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ObjectiveTo report our cumulative experience from a dedicated iron deficiency anaemia (IDA) clinic over the last 15 years—with particular emphasis on referral rate, uptake of investigation, impact on endoscopy services, diagnostic yield of gastrointestinal (GI) investigation and the issue of recurrent IDA.MethodA series of analyses of a register of 2808 referrals to the Poole IDA clinic between 2004 and 2018.ResultsThe study population of 2808 had a sex ratio of 1.9 (female/male ratio) and a median age of 72 years (IQR: 60–79). A rising referral rate over the study period appears to be plateauing at around 2 cases per 1000 population per annum. On the basis of a snapshot audit, investigation of IDA may now account for over 20% of all diagnostic endoscopies.Overall, 86% of cases underwent examination of the upper and lower GI tract. Significant GI pathology was identified in 27% of the investigated cohort. Adenocarcinoma of the upper or lower GI tract was found in 8.3%, the majority in the right colon. The prevalence of recurrent IDA was estimated at 12.4%, and the results of investigation of this subgroup are reported.ConclusionUnexplained IDA is common, particularly in those over 60 years, and may be the first indication of underlying GI malignancy in over 8% of cases. Unresolved challenges include accommodating the resulting endoscopy workload, establishing a risk/benefit ratio for investigating those with major comorbidities and the management of recurrent IDA.

OBJECTIVES Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology. DESIGN A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite. MAIN OUTCOME MEASURES Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival. RESULTS Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43 ± 50 days for control patients to 115 ± 140 days for ICR patients (P

ObjectiveTo refine and validate a model for predicting the risk of gastrointestinal (GI) cancer in iron deficiency anaemia (IDA) and to develop an app to facilitate use in clinical practice.DesignThree elements: (1) analysis of a dataset of 2390 cases of IDA to validate the predictive value of age, sex, blood haemoglobin concentration (Hb), mean cell volume (MCV) and iron studies on the probability of underlying GI cancer; (2) a pilot study of the benefit of adding faecal immunochemical testing (FIT) into the model; and (3) development of an app based on the model.ResultsAge, sex and Hb were all strong, independent predictors of the risk of GI cancer, with ORs (95% CI) of 1.05 per year (1.03 to 1.07, pConclusionThis predictive model may help rationalise the use of investigational resources in IDA, by fast-tracking high-risk cases and, with appropriate safeguards, avoiding invasive investigation altogether in those at ultra-low predicted risk.

This study investigates the mental health of victims of sexual abuse, particularly rape, in college student populations. The study identifies the connection between sexual abuse/rape and elevated scores of mental health. It indicates that even with other stressful events occurring in the lives of respondents, sexual abuse/rape has a detrimental effect on the mental health of both males and females. A death in the family was the most commonly reported stressful event for males and females, and females were more likely than males to have suffered from a sexual attack. Early negative experiences of sexual intercourse can apparently have long lasting negative effects on the victim’s mental health. These findings require society to look beyond the physical consequences of sexual abuse and rape to ensure that the long-term mental health of victims, both male and female children and adults, is not overlooked.

This paper reports the attitudes and actions on relationships with the opposite sex of 1,002 Grade 10 and Grade 12 students in New Providence. Girls were more likely than boys to use aggressive behaviours in teen relationships. Some of the behaviours noted in teen relationships informed expectations of marital relationships, such as restricted access to friends of the opposite sex. The students endorsed a number of sex-related stereotypes, such as a man being the head of the household. Both male and female students indicated that it was acceptable for men to control their wives. Participation in aggressive and controlling behaviours by teens points to the need to educate students about how to develop more respectful relationships.

Introduction: Iron deficiency anaemia (IDA) is commonly a result of colorectal cancer. Higher preoperative haemoglobin (Hb) is associated with an improved post-operative survival. The endpoint of normalising patients Hb is to reduce the need for perioperative blood transfusion which has oncological, safety and economic benefits. Methods: This study aims to compare the overall effect and cost between oral iron and two forms of parenteral iron, in raising the Hb of 53 consecutive colorectal cancer patients with IDA. The pre- and post-treatment Hb were measuring over time for oral and two formulations of parenteral iron (CosmoFer® and Venofer®), as were the need for supplemental pre-operative blood transfusions. The Total Hb rise and Hb rise/day were calculated as was the overall cost (including blood transfusions) in each of the three iron supplementation groups. Results: Both total Hb rise and Hb rise/day were significantly higher in the Venofer® (p=0.048, p=0.002) and CosmoFer® groups (p=0.034 & p=0.001) over oral iron. The oral iron group required significantly more blood than the Venofer® (p=0.04) and CosmoFer® groups (p=0.01). Although there was a trend for oral iron to cost more than parenteral, this did not reach significance. Conclusions: This study suggests that the end point of transfusion reduction is possible by the increased Hb rise rate of Venofer® or CosmoFer®. In addition, parenteral iron supplementation is no more costly than the traditional oral route, taking into account blood transfusion requirement.

Mixed sex bays are a reality on most Emergency Assessment Units (EAU). However, they are controversial having recently been the focus of political and media attention. We adapted a validated patient satisfaction questionnaire to seek the views of 1000 emergency admissions regarding mixed sex accommodation. Of 1000 respondents, 925 (92%) had been in bays and 665 (66%) shared with the opposite sex. Most 579/665 (87%) were comfortable with this, 97% (966/1000) feeling there was sufficient level of privacy, all (1000/1000) felt they were given privacy when needed. When asked ‘‘given the nature and function of EAU would you be willing to share with the opposite sex if it meant a shorter stay?’’, 857 (86%) said yes. Our study demonstrates that whilst single sex accommodation is ideal it is not the most important factor to most patients admitted to EAU.

In many hospitals a variety of triage systems are used by senior medical staff to identify likely length of stay (LOS) of acute medical admissions and thus facilitate a streamlined admission under either acute medicine or general internal medicine (GIM). The authors evaluated if senior nursing staff on the medical assessment unit could triage patients depending on their predicted LOS as accurately as consultant acute physicians. Each of 193 medical admissions were independently triaged by both groups to either acute medicine (48 hours) depending on predicted LOS. The accuracy of patient triage was identical for senior nursing staff and consultants (80.8% vs 81.9%), when 95% confidence intervals are taken into account. Nursing staff triaged patients a mean of 8.5 hours earlier than consultants. This study demonstrates that triage of acute medical admissions is a practical extension of the senior nursing role and has been successfully implemented, with accuracy of nursing triage (83.5%) being maintained in a repeat study 6 months later.

Introduction: Non-alcoholic fatty liver disease (NAFLD) is associated with Type 2 diabetes (T2DM) and the metabolic syndrome, and can progress to chronic liver disease. We examined the incidence of elevated (>35 iu/l) alanine transaminase (ALT), as a surrogate marker for NAFLD, in patients with newly diagnosed T2DM. Materials and Methods: Retrospective analysis of ALT with metabolic parameters, in 606 consecutive patients presenting to district wide education sessions for newly diagnosed T2DM. Results: ALT was elevated in 155 patients (25.6% (95% CI 22.1, 29.2)), who tended to be older (mean difference 7.3 years (5.2, 9.5), P < 0.001), heavier (body mass index (BMI) mean difference 2.0 kg/m 2 ( 1.0, 3.0), P < 0.001), and more likely to be male (M:F raised ALT 104:51, normal ALT 219:232, P < 0.001), with higher triglycerides (median difference 0.2 mmol/l, P = 0.001) and lower HDL cholesterol (mean difference 0.09 mmol/l (0.02, 0.15), P = 0.001). There were no statistically significant differences in HBA1C or total cholesterol. Conclusions: In a well-defined population of newly diagnosed people with T2DM, there is a high incidence of abnormal ALT levels, which is associated with features of the metabolic syndrome (obesity and lipid abnormalities), but not glycemic control.

BACKGROUND—Following liver injury, hepatic stellate cells (HSC) transform into myofibroblast-like cells (activation) and are the major source of type I collagen and the potent collagenase inhibitors tissue inhibitors of metalloproteinases 1 and 2 (TIMP-1 and TIMP-2) in the fibrotic liver. The reproductive hormone relaxin has been reported to reduce collagen and TIMP-1 expression by dermal and lung fibroblasts and thus has potential antifibrotic activity in liver fibrosis. AIMS—To determine the effects of relaxin on activated HSC. METHODS—Following isolation, HSC were activated by culture on plastic and exposed to relaxin (1-100 ng/ml). Collagen deposition was determined by Sirius red dye binding and radiolabelled proline incorporation. Matrix metalloproteinase (MMP) and TIMP expression were assessed by zymography and northern analysis. Transforming growth factor β1 (TGF-β1) mRNA and protein levels were quantified by northern analysis and ELISA, respectively. RESULTS—Exposure of activated HSC to relaxin resulted in a concentration dependent decrease in both collagen synthesis and deposition. There was a parallel decrease in TIMP-1 and TIMP-2 secretion into the HSC conditioned media but no change in gelatinase expression was observed. Northern analysis demonstrated that primary HSC, continuously exposed to relaxin, had decreased TIMP-1 mRNA expression but unaltered type I collagen, collagenase (MMP-13), alpha smooth muscle actin, and TGF-β1 mRNA expression. CONCLUSION—These data demonstrate that relaxin modulates effective collagen deposition by HSC, at least in part, due to changes in the pattern of matrix degradation. Keywords: relaxin; hepatic stellate cell; hepatic fibrosis; type I collagen

Background/Aims: Connective tissue growth factor is a recently described mitogenic protein implicated in a variety of fibrotic disorders. Connective tissue growth factor may be a downstream mediator of the pro-fibrotic and mitogenic actions of transforming growth factor-β, promoting extracellular matrix deposition and fibrogenesis. As transforming growth factor-β is considered important to the pathogenesis of hepatic fibrosis, we examined the possible contribution of connective tissue growth factor to this process. Methods: Connective tissue growth factor expression was examined in normal and fibrotic human and rat livers using RT-PCR and ribonuclease protection assays, and in primary cultures of rat hepatic stellate cells by Northern and Western blotting. Results: Ribonuclease protection assays demonstrated connective tissue growth factor mRNA was increased 3–5-fold in human fibrotic liver compared with normal. RT-PCR showed this mRNA was increased in carbon-tetrachloride-treated rat liver. Northern analysis showed connective tissue growth factor mRNA was increasingly expressed during progressive activation of cultured rat hepatic stellate cells. Western analysis confirmed that freshly isolated hepatic stellate cells secreted relatively little connective tissue growth factor compared with hepatic stellate cells activated in culture. Hepatic stellate cells stimulated with transforming growth factor-β1 showed increased expression of connective tissue growth factor mRNA and protein. Conclusions: Connective tissue growth factor mRNA is consistently upregulated in human liver cirrhosis of various aetiologies, supporting a role for this growth factor in hepatic fibrogenesis. Our studies suggest that hepatic stellate cells may be an important source of hepatic connective tissue growth factor in vivo , particularly following stimulation with transforming growth factor-β.

There is increasing evidence to suggest that the potent neutrophil chemoattractant interleukin-8 (IL-8) has an important role in the pathogenesis of inflammatory bowel disease. IL-8 mediates its actions via two cell surface receptors, CXCR1 and CXCR2. This paper describes the distribution of these IL-8 receptors in the normal gastrointestinal tract and how this is modified in ulcerative colitis (UC). Paraffin-embedded colonic resection specimens were stained with monoclonal antibodies directed against CXCR1 and CXCR2 in ten cases of total UC, 16 cases of appendicitis, and 11 histologically normal sections. A semiquantitative scale of 0-4 was used to assess the proportion and intensity of positively stained cells within certain defined areas of tissue. A comparative assessment was made of the distribution of various cell populations. Dual immunostaining was used to confirm the phenotype of positively staining cells. In the histologically normal colon, the antibody against CXCR1 stained a subpopulation of macrophages deep to the epithelium and germinal centre lymphocytes. A similar pattern of staining was seen in acute appendicitis, with in addition some positively stained neutrophil polymorphs. In UC, there was up-regulation of CXCR1, with a striking increase in positively stained macrophages throughout the mucosa and of B and T lymphocytes outside the germinal centre areas. There was also intense up-regulation of CXCR1 expression by the luminal epithelium, reflected in the epithelial staining score (mean+/-SE=1.8+/-0.44 for UC cases, vs. 0.23+/-0.16 for controls and 0.25+/-0.14 for acute appendicitis). CXCR2 was only expressed on a small population of lamina propria mononuclear cells and crypt epithelial cells, with no significant differences observed between the groups. These results suggest that IL-8 may, through CXCR1, have a role beyond neutrophil recruitment in mediating the immune response in UC and that this is not merely a consequence of the acute inflammation seen in UC.

Objective : Ten percent of adults presenting with iron deficiency anaemia (IDA) have underlying cancer. This study was undertaken to assess whether five simple clinical parameters can usefully predict the likelihood of gastrointestinal (GI) malignancy on subsequent investigation of patients with IDA. \ud Design : Retrospective observational study, with multivariable analysis of the predictive value of sex, age, haemoglobin concentration (Hb), mean red cell volume (MCV) and iron studies for the risk of underlying GI malignancy.\ud Setting : District General Hospital IDA clinic.\ud Patients : 720 adults with confirmed IDA.\ud Results : Sex, age, and Hb were strongly associated with the risk of GI malignancy - the parsimonious model including only these variables yielded odds ratios of 4.0 (95% confidence interval (CI): 2.3, 7.0) for males compared to females; 3.3 (95% CI: 1.7, 6.4) for age > 70 years compared to ≤70 years; and 5.3 (95% CI: 2.4, 11.7) for an Hb of ≤91.4g/l compared to ≥111.5g/l. Combining these risk factors identified a sub-group (12% of the study population) at particularly low risk (20% likelihood) of underlying GI malignancy. \ud Conclusions : Three simple and objective clinical parameters can be combined to provide a clinically useful cancer risk stratification model for subjects with IDA. This may assist with patient counselling and the prioritization of investigational resources.\ud

Objective To improve the quality of care provided to patients with iron deficiency anaemia (IDA). Design Service development. Setting District General Hospital. Patients Adults with IDA. Main outcome measures Descriptive report of the practicalities and benefits of establishing an IDA clinic. Conclusions The IDA clinic is a novel service development which enhances the management of patients with this common condition, by facilitating prompt confirmation of the diagnosis, replacement therapy and investigation for serious underlying pathology, in particular gastrointestinal malignancy.

Objective: Ten percent of adults presenting with iron deficiency anaemia (IDA) have underlying cancer. This study was undertaken to prospectively validate the observation in a previous retrospective study that three simple clinical parameters can usefully predict the likelihood of gastrointestinal (GI) malignancy on investigation of patients with IDA, and to screen for other potential clinical predictors of risk. Method: Observational study of a cohort of 643 subjects attending an IDA clinic at a District General Hospital between 2012 and 2015, with multivariable analysis of the predictive value of a series of clinical variables including sex, age and haemoglobin concentration ([Hb]) for underlying GI malignancy. Results: Analysis of the validation cohort data confirmed the original observation that sex, age, and Hb were associated with the risk of GI malignancy—the parsimonious model including only these variables yielded odds ratios of 1.9 (95% confidence interval (CI): 1.1, 3.3) for males vs. females; 1.6 (95% CI: 0.9, 2.9) for age >70 vs. ≤70 years; and 2.9 (95% CI: 1.2, 6.9) for [Hb] 112 g/l. Combining data from the observation and validation cohorts (total n = 1,363) identified sub-groups with cancer risks ranging from 0% to over 20%. No other predictive clinical variables were identified. Conclusions: Three simple and objective clinical parameters can be combined to provide a clinically useful cancer risk stratification model for subjects with IDA. This may assist with patient counselling and the prioritisation of investigational resources.

Mixed sex bays are a reality on most Emergency Assessment Units (EAU). However, they are controversial having recently been the focus of political and media attention. We adapted a validated patient satisfaction questionnaire to seek the views of 1000 emergency admissions regarding mixed sex accommodation. Of 1000 respondents, 925 (92%) had been in bays and 665 (66%) shared with the opposite sex. Most 579/665 (87%) were comfortable with this, 97% (966/1000) feeling there was sufficient level of privacy, all (1000/1000) felt they were given privacy when needed. When asked "given the nature and function of EAU would you be willing to share with the opposite sex if it meant a shorter stay?", 857 (86%) said yes. Our study demonstrates that whilst single sex accommodation is ideal it is not the most important factor to most patients admitted to EAU.

Previous studies have shown an association between cigarette smoking and coeliac disease, but it has yet to be established whether this relationship is causal. The aim of this study was to assess causality using the Bradford Hill criteria.A matched case-control study using a questionnaire to establish a detailed smoking history for 138 incident cases of adult coeliac disease and 276 age-matched and sex-matched controls. Subjects were categorized according to their active cigarette exposure prior to diagnosis of the matched case, and odds ratios and tests for linear trends were calculated.At the time of diagnosis, 10% of cases and 30% of controls were current smokers (odds ratio, 0.21 and 95% confidence interval, 0.11-0.40 for coeliac disease in current smokers versus never smokers). A biological gradient was demonstrated for total, recent and current cigarette exposure. The greatest risk reduction related to current exposure (odds ratio, 0.15, and 95% confidence interval, 0.06-0.37 for coeliac disease in current heavy smokers versus never smokers).This study strengthens the case for a causal relationship between smoking and coeliac disease by demonstrating a strong, temporally appropriate and dose-dependent effect, thus meeting the Bradford Hill criteria. This suggests that cigarette smoking truly protects against the development of adult coeliac disease.

Pancreatic stellate cells mediate fibrosis in chronic pancreatitis. Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs)-1 and -2 are crucial modulators of fibrosis. Transforming growth factor-beta (TGF-beta) is a key regulator of extracellular matrix production and myofibroblast proliferation. We have examined MMP and TIMP synthesis by transformed cultured pancreatic stellate cells and their regulation by TGF-beta 1. By Northern analysis they expressed mRNAs for procollagen 1, TIMP-1, TIMP-2, and MMP-2. Expression of membrane type-1 MMP was confirmed by Western blotting. By immunohistochemistry these enzymes localized to fibrotic areas in human chronic pancreatitis. Active TGF-beta 1 constitutes 2 to 5% of total TGF-beta 1 secreted by pancreatic stellate cells; they express TGF-beta receptors I and II. Exogenous TGF-beta 1 (10 ng/ml) significantly increased procollagen-1 mRNA by 69% and collagen protein synthesis by 34%. Similarly TGF-beta 1 at 0.1, 1, and 10 ng/ml significantly reduced cellular proliferation rate by 37%, 44%, and 44%, respectively, whereas pan-TGF-beta-neutralizing antibody increased proliferation by 40%. TGF-beta1 (10 ng/ml) down-regulated MMP-9 by 54% and MMP-3 by 34% whereas TGF-beta 1-neutralizing antibody increased MMP-9 expression by 39%. Pancreatic stellate cells express both mediators of matrix remodeling and the regulatory cytokine TGF-beta 1 that, by autocrine inhibition of MMP-3 and MMP-9, may enhance fibrogenesis by reducing collagen degradation.

Introduction Parenteral iron has been used increasingly over the last decade to treat specific patient groups with iron deficiency (ID) anaemia. There is, however, limited evidence of safety and efficacy in all patients with ID, particularly those with underlying malignancy or inflammation. Methods Data from all outpatients receiving iv iron isomaltoside (Monofer) for confirmed ID between 1st April and 31st December 2012 at our UK District General Hospital was analysed, regardless of underlying diagnosis or comorbidity. Patients received their infusions under the care of Gastroenterology on our Medical Investigations Unit, a 7-day nurse led unit that works extended hours and is located within the main hospital. ID was defined by ferritin Results 85 patients received monofer infusions for confirmed ID over the study period, with 80 of these having ID anaemia. Referrals were from a range of medical, surgical and oncological specialities. 55 patients (65%) were female and the age range was 18–92 years (median 73 years). Baseline bloods (median and interquartile range (IQR)) were Hb 90 g/l (80–99), Mean Cell Volume 81 fl (72–88), Mean Cell Haemoglobin 24.8 pg (22.2–28.0), ferritin 15mcg (9–24) and TSAT 9% (5–15). Most patients had extensive comorbidity; 29(34%) had active malignancy and 44(77%) of those without malignancy had active inflammation. The median iron dose was 14.6 mg/kg (IQR 11.2–17.5). No significant adverse reactions occurred and all patients received the full infusion. Post infusion bloods demonstrated a median increase in Hb of 23 g/l (Figure 1) with 52% having a Hb increase of >20 g/l. The Hb rise was significantly higher in individuals with a lower baseline Hb; regression slope of baseline against change in Hb = -5.9 Hb, p Conclusion Treatment of ID anaemia with parenteral iron is safe and effective in all patients including those with cancer or active inflammation. A rapid rise in Hb within 4 weeks is seen in many patients particularly where the baseline Hb is low. Disclosure of Interest None Declared.

Introduction Iron deficiency anaemia (IDA) is common. It is of particular importance because about 10% of subjects with IDA over the age of 50 will have an underlying gastro-intestinal (GI) malignancy, often in the absence of other clinical pointers to the diagnosis. IDA is therefore an accepted indication for examination of the GI tract, generally through bidirectional endoscopy. Investigation of IDA is labour-intensive however, and most examinations will not reveal significant pathology. The aim of this study was to determine whether simple and objective clinical variables can identify sub-groups of subjects with IDA who are at clinically useful extremes of risk for underlying malignancy – arbitrarily defined as 20% for high risk. Methods A retrospective study of 720 subjects referred to a single IDA clinic between 2004 and 2012. All had confirmed iron deficiency, minor or no localising symptoms, and subsequent GI tract investigation. Recorded information included age, sex, haemoglobin concentration (Hb), mean cell volume (MCV), iron studies, and final diagnosis. Results A total of 68 (9.4%) of the study population had a GI malignancy. In the model generated by logistic regression analysis, age (> 70 v Percentage of cases of GI malignancy in each subgroup (cases/number in subgroup): The prevalence of GI malignancy ranged from 0.0% in younger females with mild anaemia, to over 25% in older males with more severe anaemia. By the pre-defined criteria, the model identified sub-populations of 84 (11% of the total) at extreme low risk, and 117 (16%) at extreme high risk. Conclusion The results confirm previous work identifying age, sex and haemoglobin concentration as variables predictive of underlying malignancy in IDA. Furthermore, the findings suggest that over a quarter of subjects with IDA can be predicted to be of extremely low or high risk on the basis of these simple and objective clinical criteria. This may be of clinical relevance for patient counselling, prioritisation of investigations and allocation of resources. Work is ongoing to validate risk prediction in a prospective study, and to refine the model by inclusion of additional variables. Disclosure of Interest None Declared. Reference James MW, Chen CM, Goddard WP, Scott BB, Goddard AF. Risk factors for gastrointestinal malignancy in patients with iron deficiency anaemia. Eur J Gastroenterol Hepatol 2005; 17(11):1197–203.

Introduction Iron deficiency anaemia (IDA) is a common mode of presentation of GI disease, with 50% of symptomatic individuals having underlying GI pathology of whom a third have evidence of an underlying neoplastic process.1 The management of IDA is frequently haphazard with a myriad of referral routes and consequently random and sometimes inappropriate investigations, often with significant delays.2 Methods In 2005, following a retrospective audit which demonstrated our existing service to be suboptimal, we established a nurse-led IDA clinic to streamline, rationalise and accelerate the appropriate investigation and management of patients with asymptomatic (ie, without any GI symptoms) but proven IDA. Subsequently we prospectively collected data on all patients seen by this service. Results To date we have seen 435 patients, with a complete data set being available in 347. 329 were investigated with bi-directional endoscopy (16 declined and two were unfit for investigation). There were 130 men and 217 women, including a proportion of pre-menopausal women predominantly over the age of 40. The median age was 75 years (IQR 62-82 years). 148 patients had underlying pathology (45%), with 50 of these (34%) having an underlying neoplastic process (see Abstract 088). Furthermore, the time from assessment of IDA to investigation reduced from a median of 51 days (IQR 34–86 days) before the introduction of our nurse-led clinic, to a median of 16 days (IQR 13–24 days). However, in some patients there remained a significant delay from diagnosis of anaemia to confirmation of iron deficiency and onward referral to secondary care. Conclusion Our nurse led IDA service has optimised the management of patients referred with asymptomatic IDA. Interestingly, our findings in this asymptomatic cohort are consistent with the literature and promote the ideal that IDA should always be investigated in a timely fashion in line with the National Cancer Targets.