Objective To estimate the strength of association between exposure to selected classes of prescribed medications and the risk of developing iron deficiency anaemia (IDA), specifically considering oral anticoagulants (OACs), antidepressants, antiplatelet agents, proton pump inhibitors (PPIs) and non-steroidal anti-inflammatories.Design A case–control study involving the analysis of community repeat prescriptions among subjects referred with IDA, and unmatched controls referred as gastroenterology fast-tracks for other indications. Multivariable logistic regression modelling was used to calculate ORs for the association between IDA presentation and each medication class, adjusted for age, sex and coprescribing. For those classes showing significance, it was also used to calculate risk differences between those in the IDA group with or without haemorrhagic lesions on investigation.Results A total of 1210 cases were analysed—409 in the IDA group, and 801 in the control group. Significant associations were identified between presentation with IDA and long-term exposure to PPIs (OR 3.29, 95% CI: 2.47 to 4.41, p<0.001) and to OACs (OR 2.04, 95% CI: 1.29 to 3.24, p=0.002). IDA was not associated with long-term exposure to any of the other three drug classes. In contrast to the relationship with PPIs, the association with OACs was primarily in the IDA sub-group with haemorrhagic lesions.Conclusion Long-term exposure to PPIs and OACs are independently associated with the risk of developing IDA. There are grounds for considering that these associations may be causal, though the underlying mechanisms probably differ.

To facilitate the clinical use of an algorithm for predicting the risk of gastrointestinal malignancy in iron deficiency anaemia—the IDIOM score, a software application has been developed, with a view to providing free and simple access to healthcare professionals in the UK. A detailed requirements analysis for intended users of the application revealed the need for an automated decision-support tool in which anonymised, individual patient data is entered and gastrointestinal cancer risk is calculated and displayed immediately, which lends itself to use in busy clinical settings. Human-centred design was employed to develop the solution, focusing on the users and their needs, whilst ensuring that they are provided with sufficient details to appropriately interpret the risk score. The IDIOM App has been developed using R Shiny as a web-based application enabling access from different platforms with updates that can be carried out centrally through the host server. The application has been evaluated through literature search, internal/external validation, code testing, risk analysis, and usability assessments. Legal notices, contact system with research and maintenance teams, and all the supportive information for the application such as description of the population and intended users have been embedded within the application interface. With the purpose of providing a guide of developing standalone software medical devices in academic setting, this paper aims to present the theoretical and practical aspects of developing, writing technical documentation, and certifying standalone software medical devices using the case of the IDIOM App as an example.

BACKGROUND:Anti-drug antibodies are associated with treatment failure to anti-TNF agents in patients with inflammatory bowel disease (IBD). AIM:To assess whether immunogenicity to a patient's first anti-TNF agent would be associated with immunogenicity to the second, irrespective of drug sequence METHODS: We conducted a UK-wide, multicentre, retrospective cohort study to report rates of immunogenicity and treatment failure of second anti-TNF therapies in 1058 patients with IBD who underwent therapeutic drug monitoring for both infliximab and adalimumab. The primary outcome was immunogenicity to the second anti-TNF agent, defined at any timepoint as an anti-TNF antibody concentration ≥9 AU/ml for infliximab and ≥6 AU/ml for adalimumab. RESULTS:In patients treated with infliximab and then adalimumab, those who developed antibodies to infliximab were more likely to develop antibodies to adalimumab, than patients who did not develop antibodies to infliximab (OR 1.99, 95%CI 1.27-3.20, p = 0.002). Similarly, in patients treated with adalimumab and then infliximab, immunogenicity to adalimumab was associated with subsequent immunogenicity to infliximab (OR 2.63, 95%CI 1.46-4.80, p < 0.001). For each 10-fold increase in anti-infliximab and anti-adalimumab antibody concentration, the odds of subsequently developing antibodies to adalimumab and infliximab increased by 1.73 (95% CI 1.38-2.17, p < 0.001) and 1.99 (95%CI 1.34-2.99, p < 0.001), respectively. Patients who developed immunogenicity with undetectable drug levels to infliximab were more likely to develop immunogenicity with undetectable drug levels to adalimumab (OR 2.37, 95% CI 1.39-4.19, p < 0.001). Commencing an immunomodulator at the time of switching to the second anti-TNF was associated with improved drug persistence in patients with immunogenic, but not pharmacodynamic failure. CONCLUSION:Irrespective of drug sequence, immunogenicity to the first anti-TNF agent was associated with immunogenicity to the second, which was mitigated by the introduction of an immunomodulator in patients with immunogenic, but not pharmacodynamic treatment failure.

Introduction Gastrointestinal (GI) malignancy is a common finding in iron deficiency anaemia (IDA), with a prevalence of about 8%. We have previously reported and validated an algorithm for predicting the risk of GI malignancy in IDA – the IDIOM score. This was derived by logistic regression analysis based on four independent and objective clinical parameters - age, sex, mean corpuscular volume (MCV), and haemoglobin concentration (Hb). To facilitate the clinical use of this algorithm, a software application has been developed, with a view to providing free and simple access to healthcare professionals in the UK. Methods A detailed requirements analysis for intended users of the application revealed the need for an automated tool in which anonymised, individual, patient data is entered and GI cancer risk is calculated and displayed. The solution needed to be user-friendly and platform independent, and needed to facilitate future communication with the development team. Human-centred design (HCD) was employed to develop the solution, focusing on the users and their needs, whilst ensuring that they are provided with sufficient details to appropriately interpret the risk score. To evaluate usability, standard usability questionnaire applied. Participants include healthcare professionals such as IDA nurse specialists, gastroenterologists, etc. Results Predict GI Cancer in IDA has been developed using R Shiny as a web-based application enabling access from different platforms with central updating. The application has been evaluated and tested through literature search, internal validation exercises, code testing, risk analysis, and usability assessments. Usability assessments (n=7) has shown mean user subjective satisfaction of 8.5 out of 10. A screenshot from the application. Plans for post-production maintenance and surveillance have been established. A technical file for the application has been written according to Medical Devices Directive (MDD) and all other relevant harmonised standards. The process of registering the application with the MHRA and for CE marking is underway. Conclusions The application Predict GI Cancer in IDA generates an estimate of GI cancer risk (with 95% confidence interval), following the insertion of data for the four key variables. The whole process takes just a few seconds, which lends itself to use in busy clinical settings. Legal notices, contact system and all the supportive information for the application such as description of the population, intended users, safety information have been embedded within the application interface.

[median (range)] years. All had citrulline £21 mmol/L (10 (5– 18)). Faecal calprotectin and elastase were available in 87% and 67% and were 691 (445–2022) mg/g faeces and 217 (15384) mg/g faeces respectively. The average PN days were 41 days including PN discontinuation due to end of life/palliative care (6(40%)). All had eGFR >60 (76->90) ml/min except one patient (20 ml/min) and CRP 35 (11–201) mg/L. A significant negative correlation was observed between CRP and citrulline concentrations (p = 0.013). Plasma citrulline concentrations were 15 (5.4) vs. 5 (1.8) mmol/L (mean (SD)) (p<0.001) when CRP threshold for mild/moderate vs. severe sepsis is considered as 100 mg/L (figure 1). Conclusion In our cohort, citrulline ~21 mmol was a strong indicator of PN dependency in iGvHD. Thus, Citrulline has a useful clinical utility in the nutritional assessment of iGvHD patients. Larger studies are required to establish threshold for citrulline in septic iGvHD patients.

Background Using two large datasets from Dorset, we previously reported an internally validated multivariable risk model for predicting the risk of GI malignancy in IDA—the IDIOM score. The aim of this retrospective observational study was to validate the IDIOM model using two independent external datasets. Methods The external validation datasets were collected, in a secondary care setting, by different investigators from cohorts in Oxford and Sheffield derived under different circumstances, comprising 1117 and 474 patients with confirmed IDA respectively. The data were anonymised prior to analysis. The predictive performance of the original model was evaluated by estimating measures of calibration, discrimination and clinical utility using the validation datasets. Results The discrimination of the original model using the external validation data was 70% (95% CI 65, 75) for the Oxford dataset and 70% (95% CI 61, 79) for the Sheffield dataset. The analysis of mean, weak, flexible and across the risk groups’ calibration showed no tendency for under or over-estimated risks in the combined validation data. Decision curve analysis demonstrated the clinical value of the IDIOM model with a net benefit that is higher than ‘investigate all’ and ‘investigate no-one’ strategies up to a threshold of 18% in the combined validation data, using a risk cut-off of around 1.2% to categorise patients into the very low risk group showed that none of the patients stratified in this risk group proved to have GI cancer on investigation in the validation datasets. Conclusion This external validation exercise has shown promising results for the IDIOM model in predicting the risk of underlying GI malignancy in independent IDA datasets collected in different clinical settings.

Iron deficiency anaemia (IDA) is common in colorectal cancer (CRC), especially, in right-sided CRC which is known to have an overall worse prognosis. The associations between diagnostic pathway (Bowel Cancer Screening Programme (BCSP), IDA, symptomatic) and tumour side/stage was assessed using logistic regression models in 1138 CRC cases presenting during 2010–2016 at a single secondary-care centre in the UK. In the IDA sub-group, the relationship between CRC stage and the event of having a blood count prior to CRC diagnosis was examined using Bayesian parametric survival model. IDA was found as the only significant predictor of right-sided CRC (OR 10.61, 95% CI 7.02–16.52). Early-stage CRC was associated with both the IDA (OR 1.65, 95% CI 1.18–2.29) and BCSP pathway (OR 2.42, 95% CI 1.75–3.37). At any age, the risk of detecting CRC at late-stage was higher in those without a previous blood count check (hazard ratio 1.53, 95% credibility interval 1.08–2.14). The findings of this retrospective observational study suggest a benefit from diagnosing CRC through the detection of IDA, and warrant further research into the prognosis benefit of systematic approach to blood count monitoring of the at-risk population.

Background Faecal occult blood (FOB) positivity and iron deficiency anaemia (IDA) are common manifestations of colorectal cancer (CRC) and both potentially facilitate diagnosis at an earlier, more treatable stage. It has been assumed that both are the consequence of low-grade blood loss from the tumour bed. Method A retrospective analysis of 1121 cases of CRC diagnosed at a single centre between 2010 and 2016, comparing cases presenting via FOB-based Bowel Cancer Screening Programme (BCSP) and IDA pathways for a series of variables including age, sex, tumour location and prevalence of anaemia. Results The BCSP and IDA pathways each accounted for about 15% of the total case load. There were significant differences between the BCSP and IDA sub-groups in median age (68 vs 78 years: p<0.001), median haemoglobin (138 vs 89 g/L: p<0.001) and proportion of lesions in right colon (31.1% vs 82.5%: p<0.001). The major disparity in the prevalence of anaemia (overall 20.0% vs 98.2%: p<0.001) persisted when controlled for tumour location. Conclusion Paradoxically, CRC screening through the detection of FOB positivity and IDA identifies distinctly different sub-populations of cases. The theoretical implication is that an additional mechanism may be required to explain the development of IDA in CRC. The practical implication is that detection of IDA may have a complementary role to the BCSP in population screening for CRC.

Objective To report our cumulative experience from a dedicated iron deficiency anaemia (IDA) clinic over the last 15 years—with particular emphasis on referral rate, uptake of investigation, impact on endoscopy services, diagnostic yield of gastrointestinal (GI) investigation and the issue of recurrent IDA. Method A series of analyses of a register of 2808 referrals to the Poole IDA clinic between 2004 and 2018. Results The study population of 2808 had a sex ratio of 1.9 (female/male ratio) and a median age of 72 years (IQR: 60–79). A rising referral rate over the study period appears to be plateauing at around 2 cases per 1000 population per annum. On the basis of a snapshot audit, investigation of IDA may now account for over 20% of all diagnostic endoscopies. Overall, 86% of cases underwent examination of the upper and lower GI tract. Significant GI pathology was identified in 27% of the investigated cohort. Adenocarcinoma of the upper or lower GI tract was found in 8.3%, the majority in the right colon. The prevalence of recurrent IDA was estimated at 12.4%, and the results of investigation of this subgroup are reported. Conclusion Unexplained IDA is common, particularly in those over 60 years, and may be the first indication of underlying GI malignancy in over 8% of cases. Unresolved challenges include accommodating the resulting endoscopy workload, establishing a risk/benefit ratio for investigating those with major comorbidities and the management of recurrent IDA.

Objective To refine and validate a model for predicting the risk of gastrointestinal (GI) cancer in iron deficiency anaemia (IDA) and to develop an app to facilitate use in clinical practice.Design Three elements: (1) analysis of a dataset of 2390 cases of IDA to validate the predictive value of age, sex, blood haemoglobin concentration (Hb), mean cell volume (MCV) and iron studies on the probability of underlying GI cancer; (2) a pilot study of the benefit of adding faecal immunochemical testing (FIT) into the model; and (3) development of an app based on the model.Results Age, sex and Hb were all strong, independent predictors of the risk of GI cancer, with ORs (95% CI) of 1.05 per year (1.03 to 1.07, p<0.00001), 2.86 for men (2.03 to 4.06, p<0.00001) and 1.03 for each g/L reduction in Hb (1.01 to 1.04, p<0.0001) respectively. An association with MCV was also revealed, with an OR of 1.03 for each fl reduction (1.01 to 1.05, p<0.02). The model was confirmed to be robust by an internal validation exercise. In the pilot study of high-risk cases, FIT was also predictive of GI cancer (OR 6.6, 95% CI 1.6 to 51.8), but the sensitivity was low at 23.5% (95% CI 6.8% to 49.9%). An app based on the model was developed.Conclusion This predictive model may help rationalise the use of investigational resources in IDA, by fast-tracking high-risk cases and, with appropriate safeguards, avoiding invasive investigation altogether in those at ultra-low predicted risk.

Introduction Iron deficiency anaemia (IDA) is a common clinical presentation, and in a significant minority of cases (–0%) is the first indication of an underlying cancer in the gastro-intestinal (GI) tract. IDA is therefore considered an indication for fast-track endoscopic investigation, though the majority of cases will not actually have cancer. This study explores whether cancer risk in IDA can be predicted on the basis of simple and objective clinical variables. Method A study of the predictive value of sex, age, haemoglobin concentration (Hb), mean red cell volume (MCV) and iron studies for the risk of GI malignancy on subsequent investigation in adults with confirmed IDA attending a single IDA clinic. The study population comprised a training dataset (n = 2295) and a validation dataset (n = 602). The analysis was undertaken using logistic regression, and an App to predict the probability of GI cancer in IDA was developed as a clinical tool using R Shiny programming language. Results Using the training data, the best model showed that the risk of GI malignancy was strongly associated with sex (OR for males: 2.83, P<0.001) age, (OR: 1.05 for each added year, and Hb (OR: 0.975 for each g/l fall, P<0.001) – see figure 1 for the combined effects with their confidence intervals. GI cancer risk was less strongly associated with MCV (OR: 0.971 for each fl fall, P<0.05), with a complex relationship largely due to an increased cancer risk in those with more severe anaemia, particularly in younger age-groups. The model was tested on the validation data and produced similar results. It allowed stratification of 13% of the study population into a sub-group at high risk of cancer (arbitrarily defined as >15%), 28% into a sub-group at low risk (–%), and 16% into a sub-group at very low risk (<1%).Abstract PWE-042 Figure 1 Conclusion This study confirms that a simple clinical scoring system can effectively stratify patients with IDA according to GI cancer risk, allowing stretched investigational resources to be targeted at the high-risk group, whilst perhaps avoiding invasive investigation altogether in those predicted to be at extremely low risk. The App developed has the potential to provide a quick estimate of GI cancer risk in clinical settings, and so facilitate patient counselling.

ObjectiveTo document changes in the clinical features of coeliac disease (CD) at presentation over the last 25 years.DesignObservational study.Patients802 subjects diagnosed between 1993 and 2017 at a single general hospital.Outcome measuresDate of diagnosis, age, sex, postcode, symptoms, haematinic deficiency, smoking status, serology, family history and autoimmune phenomena.ResultsThe incidence of diagnosed CD rose threefold during the course of the study, with a rising prevalence of positive coeliac serology and positive family history of CD, and a falling prevalence of symptoms and haematinic deficiencies. There was little change in the female predominance, age at diagnosis or high prevalence of other autoimmune conditions over the 25 years, and a paucity throughout of cigarette smokers, particularly heavy smokers. A cohort of patients with seronegative CD was identified who shared many of the characteristics of seropositive CD, but with a significantly older age at diagnosis and a higher prevalence of cigarette smokers.ConclusionThere have been major changes in the epidemiology of CD over the last 25 years, of relevance to both our understanding of the aetiopathogenesis of CD and the requirement for service provision. The implications are discussed.

Objective: Ten percent of adults presenting with iron deficiency anaemia (IDA) have underlying cancer. This study was undertaken to prospectively validate the observation in a previous retrospective study that three simple clinical parameters can usefully predict the likelihood of gastrointestinal (GI) malignancy on investigation of patients with IDA, and to screen for other potential clinical predictors of risk. Method: Observational study of a cohort of 643 subjects attending an IDA clinic at a District General Hospital between 2012 and 2015, with multivariable analysis of the predictive value of a series of clinical variables including sex, age and haemoglobin concentration ([Hb]) for underlying GI malignancy. Results: Analysis of the validation cohort data confirmed the original observation that sex, age, and Hb were associated with the risk of GI malignancy—the parsimonious model including only these variables yielded odds ratios of 1.9 (95% confidence interval (CI): 1.1, 3.3) for males vs. females; 1.6 (95% CI: 0.9, 2.9) for age >70 vs. ≤70 years; and 2.9 (95% CI: 1.2, 6.9) for [Hb] <90.6 g/l vs. >112 g/l. Combining data from the observation and validation cohorts (total n = 1,363) identified sub-groups with cancer risks ranging from 0% to over 20%. No other predictive clinical variables were identified. Conclusions: Three simple and objective clinical parameters can be combined to provide a clinically useful cancer risk stratification model for subjects with IDA. This may assist with patient counselling and the prioritisation of investigational resources.

Introduction Acute upper gastro-intestinal haemorrhage (AUGIH) is a common medical emergency. Whilst frequently treated with blood transfusion, RCT evidence suggests that a restrictive transfusion policy can reduce the risk of re-bleeding and death. Yet previous audits have shown a high prevalence of over-transfusion - a situation where blood is administered in excess of requirements, with the potential for deleterious effects. This study describes the impact of a simple blood transfusion policy to address over-transfusion in AUGIH. Method A cross-match policy was devised (see Table 1) to limit the number of units initially provided for patients with AUGIH according to the pre-transfusion haemoglobin concentration ([Hb]) and presence of shock and/or suspected varices. The proposed target post-transfusion [Hb] was 90–100g/l. Anonymised data was collected for all patients with suspected AUGIH during two six-month periods, before (Group 1) and after (Group 2) introduction of the policy. Over-transfusion was arbitrarily defined as a post-transfusion [Hb] exceeding 100 g/l. Results Group 1 (n = 122) and Group 2 (n = 105) were comparable in terms of age, sex, [Hb] at presentation and Rockall score. The proportion of patients over-transfused decreased from 48% in Group 1 to 28% in Group 2 (OR 0.43; 95% CI 0.19–0.98). Logistic regression analysis of combined data from the two cohorts confirmed that “initial [Hb]” and “units transfused” were the two major independent predictors of over-transfusion. The respective total blood usage figures for Groups 1 and 2 were 259 v 148 units cross-matched (a 43% reduction), and 198 v 127 units transfused in (a 36% reduction). Contributors to the latter were (1) a reduction in the proportion of patients transfused (58% v 50%; χ2=1.36, p = 0.24), and (2) a reduction in the number of units administered to each recipient (mean 2.8 v 2.4; t test 1.95, p = 0.05). Conclusion Over-transfusion in AUGIH is common and can be substantially reduced by the introduction of a simple cross-match policy. Direct benefits include a reduction in blood usage – our figures indicate a drop from 162 to 121 units per 100 patients with AUGIH. A typical DGH managing 250 cases a year could therefore potentially save £12,000 pa on blood alone – if applied across the NHS in England this equates to over £2 million pa. Further potential benefits might include reduced morbidity and mortality, and indirect cost savings from a reduction in the interventions and extended lengths of stay for rebleeding episodes. Disclosure of interest None Declared.

Introduction Acute upper gastro-intestinal haemorrhage (AUGIH) is a common medical emergency. Whilst frequently treated with blood transfusion, RCT evidence suggests that a restrictive transfusion policy can reduce the risk of re-bleeding and death. Yet previous audits have shown a high prevalence of over-transfusion - a situation where blood is administered in excess of requirements, with the potential for deleterious effects. This study describes the impact of a simple blood transfusion policy to address over-transfusion in AUGIH. Method A cross-match policy was devised (see Table 1) to limit the number of units initially provided for patients with AUGIH according to the pre-transfusion haemoglobin concentration ([Hb]) and presence of shock and/or suspected varices. The proposed target post-transfusion [Hb] was 90–100g/l. Anonymised data was collected for all patients with suspected AUGIH during two six-month periods, before (Group 1) and after (Group 2) introduction of the policy. Over-transfusion was arbitrarily defined as a post-transfusion [Hb] exceeding 100 g/l. ResultsAbstract PWE-167 Table 1 Units for cross-match [Hb] / g/l Not shocked ANDvarices not suspected Shocked AND/ORvarices suspected 100 or more 0 0 90–99 0 2 80–89 (1) 3 70–79 2 4 60–69 3 5 Below 60 4 6 Group 1 (n = 122) and Group 2 (n = 105) were comparable in terms of age, sex, [Hb] at presentation and Rockall score. The proportion of patients over-transfused decreased from 48% in Group 1 to 28% in Group 2 (OR 0.43; 95% CI 0.19–0.98). Logistic regression analysis of combined data from the two cohorts confirmed that “initial [Hb]” and “units transfused” were the two major independent predictors of over-transfusion. The respective total blood usage figures for Groups 1 and 2 were 259 v 148 units cross-matched (a 43% reduction), and 198 v 127 units transfused in (a 36% reduction). Contributors to the latter were (1) a reduction in the proportion of patients transfused (58% v 50%; χ2=1.36, p = 0.24), and (2) a reduction in the number of units administered to each recipient (mean 2.8 v 2.4; t test 1.95, p = 0.05). Conclusion Over-transfusion in AUGIH is common and can be substantially reduced by the introduction of a simple cross-match policy. Direct benefits include a reduction in blood usage – our figures indicate a drop from 162 to 121 units per 100 patients with AUGIH. A typical DGH managing 250 cases a year could therefore potentially save £12,000 pa on blood alone – if applied across the NHS in England this equates to over £2 million pa. Further potential benefits might include reduced morbidity and mortality, and indirect cost savings from a reduction in the interventions and extended lengths of stay for rebleeding episodes. Disclosure of interest None Declared.

Blood transfusion is widely used in the management of acute upper gastrointestinal haemorrhage (AUGIH). Trial data suggests that excessive transfusion may be detrimental, yet overtransfusion remains commonplace. This study reports the impact of introducing a simple cross-match policy in a district general hospital, which resulted in a substantial fall in the prevalence of overtransfusion (odds ratio 0.43; 95% confidence interval 0.19-0.98), with potential patient benefits in terms of rebleeding, and a reduction in the total blood transfused from 162 to 121 units per 100 patients with AUGIH. For the cost of blood alone, this corresponds to projected savings across the NHS in England in excess of £2 million per annum.

Iron deficiency anaemia (IDA) is a common clinical problem, with an incidence in excess of one case per 1000 of population per annum.1 Large case series2–4 have consistently shown that about 10% of men and postmenopausal women with IDA have underlying gastrointestinal (GI) malignancy, often in the absence of any other clinical pointer to the diagnosis. It is for this reason that IDA is recognised as an urgent indication for GI investigation.5 Tumours responsible for IDA may lie anywhere along the GI tract, though the commonest site is in the proximal colon. Bidirectional endoscopy (BDE), combines gastroscopy and colonoscopy in the same session, and is an efficient means of assessing the GI tract in IDA.4 ,5 As well as identifying cancer, it may pick up a myriad of less serious GI pathology (eg, coeliac disease, vascular malformations) in a further 20% of cases.2–4 BDE is labour-intensive, however, taking up to an hour to complete for each patient, and carries a small but significant risk of complications, particularly in the elderly and those with …

Objective Ten percent of adults presenting with iron deficiency anaemia (IDA) have underlying cancer. This analysis – the Iron Deficiency as an Indicator Of Malignancy (IDIOM) study – was undertaken to assess whether five simple clinical parameters can usefully predict the likelihood of gastrointestinal (GI) malignancy on subsequent investigation of patients with IDA. Design Retrospective observational study, with multivariable analysis of the predictive value of sex, age, haemoglobin concentration (Hb), mean red cell volume (MCV) and iron studies for the risk of underlying GI malignancy. Setting District General Hospital IDA clinic. Patients 720 adults with confirmed IDA. Results Sex, age and Hb were strongly associated with the risk of GI malignancy—the parsimonious model including only these variables yielded ORs of 4.0 (95% CI 2.3 to 7.0) for males compared with females; 3.3 (95% CI 1.7 to 6.4) for age >70 years compared with ≤70 years; and 5.3 (95% CI 2.4 to 11.7) for a Hb of ≤91.4 g/L compared with ≥111.5 g/L. Combining these risk factors identified a subgroup (12% of the study population) at particularly low risk (<2% likelihood), and a second subgroup (16% of the study population) at especially high risk (>20% likelihood) of underlying GI malignancy. Conclusions Three simple and objective clinical parameters can be combined to provide a clinically useful cancer risk stratification model for subjects with IDA. This may assist with patient counselling and the prioritisation of investigational resources.

Objective To improve the quality of care provided to patients with iron deficiency anaemia (IDA). Design Service development. Setting District General Hospital. Patients Adults with IDA. Main outcome measures Descriptive report of the practicalities and benefits of establishing an IDA clinic. Conclusions The IDA clinic is a novel service development which enhances the management of patients with this common condition, by facilitating prompt confirmation of the diagnosis, replacement therapy and investigation for serious underlying pathology, in particular gastrointestinal malignancy.