Steven Bollipo

Unlike most other chronic diseases and cancers in Australia, outcomes for cirrhosis and hepatocellular cancer are not improving. Public hospitals are overwhelmed by decompensated cirrhosis and struggling to provide best practice care for the large population of patients with less severe (compensated) cirrhosis. Adding to this dysfunction is a lack of education and support for the primary care workforce. To improve the current care for patients with cirrhosis, we must recognise the current poor outcomes and develop appropriate policy responses, including increasing workforce capacity via training of the primary care workforce and establishment of shared care models.

Background: Hepatocellular carcinoma (HCC) often develops in the setting of chronic liver disease, making preservation of hepatic function central to treatment decisions. Despite this, the temporal change on liver function caused by stereotactic body radiation therapy (SBRT), particularly using objective measures such as the albumin–bilirubin (ALBI) score, remains poorly defined. This retrospective study aimed to measure temporal changes in liver function in patients with HCC treated with SBRT. Comparable data was also obtained from patients treated with microwave ablation (MWA), a liver-directed therapy with negligible impact on hepatic function, acting as a control cohort for estimating changes attributable to underlying cirrhosis rather than treatment. Methods: A total of 126 patients with HCC were included, 72 in the SBRT and 54 in the control cohorts respectively. Biochemical data was extracted before and at 3, 6 and 12 months post-treatment for calculation of albumin-bilirubin (ALBI) and Child-Pugh (CP) scores. Clinical and dosimetric data was obtained for assessment of factors associated with change in liver function following SBRT. Results: Baseline liver function was similar between the SBRT and control cohorts (ALBI score, −2.30 vs. −2.27, P=0.68). The median lesion size was significantly larger in the SBRT group (37 vs. 20 mm, PConclusions: Liver function as measured by ALBI score gradually declines following SBRT for HCC, with larger lesion size associated with greater change. However, this change is only significant in a minority of our cohort with added contributions from non-treatment-related factors including co-existing cirrhosis.

High quality esophagogastroduodenoscopy (EGD) depends on the ability to appropriately visualize upper gastrointestinal (GI) mucosa pathology. Evaluation can be limited by the presence of mucus, foam, bubbles and solid materials. Currently, there is no standardized method to assess mucosal visualization for use in clinical or research settings. To develop and establish the content validity of the Toronto Upper Gastrointestinal Cleaning Score (TUGCS) and evaluate its interrater reliability. An international panel of endoscopy experts rated potential items and their associated anchors for importance as indicators of adequacy of mucosal visualization during EGD. The survey utilized a Likert scale (1 (strongly disagree) to 5 (strongly agree)). The Delphi process was repeated until consensus was reached. Consensus was defined priori as ≥80% of experts in a given round scoring ≥4 on all survey items. To assess content validity, 48 EGD procedures were evaluated in real-time by two endoscopist reviewers using the TUGCS at a single institution. The interrater agreement between assessments was calculated for TUGCS total scores using intraclass correlation coefficient, one-way random effects model (ICC 1,1). Fourteen experts agreed to be part of the Delphi panel. An anatomical framework representing the upper GI mucosa and anchors for each mucosal portion representing various levels of visibility was generated through systematic review. Three survey rounds, with response rates of 100%, 100% and 71% respectively, achieved consensus. The final TUGCS includes four anatomical areas (fundus, body, antrum, duodenum) and mucosal visualization anchors ranging from 0 to 3 (Figure 1). TUGCS was used to assess foregut cleaning in 48 procedures (Table 1). The mean TUGCS for staff and trainee were 8.1 (±2.4) and 8.1 (±2.6), respectively. The ICC was 0.78 (95% confidence interval 0.62–0.88) indicating good reliability. We developed and generated content validity evidence for the TUGCS through rigorous Delphi methodology, reflective of practice across different centres. Planned as future research is a video survey distributed to endoscopists internationally to further validate the TUGCS to create a tool that may be used to judge mucosal visualization for EGD in research and clinical settings. Table 1. Patient Characteristics (n=48) Table 1. Patient Characteristics (n=48) Figure 1. TUGCS tool Figure 1. TUGCS tool None

Delayed post-polypectomy bleeding (DPPB) is a potentially severe complication of therapeutic colonoscopy which can result in hospital readmission and re-intervention. Over the last decade, rates of DPPB reported in the literature have fallen from over 2% to 0.3– 1.2%, largely due to improvements in resection technique, a shift towards cold snare polypectomy, better training, adherence to guidelines on periprocedural antithrombotic management, and the use of antithrombotics with more favourable bleeding profiles. However, as the complexity of polypectomy undertaken worldwide increases, so does the importance of identifying patients at increased risk of DPPB. Risk factors can be categorised according to patient, polyp and personnel related factors, and their integration together to provide an individualised risk score is an evolving field. Strategies to reduce DPPB include safe practices relevant to all patients undergoing colonoscopy, as well as specific considerations for patients identified to be high risk. This narrative review sets out an evidence-based summary of factors that contribute to the risk of DPPB before discussing pragmatic interventions to mitigate their risk and improve patient safety.

The factors contributing to burn-out among gastroenterologists include excessive clinical work load with increasing demands related to the complexity of patient care, work productivity, electronic health records (EHR), documentation to measure endoscopy standards as well as the lack of autonomy, administrative support, workplace relationships, work and home conflicts.5 6 Furthermore, the drivers of clinician burn-out may also lead to ‘moral injury’ when the knowledge of the care needs of the patient often at odds with the ability to provide it due to constraints are beyond the clinicians’ control.7