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Ulrik Deding,1,2 Lasse Kaalby,1,2 Gunnar Baatrup,1,2 Morten Kobaek-Larsen,1,2 Marianne Kirstine Thygesen,1,2 Owen Epstein,3 Thomas Bjørsum-Meyer1,2 1Department of Surgery, Odense University Hospital, Svendborg, Denmark; 2Department of Clinical Research, University of Southern Denmark, Odense, Denmark; 3Institute for Minimally Invasive Gastroenterology, Royal Free London NHS Foundation Trust, London, UKCorrespondence: Ulrik Deding, Department of Surgery, Odense University Hospital, Baagøes Allé 15, SVB Bygning 13.02, Svendborg, 5700, Denmark, Tel +45 42574243, Email ulrik.deding@rsyd.dk; udeding@health.sdu.dkPurpose: To investigate whether the prokinetic prucalopride increases the completion rate of colon capsule endoscopy (CCE). Secondary outcomes included demographic distribution, polyp detection rate (PDR), distribution of Leighton–Rex grade, and adverse events.Patients and Methods: In a nested cohort within the CareForColon2015 trial, a subgroup of 406 individuals underwent CCE in 2021. The first half (control) received the standard bowel preparation and the second half (prucalopride) was supplemented with 2 mg of prucalopride. Transit times and bowel preparations were analyzed and completion rates calculated as those having timely transit and acceptable bowel cleanliness. Major adverse events were recorded continuously and minor adverse events were quantified from questionnaires.Results: The group demographics were homogenous. The prevalence ratio for complete CCE was 1.32 (CI 95% 1.15; 1.53) in the prucalopride group compared to the control group. Completion rate was 74.9% in the prucalopride group and 56.7% in the control group. The proportions of acceptable bowel preparation and complete transits were higher in the prucalopride group. The mean CCE transit time was 2 hours and 8 minutes faster in the prucalopride group. The PDR was higher in the intervention group with 55.7% compared to 36.0% in the control group for polyps greater than 9 mm, whereas the groups’ PDRs were similar for small and diminutive polyps. In all, 589 polyps (mean 2.9) were found in the prucalopride group compared to 522 polyps (mean 2.6) in the control group.Conclusion: Prucalopride led to an increase in CCE completion rates. The proportions of complete transits and acceptable bowel preparations were higher in the prucalopride group. The PDR was higher in the prucalopride group compared to the control group. No major adverse events were identified. Nausea, diarrhea, headache and fatigue were more commonly reported in the prucalopride group.Keywords: Resolor, prokinetic, polyps, bowel preparation, Leighton–Rex, video capsule endoscopy

Background & Aims: The population prevalence of gastrointestinal (GI) disease is unclear and difficult to assess in an asymptomatic population. The aim of this study was to determine prevalence of GI lesions in a largely asymptomatic population undergoing colon capsule endoscopy (CCE). Methods: Participants aged between 50-75 years were retrieved from the Rotterdam Study, a longitudinal epidemiological study, between 2017-2019. Participants received CCE with bowel preparation. Abnormalities defined as clinically relevant were Barrett segment >3cm, severe ulceration, polyp >10 mm or ≥3 polyps in small bowel (SB) or colon, and cancer. Results: Of 2800 invited subjects, 462 (16.5%) participants (mean age 66.8 years, female 53.5%) ingested the colon capsule. A total of 451 videos were analyzed, and in 94.7% the capsule reached the descending colon. At least 1 abnormal finding was seen in 448 (99.3%) participants. The prevalence of abnormalities per GI segment, and the most common type of abnormality, were as follows: Esophageal 14.8% (Barrett's esophagus 10 mm; n = 4, severe ulcer n = 1,) and 46 (10.2%) in colon (polyp > 10 mm or ≥3 polyps n = 46, colorectal cancer n = 1). Conclusions: GI lesions are very common in a mostly asymptomatic Western population, and clinically relevant lesions were found in 12% at CCE. These findings provide a frame of reference for the prevalence rates of GI lesions in the general population.

Since its introduction to clinical practice nearly 20 years ago, wireless capsule endoscopy has revolutionized the landscape in the diagnosis and management of small bowel diseases. Over the past 10 years, capsule endoscopy has evolved beyond the small intestine and a range of capsules are now available to examine the esophagus, stomach and colon. Because of its ease of use, tolerability, paucity of complications and ability to visualize the entire gastrointestinal tract, capsule endoscopy has entered the mainstream of clinical practice. This review of the literature summarizes the current state of capsule training and highlights the limited data available to assess reader competence and standards expected of an independent practitioner. There are neither standardized teaching strategies nor national or international metrics for accreditation of physicians and non-physicians interested in mastering this examination. Summating the few publications, there appears to be consensus that diagnostic expertise improves with experience, and that trainees should be fully supervised for at least 20 full case studies. Formative and summative assessment is advisable and the number of taught cases should not be the sole determinant of competence. The review also highlights differences in recommendations from major national gastroenterology societies. Finally, the authors discuss areas of unmet needs in teaching and learning for capsule endoscopy.

Background Video capsule can illuminate the entire gastrointestinal mucosa. Upper gastrointestinal capsule endoscopy (UGICE) has the potential to survey for oesophageal, gastric and duodenal pathology and determine whether biopsy or intervention is indicated. Aims This review traces the evolution of foregut video capsule endoscopy. Methods A broad literature research was performed independently by two investigators. Extracted articles were organized and evaluated to interpret all current data. Results In contrast to small bowel capsule, UGICE required sequential innovations to deal with rapid oesophageal transit, the irregular shape of the stomach and unpredictable gastric peristalsis. Oesophageal capsule endoscopy required the development of a two-camera device operating at a high frame rate, and postural change was developed to improve image capture, especially at the level of the Z-line, thus providing good imaging of Barrett's oesophagus, erosive oesophagitis and oesophageal varices, with optimal patients’ tolerance. UGICE in patients presenting to the emergency room with acute bleeding has demonstrated accuracy when deciding on the need for emergency intervention. The latest development of a high frame rate UGICE, designed to image the oesophagus, stomach and duodenum has overtaken dedicated oesophageal capsule development. Capsule control is possible by exposing a magnetised capsule to an external magnetic field, and early reports indicate high accuracy in the oesophagus and stomach with high levels of patient acceptability. There is little information on cost-benefit. Conclusions Capsule endoscopy offers gastroenterologists a new device to investigate the upper gastrointestinal tract with promising future potential.

Background Gastric electric stimulation (GES) is a treatment approach to refractory gastroparesis, possibly acting centrally via afferent vagus nerve stimulation (VNS). Non-invasive VNS (nVNS) is a potential alternative to GES that could eliminate the safety risks of or identify likely responders to implantable neurostimulators. Objective This open-label proof-of-concept study assessed the effects of nVNS in patients with severe drug-refractory gastroparesis. Methods Patients used the Gastroparesis Cardinal Symptom Index (GCSI) to grade symptoms in diaries daily for 2 weeks before treatment (baseline) and during ≥3 weeks of nVNS therapy. Adverse events (AEs) were also diarised. Treatment was self-administered using an nVNS device (gammaCore, electroCore) and consisted of 120 s stimulations to the vagus nerve in the neck (two stimulations to each side three times daily during weeks 1 and 2; three stimulations to each side three times daily during week 3 and beyond). Response was defined as a ≥1 point decrease from baseline in GCSI score. Results Thirty-five patients enrolled; 23 were compliant with study procedures and were included in the analysis; 7 continued treatment beyond 3 weeks. Response rates were 35% (8/23) at 3 weeks and 43% (10/23) for the duration of therapy (3–6 weeks). For the entire cohort and the 10 responders, improvements from baseline were noted for mean total GCSI and GCSI subscale scores (nausea/vomiting, postprandial fullness/early satiety, bloating). No serious AEs were reported. Conclusions These preliminary results provide a signal that nVNS may be useful for treating refractory gastroparesis. Larger controlled studies are warranted.

Small bowel capsule endoscopy is a minimally-invasive endoscopic investigation that is often used in clinical practice to investigate overt or occult gastrointestinal (GI) bleeding among other clinical indications. International guidance recommends small bowel capsule endoscopy as a first-line investigation to detect abnormalities in the small bowel, when gastroscopy and colonoscopy fail to identify a cause of GI bleeding. It can diagnose with accuracy abnormalities in the small bowel. However, there has been increasing evidence indicating that small bowel capsule endoscopy may also detect lesions outside the small intestine that are within the reach of conventional endoscopy and have been probably missed during prior endoscopic investigations. Such lesions vary from vascular deformities to malignancy and their detection often alters patient management, leading to further endoscopic and/or surgical interventions. The current study attempts to review all available studies in the literature and summarise their relevant findings.

BACKGROUND Less invasive alternatives to optical colonoscopy (OC) may improve patient compliance with investigation, but study of patient preference is limited. OBJECTIVES The aims of this study were to determine patient tolerance and acceptability of OC, computed tomography colonography (CTC) and colon capsule endoscopy (CCE) and also to determine the choice of investigation made by fully informed members of the lay public. PATIENTS AND METHODS Patients assigned a Gloucester Comfort Score (GCS, 1-5; as did endoscopists), an overall test experience score (visual analogue scale, 0-10) and completed a 'Friends and Family Test' following OC, CTC or CCE. In the second part of the study, members of the public were given information detailing the nature, tolerance, acceptability, risks and outcomes and invited to choose which test they would prefer in the event that one was needed. RESULTS Assessed by endoscopist and patient, respectively, 24.2 and 49.3% (P

Introduction In most UK hospitals, clinical episodes are recorded with a letter sent to the referring general practitioners (GPs). This requires dictation, typing, proof-reading, correction, printing, sign-off and posting. We have used a mind map template to record the patient journey. We evaluated the GP responses to these Easy View Care Maps (EVCMs) and the cost comparison with the traditional GP letter. Methods An EVCM was prepared by a secretary using information available from the GP referral. The draft EVCM was available for the clinician to complete during the consultation with the patient. Three completed EVCMs were printed: one to be incorporated into the patient9s notes; the second to be given to the patient; and a third copy posted to the GP. At follow-up, the EVCM was modified to reflect results. GP responses to EVCMs were sought by a postal questionnaire sent to 266 GPs. A comparative cost analysis was performed. Results Over 10 months, 568 EVCMs were used as the sole source of information recorded for the hospital file, patient and GP. The mean turnaround time for a dictated letter is 5.2 days while EVCM generation is immediate. Ninety per cent of GPs reported that they received the necessary information with 71% indicating acceptance as an alternative to the traditional letter. Net annual departmental saving was £31 344. Conclusions EVCMs offer a new visual representation of the patient9s journey. They are easy to follow and expose the clinician9s thought processes. They provide an intuitive record at low cost.

The ward round (WR) is a complex task and medical teachers are often faced with the challenge of finding a balance between service provision and clinical development of learners. The educational value of WRs is an under-researched area. This short communication aims to evaluate the educational role of WRs for junior trainees and provides insight into current practices. It also identifies obstacles to effective teaching/training in this setting and provides suggestions for improving the quality of WR teaching.Keywords: ward round; postgraduate education; foundation training(Published: 21 April 2015)Citation: Med Educ Online 2015, 20: 27559 - http://dx.doi.org/10.3402/meo.v20.27559To access the supplementary material for this article, please see Supplementary files under ‘Article Tools’

Introduction Poor tolerance of laxatives may be associated with inadequate bowel cleansing and reduced pathology detection. [1] Colonoscopy (CS), the gold standard, is uncomfortable, may require sedation and is not without risk. [2] CT colonography (CTC) is less invasive, requires less laxatives, but involves irradiation. Colon capsule endoscopy (CCE) is non-invasive, directly visualises the mucosa, but requires a more vigorous laxative regimen. [3] In this study, patient tolerance of each was compared. Method Split dose Kleenprep (4L) was used for CS and gastrografin (3 × 30 ml) and rectal insufflation for CTC. The regimen for CCE was either (STH) split dose Kleenprep (4L) plus two phosphosoda ‘boosters’ or (RFH) split dose Moviprep (2L) with phosphosoda/gastrografin ‘boosters’. A bisacodyl suppository was used to promote capsule excretion if needed. Patients graded severity of laxative-related symptoms and recorded a Gloucester Comfort Score (GCS) for each procedure. They scored their overall experience (of bowel preparation and procedure combined) on a visual analogue scale (VAS 0–10: no-intolerable). Results CS was performed in 153 patients (86M, mn age 58.6±1.2). Prior failed CS, or refusal to have CS, occurred in 30.1% and 18.4%, respectively, of CTC patients (n=103; 36M, mn age 69.5±1.1), and 22.6% and 9.7% of CCE patients (n=31; 8M, mn age 42.9±3.6). CTC and CCE patients were predominantly female (p=0.003 cf. CS cohort, Kruskal Wallis). Moderate to severe laxative-related symptoms prior to CS, CTC and CCE (respectively) were nausea (12.4%, 2.9%, 29.1%; p Conclusion Laxatives may cause distress and the less used, the better. However, procedural discomfort accounts for the overall poorer experience of CS patients compared to CTC and CCE, even though the latter cohorts contain more patients at risk of poorer tolerance (prior failed colonoscopy, refusal of colonoscopy and female predominance.[4] Investigation should be tailored according to the likely diagnoses and patient preference. References . Holt EW, et al., J Gastrointest Liver Dis 2014;23:135–40. . Standards of practice committee of the ASGE. Gastrointest Endosc 2011;74:745–752. . Spada C, et al., Gut 2015;64:272–281. . Ojidu H, McAlindon ME. Gut2016;65(1):A61. Disclosure of Interest None Declared

Background: We studied the management of patients with acute upper gastrointestinal (GI) bleeding (AUGIB) at the Royal Free Hospital. The aim was to compare our performance with the national standard and determine ways of improving the delivery of care in accordance with the recently published ‘Scope for improvement’ report. Methods: We randomly selected patients who presented with haematemesis, melaena, or both, and had an oesophageogastroduodenoscopy (OGD) between April and October 2009. We developed local guidelines and presented our findings in various forums. We collaborated with the British Medical Journal’s Evidence Centre and Cerner Millennium electronic patient record system to create an electronic ‘Action Set’ for the management of patients presenting with AUGIB. We re-audited using the same standard and target. Results: With the action set, documentation of pre-OGD Rockall scores increased significantly ( p ≤ 0.0001). The differences in the calculation and documentation of post-OGD full Rockall scores were also significant between the two audit loops ( p = 0.007). Patients who inappropriately received proton-pump inhibitors (PPIs) before endoscopy were reduced from 73.8% to 33% ( p = 0.02). Patients receiving PPIs after OGD were also reduced from 66% to 50% ( p = 0.01). Discharges of patients whose full Rockall score was less than or equal to two increased from 40% to 100% ( p = 0.43). Conclusion: The use of the Action Set improved calculation and documentation of risk scores and facilitated earlier hospital discharge for low-risk patients. Significant improvements were also seen in inappropriate use of PPIs. Actions sets can improve guideline adherence and can potentially promote cost-cutting and improve health economics.

Background ESO-2 video capsule endoscopy provides images of the oesophageal mucosa and continues to transmit gastric, and often small bowel images, for up to 30 min. This study compares ESO capsule endoscopy capsule oesophago-gastro-duodenoscopy (Cap-OGD) with conventional endoscopy (OGD). Methods 50 outpatients with uncomplicated dyspepsia underwent Cap-OGD followed by OGD which was recorded on DVD. Cap-OGD and OGD were each reported independently by two gastroenterologists. A benchmark report was also produced by two gastroenterologists viewing both Cap-OGD and OGD on side-by-side monitors. Major findings included large hiatus hernia, Barrett9s oesophagus, oesophagitis, erosive gastritis, tumour and ulceration. Minor findings included histologically-proven superficial gastritis, pouting gastric folds and fundic gland polyps. A questionnaire assessed the patient experience. Results 49 patients completed the study. In 61%, Cap-OGD transmitted in the duodenum. In the benchmark study, all the major OGD findings were observed on Cap-OGD. Cap-OGD revealed fewer minor findings. When reported independently, Cap-OGD and OGD reports indicated differences in interpretation most marked between the capsule readers with or without previous ESO-2 experience. Patients expressed a clear preference for Cap-OGD. Conclusions When compared side-by-side, all the major findings on OGD are seen on Cap-OGD while there is under-reporting of minor findings. Previous experience of ESO-2 capsule reporting improves reading accuracy and indicates the need for training. This pilot study provides a backdrop to explore the possible role of Cap-OGD, especially where patients are reluctant to undergo conventional OGD or where there is risk of prion contamination of the endoscope.

Recent advancements in virtual reality graphics and models have allowed virtual reality simulators to be incorporated into a variety of endoscopic training programmes. Use of virtual reality simulators in training programmes is thought to improve skill acquisition amongst trainees which is reflected in improved patient comfort and safety. Several studies have already been carried out to ascertain the impact that usage of virtual reality simulators may have upon trainee learning curves and how this may translate to patient comfort. This article reviews the available literature in this area of medical education which is particularly relevant to all parties involved in endoscopy training and curriculum development. Assessment of the available evidence for an optimal exposure time with virtual reality simulators and the long-term benefits of their use are also discussed.

Aliment Pharmacol Ther 2012; 35: 222–237 Summary Background Previous reviews of bowel preparation for colonoscopy have given contradictory answers. Aim To provide a definitive insight, using PRISMA-compliant methodology. Methods A comprehensive literature review identified randomised controlled trials comparing bowel preparation regimens. Data for quality of bowel preparation were pooled in multiple meta-analyses exploring a range of inclusion criteria. Results A total of 104 qualifying studies were identified, the majority of which involved comparisons of sodium phosphate (NaP) or polyethylene glycol (PEG). There was no significant difference demonstrated between NaP and PEG overall (OR = 0.82; 95% CI = 0.56–1.21; P = 0.36). Cumulative meta-analysis demonstrated that this conclusion has been qualitatively similar since the mid 1990s, with little quantitative change for the past 10 years. Amongst studies with previous day dosing in both study arms there was a significant advantage in favour of PEG (OR = 1.78; 95% CI = 1.13–2.81; P = 0.006). Studies focussing on results in the proximal colon also favoured PEG (OR = 2.36; 95% CI = 1.16–4.77; P = 0.012). PEG was also significantly more effective than non-NaP bowel preparation regimens (OR = 2.02; 95% CI = 1.08–3.78; P = 0.03). Other comparisons showed no significant difference between regimens. Conclusions Although there is no compelling evidence favouring either of the two most commonly used bowel preparation regimens, this may reflect shortcomings in study design. Where studies have ensured comparable dosage, or the clinically relevant outcome of proximal bowel clearance is considered, PEG-based regimens offer the most effective option.

Summary Background Screening colonoscopy exposes healthy patients to the risk of serious adverse events associated with bowel preparation. Randomized controlled trials are not an effective method for evaluating this risk. Aim To search published literature in order to characterize the risk of adverse events associated with oral polyethylene glycol (PEG) or sodium phosphate (NaP). Methods A systematic review identified case reports of any serious events associated with PEG or NaP. Reports to the Food and Drug Administration (FDA) were also examined. Results Fifty-eight publications of significant events in 109 patients using NaP and 22 patients using PEG were identified. As the total number of prescriptions issued is unknown, rates for the two agents cannot be directly compared. Most commonly reported were electrolyte disturbances, renal failure and colonic ulceration for NaP and Mallory–Weiss tear, electrolyte disturbances and allergic reactions for PEG between January 2006 and December 2007; there were 171 cases of renal failure reported to the FDA following use of NaP and 10 following PEG. Conclusions Adverse events following bowel preparation are uncommon, but potentially serious. Given that many of these patients are healthy individuals undergoing screening, the benefit/risk ratio must be carefully considered when deciding which preparation to prescribe in individual patients.

— Decreased serum caeruloplasmin levels in patients with Wilson's disease have been attributed to decreased caeruloplasmin synthesis in the hepatocyte. An immunoperoxidase procedure was used to identify caeruloplasmin in liver biopsies. The pattern of staining in biopsies from patients with Wilson's disease did not differ from the pattern seen in normal adult or neonatal liver. This indicates that immunoreactive caeruloplasmin is synthesized by the liver cell in Wilson's disease. Low serum levels of caeruloplasmin may reflect an abnormality of copper incorporation into the apoprotein or an abnormality of holocaeruloplasmin export.

SUMMARY Considerable improvement in quality of life can be achieved by treating the complications of primary biliary cirrhosis. However, once fibrosis, cirrhosis, portal hypertension and hyperbilirubinaemia occur, it is unlikely that ‘medical’ treatment will cure the disorder. Trials of medical therapy should aim to delay or halt the progression of the early phase of the disease and clinicians should refer patients to centres conducting clinical trials. If the disease progresses, and the quality of life is seriously impaired, liver transplantation offers the realistic chance of a new life.

Summary Background There are many published trials of colon cleansing regimens for colonoscopy but no clear consensus regarding relative performance. Aim To identify high quality controlled trials comparing two or more bowel preparation regimens and to compare efficacy and tolerability. Methods A comprehensive systematic review was carried out to identify candidate studies. Quality appraisal was carried out on all identified studies. Results were meta-analysed where possible and qualitatively compared if not. Results Eighty-two studies qualified for analysis. Polyethylene glycol and sodium phosphate were the most frequently investigated preparations. There was no significant efficacy difference between the two, but sodium phosphate was better tolerated. Sodium picosulphate/magnesium citrate, a commonly prescribed preparation, was investigated in four studies, with no clear benefit over other regimens demonstrated. Safety was not recognized as a problem in the randomized controlled trials. Published case series demonstrate that sodium phosphate is associated with the highest risk of clinically significant electrolyte disturbances. Conclusion Shortcomings in study design limit the value of many of the studies. Based on these results, no single bowel preparation emerges as consistently superior. New preparations are required that combine better efficacy and tolerability, in addition to rigorous new validated study designs, allowing unequivocal comparisons to be made.

The goal was to describe the development of the Virtual Consulting Room (VcR), a unique intranet-based guidance application providing direct access to local specialist knowledge, and to evaluate its usability and whether it has the potential to educate staff while working in the Accident and Emergency (AE) department. Duty staff of the AE Department, The Royal Free Hospital, London, participated in a prospective observational study. Two hundred and twenty consecutive patients were identified from the triage section of their casualty card as having a presenting complaint that featured in the VcR. These casualty cards were highlighted with a red sticker alert and a short questionnaire attached. Members of staff were invited to consult with the VcR after assessing each patient by clicking on an icon located on the department's computer desktops. No prior training was provided. The questionnaire was completed in 103 of 220 (46.8%) patients. The VcR was used in the management of 38 of 220 (17.3%) patients. In 21 of 38 (55.3%), users reported the VcR supported clinical decision making, in 20 of 38 (52.6%) the VcR improved knowledge and in 11 of 38 (28.9%) the VcR helped directly influence the decision to discharge the patient. In 2 of 38 (5.3%) users changed their decision to refer and in 1 of 38 (2.6%) investigations were altered. This evaluation indicates that AE clinicians accessing the VcR found it easy to use and educational in the workplace.

Introduction Past literature has explored qualitative differences between teleconsultation and conventional face-to-face consultation in the context of diabetes care. However, designing the algorithm of such innovative consultations necessitates inclusion of patients’ ideas and concerns so as to optimise their practicality and be adequately tailored to patients’ needs. Hence, the Centre of Gastroenterology at the Royal Free Hospital in London decided to involve patients through a questionnaire focusing on the design of synchronous teleconsultation through video-conferencing. Methods We aimed to identify: 1)Patients’ responses to introducing video-conferencing and explore factors contributing to their decision and 2)Patient groups in which video-conferencing would be more applicable. We analysed responses of 137 patients attending the gastroenterology outpatient clinic between April-August 2015. ‘Positive response’ (PR) was defined as patients who would consider a video-conference consultation compared to a conventional face-to-face method/’negative response’ (NR). Further analysis identified potential factors contributing to a PR such as age and employment status as well as device, software and consultation type preferences. We were also interested as to whether video-conferencing would improve patient attendance. Results PRs (n = 68): Also refer to figure 1. >50% were The majority had current/previous work experience (full-time 62%,part-time 62% and retired 68%). Patients indicated preference towards bigger screens:computer(56%), portable device(47%) and smartphone(36%). 70% preferred Skype and 30% facetime while 1/3 preferred having a video-conference as their 1st appointment and 2/3 as their follow-up. 41% indicated they would be more likely to attend a video-conference compared to 59% who indicated their attendance would either decrease or remain unaffected. Reasons for NRs (n = 69) Lack of confidence with device (57%), Lack of privacy at home/work(12%) and Other reasons (38%). Conclusion Results suggested that a traditional face-to-face interaction is more suitable for a first consultation, however video-conferencing could be a beneficial alternative for follow-up.Video-conferencing would be more applicable to patients aged Disclosure of Interest None Declared

The ward round is a complex task, which has been described as ‘walking a tightrope’. This article reviews the available literature on the educational value of ward rounds in conveying medical knowledge and developing trainees' history taking and clinical examination skills.

AIM—To investigate gastric pacemaker activity in gastro-oesophageal reflux disease using the electrogastrogram. PATIENTS—Forty patients with gastro-oesophageal reflux disease (20 with acid reflux, 20 with the additional symptom of food regurgitation) and 30 asymptomatic controls. METHODS—Patients were studied using an electrogastrogram, oesophageal manometry, and 24 hour ambulatory oesophageal pH analysis. RESULTS—An abnormal electrogastrogram was recorded in two (7%) controls, two (10%) patients with acid reflux, and 10 (50%) patients with food regurgitation. Food regurgitators had significantly more gastric dysrhythmias (tachygastrias) both before (p

We have developed a Web-based consultation application, the Virtual Consulting Room (VCR), in order to streamline patient care by facilitating communication between healthcare professionals. Thirteen general practices took part in an eight-week study. Fifty-eight general practitioners (GPs) were offered access to the VCR. No prior training was given. Use of the VCR was monitored by Web-tracking software and a questionnaire was used to assess utility. Thirty-four GPs (59%) accessed the VCR, 19 (33%) consulted on three or more occasions. A total of 177 visits were made and 35,244 Web page hits recorded. Questionnaire responses were received from 31 GPs (53%). Of the respondents, 17 classified themselves as users. Of these, 14 (82%) found the VCR easy to use and 15 (88%) found it to be a good learning tool with potential to alter practice. The results provide evidence that an Internet-based application can be of interest to GPs, can be educational and may influence patient care.

We assessed the usability of the Virtual Consulting Room (VCR), a Web-based guidance application providing direct access to specialist knowledge. The VCR guides the user through the patient journey from first presentation to final destination. Four pre-registration house officers (PRHOs) were informed of the availability of the VCR which was accessible from all ward computers at the Royal Free Hospital. During a six-week study, 52 patients were assessed by four PRHOs. The VCR was accessed for all 52 patients. A questionnaire was completed in 49 cases (94%). In 43 of the 49 cases (88%), the PRHOs reported that the VCR supported clinical decision-making, and in 46 cases (94%) it improved their knowledge. Use of the VCR altered the PRHOs investigations in 24 cases (49%), changed the management plan in 18 cases (37%) and the decision to refer in 10 cases (20%). The present study showed that the VCR was easy to use, educational, supported clinical decision-making and affected patient management.

Background: The electrogastrogram (EGG), which records gastric myoelectrical activity, is abnormal in one-third of adult patients with non-ulcer dyspepsia (NUD). Aim: To observe the effects of cisapride on EGG in adults with NUD. Methods: Twenty-seven NUD patients who had undergone a pre- and post-prandial EGG were entered into an open study. All patients completed a dyspepsia symptom questionnaire and were then treated with cisapride 10 mg t.d.s. The dyspepsia questionnaire was repeated in all those completing 4 weeks of treatment. Those with an initial abnormal EGG (

When symptomatic gastroenterology patients have an indication for colonic imaging, clinicians have a choice between optical colonoscopy (OC) and computerized tomography colonography with three-dimensional reconstruction (3-D CTC). 3-D CTC provides a minimally invasive and rapid evaluation of the entire colon, and it can be an efficient modality for diagnosing symptoms. It allows for a more targeted use of OC, which is associated with a higher risk of major adverse events and higher procedural costs. A case can be made for 3-D CTC as a primary test for colonic imaging followed if necessary by targeted therapeutic OC; however, the relative long-term costs and benefits of introducing 3-D CTC as a first-line investigation are unknown.The aim of this study was to assess the cost effectiveness of 3-D CTC versus OC for colonic imaging of symptomatic gastroenterology patients in the UK NHS.We used a Markov model to follow a cohort of 100,000 symptomatic gastroenterology patients, aged 50 years or older, and estimate the expected lifetime outcomes, life years (LYs) and quality-adjusted life years (QALYs), and costs (£, 2010-2011) associated with 3-D CTC and OC. Sensitivity analyses were performed to assess the robustness of the base-case cost-effectiveness results to variation in input parameters and methodological assumptions.3D-CTC provided a similar number of LYs (7.737 vs 7.739) and QALYs (7.013 vs 7.018) per individual compared with OC, and it was associated with substantially lower mean costs per patient (£467 vs £583), leading to a positive incremental net benefit. After accounting for the overall uncertainty, the probability of 3-D CTC being cost effective was around 60 %, at typical willingness-to-pay values of £20,000-£30,000 per QALY gained.3-D CTC is a cost-saving and cost-effective option for colonic imaging of symptomatic gastroenterology patients compared with OC.

Adequate bowel preparation prior to colonic diagnostic procedures is essential to ensure adequate visualisation. This consensus aims to provide guidance as to the appropriate use of bowel preparation for a range of defined clinical circumstances. A consensus group from across Europe was convened and met to discuss appropriate bowel preparation. The use of polyethylene glycol (PEG), sodium picosulphate and sodium phosphate (NaP), together with other agents, prokinetics and simethicone, in colonoscopy and small bowel video capsule endoscopy were considered. A systematic review of the literature was carried out and additional unpublished data was obtained from the members of the consensus group where required. Recommendations were graded according to the level of evidence. PEG-based regimens are recommended first line for both procedures, since their use is supported by good efficacy and safety data. Sodium-picosulphate-based regimens are recommended second line as their cleansing efficacy appears less than PEG-based regimens. NaP is not recommended for bowel cleansing due to the potential for renal damage and other adverse events. However, the use of NaP is acceptable in patients in whom PEG or sodium picosulphate is ineffective or not tolerated. NaP should not be used in patients with chronic kidney disease, pre-existing electrolyte disturbances, congestive heart failure, cirrhosis or a history of hypertension. The timing of the dose, dietary restrictions, use in special patient groups and recording of the quality of bowel preparation are also considered for patients undergoing colonoscopy. During the development of the guidelines the European Society of Gastrointestinal Endoscopy (ESGE) issued guidance on bowel preparation for colonoscopy. The ESGE guidelines and these consensus guidelines share many recommendations; differences between the guidelines are reviewed. The use of bowel preparation should be tailored to the individual patient and their specific clinical circumstances

It is unclear whether small bowel visibility in video capsule endoscopy (VCE) is enhanced by the use of bowel preparation in addition to pre-procedural fasting. The objective of this study was to clarify this issue by means of a systematic review of the literature and meta-analysis.Randomised controlled trials comparing the use of laxative bowel preparation with fasting alone were identified using a literature search. Categorical measures of treatment efficacy were extracted from qualifying studies and pooled using random-effects meta-analyses. Primary analysis compared any bowel preparation with fasting alone; subsidiary analyses assessed diagnostic yield and results for each regimen.Eight studies were identified, using either polyethylene glycol (PEG) or sodium phosphate (NaP) based regimens. No qualifying studies were identified using other laxatives. Study quality was sufficiently high to warrant meta-analysis. Use of any form of bowel preparation yielded significantly better visibility than fasting alone (OR = 2.31; 95% CI = 1.46-3.63; p0.0001). Similar results were seen for diagnostic yield (OR = 1.88; 95% CI = 1.24-2.84; p = 0.023). When sub-analysed according to the treatment used, PEG-based regimens showed benefit (OR = 3.11; 95% CI = 1.96-4.94; p0.0001), while NaP-based regimens yielded no significant difference from fasting alone (OR = 1.32; 95% CI = 0.59-2.96; p0.0001).The study did not consider results from retrospective studies, nor those which did not give a categorical measure of efficacy. The impact of prokinetic and other adjunctive treatments was not considered. The results are only relevant to the most commonly used video capsule, as data for newer alternative devices have not yet been published.Based on the results of this analysis, the use of bowel preparation alongside fasting is recommended for VCE. PEG-based regimens offer a clear advantage in these patients, while the currently available evidence base does not support the use of NaP. For VCE, lower volume PEG appears to be as efficacious as higher volumes traditionally used for colonoscopy preparation.

Neonatal animals show an increased intestinal iron absorption despite being iron replete. We have used the developing guinea pig to determine whether alterations in the expression of iron binding proteins in duodenal enterocytes can account for the difference in iron absorption between neonatal and adult guinea pigs. No mRNA for transferrin was detected in the enterocytes. H ferritin mRNA remained constant from birth into adulthood whilst there was a small increase (< 2-fold) in L ferritin mRNA. Western blotting showed a clear increase in immunoreactive ferritin, levels reaching those of the adult 19 days after birth. We have also demonstrated that in the neonate, 80% of newly absorbed iron in the enterocyte is associated with a low molecular weight fraction (LMW-IBF), whereas in the adult, ferritin and LMW-IBF bind iron to the same extent. We conclude that changes in expression of ferritin during ontogeny are accompanied by a change in distribution of iron binding between ferritin and LMW-IBF implicating these proteins in the regulation of iron absorption.

Screening for, and treatment of, latent tuberculosis infection (LTBI) before anti- tumour necrosis factor α therapy has been shown to decrease the incidence of active tuberculosis by more than 80% and is recommended before initiation of treatment. In the absence of a 'gold standard' test for LTBI, current screening involves taking a clinical history of risk factors, chest radiograph and tuberculin skin test. Alternative cellular immune-based screening tests have been developed to detect Mycobacterium tuberculosis infection. This paper summarises the current position and advances in the use of newer screening strategies for LTBI.

In recent years, the rise in total student intake of medical schools across England has not been met by an increase in medical teachers. Computer aided learning (CAL) has the potential to address this disequilibrium. We conducted a survey of clinical medical students at our institution to ascertain the level of access to media devices capable of delivering vision and/or audio. The aim was to establish a baseline to assist CAL providers plan for appropriate modes of content delivery. A questionnaire was emailed to all clinical medical students at UCL. To validate the email survey, an identical paper questionnaire was distributed to a compulsory class for third year clinical medical students. The e-questionnaire and validation questionnaire response rate was 46 and 100% respectively. Eighty-six percent of students had home access to broadband Internet, and 85% of home computers were suitable for a full multimedia experience. Seventy-four percent of students indicated that their primary place of access was at home. Sixty-three percent of students had portable MP3 devices and over 50% owned an iPod. The hardware environment appears favourable for the introduction of complex multimedia teaching programs to medical students, but access is not universal. In addition to personal computers, inexpensive portable multimedia players might offer the opportunity to deliver 'on demand' learning. Medical schools planning for delivery of CAL should consider student access to desktop and portable media devices when designing an e-learning curriculum.