INTRODUCTION:Mismatch repair deficiency (MMRd) is a tumour-agnostic biomarker predicting response to immune checkpoint inhibition (ICI). Microsatellite unstable (MSI-H) colorectal cancers (CRC) display poor response to 5-Fluorouracil-based chemotherapy. ICIs demonstrate benefit in stage IV disease, but data on neoadjuvant ICI remain limited. METHODS:Prospective case series evaluating early outcomes of downstaging PD-1 inhibition for locally unresectable ± oligometastatic MMRd colorectal adenocarcinomas. Primary endpoints are complete clinical response, conversion to curative resection or disease progression. Ethical approval was granted by the institution's ethical review board. RESULTS:From October 2022-September 2024, ten patients started downstaging ICI, including six right-sided, one left-sided and three rectal tumours. Median age was 59 (IQR 54-68). One patient had stage II, six stage III and three stage IV disease. All had threatened surgical margin necessitating downstaging. Three patients with rectal cancer also received radiotherapy, and two commenced systemic chemotherapy before switching to ICI. Five patients required a defunctioning stoma. Median follow-up was 21.5 months (IQR 16-26). Objective response rate (RECIST 1.1) was 9/10. Six of ten tumours were resected, with complete pathological response (pCR) in four. Three others underwent non-operative management, following a complete or near-complete clinical response (cCR/ncCR). Nine of ten patients are alive. Four patients had grade 2/3 toxicity, while four developed a clinically significant treatment-related stricture, with one perforation. CONCLUSION:We report promising downstaging and pCR/cCR rate of ICI for initially-unresectable MMRd CRC. ICI-first can permit curative resection, with risk of local complication from significant treatment response. Larger, multi-centre studies are needed to validate these findings.

Incidence and prevalence of eosinophilic oesophagitis (EoE) may be increasing. Patients with fibrostenotic disease often present with dysphagia, food bolus obstruction and the inflammatory-predominant phenotype with vomiting and reflux [1]. Delayed diagnosis and treatment correlate with fibrosis [2]. Improved physician awareness could enable more timely diagnosis, reduce disease progression, and thus associated complications, treatment refractory disease and poorer quality of life. An Irish 2011 study indicated EoE was rare, noting an increasing referral pattern [3]. A retrospective study of St James's Hospital (SJH) pathology records (January 2016–December 2020) for patients with recorded eosinophilia on oesophageal biopsy was conducted. Those meeting the EoE [4] criteria were included. The incidence, characteristics and management of EoE patients were reviewed, when no specialty clinic existed and patients were managed by multiple disciplines. This clinical audit study was SJH Research and Innovation (7989) approved; ethics review was not required. EoE endoscopic phenotypes representing severity of inflammation versus remodelling included (i) inflammatory (oedema, furrows and exudate), (ii) fibrostenotic (rings and strictures) and (iii) mixed (i+ii combined) [1]. Remission was reviewed separately across clinical, endoscopic and histologic criteria. 'Clinical-remission' refers to complete resolution of symptoms, whereas 'clinical-response' was any improvement. A single operator reviewed endoscopic photographs and calculated EREFS. 'Endoscopic-remission' was an EREFS of 0 and 'endoscopic-response' as any improvement. 'Histological-remission' was < 15-eosinophils/hpf and 'histological-response' as any improvement in eosinophils/hpf. Other histological features of EoE were not routinely reported. New EoE patients were identified each year, divided by the Dublin City region adult population (aged ≥ 15 years) at the time of study, yielding annual incidence rate (cases/100,000-population). Cumulative prevalence was calculated similarly. Annual incidence of adult EoE diagnosis at SJH remained stable, ranging between 1.1 (2015) and 2.6 (2020); prevalence increased steadily, to a cumulative 12.2 by 2020. A total of 133-patients with biopsy eosinophilia were identified; of these, 78 met the EoE diagnostic criteria (including ≥ 15eos/hpf) [4]. Symptoms included: dysphagia (55%), reflux (8%), impacted food bolus (7%), food sticking (5%), chest pain (1%) and no indication (20%) was documented on index OGDs, with no significant difference among phenotypes. Mean age at OGD/biopsy was 33-years (SD14); males predominated (n = 61 [78%]). Mean outpatient follow-up was 46-months. Duration of pre-diagnosis symptoms was longer in phenotypes with fibrosis (mixed = 6-years; fibrostenotic = 7-years) versus inflammation (3.4-years; p = 0.0316). Endoscopic phenotype data were available for 75/78-patients. Evaluating the index OGD, the median index EREFS score was 3 and did not improve on follow-up; phenotypes were inflammatory n = 34 (45%), mixed n = 34 (45%) and fibrostenotic n = 7 (10%). Only 35% had adequate oesophageal biopsies taken for diagnosis [5], with adequate biopsy rates in 2016 = 24%, 2017–2018 = 38% and 2019–2020 = 35% and time to diagnosis of ~6-years (2016–2020). Of the 248 procedures, n = 54 (22%) involved therapeutic interventions (balloon dilatation n = 35 [63%]; food bolus extraction n = 15 [28%]; bougie dilatation n = 5[9%]). More therapeutic procedures were performed in fibrostenotic and mixed phenotypes (86% and 47%, respectively) versus the inflammatory group (6%; p = 0.0001). Thirty-three percent (n = 26/78) underwent therapeutic procedure(s) on their index OGD (n = 124/248), that is, 49% of all OGDs. These patients underwent 4.8 OGDs versus 2.4 OGDs for those not requiring intervention (p = 0.00054). Fifty-eight of 78-patients had adequate clinical follow-up data. Of these, n = 51 (88%) achieved some symptom improvement, but only n = 20 (35%) achieved full clinical-remission, leaving n = 7 (12%) with no improvement. Stricture presence (7-v-0 patients; p = 0.029) and longer symptom duration (6.1-v-3.4 years; p = 0.0316) were significantly different in those not achieving clinical-remission (Figure 1). Those achieving clinical-remission (n = 20/58) did so with OVB-alone n = 6 (30%), FP+PPI n = 4 (20%), PPI-alone n = 4 (20%), FP-alone n = 3 (15%), OVB+PPI n = 2 (10%) and dairy exclusion n = 1 (5%). Where clinical-remission had adequate follow-up (n = 13), n = 10 (77%) achieved histological-remission and no significant age or sex difference was noted. Of the 57-patients exposed to PPI-therapy, at last follow-up n = 11 (< 20%) remained on sole PPI-therapy, 3 were lost to follow-up; and of the 8 remaining (mean follow-up 4 years), 5 remained on therapy. Of those with endoscopic follow-up, 4/5 demonstrated endoscopic-remission and 3/5 remained in histological-remission. Often, PPI-response was not routinely assessed with follow-up endoscopy and patients who did not improve symptomatically were escalated to topical corticosteroids. Among steroid treated patients with follow-ups reported, 36/44 (82%) demonstrated symptomatic improvement (39% clinical-remission, 43% clinical-response); n = 20/26 (77%) demonstrated endoscopic improvement (38.5% remission, 38.5% response); and 21/28 (75%) demonstrated histological improvement (46% remission, 29% response). Poorer rates of all responses occurred in FP-versus-OVB-treated patients. Compliance was not assessed. Significantly fewer fibrostenotic group patients were exposed to steroid-therapy compared with the overall cohort (67%-v-80% p = 0.023*). Although this study is limited by its small sample size, retrospective nature, tertiary centre location, with missing data (e.g., standard reporting of histology features), it is the first detailed Irish study since 2011 and provides insight into the natural history of disease. A prospective study is required. Versus similar centres, our patient cohort demonstrated poor clinical/endoscopic and histologic-remission rates and a more severe phenotype with higher EREFS's, which did not improve in follow-up. Although our incidence of oesophageal stricturing disease agrees with literature [2, 6], such patients required multiple endoscopic interventions. Longer duration of symptoms prior to diagnosis was associated with fibrosis, poorer clinical remission rates and increased requirement of endoscopic intervention thus impacting cost and quality of life. Other contributory factors may include multifactorial refractoriness, suboptimal biopsy strategies which may negatively influence time to diagnosis, poor follow-up rates underpinned by variability in care due to absence of a dedicated clinic. Lastly, access in Ireland to approved medication is challenging. Off-label topical steroid treatments can be cumbersome and lead to compliance issues, which may influence observed stasis in clinical-remission rates and follow-up EREFS's. The end result of these factors is delayed diagnosis and lack of consistent effective treatment resulting in increased inflammation; this may account for a more severe phenotype. A dedicated clinic has since been established aimed at standardising and improving care. Improved patient outcomes and quality of life could result from improvements in (i) primary care education, (ii) access to specialist services and medications and (iii) improved outpatient follow-up. Study concept and design: Olga Fagan, Ciaran Judge, Niall Conlon, Claire L Donohoe, Joanne C. Masterson and Susan Mc Kiernan. acquisition of data: Olga Fagan, Ciaran Judge amd Ciara Ryan. Analysis and interpretation of data: Olga Fagan, Ciaran Judge, Joanne C. Masterson and Susan Mc Kiernan. Drafting of the manuscript: Olga Fagan and Joanne C. Masterson. Critical revision of the manuscript for important intellectual content: Olga Fagan, Ciaran Judge, Ciara Ryan, Niall Conlon, Claire L Donohoe, Joanne C. Masterson and Susan Mc Kiernan. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.

OBJECTIVE:To evaluate the progression rate of Barrett esophagus (BE) to esophageal adenocarcinoma (EAC) using a prospectively maintained national registry, quality-assured endoscopy, and expert pathology. BACKGROUND:BE is the sole pathologic precursor of EAC. Targeting prevention and early diagnosis through quality-assured BE programs has a compelling rationale. METHODS:A Barrett's Registry and Bioresource was founded in 2011, and data to November 2024 were prospectively documented in a web-based system (Dendrite, UK). Endoscopy and pathology (of specialized intestinal metaplasia) were strictly quality assured per current guidelines. Expert gastrointestinal pathologists classified non-dysplastic BE (NDBE), indefinite for dysplasia (IND), low-grade dysplasia (LGD), and high-grade dysplasia (HGD). Endoscopic eradication therapies were monitored. Multivariable regression models evaluated risk factors for progression, and Kaplan-Meier curves were constructed for overall progression, and progression excluding the first year after the index biopsy. RESULTS:Nine thousand four hundred thirty-six patients were registered, with a median follow-up of 4.4 years, and 5331 had at least one follow-up endoscopy. Overall, 252 cases (4.7%, 95% CI: 1.70-2.18) of HGD and 255 cases (4.7%, 95% CI: 1.72-2.20) of EAC were diagnosed. Among these, 150 cases (2.8%. 95% CI: 1.05-1.44) of HGD and 148 (2.7%, 95% CI: 1.05-1.44) of EAC were diagnosed more than 1 year after the index endoscopy. The overall incidence of HGD/EAC combined was 2.42% (95% CI: 2.14-2.73), 6.59% (95% CI: 5.14-8.46), and 13.79% (95% CI: 11.94-15.93) per year in NDBE, IND, and LGD, respectively. Independent risk factors include male sex [hazard ratio (HR): 0.655, 95% CI: 0.56-0.896, P <0.004], age (HR: 1.027, 95% CI: 1.02-1.04, P <0.001) and Barrett's length (HR: 1.635, 95% CI: 1.33-2.01, P <0.001). 604 (6.4%) patients underwent RFA, with a complete eradication of SIM in 80.5% and 10 (1%) patients required resectional surgery. Cancer-specific survival in the total cohort was 100%. CONCLUSIONS:A structured high-volume Barrett's program, underpinned by quality assurance, provides data that highlights a strategy that provides proof of concept in targeting prevention and early detection, and is anticipated to reduce mortality.

This study aimed to analyse the demographic, pathological and survival outcomes of patients with clinically predicted T1 oesophageal adenocarcinoma who underwent surgery in a high-volume national centre. Patients with clinically predicted T1 oesophageal adenocarcinoma who underwent surgery between 2010-2024 were identified from a prospectively defined dataset, excluding those who received neoadjuvant therapy. A total of 149 patients were included. Demographics, indications for surgery (after staging EMR or straight to surgery), staging investigations (EUS, PET-CT, Paris classification), surgical details, post-operative complications (Clavien-Dindo Classification), rate of nodal metastasis, survival and recurrence rates were analysed. 149 patients had surgery with mean age of 64.41 years and 79.87% were male. 62 patients underwent surgery after staging EMR due to unresectable lesions, adverse histology, positive deep margins or recurrence. 87 patients were triaged straight to surgery due to multifocal disease, predicted invasive disease or unsuitability for endoscopic therapy. 135/149 had EUS and 139/149 had PET-CT. The rate of nodal metastasis was 14.1% (21/149), with T1b being the most common pathological stage amongst positive nodes. The recurrence rate is estimated to be 6.7% (10/149). At a median follow up of 54 months (range 0.13 months – 154 months) 80.54% of our cohort were alive and the Kaplan-Meier median survival was therefore not reached. The observed rates of nodal metastasis and recurrence emphasise the importance of thorough staging and ongoing surveillance in this patient cohort at substantial risk of systemic recurrence. Further data on utility of adjuvant SACT in this cohort are required.

Abstract Background The Active Recovery Team (ART) is a new therapy lead rehabilitation team that offers supported discharge and admission avoidance from a large acute hospital. This interdisciplinary team consists of a physiotherapist, occupational therapist, medical social worker and two therapy assistants. ART accepts referrals from all services within the hospital including the emergency department. Methods As ART is a new service, a retrospective audit of the first 100 patients who discharged on the pathway was completed. Demographics included age, sex, referring specialty, presenting complaint, frailty (measured by the Clinical Frailty Score) and level of input received. ART use the coding of low, medium and high intensity to describe the intervention provided based on dosage (visits) and complexity. Results Most (67%) of the group were female and mean age was 77 years. Only 8% were pre-frail (CFS 0-3), 86% were living with mild to moderate frailty (CFS 4-6) and 6% considered severely frail (CFS 7-9). The type of intervention patients received was 31% low, 33% medium and 36% high intensity. Referrals came from a range of specialties, but the highest percentage of referrals were from emergency medicine (29%), medicine (20%), orthopaedics (18%) and geriatric medicine (16%). Most (53%) initially presented post a fall at home. Most frequent reason for ART referral (78%) was that the patient was discharging home not at their functional baseline but had potential to an achieve a specific goal(s) with further input (most frequently within domains of mobility indoors/outdoors, transfers, stairs and activities of daily living). Conclusion This is an effective pathway that improves the transition from hospital to home. ART offer patients an opportunity for further rehabilitation at home with continuity of care from the acute hospital. Future work will examine the impact of ART on length of stay, readmission rate and explore patient satisfaction with this service.

Abstract Background A need was identified for an urgent therapy follow-up at home for older adults presenting to the Emergency Department (ED). The acute floor team worked together within an established therapy outreach team (for inpatients) to develop an ED outreach pathway within existing resources. The outreach team members worked within ED to ensure standardisation of assessment, practice and build strong working relationships. A trusted assessor approach was applied. The outreach team had access to the wider acute floor team including ANP for in-reach support if needed. Methods A review of the patient group who discharged home from ED using this new pathway was completed including demographics, presenting complaint, clinical frailty score (CFS) and intervention provided. Results To date, 30 patients have discharged from the ED with the therapy outreach team. Most (70%) were female and mean age 83. Presenting complaint included fall no fracture (50%, n=15), fall with fracture (26%, n=8), musculoskeletal injury (17%, n= 5) and functional decline (6%, n=2). The mean CFS was 5.1, with most (86%) living with mild to moderate frailty (CFS 4-6). All patients were offered a next clinical day home based functional and environmental assessment, continuing the assessment commenced by the acute floor team in ED. Interventions included transfers and mobility training, activities of daily living (personal/domestic/instrumental) training, carer education, environmental advice, falls education, support with care packages, liaising with other healthcare professionals and equipment provision including mobility aids, bed-levers, toilet-aids and rails. Conclusion A therapy lead team, supported by the wider acute floor team, can provide a safe alternative discharge pathway from the ED for older adults that can avoid admission with rapid therapy input at home. Future work will examine re-admission rates, re-presentation rates to ED and patient and stakeholder satisfaction.

Abstract Background Approximately 1 in 5 older adults in Ireland experience recurrent falls. Consequences of falls include functional decline, fear of falling, reduced participation in activities, hospitalisation and mortality (TILDA, 2017). Increased prevalence of frailty and falls related admissions was identified on this acute older persons’ ward. Therapists found it increasingly difficult to provide comprehensive falls intervention given the ward’s quick turnover and increasing caseloads. Methods A joint occupational therapy and physiotherapy falls and balance group was piloted. Weekly once off group sessions were provided to patients over a two-month period. Inclusion criteria included patients who had/were at fear/risk of falling, and demonstrated the cognitive capacity to engage/attend to information in a group setting. Clinical indicators included Timed Up and Go (TUG), Clinical Frailty Scale (CFS), and the PRISMA 7. The group consisted of an educational and practical component including elements from the Otago Exercise Programme (OEP). Qualitative participant feedback was gathered post group attendance and qualitative descriptive analysis was used for evaluation. Results A total of 35 patients attended this group over the two-month pilot period. Participants’ mean age was 79 years, with 54.3% being female. 80% had a history of falling. 63% were living with mild to moderate frailty (CFS 4-6) with an average TUG time of 19.3 seconds. An open-ended questionnaire highlighted that 31 participants found the group beneficial with 68.6% valuing the peer support element. 94.2% found their knowledge on falls prevention increased, with 77.1% commenting on their increased awareness of the importance of regular physical activity in falls prevention. Conclusion This intervention successfully increased the quality of falls intervention provided on this acute older persons’ ward and effectively increased participants’ awareness/knowledge of falls intervention. It was feasible to deliver this group on an acute ward within existing therapy resources.

Abstract Background There are currently over 64,000 people living with dementia in Ireland, this number is expected to double by 2045. Direct observation from multiple disciplines highlighted a large cohort of people living with dementia experiencing disorientation, wandering, and falls at ward level. National Guidelines and Strategies state that physical ward environments should be a key consideration for dementia care. Research shows that physical ward environments can be adapted to reduce confusion and agitation and improve wayfinding for those living with dementia. Methods An environmental ward audit was conducted through direct observation, using the environmental checklist from the Irish National Audit of Dementia (INAD-2). The results of the audit were compared with national standards which showed reduced compliance. Adaptations and/or modifications including the installation of orientation clocks, orientation whiteboards and increasing signage and labels to the physical ward were implemented to increase compliance. The ward was re-audited to assess change. Results The results highlighted increased compliance with national standards. Direct observations from the multidisciplinary team identified increased wayfinding and orientation for patients living with dementia on the ward. Multidisciplinary education on dementia inclusivity is essential in fostering a person centred approach to dementia care in the acute ward environment. Conclusion Multidisciplinary collaboration and commitment to dementia inclusive care may enhance the experience of those living with dementia in the acute hospital setting. Barriers such as infection control measures emphasised the need for a collaborative approach to overcome challenges and facilitate change.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 study we sought to determine whether colonic tissue OSM immunostaining, on biopsies from pretreatment endoscopies, had utility as a biomarker of IFX treatment outcome in hospitalized patients with corticosteroid-refractory ASUC. Patients admitted for management of ASUC to St James’s Hospital in Dublin, Ireland between 2011 and 2017 were identified retrospectively. The diagnosis of UC was made using established clinical, endoscopic and histological criteria. Patients were included where they had received at least one rescue IFX infusion in the context of intravenous corticosteroid-refractory ASUC, had undergone pretreatment endoscopic assessment and had documented follow-up. IFX was administered as per the standard protocol with induction therapy consisting of 5 mg/kg infusions at 0, 2, and 6 weeks. Adjustment of induction infusion intervals was undertaken at the discretion of the treating physician. Concomitant additional treatment with mesalamine and immunomodulators was administered as indicated. Accelerated IFX induction was defined as the administration of 3 induction infusions in less than 28 days. Baseline demographic and clinical data were collected for each subject. Sigmoidoscopies performed prior to IFX initiation were reviewed and an endoscopic Mayo subscore was documented. C-reactive protein (CRP)/albumin ratio was calculated by dividing CRP concentration by albumin concentration. The study was approved by the St James’s Hospital/Adelaide and Meath Hospital incorporating the National pISSN 1598-9100 • eISSN 2288-1956 https://doi.org/10.5217/ir.2021.00073 Intest Res, Published online March 11, 2022

Introduction: Colorectal cancer (CRC) outcomes vary depending on tumour biology, with several features used to predict disease behaviour. Extramural venous invasion (EMVI) is associated with negative outcomes and its presence has been established as an indicator of more aggressive disease in CRC. Methods: A prospectively maintained database was examined for patients undergoing curative resection for non-metastatic CRC between 2012 and 2018 in a tertiary institution. Clinicopathological factors were compared to assess their impact on recurrence, all-cause mortality and cancer-related death. Kaplan Meier analysis of the association between EMVI and these endpoints was performed, and univariable and multivariable analysis was carried out to establish the relationship of predictive factors in oncological outcomes. Results: Eighty-eight (13.5%) of 654 patients developed recurrence. The mean time to recurrence was 19.8 +/- 13.5 months. There were 36 (5.5%) cancer-related deaths at a mean duration of follow-up of 46.3 +/- 21.6 months. Two hundred and sixty-six patients had extramural venous invasion (40.7%). EMVI was significantly associated with reduced overall recurrence-free survival, systemic recurrence-free survival, and increased cancer-related death on univariate analysis (p < 0.001 for all, Fig. 1), and multivariable analysis (OR 1.8 and 2.1 respectively, p < 0.05 for both). Conclusion: EMVI is associated with a poor prognosis, independent of stage, nodal status and other histopathological features. The presence of EMVI should be strongly considered as an indication for adjuvant therapy. (c) 2022 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

The first pillar of the End-TB Strategy is “early diagnosis and prompt treatment”. Nevertheless, long delays in starting tuberculosis (TB) treatment are reported. We aimed to describe the demographics and clinical features of TB in the west of Ireland and better understand the delays in treatment. We conducted a retrospective chart review of all patients diagnosed with active TB who attended the Galway University Hospital (GUH) TB clinic from 2014 to 2018. Eighty-five patients were diagnosed with TB and attended our clinic. Ten (12%) patients were receiving immunosuppressive therapy, 8 (9%) had drug resistance, and 41 (48%) had extra-pulmonary disease. Patients with extra-pulmonary disease had a longer length of stay before treatment (11 vs. 4 days; p = 0.006). Patients older than 55 had a longer length of stay before (16 vs. 5 days, p = 0.0001) and during (36 vs. 11 days, p = 0.004) treatment and were readmitted more frequently than younger patients. A total of 36% of patients were born outside Ireland. Non-Irish patients were younger (mean age 35 vs 48; p = 0.004) and more frequently had drug resistance (19% vs. 4%, p = 0.02). The median time from symptom onset to hospital presentation was 76 days (IQR 35–146 days) and the median time from first hospital presentation to TB treatment was 11 days (IQR 5–51 days). TB patients experienced long symptom durations in the community prior to presentation. Many TB patients experienced delays in diagnosis and treatment following presentation. Both pre-hospital and in-hospital delays need to be addressed in order to ‘End-TB’.

Gastroesophageal junction adenocarcinomas (GEJA) have dramatically increased in incidence in the western world since the mid-20th century. Their prognosis is poor, and conventional anti-cancer therapies do not significantly improve survival outcomes. These tumours are comprised of a heterogenous population of both cancer stem cells (CSC) and non-CSCs, with the former playing a crucial role in tumorigenesis, metastasis and importantly drug resistance. Due to the ability of CSCs to self-replicate indefinitely, their resistance to anti-cancer therapies poses a significant barrier to effective treatment of GEJA. Ongoing drug development programmes aim to target and eradicate CSCs, however their characterisation and thus identification is difficult. CSC regulation is complex, involving an array of signalling pathways, which are in turn influenced by a number of entities including epithelial mesenchymal transition (EMT), microRNAs (miRNAs), the tumour microenvironment and epigenetic modifications. Identification of CSCs commonly relies on the expression of specific cell surface markers, yet these markers vary between different malignancies and indeed are often co-expressed in non-neoplastic tissues. Development of targeted drug therapies against CSCs thus requires an understanding of disease-specific CSC markers and regulatory mechanisms. This review details the current knowledge regarding CSCs in GEJA, with particular emphasis on their role in drug resistance.

Epstein-Barr virus (EBV)-positive mucocutaneous ulcer is a lymphoproliferative disorder occurring in patients due to iatrogenic or age-related immunosuppression confined to the oropharynx, skin, and gastrointestinal tract. Here, we report the first case to our knowledge of EBV-positive mucocutaneous ulcer occurring in a gallbladder.

Summary Barrett’s esophagus (BE) is the main pathological precursor of esophageal adenocarcinoma (EAC). Progression to high-grade dysplasia (HGD) or EAC from nondysplastic BE (NDBE), low-grade dysplasia (LGD) and indefinite for dysplasia (IND) varies widely between population-based studies and specialized centers for many reasons, principally the rigor of the biopsy protocol and the accuracy of pathologic definition. In the Republic of Ireland, a multicenter prospective registry and bioresource (RIBBON) was established in 2011 involving six academic medical centers, and this paper represents the first report from this network. A detailed clinical, endoscopic and pathologic database registered 3,557 patients. BE was defined strictly by both endoscopic evidence of Barrett’s epithelium and the presence of specialized intestinal metaplasia (SIM). A prospective web-based database was used to gather information with initial and follow-up data abstracted by a data manager at each site. A total of 2,244 patients, 1,925 with no dysplasia, were included with complete follow-up. The median age at diagnosis was 60.5 with a 2.1:1 male to female ratio and a median follow-up time of 2.7 years (IQR 1.19–4.04), and 6609.25 person years. In this time period, 125 (5.57%) progressed to HGD/EAC, with 74 (3.3%) after 1 year of follow-up and 38 (1.69%) developed EAC, with 20 (0.89%) beyond 1 year. The overall incidence of HGD/EAC was 1.89% per year; 1.16% if the first year is excluded. The risk of progression to EAC alone overall was 0.57% per year, 0.31% excluding the first year, and 0.21% in the 1,925 patients who had SIM alone at diagnosis. Low-grade dysplasia (LGD) progressed to HGD/EAC in 31% of patients, a progression rate of 12.96% per year, 6.71% with the first year excluded. In a national collaboration of academic centers in Ireland, the progression rate for NDBE was similar to recent population studies. Almost one in two who progressed was evident within 1 year. Crucially, LGD diagnosed and confirmed by specialist gastrointestinal pathologists represents truly high-risk disease, highlighting the importance of expertise in diagnosis and management, and providing indirect support for ablative therapies in this context.

Oesophageal cancer has a reputation for poor survival, and a relatively high risk of major postoperative morbidity and mortality. Encouragingly, a recent international cancer registry study reports a doubling of survival outcomes in Ireland over the last 20 years. This study focused on both oncologic and operative outcomes in patients treated with curative intent requiring surgery at a high-volume center. All patients undergoing surgery or multimodal therapy with curative intent from 2009 to 2018 were studied. All data was recorded prospectively and maintained internally. The period 2009–2013 was compared with 2014–2018 to monitor any change in trends. Four hundred and seventy-five patients (adenocarcinoma 77%, mean age 65; 76% male; 64% neoadjuvant therapy) underwent open surgical resection, 54% via en bloc 2-stage, 19.8% en bloc 3-stage, and 26.5% by a transhiatal approach. New onset atrial fibrillation was the commonest index complication, in 108 (22.7%), 80 (18%) developed suspected pneumonia/respiratory tract infection, 20 (4.2%) an anastomotic leak, and 25 (5.2%) a chyle leak. The 90-day mortality rate was 1.2% and 0.8% at 30 days. The median survival was 77.17 months, with a 5-year survival of 56%. Consistent with registry data on population survival for oesophageal cancer, this study highlights markedly improved survival outcomes in patients treated curatively, reflecting international trends, as well as low mortality rates; however, cardiorespiratory complications remain significant.

Lymphoma diagnosis is complex, requiring a wide array of adjunctive tests to reach accurate diagnoses. We retrospectively examined the rates of concordance between referral and review lymphoma diagnoses on cases referred to St James's Hospital, Dublin for multidisciplinary team review between 2013 and 2016. Frequency and cost of adjunctive diagnostic tests performed were also analysed. The overall discordance rate was 7.8% (14/179), compared with rates of 6%-48% in the published literature. 13 discordant cases required a change in clinical management following review of the referred diagnosis. Of all referred cases, 33.5% (60/179) required extra analyses to reach a final diagnosis, costing the reference laboratory Euro35463.40. We conclude that establishment of centralised haematopathology diagnostic networks would help reduce the rate of revision made to lymphoma diagnoses by providing specialist haematopathologist input and access to ancillary testing.

Lymphoma diagnosis is complex, requiring a wide array of adjunctive tests to reach accurate diagnoses. We retrospectively examined the rates of concordance between referral and review lymphoma diagnoses on cases referred to St James’s Hospital, Dublin for multidisciplinary team review between 2013 and 2016. Frequency and cost of adjunctive diagnostic tests performed were also analysed. The overall discordance rate was 7.8% (14/179), compared with rates of 6%–48% in the published literature. 13 discordant cases required a change in clinical management following review of the referred diagnosis. Of all referred cases, 33.5% (60/179) required extra analyses to reach a final diagnosis, costing the reference laboratory €35463.40. We conclude that establishment of centralised haematopathology diagnostic networks would help reduce the rate of revision made to lymphoma diagnoses by providing specialist haematopathologist input and access to ancillary testing.