Abstract Aim Faecal immunochemical testing (FIT) has been used as a prioritisation tool and diagnostic adjunct for detection of colorectal cancer (CRC) patients on the fast-track pathway. Many patients referred through the pathway are on medications associated with gastrointestinal bleeding. We chose to study the impact of such medications on FIT measurements. Method A retrospective review of patients between March 2020 and August 2022 was conducted. Data on patient demographics, medication use, FIT results and colonoscopy findings were gathered. Patients who did not undergo further investigations and patients diagnosed with CRC were excluded. Patients with a FIT measurement greater than 7μg of haemoglobin/gram of faeces were deemed positive. Chi squared test was used to compare the proportion of patients with a positive FIT in those who were and were not on the above medications. A p-value of <0.05 was deemed significant. Results There were 1668 (778 male) patients. Median age was 71 (IQR 62-78) years. CRC was detected in 92 patients. In the 1576 patients without cancer, 164 (10.4%) were on anticoagulants, 242 (15.4%) were on antiplatelets and 82 (5.2%) were on NSAIDs. A significantly greater proportion of patients had a positive FIT when on anticoagulants compared with those who were not (40% vs. 23%, p-value = 0.00). Use of antiplatelets or NSAIDs had no impact on FIT measurements (29% vs 24%, p-value = 0.32 and 18% vs 25%, p-value = 0.36). Conclusions Anticoagulants can impact FIT measurements, hence thresholds for a positive result may need to be altered for these patients. We seek to study this further.

Abstract Introduction PC-CRC is an important benchmark of endoscopy performance and results in a delayed diagnosis of cancer for patients. Little is known of the impact of PC-CRC on survival; we chose to study this in a cohort of patient at our institution. Methods A retrospective analysis was performed on all PC-CRC from 2015 to 2020. Electronic endoscopic records and case-note review were performed to identify cases. Suitable patients underwent surgery in the absence of widespread metastatic disease after MDT discussion. Survival data were recorded, Kaplan-Meier curves were constructed; the log rank test was used to compare groups, a p-value of < 0.05 was deemed significant. Results There were 32 (24 male) patients with a PC-CRC out of 1207 patients during this interval. The 5-year PC-CRC rate was 2.6%. Median age was 72 (IQR 63-79) years. 10 patients had metastatic disease, 9 with large volume disease that was not resectable. All 9 were palliated with a median survival of 3 (IQR 2-23) months. Twenty-three had potentially curative disease and all underwent surgery. On follow-up a further seven patients died with recurrent disease at a median of 19 (IQR 13-35) months. Sixteen are alive with a median survival of 38 (IQR 27-52) months. The survival curves for the 3 groups are significantly divergent, p-value <0.001. Conclusion The impact of PC-CRC on individual patients is significant as a quarter die within 3 months of diagnosis. A further quarter die within 24 months despite a potentially curative operation due to metastatic disease.

Abstract Introduction Post colonoscopy colorectal cancer (PC-CRC) is an important benchmark of endoscopy performance. Previous publications have reported significant variations between institutions. We chose to perform the root cause analysis (RCA) and the impact of traditional performance indicators on the likelihood of PC-CRC. Methods A retrospective analysis was performed on all PCCRC at York Hospital. Electronic endoscopic records and case-note review was performed to identify appropriate cases. Root cause analysis was performed on all identified cases. Performance data and annual procedural volumes of endoscopist were recorded. Adjusted PC-CRC/5-year period allowed endoscopist to be divided into good (<4 PC-CRC) and poor performers (³4 PC-CRC). Mann Whitney U test used to compare groups. P-value of < 0.05 deemed significant Results 32 (24 male) patients with a PC-CRC were identified . Median age was 72 (IQR 63-79) years. Table provides PCCRC rate for the 5-year period. Root cause analysis identified that most plausible cause was missed lesions despite adequate bowel preparation (76%). The commonest subtype was non interval C (38%). Three out of 18 endoscopist had a higher 5-year adjusted PC-CRC rate and were poor performers. Median withdrawal times, CIR and ADR did not differ between good and poor performers. Conclusion The overall PC-CRC rate at our institution is within an acceptable rate. We have noted significant variation of performance between endoscopist, the exact reasons for this observation require further examination.

IntroductionThe recent 2019 BSG/ACPGBI evidence based guidelines aim to make surveillance colonoscopy more personalised, ensuring it is recommended for people who need it, and not for those who do not. The updated guidelines have resulted in a change of need and timing for this test. We chose to study whether the implementation of the new guidelines resulted in a reduction of waiting time breaches and demand for surveillance colonoscopy.MethodsMonthly reports with waiting time breaches were obtained from the information team. All demographic data were then recorded on a separate spreadsheet. A retrospective review of previous colonoscopy report(s), histology and referral/clinic letters was then conducted. The new guidelines were utilised and a local decision tree created. Validated patients fell into 4 outcomes: discharge, continued surveillance, not validated or complex patient requiring consultant input. All discharged patients received a letter and a copy was sent to their GP. A Mann-Whitney U-test was performed to compare groups, a p-value <0.05 was deemed significant.ResultsPreliminary data was collected for 8 weeks. There were a total of 611 patients. Median age for the study population was 68 (IQR 58–75) years. After implementation of the decision tree, 123 (20%) patients were not suitable for validation as they were not polyp surveillance patients. Of the remaining 488 patients, 203 (33.2%) were suitable for discharged (removed from waiting list or cancelled due to duplicate entries or changed procedures). Only six (3%) patients from the discharge population made further contact. A further 282 (46.2%) required continued surveillance (as originally planned or changed to a longer interval. Five patients required input from consultants due to complexity. Patients that were discharged were older than those that returned for surveillance (73 (IQR 63–79) vs. 68 (IQR 60–74) years, p-value=0.001. The overall discharge rate of 33.2% percent equated to a reduction in demand for 41 colonoscopy lists.ConclusionsThe new guidelines have led to a reduction in the number of waiting time breaches. Patient feedback from our process has been positive. Long-term plans are needed to ensure a continued reduction of waiting times going forwards.

Guidelines on the management of hereditary CRC were updated in 2019 and have led to more stringent use of surveillance colonoscopies. Patients with ‘family history’ (FH) CRC Surveillance programme at York Hospitals Trust were studied to assess compliance with colonoscopy recommendations. Current BSG/ACPGBI guidelines recommend biennial, quinquennial, one-off or no colonoscopy surveillance for patients with Lynch syndrome, and those deemed to have high, moderate, and average risks of developing hereditary cancer, respectively. Examination of electronic records and clinical notes were performed to determine if they were Lynch positive and/or if they could be assigned a risk category. Database of 227 patients, of which 14 were high, 61 moderate and 45 were low risk. 47 had Lynch syndrome. Compliance of colonoscopy was poor for patients with average and moderate FH risk (both 0%). Compliance was higher for patients with high risk of FH (50%) and those with Lynch syndrome (57%) Risk was indeterminate in 24 patients due to inadequate data therefore compliance could not be assessed. A large proportion of patients with low to moderate ‘FH’ risk within our current surveillance programme had unnecessary colonoscopies. Stratification of patients into the appropriate risk categories optimizes the benefit from surveillance programmes.

Abstract Introduction Guidelines on the management of hereditary colorectal cancers were updated in 2019. In this study, data from patients within the colonoscopy surveillance programme for hereditary cancer at York Teaching Hospitals Trust were analysed to assess category of risk and appropriateness of referrals to regional geneticists. Method After examination of electronic records and clinical notes, patients were assigned a risk category of average, moderate or high according to the Amsterdam criteria and latest BSG/ACPGBI/UKCGG guidelines. Patients were then assessed to see if a concurrent referral had been made to the regional cancer genetic services. Results There were 228 patients. 72(31.6%) patients were in the average, 81(35.5%) in the moderate and 41(18%) were in the high-risk category. 34 (14.9%) patients with insufficient data and/or assessments were in the indeterminate category. 18 of 72 (25%) patients with average risk were unnecessarily referred to the regional genetics team, while 5/41(12%) of high-risk patients were not. A large proportion of patients with insufficient data (19/34, 55.8%) were rightly or wrongly, referred to the regional genetics team. Conclusions Assessment of hereditary cancer risk is difficult in the absence of good quality information. Risk assessment may be improved with use of a dedicated family history questionnaire/template - this facilitates identification of high-risk patients that benefit most from referral to geneticists.

Haemoglobin expression is not restricted to erythroid cells. We investigated the gene expression of the haemoglobin subunits haemoglobin, alpha adult chain 1 (Hba-a1) and haemoglobin, beta (Hbb), 2,3-bisphosphoglycerate mutase (Bpgm) and the oxygen-regulated genes BCL2/adenovirus E1B interacting protein 3 (Bnip3), solute carrier family 2 (facilitated glucose transporter), member 1 (Slc2a1) and N-myc downstream regulated gene 1 (Ndrg1) in the murine preimplantation embryo, comparing invivo to invitro gene expression. Relatively high levels of Hba-a1 and Hbb were expressed invivo from the 2-cell to blastocyst stage; in contrast, little or no expression occurred invitro. We hypothesised that the presence of haemoglobin invivo creates a low oxygen environment to induce oxygen-regulated gene expression, supported by high expression of Slc2a1 and Ndrg1 in invivo relative to invitro embryos. In addition, analysis of an invitro-derived human embryo gene expression public dataset revealed low expression of haemoglobin subunit alpha (HBA) and HBB, and high expression of BPGM. To explore whether there was a developmental stage-specific effect of haemoglobin, we added exogenous haemoglobin either up to the 4-cell stage or throughout development to the blastocyst stage, but observed no difference in blastocyst rate or the inner cell mass to trophectoderm cell ratio. We conclude that haemoglobin in the invivo preimplantation embryo raises an interesting premise of potential mechanisms for oxygen regulation, which may influence oxygen-regulated gene expression.

Background: Peguero et al. (J Am Coll Cardiol 2017) proposed a simple criterion for diagnosing left ventricular hypertrophy (LVH) on electrocardiogram (ECG) based on adding the amplitudes of the deepest S-wave and the S-wave in V4. This study aimed to evaluate the Peguero-Lo Presti (PLP) criterion's sensitivity compared to other criteria.

Background: The benefit of percutaneous coronary intervention (PCI) in elderly patients presenting with non-ST-elevation acute coronary syndromes (NSTEACS) is controversial. Identification of risk factors for major adverse events (MAE) after PCI may help to identify the cohort of older patients most likely to benefit from an invasive management strategy.

Background: There is a paucity of data to support a particular medical regimen for the treatment of left ventricular systolic dysfunction (LVSD) in Takotsubo cardiomyopathy (TTC). Despite being adrenergically mediated, registry data suggest no benefit with beta blockers but improved survival with angiotensin blockade. We aimed to characterise prescribing patterns for TTC.

Introduction: The Heart Foundation of Australia ran the heart attack Warning Signs Campaign in Victoria between 2009 and 2013. This study aimed to examine the impact of the campaign on ambulance use in adult Victorian patients with an emergency department diagnosis of 1) acute coronary syndrome (ACS) and 2) other chest pain (CP-NEC).

Background: Readmission following percutaneous coronary intervention (PCI) is associated with poorer outcomes and increased healthcare costs. Identifying predictors of readmission may help establish preventative interventions. Methods: We retrospectively reviewed data for 1216 patients treated with PCI at Western Health between April 2013 and October 2016 enrolled in the Victorian Cardiac Outcomes Registry. Baseline, clinical and procedural characteristics were analysed using univariate and multivariate regression models to compare the group of patients readmitted at 30 days to those who were not readmitted. Results: The readmission rate was 11.7%. Compared to non-readmitted group (n = 1073), post PCI readmitted patients (n = 143) were more likely to have had ACS as initial presentation (100% vs. 71.2%, p < 0.001), out-of-hospital cardiac arrest (7% vs.1.6%, p < 0.001), cardiogenic shock (5.6% vs. 2.3%, p < 0.024), moderate to severe LV dysfunction (100% vs. 5.6%, p < 0.001), and higher peak CK (1833.3 ± 1659.3 vs. 644.1 ± 1246.5, p < 0.001). Adjunct device and thrombus aspiration during PCI were used more commonly in the readmitted group compared to the non-readmitted (23.1% vs. 6.3%, p < 0.001) and (23.1% vs. 3.8%, p < 0.001) respectively. Surprisingly, diabetes was more common in the non-readmitted group (25.8% vs. 17.5%, p = 0.03). Multivariable analysis identified STEMI (HR 47.6, 11.5 - 200, p < 0.001) and inter-hospital transfer (HR 2.14, 1.12 - 4.08, p < 0.021) to be independent predictors of 30-day re-hospitalisation. Conclusions: Patients post PCI who present initially with STEMI or who are transferred from other hospitals have significant higher risk of readmission at 30 days compared to other patients. Intensive follow-up strategies may ameliorate readmissions and requires further study.

BACKGROUND: Fecal lactoferrin is a marker of intestinal inflammation and can be assessed with a simple qualitative immunochromatographic rapid test.OBJECTIVE: We aimed to assess the sensitivity and specificity of the test in the diagnosis of pouchitis and evaluate its clinical utility in the surveillance of inflammation of the pouch after antibiotic therapy.DESIGN: Between October 2005 and September 2009, we recruited a consecutive series of patients who had their ileal pouch examined under a general anesthetic. Distinctions between healthy and inflamed pouches were made by the use of the Pouch Disease Activity Index. Fecal samples were taken before biopsy of the pouch, and a clinician blinded to the examination findings performed the lactoferrin test. After antimicrobial treatment, a number of patients with pouchitis had a repeat examination and lactoferrin test.RESULTS: There were 85 (41 male) patients. Median age was 42 (interquartile range, 36-49) years. Twenty-four patients had pouchitis. The test was positive in all 24 patients with pouchitis and 5 patients with a healthy pouch. The sensitivity and specificity of the test for pouchitis was 100% and 92%. The positive predictive value was 82%. In 7 patients who received antibiotic treatment for their pouchitis, the test was able to accurately predict the resolution and/or persistence of pouchitis.CONCLUSION: The qualitative fecal lactoferrin rapid test is a sensitive method for the diagnosis and confirmation of resolution of pouchitis. The test provides clinicians with greater confidence in the prescription of antibiotics for suspected pouchitis and its surveillance.

AIM:Neoadjuvant chemotherapy may have a role in the management of colonic carcinoma but clinical trials are required to determine whether this approach is superior to the standard policy of radical surgery, high-quality histopathology and selective postoperative chemotherapy. The selection of appropriate patients for such trials will depend on accurate locoregional staging of disease by preoperative CT scanning. We studied the outcome after radical right hemicolectomy and assessed the accuracy of preoperative CT scans in the prediction of postoperative pathology.METHOD:A retrospective analysis of right hemicolectomies performed with curative intent for colon cancer under the care of a single colorectal surgeon (D.J.A.) was performed. Preoperative CT-proven Dukes D patients were excluded. Patient demographics, postoperative histology, use of adjuvant chemotherapy and survival data were collected. Kaplan-Meier curves were constructed and log-rank testing was performed to compare cancer-specific survival. Fifty patients had their preoperative CT scan images reviewed by two radiologists both blinded to the results of the postoperative histology. The accuracy of preoperative CT for T and N staging was studied. A P-value of < 0.05 was significant.RESULTS:There were 136 patients (79 women). Median age was 76 (interquartile ratio 67-82) years. Median period of follow-up was 72 (interquartile ratio 39-92) months. There were 56 deaths (39 medical, 16 oncological and 1 postoperative). There were three groups of patients: node negative (n = 84), node positive with postoperative adjuvant chemotherapy (n = 30) and node positive without chemotherapy (n = 22). Five-year cancer-specific survival for node negative disease was 84% and was poorer for node positive patients who received adjuvant chemotherapy when compared with those who did not (62 vs 72%, P-value = 0.046 on log-rank testing). Sensitivity, specificity, positive and negative predictive value of CT scan for tumour (T) stage were 90, 33, 86 and 43% respectively, while that for nodal (N) stage was 83, 38, 57 and 69%, respectively.CONCLUSION:CT scan has limited accuracy in predicting those patients with advanced locoregional disease who might benefit from neoadjuvant treatment. When this finding is combined with relatively high cancer-specific survival with surgery alone the impact of adjuvant chemotherapy on survival after radical surgery for right colon carcinoma may be marginal.

BACKGROUND:Injectable bulking agents have been used with varying success for the treatment of faecal incontinence. This systematic review aimed to investigate the various injectable agents and techniques used for the treatment of faecal incontinence, and to assess their safety and efficacy. METHODS:Thirty-nine publications were identified and studied. The following variables were pooled for univariable analysis: type, location, route of bulking agents, and the use of ultrasound guidance, antibiotics, laxatives and anaesthetics. Predictors of the development of complications and successful outcomes were identified by multivariable logistic regression analysis. RESULTS:A total of 1070 patients were included in the analysis. On multivariable analysis, the only significant predictor of the development of complications was the route of injection of bulking agents (odds ratio 3·40, 95 per cent confidence interval 1·62 to 7·12; P = 0·001). Two variables were significant predictors of a successful short-term outcome: the use of either PTQ(®) (OR 5·93, 2·21 to 16·12; P = 0·001) or Coaptite(®) (OR 10·74, 1·73 to 65·31; P = 0·001) was associated with a greater likelihood of success. Conversely, the use of local anaesthetic was associated with a lower likelihood of success (OR 0·18, 0·05 to 0·59; P = 0·005). Failure to use laxatives in the postoperative period resulted in a poorer medium- to longer-term outcome (OR 0·13, 0·06 to 0·25; P = 0·001). CONCLUSION:This systematic review has identified variations in the practice of injection of bulking agents that appear to influence the likelihood of complications and affect the outcomes after treatment.

BACKGROUND:Enhanced recovery after surgery (ERAS) pathways has been shown to minimize the duration of hospital stay. The aim of this study was to identify which factors have the greatest impact at reducing the length of stay within an enhanced recovery programme. METHODS:A retrospective case note review of patients undergoing open elective colorectal resections between August 2007 and May 2009 was performed. Data on numerous pre, peri and postoperative variables were collected. Postoperative complications, readmissions, length of stay and fitness for discharge were recorded. Using logistic regression analysis, univariate and multivariate analysis of predictors for a shorter hospital stay was performed. Odd ratios and ninety-five percent confidence intervals were calculated and a p-value of less than 0.05 was significant. RESULTS:There were 231 patients, of which 130 were female. Median age was 68 (IQR 56-76) years. Median length of stay was 6 (IQR 5-9) days. On multivariate analysis, ASA grade (OR 2.85 (95%CI 1.17-6.89), p = 0.040), the avoidance of oral opiates in the postoperative period (OR 0.39 (95%CI 0.18-0.84), p = 0.016) and the duration of use of epidurals for postoperative analgesia (OR 0.44 (95%CI 0.12-0.94), p = 0.023) were found to be significant predictors of reduced hospital stay. CONCLUSION:Lower ASA grade, use of epidurals and avoidance of regular oral opiates are associated with an earlier discharge in an ERAS programme.