Introduction To identify symptomatology of interval cancers(IC-cancers diagnosed within 2 years of a negative Faecal Occult Blood Testing(FOBT)). Method National Bowel Cancer Audit Programme data from three centres,for all colorectal cancers(CRC)in the screening age group(60–74 years)over a 2 year period(August 2011–2013)were linked for their Faecal Occult Blood Testing(FOBT)screening status(BCSP database/Eastern Hub).Detailed symptomatology of IC were analysed.Tumours at and beyond splenic flexure were considered left-sided. Results The study covered 2 million population( 2 00 000 screening eligible). 521 CRC were diagnosed(0.11%). 231 CRC(44%)were in patients who had declined screening, 162 CRC(31%)were screen-detected and 128 CRC(25%)were IC. Of these 128 patients(M: F; 84:44),median age 67 years(SD: 3.8)the commonest presenting symptoms was change in bowel habits in 50 (39%).Others included bleeding per-rectum( 44 (34%)patients,abdominal pain 38 (30%),anaemia 36 (28%),loss of weight 14 (11%),bowel obstruction 13 (10%),bowel perforation in 3 (2%) patients. Only two patients were truly asymptomatic-CRC being identified in oneduring gynaecological surgery and during trauma laparotomy in the other. In the anaemic patients(36 (28%)) the blood picture showed Hb(mean;10.3 gm);MCV( 82.4);MCH(26.3).61% of anaemic patients had CRC in the right colon with an equal percentage being of Duke’s stage C/D. The time from negative FOB test to CRC diagnosis was 15 months (0.5–24 months). Conclusion Our findings highlight majority of IC patients were symptomatic with ‘red flag symptoms’. We raise the possibility of a natural bias in patients volunteering for the FOB test in that they may have bowel symptoms not yet discussed with their general practitioner. We highlight the need for improved awareness to reduce delays in symptomatic patients seeking medical advice against a background of a negative FOBT. Disclosure of Interest None Declared

Introduction To compare white british(WB)and ethnic minority groups(EMG)(Asian/African/Caribbean and other coloured groups)in the uptake and outcomes of the national faecal occult blood testing(FOBT)screening. Ethnicity data on FOBT screening is not available as this information is not normally collected. Method: Methods National Bowel Cancer Audit Programme data from three centres,for all colorectal cancers(CRC)in the screening age group(60–74 years)over a 2 year period(August 2011–2013)were linked for their Faecal Occult Blood Testing(FOBT)screening status(BCSP database/Eastern Hub).Ethnicity/Patient/tumour demographics and survival for Interval cancers(IC-screening patients developing cancers within 2 years of a negative FOB test)screen-detected cancers and cancers in those who declined the screening programme were analysed.All three centres were in incident rounds of screening.Tumours at and beyond splenic flexure were considered left-sided. Results The region studied had the highest distribution of ethnic groups outside of London(2011 census:10% (Derby),15%(Nottingham),16%(Mansfield)). 516 CRC were diagnosed in this region in the said time-period. WB population formed majority of these patients( 122 (96%) IC;208 (91%)cancers in the declined screening group;151 (94%)screen-detected cancers).CRC in the EMG formed 4 (3%)of IC,5 (2%) of declined screening group and 2 (1%)of screen-detected caners respectively. The demographic profile of WB and the EMG were comparable(Male:female;302:179(WB)vrs8:4(EMG);p=0.583,X2=4.69;mean age at diagnosis;67 years(WB):67 years(EMG);p=0.990,X2=0.0;age under 70 years;380(WB):9(EMG);p=0.494,X2=1.40) The tumour profile and survival of WB and EMG were comparable(Right-sided:Left-sided;341:140(WB)vrs6:5(EMG);p=0.255,X2=7.77;Duke’s Staging A and B:C and D ;229:246(WB)vrs4:5(EMG);p=0.565,X2=0.33;survival ;380(WB):8(EMG);p=0.767,X2=0.532). Conclusion This is the first report of ethnic profiling in FOBT screening. Our findings highlight a high degree of non-engagement of the EMG with the national FOBT process. With rapidly increasing proportions of ethnic groups nationally,we highlight the importance in ensuring that these socially diverse communities are not segregated from mainstream FOBT screening. Disclosure of Interest None Declared

Introduction To compare regional outcomes of Faecal Occult Blood testing(FOBT)screening Method National Bowel Cancer Audit Programme data from three NHS Hospitals,for colorectal cancers(CRC)in the screening age group(60–74 years)over a 2 year period(August 2011–2013)were linked for their FOBT screening status( BCSP database/Eastern Hub ).Patient locations were divided into 4 regions(based on home postcodes):Mansfield(Mfd)postcodes(NG17-21);Newark(Nw)postcodes(NG22-25);Nottingham(Ngh)postcodes(NG1-NG16);Derby(Drby)postcodes(DE1-DE75).Patient/tumour demographics and survival for Interval cancers(IC-screening patients developing cancers within 2 years of a negative FOB test),screen-detected cancers(SDC)and cancers in those who declined the screening programme(DSP)were analysed.All regions and centres involved were in incident rounds of screening.Tumours at and beyond splenic flexure were considered left-sided.1-year mortality was looked at as all patients had a minimum of 1 year follow-up. Results Of the 496 cancers detected,123 (25%)were IC,219 (44%)were DSP and 154 (31%)were SDC. Demographic parameters were comparable between regions including male: female ratio (Mfd (51:27); Nw (20:18); Ngh (134:88); Drby (102:58):p=0.52, X2=2.22); age (mean) at cancer diagnosis (years) (Mfd(65.9); Nw (65.9); Ngh (66.2); Drby (67.9): p=0.46, X2=4.67). Tumour characteristics including left:right-sided (Mfd(59:19); Nw(27:11); Ngh (168:54); Drby (104:54): p=0.17,X2=5.02) and Duke’s staging Low(A/B): High (C/D) (Mfd(39:39); Nw (24:14); Ngh (109:113); Drby (67:91): p=0.126,X2=5.70) were comparable.Ethnic demographics,deprivation index,d patient follow-up were comparable between the four regions.Mfd region had a higher proportion of IC compared to other regions (Mfd(n=78); IC-25 (32%), DSP-25 (32%), SDC-28 (36%); Nw (n=38); IC-7 (18%), DSP-22 (58%), SDC-9(24%); Ngh (n=222); IC-44 (20%), DSP-111 (50%), SDC-67(30%); Drby (n=158); IC-47(30%), DSP-61 (38%), SDC-50(32%): p = 0.025,X2=14.41 ). Mfd had a significantly higher 1 year mortality compared to other regions (Mfd 13:IC-5.DSP-3.SDC-5; Nw 2: IC-1. DSP-1.SDC-0; Ngh 22: IC-6, DSP-16,SDC-0; Drby 12:IC-7, DSP-5, SDC-0: p= 0.002, X2 = 20.07). The median time (months) between cancer diagnosis and death was shortest for the Mfd region (Mfd-7; Nw-13.5; Ngh-15; Drby-15.5) Conclusion Our findings for the first time highlight regional variations in CRC mortality. We cannot explain our findings based on existing literature or on the known behaviour of colorectal cancer. Though there remains the possibility that our findings may be incidental, this also raises the possibility of the existence of hitherto undetected regional variations in colorectal cancer phenotypes. Disclosure of Interest None Declared

Biennial faecal occult blood testing (FOBT) is used to screen for colorectal cancer throughout the UK. Interval cancers are tumours that develop in patients between screening rounds who have had a negative FOBT. Through a multicentre study, we compared the demographics of patients with interval cancers, FOBT screen detected cancers and cancers that developed in patients who chose not to participate in the screening programme.

Introduction To compare outcomes of the two groups Method National Bowel Cancer Audit Programme data from three centres,for all colorectal cancers(CRC)in the screening age group(60–74 years)over a 2 year period(August 2011–2013)were linked for their Faecal Occult Blood Testing(FOBT)screening status(BCSP database/Eastern Hub).Patient/tumour demographics and survival for Interval cancers(IC-screening patients developing cancers within 2 years of a negative FOB test)and cancers in those who declined the screening programme were analysed.All three centres were in incident rounds of screening.Tumours at and beyond splenic flexure were considered left-sided. 1 year mortality was looked at as all patients had a minimum of 1 year follow-up. Results Of the 521 CRC identified, 127 (25%)were IC and 228 (44%)were cancers in the declined screening group.The mean age at cancer diagnosis(66.8 years vrs 67.5 years;p=0.014 ,X2= 0.33);male:female ratio(83:44vrs 130:98;p =0.024 ,X2= 2.36)and ethnic demographics(white british:others;123:5vrs211:20; p=0.090 ,X2= 2.87)between the IC and declined screening groups were comparable.Between the IC and Declined Screening groups,the tumour location(right-sided:left-sided;48:79vrs 66:162;p =0.024 ,X2= 2.36)and polyp:non-polyp cancers(2:125vrs 1:227;p =0.262 ,X2= 1.25)were comparable. The IC had a higher proportion of advanced cancers at presentation(Dukes C/D;89 (70%)vs122(53%);p= 0.002 ,X2 = 9.28 )compared to the declined screening group. Mortality-data 1 year mortality was 20 (16%)and 25 (11%)for the IC and declined screening groups respectively.There was no gender,age or ethnic differences between the two groups.The mortality of right-sided cancers in the IC group was significantly higher than that for the declined screening group(10 (21%)vrs 4 (6%);p= 0.037 ,X2 = 4.32 ). Conclusion Our findings highlight that patients on the national FOBT screening programme who develop IC (specially right-sided)fared worse in the short-term, compared to CRC in patients who had declined FOBT screening-due to a higher tumour stage and a higher 1 year mortality. Disclosure of Interest None Declared

Sacral nerve stimulation (SNS) is used as a first-line treatment for faecal incontinence when conservative measures have failed. However, one-third of patients fail to benefit from this treatment. We hypothesised that sacral afferent stimulation can be maximised using pudendal nerve stimulation (PNS) and this may be of benefit in this patient group. The aim of this study was to assess chronic PNS for those who failed to improve with SNS.

We read the article by Tavarez et al. with interest ( 1 Tavarez M.M. Saladino R.A. Gaines B.A. Manole M.D. Prevalence, clinical features and management of pediatric magnetic foreign body ingestions. J Emerg Med. 2013; 44: 261-268 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar ). Prevalence, Clinical Features and Management of Pediatric Magnetic Foreign Body IngestionsJournal of Emergency MedicineVol. 44Issue 1PreviewForeign body (FB) ingestions are frequent in children. Whereas the majority of FBs pass spontaneously through the gastrointestinal tract, ingestion of magnetic FBs pose a particular risk for obstruction due to proximate attraction through the intestinal wall. Full-Text PDF

Introduction Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence (FI). However, only 50–60% of patients will have a good response to SNS. Further treatment is difficult for those who do not respond to SNS. Pudendal nerve stimulation (PNS) was first reported for FI in 2005. Since then only one small study has further reported its use for FI. We aimed to assess PNS for FI in those who have failed to improve with SNS. Methods Recruited patients underwent test PNS. Those who experienced a ≥ 50% reduction in frequency of FI episodes underwent permanent PNS. The primary outcome measure was the change in frequency of FI episodes. Further outcome measures were further bowel diary data, St Marks FI Score, Rockwood FI QOL Score, SF-36 QOL Score and anorectal physiological changes. Results Ten patients underwent test PNS. Five experienced a ≥ 50% improvement in frequency of FI episodes, and underwent permanent stimulation. One withdrew from the study at six months. At median follow up of 24 (3–36) months, the median frequency of FI improved from 5 (18.25) to 2.5 (3) per week; p = 0.043. Three maintained a ≥ 50% improvement in soiling. There was a significant improvement in the St Marks FI score, 19 (6) to 16 (4.5); p = 0.042. There were no significant changes in the ability to defer defecation or in quality of life measures. Conclusion PNS may be an effective treatment for FI for those who have failed to improve with SNS Disclosure of Interest None Declared.

AimChronic idiopathic anal pain is a common condition of unknown aetiology. Patients may have co-existing psychiatric disorders and existing treatments are often ineffective. A small number of published case reports suggest that sacral nerve stimulation (SNS) could treat this condition. This pilot study aimed to investigate the efficacy of SNS for the treatment of chronic anal pain.MethodTen patients with chronic idiopathic anal pain were recruited. All had failed to respond to conservative treatments. Clinical and psychological evaluation was performed in all patients prior to SNS. Temporary stimulation of the S3 foramina was performed for 3weeks and outcome assessed by comparison of a pain score diary and visual analogue score obtained during stimulation and at baseline. Primary outcome was defined as a >50% reduction in pain score.ResultsOf the 10 patients recruited, five were found to have clinical depression. Four patients withdrew from the study prior to testing and six underwent peripheral nerve evaluation (PNE). Three patients had >50% reduction in pain score and progressed to permanent SNS. Of these, only one had good pain control at latest follow-up of 5years; the remaining two patients obtained no benefit and had their devices removed or deactivated. These two patients both had depression that was also not improved by SNS.ConclusionThis study would suggest that SNS is not an effective treatment for chronic anal pain in the majority of patients. PNE is not an effective means of identifying which of these patients are likely to respond to permanent SNS.

BACKGROUND:Percutaneous, transcutaneous and sham transcutaneous posterior tibial nerve stimulation was compared in a prospective blinded randomized placebo-controlled trial.METHODS:Patients who had failed conservative treatment for faecal incontinence were randomized to one of three groups: group 1, percutaneous; group 2, transcutaneous; group 3, sham transcutaneous. Patients in groups 1 and 2 received 30-min sessions of posterior tibial nerve stimulation twice weekly for 6 weeks. In group 3, transcutaneous electrodes were placed in position but no stimulation was delivered. Symptoms were measured at baseline and after 6 weeks using a bowel habit diary and St Mark's continence score. Response to treatment was defined as a reduction of at least 50 per cent in weekly episodes of faecal incontinence compared with baseline.RESULTS:Thirty patients (28 women) were enrolled. Nine of 11 patients in group 1, five of 11 in group 2 and one of eight in group 3 had a reduction of at least 50 per cent in weekly episodes of faecal incontinence at the end of the 6-week study phase (P = 0·035). Patients undergoing percutaneous nerve stimulation had a greater reduction in the number of incontinence episodes and were able to defer defaecation for a longer interval than those undergoing transcutaneous and sham stimulation. These improvements were maintained over a 6-month follow-up period.CONCLUSION:Posterior tibial nerve stimulation has short-term benefits in treating faecal incontinence. Percutaneous therapy appears to have superior efficacy to stimulation applied by the transcutaneous route.REGISTRATION NUMBER:NCT00530933 (http://www.clinicaltrials.gov).

Neurostimulation remains the mainstay of treatment for patients with faecal incontinence who fails to respond to available conservative measures.Sacral nerve stimulation (SNS) is the main form of neurostimulation that is in use today.Posterior tibial nerve stimulation (PTNS) -both the percutaneous and the transcutaneous routes -remains a relatively new entry in neurostimulation.Though in its infancy, PTNS holds promise to be an effective, patient friendly, safe and cheap treatment.However, presently PTNS only appears to have a minor role with SNS having the limelight in treating patients with faecal incontinence.This seems to have arisen as the strong, uniform and evidence based data on SNS remains to have been unchallenged yet by the weak, disjointed and unsupported evidence for both percutaneous and transcutaneous PTNS.The use of PTNS is slowly gaining acceptance.However, several questions remain unanswered in the delivery of PTNS.These have raised dilemmas which as long as they remain unsolved can considerably weaken the argument that PTNS could offer a viable alternative to SNS.This paper reviews available information on PTNS and focuses on these dilemmas in the light of existing evidence.

Aim Pudendal nerve stimulation (PNS), which is an alternative to sacral nerve stimulation, requires neurophysiological confirmation of correct siting of the electrode. We describe a modification of the existing technique where placement is assisted by guidance to the ischial spine by a finger introduced per anum.Method Cadaveric dissection was carried out to confirm the accuracy of this new approach. The surface marking of the ischial spine is marked. A stimulating needle electrode inserted through a skin incision at this point, is advanced towards the ischial spine using a finger introduced per anum as a guide. Once effective stimulation of the pudendal nerve is confirmed by observed and palpated contraction of the anal musculature, a permanent stimulating electrode is inserted and the position confirmed by radiological screening.Results Using cadaveric studies, the correct surface markings for needle placement were confirmed. This technique was then applied successfully for in vivo insertion of the needle electrode in 20 patients with bowel dysfunction, with only one lead displacement occurring over a mean follow-up period of 12 months.Conclusion Finger-guided assistance of PNS electrode insertion is simple and reproducible without requiring neurophysiological confirmation of nerve stimulation to ensure correct lead location.

Reports of magnet ingestion are increasing rapidly globally. However, multiple magnet ingestion, the subsequent potential complications and the importance of the early identification and proper management remain both under-recognized and underestimated. Published literature on such cases could possibly represent only the tip of an iceberg with press reports, web blogs and government documents highlighting further occurrence of many more such incidents. The increasing number of complications worldwide being reported secondary to magnet ingestion point not only to an acute lack of awareness about this condition among the medical profession but also among parents and carers who will be in most cases the first to pick up on magnet ingestion. There still seems to be no consensus on the management of magnet ingestion with several algorithms being proposed for management. Prevention of this condition remains a much better option than cure. Proper education and improved awareness among parents and carers and frontline medical staff is key in addressing this rapidly emerging problem. The goal of managing such cases of suspected magnet ingestion should be aimed at reducing delays between ingestion time, diagnosis time and intervention time.

We report on a growing number of bowel complications in children secondary to inadvertent ingestion of magnets obtained from toys. We highlight two such reported cases over the past 18 months in the East Midlands region of the UK. Both children were developmentally normal with no documented history of magnet ingestion. The first was an 18-month-old child who had presented with a 5-day history of upper abdominal pain. The abdomen was soft and non-tender, with the child passing normal bowel motions. Radiography showed ten adherent metallic spheres in the upper abdomen. Failure of these spheres to progress through the bowel necessitated a laparotomy. Ten adherent magnetic spheres were identified lying partly in the stomach and distal jejunum (figure A). Pressure necrosis of the intervening bowel between the adherent spheres had developed into a gastrojejunal fistula. Subsequent to a resection anastomosis, the child made a full recovery. The second patient was an 8-year-old who presented with right ileac fossa tenderness and clinical signs and symptoms of acute appendicitis. At surgery, the appendix was found to be normal. Multiple fistulae were identified between the terminal ileum and the caecum, with two adherent 2 cm long magnetic strips lying across the fistulae (figure B). Subsequent to a limited right hemicolectomy, the child made a full recovery. Accidental ingestion of magnetic foreign bodies, which was once rare, has become more common owing to the increasing availability of toys with magnetic elements.1Lee BK Ryu HH Moon JM Jeung KW Bowel perforations induced by multiple magnet ingestion.Emerg Med Austr. 2010; 22: 189-191Crossref PubMed Scopus (12) Google Scholar A solitary ingested magnet can pass through the gut spontaneously.2Nagaraj H Sunil I Multiple foreign body ingestion and ileal perforation.Pediatr Surg Int. 2005; 21: 718-720Crossref PubMed Scopus (28) Google Scholar However, ingestion of multiple magnets or a single magnet along with another metallic part can cause them to stick to each other with forces of up to 1300 G,3Honzumi M Shigemori C Ito H Mohri Y Urata H Yamamoto T An intestinal fistula in a 3-year-old child caused by the ingestion of magnets: report of a case.Surg Today. 1995; 25: 552-553Crossref PubMed Scopus (71) Google Scholar compressing the intervening bowel and leading to subsequent fistulation and perforation.4Siddaiah-Subramanya MB Borzi P Ingestion of magnets in children: a growing concern.Med J Aust. 2009; 190: 98PubMed Google Scholar Since 2006, there have been numerous alerts and recalls from Canadian and US consumer product safety commissions issued in relation to children and the sale of toys with small ingestible magnetic parts.5Centers for Disease Control and PreventionGastrointestinal injuries from magnet ingestion in children–United States, 2003-2006.MMWR Morb Mortal Wkly Rep. 2006; 55: 1296-1300PubMed Google Scholar The occurrence of two such cases within such a short span of time in a small region in the UK raises concern, since no such alerts have been issued nationally in the UK. Parents need to be alerted to the potential risk of silent bowel perforation and fistulation from accidental ingestion of magnets in children. Additionally, the diagnosis is often delayed because it is difficult to obtain a precise history of foreign body ingestion—as it was in both our cases. We are particularly concerned about the widespread availability of cheap magnetic toys where the magnetic parts could become easily detached. Parents should be warned of the risk of magnet ingestion, particularly in small children. We believe that improvement in public awareness about this risk will be key in preventing such incidents. We declare that we have no conflicts of interest.

AIM:Increasing life expectancy will increase the number of elderly patients with faecal incontinence. The study aimed to assess the safety and efficacy of sacral nerve stimulation (SNS) in patients over the age of 65 years. METHOD:Patients aged over 65 years, who underwent temporary SNS from 1996 for faecal incontinence unresponsive to conservative treatment, were followed prospectively. RESULTS:Between January 1996 and December 2009, 30 patients [mean age 69.3 years (SD, 3.4)] underwent temporary SNS. Twenty-three (77%) had a >50% improvement in the St Mark's Continence Score and progressed to permanent SNS implantation. Their mean (±SD) score increased from 19 (3.2) at baseline to 8 (3.4) during temporary SNS and to 9 (3.4) 3 months after permanent SNS and 10 (3.7) at the latest median follow up (IQR) of 44 (20-150) months. The corresponding values at the same intervals for urgency [mean (±SD) min] were 1 (1.4), 8 (5.2), 8 (5) and 8 (5.4) and for incontinence episodes per 2 weeks [median (±IQR)] were 10 (7-14), 1 (0-5), 2 (0-5) and 0 (0-6). CONCLUSION:SNS is an effective treatment for faecal incontinence in patients over 65 years.

Methods A consecutive series of patients with complex perianal Crohn’s Disease between January 2003 and June 2008 were included. Acute sepsis was treated with antibiotics, incision and drainage (I&D), and seton insertion. Infliximab was infused at 5 mg/kg at 0, 2, and 6 weeks. MR scans done prior to IFX &Setons were empirically removed after IFX second cycle. Endpoints were complete, partial or no response documented at outpatient follow up &adverse reactions recorded.

BACKGROUND:The number of colonoscopic procedures continues to rise rapidly. With widespread adoption of colonoscopy based bowel screening programmes, this rising trend is set to continue.AIMS:This study aimed to identify whether elective colonoscopy could provoke cardiac rhythm disturbances and/or myocardial ischaemia, as evidenced by 12 lead Holter ECG recordings and troponin I (cTnI) changes.MATERIALS AND METHODS:Patients were stratified into three groups based on the presence of cardiac disease or cardiovascular risk factors. They underwent real time 12 lead Holter monitoring before, during and after colonoscopy. Bloods were taken for pre- and post-procedure cTnI estimation.RESULTS:Holter ECG recordings of the three groups showed a high incidence of new but silent ischaemic and arrhythmic ECG changes during the colonoscopy in patients with documented but stable heart disease and to a lesser extent in those patients with one or more risk factors for heart disease. Three patients had high cTnI concentrations both before and after colonoscopy. Two patients with known heart disease died within 30 days of colonoscopy.CONCLUSIONS:This study demonstrates for the first time the occurrence of potentially clinically significant ST-T wave changes and rhythm disturbances during elective colonoscopy in patients with known heart disease and to a lesser extent in those patients with a known cardiovascular risk profile.

Colorectal DiseaseVolume 12, Issue 3 p. 270-271 A possible troponin I leak arising from bowel preparation for elective colonoscopy – are there more implications than observed? A. T. George, A. T. George Department of General SurgerySearch for more papers by this authorM. Allison, M. Allison Department of Gastroenterology/General Medicine, The Royal Gwent Hospital, Newport, South Wales, UK.E-mail: [email protected]Search for more papers by this authorK. J. Swarnkar, K. J. Swarnkar Department of General SurgerySearch for more papers by this author A. T. George, A. T. George Department of General SurgerySearch for more papers by this authorM. Allison, M. Allison Department of Gastroenterology/General Medicine, The Royal Gwent Hospital, Newport, South Wales, UK.E-mail: [email protected]Search for more papers by this authorK. J. Swarnkar, K. J. Swarnkar Department of General SurgerySearch for more papers by this author First published: 17 February 2010 https://doi.org/10.1111/j.1463-1318.2009.01957.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1 Sanders G, Mercer SJ, Saeb-Parsey K et al. Randomised clinical trial of intravenous fluid replacement during bowel preparation for surgery. Br J Surg 2001; 88: 1363–5. 2 National Patient Safety Agency. Rapid Response Report. NPSA/2009/RRR012. 19 February 2009. http://www.npsa.nhs.uk. Volume12, Issue3March 2010Pages 270-271 ReferencesRelatedInformation

I was surprised that Graham Read feels that salivary steroid assays are ‘still awaiting a killer application’ in his editorial on my review. The remit for the review from the ACB Clinical Sciences Reviews Committee was to provide an up-to-date guide to those assays that were suitable for a routine diagnostic service, and the criteria for assessment were chosen with this in mind. The evidence base for the use of salivary cortisol in screening for Cushing’s is now strong and extensive, and where sensitivities and specificities have been reported these are as good or better than those cited for the conventional screening tests of urine cortisol or plasma cortisol following dexamethasone suppression. Recently, the Endocrine Society has endorsed the use of evening salivary cortisol as a screen for Cushing’s in their Clinical Practice Guideline. This is the ‘killer application’, since there is now sufficient evidence to justify the introduction of salivary cortisol into routine use for Cushing’s screening.