P054 IBD Associated Surveillance Dysplasia Program: New Integrated Model: Audit, Summary, Future Directions and Literature Review.

BACKGROUND: The recommended commencement of screening for dysplasia in IBD cases is after 8-year duration with at least E2 disease, that is proximal to the rectosigmoid junction (∼15cm) or L2 or L3 Crohn's disease involving at least one-third of the colon. At this time, the risk of colonic IBD patients having CRC approaches 1%. Exceptions: (Early starters) people with a diagnosis of PSC with concurrent IBD suggest surveillance starts annually from the date of PSC diagnosis. Those with an FDR with CRC should commence screening 10 years prior to the age of diagnosis of the affected relative. Surveillance of the ileoanal pouch following restorative proctectomy is not commented on in the new guidelines. It is usually not recommended in the absence of high-risk features (ASGE, ECCO and BSG Guidelines): PSC diagnosis, CRC or dysplasia in the resected colon, Type C pouch mucosa or Refractory pouchitis. METHODS: The aim of the multidisciplinary team (MDT) is to improve the pathway for surveillance procedures, allocate resources appropriately and identify patients for research and trials. Cases were mainly referred from the prospective months booking database. Each case that is included in the monthly MDT meeting is discussed to ensure it is appropriate/consistent with guidelines with the assistance of administrative and data managers. We collate the cases with IBD database and risk calculator, assess and prescribe bowel prep, record outcome and communicate any changes, identify patients for studies and ensure we allocate patients to appropriate endoscopy lists. RESULTS: Over a course of 12 meetings conducted monthly, a total of 356 cases were screened with 91 cases eligible of which 62 cases were considered suitable in meeting inclusion criteria. The majority of these cases were UC (E3/E2) (n = 56), Crohn's (n = 27), colonic IBD (n = 7) and IBD-U (n = 1). The majority of cases were deemed in the high-risk category for colorectal cancer (43/62). Previous known dysplasia cases were limited (two cases with adenoma). There were 17 cases with PSC (seven were large duct). Family history of dysplasia was not strongly represented. Ten new cases of PSC being investigated were identified early prior to hepatology review or critical investigations. There were ten pouchscopy cases. There were a significant number of deferrals, cancellations and reassignments identified (n = 16). Four procedures were cancelled, eight cases reassigned due to extensive pseudo polyps and 17 were placed on PSC annual surveillance. We also identified significant bowel prep deficiencies in 18 cases requiring prescriptions. IE or chromoendoscopy was identified as a potential area of improvement. A three-point specified allocation to colonoscopy lists was lacking, possibly mainly due to COVID 19 backlog of cases. The areas of improvement included attracting referrals from other settings other than the monthly booking file data (e.g hepatology clinic) and improving long-term attendance. CONCLUSION: The IBD surveillance MDT is a clinically useful tool that demonstrates significant improvement in quality and procedure reallocation. Although resource allocation is required, this clinical model can ensure that all IBD dysplasia surveillance cases including those with challenging risk factors or those outside the evidence based guidelines are appropriately monitored.

IgG4 Staining in Thyroid Eye Disease.

IgG4-related ophthalmic disease is increasingly widely recognized. Moreover, IgG4 staining can occur in other inflammatory diseases. The authors report a case of IgG4 staining of an enlarged, inflamed levator palpebrae superioris in a patient with a past history of thyroid eye disease. A 78-year-old woman with quiescent hyperthyroidism had clinical and radiological evidence of levator palpebrae superioris inflammation without superior rectus involvement. A biopsy was consistent with IgG4-related ophthalmic disease. There was a marked but incomplete response to an orbital injection of triamcinolone. The authors discuss the association between thyroid eye disease and IgG4 staining and the diagnostic issues that arise when IgG4-related ophthalmic disease criteria are fulfilled in patients with other orbital inflammatory conditions.

Agreement in Cone Density Derived from Gaze-Directed Single Images Versus Wide-Field Montage Using Adaptive Optics Flood Illumination Ophthalmoscopy.

PURPOSE: We compared cone density measurements derived from the center of gaze-directed single images with reconstructed wide-field montages using the rtx1 adaptive optics (AO) retinal camera. METHODS: A total of 29 eyes from 29 healthy subjects were imaged with the rtx1 camera. Of 20 overlapping AO images acquired, 12 (at 3.2°, 5°, and 7°) were used for calculating gaze-directed cone densities. Wide-field AO montages were reconstructed and cone densities were measured at the corresponding 12 loci as determined by field projection relative to the foveal center aligned to the foveal dip on optical coherence tomography. Limits of agreement in cone density measurement between single AO images and wide-field AO montages were calculated. RESULTS: Cone density measurements failed in 1 or more gaze directions or retinal loci in up to 58% and 33% of the subjects using single AO images or wide-field AO montage, respectively. Although there were no significant overall differences between cone densities derived from single AO images and wide-field AO montages at any of the 12 gazes and locations (P = 0.01-0.65), the limits of agreement between the two methods ranged from as narrow as -2200 to +2600, to as wide as -4200 to +3800 cones/mm2. CONCLUSIONS: Cone density measurement using the rtx1 AO camera is feasible using both methods. Local variation in image quality and altered visibility of cones after generating montages may contribute to the discrepancies. TRANSLATIONAL RELEVANCE: Cone densities from single AO images are not interchangeable with wide-field montage derived-measurements.

Semi-automated identification of cones in the human retina using circle Hough transform.

A large number of human retinal diseases are characterized by a progressive loss of cones, the photoreceptors critical for visual acuity and color perception. Adaptive Optics (AO) imaging presents a potential method to study these cells in vivo. However, AO imaging in ophthalmology is a relatively new phenomenon and quantitative analysis of these images remains difficult and tedious using manual methods. This paper illustrates a novel semi-automated quantitative technique enabling registration of AO images to macular landmarks, cone counting and its radius quantification at specified distances from the foveal center. The new cone counting approach employs the circle Hough transform (cHT) and is compared to automated counting methods, as well as arbitrated manual cone identification. We explore the impact of varying the circle detection parameter on the validity of cHT cone counting and discuss the potential role of using this algorithm in detecting both cones and rods separately.

Reporting of minimum clinically important differences in surgical trials.

BACKGROUND: The minimum clinically important difference (MCID) is the smallest difference in outcome between the groups that would be of clinical interest. It influences the estimates that are made to determine the required sample side. The aim of this study was to explore the reporting of the MCID in surgical trials. METHOD: Surgical trials that were published between January 1981 and December 2006 in five prestigious surgical journals were evaluated. Selected for study were trials that studied two groups and reported the main outcome event as a proportion. RESULTS: Only 21% (100/486) of the admissible surgical trials mentioned a value for the MCID when estimating the sample size. There was a trend, however, for compliance with these factors to increase during the study period. The present post-hoc calculations of the required sample size, which were based on the observed differences between the groups at the end of the study, suggested that one-third of the trials should have accrued at least fivefold the number of patients. Although reporting an estimate of the sample size was associated with the study of more patients (median sample size 145 vs 100), it was not associated with the reporting of more positive results, that is, 61% (95/155) versus 65% (214/331). CONCLUSION: There has been an improvement in the proportion of surgical trials reporting formal estimates of sample size during the last three decades. But the construct of these estimates is often suspect because of a failure to provide realistic values for the MCID.