Background Introduction The prognosis of dysplasia in patients with IBD is largely determined from observational studies from the pre‐videoendoscopic era (pre‐1990s) that does not reflect recent advances in endoscopic imaging and resection. Aims To better understand the risk of synchronous colorectal cancer and metachronous advanced neoplasia (ie high‐grade dysplasia or cancer) associated with dysplasia diagnosed in the videoendoscopic era, and to stratify risk according to a lesion's morphology, endoscopic resection status or whether it was incidentally detected on biopsy of macroscopically normal colonic mucosa (ie invisible). Methods A systematic search of original articles published between 1990 and February 2020 was performed. Eligible studies reported on incidence of advanced neoplasia at follow‐up colectomy or colonoscopy for IBD‐dysplasia patients. Quantitative and qualitative analyses were performed. Results Thirty‐three studies were eligible for qualitative analysis (five for the meta‐analysis). Pooled estimated proportions of incidental synchronous cancers found at colectomy performed for a pre‐operative diagnosis of visible high‐grade dysplasia, invisible high‐grade dysplasia, visible low‐grade dysplasia and invisible low‐grade dysplasia were 13.7% (95% CI 0.0‐54.1), 11.4% (95% CI 4.6‐20.3), 2.7% (95% CI 0.0‐7.1) and 2.4% (95% CI 0.0‐8.5) respectively. The lowest incidences of metachronous advanced neoplasia, for dysplasia not managed with immediate colectomy but followed up with surveillance, tended to be reported by the studies where high definition imaging and/or chromoendoscopy was used and endoscopic resection of visible dysplasia was histologically confirmed. Conclusions The prognosis of IBD‐dysplasia diagnosed in the videoendoscopic era appears to have been improved but the quality of evidence remains low. Larger, prospective studies are needed to guide management. PROSPERO registration no: CRD42019105736.

BackgroundInflammatory bowel disease (IBD) is a chronic relapsing-remitting condition affecting 600 000 people in the UK. Traditionally, patients attend outpatient clinics for monitoring regardless of their symptoms or risk of developing complications. This can lead to a mismatch between need and access: patients in remission given elective appointments displace those in need of urgent specialist attention. Novel initiatives implemented in the UK to improve outpatient monitoring have often required a well-maintained patient registry, empowered patients and significant information technology support.Design and strategyIn this large-scale quality improvement project at St Mark’s Hospital, a tertiary centre for IBD, we stratified over 1000 patients attending three non-complex IBD clinics over 12 months according to disease activity and risk profile. The aim was to offer a choice and subsequently transfer 50% of eligible patients to specialist nurse-led telephone clinics and demonstrate non-inferior satisfaction levels to existing outpatient follow-up. We also sought to ensure there was timely access to a newly established rapid access clinic for patients requiring urgent specialist attention.A core project team consisting of healthcare professionals, patients and quality improvement scientists met regularly. The team tested and scaled up interventions using ‘Plan-Do-Study-Act’ cycles within the ‘Model for Improvement’ framework and analysed data continuously using statistical process charts.ResultsOver 12 months, the average number of eligible patients transferred to telephone clinics rose from 17.6% (42/239) using a questionnaire method to 59.3% (73/123) using active discussion in clinic. Patient satisfaction scores remained high and non-inferior to baseline scores in face-to-face clinics. The median waiting time to be seen in the rapid access clinic was 6.5 days.ConclusionThis is the first published study to report on the successful stratification of patients with IBD based on disease activity and risk of complications to create a more responsive, sustainable and patient-centred model for IBD monitoring.

BackgroundAjmaline is a pharmaceutical agent now administered globally for a variety of indications, particularly investigation of suspected Brugada syndrome. There have been previous reports suggesting that repetitive use of this agent may cause severe liver injury, but little evidence exists demonstrating the same effect after only a single administration.Case presentationA 33-year-old man of Libyan origin with no significant past medical history underwent an ajmaline provocation test for investigation of suspected Brugada syndrome. Three weeks later, he presented with painless cholestatic jaundice which peaked in severity at eleven weeks after the test. Blood tests confirmed no evidence of autoimmune or viral liver disease, whilst imaging confirmed the absence of biliary tract obstruction. A liver biopsy demonstrated centrilobular cholestasis and focal rosetting of hepatocytes, consistent with a cholestatic drug reaction. Over the course of the next few months, he began to improve clinically and biochemically, with complete resolution by one year post-exposure.ConclusionWhilst ajmaline-related hepatotoxicity was well-recognised in the era in which the drug was administered as a regular medication, clinicians should be aware that ajmaline may induce severe cholestatic jaundice even after a single dose administration.

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Background Good quality Care in inflammatory bowel disease (IBD) includes the provision of patient-relevant information.1 Data on the level of patient understanding is lacking. We studied patients’ understanding of their IBD condition. Methods The IBD team and patient representatives devised a 16-item questionnaire that collected data on baseline demographics and disease-specific characteristics. Answers denoting understanding were scored positively. A sum (Q-sum) of the individual question scores was expressed as median (range). Results 150 patients were surveyed (49% male). Thirty-nine per cent had ulcerative colitis, 51% Crohn’s Disease and 10% IBD-unclassified. There were: 39 aged <30, 94 aged 30–60, and 15≥60. The median (range) Qsum was 9 (1–16). Twelve per cent of patients had a Qsum of ³13. The Qsum of patients < 60 years old was 10 (2–16) compared with 7 (1–13) of the ≥60 age group (p = 0.02). Sixty-two per cent of the younger and 60% of the older group perceived themselves as well informed (p = 0.9). The Qsum scores were 12 (2–14), 10 (2–16) and 8.5 (3–14) for patients with disease duration of ≤1 year, 2–15 and ≥15 years respectively (p < 0.05). There was no difference in scores according to disease and medication type. 96% of patients in the <60 age group were willing to access online information compared with 60% in the ≥60 age group (p < 0.01). Younger patients were more confident in recognising symptoms of a flare [86%] compared with those aged ≥60 [60%] (p = 0.01), and were also more likely to understand how their condition may progress compared with older patients (66% vs. 40%, p < 0.05). Among patients <60 years only 14% of males and 26% of females (p = 0.08) reported having enough information on fertility. Sixty-six per cent of patients on biologic drugs and 53% on non-biologic drugs considered themselves well informed (p = 0.12). Forty-six per cent of the non-biologics cohort also reported low levels of knowledge on self-management of mild flares. Seventy-six per cent of the biologics group and 87% of the non-biologics group expressed willingness for information on self-management (p = 0.1). Conclusion Older patients are less well informed, less confident in recognising symptoms of a flare, and less likely to access on-line resources. The level of knowledge inversely correlated with disease duration. This may reflect the heightened recent awareness on the inclusion of patient education in clinical care and availability of resources. There is an interest in receiving information on self-management of mild flares. Education sessions should be personalised according to patient characteristics and objective measures such as PAM score (Insignia Health), implemented to show benefits. Reference