Twitter debate: Controversies in functional gastrointestinal disorders

The new ‘Controversies In…’ series for the Frontline Gastroenterology Twitter debates addressed the difficult area of functional gastrointestinal disorders, facilitated by the former editor-in-chief Anton Emmanuel. Key topics discussed included distinguishing functional dyspepsia from genuine gastroparesis, when we should investigate for bile acid malabsorption, the current treatments for constipation-predominant irritable bowel syndrome and, importantly, how to manage consultations with complex patients presenting with functional bowel disease. The debate generated over a million impressions on twitter and this article aims to summarise the key educational points from the event

The Early Apoptotic DNA Fragmentation Targets a Small Number of Specific Open Chromatin Regions

We report here that early apoptotic DNA fragmentation, as obtained by using an entirely new approach, is the result of an attack at a small number of specific open chromatin regions of interphase nuclei. This was demonstrated as follows: (i) chicken liver was excised and kept in sterile tubes for 1 to 3 hours at 37°C; (ii) this induced apoptosis (possibly because of oxygen deprivation), as shown by the electrophoretic nucleosomal ladder produced by DNA preparations; (iii) low molecular-weight DNA fragments (∼200 bp) were cloned, sequenced, and shown to derive predominantly from genes and surrounding 100 kb regions; (iv) a few hundred cuts were produced, very often involving the same chromosomal sites; (v) at comparable DNA degradation levels, micrococcal nuclease (MNase) also showed a general preference for genes and surrounding regions, but MNase cuts were located at sites that were quite distinct from, and less specific than, those cut by apoptosis. In conclusion, the approach presented here, which is the mildest and least intrusive approach, identifies a preferred accessibility landscape in interphase chromatin

Faecal immunochemical tests (FIT) can help to rule out colorectal cancer in patients presenting in primary care with lower abdominal symptoms:a systematic review conducted to inform new NICE DG30 diagnostic guidance

__Background:__ This study has attempted to assess the effectiveness of quantitative faecal immunochemical tests (FIT) for triage of people presenting with lower abdominal symptoms, where a referral to secondary care for investigation of suspected colorectal cancer (CRC) is being considered, particularly when the 2-week criteria are not met. __Methods:__ We conducted a systematic review following published guidelines for systematic reviews of diagnostic tests. Twenty-one resources were searched up until March 2016. Summary estimates were calculated using a bivariate model or a random-effects logistic regression model. __Results:__ Nine studies are included in this review. One additional study, included in our systematic review, was provided as 'academic in confidence' and cannot be described herein. When FIT was based on a single faecal sample and a cut-off of 10 μg Hb/g faeces, sensitivity estimates indicated that a negative result using either the OC-Sensor or HM-JACKarc may be adequate to rule out nearly all CRC; the summary estimate of sensitivity for the OC-Sensor was 92.1%, based on four studies, and the only study of HM-JACKarc to assess the 10 μg Hb/g faeces cut-off reported a sensitivity of 100%. The corresponding specificity estimates were 85.8% (95% CI 78.3-91.0%) and 76.6%, respectively. When the diagnostic criterion was changed to include lower grades of neoplasia, i.e. the target condition included higher risk adenoma (HRA) as well as CRC, the rule-out performance of both FIT assays was reduced. __Conclusions:__ There is evidence to suggest that triage using FIT at a cut-off around 10 μg Hb/g faeces has the potential to correctly rule out CRC and avoid colonoscopy in 75-80% of symptomatic patients. Systematic review registration: PROSPERO 4201603772

A randomized controlled study of the prediction of diminutive/small colorectal polyp histology using didactic vs. computer based self-learning module in gastroenterology trainees.

BACKGROUND AND AIM The aim of this randomised trial was to evaluate the performance of self-training vs. didactic training, to increase the diagnostic accuracy of diminutive/small colonic polyp histological prediction by trainees. METHODS Sixteen trainees reviewed 78 videos (48 iSCAN-OE and 30 NBI) of diminutive/small polyps in a pre-training assessment. Trainees were randomised to receive computer-based self-learning (n=8) or didactic training (n=8) using identical teaching materials and videos. The same 78 videos, in a different randomised order, were assessed. The NICE (NBI International Colorectal Endoscopic) and SIMPLE (Simplified Identification Method for Polyp Labeling during Endoscopy) classification systems were used to classify diminutive/small polyps. RESULTS A higher proportion of high confidence predictions of polyps were made by the self-training vs. didactic group both using the SIMPLE classification 77.1% [95% CI 73.4-80.3] vs. 69.9% [95% CI 66.1-73.5%] (p<0.005) and the NICE classification 77% [73.2%-80.4%] vs. 69.8% [95% CI 66-73.4%] (p=0.006). When using NICE, the sensitivity of the self-training group compared with the didactic group was 72% vs. 83% (p<0.0005), and the accuracy was 66.1% vs. 69.1%. The training improved the participants' confidence and SIMPLE was preferred over NICE. CONCLUSION Self-learning for the prediction of diminutive/small polyp histology is a method of training that can achieve results similar to didactic training. The availability of adequate self-learning teaching modules could enable more widespread implementation of optical diagnosis in clinical practice. This article is protected by copyright. All rights reserved

Randomized controlled study of the prediction of diminutive/small colorectal polyp histology using didactic versus computer‐based self‐learning module in gastroenterology trainees

Background and Aim The aim of this randomized trial was to evaluate the performance of self‐training versus didactic training in order to increase the diagnostic accuracy of diminutive/small colonic polyp histological prediction by trainees. Methods Sixteen trainees reviewed 78 videos (48 iSCAN‐OE and 30 NBI) of diminutive/small polyps in a pretraining assessment. Trainees were randomized to receive computer‐based self‐learning (n = 8) or didactic training (n = 8) using identical teaching materials and videos. The same 78 videos, in a different randomized order, were assessed. The NICE (NBI International Colorectal Endoscopic) and SIMPLE (Simplified Identification Method for Polyp Labeling during Endoscopy) classification systems were used to classify diminutive/small polyps. Results A higher proportion of high‐confidence predictions of polyps was made by the self‐training group versus the didactic group using both the SIMPLE classification (77.1% [95% CI 73.4–80.3] vs 69.9% [95% CI 66.1–73.5%] [P = 0.005]) and the NICE classification (77% [95% CI 73.2–80.4%] vs 69.8% [95% CI 66–73.4%] [P = 0.006]). When using NICE, sensitivity of the self‐training group compared with the didactic group was 72% versus 83% (P = 0.0005), and the accuracy was 66.1% versus 69.1%. The training improved the confidence of participants and SIMPLE was preferred over NICE. Conclusion Self‐learning for the prediction of diminutive/small polyp histology is a method of training that can achieve results similar to didactic training. Availability of adequate self‐learning teaching modules could enable widespread implementation of optical diagnosis in clinical practice.</p