To date, empirical methods using age, type of cancer and presence of family history of cancers are used clinically to identify individuals who may benefit from genetic counselling (GC) and testing, but because these guidelines use a threshold, they provide a standard recommendation regardless of whether women have a low (e.g. 4%) or high (e.g. 40%) likelihood of being BRCA carriers. We developed the Asian Genetic Risk Calculator (ARiCa), an Asian-specific personalised genetic risk assessment tool, to determine the probability of a breast cancer patient carrying a germline BRCA1/2 pathogenic or likely pathogenic variant. The ARiCa Study was established to evaluate the impact of personalised risk score on risk perception and cancer-related distress, and uptake of GC among breast cancer patients. The ARiCa Study is a prospective observational multicentre two-arm study where 256 incident and prevalent breast cancer patients in breast surgical clinics who have previously not received GC will be randomised to receive genetic risk assessment based on current clinical criteria (controls) or ARiCa personalised risk score. The patients’ risk perception, distress level and GC uptake were determined via researcher-administered questionnaires six weeks after risk assessment. Interim analysis of 110 patients showed that compared to controls, a greater proportion of patients receiving ARiCa scores felt that the genetic risk information provided was easy to understand (92% vs 88%, p= 0.523) and influenced their decision on GC uptake (86% vs 78%, p=0.299). More participants also proceeded with GC (47% vs 39%, p=0.526) but none of the results were statistically significant. No significant distress after receiving genetic risk assessment was reported. Patients provided with personalized scores found that the visual (96%) and numerical (90%) forms of risk presentation were more helpful than the qualitative (84%) forms. These interim results showed that personalized genetic risk assessment using visual and numerical forms of risk presentation is acceptable and may be a useful tool in facilitating the uptake of GC among breast cancer patients.

Introduction To evaluate the clinical and biochemical outcomes of patients with inflammatory bowel disease to Vedolizumab- at a District General Hospital Methodology Retrospective cohort study assessing 55 patients administered Vedolizumab between 2015 and 2019. Demographics and clinical information were recorded. Response was determined using Harvey Bradshaw (HB) and partial Mayo score (pMS). Baseline indices and serum CRP were recorded at (i) prior to commencement, (ii) 6 months, and (iii) 12 months. A clinical response was determined by a decrease in pMS and HB of at least 3 points for UC and CD respectively or to a score below 5. Results A total of 55 patients (33 CD, 22 UC) were found on our electronic records. A total of 44(18 UC, 26 CD) were included with 11 patients excluded as they had started within 6 months of study commencement. Mean age for UC was 45.2 years and CD was 42.8 years, 15/18(83.3%) UC patients and 20/26 (76.9%) CD patients had prior anti TNF exposure. 56% (5/9) of all those TNF naïve were found to have a response at 6 months. UC group Mean CRP reduction at 6 and 12 months was -7.1 and -6.3 respectively. Mean pMS prior to treatment 5.8 and at 6 months was 4.8. At 6 months, 6% (n=1/18) were responders, 61% (11/18) were partial responders and 33% (n=6/18) were non responders. 67% (n=12/18) completed 12 months treatment when 8%(n=1/12) were responders, 58% (n=7/12) partial responders and 33% (n=4/12) were non responders. CD group Mean CRP reduction at 6 and 12 months were -7.7 and -7.2 respectively. Mean HB prior to treatment 7.7 and at 6 months was 5.7. At 6 months, 19%( n=5/26) were in clinical remission, 15% (n=4/26) were responders, 46% (n=12/26) were partial responders and 19% (n=5/26) non responders. 65% (n=17/26) completed 12 months treatment, of those 23.5% (n=4/17) were in clinical remission, 17.6%( n=3/17) were responders, 41% (n=7/17) were partial responders and 17.6% (n= 3/17) were non responders. Reasons for stopping treatment in all patients: treatment was stopped prior to completion of 12 months in 15/44(34%) patients. This included need for surgery 4.5% (2/44), abnormal liver function tests 9%(n=4/44), intolerance 18% (8/44), and pregnancy 2.2% (1/44). Conclusion Our results reflect similar safety and efficacy of Vedolizumab to published data. Vedolizumab was generally well tolerated with no serious adverse effects.

Introduction Research of age-related treatment failure with biologics for inflammatory bowel disease (IBD) is limited. Previous studies have suggested a higher failure risk for Adults >60 years (>60), but focused on anti-TNFα agents. Newer biologics are revolutionising treatment for Adults with IBD, but to date treatment failure or intolerance in the >60 is poorly understood. RAB-IBD (Retrospective analysis of biologic treatment failure in IBD) at Royal Wolverhampton NHS Trust, is a real-life, longitudinal retrospective single-centre study comparing failure rates for biologics/biosimilar agents. These include anti-TNFα’s, integrin-inhibitors, interleukins-inhibitors and JAK-inhibitors. The primary outcome was to evaluate whether treatment failure at 12 months was impacted by age (>60s versus <60s). The secondary outcomes were to analyse if failure to complete 12 months of therapy were a result of the; type of biologic used, use of concomitant drugs, or demographic factors. Methods 632 patients were identified from the Trust IBD database, who were initiated on biologics from January 2015 to December 2019. 465 matched our inclusion and exclusion criteria. Baseline characteristics, such as gender, biologic, type of IBD and number of biologics used previously, were matched to produce two cohorts, each of 98 participants comprising >60s and <60s. Results Adverse effects, hospitalisation and need for emergency surgery was seen in 5.1% of under 60s (n=5) and 13.3% of over 60s (n=13). There was no significant difference in the proportion of patients who failed to complete 12 months of biologic treatment from the >60s (n=20, 20.4%) versus <60s (n=12, 12.2%) (OR 1.838, p=0.126). A larger proportion of biologic failure was seen in those on anti-TNFα vs. non-anti-TNFα biologics, but this was not significant (OR 2.35, p=0.051). IBD type (Crohn’s vs. Colitis) was not a predictor of biological failure (OR 1.856, p=0.176), nor was previous biologic use (OR 0.644, p=0.118); concomitant thiopurines/methotrexate (OR 0.46, p=0.134); co-morbidities (OR 0.834, p<=0.752); smoking status (OR 0.956, p=0.888); severity score (OR 0.939, p=0.420); baseline CRP (OR 1.024, p=0.250); faecal calprotectin (OR 1.00, p=0.746). Risk of biological failure at 12 months was greater in women than in men (OR 2.5, p=0.023). Conclusions Age is not an independent predictor of pooled biological failure at 12 months post-initiation. This finding may be factored in when personalised treatment approaches are sought for >60s who are not respondent to conventional therapy. However, more research is required in a higher-powered study to investigate whether treatment failure is influenced by various demographic factors and by biologic type.

Background. Preoperative anemia and red blood cell (RBC) transfusion are both associated with in-hospital mortality after cardiac surgery. The aim of this study was to investigate the interactions between preoperative anemia and RBC transfusion and their effect on the long-term survival of patients undergoing cardiac surgery. Methods. Between 2005 and 2012, 1170 patients with anemia who underwent elective or urgent cardiac surgery were included. A matched group of 1170 nonanemic patients was used as a control group. A binary logistic regression model was used. Results. The median follow-up period was 64 months (range, 0-127). Anemic patients had higher mortality (45%, n = 526) than nonanemic patients (32%, n = 374; P < .001). Preoperative anemia was independently associated with long-term mortality (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.46-2.1; P < .001), with both moderate (OR, 2.27; 95% CI, 1.72-2.99; P < .001) and mild anemia (OR, 1.39; 95% CI, 1.13-1.71; P = .002) contributing significantly. RBC transfusion was not associated with long-term mortality (OR, 1.07; 95% CI, 0.88-1.31; P = .49). There was no interaction between preoperative anemia and RBC transfusion (P = .947). Conclusions. Long-term mortality is significantly high in patients who are anemic, regardless of their transfusion status. Preoperative anemia is a strong, independent predictor of mortality and therefore should be managed before cardiac surgery. (C) 2019 by The Society of Thoracic Surgeons

Background. Preoperative anemia is common in patients scheduled for cardiac surgery. However, its effect on postoperative outcomes remains controversial. This meta-analysis aimed to clarify the impact of anemia on outcomes after cardiac surgery. Methods. A literature search was conducted on MEDLINE, Embase, Cochrane, and Web of Science databases. The primary outcome was 30-day postoperative or inhospital mortality. Secondary outcomes included acute kidney injury, stroke, blood transfusion, and infection. A meta-analytic model was used to determine the differences in the above postoperative outcomes between anemic and nonanemic patients. Results. Of 1103 studies screened, 22 met the inclusion criteria. Of 114,277 patients, 23,624 (20.6%) were anemic. Anemia was associated with increased mortality (odds ratio [OR], 2.74; 95% confidence interval [CI], 2.32-3.24; I-2 = 69.6%; P <.001), acute kidney injury (OR, 3.13; 95% CI, 2.37-4.12; I-2 = 71.1%; P <.001), stroke (OR, 1.46; 95% CI, 1.24-1.72; I-2 = 21.6%; P <.001), and infection (OR, 2.65; 95% CI, 1.98-3.55; I-2 = 46.7%; P <.001). More anemic patients were transfused than nonanemic patients (33.3% vs 11.9%, respectively). No statistically significant association was found between mortality and blood transfusion (OR, 1.35; 95% CI, 0.92-1.98; I-2 = 83.7%; P = .12), but we were not able to compare mortality with or without transfusion in those who were or were not anemic. Conclusions. Preoperative anemia is associated with adverse outcomes after cardiac surgery. These findings support the addition of preoperative anemia to future risk prediction models and as a target for risk modification. (C) 2019 by The Society of Thoracic Surgeons

OBJECTIVESPreoperative anaemia is a strong predictor of blood transfusion requirements and must be assessed for appropriate optimization before elective surgery. Iron therapy is a transfusion-sparing approach effective for increasing haemoglobin concentrations. However, its role in elective cardiac surgery and the optimal route of administration remain unknown. This single-centre, non-blinded, randomized, controlled trial compared the effectiveness of intravenous ferric carboxymaltose therapy with oral iron for anaemic patients undergoing elective cardiac surgery.METHODSFifty anaemic patients scheduled for elective cardiac surgery were randomized to receive either oral or intravenous iron therapy 3-8 weeks preoperatively. Changes in haemoglobin concentration were measured. Blood transfusion and postoperative outcome data were collected.RESULTSPreoperative median increases in haemoglobin were 1.0 g/l (interquartile range -3.25 to 7.25 g/l) and 3.0 g/l (interquartile range -1.25 to 6.25 g/l) for patients receiving intravenous and oral iron, respectively (P = 0.42). The median first 12-h blood loss was significantly higher in the intravenous group (655 ml; interquartile range 162-1540 ml) compared to the oral group (313 ml; interquartile range 150-1750 ml; P < 0.007). Median increments in serum ferritin were superior for the intravenous group (median difference 313 µg/l; interquartile range 228-496) compared to the oral group (median difference 5.5 µg/l; interquartile range -1.4 to 19.4; P < 0.001).CONCLUSIONSIncreases in ferritin after intravenous iron administration were significantly greater than those after oral iron administration. There was no significant difference in haemoglobin increments between groups. Despite significantly higher intraoperative blood loss in the group receiving intravenous iron, blood transfusion requirements for both groups were not statistically different.CLINICAL TRIAL REGISTRATIONISRCTN22158788.

Anaemia is associated with a reduction in quality of life, and is common in patients with colorectal cancer . We recently reported the findings of the intravenous iron in colorectal cancer-associated anaemia (IVICA) trial comparing haemoglobin levels and transfusion requirements following intravenous or oral iron replacement in anaemic colorectal cancer patients undergoing elective surgery. In this follow-up study, we compared the efficacy of intravenous and oral iron at improving quality of life in this patient group. We conducted a multicentre, open-label randomised controlled trial. Anaemic colorectal cancer patients were randomly allocated at least two weeks pre-operatively, to receive either oral (ferrous sulphate) or intravenous (ferric carboxymaltose) iron. We assessed haemoglobin and quality of life scores at recruitment, immediately before surgery and at outpatient review approximately three months postoperatively, using the Short Form 36, EuroQoL 5-dimension 5-level and Functional Assessment of Cancer Therapy - Anaemia questionnaires. We recruited 116 anaemic patients across seven UK centres (oral iron n = 61 (53%), and intravenous iron n = 55 (47%)). Eleven quality of life components increased by a clinically significant margin in the intravenous iron group between recruitment and surgery compared with one component for oral iron. Median (IQR [range]) visual analogue scores were significantly higher with intravenous iron at a three month outpatient review (oral iron 70, (60-85 [20-95]); intravenous iron 90 (80-90 [50-100]), p = 0.001). The Functional Assessment of Cancer Therapy - Anaemia score comprises of subscales related to cancer, fatigue and non-fatigue items relevant to anaemia. Median outpatient scores were higher, and hence favourable, for intravenous iron on the Functional Assessment of Cancer Therapy - Anaemia subscale (oral iron 66 (55-72 [23-80]); intravenous iron 71 (66-77 [46-80]); p = 0.002), Functional Assessment of Cancer Therapy - Anaemia trial outcome index (oral iron 108 (90-123 [35-135]); intravenous iron 121 (113-124 [81-135]); p = 0.003) and Functional Assessment of Cancer Therapy - Anaemia total score (oral iron 151 (132-170 [69-183]); intravenous iron 168 (160-174 [125-186]); p = 0.005). These findings indicate that intravenous iron is more efficacious at improving quality of life scores than oral iron in anaemic colorectal cancer patients.

Introduction Anaemia is associated with multiple symptoms including fatigue which in turn can contribute to impaired quality of life. It is a common finding in colorectal cancer as a result of chronic insidious haemorrhage and impaired iron haemostasis. Consequently, colorectal cancer patients are at risk of the symptomatology of anaemia. Method Preoperative colorectal cancer patients (n=116) who were found to be anaemic (>1g/dL below the World Health Organisation definition) were randomised to receive either intravenous (IV) or oral iron. Quality of life (QOL) questionnaires were performed at; [i] recruitment, [ii] at least 14 days after iron therapy and [iii] post-operatively in the first outpatient follow-up. QOL assessments undertaken included the following; [a] Functional Assessment of Cancer Therapy-Anaemia (FACT-AN) [b] EuroQol EQ-5D-5L (EQ5D) and [c] modified Short-Form 36 (SF36) v1 questionnaires. Results Both groups were comparable in patient demographics, starting haemoglobin, operative details, tumour histology and time from recruitment to postoperative review (oral 101 days [IQR 62-193]; IV 91 days [IQR 61-135, P=0.98]. Despite homogeneity in all initial QOL scores at recruitment significant differences were evident between groups at outpatient review in the all bar two of the SF36 components including: General Health (Oral 64.79u [58.8-70.8]; IV 73.63u [68.4-78.8]; P<0.01), Vitality (Oral 60.49u [53.7-67.3]; IV 74.83u [69.2-80.5]; P<0.001). EQ5D scores for the visual analogue scale were also significantly higher in the IV group at outpatient review (OI 70.9u [65.1-76.8]; IV 82.53u [77.8-87.2]; P<0.001), with parity in the remaining 4 components. Furthermore, significant differences were evident in FACT-AN Total scores (Oral 148.3u [139-158];IV 166.1u [160-172.3]; P<0.01), FACT-AN Anaemia subscale scores (Oral 59.6u [54.4-64.8]; IV 69.1u [65.7-72.5]; P<0.01), Functional Well Being (Oral 20.2u [17.9-22.5]; IV 24.1u [22.2-26];P<0.01) and Emotional Well Being (Oral 19.9u [18.5-21.2]; IV 21.5u [20-23]; P<0.05) at outpatient review. None of the QOL measures had higher scores in the oral group. Conclusion Intravenous iron is more efficacious than oral iron at improving the post-operative quality of life of anaemic colorectal cancer patients. The usage of intravenous iron should be considered in patients who are found to have colorectal cancer during evaluation of anaemia by Gastroenterologists to optimise these outcomes. Disclosure of Interest: M. Brookes Conflict with: Vifor International, Conflict with: Vifor International, B Keeler: None Declared, O Ng: None Declared, H Padmanabhan: None Declared, A Simpson: None Declared, A Acheson Conflict with: Vifor International

BACKGROUND:Treatment of preoperative anaemia is recommended as part of patient blood management, aiming to minimize perioperative allogeneic red blood cell transfusion. No clear evidence exists outlining which treatment modality should be used in patients with colorectal cancer. The study aimed to compare the efficacy of preoperative intravenous and oral iron in reducing blood transfusion use in anaemic patients undergoing elective colorectal cancer surgery. METHODS:Anaemic patients with non-metastatic colorectal adenocarcinoma were recruited at least 2 weeks before surgery and randomized to receive oral (ferrous sulphate) or intravenous (ferric carboxymaltose) iron. Perioperative changes in haemoglobin, ferritin, transferrin saturation and blood transfusion use were recorded until postoperative outpatient review. RESULTS:Some 116 patients were included in the study. There was no difference in blood transfusion use from recruitment to trial completion in terms of either volume of blood administered (P = 0·841) or number of patients transfused (P = 0·470). Despite this, increases in haemoglobin after treatment were higher with intravenous iron (median 1·55 (i.q.r. 0·93-2·58) versus 0·50 (-0·13 to 1·33) g/dl; P < 0·001), which was associated with fewer anaemic patients at the time of surgery (75 versus 90 per cent; P = 0·048). Haemoglobin levels were thus higher at surgery after treatment with intravenous than with oral iron (mean 11·9 (95 per cent c.i. 11·5 to 12·3) versus 11·0 (10·6 to 11·4) g/dl respectively; P = 0·002), as were ferritin (P < 0·001) and transferrin saturation (P < 0·001) levels. CONCLUSION:Intravenous iron did not reduce the blood transfusion requirement but was more effective than oral iron at treating preoperative anaemia and iron deficiency in patients undergoing colorectal cancer surgery.

Introduction Preoperative anaemia is a strong predictor of blood transfusion requirement. Patient Blood Management guidelines highlight the need for preoperative anaemia assessment and management in order to optimise haemoglobin prior to elective surgery. However, there is no randomised control trial elucidating the clinical effectiveness of the type of iron preparation that should be used preoperatively. The main objective of this study is to compare the efficacy of intravenous ferric carboxymaltose (Ferinject) therapy and oral iron on pre-operative haemoglobin levels in anaemic patients undergoing elective cardiac surgery. Method 50 anaemic patients who were listed for elective cardiac surgery were recruited preoperatively and randomised to receive either oral iron (ferrous sulphate) or intravenous iron (ferric carboxymaltose). Change in haemoglobin level after an intervention was measured and data were collected on blood transfusion use and postoperative outcomes. Comparisons of continuous variables were performed using the t-test for normally distributed variables and the Mann-Whitney U test for skewed distributions. Comparisons of categorical variables were performed using chi-square test. Results There were no differences in the baseline clinical, demographic characteristics and surgical procedures between the two groups. The median rise in haemoglobin is higher in the oral iron group (3.5 g/L; p= 0.72) compared to intravenous group (2 g/L) but was not statistically significant. The first 12 hour blood loss was high in the intravenous group (median 655 (IQR 162–1540) ml versus 312.5 (150–1750) ml in oral iron group ml; p=0.007). There were no comparable differences observed in post operative outcomes but the mean transfusion was more in the intravenous group (2.6 vs 1.8, p=0.1). At surgery, intravenous group had higher ferritin levels than oral group (median 392 µg/L vs 49) µg/l; p<0.0001) Conclusion Intravenous iron was not effective in improving preoperative haemoglobin after elective cardiac surgery and did not reduce blood transfusion requirements. Moreover, intravenous iron appears to significantly increase the risks of intraoperative bleeding. Larger randomised controlled trials are needed examining the effect of intravenous iron on preoperative anaemia and subsequent outcome after cardiac surgery. Disclosure of Interest H Padmanabhan: None Declared, K Siau: None Declared, A Nevill: None Declared, H Luckraz: None Declared, MJ Brookes Conflict with: Vifor Pharma

Aim. To determine whether preassessment improves bowel preparation quality and prevents renal deterioration for chronic kidney disease (CKD) patients. Methods. Data was collected prospectively starting in January 2011 for 12 months. Patients were divided according to the presence or absence of preassessment and stratified to one of three risk groups based on patient’s comorbidities and identified risk factors for poor bowel preparation; group 1 had no risk factors, group 2 had 1 risk factor, and group 3 patients had 2 or more risk factors. The association between preassessment and bowel preparation quality was analyzed using binary logistic regression. Results. 1840 colonoscopies were carried out during the period. Total number analyzed was 1704. 404 patients were preassessed. Preassessment patients had significantly better bowel preparation across all groups (OR 1.605; p=0.002). Group 3 patients were 52% more likely to have good bowel preparation (p=0.04) if they had been preassessed. Eighty-eight patients were identified with an eGFR < 60 mL/min. There was a significant difference in the eGFR percentage change between patients with preassessment and those without (p=0.006). Conclusions. Face-to-face preassessment appears to improve the quality of bowel preparation and aids in minimizing the risk of renal injury in patients with CKD.

Question: A 59-year-old woman presented with a 4-day history of abdominal pain, diarrhea, and vomiting. During her stay she had an episode of melena and her hemoglobin dropped from 116 to 86 g/L. She had a past medical history of gallstone disease for which she underwent an elective laparoscopic cholecystectomy in 2014. Clinical examination revealed tenderness in the epigastric region. Esophagogastroduodenoscopy revealed a foreign object at anterior wall of the first part of duodenum (Figure A). There was no sign of recent bleeding at this site. A computed tomography scan was also undertaken and showed the changes illustrated in (Figure B). Based on the image findings, what is your diagnosis and how would you manage the condition? Look on page 1536 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. Esophagogastroduodenoscopy showed a Hem-o-Lok clip at anterior wall of the first part of duodenum (Figure A). A computed tomography scan demonstrated a 10-mm hyperattenuating “clip” noted in the duodenal wall with no evidence of retroperitoneal or intraperitoneal collection or free air (Figure B). Our patient had a Hem-o-Lok clip for ligation of cystic duct and its proximity to duodenum could have led to fistula formation. The patient underwent laparoscopic removal of the clip and her hemoglobin increased to 124 g/L at 2 months after the procedure. Laparoscopic cholecystectomy and common bile duct exploration is the standard surgical procedure for patients with cholecystolithiasis. A Hem-o-Lok clip is a polymer ligation clip system used to ligate gallbladder vessels and cystic duct during laparoscopic cholecystectomy. Hem-o-Lok clips have been also used for vascular control in urologic, gynecologic, general, and colorectal laparoscopic surgery. Surgical clip migration into the common bile duct is a known but very rare complication.1Martinez J. Combs W. Brady P.G. Surgical clips as a nidus for biliary stone formation: diagnosis and therapy.Am J Gastroenterol. 1995; 90: 1521-1524PubMed Google Scholar Liu et al2Liu Y. Ji B. Wang Y. et al.Hem-o-lok clip found in common bile duct after laparoscopic cholecystectomy and common bile duct exploration: a clinical analysis of 8 cases.Int J Med Sci. 2012; 9: 225-227Crossref PubMed Scopus (12) Google Scholar showed that the Hem-o-Lok clip migrated in the common bile duct after laparoscopic cholecystectomy and common bile duct exploration in 8 of 1600 patients. Endoscopic removal is successful in most cases. In the international literature there is only 1 such similar report, where the clip was found to migrate into the duodenum without any features of upper gastrointestinal hemorrhage. In this previous report, Seyyedmajidi et al removed the clip safely at endoscopy.3Seyyedmajidi M. Hosseini S.A. Hajiebrahimi S. et al.Hem-o-Lok clip in the first part of duodenum after laparoscopic cholecystectomy.Case Rep Gastrointest Med. 2013; 2013: 251634PubMed Google Scholar In our case, because of the recent brisk hemorrhage, we felt it safer to remove the clip at laparoscopy. Therefore, there is risk that Hem-o-Lok clips can migrate during postoperative period and we should be aware of the potential complications that might occur.

Introduction Therapeutic anti-TNFα monitoring enables optimisation of anti-TNFα therapy. Recently, NICE supported therapeutic monitoring of TNFα inhibitors in patients with Crohn’s disease who fail to respond. However, NICE found the evidence for routine monitoring in patients responding adequately to be insufficient. Small studies show high Infliximab (INF) trough levels and low antibody levels to be associated with successful maintenance of remission. Methods A retrospective review of drug level monitoring in patients with Crohn’s disease taking anti-TNFα drugs was conducted. Patient demographics, IBD type, duration and distribution were recorded. Data were collected to compare against the NICE guidance (DG22). Trough levels, antibody presence and the use of concomitant immunosuppression (thiopurine and/or methotrexate) were noted. Any clinical impact of monitoring was recorded. Results Over 26 months monitoring was performed 93 times in 80 patients. 60% of all monitoring was clinically indicated in patients suspected to be non-responders. The remaining 40% were part of routine care. Of the 80 patients, 53% were male. Median age at first monitoring was 36 years (range 17–79). Median time from diagnosis of Crohn’s was 86 months (range 5–528). 26% had ileal, 30% had colonic and 44% had ileocolonic disease. 30% had stricturing and 8% had penetrating disease phenotypes. 39% had perianal disease. At diagnosis, 19% were aged 16 or below, 56% were aged 17 to 40 and 24% were aged over 40. Onset was unknown in 1%. For all drug monitoring, the median time from anti-TNFα initiation (59% INF; 41% Adalimumab (ADA)) was 60 weeks (range 6–470). 31% had concomitant immunosuppression. Antibodies were detected in 16% (22% INF; 8% ADA). Overall, as a result of monitoring, 49% continued their current anti-TNFα, 37% dose-escalated, 1% de-escalated, 8% stopped, 3% switched to ADA, 1% switched to INF and 1% changed to Vedulizumab. 13% started or increased thiopurine or methotrexate and 8% proceeded to surgery. Of those patients monitored as a part of routine care, 24% dose-escalated, 11% stopped anti-TNFα drugs and 5% switched to ADA. Doses were unchanged in 60%. Conclusion A large proportion of monitoring in our population was for the routine evaluation in patients on anti-TNFα drugs. These patients are now considered outside of NICE practice guidelines. Thus, adhering to NICE guidelines will lead to a substantial reduction in the number of our patients tested. However, in this group, the evaluation of drug levels influenced care in 40% of cases. Thus, further studies are needed to determine the benefits of routine drug level monitoring in stable patients on anti-TNFα drugs. Disclosure of Interest None Declared

Background Varying rates of oesophageal adenocarcinoma (OAC) complicating Barrett’s oesophagus (BO) have been reported. Recent studies and meta‐analyses suggest a lower incidence, questioning the value of endoscopic surveillance. Aim We aimed to retrospectively examine the rate of OAC, risk factors and causes of death in a prospectively recruited BO cohort. Methods Data from patients with BO from a cohort from 1982–2007 were studied. Patients were subdivided into surveyed, failed to attend surveillance and unfit for surveillance. Standardised mortality ratios (SMR) were calculated for common causes of death. Cox proportional hazards models were used to determine which factors were associated with progression to OAC. Results In total, 671 BO patients (61% male) were studied; 37 (76% male) were diagnosed with OAC. OAC incidence was 0.47% per annum and stable across three decades (1982–1991 0.56%, 1992–2001 0.46%, 2002–2012 0.41% ( p = 0.8)). All‐cause mortality was increased for the whole cohort (SMR 163(95% CI 145–183)). Mortality from OAC appeared higher in patients who failed to attend surveillance (SMR 3216(95% CI 1543–5916)) compared with surveyed (SMR 1753(95% CI 933–2998)) and those unfit for surveillance due to co‐morbidity (SMR 440(95% CI 143–1025)). Multivariable analysis identified low‐grade dysplasia (HR 4.4(95% CI 1.56–12.43), p = 0.005) and length of BO (HR 1.2(95% (1.1–1.3)), p < 0.001)) as associated with OAC. Conclusions Progression to OAC appeared stable over three decades at 0.47% per annum. Patients with BO had a modest increase in all‐cause mortality and a large increase in OAC mortality, particularly if fit for surveillance. Low‐grade dysplasia and the length of the BO segment were associated with developing OAC.

Iron is a vital trace element essential for mammalian life. It is involved in numerous biological and cellular processes such as oxygen transport, oxidative phosphorylation, and DNA synthesis, as well as cell cycle progression and growth. Normal and neoplastic cells have similar qualitative requirements for iron. In addition, research shows that iron promotes cancer cell growth. An adequate balance of iron is, therefore, critical for health. In states of iron deficiency, anemia can develop, whereas iron excess increases oxidative stress in body tissues, leading to lipid, protein, and DNA damage via the Fenton reaction, which results in the synthesis of hydroxyl radicals and other oxidants. It is thought that some of these processes are implicated in the pathogenesis of colorectal cancer. This review provides the clinician with an up-to-date summary of the recent advances in this field using established in vitro and animal models.

Background and aims The literature on colorectal cancer (CRC) screening and ethnic diversity is dominated by studies from the USA. There are no such published data from the UK bowel cancer screening programme (BCSP) population. The Wolverhampton Bowel Cancer Screening Centre serves a population of 900 000 in the Black Country and South Staffordshire. South Asians (SA) comprise 9% of the population. We aimed to determine the effects of ethnicity and sex on the risk for cancer or adenoma detected by colonoscopy following a positive faecal occult blood test over a 5-year period (2007–2011). Methods Data were collected from the prospectively maintained BCSP cohort. South Asian patients were identified and compared with those of non-South Asian ethnicity, and colonoscopy outcomes were determined. Results A total of 3552 participants underwent BCSP colonoscopy (non-South Asian=3363; SA=189). There were 271 cancers (7.6%) detected within the non-South Asian group and seven cancers (0.2%) in the South Asian population (P<0.05). The probability of colon cancer is higher [odds ratio (OR)=3.84, P<0.05] in non-South Asians compared with South Asians. Patients in the 65–70-year age group have the highest risk (OR=1.60; P<0.05) for CRC. During the study 1313 adenomas were detected. A total of 771 high-risk and intermediate-risk adenomas were detected in the non-South Asian group, and 14 were detected in the South Asian group. The risk of adenoma in non-South Asians is six times higher than in South Asians (OR=5.99, P<0.001) following positive faecal occult blood testing. Conclusion There are fewer colorectal cancers in South Asians compared with the non-South Asian population in this regional study. This is the first such study in the BCSP population.

Introduction Perioperative allogeneic red blood transfusions (ARBT) are associated with impaired short and long term outcomes.1Consequently, perioperative ARBT should be avoided, yet preoperative anaemia increases this need. The study aimed to compare the efficacy of preoperative intravenous (IVI) and oral iron (OI) in reducing ARBT use in anaemic patients undergoing colorectal cancer (CRC) surgery. Method 116 anaemic patients with non-metastatic CRC adenocarcinoma were recruited preoperatively and randomised to receive either OI (ferrous sulphate) or IVI (ferric carboxymaltose). Perioperative changes in Haemoglobin (HB) and ARBT were recorded across groups. Parametric data was compared with 2 tailed T-test and non-parametric data with Wilcoxon Rank test, and Mann-Whitney U test. Nominal data was compared with 2 tailed Chi squared test. Results There was no difference in demographic data between groups. HB levels at recruitment were comparable (OI 10.4g/dL 95% CI 10.1–10.7; IVI 10.2g/dL 95% CI 9.8–10.5;P = 0.24), as was median treatment duration (OI 21days IQR15–33; IVI 21days IQR15–34;P = 0.75). However, HB was higher on day of Surgery with IVI (11.9g/dL 95% CI 11.5–12.3 vs OI 11g/dL 95% CI 10.6–11.4;P < 0.01). Median preoperative HB change in patients not transfused preoperatively was higher with IVI (1.5g/dL IQR0.9–2.6 vs. OI 0.5g/dL IQR-0.1–1.3;P < 0.01). There were fewer anaemic patients at surgery in the IVI group after treatment (75% vs. 90%; P < 0.05). OI patients received a mean 0.63u (95% CI 0.26–1) from recruitment to day 28 postoperatively vs. mean 0.47u (95% CI 0.1–0.84) for IVI. Neither number of patients transfused (P = 0.33) nor mean units transfused (P = 0.54) differed over this period. When patients with heavy intraoperative losses (>1.5L) were excluded, a significant difference in mean units of blood transfused was seen up to 7 days post operatively (n = 108; OI 0.6u 95% CI 0.23–0.96; IVI 0.16u 95% CI 0.01–0.3; P < 0.05) and significantly less IVI patients were transfused (10% vs. 25%;P < 0.05). Conclusion In patients undergoing CRC surgery, IVI appears more efficacious than OI at treating preoperative anaemia. It does not appear to minimise overall ARBT requirement, but may reduce ARBT use in the immediate perioperative period when the implications of ARBT are probably at their greatest.2 Disclosure of interest B. Keeler: None Declared, J. Simpson: None Declared, O. Ng: None Declared, H. Padmanabhan: None Declared, M. Brookes Grant/ Research Support from: MB’s research department has received grant support from Syner-Med, UK, and Vifor Pharma, Switzerland, Speaker Bureau of: He has received honoraria or travel support for consulting or lecturing from the following companies: Vifor Pharma Ltd, Glattbrugg, Switzerland; Merck Sharp and Dohme Limited, UK. MB is also an advisory board member to Vifor International and to Sanofi UK, A. Acheson Grant/ Research Support from: AA’s research department has received grant support from Syner-Med, UK, Vifor Pharma, Switzerland, and Pharmacosmos A/S, Denmark, Consultant for: He is an advisory board member for Pharmacosmos A/S, Denmark., Conflict with: received honoraria or travel support for consulting or lecturing from the following companies: Ethicon Endosurgery, Johnson and Johnson Ltd, UK; Olympus, Essex, UK; and Vifor Pharma Ltd, Glattbrugg, Switzerland. References Acheson AG; Brookes MJ; Spahn DR. Effects of allogeneic red blood cell transfusions on clinical outcomes in patients undergoing colorectal cancer surgery:a systematic review and meta-analysis. Ann Surg. 2012;256(2):235–44 Nielsen HJ. Detrimental effects of perioperative blood transfusion. BJS 1995;82(5):582–7

Objective To assess the effects of preoperative anemia on outcomes of cardiac surgery and to explore the trend in mortality over an 8-year period. Methods During the study period (2005–2012), all 1170 patients undergoing elective or urgent cardiac surgery and classed as anemic were included. A matched group of non-anemic 1170 patients was used as a control group. Postoperative outcomes were compared between the 2 groups. The association between preoperative anemia and postoperative outcomes was analyzed using a logistic regression model. Results Compared with patients without anemia, the need for airway support (15% vs. 12%, p = 0.05), renal replacement therapy (13% vs. 8%, p < 0.01) and the rate of in-hospital surgical site infection (9% vs. 7%, p = 0.05) were higher in the anemic group. Anemia was associated with greater need for renal replacement therapy (odds ratio = 1.76, confidence interval: 1.21–2.37, p = 0.002) and prolonged (> 7 days) hospital stay (odds ratio = 1.21, confidence interval: 0.97–1.51, p = 0.08). The blood transfusion rate (54% vs. 33%, p < 0.01) and hospital mortality (5.6% vs. 3.5%, p = 0.02) were higher in the anemic group. Over the 8-year period, there was a significant improvement in mortality in the non-anemic group (from 6.5% to 1.6%) but less so in the anemic group (from 6.7% to 4.7%). Conclusion Anemia impacts significantly on morbidity and mortality after cardiac surgery, with less improvement over time compared to patients without anemia. Preoperative correction of anemia, when feasible, could potentially help to improve cardiac surgery outcomes.