Straight To Test (STT)services has been adopted by hospitals throughout the UK to improve the efficiency of pathways for early cancer diagnosis. Our previous results suggest that STT colonoscopies for suspected colorectal malignancy are feasible, safe and accurate1. There has been no studies however on the long term (5 years or greater) outcomes after a normal colonoscopy in these patients. It is unclear if it is safe to discharge them back to primary care. We aimed to look at the 5 year outcomes after a negative STT colonoscopy for patient s referred for suspected colorectal malignancy in 2007.
Methods
In 2008 we conducted a retrospective study of all straight to test colonoscopies (Jan 2007 to Dec 2007) in Seacroft Hospital, Leeds1. Of the 195 colonoscopies (150 for rectal bleeding and change in bowel habits and 45 for iron deficiency anaemia), 104 were either normal or had insignificant findings and were discharged back to GPs without hospital follow-up. We looked at hospital records of all these patients in Dec 2012 (5 years after their index procedure) for further hospital contact, investigations or other diagnosis. Data was collected from the hospitals electronic patient record (patient pathway management system or PPM which records all secondary care hospital episodes in West Yorkshire) and the results server. All secondary care contacts and investigations by these patients would have been captured by PPM and results server.
Results
Of the 104 included patients, we collected follow-up data on 96 (In 8 data could not be traced). 76 of these were never referred back to secondary care. 20 were referred back with various symptoms, 6 of whom had normal investigations, 9 had benign gastrointestinal disease and 5 developed cancers as detailed in table below.
Conclusion
Only 1 patient developed colorectal malignancy on follow-up, but presented more than 5 years after the index colonoscopy with weight loss and but had a normal CT abdomen in the interim. 4 other had other malignancies with weight loss as the presenting feature in 50%. Patients who undergo STT colonoscopies for suspected colorectal malignancy can be discharged back to the GP with confidence by the endoscopist without follow-up in secondary care, but patients need to be warned to seek urgent help if losing weight.
Disclosure of Interest
None Declared.
Reference
THE LEEDS EXPERIENCE OF THE STRAIGHT TO TEST PATHWAY F. A. Butt*(1), P. Mundre (2), G. G. Robins (2), M. Chadwick (2), M. E. Denyer (2), (1)(2)Gastroenterology, St James’s Hospital, Leeds, United Kingdom
5-aminosalicylates (5-ASA) have a proven efficacy in induction and maintenance of ulcerative colitis (UC). The evidence that 5-ASAs have efficacy in the induction and maintenance of remission in Crohn’s disease (CD) is weak and not supported by recent meta-analyses1or current guidelines. Our aim was to determine if patients with CD and UC were being appropriately prescribed 5-ASAs
Method
We constructed an incident cohort of patients with CD and UC diagnosed between 1990 and 2009 using the Clinical Practice Research Datalink (CRPD), a validated research database representing an 8% sample of the UK population. We divided our cohort to compare patterns between era: era 1 (1990–1993), era 2 (1994–1997), era 3 (1998–2001), era 4 (2002–2005) and era 5 (2006–2009). We performed a Kaplan-Meier survival analysis to quantify the 3 year probability of receiving a 5-ASA. We identified patients with “prolonged 5-ASA use” defined as use for greater than 12 months duration to determine whether patients were inappropriately maintained on 5-ASAs for CD. We compared the proportion (number of users/total number within the era) of prolonged 5-ASA use between time periods using the 2-group proportion test.
Results
In CD, there were 6997 patients who met our inclusion criteria. The 3 year cumulative probability of receiving a 5-ASA was 40.5% (95% CI: 35.9–45.4), 49.7% (95% CI: 45.7–53.8), 50.8% (95% CI: 48.0–53.6), 52.5% (95% CI: 50.1–54.9) and 61.8% (95% CI: 58.9–64.8) for era 1, 2, 3, 4 and 5 respectively. Prolonged oral 5-ASA use was prevalent throughout the study period in CD, although decreased between era 3 and era 5 from 59.2% to 47.2% (p < 0.001). In UC, there were 16,512 patients who met our inclusion criteria. The 3 year cumulative probability of receiving a 5-ASA was 31.7% (95% CI: 29.3–34.3), 36.6% (95% CI: 34.3–39.0), 42.9% (95% CI: 41.0–44.7), 46.2% (95% CI: 44.6–47.8) and 55.4% (95% CI: 53.4–57.4) for era 1, 2, 3, 4 and 5 respectively. Prolonged oral 5-ASA use was increasing throughout the study period in UC, 43.3% to 53.0% between era 1 and era 4 (p < 0.001).
Conclusion
In CD, 5-ASA use remains common with over 50% of patients receiving the medication, including maintenance therapy, despite a lack of evidence to support this clinical practice. In UC, 5-ASA use has increased appropriately although not all patients appeared to be maintained on these drugs.
Disclosure of interest
None Declared.
Reference
Ford AC, Kane S V, Khan KJ, Achkar J-P, Talley NJ, Marshall JK, Moayyedi P. Efficacy of 5-aminosalicylates in Crohn’s disease: systematic review and meta-analysis. Am J Gastroenterol 2011;106:617–29
Conclusions: Endoscopy at M12 can help to identify long-term responders to thiopurines monotherapy in active CD.A PR could represent the minimal clinically important improvement in endoscopic disease activity.
Conclusions: Endoscopy at M12 can help to identify long-term responders to thiopurines monotherapy in active CD.A PR could represent the minimal clinically important improvement in endoscopic disease activity.
Severe Clostridium difficile associated diarrhoea (CDAD) is an important nosocomial infection, often resulting in severe morbidity or death. The rates of CDAD have increased significantly in the last 2 decades, but predictors of outcome are poorly understood.
Methods
A retrospective cohort study was performed in patients with a diagnosis of CDAD hospitalised at Leeds Teaching Hospitals NHS Trust (LTHT) between January 2011 and December 2011. The data on these cases was collected from electronic patient records and medical notes. Data collected included general demographics, underlying medical conditions, Horn Index, Charlson co-morbidity score, clinical and laboratory data, and the medical treatment given. Death due to any cause either during that hospital stay or within 30 days of discharge from hospital was the primary outcome. Severe CDAD was defined according to the UK Health Protection Agency (HPA) guidelines as WCC > 15 X 109/L, or an acute rising serum creatinine (i.e. > 50% increase above baseline), or a temperature of > 38.5°C, or evidence of severe colitis (abdominal or radiological signs). Logistic Regression analysis was used to identify parameters associated with mortality. SPSS version 17 (IBM Corp, NY) was used to perform the statistical analysis.
Results
There were 247 patients with a diagnosis of CDAD made in 2011 at LTHT of which 16 were wrongly coded, 5 were treated in the community, 12 had insufficient information in the notes and in 68 patients the medical notes could not be traced. A total of 170 episodes in 146 patients were finally analysed. There were 36 deaths in this group. Patients who were dead were older (mean age 78±12.9 vs 76.6±17.6). Independent predictors of mortality on multivariate analysis included age (OR 1.051, 95% CI 1.009–1.095), Charlson co-morbidity score of ≥3 (OR 3.036, 95% CI 1.209–7.622), Horn Index (Major or Extreme) (OR 4.725, 95% CI 1.818–12.283), Severe CDAD (OR 3.454, 95% CI 1.222–9.760) and in-appropriate treatment of severe CDAD with metronidazole as first line therapy (OR 4.642, 95% CI 1.213–19.193). Factors not found significant included gender, prior use of antibiotics, PPI use, opioid use, prior episodes of CDAD and treatment with vancomycin.
Conclusion
Predictors of all-cause mortality in patients with CDAD include older age, Charlson score≥3, Horn index ≥3, severe CDAD as defined by the UK HPA and in-appropriate use of metronidazole in severe CDAD. Patients with severe CDAD should not be treated with Metronidazole as first line therapy. Further prospective validation of these results is needed in a multicenter setting.
Surveillance endoscopy is crucial to the management of Barrett’s oesophagus to diagnose and treat dysplasia. Recent studies have confirmed that increased time of inspection of the Barrett’s mucosa increases detection rates. However increasing inspection time has both clinical and economic implications. Advanced imaging techniques like autofluoresence imaging (AFI) improves detection of dysplastic lesions, but little on known about the time taken to detect abnormalities with these modalities.
Methods
We presented a series of endoscopic images of dysplastic lesions within the oesophagus to novice endoscopists on a computer screen. Each of the 10 lesions was presented in white light endoscopy (WLE) and AFI modes. The subjects reviewed these images in a random order with 10 seconds for each image. They were tasked with identifying the lesion as fast as possible and fixating on it for the duration of presentation. An eye tracking system (Grinbath eye tracker, College Station Texas) was used to record eye movements of the subjects and we calculated the amount of time it took to fixate on the lesion and the percentage attention time on each lesion.
Results
A total of 26 novice endoscopists were recruited to the study, resulting in a total of 260 presentations of WLE images and 260 presentations of AFI images. The average time to fixation on the lesion was significantly less (p < 0.05) in AFI (5.47 seconds) compared to WLE (6.17). In addition, the percentage attention span on the lesion following detection was significantly greater for AFI (58.12%) than WLE (49.96) (p < 0.0005).
Conclusion
AFI reduces time to detection in novice endoscopists and could be a valuable training tool for trainees to improve their skills in detecting dysplasa in a time efficient manner. Advanced imaging endoscopic techniques may therefore help trainee endoscopists more than experienced endoscopists.
A 44-year-old woman was admitted with recurrent hematemesis. She had a history of intermittent upper abdominal pain, which was investigated by computed tomography (CT) scan 1 year prior to the presentation ([Fig. 1]). She was taking aspirin for ischemic heart disease.
Presentationsthe severity of CD recurrence as assessed by the 2 techniques, the bowel wall thickness detected by SICUS was significantly correlated with the Rutgeerts' score (p<0.0001;r=0.506).This difference was observed in pts with SICUS and IC performed ≥ 3 yrs (n=28) after surgery, but not < 3 yrs (n=43) after surgery (p<0.001,r=0.59 vs p=0.07, r=0.2).The median bowel wall thickness was significantly higher in pts with endoscopic score of recurrence ≥ 3 vs <3 (p<0.001).Conclusions: Although SICUS and IC provide different views of the small bowel, SICUS shows a high sensitivity and accuracy in detecting CD recurrence and a significant correlation with endoscopic findings.SICUS may represent an alternative non-invasive technique for assessing CD recurrence after ileocolonic resection.
Autofluorescence endoscopy (AFE) is a novel technique that identifies early neoplasia in Barrett9s oesophagus (BE) by highlighting differences in tissue autofluoresence (AF). It has high sensitivity but is associated with false positive rates up to 80%. We aimed to develop numerical measures of AF to reduce the false positive rates of AFE.
Methods
Images of AFE lesions in patients with BE were prospectively collected. Blinded anonymised images were de-gamma corrected and average grayscale values in the red, green and blue channels of the abnormal and background normal area were quantified. The autofluoresence intensity (ratio of average red to green channel greyscale value of lesion compared to background), colour contrast index (between lesion and background), hue, saturation and lightness (of the lesion) were calculated. A decision tree based on the training set was developed with the J48 algorithm in WEKA3.2.4, using a 10-fold cross validation strategy. The performance of the model developed was assessed on an independently collected test dataset.
Results
There were 82 images (37 high grade dysplasia/cancer) in the training set and 164 images (51 high grade dysplasia/cancer) in the test set. The decision tree classifier developed utilised only autofluoresence intensity and colour contrast index and had a sensitivity of 97%, specificity of 77%, and negative predictive value of 98% in detecting high grade dysplasia/cancer in the independent test set. The false positive rate of AFE was reduced from 70% to 16%.
Conclusion
Numerical analysis of colour fluorescence and contrast is a reliable, objective and accurate method of reducing the false positive rate of AFE and can be easily incorporated into real time endoscopy.
Competing interests
V Subramanian: None declared, J Mannath: None declared, D Boerwinkel: None declared, L Alvarez-Herrero: None declared, W Curvers: None declared, C Hawkey: None declared, J Bergman Grant/Research Support from: Olympus Medical, K Ragunath Grant/Research Support from: Olympus Medical.
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