Despite their daily use in our practice, there is as yet no standardised way of assessing the patient's experience of bowel preparation. When patient tolerability of bowel preparation has such a critical role in the safety and utility of colonoscopy, this is a vital area. There is a complex process for the development of such patient reported outcome measures, and a multi-author group of experts have helped develop such an instrument following the ‘gold standard’ methodology. The tool they have devised, which we are delighted to publish in Frontline Gastroenterology, has great potential for use in everyday clinical practice and will provide evidence to inform any planned change of preparation regime. We look forward to other authors using the tool in their practice and writing up their experience in future editions.
Cost containment in prescribing budgets is, and always will be, a key priority in any health service with limited resources. Therefore, a number of primary care trusts (PCT) have recently initiated pharmacy-led switches of 5-aminosalicylic acids (5-ASAs), with the intention of reducing prescribing budgets. However, this has generated considerable controversy among gastroenterologists, as there is concern that the clinical consequences of such programmes have not been adequately explored.
PCTs are currently under no obligation to consult secondary care prior to initiating pharmacy-led switches. In a secondary care-led condition such as inflammatory bowel disease (IBD), this seems highly counterintuitive. If gastroenterologists were to be consulted, how would we respond, and what could we contribute? This article examines the clinical consequences of PCT-initiated switch programmes in IBD, and the knock-on effects on patients and the secondary care gastroenterology community.
For a switch programme to...]]>
ESO-2 video capsule endoscopy provides images of the oesophageal mucosa and continues to transmit gastric, and often small bowel images, for up to 30 min. This study compares ESO capsule endoscopy capsule oesophago-gastro-duodenoscopy (Cap-OGD) with conventional endoscopy (OGD).
50 outpatients with uncomplicated dyspepsia underwent Cap-OGD followed by OGD which was recorded on DVD. Cap-OGD and OGD were each reported independently by two gastroenterologists. A benchmark report was also produced by two gastroenterologists viewing both Cap-OGD and OGD on side-by-side monitors. Major findings included large hiatus hernia, Barrett's oesophagus, oesophagitis, erosive gastritis, tumour and ulceration. Minor findings included histologically-proven superficial gastritis, pouting gastric folds and fundic gland polyps. A questionnaire assessed the patient experience.
49 patients completed the study. In 61%, Cap-OGD transmitted in the duodenum. In the benchmark study, all the major OGD findings were observed on Cap-OGD. Cap-OGD revealed fewer minor findings. When reported independently, Cap-OGD and OGD reports indicated differences in interpretation most marked between the capsule readers with or without previous ESO-2 experience. Patients expressed a clear preference for Cap-OGD.
When compared side-by-side, all the major findings on OGD are seen on Cap-OGD while there is under-reporting of minor findings. Previous experience of ESO-2 capsule reporting improves reading accuracy and indicates the need for training. This pilot study provides a backdrop to explore the possible role of Cap-OGD, especially where patients are reluctant to undergo conventional OGD or where there is risk of prion contamination of the endoscope.
A nurse practitioner-led dysphagia service was introduced to improve appropriateness of investigations.
To determine the clinical outcomes and efficacy of this service.
A 7-year prospective audit of the first 2000 patients referred for investigation of dysphagia.
Royal Cornwall Hospitals NHS Trust.
An innovative nurse practitioner-led telephone dysphagia hotline (DHL) assessment service for all patients and consultant review following investigation prior to discharge.
Clinical outcomes, service efficiency and cost effectiveness.
2000 patients (median age 70 years, 48% male) were referred in less than 7 years, 1775 being managed fully through the DHL. 67% patients had gastroscopy only, 13% barium swallow only and 8.8% both and 11.2% had no investigation. Reflux was the commonest cause (41.3%), 9% had peptic stricture, 10% malignancy 1.9% pharyngeal pouches and 0.8% achalasia. The did not attend rate was reduced from 3.9% to 1.1% and 151 patients either refused or did not require investigation saving a potential £53 040. Although some patients with pharyngeal pouches had gastroscopy as initial investigation, no complications resulted.
The nurse practitioner-led DHL service has improved efficiency and resulted in a safe prompt service to patients.
In recent years, policies have been proposed in order to guide the safer use of non-steroidal anti-inflammatory drugs (NSAIDs) and antiulcer therapy. We aimed to investigate the incidence of upper gastrointestinal bleeding (UGIB) before and after the introduction of these policies, 2007–2009, in a well-defined population in southwest Scotland.
All patients with non-variceal upper gastrointestinal bleeding (NV-UGIB), diagnosed at a single regional unit, were included. Total drugs prescribed in our population were noted, including antiulcer drugs, antithrombotic drugs and both cyclo-oxygenase-2 enzyme-selective and non-selective inhibiting NSAIDs.
The incidence, the number of cases per 100 000 population per annum, of NV-UGIB fell from 134.7 in 2007 to 125.1 in 2008, and to 90.3 cases in 2009 (p<0.001). There was also a significant rise in the use of non-selective NSAIDs, proton pump inhibitors and antithrombotic drugs.
Although a cause-and-effect relationship cannot be fully proven, physician education through drug-use policies is associated with a drop in the incidence of NV-UGIB. This is relevant to the prevention of this common condition.
Acceptability and tolerability of bowel cleansers influence whether patients are able to complete the prescribed dose and, consequently, the quality of the cleansing achieved. No standardised means of assessing patients’ experience of using bowel cleansing is currently available. The aim of the study was to develop the Bowel Cleansing Impact Review (BOCLIR) to assess patient response to bowel cleansing products.
Content was derived from qualitative interviews. Face and content validity were assessed via cognitive-debriefing interviews. Finally, patients completed the BOCLIR and a demographic questionnaire. Item response theory (Rasch analysis) was employed for item reduction and assessment of unidimensionality. Internal consistency and construct validity were also assessed.
Analysis of 40 interviews resulted in the production of three scales; patient satisfaction, symptomatic impact and activity limitations. Scales were designed to be used alone or together. 19 debriefing interviews demonstrated BOCLIR acceptability, relevance and ease of completion. The validation survey involved 166 patients (52% male, mean (SD) age 54.3 (15.2) years). After misfitting and redundant items were removed all scales fit the Rasch model confirming their unidimensionality. Cronbach's α-coefficients were high (0.77–0.94) indicating good internal consistency. Scores on the BOCLIR were related to patients’ willingness to use the product in future and ease of drinking the full preparation (p<0.01 for each scale).
The BOCLIR is a new measure consisting of three unidimensional scales (satisfaction, symptoms and activity limitations) with good psychometric and scaling properties. The BOCLIR will allow accurate assessment of patients’ response to bowel cleansing preparations.
There is limited data on the risk of developing diarrhoea in travelling patients with inflammatory bowel disease (IBD). We analysed the rate of developing diarrhoea among travellers suffering from IBD and their healthy controls.
We performed a retrospective case-controlled study among 78 patients with IBD and their healthy travelling companion controls, thus matching both groups to the same environmental conditions. Data was retrieved through a structured questionnaire, interview and clinical case notes review.
Sixteen (20.5%) patients with IBD developed diarrhoea while abroad (p –0.0001) Statistical analysis using a 2 test for independence (with Yates Continuity Correction). Prior to travelling, they were in clinical remission. Only one healthy control (1.3%) developed diarrhoea while abroad. In 11 patients (14.1%), the duration of diarrhoea was 3 days or less, and resolved on its own without antibiotics, any increase in their IBD medications and without a medical consultation. The other five patients had a flare-up of their disease and needed medications to put them back into remission. There was no statistically significant difference between patients having immunomodulator medications versus those having aminosalicylates only in developing diarrhoea when abroad.
Patients with IBD have a higher rate of developing diarrhoea compared with controls when travelling. Thus, such patients must always seek a pretravel medical consultation.
Chronic hepatitis C infection (HCV) is common in injecting drug users and is a major cause of liver disease. Antiviral treatment can ‘cure’ HCV, but is frequently associated with side effects and requires regular monitoring. Non-attendance at hospital appointments is frequent. To try and improve attendance and increase the number of current and previous injecting drug users treated we developed three outreach clinics.
To review the outcome of patients referred to the outreach clinics.
Retrospective service review of three clinics at drug treatment centres in Newcastle and Northumberland. Data was collected on attendance rates, patient demographics, treatment rates and outcomes.
141 referrals were received across the three sites with an overall attendance rate of 75% (106 patients, 79% men and median age 36), which compared favourably with that at our hospital (50%). All patients were on methadone/subutex. 45% were infected with Genotype 1 HCV. 10% were cirrhotic. To date, 30% have started treatment and 21% are waiting to start or are still in workup. 13% elected to delay treatment due to early stage disease and 11% were not ready for treatment on psychological or social grounds. Only 12% failed to attend follow up after initial assessment. To date, 24 patients have completed full courses of treatment with sustained viral response in 13 patients. Results are awaited for seven patients.
The development of outreach clinics for HCV in drug treatment centres can substantially improve clinic attendance and increase access to treatment in this marginalised group.
Alcohol-related admissions are increasing. A significant number of these admissions are attributable to a small number of complex patients with other comorbidities who do not engage well with mainstream services. Assertive outreach teams have been used in the field of psychiatry to engage patients who are poorly compliant. This study examines whether an alcohol assertive outreach team (AAOT) can engage with this group and reduce hospital admissions.
The AAOT is a multidisciplinary team with medical, psychiatric, substance misuse, psychology, nursing and social work specialists. The team worked with patients with the highest number of alcohol-related admissions and case managed in a community setting for 6 months. The admission and emergency department attendances of the cohort were compared for the 3-month period before and after the intervention. Christo inventory for substance misuse services (CISS) scores were determined pre and post the intervention period.
54 patients were case managed. The total number of admissions in 3 months fell from 151 prior to the intervention period to 50 following the intervention. Emergency department attendances also fell from 360 in 3 months to 146 following the intervention period. CISS scores fell from 11 preintervention to eight postintervention.
An AAOT model appears to reduce hospital admissions and emergency department attendances in a complex group of patients that display high alcohol-related admissions.
Emergency ERCP may be required in patients with severe cholangitis who rapidly deteriorate with multi-organ dysfunction and who cannot wait until the next available elective list. A significant proportion of patients require ventilatory and inotropic support. We describe our experience on the outcome of emergency ERCP in this cohort of critically ill patients.
Medical records of cases undergoing ERCP between November 2008 and November 2011 were retrospectively reviewed. Patients who were in intensive care unit or required general anaesthesia due to haemodynamic compromise at the time of ERCP were included.
Total of 2237 ERCPs were performed during this period, of which 36 (2%) emergency ERCP's were performed in 33 patients. The median age was 79 years. All procedures were performed under general anaesthesia in emergency operating room. In 27/36 procedures (75%), the patients required inotropes. Indications included cholangitis (78%), pancreatitis (14%) and post-operative bile leak (8%). Biliary cannulation was achieved in 100% of cases. Endoscopic findings included CBD stones (64%), CBD stones and an additional pathology (8%), bile leak (8%), CBD stricture (5%), Mirizzi's (3%) and blocked plastic stent (3%). In 23/36 (64%) procedures a stent was inserted. In 11/36 (30%) procedures a balloon trawl was sufficient to clear the bile duct. Thirty-day mortality was 25%. Although the 30-day mortality remains high due to multi-organ failure, ERCP is successful and effective in the majority of patients and results in a good outcome for this cohort of critically ill patients, in whom the prognosis is inevitably poor without emergency biliary drainage.
]]>It is the end of another busy week in a full time clinical job and a good time to reflect on the last few years doing clinical research. Hopefully looking back has not become disproportionally rose tinted already, but like many trainees I now face the difficulty of trying to perform studies and publish work while doing a full time job. So what was different about a research post and would I recommend it?
Training in academic medicine alongside specialty training is accessible through the National Institute for Health Research (NIHR) integrated academic training programme. Before starting my 3.5-year period of out of programme research (OOPR) I had already performed pilot studies during an Academic Clinical Fellowship (part of the NIHR program) which had included a 6-month block of research early in my registrar training. This was clearly a massive benefit to my research as I already knew...]]>
Crohn's disease (CD) is characterised by periods of relapse and remission. Over time the disease leads almost inevitably to the complications of stricturing, penetration and fistulisation. Perianal CD involves areas of chronic abscess formation, ulceration, skin tags or fistula formation. This can be a particularly challenging and complex problem to manage, and a range of potential treatment modalities exist.
This review covers the management of perianal CD and provides recommendations for practice for the multidisciplinary team (MDT), including the use of wound management products and relevant clinical images.
Current practice focuses predominantly on the use of antibiotic therapy, immunosuppression, immunomodulation and surgery. These therapies are used individually or in combination. The majority of evidence suggests that a combination of medical and surgical management produces the best disease outcomes. However, this treatment regime can be debilitating for the patient and compliance can be difficult. Published work on the use of topical therapy in the management of perianal CD focuses specifically on topical drug therapy; it does not, however, address the basic guiding principles of chronic wound management—in particular, optimal moisture control and the management of bacterial burden on the wound surface. Honey and silver-containing wound management products act as topical antimicrobial agents and therefore address these principles.
Perianal CD is the archetypal condition that exemplifies the need for an MDT approach in caring for patients with inflammatory bowel disease. A combination of treatment modalities that includes topical wound management is likely to produce the best patient outcomes.
The Dr Falk/Core awards recognise those who bring new knowledge and insight to the field of gastroenterology and hepatology.
Edwin Halliday, UCL Medical School and the Department of Neurophysiology, Royal Free Hampstead NHS Trust
Title of the project: The performance validity of breath sample analysis in the diagnosis of hepatic encephalopathy in patients with cirrhosis
Project Supervisor: Dr Marsha Y Morgan
George Couch, Department of Pathology, University of Cambridge
Title of the project: Non-endoscopic screening biomarkers for squamous-cell carcinoma of the oesophagus
Project Supervisors: Dr Rebecca Fitzgerald and Dr Pierre Lao-Sirieix
Greta Pells, Institute of Cellular Medicine (Hepatology), Newcastle University
Title of the project: The genetic basis of fatigue in PBC: Insights into pathogenesis and targets for treatment
Project Supervisor: Professor D E Jones
Rebeca Carter, Department of Hepatology, Royal Free Hospital
Title of the project: The role of...]]>