too          low, are so important.
ENT (ear, nose and throat) col-           often patients are ‘topped up’ with           Hitherto patients have taken the
leagues after consecutive American        insufficient thought about whether         expertise of doctors for granted.
drowsy driving warning system.            they actually need the blood or            In this study they rate the technical
We have, at last, in this edition of      whether some other form of vol-            and personal attributes of the endo-
Frontline Gastroenterology, a sen-        ume replacement would suffice. A           scopist and the comfort of the pro-
sible and digestible summary of           cautious approach, until we have           cedure as their top three concerns.
the issues and some very practical        more secure evidence, must make            Our challenge is not just to get these
advice for clinicians.                    sense – and save money.                    things right, but to be able to show
See page 212                              See page 218                               patients information about quality


                                                                                           Frontline Gastroenterology 2011;2:195–196   195
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      and comfort that they can under-                 before they are given inflixi-             would be needed in an RCT to
      stand and that will inform their                 mab infusions. This is not a ran-          detect an increase in events from
      choices of where they have their                 domised controlled trial (RCT)             0.2% to 0.4%. The real difference
      endoscopy. If we achieve this then               but it should encourage IBD teams          in serious adverse events (if there
      patient power will be the strongest              to audit their practice, reflect on        is one) in patients not given pre-
      driver of quality in future years.               outcomes and consider chang-               medication is likely to be smaller
      See page 242                                     ing protocols. Of course the key           than this and, if so, the sample
                                                       issue is the rate of serious adverse       would need to be huge to detect a
      Premedications for infliximab                     events (0.2% or 5.5% of 4% in              difference. We are unlikely to get
      infusions does not impact the                    this study). It is unlikely that the       better evidence without a central
      risk of acute adverse drug                       sample in this study is big enough         reporting system – the sooner the
      reactions                                        to determine an important differ-          better.
      This Canadian study questions the                ence when the rate of events is so         See page 249
      need for premedicating patients                  low: I calculate 12 000 patients




196    Frontline Gastroenterology 2011;2:195–196
                     Downloaded from fg.bmj.com on March 20, 2013 - Published by group.bmj.com




                                  UpFront
                                  Roland Valori

                                  Frontline Gastroenterol 2011 2: 195-196
                                  doi: 10.1136/flgastro-2011-100040


                                  Updated information and services can be found at:
                                  http://fg.bmj.com/content/2/4/195.full.html




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