Depression is associated with constipation within and outside Parkinson’s disease (PD). Since inefficient cognitive-processing (bradyphrenia) features in PD and an enterokinetic agent improved cognitive performance in healthy individuals, bradyphrenia may be associated with constipation. We aim to define the archetypical bowel function of PD, and its association with cognition, mood, and motor features within and outside PD. We assessed colonic transit time (oral radio-opaque markers over 6 days), bowel function and psychometric questionnaires and measures of PD facets, including bradyphrenia, in 58 participants with diagnosed PD, and 71 without (controls). The best abdominal X-ray (day 7) predictors of PD status were total retained marker count and transverse colon segmental delay. However, Rome functional constipation status complemented segmental delay better, giving good specificity (85%) but low sensitivity (56%). Transverse colon marker count appeared to be age-associated only in PD. In PD, those correctly classified by bowel dysfunction had higher depression scores (p = 0.02) and longer cognitive-processing times than the misclassified (p = 0.05). Controls misclassified as PD by bowel dysfunction had higher depression and anxiety scores than the correctly classified (p = 0.002 and 0.003, respectively), but not slower cognitive processing. Measures of motor features were independent of sub-classification by bowel function in PD and in controls. In conclusion, constipation in PD has distinct localized pathophysiology, and is associated with bradyphrenia.
Aims Plastic pancreatic stents are widely used for the prevention of post-ERCP pancreatitis (PEP). However, these patients require further care post-procedure to confirm spontaneous stent passage and repeat endoscopy for stent removal if migration has not occurred (in approximately 20%). The development of a 6F biodegradable (BD) stent (Archimedes, Q3 Medical, Dublin, Ireland), which can be used for the same indications, removes the need for additional post-procedure care. This study aimed to evaluate the additional carbon footprint related to the environmental impact of the care pathway using plastic (non-BD) pancreatic stents compared with using BD stents.
Infection prevention and control (IPC) measures put in place during the first phases of the COVID-19 pandemic were effective in reducing endoscopy-related transmission while allowing recovery of activity.
In late 2020 a novel, more infectious, SARS-CoV-2 variant (VOC 202012/01) was associated with a second ’surge' or acceleration phase in the UK. We sought to measure whether pre-existing IPC guidance would be sufficient to prevent transmission in this scenario. Prospective data were collected from eight UK centres for n=2440 procedures. Pre-endoscopy, nine (0.37%) asymptomatic patients were positive for SARS-CoV-2 by nasopharyngeal swab (NPS) testing and their procedures deferred. Post endoscopy, 30 (1.27%) developed symptoms suspicious for COVID-19, with 15 (0.65%) testing positive on NPS. Three (0.12%) cases were attributed to potential transmission from endoscopy attendance. All 15 patients recovered fully requiring only community treatment.
Although we report cases potentially transmitted by endoscopy attendance in this latest study, the risk of COVID-19 transmission following outpatient endoscopy remains very low. Thus, IPC measures developed in earlier pandemic phases appear robust, but our data emphasise the need for vigilance and strict adherence to these measures in order to optimally protect both patients and staff.
The effects of the COVID-19 pandemic continue to extend beyond direct care of affected patients,1 particularly impacting outpatient diagnostics including GI endoscopy. Considerable concerns remain around the potential impact on detection of, and survival from, significant disease such as cancer.2 3 In mid-2020, a pandemic deceleration phase4 in the UK led to a period of intense ‘restart and recovery’ activity in endoscopy to mitigate the effects of delayed or cancelled procedures. This was supported by professional society guidance on the development of ‘COVID-minimised’ or ‘green’ pathways with NPS testing of patients before their attendance for the procedure.5–7 Activity was limited by the impact on endoscopy staff …
The contribution of rare coding sequence variants to genetic susceptibility in complex disorders is an important but unresolved question. Most studies thus far have investigated a limited number of genes from regions which contain common disease associated variants. Here we investigate this in inflammatory bowel disease by sequencing the exons and proximal promoters of 531 genes selected from both genome-wide association studies and pathway analysis in pooled DNA panels from 474 cases of Crohn's disease and 480 controls. 80 variants with evidence of association in the sequencing experiment or with potential functional significance were selected for follow up genotyping in 6,507 IBD cases and 3,064 population controls. The top 5 disease associated variants were genotyped in an extension panel of 3,662 IBD cases and 3,639 controls, and tested for association in a combined analysis of 10,147 IBD cases and 7,008 controls. A rare coding variant p.G454C in the BTNL2 gene within the major histocompatibility complex was significantly associated with increased risk for IBD (p = 9.65x10−10, OR = 2.3[95% CI = 1.75–3.04]), but was independent of the known common associated CD and UC variants at this locus. Rare (<1%) and low frequency (1–5%) variants in 3 additional genes showed suggestive association (p<0.005) with either an increased risk (ARIH2 c.338-6C>T) or decreased risk (IL12B p.V298F, and NICN p.H191R) of IBD. These results provide additional insights into the involvement of the inhibition of T cell activation in the development of both sub-phenotypes of inflammatory bowel disease. We suggest that although rare coding variants may make a modest overall contribution to complex disease susceptibility, they can inform our understanding of the molecular pathways that contribute to pathogenesis.
Cystic fibrosis (CF) is a common genetic disorder affecting 10,500 people in the UK. While pulmonary manifestations are often most severe, CF also affects the liver, intestine, and pancreatobiliary system, leading to a considerable burden of gastrointestinal (GI) disease. However the provision of GI services within UK CF centres has not been extensively studied.
Methods
This work examined the models of GI care delivered to adults and children with CF in the UK. An online survey was distributed to CF clinicians and centres in December 2019.
Results
Forty-nine responses were received from 42 UK CF centres (20 adult; 22 paediatric) caring for over 8,000 patients. Adult centres were larger with a mean of 263 patients (range 90–600), compared to 140 patients (range 6–365) in paediatric centres. GI symptoms requiring investigation or treatment were common, affecting 60% of patients in adult centres, and 30% of patients in paediatric centres. Twenty-eight centres (57%) made CF-GI referrals to the general gastroenterology service, 13 (26%) had a named gastroenterologist to which they referred, and three centres had a gastroenterologist within the CF team. For inpatient GI review, 30 centres (61%) referred to the general GI service, with only eight centres having access to a named gastroenterologist with CF interest. Eleven centres (22%) reported no access to face-to-face inpatient review. Only 9% of respondents had a dedicated CF-GI clinic, and formal joint working with the CF team only occurred in two centres. Two-thirds of units lacked specific CF bowel cancer surveillance guidelines. While 47% of respondents said that their service provided good/excellent GI care, 23% reported that they were unable to provide adequate GI care for patients. Respondents stated that increased gastroenterologist interest and expertise in CF would help improve GI services, as would more coordinated working practices, including joint CF-GI clinics, MDTs, and teaching. Respondents identified barriers to service improvement including limited clinician time, a lack of specific funding, and the challenges of clinic capacity and infection control.
Conclusions
Patients living with CF have a substantial need for specialist GI care. There is considerable unwarranted variation in GI provision between UK CF centres. We propose the development of inter-specialty service standards that highlight successful models of care, and identifying ring-fenced funding for CF-GI services via specialist commissioning budgets could improve patient care. In addition, we plan a tandem survey this Spring of gastroenterologist confidence in CF-GI management.
Delay in diagnosis of colorectal cancer (CRC) is associated with worse outcomes. Although studies have shown the incidence of CRC missed at endoscopy to be 2.5%-7.7% (Morris et al., 2014), there are additional non-endoscopic factors that may lead to delays. This study aimed to identify all factors leading to a delayed diagnosis, including endoscopic "misses".
Methods
All patients diagnosed with CRC at Kings College Hospital, London between 2011 – 2018 were included. We identified patients seen in an outpatient clinic or underwent endoscopy within 36 months preceding diagnosis. 'Delayed' cancers were grouped into 'clinical factors' and 'technical factors'. 'Clinical factors' included the subset of post-colonoscopy colorectal cancers (PCCRC). The Joint Advisory Group on GI endoscopy (JAG) have defined PCCRC as being cancers diagnosed within 36 months of an endoscopy.
Results
797 cases of CRC were diagnosed in the study period and 60(7.5%) were seen in the preceding 36 months. 46 patients (5.8%) were determined to have a delayed diagnosis, of which 24(52.2%) were diagnosed within 1 year of initial investigation. 38 delayed diagnoses were due to clinical factors: PCCRC (n=23), incomplete endoscopy (n=2), inadequate investigation (n=7), missed on rigid sigmoidoscopy (n=1) and incomplete bowel preparation (n=5) with an average delay of 172 days. 8 delays were caused by technical factors: Incomplete follow up (n=4), delayed investigation (n=2), histology not reviewed (n=1), missed on CT (n=1). The rate of missed cancer in the 2WW, Bowel Cancer Screening and Routine referral pathways was 4.8% (n=14), 5.1% (n=8), 7.3% (n=28) respectively. The incidence of missed cancer in the right colon was significantly higher (p=0.068, 95% CI 0.9–.57). Further interrogation showed the highest incidence in the hepatic flexure (10.5%), splenic flexure (9.4%), caecum (7.5%), and anal canal (6.5%). 91.3% of PCCRCs versus 47.8% of other missed cancers identified another pathology at the initial endoscopy which was documented on the report (p=0.003, 95% Confidence interval 2.1–0.6). A delay in diagnosis was not associated with more advanced TNM staging or K-ras mutations.
Conclusions
Our rate of missed cancers is equivalent to that published in the literature, with the majority of missed cancers due to PCCRC. Delays in diagnosis are related to avoidable factors, such as improving the quality of bowel prep or ensuring further investigations in patients with incomplete endoscopies. Endoscopists should also be aware of the increased miss rate in specific locations. Non-cancer pathology identified at endoscopy is also associated with missed cancer, so endoscopists should be careful to maintain a careful examination for concomitant cancers.
Abstract Background Topical hemostatic powders are a reliable second-line approach in acute gastrointestinal (GI) bleeding (AGIB) treatment, according to the existing guidelines. Increasing evidence supports the use of hemostatic powder TC-325 (Hemospray®) as monotherapy in specific GI bleeding scenarios. This prospective, multi-center study evaluated the performance of TC-325 as monotherapy for GI hemorrhage. Methods Eighteen centres across Europe, and USA contributed between 2016 and 2022 to an international multicentre prospective registry. Adults with AGIB were eligible (melena, hematemesis, hematochezia, Glasgow-Blatchford score ≥ 1 or abnormal Oakland score), unless TC-325 was part of combined hemostasis (adjunctive to clips or thermocautery). The primary endpoint was immediate haemostasis. Secondary outcomes were rebleeding, 7- and 30-day mortality rates. Potential associations with risk factors were investigated with statistical significance set for p ≤ 0.05. Results One hundred and ninety patients were included (age range = 51–81, male:female = 2:1). Peptic ulcer (n = 48), upper GI malignancy (n = 79), post endoscopic treatment-related hemorrhage (n = 37), and lower GI lesions (n = 26) were diagnosed. The primary outcome was recorded in 96.3% (95%CI:92.6–98.5) with rebleeding in 17.4% (95%CI:11.9–24.1) when TC-325 was used as primary monotherapy. Post-hemostasis, 9.9% (95%CI:5.8–15.6) died within 7 days and 21.7% (95%CI:15.6–28.9) within 30 days. Regarding peptic ulcer, the immediate hemostasis was achieved in 88% (95%CI:75–95) and 26% (95%CI:13–43) rebled. Increased American Society of Anaesthesiologists (ASA) score was associated with mortality [OR:23.5 (95%CI:1.60–345); p = 0.02]. The primary outcome was achieved in 100% of cases with malignancy and post GI intervention bleeding, with rebleeding in 17% and 3.1%, respectively. Twenty-six patients received Hemospray® for lower GI bleeding, and in all but one the primary outcome was achieved. Conclusions TC-325 powder as monotherapy represents a safe and effective modality especially in malignancy- or post-endoscopic intervention-related bleeding. In peptic ulcer bleeding it could be helpful when the standard of care treatment is not feasible or unavailable, to stabilise patients.
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