Significant Differences in IBD Care and Education across Europe: Results of the Pan-European VIPER Survey.

BACKGROUND: Inflammatory bowel disease (IBD) care and education might differ around Europe. Therefore, we conducted this European Variation In IBD PracticE suRvey (VIPER) to investigate potential differences between countries. METHODS: This trainee-initiated survey, run through SurveyMonkey®, consisted of 47 questions inquiring basic demographics, IBD training, and clinical care. Results were compared according to gross domestic product (GDP) per capita, for which countries were divided into 2 groups (low/high income, according to the World Bank). RESULTS: The online survey was completed by 1,285 participants from 40 European countries, with a majority of specialists (65.3%) working in academic institutions (50.4%). Significant differences in IBD-specific training (55.9% vs. 38.4%), as well as availability of IBD units (58.4% vs. 39.7%) and multidisciplinary meetings (73.2% vs. 40.1%), were observed between respondees from high and low GDP countries (p < 0.0001). In high GDP countries, IBD nurses are more common (85.9% vs. 36.0%), also mirrored by more nurse-led IBD clinics (40.6% vs. 13.7%; p < 0.0001). IBD dieticians (33.4% vs. 16.5%) and psychologists (16.8% vs. 7.5%) are mainly present in high GDP countries (p < 0.0001). In the current COVID era, telemedicine is available in 73.2% versus 54.1% of the high/low GDP countries, respectively (p < 0.0001). Treat-to-target approaches are implemented everywhere (85.0%), though access to biologicals and small molecules differs significantly. CONCLUSION: Much variability in IBD practice exists across Europe, with marked differences between high and low GDP countries. Further work is required to help address some of these inequalities, aiming to improve and standardize IBD care and training across Europe.

Vitamin D and Ulcerative Colitis: Is There a Relationship with Disease Extent?

INTRODUCTION: Patients with ulcerative colitis (UC) can suffer from low serum vitamin D that can result in complications such as low bone mineral density. It can also reflect underlying disease severity. METHODS: One hundred and ninety-seven patients previously diagnosed with UC from 2 European centers were prospectively recruited through the out-patient clinics. Clinical features (Montreal Classification, age, gender, previous and current medications, surgery), disease activity (Simple Clinical Colitis Activity Index [SCCAI]), blood investigations including serum inflammatory markers, and serum vitamin D were analyzed. The vitamin D levels were compared to a group of age- and gender-matched healthy controls. RESULTS: Mean vitamin D levels were lower in patients with UC (54.6 nmol/L) than in controls (80.7 nmol/L; p = 0.0001). Mean vitamin D levels was lowest in patients with extensive UC (E3; p = 0.0001). Serum vitamin D was not significantly different across treatment groups (p = 0.876). There was no statistical difference in vitamin D levels across patients receiving calcium and vitamin D supplements (p = 0.35) and there was no statistical correlation with SCCAI (p = 0.22). CONCLUSIONS: This study confirms the existence of low serum vitamin D in patients with UC when compared to healthy controls. It also provides evidence of an existing relationship between disease extent and serum vitamin D.

Microbial Dynamics in Newly Diagnosed and Treatment Naïve IBD Patients in the Mediterranean.

BACKGROUND: Microbial communities have long been suspected to influence inflammatory processes in the gastrointestinal tract of patients with inflammatory bowel disease. However, these effects are often influenced by treatments and can rarely be analyzed in treatment-naïve onset cases. Specifically, microbial differences between IBD pathologies in new onset cases have rarely been investigated and can provide novel insight into the dynamics of the microbiota in Crohn's disease (CD) and ulcerative colitis (UC). METHODS: Fifty-six treatment-naïve IBD onset patients (67.3% CD, 32.7% UC) and 97 healthy controls were recruited from the Maltese population. Stool samples were collected after diagnosis but before administration of anti-inflammatory treatments. Fecal microbial communities were assessed via 16S rRNA gene sequencing and subjected to ecological analyses to determine disease-specific differences between pathologies and disease subtypes or to predict future treatment options. RESULTS: We identified significant differences in community composition, variability, and diversity between healthy and diseased individuals-but only small to no differences between the newly diagnosed, treatment-naïve UC and CD cohorts. Network analyses revealed massive turnover of bacterial interactions between healthy and diseased communities, as well as between CD and UC communities, as signs of disease-specific changes of community dynamics. Furthermore, we identified taxa and community characteristics serving as predictors for prospective treatments. CONCLUSION: Untreated and newly diagnosed IBD shows clear differences from healthy microbial communities and an elevated level of disturbance, but only the network perspective revealed differences between pathologies. Furthermore, future IBD treatment is to some extent predictable by microbial community characteristics.

Treatment-naïve IBD onset patients from Malta show clear differences from healthy microbial communities and an elevated level of community disturbance, although differences between pathologies are only revealed by a network perspective. Furthermore, future IBD treatment is predictable by microbial community characteristics.

An Updated Comparative Study on the Impact of COVID-19 Infection and Vaccination in Patients with Inflammatory Bowel Disease and Irritable Bowel Syndrome.

BACKGROUND AND AIMS: This study assessed the differences in swabbing rates, vaccine uptake, COVID-19 infection, hospitalization rates and outcomes in patients suffering from inflammatory bowel disease (IBD) on immunomodulation and patients diagnosed with irritable bowel syndrome (IBS). METHODS: A population consisting of 250 IBD and 250 IBS patients was randomly selected from the local database. Apart from demographic data, the following data was collected: number of COVID-19 swabs taken, vaccination rates, type of vaccine administered, infection secondary to COVID-19, hospitalization and outcomes. RESULTS: IBD patients performed significantly more swabs tests for SARS-CoV-2 detection compared with IBS patients in both phases of the study. Whilst the IBS cohort recorded a larger number of COVID-19 infection and less hospitalisations whilst infected, IBD patients had a better outcome whilst infected since hospitalisation reason in the latter was not related to COVID-19 infection. IBD patients had a larger uptake of COVID-19 vaccines. CONCLUSIONS: This study was the first of its nature locally and internationally as it compared two unrelated cohorts of patients followed up in gastroenterology. Vaccination rates in both cohorts were higher than those reported internationally. In concordance with international studies, IBD patients are not at an increased risk of worse outcomes from COVID-19 infection compared to non-IBD cohorts.

Dysbiosis in the Gut Microbiota in Patients with Inflammatory Bowel Disease during Remission.

Inflammatory bowel disease (IBD) is a chronic, relapsing, inflammatory disorder which comprises two main conditions: Crohn's disease (CD) and ulcerative colitis (UC). Although the etiology of IBD has not been fully elucidated, the gut microbiota is hypothesized to play a vital role in its development. The aim of this cross-sectional study was to characterize the fecal microbiota in CD or UC patients in a state of remission to reveal potential factors sustaining residual levels of inflammation and triggering disease relapses. Ninety-eight IBD patients in a state of clinical remission (66 UC, 32 CD) and 97 controls were recruited, and stool samples, as well as detailed patient data, were collected. After DNA extraction, the variable regions V1 and V2 of the 16S rRNA gene were amplified and sequenced. Patients with IBD had a decrease in alpha diversity compared to that of healthy controls, and the beta diversity indices showed dissimilarity between the cohorts. Healthy controls were associated with the beneficial organisms unclassified Akkermansia species (Akkermansia uncl.), Oscillibacter uncl., and Coprococcus uncl., while flavonoid-degrading bacteria were associated with IBD. Network analysis identified highly central and influential disease markers and a strongly correlated network module of Enterobacteriaceae which was associated with IBD and could act as drivers for residual inflammatory processes sustaining and triggering IBD, even in a state of low disease activity. The microbiota in IBD patients is significantly different from that of healthy controls, even in a state of remission, which implicates the microbiota as an important driver of chronicity in IBD. IMPORTANCE Dysbiosis in inflammatory bowel disease (IBD) has been implicated as a causal or contributory factor to the pathogenesis of the disease. This study, done on patients in remission while accounting for various confounding factors, shows significant community differences and altered community dynamics, even after acute inflammation has subsided. A cluster of Enterobacteriaceae was linked with Crohn's disease, suggesting that this cluster, which contains members known to disrupt colonization resistance and form biofilms, persists during quiescence and can lead to chronic inflammation. Flavonoid-degrading bacteria were also associated with IBD, raising the possibility that modification of dietary flavonoids might induce and maintain remission in IBD.

Implementation and Short-term Adverse Events of Anti-SARS-CoV-2 Vaccines in Inflammatory Bowel Disease Patients: An International Web-based Survey.

INTRODUCTION: Anti-SARS-CoV-2 vaccine clinical trials did not include patients with immune-mediated conditions such as inflammatory bowel disease [IBD]. We aimed to describe the implementation of anti-SARS-CoV-2 vaccination among IBD patients, patients' concerns, and the side effect profile of the anti-SARS-CoV-2 vaccines, using real-world data. METHODS: An anonymous web-based self-completed survey was distributed in 36 European countries between June and July 2021. The results of the patient characteristics, concerns, vaccination status, and side effect profile were analysed. RESULTS: In all 3272 IBD patients completed the survey, 79.6% had received at least one dose of anti-SARS-CoV-2 vaccine, and 71.7% had completed the vaccination process. Patients over 60 years old had a significantly higher rate of vaccination [p < 0.001]. Patients' main concerns before vaccination were the possibility of having worse vaccine-related adverse events due to their IBD [24.6%], an IBD flare after vaccination [21.1%], and reduced vaccine efficacy due to IBD or associated immunosuppression [17.6%]. After the first dose of the vaccine, 72.4% had local symptoms and 51.4% had systemic symptoms [five patients had non-specified thrombosis]. Adverse events were less frequent after the second dose of the vaccine and in older patients. Only a minority of the patients were hospitalised [0.3%], needed a consultation [3.6%], or had to change IBD therapy [13.4%] after anti-SARS-CoV-2 vaccination. CONCLUSIONS: Although IBD patients raised concerns about the safety and efficacy of anti-SARS-CoV-2 vaccines, the implementation of vaccination in those responding to our survey was high and the adverse events were comparable to the general population, with minimal impact on their IBD.

The Impact of the SARS-CoV-2 (COVID-19) Pandemic on Gastroenterology Training.

INTRODUCTION: The SARS-CoV-2 (COVID-19) pandemic has brought about a radical change in our working patterns. These changes can affect the training that gastroenterology trainees undergo, especially endoscopy since these are aerosol-generating procedures. The aim of this survey was to assess the effect of the COVID-19 pandemic on gastroenterology training across the European countries. METHODOLOGY: A questionnaire was set up whereby the different elements of training were analysed. The questionnaire (online) was distributed among trainees through the National Representatives of the European Board of Gastroenterology and Hepatology. RESULTS: In total, 86 trainees (females: 55%; mean age: 32.5 years [SD ±4.57 years]; mean training duration of 2.68 years [SD ±1.63]) from 22 different countries were recruited. From the cohort, 10.5% were considered as vulnerable for acquiring COVID-19. During their job, 4.7% acquired the infection and 26.7% were placed in quarantine. Most trainees noted that their various aspects of gastroenterology training were moderately or severely affected during the initial height of the pandemic: clinical gastroenterology training (67.4%), outpatients (75.5%), didactic teaching (88.3%), multidisciplinary team meetings (65.2%) and endoscopy training (75.6%). Later, when the number of COVID-19-related infections decreased across Europe, the above modalities returned to normal for <50% of the trainees. CONCLUSION: This European-wide survey has demonstrated that gastroenterology training has been severely impacted during both the initial height of the pandemic and afterwards. Furthermore, the psychological impact on trainees, in terms of training quality, duration and exposure to COVID-19, is unknown. A re-assessment of each centre training programme should be done as to ensure that a high standard of training is still being delivered.

INTRODUÇÃO: A pandemia SARS-CoV-2 (COVID-19) trouxe uma mudança radical nas nossas rotinas de trabalho. Estas mudanças afetaram a formação dos internos de gastroenterologia, em particular nas técnicas endoscópicas, uma vez que se tratam de procedimentos geradores de aerossóis. O objetivo desta pesquisa foi avaliar o efeito da pandemia COVID-19 na formação gastrenterológica em todos os países europeus. METODOLOGIA: Foi elaborado um questionário onde foram analisados dos diferentes componentes da formação. O questionário (online) foi distribuído entre os internos de gastrenterologia através dos Representantes Nacionais do European Board de Gastroenterologia e Hepatologia. RESULTADOS: No total, obtivemos respostas de 86 internos (mulheres: 55%; idade média: 32,5 anos (DP ±4,57 anos); duração média de internato complementar de 2,68 anos (DP ±1,63), provenientes de 22 países, dos quais 10,5% foram considerados de risco para adquirir COVID-19. Durante a sua prática clínica, 4,7% contraíram a infeção e 26,7% foram colocados em quarentena. A maioria dos internos respondeu que vários aspetos da sua formação gastrenterológica foram moderada ou gravemente afetados durante a altura inicial da pandemia: formação gastrenterológica clínica (67,4%), consulta externa (75,5%), formação teórica (88,3%), reuniões multidisciplinares (65,2%) e ensino em endoscopia (75,6%). Mais tarde, quando o número de infeções relacionadas com COVID-19 diminuiu em toda a Europa, as atividades acima descritas voltaram à normalidade para menos de 50% dos internos. CONCLUSÃO: Esta pesquisa em toda a Europa demonstrou que a formação dos internos em gastrenterologia foi gravemente afetada durante a fase inicial da pandemia e nos meses seguintes. Além disso, o impacto psicológico nos internos, em termos de qualidade de treino, duração e exposição ao COVID-19, é desconhecido. Deve ser realizada uma reavaliação dos programas de formação de cada centro a fim de garantir a manutenção de um elevado padrão de ensino.

Identification of antibiotic resistance patterns in Helicobacter pylori strains isolated from gastric biopsies using real-time PCR and genotypic analysis.

BACKGROUND: Helicobacter pylori (H. pylori) is associated with dyspepsia, mucus-associated lymphoid tissue lymphoma, gastritis, and peptic ulcer disease. Treatment in Malta consists of triple therapy, which consists of a proton pump inhibitor and 2 of the antibiotics amoxicillin, clarithromycin, metronidazole and fluoroquinolones. We aimed to determine the resistance rates for clarithromycin and fluoroquinolones in patients with H. pylori, and its incidence, in patients undergoing an esophagogastroduodenoscopy (EGD) using real-time polymerase chain reaction (RT-PCR). METHODS: Patients undergoing an EGD were recruited. A rapid urease test (RUT) was performed, and 4 gastric biopsies were also taken (2 from antrum, 2 from corpus) and analyzed using RT-PCR. Positive samples were tested for antibiotic resistance using amplification and reverse hybridization techniques. RESULTS: Two hundred patients (mean age 53.6 [range 20-92] years; 53.1% female) were recruited; the majority were (78%) non-smokers. H. pylori was identified in 21.0% of the patients. Fluoroquinolone resistance was detected in 21.4% of the patients. Clarithromycin resistance was observed in 26.2%, with dual resistance identified in 4.8% of the patients. A high concordance was present with patients testing negative for H. pylori with both RUT and RT-PCR (94.3%). Only 57.6% of patients tested positive with both tests. However, 92.9% of RT-PCR positive patients had a positive genotype HelicoDR test. CONCLUSIONS: This data demonstrates a high rate of H. pylori resistance to both clarithromycin and fluoroquinolones. These should be avoided when treating H. pylori by utilizing different treatment regimes. Furthermore, we derived important data on the role of RT-PCR, which may be implemented in routine clinical practice.

Medical and surgical management of perianal Crohn's disease.

Crohn's disease is increasingly thought to encompass multiple possible phenotypes. Perianal manifestations account for one such phenotype and represent an independent disease modifier. In its more severe form, perianal Crohn's disease confers a higher risk of a severe and disabling disease course, relapses, hospital admissions and operations. This, in turn, imposes a considerable burden and disability on patients. Identification of the precise manifestation is important, as management is nuanced, with both medical and surgical components, and is best undertaken in a multidisciplinary setting for both diagnosis and ongoing treatment. The introduction of biologic medication has heralded a significant addition to the management of fistulizing perianal Crohn's disease in particular, albeit with modest results. It remains a very challenging condition to treat and further work is required to optimize management in this group of patients.