An audit of hepatitis C service provision in a representative sample of prisons in England.

BACKGROUND: Prisons are an important setting to address prevention, testing and treatment of hepatitis C virus (HCV) and other blood-borne viruses. This audit examined current practice against national standards in a representative sample of prisons in England. METHODS: The audit tool was developed based on best practice guidelines and piloted in one prison. In December 2012, the audit was conducted in a further 20 prisons, which were chosen to represent different types, sizes and geographical spread across England. RESULTS: Testing for HCV was offered in the majority of prisons audited (20 of 21), but only two-thirds had a written policy on testing and treatment; less than a third had a steering group to oversee the process. The nature of services varied greatly. There were inconsistencies across data sources on testing. CONCLUSIONS: This audit found that while there were many areas of good practice, the quality and content of hepatitis C service provision varied. It highlighted the need to provide appropriate guidance for prisons in delivering a high-quality service, ensuring that relevant training is available for different staff and that adequate psychosocial support is provided to patients.

Enhanced liver fibrosis test can predict clinical outcomes in patients with chronic liver disease.

BACKGROUND: Clinicians use fibrosis in a liver biopsy to predict clinical outcomes of chronic liver disease. The performance of non-invasive tests has been evaluated against histological assessment of fibrosis but use of clinical outcomes as the reference standard would be ideal. The enhanced liver fibrosis (ELF) test was derived and validated in a large cohort of patients and shown to have high diagnostic accuracy (area under the curve (AUC)=0.80 95% CI 0.76 to 0.85) in identification of significant fibrosis on biopsy. OBJECTIVE: To evaluate ELF performance in predicting clinical outcomes by following up the original ELF cohort. METHODS: Patients recruited to the ELF study at seven English centres were followed up for liver morbidity and mortality by examination of clinical data. Defaulting/discharged patients were followed up by family practitioner questionnaires. Primary outcome measure was liver-related morbidity/liver-related death. RESULTS: 457 patients were followed up (median 7 years), with ascertainment of clinical status in 92%. There were 61 liver-related outcomes (39 deaths). Survival analysis showed that the ELF score predicts liver outcomes, with people having the highest ELF scores being significantly more likely to have clinical outcomes than those in lower-score groups. A Cox proportional hazards model showed fully adjusted HRs of 75 (ELF score 12.52-16.67), 20 (10.426-12.51) and 5 (8.34-10.425) compared with patients with ELF <8.34. A unit change in ELF is associated with a doubling of risk of liver-related outcome. CONCLUSIONS: An ELF test can predict clinical outcomes in patients with chronic liver disease and may be a useful prognostic tool in clinical practice.

Transjugular intrahepatic portosystemic stent shunt: 11 years' experience at a regional referral centre.

OBJECTIVES: Transjugular intrahepatic portosystemic stent shunt (TIPSS) is now widely used in the treatment of uncontrolled and recurrent variceal haemorrhage. This study reports the outcome and long-term follow-up of 125 patients who were referred to a single centre for TIPSS. METHODS: One hundred and twenty-five patients were referred to undergo TIPSS. All but 10 had variceal haemorrhage. The 10 patients referred with refractory ascites were excluded from the analysis. Our follow-up protocol was to assess shunt patency only if bleeding recurred or there was a clinical indication. The mean age was 51.5 years (range 18-87 years) and 64 patients (56%) were male. The commonest aetiology for chronic liver disease was alcohol (80%). At referral, 19 patients (16%) were Child-Pugh class A, 26 patients (23%) were Child-Pugh class B and 70 patients (61%) were Child-Pugh class C. The mean follow-up period was 20.4 months (range 0-95 months). RESULTS: TIPSS was successfully placed in 108 of 115 patients (94%). The thirty-day mortality was 30%. One-year and 2-year overall cumulative survival was 52% (survival ratio, 0.525; 95% confidence interval, 0.432-0.619) and 43% (survival ratio, 0.436; 95% confidence interval, 0.340-0.532), respectively. CONCLUSION: TIPSS is effective in the treatment of uncontrolled or recurrent variceal bleeding. In comparison with previously published studies, our study suggests no value in regular or routine shunt surveillance to reduce rebleeding episodes or mortality, but this needs to be further assessed in prospective randomized studies.

Colonoscopy performance is stable during the course of an extended three-session working day.

BACKGROUND: Three-session days were introduced in our endoscopy unit to accommodate the increased demand resulting from the introduction of the National Health Service Bowel Cancer Screening Programme (BCSP). Cecal intubation rate (CIR) and adenoma detection rate (ADR) may decline with time during a standard working day, but data are lacking for an extended three-session day. We assessed colonoscopy performance in an extended three-session day. METHODS: Colonoscopies performed during the year 2011 were retrospectively analyzed. The CIR and ADR were analyzed according to the time of day when procedures were done: morning (AM), afternoon (PM), or evening (EVE). Because of an expected higher incidence of adenomas in the BCSP patients, ADR was analyzed according to indication (BCSP or non-BCSP). RESULTS: Of the 2574 colonoscopies, 1328 (51.7 %) were in male patients and 1239 (48.3 %) in female patients with a median age of 63 years (interquartile range [IQR], 51 - 70). Of the 2574 colonoscopies, 1091 (42.4 %) were performed in AM lists, 994 (38.6 %) in PM lists, and 489 (19 %) in EVE lists. Time of day did not affect the CIRs for the AM, PM, and EVE lists (90.5 %, 90.1 %, and 89.9 %, respectively; χ (2) [2, N = 2540] = 0.15, P = 0.927). The CIR was reduced in female patients and those with poor bowel preparation (P < 0.05). After exclusion of the BCSP patients, the ADR was lower in the EVE lists than in the AM and PM lists on univariate analysis, but on multivariate analysis, this difference was not significant (P > 0.05). The ADR was significantly higher in patients older than 60 years and in men (P < 0.001). Queue position did not independently influence the CIR or ADR. CONCLUSIONS: Colonoscopy quality does not appear to depend on time of day or queue position in an extended three-session day.

Incidence of post-ERCP pancreatitis from direct pancreatic juice collection in hereditary pancreatitis and familial pancreatic cancer before and after the introduction of prophylactic pancreatic stents and rectal diclofenac.

OBJECTIVES: Individuals from hereditary pancreatitis (HP) and familial pancreatic cancer (FPC) kindreds are at increased risk of developing pancreatic cancer. Premalignant molecular changes may be detected in pancreatic juice collected by endoscopic retrograde cholangiopancreatography (ERCP). The objective was to determine the risk of post-ERCP pancreatitis (PEP). METHODS: A prospective study (1999-2013) was undertaken of 80 ERCPs (24 in HP and 56 in FPC) from 60 individuals and the impact of PEP prophylaxis using a self-expelling pancreatic stent and 50 mg diclofenac per rectum from 2008. RESULTS: There was no PEP in the HP cohort and 13 (23.2%) PEP from 56 procedures in the FPC cohort (P = 0.0077). Up to 2008 PEP had occurred in 7 (43.8%) of 16 procedures in FPC individuals versus none of 18 procedures in HP individuals (P = 0.0021). After the introduction of prophylaxis, the incidence of PEP fell to 6 (15.0%) of 40 procedures in FPC individuals (P = 0.0347).The odds ratio (95% confidence interval) was 0.23 (0.06-0.84) in favor of prophylaxis (0.035). CONCLUSIONS: Individuals with HP are at minimal risk for PEP. Although the risk of PEP in individuals with FPC can be reduced by using prophylactic self-expelling stents and diclofenac, it remains too high for routine screening.

Consenting patients for endoscopic retrograde cholangiopancreatography: results of a survey of 182 UK endoscopists and 2059 of their patients.

OBJECTIVES: To describe the endoscopic retrograde cholangiopancreatography (ERCP) consent process. METHOD: A prospective, multicentre study of ERCP, supplemented by questionnaires administered to participating endoscopists and their patients. RESULTS: A total 165 of 182 (91%) endoscopists completed a questionnaire describing personal practice with 140 of 165 (85%) routinely providing written information to patients; 120 of 165 (73%) routinely acquiring verbal consent on the day of ERCP; 23 of 165 (14%) delegating acquisition of consent to another team member and 59 of 165 (36%) usually/always describing alternative treatments to patients. Types of complication disclosed (and percentage of incidence quoted) varied significantly. A total of 2059 of 4561 (45%) patients completed the questionnaire following their first recorded procedure, at a mean of 11 days post-ERCP. Most (1968/2059; 96%) patients were satisfied with the explanation provided; they understood why ERCP was recommended (1935/2059; 94%) and recalled being informed of complications (1745/2059; 85%). Regression analysis of first-ever (nonurgent) ERCP suggested that patients were more likely to recall being informed of risk (odds ratio; 95% confidence interval) if they were younger (1.04 per 5-year decrease, 1.02-1.05), had an American Society of Anesthesiology score of less than 3 (2.0; 1.18-3.4); or had verbally consented more than 1 week in advance of ERCP (2.41, 1.02-5.71, when compared with those who consented on the day of ERCP). After ERCP 964 of 2059 (47%) patients were warned of specific symptoms that could arise. CONCLUSION: The ERCP consent process could be improved by consistent disclosure of risk, acquisition of verbal consent well in advance of the procedure, provision of information after ERCP and increased attention to older and more sick patients.

Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice.

OBJECTIVE: To examine endoscopic retrograde cholangio-pancreatography (ERCP) services and training in the UK. DESIGN: Prospective multicentre survey. SETTING: Five regions of England. PARTICIPANTS: Hospitals with an ERCP unit. OUTCOME MEASURES: Adherence to published guidelines, technical success rates, complications and mortality. RESULTS: Organisation questionnaires were returned by 76 of 81 (94%) units. Personal questionnaires were returned by 190 of 213 (89%) ERCP endoscopists and 74 of 91 (81%) ERCP trainees, of whom 45 (61%) reported participation in <50 ERCPs per annum. In all, 66 of 81 (81%) units collected prospective data on 5264 ERCPs, over a mean period of 195 days. Oximetry was used by all units, blood pressure monitoring by 47 of 66 (71%) and ECG monitoring by 37 of 66 (56%) units; 1484 of 4521 (33%) patients were given >5 mg of midalozam. Prothrombin time was recorded in 4539 of 5264 (86%) procedures. Antibiotics were given in 1021 of 1412 (72%) cases, where indicated. Patients' American Society of Anesthesiology (ASA) scores were 3-5 in 670 of 5264 (12.7%) ERCPs, and 4932 of 5264 (94%) ERCPs were scheduled with therapeutic intent. In total, 140 of 182 (77%) trained endoscopists demonstrated a cannulation rate >/=80%. The recorded cannulation rate among senior trainees (with an experience of >200 ERCPs) was 222/338 (66%). Completion of intended treatment was done in 3707 of 5264 (70.4%) ERCPs; 268 of 5264 (5.1%) procedures resulted in a complication. Procedure-related mortality was 21/5264 (0.4%). Mortality correlated with ASA score. CONCLUSION: Most ERCPs in the UK are performed on low-risk patients with therapeutic intent. Complication rates compare favourably with those reported internationally. However, quality suffers because there are too many trainees in too many low-volume ERCP centres.

Molecular analysis to detect pancreatic ductal adenocarcinoma in high-risk groups.

BACKGROUND & AIMS: Screening of high-risk groups for pancreatic cancer has not been adopted because of concerns regarding specificity and sensitivity. Suitability of a combination of 3 novel molecular screening techniques was investigated. METHODS: Pancreatic juice was extracted from 146 patients with pancreatic ductal adenocarcinoma, chronic pancreatitis, or biliary tract stones. p53 mutations were analyzed by using a modified yeast functional assay, K-ras status was analyzed using mutation-specific real-time PCR and the proportion of p16(INK4a) promoter methylation was estimated using comparative methylation-specific real-time PCR. RESULTS: p53 mutations were detected in 20 of 48 (42%) cancer cases, none of 49 controls, and 2 of 49 (4%) patients with pancreatitis. K-ras mutations were detected in 31 of 57 (54%) cancer patients, 13 of 61 (21%) controls, and 23 of 67 (34%) patients with pancreatitis. Twenty-six of 42 (62%) cancer patients had promoter methylation levels > 12%, compared with 3 of 24 (13%) controls, and 2 of 26 (8%) with pancreatitis. Mutations in p53 or high-level p16(INK4a) promoter methylation occurred in 29 of 36 (80%) patients with cancer, 3 of 24 (13%) controls, and 3 of 22 (13%) with pancreatitis. Three patients (8%) of 36 with cancer; 14 of 24 (58%) controls, and 13 of 22 (59%) patients with pancreatitis had no marker. The gallstone disease patients had a high rate of positive K-ras mutations, possibly reflecting the fact that they were not disease free. CONCLUSIONS: Combination molecular analysis increased the discrimination between patients with malignant and benign disease. This level of discrimination would allow patients in high-risk groups to be stratified from negligible risk to over 50% probability of an early cancer.