Towards NHS Zero: greener gastroenterology and the impact of virtual clinics on carbon emissions and patient outcomes. A multisite, observational, cross-sectional study.

Objective: The 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. Method: 2140 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. Results: Remote 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. Conclusion: Teleconsultations 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.

Network meta-analysis: efficacy and safety of treatments for fistulising Crohn's disease.

INTRODUCTION: Fistulas are a debilitating complication of Crohn's disease and treatment options remain limited. There is a lack of head-to-head comparisons between treatments. To our knowledge, this is the first network meta-analysis on the efficacy of medical therapies in achieving fistula remission and maintenance of fistula closure in Crohn's disease. METHODS: Biomedical databases and the Cochrane Central Registry were searched between 1978 and 2022 for randomized controlled trials (RCTs) reporting on treatments. A network meta-analysis was performed using the frequentist model with pooled relative risks (RRs) and P -scores used to rank treatments. RESULTS: Twenty-five RCTs were included for analysis with 2239 patients included. At the 16-24 week time point, infliximab produced the only statistically significant result with the 5 mg/kg dose proving the most effective [RR, 2.30; 95% confidence interval (CI), 1.40-3.77]. At 44 weeks, ustekinumab was found to be most superior with it being 2.38 times (RR, 2.38; 95% CI, 1.24-4.56) more superior to placebo, with adalimumab (RR, 2.06; 95% CI, 1.06-3.99) and infliximab 5 mg/kg (RR, 1.68; 95% CI, 1.03-2.75) also producing a statistically significant result. CONCLUSION: Despite infliximab being favoured in international guidelines for the treatment of perianal fistulising Crohn's disease, biologics such as ustekinumab, vedolizumab and adalimumab show promising results.

Pancreatic Incidentalomas on CT Colonography: Ignore, Follow up or Investigate?

Background: Increasing use of cross-sectional abdominal imaging such as CT colonography (CTC), has resulted in increased identification of incidental pancreatic cystic lesions. Such incidental findings are a cause for anxiety amongst patients and clinicians and can result in increased cost to healthcare delivery resultant from referral to subsequent investigations. Our study explored the prevalence of incidental cystic pancreatic lesions on CTC at a tertiary pancreatic centre, and their management. Methods: A detailed review of CTC reports and patient case notes between 2010-2016 was undertaken. Patients from both screening (National Bowel Cancer Screening) and non-screening cohorts were included in our study. Results: 136 of 4666 patients who underwent CTC had an incidental finding of a pancreatic lesion (2.9%) and 117 confirmed cystic pancreatic lesions (2.5%). Radiological diagnosis of intraductal papillary mucinous neoplasm (IPMN) was available in the CTC report for 71 patients. Twelve patients (0.2%) were found to have pancreatic ductal adenocarcinoma (PDAC) incidentally at CTC, 2 resectable and 10 unresectable with the diagnosis confirmed on biopsy. Follow-up surveillance imaging recommendations were made for 39.3% of patients within one year of the diagnosis of a cystic pancreatic lesion on CTC. One patient with pancreatic duct dilatation of 7mm was lost in follow-up and was found to develop PDAC at 21 months. Conclusions: Pancreatic lesions are increasingly found incidentally on CTC. All patients with pancreatic cystic tumour should be referred to pancreatic multidisciplinary team for discussion to determine management pathway.

Whether Screening for Non-alcoholic Fatty Liver Disease in Patients With Psoriasis Is Necessary: A Pilot Quality Improvement Project.

Background Psoriasis is a chronic inflammatory skin disease that is strongly associated with non-alcoholic fatty liver disease (NAFLD). Both conditions are associated with excess cardiovascular and liver-related morbidity and mortality. The severity of psoriasis correlates with the degree of liver inflammation and scarring, which can be further exacerbated by systemic immunomodulators such as methotrexate. Currently, no clinical pathway exists to screen psoriasis patients for NAFLD in our Trust. We aimed to develop a shared clinical pathway between our hepatology and dermatology departments to allow early identification and management of NAFLD in this patient group. Methods A multidisciplinary team was assembled to identify patient priorities, management goals, and screening criteria. We identified gaps in our service and reviewed current clinical best practice guidelines. A clinical pathway was developed using a process map and revised according to feedback received. We piloted this pathway on a prospective cohort of psoriasis patients identified by our dermatology department. Patients were invited for transient elastography if fatty liver was identified on an ultrasound scan. Baseline demographics, biochemistry and imaging results were collected and analysed. Results Of 57 psoriasis patients, 30 (52.6%) had sonographic evidence of hepatic steatosis. The median age was comparable between groups with 56 and 55 years in the psoriasis-NAFLD (Ps-NAFLD) and no-NAFLD groups respectively. There were more males in the Ps-NAFLDgroup (56.7%) compared to the no-NAFLD group (37%). Fifteen out of 30 patients were eligible for transient elastography (two were excluded due to body habitus). Seven (53.8%) patients had no-to-mild fibrosis indicated by liver stiffness measurement (LSM) ≤7kPa, while six (46.1%) had moderate-to-severe fibrosis. Three (23.0%) patients had scores suggestive of cirrhosis (LSM>13kPa). Conclusions The introduction of a new shared-care pathway at our Trust has resulted in a streamlined way in which psoriasis patients can be screened and treated for NAFLD.

The impact of the ileoanal pouch on female fertility in ulcerative colitis: A systematic review and meta-analysis.

AIM: Ileal pouch-anal anastomosis is a restorative option for patients with ulcerative colitis (UC) requiring surgery. The primary outcome of this study was the relative risk of infertility in women with UC undergoing restorative proctocolectomy (RPC) compared to the same patients before undergoing RPC. Infertility was defined as the inability to conceive after 1 year of regular sexual intercourse without contraception. METHODS: A systematic review and meta-analysis were performed to include all relevant articles from 1946 from MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Studies included reported on the fertility rate of a cohort with UC and also reported the rate after RPC in those within the cohort who underwent surgery. This study was registered on PROSPERO (CRD42021259745). RESULTS: Thirteen studies met the inclusion criteria and accounted for 793 patients pre-pouch and 802 post-pouch. The mean and median age of the patients at analysis was 36.8 and 32.7 years respectively; and the median duration of follow-up following ileal pouch-anal anastomosis was 110.4 (68-139) months. Our results highlight that following RPC the relative risk of infertility is 4.17 (95% CI 1.99, 8.74) compared with patients before RPC who had UC. CONCLUSIONS: The findings of this meta-analysis provide an update on a previous meta-analysis published over a decade ago and results remain congruent. This suggests that despite advancements in surgical techniques the risk to fertility remains similar to a decade ago. However, further high quality studies are needed to try and decipher independent risk factors associated with a decrease in infertility.

Network meta-analysis: efficacy of treatment for acute, chronic, and prevention of pouchitis in ulcerative colitis.

INTRODUCTION: Pouchitis is a clinically significant complication of ileal pouch-anal anastomosis. There is a paucity of head-to-head comparisons between treatments and no data were available about how each treatment rank against each other. A network meta-analysis of the different treatments used for acute, chronic and prevention of pouchitis was conducted. METHODS: Biomedical databases and the Cochrane Central registry were searched between 1978 and 2021 for randomised controlled trials examining treatment for acute, chronic and prevention of pouchitis. A network meta-analysis was performed using the frequentist model with pooled relative risks and P scores used to rank treatments. RESULTS: 18 studies were included from a screen of 4291 abstracts. When compared to placebo, rifaximin was found to be the best antibiotic for acute pouchitis whereas ciprofloxacin ranked highest against metronidazole. For chronic pouchitis, metronidazole followed by probiotics was statistically significant and effective treatments in inducing remission although metronidazole had the highest adverse events. Adalimumab and bismuth were also found to be superior to placebo; however, they did not reach statistical significance. Probiotics proved superior to placebo in the prevention of pouchitis development. CONCLUSIONS: This is the first network meta-analysis which compares the efficacy and tolerability of treatments in the management and prevention of acute and chronic pouchitis. It confirms that antimicrobial therapy remains the mainstay of treatment and adds weight to current guideline recommendations. Our results demonstrate that rifaximin and probiotics may deserve a more prominent role. While biologics are starting to show promise, large-scale head-to-head comparisons are warranted to validate the efficacy of these treatments.

Long-term follow-up of the use of maintenance antibiotic therapy for chronic antibiotic-dependent pouchitis.

OBJECTIVE: Restorative proctolectomy is considered the procedure of choice in patients with ulcerative colitis who have failed medical therapy. Chronic pouchitis occurs in 10%-15% of patients, which often require long-term antibiotics to alleviate symptoms. Safety and efficacy of long-term maintenance antibiotics for chronic pouchitis has yet to be established. We aimed to assess the long-term safety and efficacy of maintenance antibiotic therapy for chronic pouchitis. DESIGN: This was an observational study. We followed up patients who were diagnosed with chronic antibiotic-dependent pouchitis. SETTING: Data were collected from our single specialist pouch centre. PATIENTS: Patients with chronic antibiotic-dependent pouchitis who had been maintained on antibiotics continuously for at least 1 year with a least one follow-up visit. MAIN OUTCOME MEASURE: Development of pouch failure defined by the need for an ileostomy, patient-reported side effects of antibiotics and development of antibiotic resistance found on stool coliform testing. RESULTS: Long-term use of antibiotics achieve remission in 21% of patients over a median follow-up of 102 (range 9-125). Pouch failure in association with chronic pouchitis after a median follow-up of 8.5 years occurred in 18%. Side effects of long-term antibiotic use occurred in 28% of patients, with resistance to antibiotics from at least one stool sample occurring in 78% patients. CONCLUSIONS: Although the use of antibiotics in chronic pouchitis may be justified, the use of long-term antibiotics must be weighed against potential complications associated with pouchitis and antibiotics.

"The Longest Way Round Is The Shortest Way Home": An Overhaul of Surgical Ward Rounds.

BACKGROUND: Ward rounds, a keystone of hospital surgical practice, have recently been under the spotlight. Poor-quality ward rounds can lead to a greater number of adverse events, thereby cascading to an increased financial strain on our already burdened healthcare systems. Faced with mounting pressures from both outside and inside health organizations, concerted efforts are required to restore it back into prominence where it can no longer take a backseat to the other duties of a surgeon. METHODS: The nucleus of this narrative review is derived from an extensive literature search on surgical ward rounds. RESULTS: In this review, we focus on the need for reforms, current characteristics of surgical ward rounds, obstacles encountered by competing interests and proposed solutions in delivery of effective ward rounds that can meet with newly laid guidelines. CONCLUSION: Ward rounds should be standardized and prioritized to improve patient care.

Investigating upper urinary tract urothelial carcinomas: a single-centre 10-year experience.

OBJECTIVES: Evidence of the accuracy of predictive tests in confirming the presence and grade of upper urinary tract urothelial carcinomas (UUTUC) is limited. We present the largest series evaluating the diagnostic value of pre- and intra-operative parameters in the detection of UUTUC. MATERIALS AND METHODS: We retrospectively analysed records of patients who underwent diagnostic ureteroscopy between 2005 and 2014 for suspected UUTUC. Pre-operative workup included voided urine cytology and CT imaging. Intra-operative assessments involved ureteroscopy to directly visualise suspicious lesions, and where possible selective cytology and biopsy. Primary outcomes were the visualisation of UUTUC and histopathological confirmation of tumour. RESULTS: Hundred out of 160 (63 %) patients presenting with suspected upper tract malignancy had UUTUC. Voided and selective urine cytology and CT individually predicted UUTUC with a sensitivity/specificity of 63/67, 76/73, and 95/26 %, respectively. Forty out of 48 (83 %) patients who had abnormal CT and abnormal voided urine cytology had UUTUC, while 100 % of those with normal CT and normal voided cytology (investigated for ongoing symptoms) were normal. Comparing endoscopic biopsy to nephroureterectomy specimen grade, 19 (46 %), 18 (44 %), and 4 (10 %) were identical, upgraded, and downgraded, respectively. CONCLUSION: Pre-operative investigations can predict UUTUCs. When these investigations were normal, the risk of UUTUC is negligible. In selective patients with abnormal investigations, ureteroscopy should be performed to confirm and predict the grade of UUTUC, in order to guide future management. Selective cytology is unlikely to significantly contribute to the diagnostic workup of UUTUC.

Atypical Antipsychotics for Schizophrenia and/or Bipolar Disorder in Pregnancy: Current Recommendations and Updates in the NICE Guidelines.

BACKGROUND: The gold standard pharmacological agents used to treat schizophrenia and bipolar disorder in adults are antipsychotics. Atypical or second-generation antipsychotics have superseded or used as alternatives to typical first-generation antipsychotics due to better tolerability and safety profile. However the efficacy and safety of these drugs are severely limited in pregnancy and/or women of childbearing potential. There are very few guidelines to guide the clinical management of schizophrenia and/or bipolar disorder in this subgroup. AIM: We aimed to review current evidence of atypical antipsychotics used in pregnancy where available, with considerations to its efficacy and safety to both the mother and fetus, in conjunction with the recently updated NICE guidelines. METHODS: The latest NICE CG192 guidelines on antenatal and postnatal mental health, published in December 2014 was reviewed and summarized, and the BNF-approved list of atypical antipsychotics were identified. Clinically relevant MEDLINE-linked publications were searched and selected where available using the PubMed search engine to identify evidence for or against the use of atypical antipsychotics in pregnancy. RESULTS AND CONCLUSIONS: NICE CG192 improved clarity on the prediction, support and holistic management of mental illness in pregnancy and puerperium; however there were no specific recommendations in terms of pharmacological agents used to treat schizophrenia and/or bipolar disorder in this subgroup. Evidence from the literature on atypical antipsychotics yielded discordant results. Nonetheless, our report presents preliminary findings of certain antipsychotics which appear to be effective and safe in pregnancy. Future research would benefit from larger, prospective randomized controlled trials, and perhaps include newer atypical antipsychotics for consideration in this subgroup.

Atypical Anti-Psychotics in Adult Bipolar Disorder: Current Evidence and Updates in the NICE guidelines.

BACKGROUND: The introduction of atypical antipsychotics in the management of adult bipolar disorder has been increasingly adopted in clinical setting. While new studies continue to emerge, NICE has recently updated the guidelines on the assessment and management of bipolar disorder. AIM: To review the efficacy and tolerability profiles of atypical antipsychotics used to treat adult bipolar disorder in clinical practice, in relation to the latest NICE guidelines. METHODS: The recent NICE guidelines (CG185), published in September 2014 was analysed to identify second generation antipsychotics (SGA) for the various presentations of bipolar disorder in adults. A qualitative literature search was conducted to review the evidence to support these changes, and identify randomized controlled trials on off-label and newer SGAs. RESULTS AND CONCLUSIONS: With respect to atypical antipsychotics, NICE guidelines introduced olanzapine and fluoxetine combination therapy as first line treatment for moderate to severe bipolar depression; and improved clarity on the treatment of mania, hypomania and rapid cycling bipolar disorder. Evidence from our literature search favour these changes; and recognized other atypical antipsychotics such as aripiprazole, asenapine, lurasidone, ziprasidone and clozapine which could be of potential clinical benefit.