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Progressing pancreatobiliary medicine in the UK
In this issue Andrew Hart, Gavin Johnson and Matthew Huggett highlight the rapidly developing field of pancreatobiliary medicine discussing the specialty and why there is a need including the components of the specialty, training and infrastructure and future developments. This is accompanied by a series of seven articles on pancreatobiliary medicine written by experts and covering a wide range of topics including the diagnosis and management of—plus recent advances in—acute and chronic pancreatitis, IgG4-related disease, pancreatic cysts, pancreatic cancer, pancreatic neuroendocrine tumours and cholangiopathies.
Management of acute and chronic pancreatitis are highlighted as joint editor’s choice this month. (see page 206)
Management of acute pancreatitis
Acute pancreatitis is common and potentially life threatening with a broad range of clinical presentations. Alcohol is the most common aetiology in males and gall stone disease in females over age 60 years, although there are many other causes. There are multiple national and international guidelines. In this issue Goodchild and colleagues discuss the diagnosis (set criteria—typical history, raised amylase/lipase, consistent imaging) management challenges (including the role of antibiotics) and address common dilemmas seen including the role of nutrition and the management of pancreatic and per-pancreatic collections. The review is an authoritative and up to date summary of an important condition and joint editor’s choice this month. (see page 292)
Management of chronic pancreatitis
Chronic pancreatitis is an irreversible fibro inflammatory disorder of the pancreas which presents with relapsing, remitting upper abdominal pain accompanied by features of malabsorption secondary to pancreatic insufficiency and endocrine deficiency with the development of diabetes. Early diagnosis is challenging and the condition is probably under recognised. Alcohol consumption accounts for up to 80% of cases in the Western World. Multidisciplinary management is essential to guide treatment and manage complications. Jalal and colleagues, in a comprehensive review, discuss the aetiology (including rare causes), risk factors, diagnosis and management including medical, nutritional, endoscopic and surgical. Authoritative and up to date the article is essential reading for the busy clinician. Joint editor’s choice this month. (see page 253)
Are gluten-free food staples accessible to all patients with coeliac disease
The treatment of coeliac disease is life-long gluten exclusion. The reduction in prescription of gluten free foods has resulted in greater reliance on commercial foods by children and adults with coeliac disease. Poor dietary compliance is associated with a less good outcome. In this issue Hanci and colleagues explore the cost and availability of gluten free products and if this has changed in the last 6 years by looking at data from 60 stores and 10 internet outlets. In summary, availability has increased in premium stores and internet outlets, although most are significantly more expensive that gluten containing products with, for example, gluten free bread being four times more expensive. Availability of gluten free products was less in budget supermarket and convenience stores. In summary little has changed in recent years despite the increase in use of gluten free diets. The issues with availability and life-long cost burden has significant implications for children and adults with coeliac disease particularly as good compliance leads to better outcomes. (see page 222)
Dietician first gastroenterology clinic
There are considerable pressures on new patient clinic slots in gastroenterology and other medical specialities with, as a consequence, long waiting times to be seen. In this issue Mutsekwa and colleagues report on the development of a dietician first Gastroenterology clinic model and use a mixed methods approach to evaluate the impact. The development very positive with large numbers of patients being seen and a significant reduction in waiting times for eligible patients. Ten per cent had an expedited medical review as a consequence of red flags not highlighted in the referral letter. Patient satisfaction levels were high. The initiative had a significant impact on patient flow and should be considered as a strategy to improve access to specialist help and thereby impact on quality of care and outcomes. (see page 229)
Facilitating treatment of hepatitis C virus in primary care
Globally up to 80 million people are estimated to be living with hepatitis C virus infection. Highly effective and well tolerated treatment is available although there are (ongoing) issues with failure to identify affected individuals and access to treatment. In this issue Higgins et al report a local initiative to bridge the access gap. This involved implementation of a community based Transient Elastography service (required as part of the diagnostic work up) plus a weekly multidisiplinary team (MDT) to discuss treatment which is then prescribed and monitored in primary care. Over the study period 327 started treatment. Intention to treat Sustained Virological Reponse was 87%, that is, equivalent to that seen in secondary care. This integrated care pathway effectively ‘scaled up’ and ‘simplified’ treatment with the potential to treat vulnerable patients who wouldn’t otherwise access healthcare and so is a step closer in the global mission to eliminate hepatitis C infection.
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Competing interests None declared.
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