What is the current provision of service for gastrostomy insertion in England?

Background

Significant morbidity and mortality can be associated with gastrostomy insertion, likely influenced by patient selection, indication and aftercare. We aimed to establish what current variation in practice exists and how this has improved by comparison to our previously published British Society of Gastroenterology survey of 2010.

Methods

We approached all National Health Service (NHS) hospitals in England (n=198). Email and web-based questionnaires were circulated. These data were correlated with the National Endoscopy Database (NED).

Results

The response rate was 69% (n=136/198). Estimated Percutaneous Endoscopic Gastrostomy (PEG) placements in the UK are currently 6500 vs 17 000 in 2010 (p<0.01). There is a dedicated PEG consultant involved in 59% of the centres versus 30% in 2010 (p<0.001). Multidisciplinary team meeting (MDT) discussion occurs in 66% versus 40% in 2010 (p<0.05). Formal aftercare provision occurs in 83% versus 64% in 2010 (p<0.001). 74/107 respondents (69%) reported feeling pressurised to authorise a gastrostomy.

Conclusion

This national survey, validated by the results from NED, demonstrates a reduction of over 60% for PEG insertion rates compared with previous estimates. There has also been an increase in consultant involvement, MDT discussion and aftercare provision. However, two-third of responders described 'pressure' to insert a gastrostomy. Perhaps further efforts are needed to include and educate other specialty teams, patients and next of kin.

Bowel cancer screening workforce survey: developing the endoscopy workforce for 2025 and beyond

AIM

The demand for bowel cancer screening (BCS) is expected to increase significantly within the next decade. Little is known about the intentions of the workforce required to meet this demand. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG), the British Society of Gastroenterology (BSG) and Association of Coloproctology of Great Britain and Ireland (ACPGBI) developed the first BCS workforce survey. The aim was to assess endoscopist career intentions to aid in future workforce planning to meet the anticipated increase in BCS colonoscopy.

METHODS

A survey was developed by JAG, BSG and ACPGBI and disseminated to consultant, clinical and trainee endoscopists between February and April 2020. Descriptive and comparative analyses were undertaken, supported with BCS data.

RESULTS

There were 578 respondents. Screening consultants have a median of one programmed activity (PA) per week for screening, accounting for 40% of their current endoscopy workload. 38% of current screening consultants are considering giving up colonoscopy in the next 2-5 years. Retirement (58%) and pension issues (23%) are the principle reasons for this. Consultants would increase their screening PAs by 70% if able to do so. The top three activities that endoscopists would relinquish to further support screening were outpatient clinics, acute medical/surgical on call and ward cover. An extra 155 colonoscopists would be needed to fulfil increased demand and planned retirement at current PAs.

CONCLUSION

This survey has identified a serious potential shortfall in screening colonoscopists in the next 5-10 years due to an ageing workforce and job plan pressures of aspirant BCS colonoscopists. We have outlined potential mitigations including reviewing job plans, improving workforce resources and supporting accreditation and training.

Assessing the sensitivity and specificity of cognitive screening measures for people with Parkinson's disease

INTRODUCTION

While cognitive impairment is a recognised feature of Parkinson's disease (PD), few studies have evaluated the validity of brief cognitive screening measures compared to a comprehensive neuropsychological assessment. This studies aim was to evaluate the sensitivity and specificity of the Mini-Mental State Examination (MMSE), Modified Mini-Mental State Examination and Dementia Rating Scale (DRS-2) to detect cognitive impairment in individuals with PD.

METHOD

Fifty-eight participants were administered the MMSE, 3MS, DRS-2 and a neuropsychological battery. ROC analyses were conducted to assess their effectiveness in classifying cognitive impairment.

RESULTS

None of the three measures demonstrated good sensitivity or specificity to detect single domain cognitive impairment. For detecting impairment on two or more cognitive domains, the MMSE and DRS-2 yielded excellent sensitivity (88%) and specificity (78% and 76% respectively), at cut-off scores of 28 and 136 respectively. The 3MS demonstrated excellent sensitivity (88%) and good specificity (60%) at cut off score of 94.

CONCLUSION

The MMSE and DRS-2 have excellent discriminant ability to classify multi-domain cognitive impairment in PD, however, their ability to detect more focal cognitive impairment is limited. Given that focal domain may be an indicator that could be useful in early detection of cognitive impairment for people with PD, this finding has implication for the use of these measures as screening tools in clinical practice.

Design Issues for Socially Intelligent User Interfaces

Objectives: This study aims to demonstrate the usability of discourse analyses as a means of evaluating medical informatics systems by examining one particular computer-based data-to-text system for delivering neonatal health care information.

Methods: Six textual summaries of clinical information, three produced by human clinicians and three by the data-to-text system, were subjected to fine-grain discourse analysis. Analysis was performed ‘blind’ on all six textual summaries. Analysis focused on the identification of lexical items and on the potential effects of these items on users of these clinical information summaries.

Results: Results showed that there were clear differences between human- and system-generated clinical summaries, with human clinicians providing better narrative flow and textual detail. The data-to-text system successfully produced textual summaries although it fell short of human abilities.

Conclusions: These results indicate potential future improvements to the system. Discourse analysis as used here may offer significant advantages in evaluating and developing similar medical informatics systems.

Preinjury characteristics of children with mild traumatic brain injury: Is "other injury" an appropriate comparison group"?

BACKGROUND

Mild traumatic brain injury (mTBI) has been associated with ongoing problems in children and young people. However, there remains to be considerable debate regarding whether outcomes are a result of brain impairment, or simply reflect preinjury characteristics of the child or family. To reliably assess outcomes, an appropriate control group is required.

AIMS

This study aimed to identify the preinjury characteristics of children with mTBI, and to examine whether an "other injury to the head" group is an appropriate comparison to control for preinjury characteristics of children with mTBI.

METHOD

Parents of 290 children admitted to the emergency department with either a diagnosis of mTBI (n = 186, M = 6.44 years) or a superficial injury to the head (SIH) (n = 104, M = 5.40 years) were assessed. Parents completed three questionnaires examining behavioral problems (Clinical Assessment of Behavior), parental stress (Parenting Stress Index), and background variables (e.g., medical issues, socioeconomic factors).

RESULTS

A series of chi-square analyses and multivariate analysis of variance tests revealed no differences for behavior, parental stress, and other preexisting problems between children with mTBI and those with SIH.

CONCLUSIONS

Children who experience a mTBI event present similarly to individuals with a SIH, and SIH is an appropriate comparison group to examine the outcomes of childhood mTBI, as it may help minimize any confounding effects of preexisting issues associated with mTBI.

Long-term behavioural outcomes of pre-school mild traumatic brain injury

Abstract Background Mild traumatic brain injury (MTBI) is a leading cause of injury for children during their pre-school years. However, there is little information regarding the long-term outcomes of these injuries. Method We used fully prospective data from an epidemiological study of a birth cohort to examine behavioural effects associated with MTBI during the pre-school years. Cases of confirmed MTBI were divided into two groups, those that had received outpatient medical attention, and those that had been admitted to hospital for a brief period of observation (inpatient cases). The remainder of the cohort served as a reference control group. Results Mother/teacher ratings for behaviours associated with attention deficit/hyperactivity disorder and oppositional defiant/conduct disorder, obtained yearly from age 7 to 13, revealed evidence of deficits after inpatient MTBI (n = 21), relative to more minor outpatient injury MTBI (n = 55) and the reference control group (n = 852). For the inpatient group there was evidence of increasing deficits over years 7-13. Conclusions More severe pre-school MTBI may be associated with persistent negative effects in terms of psychosocial development. The vulnerability of pre-school children to MTBI signals a pressing need to identify high-risk cases that may benefit from monitoring and early intervention.

Cognitive characteristics associated with mild cognitive impairment in Parkinson's disease

BACKGROUND

Cognitive deficits are common in Parkinson's disease (PD), but the range of deficits is variable. The aim of this study was to identify different cognitive subgroups associated with PD.

METHODS

A broad range of neuropsychological measures and cognitive domains were used in a cluster analysis to identify subgroups of patients.

RESULTS

Three subgroups of patients were identified. Compared to controls, one PD subgroup showed no or minimal cognitive impairment (PD-NCI), a second group showed a variable or uncertain pattern of mild to severe cognitive impairments (PD-UCI), and a third group had evidence of severe cognitive impairment across most cognitive domains (mild cognitive impairment; PD-MCI). The subgroups did not differ with regard to age, motor impairment, or disease duration.

CONCLUSIONS

Patients with PD are heterogeneous with regard to cognitive presentation and it may be possible to identify patients in the preclinical stage of dementia. The identification of preclinical dementia in PD patients (PD-MCI) provides an opportunity to understand cognitive decline in PD and its progression to dementia.

A profile of neuropsychiatric problems and their relationship to quality of life for Parkinson's disease patients without dementia

Neuropsychiatric problems are common in Parkinson's disease (PD) but there is little information regarding how they impact on quality of life. PD patients without dementia (49) were assessed for low mood/depression, fatigue, apathy, sleep problems and hallucinations. Measures of quality of life and motor function were also obtained. Over 77% of the patients reported symptoms consistent with one or more neuropsychiatric problems. Low mood/depression, anxiety and the presence of hallucinations predicted poorer quality of life after controlling for motor symptoms. Additional to the motor symptoms, we found that specific neuropsychiatric problems may impact on quality of life for PD patients.

Detection of Echinococcus granulosus coproantigens in faeces from naturally infected rural domestic dogs in south eastern Australia

OBJECTIVE

To investigate the occurrence of Echinococcus granulosus in rural domestic dogs in farming areas around Yass, New South Wales, and Mansfield and Whitfield, Victoria.

DESIGN

Faeces were collected per-rectally from farm dogs voluntarily presented by their owners in four farming districts in New South Wales and two in Victoria.

PROCEDURE

Faeces were collected in the field, an extract prepared from each sample and E granulosus coproantigens detected in an ELISA. Farmers were also questioned about their dog feeding and worming practices.

RESULTS

Echinococcus granulosus coproantigens were detected in 99 of 344 dogs (29%) from 95 farms in south eastern New South Wales and 38 of 217 dogs (17.5%) from 43 farms in Victoria. Cross-reactions between E granulosus coproantigen trapping antibody and coproantigens in faeces from dogs monospecifically infected with other species of intestinal helminthes (Taenia ovis, T hydatigena, T pisiformis, Spirometra ericacei, Dipylidium caninum, hookworm, Toxocara canis, Trichuris vulpis) were not evident. Dietary and worming data revealed many owners fed raw meat and occasionally offal from domestic livestock and wildlife to their dogs and few owners wormed their dogs frequently enough to preclude the chance of patent E granulosus being present in their dogs.

CONCLUSION

Echinococcus granulosus occurs commonly in rural dogs in south eastern Australia and an education program promoting the public health importance of responsible management of rural dogs is urgently needed.

Long term psychosocial outcomes after mild head injury in early childhood

OBJECTIVES

The question of whether any adverse cognitive or psychosocial outcomes occur after mild head injury in early childhood has evoked considerable controversy. This study examined mild head injury before age 10 and potential differences in late childhood/early adolescence as a function of severity of mild injury and age at injury.

METHODS

A fully prospective longitudinal design tracked a large birth cohort of children. Confirmed cases of mild head injury before age 10 were divided on the basis of outpatient medical attention (n=64-84) or inpatient observation (hospital overnight; n=26-28 ) and compared with the non-injured remainder of the cohort (reference group; n=613-807). A range of pre-injury and post-injury child and family characteristics were used to control for any potential confounds. Outcome after injury before and after age 5 was also assessed.

RESULTS

After accounting for several demographic, family, and pre-injury characteristics, the inpatient but not the outpatient group displayed increased hyperactivity/inattention and conduct disorder between ages 10 to 13, as rated by both mothers and teachers. Psychosocial deficits were more prevalent in the inpatient subgroup injured before age 5. No clear effects were evident for various cognitive/academic measures, irrespective of severity of mild injury or age at injury.

CONCLUSIONS

Most cases of mild head injury in young children do not produce any adverse effects, but long term problems in psychosocial function are possible in more severe cases, perhaps especially when this event occurs during the preschool years. The view that all mild head injuries in children are benign events requires revision and more objective measures are required to identify cases at risk.

Nurses' behavioural intentions towards self-poisoning patients: a theory of reasoned action, comparison of attitudes and subjective norms as predictive variables

BACKGROUND

The incidence of self-poisoning is on the increase. Most patients who self-poison are dealt with initially in the general hospital. Therefore, the type and quality of care self-poisoning patients receive will depend, in part, on how they are viewed by nursing staff within the general hospital setting. A knowledge and understanding of the attitudes held by nurses towards self-poisoning patients is therefore important to those involved in the planning and delivery of care towards this client group. Previous studies have examined health care professionals' attitudes towards people who self-poison. Usually, however, these have not focused specifically on nurses' attitudes, and they have ignored the relationship between the attitudes expressed by staff and their intentions to engage in subsequent caring behaviour of one sort or another. It is hence unclear how the findings of such studies are relevant or applicable to nursing policy and practice.

AIMS

The present study aims to address these limitations using a methodology informed by the theory of reasoned action. The study aims to separate out the distinctive roles played by nurses' own attitudes, and the social pressures represented by other people's attitudes, in determining the types of caring behaviour in which nurses intend to engage when dealing with self-poisoning patients.

DESIGN/METHODS

The study adopts a questionnaire-based approach incorporating two specially designed vignettes.

RESULTS

The results show that nurses' own attitudes, and what they believe about the attitudes of others, predict their behavioural intentions towards self-poisoning patients. The study also shows that nurses with a more positive orientation towards self-poisoning patients differ in behavioural and normative beliefs from nurses who have a less positive orientation.

CONCLUSIONS

The implications for future attempts to explore the relationship between nurses' attitudes and subsequent caring behaviour are considered, along with implications for nursing policy and practice.

The role of an open-access bleeding unit in the management of colonic haemorrhage. A 2-year prospective study

BACKGROUND

Major colonic haemorrhage poses difficult diagnostic and therapeutic problems and, in contrast to upper gastrointestinal bleeding, has no generally accepted plan of management.

METHODS

We report community-based prospective data accumulated over 2 years (1991-93) on 1602 patients referred to an open-access bleeding unit with suspected gastrointestinal haemorrhage.

RESULTS

Of 278 (17%) admissions with suspected lower GI haemorrhage, 252 were confirmed. Forty-eight per cent were defined as "significant' bleeds, with a decrease in haemoglobin and cardiovascular compromise. Of 102 significant bleeds in subjects more than 60 years old, 29% rebled, and 12.6% required emergency surgery. Diverticular disease (24%) was the commonest diagnosis, with tumours, infective colitis, and inflammatory colitis each at 10%. The overall 30-day mortality for colonic bleeding was 5.1% (13 of 252), with only 1 death occurring in the group less than 60 years old.

CONCLUSIONS

This study provides a unique database for the natural history of colonic bleeding and its management within the setting of a specialized bleeding unit.

Developing a condition-specific measure of health for patients with dyspepsia and ulcer-related symptoms

A patient-administered instrument for dyspepsia and symptoms suggestive of duodenal or gastric ulcer, based on the type of questions asked when taking a patient's history, was developed and tested using the following steps: literature reviews, devising the questions, testing the responses to the questions using factor analysis and internal consistency, assessing test-retest reliability, and validating the questionnaire by comparing patient responses to the SF-36 health survey questionnaire. The main sample consisted of 135 patients referred to an outpatient clinic with dyspepsia, and 152 patients in general practice who were not referred to a specialist. The final instrument produced a Cronbach's alpha of 0.72 and an intraclass correlation coefficient of 0.69. Patient scores on the dyspepsia questionnaire had small to moderate correlations with the SF-36 health survey, the largest correlation being with the SF-36 scale of pain. Patient scores were significantly related to general practitioner perceptions of symptom severity, family history of gastric ulcer disease, and whether the patient was referred. The questions asked in taking a clinical history from a patient with dyspepsia and other symptoms suggestive of ulcer disease can be used to construct a valid and reliable measure of the effect of dyspepsia on health.

Feasibility of monitoring patient based health outcomes in a routine hospital setting

OBJECTIVE

To assess the feasibility of monitoring health outcomes in a routine hospital setting and the value of feedback of outcomes data to clinicians by using the SF 36 health survey questionnaire.

DESIGN

Administration of the questionnaire at baseline and three months, with analysis and interpretation of health status data after adjustments for sociodemographic variables and in conjunction with clinical data. Exploration of usefulness of outcomes data to clinicians through feedback discussion sessions and by an evaluation questionnaire.

SETTING

One gastroenterology outpatient department in Aberdeen Royal Hospitals Trust, Scotland.

PATIENTS

All (573) patients attending the department during one month (April 1993).

MAIN MEASURES

Ability to obtain patient based outcomes data and requisite clinical information and feed it back to the clinicians in a useful and accessible form.

RESULTS

Questionnaires were completed by 542 (95%) patients at baseline and 450 (87%) patients at follow up. Baseline health status data and health outcomes data for the eight different aspects of health were analysed for individual patients, key groups of patients, and the total recruited patient population. Significant differences were shown between patients and the general population and between different groups of patients, and in health status over time. After adjustment for differences in sociodemography and main diagnosis patients with particularly poor scores were identified and discussed. Clinicians judged that this type of assessment could be useful for individual patients if the results were available at the time of consultation or for a well defined group of patients if used as part of a clinical trial.

CONCLUSIONS

Monitoring routine outcomes is feasible and instruments to achieve this, such as the SF 36 questionnaire, have potential value in an outpatient setting.

IMPLICATIONS

If data on outcomes are to provide a basis for clinical and managerial decision making, information systems will be required to collect, analyse, interpret, and feed it back regularly and in good time.

Gastric mucosal prostaglandin synthesis in the presence of Campylobacter pylori in patients with gastric ulcers and non-ulcer dyspepsia

It is unclear how Campylobacter pylori (CP) interacts with gastric mucosal prostaglandins (PG). In a double-blind study we measured gastric PG synthesis in 22 patients with benign gastric antral ulcers (GU) and 26 with non-ulcer dyspepsis (NUD). CP status was determined by histology and bacteriology: 26 (16 GU plus 10 NUD) were CP positive, and 22 (6 GU plus 16 NUD) were CP negative. Patients with severe gastritis regardless of CP status) had significantly higher PGE2 and PGI2 values than those with mild gastritis. Severe gastritis was found in 36% of CP-negative subjects and 77% of the CP-positive patients (chi 2 = 8.64, p less than 0.01), but no significant differences in PG values were found between CP-positive or -negative patients.

Campylobacter pylori associated gastritis in patients with rheumatoid arthritis taking nonsteroidal anti-inflammatory drugs

Fifty-two patients with rheumatoid arthritis taking nonsteroidal anti-inflammatory drugs were studied in order to assess the carriage rate of Campylobacter pylori (C. pylori) with reference to dyspeptic symptoms, endoscopic appearance and antral histology. All patients were interviewed using a standard gastrointestinal symptom scoring questionnaire and underwent endoscopy at which two antral biopsies were obtained. Sections were examined for the presence and severity of gastritis and of C. pylori. Forty-four of 52 patients (85%) had histological evidence of gastritis. Twenty-six of 44 (59%) patients with gastritis were positive for C. pylori. Twenty-six of 28 patients with 'active' (polymorph infiltration) chronic gastritis were positive for C. pylori (p less than 0.002). Sixteen of 26 bacteria-positive patients had gastrointestinal symptoms compared with eight of 26 bacteria-negative patients (p less than 0.05) and this may have therapeutic implications. There was no correlation between the presence of organisms and the appearances at endoscopy.