INTRODUCTION: General practitioners (GPs) have the potential to promote alcohol harm minimisation via discussion of alcohol use with patients, but knowledge of GPs’ current practice and attitudes on this matter is limited. Our aim was to assess GPs’ current practice and attitudes towards discussing alcohol use with their patients. METHODS: This qualitative study involved semi-structured, face-to-face interviews with 19 GPs by a group of medical students in primary care practices in Wellington, New Zealand. FINDINGS: Despite agreement amongst GPs about the importance of their role in alcohol harm minimisation, alcohol was not often raised in patient consultations. GPs’ usual practice included referral to drug and alcohol services and advice. GPs were also aware of national drinking guidelines and alcohol screening tools, but in practice these were rarely utilised. Key barriers to discussing alcohol use included its societal ‘taboo’ nature, time constraints, and perceptions of patient dishonesty. CONCLUSION: In this study there is a fundamental mismatch between the health community’s expectations of GPs to discuss alcohol with patients and the reality. Potential solutions to the most commonly identified barriers include screening outside the GP consultation, incorporating screening tools into existing software used by GPs, exploring with GPs the social stigma associated with alcohol misuse, and framing alcohol misuse as a health issue. As it is unclear if these approaches will change GP practice, there remains scope for the development and pilot testing of potential solutions identified in this research, together with an assessment of their efficacy in reducing hazardous alcohol consumption. KEYWORDS: Primary health care; general practice; alcohol drinking; alcohol-related disorders, attitude of health personnel

BenedictDevereaux is a consultant and member on advisory board for Boston Scientific. Milan Bassan is a consultant for Boston Scientific. Payal Saxena is a consultant for Boston Scientific. Thawee Ratanachu-EK is a proctor for Boston Scientific. All other authors have no relevant conflicts of interest to disclose. Financial support: There were no sources of financial grants or other funding for this study.

Summary Background The Disease Severity Index (DSI) is a novel tool to predict disease severity in inflammatory bowel disease (IBD). However, its ability to predict disease complications and the presence of psychosocial comorbidity is unclear. Aims: To assess prospectively associations between the DSI and psychological symptoms, quality‐of‐life (QoL) and disease outcomes in an IBD cohort. Methods Patients with IBD undergoing ileocolonoscopy were followed prospectively for 12 months. DSI, psychological symptoms (perceived stress (PSS‐10), depression (PHQ‐9), anxiety (GAD‐7)) and QoL (IBDQ‐32) scores were assessed at baseline. Logistic regression identified variables predicting a complicated IBD course at 12 months (composite outcome of need for escalation of biological/immunomodulator for disease relapse, recurrent corticosteroid use, IBD‐related hospitalisation and surgery). Receiver operating characteristics (ROC) analysis identified optimal DSI thresholds predicting a complicated disease course and multivariable logistic regression assessed the risk of reaching this outcome. Results One hundred and seventy‐two patients were recruited (100 Crohn's disease, 91 female). Median DSI was 21 (IQR 11–32) and 97 patients had endoscopically active disease at baseline. The DSI was significantly higher in patients with symptoms of moderate–severe stress (PSS‐10 > 14, p < 0.01), depression (PHQ‐9 ≥ 10, p < 0.01), anxiety (GAD‐7 ≥ 10, p < 0.05) and impaired quality‐of‐life (IBDQ‐32 < 168, p < 0.01). Only the baseline DSI (OR 1.05, p < 0.01) and endoscopically active disease (OR 6.12, p < 0.01) were associated with a complicated IBD course. A DSI > 23 was strongly predictive of a complicated IBD course (OR 8.31, p < 0.001). Conclusions The DSI is associated with psychological distress, impaired QoL and predicts a more complicated disease course in patients with IBD.

Background: Disease activity may be a risk factor for psychological illness in patients with inflammatory bowel disease (IBD). Aim:To correlate objective measures of disease activity with psychological symptoms.Methods: Adult patients with IBD undergoing ileocolonoscopy were prospectively recruited. Demographic, psychological symptoms (depression, anxiety, stress), disease activity (symptoms, biomarkers, endoscopy), and quality of life (QoL) data were collected. One-way ANOVA and multivariable analyses examined the associations between disease activity and symptoms of psychological illness, and identified other predictors of mental illness and reduced QoL.Results: A total of 172 patients were included, 107 with Crohn's disease (CD) and 65 with ulcerative colitis (UC). There was no significant association between objec-

The intestinal barrier is a dynamic multi‐layered structure which can adapt to environmental changes within the intestinal lumen. It has the complex task of allowing nutrient absorption while limiting entry of harmful microbes and microbial antigens present in the intestinal lumen. Excessive entry of microbial antigens via microbial translocation due to ‘intestinal barrier dysfunction’ is hypothesised to contribute to the increasing incidence of allergic, autoimmune and metabolic diseases, a concept referred to as the ‘epithelial barrier theory’. Helminths reside in the intestinal tract are in intimate contact with the mucosal surfaces and induce a range of local immunological changes which affect the layers of the intestinal barrier. Helminths are proposed to prevent, or even treat, many of the diseases implicated in the epithelial barrier theory. This review will focus on the effect of helminths on intestinal barrier function and explore whether this could explain the proposed health benefits delivered by helminths.

Background and aims Inflammatory bowel disease (IBD), consisting of Crohn’s disease (CD) and ulcerative colitis (UC), is a relapsing-remitting illness. Treat-to-target IBD management strategies require monitoring of gastrointestinal inflammation. This study aimed to investigate faecal myeloperoxidase (fMPO), a neutrophil granule enzyme, as a biomarker of IBD activity. Methods Prospectively recruited participants with IBD undergoing ileocolonoscopy for disease assessment provided biological samples and completed symptom questionnaires prior to endoscopy. fMPO, C-reactive protein (CRP) and faecal calprotectin (fCal) were compared with validated endoscopic indices (simple endoscopic score for CD and UC endoscopic index of severity). Receiver operating characteristics (ROC) curves assessed the performance of fMPO, CRP, and fCal in predicting endoscopic disease activity. Baseline biomarkers were used to predict a composite endpoint of complicated disease at 12 months (need for escalation of biological/immunomodulator due to relapse, steroid use, IBD-related hospitalisation and surgery). Results One hundred and seventy-two participants were recruited (91 female, 100 with CD). fMPO was significantly correlated with endoscopic activity in both CD (r=0.53, p&lt;0.01) and UC (r=0.63, p&lt;0.01), and with fCal in all patients with IBD (r=0.82, p&lt;0.01). fMPO was effective in predicting moderate-to-severely active CD (AUROC 0.86, p&lt;0.01) and UC (AUROC 0.92, p&lt;0.01). Individuals with a baseline fMPO &gt;26 µg/g were significantly more likely to reach the composite outcome at 12 months (HR 3.71, 95% CI 2.07-6.64, p&lt;0.01). Conclusions Faecal myeloperoxidase is an accurate biomarker of endoscopic activity in IBD and predicted a more complicated IBD course during follow-up.

Background Increased disease activity may be a risk factor for sexual dysfunction (SD) in patients with inflammatory bowel disease (IBD). This study investigated associations between objective measures of disease activity and sexual function. Methods Adults with IBD undergoing ileocolonoscopy were prospectively recruited. Demographic, sexual function (Female Sexual Function Index and International Index of Erectile Function), disease activity (endoscopic, biomarker, and symptoms), psychological symptoms, and quality-of-life data were collected. Rates of SD and erectile dysfunction (ED) were compared between patients with active and inactive inflammation and symptoms using the Fisher’s exact test. Logistic regression examined associations between SD and ED, and disease characteristics and psychological symptoms. Results A total of 159 participants were included, 97 had Crohn’s disease and 85 were women. SD was reported in 36 of 59 and 13 of 59 sexually active women and men, respectively and ED in 22 of 59 sexually active men. Rates of SD and ED were similar between individuals with active and inactive IBD based on endoscopic indices (P &gt; .05) and biomarkers (P &gt; .05). Women with active IBD symptoms experienced significantly higher rates of SD (P &lt; .05), but men did not (P &gt; .05). Multivariable logistic regression identified that symptoms of severe depression (odds ratio, 5.77; 95% confidence interval, 1.59-20.94) were associated with SD in women, and severe anxiety (odds ratio, 15.62; 95% confidence interval, 1.74-140.23) was associated with ED in men. Conclusions Objective measures of disease activity are not associated with SD or ED in patients with IBD. Clinicians should consider concomitant psychological symptoms contributing to the sexual health of patients with IBD.

Background Human hookworm has been proposed as a treatment for ulcerative colitis (UC). This pilot study assessed the feasibility of a full-scale randomized control trial examining hookworm to maintain clinical remission in patients with UC. Methods Twenty patients with UC in disease remission (Simple Clinical Colitis Activity Index [SCCAI] ≤4 and fecal calprotectin (fCal) &lt;100 ug/g) and only on 5-aminosalicylate received 30 hookworm larvae or placebo. Participants stopped 5-aminosalicylate after 12 weeks. Participants were monitored for up to 52 weeks and exited the study if they had a UC flare (SCCAI ≥5 and fCal ≥200 µg/g). The primary outcome was difference in rates of clinical remission at week 52. Differences were assessed for quality of life (QoL) and feasibility aspects including recruitment, safety, effectiveness of blinding, and viability of the hookworm infection. Results At 52 weeks, 4 of 10 (40%) participants in the hookworm group and 5 of 10 (50%) participants in the placebo group had maintained clinical remission (odds ratio, 0.67; 95% CI, 0.11-3.92). Median time to flare in the hookworm group was 231 days (interquartile range [IQR], 98-365) and 259 days for placebo (IQR, 132-365). Blinding was quite successful in the placebo group (Bang’s blinding index 0.22; 95% CI, −0.21 to 1) but less successful in the hookworm group (0.70; 95% CI, 0.37-1.0). Almost all participants in the hookworm group had detectable eggs in their faeces (90%; 95% CI, 0.60-0.98), and all participants in this group developed eosinophilia (peak eosinophilia 4.35 × 10^9/L; IQR, 2.80-6.68). Adverse events experienced were generally mild, and there was no significant difference in QoL. Conclusions A full-scale randomized control trial examining hookworm therapy as a maintenance treatment in patients with UC appears feasible.