British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults.

Iron deficiency anaemia (IDA) is a major cause of morbidity and burden of disease worldwide. It can generally be diagnosed by blood testing and remedied by iron replacement therapy (IRT) using the oral or intravenous route. The many causes of iron deficiency include poor dietary intake and malabsorption of dietary iron, as well as a number of significant gastrointestinal (GI) pathologies. Because blood is iron-rich it can result from chronic blood loss, and this is a common mechanism underlying the development of IDA-for example, as a consequence of menstrual or GI blood loss.Approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract. Therefore optimal management of IDA requires IRT in combination with appropriate investigation to establish the underlying cause. Unexplained IDA in all at-risk individuals is an accepted indication for fast-track secondary care referral in the UK because GI malignancies can present in this way, often in the absence of specific symptoms. Bidirectional GI endoscopy is the standard diagnostic approach to examination of the upper and lower GI tract, though radiological scanning is an alternative in some situations for assessing the large bowel. In recurrent or refractory IDA, wireless capsule endoscopy plays an important role in assessment of the small bowel.IDA may present in primary care or across a range of specialties in secondary care, and because of this and the insidious nature of the condition it has not always been optimally managed despite the considerable burden of disease- with investigation sometimes being inappropriate, incorrectly timed or incomplete, and the role of IRT for symptom relief neglected. It is therefore important that contemporary guidelines for the management of IDA are available to all clinicians. This document is a revision of previous British Society of Gastroenterology guidelines, updated in the light of subsequent evidence and developments.

Therapeutic resolution of focal, predominantly anastomotic Crohn's disease strictures using removable stents: outcomes from a single-center case series in the United Kingdom.

BACKGROUND AND AIMS: Intestinal and anastomotic strictures in Crohn's disease (CD) produce considerable morbidity. The development of surgery-sparing, endoscopic modalities for stricture resolution is essential. Removable stent therapy is emerging as an efficacious and safe means of stricture resolution. We present outcomes from the largest, single-center series of patients with CD undergoing removable self-expanding metal stent (SEMS) therapy to resolve focal intestinal strictures. METHODS: Patients with symptomatic CD were assessed with magnetic resonance enterography. Short (≤6 cm), fibrostenotic strictures of the terminal ileum or ileocolonic anastomoses were considered by a multidisciplinary team and put forward for stent therapy. Strictures were examined endoscopically and impassable strictures were treated with SEMSs. The Hanaro HRC-20-080-230 partially covered SEMS was used for all patients. Endoscopically inaccessible or inflammatory strictures were excluded. Stent retrieval was scheduled for 7 days after insertion. Therapeutic benefit was assessed with validated inflammatory bowel disease scoring tools. RESULTS: Twenty-one patients underwent 23 stent episodes, with 2 patients requiring repeat therapy in the follow-up period. Most treated strictures were anastomotic (19 of 21); 2 of 21 were de novo. Of those patients attending follow-up, 81% (13 of 16) reported symptom improvement or resolution; 88% (14 of 16) were in clinical remission at follow-up. Across all stent episodes, only 5 adverse events were noted (2 episodes of stent-related discomfort, 3 asymptomatic stent migrations). There were no direct stent-related adverse events such as perforation, impaction, or bleeding. No patient has required stricture-related surgery in the follow-up period (range, 3-50 months). CONCLUSIONS: In this series, removable SEMS therapy for ileal and anastomotic strictures was found to be clinically efficacious. The absence of perforation events and need for stricture-related surgery are noteworthy. These results suggest that the efficacy of stent therapy in this context merits powered, head-to-head investigation with other modalities for stricture resolution.

A controlled trial of quetiapine XR coadministration treatment of SSRI-resistant panic disorder.

BACKGROUND: Open-label quetiapine coadministration with SSRI therapy, in a diagnostically mixed sample of comorbid anxiety patients, offered additional anxiolytic benefit. Therefore, we designed the following controlled trial to confirm these findings in a comorbid, SSRI-resistant, panic disorder (PD) patient sample. METHODS: This was a single-site, double-blind, placebo-controlled (PLAC), randomized, parallel group (2 groups), 8-week, quetiapine extended release (XR) coadministration trial. SSRI resistance was determined either historically or prospectively. Patients were randomized if they remained moderately ill (CGI-S score ≥ 4). Change in the PDSS scale total score was the primary efficacy outcome measure. Responders were identified as those with a ≥50 % decrease from their baseline PDSS score. In the early weeks of therapy, XR was flexibly and gradually titrated from 50 to 400 mg/day. RESULTS: 43 patients were screened in total, and 26 of these were randomized and evaluable. 21 patients (78 % of the randomized group) completed the trial (10 XR; 11 PLAC). The endpoint quetiapine XR mean daily dose ± SD was 150 ± 106 mg. While, in the sample as a whole, there was improvement in PDSS scores across the 8-week trial (ANOVA main effect of time, F = 10.9, df 8,192, p < 0.0001), the treatment × time interaction effect was not statistically significant (F = 0.8, df 8,192, p = 0.61). There was no between-group difference in responder frequency at endpoint. CONCLUSIONS: This proof-of-concept RCT did not support the efficacy of this treatment strategy for SSRI-resistant PD. Quetiapine XR was generally well-tolerated. Important limitations were the small sample size, and the relatively low average dose of quetiapine XR used. ClinicalTrials.gov ID#: NCT00619892.

Use of CT colonography in the English Bowel Cancer Screening Programme.

OBJECTIVE: To examine use of CT colonography (CTC) in the English Bowel Cancer Screening Programme (BCSP) and investigate detection rates. DESIGN: Retrospective analysis of routinely coded BCSP data. Guaiac faecal occult blood test (gFOBt)-positive screenees undergoing CTC from June 2006 to July 2012 as their first-line colonic investigation were included. Abnormalities found at CTC, subsequent polyp, adenoma and cancer detection and positive predictive value (PPV) were calculated. Detection rates were compared with those observed in gFOBt-positive screenees investigated by colonoscopy. Multilevel logistic regression was used to examine factors associated with variable detection. RESULTS: 2731 screenees underwent CTC. Colorectal cancer (CRC) or polyps were suspected in 1027 individuals (37.6%; 95% CI 33.8% to 41.4%); 911 of these underwent confirmatory testing. 124 screenees had CRC (4.5%) and 533 had polyps (19.5%), 468 adenomatous (17.1%). Overall detection was 24.1% (95% CI 21.5% to 26.6%) for CRC or polyps and 21.7% (95% CI 19.2% to 24.1%) for CRC or adenoma. Advanced neoplasia was detected in 504 screenees (18.5%; 95% CI 16.1% to 20.8%). PPV for CRC or polyp was 72.1% (95% CI 66.6% to 77.6%). By comparison, 9.0% of 72 817 screenees undergoing colonoscopy had cancer and 50.6% had polyps; advanced neoplasia was detected in 32.7%. CTC detection rates and PPV were higher at centres with experienced radiologists (>1000 examinations) and at high-volume centres (>175 cases/radiologist/annum). Centres using three-dimensional interpretation detected more neoplasia. CONCLUSIONS: In the BCSP, detection rates after positive gFOBt are lower for CTC than colonoscopy, although populations undergoing the two tests are different. Centres with more experienced radiologists have higher detection and accuracy. Rigorous quality assurance of BCSP radiology is needed.

Survey of core medical trainees in the United Kingdom 2013 - inconsistencies in training experience and competing with service demands.

There is currently considerable concern about the attractiveness of hospital medicine as a career and experiences in core medical training (CMT) are a key determinant of whether trainees continue in the medical specialties. Little is understood about the quality and impact of the current CMT programme and this survey was designed to assess this. Three key themes emerged. Firstly, the demands of providing service have led to considerable loss of training opportunities, particularly in outpatients and formal teaching sessions. Trainees spend a lot of this service time doing menial tasks and over 90% report that service takes up 80-100% of their time. Secondly, clinical and educational supervision is variable, with trainees sometimes getting little consultant feedback on their clinical performance. Finally, 44% of trainees report that CMT has not prepared them to be a medical registrar and many trainees are put off acute medical specialties by their experiences in CMT.

Career choices of junior doctors: is the physician an endangered species?

There are increasing concerns regarding the recruitment and retention within general medicine. National surveys were conducted among foundation year 2 doctors (FY2), year 1 and year 2 core medical trainees (CT1 and CT2) and medical registrars (StR/ST3+) exploring their enjoyment of medicine, overall satisfaction, career aspirations, influencing factors and perceptions of the medical registrar. The results highlight that many doctors at the FY2, CT1 and CT2 levels are being deterred from general medicine by the perceived unmanageable workload and poor work-life balance of the medical registrar. Medical registrars themselves are less satisfied in general internal medicine than they are in their main specialties. Therefore, priority needs to be placed on clarifying the roles, and improving the morale, of medical registrars. If current trends persist, these will have a significant impact on patient safety, patient care and workforce planning.

Training in general medicine - are juniors getting enough experience?

There is a widespread perception that trainees in medicine in the UK are 'not as good as they used to be' and reduction in hours of training is often cited as one cause. However, there are no data on the current experience of medical trainees in general medicine. The experience of foundation year doctors (FY1/2) and core medical trainees (CTs) in the management of 10 common medical conditions, eight common medical procedures and other aspects of medical training were collected by national survey in 2011. Trainees reported finding out-of-hours care the best setting for acute general medical experience and that the medical registrar was a key part of training. There was a significant lack of experience in both the management of medical conditions and the use of common procedures. These results highlight the challenges in general medical training and show that there is substantial room for improvement.

Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme.

OBJECTIVES: Colonoscopy is central to colorectal cancer (CRC) screening. Success of CRC screening is dependent on colonoscopy quality. The NHS Bowel Cancer Screening Programme (BCSP) offers biennial faecal occult blood (FOB) testing to 60-74 year olds and colonoscopy to those with positive FOB tests. All colonoscopists in the screening programme are required to meet predetermined standards before starting screening and are subject to ongoing quality assurance. In this study, the authors examine the quality of colonoscopy in the NHS BCSP and describe new and established measures to assess and maintain quality. DESIGN: The NHS BCSP database collects detailed data on all screening colonoscopies. Prospectively collected data from the first 3 years of the programme (August 2006 to August 2009) were analysed. Colonoscopy quality indicators (adenoma detection rate (ADR), polyp detection rate, colonoscopy withdrawal time, caecal intubation rate, rectal retroversion rate, polyp retrieval rate, mean sedation doses, patient comfort scores, bowel preparation quality and adverse event incidence) were calculated along with measures of total adenoma detection. RESULTS: 2,269,983 individuals returned FOB tests leading to 36,460 colonoscopies. Mean unadjusted caecal intubation rate was 95.2%, and mean withdrawal time for normal procedures was 9.2 min. The mean ADR per colonoscopist was 46.5%. The mean number of adenomas per procedure (MAP) was 0.91; the mean number of adenomas per positive procedure (MAP+) was 1.94. Perforation occurred after 0.09% of procedures. There were no procedure-related deaths. CONCLUSIONS: The NHS BCSP provides high-quality colonoscopy, as demonstrated by high caecal intubation rate, ADR and comfort scores, and low adverse event rates. Quality is achieved by ensuring BCSP colonoscopists meet a high standard before starting screening and through ongoing quality assurance. Measuring total adenoma detection (MAP and MAP+) as adjuncts to ADR may further enhance quality assurance.

The role of the medical registrar.

The medical registrar in the acute on-call and out-of-hours setting is usually considered to be one of the busiest and most challenging jobs in the entire hospital. This is perhaps a reflection of the changes in the structure and organisation of acute medicine precipitated by the European Working Time Directive and Modernising Medical Careers. As well as the general feeling that medicine is being increasingly viewed as a default referral option by other specialties who are themselves becoming ever more sub-specialised. This article explores what the pragmatic role of the medical registrar broadly should be. The Medical Workforce Unit at the Royal College of Physicians is launching an initiative, part funded by the Department of Health, to answer this difficult question.

Guidelines for the management of iron deficiency anaemia.

BACKGROUND: Iron deficiency anaemia (IDA) occurs in 2-5% of adult men and postmenopausal women in the developed world and is a common cause of referral to gastroenterologists. Gastrointestinal (GI) blood loss from colonic cancer or gastric cancer, and malabsorption in coeliac disease are the most important causes that need to be sought. DEFINING IRON DEFICIENCY ANAEMIA: The lower limit of the normal range for the laboratory performing the test should be used to define anaemia (B). Any level of anaemia should be investigated in the presence of iron deficiency (B). The lower the haemoglobin the more likely there is to be serious underlying pathology and the more urgent is the need for investigation (B). Red cell indices provide a sensitive indication of iron deficiency in the absence of chronic disease or haemoglobinopathy (A). Haemoglobin electrophoresis is recommended when microcytosis and hypochromia are present in patients of appropriate ethnic background to prevent unnecessary GI investigation (C). Serum ferritin is the most powerful test for iron deficiency (A). INVESTIGATIONS: Upper and lower GI investigations should be considered in all postmenopausal female and all male patients where IDA has been confirmed unless there is a history of significant overt non-GI blood loss (A). All patients should be screened for coeliac disease (B). If oesophagogastroduodenoscopy (OGD) is performed as the initial GI investigation, only the presence of advanced gastric cancer or coeliac disease should deter lower GI investigation (B). In patients aged >50 or with marked anaemia or a significant family history of colorectal carcinoma, lower GI investigation should still be considered even if coeliac disease is found (B). Colonoscopy has advantages over CT colography for investigation of the lower GI tract in IDA, but either is acceptable (B). Either is preferable to barium enema, which is useful if they are not available. Further direct visualisation of the small bowel is not necessary unless there are symptoms suggestive of small bowel disease, or if the haemoglobin cannot be restored or maintained with iron therapy (B). In patients with recurrent IDA and normal OGD and colonoscopy results, Helicobacter pylori should be eradicated if present. (C). Faecal occult blood testing is of no benefit in the investigation of IDA (B). All premenopausal women with IDA should be screened for coeliac disease, but other upper and lower GI investigation should be reserved for those aged 50 years or older, those with symptoms suggesting gastrointestinal disease, and those with a strong family history of colorectal cancer (B). Upper and lower GI investigation of IDA in post-gastrectomy patients is recommended in those over 50 years of age (B). In patients with iron deficiency without anaemia, endoscopic investigation rarely detects malignancy. Such investigation should be considered in patients aged >50 after discussing the risk and potential benefit with them (C). Only postmenopausal women and men aged >50 years should have GI investigation of iron deficiency without anaemia (C). Rectal examination is seldom contributory, and, in the absence of symptoms such as rectal bleeding and tenesmus, may be postponed until colonoscopy. Urine testing for blood is important in the examination of patients with IDA (B). MANAGEMENT: All patients should have iron supplementation both to correct anaemia and replenish body stores (B). Parenteral iron can be used when oral preparations are not tolerated (C). Blood transfusions should be reserved for patients with or at risk of cardiovascular instability due to the degree of their anaemia (C).

Medical registrars in 2010: experience and expectations of the future consultant physicians of the UK.

In 2010, 2,176 medical registrars in England (43%) responded to a survey of attitudes to current and future working conditions. Regarding current working, 88% were currently happy with their job with respect to their specialty but only 49% were happy with respect to acute medicine. Even if pay was increased, 59% would only want to work a 48-hour week or less. Regarding future jobs, 59% were worried about future job prospects with 91% exploring ways of extending their training. Only 36% would consider working away from their current location as a consultant, only 42% of those trained in acute medicine wish to take part in the acute take, 15% would consider a 'sub-consultant' post and only 60% were looking forward to becoming a consultant. The findings of this survey show that medical registrars are very concerned about their future. From their perspective, clinical medicine in England is in poor health.

The management of gastric polyps.

BACKGROUND: Gastric polyps are important as some have malignant potential. If such polyps are left untreated, gastric cancer may result. The malignant potential depends on the histological type of the polyp. The literature base is relatively weak and any recommendations made must be viewed in light of this. DEFINITION: Gastric polyps are sessile or pedunculated lesions that originate in the gastric epithelium or submucosa and protrude into the stomach lumen. MALIGNANT POTENTIAL: Depending on histological type, some gastric polyps (adenomas and hyperplastic polyps) have malignant potential and are precursors of early gastric cancer. They may also indicate an increased risk of intestinal or extra-intestinal malignancy.

The road to the Inequalities in Health Alliance.

In late 2020, the Royal College of Physicians (RCP) established the Inequalities in Health Alliance (IHA) to campaign for a cross-government strategy to reduce health inequalities. In this article, RCP president Prof Andrew Goddard charts the evolution of the IHA and explains what comes next.

Reversal of 'the dying' diagnosis.

A 75-year-old woman was admitted with sepsis and treated with broad-spectrum antibiotics until examination of her lower limbs noted necrotising wounds. Surgical intervention was advised by the plastic surgeons; however, she was deemed unsuitable for intensive care. She underwent incision and drainage of the necrotic area and biopsies were taken. She deteriorated clinically and the decision was made for best supportive care and was therefore transferred to the inpatient palliative care unit for end-of-life care. However, she stabilised, and based on culture sensitivities, antibiotics were restarted. It was also noted that the patient had a 3-month history of loose stools, which had not been addressed previously. The biopsies were suggestive of pyoderma gangrenosum, prompting a dermatology review, and prednisolone and doxycycline were started. The wounds and her loose stools improved, and with ongoing rehabilitation, she made a full recovery. Referral to gastroenterology was made.

The UK physician workforce: one-third at increased risk of death from COVID-19.

INTRODUCTION: 21% of NHS staff are from Black, Asian and minority ethnic (BAME) backgrounds yet account for a disproportionately high number of medical-staff deaths from COVID-19. Using data from the published OpenSAFELY Collaborative, we analysed consultant physicians to determine those at increased risk of COVID-19 related death. METHODS: Data from 13,500 consultant physicians collected by the Royal College of Physicians were analysed to determine those at an increased risk of death from COVID-19, assuming no comorbidities. RESULTS: The data reveal a picture in which a third of consultant physicians have a hazard ratio (HR) >1 for dying from COVID-19; one in five have HR >2; one in 11, HR >3; and one in 40, HR >4. Of concern are the risks to male physicians aged ≥60 with HR >3.8. Sub-specialties including cardiology, endocrine and diabetes, gastroenterology, haematology, neurology and rheumatology have a greater risk profile due to high proportion of men, physicians of older age, and proportion of BAME individuals. CONCLUSION: A third of consultant physicians have an increased risk of a COVID-19-related death, and one in five have a higher relative risk (HR >2). The risk is mainly driven by age, gender, and ethnicity, the risk is highest in male consultant physicians over 60, especially from BAME backgrounds.