Radiofrequency ablation (RFA) has now been given the go-ahead

RFA has been given the go-ahead by our “National Institute for Clinical Excellence” (http://guidance.nice.org.uk/IPG344) for use in patients with Barrett’s harbouring high-grade dysplasia.  As a result some 31 units around the UK have now begun to offer this treatment to their patients.  It may sound like good news but I am predicting a disaster.
The problem is that NICE never stated that the therapy should only be offered by units with particular experience in managing early oesophageal cancer.  
The NICE guidelines states that only “flat dysplasia” should be treated by RFA.  The problem is that some invasive cancer appear as  “flat dysplasia” at endoscopy.   Please click on the photo to seen an example of a small ulcerated lesion (i.e. a IIc lesion) within a long stretch of Barrett's. Repeated biopsies could only confirm high-grade dysplasia and neither EUS nor CT could refute this.  However, to an experienced endoscopist, a IIc lesion within the Barrett's is suspicious and if histology confirms dysplasia it's probably an invasive cancer.  The patient was not offered RFA and was instead referred for an oesophagectomy and a T2, N1 adenocarcinoma was confirmed. Personally, I don't think that it is  possible to make a reliable distinction between early invasive cancer, intramucosal cancer or high grade dysplasia by EUS, CT or surface biopsies.   The diagnosis is best made by an endoscopist with experience in staging early oesophageal cancer and with experience of oesophageal EMR (which at worst provides great staging and at best a cure). 
Am I over-reacting?  Perhaps creating a mountain out of a mole-hill?  I don’t think so!  An abstract from the recent Digestive Disorders Federation meeting in Liverpool (17-20 June 2012) provided alarming reading (BSG endoscopy section symposium and free papers: Dealing with endoscopic disasters – “How do I do it” Gut 2012;61(2): Abstract OC-011).  
The abstract is somewhat difficult to understand and I urge you to read it for yourself (just click the link). Essentially a  large centre treated 59 patients with Barrett's harbouring HGD or IMca with RFA.  Only half of the patients were thought to have a visible nodule requiring EMR before RFA.   The results were not encouraging.  Nine of the patients PROGRESSED TO INVASIVE CANCER within 12 months!   We can only hope that the 12 month delay did not result in some patients becoming incurable.
In the Euro-II study some 130 patients with dysplastic Barrett's have now been treated in selected centres.  There have been no cases of progression from HGD/IMca to invasive cancer.  However, the high success rate in the Euro-II study can not be entirely attributed to RFA as quite a few patients required an EMR to remove a stubborn patch of Barrett’s which RFA could not shift. My own experience is limited to some 20 patients.  The only complication I have had is a single very troublesome stricture.  I have carried out lots of dilatations and it still keeps narrowing down a week or so later.  I am beginning to think that we will have to place 2-3 biodegradable stents to allow this patient to eat anything more solid than yoghurt.  

After analysing the results of our online survey, I have an update to our earlier issue on sampling bleeding gastric ulcers

Please have a look at my earlier Blog on “Finding myself on the wrong side of common opinion”) which sets out the problem.  The Survey confirms that our unit is representative of “European practise” (assuming that the surveys 112 responders are representative).  
To summarise the results (so far –it’s still open!), about one third of responders work in units with No particular policy on when to sample gastric ulcers.  Another third work in units with a policy to Never Sample a gastric ulcer (at the time of emergency endoscopy).  The final third, would only permit samples to be taken Only IF there are no stigmata of recent bleeding from the ulcer.  
Half of the responders had no recollection of a case of bleeding being precipitated by sampling the ulcer edge.  However, another half could recall such a case of re-bleeding being linked to sampling.  
When should samples be taken (if not at the emergency examination)?  In roughly half the cases, the policy was to obtain samples before discharge and in the other half, to organise these samples soon after discharge.  
However, the potential drawbacks of a “sample later” policy was recognised by about half of the responders who could recall the odd case when the diagnosis of cancer had been delayed because the follow-up endoscopy was not carried out in a timely fashion. 
Where does this leave us?  I do find it reassuring when my prejudices are found to be backed up by some scant evidence.  My concern that the diagnosis of gastric cancer may be delayed, is shared by half of my peers.  
Unfortunately, a similar proportion could recall a case of re-bleeding being linked with taking samples.  Of course, these ulcers would have re-bled anyway!   However, the mere association clinches my decision.  I will now stop taking biopsies from gastric ulcers at the time of the emergency endoscopy.  Why leave yourself open to criticism when that ulcer re-bleeds after your samples?  Particularly, when you so easily could find yourself “On the side of the Righteous”, condemning poor management when circumstances conspire to delay a timely follow-up endoscopy?  

I am the most spiritual of atheist and rigidly observe Lent (fasting) in the 40 days leading up to Easter.  My fervour has nothing to do with a belief in the divine.  As many religions include a period of fasting, I reason that there must be some merit in the practise?  It’s a leap of faith!

In fact, my medical training is providing a powerful defence against any religious stirrings.  Epidemiology is perhaps the most powerful antidote.  Leeds is taking part in a new pilot study to screen for “Maple Syrup Disease”, “Homocysteinuria”, Glutaric acidaemia type 1”, Isovaleric acidaemia” and “Long chain fatty acidaemia”.  Our Chief Medical Officer, Prof Dame Sally Davies has announced that this pilot will give the 1:100.000 children, born with one of these diseases, a chance to live a long and healthy life.  This is a chance which, “Nature” can not provide and “Darwinian evolution” has not yet fixed. 

At work, I fight against “Nature” on a daily basis.  After all, if we left things to work out the “natural way”, few of us would live beyond 50.  Believing in the theory of evolution, I do understand that in hard times, it may have been detrimental to have old folks hanging around requiring feeding and warmth.  For this reason, “nature” introduced a natural and progressive cull, to start take effect at the age of 50 in men and a little later in women. 

Armed with education, sanitation, vaccination and medication, we now battle against "Cruel Mother Nature” on a daily basis!   Indeed, if I hear the word “Natural”, I instinctively reach for my stethoscope.

Recently, one of my more grateful patients commented that Doctors were only second to God in looking after people.  I didn’t have the heart to tell her that she got it the wrong way around. 

I am the most spiritual of atheist and rigidly observe Lent (fasting) in the 40 days leading up to Easter.  My fervour has nothing to do with a belief in the divine.  As many religions include a period of fasting, I reason that there must be some merit in the practise?  It’s a leap of faith!

In fact, my medical training is providing a powerful defence against any religious stirrings.  Epidemiology is perhaps the most powerful antidote.  Leeds is taking part in a new pilot study to screen for “Maple Syrup Disease”, “Homocysteinuria”, Glutaric acidaemia type 1”, Isovaleric acidaemia” and “Long chain fatty acidaemia”.  Our Chief Medical Officer, Prof Dame Sally Davies has announced that this pilot will give the 1:100.000 children, born with one of these diseases, a chance to live a long and healthy life.  This is a chance which, “Nature” can not provide and “Darwinian evolution” has not yet fixed. 

At work, I fight against “Nature” on a daily basis.  After all, if we left things to work out the “natural way”, few of us would live beyond 50.  Believing in the theory of evolution, I do understand that in hard times, it may have been detrimental to have old folks hanging around requiring feeding and warmth.  For this reason, “nature” introduced a natural and progressive cull, to start take effect at the age of 50 in men and a little later in women. 

Armed with education, sanitation, vaccination and medication, we now battle against "Cruel Mother Nature” on a daily basis!   Indeed, if I hear the word “Natural”, I instinctively reach for my stethoscope.

Recently, one of my more grateful patients commented that Doctors were only second to God in looking after people.  I didn’t have the heart to tell her that she got it the wrong way around. 

To my surprise I recently found myself at odds with my colleagues on a common clinical problem.

An elderly patient had been admitted with a bleeding gastric ulcer.  At her emergency endoscopy the ulcer was treated with “dual modality therapy” (injection of adrenaline followed by the application of heat).  Eight samples were then taken from the edge of the gastric ulcer.  Twenty four hours later we had confirmation that the ulcer was malignant.  Unfortunately, the ulcer re-bled and the patient subsequently died.  
Our disagreement is over the samples taken at the time of her emergency endoscopy.  My colleagues unanimously believe that these samples should NOT have been taken.  I believe that all gastric ulcers should be sampled at the earliest opportunity to avoid potential delays.

According to our limited “Bolam’s test” I am wrong and my colleagues are correct.  However, I still believe that there is no risk of precipitating a re-bleed and that there is a real possibility of delayed diagnosis when no samples are taken at the first opportunity.  Although we are in the era of “Evidence Based Medicine”, there is no published literature to help us.  There are no studies but I am aware of several in-house cases in which there has been a delay in the diagnosis when biopsies were postponed.  I also do know that the re-bleeding rate of a high-risk ulcer (Forrest I or IIa) is about 20% after dual modality therapy. 
Of course, we have local guidelines to state that no patient should be discharged without samples having been obtained from a gastric ulcer.  However, I believe that guidelines are not enough.  Instead “doing the right thing” must be built into our working practises.  In the case of gastric ulcers, I believe that the correct advice would be “If you see a gastric ulcer – you should always take 8 biopsies from its edge”.   The aviation industry understood that   some 50 years ago and now build “doing the right things right” into the working practises.   The truth is that “Guidelines from above” and “Evidence Based Medicine” only help in a small part of our clinical decision making.  For this reason, most doctors are intuitive and aim to make a “good enough decision” based on plausibility.  Unfortunately, plausibility is not infallible.  I am old enough to remember getting into trouble by forgetting to stop beta-blockers after a myocardial infarction.  The younger reader may be surprised to hear that for many years, stopping beta blockers after a cardiac event seemed the right thing to do!  In the hope of shedding some light onto our dilemma of what to do with bleeding gastric ulcers, I would be grateful for your views!    Please, click this link to take part in a 20 second, anonymous survey which would inform all of us!  Thanks  Björn Rembacken

I wonder if our Academics are congratulating themselves on what they have achieved?

In England, it now takes an average of 621 days to get a trial up and running because of our cumbersome Ethics and R&D application process.  Make no mistake, it takes this long when someone who knows what they are doing is submitting an application.  If you have not done it before, it is likely to take MUCH  longer as the process is frustrating and cumbersome!  
Paradoxically, it does not matter if you are planning on a trial comparing two types of standard bowel preparations OR are planning on putting probes into the brains of newborn children.  The turgid application process remains rigidly the same!  
What does this means for our patients?  There are several, predictable consequences;  1) patients are unlikely to be offered any new, potentially life saving trial medication, 2) patients are likely to be offered drugs which have only be shown to be efficacious in Chinese or Indian patients and 3) the NHS does not benefit from an infusion of research money. The reason for the last point is that “UK Pharma” is now taking business to the third world where trials are cheaper and can be launched within a more reasonable time frame.  Who could blame them? 
At the same time, being an “Academic” is becoming an unpopular prospect in the UK.  There is little job security and Universities are notoriously stingy and may not provide any secretarial support and may even choose not to renew your contract after 5 years.  
England was once the LEADER in Phase 1 to 4 Clinical Trials.  Now we are down to less than 2% of the World research output.   I guess that our Legacy will be;  "The Generation which killed off Clinical Trials"

On the radio this morning I heard that the UK Olympic committee had set a target to get a million more people involved in Sport.

For the British Olympic committee, it is not enough to get a million people “a little more active”, perhaps cycling to work or joining a gym.  No, people have to commit to a SPORT!   As the radio presenter put it;  “simply “splashing about in a pool is not enough”. 

My own 2012 New Year resolution will NOT be to start cycle to work (although it’s only some 5 miles and downhill most of the way).  The reason are those bony, lycra-clad bottoms which roll past me on 750 gram bicycles with razor-thin tyres.  I am sorry but I will not buy a pair of ridiculous looking shorts and I can’t spend thousands on an impractical bike. 

And here lies the paradox, these “lycra cyclists” are actually preventing the General Public from cycling to work.  In our garages most have comfortable, upright bikes (those with baskets in front) but we will not risk ridicule by using these to get to work.  Beside the “Lycra-bottoms” most of us would look at tit!

Both the Olympic committee’s target to boost SPORT and the “lycra-bottoms” on our roads are reflections of the British “only serious, competitive Sport, preferably done in Lycra is worthy” - attitude.   No wonder that they have only reached 11% of their ill-conceived target.  

This attitude has serious consequences beyond confining people to their cars and homes.  I have several friends who have decided to dedicate themselves to their own physical development.  These are extremely intelligent, high-achieving professionals who have decided against having children because their exercise schedules would not allow it.  You can’t become an “iron-man/woman” whilst looking after children!  

What effect will their decisions have on the average activity levels and IQ of future generations?

A recent trip to Leeds city centre on a Saturday evening raised questions. How can so many young people stagger around in such cold weather with such few clothes?

The answer is the invigorating effect of alcohol which insulates us from cold, gives confidence and makes ugly people look better!  The United Kingdom’s alcohol policy is also proving a huge success for the alcohol industry.  Alcohol is now affordable for everyone – “poor” or “rich” as it is cheaper than bottled  water in our supermarkets.  As a result we now drink 10% more than just 10 years ago.  
Although, I had limited by alcohol consumption to no more than 3-4 glasses of red wine per week.  I decided to have a look at the Governments “drink aware” website for an update.  It issued the helpful guidance that the “daily recommended amount of alcohol for men was 3-4 units“.  To take advantage of the health benefits of regular drinking, I calculated that a bottle of wine on Saturday evening and another 15 units spread over the week would do the trick.  
I duly increased my consumption but apart from a slight increase in girth and a heavy head in the morning, I can’t say that I noticed many benefits.  Presumably the health benefits are to be found in the long game of regular drinking over 3-4 decades?   However, the seeds of doubt had been sowed and I returned to www.drinkaware.co.uk.  I found that the wording had now changed (!) so that they now stated that men “should NOT regularly drink more than  3-4 units of alcohol a day”.  
Dismayed by the mixed messages, I looked further into the literature.  It turns out that rinking 4 units a day over a lifetime is consistent with a 1% risk of dying from alcohol related disease and another 1% risk of dying in an accident (Int J Methods in Psych Res 2008;17:141-51).  
These answers raised further questions.  What were the risks of getting mugged, beaten up, raped or acquiring an incurable “STD”?  
During a stroll down our ward, I began to further doubt the concept of “health protection by alcohol”.  Nowadays our general Gastro wards in Leeds (55 beds) is a third full of alcoholics (“ALD’s”) in different stages of detoxification or dying.  Things have got so bad that we are considering appointing a gastroenterologist with a particular interest in these patients.  What is needed is a hybrid Psychiatrist/Gastroenterologist, a “Gastrochiatrist”!   We are now in new territory and it is uncertain if such a specialist could be nurtured and thrive on a Gastro ward with a strict non-smoking policy. Anyway, I suspect that most of our yellow clientele are beyond salvage and it’s not clear what a dedicated Gastrochiatrist could achieve.  Presumably that decisive intervention needed to stop the emerging addiction, should have been applied some 15—30 years earlier by caring friends, loving partners or wise parents?  
I am now searching for meta-analysis to confirm that it is cost-effective to divert funds away from the care of patients with dementia or cancer or population screening or whatever, in favour of patients who are a few years away from drinking themselves to death.  There appears to be some  27 economical evaluations in the public domain but the cost never falls below £30.000/QALY's.  That business case for a "Gastrochiatrist" will have to be very convincing! 

On the topic of Hormones, Robbery and absence of Surgeons in Stockholm.

It’s rather cruel.  When your young body is boiling with testosterone, the same hormone covers you in spots making you unattractive to the opposite sex.  As a young spotty man, I was repeatedly refused entry into the “Café Opera” nightclub.  Twenty years later, I not only had a UEGW ticket, it came with free drinks vouchers!  Two fingers in the face of the UEGW Alcohol policy! The following morning a coach picked up our small group of bleary-eyed endoscopists for the live demonstrations.  We were dropped off at “Karolinska Sjukhuset” north of Stockholm.  Sadly this was the wrong hospital.  We were expected at ”Karolinska Sjukhuset - South”.  With minutes to spare, we arrived at the correct endoscopy unit.  However, I found the extra minutes of restorative sleep on the coach particularly refreshing. By the way, it wasn’t just coach drivers which gave a disappointing service in Stockholm.  Some taxi drivers delivered “day-time robbery”.  I turned out that taxi firms which did not belong to two main firms (“Taxi Stockholm” or “Taxi Kuriren”), could charge you any sum.  The normal flat-rate to the airport was 490 Kr whilst one delegate was charged 2000 Kr after taking “the wrong taxi”!  I didn’t expect this kind of stuff going on in my home town.  Perhaps a warning insert should have been placed in the delegate packs?  My personal highlight from the UEGW was seeing Dr Inoue performing his POEMS procedure.  Subsequently, the Top Brass of Cook and Boston Scientific agreed that Endoscopy is very exciting at the moment.  The pace of development in Endoscopy is far beyond that of cardiology.  We are in the middle of an “Endoscopic Arms Race”! Technological advances apart, what I feel was still missing was an insight into the different ways of "doing things".  Endoscopically treating a Zenker’s diverticulum is clearly feasible but in the UK, this condition is treated by ENT surgeons.  They use a simple "Stapling & Cutting" device which does the job in a couple of minutes with no risk of either bleeding or perforation.  Similarly, a discussion of when POEMS my be better than Laparoscopic Myotomy and Fundoplication would have been welcome. Sadly no surgeon was invited.  Rather than demonstrating “What can be done endoscopically”, perhaps we should try to address the more difficult question “What should be done endoscopically”.  However, inviting interventional Radiologists and GI Surgeons to speak at a Gastroenterology Conference would not be welcomed by everyone.  In mainland Europe where institutions have to jostle for business, the idea of inviting “the competition” may seem as crazy as training nurses to carry out Colonoscopy. Nevertheless, we do have a duty to determine what is Best for our Patients. 

Most gastroenterologists would agree that colonoscopy is the gold standard for examining the colon.

For this reason most screening programs hinges on colonoscopy.  We all know that polyps can be missed.  However, did you know that around 6% of patients who develop cancer, has had a colonoscopy in the preceding 3 years?  The reason why colonoscopy does not provide a near 100% protection against colorectal cancer, is that we miss lesions proximal to the splenic flexure.   Many radiologists believe that colonoscopists can not see behind folds and frequently fail to reach the caecum.  Indeed, you may have been tempted to state that the "examination was complete", even when you could only see the caecum at a distance.   As a professional endoscopist, I only state that the examination was complete if I can achieve deep caecal intubation allowing full examination of the recess behind the ileo-caecal valve. My concern is that flat and depressed lesions are most common beyond the splenic flexure and unless indigo carmine or methylene blue dye is used, these lesions are missed.  It is something of a paradox that a 7mm depressed cancer is featured on the front cover of the European Commission report on Quality in Screening colonoscopy without any mention within the text on how these lesions are to be found! Let me address this omission!  First of all, you must insist on good or excellent bowel cleansing in at least 90% of your examinations. Practically, this means that there is no stool remaining, no mucosal washing is required and that only some, shallow pools of cloudy liquid requires aspiration.  If 90% of your patients do not fulfill this benchmark, you need to adjust the bowel cleansing regimen provided by your institution.  Although bowel cleansing has been likened to drinking rocket fuel, achieving a clean colon is no "rocket science".  The best result is achieved by taking 2 litres of PEG solution in the 3-5 hours leading up to the examination (a glassful every 10 minutes). Unfortunately, this may be impractical, particularly for elderly patients attending a morning list (there may be a strong argument for scheduling all colonoscopy lists in the afternoon).  My "second best" regimen is the combination of a stimulant laxative such as sodium picosulphate, senna or bisacodyl followed by 2 litres of PEG solution, given in the afternoon before the examination.  I have been told that in Japan, photographs are provided to illustrate how the effluent should appear to guide patients. Secondly, you need to painstakingly look behind every fold in the ascending colon where the haustral folds are particularly deep.  I have found that the use of a biopsy forceps allows the folds to be separated and pushed away from the tip of your endoscope.  Using a thin plastic cap may perhaps achieve the same. Thirdly, you need to spray a blue dye onto every red spot, mucosal irregularity or greasy patch that you see.  Why worry about greasy patches?  - because these may be "sessile, serrated" lesions which also have malignant potential.  In Leeds, I am aware of two such lesions harboring a tiny focus of invasive cancer in the ascending colon.  Even with indigo carmine dye, these "new guys on the block" can not be reliably distinguished from ordinary hyperplastic polyps.  For this reason, every sessile polyp, with a hyperplastic crypt pattern, larger than 10mm, beyond the splenic flexure should be removed (clinical circumstances allowing).  Oh, there is one more thing.  Make sure that your consent includes a written statement that some 1 in 20 "significant colonic lesions" are missed by colonoscopy. 

In the last few years I have noted a definite souring of the mood at my local gym.  Whilst previously my broad grin would be met with a smile and a nod, all that I get now are stony faces and blank stares. 

This is particularly surprising as the gym is the most expensive in town.  (I only signed up after being offered a cheap deal).  The number of large, new cars parked outside and firm bodies inside, leaves little doubt that I am rubbing shoulders with the wealthiest and healthiest in Leeds.

However, research has found that “happiness” is unrelated to what most of us would presume makes us happy.  For example, ugly people are no more unhappy than beautiful people.  Black & white, men & women, young & old are all equally happy.  Getting a salary increase, raising the annual salary beyond $50.000, has very little effect on our happiness levels.

Our patients live longer and healthier lives than at any time in the past.  In spite of this, they worry more about the possibility of disease.  In fact, “imagined disease” is much worse than “real disease”.  Having a treatable chronic disease such as diabetes or renal impairment has been shown not to reduce the total level of happiness.  In contrast patients with irritable bowel syndrome and neurasthenia are usually profoundly unhappy.

It is meaningful relationships which have consistently been shown to increase happiness levels.  Recently, the British government has misguidedly proposed that “population un-happiness” should be measured regularly.  Sadly I predict a direct relationship between the British divorce rates and unhappiness levels.

Perhaps being discontented is not so bad?  There may be an inverse relationship between “life achievement” and “happiness level”.  Some of the most “successful and influential people in history have also been the most miserable.  The miserable and worried may also live longer than average. If “necessity” is the mother of invention then “discontent” may be the father!   I am convinced that humans are most creative when most discontented !  When I see all the miserable faces in my local gym, I am certain that the future is bright for humanity!

In the last few years I have noted a definite souring of the mood at my local gym.  Whilst previously my broad grin would be met with a smile and a nod, all that I get now are stony faces and blank stares.  This is particularly surprising as the gym is the most expensive in town.  (I only signed up after being offered a cheap deal).  The number of large, new cars parked outside and firm bodies inside, leaves little doubt that I am rubbing shoulders with the wealthiest and healthiest in Leeds. However, research has found that “happiness” is unrelated to what most of us would presume makes us happy.  For example, ugly people are no more unhappy than beautiful people.  Black & white, men & women, young & old are all equally happy.  Getting a salary increase, raising the annual salary beyond $50.000, has very little effect on our happiness levels. Our patients live longer and healthier lives than at any time in the past.  In spite of this, they worry more about the possibility of disease.  In fact, “imagined disease” is much worse than “real disease”.  Having a treatable chronic disease such as diabetes or renal impairment has been shown not to reduce the total level of happiness.  In contrast patients with irritable bowel syndrome and neurasthenia are usually profoundly unhappy. It is meaningful relationships which have consistently been shown to increase happiness levels.  Recently, the British government has misguidedly proposed that “population un-happiness” should be measured regularly.  Sadly I predict a direct relationship between the British divorce rates and unhappiness levels. Perhaps being discontented is not so bad?  There may be an inverse relationship between “life achievement” and “happiness level”.  Some of the most “successful and influential people in history have also been the most miserable.  The miserable and worried may also live longer than average. If “necessity” is the mother of invention then “discontent” may be the father!   I am convinced that humans are most creative when most discontented !  When I see all the miserable faces in my local gym, I am certain that the future is bright for humanity!

Companies make their money by selling medication or equipment.  The more patients in need, the more profit can be accrued. Apart from trying to convince doctors that their products have advantages, how can the profit-margins be increased? 

The other obvious way to raise profits is to increase the number of patients eligible for therapy.  You would be forgiven to think that this would be an impossible task?   Not so!  Researchers are willing advocates for their pet conditions.  Furthermore, specialists loath the idea of missing a potential patient even if it means branding a huge swathe of healthy individuals as “diseased”.  It seems that having a narrow research focus can render the specialist unable to understand the wider consequences of marching polypharmacy.

New disease entities can be created or, failing this, the diagnostic criteria can be expanded to “make more patients” from the population stock.  To achieve this, specialists allied to the company will need to be on the panels which decide on disease definitions.

It has been such successful strategies that even the research community is beginning to question the results.   The controversial new diagnostic entity of “pre-hypertension”, has been accused of labelling nearly 60% of the adult American population as having a chronic disease (Ann Rev Public Health 2007;28:321-44).  Critics have also labelled “female hypoactive sexual desire disorder” as another dangerous pseudo-disease (BMJ 2011;342:1054-56).  Until I came across this entity, I had thought that it was my stuttering conversation and cheap aftershave which was to blame.  Now I realise that the problem lies with the women who are affected by a disease of epidemic proportions.

An example of how changing diagnostic thresholds can create more patients is the change of the normal cholesterol range to develop the new condition “above optimal cholesterol level”.  Another example is the change of normal range of blood sugar during pregnancy which has now successfully labelled nearly 20% of the pregnant population as “diseased” (Diabetes Care 2010;33:676-82).

A jobbing gastroenterologist, I may be forgiven to believe that research will come to our rescue.  Sadly research has also been infiltrated by the company stooges.  An international team of researchers recently analysed 29 meta-analyses of more than 500 studies published in LEADING medical journals (JAMA 2011;305:1008-17).  Almost 70% of the trials were company sponsored and the financial ties were not reported in the meta-analyses. 

There is no doubt that being on the company payroll will affect what is published.  A review of almost 200 trials looking at cholesterol lowering drugs found that company sponsored trials were 20 times more likely to come out in favour of the drug manufactured by the sponsoring company (PLoS Med 2007;4(6):e184).  Similarly an article in NEJM (2008;358:252-60) concluded that the world is being misled about the benefits of widely prescribed antidepressants as many studies with unfavourable results are simply not published. 

A recent BMJ article (BMJ 2011;342;1183) came to the sad conclusion that pharmaceutical giants and the doctors on their payrolls have hijacked and is now poisoning healthcare research.  It is perhaps not surprising that the transparency of the approval process for new medication by the European Medicines Agency has been critisised (Lancet 2010;375:1753).

From now, I will not bother to read any research published by compromised authors.  I would also propose that future symposia asks researchers to publically declare any company ties BEFORE they start presenting their (i.e. their companies) findings.  This will give us time to leave the lecture theatre before their presentation starts. 

Companies make their money by selling medication or equipment.  The more patients in need, the more profit can be accrued. Apart from trying to convince doctors that their products have advantages, how can the profit-margins be increased? 

The other obvious way to raise profits is to increase the number of patients eligible for therapy.  You would be forgiven to think that this would be an impossible task?   Not so!  Researchers are willing advocates for their pet conditions.  Furthermore, specialists loath the idea of missing a potential patient even if it means branding a huge swathe of healthy individuals as “diseased”.  It seems that having a narrow research focus can render the specialist unable to understand the wider consequences of marching polypharmacy. New disease entities can be created or, failing this, the diagnostic criteria can be expanded to “make more patients” from the population stock.  To achieve this, specialists allied to the company will need to be on the panels which decide on disease definitions. It has been such successful strategies that even the research community is beginning to question the results.   The controversial new diagnostic entity of “pre-hypertension”, has been accused of labelling nearly 60% of the adult American population as having a chronic disease (Ann Rev Public Health 2007;28:321-44).  Critics have also labelled “female hypoactive sexual desire disorder” as another dangerous pseudo-disease (BMJ 2011;342:1054-56).  Until I came across this entity, I had thought that it was my stuttering conversation and cheap aftershave which was to blame.  Now I realise that the problem lies with the women who are affected by a disease of epidemic proportions.

An example of how changing diagnostic thresholds can create more patients is the change of the normal cholesterol range to develop the new condition “above optimal cholesterol level”.  Another example is the change of normal range of blood sugar during pregnancy which has now successfully labelled nearly 20% of the pregnant population as “diseased” (Diabetes Care 2010;33:676-82).

A jobbing gastroenterologist, I may be forgiven to believe that research will come to our rescue.  Sadly research has also been infiltrated by the company stooges.  An international team of researchers recently analysed 29 meta-analyses of more than 500 studies published in LEADING medical journals (JAMA 2011;305:1008-17).  Almost 70% of the trials were company sponsored and the financial ties were not reported in the meta-analyses. 

There is no doubt that being on the company payroll will affect what is published.  A review of almost 200 trials looking at cholesterol lowering drugs found that company sponsored trials were 20 times more likely to come out in favour of the drug manufactured by the sponsoring company (PLoS Med 2007;4(6):e184).  Similarly an article in NEJM (2008;358:252-60) concluded that the world is being misled about the benefits of widely prescribed antidepressants as many studies with unfavourable results are simply not published. 

A recent BMJ article (BMJ 2011;342;1183) came to the sad conclusion that pharmaceutical giants and the doctors on their payrolls have hijacked and is now poisoning healthcare research.  It is perhaps not surprising that the transparency of the approval process for new medication by the European Medicines Agency has been critisised (Lancet 2010;375:1753). From now, I will not bother to read any research published by compromised authors.  I would also propose that future symposia asks researchers to publically declare any company ties BEFORE they start presenting their (i.e. their companies) findings.  This will give us time to leave the lecture theatre before their presentation starts. 

In the UK alone some 35.000 lives are lost every year to the disease! The cancer is only behind lung cancer (in smokers) and breast cancer (in women). Yet nobody would die if only the disease was detected at an early stage.

Surely the Yellow Emperor was right 4500 years ago when he stated that “the superior physician nips the early buds of disease”. How do we nip the early buds of colorectal cancer?  “Clean Living” with plenty of fruit and exercise with only a small amount of red meat would do it (unless you are genetically challenged).  Furthermore, “Clean Living” would reduce the risk of dying early from “the big killer” (cardiovascular disease, stupid).  Unfortunately, if we lived in a world where nobody died from colorectal cancer, the average life expectancy would only be some 2 – 3 weeks longer.  Why is that?  - Because colorectal cancer doesn’t kill that many.  Cardiovascular disease alone kills some 40% of the population compared with the paltry 2-3% who succumb to colorectal cancer.  Furthermore, we are now in a middle of an obesity epidemic which will result in a future explosion in the number of people dying from cardiovascular disease, complications of diabetes or fatty liver disease.   If you doubt this, flick through some photo-albums from your childhood and take note of the size of yourself and your friends.  Then compare this to the size of children you see around today! Unfortunately, most people can not adopt the “Clean Living” concept.  Smokers can not be forced to stop and Governments are unwilling to commit political suicide and tax tobacco beyond affordability.  “Screening for the early buds of disease” therefore seem a far easier prospect than trying to rescue people from themselves.  As an endoscopists and gastroenterologist I believe in the benefits of a careful colonoscopy carried out by an expert.  However, as a modern doctor, I also believe in evidence based medicine (rather than personal prejudice and anecdote).  There is solid trial evidence (only randomised controlled, prospective trials will make me take notice) to support “Faecal Occult Blood –based screening” or screening by “once-in-a-lifetime, flexible sigmoidoscopy”.  FOB screening reduces the risk of dying from colorectal cancer by about 16% whilst Flex/Sig screening reduced the risk by about 24%.  Sadly the numbers required to screen to prevent one colorectal cancer death is staggering.  In the UK flexible sigmoidoscopy trial, more than 40.000 flexible sigmoidoscopies and several thousand colonoscopies had to be carried out to save some 60 patients from dying from colorectal cancer over a 10 year period (please someone tell me that I’ve got the maths wrong when reading Wendy’s, please!).  Not only do we need to screen a colossal number of individuals, there is evidence from the British, American and Danish FOBt studies that the reduction in risk of dying from bowel cancer is directly offset by a corresponding increase in risk of dying from heart disease!  Is there a way ahead?  Yes, there is!   We know from the Nurses Health Study that aspirin does protect against many cancers.  More recently, from a study published in GUT last year we know that it only takes 75mg of aspirin to reduce the risk of colorectal cancer by 22% after 5 years (95% confidence intervals 8% - 35%).  The additional reduction in risk of oesophageal cancer, prostate cancer, pancreatic cancer, brain cancer, Alzheimer’s and cardiovascular disease means that the health benefits of 75mg of aspirin outweighs the effect of screening many times over. THE WRITING IS ON THE WALL!  FORGET SCREENING, PUT ASPIRIN IN THE DRINKING WATER !!!

The UK audit of UGI bleeding makes sad reading. Most patients are managed on normal wards, a large proportion of consultants on call for emergency endoscopy were not competent at the basic endoscopic techniques. The median delay between presentation and endoscopy was 23 hours.

The 30 year old man had been lying in the resuscitation room of our Accident & Emergency department for several hours.  The A&E staff was now getting impatient as their 4 hour treatment target to transfer the patient to a ward was about to be breached.

As the junior doctor on call for GI emergencies was staffing an endoscopy list, they delay was brought to my attention and I went to assess the patient myself.  It turned out to be a familiar patient with alcoholic liver disease and two previous admissions with bleeding oesophageal varices. 

Unfortunately, he was in a bad way today.  Pale and clammy, lying on his side with a bowl half-full with dark blood.  In spite of a shot of terlipressin, the transfusion of a fourth bag of blood was barely maintaining his BP. 

Half an hour later, with the Minnesota tube in place, he stabilised and we were later able to apply another set of bands to his oesophageal varices.  The previous governments initiative to extend the opening hours of pubs to allow a more “continental style of drinking” presumably got in the way of his hospital appointments as he defaulted from our variceal ablation programme.

On leaving “rescus”, I commented that it seemed to be a quiet day.  The A&E consultant agreed.  The only other afternoon patient had been an elderly man with a myocardial infarction who had been in rescus a few minutes only as he was a “fast-track” to the angiography suite were three stents had been placed.

Walking back to the endoscopy unit, I reflected on the fact that GI bleeding has a mortality rate of about 20%, largely unchanged since records began.   In contrast, the elderly patient with myocardial infarction has a greater than 90% chance of being alive in 30 days. 

Surprisingly, British soldiers shot in Afghanistan now also have a 90% chance of surviving.  The Royal Army Medical Corps have had ample experience from war zones around the world and follow a strict protocol for resuscitation (BMJ 2009;338:1436-40).  Wounded soldiers are given “damage control resuscitation” and only enough fluids are given to restore a radial pulse.  The reason for this is that further fluids open up the circulation which leads to further blood loss. 
On arrival to the field hospital the injured soldier is simultaneously given pack red cells, fresh frozen plasma and platelets. IV bicarbonate is avoided even in severe acidosis as it reduces peripheral vascular resistance and increases minute volume.   As the “haemostatic resuscitation” is given, the patient is taken to the operating theatre where up to 4-5 consultants simultaneously attend to the injuries prior to airlift home.  This is a far cry from how we treat our patients admitted with an emergency upper gastrointestinal bleed (read audit). 

It is a sad indictment of our profession that we have been unable to reduce the appalling mortality rate of patients with upper GI bleeding.  It is telling that we still define a “timely emergency endoscopy” as a procedure which is carried out within 24 hours of admission (read guideline).

A Royal College of Endoscopy ?

It must have been a brave decision all these years ago. Who would have imagined that there would be doctors willing to work in darkened rooms, surrounding by deadly radiation to stare at faint and blurry, monochrome X-ray images?

Do We Need to Raise our Game in Endoscopy?

Unfortunately, there is evidence of varying Quality in Endoscopy. In the UK colonoscopy audit of 2004, the confirmed caecal intubation rate was only 57% [Gut 2004; 53: 277–283].

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