Towards NHS Zero: greener gastroenterology and the impact of virtual clinics on carbon emissions and patient outcomes. A multisite, observational, cross-sectional study.

Objective: The National Health Service (NHS) produces more carbon emissions than any public sector organisation in England. In 2020, it became the first health service worldwide to commit to becoming carbon net zero, the same year as the COVID-19 pandemic forced healthcare systems globally to rapidly adapt service delivery. As part of this, outpatient appointments became largely remote. Although the environmental benefit of this change may seem intuitive the impact on patient outcomes must remain a priority. Previous studies have evaluated the impact of telemedicine on emission reduction and patient outcomes but never before in the gastroenterology outpatient setting. Method: 2140 appointments from general gastroenterology clinics across 11 Trusts were retrospectively analysed prior to and during the pandemic. 100 consecutive appointments during two periods of time, from 1 June 2019 (prepandemic) to 1 June 2020 (during the pandemic), were used. Patients were telephoned to confirm the mode of transport used to attend their appointment and electronic patient records reviewed to assess did-not-attend (DNA) rates, 90-day admission rates and 90-day mortality rates. Results: Remote consultations greatly reduced the carbon emissions associated with each appointment. Although more patients DNA their remote consultations and doctors more frequently requested follow-up blood tests when reviewing patients face-to-face, there was no significant difference in patient 90-day admissions or mortality when consultations were remote. Conclusion: Teleconsultations can provide patients with a flexible and safe means of being reviewed in outpatient clinics while simultaneously having a major impact on the reduction of carbon emissions created by the NHS.

BSG cross-sectional survey on impact of COVID-19 recovery on workforce, workload and well-being.

Objective: The aim of this survey was to understand the impact of the COVID-19 pandemic and recovery phase on workload, well-being and workforce attrition in UK gastroenterology and hepatology. Design/method: A cross-sectional survey of British Society of Gastroenterology physician and trainee members was conducted between August and October 2021. Multivariable binary logistic regression and qualitative analyses were performed. Results: The response rate was 28.8% (180/624 of opened email invites). 38.2% (n=21/55) of those who contracted COVID-19 felt pressured to return to work before they felt ready. 43.8% (71/162) had a regular increase in out-of-hours working. This disproportionately affected newly appointed consultants (OR 5.8), those working full-time (OR 11.6), those who developed COVID-19 (OR 4.1) and those planning early retirement (OR 4.0). 92% (150/164) believe the workforce is inadequate to manage the service backlog with new consultants expressing the highest levels of anxiety over this. 49.1% (80/163) felt isolated due to remote working and 65.9% (108/164) felt reduced face-to-face patient contact made their job less fulfilling. 34.0% (55/162) planned to work more flexibly and 54.3% (75/138) of consultants planned to retire early in the aftermath of the pandemic. Early retirement was independently associated with male gender (OR 2.5), feeling isolated from the department (OR 2.3) and increased anxiety over service backlog (OR 1.02). Conclusion: The pandemic has placed an additional burden on work-life balance, well-being and workforce retention within gastroenterology and hepatology. Increased aspirations for early retirement and flexible working need to be explicitly addressed in future workforce planning.

Towards NHS Zero: greener gastroenterology and the impact of virtual clinics on carbon emissions and patient outcomes. A multisite, observational, cross-sectional study.

Objective: The National Health Service (NHS) produces more carbon emissions than any public sector organisation in England. In 2020, it became the first health service worldwide to commit to becoming carbon net zero, the same year as the COVID-19 pandemic forced healthcare systems globally to rapidly adapt service delivery. As part of this, outpatient appointments became largely remote. Although the environmental benefit of this change may seem intuitive the impact on patient outcomes must remain a priority. Previous studies have evaluated the impact of telemedicine on emission reduction and patient outcomes but never before in the gastroenterology outpatient setting. Method: 2140 appointments from general gastroenterology clinics across 11 Trusts were retrospectively analysed prior to and during the pandemic. 100 consecutive appointments during two periods of time, from 1 June 2019 (prepandemic) to 1 June 2020 (during the pandemic), were used. Patients were telephoned to confirm the mode of transport used to attend their appointment and electronic patient records reviewed to assess did-not-attend (DNA) rates, 90-day admission rates and 90-day mortality rates. Results: Remote consultations greatly reduced the carbon emissions associated with each appointment. Although more patients DNA their remote consultations and doctors more frequently requested follow-up blood tests when reviewing patients face-to-face, there was no significant difference in patient 90-day admissions or mortality when consultations were remote. Conclusion: Teleconsultations can provide patients with a flexible and safe means of being reviewed in outpatient clinics while simultaneously having a major impact on the reduction of carbon emissions created by the NHS.

Two-year outcomes of using a stepwise thrombolysis protocol for the management of acute non-malignant portomesenteric thrombosis

IntroductionAcute extensive non-malignant non-cirrhotic portomesenteric thrombosis can lead to bowel infarction and frequently does not resolve with anticoagulation. In 2019 we published our first case series of a stepwise thrombolysis protocol involving the use of low dose tissue plasminogen activator (L-tPa) followed, if indicated, by Catheter-Directed Thrombolysis (CDT) and Transjugular Intrahepatic Portosystemic Shunt (TIPSS). We present an updated series, aiming to explore the recanalization rates, symptom resolution and any adverse events for patients who received this protocol.MethodWe retrospectively reviewed the clinical records of patients who received the stepwise regimen at Royal Free Hospital between December 2019 & March 2022.ResultsA total of 35 patients were included with a mean age of 47 (SD=14) years;63% were males. Thrombophilia was identified in 13 (37%) cases and 14 (40%) had other local or systemic causes for thrombosis (1 had COVID-19;3 received ChAdOx1 vaccination). Three patients had underlying chronic liver disease. All patients had ongoing abdominal pain despite anticoagulation. Occlusive portal vein thrombosis (PVT) was found in 30 (86%) patients with 18 (51%) having thrombosis of all three vessels (PVT + splenic vein + superior mesenteric vein). While all patients received L-tPa within a median of 15 (IQR =18) days of symptoms, CDT was applied in 17 (49%) patients and TIPSS was inserted in 15 (43%). CDT was delivered through EKOS™ endovascular system in 11/17 (65%). A degree of recanalization was observed in 24 (69%). TIPSS was patent at discharge in 14/15 (93%).The majority 28 (80%) were maintained on warfarin and 11 had concomitant anti-platelet therapy. Fifteen patients had imaging follow-up available [median duration of 9 (IQR = 11) months]. Recanalization was maintained in 9/15 (60%) and TIPSS remained patent in 6/9 (67%). At a median follow up of 6.5 (IQR = 9) months, complete symptom resolution was achieved in 30/34 (88%).Nine patients underwent bowel resection within a median duration of 11 (IQR= 10.5) days from presentation;mean length of bowel resected was 67 cm (SD = 50). One patient was discharged on parenteral nutrition and had a stoma. One patient died during the initial admission (related to bowel ischemia) and 1 had intracranial haemorrhage. Minor bleeding was recorded in 8 patients.ConclusionOur protocol resulted in good recanalization and patency rates with the majority achieving symptom resolution. While some patients required surgical intervention, bowel continuity was maintained and only one patient had a stoma.

The story of transjugular intrahepatic portosystemic shunt (TIPSS) at the Royal Free Hospital, 2021–2022: indications and outcomes of 84 procedures

Transjugular intrahepatic portosystemic shunt (TIPSS) is an effective treatment for decompression of portal hypertension and is most commonly indicated in patients with chronic liver disease (CLD) or portal vein thrombosis (PVT). It is a technically challenging intervention. CLD patients are often frail with comorbidities conferring increased procedural risk. We tell the story of one year of procedures at the Royal Free Hospital (RFH), one of the major centres for TIPSS in Europe.A retrospective electronic casenote review was carried out for all patients who underwent TIPSS procedure at the RFH between April 2021 and April 2022. The outcomes of interest were success rate, complications and survival including those who went on to transplantation. A successful procedure was defined as a correctly placed stent with no procedural complications and symptom resolution. Eighty-four (84) patients underwent TIPSS during the 12-month period. Of these, 3 were abandoned: 2 because portal hypertension was absent on direct measurement and 1 due to anatomical infeasibility. Of the 81 completed, the most common indication was diuretic-intolerant ascites (n=32), followed by variceal bleeding (n=27), PVT (n=14), and other indications (n=8). The clinical success rates post-TIPSS for each indication are as follows. For diuretic intolerant ascites, 53.1% (17/32) of patients no longer require large volume paracentesis (LVP), 28.1% (9/21) require LVP at a reduced frequency, 6.3% (2/32) have been transplanted and 1 patient continues to have LVP at the same rate. For variceal bleeding, 85.2% (23/27) of patients have had no further episodes of bleeding. For PVT, 85.7% (12/14) of TIPSS remain patent with no patient requiring surgical intervention. No procedural complications were reported. Overall survival post-TIPSS is 87.7% (71/81) with procedure-related mortality accounting for no deaths. 8 patients who received TIPSS went on to be listed for liver transplant, of those 3 successfully received a graft, 4 remain listed and 1 has died while listed.A high number of TIPSS procedures were performed. The majority were successful with favourable clinical outcomes. Major challenges faced by the service during this time included staff shortages, bed capacity, transfer logistics and the wider impacts of the COVID-19 pandemic. This service depends on the collective expertise and close working of multiple specialties including hepatology, interventional radiology, intensive care and anaesthetics along with logistical and operational support. In an environment where all of these healthcare professionals work together to support the provision of TIPSS, patients can benefit from positive outcomes.

Prescribing behavior of antidepressants for depressive disorders: A systematic review.

Objective: Guidelines for the prescription of antidepressants for Depressive Disorders (DD) have been in place for a long time. However, there is a lack of systematic information on the prescribing behavior of antidepressants in evidence-based clinical practice in psychopharmacotherapy of depressive disorders. This may suggest a lack of implementation of clinical guidelines by clinicians. Existing literature mainly focuses on specific issues or medications. To provide general information on the prescribing behavior of antidepressants for depressive disorders, a systematic review of available studies since 2013 was conducted. Methods and materials: To ensure a structured and systematic approach for the literature search and subsequent review process, the PRISMA guidelines for systematic reviews were followed. Major medical and health and psychological databases were used for the literature search. These included Ebsco Host, OVID, PubMed, Science Direct, Scopus, and Web of Science. The online application "Covidence" was employed to manage the titles collected and the full articles retrieved from the initial literature search. Upon finalizing the list of selected studies, data extraction was then conducted using a build-in function of the Covidence platform with the required information pre-set on a template for data extraction. The extracted information was tabulated and summarized in a table. Results: Forty-one studies were identified after an extensive search of the literature following the PRISMA guidelines. Of these, 37 quantitative studies providing useful information were systematically reviewed and information extracted. There was a high level of heterogeneity among these studies with different foci or characteristics. Most studies were conducted in or utilized data obtained from hospital and primary healthcare settings. SSRIs were the most commonly prescribed type of antidepressant in the past decade, particularly among younger patients. Among these studies, antidepressants were mainly prescribed by psychiatrists with some by other physicians and general practitioners. This might reflect differences in legislation regarding professional requirements for prescribers or clinical practices. Conclusions: A few themes that would be considered important in terms of the effect of prescription behavior on depression, specifically children/adolescents, special target populations, and off-label prescription. The results highlighted the need for more studies on a community-based approach and the role of GPs in the treatment of DD.

Unlocking the benefits of the Baveno VI guidance when screening for varices: an audit of clinical practice across London.

Background: The Baveno VI consensus identifies patients with compensated advanced chronic liver disease (cACLD) who can safely avoid screening endoscopy. However, concordance in clinical practice with this guidance is unknown. We audited clinical practice and the provision of transient elastography (TE) aiming to identify potential cost savings and benefits. Methods: Retrospective data collection from 12 sites across London over 6 months by reviewing oesophagogastroduodenoscopy (OGD) reports, platelet count and TE results as well as information on site-specific provision of TE. Results: Three-hundred and fifty-one screening procedures were identified; 177 (50.43%) had a TE test performed within the preceding 12 months; 142 (80.23%) patients with a recent TE test did not meet criteria for screening OGD. TE provision varied widely between sites. Conclusion: Improving concordance with the Baveno criteria through improved provision of TE would have benefits for patients, healthcare systems and the environment and would help to address the challenges of moving on from the COVID-19 pandemic.

Australian Paediatric Surveillance Unit (APSU) Annual Surveillance Report 2020.

ABSTRACT: For 27 years, national prospective data on selected rare childhood diseases have been collected monthly by the Australian Paediatric Surveillance Unit (APSU) from paediatricians and other clinical specialists who report cases in children aged up to 16 years. We report here the annual results of APSU surveillance in 2020 for ten rare communicable diseases and complications of communicable diseases, namely: acute flaccid paralysis (AFP); congenital cytomegalovirus (CMV) infection; neonatal herpes simplex virus (HSV) infection; perinatal exposure to human immunodeficiency virus (HIV); paediatric HIV infection; severe complications of seasonal influenza; juvenile onset recurrent respiratory papillomatosis (JoRRP); congenital rubella syndrome; congenital varicella syndrome; and neonatal varicella infection. We describe the results for each disease in the context of the total period of study, including demographics, clinical characteristics, treatment and short-term outcomes. Despite challenges presented by the coronavirus disease 2019 (COVID-19) pandemic in 2020, more than 1,400 paediatricians reported regularly to the APSU and an overall monthly reporting rate of > 90% was achieved. The minimum AFP target of 1 case per 100,000 children aged less than 15 years was achieved and there were few cases of vaccine-preventable diseases (JoRRP, rubella, varicella). However, high cases of congenital CMV, neonatal HSV and perinatal exposure to HIV persist. There were no severe complications of seasonal influenza reported for the first time in 13 years. This is consistent with other surveillance data reporting a decline of influenza and other communicable diseases in 2020, and likely reflects the wider effects of public health measures to reduce transmission of SARS-CoV-2 in the Australian community.

A decentralised point-of-care testing model to address inequities in the COVID-19 response.

The COVID-19 pandemic is growing rapidly, with over 37 million cases and more than 1 million deaths reported by mid-October, 2020, with true numbers likely to be much higher in the many countries with low testing rates. Many communities are highly vulnerable to the devastating effects of COVID-19 because of overcrowding in domestic settings, high burden of comorbidities, and scarce access to health care. Access to testing is crucial to globally recommended control strategies, but many communities do not have adequate access to timely laboratory services. Geographic dispersion of small populations across islands and other rural and remote settings presents a key barrier to testing access. In this Personal View, we describe a model for the implementation of decentralised COVID-19 point-of-care testing in remote locations by use of the GeneXpert platform, which has been successfully scaled up in remote Aboriginal and Torres Strait Islander communities across Australia. Implementation of the decentralised point-of-care testing model should be considered for communities in need, especially those that are undertested and socially vulnerable. The decentralised testing model should be part of the core global response towards suppressing COVID-19.