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Upfront January 2013
  1. Anton V Emmanuel

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Auto-immune hepatitis guidelines: everything summarised in one article

We are delighted to have a piece from the King's group summarising expertly the recent guidance around this condition which can present with a wide range of severities. The consensus around short- and long-term management of the common clinical presentations is summarised, as well as focussing on the occasional more complex situation or when first-line treatments fail. We suspect the clear messages emerging will make this one of the most highly read Frontline articles.

Inflammatory bowel disease in the non-caucasian population

There is an increasing body of data on the prevalence of ulcerative colitis and Crohn's disease in Asian and (to a lesser extent) Afro-Caribbean populations. In a paper from the group in St George's London (Chatu et al), serving an ethnically diverse population, come insights about Vitamin D metabolim in their IBD cohort. The paper introduces us to the Endocrine Society definition of Vitamin D deficiency as 50 nmol/l. The findings offer an insight for non-response or infection risk in some treatment-refractory patients, and makes the case for larger controlled studies on this topic. It challenges the reader to not just measure baseline Vitamin D levels, but think about monitoring of replacement therapy in light of the emerging literature on the potential adverse effects of hypervitaminosis D.

A(nother?) hidden cost of bariatric surgery

Roux-en-Y gastric bypass is an increasingly performed part of the bariatric surgeon's treatment options. Whilst undoubtedly improving the metabolic state, there is a well described morbidity associated with anastomotic stricturing. In a large cohort of patients, Steed et al in this edition have analysed the endoscopic burden of these procedures. It may be news to many readers that there are technical considerations and medical therapy that can make this complication of stricturing less likely. Knowledge of this should help tailor referrals for early endoscopy after this form of bypass surgery. Importantly, the manuscript highlights the need to factor in endoscopic services when drawing up the ever-expanding plans for establishing bariatric surgical centres.

Curriculum-mapped clinical reviews: a new Frontline series

We launch this series with a piece by Lamb et al on the differential diagnosis around a presentation with proctitis. This common clinical scenario often provokes an appropriate search for inflammatory bowel disease. However, there will be occasions where the epidemiology and clinical features should promote wider thought—and this principle allied to knowledge of the appropriate diagnostics is the essence of the series. The series will feature articles that are different to CPD reviews, but which are mapped to specific competencies in the Gastroenterology curriculum of doctors and nurses. Articles are linked to ‘best of five’ questions to help with self-assessment and ensure coverage of the topic.

Double balloon endoscopy in paediatric practice

There is a large body of literature supporting advanced endoscopic diagnostic and therapeutic procedures for adults but not as much in the paediatric literature. The adult literature is often cited or extrapolated and interpreted in a paediatric context, which is not always applicable. The paper by Rahhal et al from Iowa makes a significant contribution to the field of paediatric endoscopy, and will hopefully inspire paediatric gastroenterologists to seek training for and subsequently perform such procedures.

Optimising biologic therapy in inflammatory bowel disease: the state of the art

Many hours of symposia at international meetings are devoted to this subject. This edition of Frontline features an article from Vermiere and Gils which informs the clinician about when to consider measuring drug and antibody levels. The information is derived from analysis of recent large randomised trials and retrospective series, and leads to a clear algorithm of how to treat non-responders based on measurement of trough levels of drug. In the era of risk assessment for the patient and cost-efficacy for the service, this sort of pragmatic pathway will have an impact on care provision.

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