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Goodoory VC, Morris AJ, Veitch AM. Twitter debate: should upper gastrointestinal bleeding training and certification be formalised? Frontline Gastroenterol 2024; 15:258-260. [PMID: 38665791 PMCID: PMC11042463 DOI: 10.1136/flgastro-2023-102549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 04/28/2024] Open
Affiliation(s)
- Vivek Chand Goodoory
- Leeds Institute of Medical Research at St. James's, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Biomedical & Clinical Sciences, University of Leeds, Leeds, UK
| | - Allan John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
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2
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Omary MB, Leddin D, Metz G, Veitch AM, El-Omar EM, Macedo G, Perman ML. World Gastroenterology Organisation - Gut commentary series on digestive health and climate change. Gut 2023; 72:2193-2196. [PMID: 37977581 DOI: 10.1136/gutjnl-2023-331193] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 11/19/2023]
Affiliation(s)
- M Bishr Omary
- Rutgers Biomedical and Health Sciences, Rutgers University, Piscataway, New Jersey, USA
| | | | - Geoffrey Metz
- The University of Melbourne and Monash University, Melbourne, Victoria, Australia
| | | | - Emad M El-Omar
- UNSW Microbiome Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Guilherme Macedo
- Gastroenterology, Centro Hospitalar de São João, Porto, Portugal
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3
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Sebastian S, Dhar A, Baddeley R, Donnelly L, Haddock R, Arasaradnam R, Coulter A, Disney BR, Griffiths H, Healey C, Hillson R, Steinbach I, Marshall S, Rajendran A, Rochford A, Thomas-Gibson S, Siddhi S, Stableforth W, Wesley E, Brett B, Morris AJ, Douds A, Coleman MG, Veitch AM, Hayee B. Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy. Gut 2023; 72:12-26. [PMID: 36229172 PMCID: PMC9763195 DOI: 10.1136/gutjnl-2022-328460] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/12/2022] [Indexed: 12/08/2022]
Abstract
GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.
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Affiliation(s)
- Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, East Riding of Yorkshire, UK .,Clinical Sciences Centre, Hull York Medical School, Hull, UK
| | - Anjan Dhar
- Department of Gastroenterology, Darlington Memorial Hospital, Darlington, UK,School of Health & Life Sciences, Teesside University, Middlesbrough, UK
| | - Robin Baddeley
- Institute for Therapeutic Endoscopy, King's College Hospital, London, UK,Department of Gastroenterology, St Mark's National Bowel Hospital & Academic Institute, London, UK
| | - Leigh Donnelly
- Department of Gastroenterology, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Rosemary Haddock
- Department of Gastroenterology, Ninewells Hospital & Medical School, Dundee, UK
| | - Ramesh Arasaradnam
- Applied Biological and Experimental Sciences, Coventry University, Coventry, UK,Department of Gastroenterology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Archibald Coulter
- Department of Gastroenterology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Benjamin Robert Disney
- Department of Gastroenterology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Helen Griffiths
- Department of Gastroenterology, Brecon War Memorial Hospital, Brecon, UK
| | - Christopher Healey
- Department of Gastroenterology, Airedale NHS Foundation Trust, Keighley, UK
| | | | | | - Sarah Marshall
- Bowel Cancer Screening & Endoscopy, London North West University Healthcare NHS Trust, Harrow, UK,Joint Advisory Group on GI Endoscopy, London, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
| | - Andrew Rochford
- Department of Gastroenterology, Royal Free Hospitals, London, UK
| | - Siwan Thomas-Gibson
- Department of Gastroenterology, St Mark's National Bowel Hospital & Academic Institute, London, UK
| | - Sandeep Siddhi
- Department of Gastroenterology, NHS Grampian, Aberdeen, UK
| | - William Stableforth
- Departments of Gastroenterology & Endoscopy, Royal Cornwall Hospital, Truro, UK
| | - Emma Wesley
- Departments of Gastroenterology & Endoscopy, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Bernard Brett
- Department of Gastroenterology, Norfolk and Norwich Hospitals NHS Trust, Norwich, UK
| | | | - Andrew Douds
- Department of Gastroenterology, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Mark Giles Coleman
- Joint Advisory Group on GI Endoscopy, London, UK,Department of Colorectal Surgery, Plymouth University Hospitals Trust, Plymouth, UK
| | - Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Bu'Hussain Hayee
- King's Health Partners Institute for Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
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4
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Ching HL, Lau MS, Azmy IA, Hopper AD, Keuchel M, Gyökeres T, Kuvaev R, Macken EJ, Bhandari P, Thoufeeq M, Leclercq P, Rutter MD, Veitch AM, Bisschops R, Sanders DS. Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2022; 54:712-722. [PMID: 35636453 DOI: 10.1055/a-1832-4232] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).
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Affiliation(s)
- Hey-Long Ching
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Michelle S Lau
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Iman A Azmy
- Department of Breast Surgery, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, UK
| | - Andrew D Hopper
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Martin Keuchel
- Clinic for Internal Medicine, Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Tibor Gyökeres
- Department of Gastroenterology, Medical Center Hungarian Defence Forces, Budapest, Hungary
| | - Roman Kuvaev
- Endoscopy Department, Yaroslavl Regional Cancer Hospital, Yaroslavl, Russian Federation.,Gastroenterology Department, Faculty of Additional Professional Education, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Elisabeth J Macken
- Division of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Mo Thoufeeq
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | | | - Matthew D Rutter
- North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK.,Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Andrew M Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Belgium
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
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5
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Leddin D, Omary MB, Metz G, Veitch AM. Climate change: a survey of global gastroenterology society leadership. Gut 2022; 71:gutjnl-2022-327832. [PMID: 35688613 DOI: 10.1136/gutjnl-2022-327832] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/24/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Desmond Leddin
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - M Bishr Omary
- Department of Medicine, Rutgers University, New Brunswick, New Jersey, USA
| | - Geoffrey Metz
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Andrew M Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, UK
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6
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Cross AJ, Robbins EC, Pack K, Stenson I, Kirby PL, Patel B, Rutter MD, Veitch AM, Saunders BP, Little M, Gray A, Duffy SW, Wooldrage K. Colonoscopy surveillance following adenoma removal to reduce the risk of colorectal cancer: a retrospective cohort study. Health Technol Assess 2022; 26:1-156. [PMID: 35635015 DOI: 10.3310/olue3796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Colonoscopy surveillance is recommended for some patients post polypectomy. The 2002 UK surveillance guidelines classify post-polypectomy patients into low, intermediate and high risk, and recommend different strategies for each classification. Limited evidence supports these guidelines. OBJECTIVES To examine, for each risk group, long-term colorectal cancer incidence by baseline characteristics and the number of surveillance visits; the effects of interval length on detection rates of advanced adenomas and colorectal cancer at first surveillance; and the cost-effectiveness of surveillance compared with no surveillance. DESIGN A retrospective cohort study and economic evaluation. SETTING Seventeen NHS hospitals. PARTICIPANTS Patients with a colonoscopy and at least one adenoma at baseline. MAIN OUTCOME MEASURES Long-term colorectal cancer incidence after baseline and detection rates of advanced adenomas and colorectal cancer at first surveillance. DATA SOURCES Hospital databases, NHS Digital, the Office for National Statistics, National Services Scotland and Public Health England. METHODS Cox regression was used to compare colorectal cancer incidence in the presence and absence of surveillance and to identify colorectal cancer risk factors. Risk factors were used to stratify risk groups into higher- and lower-risk subgroups. We examined detection rates of advanced adenomas and colorectal cancer at first surveillance by interval length. Cost-effectiveness of surveillance compared with no surveillance was evaluated in terms of incremental costs per colorectal cancer prevented and per quality-adjusted life-year gained. RESULTS Our study included 28,972 patients, of whom 14,401 (50%), 11,852 (41%) and 2719 (9%) were classed as low, intermediate and high risk, respectively. The median follow-up time was 9.3 years. Colorectal cancer incidence was 140, 221 and 366 per 100,000 person-years among low-, intermediate- and high-risk patients, respectively. Attendance at one surveillance visit was associated with reduced colorectal cancer incidence among low-, intermediate- and high-risk patients [hazard ratios were 0.56 (95% confidence interval 0.39 to 0.80), 0.59 (95% confidence interval 0.43 to 0.81) and 0.49 (95% confidence interval 0.29 to 0.82), respectively]. Compared with the general population, colorectal cancer incidence without surveillance was similar among low-risk patients and higher among high-risk patients [standardised incidence ratios were 0.86 (95% confidence interval 0.73 to 1.02) and 1.91 (95% confidence interval 1.39 to 2.56), respectively]. For intermediate-risk patients, standardised incidence ratios differed for the lower- (0.70, 95% confidence interval 0.48 to 0.99) and higher-risk (1.46, 95% confidence interval 1.19 to 1.78) subgroups. In each risk group, incremental costs per colorectal cancer prevented and per quality-adjusted life-year gained with surveillance were lower for the higher-risk subgroup than for the lower-risk subgroup. Incremental costs per quality-adjusted life-year gained were lowest for the higher-risk subgroup of high-risk patients at £7821. LIMITATIONS The observational design means that we cannot assume that surveillance caused the reductions in cancer incidence. The fact that some cancer staging data were missing places uncertainty on our cost-effectiveness estimates. CONCLUSIONS Surveillance was associated with reduced colorectal cancer incidence in all risk groups. However, in low-risk patients and the lower-risk subgroup of intermediate-risk patients, colorectal cancer incidence was no higher than in the general population without surveillance, indicating that surveillance might not be necessary. Surveillance was most cost-effective for the higher-risk subgroup of high-risk patients. FUTURE WORK Studies should examine the clinical effectiveness and cost-effectiveness of post-polypectomy surveillance without prior classification of patients into risk groups. TRIAL REGISTRATION This trial is registered as ISRCTN15213649. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 26. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Amanda J Cross
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Emma C Robbins
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kevin Pack
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Iain Stenson
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Paula L Kirby
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Bhavita Patel
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | | | - Matthew Little
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
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7
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Veitch AM. Greener gastroenterology and hepatology: the British Society of Gastroenterology Strategy for Climate Change and Sustainability. Frontline Gastroenterol 2022; 13:e3-e6. [PMID: 35812022 PMCID: PMC9234742 DOI: 10.1136/flgastro-2022-102134] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
There is a global climate emergency, and also a global health concern related to climate change. The British Society of Gastroenterology (BSG) acknowledges these issues, and supports the concerns of its members to address them. Climate change has adverse effects on gastroenterological and liver disease, and on healthcare systems. The healthcare industry, itself, is also a major contributor to greenhouse gases. BSG has developed a strategy on Climate Change and Sustainability, which encompasses all of the activities of the society, and its members: personal, professional, organisational, political, international and research.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
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8
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Cross AJ, Robbins EC, Pack K, Stenson I, Rutter MD, Veitch AM, Saunders BP, Duffy SW, Wooldrage K. Post-polypectomy surveillance interval and advanced neoplasia detection rates: a multicenter, retrospective cohort study. Endoscopy 2022; 54:948-958. [PMID: 35405762 PMCID: PMC9500009 DOI: 10.1055/a-1795-4673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Longer post-polypectomy surveillance intervals are associated with increased colorectal neoplasia detection at surveillance in some studies. We investigated this association to inform optimal surveillance intervals. METHODS Patients who underwent colonoscopy and post-polypectomy surveillance at 17 UK hospitals were classified as low/high risk by baseline findings. We compared detection rates of advanced adenomas (≥ 10 mm, tubulovillous/villous, high grade dysplasia), high risk findings (HRFs: ≥ 2 serrated polyps/[adenomas] of which ≥ 1 is ≥ 10 mm or has [high grade] dysplasia; ≥ 5 serrated polyps/adenomas; or ≥ 1 nonpedunculated polyp ≥ 20 mm), or colorectal cancer (CRC) at surveillance colonoscopy by surveillance interval (< 18 months, 2, 3, 4, 5, 6 years). Risk ratios (RRs) were estimated using multivariable regression. RESULTS Of 11 214 patients, 7216 (64 %) were low risk and 3998 (36 %) were high risk. Among low risk patients, advanced adenoma, HRF, and CRC detection rates at first surveillance were 7.8 %, 3.7 %, and 1.1 %, respectively. Advanced adenoma detection increased with increasing surveillance interval, reaching 9.8 % with a 6-year interval (P trend < 0.001). Among high risk patients, advanced adenoma, HRF, and CRC detection rates at first surveillance were 15.3 %, 10.0 %, and 1.5 %, respectively. Advanced adenoma and CRC detection rates (P trends < 0.001) increased with increasing surveillance interval; RRs (95 % confidence intervals) for CRC were 1.54 (0.68-3.48), 4.44 (1.95-10.08), and 5.80 (2.51-13.40) with 3-, 4-, and 5-year intervals, respectively, versus an interval of < 18 months. CONCLUSIONS Metachronous neoplasia was uncommon among low risk patients, even with long surveillance intervals, supporting recommendations for no surveillance in these patients. For high risk patients, a 3-year surveillance interval would ensure timely CRC detection.
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Affiliation(s)
- Amanda J. Cross
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Emma C. Robbins
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Kevin Pack
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Iain Stenson
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Matthew D. Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, United Kingdom,Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Andrew M. Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, United Kingdom
| | - Brian P. Saunders
- Wolfson Unit for Endoscopy, St Mark’s Hospital, London, United Kingdom
| | - Stephen W. Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University, London, United Kingdom
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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9
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Siau K, Beales ILP, Haycock A, Alzoubaidi D, Follows R, Haidry R, Mannath J, McConnell S, Murugananthan A, Ravindran S, Riley SA, Williams RN, Trudgill NJ, Veitch AM. JAG consensus statements for training and certification in oesophagogastroduodenoscopy. Frontline Gastroenterol 2022; 13:193-205. [PMID: 35493618 PMCID: PMC8996097 DOI: 10.1136/flgastro-2021-101907] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Training and quality assurance in oesophagogastroduodenoscopy (OGD) is important to ensure competent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for OGD training and certification. METHODS Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted with stakeholder representation from British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on OGD training and certification were formulated following literature review and appraised using Grading of Recommendations Assessment, Development and Evaluation. These were subjected to electronic voting to achieve consensus. Accepted statements were incorporated into the updated certification pathway. RESULTS In total, 32 recommendation statements were generated for the following domains: definition of competence (4 statements), acquisition of competence (12 statements), assessment of competence (10 statements) and post-certification support (6 statements). The consensus process led to following certification criteria: (1) performing ≥250 hands-on procedures; (2) attending a JAG-accredited basic skills course; (3) attainment of relevant minimal performance standards defined by British Society of Gastroenterology/Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, (4) achieving physically unassisted D2 intubation and J-manoeuvre in ≥95% of recent procedures, (5) satisfactory performance in formative and summative direct observation of procedural skills assessments. CONCLUSION The JAG standards for diagnostic OGD have been updated following evidence-based consensus. These standards are intended to support training, improve competency assessment to uphold standards of practice and provide support to the newly-independent practitioner.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK,Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ian L P Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Adam Haycock
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Durayd Alzoubaidi
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
| | | | - Rehan Haidry
- Department of Gastroenterology, Division of Surgery and Interventional Science, University College London Hospital NHS Foundation Trust, London, UK
| | - Jayan Mannath
- Department of Gastroenterology, Coventry and Warwickshire NHS trust, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Susan McConnell
- Endoscopy Department, University Hospital of North Durham, Durham, UK
| | - Aravinth Murugananthan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Srivathsan Ravindran
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK,Surgery and Cancer, Imperial College London, London, UK
| | - Stuart A Riley
- Department of Gastroenterology, Northern General Hospital, Sheffield, UK
| | - R N Williams
- Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nigel John Trudgill
- Gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Andrew M Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK,President-Elect, British Society of Gastroenterology, London, UK
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10
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Cross AJ, Robbins EC, Pack K, Stenson I, Patel B, Rutter MD, Veitch AM, Saunders BP, Duffy SW, Wooldrage K. Colorectal cancer risk following polypectomy in a multicentre, retrospective, cohort study: an evaluation of the 2020 UK post-polypectomy surveillance guidelines. Gut 2021; 70:2307-2320. [PMID: 33674342 PMCID: PMC8588296 DOI: 10.1136/gutjnl-2020-323411] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/14/2020] [Accepted: 01/01/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Colonoscopy surveillance aims to reduce colorectal cancer (CRC) incidence after polypectomy. The 2020 UK guidelines recommend surveillance at 3 years for 'high-risk' patients with ≥2 premalignant polyps (PMPs), of which ≥1 is 'advanced' (serrated polyp (or adenoma) ≥10 mm or with (high-grade) dysplasia); ≥5 PMPs; or ≥1 non-pedunculated polyp ≥20 mm; 'low-risk' patients without these findings are instead encouraged to participate in population-based CRC screening. We examined the appropriateness of these risk classification criteria and recommendations. DESIGN Retrospective analysis of patients who underwent colonoscopy and polypectomy mostly between 2000 and 2010 at 17 UK hospitals, followed-up through 2017. We examined CRC incidence by baseline characteristics, risk group and number of surveillance visits using Cox regression, and compared incidence with that in the general population using standardised incidence ratios (SIRs). RESULTS Among 21 318 patients, 368 CRCs occurred during follow-up (median: 10.1 years). Baseline CRC risk factors included age ≥55 years, ≥2 PMPs, adenomas with tubulovillous/villous/unknown histology or high-grade dysplasia, proximal polyps and a baseline visit spanning 2-90 days. Compared with the general population, CRC incidence without surveillance was higher among those with adenomas with high-grade dysplasia (SIR 1.74, 95% CI 1.21 to 2.42) or ≥2 PMPs, of which ≥1 was advanced (1.39, 1.09 to 1.75). For low-risk (71%) and high-risk (29%) patients, SIRs without surveillance were 0.75 (95% CI 0.63 to 0.88) and 1.30 (1.03 to 1.62), respectively; for high-risk patients after first surveillance, the SIR was 1.22 (0.91 to 1.60). CONCLUSION These guidelines accurately classify post-polypectomy patients into those at high risk, for whom one surveillance colonoscopy appears appropriate, and those at low risk who can be managed by non-invasive screening.
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Affiliation(s)
- Amanda J Cross
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Emma C Robbins
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kevin Pack
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Iain Stenson
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Bhavita Patel
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
- Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Brian P Saunders
- Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, London, UK
| | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
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11
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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12
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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13
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Ravindran S, Munday J, Veitch AM, Broughton R, Thomas-Gibson S, Penman ID, McKinlay A, Fearnhead NS, Coleman M, Logan R. Bowel cancer screening workforce survey: developing the endoscopy workforce for 2025 and beyond. Frontline Gastroenterol 2021; 13:12-19. [PMID: 34970428 PMCID: PMC8666856 DOI: 10.1136/flgastro-2021-101790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/12/2021] [Accepted: 02/14/2021] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Srivathsan Ravindran
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK,Surgery and Cancer, Imperial College London, London, UK
| | | | - Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK,Bowel Screening Advisory Committee, Public Health England, London, UK
| | - Raphael Broughton
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
| | - Siwan Thomas-Gibson
- Wolfson Endoscopy Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK,Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Ian D Penman
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK,British Society of Gastroenterology, London, UK
| | - Alistair McKinlay
- British Society of Gastroenterology, London, UK,Department of Gastroenterology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Nicola S Fearnhead
- Colorectal Surgery, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK,Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - Mark Coleman
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK,Colorectal Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Robert Logan
- Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK,NHS England and NHS Improvement London, London, UK
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14
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Cross AJ, Robbins EC, Pack K, Stenson I, Kirby PL, Patel B, Rutter MD, Veitch AM, Saunders BP, Duffy SW, Wooldrage K. Long-term colorectal cancer incidence after adenoma removal and the effects of surveillance on incidence: a multicentre, retrospective, cohort study. Gut 2020; 69:1645-1658. [PMID: 31953252 PMCID: PMC7456728 DOI: 10.1136/gutjnl-2019-320036] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Postpolypectomy colonoscopy surveillance aims to prevent colorectal cancer (CRC). The 2002 UK surveillance guidelines define low-risk, intermediate-risk and high-risk groups, recommending different strategies for each. Evidence supporting the guidelines is limited. We examined CRC incidence and effects of surveillance on incidence among each risk group. DESIGN Retrospective study of 33 011 patients who underwent colonoscopy with adenoma removal at 17 UK hospitals, mostly (87%) from 2000 to 2010. Patients were followed up through 2016. Cox regression with time-varying covariates was used to estimate effects of surveillance on CRC incidence adjusted for patient, procedural and polyp characteristics. Standardised incidence ratios (SIRs) compared incidence with that in the general population. RESULTS After exclusions, 28 972 patients were available for analysis; 14 401 (50%) were classed as low-risk, 11 852 (41%) as intermediate-risk and 2719 (9%) as high-risk. Median follow-up was 9.3 years. In the low-risk, intermediate-risk and high-risk groups, CRC incidence per 100 000 person-years was 140 (95% CI 122 to 162), 221 (195 to 251) and 366 (295 to 453), respectively. CRC incidence was 40%-50% lower with a single surveillance visit than with none: hazard ratios (HRs) were 0.56 (95% CI 0.39 to 0.80), 0.59 (0.43 to 0.81) and 0.49 (0.29 to 0.82) in the low-risk, intermediate-risk and high-risk groups, respectively. Compared with the general population, CRC incidence without surveillance was similar among low-risk (SIR 0.86, 95% CI 0.73 to 1.02) and intermediate-risk (1.16, 0.97 to 1.37) patients, but higher among high-risk patients (1.91, 1.39 to 2.56). CONCLUSION Postpolypectomy surveillance reduces CRC risk. However, even without surveillance, CRC risk in some low-risk and intermediate-risk patients is no higher than in the general population. These patients could be managed by screening rather than surveillance.
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Affiliation(s)
- Amanda J Cross
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Emma C Robbins
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kevin Pack
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Iain Stenson
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Paula L Kirby
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Bhavita Patel
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | | | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
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15
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Siau K, Hearnshaw S, Stanley AJ, Estcourt L, Rasheed A, Walden A, Thoufeeq M, Donnelly M, Drummond R, Veitch AM, Ishaq S, Morris AJ. British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding. Frontline Gastroenterol 2020; 11:311-323. [PMID: 32582423 PMCID: PMC7307267 DOI: 10.1136/flgastro-2019-101395] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Medical care bundles improve standards of care and patient outcomes. Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency which has been consistently associated with suboptimal care. We aimed to develop a multisociety care bundle centred on the early management of AUGIB. Commissioned by the British Society of Gastroenterology (BSG), a UK multisociety task force was assembled to produce an evidence-based and consensus-based care bundle detailing key interventions to be performed within 24 hours of presentation with AUGIB. A modified Delphi process was conducted with stakeholder representation from BSG, Association of Upper Gastrointestinal Surgeons, Society for Acute Medicine and the National Blood Transfusion Service of the UK. A formal literature search was conducted and international AUGIB guidelines reviewed. Evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation tool and statements were formulated and subjected to anonymous electronic voting to achieve consensus. Accepted statements were eligible for incorporation into the final bundle after a separate round of voting. The final version of the care bundle was reviewed by the BSG Clinical Services and Standards Committee and approved by all stakeholder groups. Consensus was reached on 19 statements; these culminated in 14 corresponding care bundle items, contained within 6 management domains: Recognition, Resuscitation, Risk assessment, Rx (Treatment), Refer and Review. A multisociety care bundle for AUGIB has been developed to facilitate timely delivery of evidence-based interventions and drive quality improvement and patient outcomes in AUGIB.
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Affiliation(s)
- Keith Siau
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK,Medical and Dental Sciences, University of Birmingham, Birmingham, UK,Endoscopy Unit, Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK
| | - Sarah Hearnshaw
- Department of Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Ashraf Rasheed
- Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, London, UK,Upper GI Surgery, Royal Gwent Hospital, Newport, UK
| | - Andrew Walden
- Society for Acute Medicine, London, UK,Intensive Care Unit, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Mo Thoufeeq
- Endoscopy Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mhairi Donnelly
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Russell Drummond
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Andrew M Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Sauid Ishaq
- Endoscopy Unit, Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK,School of Health Sciences, Birmingham City University, Birmingham, West Midlands, UK
| | - Allan John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK,Endoscopy Quality Improvement Programme (EQIP), British Society of Gastroenterology, London, UK
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16
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Alzoubaidi D, Ragunath K, Wani S, Penman ID, Trudgill NJ, Jansen M, Banks M, Bhandari P, Morris AJ, Willert R, Boger P, Smart HL, Ravi N, Dunn J, Gordon C, Mannath J, Mainie I, di Pietro M, Veitch AM, Thorpe S, Magee C, Everson M, Sami S, Bassett P, Graham D, Attwood S, Pech O, Sharma P, Lovat LB, Haidry R. Quality indicators for Barrett's endotherapy (QBET): UK consensus statements for patients undergoing endoscopic therapy for Barrett's neoplasia. Frontline Gastroenterol 2019; 11:259-271. [PMID: 32587669 PMCID: PMC7307052 DOI: 10.1136/flgastro-2019-101247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/25/2019] [Accepted: 07/29/2019] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Endoscopic therapy for the management of patients with Barrett's oesophagus (BE) neoplasia has significantly developed in the past decade; however, significant variation in clinical practice exists. The aim of this project was to develop expert physician-lead quality indicators (QIs) for Barrett's endoscopic therapy. METHODS The RAND/UCLA Appropriateness Method was used to combine the best available scientific evidence with the collective judgement of experts to develop quality indicators for Barrett's endotherapy in four subgroups: pre-endoscopy, intraprocedure (resection and ablation) and postendoscopy. International experts, including gastroenterologists, surgeons, BE pathologist, clinical nurse specialist and patient representative, participated in a three-round process to develop 15 QIs that fulfilled the RAND/UCLA definition of appropriateness. RESULTS 17 experts participated in round 1 and 20 in round 2. Of the 24 proposed QIs in round 1, 20 were ranked as appropriate (put through to round 2) and 4 as uncertain (discarded). At the end of round 2, a final list of 15 QIs were scored as appropriate. CONCLUSIONS This UK national consensus project has successfully developed QIs for patients undergoing Barrett's endotherapy. These QIs can be used by service providers to ensure that all patients with BE neoplasia receive uniform and high-quality care.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Krish Ragunath
- Department of Gastroenterology, Queens Medical Centre, University Hospital Nottingham, Nottingham, UK
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ian D Penman
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK
| | | | - Marnix Jansen
- Department of Histopathology, University College London Hospital, London, UK
| | - Matthew Banks
- Department of Gastroenterology, University College London Hospital, London, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital Portsmouth, Portsmouth, UK
| | - Allan John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Robert Willert
- Department of Gastroenterology, Manchester Royal Infirmary, Manchester, UK
| | - Phil Boger
- Department of Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Howard L Smart
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, Merseyside, UK
| | | | - Jason Dunn
- Department of Gastroenterology, Guy's and St Thomas' Hospital, London, UK
| | - Charles Gordon
- Department of Gastroenterology, Royal Bournemouth Hospital, Bournemouth, UK
| | - Jayan Mannath
- Department of Gastroenterology, Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Inder Mainie
- Department of Gastroenterology, Belfast City Hospital, Belfast, UK
| | | | - Andrew M Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Sally Thorpe
- Department of Gastroenterology, University Colleg London Hospital, London, UK
| | - Cormac Magee
- Department of Gastroenterology, University College London Hospital, Londons, UK
- Metabolism and Experimental Therapeutic, University College London Division of Biosciences, London, UK
| | - Martin Everson
- Department of Gastroenterology, University Colleg London Hospital, London, UK
| | - Sarmed Sami
- Department of Gastroenterology, University Colleg London Hospital, London, UK
| | | | - David Graham
- Department of Gastroenterology, University Colleg London Hospital, London, UK
| | - Stephen Attwood
- Department of Health Services Research, Durham University, Durham, UK
| | - Oliver Pech
- Department of Medicine, HSK Wiesbaden, Wiesbaden, Germany
| | - Prateek Sharma
- Department of Gastroenterology, University of Kansas, Kansas City, Kansas, USA
| | - Laurence B Lovat
- Division of Surgery and Interventional Science, University College London (UCL), Londons, UK
| | - Rehan Haidry
- Department of Gastroenterology and Division of Surgery and Interventional Science, University College London Hospitals NHS Foundation Trust, London, UK
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17
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Rees CJ, Koo S, Anderson J, McAlindon M, Veitch AM, Morris AJ, Bhandari P, East JE, Webster G, Oppong KW, Penman ID. British society of gastroenterology Endoscopy Quality Improvement Programme (EQIP): overview and progress. Frontline Gastroenterol 2019; 10:148-153. [PMID: 31205655 PMCID: PMC6540284 DOI: 10.1136/flgastro-2018-101073] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/08/2019] [Indexed: 02/04/2023] Open
Abstract
High quality gastrointestinal (GI) endoscopy improves patient care. Raising standards in endoscopy improves diagnostic accuracy, management of pathology and ultimately improves outcomes. Historical identification of significant variation in colonoscopy quality led to the development of the Joint Advisory Group (JAG) on GI Endoscopy, the Global Rating Scale (GRS), JAG Endoscopy Training System (JETS) training and certification. These measures led to major improvements in UK endoscopy but significant variation in practice still exists. To improve quality further the British Society of Gastroenterology Endoscopy Quality Improvement (EQIP) has been established with the aim of raising quality and reducing variation in the quality of UK endoscopy. A multifaceted approach to quality improvement (QI) will be undertaken and is described in this manuscript. Upper GI EQIP will support adoption of standards alongside regional upskilling courses. Lower GI EQIP will focus on supporting endoscopists to achieve current standards alongside approaches to reducing postcolonoscopy colorectal cancer rates. Endoscopic retrograde cholangiopancreatography EQIP will adopt a regional approach of using local data to support network-based QI. Newer areas of endoscopy practice such as small bowel endoscopy and endoscopic ultrasound will focus on identifying key performance indicators as well as standardising training and accreditation pathways. EQIP will also support QI in management of GI bleeding as well as standardising the approach to new techniques and technologies. Where evidence is lacking, approaches to gather new evidence and support the translation into clinical practice will be supported.
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Affiliation(s)
- Colin J Rees
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK,Department of Gastroenterology, South Tyneside, South Shields, UK
| | - Sara Koo
- Department of Gastroenterology, South Tyneside, South Shields, UK
| | - John Anderson
- Department of Gastroenterology, Cheltenham General Hospital, Gloucestershire Hospitals, Cheltenham, Gloucestershire, UK
| | - Mark McAlindon
- Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Andrew M Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals, Wolverhampton, UK
| | - Allan John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital Portsmouth, Southhampton, UK
| | - James E East
- Translational Gastroenterology Unit, and Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - George Webster
- Department of Gastroenterology, University College Hospital, London, UK
| | - Kofi W Oppong
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Ian D Penman
- Department of Gastroenterology, Royal Infirmary of Edinburgh, Edinburgh, UK
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18
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Bevan R, Blanks RG, Nickerson C, Saunders BP, Stebbing J, Tighe R, Veitch AM, Garrett W, Rees CJ. Factors affecting adenoma detection rate in a national flexible sigmoidoscopy screening programme: a retrospective analysis. Lancet Gastroenterol Hepatol 2019; 4:239-247. [PMID: 30655218 DOI: 10.1016/s2468-1253(18)30387-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/10/2018] [Accepted: 11/12/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND A national colorectal cancer screening programme started in England in 2013, offering one-off flexible sigmoidoscopy to all men and women aged 55 years in addition to the biennial faecal occult blood testing programme offered to all individuals aged 60-74 years. We analysed data from six pilot flexible sigmoidoscopy screening centres to examine factors affecting the adenoma detection rate (ADR). METHODS We did a retrospective analysis of flexible sigmoidoscopy screening procedures performed in individuals aged 55 years at six pilot sites in England as part of the National Health Service Bowel Scope Screening programme. ADR (number of procedures in which at least one adenoma was removed or biopsied, divided by total number of procedures) was calculated for each site and each endoscopist. Multiple regression models were used to examine the variation in ADR with withdrawal time and extent of examination, and the effect of other factors including comfort and bowel preparation on extent of examination. FINDINGS The analysis included 8256 procedures done between May 7, 2013, and May 6, 2014. The overall ADR was 9·1% (95% CI 8·5-9·8; 755 of 8256 procedures), varying from 7·4% (6·2-8·9) to 11·0% (9·1-13·4) by screening centre. The ADR was 11·5% (95% CI 10·6-12·5; 493 of 4299 procedures) in men and 6·6% (5·9-7·4; 262 of 3957 procedures) in women (p<0·0001). On multivariate analysis, factors associated with adenoma detection were male sex (relative risk 1·69, 95% CI 1·46-1·95; p<0·0001) and a withdrawal time from the splenic flexure of at least 3·25 min in negative procedures (1·22, 1·00-1·48; p=0·045). However, increasing the withdrawal time to 4·0 min or more did not increase the likelihood of adenoma detection (1·22, 0·99-1·51; p=0·057). Procedures not reaching the splenic flexure were associated with lower chance of adenoma detection (eg, 0·77, 0·66-0·91; p=0·0015 for procedures reaching the descending colon), but there was no additional benefit associated with reaching the transverse colon (0·83, 0·67-1·02; p=0·069). Women (0·83, 0·80-0·87; p<0·0001), individuals with adequate (0·79, 0·76-0·83; p<0·0001) or poor (0·58, 0·51-0·67; p<0·0001) bowel preparation (compared with good bowel preparation), and those with mild (0·82, 0·76-0·88; p<0·0001) or moderate or severe (0·58, 0·51-0·66; p<0·0001) discomfort (compared with no discomfort) were less likely to have a procedure reaching the splenic flexure. INTERPRETATION Key performance indicators for flexible sigmoidoscopy screening should be defined, including standards for insertion and withdrawal times, optimal depth, and bowel preparation. ADR could be improved by recommending a withdrawal time from the splenic flexure of at least 3·25 min (ideally 3·5-4·0 min). FUNDING None.
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Affiliation(s)
- Roisin Bevan
- North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK.
| | - Roger G Blanks
- Cancer Epidemiology Unit, University of Oxford, Oxford, UK
| | | | | | - John Stebbing
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Richard Tighe
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | - Colin J Rees
- South Tyneside NHS Foundation Trust, South Shields, UK; Newcastle University, Newcastle-upon-Tyne, UK
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Dunkley I, Griffiths H, Follows R, Ball A, Collins M, Dodds P, Gardner R, Jackson V, Rodgers C, Simpson B, Taggart N, Tham TC, Wilkin V, Veitch AM. UK consensus on non-medical staffing required to deliver safe, quality-assured care for adult patients undergoing gastrointestinal endoscopy. Frontline Gastroenterol 2019; 10:24-34. [PMID: 30651954 PMCID: PMC6319155 DOI: 10.1136/flgastro-2017-100950] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/27/2018] [Accepted: 04/09/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Irene Dunkley
- British Society of Gastroenterology Nurses’ Association, London, UK
| | | | | | - Alison Ball
- Royal College of Nursing Gastroenterology Forum, London, UK
| | - Mandy Collins
- Associates Committee, Welsh Association for Gastroenterology and Endoscopy, Newport, UK
| | - Phedra Dodds
- Associates Committee, Welsh Association for Gastroenterology and Endoscopy, Newport, UK
| | | | - Victoria Jackson
- British Society of Gastroenterology Nurses’ Association, London, UK
| | - Claire Rodgers
- British Society of Gastroenterology Nurses’ Association, London, UK
| | - Barbara Simpson
- Ulster Society of Gastroenterology Nurse Representative, Belfast, UK
| | - Nicky Taggart
- British Society of Gastroenterology Nurses’ Association, London, UK
| | - Tony C Tham
- Clinical Standards and Services Committee, British Society of Gastroenterology, London, UK
| | | | - Andrew M Veitch
- Endoscopy Committee, British Society of Gastroenterology, London, UK
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Siau K, Yew AC, Hingley S, Rees J, Trudgill NJ, Veitch AM, Fisher NC. The 2015 upper gastrointestinal "Be Clear on Cancer" campaign: its impact on gastroenterology services and malignant and premalignant diagnoses. Frontline Gastroenterol 2017; 8:284-289. [PMID: 29067155 PMCID: PMC5641852 DOI: 10.1136/flgastro-2017-100820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/18/2017] [Accepted: 05/06/2017] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To assess the impact of the upper gastrointestinal 'Be Clear on Cancer' campaign launched by Public Health England between January and February 2015 on open-access gastroscopy referrals, incidence of target diagnoses (oesophagogastric cancer and Barrett's oesophagus), cancer staging at presentation, 1-year survival and cost per additional diagnosis. DESIGN We performed a retrospective study of patients referred for 2-week-wait (2WW), open-access endoscopy 3 months following the campaign with diagnoses, endoscopic findings, staging and 12-month survival compared with data from corresponding months in 2014. SETTING Three adjacent National Health Service trusts in the West Midlands with a combined population of 1.34 million in 2015. RESULTS 2WW open-access referrals increased by 48% (95% CI 1.35 to 1.61, p<0.001). The proportion of target diagnoses fell from 6.7% to 6.1% (p=0.62). There were no significant overall increases in target diagnoses (OR 1.35, 95% CI 0.95 to 1.92, p=0.11) or cancer (OR 1.30, 95% CI 0.80 to 2.07, p=0.36). There was no change in tumour, node, metastasis (TNM) staging for oesophageal or gastric cancer. Overall 1-year survival did not alter significantly (HR 1.10, 95% CI 0.56 to 2.19, p=0.76). DISCUSSION The 'Be Clear on Cancer' campaign led to a 48% increase in demand for 2WW gastroscopies but did not significantly affect the incidence of target diagnoses, cancer staging or 1-year survival.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Russell’s Hall Hospital, Dudley, UK
| | - Andrew Chong Yew
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Samantha Hingley
- Department of Gastroenterology, Russell’s Hall Hospital, Dudley, UK
| | - James Rees
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
| | - Nigel John Trudgill
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
| | - Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Neil C Fisher
- Department of Gastroenterology, Russell’s Hall Hospital, Dudley, UK
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21
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Chattree A, Barbour JA, Thomas-Gibson S, Bhandari P, Saunders BP, Veitch AM, Anderson J, Rembacken BJ, Loughrey MB, Pullan R, Garrett WV, Lewis G, Dolwani S, Rutter MD. Report of the Association of Coloproctology of Great Britain and Ireland/British Society of Gastroenterology Colorectal Polyp Working Group: the development of a complex colorectal polyp minimum dataset. Colorectal Dis 2017; 19:67-75. [PMID: 27610599 DOI: 10.1111/codi.13504] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 07/04/2016] [Indexed: 02/08/2023]
Abstract
AIM The management of large non-pedunculated colorectal polyps (LNPCPs) is complex, with widespread variation in management and outcome, even amongst experienced clinicians. Variations in the assessment and decision-making processes are likely to be a major factor in this variability. The creation of a standardized minimum dataset to aid decision-making may therefore result in improved clinical management. METHOD An official working group of 13 multidisciplinary specialists was appointed by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG) to develop a minimum dataset on LNPCPs. The literature review used to structure the ACPGBI/BSG guidelines for the management of LNPCPs was used by a steering subcommittee to identify various parameters pertaining to the decision-making processes in the assessment and management of LNPCPs. A modified Delphi consensus process was then used for voting on proposed parameters over multiple voting rounds with at least 80% agreement defined as consensus. The minimum dataset was used in a pilot process to ensure rigidity and usability. RESULTS A 23-parameter minimum dataset with parameters relating to patient and lesion factors, including six parameters relating to image retrieval, was formulated over four rounds of voting with two pilot processes to test rigidity and usability. CONCLUSION This paper describes the development of the first reported evidence-based and expert consensus minimum dataset for the management of LNPCPs. It is anticipated that this dataset will allow comprehensive and standardized lesion assessment to improve decision-making in the assessment and management of LNPCPs.
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Affiliation(s)
- A Chattree
- Department of Gastroenterology, University Hospital of North Tees, Stockton on Tees, UK.,University School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | - J A Barbour
- Department of Gastroenterology, Queen Elizabeth Hospital, Gateshead, UK
| | | | - P Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - B P Saunders
- Wolfson Unit for Endoscopy, St Mark's Hospital, London, UK
| | - A M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - J Anderson
- Department of Gastroenterology, Cheltenham General Hospital, Cheltenham, UK
| | - B J Rembacken
- Department of Gastroenterology, Leeds General Infirmary, Leeds, UK
| | - M B Loughrey
- Department of Histopathology, Royal Victoria Hospital, Belfast, UK
| | - R Pullan
- Department of Colorectal Surgery, Torbay Hospital, Torquay, UK
| | - W V Garrett
- Department of Colorectal Surgery, Medway Maritime Hospital, Gillingham, UK
| | - G Lewis
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
| | - S Dolwani
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
| | - M D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton on Tees, UK.,University School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
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22
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Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy 2016; 48:385-402. [PMID: 26890676 DOI: 10.1055/s-0042-102652] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage vs. thrombosis due to discontinuation of therapy. P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor): For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation);For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation).For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). Warfarin: The advice for warfarin is fundamentally unchanged from BSG 2008 guidance. Direct Oral Anticoagulants (DOAC): For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation). For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥ 48 hours before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30 - 50 mL/min we recommend that the last dose of DOAC be taken 72 hours before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).
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Affiliation(s)
- Andrew M Veitch
- Consultant Gastroenterologist, Clinical Director of Endoscopy and Bowel Cancer Screening, New Cross Hospital, Wolverhampton
| | | | - Anthony H Gershlick
- Honorary Professor of Interventional Cardiology, Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital
| | - Christian Boustiere
- Secrétaire Général de la FMCHGE, Chef de Service Unité Endoscopie Digestive, Hopital Saint Joseph, Marseille, France
| | - Trevor P Baglin
- Consultant Haematologist, Department of Haematology, Addenbrookes Hospital, Cambridge
| | - Lesley-Ann Smith
- Consultant Gastroenterologist, Level 6, Support Building, Auckland City Hospital
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center Afula, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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23
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Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy 2016; 48:c1. [PMID: 28114689 DOI: 10.1055/s-0042-122686] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Andrew M Veitch
- Consultant Gastroenterologist, Clinical Director of Endoscopy and Bowel Cancer Screening, New Cross Hospital, Wolverhampton
| | | | - Anthony H Gershlick
- Honorary Professor of Interventional Cardiology, Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital
| | - Christian Boustiere
- Secrétaire Général de la FMCHGE, Chef de Service Unité Endoscopie Digestive, Hopital Saint Joseph, Marseille, France
| | - Trevor P Baglin
- Consultant Haematologist, Department of Haematology, Addenbrookes Hospital, Cambridge
| | - Lesley-Ann Smith
- Consultant Gastroenterologist, Level 6, Support Building, Auckland City Hospital
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center Afula, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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24
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Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65:374-89. [PMID: 26873868 PMCID: PMC4789831 DOI: 10.1136/gutjnl-2015-311110] [Citation(s) in RCA: 189] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). WARFARIN The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance. DIRECT ORAL ANTICOAGULANTS DOAC For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).
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Affiliation(s)
- Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Geoffroy Vanbiervliet
- Department of Gastroenterology, Hôpital Universitaire L'Archet 2, Nice Cedex 3, France
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | | | - Trevor P Baglin
- Department of Haematology, Addenbrookes Hospital, Cambridge, UK
| | - Lesley-Ann Smith
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce, Como, Italy
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel,Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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Rutter MD, Chattree A, Barbour JA, Thomas-Gibson S, Bhandari P, Saunders BP, Veitch AM, Anderson J, Rembacken BJ, Loughrey MB, Pullan R, Garrett WV, Lewis G, Dolwani S. British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps. Gut 2015; 64:1847-73. [PMID: 26104751 PMCID: PMC4680188 DOI: 10.1136/gutjnl-2015-309576] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/25/2015] [Accepted: 05/29/2015] [Indexed: 02/07/2023]
Abstract
These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs.
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Affiliation(s)
- Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton on Tees, UK School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | - Amit Chattree
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | - Jamie A Barbour
- Department of Gastroenterology, Queen Elizabeth Hospital, Gateshead, UK
| | | | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | | | - Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - John Anderson
- Department of Gastroenterology, Cheltenham General Hospital, Cheltenham, UK
| | | | | | - Rupert Pullan
- Department of Colorectal Surgery, Torbay Hospital, Torquay, UK
| | - William V Garrett
- Department of Colorectal Surgery, Medway Maritime Hospital, Gillingham, UK
| | - Gethin Lewis
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
| | - Sunil Dolwani
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
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26
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Abstract
AIMS South Asians comprise 13.6% of the Wolverhampton population. We aimed to compare the incidence and trend of colorectal cancer in this subgroup with the non South Asian population over a 20-year period. METHOD Patients of South Asian origin diagnosed with colorectal cancer from 1989 to 2008 were identified from the hospital histopathology database and compared with those of non South Asian origin. 1991 and 2001 census data were used to standardize for differing age and sex distributions in the two study populations. RESULTS The median unadjusted incidence of colorectal cancer from 1989 to 2008 was 6.17 per 100,000 per year in South Asians compared with 71.70 per 100,000 per year in non South Asians (77.79% white British). The age and sex adjusted odds ratio for colorectal cancer in South Asians was 0.2 (P < 0.001). There was an equal increased trend in the incidence in both the South Asians and non South Asians over the study period (0.8% per year). In patients < 50 years, the gender difference in the incidence of cancer was not significant, but as age increased this rose significantly (males > females). CONCLUSION There was a markedly lower incidence of colorectal cancer in South Asians compared with non South Asians, maintained over 20 years. Colorectal cancer incidence increased by a small and similar amount over the period in both groups. There was a male preponderance of colorectal cancer in both populations over 50 years.
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Affiliation(s)
- S Hebbar
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
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27
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Affiliation(s)
- A M Veitch
- Radiology Department, Salisbury District Hospital, Salisbury, UK.
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28
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Ellul P, Fogden E, Simpson CL, Nickerson CLR, McKaig BC, Swarbrick ET, Veitch AM. Downstaging of colorectal cancer by the National Bowel Cancer Screening programme in England: first round data from the first centre. Colorectal Dis 2010; 12:420-2. [PMID: 19843116 DOI: 10.1111/j.1463-1318.2009.02069.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Data from randomized controlled trials of Colorectal Cancer (CRC) screening in Nottingham, UK and Funen, Denmark and pilot data from the English and Scottish arms of the National Bowel Cancer Screening Programme (NBCSP) have demonstrated predominantly early-stage disease amongst the screened population. The aim of this study was to investigate whether downstaging of cancers occurred in the NBCSP in Wolverhampton. METHOD A case-control study was performed to compare the staging of CRC diagnosed in the NBCSP-screened population during the prevalent round (2 years) of screening, with cancers diagnosed prior to the introduction of the NBCSP. RESULTS The total population in the screening area is 899 000. A total of 108 346 FOB kits were sent out of which 55 931 were returned (51.6% uptake), A total of 1039 colonoscopies were performed with a 94.75% unadjusted caecal intubation rate. There were three complications (haemorrhages 3) and no perforations. The NBCSP in Wolverhampton identified 106 (75% male) CRC in the first 2 years with 45.3% Dukes A, 21.7% B, 29.2% C and 3.8% D. Two hundred and fifty-six (61% male) CRC were identified in the control group, 10.1% Dukes A, 50.0% B, 36.3% C and 3.5% D. There was a highly significant shift towards earlier stage disease in the screened group (P < 0.0001). CONCLUSION The 2-year data from the first English centre to start bowel cancer screening demonstrates significant downstaging of cancer, consistent with both the RCT and pilot data.
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Affiliation(s)
- P Ellul
- New Cross Hospital, Wolverhampton, UK
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29
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Veitch AM, Baglin TP, Gershlick AH, Harnden SM, Tighe R, Cairns S. Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008; 57:1322-9. [PMID: 18469092 DOI: 10.1136/gut.2007.142497] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- A M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK.
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Manghat NE, Rachapalli V, Van Lingen R, Veitch AM, Roobottom CA, Morgan-Hughes GJ. Imaging the heart valves using ECG-gated 64-detector row cardiac CT. Br J Radiol 2008; 81:275-90. [PMID: 18344273 DOI: 10.1259/bjr/16301537] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Multi-detector row cardiac CT imaging demonstrates clinical usefulness in valvular heart disease, for which CT has not been traditionally used. Electrocardiographic (ECG)-gated CT coronary angiography also has an established clinical role with an increasingly solid evidence base, and the same data set in these patients also provides valuable information about chamber and valvular structure and function; this information should also be considered when interpreting cardiac CT and non-ECG gated thoracic imaging. Although true flow data cannot be achieved using CT, as with echocardiography and MRI, there are a number of imaging features that may be used when interpreting and inferring valve pathology. This article discusses the role of currently available imaging modalities and the rationale for cardiac CT, while focusing on the CT interpretation of valvular heart disease with respect to the relevant pathophysiology and management options that have importance to the radiologist. A suggested method of post-processing image review is provided with reference to a variety of normal and pathological pictorial illustrations.
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Affiliation(s)
- N E Manghat
- Department of Clinical Radiology, Plymouth NHS Trust, Derriford Hospital, Plymouth, UK.
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31
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Jenkins EJ, Veitch AM, Kutz SJ, Bollinger TK, Chirino-Trejo JM, Elkin BT, West KH, Hoberg EP, Polley L. Protostrongylid parasites and pneumonia in captive and wild thinhorn sheep (Ovis dalli). J Wildl Dis 2007; 43:189-205. [PMID: 17495303 DOI: 10.7589/0090-3558-43.2.189] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe health significance of protostrongylid parasites (Parelaphostrongylus odocoilei and Protostrongylus stilesi) and other respiratory pathogens in more than 50 naturally infected Dall's sheep (Ovis dalli dalli) from the Mackenzie Mountains, Northwest Territories (1998-2002) as well as in three Stone's sheep (O. d. stonei) experimentally infected with P. odocoilei (2000-2002). Histological lesions in the brain and distribution of P. odocoilei in the muscles of experimentally and naturally infected sheep were consistent with a previously hypothesized "central nervous system to muscle" pattern of migration for P. odocoilei. Dimensions of granulomas associated with eggs of P. odocoilei and density of protostrongylid eggs and larvae in the cranial lung correlated with intensity of larvae in feces, and all varied with season of collection. Prevalence of P. stilesi based on the presence of larvae in feces underestimated true prevalence (based on examination of lungs) in wild Dall's sheep collected in summer and fall. Similarly, counts of both types of protostrongylid larvae in feces were unreliable indicators of parasitic infection in wild Dall's sheep with concomitant bacterial pneumonia associated with Arcanobacterium pyogenes, Pasteurella sp., and Mannheimia sp. Diffuse, interstitial pneumonia due to P. odocoilei led to fatal pulmonary hemorrhage and edema after exertion in one experimentally infected Stone's sheep and one naturally infected Dall's sheep. Bacterial and verminous pneumonia associated with pathogens endemic in wild Dall's sheep in the Mackenzie Mountains caused sporadic mortalities. There was no evidence of respiratory viruses or bacterial strains associated with domestic ruminants, from which this population of wild sheep has been historically isolated.
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Affiliation(s)
- E J Jenkins
- Department of Veterinary Microbiology, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
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Jenkins EJ, Veitch AM, Kutz SJ, Hoberg EP, Polley L. Climate change and the epidemiology of protostrongylid nematodes in northern ecosystems:Parelaphostrongylus odocoileiandProtostrongylus stilesiin Dall's sheep (Ovis d. dalli). Parasitology 2005; 132:387-401. [PMID: 16332289 DOI: 10.1017/s0031182005009145] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2005] [Revised: 09/09/2005] [Accepted: 09/09/2005] [Indexed: 11/07/2022]
Abstract
We describe the epidemiology of the protostrongylid parasitesParelaphostrongylus odocoileiandProtostrongylus stilesiin Dall's sheep (Ovis dalli dalli) from the Mackenzie Mountains, Northwest Territories, Canada (65 °N; 128 °W). Peak numbers of 1st-stage larvae of both parasites were shed by Dall's sheep on their winter range from March until May. In larval development experiments in the Mackenzie Mountains, peak numbers of infective 3rd-stage larvae ofP. odocoileiwere available in gastropod intermediate hosts in August–September. For both protostrongylids, the majority of transmission likely occurs on the winter range, with infection of gastropods when they emerge from hibernation in spring, and infection of Dall's sheep upon their return in fall. We validated a degree-day model for temperature-dependent development of larvalP. odocoileiin gastropods, and applied degree-day models to describe and predict spatial and temporal patterns in development ofP. odocoileiandP. stilesiin northern North America. Temperature-dependent larval development may currently limit northward range expansion ofP. odocoileiinto naïve populations of Dall's sheep in the Arctic, but climate warming may soon eliminate such constraints. In Subarctic regions where bothP. odocoileiandP. stilesiare endemic, the length of the parasite ‘growing season’ (when temperatures were above the threshold for larval development) and amount of warming available for parasite development has increased over the last 50 years. Further climate warming and extension of the seasonal window for transmission may lead to amplification of parasite populations and disease outbreaks in host populations.
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Affiliation(s)
- E J Jenkins
- Department of Veterinary Microbiology, Western College of Veterinary Medicine, 52 Campus Drive, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, S7N 5B4.
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Abstract
A 47-year-old, West Indian male was referred for investigation of mild iron-deficiency anemia. He was asymptomatic. Two years earlier, he had an episode of transient facial weakness and a separate episode of diplopia. Gastroscopy and duodenal biopsies were normal. Barium enema demonstrated multiple small polyps throughout the colon. At colonoscopy, these polyps had the appearance of adenomatous polyps. Histology revealed noncaseous epithelioid granulomas. There were no acid-fast bacilli, no intervening colitis, and no features of Crohn's disease on small-bowel radiology. Chest x-ray demonstrated bilateral hilar lymphadenopathy. A diagnosis of sarcoidosis with colonic involvement has been made. Sarcoid has been described at various sites in the gastrointestinal tract, presenting with stricturing or ulceration. There have been no previous reports of sarcoidosis presenting as discreet colonic polyps.
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Affiliation(s)
- Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, United Kingdom.
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Veitch AM, Higgins LM, Bajaj-Elliot M, Farthing MJG, MacDonald TT. Impaired rejection and mucosal injury of small intestinal allografts lacking the interferon-gamma receptor. Int J Exp Pathol 2003; 84:107-13. [PMID: 12974940 PMCID: PMC2517553 DOI: 10.1046/j.1365-2613.2003.00342.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2002] [Accepted: 04/30/2003] [Indexed: 12/31/2022] Open
Abstract
Small intestinal mucosal T cell activation results in villous atrophy and crypt hyperplasia. There is conflicting evidence as to whether a Th1 IFN-gamma response may be involved. Using a murine intestinal transplant model of T cell-mediated enteropathy we aimed to study the role of IFN-gamma on the development of villous atrophy and crypt hyperplasia. Isografts or allografts of foetal small intestine from 129SV-/- IFN-gamma receptor knockout mice or wild type mice were implanted under the kidney capsule of Balb/c recipient mice. Grafts were examined histologically at intervals from 2 to 9 days post implantation for signs of rejection. Quantitative rtPCR for IFN-gamma, TNFalpha and IL-4 was conducted on grafts at 5 and 9 days post implantation. In allografts, rejection accompanied by the development of villous atrophy and crypt hyperplasia, occurred in a time-dependent manner. However this process was markedly slower in the IFN-gamma receptor knockout grafts compared to the wild type grafts at 5 days (chi2 = 10.08, P = 0.007) and 9 days post implantation (chi2 = 13.25, P = 0.004). There were also significantly fewer TNFalpha transcripts in allografts of IFN-gamma-/- intestine than in wild type allografts (P = 0.02). IFN-gamma has a partial, but not obligatory, role in the development of villous atrophy and crypt hyperplasia during T cell mediated rejection of intestinal allografts.
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Affiliation(s)
- Andrew M Veitch
- Digestive Diseases Research Centre, St Bartholomew's and the Royal London School of Medicine and Dentistry, London UK.
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Abstract
OBJECTIVE Tropical enteropathy is widespread throughout the tropics, but its pathogenesis is unknown. T-cell activation has been demonstrated to result in enteropathy in vitro and in animal models, and occurs in untreated patients with coeliac disease. We have therefore examined the hypothesis that T-cell activation is important in the pathogenesis of tropical enteropathy. PATIENTS AND METHODS Healthy black Zambian subjects were compared with black and white South Africans. Quantitative microscopy was conducted on distal duodenal biopsies. Mucosal T-cell activation was quantitated by dual colour immunofluorescence staining for CD3 plus CD69 or HLA-DR. Crypt proliferation was measured by direct counting of Feulgen-stained mitotic figures, and systemic immune activation by assay of serum tumour necrosis factor alpha (TNF-alpha). RESULTS Villous height was reduced (P = 0.0004), crypt depth increased (P < 0.0001), and mitoses per crypt increased (P = 0.014) in black Zambians compared with black and white South Africans. Mucosal thickness was similar. Intraepithelial lymphocyte count was increased in the black groups compared with whites (P = 0.03). CD3+CD69+ (P = 0.0007) and CD3+HLA-DR+ (P < 0.0001) expression was increased in black Zambians compared with black and white South Africans. Serum TNF-alpha was similar in all groups. CONCLUSIONS Tropical enteropathy is associated with mucosal T-cell activation and crypt hyperplasia. Tropical enteropathy occurs in the absence of malnutrition, diarrhoea or systemic illness.
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Affiliation(s)
- A M Veitch
- Digestive Diseases Research Centre, St. Bartholomew's and the Royal London School of Medicine and Dentistry, London, UK.
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Abstract
Biodiversity survey and inventory have resulted in new information on the distribution of Protostrongylidae in Dall's sheep (Ovis dalli dalli) from the Northwest Territories (NT, Canada) and from Alaska (AK, USA). In 1998, Parelaphostrongylus odocoilei adults were found for the first time in the skeletal muscles of Dall's sheep in the Mackenzie Mountains (NT). Adult P. odocoilei were associated with petechial and ecchymotic hemorrhages and localized myositis; eggs and larvae in the lungs were associated with diffuse granulomatous pneumonia. Experimental infections of the slugs Deroceras laeve and Deroceras reticulatum with dorsal-spined first-stage larvae assumed to be P. odocoilei, from ground-collected feces from Dall's sheep in the Mackenzie Mountains, yielded third-stage larvae by at least 28 (in D. laeve) and 48 (in D. reticulatum) days post-infection. Third-stage larvae emerged from D. laeve between days 19 and 46 post-infection and emergence occurred both at room temperature and at 10 to 12 C. Protostrongylus stilesi were definitively identified from the lungs of Dall's sheep collected in the Mackenzie Mountains, NT in 1998. Specimens collected from sheep in the Mackenzie Mountains, NT in 1971-72, and the Alaska Range, AK in 1972 were also confirmed as P. stilesi. Lung pathology associated with adults, eggs, and larvae of P. stilesi was similar to that described in bighorn sheep (Ovis canadensis). Concurrent infections with P. odocoilei and P. stilesi in a single host have not been previously reported.
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Affiliation(s)
- S J Kutz
- Department of Veterinary Microbiology, Western College of Veterinary Medicine, 52 Campus Drive, University of Saskatchewan, Saskatoon, Saskatchewan, S7N 5B4, Canada.
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Veitch AM, Kelly P, Zulu I, MacDonald TT, Farthing MJ. Lack of evidence for small intestinal mucosal T-cell activation as a pathogenic mechanism in African HIV-associated enteropathy. Dig Dis Sci 2001; 46:1133-8. [PMID: 11341660 DOI: 10.1023/a:1010738818127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
The role of mucosal T-cell activation in HIV-associated enteropathy is uncertain. Twenty Zambian patients with AIDS and chronic diarrhea were studied, as were nine controls. Distal duodenal biopsies were taken at endoscopy. Morphometric analysis and dual color immunofluorescence staining were performed. Villous height was reduced [177 (118-228) vs 305 (244-358) microm P = 0.002] and crypt depth increased [220 (164-202) vs 194 (164-202) microm P = 0.008] in AIDS patients compared to controls. CD3+CD4+ T cells were reduced in AIDS patients compared to controls [12.9 (5.7-25.2) vs 47.6 (33.4-65.5)% P = 0.04]. There was no significant difference in expression of CD8, CD25, CD69, HML-1, or HLA-DR on T cells between the AIDS patients and controls, with the exception of CD3+HML-1+ cells, which were increased in AIDS patients (P = 0.05). Small intestinal T-cell activation was similar between AIDS patients and controls. We conclude, therefore, that this mechanism is not likely to be important in the pathogenesis of HIV-associated enteropathy.
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Affiliation(s)
- A M Veitch
- Digestive Diseases Research Centre, St Bartholomew's and the Royal London School of Medicine and Dentistry, UK
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Abstract
In fall 1991, a radio-collared black bear (Ursus americanus) in northern Labrador (Canada) died from valvular endocarditis caused by coagulase-positive Staphylococcus aureus, with widespread dissemination of the infection to other organs shortly before death. Apparently, this is the first reported case of bacterial valvular endocarditis in a wild black bear.
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Affiliation(s)
- S McBurney
- Canadian Cooperative Wildlife Health Centre Atlantic region, Department of Pathology & Microbiology, Atlantic Veterinary College, University of Prince Edward Island.
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Abstract
Persistent diarrhoea and small bowel enteropathy are important features of HIV infection. At least 80% of cases of persistent diarrhoea in patients with HIV/AIDS can be attributed to a specific enteropathogen. The coccidian parasites Cryptosporidium parvum, Isospora belli and Cyclospora and the Microsporidia account for at least 50% of cases of persistent diarrhoea in the industrialised and developing world with major contributions from Mycobacterium avium complex and other bacteria and cytomeglovirus. The intracellular protozoa can be detected on faecal microscopy although confirmation may be required by intestinal mucosal biopsies. Although up to 20% of cases of persistent diarrhoea can not be attributed to a specific infection, the question as to whether HIV infection itself can produce enteropathy remains uncertain. Recent developments in the treatment of persistent diarrhoea in HIV include the use of albendazole for microsporidial diarrhoea and co-trimoxazole for the treatment and eradication of Cyclospora.
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Affiliation(s)
- M J Farthing
- Digestive Diseases Research Centre, Medical College of St Bartholomew's Hospital, London, UK
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