Showing papers by "Michael P. Jones published in 2017"

Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013–2015

Abstract: The geographical maldistribution of the health workforce is a persisting global issue linked to inequitable access to health services and poorer health outcomes for rural and remote populations. In the Northern Territory (NT), anecdotal reports suggest that the primary care workforce in remote Aboriginal communities is characterised by high turnover, low stability and high use of temporary staffing; however, there is a lack of reliable information to guide workforce policy improvements. This study quantifies current turnover and retention in remote NT communities and investigates correlations between turnover and retention metrics and health service/community characteristics. This study used the NT Department of Health 2013–2015 payroll and financial datasets for resident health workforce in 53 remote primary care clinics. Main outcome measures include annual turnover rates, annual stability rates, 12-month survival probabilities and median survival. At any time point, the clinics had a median of 2.0 nurses, 0.6 Aboriginal health practitioners (AHPs), 2.2 other employees and 0.4 additional agency-employed nurses. Mean annual turnover rates for nurses and AHPs combined were extremely high, irrespective of whether turnover was defined as no longer working in any remote clinic (66%) or no longer working at a specific remote clinic (128%). Stability rates were low, and only 20% of nurses and AHPs remain working at a specific remote clinic 12 months after commencing. Half left within 4 months. Nurse and AHP turnover correlated with other workforce measures. However, there was little correlation between most workforce metrics and health service characteristics. NT Government-funded remote clinics are small, experience very high staff turnover and make considerable use of agency nurses. These staffing patterns, also found in remote settings elsewhere in Australia and globally, not only incur higher direct costs for service provision—and therefore may compromise long-term sustainability—but also are almost certainly contributing to sub-optimal continuity of care, compromised health outcomes and poorer levels of staff safety. To address these deficiencies, it is imperative that investments in implementing, adequately resourcing and evaluating staffing models which stabilise the remote primary care workforce occur as a matter of priority.

Long-term trends in supply and sustainability of the health workforce in remote Aboriginal communities in the Northern Territory of Australia

Abstract: International evidence suggests that a key to improving health and attaining more equitable health outcomes for disadvantaged populations is a health system with a strong primary care sector. Longstanding problems with health workforce supply and turnover in remote Aboriginal communities in the Northern Territory (NT), Australia, jeopardise primary care delivery and the effort to overcome the substantial gaps in health outcomes for this population. This research describes temporal changes in workforce supply in government-operated clinics in remote NT communities through a period in which there has been a substantial increase in health funding. Descriptive and Markov-switching dynamic regression analysis of NT Government Department of Health payroll and financial data for the resident health workforce in 54 remote clinics, 2004–2015. The workforce included registered Remote Area Nurses and Midwives (nurses), Aboriginal Health Practitioners (AHPs) and staff in administrative and logistic roles. Main outcome measures: total number of unique employees per year; average annual headcounts; average full-time equivalent (FTE) positions; agency employed nurse FTE estimates; high and low supply state estimates. Overall increases in workforce supply occurred between 2004 and 2015, especially for administrative and logistic positions. Supply of nurses and AHPs increased from an average 2.6 to 3.2 FTE per clinic, although supply of AHPs has declined since 2010. Each year almost twice as many individual NT government-employed nurses or AHPs are required for each FTE position. Following funding increases, some clinics doubled their nursing and AHP workforce and achieved relative stability in supply. However, most clinics increased staffing to a much smaller extent or not at all, typically experiencing a “fading” of supply following an initial increase associated with greater funding, and frequently cycling periods of higher and lower staffing levels. Overall increases in workforce supply in remote NT communities between 2004 and 2015 have been affected by continuing very high turnover of nurses and AHPs, and compounded by recent declines in AHP supply. Despite substantial increases in resourcing, an imperative remains to implement more robust health service models which better support the supply and retention of resident health staff.

Systematic Review and Meta-Analysis: Prevalence of Small Intestinal Bacterial Overgrowth in Chronic Liver Disease.

Abstract: The authors conducted a meta-analysis of the prevalence of small intestinal bacterial overgrowth (SIBO) in patients with chronic liver disease (CLD) and controls. Using the search terms "small intestinal bacterial overgrowth (SIBO)" and "chronic liver disease (CLD)" or "cirrhosis," 19 case-control studies were identified. Utilizing breath tests, the prevalence of SIBO in CLD was 35.80% (95% CI, 32.60-39.10) compared with 8.0% (95% CI, 5.70-11.00) in controls. Using culture techniques, the prevalence was 68.31% (95% CI, 59.62-76.00) in CLD patients as compared with 7.94% (95% CI, 3.44-12.73) in controls. No difference between cirrhotic and noncirrhotic patients was found. SIBO is significantly more frequent in CLD patients as compared with controls. The association of SIBO and CLD was not confined to patients with advanced CLD, suggesting that SIBO is not a consequence of advanced liver disease but may play a role in the progression of CLD.

The Validity of a New Structured Assessment of Gastrointestinal Symptoms Scale (SAGIS) for Evaluating Symptoms in the Clinical Setting

Abstract: The clinical assessments of patients with gastrointestinal symptoms can be time-consuming, and the symptoms captured during the consultation may be influenced by a variety of patient and non-patient factors To facilitate standardized symptom assessment in the routine clinical setting, we developed the Structured Assessment of Gastrointestinal Symptom (SAGIS) instrument to precisely characterize symptoms in a routine clinical setting We aimed to validate SAGIS including its reliability, construct and discriminant validity, and utility in the clinical setting Development of the SAGIS consisted of initial interviews with patients referred for the diagnostic work-up of digestive symptoms and relevant complaints identified The final instrument consisted of 22 items as well as questions on extra intestinal symptoms and was given to 1120 consecutive patients attending a gastroenterology clinic randomly split into derivation (n = 596) and validation datasets (n = 551) Discriminant validity along with test–retest reliability was assessed The time taken to perform a clinical assessment with and without the SAGIS was recorded along with doctor satisfaction with this tool Exploratory factor analysis conducted on the derivation sample suggested five symptom constructs labeled as abdominal pain/discomfort (seven items), gastroesophageal reflux disease/regurgitation symptoms (four items), nausea/vomiting (three items), diarrhea/incontinence (five items), and difficult defecation and constipation (2 items) Confirmatory factor analysis conducted on the validation sample supported the initially developed five-factor measurement model ( $$\chi_{193}^{2} = 8922$$ , p < 00001, χ 2/df = 46, CFI = 090, TLI = 088, RMSEA = 008) All symptom groups demonstrated differentiation between disease groups The SAGIS was shown to be reliable over time and resulted in a 38% reduction of the time required for clinical assessment The SAGIS instrument has excellent psychometric properties and supports the clinical assessment of and symptom-based categorization of patients with a wide spectrum of gastrointestinal symptoms

Soil Organic Carbon (SOC) Equilibrium and Model Initialisation Methods: an Application to the Rothamsted Carbon (RothC) Model

Abstract: Carbon (C) emissions from anthropogenic land use have accelerated climate change. To reduce C emissions, dynamic models can be used to assess the impact of human drivers on terrestrial C sequestration. Model accuracy requires correct initialisation, since incorrect initialisation can influence the results obtained. Therefore, we sought to improve the initialisation of a process-based SOC model, RothC, which can estimate the effect of climate and land-use change on SOC. The most common initialisation involves running the model until equilibrium (‘spin-up run’), when the SOC pools stabilise (method 1). However, this method does not always produce realistic results. At our experimental sites, the observed SOC was not at equilibrium after 10 years, suggesting that the commonly used spin-up initialisation method assuming equilibrium might be improved. In addition to method 1, we tested two alternative initialisations for RothC that involved adjusting the total or individual SOC pool equilibrium values by regulating the C input during the entire spin-up initialisation period (method 2) and initialising each SOC pool with recently measured SOC values obtained by SOC fractionation (method 3). Analysis of the simulation accuracy for each model initialisation, quantified using the root mean square error (RMSE), indicated that a variant of method 2 that involved adjusting the equilibrium total SOC to observed values (method 2-T) generally showed less variation in the individual SOC pools and total SOC. Furthermore, as total SOC is the sum of all SOC pools, and because total SOC data are more readily available than the individual SOC pool data, we conclude that method 2-T is best for initialising RothC.

Mixture model analysis identifies irritable bowel syndrome subgroups characterised by specific profiles of gastrointestinal, extraintestinal somatic and psychological symptoms.

Abstract: SummaryBackground Current subgrouping of Irritable Bowel Syndrome (IBS) is exclusively based on stool consistency without considering other relevant gastrointestinal (GI), extraintestinal somatic or psychological features. Aim To identify subgroups based on a comprehensive set of IBS-related parameters. Methods Mixture model analysis was used, with the following input variables: 13 single-item scores from the IBS-specific Gastrointestinal Symptom Rating Scale, average stool consistency and frequency from a 7-day Bristol Stool Form diary, 12 single-item extraintestinal symptom scores from the Patient Health Questionnaire-12, and anxiety and depression subscale scores from the Hospital Anxiety and Depression scale. The resulting latent subgroups were compared regarding symptom profiles using analysis of variance followed by pair-wise comparisons. Results One hundred and seventy-two IBS patients (Rome III; 69% female; mean age 33.7 [range 18-60] years) were included. The optimal subgrouping showed six latent groups, characterised by: (I) constipation with low comorbidities, (II) constipation with high comorbidities, (III) diarrhoea with low comorbidities, (IV) diarrhoea and pain with high comorbidities, (V) mixed GI symptoms with high comorbidities, (VI) a mix of symptoms with overall mild severity. The subgroups showed differences in the distribution of Rome III-subtypes, IBS severity, presence of anxiety and depression, and gender, but not regarding age, IBS duration or reported post-infectious onset of IBS. Conclusions This model-based subgrouping of IBS partly supports the distinction of subgroups based on bowel habits, but additionally distinguishes subgroups with or without co-morbid extraintestinal somatic and psychological symptoms. The resulting groups show specific profiles of symptom combinations.

Undiagnosed pancreatic exocrine insufficiency and chronic pancreatitis in functional GI disorder patients with diarrhea or abdominal pain.

Abstract: Background and Aim A previous UK study showed that 6.1% of patients with diarrhea-predominant irritable bowel syndrome (IBS-D) had evidence of severe pancreatic exocrine insufficiency (PEI), but these findings need replication. We aimed to identify the prevalence of PEI based on fecal elastase stool testing in consecutive outpatients presenting with chronic unexplained abdominal pain and/or diarrhea and/or IBS-D. Methods Patients aged over 40 years presenting to hospital outpatient clinics from six sites within Australia with unexplained abdominal pain and/or diarrhea for at least 3 months and/or IBS-D were studied. Patients completed validated questionnaires and donated a stool sample in which elastase concentration was measured by ELISA. A concentration of < 100 mcg/g stool represented severe and < 200 mcg/g mild to moderate PEI. Patients whose fecal elastase was < 200 mcg/g underwent testing for pancreatic pathology with an endoscopic ultrasound or abdominal CT. Results Two hundred eighteen patients (mean age of 60 years, 29.4% male) were studied. PEI was found in 4.6% (95% CI 2.2–8.3%) (n = 10), with five patients (2.3% (95% CI 0.8–5.3%) having severe PEI. Only male sex and heavy alcohol use were significantly associated with abnormal versus normal pancreatic functioning. Of seven patients who underwent endoscopic ultrasound or CT, two had features indicative of chronic pancreatitis. Conclusion One in 50 patients with IBS-D or otherwise unexplained abdominal pain or diarrhea have an abnormal fecal elastase, but unexpected pancreatic insufficiency was detected in only a minority of these. This study failed to confirm the high prevalence of PEI among patients with unexplained GI symptoms previously reported.

The epidemiology of irritable bowel syndrome: Symptom development over a 3‐year period in Denmark. A prospective, population‐based cohort study

Abstract: Background We aimed to explore the natural history of irritable bowel syndrome (IBS) in Denmark over 3 years by studying development of IBS symptoms and associated factors. Methods A cohort study was carried out using a web panel representative of the Danish general population 18-50 years. The survey, including a questionnaire based on the Rome III criteria for IBS, was conducted in January 2010, January 2011, and March 2013. Key Results The prevalence of IBS was 15.4% (920/5986). The incidence was 10.3%, and was three times higher for persons with unspecific gastrointestinal (GI) symptoms compared to asymptomatic persons. Of respondents with IBS symptoms in both 2010 and 2011, 69% (131/191) also reported symptoms of IBS in 2013, which was significantly more compared to respondents with IBS symptoms in 2010 reporting to be asymptomatic or having unspecific GI symptoms in 2011 (20% and 39%, respectively, P<.001). Being diagnosed with IBS predicted fulfilling the criteria for IBS 3 years later (OR: 2.59, 95% CI: 1.11-6.10). Fulfilling criteria for IBS after 1 year also led to a high risk of IBS symptoms 3 years later in asymptomatic persons and persons with unspecific symptoms at baseline. Conclusions & Inferences The vast majority of persons fulfilling criteria for IBS report GI symptoms after one and 3 years. Fulfilling IBS criteria after 1 year led to a high risk of reporting IBS symptoms after 3 years. In the general population having an IBS diagnosis predicts persistently fulfilling the Rome III criteria for IBS 3 years later.

Preferred practice location at medical school commencement strongly determines graduates' rural preferences and work locations.

Abstract: Objective To identify factors influencing whether Australian medical graduates prefer to, or actually, work rurally. Design Secondary analysis of longitudinal data from Medical Schools Outcomes Database (MSOD) using univariate and multivariate logistic regression. Setting Twenty Australian medical schools. Participants Australian or New Zealand citizens and Australian permanent residents who completed MSOD questionnaires between 2006 and 2013. Main outcome measures Preferred and actual work locations 1 (PGY1) and 3 (PGY3) years postgraduation. Results Of 20 784 participants, 4028 completed a PGY1 or PGY3 questionnaire. Self-reported preference for rural practice location at medical school commencement was the most consistent independent predictor of whether a graduate would have a rural location preference at PGY1 (odds ratio (OR) 6.07, 95% confidence interval (CI) 4.91–7.51) and PGY3 (OR 7.95, 95% CI 4.93–12.84), and work rurally during PGY1 (OR 1.38, 95% CI 1.01–1.88) and PGY3 (OR 1.86, 95% CI 1.30–2.64). The effect of preferred practice location at medical school commencement is independent of, and enhances the effect of, rural background. Graduates of graduate-entry programs or with dependent children were less likely to have worked rurally during PGY1 and PGY3 respectively. Conclusion The most consistent factor associated with rural preferences and work location was students' preferred location of practice at medical school commencement; this association is independent of, and enhances the effect of, rural background. Better understanding of what determines rural preference at medical school commencement and its influence on rural workplace outcomes beyond PGY3 is required to inform Australian medical school selection policies and rural health curricula.

Unique pathology of colonic spirochaetosis characterised by mucosal eosinophilia is linked to diarrhoea and IBS

Abstract: Dear Sir, We read with interest the commentary of Raes1 on the growing clinical role of microbiome-based companion diagnostics. We agree that the future of microbiome in medical practice will be in using markers for diagnosis as well as predicting and personalising treatment. We report here new observations on a colonic bacteria that, while traditionally considered a commensal, may be important in chronic diarrhoea and IBS. Colonisation of the colon by Brachyspira aalborgi and B. pilosicoli is characterised by the histological finding of extensive, densely packed, end-on attachment of spirochaetes to the mucosal wall, which is visible on HE bacterial colonisation is dramatically demonstrated by Warthin-Starry staining like Helicobacter pylori (figure 1).2 ,3 The significance of this finding and its role in human disease has been debated in the literature and generally colonic spirochaetosis (CS) is considered to be a …

Is there a link between H. Pylori and the epidemiology of Crohn’s disease?

Abstract: Case control studies suggest an inverse association between Helicobacter pylori (H. pylori) and Crohn’s disease (CD). It is possible this could be accounted for by confounders such as antibiotic therapy. Analyzing the geographic distribution of H. pylori and the links with the incidence and prevalence of CD would be an alternative approach to circumvent these confounders. The literature was searched for studies published between 1990 and 2016 that reported incidence or prevalence data for CD in random population samples in developed countries (GDP per capita >20,000 USD/year). Corresponding prevalence studies for H. pylori in these same regions were then sought matched to the same time period (±6 years). The association between the incidence and prevalence of CD and H. pylori prevalence rates were assessed before and after adjusting for GDP and life expectancy. A total of 19 CD prevalence and 22 CD incidence studies from 10 European countries, Japan, USA, and Australia with date-matched H. pylori prevalence data were identified. The mean H. pylori prevalence rate was 43.4% (range 15.5–85%), and the mean rates for incidence and prevalence for CD were 6.9 and 91.0/100,000 respectively. The incidence (r = −0.469, p < 0.03) and prevalence (r = −0.527, p = 0.02) of CD was inversely and significantly associated with prevalence of H. pylori infection. Our data demonstrate a significant inverse association between geographic distribution of H. pylori and CD. Thus, it is highly unlikely that the findings of previous case control studies were simply due to confounding factors such as concomitant antibiotic use in CD patients.

Deconfounding confounding part 2: using directed acyclic graphs (DAGs).

Abstract: One of the few true innovations in epidemiological methods has been the emergence of directed acyclic graphs (DAGs) to identify confounding. This development began in the early 1990s with work by Pearl and Robins based on formal logic and machine learning. DAGs are a formal system of mapping variables and the direction of causal relationships among them. “Directed” refers to arrows indicating the direction of causality between variables, and “acyclic” means that it should not be possible to start from any one variable and follow a series of arrows back to the original variable. Entire books are devoted to this method, but just a few highlights are sufficient to help clinicians understand confounding.

Equitable resourcing of primary health care in remote communities in Australia's Northern Territory: a pilot study.

Abstract: Background Improved Primary Health Care (PHC) utilisation is central to reducing the unacceptable morbidity and mortality rates characterising populations living in remote communities. Despite poorer health, significant inequity characterises the funding of PHC services in Australia’s most remote areas. This pilot study sought to ascertain what funding is required to ensure equitable access to sustainable, high quality primary health care irrespective of geographical remoteness of communities. Methods High performing remote Primary Health Care (PHC) services were selected using improvement measures from the Australian Primary Care Collaboratives Program and validated by health experts. Eleven PHC services provided data relating to the types of services provided, level of service utilisation, human resources, operating and capital expenses. A further four services that provide visiting PHC to remote communities provided information on the level and cost of these services. Demographic data for service catchment areas (including estimated resident population, age, Indigenous status, English spoken at home and workforce participation) were obtained from the Australian Bureau of Statistics 2011 census. Formal statistical inference ( p -values) were derived in the linear regression via the nonparametric bootstrap. Results A direct linear relationship was observed between the total cost of resident PHC services and population, while cost per capita decreased with increasing population. Services in smaller communities had a higher number of nursing staff per 1000 residents and provided more consultations per capita than those in larger communities. The number of days of visiting services received by a community each year also increased with population. A linear regression with bootstrapped statistical inference predicted a significant regression equation where the cost of resident services per annum is equal to $1,251,893.92 + ($1698.83 x population) and the cost of resident and visiting services is equal to $1,378,870.85 + ($2600.00 x population). Conclusions The research findings provide empirical evidence based on real costs to guide funding for remote PHC services that takes into account the safety and equity requirements for a minimum viable service. This method can be used as a transparent, coordinated approach to ensure the equitable delivery of sustainable, high quality PHC in remote communities. This will in turn contribute to improved health outcomes.

Novel insights into fecal incontinence in men.

Abstract: Fecal incontinence in men is common, yet data on sex differences in clinical features, physiology, and treatment are scarce. We provide evidence that men, compared with women, with fecal incontinen...

Understanding women who self-harm: Predictors and long-term outcomes in a longitudinal community sample.

Abstract: Objective:There is growing awareness of the range of psychosocial, lifestyle, and sociodemographic factors related to self-harm, however this research is often limited by using cross-sectional or c...

Factors related to doctors' choice of rural pathway in general practice specialty training.

Abstract: Objective To investigate the factors eligible applicants consider in electing for a rural pathway into specialty training. Design Cohort study. Setting Australia. Participants Applicants to the Australian General Practice Training program. Main outcome measures Applicants’ initial preference of either a general or rural pathway to undertake specialty training. Results Of the 2,221 applicants, 45% were Australian Medical Graduates (AMGs), 27% Foreign Graduates of Accredited Medical Schools (FGAMS) and 29% International Medical Graduates (IMGs). Through government regulation, two thirds (70%) were eligible to train on both general and rural pathways and a third (30%) were required to train rurally. For applicants eligible for general pathway (n = 1552), those with rural background [Odds Ratio (OR) = 3.7, 95% CI 2.7–5.2] and rural clinical school experience (OR = 2.0, 95% CI 1.5–2.8) were more likely to choose the rural pathway. In addition, FGAMS who were eligible for the general pathway were less likely to choose a rural pathway when compared with IMGs (OR = 0.33, 95%CI 0.1 = 0.7). In applicants who changed their training pathway from their initial to revised preference, lower Multiple-Mini-Interview (OR = 0.54, 95% CI 0.43–0.66) and Situational Judgement Test z-scores (OR = 0.68, 95% CI 0.56–0.83) were associated with a higher probability of changing from a general to rural pathway preference. Conclusion For those eligible for a general or rural pathway, rural background and rural clinical school experience are associated with the decision to elect for rural training. Targeted support for international and foreign graduates of Australia/New Zealand schools may influence them to train rurally.

Understanding statistical principles in correlation, causation and moderation in human disease

Abstract: e are all familiar with the expression “corre1 Hypothetical association between mast cell count lation does not imply causation”, but often and patient score on abdominal symptoms W causation is exactly what we need to determine. For example, onemaywant to understandwhether the use of MP3 players with earbuds causes partial hearing loss, whether holding mobile telephones to the ear causes brain cancer or whether parents’ exposure to toxic chemicals during conception or pregnancy causes birth defects in children. Non-causal risk factors can be useful, but eventually, what we really want to understand is causation. Because the causal connection between exposure to risk factor and disease outcome is often complex or poorly understood, what researchers can truly study is whether an association exists or not. This article explains how we can move from correlation and association to causal interpretation of data, andwhat statistical evidence is needed to support causal conclusions.

Deconfounding confounding part 1: traditional explanations.

Abstract: Selection and measurement bias should be managed pre-emptively by good design before the start of the study, but can be detected post hoc by critical appraisal. No statistical method removes the effect of selection or measurement bias post hoc, although there are methods that allow us to model different degrees of bias and evaluate the effect on the measure of association. Confounding is slightly different in that it can be adjusted for in the analysis, as long as its sources are understood and measured without too much error.

Psychiatric disorders among people with cancer in low- and lower-middle-income countries: study protocol for a systematic review and meta-analysis

Abstract: Introduction Cancer is a rapidly growing public health problem in low- and lower-middle-income countries (LLMICs). There is evidence from upper-income countries that comorbid mental illness is common and can adversely impact cancer outcomes. Little is known about this burden in LLMICs. This systematic review has two aims. The first is to review the prevalence and patterns of psychiatric comorbidity in adults with cancer in LLMICs. The second is to review psychiatric treatment outcomes in this population. Methods and analysis The review will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A systematic search of electronic databases (MEDLINE, PsycInfo, Embase and CINAHL) will be conducted. Studies will be included if they report the prevalence of psychiatric comorbidity, or if they evaluate psychiatric treatment outcomes, in adults with cancer living in LLMICs. The search will be limited to studies published in peer-reviewed journals between March 2002 and March 2017. The reference lists of included studies will be hand searched. Critical appraisal will be performed using Quality Assessment Tools from the National Institute of Health. Pooled prevalence meta-analysis is planned. Ethics and dissemination Ethics approval is not required as no primary data will be collected. The results will be presented at conferences and published in a peer-reviewed journal. Systematic review registration PROSPERO CRD42017057103.

Understanding statistical hypothesis tests and power.

Abstract: edical researchers often attempt to understand whether a risk factor is involved in the aetiology Mof disease or whether an intervention reduces disease; this has been the subject of another article in this series. We typically do this by proposing scientific hypotheses fromwhich testable statistical hypotheses can be developed. For example, our scientific hypothesis could be that people with irritable bowel syndrome (IBS) have higher risk of depression compared with those who do not have IBS. A small studymight show that one in ten in the control group have depression, comparedwith two in ten in the IBS group. This might reflect a real difference in the rate of depression between IBS and non-IBS populations, or the difference of one person between groups might simply be the play of chance. An empirical approach to answering this question might be to repeat the studymultiple times,with larger numbers, and to look at the consistency of the results. Unfortunately, this is an expensive and time-consuming solution.

Editorial: subgroups in irritable bowel syndrome-more than just diarrhoea and constipation? Authors' reply.

Abstract: We have read the comments of Drs Black and Ford regarding our subgrouping approach with great interest. The potential clinical implications and limitations have been described accurately in their editorial commentary, and the points raised give us the opportunity to elaborate on some details. The complexity and heterogeneity of IBS is well-documented, as is the significant impact IBS has on the quality of life of the affected persons. In addition, the economic impact of IBS on healthcare and society should not be underestimated. While modern medicine has a multitude of treatment options, the big challenge lies in identifying the right treatment strategies for the individual patient, a challenge that is not limited to IBS only. In light of this challenge, stratification strategies, which aim to identify subgroups of patients with similar clinical symptom profiles, may help the clinician to identify which patients benefit from therapeutic options primarily targeting extra-intestinal somatic and psychological symptoms, and for which patients it may suffice with gut-directed therapeutic approaches. By this strategy, the overall symptom burden of the respective patients is acknowledged, and can hopefully be improved in a more successful and cost-effective way. Additional hopes lie on this approach: The underlying pathophysiology of IBS remains poorly understood, and it is unclear whether we are facing a multifactorial disorder or a multiaetiological syndrome. Careful stratification of patient phenotypes, such as performed in our study, may enable researchers to associate these subgroups to distinct mechanisms, and thus potentially identify distinct disease entities. Successful stratification approaches have recently been described in other common and complex diseases such as asthma and diabetes, further supporting the relevance of this approach. In order to fulfil the above-mentioned hopes, our approach needs to be tested regarding three things: reproducibility, potential differences in underlying pathophysiology and the usefulness of group membership as a predictor for treatment outcome. Regarding reproducibility, we are currently applying the same analysis method on general population data from an English speaking cohort, to see if similar subgroups can be identified at the population level as in our clinical sample. Regarding underlying pathophysiological mechanisms, our group also has ongoing projects to identify associations between IBS symptom clusters and pathophysiological mechanisms, so we expect results within the near future also in this regard. The usefulness of group membership as a predictor for treatment outcome will require larger intervention studies, so it will take some time until definite results can be expected. Despite this, we think that our results already suggest the importance of screening patients for extraintestinal somatic and psychological symptoms, and not only focus on bowel-related symptoms, and to consider these symptoms for clinical decisions, as suggested also by the Rome committee in the multidimensional clinical profile concept.

Management of early anal cancer: need for guidelines and standardisation

Abstract: The optimal management of early squamous cell carcinoma of the anal canal (AC) is yet to be determined. This study investigated current practice in the management of early AC. A patterns of care survey was completed by Australian surgeons and radiation oncologists. Specific topics addressed were as follows: geographical location of practice, staging of disease, treatment approaches to T1N0 tumours and grade 3 anal intra-epithelial neoplasia (AIN3) lesions, radiotherapy planning, toxicities, follow-up and clinical trial involvement. Sixty-four responses were obtained. For the management of T1N0 disease, half the respondents recommended standard dose chemo-radiotherapy (CRT) and one third recommended wide local excision (WLE). For the management of AIN3, half recommended WLE while a quarter advocated observation. This study reveals a significant variation in the management of early AC. The development of guidelines specific to the treatment of early AC could standardise treatment while further research is required to define the optimal management of T1N0 AC and AIN.

Worm infestations and development of autoimmunity in children - The ABIS study

Abstract: Worm infestations influence the immune system and may therefore decrease the risk for autoimmune diseases. The aim of the study was to determine whether children who have developed autoimmune disease were less likely to have had worm infestations in childhood. The ABIS-study is a prospective population-based cohort study of children born in southeast Sweden 1997/99. 17.055 children participated. As of June 2014 116 individuals had developed Type 1 diabetes, 181 celiac disease, and 53 Juvenile Rheumatoid Arthritis. The parents answered questions on worm infestations when the children were 1, 5 and 8 years of age. The ABIS registry was connected to the National Registry of Drug Prescriptions, and national registries for diagnosis of the studied diseases. We found no differences in incidence of worm infestations at 1, 5 or 8 years of age between children who developed autoimmune disease(s) or healthy controls. At 8 years in total 20.0% of the general child population had experienced a worm infestation; children who developed Type 1 diabetes, 21,3%, celiac disease 19,5% and JRA 18,8%. There was no difference in prescriptions of drugs for treatment of worm infestations between those who had and who had not developed Type 1 diabetes, celiac disease, Juvenile Rheumatoid Arthritis. We found no associations indicating that worm infestations in childhood does not play a role in the development of autoimmune diseases in Sweden.

Sampling: how you choose people is as important as how you analyse their data.

Abstract: uch attention is paid in research publications to the methods of statistical analysis. Research Mdesign, in contrast, receives less consideration, despite the fact that it is critical; if the research design is poor, no amount of complex statistical analysis can extract useful information from the data collected. In this article, we focus on the selection of subjects for medical research studies, and outline several sampling strategies and their implications for statistical analysis. As a high level overview of sampling in medical research, we do not go into deep technical detail. Further, we discuss how to obtain a sample, but not how large the sample should be; we refer readers to Lachin for an introduction to the important topic of sample size and statistical power calculations.

Systematic review and meta-analysis: Prevalence of small intestinal bacterial overgrowth in chronic liver disease

Abstract: The authors conducted a meta-analysis of the prevalence of small intestinal bacterial overgrowth (SIBO) in patients with chronic liver disease (CLD) and controls. Using the search terms \"small intestinal bacterial overgrowth (SIBO)\" and \"chronic liver disease (CLD)\" or \"cirrhosis,\" 19 case-control studies were identified. Utilizing breath tests, the prevalence of SIBO in CLD was 35.80% (95% CI, 32.60-39.10) compared with 8.0% (95% CI, 5.70-11.00) in controls. Using culture techniques, the prevalence was 68.31% (95% CI, 59.62-76.00) in CLD patients as compared with 7.94% (95% CI, 3.44-12.73) in controls. No difference between cirrhotic and noncirrhotic patients was found. SIBO is significantly more frequent in CLD patients as compared with controls. The association of SIBO and CLD was not confined to patients with advanced CLD, suggesting that SIBO is not a consequence of advanced liver disease but may play a role in the progression of CLD.