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Contains fulltext : 291657.pdf (Publisher’s version ) (Open Access) BACKGROUND: Anti-TNF drugs, such as infliximab, are associated with attenuated antibody responses after SARS-CoV-2 vaccination. We aimed to determine how the anti-TNF drug infliximab and the anti-integrin drug vedolizumab affect vaccine-induced neutralising antibodies against highly transmissible omicron (B.1.1.529) BA.1, and BA.4 and BA.5 (hereafter BA.4/5) SARS-CoV-2 variants, which possess the ability to evade host immunity and, together with emerging sublineages, are now the dominating variants causing current waves of infection. METHODS: CLARITY IBD is a prospective, multicentre, observational cohort study investigating the effect of infliximab and vedolizumab on SARS-CoV-2 infection and vaccination in patients with inflammatory bowel disease (IBD). Patients aged 5 years and older with a diagnosis of IBD and being treated with infliximab or vedolizumab for 6 weeks or longer were recruited from infusion units at 92 hospitals in the UK. In this analysis, we included participants who had received uninterrupted biological therapy since recruitment and without a previous SARS-CoV-2 infection. The primary outcome was neutralising antibody responses against SARS-CoV-2 wild-type and omicron subvariants BA.1 and BA.4/5 after three doses of SARS-CoV-2 vaccine. We constructed Cox proportional hazards models to investigate the risk of breakthrough infection in relation to neutralising antibody titres. The study is registered with the ISRCTN registry, ISRCTN45176516, and is closed to accrual. FINDINGS: Between Sept 22 and Dec 23, 2020, 7224 patients with IBD were recruited to the CLARITY IBD study, of whom 1288 had no previous SARS-CoV-2 infection after three doses of SARS-CoV-2 vaccine and were established on either infliximab (n=871) or vedolizumab (n=417) and included in this study (median age was 46·1 years [IQR 33·6-58·2], 610 [47·4%] were female, 671 [52·1%] were male, 1209 [93·9%] were White, and 46 [3·6%] were Asian). After three doses of SARS-CoV-2 vaccine, 50% neutralising titres (NT50s) were significantly lower in patients treated with infliximab than in those treated with vedolizumab, against wild-type (geometric mean 2062 [95% CI 1720-2473] vs 3440 [2939-4026]; p

BACKGROUND & AIMS: The Primary Biliary Cholangitis (PBC) Obeticholic Acid (OCA) International Study of Efficacy (POISE) randomized, double-blind, placebo-controlled trial demonstrated that OCA reduced biomarkers associated with adverse clinical outcomes (ie, alkaline phosphatase, bilirubin, aspartate aminotransferase, and alanine aminotransferase) in patients with PBC. The objective of this study was to evaluate time to first occurrence of liver transplantation or death in patients with OCA in the POISE trial and open-label extension vs comparable non-OCA-treated external controls. METHODS: Propensity scores were generated for external control patients meeting POISE eligibility criteria from 2 registry studies (Global PBC and UK-PBC) using an index date selected randomly between the first and last date (inclusive) on which eligibility criteria were met. Cox proportional hazards models weighted by inverse probability of treatment assessed time to death or liver transplantation. Additional analyses (Global PBC only) added hepatic decompensation to the composite end point and assessed efficacy in patients with or without cirrhosis. RESULTS: During the 6-year follow-up, there were 5 deaths or liver transplantations in 209 subjects in the POISE cohort (2.4%), 135 of 1381 patients in the Global PBC control (10.0%), and 281 of 2135 patients in the UK-PBC control (13.2%). The hazard ratios (HRs) for the primary outcome were 0.29 (95% CI, 0.10-0.83) for POISE vs Global PBC and 0.30 (95% CI, 0.12-0.75) for POISE vs UK-PBC. In the Global PBC study, HR was 0.20 (95% CI, 0.03-1.22) for patients with cirrhosis and 0.31 (95% CI, 0.09-1.04) for those without cirrhosis; HR was 0.42 (95% CI, 0.21-0.85) including hepatic decompensation. CONCLUSIONS: Patients treated with OCA in a trial setting had significantly greater transplant-free survival than comparable external control patients. ispartof: Gastroenterology vol:163 issue:6 pages:1630-1642.e3 ispartof: location:United States status: published

Anorexia nervosa (AN) is a complex eating disorder associated with a high morbidity and mortality, however, there is a lack of dedicated training for healthcare professionals outside of mental health specialities. There has been a reported increase in acute admissions of patients with AN, which may have been precipitated by the isolation and loss of support networks created by the COVID-19 pandemic. The purpose of this review is to highlight that AN can present with a wide variety of signs and symptoms relating to both the hollow and solid organs of the gastrointestinal (GI) tract some of which may even be life threatening. The overlap of symptoms with several other functional and organic GI diseases makes diagnosis challenging. Gastroenterologists and allied healthcare professionals need to be aware of the wide array of possible GI manifestations not only to help rationalise investigations but to also facilitate early involvement of the relevant multidisciplinary teams. Many of the GI manifestations of AN can be reversed with careful nutritional therapy under the guidance of nutrition support teams.

ObjectiveIn situ simulation (ISS) is an effective training method for multiprofessional teams dealing with emergencies in high pressured environments. A regular ISS programme was organised for the multiprofessional gastroenterology team with a primary objective of identifying, classifying and addressing latent patient safety threats and secondary objectives of improving team confidence and individual role recognition.Method22 unannounced ISS sessions (averaging approximately one session every 6 weeks and four participants per session) were conducted between February 2017 and August 2019 involving multiprofessional team members. The sessions centred around the following four common gastrointestinal emergency scenarios: massive upper gastrointestinal haemorrhage; biliary sepsis (cholangitis) and shock; postendoscopic retrograde cholangiopancreatography complications including perforation and cardiac arrest. Following the simulation, the faculty, which included nurses and doctors, facilitated a structured debrief session and action plan to identify and address latent errors.Results96 participants from nursing, medical, physician associate and pharmacy backgrounds took part in the simulation programme. Analysis of collected latent safety threats identified the following four themes: education and training; equipment; medication and team working. Analysis of anonymously completed questionnaires identified that 95% of participants had a perceived better understanding of their role and 86% felt more confident in assessing an unwell patient. 96% of participants felt comfortable during the debrief.ConclusionISS provides a unique opportunity to train the multiprofessional gastroenterology team in their own high-pressured environment, helping identify and address latent patient safety threats and improve perceived participant confidence and role recognition.

Introduction Identifying errors in the ward environment, healthcare organisation or interaction between the multiprofessional team members is crucial. Such identification may prevent serious mistakes that can occur in high pressure gastroenterology emergencies. Unannounced multiprofessional in situ simulation can be an effective means of identifying latent patient safety threats before they occur. We set up a standardised in situ simulation programme centred around speciality specific emergency scenarios not only to improve skills, team working and communication but also to identify and address latent errors. The in situ faculty consisted of a consultant gastroenterologist; skills tutor; education fellow and director of medical education. Methods We identified key learning objectives for several different emergency scenarios including: massive upper gastrointestinal haemorrhage; septic shock; post-procedure complications and cardiac arrest. Using a wireless high fidelity simulation manikin we ran 15 unannounced sessions between February 2017 and January 2019. There was a minimum of three faculty in attendance in each of the sessions and an overall total of 67 participants representing the spectrum of different professions including: doctors; nurses; health care assistants and students from nursing, medical, and physician associate backgrounds. Following completion of the scenario a structured debrief was conducted. Latent errors affecting patient safety at an individual, team or organisational level were identified and discussed. Following the scenarios, actions were put in place designed to address the identified errors in a timely fashion. Results During the 15 unannounced sessions between February 2017 and January 2019 we identified the following latent errors: shortage of Sengstaken-Blakemore tubes, Bair Hugger and a step for CPR on the ward; lack of awareness as to how to activate the major haemorrhage protocol; junior doctors without working pagers; deficiencies in resuscitation skills amongst non-training grade doctors; members of the multiprofessional team forgetting each others’ names and parts of the ALS algorithm; not knowing where the oral glucose gel is kept on the ward. Since the identification of these errors corrective measures have included: laminated ALS algorithms attached to the resuscitation trolleys and dedicated major haemorrhage protocol training at junior doctor induction. Equipment shortages including sourcing the relevant equipment has been undertaken by ward management. Dedicated training days for the non-training grade doctors has also been undertaken. Conclusions In situ simulation is highly effective in identifying latent errors that could have potentially deleterious consequences on patient safety. This allows corrective measures to be undertaken in advance of real-life emergencies.

Introduction Simulation is a powerful tool for learning, and has been shown to be effective for a wide range of skills. In situ simulation (ISS) is delivered in the clinical setting with the objective of incorporating simulated learning into real working environments. This provides additional scope for learning, not only team working and clinical skills, but also in identifying latent errors (Rosen 2012). We established an ISS programme across our Gastroenterology, Acute Medicine and Paediatric departments. This was underpinned by the recent key standards published by the Association for Simulated Practice in Healthcare (ASPiH): clearly defined learning objectives, authentic delivery and faculty proficient in simulation based education (ASPiH 2016). Methods We identified key learning objectives for each scenario, focusing on human factors (at an individual, team and organisational level) and clinical competencies pertinent to each specialty. Appropriately accredited faculty ran fourteen sessions over a six month period, involving sixty nine members of multi-disciplinary teams. Following each ISS we facilitated a short structured debrief session adapting the SHARP five step approach, highlighting key learning points, providing feedback and enabling reflection (Imperial College 2010). Results Sixty eight of our sixty nine participants reported enjoying the simulation by the end of the session. 91% stated being involved would help their further practice and 96% felt better prepared for a similar real life clinical scenario. Importantly all team members felt well supported during the debrief process. Through our sessions we recognised both latent error and resource requirements. Conclusions In conclusion, ISS has proved a useful modality to deliver teaching in the clinical setting and the response from across the multi-disciplinary teams has been overwhelmingly positive. In addition to acting on identified latent errors, we are now working alongside senior nursing colleagues to embed these actions locally. We have highlighted specific teaching needs and established mandatory teaching days for our Junior and Senior Clinical Fellows. Our team is currently expanding our ISS programme; July will be our ISS takeover month where the faculty will engage and support clinical teams across the hospital through simulation teaching. References Association for Simulation Practice in Healthcare. Simulation-based education in healthcare. Standards framework and guidance 2016. Available from http://aspih.org.uk/wp-content/uploads/2017/07/standards-framework.pdf [Accessed: 28 May]. The London Handbook for Debriefing: Enhancing performance debriefing in clinical and simulated settings2010. Imperial College London. Available at https://emergencypedia.files.wordpress.com/2014/03/london-debriefing.pdf [Accessed: 22 May 2018]. Rosen MA, Hunt EA, Pronovost PJ, Federowicz MA, Weaver SJ. In situ simulation in continuing education for the health care professions: A systematic review. Journal of Continuing Education in the Health Professions2012;32(4):243–54.

Introduction The 2004 NCEPOD report highlighted the high 30 day mortality following PEG (percutaneous endoscopic gastrostomy) insertion secondary to inappropriate patient selection[1]. This led to the 2010 BSG guidelines which recommended that a designated nutrition support team (NST) should provide a framework for patient selection to reduce unsuitable patients receiving PEGs[2]. Prior to 2013 in Stockport NHS Foundation trust PIGs (per-oral image-guided gastrostomy) were inserted or patients referred to another trust for PEG placement. There was no formalised referral or screening process. Subsequently a nutrition team was appointed with inpatient assessment of patients and MDT for complex cases. Our Aim was to assess whether the implementation of a nutritional team PEG service reduced 30 day all-cause mortality. Methods Retrospective analysis of electronic patient records for 30 day all-cause mortality for all PIG and PEG insertions between 2013 and 2017. Statistical analysis was performed using chi-squared. Results 48 patients (2 excluded as paediatric case and no notes available) had a PIG inserted without formal nutrition team review and 135 patients had PEG following nutrition nurse or MDT assessment. The 2 groups were similar with an average age of 79 years (PIG) and 76 years (PEG) and the majority inserted for stroke (62% PIG and 50% PEG). 30 day mortality on the non-vetted PIG group was 17.4% compared to 5.2% in the PEG group. This was statistically significant with p=0.0048 Conclusions For the unassessed PIG service mortality was similar to that detailed by the NCEPOD report, demonstrating that despite this and BSG guidelines attitudes towards PEG/PIG insertion among non-specialists have not changed since 2004. By introducing an NTS and PEG service mortality has reduced significantly. With an ever increasing ageing population, trends in PEG placement are rising[3]. It is a necessity to ensure that patients are being appropriately assessed to prevent futile procedures. References . Ponsky JL. Percutaneous Endoscopic Gastrostomy 2004;719:901–4. doi:10.1016/j.gassur.2003.12.002 . Westaby D, Young A, O’Toole P, et al. The provision of a percutaneously placed enteral tube feeding service. Gut 2010;59:1592–605. doi:10.1136/gut.2009.204982 . Mendiratta P, Tilford JM, Prodhan P, et al. Trends in percutaneous endoscopic gastrostomy Placement in the Elderly From 1993 to 2003. Am J Alzheimer’s Dis Other Dementiasr 2012;27:609–13. doi:10.1177/1533317512460563

Introduction Simulation is a powerful tool for learning, and has been shown to be effective for a wide range of skills. In situ simulation is delivered in the clinical setting with the objective of incorporating simulated learning into real working environments. This provides additional scope for learning, not only team working and clinical skills, but also in identifying latent errors. We established an in situ simulation programme within our gastroenterology department using the recent Association for Simulated Practice in Healthcare (ASPiH)¹ key standards: clearly defined learning objectives, authentic delivery and faculty proficient in simulation-based education. Methods We identified key learning objectives, highlighting both human factors (at an individual, team and organisational level) and clinical teaching pertinent to the gastroenterology team, to cover over the programme. We incorporated this into a series of clinically relevant scenarios including massive upper gastrointestinal haemorrhage, biliary sepsis and post-ERCP complications. We ran five sessions over a six month period with three faculty, involving twenty four participants across the spectrum of the multi-disciplinary team (MDT). Following each in situ simulation, we facilitated a short, structured debrief session highlighting key learning points, providing feedback and enabling reflection. Results Twenty three of twenty four participants enjoyed the sessions and felt better prepared for similar real life clinical scenarios. All team members involved felt well supported during the debrief process. Through our sessions we recognised both latent error (confusion over the new massive haemorrhage protocol contact number) and resource requirements (no Sengstaken–Blakemore tube on the ward). Following the sessions we highlighted specific teaching needs, and established a mandatory teaching day for our Junior and Senior Clinical Fellows, focusing on the management of the acutely unwell adult. Conclusions In conclusion, in situ simulation has proved a useful modality to deliver teaching in the clinical setting. The response from the multi-disciplinary team has been overwhelmingly positive, especially with feedback reporting it improved team dynamics. The team is currently expanding the in situ simulation programme across other wards to provide ongoing simulation teaching and consequently improve patient safety. Reference . SIMULATION-BASED EDUCATION IN HEALTHCARE– STANDARDS FRAMEWORK AND GUIDANCE. (2016). 1st ed. Health Education England. Available at: http://aspih.org.uk/wp-content/uploads/2017/07/standards-framework.pdf [Accessed 8 Feb. 2018].

Introduction Upper GI bleeding (UGIB) is a common presentation to the emergency department.1 Studies assessing the effectiveness of the Glasgow Blatchford Score (GBS) as a risk stratification tool are well documented in the literature. National Institute of Clinical Excellence (NICE) recommends that all patients admitted with suspected UGIB require a GBS score. This study evaluated the effectiveness of the GBS in predicting the need for endoscopic therapy. It also evaluated whether there was any correlation between the GBS with re-bleeding rates and 30 day mortality. Methods Electronic UGIB requests between January to July 2015 were evaluated retrospectively. Patients who were deemed medically fit for the procedure and underwent a gastroscopy as an in-patient were included in this study. Patients deemed medically unfit for a gastroscopy or were discharged prior to in-patient gastroscopy being performed were excluded from the study. The OGD reports were subsequently retrieved from electronic endoscopy reporting system “Unisoft” and the GBS was retrieved from the electronic request system. The re-bleeding rate and 30 day mortality were evaluated from the review of the electronic patient records. The data collected was entered onto Microsoft Excel 2010 spreadsheet and a chi-square test was applied. Results There were a total of 182 requests for urgent in-patient gastroscopy. 25 patients were excluded from the study - 3 were medically unfit for OGD on arrival, 3 unable to intubate, 1 request was later deemed not required, 1 was changed to outpatients and 17 no OGD reports could be retrieved from Unisoft. The remaining 157 underwent urgent in-patient gastroscopy. Age distribution ranged from 22 to 103 with mean age of 63. 90 patients were male (57%) and 67 were female (43%). Of the 157 patients, 48 (31%) required endoscopic intervention compared to 109 (69%) who did not. Of the 48 patients that required endoscopic intervention, 8 scored GBS Conclusion This study identified that a GBS ≥ 6 significantly correlates with the likelihood of requiring endoscopic intervention as compared to a GBS Reference 1 Longstreth GF. Epidemiology of hospitalisation for acute upper GI haemorrhage: a population-based study. Am J Gastroenterol 1995;90:206. Disclosure of Interest None Declared