Summary Background Upper gastrointestinal bleeding (UGIB) remains a common cause of presentation and admission to hospital in the UK, with the incidence in Scotland one of the highest in the world. Aims To investigate the difference in demographics, deprivation quintiles, aetiology of bleeding and clinical outcomes in patients presenting with UGIB to hospitals across Scotland over a 16‐year period Methods Data were collected using the National Data Catalogue and analysed retrospectively using the National Safe Haven. Results We included 129 404 patients. The annual number of patients presenting with UGIB remained similar over the 16‐year period. Mean age at admission increased from 59.2 to 61.4 years. There was a significant drop in variceal bleeding over time from 2.2% to 1.7% ( P < 0.001). The incidence of UGIB was highest in the more deprived quintiles. There was a significant decrease in 30‐day case‐fatality from 10.1% in 2000 to 7.9% in 2015 ( P < 0.001), which was observed across all deprivation quintiles. Mean length of stay fell from 3.9 to 2.1 days. There was no difference in 30‐day case‐fatality or mean length of stay between patients presenting on weekdays or at weekends. Conclusions In this national study, we demonstrated that case‐fatality and mean length of stay after presentation with UGIB in Scotland has fallen over the past 16 years, despite a rise the in mean age of patients. There is a positive correlation between the incidence of UGIB and deprivation. We found no evidence of worse outcomes among patients presenting at weekends.
TO THE EDITOR: We would like to thank Matsushita et al. for their interest in our article. They raise specific points concerning the type of steroid therapy for acute autoimmune pancreatitis (AIP) and the use of azathioprine in disease relapse. These points are part of the broader question: What is the optimum therapy for autoimmune pancreatitis (AIP)? This question remains unanswered, as published data include only small case series and case reports. No randomized controlled data exist.
Benign biliary strictures are a common complication of liver transplantation, mainly as a result of constriction at the site of biliary anastomosis or ischaemic cholangiopathy. Placement of fully covered self-expanding metal stents (FCSEMS) by ERCP has been shown to be an effective treatment for benign and malignant biliary strictures and offers advantages over plastic stents of greater patency rates and the potential for stricture remodeling. The aim of this study was to assess the incidence of post-ERCP pancreatitis following placement of FCSEMS for benign biliary strictures after liver transplantation in a high-volume centre.
Methods
Retrospective analysis of prospectively maintained local databases was performed. Endoscopy reports were reviewed for every ERCP (any indication) performed for liver transplant recipients between 1stJanuary 2014 and 1st January 2018. Patient outcomes were gathered from electronic patient records. Severity of pancreatitis was graded according to the Revised Atlanta Classification. Statistical comparison of two groups was performed with Fisher's exact test.
Results
Over a four-year period, 36 out of 393 consecutive liver transplant recipients underwent ERCP for treatment of benign biliary strictures. A total of 97 ERCPs were performed for this patient group (mean 2.7 per patient, range 1–13). Placement of temporary fully covered self-expanding metal stents successfully achieved long-term stricture resolution in 92% of patients (22/24). However, ERCP involving placement of a first FCSEMS was associated with a considerably higher rate of post-ERCP pancreatitis than any other ERCP performed in this study population (34.5% vs 2.8%, P<0.0001); 89% (8/9) of episodes of pancreatitis were classified as mild, 11% (1/9) as severe.
Conclusions
In the experience of a single high-volume centre, placement of FCSEMS by ERCP is an effective treatment for the management of benign biliary strictures, but one that is associated with a particularly high risk of pancreatitis. Patients should give informed consent accordingly. Further research into the mechanisms behind this effect (e.g. sudden occlusion of a normal pancreatic duct) and the effectiveness of additional specific prophylactic measures is underway.
Seizures after ischemic stroke have not been well-studied. We aim to determine the frequency, determinants, and significance of early seizures after thrombolysis for acute ischemic stroke.Data are from the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED), an international, multicenter, randomized controlled trial where patients with acute ischemic stroke were randomized to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) IV alteplase. The protocol prespecified prospective data collection on in-hospital seizures over 7 days postrandomization. Logistic regression models were used to determine variables associated with seizures and their significance on poor outcomes of death or disability (modified Rankin scale scores 3-6), symptomatic intracerebral hemorrhage (sICH), and European Quality of Life 5-Dimensions questionnaire [EQ-5D] over 90 days.Data were available for 3,139 acute ischemic stroke participants, of whom 42 (1.3%) had seizures at a median 22.7 hours after the onset of symptoms. Baseline variables associated with seizures were male sex (odds ratio [OR] 2.19, 95% confidence interval [CI] 1.07-4.50), severe neurologic impairment (NIH Stroke Scale score ≥10; OR 2.16, 95% CI 1.06-4.40), and fever (OR 4.55, 95% CI 2.37-8.71). Seizures independently predicted poor recovery: death or major disability (OR 2.88, 95% CI 1.28-6.47), unfavorable ordinal shift of mRS scores (OR 1.94, 95% CI 1.10-3.39), and lower than median EQ-5D health utility index score (OR 3.50, 95% CI 1.37-8.91). There was no association of seizures with sICH in adjusted analysis.In thrombolysis-treated patients with acute ischemic stroke, seizures are uncommon, occur early, and predict poor recovery.NCT01422616.
In the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification.Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway.In total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (2) minimum procedure count 280+; (3) performing 15+ procedures over the preceding 3 months; (4) attendance of the JAG Basic Skills in Colonoscopy course; (5) terminal ileal intubation rates of 60%+ in inflammatory bowel disease; (6) satisfying requirements for formative direct observation of procedure skills (DOPS) and direct observation of polypectomy skills (Size, Morphology, Site, Access (SMSA) level 2); (7) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool; (8) successful performance in summative DOPS.The UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.
Introduction Joint Advisory Group (JAG) certification in endoscopy is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update standards for training and certification in flexible sigmoidoscopy (FS). Methods A modified Delphi process was conducted between 2019 and 2020 with multisociety representation from experts and trainees. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on FS training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer-reviewed by national stakeholders for incorporation into the JAG FS certification pathway. Results In total, 41 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (17), assessment of competence (7) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (A) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, rectal retroversion >90%, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (B) minimum procedure count ≥175; (C) performing 15+ procedures over the preceding 3 months; (D) attendance of the JAG Basic Skills in Lower gastrointestinal Endoscopy course; (E) satisfying requirements for formative direct observation of procedural skill (DOPS) and direct observation of polypectomy skill (SMSA level 1); (F) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool and (G) successful performance in summative DOPS. Conclusion The UK standards for training and certification in FS have been updated to support training, uphold standards in FS and polypectomy, and provide support to the newly independent practitioner.
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