Professor Susan Mckiernan

Summary

Introduction: Functional disorders account for 40% of gastroenterology referrals.The NICE guidelines recommend Rome IV criteria and non-invasive tests to facilitate diagnosis and avoid unnecessary endoscopy. First-line management involves dietary education/intervention provided by experienced Dieticians, resulting in adequate symptom relief in 80%. This pathway is rarely followed and patients undergo reassuringly negative endoscopies and are sent back to the GP without symptom resolution. Aim: In patients under 50 referred for colonoscopy for the investigation of diarrhoea and/or constipation at St James's Hospital our aim is to assess the impact of a dedicated clinical /dietetic review on 1) symptom relief, and 2) reducing colonoscopy numbers Methods: Patients underwent blood (FBC/electrolytes/CRP/TSH/tTG) and stool (C&S/Calprotectin) tests before attending a medical assessment. Patients fulfilling a diagnosis of IBS then underwent dietetic intervention (1st line-education +/-2nd line-FODMAPs) with a senior Dietician. Response was assessed using a symptom survey pre and post-intervention. Those with an inadequate response underwent further investigation. Results: Of 105 patients, 75(71%) were referred to Dietetics, 24(23%) required endoscopy, and 6(6%) required no intervention. To date, 47 patients have completed dietary intervention. Of these, 44(93.6%) were discharged following adequate symptom relief (74%-1st line and 26%-2nd line intervention), and 3 patients were referred for endoscopy. This has led to the avoidance of 78 colonoscopies and 23 gastroscopies so far - equating to an 80% reduction in endoscopy requirement in this cohort of patients. Conclusions: The implementation of a dedicated clinical diagnostic and dietetic management service has significantly reduced the number of unnecessary endoscopic procedures and facilitated the discharge of these patients following adequate symptom relief. As proof of concept was successful, the programme has now received recurrent funding for wte 0.54 clinical nutrition, and is being presented for national approval.

Funding Agency

nil

Project Type

health economics, health efficiencies, patient satisfaction

Person Months

12

Summary

All prisoners remanded in custody are committed to one of three remand prisons. A screen to treat program will be highly effective in identifying those with chronic HCV in a high prevalence population and will provide a public health benefit in reducing prevalence, transmission and engage otherwise difficult to engage patients in a closed setting In the Midlands and Portlaoise prison a micro elimination project will take place whereby all existing inmates are screened through a mass screening methodology. Screening will be carried out by a CNM prisons liaison nurse using mobile point of care HCV quantitative RNA technology using a finger stick blood sample.The CNM will link all HCV positive prisoners to care for continuation or initiation of treatment prior to transfer or release to the community. Methodology Screening . All new inmates on remand in Cloverhill prison will be screened by the CNM working for 3of 4 weeks in this location. As the service is developed screening at Castlerea prison will be advanced. . A mobile point of care HCV quantitative RNA technology using a finger stick blood sample which negates the need for phlebotomy services, with a 60 minute turnaround time for results which will enable rapid engagement into care. . A micro elimination program will commence in the Midlands and Portlaois prisons whereby all existing inmates will be screened by the CNM through mass screening methodology using the same POC RNA technology . Prisoners will be educated on liver health, risk factors for fibrosis progression and DAA treatment for Hepatitis C by the Red Cross and the HCV prison Liaison CNM. . Those prisoners found to have active replicating HCV will have an assessment of their fibrosis/cirrhosis stage using a mobile Fibroscan or biomarkers such as APRI/FIB-4. . The IPS health records will be updated with the results. . In the remand prisons HCV positive patients will be offered treatment on-site by the CNM if the duration of their incarceration from the point of engagement is 8 weeks or more . If a prisoner on remand chooses not to be treated whilst on remand and does not get a custodial sentence they will be referred for treatment in the community . If they are committed under sentence and are awaiting treatment or have already commenced treatment on remand the HCV liaison CMN will link in with the prison that the patient is being transferred to. . Patients who refuse treatment or cannot be treated at this point will be linked to care with community services. . On-site treatment will then continue for all new committals from the remand prisons. Governance . This project will be led by Prof McKiernan, the IPS and NHCTP and all decisions with regard to the screening methodology and treatment will be made by these bodies. . The support from AbbVie will be limited strictly to initial funding for equipment & screening only in each prison. . Abbvie will fund in stages two POC RNA machines and the number of test kits based on the operational capacity of each prison at commencement of the project , 1 for use in the 3 remand prisons and 1 to be used in the Midlands and Portlaoise the initial microelimination sites which could then be transferred to other prisons in the future. . Abbvie will also fund 2 fibroscans, 1 for the 3 remand prisons and one for the micro elimination sites which could then be transferred to other prisons. as part of NHCTP & IPS screen to treat elimination program . All other resource requirements such as funding for the HCV prison liaison CNM headcount will be determined and funded by the NHCTP or IPS as appropriate . The funding provided is in alignment with the rollout of the planned NHCTP/ IPS on-site screen to treat program, specifically that the infrastructure and resources will be in place to roll out the project in the same timescale.

Funding Agency

Abbvie Ltd

Project Type

proof of concept, health economics, health,

Person Months

12

Summary

Introduction Helicobacter Pylori (H.Pylori) infection is a recognized cause for chronic gastritis, peptic ulcer disease, gastric adenocarcinoma, and gastric mucosa associated lymphoid tissue lymphoma. There has been an increase in the prevalence of antibiotic-resistant bacteria. The Irish Helicobacter Pylori Working Group Consensus has stated that standard triple therapy for 7 days' duration can no longer be recommended. Aim To investigate H.Pylori resistance patterns in patients having gastroscopy with culture & sensitivity(C&S) at St. James's Hospital, over last 14 years. Methods This is a retrospective study, evaluating H.Pylori C&S sent over the last 14 years. Resistance patterns were analysed for the positive C&S. Results Out of a total of 1228 C&S sent for H.pylori, 643 (52.36%) were positive while, 585 (47.64%) were negative for the bacteria. Within positive C&S, 402(62.52%) were female, with the mean age of 42.69 years. The sensitivity testing for amoxicillin and metronidazole were discontinued after 2010. Resistance rate for clarithromycin and metronidazole were 78.08% and 66.37% respectively. Comparing the period from 2004-2009 to 2010-2017, the resistance rate for clarithromycin was rising from 69.27% to 81.51%. Resistance rate for amoxicillin, tetracycline, and rifampicin were 3.44%, 0.31% and 1.09% respectively. 35.87% were resistant while 3.26% were intermediate sensitivity to levofloxacin. Conclusion In the cohort of patients with previous H Pylori eradication failure, resistance to Clarithromycin and Metronidazole is common, with increasing resistance rate to clarithromycin over the years. Resistance pattern to levofloxacin is also on the rise. This further validates the use of H Pylori C&S to guide the antibiotic regimen in this cohort.

Funding Agency

nil

Project Type

Audit, change of clinical practice

Person Months

3