The Imbalance in Medico-Legal Cover Awareness and Uptake Between Overseas Junior Doctors and Local Graduates in the NHS.

Background Recent reports showed that overseas doctors were more likely than UK graduates to be referred by their employers to the General Medical Council (GMC). We investigated the trend of medico-legal insurance awareness and uptake of medical defence organisations (MDOs) by junior doctors and to examine if there is a difference between overseas and UK graduates. Methods Online questionnaire survey sent to junior doctors within the Yorkshire and Humber Deanery. Data regarding year of graduation, country of origin of primary medical qualification, year of starting work in the National Health Service (NHS) and date of joining an MDO were collected. Participant-identifiable information was not collected. Results A total of 202 junior doctors completed the survey: 153 (76%) UK graduates and 49 (24%) overseas. Overseas doctors were less likely to know about MDO compared to UK graduates prior to working in the NHS (13 [26.5%] vs. 146 [95.4%]; p < 0.0001). At the time of starting practice, MDO uptake was still significantly lower amongst overseas graduates (4 [8.2%] vs. 144 [94.1%]; p < 0.0001). Uptake by overseas doctors increased after starting work to 33 (67.3%). However, despite improvement in MDO uptake, a significant number of overseas doctors still did not have independent cover compared with UK graduates (16 [32.7%] vs. 3 [2%]; p < 0.0001). Conclusions Overseas graduates joining the NHS are still less likely to be aware of the requirement of adequate medico-legal cover and are less likely to join an MDO compared with UK graduates. Healthcare providers and regulators should work to decrease the existing gap and increase awareness amongst newly arrived overseas doctors.

INTERNATIONAL: Overseas doctors of the NHS: migration, transition, challenges and towards resolution.

Overseas doctors are playing an important role in the successful running of the NHS. They represent one-third of the total number of UK doctors and include doctors from the European Economic Area and international medical graduates. The main aim of this review is to explore the challenges that overseas doctors might face when they take up their first job in the UK. We conducted literature search using MEDLINE and EMBASE databases. The inclusion and exclusion criteria were designed to include published literature concerning overseas doctors in the UK and the NHS. Lack of information about the UK health system; language and communication challenges; clinical, educational and work-culture challenges; and discrimination challenges are some of the difficulties that overseas doctors might experience. Understanding these challenges and providing support are important steps in helping overseas doctors to make a smooth transition.

A novel diagnostic aid for intra-abdominal adhesion detection in cine-MRI: pilot study and initial diagnostic impressions.

OBJECTIVE: A non-invasive diagnostic technique for abdominal adhesions is not currently available. Capture of abdominal motion due to respiration in cine-MRI has shown promise, but is difficult to interpret. This article explores the value of a complimentary diagnostic aid to facilitate the non-invasive detection of abdominal adhesions using cine-MRI. METHOD: An image processing technique was developed to quantify the amount of sliding that occurs between the organs of the abdomen and the abdominal wall in sagittal cine-MRI slices. The technique produces a "sheargram" which depicts the amount of sliding which has occurred over 1-3 respiratory cycles. A retrospective cohort of 52 patients, scanned for suspected adhesions, made 281 cine-MRI sagittal slices available for processing. The resulting sheargrams were reported by two operators and compared with expert clinical judgment of the cine-MRI scans. RESULTS: The sheargram matched clinical judgment in 84% of all sagittal slices and 93-96% of positive adhesions were identified on the sheargram. The sheargram displayed a slight skew towards sensitivity over specificity, with a high positive adhesion detection rate but at the expense of false positives. CONCLUSION: Good correlation between sheargram and absence/presence of inferred adhesions indicates quantification of sliding motion has potential to aid adhesion detection in cine-MRI. ADVANCES IN KNOWLEDGE: This is the first attempt to clinically evaluate a novel image processing technique quantifying the sliding motion of the abdominal contents against the abdominal wall. The results of this pilot study reveal its potential as a diagnostic aid for detection of abdominal adhesions.

Distinguishing Motor Weakness From Impaired Spatial Awareness: A Helping Hand!

Our patient, aged 73 years, had background peripheral neuropathy of unknown cause, stable for several years, which caused some difficulty in walking on uneven ground. He attended for a teaching session but now staggered in, a new development. He had apparent weakness of his right arm, but there was difficulty in distinguishing motor weakness from impaired spatial awareness suggestive of parietal lobe dysfunction. With the patient seated, eyes closed, and left arm outstretched, S.A.R. lifted the patient's right arm and asked him to indicate when both were level. This confirmed motor weakness. Urgent computed tomographic scan confirmed left subdural haematoma and its urgent evacuation rapidly resolved the patient's symptoms. Intrigued by our patient's case, we explored further and learnt that in rehabilitation medicine, the awareness of limb position is commonly viewed in terms of joint position sense. We present recent literature evidence indicating that the underlying mechanisms are more subtle.

Mechanisms of triglyceride metabolism in patients with bile acid diarrhea.

Bile acids (BAs) are essential for the absorption of lipids. BA synthesis is inhibited through intestinal farnesoid X receptor (FXR) activity. BA sequestration is known to influence BA metabolism and control serum lipid concentrations. Animal data has demonstrated a regulatory role for the FXR in triglyceride metabolism. FXR inhibits hepatic lipogenesis by inhibiting the expression of sterol regulatory element binding protein 1c via small heterodimer primer activity. Conversely, FXR promotes free fatty acids oxidation by inducing the expression of peroxisome proliferator-activated receptor α. FXR can reduce the expression of microsomal triglyceride transfer protein, which regulates the assembly of very low-density lipoproteins (VLDL). FXR activation in turn promotes the clearance of circulating triglycerides by inducing apolipoprotein C-II, very low-density lipoproteins receptor (VLDL-R) and the expression of Syndecan-1 together with the repression of apolipoprotein C-III, which increases lipoprotein lipase activity. There is currently minimal clinical data on triglyceride metabolism in patients with bile acid diarrhoea (BAD). Emerging data suggests that a third of patients with BAD have hypertriglyceridemia. Further research is required to establish the risk of hypertriglyceridaemia in patients with BAD and elicit the mechanisms behind this, allowing for targeted treatment.

The evolution and outcome of surveillance of Barrett's oesophagus over four decades in a UK District General Hospital.

INTRODUCTION: We present the long-term outcome of Barrett's oesophagus (BO) at a District General Hospital set against the increasing numbers of patients with gastro-oesophageal reflux disease (GORD). METHODS: Data were collected prospectively over 37 years. Comparison of GORD without Barrett's (NoBO) versus BO was performed from 1/1/1977 to 31/12/2001 when the NoBO database closed and outcomes of all cases of BO diagnosed until 31/12/2011 and followed up until 31/12/2013 have been reported. RESULTS: During the period 1977-2001 the number of GORD NoBO cases was 11 610, and that of BO cases was 764 (6.2% of all GORD); total number of BO cases in 1977-2011 was 1468. NoBO patients were younger than BO patients: 52.2 versus 61.6 years. There was a male predominance in both groups: NoBO 55% and BO 62% (P<0.0001). The prevalence of oesophageal adenocarcinoma (OAC) was 87/1468 (5.9%) BO cases. Its incidence was 54/1381 (3.9%); the mean interval between the diagnosis of BO and incident OAC was 9 years (range 13 months-25.4 years); there was one OAC per 192 patient-years of follow-up (0.52% per year). Mortality was significantly lower in 37 patients under endoscopic surveillance at the time OAC was diagnosed (51 vs. 88% P=0.0141) partly because of older age and comorbidity of the other 17, in whom serial endoscopy was contraindicated. A proportional hazards model to allow for age estimated that the hazard rate ratio was lower in the surveillance group; however, this difference did not reach statistical significance (0.64, 95% confidence interval 0.30-1.48, P=0.08). Excluding prevalent cancers from both groups, mortality in BO was double that in NoBO (47 vs. 24%). CONCLUSION: These 37 years of observation suggest, but do not confirm, that endoscopic surveillance may reduce the risk of death from OAC. Modern technology is likely to yield better results, but larger prospective studies are needed to confirm the benefits.

A Novel Diagnostic Aid for Detection of Intra-Abdominal Adhesions to the Anterior Abdominal Wall Using Dynamic Magnetic Resonance Imaging.

Introduction. Abdominal adhesions can cause serious morbidity and complicate subsequent operations. Their diagnosis is often one of exclusion due to a lack of a reliable, non-invasive diagnostic technique. Development and testing of a candidate technique are described below. Method. During respiration, smooth visceral sliding motion occurs between the abdominal contents and the walls of the abdominal cavity. We describe a technique involving image segmentation and registration to calculate shear as an analogue for visceral slide based on the tracking of structures throughout the respiratory cycle. The presence of an adhesion is attributed to a resistance to visceral slide resulting in a discernible reduction in shear. The abdominal movement due to respiration is captured in sagittal dynamic MR images. Results. Clinical images were selected for analysis, including a patient with a surgically confirmed adhesion. Discernible reduction in shear was observed at the location of the adhesion while a consistent, gradually changing shear was observed in the healthy volunteers. Conclusion. The technique and its validation show encouraging results for adhesion detection but a larger study is now required to confirm its potential.

Towards radiological diagnosis of abdominal adhesions based on motion signatures derived from sequences of cine-MRI images.

This paper reports novel development and preliminary application of an image registration technique for diagnosis of abdominal adhesions imaged with cine-MRI (cMRI). Adhesions can severely compromise the movement and physiological function of the abdominal contents, and their presence is difficult to detect. The image registration approach presented here is designed to expose anomalies in movement of the abdominal organs, providing a movement signature that is indicative of underlying structural abnormalities. Validation of the technique was performed using structurally based in vitro and in silico models, supported with Receiver Operating Characteristic (ROC) methods. For the more challenging cases presented to the small cohort of 4 observers, the AUC (area under curve) improved from a mean value of 0.67 ± 0.02 (without image registration assistance) to a value of 0.87 ± 0.02 when image registration support was included. Also, in these cases, a reduction in time to diagnosis was observed, decreasing by between 20% and 50%. These results provided sufficient confidence to apply the image registration diagnostic protocol to sample magnetic resonance imaging data from healthy volunteers as well as a patient suffering from encapsulating peritoneal sclerosis (an extreme form of adhesions) where immobilization of the gut by cocooning of the small bowel is observed. The results as a whole support the hypothesis that movement analysis using image registration offers a possible method for detecting underlying structural anomalies and encourages further investigation.

Utility of testing patients, on presentation, for serologic features of celiac disease.

BACKGROUND & AIMS: Celiac disease shares features of other disorders. It can be diagnosed conclusively only based on duodenal histology analysis, which is not practical for screening purposes. Serologic analysis might be used to identify candidates for biopsy analysis. We aimed to develop a simple diagnostic approach that all clinicians could follow to increase the percentage of patients accurately diagnosed with celiac disease at initial presentation. METHODS: We performed a retrospective analysis of data from 752 patients (88 with celiac disease, none were IgA deficient) who attended a UK district general hospital from January 2007 through December 2008 and underwent biopsy analysis and serologic tests to measure endomyseal antibodies and IgA antibodies against tissue transglutaminase (tTG). Patients avoiding gluten in their diet were excluded. Patients were assigned to 1 of 4 groups: high-risk (based on presence of anemia, chronic diarrhea, unintentional weight loss, or dermatitis herpetiformis), low-risk (based on such factors as dyspepsia, abnormal liver function, ataxia, or chronic cough), nutrient deficiency (based on levels of iron, vitamins B12 and D, or folate), or screening (because they had type 1 diabetes or a family history of celiac disease). Patients with celiac disease were identified using the modified Marsh criteria (grades 1-3) for interpreting duodenal histology. We compared clinical category, serology profiles, and biopsy results between patients with and without celiac disease. RESULTS: Celiac disease was diagnosed in 64 of 565 patients in the high-risk group (11%), 14 of 156 patients in the low-risk group (9%; P = .47 compared with high-risk group), 7 of 28 patients in the nutrient-deficiency group, and 3 of 3 patients in the screening group. Among 71 patients who tested positive for both antibodies (tTG and endomyseal antibodies), the positive predictive value for celiac disease was 97%; a negative test result for tTG had a negative predictive value of 98%. Among 708 patients with normal-looking biopsy samples, only 62 had celiac disease (9%). Among 44 patients with abnormal biopsy samples, 26 had celiac disease (59%). CONCLUSIONS: Based on a retrospective analysis, patients with and without celiac disease cannot be distinguished based on clinical features. Patients who present with symptoms of celiac disease should be tested for tTG, to identify candidates for duodenal biopsy analysis.

Reflux revisited: advancing the role of pepsin.

Gastroesophageal reflux disease is mediated principally by acid. Today, we recognise reflux reaches beyond the esophagus, where pepsin, not acid, causes damage. Extraesophageal reflux occurs both as liquid and probably aerosol, the latter with a further reach. Pepsin is stable up to pH 7 and regains activity after reacidification. The enzyme adheres to laryngeal cells, depletes its defences, and causes further damage internally after its endocytosis. Extraesophageal reflux can today be detected by recognising pharyngeal acidification using a miniaturised pH probe and by the identification of pepsin in saliva and in exhaled breath condensate by a rapid, sensitive, and specific immunoassay. Proton pump inhibitors do not help the majority with extraesophageal reflux but specifically formulated alginates, which sieve pepsin, give benefit. These new insights may lead to the development of novel drugs that dramatically reduce pepsinogen secretion, block the effects of adherent pepsin, and give corresponding clinical benefit."For now we see through a glass, darkly."-First epistle, Chapter 13, Corinthians.

Dietary Phytosterols Protective Against Peptic Ulceration.

BACKGROUND: In developing countries the prevalence of duodenal ulceration is related to the staple diet and not to the prevalence of Helicobacter pylori. Experiments using animal peptic ulcer models show that the lipid fraction in foods from the staple diets of low prevalence areas gives protection against ulceration, including ulceration due to non-steroidal anti-inflammatory drugs (NSAIDs), and also promotes healing of ulceration. The lipid from the pulse Dolichos biflorus (Horse gram) was highly active and used for further investigations. Further experiments showed the phospholipids, sterol esters and sterols present in Horse gram lipid were gastroprotective. Dietary phospholipids are known to be protective, but the nature of protective sterols in staple diets is not known. The present research investigates the nature of the protective phytosterols. METHODS: Sterol fractions were extracted from the lipid in Dolichos biflorus and tested for gastroprotection using the rat ethanol model. The fractions showing protective activity were isolated and identification of the components was investigated by Gas Chromatography-Mass Spectrometry (GC-MS). RESULTS: The protective phytosterol fraction was shown to consist of stigmasterol, ß-sitosterol and a third as yet unidentified sterol, isomeric with ß-sitosterol. CONCLUSIONS: Dietary changes, affecting the intake of protective phospholipids and phytosterols, may reduce the prevalence of duodenal ulceration in areas of high prevalence and may reduce the incidence of recurrent duodenal ulceration after healing and elimination of Helicobacter pylori infection. A combination of phospholipids and phytosterols, such as found in the lipid fraction of ulceroprotecive foods, may be of value in giving protection against the ulcerogenic effect of NSAIDs.

The construction of a new evaluative GERD questionnaire--methods and state of the art.

Gastroesophageal reflux disease (GERD) is one of the most prevalent diseases worldwide, and it is becoming increasingly important to monitor the effect of various interventions on GERD symptoms. There can be rapid temporal changes in the severity and frequency of patients' symptoms as well as their health status and well-being, all of which could, theoretically, be monitored using diaries or questionnaires. However, current GERD monitoring instruments are not appropriate because they do not assess symptoms daily, they are not sufficiently responsive to short-term changes in health status or they are not adequately validated. To address these problems, the conceptual and psychometric requirements for a GERD symptom assessment questionnaire were identified. A dimension-based scale was designed to reduce the number of symptoms monitored on a daily basis, and the validation process was defined to produce parallel long and short forms of a scale for patients' self-assessment of their GERD symptom response to therapy. These basic principles which underlie the successful development of a new, self-assessed symptomatic reflux questionnaire (ReQuest) are also applicable to the development of validated questionnaires for daily symptom self-assessment in other disease areas.

Determination of ReQuest-based symptom thresholds to define symptom relief in GERD clinical studies.

BACKGROUND/AIMS: The growing importance of symptom assessment is evident from the numerous clinical studies on gastroesophageal reflux disease (GERD) assessing treatment-induced symptom relief. However, to date, the a priori selection of criteria defining symptom relief has been arbitrary. The present study was designed to prospectively identify GERD symptom thresholds for the broad spectrum of GERD-related symptoms assessed by the validated reflux questionnaire (ReQuest) and its subscales, ReQuest-GI (gastrointestinal symptoms) and ReQuest-WSO (general well-being, sleep disturbances, other complaints), in individuals without evidence of GERD. METHODS: In this 4-day evaluation in Germany, 385 individuals without evidence of GERD were included. On the first day, participants completed the ReQuest, the Gastrointestinal Symptom Rating Scale, and the Psychological General Well-Being scale. On the other days, participants filled in the ReQuest only. GERD symptom thresholds were calculated for ReQuest and its subscales, based on the respective 90th percentiles. RESULTS: GERD symptom thresholds were 3.37 for ReQuest, 0.95 for ReQuest-GI, and 2.46 for ReQuest-WSO. CONCLUSION: Even individuals without evidence of GERD may experience some mild symptoms that are commonly ascribed to GERD. GERD symptom thresholds derived in this study can be used to define the global symptom relief in patients with GERD.

Novel measurement of rapid treatment success with ReQuest: first and sustained symptom relief as outcome parameters in patients with endoscopy-negative GERD receiving 20 mg pantoprazole or 20 mg esomeprazole.

BACKGROUND/AIMS: A prime concern for gastroesophageal reflux disease (GERD) patients is fast symptom control. Sparse valid information is available on the rapidity of the effect of proton pump inhibitors in providing symptom relief. The new reflux questionnaire ReQuest is validated for daily assessment of changes in GERD symptoms. Therefore, this study investigated the efficacy of 20 mg pantoprazole and 20 mg esomeprazole with regard to the time to symptom relief in patients with endoscopy-negative GERD (enGERD) using ReQuest. METHODS: 529 patients were treated with pantoprazole or esomeprazole over 4 weeks. ReQuest symptom scores were assessed daily. The mean and median times to first and sustained symptom relief were determined. RESULTS: Median time to first symptom relief was 2 days for both drugs (intention-to-treat population). The median time to sustained symptom relief was 3 days shorter with pantoprazole (10.0 vs. 13.0 days). The Hodges-Lehmann estimator for the difference in time to reach first and sustained symptom relief between both groups was 0.00 days. For both variables the one-sided 95% CI (Moses) was [0.00; infinity[, documenting no significant differences between the treatment groups. CONCLUSIONS: The rapidity of symptom control can be evaluated by clinically significant parameters using ReQuest. Pantoprazole and esomeprazole are equally effective in the time to first and sustained symptom relief.

A framework for the modeling of gut blood flow regulation and postprandial hyperaemia.

After a meal the activity of the gut increases markedly as digestion takes place. Associated with this increase in activity is an increase in blood flow, which has been shown to be dependent on factors such as caloric content and constitution of the meal. Much qualitative work has been carried out regarding mechanisms for the presence of food in a section of gut producing increased blood flow to that section, but there are still many aspects of this process that are not fully understood. In this paper we briefly review current knowledge on several relevant areas relating to gut blood flow, focusing on quantitative data where available and highlighting areas where further research is needed. We then present new data on the effect of feeding on flow in the superior mesenteric artery. Finally, we describe a framework for combining this data to produce a single model describing the mechanisms involved in postprandial hyperaemia. For a section of the model, where appropriate data are available, preliminary results are presented.

Determination of ReQuest-based symptom thresholds to define symptom relief in GERD clinical studies.

BACKGROUND/AIMS: The growing importance of symptom assessment is evident from the numerous clinical studies on gastroesophageal reflux disease (GERD) assessing treatment-induced symptom relief. However, to date, the a priori selection of criteria defining symptom relief has been arbitrary. The present study was designed to prospectively identify GERD symptom thresholds for the broad spectrum of GERD-related symptoms assessed by the validated reflux questionnaire (ReQuest) and its subscales, ReQuest-GI (gastrointestinal symptoms) and ReQuest-WSO (general well-being, sleep disturbances, other complaints), in individuals without evidence of GERD. METHODS: In this 4-day evaluation in Germany, 385 individuals without evidence of GERD were included. On the first day, participants completed the ReQuest, the Gastrointestinal Symptom Rating Scale, and the Psychological General Well-Being scale. On the other days, participants filled in the ReQuest only. GERD symptom thresholds were calculated for ReQuest and its subscales, based on the respective 90th percentiles. RESULTS: GERD symptom thresholds were 3.37 for ReQuest, 0.95 for ReQuest-GI, and 2.46 for ReQuest-WSO. CONCLUSION: Even individuals without evidence of GERD may experience some mild symptoms that are commonly ascribed to GERD. GERD symptom thresholds derived in this study can be used to define the global symptom relief in patients with GERD.

Novel measurement of rapid treatment success with ReQuest: first and sustained symptom relief as outcome parameters in patients with endoscopy-negative GERD receiving 20 mg pantoprazole or 20 mg esomeprazole.

BACKGROUND/AIMS: A prime concern for gastroesophageal reflux disease (GERD) patients is fast symptom control. Sparse valid information is available on the rapidity of the effect of proton pump inhibitors in provid ing symptom relief. The new reflux questionnaire ReQuest is validated for daily assessment of changes in GERD symptoms. Therefore, this study investigated the efficacy of 20 mg pantoprazole and 20 mg esomeprazole with regard to the time to symptom relief in patients with endoscopy-negative GERD (enGERD) using ReQuest. METHODS: 529 patients were treated with pantoprazole or esomeprazole over 4 weeks. ReQuest symptom scores were assessed daily. The mean and median times to first and sustained symptom relief were determined. RESULTS: Median time to first symptom relief was 2 days for both drugs (intention-to-treat population). The median time to sustained symptom relief was 3 days shorter with pantoprazole (10.0 vs. 13.0 days). The Hodges-Lehmann estimator for the difference in time to reach first and sustained symptom relief between both groups was 0.00 days. For both variables the one-sided 95% CI (Moses) was [0.00; infinity] documenting no significant differences between the treatment groups. CONCLUSIONS: The rapidity of symptom control can be evaluated by clinically significant parameters using ReQuest. Pantoprazole and esomeprazole are equally effective in the time to first and sustained symptom relief.