The immunoregulatory potential of eosinophil subsets.

Eosinophils have traditionally been viewed as pathological effector cells primarily involved in antiparasitic and allergic immune reactions; however, it is becoming increasingly apparent that eosinophils are multifaceted leukocytes that contribute to a variety of roles in both health and disease. Recent research shows that eosinophils play important immunoregulatory roles across various tissue sites including the gastrointestinal tract, adipose tissue, lung, liver, heart, muscles, thymus and bone marrow. With recent advances in our knowledge and appreciation of eosinophil immunoregulatory functions at these tissue sites, as well as emerging research demonstrating the existence of distinct subsets of eosinophils, a review of this topic is timely. Although some questions remain regarding eosinophil function and heterogeneity, this review summarizes the contemporary understanding of the immunoregulatory roles of eosinophils across various tissues and discusses the latest research on eosinophil heterogeneity and subsets.

Helminth infection induces a distinct subset of CD101hi lung tissue-infiltrating eosinophils that are differentially regulated by type 2 cytokines.

Eosinophils play divergent roles in health and disease, contributing to both immunoregulatory and proinflammatory responses. Helminth infection is strongly associated with eosinophilia and the induction of the type 2 cytokines interleukin (IL)-5, IL-4 and IL-13. This study aimed to elucidate the heterogeneity of pulmonary eosinophils in response to helminth infection and the roles of IL-5, IL-4 and IL-13 in driving pulmonary eosinophil responses. Using the murine helminth model Nippostrongylus brasiliensis (Nb), we characterize a subtype of eosinophils, defined by high expression of CD101, that is induced in the lungs of Nb-infected mice and are phenotypically distinct from lung eosinophils that express low levels of CD101. Strikingly, we show that the two eosinophil subtypes have distinct anatomical localization within the lung: CD101low eosinophils are predominantly localized in the lung vasculature, whereas Nb-induced CD101hi eosinophils are predominantly localized in the extravascular lung niche. We show that CD101hi eosinophils are also induced across other models of pulmonary infection and inflammation, including a nonlung-migrating helminth infection, house dust mite-induced allergic inflammation and influenza infection. Furthermore, we demonstrate that the induction of CD101hi tissue eosinophils is independent of IL-5 and IL-4 signaling, but is dependent on intact IL-13 signaling. These results suggest that IL-13 produced during helminth infection and other disease states promotes a pulmonary tissue-infiltrating program in eosinophils defined by high expression of CD101.

Modulation of intestinal epithelial permeability by chronic small intestinal helminth infections.

Increased permeability of the intestinal epithelial layer is linked to the pathogenesis and perpetuation of a wide range of intestinal and extra-intestinal diseases. Infecting humans with controlled doses of helminths, such as human hookworm (termed hookworm therapy), is proposed as a treatment for many of the same diseases. Helminths induce immunoregulatory changes in their host which could decrease epithelial permeability, which is highlighted as a potential mechanism through which helminths treat disease. Despite this, the influence of a chronic helminth infection on epithelial permeability remains unclear. This study uses the chronically infecting intestinal helminth Heligmosomoides polygyrus to reveal alterations in the expression of intestinal tight junction proteins and epithelial permeability during the infection course. In the acute infection phase (1 week postinfection), an increase in intestinal epithelial permeability is observed. Consistent with this finding, jejunal claudin-2 is upregulated and tricellulin is downregulated. By contrast, in the chronic infection phase (6 weeks postinfection), colonic claudin-1 is upregulated and epithelial permeability decreases. Importantly, this study also investigates changes in epithelial permeability in a small human cohort experimentally challenged with the human hookworm, Necator americanus. It demonstrates a trend toward small intestinal permeability increasing in the acute infection phase (8 weeks postinfection), and colonic and whole gut permeability decreasing in the chronic infection phase (24 weeks postinfection), suggesting a conserved epithelial response between humans and mice. In summary, our findings demonstrate dynamic changes in epithelial permeability during a chronic helminth infection and provide another plausible mechanism by which chronic helminth infections could be utilized to treat disease.

Helminths' therapeutic potential to treat intestinal barrier dysfunction.

The intestinal barrier is a dynamic multi-layered structure which can adapt to environmental changes within the intestinal lumen. It has the complex task of allowing nutrient absorption while limiting entry of harmful microbes and microbial antigens present in the intestinal lumen. Excessive entry of microbial antigens via microbial translocation due to 'intestinal barrier dysfunction' is hypothesised to contribute to the increasing incidence of allergic, autoimmune and metabolic diseases, a concept referred to as the 'epithelial barrier theory'. Helminths reside in the intestinal tract are in intimate contact with the mucosal surfaces and induce a range of local immunological changes which affect the layers of the intestinal barrier. Helminths are proposed to prevent, or even treat, many of the diseases implicated in the epithelial barrier theory. This review will focus on the effect of helminths on intestinal barrier function and explore whether this could explain the proposed health benefits delivered by helminths.

Intravenous Iron Replacement Improves Quality of Life in Hypoferritinemic Inflammatory Bowel Disease Patients with and without Anemia.

BACKGROUND: No study has compared changes in quality of life (QoL) following iron therapy between anemic and non-anemic, hypoferritinemic patients. This study compares the impact of parenteral iron replacement on QoL in inflammatory bowel disease (IBD) patients with anemia, or in those with hypoferritinemia alone. METHODS: Consecutive IBD patients diagnosed with anemia or hypoferritinemia were enrolled. IBD questionnaire (IBDQ) and 36-Item Short Form Survey (SF36) at diagnosis and 6 weeks post treatment were measured. RESULTS: Ten patients with anemia and 13 with hypoferritinemia were treated with intravenous iron polymaltose. Across all patients, there was a significant improvement in median SF36 mental component score by 8.5 (p = 0.004) and median IBDQ by 12 (p = 0.02). There was a trend towards improved median SF36 physical component score by 3.2 (p = 0.6). These changes were not significantly different when comparing anemic with hypoferritinemic patients. In IBDQ, there was a trend toward greater improvement in hypoferritinemic vs. anemic patients (20 vs. 1.5, p = 0.31). CONCLUSIONS: This is the first study to show that improvements in QoL in hypoferritinemic patients are similar to those with anemia. Based on these results, patients with IBD should be offered the option of iron therapy when they are found to be hypoferritinemic, even in the absence of anemia.

Quality of Life Factors in Adults with Eosinophilic Oesophagitis in New Zealand.

BACKGROUND: Eosinophilic oesophagitis (EoE) is an immune-mediated oesophageal disorder causing dysphagia. Patients with EoE experience reduced QoL due to symptoms; however, this has not been assessed in the New Zealand population. The aim of this study was to assess QoL in patients with EoE in New Zealand. METHODS: This observational study recruited participants from two New Zealand hospitals. Records were reviewed to confirm diagnoses, and consenting participants completed an electronic survey, consisting of the Dysphagia Symptom Questionnaire (DSQ) score and the QoL-specific EoE (EoE-QoL-A) questionnaire score. Correlation analysis examined the relationship between the DSQ and EoE-QoL-A scores. Differences in baseline variables were assessed. Univariate logistic regression assessed the association of variables with disease activity and QoL. RESULTS: Fifty-four participants responded, and four were excluded due to incomplete surveys. The majority (76%) were male, and the median age was 47 years (IQR 42-58). The median DSQ was 49 (IQR 0-60), and the median EoE-QoL-A score was 68 (IQR 48-80). A reduced EoE-QoL-A score was associated with active disease (OR = 0.96,95% CI 0.926-0.995). Significant associations were found between disease activity and overall EoE-QoL-A score (r = -0.37, p < 0.01) as well as the sub-categories eating and diet (r = -0.54, p < 0.001), social (r = 0.30, p < 0.05), and emotional impact (r = -0.44, p < 0.01). The EOE-QoL-A score was higher in those on PPI (75 vs. 60, p = 0.02). CONCLUSION: This study identified a decreased quality of life (QoL) in individuals with EoE in New Zealand, aligning with international literature. The increased DSQ scores suggest a possible gap in current management approaches. The correlation between the DSQ and QoL highlights the need for improved care models of care for EoE.

Controlled infection with cryopreserved human hookworm induces CTLA-4 expression on Tregs and upregulates tryptophan metabolism.

Infecting humans with controlled doses of helminths, such as human hookworm (termed hookworm therapy), is proposed to prevent or treat various intestinal and extraintestinal diseases. However, full-scale clinical trials examining hookworm therapy are limited by the inability to scale-up the production of hookworm larvae to infect sufficient numbers of patients. With the aim of overcoming this challenge, this study infected four healthy individuals with hookworm larvae that had been reanimated from cryopreserved eggs to examine their viability and immunogenicity. We demonstrate that reanimated cryopreserved hookworm larvae establish a viable hookworm infection and elicit a similar immune response to larvae cultured from fresh stool. Furthermore, a refined understanding of the therapeutic mechanisms of hookworm is imperative to determine which diseases to target with hookworm therapy. To investigate potential therapeutic mechanisms, this study assessed changes in the immune cells, microbiome, and plasma metabolome in the four healthy individuals infected with cryopreserved hookworm larvae and another nine individuals infected with larvae cultured from freshly obtained stool. We identified potential immunoregulatory mechanisms by which hookworm may provide a beneficial effect on its host, including increased expression of CTLA-4 on regulatory T cells (Tregs) and upregulation of tryptophan metabolism. Furthermore, we found that a participant's baseline microbiome predicted the severity of symptoms and intestinal inflammation experienced during a controlled hookworm infection. In summary, our findings demonstrate the feasibility of full-scale clinical trials examining hookworm therapy by minimizing the reliance on human donors and optimizing the culturing process, thereby enabling viable hookworm larvae to be mass-produced and enabling on-demand inoculation of patients. Furthermore, this study provides insights into the complex interactions between helminths and their host, which could inform the development of novel therapeutic strategies.

Comparative Analysis of Body Image Dissatisfaction, Depression, and Health-Related Quality of Life in Adults with Type 1 Diabetes: A Case-Control Study.

(1) Objective: This case-control study investigated body image dissatisfaction, depression, and health-related quality of life (HRQoL) in adults with type 1 diabetes. (2) Methods: A total of 35 adults with diabetes and an equal number of age- and gender-matched controls were included. Assessment tools used were the Body Image Disturbance Questionnaire (BIDQ), the Hospital Anxiety and Depression Scale (HADS), and the RAND 36-Item Health Survey. Both quantitative and qualitative data were analyzed. (3) Results: Body image dissatisfaction did not differ significantly between the groups. However, adults with diabetes reported higher levels of depression (p = 0.002) and lower scores for physical health (p = 0.015) and general health (p < 0.001) on the HRQoL measure. Qualitative analysis identified common themes related to physical disturbance, effect on activities, and psychosocial concerns. (4) Conclusions: Despite similar body image dissatisfaction, adults with type 1 diabetes exhibited increased depression and reduced HRQoL. These findings emphasize the need to integrate psychological well-being into type 1 diabetes management. They also support further research into the impact of body image dissatisfaction in T1D and potential interventions to address it.

Controlled Hookworm Infection for Medication-free Maintenance in Patients with Ulcerative Colitis: A Pilot, Double-blind, Randomized Control Trial.

BACKGROUND: Human hookworm has been proposed as a treatment for ulcerative colitis (UC). This pilot study assessed the feasibility of a full-scale randomized control trial examining hookworm to maintain clinical remission in patients with UC. METHODS: Twenty patients with UC in disease remission (Simple Clinical Colitis Activity Index [SCCAI] ≤4 and fecal calprotectin (fCal) <100 ug/g) and only on 5-aminosalicylate received 30 hookworm larvae or placebo. Participants stopped 5-aminosalicylate after 12 weeks. Participants were monitored for up to 52 weeks and exited the study if they had a UC flare (SCCAI ≥5 and fCal ≥200 µg/g). The primary outcome was difference in rates of clinical remission at week 52. Differences were assessed for quality of life (QoL) and feasibility aspects including recruitment, safety, effectiveness of blinding, and viability of the hookworm infection. RESULTS: At 52 weeks, 4 of 10 (40%) participants in the hookworm group and 5 of 10 (50%) participants in the placebo group had maintained clinical remission (odds ratio, 0.67; 95% CI, 0.11-3.92). Median time to flare in the hookworm group was 231 days (interquartile range [IQR], 98-365) and 259 days for placebo (IQR, 132-365). Blinding was quite successful in the placebo group (Bang's blinding index 0.22; 95% CI, -0.21 to 1) but less successful in the hookworm group (0.70; 95% CI, 0.37-1.0). Almost all participants in the hookworm group had detectable eggs in their faeces (90%; 95% CI, 0.60-0.98), and all participants in this group developed eosinophilia (peak eosinophilia 4.35 × 10^9/L; IQR, 2.80-6.68). Adverse events experienced were generally mild, and there was no significant difference in QoL. CONCLUSIONS: A full-scale randomized control trial examining hookworm therapy as a maintenance treatment in patients with UC appears feasible.

This pilot study has shown a full-scale RCT examining hookworm therapy as maintenance therapy in patients with ulcerative colitis is feasible, safe, and will be well-tolerated.

Ethnicity data audit in a secondary care gastroenterology service.

AIM: To audit the quality of ethnicity data stored under National Health Index (NHI) in the Hutt Hospital database against a fresh collection of self-identified ethnicity to identify the level of (mis)match present between the datasets. METHOD: Self-identified ethnicity data was collected from 200 consecutive patients presenting to outpatient gastroenterology services and compared to National Health Index (NHI) in the Hutt Hospital database, using the process outlined in the Primary Care Ethnicity Data Audit Toolkit. RESULTS: The overall level of match between the individual's self-identified ethnicity and that recorded in the hospital database was 89% (95% CI [83.8-93.0]). Eighteen patients (9%) self-identified as Maori, 16.7% (95% CI [3.6-41.4]) of whom were not recorded as Maori in the hospital database. Three patients were recorded as Maori in the hospital database but did not self-identify as Maori. CONCLUSION: Ethnicity data are fundamental to the monitoring and provision of equitable health and healthcare, with a range of applications in the health sector. Our findings of poor-quality ethnicity data for Maori in a hospital NHI database are consistent with previous studies. The assessment of ethnicity data quality must be done in multiple ways to reflect its multiple uses.

Constipation screening in people taking clozapine: A diagnostic accuracy study.

OBJECTIVE: Clozapine is the favoured antipsychotic for treatment-refractory schizophrenia but its safe use requires careful adverse-effect management. Clozapine-induced gastrointestinal hypomotility (CIGH or 'slow-gut') is one of the most common and serious of clozapine's adverse effects. CIGH can lead to paralytic ileus, bowel obstruction, gastrointestinal ischaemia, toxic megacolon, and death. Enquiring about constipation is a simple and commonly used screening method for CIGH but its diagnostic accuracy has not previously been assessed. METHODS: First, we examined the reliability of asking about constipation compared with asking about Rome constipation criteria in inpatients treated with clozapine (n = 69). Second, we examined the diagnostic accuracy of (1) self-reported constipation and (2) the Rome criteria, compared with the reference standard of gastrointestinal motility studies. RESULTS: After 30 motility tests, it was clear constipation screening had very poor diagnostic properties in this inpatient group and the study was terminated. Although 73% of participants had objective CIGH on motility testing, only 26% of participants self-reported constipation, with sensitivity of 18% (95% CI: 5-40%). Specificity and positive predictive values were higher (95% CI: 63-100% and 40-100%, respectively). Adding in Rome criteria improved sensitivity to 50% (95% CI: 28.2-71.8%), but half the cases were still missed, making this no more accurate than tossing a coin. CONCLUSIONS: CIGH is often silent, with self-reported constipation having low sensitivity in its diagnosis. Treating CIGH based on self-reported symptoms questions will miss most cases. However, universal bowel motility studies are impractical. In the interests of patient safety, prophylactic laxatives are suggested for people taking clozapine.

A Noninferiority Randomized Clinical Trial of the Use of the Smartphone-Based Health Applications IBDsmart and IBDoc in the Care of Inflammatory Bowel Disease Patients.

BACKGROUND: Providing timely follow-up care for patients with inflammatory bowel disease in remission is important but often difficult because of resource limitations. Using smartphones to communicate symptoms and biomarkers is a potential alternative. We aimed to compare outpatient management using 2 smartphone apps (IBDsmart for symptoms and IBDoc for fecal calprotectin monitoring) vs standard face-to-face care. We hypothesized noninferiority of quality of life and symptoms at 12 months plus a reduction in face-to-face appointments in the smartphone app group. METHODS: Inflammatory bowel disease outpatients (previously seen more often than annually) were randomized to smartphone app or standard face-to-face care over 12 months. Quality of life and symptoms were measured quarterly for 12 months. Acceptability was measured for gastroenterologists and patients at 12 months. RESULTS: One hundred people (73 Crohn's disease, 49 male, average age 35 years) consented and completed baseline questionnaires (50 in each group). Intention-to-treat and per-protocol analyses revealed noninferiority of quality of life and symptom scores at 12 months. Outpatient appointment numbers were reduced in smartphone app care (P < 0.001). There was no difference in number of surgical outpatient appointments or number of disease-related hospitalizations between groups. Adherence to IBDsmart (50% perfect adherence) was slightly better than adherence to IBDoc (30% perfect adherence). Good acceptability was reported among most gastroenterologists and patients. CONCLUSIONS: Remote symptom and fecal calprotectin monitoring is effective and acceptable. It also reduces the need for face-to-face outpatient appointments. Patients with mild-to-moderate disease who are not new diagnoses are ideal for this system. CLINICAL TRIAL REGISTRATION NUMBER: ACTRN12615000342516.

New Zealand National Audit of Outpatient Inflammatory Bowel Disease Standards of Care.

AIM: This study audits the delivery and standards of New Zealand (NZ) inflammatory bowel disease (IBD) care against international standards, with emphasis on the IBD nursing role. METHODS: Utilising international standards in IBD care, a 3 phase national multicentre survey study was performed between 2015 and 2019. We 1) evaluated the current role and practices of IBD nurses, 2) evaluated IBD service provision and identified areas for improvement, and 3) audited key aspects of IBD patient care, directly comparing nurse-led and doctor-led outpatient clinics. RESULTS: The median duration spent in an IBD nursing role was 21 months (range 2 to 120 months) with the majority (12/15) performing two or more nursing roles. The median IBD nurse full-time equivalent (FTE) was 0.8 (range 0.2 to 1.25). The average number of hours spent undertaking IBD nursing tasks was 22.2 - a 6.8-hour shortfall compared to rostered hours. No service had a per capita IBD multidisciplinary team (MDT) FTE which met international standards. Just under two-thirds (62.5%) of departments held a regular MDT meeting. All responding services could be contacted directly by IBD patients and respond within 48 hours of contact. During 492 doctor-led and 196 nurse-led scheduled outpatient clinic visits, nurses were significantly more likely to document weight, smoking status and organise appropriate colonoscopic surveillance than doctors. CONCLUSION: Multiple nursing job roles resulted in rostered hours being insufficient to complete IBD specific tasks. IBD FTE did not meet international standards. The IBD care was patient-centred, encouraging direct contact from patients with prompt response. IBD nurses in NZ provide high-quality outpatient care when measured against auditable standards. As the IBD nursing role continues to develop, following the implementation of an educational framework and education programme, an increase in numbers is required in order to achieve the recommended minimum FTE per 250 000 population.

Eosinophilic esophagitis incidence in New Zealand: high but not increasing.

BACKGROUND AND AIM: Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory condition of the esophagus. Recent literature has shown an increasing incidence of the disease. However, no epidemiological data exist regarding New Zealand rates of EoE. The disease is associated with atopy, and New Zealand's high rate of atopic disease means the disease may be important in our population. We carried out a retrospective study to describe the incidence of EoE in the Wellington region of New Zealand, as well as key histological and clinical factors associated with the disease. METHOD: A search was made of laboratory and endoscopic databases in the Wellington region to identify all diagnosed cases in the five years between January 1, 2011, and December 31, 2015. Case notes were examined to determine the key demographic and clinical parameters in the cases. Incidence rates were calculated for each year, and the effects of age group and sex on the incidence rates were analyzed. RESULT: We found 152 cases of EoE in the Wellington region with an annual incidence of 6.95 per 100,000 person/years. We found no evidence of a significant difference in incidence rates by year in our study population. There was a significantly lower incidence rate in those aged <16 compared to those aged ≥16 (RR=0.26). Males had a higher incidence rate than females with an estimated rate ratio of 2.45 (p<0.05). CONCLUSION: Our results are in contrast to previous reports of increasing incidence rates and may reflect a leveling off of incidence. Further research is needed to determine whether the low incidence in our pediatric age group is due to ascertainment bias or due to a real difference in the epidemiology of EoE in NZ compared to other countries.

Effects of Clozapine on the Gut: Cross-Sectional Study of Delayed Gastric Emptying and Small and Large Intestinal Dysmotility.

BACKGROUND: Gastrointestinal hypomotility in people taking clozapine is common, poorly understood and potentially dangerous. It causes distress and sometimes sudden death, with greater associated morbidity than the better known adverse effect of clozapine, agranulocytosis. Neither the mechanism nor prevalence of clozapine-induced gastrointestinal hypomotility is well understood. Previous studies show clozapine impedes colon transit, likely owing to anticholinergic and anti-serotonergic properties. However, regional gastrointestinal transit times (including gastric and small bowel emptying) have not been quantified. METHODS: We used wireless motility capsules to measure gastric emptying and small and large bowel transit times in clozapine-treated individuals. We tested 17 clozapine-treated patients without any known gastrointestinal dysfunction, and compared data with matched normative transit times. RESULTS: Clozapine-treated participants had significant 'slow gut', with dysmotility in at least one region of the gastrointestinal tract evident in 82%, with 59% experiencing multi-regional dysmotility. Delayed gastric emptying was diagnosed in 41%, delayed small bowel transit in 71% and delayed colon transit in 50%. Only 18% of participants had normal studies. Hypomotility was not correlated with ethnicity, sex or duration of treatment. Subjective reporting of constipation had low sensitivity in predicting dysmotility. Delayed gastric emptying had been unrecognised clinically for all participants. CONCLUSION: Clozapine is associated with significant multi-regional gastrointestinal dysfunction. This is relevant when considering the relationship between clozapine use and conditions such as gastroparesis, choking, aspiration pneumonia, constipation, ileus and intestinal pseudo-obstruction. While the constipating properties of clozapine are now well recognised, this study shows a high degree of vigilance is required for both lower and upper gastrointestinal dysmotility in people taking this antipsychotic.

VITALITY: impact of adalimumab on health and disability outcomes in patients with Crohn's disease, rheumatoid arthritis, or psoriasis treated in clinical practice in New Zealand.

Objective: VITALITY, a 6-month, multicenter, prospective, observational study, assessed the effects of originator adalimumab (HUMIRA) on health and disability outcomes in patients with Crohn's disease (CD), rheumatoid arthritis (RA), or psoriasis treated in routine clinical practice in New Zealand (NZ). Methods: Biologic-naïve adults initiating adalimumab in accordance with NZ funding requirements were recruited. The primary endpoint was 6-month change from baseline in World Health Organization Disability Assessment Schedule (WHODAS) 2.0 score in all participants completing the study (full analysis set). Secondary endpoints included 6-month change in other patient-reported outcomes (PROs) of work activity and wellbeing (Work Productivity and Activity Impairment Questionnaire: General Health, Kessler Psychological Distress Scale, Flourishing Scale, and Subject Vitality Scale) and in disease-specific PRO measures. Results: In total, 164 participants with severe disease initiating adalimumab completed the WHODAS 2.0 at baseline, of whom 114 (69.5%) completed the study at 6 months. Mean WHODAS 2.0 score halved from 15.2 points (SD = ±9.1) at baseline to 7.3 points (SD = ±7.2) after 6 months' adalimumab treatment (mean difference = 7.9 points; 95% CI = 6.4-9.4; p < .001), with statistically significant improvements seen as early as 2 months after adalimumab initiation (p < .001). The proportion of participants with a WHODAS 2.0 score ≥ 10 more than halved, from 68.3% to 28.9%, between baseline and 6 months. Other PROs also improved significantly at 6 months, as did disease-specific measures. No new adalimumab safety signals were observed. Conclusions: Health and disability outcomes improved significantly after 6 months of adalimumab use in NZ patients with severe CD, RA, or psoriasis. Clinicaltrials.gov: NCT02451839.

Agreement of triage decisions between gastroenterologists and nurses in a hospital endoscopy unit.

INTRODUCTION: Efficient and accurate triage of endoscopy referrals is essential. Many of the decisions made are based on national and local triage criteria. Standardizing this approach for nurse use could maintain quality, address clinical risk and significantly improve resource utilization. AIMS: This study aimed to compare gastroenterologist and nurse triage of unselected gastroenterology referrals in order to evaluate the proportion of referrals felt able to be triaged to endoscopy and the inter-rater agreement between a triage gastroenterologist and endoscopy nurses for clinical triage decisions regarding the urgency of gastroscopy and colonoscopy. METHODS: The proportion of referrals triaged to endoscopy by a consultant gastroenterologist performing triage as a part of normal practice and two endoscopy nurses using a decision algorithm was measured. The inter-rater agreement for the triage category decision (urgency of referral) between the three triage clinicians was assessed. An adjudication panel provided a consensus decision triage category decision in cases where there was not complete agreement between the three triage clinicians. RESULTS: Each clinician assessed 105 referrals. Nurse A was able to triage 54 (51%) referrals to a triage category and Nurse B 44 (42%) referrals. Cohen's κ was run to determine if there was agreement between clinicians for the triage categories allocated. The agreement between the two nurses was substantial (k=0.645, P<0.0005). Between the gastroenterologist and each nurse, moderate agreement was seen (Nurse A, k=0.589, P<0.0005; Nurse B, k=0.437, P<0.0005). Moderate agreement was seen between the nurses and an adjudication panel (Nurse A, k=0.423, P<0.0005; Nurse B, k=0.464, P<0.0005). However, there was only slight agreement between the adjudication panel and the gastroenterologist (k=0.099, P=0.010). CONCLUSION: Nurse triage using a decision algorithm is feasible, and inter-rater agreement is substantial between nurses and moderate to substantial between the nurses and a gastroenterologist. An adjudication panel demonstrated moderate agreement with the nurses but only slight agreement with the triage gastroenterologist. This suggests that nurse triage using a decision algorithm can approximate decision making by an experienced gastroenterologist.

New Zealand Society of Gastroenterology Guidelines for the Management of Refractory Ulcerative Colitis.

The management of patients with ulcerative colitis who are dependent on corticosteroid for control of symptoms, or refractory to corticosteroids or standard immunosuppressive therapy, is challenging. The development of newer medical therapies has increased the options for managing patients in this situation, but access and funding remain limited. This guideline summarises the literature regarding this situation and provides guidance as to the management of refractory colitis in the New Zealand setting.

Adalimumab for Crohn's disease in New Zealand--a prospective multicentre experience.

AIM: Adalimumab is an effective treatment for Crohn's disease (CD). We aimed to describe the early patterns of use, efficacy and response to adalimumab in four regions of New Zealand. METHODS: Prospectively collected CDAI data were used to examine adalimumab continuation rates in CD patients. Reasons for adalimumab cessation were determined and phenotypic characteristics of those remaining on adalimumab were examined. RESULTS: 194 patients (100 female) from four centres were included. Indications for adalimumab included CDAI>300 (59.8%), extensive small intestinal disease (21.1%), stoma with active disease (4.6%), risk of short gut syndrome (7.7%) and other (6.7%). The mean follow-up was 20 months (252.8 patient years of data). Adalimumab continuation rates at 6, 12, 24 and 30 months were 92.7%, 87.3%, 76.6% and 67.4%, respectively. Patients with penetrating disease behaviour were more likely to continue on adalimumab (p<0.005). There was a significant reduction in mean CDAI from 357 to 110 (p<0.0001) over a 6-month period. The mean (range) number of days spent in hospital per patient in the year prior and after adalimumab initiation were 3.5 (0-38) days and 1.9 (0-67) days, respectively (p<0.0001). CONCLUSIONS: Adalimumab continuation rate in this multicentre CD population was higher than other populations. This may be due to adalimumab being used more commonly as the initial biologic drug in New Zealand.

Survey of UK and New Zealand gastroenterologists' practice regarding dietary advice and food exclusion in irritable bowel syndrome and inflammatory bowel disease.

BACKGROUND: This study aimed to assess the dietary advice practice of UK and New Zealand (NZ) adult gastroenterologists in inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). METHODS: A questionnaire regarding dietary advice practice was emailed or mailed to all members of the British Society of Gastroenterology (n=983) and the NZ Society of Gastroenterology (n=54). RESULTS: 363 questionnaires were returned in the UK (response rate 37%) and 51 in NZ (94%). More respondents gave specific dietary advice to more than 25% of their patients on IBS than IBD (84% vs 27% UK, 90% vs 55% NZ; p=0.001 for both) and gave advice about dietary exclusions to more than 25% of patients on IBS than IBD (61% vs 13% UK, 77% vs 14% NZ; p<0.001 for both). They were most likely to provide dietary advice to patients with small bowel Crohn's disease, difficult to control IBD, diarrhoea predominant IBS and difficult to control IBS. The majority of respondents agreed strongly or a little that dietary exclusion was effective in the treatment of IBS, compared to the minority in IBD (71% vs 39% UK, 84% vs 43% p<0.05 for both). CONCLUSIONS: UK and NZ gastroenterologists give dietary advice more commonly to IBS than IBD patients. The majority of gastroenterologists have some confidence in the use of dietary exclusion in IBS, the converse is true in IBD. However, the advice given is largely empiric and mostly comprises the exclusion of fibre, dairy and wheat.