Epidermal growth factor enemas with oral mesalamine for mild-tomoderate left-sided ulcerative colitis or proctitis Sinha, A; Nightingale, JMD; West, KP; Berlanga-Acosta, J; Playford, RJ For additional information about this publication click this link.https://qmro.qmul.ac.uk/jspui/handle/123456789/224 Information about this research object was correct at the time of download; we occasionally make corrections to records, please therefore check the published record when citing. For more information contact scholarlycommunications@qmul.ac.uk original articleThe new england journal of medicine n engl j med 349;4 www.nejm.org

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Background: Recent guidelines from the British Society of Gastroenterology published in April 2018, recommended performing random colonic biopsies (RCB) in endoscopically normal colonic mucosa when investigating chronic diarrhoea in adults to rule out microscopic colitis; however, cost effectiveness was not accounted for due to poor evidence base. There is now more evidence that RCBs are of low yield and of significant cost. Methods: A two-centre audit of current practice was conducted at Rockingham General Hospital and Fremantle Hospital in Western Australia, aiming to determine the yield of RCB in macroscopically normal mucosa for microscopic colitis, from 1 January 2009 to 30 June 2018, with comparisons of practice and results between gastroenterologists and general surgeons. Variability in the indications (diarrhoea and non-diarrhoea indications) for RCBs was determined and the cost of consumables, additional endoscopy time and histopathology analysis were calculated. Results: A total of 872 normal colonoscopies with RCBs were included; 48.7% of colonoscopies with RCB were for diarrhoea. Only 1.5% of RCBs were positive for microscopic colitis; 3.1% of patients with diarrhoea had microscopic colitis. Only one patient received pharmacologial treatment as a result of the test. The calculated cost per positive diagnosis of microscopic colitis was $10 862.42. Conclusion: RCBs from normal colonic mucosa have poor yield and are costly. Local guidelines should be updated, so RCBs are performed only in patients with a high degree of suspicion of an organic cause of chronic diarrhoea.

IntroductionThere is well documented evidence linking Streptococcus bovis (S bovis) bacteraemia to colonic neoplasms and polyps. As patients with S bovis bacteraemia can be found across various specialities, our aim was to audit the consistency of appropriate specialist referral for assessment of colonic pathology.MethodsAll cases of S bovis bacteraemia occurring between October 2000 and June 2009 were identified using information provided by the department of microbiology. Medical records were reviewed for clinical details, evidence of features of endocarditis and referral to gastroenterologists. The standard of best practice was all cases should be referred for appropriate specialist review.ResultsThere were 20 cases of S bovis bacteraemia from the total of 3454 positive cultures (0.6%). There were 11 male and 9 female and all were Caucasian with a mean age of 80.7 years. Four (20%) had endocarditis and four had abnormal liver enzymes. Seventeen patients had a microbiology report in the notes and 13 had Microbiologist advice to consider cardiac and/or colonic pathology. The gastroenterology team's opinion was sought for 10 (50%) patients and 10 patients underwent one or more investigations including gastroscopy, colonoscopy, flexible sigmoidoscopy and CT of the abdomen.60% of these investigations were performed on gastroenterology team's advice and the rest were done on the admitting team's initiative. In seven patients (35%) their prognosis at the time the bacteraemia was judged to be so poor as to preclude further investigation.Of the 10 patients who were investigated, six (60%) had positive findings. Two patients had colorectal adenocarcinoma (one rectum and one sigmoid); one had a stricture diagnosed on CT abdomen; and three had significant polyps (one or more tubulovillous adenomas with low grade dysplasia >1 cm). 60% of the patients in the study (12) were already deceased at the time of the audit and one patient had had a repeat colonoscopy after 1 year and had further polyps removed.ConclusionA lack of uniformity was observed in proper referral for gastroenterologist assessment and investigation. The age and multiple comorbidities of these patients made further investigations clinically inappropriate in 35% in this study. In the absence of proper guidelines regarding investigation of patients with S bovis bacteraemia for bowel pathology, we recommend seeking formal gastroenterology advice in all such patients. At the Royal Bournemouth Hospital, the department of microbiology has decided to inform the gastroenterology team of all S bovis positive cultures. Following these measures, this audit will be repeated.

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Objective: Hard-to-heal wounds are a common problem, worsened by ageing, and the increased prevalence of diabetes and morbid obesity. The provider–patient relationship has undergone a transformation, from a paternalistic to a mutual participation model, in which ‘the physician tries to enter the patient's world to see the illness through the patient's eyes’. The indepth assessment of the impact of psychosocial, physical issues and provider–patient dynamics is crucial to wound healing and patient wellbeing. It can customise future treatment including physical therapy, psychological and social interventions to improve outcomes. Method: A new health-related quality of life instrument (HRQOL) proposal based on a survey consisting of 20 questions was completed by patients as a pilot project. The psychosocial, physical and provider–patient dynamics were evaluated. A total wound impact score (WIs) was tabulated, ranging from 20–80 points. A wound assessment and plan (PBW–AP) was created. Results: In our sample of 25 patients, 75% experienced a moderate WIs (50–69) and 5% experienced a severe WIs (31–49). Feeling angry about having a wound was reported by 40% of patients. A majority of patients (60%) thought about their wounds >1 hour per day. Importantly, 24% answered that their primary care physicians never mentioned their wounds. Conclusion: It is important for all physicians taking care of patients with hard-to-heal wounds to see ‘the patient behind the wound’. The PBW–AP algorithm is an individualised, multidisciplinary assessment and intervention based on a WIs. It is designed not only to identify but also to tackle psychosocial, physical, and provider–patient issues, to improve overall quality of life, patient satisfaction and clinical outcomes. Based on the results, the PBW–AP algorithm was designed to be used at initial and subsequent visits as a roadmap for problem identification and intervention.

uL, and high CMV PCR at 4,068 IU/mL. Qualitative fecal fat positive. Negative blood cultures, fungal culture, mycobacterial blood, and sputum cultures. Negative stool testing for Clostridium difficile, fecal leukocyte antigen, cryptosporidium, Giardia antigen, Salmonella, Shigella, Campylobacter species, ova and parasites. CT abdomen/pelvis showed a loculated fluid collection in the splenic bed that was drained with negative cultures. On EGD and colonoscopy, the duodenum and terminal ileum (TI) had petechial lesions which on pathologic examination revealed diffuse AFB and villous blunting in TI. Normal colonic biopsies. Biopsies were negative for CMV, celiac disease, and Whipple's disease. Diagnosed with disseminated atypical MAC(most likely M. kansasii) in the setting of HIV-AIDS. CMV viremia was thought to be an incidental finding without GI manifestations. Treatment for disseminated MAC with ethambutol, isoniazid, rifampin, azithromycin, pyridoxine, and for HIV with Dolutegravir & Truvada started. However, he deteriorated despite treatment and died from multi-organ failure 16 days later. (Figure ) Discussion: Diarrhea, a common gastrointestinal symptom in AIDS, has many etiologies. DMAC is associated with higher morbidity and mortality. So physicians must be familiar with the causes and utilize endoscopic interventions as needed for effective diagnosis and treatment in AIDS patients.[3377] Figure 1. Petechial lesions in the terminal ileum noted on endoscopy.