Upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding is one of the most common medical emergencies in the UK (85 000 cases per year, 4000 deaths). It has a significant impact on resources with the need for 24/7 on call bleeding rotas. Endoscopic therapy is the gold standard of treatment. In this issue, Alzoubaidi et al (see page 35) discuss non-variceal causes (80%–90%). The review includes helpful sections on the epidemiology, comorbidities, blood transfusion before endoscopy, risk stratification tools, the optimal timing of endoscopy, common pharmacological therapies, endoscopic haemostatic techniques and postprocedure management. The review is clear, helpful, focused and up to date with a section on future developments including the role of video capsule endoscopy, hemospray and Endclot. Essential Continuing Professional Development and Editor’s Choice this month.

Autoimmune hepatitis

Autoimmune hepatitis is a rare heterogeneous immune-related liver disease that in most cases is treated effectively with corticosteroids and azathioprine and has an excellent prognosis, although in a proportion second-line therapeutic options including transplantation may be required. In this issue, Janmohamed and Hirschfield review the epidemiology, clinical presentation, diagnosis and management including a proposed treatment algorithm which includes when to seek specialist advice and then use a case-based approach to discuss clinically relevant dilemmas faced when managing the condition (see page 77). The authors address the clinical competencies described in the 2010 gastroenterology curriculum and in doing so also provide a well-written and authoritative review for the busy clinician who wants an update on what’s new and how best to manage autoimmune hepatitis.

Quality improvement initiative: reducing overfeeding in patients on parenteral nutrition

Giving too much parenteral nutrition (PN) is a potential risk factor in the development infections and other complications including hyperglycaemia, refeeding syndrome and liver dysfunction particularly in patients are unwell. In this issue, Franck reports the outcome of a quality improvement initiative to reduce overfeeding (see page 67). Interventions included the use of standardised PN products with lower dextrose to amino acid ratios, reduced use of intravenous lipid emulsion and use of adjusted body weights or guideline-recommended predictive equations for energy requirements—in essence a systematic approach to prescribing implemented by the Nutrition Support Team. Mean total calorie intake reduced (30.2 kcal/kg/day preintervention, n=86 to 23.4 kcal/kg/day postintervention, n=62, p<0.001) while maintaining amino acid intake with significantly fewer cases of central line-associated bloodstream infections, hyperglycaemia and liver dysfunction—the detail is in the paper. These findings are important and may assist practitioners in reducing PN overfeeding and its associated risks in other units.

Looking after the workforce

The importance of caring for your workforce has rightly received prominence in the last few years with increased recognition of stress and burnout in the complex and demanding healthcare environment. In this issue, Gleeson et al report the outcome of a questionnaire evaluating stress and its causes in UK gastroenterologists (567/1932 responded) (see page 43). One hundred and seven out of 567 recorded their stress levels as 4 or 5 out of 5. Stress levels were higher in women and in those working full-time. A significant proportion of respondents had seen their general practitioner, attended occupational health, taken planned time off and taken anxiolytics/antidepressants in the last 12 months. Ranked causes of stress included excessive clinical work, working conditions beyond control, inadequate information technology (IT) systems, workspace and secretarial staff and conflict (ranked top by 9%). It is a real concern that talking to someone at work about stress was ranked difficult or impossible by 35%. How do we at least start to address this—better awareness and recognition, improved mentoring and better practical support, developing strategies to deal with conflict, promoting well-being, and provision of better IT and administration support to better deliver clinical care and retain the workforce.

Promoting research

In this issue, McFarlane et al report on the attitudes towards academic medicine and out-of-programme research of two cohorts of gastroenterology trainees (2007, 2016) and highlight that interest remains high with most trainees believing that research/academic medicine is important to the future of the National Health Service (see page 57). Higher degrees were the preferred out of programme research (OOP-R) in both cohorts although there are multiple other options available and discussed. Successful fellowship applications increased in 2016. Most respondents felt the development of trainee-led research networks was important and were keen to get involved with 63% holding a current Good Clinical Practice certificate, 64% having published a peer-reviewed publication within the last 2 years and 47% recruited into a Clinical Research Network portfolio research study. These findings are very positive. In the current healthcare environment with increased pressures on recruitment and service delivery we need to deal with potential barriers to OOP-R and support trainees to pursue research active careers.

On a personal note

I am delighted to have taken up the role of editor in chief of the Frontline Gastroenterology and look forward to working with readers, researchers, authors, editors and the British Society of Gastroenterology and British Medical Journal to get the best content into the journal. The journal’s mission is to help clinicians in their practice by publishing the best of innovative practice, clinical research, evidence-based guidance and clinical reviews. We are open to submissions of many different article types including original research, quality improvement, clinical reviews, guideline reviews, education in practice (how to, my approach to), curriculum-based clinical reviews, commentaries, interesting cases with a message, images (inside view) and journal watch.

Please contact me if you have a topic you feel we should cover, would like to write about or with any other thoughts about we should best develop the journal to help you in your clinical practice.

R. Mark Beattie,

Editor in Chief