St James's University Hospital Research Articles

#6884 THE BARRIERS TO TRANSPLANTATION IN OUR DIABETIC HAEMODIALYSIS POPULATION AT THE LEEDS TEACHING HOSPITALS NHS TRUST

Abstract Background and Aims According to the 24th Annual Renal Registry Report, diabetes is the most common identified primary renal disease in patients starting renal replacement therapy (RRT). The prevalence of this underlying disease amounted to 30.5% by the end of 2020, a statistic which increased from 27% in 2015. This highlights the challenges faced by healthcare services in meeting the accrescent demands of this cohort of patients. The Renal Association and British Transplantation Society suggest that patients with a BMI >30 kg/m2 are at a heightened risk of complications and is therefore discouraged. Our local transplant centre at St James's University Hospital accepts recipients with a BMI of up to 35 kg/m2 for kidney alone transplantation should no other medical/ surgical contraindications to transplantation prevail. Despite this threshold, there remains a significant proportion of patients suspended from the deceased donor transplant waiting list due to an unacceptably raised BMI. Method Data was collected through the use of clinic letters or GP records uploaded to Patient Pathway Manager and BHLY (Bradford, Hull, Leeds and York) Renal Patient System. Our patient population consisted of those diabetic patients on home and in-centre haemodialysis (Leeds St James's University Hospital, Pontefract, Seacroft, Beeston, Dewsbury, Calderdale and Huddersfield). The aims of our study are to assess the demographics of the diabetic haemodialysis (HD) population at the Leeds Teaching Hospitals NHS Trust, to determine the reasons for suspension from the renal transplant waiting list, with a particular interest in obesity. We also assessed the commonest treatment modality (insulin vs other) and the use of continuous glucose monitoring. Results The Leeds renal services provide haemodialysis for 631 patients, 248 of these being diabetic patients - 66% of whom are male, with a mean age of 60. Just over 50% of this cohort of patients are Caucasian in ethnicity, while 30% are South Asian. By the end of December 2022, just below 20% (n = 119) of all haemodialysis patients were active on the national deceased transplant waiting list. On the other hand, only 14% (n = 35) of the diabetic haemodialysis subpopulation were active by the end of 2022, while 13% (n = 31) were under assessment, 14% (n = 35) declined and/or disengaged from assessment for transplantation, while the rest were either temporarily or permanently suspended. Almost 10% (n = 24) of all diabetic haemodialysis patients are suspended due to a BMI >35 kg/m2. Conclusion Our audit reveals that only 14% of the haemodialysis diabetic population is presently active on the deceased transplant waiting list. This remains suboptimal, as renal or simultaneous pancreas kidney transplantation is the gold standard for diabetes-induced ESKD. Obesity (BMI >35) was a reason for temporary suspension in 10% of our haemodialysis diabetic population. Therefore we need to target this comorbidity in a timely manner in order to optimise patients for transplantation. NICE recommend pharmacological weight-lowering therapy for people who have failed to achieve a healthy BMI following conservative methods. Such medical therapy (eg. liraglutide) is still yet to be evaluated in depth in the ESKD-haemodialysis obese population. Only one patient in our cohort was being treated with liraglutide, while the rest was either on insulin, linagliptin, gliclazide or non-pharmacological dietary modification. The authors of this study encourage the inclusion of CKD5 patients on liraglutide, before they are started on haemodialysis, in order to pave their way to transplantation before it is too late.

MAGNETIC RESONANCE IMAGING FINDINGS OF PERIANAL FISTULAE AND ITS CORRELATION WITH DEMOGRAPHICS, CO-MORBITIES AND SURGICAL OUTCOMES IN A TERTIARY HEALTH CARE CENTRE IN MAHARASHTRA, INDIA :A CROSS SECTIONAL STUDY.

Introduction:. Perianal stulas have been traditionally imaged by conventional stulogram, CT stulography and endoanal USG. The advantages of MR imaging include multiplanar imaging and a high degree of soft-tissue differentiation, which show the stulous track in relation to the underlying anatomy in a projection relevant to surgical exploration, thus providing an edge over previous diagnostic modalities To . Objectives: identify the stulous track in relation to sphincter complex. To classify the perianal stula according to St James's University Hospital Classication. To correlate imaging ndings with demographics, commorbities and surgical outcomes. Methodology: A cross sectional, observational study was conducted on 60 patients with clinically diagnosed perianal stulae using 1.5 Tesla HDxt MRI machine over a period of 18 months. Results MRI helped in the adequate grading of the perianal stula as per the St James University Hospital grading and further surgical follow up showed good association in grade III, IV and V perianal stula. MRI of the peri Conclusion: anal stula provided information about the primary stulous track and their different stulizing patterns, internal openings with great anatomic detail of the surrounding pelvic organs and the sphincter complex

The role of cholecystectomy following endoscopic sphincterotomy and bile duct stone removal.

Choledocholithiasis is common, with patients usually treated with endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focused on recurrent CBD stones, negating the risks of cholecystectomy. This article appraises the role of cholecystectomy following successful endoscopic clearance of bile duct stones. Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James's University Hospital January 2015-December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated. Eight hundred and forty-four patients received ERCP and CBD clearance with 3.9 years follow-up. Two hundred and nine patients underwent cholecystectomy with 15% requiring complex surgery. Three hundred and seventy-three patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive. The majority of patients do not require readmission following ERCP for CBD stones, and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but complex biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.

Role of Transcutaneous Perianal Ultrasonography in Evaluation of Perianal Fistulae with MRI Correlation.

Purpose: The aim of this study was to evaluate the role of transcutaneous perianal ultrasonography (TPUS) in patients with perianal fistula and to correlate the findings with magnetic resonance imaging (MRI) as gold standard. Materials and Methods: This prospective study included patients who presented with suspicion of perianal fistula. After clinical examination, TPUS and MRI of perianal region were performed on each of them. Clockwise position of internal opening of the fistula was described. The entire length of the tract was evaluated up to the external opening. Also, any ramifications along the primary tract were described. Parks et al and St James's University Hospital MR Imaging Classification of Perianal Fistulas were used for classifying the fistulas. Results: Out of total 37 patients, the most common age group of presenting individuals was 45 to 60 years with male to female ratio of 6.4:1. There was excellent agreement between TPUS and MRI for detecting primary fistulous tract with kappa correlation coefficient of 1. The kappa correlation coefficient for detecting secondary fistulous tracts and abscess on TPUS and MRI was 0.839 and 0.937 showing excellent agreement. Moderate agreement was seen with kappa correlation coefficient of 0.839 in the detection of internal opening on TPUS and MRI. Conclusion: TPUS showed promising results in diagnosis and classification of perianal fistulae with MRI as gold standard. A wide availability, cost-effectiveness, and better tolerability of TPUS can make it an imaging modality of first choice for evaluating perianal fistulae.

English

BACKGROUND Perianal fistulas account for a substantial discomfort and morbidity to the patient thus affecting productive man hours and quality of life. Accurate pre-operative assessment of course of the primary fistulous track and secondary extension or abscesses is required for successful surgical management of anal fistulas. The purpose of this study was to diagnose and classify pre-operative perianal fistulas. METHODS This is a cross-sectional study at Department of Radiodiagnosis in a tertiary level hospital of southern Rajasthan from November 2018 to November 2020. The study included a total of 50 patients referred to department of radiology for magnetic resonance imaging (MRI). Statistical analysis was done using chi square test and student t test. RESULTS Out of these patients, 56 % were having secondary tract on MRI, 12 % patients were having abscess and 4 % were having horseshoe abscess on MRI. The commonest type of ano-rectal fistula encountered in the study was Grade -II seen in 32 %. CONCLUSIONS MRI is a highly accurate, rapid and non-invasive tool in pre-operative evaluation of the perianal and anal fistulas. MRI evaluation and classification of perianal fistulae has a high degree of diagnostic accuracy. The use of MRI for the diagnosis and classification of perianal fistula can provide reliable information which has both pre-operative and prognostic value. St James University Hospital classification, which is an MR imaging-based grading system for perianal fistula is very useful for effective radiological-surgical communication thus contributing to improved patient care and reduced rate of recurrence. KEYWORDS MR Fistulogram, Perianal Fistula, Anal Fistula, Fistula Classification, Fistulography

P029. An 11-year unit experience on management and outcome of B3 lesions without atypia using the leeds management pathway at ST James University Hospital in Leeds

P029. An 11-year unit experience on management and outcome of B3 lesions without atypia using the leeds management pathway at ST James University Hospital in Leeds

Average recovery time from delayed visual maturation.

The research aimed to investigate the average age of recovery in infants with delayed visual maturation (DVM). DVM is diagnosed retrospectively and there are currently no management guidelines. This study gives an evidence-based recovery time which can help clinicians to appropriately reassure anxious parents about DVM prognosis. This research is significant as this is the largest participant study about DVM to date. This is a retrospective service evaluation of 50 infants with DVM presenting to St James University Hospital between 2012 and 2017. The DVM was classified into either type I or type II. Several key variables were recorded including: patient gender, age at recovery, type of DVM and whether Electrodiagnostic testing was used. STATA analysis showed that the average age of recovery for type I and type II DVM was 6.708 and 13.464months, respectively. A multivariable linear regression adjusted for gender as a confounder. The average age of recovery was 6.179months longer for infants with type II DVM which is a statistically significant difference (95% CI: 3.214-9.143, P value: < 0.001). This research supports the hypothesis that the age of recovery in type I DVM is significantly shorter than type II when adjusted for gender. The main limitation is that recovery age is recorded from when the infants attended clinic, however; their vision could have recovered prior to this. In the future, additional multi-centre research needs to be conducted looking at larger patient samples to allow for further sub-categorisation of DVM types.

Assessing validity of existing fistula-in-ano classifications in a cohort of 848 operated and MRI-assessed anal fistula patients – Cohort study

Aim/backgroundThe commonly used fistula-in-ano classifications, Park or St. James's University hospital(SJUH), neither grade fistulas as per their severity nor guide regarding their management. A new classification(NC), published in 2017, proposed to classify fistulas as per their severity and also guided in its management. The early grades (NC grade I & II) were simple fistulas and were amenable to fistulotomy whereas higher grades (NC grade III-V) were complex fistulas and were not amenable to fistulotomy. MethodsLower grades of all the three classifications were classified as simple (Parks: I, SJUH:I-II, NC:I-II) whereas higher grades were classified as complex (Parks: II-IV, SJUH: III-V, NC: III-V) fistulas. Fistulotomy should be possible in simple fistulas but not in complex fistulas. This was analysed for all these classifications. The long-term follow-up of continence was done by an objective scoring system (Vaizey's scores). ResultsThe SJUH & Parks classifications categorized 504/828 fistulas as ‘complex’ which was quite inaccurate as 42.7%(215/504) of these fistulas were safely amenable to fistulotomy. On the other hand, the New classification (NC) classified 282/828 fistulas as ‘complex’ which was very accurate as 99% (279/282) of these were actually complex and were not amenable to fistulotomy. The change in the preoperative and the postoperative continence scores in the patients who underwent fistulotomy, as per these classifications, Parks & SJUH vs NC, was 0.064 ± 0.62 and 0.089 ± 0.85 respectively and was not significantly different(p = 0.80, Mann-Whitney U test). ConclusionsThe New classification(NC) seems better than the existing classifications for grading the disease as well as in guiding the management of the disease.

Role of Mr Fistulogram in preoperative assessment of anorectal fistulas and its correlation with intraoperative findings

The anorectal fistulas can be inter sphincteric, Trans sphincteric, extra sphincteric or supra sphincteric. Detailed understanding of anorectal anatomy is needed for identification and management of anorectal fistulas. Park’s and St James University Hospital classification are used of which the latter gives better details of perianal fistulas. Unenhanced and enhanced MRI helps in identification of primary and secondary tracks, complications like abscesses and hence guides the surgeons to plan appropriate treatment strategy. During the study period, around 30 patients who were diagnosed to have perianal fistula clinically and referred for MR fistulogram to the Department of Radiology were included in the study. In our study, there was significant correlation between the fistulous tracts identified on MRI and the surgical findings. Fistulotomy is the preferred method of management in our institution. And for patients with abscess, abscess drainage is done. Fistulotomy was done in about 24 out of 30 patients which correlated well with the MRI findings for grades III to V. Grade I and II fistulas showed discrepancies in identification. Abscess drainage was also done in 5 patients (8.35%) which were also in accordance with MRI findings.

Garg Classification for Anal Fistulas: Is It Better than Existing Classifications?—a Review

Classifying a disease is important as it helps in categorizing the disease according to its severity and also guide the treating physician regarding the management of the disease. There are three classifications in vogue for fistula-in-ano—Parks, St James university hospital, and Standard Practice Task Force classification. These existing classifications were compared with the recently proposed Garg classification. The grading of earlier three classifications do not correlate with the severity of the disease and also does not provide any input about the management. Garg classification correlate quite well with the disease severity and also guides the surgeon regarding the management of the disease (fistulotomy can be safely done in Garg grade I-II and should never be attempted in Garg grade III-V). Thus, Garg classification should be used by surgeons and radiologists.

Is fistulotomy still the gold standard in present era and is it highly underutilized?: An audit of 675 operated cases

AimDue to fear of incontinence, fistulotomy perhaps remains highly underutilized. The aim was to analyze the efficacy of fistulotomy in a large cohort, to assess the magnitude of underutilization of fistulotomy by current classifications and to identify the subgroup in whom the fistulotomy should be done. MethodsAll consecutive operated patients of fistula-in-ano were included in the study retrospectively. The fistulas were classified as per existing classifications-Parks, St James University Hospital (SJUH) and Garg classification. Smaller grades of each classification (Parks I, SJUH I-II, Garg I-II) were expected to be simple fistulas and thus amenable to fistulotomy. Objective incontinence scores were done preoperatively and postoperatively. Results675 patients were operated over a 5.5 year period (median-27 months). 25 patients were excluded. Fistulotomy was done in 353/650 (54.3%) patients and sphincter-saving procedures (SSP) performed in 297/650 (45.7%) patients. After fistulotomy, 346/353 (98%) fistulas healed after the first operation. Seven patients with recurrent fistula were cured after a repeat fistulotomy surgery. Thus the overall healing rate was 353/353 (100%). There was no significant change in continence scores.The 353 fistulotomy patients were classified as per different classifications- Parks (I-225,II-112,III-16,IV-0), SJUH(I-138,II-87,III-47,IV-65,V-16) and Garg (I-188,II-165,III-0,IV-0,V-0). 123 (36.3%) patients who could undergo fistulotomy successful were erroneously classified as complex fistula by Parks and SJUH classifications. Garg classification accurately identified all 353/353 (100%) patients were amenable to fistulotomy. ConclusionsFistulotomy is a safe procedure with remarkably high success rate (100%) and is gold-standard in majority of patients (>50%). Parks and SJUH classifications are inaccurate in selecting patients for fistulotomy. Garg classification predicts amenability to fistulotomy with very high accuracy.

An interview with Professor David Jayne at the NCRI 2017 Cancer Conference

David Jayne speaks to Roshaine Wijayatunga, Managing Commissioning Editor: David Jayne is the Professor of Surgery at the University of Leeds and a Consultant General Surgeon at St James's University Hospital. He has a specialist interest in laparoscopic and minimal access surgery and is one of the few surgeons in the UK with experience in surgical robotics for abdominal disorders. He also has an interest in pelvic floor dysfunction, including the treatment of fecal incontinence and constipation. David has an active research interest in both these areas of surgical practice, which has led to the publication of many original research papers and two books. He sits on several NIHR funding bodies, is Clinical Director for the NIHR Healthcare Technology Co-operative in Colorectal Therapies and Co-Director for the NIHR Global Health Research Group in Surgical Technologies.

Perianal fistülün tanısında, sınıflandırılmasında ve değerlendirilmesinde Manyetik Rezonans Görüntüleme’nin önemi

Aim: Magnetic resonance imaging (MRI) is a non-invasive and high reliability procedure for evaluation of perianal area. In this study, our purpose is to present preoperative MRI findings and classification with images in diagnosed perianal fistula patients. Methods: Contrast enhanced (CE) conventional MRI images, diffusion weighted MRI images and demographics of 57 patients were retrospectively evaluated. Perianal fistula classification is based on St James University Hospital (SJUH) classification system. Results: 57 patients (44 men and 13 women, average of 18 to 72 years, average age of 45.7 year) were included in this study. Most of the patients had symptoms of rectal pain and discharge. Some patients had additional complaints like rectal itching, swelling and erythema. 37 patients had grade 1, nine patients had grade 2, four patients had grade 3, five patients had grade 4 and two patients had grade 5 fistula. Fistula opening positions into anal canal were 6 o'clock in 21 patients, 7 o'clock in 10 patients. Fistula tract, its opening position into anal canal, presence of abscess and its relationship with sphincters or neighboring anatomical structures were clearly appreciated with conventional and diffusion weighted MRI in all patients. Conclusion: Perianal fistula is the abnormal connection between anal canal and perinea. It is usually a complication of anorectal abscess. It could occur secondary to inflammatory processes like Crohn's disease, tuberculosis or malignancy. Surgery is considered as the primary treatment. Recurrence due to surgical inadequacy is common. Recurrence rates could be minimized with a good knowledge of MRI findings and well informing the surgeon.

Magnetic Resonance Imaging (MRI) Characterization of Perianal Fistulous Disease in a Rural Based Tertiary Hospital of North India

SummaryBackgroundTo diagnose and characterize the perianal fistulous disease using Magnetic resonance imaging (MRI) in a hilly and rural area of North India.Material/MethodsThis prospective hospital based study was conducted for a period of one year from April 2014 to April 2015 in the departments of Radiodiagnosis and Surgery of our institute. A total of 50 consecutive patients presenting with perianal fistulous disease fulfilling the inclusion and exclusion criteria were included in the study and taken up for MRI. The perianal fistulae were classified according to St James University hospital classification and tracks were assessed with regard to anatomical plane, length, ramifications, abscess formation, enteric communication, external cutaneous opening, enhancement and suprasphincteric extension. Surgical correlation was done in 31 patients who opted for surgical treatment. Rest of the 19 patients preferred alternative medicine for treatment or chose to postpone their surgery.ResultsThe disease was much more prevalent in males in comparison to females with male to female ratio of 24:1. Grade 4 was the most common type of fistula (34%) while Grade 5 was the least common type (4%).MRI showed a high sensitivity of 93.7% and positive predictive value (PPV) of 96.7% when correlated with surgical findings. A substantial number of patients (38%) preferred alternative medicine or non surgical form of treatment.ConclusionsMRI is a very sensitive modality for the evaluation of perianal fistula. In our study group, the disease predominantly affected middle aged men. Ramifications and abscesses were commonly seen, affecting nearly half of the patients and majority of the patients had active fistulous tracks with posteriorly located enteric opening. Overall, transsphincteric fistulae were most common. Significant number of patients avoided surgery or showed preference for non surgical treatment.

Characterization ofCDH3-Related Congenital Hypotrichosis With Juvenile Macular Dystrophy

Congenital hypotrichosis with juvenile macular dystrophy (HJMD) is a rare disorder presenting in childhood and adolescence with central visual disturbance and sparse scalp hair. Reported retinal imaging is lacking, and whether the condition is progressive remains unclear. To investigate a series of patients with HJMD due to biallelic mutations in CDH3 and thereby characterize the disorder. Ten patients from 10 families underwent detailed clinical assessment, including serial retinal imaging and electrophysiologic evaluation, at Moorfields Eye Hospital, St James's University Hospital, and Calderdale Royal Infirmary. Patients ranged in age from 3 to 17 years at onset and 5 to 57 years at last assessment. The molecular genetic investigation included bidirectional Sanger sequencing of all exons and intron-exon boundaries of CDH3 and whole-exome sequencing in 2 patients. The study was conducted from June 5, 2013, to January 15, 2016, with final follow-up completed on December 15, 2015. Results of clinical assessment and molecular genetic testing. All 10 patients (7 male and 3 female) presented with central visual disturbance in childhood and had lifelong sparse scalp hair with normal facial hair. Fundus examination revealed chorioretinal atrophy of the posterior pole contiguous with the disc in all but 1 patient that was associated with marked loss of autofluorescence on fundus autofluorescence imaging. Optical coherence tomography (OCT) demonstrated variable degrees of atrophy of the outer retina, retinal pigment epithelium, and choroid, with outer retinal tubulations frequently observed. One patient had mild disruption of the inner segment ellipsoid band on OCT and additional mild digit abnormalities. Electrophysiologic evaluation in 5 patients demonstrated macular dysfunction with additional mild, generalized retinal dysfunction in 2 patients. Eight patients had more than 1 evaluation; of these, 5 patients showed deterioration of visual acuity over time, 1 patient remained stable, and 2 patients had severe visual loss at presentation that precluded assessment of visual deterioration. The area of atrophy did not progress with time, but retinal thickness decreased on OCT. Electrophysiologic evaluation in 1 patient found deterioration of macular function after 13 years of follow-up, but the mild, generalized photoreceptor dysfunction remained stable. Biallelic mutations were identified in all patients, including 6 novel mutations. These results suggest that CDH3-related disease is characterized by a childhood-onset, progressive chorioretinal atrophy confined to the posterior pole. The disease is readily distinguished from other juvenile macular dystrophies by the universally thin and sparse scalp hair. Patients may have additional limb abnormalities.

Magnetic resonance imaging of perianal Crohn's disease.

Successful treatment of perianal Crohn's disease requires knowledge of the location and nature of the fistulous tracts. Both Magnetic resonance imaging (MRI) and ultrasound are superior to clinical evaluation for complex disease.1 Preoperative assessment leads to a significant decrease in recurrences from undiagnosed extensions and abscesses.2 Ultrasound using an endoanal, transvaginal, or transperineal approach, with or without the use of hydrogen peroxide, is accurate in determining this information. This is however operator dependent and relies on the availability of local expertise. MRI using a body coil provides accurate assessment but, unlike ultrasound, is less dependent on operator expertise.1 A standard study should be aligned along the length of and perpendicular to the anal canal and include three-plane T2 fat saturated and T1 fat saturated post contrast imaging. A T1 sequence without fat saturation is useful to determine the site of fibrotic tracts from prior surgery, successful medical therapy, and after complex graft surgery. The advantage of post contrast imaging is in defining the tracts and differentiating between granulation tissue and abscess formation. Additional sequences such as 3D-volume post contrast and diffusion weighted imaging may be of assistance in demonstrating active disease; however, the latter may lack anatomical registration.3 Anatomically, cranially, the internal sphincter extends above the external sphincter, while caudally the external sphincter extends below the internal sphincter. The external sphincter may be shorter in women and is often partly deficient anteriorly because of prior obstetric trauma.4 Important information to convey to the treating physician is the number and course of the tracts, the level of the internal openings, the length of sphincter involvement, presence of secondary fistula tracts/ramifications, supralevator extension, and abscesses. The standard Park's classification allows clear communication; however, the St James University Hospital MRI fistula classification may also be used.5, 6 The Leuven scoring system provides quantitative assessment for use in research studies.7 Fistula tracts may be composed entirely of granulation tissue or contain a thin ribbon of fluid. Any fluid component over 3 mm should be considered an abscess.8 Any fistula tract that extends cranial to the anal canal midpoint should be specifically noted to the surgeon, as surgical division of the sphincter in these cases may lead to incontinence.9 Where an anti-tumor necrosis factor agent has healed the external opening, MRI is useful to demonstrate residual unhealed tracts that may predispose to early relapse if treatment is discontinued prematurely.10 In cases with chronic ongoing sepsis, it is important to assess for malignant transformation evidenced by lobular and septated high T2 signal and contrast enhancing tissue expansion of a fistula tract.11 Clear communication between the referrer and radiologist is paramount in achieving successful outcomes. This should include any prior surgical history describing clinically evident fistula openings according to the clock face location and the level of expected internal openings, preferably the most recent operative note indicating the site of surgery and Seton placement. If there has been complex fistulization to the vagina and urethra, this should be noted as this may not be encompassed in the standard imaging field of view.

Negative Effects on Psychological Health and Quality of Life of Genuine Irritable Bowel Syndrome-type Symptoms in Patients With Inflammatory Bowel Disease.

Symptoms compatible with irritable bowel syndrome (IBS) are common in patients with inflammatory bowel disease (IBD), but it is unclear whether this relates to occult IBD activity. We attempted to resolve this issue in a secondary care population by using a cross-sectional study design. We analyzed Rome III IBS symptoms, disease activity indices, and psychological, somatization, and quality of life data from 378 consecutive, unselected adult patients with IBD seen in clinics at St James's University Hospital in Leeds, United Kingdom from November 2012 through June 2015. Participants provided a stool sample for fecal calprotectin (FC) analysis; levels ≥250 μg/g were used to define mucosal inflammation. By using symptom data and FC levels we identified 4 distinct groups of patients: those with true IBS-type symptoms (IBS-type symptoms with FC levels <250 μg/g, regardless of disease activity indices), quiescent IBD (no IBS-type symptoms with FC levels <250 μg/g, regardless of disease activity indices), occult inflammation (normal disease activity indices and FC levels ≥250 μg/g, regardless of IBS symptom status), or active IBD (abnormal disease activity indices with FC levels ≥250 μg/g, regardless of IBS symptom status). We compared characteristics between these groups. Fifty-seven of 206 patients with Crohn's disease (27.7%) and 34 of 172 patients with ulcerative colitis (19.8%) had true IBS-type symptoms. Levels of psychological comorbidity and somatization were significantly higher among patients with true IBS-type symptoms than patients with quiescent IBD or occult inflammation. Quality of life levels were also significantly reduced compared with patients with quiescent disease or occult inflammation and were similar to those of patients with active IBD. By using FC levels ≥100 μg/g to define mucosal inflammation, we found a similar effect of IBS-type symptoms on psychological health and quality of life. In a cross-sectional study, we identified a distinct group of patients with IBD and genuine IBS-type symptoms in the absence of mucosal inflammation. These symptoms had negative effects on psychological well-being and quality of life to the same degree as active IBD. New management strategies are required for this patient group.

Guidelines for the diagnosis and management of adult aplastic anaemia.

Sally B. Killick (Writing Group Chair), Nick Bown, Jamie Cavenagh, Inderjeet Dokal, Theodora Foukaneli, Peter Hillmen, Robin Ireland, Austin Kulasekararaj, Ghulam Mufti, John A Snowden, Sujith Samarasinghe, Anna Wood (BCSH Task Force Member), Judith C.W. Marsh on behalf of the British Society for Standards in Haematology. The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Northern Genetics Service, Newcastle upon Tyne, St Bartholomew’s Hospital, Barts Health NHS Trust, London, Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, Addenbrooks Hospital, University of Cambridge, Cambridge, Leeds Teaching Hospitals, Leeds, Kings College Hospital NHS Foundation Trust, London, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Great Ormond Street Hospital for Children NHS Foundation Trust, London, West Hertfordshire NHS Trust, Watford.

P094. Clinical feasibility of Cerenkov Luminescence Imaging (CLI) for intraoperative assessment of tumour excision margins and sentinel lymph node metastases in breast-conserving surgery

P094. Clinical feasibility of Cerenkov Luminescence Imaging (CLI) for intraoperative assessment of tumour excision margins and sentinel lymph node metastases in breast-conserving surgery

P051. Neo-adjuvant chemotherapy in breast cancer; predictors of pathological complete response

P051. Neo-adjuvant chemotherapy in breast cancer; predictors of pathological complete response