BMJ Frontline Gastroenterology Latest Issue

Upfront April 2012

Emmanuel, A. V. — 2012-03-13T03:50:34-07:00

Getting involved in clinical trials

The prevailing increases in clinical workload are occurring at a time when there are expanding opportunities for advances in clinical research. Our lead-off article in this edition, is authored by a team comprising the National Leads for the two Networks along with active clinical researchers and the ex-chair of the BSG Research Committee. It highlights how a national research network can help with accrual into clinical trials as well as improve opportunities for clinical research in gastrointestinal and liver disease.

Safe endoscopy in patients with implanted devices

This edition's Editor's Choice reflects another challenge, in an era of increasingly specialised practice: how gastroenterologists interface with the emerging technology in other specialities. This is especially the case in safety issues, and Corbett et al have described the state of knowledge to help endoscopists confronted with patients who have had implanted cardiology or...

Getting involved in clinical trials research in the UK: how can Clinical Research Networks help?

Hull, M. A., Yiannakou, Y., Gower, J., Ryder, S. D., Bloom, S. L., Rees, C. R. — 2012-03-13T03:50:34-07:00

The Clinical Research Networks of the National Institute of Health Research have transformed clinical research in the UK, leading to a doubling in the number of patients involved in clinical research studies over the past 3 years. This has been achieved by streamlining the trials approvals process, by providing local infrastructure such as research nurse support for clinical trials recruitment and through recognition of the time and funding necessary for clinicians to contribute to clinical research. Here, we describe the structure and roles of the Comprehensive Clinical Research Networks in gastrointestinal disease and hepatology, particularly in England. We will explain how the networks have already accelerated clinical research in gastrointestinal and liver disease, as well as provide a simple guide about how individual clinicians can contribute to ongoing studies via the networks.

Endoscopy and implantable electronic devices

Corbett, G. D., Buttery, P. C., Pugh, P. J., Cameron, E. A. B. — 2012-03-13T03:50:34-07:00

The increasing use of implantable electronic devices such as cardiac pacemakers and neurostimulators means that they are being increasingly encountered in endoscopy departments. The electromagnetic fields generated during electrosurgery and with magnetic imaging systems have the potential to interfere with such devices. The authors present a case that highlights some of the steps necessary for minimising risk, review the evidence and summarise the currently available guidance.

Improving outpatient services: the Southampton IBD virtual clinic

2012-03-13T03:50:34-07:00

The follow-up of inflammatory bowel disease (IBD) patients is challenging due to the relapsing remitting nature of the diseases, the wide spectrum of severity and complexity as well as the need for monitoring of long-term complications and drug treatments. Conventional outpatient follow-up lacks flexibility for patients and there are competing pressures for clinic time. Alternative follow-up pathways include telephone clinics, self-management programmes or discharging patients. The IBD virtual clinic (VC) is a further option. Patients with an established diagnosis for >2 years, who have been stable for >1 year, do not have primary sclerosing cholangitis and who give their consent, are entered into the VC system. Two months before their annual follow-up is due patients are sent blood test forms and a simple questionnaire with an information sheet. If they meet any of the criteria on the questionnaire, they are asked to contact the IBD specialist nursing team to discuss their situation. The blood test results and the patient's database entry are reviewed to ensure that they are not due surveillance investigations. The patients and their GPs then receive a letter informing them of their management plan. We currently follow-up 20% of the Southampton IBD cohort using the VC. The VC system is an innovative, efficient and patient-responsive method for following up mild to moderate IBD. It is well liked by patients but is dependent on a well-maintained database with good integration of IT systems and requires both clerical and IBD nurse specialist support.

Positive tissue transglutaminase antibodies with negative endomysial antibodies: coeliac disease or not?

Hornung, T., Gordins, P., Parker, C., Thompson, N. — 2012-03-13T03:50:34-07:00

Introduction

Coeliac disease (CD) is a chronic autoimmune disorder of the small intestine induced in genetically susceptible individuals by the ingestion of gluten, the major storage protein of wheat, rye and barley.1 It has been estimated that overall prevalence of CD in the general population is as high as 1/160 or 0.62%.2 The current diagnostic algorithm for CD includes initial serological screening test, followed by a confirmatory small intestinal biopsy showing the autoimmune insult typical of CD.3 4 In following such an approach, serological screening is primarily used to identify those individuals in need of a diagnostic endoscopic biopsy.3 5

The most sensitive and specific serological tests for the diagnosis of CD are based on the detection of immunoglobulin A (IgA) antibodies against human tissue transglutaminase (tTGA) enzyme and connective tissue elements covering individual smooth muscle...

The era of modern medicine: implants and all

Guha, K., Sharma, R. — 2012-03-13T03:50:34-07:00

Editorial

Modern medicine is awash with technological advance. Though the last three decades have witnessed countless pharmacological successes, the pace of novel drug development has slowed down. Since the dawn of the new century, medicine has embraced technological changes with a resultant increase in implantable devices. Though the attendant physician may feel that medical devices are the remit of the specialist, with the expanding indications for medical implants, it is likely that physicians will encounter unfamiliar devices in routine and emergency clinical practice.

Corbett et al highlight such issues within the sphere of endoscopy.1 Using an initial case of nucleus stimulators, the authors describe a successful endoscopic examination using a multidisciplinary approach. The authors indicate that the number of neurological and cardiac devices is rising. The Heart Rhythm network data indicates an increase in cardiac pacing (both basic and complex) and cardiac defibrillators.2 This...

Effective teamworking in gastroenterology

Haycock, A., Matharoo, M. K., Thomas-Gibson, S. — 2012-03-13T03:50:34-07:00

The majority of healthcare provision within the NHS is delivered by teams, but most attempts at improving team functioning are limited to promoting working relationships within the team. This contrasts with other high risk industries, where formalised team training is recognised to be of paramount importance in reducing error. Some medical specialities have adapted such training methodologies with the aim of improving productivity and clinical outcomes. There are many teams within gastroenterology that could benefit from such attention. Formal analysis of team objectives and identification of essential task sequences can allow redesign of team organisation and enable structured training to strengthen team cohesion, enhance critical team skills and improve clinical outcomes. The challenge is to change teams of experts into expert teams.

Aviation: a pilot study for safety in gastroenterology?

Gordon, H. — 2012-03-13T03:50:34-07:00

In 1999, a Korean Airline aeroplane took off from Stansted, UK. The Captain's artificial horizon failed, which therefore gave inaccurate readings; the first officer had a correctly functioning horizon and the flight engineer had a clear view of both. Neither flight engineer nor first officer felt able to point out the captain's instruments failing, with the clear cultural training of ‘I must not question the captain’. The result was the aeroplane was flown into the ground by the commander and all the crew died. The outcome of this disaster was ultimately that worldwide pilots came to be taught enhanced mandatory safety standards.

Aviation has many similarities to medicine in that both involve professional teams responsible for complex decision making, using specialised technology, within a high-risk environment. Both have in place accepted practices to minimise potentially life threatening situations. Currently, there is approximately one passenger death per 10 million flights,...

Safety in the endoscopy suite: lessons from the aviation industry

Brown, J. L. — 2012-03-13T03:50:34-07:00

Human error is inevitable. Although society's sense of justice is satisfied by counselling, retraining, suspending or dismissing defective perpetrators and compensating victims, healthcare professionals have been slow to adopt alternative strategies to address iatrogenic morbidity and mortality. In recent years, the concept that human factor techniques validated in the aviation industry may be relevant to medicine has gained some momentum1 2 3. In this issue of the journal, Dr Gordon reminds us that 75% of aviation accidents have human error as a co-factor with poor interpersonal communication, decision making and leadership as major themes. She explains why standard operating procedures, crew resource management, incentivised no-fault reporting and the confidential human factors incident reporting programme have become an integral part of pilot training and how the concepts could be applied to the National Health Service.

Implementation of the WHO surgical safety checklist4...

Improvement of parenteral nutrition-associated cholestasis in an adult using fish oil-based parenteral nutrition

Moyes, L. H., Hamid, R., Clutton, J., Oien, K. A., McKee, R. F., Forrest, E. H. — 2012-03-13T03:50:34-07:00

Parenteral nutrition-associated cholestasis (PNAC) is a severe complication of parenteral nutrition. Standard feed preparations contain soybean and olive oil that are rich in -6 polyunsaturated fats, and which studies suggest can be hepatotoxic. Preparations containing fish oil, rich in -3 polyunsaturated fats, may be hepatoprotective and have been used in the critical care setting as immunotherapy. A case demonstrating dramatic improvement in liver function and overall clinical condition in an adult with PNAC and intestinal failure within 8 weeks of changing to a fish oil-based parenteral feed is reported. As far as is known, this is the first report of an adult patient whose parenteral nutrition-associated liver disease resolved after a parenteral nutrition lipid emulsion was changed to the fish oil-containing emulsion, SMOFlipid.

Provision of service and training for small bowel endoscopy in the UK

2012-03-13T03:50:34-07:00

Objective

To determine the location and use of small bowel endoscopy services in the UK and to analyse training uptake to assess future demand and shape discussions about training and service delivery.

Design

Surveys of British Society of Gastroenterology (BSG) members by web-based and personal contact were conducted to ascertain capsule endoscopy practice and numbers of procedures performed. This was compared with expected numbers of procedures calculated using BSG guidelines, hospital episode statistics and published data of capsule endoscopy in routine practice. Analysis of data from two national training courses provided information about training.

Results

45% of UK gastroenterology services offered in-house capsule endoscopy. 91.3% of survey responders referred patients for capsule endoscopy; 67.7% felt that local availability would increase referrals. Suspected small bowel bleeding and Crohn's disease were considered appropriate indications by the majority. Demand is increasing in spite of restricted use in 21.6% of centres. Only two regions performed more than the minimum estimate of need of 45 procedures per 250 000 population. Eight centres perform regular device-assisted enteroscopy; 14 services are in development. 74% of trainees were interested in training and of those training in image interpretation, 67% are doctors and 28% are nurses.

Conclusions

Capsule endoscopy is used by the majority of UK gastroenterologists but appears to be underused. Current demand for device-assisted enteroscopy seems likely to be matched if new services become established. Future demand is likely to increase, however, suggesting the need to formalise training and accreditation for both doctors and nurses.

The endoscopically normal colon: when is mapping biopsy histopathologically justifiable?

Elliot, V. J., Bateman, A. C., Green, B. — 2012-03-13T03:50:34-07:00

Objective

Mapping biopsy of endoscopically normal colon is a contentious area and generates considerable work for histopathology services. Managing demand for pathological testing is a current healthcare priority. In this retrospective audit, the authors aimed to establish diagnostic yield of mapping biopsy in this specific subgroup and identify situations where practice could be safely streamlined.

Design

Cases were retrieved over a 10-month period. Histopathology results were correlated with relevant endoscopy reports. The data were anonymised and analysed.

Setting

Department of Cellular Pathology, Southampton General Hospital, UK.

Results

717 cases were retrieved. 308 (43%) cases were reported as endoscopically normal. 278 (90%) cases with endoscopically normal/near normal mucosa showed normal/near normal histology. 30/308 (9.7%) endoscopically normal cases showed pathological abnormalities. 9/308 (2.9%) cases of microscopic colitis were detected. Of the 30 cases with pathological abnormalities, 20 (66.7%) presented with change in bowel habit and 6 (20%) had a pre-existing diagnosis of inflammatory bowel disease.

Conclusions

Pathological abnormalities in endoscopically normal colon are found most frequently in those who present with change in bowel habit or a known history of inflammatory bowel disease. The authors support biopsy in these individuals and believe that mapping biopsy of endoscopically normal colon in patients referred for other reasons (eg, bright red rectal bleeding or iron deficiency anaemia) should not be performed routinely as diagnostic yields are very low. Guidelines on appropriate use of mapping biopsy in this setting are limited. Streamlining patients based on reason for referral or presenting symptoms may be a useful step towards more effective management of histopathological demand.

Efficacy of nasal bridles in avoiding percutaneous endoscopic gastrostomy placement

Webb, G., Gupta, P., Fitchett, J., Simmons, J., De Silva, A. — 2012-03-13T03:50:34-07:00

Objective

The aim of the study was to report the use of nasogastric tube bridles to avoid dislodging of percutaneous endoscopic gastrostomy tubes. Specifically it was intended to see if they reduced feeding time, medical input and costs.

Design

and setting This was a cohort study in a district hospital setting.

Patients

164 patients admitted with conditions causing acutely impaired swallowing.

Interventions

140 of 164 patients referred received a NGT bridle.

Results

Of these, 49 (35%) died by 28 days and 68 (48.6%) at 1 year; 73 (52.1%) had regained adequate oral intake at 28 days and 27 (19.2%) had proceeded to PEG. Of those not bridled, nine (37.5%) died by 28 days and 10 (41.7%) at 1 year with the remainder eating. There was no significant difference in mortality between groups. There were no complications attributed to bridles.

Conclusion

We conclude that nasogastric bridles are safe and represent an appropriate method to maintain nutrition while seeing if the underlying disease process will stabilise in these critically ill patients. They have the benefits of avoiding unnecessary PEG and the associated complications and cost.

Teaching and learning on the ward round

Johnston, B. T., Valori, R. — 2012-03-13T03:50:34-07:00

Because of the European Working-Time Directive and ‘the New Deal’, there has been a significant reduction in opportunities for training. To address this deficit, consultants and junior doctors will need to alter their approach, making greater use of the learning opportunities that arise ‘on the job’. This paper provides some ideas on how to maximise learning without radically increasing workload. The paper first looks at attitudes and behaviours that influence the learning environment. If the senior doctor encourages discussion and shows enthusiasm during clinical duties, junior doctors will learn more. Second, the paper focuses on key skills that can be adopted to ensure appropriate learning. These attitudes, behaviours and skills can help consultants and senior doctors improve the effectiveness of their teaching in an era when the time available for junior doctors to learn has been reduced.

Quality assurance in the endoscopy unit: the view of endoscopy personnel

de Jonge, V., Kuipers, E. J., van Leerdam, M. E. — 2012-03-13T03:50:34-07:00

Introduction

Quality of health services depend on the entire medical team. A supportive team culture and effective leadership is required for successful quality assurance (QA). The opinion of endoscopy personnel towards QA is unknown, while they have to collaborate in many quality projects.

Methods

A survey was sent to all endoscopy nurses, assistants and managers. It focused on the implementation of a QA programme. Further, a team assessment was included, focusing on leadership and team functioning, using scores on 5-point Likert scales, with 1 being a very positive opinion, and 5 being a very negative opinion towards the item.

Results

294 persons completed the questionnaire (44%). 87% expressed a positive attitude towards a QA programme, and 54% thought that the implementation of a nationwide QA programme for endoscopy would be feasible. Positive effects of QA were expected on publicity (62%) and overall quality (70%). Most important QA aspects were aftercare (97%) and patient experiences (96%). Concerns were raised about the time investment (18%) and disclosure of results towards media (24%). Team assessment showed good scores on `team working' with a mean score of 1.97. Lower scores were given to the `wider organization' (3.00) and `team process' (2.42).

Conclusion

Endoscopy personnel have a positive attitude towards a QA programme. Besides, the team culture and its leadership are ready for the implementation of a QA programme. Efforts should be made to improve team processes and the relation with the wider organisation to ensure an optimal team culture, aimed at quality improvement.