Search

Background and aimsThe Simple Endoscopic Score for Crohn’s disease (SES-CD) is the primary tool for measurement of mucosal inflammation in clinical trials but lacks prognostic potential. We set to develop and validate a modified multiplier of the SES-CD (MM-SES-CD), which takes into consideration each individual parameter’s prognostic value for achieving endoscopic remission (ER) while on active therapy.MethodsIn this posthoc analysis of three CD clinical trial programmes (n=350 patients, baseline SES-CD ≥ 3 with confirmed ulceration), data were pooled and randomly split into a 70% training and 30% testing cohort. The MM-SES-CD was designed using weights for individual parameters as determined by logistic regression modelling, with 1-year ER (SES-CD < 3) being the dependent variable. A cut point score for low and high probability of ER was determined by using the maximum Youden Index and validated in the testing cohort.ResultsBaseline ulcer size, extent of ulceration and presence of non-passable strictures had the strongest association with 1-year ER as compared with affected surface area, with differential weighting of individual parameters across disease segments being observed during logistic regression. The MM-SES-CD was generated using this weighted regression model and demonstrated strong discrimination for ER in the training dataset (area under the receiver operator curve (AUC) 0.83, 95% CI 0.78 to 0.94) and in the testing dataset (AUC 0.82, 95% CI 0.77 to 0.92). In comparison to the MM-SES-CD scoring model, the original SES-CD score lacks accuracy (AUC 0.60, 95% CI 0.55 to 0.65) for predicting the achievement of ER.ConclusionsWe developed and internally validated the MM-SES-CD as an endoscopic severity assessment tool to predict one-year ER in patients with CD on active therapy.

Identification of risk factors for the development of hepatocellular carcinoma (HCC) is important for HCC surveillance in chronic hepatitis B virus (HBV) infection. Our aim was to study the independent risk factors and effect of HBV genotypes on HCC development in a prospective longitudinal cohort of chronic hepatitis B patients.Chronic hepatitis B patients recruited since 1997 were prospectively followed up for the development of HCC. HCC was diagnosed by a combination of alpha fetoprotein, imaging, and histology. Liver cirrhosis was defined as ultrasonic features of cirrhosis together with hypersplenism, ascites, varices, and/or encephalopathy.In total, 426 patients were followed up for 1664 person years; median 225 (range 12-295) weeks. Forty nine (11%) patients had underlying clinical liver cirrhosis. A total of 242 (57%) and 179 (42%) patients had HBV genotypes C and B, respectively. Twenty five patients developed HCC in a median follow up of 121 (range 14-236) weeks. The overall incidence of HCC was 1502 cases per 100 000 person years. On multivariate analysis, clinical liver cirrhosis and HBV genotype C infection were independently associated with HCC development, with an adjusted relative risk of 10.24 (95% confidence interval (CI) 4.39-23.89; p0.001) and 2.84 (95% CI 1.05-7.72; p = 0.040), respectively. Patient age, sex, hepatitis B e antigen (HBeAg) status, alanine aminotransferase (ALT) levels, and basal core promoter mutations did not predict HCC development. Patients infected with HBV genotype C tended to have persistently positive HBeAg or fluctuating HBeAg status and higher ALT levels during the follow up period.Genotype C HBV infection is an independent risk factor for HCC development in addition to liver cirrhosis.

Introduction Hyperlipidaemia is a recognised risk factor for the development of non-alcoholic fatty liver disease (NAFLD). Aspartate aminotransferase (AST):alanine aminotransferase (ALT) ratio, AST-to-Platelet Ratio Index (APRI) and Fibrosis-4 (FIB-4) scores are validated, indirect, non-invasive methods which can be employed to exclude the possibility of hepatic fibrosis in the context of NAFLD. 1 The aim of this study was to apply these indices to patients attending a lipid clinic, with an elevated ALT to determine what proportion would merit further hepatology assessment. Methods We performed retrospective analysis of patients attending a lipid clinic in a university teaching hospital from 2011–2013. None of the patients were under gastroenterology/hepatology follow-up. In those with elevated ALT (>30 IU/L male, >19 IU/L female 2 ) we calculated the AST:ALT ratio, APRI and FIB-4 scores. Results 130 patients were included (68 male, 62 female; mean age 54 (17–93)). Platelet data was available for 113 patients and 69 (53.0%) had elevated ALT (52% male). In these patients the scoring systems demonstrated an AST:ALT ratio >0.8 in 32 (46.4%), APRI >0.51 in 20 (30.0%) and FIB-4 >1.46 score in 14 (20.3%). 11 (15.9%) had high scores across all 3 indices. Conclusion We have demonstrated that a significant proportion of patients with lipid abnormalities and raised ALT may be at risk of NAFLD with fibrosis. By using a composite of these scoring systems it may be possible to identify those who would benefit most from assessment in hepatology outpatients with staging of fibrosis. References Stuart McPherson, Stephen F Stewart, Elsbeth Henderson, Alastair D Burt, Christopher P Day. Simple non-invasive fibrosis scoring systems can reliably exclude advanced fibrosis in patients withnon-alcoholic fatty liver disease. Gut 2010:59:1265–1269 Prati D, Taioli E, Zanella A, Della Torre E, Butelli S, Del Vecchio E, Vianello L, Zanuso F, Mozzi F, Milani S, Conte D, Colombo M, Sirchia G. Updated definitions of healthy ranges for serum alanine aminotransferase levels. Ann Intern Med 2002 Jul 2;137(1):1–10 Disclosure of Interest None Declared.

Introduction The majority of patients with Hepatitis C Virus (HCV) in England remain undiagnosed. There are an estimated 1298 patients infected with HCV in North Yorkshire, 1 but a fraction of these patients have been identified and successful treatment is rare. As part of the development process for an effective service in York, we audited existing referral patterns and outcomes for patients with a positive HCV serology test. Methods A total of 9495 patients who had HCV serology checked from January 2009 to December 2011 were identified via the York hospital microbiology database. Retrospective collection of data was performed on all patients with positive serology test, using online patient database and patients’ case notes where available. Analysis of data focused on further investigations and management of these patients. Results Out of the 9495 patients who had HCV serology tested, 330 tested positive (199 new positives, 47 known PCR positive, 1 known false-positive and 83 duplicates). Majority of the referral sources were from primary care (37%), followed by medical services (31%), drug-dependence services (9.3%), GUM (8.1%), prison (7.3%) and obstetrics (6.9%). Intravenous drug use was the most common route of acquisition. Of the 199 new positives, 113 (57%) did not receive any further investigations. 61 (31%) patients were referred to gastroenterology and 10 patients per year successfully accessed treatment. Conclusion This audit shows the majority of HCV positives had no further investigations and only 15% of patients received curative treatment. There was significant duplication of serology testing and only 72/ 199 (36%) underwent an HCV PCR, which is the next appropriate test. Throughout the UK a variety of initiatives are ongoing to increase public awareness of hepatitis C, and encourage testing. However, unless HCV service development improves, a positive test for HCV may have little or no consequence. Reference Public Health England, Hepatitis C in the UK: 2013 reportURL: //http:/www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317139502302 Disclosure of Interest None Declared.

Introduction Nasogastric tube (NGT) insertion for enteral feeding is common practise, but is associated with the risk of tube misplacement or malposition in both the immediate and subsequent time points. 1 Between 2005 to 2010, 21 deaths and 79 other cases of harm have been reported on the updated National Patient Safety Agency (NPSA) Alert (2011), “Reducing harm caused by nasogastric feeding tubes”. In 45% of cases, misinterpretation of the chest X-ray was directly responsible for the harm inflicted. The General Medical Council’s (GMC) guidance for undergraduate education, “Tomorrow’s Doctors (2009)” does not specify NGT placement as a core competency for a graduate or Foundation Trainee. 2 The purpose of this survey was to ascertain the number of medical schools in the United Kingdom (UK) which provide specific teaching on NGT placement and correct identification of tube position (using either pH method or clinical interpretation of a plain chest X-ray film). Furthermore, the authors sought to identify whether these medical schools included formative or summative assessment of the respective methods. Methods All 30 GMC recognised Medical Schools within the UK were invited to participate by means of a standardised survey proforma. This proforma was emailed to relevant staff members who were either responsible for course development or were personnel within the clinical skills faculty. Results To date, there has been a 57% (17/30) response rate ( Table 1 ). Of the 10 medical schools that provide formal teaching on NGT insertion, 8 of them required formative assessment for both the practical technique and the interpretation of correct tube position. Of the 7 medical schools that do not to provide formal teaching of NGT insertion, 6 of them stated that this was due to the GMC’s “Tomorrow’s Doctors” guidance not including NGT placement as a mandatory proficiency for a graduate. Conclusion This survey found that 59% (10/17) of the participating UK medical schools provide formal teaching on NGT placement and correct identification of tube position. There is variable emphasis on NGT procedure proficiency in undergraduate medical education. Given the risks highlighted by the 2011 NPSA report, we would suggest that NGT placement instruction and training should be facilitated at the undergraduate level. Disclosure of Interest None Declared References National Patient Safety Alert (PSA 002): Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants; Mar 2011. URL: http://www.nrls.npsa.nhs.uk/alerts/?entryid45 = 129640 General Medical Council (GMC) Tomorrow’s Doctors 2009; URL: http://www .gmc-uk.org/TomorrowsDoctors_2009.pdf_39260971.pdf

Introduction The Hepatitis C action plan of 2004 identified a need to “reduce the level of undiagnosed infection and provide better, more co-ordinated pathways of care for people with hepatitis C, from their initial diagnosis to specialist care and treatment”(1). Our aim was to audit the outcome of Hepatitis C testing in a large secondary care facility in UK against the established management pathway (2). Methods Using the hospital microbiology database, we identified 3166 requests for hepatitis C serology from January to December 2011. All positive results were retrospectively analysed at least 12 months after test requests, to include: referral source, demographics, route of acquisition etc. In addition, evidence of HCV PCR testing, outpatient referral and outcomes were sought from referrers and laboratory records. Results Age range of Hepatitis C positives was from 10 months to 71 years. 41% referrals came from primary care and drug dependence services, 30% from medical service, 5% from obstetrics and 5% from GUM. 76% had acquired HCV from intravenous drug use. Alcohol dependence was recorded in 34%. Of 122 positive HCV antibodies requested, 49 (40%) were already known about. Of the remaining 73, 48 (66%) had no further investigation requested. Of these 48, 34 were not referred or investigated further (15 from primary care, 13 from secondary care, 6 from prisons). 13 were referred without PCR result, 11 did not attend (DNA’d) at first (6) or second (5) appointments, 2 have appointments outstanding and 1 had previously failed treatment but was not re-referred. Conclusion The Hepatitis C action plan has failed to deliver. This audit demonstrates almost half the serology tests are unnecessary repeats, 2/3rd of true new positives never progress down the management pathway and only 3% access treatment. Disclosure of Interest None Declared. References www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4084521 http://www.nhs.uk/hepatitisc/hcp/testing-for-hepatitis-c/Pages/from-diagnosis-to-treatment–a-flowchart.aspx

Introduction In adults, duodenal biopsy is mandatory for diagnosis of coeliac disease. This is usually preceded by serological tests for coeliac specific antibodies—anti-tissue transglutaminase (tTG) and endomysial antibodies (EMA). However, the recent guidelines produced by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) 1 in 2010 recommend that histological assessment (duodenal biopsy) might be omitted in cases of anti-tTG more than 10 times the upper limit of normal which have been verified by endomysial positivity, a typical history for coeliac disease and HLA DQ2 or DQ8 positivity. Our aim was to analyse our adult population of patients with possible diagnosis of coeliac disease to ascertain the proportion of patients with anti-tTG levels more than 10 times the upper limit of normal. Methods Retrospective collection of data were obtained from the electronic clinical patient database from 2008 to 2011 at York Hospital. Inclusion criteria were all patients with positive anti-tTG and available duodenal histology results while on normal diet. York Hospital uses the Orgentec Anti-tTG IgA kit. Results 113 (70%) of the 161 patients were female. The median age was 49 years (Range 16–89 years). 52 patients (32%) had anti-tTG levels greater than 10 times the upper limit of normal (ie, with a value ≥100 u/ml). All 52 had positive EMA. 51/52 had typical symptoms (chronic diarrhoea, weight loss, fatigue, anaemia) while one patient had leg weakness and a positive family history for coeliac disease. All 52 patients had biopsies consistent with coeliac disease. One patient had HLA DQ2/DQ8 status checked, which was positive. The test was done due to equivocal IgA levels, weakly positive anti-tTG and Marsh I findings. Conclusion In our local adult population of patients with known positive anti-tTG and duodenal histology, about a third of the patients had anti-tTG levels greater than 10 times the upper limit of normal. This group had biopsies consistent with coeliac disease. Therefore, the ESPGHAN diagnostic guideline recommending the omission of duodenal biopsies in patients with anti-tTG levels greater than 10 times the upper limit of normal may be applicable for a significant proportion of the adult population (other similar studies 2 3 have found rates of 45–58%). Competing interests None declared. References 1. ESPGHAN Guidelines Diagnosis Coeliac Disease Children/Adolescents . 2010. http://www.celiac-disease-consortium.nl/attachments/080_Mearin%20ESPGHAN%20CD%20WG%20voor%20CDC%20november%202010.pdf 2. Mubarak A , Wolters VM, Gerritsen SA, et al. A biopsy is not always necessary to diagnose celiac disease. J Pediatr Gastroenterol Nutr 2011; 52 :554–7. 3. Hill PG , Holmes GK. Coeliac disease: a biopsy is not always necessary for diagnosis. Aliment Pharmaco Ther 2008; 27 :572–7.

Introduction Clostridium difficile associated diarrhoea (CDAD) causes significant morbidity and mortality in susceptible patients. There are no validated risk stratification scores to identify those patients at the greatest risk of death. Methods Data were collected on 125 sequential patients diagnosed with CDAD in our institution between August 2008 and October 2010. Data on age, co-morbidities, number of antibiotics prescribed and course length as well as other relevant medications such as proton pump inhibitor (PPI) were recorded. The length of and timing of any admissions in the preceding 13-month and physiological variables such as the patient9s temperature, blood pressure and pulse at diagnosis of CDAD were recorded as were any haematological and biochemical investigations taken within 24 h of diagnosis. Results Hospital admissions between 14 and 30 days (p=0.031), increasing co-morbidities (p=0.05), systolic blood pressure 85 years (p=0.947) and current PPI use (p=0.224). From the data, a scoring system was derived whereby 1 point was given to the non-statistically significant trends and 2 points to the statistically significant trends. If there were 1 to 3 co-morbidities, this was scored as 1 and greater than 3 co-morbidities scored as 2. There was a maximum score of 14. On applying this retrospectively to the existing database, 39 patients were identified where all the parameters in the scoring system were available. Of these, a score of 4 or less was associated with low risk of 30-day mortality (0% mortality in 13 patients). A score of 5 to 7 was associated with moderate risk of 30-day mortality (33.3% mortality in 15 patients) and a score of 8 or more to be associated with a high risk of 30-day mortality (72.7% mortality in 11 patients). Conclusion A simple scoring system holds promise for defining those patients at greatest risk of 30-day mortality from CDAD in our population. However a note of caution should be exercised. Applying a scoring system retrospectively to a dataset from which information has been used to derive the score does not validate it and a prospective study is planned to validate the York scoring system. Competing interests None declared.