No abstract

Cancer morbidity has been evaluated in a series of 513 patients with Crohn's disease under long-term review between 1944-76. In comparison with morbidity rates for cancer in the West Midlands Region (the geographical area from which these patients were drawn) the 31 tumours that occurred represented a relative risk of 1.7 (p < 001) of cancer at all sites. For tumours at sites within the digestive system the relative risk was 3.3 (p < 000 1). A significant excess of tumours was found in both the upper (P < 0.01) and lower (P < 0.001) gastrointestinal tract. There was no excess of tumours at any site outside the digestive system.

Twenty of 81 patients treated by restorative proctocolectomy for presumed ulcerative colitis had some features of Crohn's disease: 10 were classified as definite Crohn's disease and 10 as indeterminate colitis. These pathological features were first apparent during synchronous colectomy and pouch construction in 10 of 11 cases. In the remainder, histological features of possible Crohn's disease were first identified during rectal excision (n=6), preliminary subtotal colectomy (n=2), and after pouch excision (=2

SUMMARY Cancer morbidity at all sites has been studied in a series of 676 patients with ulcerative colitis under long-term review, of whom more than two-thirds had extensive disease, and the level and pattern of risk over time examined. Age-, sex-, and site-specific incidence rates were used to compute the number of cancers that might have been expected to occur. A highly significant excess of cancers was observed overall but the excess was due entirely to cancers of the digestive system. In women there was no excess or deficit of cancers outside the digestive system. In men there was a small deficit of cancers of the respiratory system. An overall 11-fold excess colorectal cancer risk was found in the series compared with that in a relevant general population after patient-years at risk had been corrected for surgical resection and patients with colorectal cancer at their first referral had been excluded. When these data were expressed in an actuarial form the cumulative probability of developing colorectal cancer in the series was 8% (3.5-13%) at 25 years, after the diagnosis of ulcerative colitis had been established. The relative risk of developing colorectal cancer was highest in those patients developing colitis before the age of 30 years, and the relative risk fell as the age at diagnosis of their colitis increased. The pattern of risk of colorectal cancer over time suggests that there is an association between cancer and colitis in susceptible individuals and that the level of risk is related to age at onset of colitis.Previous studies of the cancer risk in ulcerative colitis 1-8 have been confined almost exclusively to colorectal cancer, with the exception of the hepatobiliary system, which has received some attention.10 There is little information about the cancer incidence at other sites. We have therefore studied the whole spectrum of cancer morbidity in a series of patients with ulcerative colitis. This enabled us to examine some aspects of patient selection (analysis of clinical series being subject to many elements of bias3) to provide a basis from which to approach the specific problem of colorectal cancer.Estimates of the incidence of colorectal cancer complicating ulcerative colitis in the early literature were based on crude percentages. 1 Actuarial methods are now used which take into account the decreasing numbers of patients at risk for cancer over extended periods of observation. of colorectal cancer over time, although only a few2 4-7 have compared the risk in the series with that in a relevant general population. Despite these reports, the magnitude and the pattern of risk is uncertain and varies from one reported series to another. These variations probably reflect differences in the composition of the reported series and in the methods used to evaluate the risk rather than real differences in the underlying cancer risk. The differing approaches to analysis have been discussed both in general3 611 and in individual series.7We have attempted to identify and, where possible, to correct fo...

Background Corticosteroid injections and physiotherapy exercise programmes are commonly used to treat rotator cuff disorders but the treatments' effectiveness is uncertain. We aimed to compare the clinical effectiveness and costeffectiveness of a progressive exercise programme with a single session of best practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder.Methods In this pragmatic, multicentre, superiority, randomised controlled trial (2 × 2 factorial), we recruited patients from 20 UK National Health Service trusts. We included patients aged 18 years or older with a rotator cuff disorder (new episode within the past 6 months). Patients were excluded if they had a history of significant shoulder trauma (eg, dislocation, fracture, or full-thickness tear requiring surgery), neurological disease affecting the shoulder, other shoulder conditions (eg, inflammatory arthritis, frozen shoulder, or glenohumeral joint instability), received corticosteroid injection or physiotherapy for shoulder pain in the past 6 months, or were being considered for surgery. Patients were randomly assigned (centralised computer-generated system, 1:1:1:1) to progressive exercise (≤6 sessions), best practice advice (one session), corticosteroid injection then progressive exercise, or corticosteroid injection then best practice advice. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score over 12 months, analysed on an intention-to-treat basis (statistical significance set at 1%). The trial was registered with the International Standard Randomised Controlled Trial Register, ISRCTN16539266, and EuDRACT, 2016-002991-28.Findings Between March 10, 2017, and May 2, 2019, we screened 2287 patients. 708 patients were randomly assigned to progressive exercise (n=174), best practice advice (n=174), corticosteroid injection then progressive exercise (n=182), or corticosteroid injection then best practice advice (n=178). Over 12 months, SPADI data were available for 166 (95%) patients in the progressive exercise group, 164 (94%) in the best practice advice group, 177 (97%) in the corticosteroid injection then progressive exercise group, and 175 (98%) in the corticosteroid injection then best practice advice group. We found no evidence of a difference in SPADI score between progressive exercise and best practice advice when analysed over 12 months (adjusted mean difference -0•66 [99% CI -4•52 to 3•20]). We also found no evidence of a difference between corticosteroid injection compared with no injection when analysed over 12 months (-1•11 [-4•47 to 2•26]). No serious adverse events were reported.Interpretation Progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function. Subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders.