Introduction and Aims The healthcare industry has a substantial carbon footprint and the recent 2022 Health and Care Act has committed the NHS to net zero carbon by 2040. In 2022, BASL published its Sustainability Strategy and committed to reduce the Association's carbon footprint. The sustainability of different ways of presenting posters is not known. The aim of this study was, therefore, to analyse and compare the carbon footprint of three different options of organising and displaying posters during the 2022 BASL annual conference. Methods A comparative analysis of the carbon footprint of three different models of poster display was performed using a cradle to grave process-based carbon footprinting methodology; namely Individual delegate printing and transporting to the venue Central printing of all posters in the host city Electronic displays This included raw material extraction, production, delivery, use and disposal of items. This was based on the 80 posters displayed. Of note only 66 of the posters displayed in Leeds were printed centrally and the analysis was split into option 2a (this scenario) and option 2b (all 80 posters printed centrally). It is important to note that local printing was on fully recycled material that was then recycled at the end of the meeting. Results The carbon footprint of option 1 (individual delegate printing) was estimated at 117 kg of carbon dioxide equivalent (kgCO2e); the equivalent of driving 345 miles. Option 2a had a carbon footprint of 46 kgCO2e, 40% of option 1's carbon footprint. Option 2b reduced the footprint further to 31 kgCO2e (figure 1). Displaying 80 posters on 6 digital screens over 3 days had an estimated carbon footprint of 38 kgCO2e (or 112 miles; a return trip from London to Oxford). In all three options, the majority of the carbon footprint burden was the result of transportation of materials to and from the venue. Discussion and Conclusions Substantial carbon saving can be achieved by moving away from the traditional model of individual delegates printing and transporting their own posters. Surprisingly, local printing and display on poster boards had a better carbon footprint than electronic displays. In addition, this model has the added advantage of allowing researchers to continuously stand by their posters and interact/network with other meeting delegates. This data underlines the importance of not making assumptions about relative environmental impacts of current and future practices without undertaking specific analyses comparing them.

Climate change and the destruction of ecosystems by human activities are among the greatest challenges of the 21st century and require urgent action. Health care activities significantly contribute to the emission of greenhouse gases and waste production, with gastrointestinal (GI) endoscopy being one of the largest contributors. This Position Statement aims to raise awareness of the ecological footprint of GI endoscopy and provides guidance to reduce its environmental impact. The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) outline suggestions and recommendations for health care providers, patients, governments, and industry. MAIN STATEMENTS 1: GI endoscopy is a resource-intensive activity with a significant yet poorly assessed environmental impact. 2: ESGE-ESGENA recommend adopting immediate actions to reduce the environmental impact of GI endoscopy. 3: ESGE-ESGENA recommend adherence to guidelines and implementation of audit strategies on the appropriateness of GI endoscopy to avoid the environmental impact of unnecessary procedures. 4: ESGE-ESGENA recommend the embedding of reduce, reuse, and recycle programs in the GI endoscopy unit. 5: ESGE-ESGENA suggest that there is an urgent need to reassess and reduce the environmental and economic impact of single-use GI endoscopic devices. 6: ESGE-ESGENA suggest against routine use of single-use GI endoscopes. However, their use could be considered in highly selected patients on a case-by-case basis. 7: ESGE-ESGENA recommend inclusion of sustainability in the training curricula of GI endoscopy and as a quality domain. 8: ESGE-ESGENA recommend conducting high quality research to quantify and minimize the environmental impact of GI endoscopy. 9: ESGE-ESGENA recommend that GI endoscopy companies assess, disclose, and audit the environmental impact of their value chain. 10:  ESGE-ESGENA recommend that GI endoscopy should become a net-zero greenhouse gas emissions practice by 2050.

GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.

Background The Climate Crisis represents the biggest global health threat of the 21st century.1 Healthcare has a significant carbon footprint which needs to be urgently reduced.2 Importing the principles of sustainable healthcare into Hepatology (figure 1) can yield carbon savings alongside opportunities for more economical, improved care which is better for our planet.3 Baseline carbon footprint data is required for patients with liver disease to help plan the journey towards Net Zero. Aim We aimed to estimate the carbon footprint of alcohol-related liver disease (ArLD)-specific admissions to hospitals in England and Scotland in 2020/21. Method Data was obtained from NHS Scotland using Hospital Episode Statistics for 2020/21 relating to annual admissions due to ArLD (codes K70.0, K70.1, K70.2, K70.3, K70.4, k70.9 as primary diagnosis). For England, National Hospital Episodes Statistics from 2020/21 were analysed by collaborators from the Office of Heath Improvements and Disparities using a previously described coding algorithm.4 Total bed days in 2020/21 were calculated; patients with a same day discharge were assigned a length of stay of 0.25 days. A 'Top Down' Carbon footprint was calculated using Sustainable Development Unit (2015). Care Pathways guidance on appraising sustainability. The carbon footprint for a low intensity bed day is 37.9 Kg CO2equivalent (KgCO2e). Results For 2020–2021 in Scotland there were 7092 admissions with a mean length of stay of 11.3 days accounting for 80,150 bed days for ArLD as a primary diagnosis. In England there were 39856 admissions with a mean length of stay of 8.1 days totalling 324791 bed days for ArLD. Total bed days in 2020/21 were 404,941. The estimated carbon footprint of inpatient ArLD in England and Scotland is 15,347 Metric Tons CO2e. Conclusion ArLD hospital admissions have a large carbon footprint in England and Scotland, equivalent to approximately 13,000 return transatlantic flights in 2020/21. These are the first data documenting the environmental impact of ArLD. Tackling the rising prevalence of ArLD through improved care combined with public health strategies will not only improve patient outcomes, but will reduce the significant carbon footprint associated with hospital admissions. References Wang H, Horton R. Tackling climate change: the greatest opportunity for global health. Lancet 2015;386:1798–9. http://dx.doi.org/10.1016/S0140-6736(15)60931-X https://www.arup.com/-/media/arup/files/publications/h/health-cares-climate-footprint.pdf https://q.health.org.uk/document/sustainability-in-quality-improvement-redefining-value/?bp-attachment=FHJv5n2-Mortimer1.pdf Kallis C, Dixon P, Silberberg B, et al. Reducing variation in hospital mortality for alcohol-related liver disease in North West England. Aliment Pharmacol Ther 2020 Jul;52(1):182–195. doi: 10.1111/apt.15781. Epub 2020 May 22.

The climate crisis is one of the biggest threats to global health of the 21st century1 because climate change is accompanied by numerous medical consequences.2 We are already seeing these negative global health impacts due to excessive ambient temperatures and air pollution. One notable episode was the extreme heatwave in Europe in summer 2003, which resulted in approximately 70,000 more deaths across Europe, of which 20% in London and 70% in Paris were attributed to human-induced or anthropogenic climate change.

Climate change represents a major threat to health now and in the future and must be at the forefront of healthcare planning and delivery. Endoscopy has a bigger environmental impact than many other areas of healthcare. Endoscopists and other healthcare professionals should lead the way in healthcare sustainability for the benefit of our patients and the future of the planet. The principles of sustainable healthcare among others may help us reduce the environmental impact of endoscopy and be beneficial for patients. Individual and profession-wide efforts will be needed to progress and achieve this goal.

We read with interest the paper by Bang et al on the equivalence of single-use duodenoscopes compared with conventional reusable duodenoscopes to prevent transmissible infections.1 We congratulate the authors for their study demonstrating the economic, technical and safety equivalence of single-use duodenoscopes to conventional reusable duodenoscopes for endoscopic retrograde cholangiopancreatography (ERCP). The drive toward single-use endoscopes was generated by the incidence of duodenoscope-related infections in the USA, prompting the Food and Drug Administration in 2019 to recommend that healthcare providers and manufacturers transition to disposable components in duodenoscopes to reduce transmissible infections. A systematic review and meta-analysis of the rate and impact of duodenoscope infection involved 15 studies with over 13 000 duodenoscope analysis and found a 15.25% rate of contamination from preprocessed patient-ready duodenoscopes.2 It must be stated that the risk …

The coronavirus disease 2019 (COVID-19) pandemic has led to radical curtailing and reconfiguring of health services across the world to slow the spread of the disease. Planning for acute COVID-19 services has inevitably resulted in a precipitous reduction in endoscopy activity, but in the deceleration phase of the pandemic, endoscopy units will aim to restart. The primary concern will understandably be to protect patients and staff, while providing enough capacity to meet demand and manage postponed appointments. However, it is crucial that we also use this time to analyse current practice in the context of another sustained and serious threat: climate change. The climate crisis has major consequences for global health, including food insecurity, respiratory and vector-borne diseases, and excess heat-related deaths, even in the UK.1Royal College of PhysiciansBreaking the fever: sustainability and climate change in the NHS.https://www.rcplondon.ac.uk/projects/outputs/breaking-fever-sustainability-and-climate-change-nhsDate: March 15, 2017Date accessed: May 4, 2020Google Scholar The National Health Service (NHS) accounts for 5·4% of UK carbon dioxide emissions,2Pichler P-P Jaccard IS Weisz U Weisz H International comparison of health care carbon footprints.Environ Res Lett. 2019; 14064004Crossref Scopus (327) Google Scholar which, in 2015, amounted to 26·6 million tonnes of carbon dioxide equivalent—equating to 39% of all public sector emissions in England.3National Institute for health and CareSustainability.https://www.nice.org.uk/about/who-we-are/sustainabilityDate accessed: May 4, 2020Google Scholar Even during the brief period of lockdown around the world, the reduction in global activity has led to a decrease in greenhouse gas emissions by as much as 5·5%,4UN NewsFall in COVID-linked carbon emissions won't halt climate change—UN weather agency chief.https://news.un.org/en/story/2020/04/1062332Date: April 22, 2020Date accessed: May 5, 2020Google Scholar and potentially thousands of lives saved through cleaner air.5The GuardianClean air in Europe during lockdown 'leads to 11,000 fewer deaths'.https://www.theguardian.com/environment/2020/apr/30/clean-air-in-europe-during-lockdown-leads-to-11000-fewer-deathsDate: April 30, 2020Date accessed: May 6, 2020Google Scholar This drop might seem substantial but emissions will rebound rapidly once lockdowns end. If there is to be any chance of limiting global heating to less than 1·5°C above pre-industrial temperatures, year-on-year reductions of more than 7·6% are required for the next decade.6UN Environment ProgrammeCut global emissions by 7.6 percent every year for next decade to meet 1.5°C Paris target—UN report.https://www.unenvironment.org/news-and-stories/press-release/cut-global-emissions-76-percent-every-year-next-decade-meet-15degcDate: Nov 26, 2019Date accessed: May 4, 2020Google Scholar Radical change is necessary across every part of society, and health care must be included in the process, both because of the health service's role as a major contributor to the problem but also because of the serious public health risks posed by climate change.1Royal College of PhysiciansBreaking the fever: sustainability and climate change in the NHS.https://www.rcplondon.ac.uk/projects/outputs/breaking-fever-sustainability-and-climate-change-nhsDate: March 15, 2017Date accessed: May 4, 2020Google Scholar Endoscopy appears to be a major contributor to the environmental footprint of health care, generating about 3·09 kg of waste per bed per day (the third highest emitting hospital department).7Vaccari M Tudor T Perteghella A Costs associated with the management of waste from healthcare facilities: an analysis at national and site level.Waste Manag Res. 2018; 36: 39-47Crossref PubMed Scopus (73) Google Scholar High throughput caseloads, multiple non-renewable waste streams, numerous hospital visits for patients and relatives, and resource-heavy decontamination processes all contribute. Although some processes are necessary, others are ripe for change. Endoscope decontamination, for example, requires high volumes of water per decontamination cycle and multiple disinfectants, and has a major environmental impact as a result. There are no robust data on transport for patients and relatives, departmental energy use, and reusable versus disposable equipment. The call for evidence to inform the NHS Net Zero8NHS EnglandNHS Net Zero—Call for evidence.https://www.engage.england.nhs.uk/survey/nhs-net-zero/Date: Jan 25–March 22, 2020Date accessed: May 4, 2020Google Scholar plan is an important development, seeking practical ideas to achieve net carbon zero by 2050. The National Institute for Health and Care Excellence (NICE) has placed sustainability at the centre of their strategy,3National Institute for health and CareSustainability.https://www.nice.org.uk/about/who-we-are/sustainabilityDate accessed: May 4, 2020Google Scholar and numerous other organisations are springing up among concerned health-care professionals to make a difference on a regional, national, and international level. The gastroenterology community should be a part of this movement. Practitioners ought to review procedures against the principles of sustainable health care—prevention, patient empowerment and self-care, lean systems, and low-carbon alternatives—and identify areas amenable to transformation. We can begin by looking at the total number of procedures done, the reasons leading to potentially unnecessary processes, and the waste products involved (figure). Small but successive steps to analyse and change practice can have a substantial cumulative benefit. The magnitude of the problem as a whole should not engender inertia or act as a barrier to change. Undoubtedly, the approach likely to have the greatest impact will be to do fewer procedures, while recognising that endoscopy is a key component in the management of digestive diseases. Robust management of demand is axiomatic but will require an honest appraisal of our current values—for many, the natural inclination is to do more procedures, yet a reduction in endoscopic burden could be beneficial for patients. There are many drivers of increased endoscopy activity (figure, A), many of which result in unnecessary endoscopies. Identifying these unnecessary procedures and their primary drivers is an important first step. Potential solutions include rigorously checking the appropriateness of referrals, using low-waste alternatives (eg, faecal immunochemical tests, faecal calprotectin, video capsules, or CT where appropriate), or home testing to reduce travel (where technology allows and after effectiveness and safety have been established). Such a strategy could pose a challenge for health-care systems that rely on the income generated by low-risk, high-throughput endoscopy. A considerable change in outlook from society as a whole is required but we argue that, although eschewing value-based health care for financial gain remains very much part of the problem, sustainable health care is not necessarily associated with financial losses in most settings. A clear indication of the environmental impact of each procedure is required (figure). This insight could generate targeted interventions such as improved waste segregation, increased recycling, or the avoidance of single-use items where possible. Detailed analyses of the sustainability of each step in endoscopy activities would allow the identification of small but cumulative beneficial changes that could decrease our environmental impact. There is an urgent unmet need for research on sustainable practice in endoscopy: from optimal service delivery models to greener technology and the effects of climate change on the health of patients with gastrointestinal disease. As our knowledge base develops, there needs to be a renewed drive to disseminate this information. Sustainable health care should be a central theme in undergraduate and postgraduate curricula, and a major consideration for patient groups who educate patients about developments in practice and technology. Finally, physicians and researchers need to re-invent what endoscopy will look like in the long term. Practitioners should commit to importing the principles of sustainable health care into a new system for doing endoscopy. National bodies could also assist by evaluating endoscopy units, which could involve so-called green accreditation through meeting certain standards of sustainable practice. Action can, and must, also be taken at an individual level: an all-or-nothing approach risks inertia and prevents adoption of small changes that together could have a large effect. This vision for disruptive innovation seemed challenging just a few months ago, but the COVID-19 pandemic has shown how rapidly processes can change when faced with a crisis. Although the recent pause has given us time to reflect on current practice, the climate crisis is still accelerating. Endoscopy and its associated specialities remain part of the problem. As we consider restarting endoscopy services, we should use this opportunity to rapidly embed sustainability principles into everyday practice and trigger action in a timely and strategic manner. We can and must act quickly and radically with our colleagues across health care, the public, and government. We must reinvent endoscopy and how we live our professional lives with a view to protecting the planet on which we rely. For organisations engaging health-care workers in action on climate change see http://noharm.org/, https://www.medact.org/, and http://www.ukhealthalliance.org/ For organisations engaging health-care workers in action on climate change see http://noharm.org/, https://www.medact.org/, and http://www.ukhealthalliance.org/ JBM reports non-financial support from Norgine and personal fees and non-financial support from Intercept Pharma, outside the submitted work. SS reports research grants from Takeda, Pfizer, Tillotts Pharma, and Amgen; speaker fees or advisory board honoraria fees, or both, from Pfizer, Takeda, Tillotts Pharma, Pharmacosmos, Janssen, Amgen, and AbbVie, outside the submitted work. BH reports grants from Olympus Medical UK and Fujifilm Europe; personal fees from Takeda and AbbVie; and board membership and shares in Ampersand Health and Surgease Medical; none of these relationships represent interests that relate to the work presented in this manuscript. All other authors declare no competing interests.

Many people who inject drugs (PWID) who are infected with chronic hepatitis C virus (HCV) cannot engage with secondary care services due to social and geographical difficulties. The Cornish HCV management model integrates hospital-based hepatology and community drug and alcohol services, such as Addaction. Community blood-borne virus (BBV) screening is performed by Addaction staff. BBV nurses discuss results with patients. Results are reviewed at multidisciplinary meetings with the hepatology secondary care team with regard to a management plan. Patients were then treated either in the community by a BBV nurse or in secondary care. The community-based treatment of 43 HCV-positive PWID (2008–2012) resulted in a sustained virological response rate of 72% across genotypes 1–3 with only a 5% failure to complete therapy. This integrated model can help to increase HCV treatment rates in Cornwall and provide a national model for HCV treatment, particularly in non-urban areas.

BackgroundSeronegative hepatitis is a recognized cause of liver failure requiring transplantation. The aetiology is unknown, but might relate to an unidentified virus or immune dysregulation. There are few data on seronegative hepatitis presenting to nontransplant centres.ObjectivesTo describe the clinical/laboratory features and natural history of seronegative hepatitis and compare these with viral/autoimmune hepatitis.MethodsCases of seronegative, viral and autoimmune hepatitis were identified from 2080 consecutive patients attending a rapid-access jaundice clinic over a 14-year period.ResultsOf 881 patients with hepatocellular jaundice, 27 (3%) had seronegative hepatitis, 44 (5%) autoimmune and 62 (7%) viral hepatitis (acute hepatitis A, B, C and E viruses). Fifteen out of 27 (56%) patients with seronegative hepatitis were male, median age 60 years (range 14-74). Peak bilirubin was 63 mol/l (range 9-363), alanine aminotransferase 932 IU/l (range 503-3807). Duration of illness was 7 weeks (range 4-12). No patients developed liver failure or had further bouts of hepatitis. One patient developed acute lymphoblastic leukaemia shortly after presentation.There was no difference in age/sex of patients with seronegative hepatitis and those with viral hepatitis. Compared with autoimmune hepatitis (age 65 years, range 15-91), patients with seronegative hepatitis were younger (P=0.002) and more likely to be male (P=0.004). Patients with autoimmune hepatitis were more likely (P<0.0001) to have an albumin less than 35 g/l, international normalized ratio greater than 1.2, raised IgG and positive antinuclear/smooth muscle antibody, compared with patients with seronegative hepatitis.ConclusionSeronegative hepatitis presenting to a nontransplant centre is generally a self-limiting illness. The aetiology is more likely to be viral than autoimmune.

Introduction In developed countries autochthonous hepatitis E infection is caused by hepatitis E virus (HEV) genotype 3 or 4 and mainly affects middle aged/elderly men. Host factors might explain why older men develop clinically overt disease. Methods Retrospective review of 53 patients with symptomatic autochthonous hepatitis E infection to determine putative host risk factors. Patients were compared with 564 controls with adjustment for age and sex. Anti-HEV seroprevalence was determined in controls and 189 patients with chronic liver disease. Results Mean age of the patients was 62.4 years, 73.6% were men. Compared with controls, patients with hepatitis E were more likely to drink at least 22 U alcohol/week (OR=9.4; 95% confidence interval=3.8–25.0; P<0.001). The seroprevalence of anti-HEV IgG in controls increased with age (P<0.001) but was similar in men and women. There was no association between alcohol consumption and anti-HEV IgG seroprevalence in the control group. There was no difference in the anti-HEV IgG seroprevalence between the controls and patients with chronic liver disease of all aetiologies, but seroprevalence was higher in controls (13.8%) than patients with alcoholic liver disease (4.8%, P=0.04). Conclusion Clinically apparent hepatitis E infection is more common in individuals who consume at least 22 U alcohol/week. Patients with established chronic alcoholic liver disease have a low seroprevalence compared with controls. The reason for this observation is uncertain, but patients with alcoholic liver disease have clinically severe disease with a high mortality when exposed to HEV. The low seroprevalence in this group may represent a 'culled' population.

Aims To report the natural history of autochthonous hepatitis E and hepatitis E virus (HEV) IgG seroprevalence in Southwest England.Methods Patients with unexplained hepatitis were tested for hepatitis E and cases followed until recovery or death. Five hundred blood donors, 336 individuals over the age of 60 years and 126 patients with chronic liver disease were tested for HEV IgG.Results Forty cases of autochthonous hepatitis E (genotype 3) were identified. Hepatitis E was anicteric in 25% of cases and usually caused a self-limiting hepatitis predominantly in elderly Caucasian males. Six of 40 had a significant complication and three patients died, two of who had previously undiagnosed cirrhosis. Hepatitis E shows a seasonal variation with peaks in the spring and summer and no cases in November and December. HEV IgG prevalence increases with age, is more common in men and is 16% in blood donors, 13% in patients with chronic liver disease and 25% in individuals over 60 years.Conclusion Autochthonous hepatitis E is more common than previously recognized, and should be considered in the differential diagnosis in patients with hepatitis, whatever their age or travel history. It carries a significant morbidity and when seen in the context of chronic liver disease carries an adverse prognosis.