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Contains fulltext : 291657.pdf (Publisher’s version ) (Open Access) BACKGROUND: Anti-TNF drugs, such as infliximab, are associated with attenuated antibody responses after SARS-CoV-2 vaccination. We aimed to determine how the anti-TNF drug infliximab and the anti-integrin drug vedolizumab affect vaccine-induced neutralising antibodies against highly transmissible omicron (B.1.1.529) BA.1, and BA.4 and BA.5 (hereafter BA.4/5) SARS-CoV-2 variants, which possess the ability to evade host immunity and, together with emerging sublineages, are now the dominating variants causing current waves of infection. METHODS: CLARITY IBD is a prospective, multicentre, observational cohort study investigating the effect of infliximab and vedolizumab on SARS-CoV-2 infection and vaccination in patients with inflammatory bowel disease (IBD). Patients aged 5 years and older with a diagnosis of IBD and being treated with infliximab or vedolizumab for 6 weeks or longer were recruited from infusion units at 92 hospitals in the UK. In this analysis, we included participants who had received uninterrupted biological therapy since recruitment and without a previous SARS-CoV-2 infection. The primary outcome was neutralising antibody responses against SARS-CoV-2 wild-type and omicron subvariants BA.1 and BA.4/5 after three doses of SARS-CoV-2 vaccine. We constructed Cox proportional hazards models to investigate the risk of breakthrough infection in relation to neutralising antibody titres. The study is registered with the ISRCTN registry, ISRCTN45176516, and is closed to accrual. FINDINGS: Between Sept 22 and Dec 23, 2020, 7224 patients with IBD were recruited to the CLARITY IBD study, of whom 1288 had no previous SARS-CoV-2 infection after three doses of SARS-CoV-2 vaccine and were established on either infliximab (n=871) or vedolizumab (n=417) and included in this study (median age was 46·1 years [IQR 33·6-58·2], 610 [47·4%] were female, 671 [52·1%] were male, 1209 [93·9%] were White, and 46 [3·6%] were Asian). After three doses of SARS-CoV-2 vaccine, 50% neutralising titres (NT50s) were significantly lower in patients treated with infliximab than in those treated with vedolizumab, against wild-type (geometric mean 2062 [95% CI 1720-2473] vs 3440 [2939-4026]; p

Introduction Healthcare organisations have had to make adaptations to reduce the impact of the Coronavirus 2019 (COVID-19) pandemic. This has necessitated urgent reconfiguration within inflammatory bowel disease (IBD) services to ensure safety of patients and staff and seamless continuity of care provision. Aim To describe the adaptations made by a large inflammatory bowel disease service, caring for over 3,500 IBD patients, in response to the COVID-19 pandemic. Methods A diary record of responses to the pandemic were logged, and meeting minutes were reviewed. Data were recorded from IBD advice lines, multidisciplinary team (MDT) meeting minutes, infusion unit attendances, and electronic referral systems for the 8-week period from 9 March 2020 until 2 May 2020. Descriptive analysis was performed. Results The IBD service at Hull University Teaching Hospitals NHS Trust (IBD Hull) instituted rapid structural and functional changes to the service. Outpatient services were suspended and substituted by virtual consultations, and inpatient services were reduced and moved to ambulatory care where possible. The delivery of biologic and immunomodulatory therapies was significantly modified to ensure patient and staff safety. There was a substantial increase in IBD advice line calls. Conclusion The rapidly evolving COVID-19 pandemic required a prompt response, regular reassessment and planning, and continues to do so. We share our experience in of the successful adaptations made to our IBD service.

BACKGROUND: Inflammatory bowel disease (IBD) places a significant burden on health-care systems because of its chronicity and need for expensive therapies and surgery. With increasing use of biological therapies, contemporary data on IBD health-care costs are important for those responsible for allocating resources in Europe. To our knowledge, no prospective long-term analysis of the health-care costs of patients with IBD in the era of biologicals has been done in Europe. We aimed to investigate cost profiles of a pan-European, community-based inception cohort during 5 years of follow-up.METHODS: The Epi-IBD cohort is a community-based, prospective inception cohort of unselected patients with IBD diagnosed in 2010 at centres in 20 European countries plus Israel. Incident patients who were diagnosed with IBD according to the Copenhagen Diagnostic Criteria between Jan 1, and Dec 31, 2010, and were aged 15 years or older the time of diagnosis were prospectively included. Data on clinical characteristics and direct costs (investigations and outpatient visits, blood tests, treatments, hospitalisations, and surgeries) were collected prospectively using electronic case-report forms. Patient-level costs incorporated procedures leading to the initial diagnosis of IBD and costs of IBD management during the 5-year follow-up period. Costs incurred by comorbidities and unrelated to IBD were excluded. We grouped direct costs into the following five categories: investigations (including outpatient visits and blood tests), conventional medical treatment, biological therapy, hospitalisation, and surgery.FINDINGS: The study population consisted of 1289 patients with IBD, with 1073 (83%) patients from western Europe and 216 (17%) from eastern Europe. 488 (38%) patients had Crohn's disease, 717 (56%) had ulcerative colitis, and 84 (6%) had IBD unclassified. The mean cost per patient-year during follow-up for patients with IBD was €2609 (SD 7389; median €446 [IQR 164-1849]). The mean cost per patient-year during follow-up was €3542 (8058; median €717 [214-3512]) for patients with Crohn's disease, €2088 (7058; median €408 [133-1161]) for patients with ulcerative colitis, and €1609 (5010; median €415 [92-1228]) for patients with IBD unclassified (pINTERPRETATION: Overall direct expenditure on health care decreased over a 5-year follow-up period. This period was characterised by increasing expenditure on biologicals and decreasing expenditure on conventional medical treatments, hospitalisations, and surgeries. In light of the expenditures associated with biological therapy, cost-effective treatment strategies are needed to reduce the economic burden of inflammatory bowel disease.FUNDING: Kirsten og Freddy Johansens Fond and Nordsjællands Hospital Forskningsråd.

BACKGROUND: Serum vitamin D level is commonly low in patients with inflammatory bowel disease (IBD). Although there is a growing body of evidence that links low vitamin D level to certain aspects of IBD such as disease activity and quality of life, data on its prevalence and how it varies across disease phenotype, smoking status and treatment groups are still missing.MATERIALS AND METHODS: Patients diagnosed with IBD between 2010 and 2011 were recruited. Demographic data and serum vitamin D levels were collected. Variance of vitamin D level was then assessed across different treatment groups, disease phenotype, disease activity and quality of life scores.RESULTS: A total of 238 (55.9% male) patients were included. Overall, 79% of the patients had either insufficient or deficient levels of vitamin D at diagnosis. Patients needing corticosteroid treatment at 1 year had significantly lower vitamin D levels at diagnosis (median 36.0 nmol/l) (P=0.035). Harvey-Bradshaw Index (P=0.0001) and Simple Clinical Colitis Activity Index scores (P=0.0001) were significantly lower in patients with higher vitamin D level. Serum vitamin D level correlated significantly with SIBQ score (P=0.0001) and with multiple components of SF12. Smokers at diagnosis had the lowest vitamin D levels (vitamin D: 34 nmol/l; P=0.053).CONCLUSION: This study demonstrates the high prevalence of low vitamin D levels in treatment-naive European IBD populations. Furthermore, it demonstrates the presence of low vitamin D levels in patients with IBD who smoke.

As part of an NHS-funded research programme, pregnant women and mothers of preschool children were interviewed about their views on smoking in pregnancy and parenthood. Their partners were also interviewed where consent was obtained. In this paper, respondents' opinions on the perceived effectiveness of smoking cessation interventions aimed at pregnant women are reported. Research participants were able to describe a number of smoking cessation interventions that were perceived as being effective at preventing smoking activity during pregnancy. However, smokers reported less interventions than other respondents. Over half of smokers in the present study were contemplating cessation at the time of the interview, but none of these individuals had set a date to quit or made a plan of action on how to quit. While the majority of former-smokers and non-smokers felt that health professionals were the ‘right people' to give smoking cessation advice to pregnant women, nearly all of the current smokers disagreed with this statement. Therefore, health professionals' need to be aware of individual differences in how their patients interpret evidence-based information on smoking cessation and plan interventions accordingly.

A qualitative study was undertaken to explore social attitudes towards smoking by pregnant women, mothers of preschool children and their partners based in Merstham and Horley, East Surrey. All respondents felt that smoking in pregnancy was associated with considerable social stigma and negative social attitudes. Non-smokers were particularly negative in their views on smoking in pregnancy feeling that it was socially unacceptable. Women who smoked during pregnancy reported various negative social experiences such as receiving criticism from health professionals and community associates. They reported feeling under pressure to quit to achieve social acceptability as much as for health improvements. Some pregnant smokers denied smoking to health professionals, partners and colleagues and used private smoking places out of public view to reduce the chances of detection. Women who smoked or had a partner who smoked were more accepting of smoking in pregnancy than non-smokers and former smokers. Moreover, residents from the more socio-economically deprived area of Merstham were more tolerant of smoking in pregnancy and parenthood, compared to Horley-based respondents, regardless of their personal smoking status. They gave examples of local women they knew who had smoked in pregnancy without apparent complication. While all respondents were aware of health risks associated with smoking, smokers did not feel the risks were personally relevant to them and were exaggerated in an anti-smoking society. Health professionals need to be aware that pregnant women may not disclose smoking activity due to perceived social stigma and may require more intensive smoking cessation support services in socio-economically deprived areas.

Quantitative research has identified many common features of anaesthetic awareness, including anxiety and auditory perceptions. However, there is a poverty of literature using qualitative techniques to investigate this experience. The present study aimed to address this. Two women who had regained consciousness during surgery were interviewed about their experiences. Using Interpretative Phenomenological Analysis, four themes emerged from the interview transcripts. They were: powerlessness, taking control, development of new fears, and resistance. These themes demonstrate that anaesthetic awareness is experienced more profoundly than existing literature illustrates. The present research has implications for the care of patients reporting awareness and also the staff responsible.

A survey was undertaken to examine the attitudes, knowledge and practice of health visitors, midwives and practice nurses in relation to smoking cessation intervention with pregnant women and new parents. In total, 65 questionnaires were completed (52.42% return rate). Health visitors, midwives and practice nurses were aware of the reasons why pregnant women smoke as well as the health risks associated with smoking. All claimed to intervene by asking if their patients smoked. Most respondents claimed to record smoking status on health records and to give cessation advice to their patients. However, fewer of the health professionals provided advice to partners of women in their care and only a minority had read the NICE clinical guidelines on nicotine replacement therapies. There were limitations to the health professionals' attitudes, knowledge and practice that could affect the quality of smoking cessation service offered to patients. Further training in evidence-based practice is required.

This paper presents some of the findings from the Smoking in Pregnancy study of attitudes towards smoking among pregnant women, mothers of young children and their partners in East Surrey. As part of the study, respondents completed a General Health Questionnaire to identify mental health difficulties and, if they were smoking at the time of the study, they also completed the Fagerstrom nicotine addiction test. Eleven female respondents had high scores on the General Health Questionnaire, suggesting symptoms of depression, anxiety and/or social dysfunction for these women. There was no evidence that smokers were suffering from greater mental health difficulties than ex-smokers or non-smokers. However, the General Health Questionnaire scores of smokers were positively associated with their level of nicotine dependence. Furthermore, when General Health Questionnaire scores of all respondents were compared with self-reported health status there was a marked discrepancy suggesting under-reporting of symptoms ...

Strong primary health care is critical to secure sustainable health care.1 The International Implementation Research Network in Primary Care (IIRNPC) was founded to facilitate exchanges of experiences between countries in primary health care implementation.2,3 Involvement of all stakeholders, and

Outlines the changes in office processes and procedures resulting from a change from paper‐based to network‐based technologies. Suggests that these changes need a review of the supply and management of office technologies. Offers simple guidelines as to how this review might be undertaken.

Introduction Patients with IBD are exposed to a number of preventable and treatable opportunistic infections. Some of these infections can have potential serious and occasionally life threatening consequences and hence screening for these infections to assess and modify this when possible is recommended. ECCO consensus guidelines promote screening soon as possible following diagnosis of IBD and if feasible vaccination or treatments particularly before considering immunomodulatory treatment. However the uptake of these guidelines by clinicians and indeed patients in real world practice is limited. Methods We collected data from a structured screening programme in a large cohort of IBD patients who were to be started on anti TNF therapy. Baseline characterestics were recorded. For this analysis we focussed on Varicella Zoster, Hepatitis B, hepatitis C, HIV, EBV and Tuberculosis. VZV IgG negative or equivocal patients were considered non-immune. We collected data on self reported varciella exposure in VZV IgG negative patients. All patients with indeterminate Quantiferon were subjected to a T-SPOT test. Results 254 adult and paediatric onset IBD patients (138 females, 116 males) who received or considered for biologics were included in this study. Median age at diagnosis was 28 years (range 6–71). Majority of patients (189) had Crohn’s disease. 19 patients (7.5%) were Varicella non immune at screening and all had self reported history of Varicella zoster or uncertain history. 3 of these patients who did not receive vaccination (2 patient preference) had disseminated Varicella Zoster infection. Abnormal TB screening was identified in 16 patients (6.2%). Indeterminate Quantiferon with negative T-SPOT test was noted in 12 patients. 3 patients had positive Quantiferon and T-SPOT and received anti tuberculous chemoprophylaxis. I patient with Indeterminate Quantiferon and Indeterminate T-SPOT was considered low risk . EBV negative status was identified in 7 patients (2.8%) and 3 of these were young males and Thiopurines were not used or stopped in these patients. I patient each were Hepatitis C and HIV positive without clear preidentified risk profile and both received anti viral treatment. I patient identified with hepatitis B is awaiting treatment Conclusion A significant number of preventable and treatable opportunistic infections were identified at screening in a large cohort of IBD patients receiving anti TNF therapy. Clinical assessment of risk alone without approapriate serology will overlook a number of these patients.This study highlights the need for early targeted screening in IBD patients. Cost effectiveness of this structured targetted screening needs further evaluation. Disclosure of Interest None Declared

Introduction There is limited data on the concerns experiences of adolescent IBD patients in relation to surgery in a period of significant physical and emotional changes in their lives in addition to the added burden of a chronic disease. Understanding this may impact on the provision of care that is provided for these young patients for decision making, coping skills and overall adjustment. We aimed to study the experiences and concerns in adolescent IBD patients undergoing surgery to facilitate development of a programme aimed at improving this area of care. Methods This was a qualitative questionnaire study. IBD patients between the ages of 18–24 with history of surgery for IBD during adolescent years were invited to participate and informed consent was obtained. All had undergone structured transition into adult services from paediatric care. Results 24 patients (12 males, 12 females) were included. 23 patients included had Crohn’s disease. 16 (66.6%) had undergone resection and 6 (37.5%) had resulted in a stoma, 3 of which was permanent. 6 (25%) had undergone EUA with drainage and Seton insertion for perianal CD. Two patients underwent gastrojejunostomy and I patient had panproctocolectomy. Four patients (16.6%) had multiple surgeries. The main concerns pre surgery were: physical changes of having a scar or stoma (17 Patients, 71%), being away from family, friends and partners (17 patients, 71%) and anxiety regarding post-operative complications (13 patient, 54%). All patients discussed their concerns with family and friends but only 15 (62.5%) spoke with their Consultant or IBD/Stoma Nurse regarding their concerns. Of the 17 (70.83%) who had opportunity to speak to other patients, only 8 found this to be beneficial. Majority (20, 83%) accessed literature in preparation for their procedure but 8 (40%) felt this provided little or no help to them. Post procedure, all patients felt they got support from friends and family. In addition 8 had (45.8%) turned to a partner for support. Use of support from health care professionals was not mentioned. Coping strategies post-operatively by patients varied greatly and included family support, and spiritual support. However in a proportion of patients there were significant difficulties in coping post-surgery leading to ‘giving up’, self-blame and substance and/or alcohol use. Despite this Only 1 (4.1%) patient wished they had not gone ahead with it. Concerns regarding residual surgical scars were reported by only 5 (20.8%) patients. Conclusion This study gives valuable insights into young people’s concerns and experiences when facing surgery for their IBD and areas of intervention which will benefit. Personalised approach to these patients in their most vulnerable stage of life would be beneficial and an IBD nurse involved in transition may be an integral part in providing this. Disclosure of Interest None Declared

Taking the recent US elections as an example, Emma Whitehead explains how following history in the making can fuel your students’ interest and engagement in politics

Clinical correspondence between general practitioners and specialists remains fundamental to the process of referral from primary care and transmission of management advice from consultants. However, both older and more recent studies indicate that opportunities for good communication are commonly missed.1–3 Newton and colleagues explored the views of general practitioners and consultants on the desirable content of letters, and proposed standards against which the content of letters might be audited.4 After a decade of increasing emphasis on good communication, clear records, and patient involvement, we repeated that study, and also audited letters written by doctors who responded to the questionnaire. Questionnaires were sent to 360 general practitioners, 157 in areas served by the Royal Devon and Exeter Hospital and 203 in areas served by the Freeman Hospital, Newcastle, and to the consultants doing outpatient clinics (107 in …