Bariatric surgeons' views on pre-operative factors associated with improved health-related quality of life following surgery

Bariatric surgery is an effective treatment for severe obesity, affording significant improvements in weight loss and health-related quality of life. However, bariatric surgeons' views on whether certain pre-operative factors predict improvements in post-operative health-related quality of life, and if so, which ones, are largely unknown. This cross-sectional survey study examined the views of 58 bariatric surgeons from Australia and New Zealand. A total of 18 factors were selected for exploration based on their mention in the literature. Participants rated the extent to which they thought these pre-operative factors would improve post-operative health-related quality of life. Responses showed that bariatric surgeons held diverse perspectives and revealed a lack of consensus regarding "predictive" factors. Generally, respondents agreed that better than average health literacy, higher socioeconomic status, good physical and psychological health, and positive social support were predictors of improved health-related quality of life following surgery. However, poor eating behaviours, smoking, and the use of alcohol or other substances were deemed negative predictors. Interestingly, aside from higher socioeconomic status, good psychological health, and positive social support, none of the aforementioned views aligned with existing literature. This study offers an initial insight into bariatric surgeons' views on the influence of different pre-operative factors on post-operative health-related quality of life. The array of views identified suggests that there may be an opportunity for medical education, but the findings warrant caution due to the sample size. Replication with a larger survey may be useful, especially as predicted health-related quality of life outcomes could guide decisions regarding surgical (non)progression.

Performance of an algorithm-based approach to the diagnosis and management of functional gastrointestinal disorders: A pilot trial

BACKGROUND

Recent advances in the development of diagnostic criteria and effective management options for functional gastrointestinal disorders (FGIDs) have not yet been integrated into clinical practice. There is a clear need for the development and validation of a simple clinical pathway for the diagnosis and management of FGIDs which can be used in primary care.

METHODS

In this controlled pilot study, we designed and evaluated a non-specialist-dependent, algorithm-based approach for the diagnosis and management of FGIDs (ADAM-FGID). Patients referred to 1 tertiary referral center with clinically suspected functional gastrointestinal disorders were allocated to waitlist control or algorithm group. The algorithm group was screened for organic disease, and those without clinical alarms received a written FGID diagnosis and management options. All participants were followed up for 1 year.

KEY RESULTS

The ADAM-FGID was found to be feasible and acceptable to both patients and primary healthcare providers. The diagnostic component identified that 39% of referrals required more urgent gastroenterological review than original triage category, with organic disease subsequently diagnosed in 31% of these. The majority of patients (82%) diagnosed with a FGID did not receive a relevant alternative diagnosis during follow-up. Patient buy-in to the model was good, with all reading the diagnostic/management letter, 80% entering management, and 61% reporting symptom improvement at 6 weeks. Moreover, 68% of patients and all referring doctors found the approach to be at least moderately acceptable. Patients reported being reassured by the approach and found the management options useful. Primary healthcare providers acknowledged the potential of this approach to reduce waiting times for endoscopic procedures and to provide reassurance to both patients and themselves.

CONCLUSIONS & INFERENCES

This pilot study provides preliminary evidence to support a clinical pathway for the diagnosis and management of FGIDs which does not depend upon specialist review. Further rigorous testing within primary care is needed to conclusively establish safety and efficacy. However, this approach is safer than current management and has potential to build capacity by reducing specialist burden and expediting effective care.

Review article: consensus statements on therapeutic drug monitoring of anti-tumour necrosis factor therapy in inflammatory bowel diseases

BACKGROUND

Therapeutic drug monitoring (TDM) in inflammatory bowel disease (IBD) patients receiving anti-tumour necrosis factor (TNF) agents can help optimise outcomes. Consensus statements based on current evidence will help the development of treatment guidelines.

AIM

To develop evidence-based consensus statements for TDM-guided anti-TNF therapy in IBD.

METHODS

A committee of 25 Australian and international experts was assembled. The initial draft statements were produced following a systematic literature search. A modified Delphi technique was used with 3 iterations. Statements were modified according to anonymous voting and feedback at each iteration. Statements with 80% agreement without or with minor reservation were accepted.

RESULTS

22/24 statements met criteria for consensus. For anti-TNF agents, TDM should be performed upon treatment failure, following successful induction, when contemplating a drug holiday and periodically in clinical remission only when results would change management. To achieve clinical remission in luminal IBD, infliximab and adalimumab trough concentrations in the range of 3-8 and 5-12 μg/mL, respectively, were deemed appropriate. The range may differ for different disease phenotypes or treatment endpoints-such as fistulising disease or to achieve mucosal healing. In treatment failure, TDM may identify mechanisms to guide subsequent decision-making. In stable clinical response, TDM-guided dosing may avoid future relapse. Data indicate drug-tolerant anti-drug antibody assays do not offer an advantage over drug-sensitive assays. Further data are required prior to recommending TDM for non-anti-TNF biological agents.

CONCLUSION

Consensus statements support the role of TDM in optimising anti-TNF agents to treat IBD, especially in situations of treatment failure.

Systematic review with meta-analysis: faecal microbiota transplantation for the induction of remission for active ulcerative colitis

BACKGROUND

Faecal microbiota transplantation (FMT) is emerging as a novel therapy for ulcerative colitis (UC). Interpretation of efficacy of FMT for UC is complicated by differences among studies in blinding, FMT administration procedures, intensity of therapy and donor stool processing methods.

AIM

To determine whether FMT is effective and safe for the induction of remission in active UC.

METHODS

Medline (Ovid), Embase and the Cochrane Library were searched from inception through February 2017. Original studies reporting remission rates following FMT for active UC were included. All study designs were included in the systematic review and a meta-analysis performed including only randomised controlled trials (RCTs).

RESULTS

There were 14 cohort studies and four RCTs that used markedly different protocols. In the meta-analysis of RCTs, clinical remission was achieved in 39 of 140 (28%) patients in the donor FMT groups compared with 13 of 137 (9%) patients in the placebo groups; odds ratio 3.67 (95% CI: 1.82-7.39, P<.01). Clinical response was achieved in 69 of 140 (49%) donor FMT patients compared to 38 of 137 (28%) placebo patients; odds ratio 2.48 (95% CI: 1.18-5.21, P=.02). In cohort studies, 39 of 168 (24%; 95% CI: 11%-40%) achieved clinical remission.

CONCLUSIONS

Despite variation in processes, FMT appears to be effective for induction of remission in UC, with no major short-term safety signals. Further studies are needed to better define dose frequency and preparation methods, and to explore its feasibility, efficacy and safety as a maintenance agent.

Infliximab vs. adalimumab in Crohn's disease: results from 327 patients in an Australian and New Zealand observational cohort study

BACKGROUND

Maintenance anti-tumour necrosis factor-α (anti-TNFα) treatment for Crohn's disease is the standard of care for patients with an inadequate response to corticosteroids and immunomodulators.

AIM

To compare the efficacy and safety of infliximab and adalimumab in clinical practice and assess the value of concomitant immunomodulator therapy.

METHODS

We performed an observational cohort study in consecutive patients with Crohn's disease qualifying for anti-TNFα treatment in Australia and New Zealand between 2007 and 2011. Demographic and clinical data were prospectively recorded to identify independent factors associated with induction and maintenance of response to infliximab or adalimumab, or to either anti-TNFα therapy.

RESULTS

Three hundred and twenty-seven patients (183 infliximab, 144 adalimumab) successfully applied for treatment. Eighty-nine percent responded in all groups and median maintenance of response was similar for the two agents. Concomitant immunomodulator with infliximab, but not adalimumab, demonstrated a significantly longer response overall (P = 0.002), and significantly fewer disease and treatment-related complications (P = 0.017). Corticosteroids at baseline, and/or in the preceding 12 months, were associated with a 9-13 times greater risk of disease flare during maintenance treatment as compared to no corticosteroids (P < 0.0001). Maintenance of response was similar in the anti-TNF naïve and anti-TNF experienced subgroups.

CONCLUSIONS

In this large, real-life study, we demonstrate infliximab and adalimumab to have similar response characteristics. However, infliximab requires concomitant immunomodulator to achieve optimal maintenance of response comparable to adalimumab monotherapy. The results of this study will assist clinicians in further optimising patient care in their day-to-day clinical practice.

Inpatient healthcare utilisation in patients with alcoholic liver disease: what are the costs and outcomes?

BACKGROUND

Alcoholic liver disease (ALD) carries a significant cost burden and often leads to inpatient care. It is unclear whether inpatient care for ALD is any more costly than admission for other reasons.

AIMS

To compare the costs and outcomes of inpatient care for ALD to two groups: a control group of matched cases admitted in the same time frame and people admitted for other chronic liver diseases (CLD).

METHODS

All admissions for ALD and other CLD in a 3-month period were retrospectively identified. Five randomly identified gender- and age-matched contemporaneously admitted controls were allocated. Length of stay (LoS), mortality, inpatient costs, blood product utilisation and discharge destination were compared.

RESULTS

Of the 71 admissions due to CLD, ALD was the most frequent cause (53/71, 75%). ALD admissions cost more (median $10 100 vs $5294; P = 0.0012) and had greater LoS (median LoS 7.2 days (interquartile range (IQR) 0.2-40.7)) than controls (2.6 days (IQR 1.1-6.8); P = 0.0001). A larger proportion of the ALD cohort required blood transfusion and had a higher mortality than controls (24.5 vs 6.4%, P = 0.002 and 13.2 vs 0.2%; P < 0.0001 respectively). Self-discharge was more common in the ALD group (13.2 vs 1.1%, P < 0.0001).

CONCLUSIONS

ALD inpatient hospital admissions have greater median total cost, longer LoS, greater blood product utilisation, higher mortality and greater rate of discharge against medical advice than age- and gender-matched controls. These data emphasise the large inpatient care burden, high mortality and suboptimal engagement in those with ALD, which justifies the more active provision of services for ALD.

Review article: acute severe ulcerative colitis - evidence-based consensus statements

BACKGROUND

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening complication of ulcerative colitis.

AIM

To develop consensus statements based on a systematic review of the literature of the management of ASUC to improve patient outcome.

METHODS

Following a literature review, the Delphi method was used to develop the consensus statements. A steering committee, based in Australia, generated the statements of interest. Three rounds of anonymous voting were carried out to achieve the final results. Acceptance of statements was pre-determined by ≥80% votes in 'complete agreement' or 'agreement with minor reservation'.

RESULTS

Key recommendations include that patients with ASUC should be: hospitalised, undergo unprepared flexible sigmoidoscopy to assess severity and to exclude cytomegalovirus colitis, and be provided with venous thromboembolism prophylaxis and intravenous hydrocortisone 100 mg three or four times daily with close monitoring by a multidisciplinary team. Rescue therapy such as infliximab or ciclosporin should be started if insufficient response by day 3, and colectomy considered if no response to 7 days of rescue therapy or earlier if deterioration. With such an approach, it is expected that colectomy rate during admission will be below 30% and mortality less than 1% in specialist centres.

CONCLUSION

These evidenced-based consensus statements on acute severe ulcerative colitis, developed by a multidisciplinary group, provide up-to-date best practice recommendations that improve and harmonise management as well as provide auditable quality assessments.

Compassionate access anti-tumour necrosis factor-α therapy for ulcerative colitis in Australia: the benefits to patients

BACKGROUND

The efficacy of infliximab has been demonstrated in patients with both acute severe and moderate-severe ulcerative colitis (UC). However, there is a need for 'real-life data' to ensure that conclusions from trial settings are applicable in usual care. We therefore examined the national experience of anti-tumour necrosis factor-α (TNF-α) therapy in UC.

METHODS

Case notes review of patients with UC who had received compassionate access (CA) anti-TNF-α therapy from prospectively maintained inflammatory bowel disease databases of six Australian adult teaching hospitals.

RESULTS

Patients either received drug for acute severe UC (ASUC) failing steroids (n = 29) or for medically refractory UC (MRUC) (n = 35). In ASUC, the treating physicians judged that anti-TNF-α therapy was successful in 20/29 patients (69%); in these cases, anti-TNF-α was able to be discontinued (after 1-3 infusions in 19/20 responders) as clinical remission was achieved. Consistent with this perceived benefit, only 7/29 (24%) subsequently underwent colectomy during a median follow up of 12 months (interquartile range (IQR) 5-16). Eight of the 35 patients with MRUC (23%) required colectomy during a median follow up of 28 months (IQR 11-43). The majority of these patients (20/35 or 57%) had anti-TNF-α therapy for ≥4 months, whereas, 27/29 (93%) of ASUC patients had CA for ≤3 months.

CONCLUSIONS

These data show an excellent overall benefit for anti-TNF-α therapy in both ASUC and MRUC. In particular, only short-duration anti-TNF-α was required in ASUC. These real-life data thus support the clinical trial data and should lead to broader use of this therapy in UC.

Efficacy of thiopurines and adalimumab in preventing Crohn's disease recurrence in high-risk patients - a POCER study analysis

BACKGROUND

Crohn's disease recurs in the majority of patients after intestinal resection.

AIM

To compare the relative efficacy of thiopurines and anti-TNF therapy in patients at high risk of disease recurrence.

METHODS

As part of a larger study comparing post-operative management strategies, patients at high risk of recurrence (smoker, perforating disease, ≥2nd operation) were treated after resection of all macroscopic disease with 3 months metronidazole together with either azathioprine 2 mg/kg/day or mercaptopurine 1.5 mg/kg/day. Thiopurine-intolerant patients received adalimumab induction then 40 mg fortnightly. Patients underwent colonoscopy at 6 months with endoscopic recurrence assessed blind to treatment.

RESULTS

A total of 101 patients [50% male; median (IQR) age 36 (25-46) years] were included. There were no differences in disease history between thiopurine- and adalimumab-treated patients. Fifteen patients withdrew prior to 6 months, five due to symptom recurrence (of whom four were colonoscoped). Endoscopic recurrence (Rutgeerts score i2-i4) occurred in 33 of 73 (45%) thiopurine vs. 6 of 28 (21%) adalimumab-treated patients [intention-to-treat (ITT); P = 0.028] or 24 of 62 (39%) vs. 3 of 24 (13%) respectively [per-protocol analysis (PPA); P = 0.020]. Complete mucosal endoscopic normality (Rutgeerts i0) occurred in 17/73 (23%) vs. 15/28 (54%) (ITT; P = 0.003) and in 27% vs. 63% (PPA; P = 0.002). The most advanced disease (Rutgeerts i3 and i4) occurred in 8% vs. 4% (thiopurine vs. adalimumab).

CONCLUSIONS

In Crohn's disease patients at high risk of post-operative recurrence adalimumab is superior to thiopurines in preventing early disease recurrence.

Faecal microbiota transplant for recurrent Clostridium difficile infection using long-term frozen stool is effective: clinical efficacy and bacterial viability data

BACKGROUND

Faecal microbial transplant (FMT) for recurrent Clostridium difficile infection (rCDI) is greatly facilitated by frozen stool banks. However, the effect of frozen storage of stool for greater than 2 months on the viability of stool bacteria is unknown and the efficacy of FMT is not clear.

AIM

To evaluate the viability of bacteria in stool frozen for up to 6 months, and the clinical efficacy of FMT with stool frozen for 2-10 months, for the treatment of rCDI.

METHODS

Viability of six representative groups of faecal bacteria after 2 and 6 months of storage at -80 °C, in normal saline (NS) or 10% glycerol were assessed by culture on plate media. The clinical outcomes of 16 consecutive patients with rCDI treated with aliquots of stool frozen in 10% glycerol and stored for 2-10 months were also examined.

RESULTS

Viability at both 2 and 6 months was similar to baseline, in specimens stored in 10% glycerol and at 2 months in stool stored in NS, but was reduced by >1 log at 6 months for Aerobes (P < 0.01), total Coliforms (P < 0.01) and Lactobacilli (P < 0.01) in NS. Using stool frozen for 2-10 months in 10% glycerol, the cure rate for rCDI was 88% with one FMT and 100% after repeat FMT in those who relapsed.

CONCLUSION

Stool for faecal microbial transplant to treat rCDI can be safely stored frozen in 10% glycerol for at least 6 months without loss of clinical efficacy or viability in the six bacterial groups tested.

Ulcerative colitis outpatient management: development and evaluation of tools to support primary care practitioners

BACKGROUND

Current models of care for ulcerative colitis (UC) across healthcare systems are inconsistent with a paucity of existing guidelines or supportive tools for outpatient management.

AIMS

This study aimed to produce and evaluate evidence-based outpatient management tools for UC to guide primary care practitioners and patients in clinical decision-making.

METHODS

Three tools were developed after identifying current gaps in the provision of healthcare services for patients with UC at a Clinical Insights Meeting in 2013. Draft designs were further refined through consultation and consolidation of feedback by the steering committee. Final drafts were developed following feasibility testing in three key stakeholder groups (gastroenterologists, general practitioners and patients) by questionnaire. The tools were officially launched into mainstream use in Australia in 2014.

RESULTS

Three quarters of all respondents liked the layout and content of each tool. Minimal safety concerns were aired and those, along with pieces of information that were felt to be omitted, that were reviewed by the steering committee and incorporated into the final documents. The majority (over 80%) of respondents felt that the tools would be useful and would improve outpatient management of UC.

CONCLUSION

Evidence-based outpatient clinical management tools for UC can be developed. The concept and end-product have been well received by all stakeholder groups. These tools should support non-specialist clinicians to optimise UC management and empower patients by facilitating them to safely self-manage and identify when medical support is needed.

Smoking prevalence and its influence on disease course and surgery in Crohn's disease and ulcerative colitis

BACKGROUND

Smoking demonstrates divergent effects in Crohn's disease (CD) and ulcerative colitis (UC). Smoking frequency is greater in CD and deleterious to its disease course. Conversely, UC is primarily a disease of nonsmokers and ex-smokers, with reports of disease amelioration in active smoking.

AIM

To determine the prevalence of smoking and its effects on disease progression and surgery in a well-characterised cohort of inflammatory bowel diseases (IBD) patients.

METHODS

Patients with smoking data of the Sydney IBD Cohort were included. Demographic, phenotypic, medical, surgical and hospitalisation data were analysed and reported on the basis of patient smoking status.

RESULTS

1203 IBD patients were identified comprising 626 CD and 557 UC with 6725 and 6672 patient-years of follow-up, respectively. CD patients were more likely to smoke than UC patients (19.2% vs. 10.2%, P < 0.001). A history of smoking in CD was associated with an increased proportional surgery rate (45.8% vs. 37.8%, P = 0.045), requirement for IBD-related hospitalisation (P = 0.009) and incidence of peripheral arthritis (29.8% vs. 22.0%, P = 0.027). Current smokers with UC demonstrated reduced corticosteroid utilisation (24.1% vs. 37.5%, P = 0.045), yet no reduction in the rates of colectomy (3.4% vs. 6.6%, P = 0.34) or hospital admission (P = 0.25) relative to nonsmokers. Ex-smokers with UC required proportionately greater immunosuppressive (36.2% vs. 26.3%, P = 0.041) and corticosteroid (43.7% vs. 34.5%, P = 0.078) therapies compared with current and never smokers.

CONCLUSIONS

This study confirms the detrimental effects of smoking in CD, yet failed to demonstrate substantial benefit from smoking in UC. These data should encourage all patients with IBD to quit smoking.

Low muscle mass and sarcopenia: common and predictive of osteopenia in inflammatory bowel disease

BACKGROUND

Body composition is poorly studied in inflammatory bowel disease (IBD). Sarcopenia describes a loss of muscle mass and strength.

AIM

To assess the prevalence of low lean mass (LM), sarcopenia and associated morbidity in an adult IBD cohort.

METHODS

Cross-sectional data were gathered on pre-menopausal 18- to 50-year-old patients with IBD. Whole-body dual-energy X-ray absorptiometry, anthropometric assessment and grip strength were performed. Low LM was defined as ≥1 s.d. below the population mean for appendicular skeletal muscle index [ASMI (kg)/height (m)²], and sarcopenia as both ASMI and grip strength ≥1 s.d. below population mean. Multivariate regression analyses were performed.

RESULTS

Of 137 participants (median age 31 years, BMI 24.8 kg/m(2) ), 56% were male and 69% had Crohn's disease (CD). Low LM and sarcopenia were observed in 21% and 12% of patients, respectively, and osteopenia/osteoporosis in 38% of patients (mean lumbar spine t-score -0.3 ± s.d. 1.1). Grip strength predicted low LM and sarcopenia better than did body mass index (BMI) (OR 4.8 vs. OR 0.7 for low-LM, P < 0.05 both). Normal BMI was falsely reassuring in 72% and 76% of patients with low ASMI and sarcopenia, respectively. Low LM and sarcopenia (OR = 3.6, P = 0.03; OR = 6.3, P = 0.02; respectively), but not BMI nor fat mass, predicted osteopenia/osteoporosis.

CONCLUSIONS

Low lean mass and sarcopenia are common in patients with IBD, and important to recognise as they predict osteopenia/osteoporosis. Grip strength testing should be incorporated into routine clinical practice to detect low lean mass deficits, which may go unrecognised using BMI alone.

Perspectives of paediatric and adult gastroenterologists on transfer and transition care of adolescents with inflammatory bowel disease

BACKGROUND

Programmes specific to inflammatory bowel disease (IBD) that facilitate transition from paediatric to adult care are currently lacking.

AIM

We aimed to explore the perceived needs of adolescents with IBD among paediatric and adult gastroenterologists and to identify barriers to effective transition.

METHODS

A web-based survey of paediatric and adult gastroenterologists in Australia and New Zealand employed both ranked items (Likert scale; from 1 not important to 5 very important) and forced choice items regarding the importance of various factors in facilitating effective transition of adolescents from paediatric to adult care.

RESULTS

Response rate among 178 clinicians was 41%. Only 23% of respondents felt that adolescents with IBD were adequately prepared for transition to adult care. Psychological maturity (Mean = 4.3, standard deviation (SD) = 0.70) and readiness as assessed by adult caregiver (Mean = 4, SD = 0.72) were prioritised as the most important factors in determining timing of transfer. Self-efficacy and readiness as assessed by adult caregiver were considered the two most important factors to determine timing of transition by both groups of gastroenterologists. Poor medical and surgical handover (Mean = 4.10, SD = 0.8) and patients' lack of responsibility for their own care (Mean= 4.10, SD = 0.82) were perceived as major barriers to successful transition by both paediatric and adult gastroenterologists.

CONCLUSIONS

Deficiencies exist in current transition care of adolescents with IBD in Australia and New Zealand. Standardising transition care practices with strategies aimed at optimising communication, patient education, self-efficacy and adherence may improve outcomes.

Clinical audit: recent practice in caring for patients with acute severe colitis compared with published guidelines--is there a problem?

BACKGROUND

Acute severe colitis (ASC) is a serious condition with possible outcomes of emergency colectomy and mortality. Validated guidelines exist to help avoid these.

AIMS

To examine local adherence to guidelines and identify (a) opportunities to improve care and (b) possible barriers to adherence.

METHODS

Retrospective, hospital-wide audit of all patients with ASC during a 2-year period (2009-2010) at a major metropolitan hospital. Cases were identified by an electronic search of all discharges with International Classification of Diseases-10 codes for colitis, colectomy, ulcerative colitis or Crohn disease.

RESULTS

Twenty-six patients had 30 ASC admissions (14 female). Most admissions were under gastroenterology (25), 4 (13%) were under general medicine and 1 was under general surgery. Only 8 patients' (26%) management (all under gastroenterology) included all major details: blood investigations, Clostridium difficile test, abdominal X-ray, colonic examination and venous thromboembolism prophylaxis. Only one patient had formal severity scoring on admission, and seven patients (24%) had descriptive severity recorded. On day 3, nine patients (30%) had some recorded severity assessment; however, no formal criteria were used. Four had colectomy, three during first admission and one on re-admission. Of these patients, three received cyclosporine prior to colectomy. The mean duration of admission was 10 days (standard deviation 10.54, range 1-61).

CONCLUSION

Opportunities to optimise care exist including formal severity assessments on days 1 and 3, better deep vein thrombosis/pulmonary embolism prophylaxis and prompt colonic examination. Admission under teams other than gastroenterology appeared to be a barrier to better care. Despite the low rate of ideal management, the colectomy rate was acceptably low at 20%.

Thiopurine metabolite measurement leads to changes in management of inflammatory bowel disease

BACKGROUND

The thiopurines azathioprine and 6-mercaptopurine are recommended for maintenance of remission in inflammatory bowel disease (IBD). Measurement of concentrations of the metabolites 6-thioguanine nucleotide and 6-methylmercaptopurine helps delineate interindividual variation in metabolism that may underlie variability in efficacy and toxicity.

AIMS

We aimed to perform a retrospective observational study to determine the utility of thiopurine metabolite testing following its introduction into South Australia.

METHODS

All patients having thiopurine metabolite tests done at Flinders Medical Centre between November 2008 and January 2010 were identified. Case notes of patients with testing done in the context of treatment for IBD were interrogated to determine the reason for testing, clinical context and outcome.

RESULTS

One hundred and fifty-one patients were identified with thiopurine metabolite testing for IBD with 157 testing episodes. Eighty (51.0%) had testing done for flare or inefficacy, 18 (11.5%) for adverse effects, 5 (3.2%) for a combination of inefficacy and adverse effects, and 54 (34.4%) for routine or other reasons. Testing was followed by improved outcomes of increased efficacy, reduced toxicity or change to alternative therapy in 55.0% of the inefficacy/flare group, 27.8% of the suspected adverse reaction group, 60.0% of the combination group, and 13.0% of the routine/other group. Allopurinol was used as cotherapy in 16 patients and led to marked improvements in metabolite concentrations.

CONCLUSIONS

Thiopurine metabolite testing has quickly become established in South Australia. When used for inefficacy or adverse effects, it often leads to improved outcomes. Prospective studies are needed to determine whether routine testing to guide dosing is of benefit.

Systematic review: IBD-associated pyoderma gangrenosum in the biologic era, the response to therapy

BACKGROUND

Pyoderma gangrenosum (PG) in inflammatory bowel disease (IBD) is uncommon and therapeutically challenging. Its treatment remains poorly characterised due to limited individual centre or practitioner experience. No large series are reported since 2003, yet IBD treatment has changed substantially.

AIM

To provide an up-to-date review of the published treatment efficacy of currently available therapies for IBD-related PG in the biologic era.

METHODS

Systematic review of cases published post-2003 since the broad availability of anti-tumour necrosis factor-alpha (TNFα) therapy. Cases which did not have coexistent IBD, were non-English language, of paediatric age or without data on response to therapy were excluded.

RESULTS

Sixty cases were identified; 55% female, 50% UC, 45% CD, 5% IBD-U. At PG diagnosis, 58% had active and only 15% inactive IBD, with 27% with IBD activity unspecified. Predominant sites were lower limb (48%) and peristomally (25%); 42% had multiple lesions. In 12%, trauma preceded PG. In 42%, new PG appeared whilst on IBD-specific therapy, whilst 28% were on no therapy and in 30%, IBD therapy was unspecified. Of patients on no therapy at PG onset (n = 17), 16 healed; seven with first- and eight with second-line therapy. In total, 34/60 patients received infliximab, four received adalimumab, two had both; with 33 (92%) responding to one or the other. There was no correlation of PG duration or size with healing times.

CONCLUSIONS

Pyoderma gangrenosum appears predominantly during active IBD and is seen equally in CD and UC. New PG may be a manifestation of recrudescent IBD or it follow trauma. Anti-TNFα therapy as a first-line agent for PG should be considered, as it appears to be highly effective.

Systematic review: body composition in adults with inflammatory bowel disease

BACKGROUND

There is a paucity of data on body composition in patients with inflammatory bowel disease (IBD). Alterations of fat and muscle may affect bone health, muscle performance, quality of life (QoL) and overall morbidity.

AIMS

To systematically review the literature on body composition in adults with IBD, and to discuss potential contributory factors and associations.

METHODS

A systematic search was performed in July 2012 of OVID SP MEDLINE, OVID EMBASE and National Library of Medicine's PubMed Central Medline (Limitations: English, humans, from 1992). A total of 19 articles comparing body composition in patients with IBD with healthy age- and sex-matched control populations were included in the primary analysis.

RESULTS

A total of 631 patients with Crohn's disease (CD) and 295 with ulcerative colitis (UC), mean age 37.1 (s.d. ± 9.2) years; 485 (52%) female, were reported upon. Data were heterogeneous and methodology varied. Compared with controls, a statistically significant reduction in body mass index (BMI) was reported in 37% of CD and 20% of UC patients; reduced fat-free mass in 28% CD and 13% UC patients, and reduced fat mass in 31% CD and 13% UC patients. There was no consistent association between body composition and disease activity, duration, extent or therapies. BMI did not accurately predict body composition.

CONCLUSIONS

Current data, although heterogeneous, suggest that many patients with IBD are affected by aberrations in fat and lean mass, which may not be detected during routine clinical assessment. The prevalence and impact of altered body composition amongst this population warrant further investigation.

Probiotics in luminal gastroenterology: the current state of play

In recent years, there has been a growing interest in the use of probiotics in various areas of gastrointestinal (GI) health. Probiotics are defined as live microorganisms that provide beneficial health effects on the host when administered in adequate amounts. Various probiotics have been shown to suppress bacterial growth, modulate the immune system and improve intestinal barrier function. However, despite several studies with promising results, most trials are small and many have substantial methodological limitations. However, with better targeting and appropriate randomised controlled trials, this area may soon yield important therapeutic strategies to optimise GI health. Here, we review the current knowledge of probiotics of relevance to luminal GI health.

General practitioners' knowledge of and attitudes to inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic disease requiring long-term management. General practitioners (GPs) are often the first point of contact for initial symptoms and flares. Thus we assessed GPs' attitudes to and knowledge of IBD.

METHODS

A state-wide postal survey of GPs was performed collecting demographic details, practice and attitudes in IBD-specific management and knowledge.

RESULTS

Of 1800 GPs surveyed in South Australia, 409 responded; 58% were male, 80% Australian trained and 73% practised in metropolitan areas. Most GPs (92%) reported seeing zero to five IBD patients per month. Overall, 37% of the GPs reported being generally 'uncomfortable' with IBD management. Specifically, they were only somewhat comfortable in providing/using maintenance therapy, steroid therapy or unspecified therapy for an acute flare. They were uncomfortable with the use of immunomodulators and biologicals (71 and 91% respectively). No GP reported never referring, referring sometimes (12%), often (34%) or always (55%). Most (87%) GPs rated their communication with private specialists positively; while only 32% were satisfied with support from public hospitals. Of concern, most (70%) monitored patients on immunosuppression on a case-by-case basis rather than by protocol. In multivariable analyses, GPs' IBD-specific knowledge did not influence comfort with overall management, nor did knowledge influence GP comfort with any particular therapy.

CONCLUSION

Individual GPs care for few IBD patients and have variable attitudes in their practice. Whether improvement can realistically be achieved given individual GP's paucity of patients is questionable. These data support the provision of better support and specific action plans for IBD patients.

A chronic care model significantly decreases costs and healthcare utilisation in patients with inflammatory bowel disease

INTRODUCTION

Inflammatory bowel disease (IBD) is a chronic condition, yet the model of care is often reactive. We sought to examine whether a formal IBD service (IBDS) reduced inpatient healthcare utilisation or lowered costs for inpatient care.

MATERIAL AND METHODS

With protocols, routine nurse phone follow-up a help-line, more proactive care was delivered, with many symptoms and concerns dealt with prior to routine presentation. Over two five month periods before (2007/8) and after (2009/10) introducing a formal IBDS two discrete cohorts of admitted IBD patients were identified at a single centre. Each patient was assigned five contemporaneously admitted, age and gender matched controls. Inpatient healthcare utilisation was compared between patients and controls and disease-specific factors amongst the two IBD cohorts.

RESULTS

The initial audit captured 102 admitted IBD patients (510 controls, median age 44 years, 57% female); the second audit 95 patients (475 controls, median age 46 years, 45.3% female). In 2009/10, the number of admissions was lower in IBD patients than in controls (mean 1.53+/-1.03 vs. 2.54+/-2.35; p<0.0001). This contrasts with the first audit, where IBD patients had more admissions than controls. Following IBDS introduction, the mean total cost of inpatient care was lower for IBD patients than controls (US$12,857.48 (US$15,236.79) vs. US$ 30,467.78 (US$ 53,760.20), p=0.005). In addition, patients known to a specialist gastroenterologist (GE) and the IBD Service tended to have the lowest mean number of admissions (GE and IBDS 1.14 (+/-0.36) vs. no GE/IBDS 1.64 (+/-1.25)).

CONCLUSIONS

Healthcare utilisation and disease burden in IBD decreased significantly since introducing an IBDS. These data suggest that proactive management improved outcomes. Contact with a gastroenterologist and IBDS seemed to give best results.

A 13-nation population survey of upper gastrointestinal symptoms: prevalence of symptoms and socioeconomic factors

BACKGROUND

Previous data collected in separate studies using various different survey instruments have suggested some variability in the prevalence of symptoms between nations. However, there is a lack of studies which assess and compare the prevalence of upper gastrointestinal symptoms contemporaneously in various countries using a uniform, standardised method.

AIM

To determine the prevalence of upper gastrointestinal (UGI) symptoms in 13 European countries, and the association between socioeconomic factors and symptoms using a standardised method.

METHODS

A representative age- and gender-stratified sample of 23,163 subjects (aged 18-69 years) was surveyed.

RESULTS

The prevalence of UGI symptoms was 38%. UGI symptoms were most prevalent in Hungary [45%, 95% confidence interval (CI): 42.2-48.4] and lowest in the Netherlands (24%, 95% CI: 21.0-26.2). UGI symptoms were more prevalent in women (39%, 95% CI: 38.4-39.6) vs. men (37%, 95% CI: 36.4-37.6). Heartburn (24%, 95% CI: 23.4-24.6) and acidic reflux (14%, 95% CI: 13.6-14.4) were most common. With age, the prevalence of UGI symptoms decreased (e.g. 18-29 years: 43%, 95% CI: 41.4-44.3 vs. 50-69 years: 33%, 95% CI: 32.3-34.4); in contrast, the frequency of symptom episodes/year increased with age (e.g. 18-29 years: 11.3 episodes per years, 95% CI: 10.5-12.1 vs. 50-69 years: 21.8, 95% CI: 20.7-22.9). Socioeconomic status as measured by gross domestic product was inversely associated with symptoms and in total, socioeconomic factors, gender, body mass index, smoking habits and alcohol consumption explained 83% of the variance of UGI symptoms.

CONCLUSIONS

There are marked differences in the country specific prevalence of upper gastrointestinal complaints. Socioeconomic factors are closely associated with the prevalence of upper gastrointestinal symptoms.

Potentially avoidable surgery in inflammatory bowel disease: what proportion of patients come to resection without optimal preoperative therapy? A guidelines-based audit

BACKGROUND

Recently, promulgated inflammatory bowel disease (IBD) guidelines seek to decrease the need for surgery by improving disease control. However, resection rates remain static.

AIMS

We therefore sought to determine the proportion of patients coming to surgery where preoperative management was not optimal according to guidelines.

METHODS

Case notes of all patients with resection surgery for IBD from January 2007 to March 2008 at a metropolitan teaching hospital were retrospectively reviewed. Judgement was made as to whether preoperative management was optimal or suboptimal depending on whether it met guidelines.

RESULTS

A total of 22 subjects with IBD-related resections were identified (15 males and seven females). In total, 17 had Crohn's disease (CD) (11 males) and five ulcerative colitis (UC) (four males). There were 10 smokers (nine CD and one UC). The two most common indications for surgery were inflammatory mass/abscess (n= 8) and refractory to medical therapy (n= 7). While all patients with known IBD (20/22) had seen a gastroenterologist in the past, five known IBD patients had resections undertaken without preoperative gastroenterologist input. Overall preoperative management was judged as optimal in only (9/22) 41%. Of those whose therapy did not meet guidelines (n= 13), five had azathioprine at doses <2 mg/kg, one declined therapy and nine with CD were current smokers.

CONCLUSIONS

Over 50% of IBD resection patients had suboptimal preoperative management, with sub-therapeutic thiopurine dosing and smoking in CD the main problems. Thus, there are significant gains to be made with better use of standard therapies, as it appears that ∼50% of resection surgery was 'potentially avoidable'.

Concentrations of ceftibuten in plasma and the respiratory tract following a single 400 mg oral dose

Concentrations of ceftibuten in bronchial mucosa, epithelial lining fluid (ELF) and alveolar macrophages were determined from samples taken from 15 subjects at bronchoscopy following a single 400 mg oral dose. Concentrations at all sites were determined using a microbiological assay method which was unaffected by the trans-isomer of ceftibuten. The time from dosage to bronchoscopy ranged from 1.4 to 20.3 h and the subjects were analysed in three groups according to time after dosing. Group A had a mean time since dosing of 1.9 h with mean serum, mucosal and ELF concentrations of 15.2 mg/l, 5.7 mg/kg and 1.6 mg/l. Group B had a mean time of 6.5 h after dosing with mean serum, mucosal and ELF concentration of 14.0 mg/l, 3.2 mg/kg and 1.6 mg/l. Group C had a mean time of 13.3 h with mean serum, mucosal and ELF levels of 4.1 mg/l, 1.8 mg/kg and 1.2 mg/l. Macrophage-related ceftibuten could only be detected in two subjects. These levels are related to the minimum inhibitory concentrations of ceftibuten against common respiratory pathogens with the exception of Strep. pneumoniae.

Pregnancy and IBD treatment: this challenging interplay from a patients' perspective

INTRODUCTION

Current data suggest that exacerbations of Inflammatory Bowel Disease (IBD) during pregnancy worsen perinatal outcomes. However, patients' perceptions regarding the interaction between pregnancy and IBD management are unexplored.

AIMS

To (1) obtain pregnancy outcome data from local female IBD patients, and (2) to gain insight into patients' understanding of the interaction between IBD and pregnancy, and how this affects medication-taking behaviour.

METHODS

Female IBD subjects aged 18-50 years were surveyed by questionnaire. This large retrospective study sought patient who reported pregnancy outcomes and examined the relationship between major adverse outcomes, IBD activity and treatment. Subjective data regarding patients' perceptions about IBD management and pregnancy were sought.

RESULTS

219 females were surveyed, 143 completing a questionnaire (68.1%). 342 pregnancies occurred, 298 of which outcome data were available. Overall IBD women reported adverse pregnancy outcome rates comparable to the local population. Major adverse outcomes were more frequent in the subgroup with severe disease during pregnancy (5/14 (35.7%)) than those with inactive disease (14/284 (4.9%)), (OR 6.8 (95% CI 1.7-26.3), p=0.006). Adjusting for disease severity, neither corticosteroid, azathioprine nor 5ASA affected pregnancy outcome. Most female patients (84%) reported (unwarranted) concerns about the effect of IBD medications on pregnancy, free text responses indicating that this was of greater concern than any effect of IBD exacerbation.

CONCLUSIONS

Unwarranted fear of adverse medication effect on pregnancy is highly prevalent in women with IBD, yet awareness of the harmful effect of IBD exacerbation during pregnancy is poor. This information gap between patients and their gastroenterologists warrants attention.

The pharmacokinetics and tissue penetration of ceftazidime and cefamandole in healthy volunteers

Eight healthy male volunteers received either 1 g of ceftazidime or cefamandole as an intravenous bolus injection. Serial blood samples were taken over the following 8 h. Urine samples were collected over 24 h. Tissue fluid levels of the antibiotics were studied using a cantharides blister technique. Both drugs achieved high serum levels after intravenous injection (ceftazidime 83.3 mg/l, cefamandole 77.7 mg/l at 0.25 h). The serum half-lives were ceftazidime 1.8 h (S.D. 0.22), cefamandole 0.8 h (S.D. 0.07). The mean apparent volume of distribution of ceftazidime was greater than cefamandole (13.6 l compared with 9.8 l, respectively). The total clearance of ceftazidime was 111 ml/min (S.D. 16.6) compared to 216 ml/min (S.D. 30.1) for cefamandole. The maximum concentration of each drug in blister fluid was greater after ceftazidime (44.7 mg/l) than cefamandole (20.2 mg/l). The terminal half-life of ceftazidime in blister fluid (2.1 h) was similar to that in serum but the blister fluid halflife of cefamandole (1.22 h) was slightly prolonged compared with that in serum. suggested that ceftazidime attains levels in this tissue fluid model after a 1 g intravenous dose which might be sufficient to treat infections caused by Staphylococcus aureus, Pseudomonas aeruginosa as well as the common Gram-negatives.

Un-promoted issues in inflammatory bowel disease: opportunities to optimize care

Inflammatory bowel diseases (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC), are chronic inflammatory disorders of the gut, which lead to significant morbidity and impaired quality of life (QoL) in sufferers, without generally affecting mortality. Despite CD and UC being chronic, life-long illnesses, most medical management is directed at acute flares of disease. Moreover, with more intensive medical therapy and the development of biological therapy, there is a risk that management will become even more narrowly focused on acute care, and be directed only at those with more severe disease, rather than encompassing all sufferers and addressing important non-acute issues. This imbalance of concentration of medical attention on 'high-end' care is in part driven by the need to perform and publish randomized clinical trials of newer therapies to obtain registration and licensing for these agents, which thus occupy a large proportion of the recent IBD treatment literature. This leads to less attention on relatively 'low-technology' issues including: (i) the psychosocial burden of chronic disease, QoL and specific psychological comorbidities; (ii) comorbidity with functional gastrointestinal disorders (FGIDs); (iii) maintenance therapy, monitoring and compliance; (iv) smoking (with regard to CD); (v) sexuality, fertility, family planning and pregnancy; and (vi) iron deficiency and anaemia. We propose these to be the 'Un-promoted Issues' in IBD and review the importance and treatment of each of these in the current management of IBD.

Un-promoted issues in inflammatory bowel disease: opportunities to optimize care

Inflammatory bowel diseases (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC), are chronic inflammatory disorders of the gut, which lead to significant morbidity and impaired quality of life (QoL) in sufferers, without generally affecting mortality. Despite CD and UC being chronic, life-long illnesses, most medical management is directed at acute flares of disease. Moreover, with more intensive medical therapy and the development of biological therapy, there is a risk that management will become even more narrowly focused on acute care, and be directed only at those with more severe disease, rather than encompassing all sufferers and addressing important non-acute issues. This imbalance of concentration of medical attention on 'high-end' care is in part driven by the need to perform and publish randomized clinical trials of newer therapies to obtain registration and licensing for these agents, which thus occupy a large proportion of the recent IBD treatment literature. This leads to less attention on relatively 'low-technology' issues including: (i) the psychosocial burden of chronic disease, QoL and specific psychological comorbidities; (ii) comorbidity with functional gastrointestinal disorders (FGIDs); (iii) maintenance therapy, monitoring and compliance; (iv) smoking (with regard to CD); (v) sexuality, fertility, family planning and pregnancy; and (vi) iron deficiency and anaemia. We propose these to be the 'Un-promoted Issues' in IBD and review the importance and treatment of each of these in the current management of IBD.

Systematic review: does concurrent therapy with 5-ASA and immunomodulators in inflammatory bowel disease improve outcomes?

BACKGROUND

With greater use of immunomodulators in inflammatory bowel disease (IBD), it is uncertain whether concurrent therapy with both 5-aminosalicylic acid [5-ASA, mesalazine (mesalamine)] and an immunomodulator is necessary.

AIM

To determine whether concurrent therapy with both 5-ASA and immunomodulator(s) improves outcomes in IBD.

METHODS

Systematic review with search terms 'azathioprine, 6-mercaptopurine, thiopurine(s), 5 aminosalicylic acid, mesalazine, inflammatory bowel disease, ulcerative colitis, Crohn's disease, immunosuppressant(s), immunomodulator and methotrexate' in November 2007 to identify clinical trials on concurrent 5-ASA and immunomodulator therapy.

RESULTS

Two small controlled studies were found. Neither showed a benefit on disease control beyond immunomodulator monotherapy. Potential pharmacological interactions exist between 5-ASA and thiopurines. Whilst circumstantial, epidemiological and laboratory evidence suggests that 5-ASA may assist colorectal cancer (CRC) chemoprevention, it may simply be via anti-inflammatory effects. With changes in practice, ethical issues and the long lead-time needed to demonstrate or disprove an effect, no clinical studies can/will directly answer this. The costs of avoiding one CRC in IBD may be as low as 153 times the annual cost of 5-ASA therapy.

CONCLUSIONS

It is unclear whether concurrent 5-ASA and immunomodulator therapy improves outcomes of disease control, drug toxicity or compliance. Concurrent therapy of 5-ASA and immunomodulators may decrease CRC risk at 'acceptable' cost.