Search

BACKGROUND: The Baveno VI consensus identifies patients with compensated advanced chronic liver disease (cACLD) who can safely avoid screening endoscopy. However, concordance in clinical practice with this guidance is unknown. We audited clinical practice and the provision of transient elastography (TE) aiming to identify potential cost savings and benefits. METHODS: Retrospective data collection from 12 sites across London over 6 months by reviewing oesophagogastroduodenoscopy (OGD) reports, platelet count and TE results as well as information on site-specific provision of TE. RESULTS: Three-hundred and fifty-one screening procedures were identified; 177 (50.43%) had a TE test performed within the preceding 12 months; 142 (80.23%) patients with a recent TE test did not meet criteria for screening OGD. TE provision varied widely between sites. CONCLUSION: Improving concordance with the Baveno criteria through improved provision of TE would have benefits for patients, healthcare systems and the environment and would help to address the challenges of moving on from the COVID-19 pandemic.

Background The development of delirium has been previously demonstrated to be associated with an increased risk of mortality and length of stay post liver transplant (LTx) with multiple risk factors being identified in previous studies. In this study, we have aimed to identify the most important variables associated with the onset of post-LTx delirium and understand the effect on length of stay (LOS). Methods All liver transplants for chronic liver disease between 1 August 2012 and 1 August 2017 were included (n = 793). Data were collected for analysis retrospectively from electronic patient records. Results Delirium is associated with an overall increased hospital and ICU LOS but not one-year mortality. The risk of developing post-LTx delirium was the greatest among patients: with post-LTx sepsis, who required renal sparing immunosuppression, who received donation after cardiac death (DCD) grafts and who were older. Patients with autoimmune hepatitis, primary biliary cholangitis or primary sclerosing cholangitis seemed to be at lower risk of post-LTx delirium. However, global patient LOS was only prolonged in patients with sepsis and renal failure. Conclusion Many of the risk factors previously described to be associated with the development of post-LTx delirium were not demonstrated to be significant in this study. Sepsis, renal failure, older age and DCD use are associated with delirium post-LTx. It is unclear if this syndrome is an independent risk factor for increased LOS or if it is a symptom of well established syndromes associated with increased LOS. The role for prophylactic strategies to reduce the incidence of post-LTx delirium is therefore unclear.

ObjectiveThe National Health Service (NHS) produces more carbon emissions than any public sector organisation in England. In 2020, it became the first health service worldwide to commit to becoming carbon net zero, the same year as the COVID-19 pandemic forced healthcare systems globally to rapidly adapt service delivery. As part of this, outpatient appointments became largely remote. Although the environmental benefit of this change may seem intuitive the impact on patient outcomes must remain a priority. Previous studies have evaluated the impact of telemedicine on emission reduction and patient outcomes but never before in the gastroenterology outpatient setting.Method2140 appointments from general gastroenterology clinics across 11 Trusts were retrospectively analysed prior to and during the pandemic. 100 consecutive appointments during two periods of time, from 1 June 2019 (prepandemic) to 1 June 2020 (during the pandemic), were used. Patients were telephoned to confirm the mode of transport used to attend their appointment and electronic patient records reviewed to assess did-not-attend (DNA) rates, 90-day admission rates and 90-day mortality rates.ResultsRemote consultations greatly reduced the carbon emissions associated with each appointment. Although more patients DNA their remote consultations and doctors more frequently requested follow-up blood tests when reviewing patients face-to-face, there was no significant difference in patient 90-day admissions or mortality when consultations were remote.ConclusionTeleconsultations can provide patients with a flexible and safe means of being reviewed in outpatient clinics while simultaneously having a major impact on the reduction of carbon emissions created by the NHS.

IntroductionThe Baveno VI consensus provides guidance on using non-invasive methods to identify patients with compensated advanced chronic liver disease (cACLD) who are unlikely to have clinically significant portal hypertension (CSPH) Patients with a platelet count of 150,000/Litre and a liver stiffness of 20kPa, assessed using transient elastography (TE), have a sufficiently low risk of variceal bleeding that they do not require variceal screening endoscopy to examine for oesophageal varices (OV) costing approximately £342 per procedure This identifies potential substantial cost savings to healthcare systems and reduces risk to patients from unnecessary investigations However, concordance with these guidelines, availability of TE and number of avoidable endoscopies is unknown MethodRetrospective data collection from 10 sites across London, 6 teaching hospitals and 4 district general hospitals (DGH), over a 6 month period from 1st January to 30th June 2019 by reviewing oesophagogastroduodenoscopy (OGD) requests and analysing those with indications of ‘variceal screening’, ‘cirrhosis’, ‘liver disease’ or ‘variceal surveillance’ Patient platelet count and TE result within a year of OGD was recorded ResultsData was collected for 353 endoscopies, 7 were excluded due to incomplete data and 89 due to decompensation at the time of endoscopy 141 screening procedures were included Endoscopic findings included: 74 5% no OV, 16 3% grade I OV and 9 2% ≥grade II OV or high risk stigmata 49 7% did not have a recent TE (48 5% in teaching hospitals vs 52 4% in DGH) Of those who did have a recent TE result, 54 (76 1%) met the Baveno criteria for absence of CSPH, of whom 5 (9 3%) were found to have clinically significant varices Median follow-up was 350 5 days and 0 of these patients subsequently bled The performance of the Baveno criteria in this study was: sensitivity 64 3%, specificity 85 9%, positive predictive value 52 9% and negative predictive value 90 7% Avoiding OGD in patients meeting Baveno criteria in this cohort would have potentially saved over £18000 DiscussionOur study shows that TE is not widely used for risk stratifying patients with cACLD across London prior to screening OGD These simple non-invasive markers can achieve substantial cost savings, avoid exposing patients to unnecessary investigations and relieve pressure on endoscopy departments under increased strain due to the Coronavirus pandemic Whilst a small proportion of OV will be missed, the bleeding risk in these is low with adequate follow-up Availability and utilisation of TE for risk stratification in cACLD should be improved

Background Out-of-hospital cardiac arrest survival rates in the UK are poor, and non-medically trained individuals have been identified to perform substandard cardiopulmonary resuscitation (CPR). Millions watch televised medical dramas and, for many, these comprise their only education on CPR. This study aims to investigate the quality of CPR portrayed on these programmes and whether this has an effect on public knowledge. Methods Prospective observational study of 30 consecutive episodes of three popular medical dramas. Public knowledge of CPR and viewing habits were assessed with a survey of non-medically trained personnel. Results 90 episodes were reviewed with 39 resuscitation attempts shown. Chest compression rates varied from 60 to 204 compressions per minute with a median of 122 (95% CI 113 to 132). Depth varied from 1.5 to 7.5 cm with a median of 3 (3.15–4.31). Rate and depth were significantly different from the UK Resuscitation Council Guidelines (2010) (p Conclusion Televised medical dramas depict CPR inaccurately and laypersons may be less well informed about the correct technique the more they tune into these programmes. While there may be other confounding variables, given the popularity of television medical dramas, the poor depiction may be significantly contributing to poor public CPR knowledge and represent a potential new avenue of public education.

Introduction Anti-tumour necrosis factor (TNF) therapy has revolutionised ulcerative colitis (UC) treatment, particularly in moderate-to-severe disease. However, these drugs tend to perform less well in the maintenance of remission. Route of administration may influence efficacy and network meta-analyses of trial data indicate a superiority of intravenous drugs (IV; Infliximab; IFX) over subcutaneous (SC; adalimumab; ADA). We conducted a retrospective multicentre case-control study to compare the efficacy of these two drugs. Methods Patients administered IFX or ADA as their first biologic, identified from therapy databases of five UK hospitals, were included, if they had completed induction dosing and entered maintenance. Patients receiving IFX as ‘rescue’ therapy were excluded. Data was collected for pre-biologic disease activity (Simple Clinical Colitis Activity Index (SCCAI), C-reactive protein and calprotectin) and throughout anti-TNF therapy. The primary end-point for comparison was the number of patients in clinical remission at 52 weeks (combined features of continuing IFX or ADA therapy and SCCAI score ≤3). Data was collected for duration of therapy, or up to last follow-up, if beyond 52 weeks. Results 78 IFX (40.3±14.6 years, 33F) and 63 ADA (36.8±14.6 years, 27F) patients were analysed. There were no statistically significant differences in demographics or pre-biologic disease activity between the two groups. At 52 weeks, 58 (74%) IFX patients and 29 (46%) ADA patients remained on therapy (p=0.009) and in remission (26 (33%) vs 5 (8%), p=0.0003). Primary non response was the reason for treatment cessation in 15 (24%) ADA patients and 4 (5%) IFX patients (p=0.0012). Conclusions Our results from a real-world cohort mirror those produced in the network meta-analyses of clinical trials for these agents, suggesting that IFX is superior to ADA in UC maintenance of remission, demonstrated by improvement in SCCAI scores and treatment continuation at 52 weeks. There were no significant differences in colectomy rates, hospital admission for acute flares or adverse events in the study timeframe. Reference . Danese S, Fiorino G, Peyrin-Biroulet L, Lucenteforte E, Virgili G, Moja L, Bonovas S, (2014), Biological agents for moderately to severely active ulcerative colitis: a systematic review and network meta-analysis., Ann Intern Med, 160:704–11.

1. Three cases of osteomyelitis of a metatarsal sesamoid bone are described. 2. The diagnosis should be considered in patients with acute pain under the first metatarsophalangeal joint, particularly if the temperature is elevated. 3. Failure ofdiagnosis may lead to persistent disability until sinus formation and sequestration dictate operative intervention. 4. Early antibiotic therapy may lead to resolution of the infection.