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23-24 November 2017, Killashee Hotel, Naas, Co Kildare
New clinical programme for gastroenterology
The HSE’s first Clinical Programme for Gastroenterology is being developed and it will advertise for a Clinical Lead shortly, the recent Irish Society of Gastroenterology (ISG) Winter Meeting heard.
Dr Colm Henry, HSE National Clinical Advisor and Group Lead, Acute Hospitals Division, gave an update on the development of the long-called-for programme, acknowledging that “gastroenterology has been one of the orphan specialties in terms of the programmes”.
The key areas to be addressed by the programme include inflammatory bowel disease (IBD), endoscopy (work already ongoing on addressing waiting lists), liver disease, intestinal failure, haemochromatosis (two clinical guidelines already produced), and GI physiology, Dr Henry informed delegates.
The challenges facing the specialty include consultant and nursing manpower, a lack of established networks, pathways and models of care and long waiting lists, which will be addressed under the new programme.
The programme will also seek to define best practice for the effective use of biosimilar agents, create referral guidelines for GPs, increase public health education and reduce waste, while hopefully increasing resources for gastroenterology. Dr Henry also expressed a desire to increase the use of allied health professionals and clinical nurse specialists, as well as involving the patient voice in designing services.
Speaking about the success of existing HSE models of care, Dr Henry highlighted the example of the Acute Coronary Syndrome (ACS) Programme’s model for standardising heart attack (STEMI) care across the country. There is now an embedded model of care for primary percutaneous coronary intervention (PPCI), with a network of six 24/7 PPCI centres and a Monday-to-Friday, 9am-5pm service in Waterford.
“With the addition of Altnagelvin [Hospital in Derry] for Donegal, that means 92 per cent of the population is covered within an hour-and-a-half by PPCI,” he said, saying this offered a good example for developing gastroenterology pathways of care.
Dr Henry noted that some of the clinical programmes have been “very successful” in obtaining resources for their particular specialty, adding that “their advocacy [role] is also very important”.
During his presentation, Dr Henry acknowledged the pressure on the health system and the impact the budget cuts during the recession have had on services. He said healthcare costs are becoming unaffordable internationally against a background of rising demand, an ageing population and an epidemic of chronic conditions.
Commenting on public hospital waiting lists, he said while the National Treatment Purchase Fund (NTPF) “is popular with politicians as it delivers within the political cycle”, it does not address the long-term needs of the service. Dr Henry said he prefers “in-sourcing”, ie using unused public hospital capacity, with a view to properly addressing the system’s bed and staffing deficit.
Speaking to the Medical Independent (MI) during the meeting, ISG President Dr Laurence Egan said it will be a step forward for the specialty to have a national clinical programme, and that improved co-ordination and funding of services will be important. He also praised the quality of the speakers and research at the two-day meeting in Kildare, which drew record attendances.
Anaesthesia during endoscopy debated
A major debate on who should administer sedation during GI endoscopies and colonoscopies took place at the recent ISG Annual Winter Meeting in Kildare.
During the session on sedation during GI procedures, it was posited that endoscopists should administer their own patient sedation, or that ‘anaesthetic nurse practitioners’ in future could assist them, while on the other hand it was argued that anaesthetists should always be the ones administering sedation, particularly agents like propofol.
One gastroenterologist, speaking from the audience, said that having administered propofol himself for colonoscopies versus having an anaesthetist do it, he far prefers having the specialist on hand, saying the thoroughness and completeness of the procedure is far superior when he can give it his full attention and not have to be administering and monitoring the sedation of the patient.
However, it was also argued that given the rising demand for investigative GI procedures, it is not practical to expect full anaesthesia cover.
At the ISG meeting, speakers noted that the demand for colonoscopies in Ireland has increased significant in recent years, partly down to the introduction of BowelScreen, as well as an ageing population, against a background of a medical manpower shortage.
Dr Colm Henry, HSE National Clinical Advisor and Group Lead, Acute Hospitals Division, cited HSE figures showing that in 2005, 99,974 endoscopy procedures were carried out, rising to 133,277 in 2016 — a 5 per cent year-on-year growth. There are 2,500 endoscopies performed each week in the public sector. Currently, 39 acute public hospitals carry out endoscopies, with 10 of these carrying out 49 per cent of all endoscopy procedures, he reported.
During the sedation session, it was pointed out by audience members that endoscopists in Ireland urgently need anaesthesia training, as it is currently a serious medical education gap. It was agreed that the ISG should liaise with the College of Anaesthetists of Ireland on the matter, and that ideally, all those administering sedation should obtain a certificate of competency.
Dr Jan Steiner, Consultant Anaesthetist/Intensivist, Galway Clinic, maintained that for optimal patient care and safety, sedation should be conducted by anaesthetists or by practitioners with near-anaesthetist skills.
Highlighting the risks of anaesthesia, he said it is essential to have a detailed knowledge of the pharmacology of sedation agents. The brain becomes more sensitive to all hypnotic agents with age, thus there is increased sensitivity to propofol in elderly patients. Dr Steiner noted that the onset of action of all anaesthetic drugs used in elderly patients is much slower.
Dr Steiner also emphasised the urgent need for specialist sedation training for endoscopists and for the training bodies to address the issue.
Also speaking during the session, Dr Christian Maaser, Gastroenterologist, Lueneburg, Germany, said that is now widely accepted in Europe that some form of sedation should ideally be provided when carrying out GI endoscopies, as it is much more comfortable for the patient and is more likely to ensure a completed procedure.
Quoting US data, he said only 12 per cent of surveyed endoscopists would agree to perform a procedure without sedation, with propofol the preferred sedation agent. He cited a number of other studies showing superior outcomes for propofol.
Dr Maaser drew attention to the European Society of Gastrointestinal Endoscopy position on the issue, which notes that sedation management in gastrointestinal endoscopy varies between European countries according to the different legal frameworks and different healthcare systems.
The Society advocates for specialist training for gastrointestinal endoscopy staff and says a multidisciplinary approach is the best response to current needs.
Dr Maaser added that listening to music during endoscopies has been found to reduce pain and anxiety in patients.
100 per cent cure rate reported in Irish arm of real-world hepatitis C treatment study
A real world study of a combination direct-acting antiviral (DAA) treatment in hepatitis C (HCV) patients “has had excellent results of a 100 per cent cure rate”, the lead of the Irish arm of the REACH study told the ISG Winter Meeting in Kildare.
The purpose of the REACH study was to evaluate the effectiveness of an interferon-free combination DAA regimen of viekirax/exviera +/- ribavirin in genotype 1 (GT1) HCV patients with compensated cirrhosis (CHC), as evidenced by sustained virologic response at 12 weeks (SV12) in routine clinical practice.
Dr Diarmaid Houlihan, Consultant Hepatologist, St Vincent’s University Hospital, Dublin, outlined the interim results of the Irish arm of the study, which covered five academic centres and consisted of primarily female patients who had contracted HCV from contaminated blood products, about half of whom had various comorbidities.
He noted that traditionally, positive HCV treatment clinical trial results do not always translate into the same outcomes and side-effect profiles in real-life clinical practice.
Detailing the Irish study results of 100 per cent SVR12 in the eventual treatment completed cohort of 67 patients, Dr Houlihan said that it was clear this real-world evidence confirms the effectiveness and safety profile of the studied DAAs in HCV GT1 patients, irrespective of CHC and previous treatment experience, and that baseline comorbidities do not impact SVR.
The reported side-effects were minor — headache, nausea, diarrhoea and fatigue (one major adverse event of a visual disturbance was deemed to be unrelated to treatment), “and importantly, no-one discontinued treatment during the study”. Dr Houlihan added that the initial results of a survey of the patients on their quality of life due to their SVR were also very positive, with the full results due to be outlined at a future ISG meeting,
“I think AbbVie did a great job with this because not all pharma go and analyse this. Our results were 100 per cent cure, no discontinued drug, and the quality of life went up. The quality of life was unique to this study; how viral eradication impacts on [patients] so it was a very positive outcome,” he told MI.
Faecal transplantation effective in recurrent C.diff
Faecal transplantation for patients with intractable Clostridium difficile is an effective and increasingly accepted procedure, the 2017 ISG Winter Meeting heard.
Dr John Keohane, Consultant Gastroenterologist, Our Lady of Lourdes Hospital, Drogheda, gave a practical presentation on how to administer a faecal transplant and reported patient outcomes to date.
Presenting details of a recent systematic review of 35 studies (516 patients) of faecal transplantation for patients with recurrent C.diff infection, he reported an 85 per cent resolution rate, with few adverse events. Other studies have shown resolution rates of 92-to-95 per cent, with no difference between fresh and frozen stool material, and that it is far more effective than vancomycin.
Guideline-wise, he said American, European and UK gastroenterology societies now endorse faecal transplantation for recurrent C.diff, while in Ireland it is also endorsed in HSE clinical guidelines.
Dr Keohane reported that eight centres in Ireland have performed 53 faecal treatments to date.
Discussing the practicalities of performing a faecal transplant, Dr Keohane said his unit orders its material from a US company, which has established donor selection, screening and traceability procedures for its faecal products, and it arrives in Ireland shipped on frozen dry ice via FedEx and must be confirmed as still frozen on arrival. It is then stored at -20 degrees Celsius and has specific defrosting and usage timing guidelines.
Dr Keohane reported good results to date and said he has found patients are quite open to trying faecal transplantation for their C.diff, “as they have usually been in hospital a long time at that stage and are fed up and willing to try anything”. There was significant delegate interest in his presentation, with many practical questions from the floor.
Liver disease now an epidemic in Ireland and UK
Liver disease is now a huge epidemic of preventable mortality and morbidity, with inadequate awareness, prevention strategies and treatment resources, the recent 2017 ISG Winter Meeting heard
During a session dedicated to liver disease, Dr Diarmaid Houlihan, Consultant Hepatologist, St Vincent’s University Hospital, Dublin, gave an update on the incidence and treatment of hepatocellular carcinoma (HCC) in Ireland, and highlighted how patients from outside Dublin are two-thirds less likely to be diagnosed early enough to be cured.
Criticising the lack of Irish data, he said “liver disease is the third-commonest killer of under-65 year-olds in the UK, and the commonest preventable cause of death in the UK currently. So there is an avalanche of liver disease”.
Explaining the pathology of HCC, Dr Houlihan said it “occurs almost exclusively on the background of liver cirrhosis. Ninety per cent of the patients I see have cirrhosis when they get a diagnosis of HCC.”
He quoted data from the National Cancer Registry Ireland (NCRI) showing a 300 per cent increase in the incidence of HCC in the last three decades.
The diagnosis of HCC is imaging based but NCRI data is biopsy based, according to Dr Houlihan, “so I think their estimates are a [huge] underestimate of the true incidence of HCC in the country”.
While curable in the early stages, HCC treatment is just life-prolonging with late diagnosis, he said, raising concern about the lack of resources for hepatology services outside Dublin, with regional patients far more likely to be diagnosed too late for curative therapy.
Citing data from his unit, Dr Houlihan said 60 per cent of Dublin patients were referred at an early stage of HCC, versus only 19 per cent of patients from outside Dublin.
The five-year HCC survival rate is about 60-to-90 per cent in St Vincent’s, which offers all treatment options for HCC, including chemotherapy, thermal ablation, resection and transplantation, outlined Dr Houlihan. There is a significant shortage of available organs, he acknowledged, so there is about a 15 per cent mortality rate on the transplant waiting list, while there is a 10 per cent transplant-related mortality rate. While his unit uses the Milan criteria when considering HCC patients for transplant (single tumour ≤5cm, or up to three tumours each with diameter ≤3cm), it has transplanted 26 patients outside of the criteria in the last decade, with good five-year survival, less so at 10 years, Dr Houlihan revealed, “but still, 60 per cent survival at 10 years is pretty good for a patient with a large hepatoma”.
“Picking up this cancer early is crucial,” he reiterated.
“I think liver disease is a massive problem in Ireland. We just don’t have the data like the UK to reflect the problem. I think there is an issue with resources around the country and I think we require dedicated cirrhosis centres around the country. The Dublin centres are pretty well established and robust. I think we need to move to a hub-and-spoke model,” Dr Houlihan concluded.
Also speaking during this session, a UK expert on non-alcoholic fatty liver disease (NAFLD), Dr Matthew Armstrong, Consultant in Hepatology and Transplant Medicine, Queen Elizabeth University Hospital, Birmingham, highlighted how the disease is reaching epidemic levels in the UK and Ireland.
“I think we all aware now in the UK and Ireland that one-in-three people are obese, 5 per cent of patients have type 2 diabetes and most concerningly, if you go into the last year of primary schools in England, 30 per cent of the children are now classed as overweight,” he told ISG delegates.
Now the most common form of liver disease in the UK, “NAFLD will become the leading indication for liver transplant by 2020”, Dr Armstrong told the meeting.
NAFLD is also an independent risk factor for type 2 diabetes, cardiovascular disease, heart attack and stroke, he stated.
“One of the biggest worries is fibrosis, rather than actual inflammation,” Dr Armstrong commented when discussing which patients are suitable for discharge, adding that FibroScan availability in the community, as opposed to just hospitals, would be useful for monitoring fibrosis levels.
Treatment-wise, he advocated lifestyle changes as the most important, ie, reduce alcohol, cease smoking, exercise more, and “the best diet so far in the literature is Mediterranean”, adding that “statins are safe”.
“Weight-loss wise, these patients have to lose 10 per cent of their body weight, it will start to improve their fibrosis, so they’ve got to show a significant amount of weight loss before you start to see improvements,” Dr Armstrong stated, while acknowledging the role of bariatric surgery for curing non-alcoholic steatohepatitis (NASH) in morbidly obese patients.
Regarding future treatments, especially for NASH, for which there are currently no licensed treatments, there are a number of promising drugs in the pipeline, with a lot of interest in vitamin E and some existing drugs for type 2 diabetes, with metabolic and antifibrotic actions in emerging novel agents, he reported.
Concluding, Dr Armstrong said that currently, lifestyle is the most effective treatment for NAFLD, with little negative side-effects and the benefit of being cheap, though it is not popular with patients, while new drug therapies are on the way, which will likely be popular with patients but will ultimately
Doctors told to have low level of suspicion for Barrett’s oesophagus
Selective screening for Barrett’s oesophagus should be introduced, and all doctors need to have a low threshold for suspecting
the condition in older, obese male patients, the ISG Annual Winter Meeting heard.
A leading US researcher and clinician on Barrett’s oesophagus, Dr Ken Wang, Director of the Advanced Endoscopy Group, Mayo
Clinic, Minnesota, US, gave an endoscopic overview of Barrett’s oesophagus diagnosis
and management to
During his presentation, Dr Wang emphasised that selective screening of patients is key, as presentation of Barrett’s oesophagus is typically very late and over 80 per cent of patients do not realise they had it when diagnosed (US data).
The condition is most common in older, obese male patients, particularly those with visceral fat and a current or prior history of smoking.
Citing US research data, Dr Wang acknowledged that uptake rates for colon cancer screening are approximately 60 per cent in established programmes, with the target being 80 per cent; “no one likes getting a colonoscopy”.
Showcasing the latest technological advances in screening, including a new breath test for detecting Barrett’s oesophagus, he called for the introduction of minimally-invasive bowel screening.
“Screening for Barrett’s oesophagus is advocated by many societies, both in the US and the UK. I think it is something we can start to practise; selective screening of people at higher risk of Barrett’s oesophagus, like those who are male, Caucasian, over age 50, obese, family members with a history of Barrett’s carcinoma [as per the American College of Gastroenterology guidelines],” Dr Wang told the Medical Independent (MI).
“The other thing is, I would encourage people to start developing their skills in finding dysplasia using imaging techniques, because I think the old recommendations regarding trying to find dysplasia by random biopsies is probably outdated.”
Continuing, he said: “And clearly the evidence shows that, in experienced hands, imaging alone is sufficient to exclude dysplastic
lesions. And lastly, I think Irish physicians should keep their eyes open and develop skills and perform resections of the mucosa, as the future is that there will be a lot more opportunities for us to benefit our patients long-term with these techniques.”
Meanwhile, discussing the surgical management of Barrett’s oesophagus during the same session, Prof John Reynolds, Professor of Clinical Surgery at St James’s Hospital and Trinity College Dublin, noted that there are few trials in the area.
Highlighting his thresholds for anti-reflux surgery, Prof Reynolds said it should only be a last resort, after failure of medical therapy, where there is high-volume reflux, in particular the combination of severe regurgitation and heartburn, or severe oesophagitis at first endoscopy. Surgery is also indicated in symptomatic Barrett’s oesophagus, in particular long-segment, especially with hiatus hernia, inflammation and suboptimal medical control, he said.
Citing research he was involved in, Prof Reynolds said the development of de novo Barrett’s oesophagus post-oesophagectomy is bile and acid related and, like Dr Wang, he stated doctors need to have “a low threshold for suspecting
Barrett’s oesophagus in patients with difficult to manage reflux disease, particularly if they are male, are in their 50s, are obese, because that is the sort of cohort… [that might have Barrett’s oesophagus or cancer]”.
IBD database could have useful clinical applications
A pilot cloud-based inflammatory bowel disease (IBD) database from the European Crohn’s and Colitis Organisation (ECCO) could enable Irish clinicians to assemble “incredibly useful” local and national data on their patients and ultimately improve patient outcomes.
United Registries for Clinical Assessment and Research (UR-CARE) is an online registry capturing IBD patients’ records, designed for daily clinical practice and research studies.
A workshop on how the UR-CARE platform works (it is being trialled in Tallaght Hospital, Dublin) was held during the ISG Annual Winter Meeting in Naas last month and sought feedback from delegates.
Speaking during the workshop, ISG President Prof Larry Egan said while there was some work involved in getting used to using the database and filling in the detailed data fields, if set up and integrated correctly with existing hospital systems, it could print out a report at the end of a patient’s visit, thus also being useful in day-to-day clinical practice and removing the need to enter data twice. Other audience members acknowledged how useful having easy-to-access, up-to-date all-Ireland data would be.
Speaking to the Medical Independent (MI), Dr Glen Doherty, Chair of the INITIative Research Network for IBD in Ireland and Consultant Gastroenterologist, St Vincent’s University Hospital, Dublin, said the UR-CARE database was designed primarily as a research tool but is developing “to incorporate functionality that would make it useful to aid clinical care on a day-to-day basis”.
“We recognised in the ISG the value of a clinical database for patients with IBD, both as a means of a research tool, but also a means of being able to track which patients are on what medication and also for health maintenance purposes as well; as a way of tracking if patients have had side-effects from medications, have had their vaccinations, other sorts of health promotion, such as smoking cessation, etc,” he explained.
Dr Doherty said the research and feedback to the Network to date has been that the database is useful and there is an appetite to roll it out in Ireland. “The ISG would like to support other sites that don’t have such a good infrastructure to aid them in establishing the database,” he said.