1
|
Denholm J, Schreiber BA, Jaeckle F, Wicks MN, Benbow EW, Bracey TS, Chan JYH, Farkas L, Fryer E, Gopalakrishnan K, Hughes CA, Kirkwood KJ, Langman G, Mahler-Araujo B, McMahon RFT, Myint KLW, Natu S, Robinson A, Sanduka A, Sheppard KA, Tsang YW, Arends MJ, Soilleux EJ. CD, or not CD, that is the question: a digital interobserver agreement study in coeliac disease. BMJ Open Gastroenterol 2024; 11:e001252. [PMID: 38302475 PMCID: PMC10870791 DOI: 10.1136/bmjgast-2023-001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/11/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE Coeliac disease (CD) diagnosis generally depends on histological examination of duodenal biopsies. We present the first study analysing the concordance in examination of duodenal biopsies using digitised whole-slide images (WSIs). We further investigate whether the inclusion of immunoglobulin A tissue transglutaminase (IgA tTG) and haemoglobin (Hb) data improves the interobserver agreement of diagnosis. DESIGN We undertook a large study of the concordance in histological examination of duodenal biopsies using digitised WSIs in an entirely virtual reporting setting. Our study was organised in two phases: in phase 1, 13 pathologists independently classified 100 duodenal biopsies (40 normal; 40 CD; 20 indeterminate enteropathy) in the absence of any clinical or laboratory data. In phase 2, the same pathologists examined the (re-anonymised) WSIs with the inclusion of IgA tTG and Hb data. RESULTS We found the mean probability of two observers agreeing in the absence of additional data to be 0.73 (±0.08) with a corresponding Cohen's kappa of 0.59 (±0.11). We further showed that the inclusion of additional data increased the concordance to 0.80 (±0.06) with a Cohen's kappa coefficient of 0.67 (±0.09). CONCLUSION We showed that the addition of serological data significantly improves the quality of CD diagnosis. However, the limited interobserver agreement in CD diagnosis using digitised WSIs, even after the inclusion of IgA tTG and Hb data, indicates the importance of interpreting duodenal biopsy in the appropriate clinical context. It further highlights the unmet need for an objective means of reproducible duodenal biopsy diagnosis, such as the automated analysis of WSIs using artificial intelligence.
Collapse
Affiliation(s)
- James Denholm
- Department of Pathology, University of Cambridge, Cambridge, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
- Lyzeum Ltd, Cambridge, UK
| | - Benjamin A Schreiber
- Department of Pathology, University of Cambridge, Cambridge, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
| | - Florian Jaeckle
- Department of Pathology, University of Cambridge, Cambridge, UK
- Lyzeum Ltd, Cambridge, UK
| | - Mike N Wicks
- Department of Pathology, The University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, UK
| | - Emyr W Benbow
- Division of Medical Education, The University of Manchester, Manchester, UK
- Department of Histopathology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Tim S Bracey
- Department of Diagnostic and Molecular Pathology, Royal Cornwall Hospitals NHS Trust, Truro, UK
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - James Y H Chan
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lorant Farkas
- Department of Pathology, Akershus University Hospital, Nordbyhagen, Norway
- Institute of Clinical Medicine, University of Oslo, Nordbyhagen, Norway
| | - Eve Fryer
- Department of Cellular Pathology, Oxford University Hospitals NHS foundation Trust, Oxford, UK
| | - Kishore Gopalakrishnan
- Department of Histopathology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Caroline A Hughes
- Department of Cellular Pathology, Oxford University Hospitals NHS foundation Trust, Oxford, UK
| | | | - Gerald Langman
- Department of Cellular Pathology, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Betania Mahler-Araujo
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- MRC Institute of Metabolic Science, Wellcome Trust, Cambridge, UK
| | - Raymond F T McMahon
- Division of Medical Education, The University of Manchester, Manchester, UK
- Department of Histopathology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Khun La Win Myint
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Sonali Natu
- University Hospital of North Tees, North Tees and Hartlepool NHS Foundation Trust, Stockton on Tees, UK
| | - Andrew Robinson
- Department of Histopathology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Ashraf Sanduka
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Katharine A Sheppard
- Department of Cellular Pathology, Oxford University Hospitals NHS foundation Trust, Oxford, UK
| | - Yee Wah Tsang
- Department of Histopathology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Mark J Arends
- Division of Pathology, University of Edinburgh, Edinburgh, UK
| | - Elizabeth J Soilleux
- Department of Pathology, University of Cambridge, Cambridge, UK
- Lyzeum Ltd, Cambridge, UK
| |
Collapse
|
2
|
Akasaki M, Kivimäki M, Steptoe A, Nicholas O, Shipley MJ. Association of attrition with mortality: findings from 11 waves over three decades of the Whitehall II study. J Epidemiol Community Health 2020; 74:824-830. [PMID: 32586986 PMCID: PMC8071845 DOI: 10.1136/jech-2019-213175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 03/25/2020] [Accepted: 05/19/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Attrition, the loss of participants as a study progresses, is a considerable challenge in longitudinal studies. This study examined whether two forms of attrition, 'withdrawal' (formal discontinued participation) and 'non-response' (non-response among participants continuing in the study), have different associations with mortality and whether these associations differed across time in a multi-wave longitudinal study. METHODS Participants were 10 012 civil servants who participated at the baseline of the Whitehall II cohort study with 11 data waves over an average follow-up of 28 years. We performed competing-risks analyses to estimate sub-distribution HRs and 95% CIs, and likelihood ratio tests to examine whether hazards differed between the two forms of attrition. We then applied linear regression to examine any trend of hazards against time. RESULTS Attrition rate at data collections ranged between 13% and 34%. There were 495 deaths recorded from cardiovascular disease and 1367 deaths from other causes. Study participants lost due to attrition had 1.55 (95% CI 1.26 to 1.89) and 1.56 (1.39 to 1.76) times higher hazard of cardiovascular and non-cardiovascular mortality than responders, respectively. Hazards for withdrawal and non-response did not differ for either cardiovascular (p value =0.28) or non-cardiovascular mortality (p value =0.38). There was no linear trend in hazards over the 11 waves (cardiovascular mortality p value =0.11, non-cardiovascular mortality p value =0.61). CONCLUSION Attrition can be a problem in longitudinal studies resulting in selection bias. Researchers should examine the possibility of selection bias and consider applying statistical approaches that minimise this bias.
Collapse
Affiliation(s)
- Mifuyu Akasaki
- Department of Behavioural Science and Health, University College London, London, UK
| | - Mika Kivimäki
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Andrew Steptoe
- Department of Behavioural Science and Health, University College London, London, UK
| | - Owen Nicholas
- Department of Statistical Science, University College London, London, UK
| | - Martin J Shipley
- Department of Epidemiology and Public Health, University College London, London, UK
| |
Collapse
|
3
|
Th'ng F, Skouras C, Paterson-Brown A, Ravindran R, Lamb P, de Beaux A, Paterson-Brown S, Mole DJ. Emergency general surgery 'Hot Clinics' reduce admission rates and duration of inpatient stay. Frontline Gastroenterol 2017; 8:53-61. [PMID: 28839885 PMCID: PMC5369429 DOI: 10.1136/flgastro-2015-100634] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 11/05/2015] [Accepted: 11/10/2015] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To determine the impact of a 'Hot Clinic' (HC) on emergency general surgery patient flow-through. DESIGN Prospective service evaluation study. SETTING HC is a four-bedded area coordinated by a specialist nurse. The HC consultant sees emergency patients referred from the emergency department, general practitioners or those in preceding 24 h considered suitable for interim discharge while awaiting investigations and HC reassessment. PATIENTS All patients with acute abdominal pain were evaluated in three 4 week groups: before (group 1), 1 month (group 2) and 6 months after the HC was introduced (group 3). Interhospital transfers, intrahospital ward referrals and trauma patients were excluded. INTERVENTION Introduction of consultant-led surgical HC every weekday afternoon. MAIN OUTCOME MEASURES Proportion of patients admitted under general surgeons, length of inpatient stay and the proportion of patients referred again within 3 months were investigated. RESULTS 1409 patients were referred, of which 1061 met the inclusion criteria: 307 in group 1, 326 in group 2 and 428 in group 3. There was no difference in gender distribution (p=0.759). Inpatient admissions were significantly reduced (85.0% vs 78.2% vs 54.4%; p<0.001) and the inpatient duration of stay was significantly shorter after HC introduction (median (IQR) (95% CI) 63.8 (29.0-111.6) (51.8 to 72.8) hours vs 48.8 (21.7-101.2) (42.0 to 55.6) hours vs 47.7 (20.9-92.7) (42.8 to 56.9) hours; p=0.011). CONCLUSIONS Emergency general surgery HCs are associated with significant reductions in admission rates and inpatient bed occupancy. This service redesign has the potential to dramatically relieve pressure on acute surgical services.
Collapse
Affiliation(s)
- Francesca Th'ng
- Department of Clinical Surgery, School of Clinical Sciences and Community Health, The University of Edinburgh, Edinburgh, UK
| | - Christos Skouras
- Department of Clinical Surgery, School of Clinical Sciences and Community Health, The University of Edinburgh, Edinburgh, UK
| | | | - Rajan Ravindran
- General Surgery Department, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Peter Lamb
- General Surgery Department, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Andrew de Beaux
- General Surgery Department, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Simon Paterson-Brown
- General Surgery Department, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Damian J Mole
- Department of Clinical Surgery, School of Clinical Sciences and Community Health, The University of Edinburgh, Edinburgh, UK,General Surgery Department, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| |
Collapse
|
4
|
Thompson C, Ismail T, Radley S, Walt R, Ward ST. Conversion of colonoscopy to flexible sigmoidoscopy: an unintended consequence of quality measurement in endoscopy. Frontline Gastroenterol 2016; 7:202-206. [PMID: 27429734 PMCID: PMC4941159 DOI: 10.1136/flgastro-2015-100626] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 11/01/2015] [Accepted: 11/10/2015] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To quantify the proportion of requests for colonoscopy that are performed as flexible sigmoidoscopy and documented reasons for this in ordinary UK hospital practice. To determine the effect these requests have on colonoscopy completion rate if they are included in the denominator of the calculated rate by individual endoscopist. DESIGN Retrospective study of 22 months flexible sigmoidoscopy practice at a major UK teaching hospital. All flexible sigmoidoscopies performed had their associated request form examined. SETTING UK NHS University Hospital. PATIENTS All patients receiving outpatient flexible sigmoidoscopy from January 2013 to October 2014 with no exclusions. INTERVENTION Conversion of colonoscopy to flexible sigmoidoscopy. MAIN OUTCOME MEASURES Conversion of colonoscopy to flexible sigmoidoscopy, reason for conversion and adjusted colonoscopy completion rate. RESULTS 71 of the 3526 flexible sigmoidoscopies performed (2.0%), representing 71 of 5905 colonoscopy requests (1.2%). Conversion reason was noted only in 26 (37%) of converted cases. Adjustment of colonoscopy completion rate to include conversions pushed four of our unit's 22 endoscopists below the UK national 90% standard. CONCLUSIONS Conversion to flexible sigmoidoscopy occurs in 1.2% of patients originally booked for colonoscopy. The reason for this conversion is often unqualified and may be inappropriate. Conversion can affect the colonoscopy completion rate, and therefore, should be included in endoscopists' overall performance statistics.
Collapse
Affiliation(s)
- Chris Thompson
- Department of Colorectal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tariq Ismail
- Department of Colorectal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon Radley
- Department of Colorectal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Robert Walt
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stephen Thomas Ward
- Department of Colorectal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
5
|
Abstract
Aim To determine the hospital autopsy rate for the UK in 2013. Methods A study of data from a ‘Freedom of Information’ request to all (n=186) acute NHS Trusts within England (n=160), NHS Boards in Scotland (n=14) and Wales (n=7) and Social Care Trusts in Northern Ireland (n=5). Hospital autopsy rates were calculated from the number of hospital autopsies performed in 2013 as a percentage of total inpatient deaths in the Trust that year. Results The UK response rate was 99% (n=184), yielding a mean autopsy rate of 0.69%. The mean rates were 0.51% (England), 2.13% (Scotland), 0.65% (Wales) and 0.46% (Northern Ireland). 23% (n=38) of all included respondents had a rate of 0% and 86% (n=143) a rate less than 1%. Conclusions The decline in hospital autopsy has continued relentlessly and, for better or for worse, the practice is on the verge of extinction in the UK. The study highlights to health professionals and policy makers the magnitude of this decline. Further research should investigate the impact of this on patient safety, clinical audit, public health and medical education.
Collapse
Affiliation(s)
| | - Michael Osborn
- Department of Cellular Pathology, Imperial College Healthcare NHS Trust, London, UK
| | - Nick Nicholas
- Hillingdon Hospital Foundation Trust, Uxbridge, London, UK
| |
Collapse
|