What is the role of out of programme clinical fellowships in the era of Shape of Training? A single-centre cohort study.

BACKGROUND: The updated Shape of Training curriculum has shortened the duration of specialty training. We present the potential role of out of programme clinical fellowships. METHOD: An electronic online survey was sent to all current fellows to understand their experiences, training opportunities and motivations.Data were collected on fellows' endoscopic experiences and publications using PubMed for all previous doctors who have completed the Sheffield Fellowship Programme. RESULTS: Since 2004, 39 doctors have completed the Sheffield Fellowship.Endoscopic experience: current fellows completed a median average of 350 (IQR 150-500) gastroscopies and 150 (IQR 106-251) colonoscopies per year. Fellows with special interests completed either 428 hepato-pancreato-biliary procedures or 70 endoscopic mucosal resections per year.Medline publications: Median average 9 publications(IQR 4-17). They have also received multiple national or international awards and 91% achieved a doctoral degree.The seven current fellows in the new Shape of Training era (57% male, 29% Caucasian, aged 31-40 years) report high levels of enjoyment due to their research projects, supervisory teams and social aspects. The most cited reasons for undertaking the fellowship were to develop a subspecialty interest, take time off the on-call rota and develop endoscopic skills. The most reported drawback was a reduced income.All current fellows feel that the fellowship has enhanced their clinical confidence and prepared them to become consultants. CONCLUSION: Out of programme clinical fellowships offer the opportunity to develop the required training competencies, subspecialty expertise and research skills in a supportive environment.

Sheffield Clinical Research Fellowship programme: a transferable model for UK gastroenterology.

Out of programme (OOP) opportunities are to be encouraged. This article gives an insightful view of the Sheffield Clinical Research Fellowship Programme. Unique trainee feedback is provided. The take home message is clear - trainees should grab OOP experiences with both hands! For consultants the logistics described are potentially transferrable to their own regions.

Refractory bleeding from portal hypertensive gastropathy: a further novel role for thalidomide therapy?

Bleeding from portal hypertensive gastropathy (PHG) can pose a therapeutic challenge. Thalidomide, which selectively inhibits tumour necrosis factor-alpha production by enhancing messenger RNA degradation, has been shown to reduce portal venous pressure in cirrhotic and non-cirrhotic portal hypertension. Thalidomide is also a potent inhibitor of angiogenesis. We describe a case of intractable bleeding from PHG secondary to extrahepatic portal vein obstruction due to malignancy, which was managed successfully by thalidomide, thus obviating the need for major surgery. Although the use of thalidomide for treatment of severe intestinal bleeding has been described previously, this is the first case report, to our knowledge, describing its efficacy in bleeding secondary to PHG. We discuss the possible therapeutic mechanisms for thalidomide in PHG.

Alcohol-related cerebellar degeneration: not all down to toxicity?

BACKGROUND: Alcohol-related cerebellar degeneration is one of the commonest acquired forms of cerebellar ataxia. The exact pathogenic mechanisms by which alcohol leads to cerebellar damage remain unknown. Possible autoreactive immune mediated mechanisms have not been explored previously. In this study, we aim to investigate the potential role of alcohol-induced immune mediated cerebellar degeneration. METHODS: Patients with ataxia and a history of alcohol misuse were recruited from the Ataxia and Hepatology tertiary clinics at Sheffield Teaching Hospitals NHS Trust. We determined the pattern of cerebellar involvement both on clinical (SARA score) and imaging (MRI volumetry and MR spectroscopy) parameters. In addition, HLA genotyping, serological markers for gluten-related disorders and serological reactivity on rat cerebellar tissue using indirect immunohistochemistry were assessed. RESULTS: Thirty-eight patients were included in the study all of whom had ataxia. The gait (97 %), stance (89 %) and heel-shin slide (89 %) were the predominant SARA elements affected. MRI volumetric and spectroscopy techniques demonstrated significant structural, volumetric and functional deficits of the cerebellum with particular involvement of the cerebellar vermis. Circulating anti-gliadin antibodies were detected in 34 % patients vs. 12 % in healthy controls. Antibodies to transglutaminase 6 (TG6) were detected in 39 % of patients and 4 % of healthy control subjects. Using immunohistochemistry, Purkinje cell and/or granular layer reactivity was demonstrated in 71 % of patient sera. CONCLUSIONS: Alcohol induced tissue injury to the CNS leading to cerebellar degeneration may also involve immune mediated mechanisms, including sensitisation to gluten.

Clearance of hepatitis C virus is not associated with single nucleotide polymorphisms in the IL-1, -6, or -10 genes.

Hepatitis C virus (HCV) commonly causes a chronic infection, but a minority of patients are able to clear the virus and do not run the risk of developing HCV-induced organ damage. Genetic associations between immunoregulatory cytokines interleukin (IL)-1, -6, and -10 with clinical features of HCV, including virus clearance, have been inconsistent. We determined cytokine genotypes in 606 patients who had serologic evidence of HCV exposure, 190 (18%) of whom were consistently negative for HCV RNA, indicating successful virus clearance. There was no significant difference in genotype frequencies between HCV clearance and nonclearance groups for IL-1B (-511 and +3954), IL-1A (+4845), IL-1RN (+2018), IL-6 (-174), or IL-10 (-1082). We conclude that these single nucleotide polymorphisms are unlikely to play an important, if any, role in determining the likelihood of clearing HCV infection.

Effectiveness of an upper-gastrointestinal haemorrhage unit: a prospective analysis of 900 consecutive cases using the Rockall score as a method of risk standardisation.

OBJECTIVES: To assess the effectiveness of a centralised upper-gastrointestinal haemorrhage (UGIH) unit. METHODS: The UK Audit of acute UGIH resulted in the formulation of a simple numerical scoring system. The Rockall score categorises patients by risk factors for death and allows case-mix comparisons. A total of 900 consecutive patients admitted to a UGIH unit between October 1995 and July 1998 were analysed prospectively. Patients were given an initial Rockall score and, if endoscopy was performed, a complete score. This method of risk stratification allowed the proportion of deaths (in our study) to be compared with the National Audit using risk standardised mortality ratios. RESULTS: The distribution of both initial and final Rockall scores was significantly higher in our study than in the National Audit. A total of 73 (8.1%) patients died, compared with the National Audit mortality of 14%. Risk-standardised mortality ratios using both initial and complete Rockall scores were significantly lower in our study when compared with those in the National Audit. CONCLUSION: A specialised UGIH unit is associated with a lower proportion of deaths from UGIH, despite comprising a greater number of high-risk patients than the National Audit. This lower mortality therefore cannot be attributed to a more favourable case mix and demonstrates that further improvements in mortality for UGIH can be made.