Biologics, small molecule therapies and surgery in small bowel Crohn's disease.

PURPOSE OF REVIEW: The terminal ileum and small bowel (SB) are involved in 30-45% of patients with Crohn's disease, while 20% have both small and large bowel involvement. Ileal Crohn's is associated with higher risk of progression to stricturing and penetrating disease 1 , hence it's imperative to utilize effective therapies to induce and maintain clinical and endoscopic remission and prevent intestinal complications. We review the available data of biologics and upadacitinib in small bowel disease, and the emerging data on the role of surgery as first line therapy for isolated Crohn's ileitis. RECENT FINDINGS: Most trials assessing drug efficacy do not report efficacy by disease location, and robust data on efficacy of therapies in isolated small bowel Crohn's is sparse. Several studies indicate that small bowel disease is generally less responsive to biologics, and could require higher drug trough levels to achieve endoscopic healing. SUMMARY: Current therapies for induction and maintenance of remission in moderate to severe Crohn's disease include several classes of monoclonal antibodies and a Janus Kinase inhibitor, upadacitinib. While small bowel Crohn's disease is generally less responsive to treatment, anti-TNFs are still preferred as first line therapy, and the option of early ileocecal resection in early limited ileal disease is gaining interest.

@MondayNightIBD and the Expanding Gastroenterology Twitterverse: A Study on Continuing Medical Education on #GITwitter.

INTRODUCTION: @MondayNightIBD provides weekly continuing medical education (CME) activities focused on inflammatory bowel diseases to clinicians on Twitter. Given its novelty, we assessed whether @MondayNightIBD improves learner knowledge and leads to practice change. We also examined whether inflammatory bowel disease topics addressed in @MondayNightIBD are aligned with entrustable professional activities (EPA) set forth by national gastroenterology societies. METHODS: @MondayNightIBD CME sessions from February 2020 (date the handle was accredited to provide CME) to May 2021 were analyzed. Preactivity and postactivity knowledge was assessed for average score improvement using the Student t test and Cohen d effect size. Postactivity surveys examined for learners' perceptions of whether activities met educational goals and affected willingness to change clinical practice using descriptive percentages. In addition, activities from April 2019 (date of @MondayNightIBD inception) to May 2021 were assessed for whether they address EPA set forth by national gastroenterology societies. RESULTS: Learners' knowledge improved after @MondayNightIBD activities with average preactivity correct answers of 58% to a postactivity average of 79% ( P < 0.001). Greater than 95% of learners found that activities met learning objectives and enhanced knowledge. A total of 92% of learners were committed to practice change because of their @MondayNightIBD participation. Finally, 78% of EPA set forth by a national gastroenterology society have been covered by @MondayNightIBD since its inception. DISCUSSION: @MondayNightIBD is a Twitter-based CME activities platform for gastroenterologists and other clinicians that is embraced by learners, improves knowledge, and encourages practice change. Topics covered during @MondayNightIBD are aligned with EPA set forth by national gastroenterology societies. @MondayNightIBD is a successful model of social media medical education and a novel approach to effectively provide evidence-based CME.

The Toronto Upper Gastrointestinal Cleaning Score: a prospective validation study.

BACKGROUND : Assessment of mucosal visualization during esophagogastroduodenoscopy (EGD) can be improved with a standardized scoring system. To address this need, we created the Toronto Upper Gastrointestinal Cleaning Score (TUGCS). METHODS : We developed the TUGCS using Delphi methodology, whereby an international group of endoscopy experts iteratively rated their agreement with proposed TUGCS items and anchors on a 5-point Likert scale. After each Delphi round, we analyzed responses and refined the TUGCS using an 80 % agreement threshold for consensus. We used the intraclass correlation coefficient (ICC) to assess inter-rater and test-retest reliability. We assessed internal consistency with Cronbach's alpha and item-total and inter-item correlations with Pearson's correlation coefficient. We compared TUGCS ratings with an independent endoscopist's global rating of mucosal visualization using Spearman's ρ. RESULTS : We achieved consensus with 14 invited participants after three Delphi rounds. Inter-rater reliability was high at 0.79 (95 %CI 0.64-0.88). Test-retest reliability was excellent at 0.83 (95 %CI 0.77-0.87). Cronbach's α was 0.81, item-total correlation range was 0.52-0.70, and inter-item correlation range was 0.38-0.74. There was a positive correlation between TUGCS ratings and a global rating of visualization (r = 0.41, P = 0.002). TUGCS ratings for EGDs with global ratings of excellent were significantly higher than those for EGDs with global ratings of fair (P = 0.01). CONCLUSION : The TUGCS had strong evidence of validity in the clinical setting. The international group of assessors, broad variety of EGD indications, and minimal assessor training improves the potential for dissemination.

Medical Treatment Options for Ulcerative Colitis.

The landscape of management of ulcerative colitis, a type of inflammatory bowel disease, continues to change with advancement in pharmaceutical options as well as clinical treatment targets. Ulcerative colitis primarily involves the superficial layers of the large bowel, and cause active inflammation that can affect the colon from the rectum to the cecum in a relapsing and a remitting course. In this review, we provide evidence-based guidance on the selection of appropriate medical therapies based on individual patient and disease characteristics, with a focus on biologics and small molecules. We also review the role of surgery and management of acute severe ulcerative colitis.

P033 Moving the Needle on Speaker Diversity at AIBD.

BACKGROUND: Diversity of invited speakers at academic conferences is a topic of increased focus in recent years. While there have been efforts to improve speaker diversity, an evaluation of this in the IBD field has not been undertaken to date. We aimed to address gaps in knowledge of speaker gender, race, and experience at a major annual IBD conference over time. METHODS: AIBD program brochures from 2014 to 2020 were reviewed by two providers to evaluate speaker demographic information including gender, race, topic of discussion, institutional affiliation, and, for those trained in gastroenterology, years post-fellowship. In addition, the proportion of all-male panels was calculated. As a comparator, the proportion of female speakers and all-male panels was then compared to a control conference run by the same CME organization (Personalized Therapies in Thoracic Oncology). RESULTS: The percentage of female speakers of any specialty at AIBD increased from 25% in 2016 to 39% in 2020. Female adult gastroenterologist speakers increased from 12% in 2015 to 27% in 2020. The percentage of all gastroenterologists that are female in the US is 19%. All-male panels also decreased from an average of 47% in 2014-2017, to 11% in 2018-2020. As a comparator, 47% of speakers at the control conference were female and there were no all-male panels in 2020. For race, in any given year an average of 13% of speakers were Asian, 5% Hispanic/Latinx, and 1% Black. This remained static over time. The percentage of Asian, Hispanic/Latinx, and Black gastroenterologists in the US is 29%, 5%, and 6%, respectively. Average years of experience of speakers at AIBD appeared relatively static, with a mean of 15 years since fellowship training per speaker. CONCLUSION: From 2014-2020, the proportion of female speakers at AIBD has increased to over one third in main programming. There remains room for improvement, particularly in increasing the racial and ethnic diversity of speakers and inviting more gastroenterologists in the early stages of their careers.

Social media in inflammatory bowel disease: the patient and physician perspective.

PURPOSE OF REVIEW: Social media use by patients with inflammatory bowel disease (IBD) and their respective providers continues to increase, promoting disease awareness and scholarship. In this review article, we summarize the current literature regarding social media use and IBD, discuss both the patient and physician perspective, and provide guidance to avoid commonly encountered pitfalls. RECENT FINDINGS: Patients and providers commonly rely on social media to share medical information, advocate for improved IBD care, and to network and collaborate on common research interests. This shift from more traditional formats of education and networking continues to grow exponentially, and even more rapidly so during the COVID-19 pandemic. SUMMARY: Social media use in the IBD community will continue to grow and lead to further innovation. Providers should be aware of social media as a valuable tool for their patients and themselves.

Impact of COVID-19 on endoscopy trainees: an international survey.

BACKGROUND AND AIMS: Although coronavirus disease 2019 (COVID-19) has affected endoscopy services globally, the impact on trainees has not been evaluated. We aimed to assess the impact of COVID-19 on procedural volumes and on the emotional well-being of endoscopy trainees worldwide. METHODS: An international survey was disseminated over a 3-week period in April 2020. The primary outcome was the percentage reduction in monthly procedure volume before and during COVID-19. Secondary outcomes included potential variation of COVID-19 impact between different continents and rates and predictors of anxiety and burnout among trainees. RESULTS: Across 770 trainees from 63 countries, 93.8% reported a reduction in endoscopy case volume. The median percentage reduction in total procedures was 99% (interquartile range, 85%-100%), which varied internationally (P < .001) and was greatest for colonoscopy procedures. Restrictions in case volume and trainee activity were common barriers. A total of 71.9% were concerned that the COVID-19 pandemic could prolonged training. Anxiety was reported in 52.4% of respondents and burnout in 18.8%. Anxiety was independently associated with female gender (odds ratio [OR], 2.15; P < .001), adequacy of personal protective equipment (OR, 1.75; P = .005), lack of institutional support for emotional health (OR, 1.67; P = .008), and concerns regarding prolongation of training (OR, 1.60; P = .013). Modifying existing national guidelines to support adequate endoscopy training during the pandemic was supported by 68.9%. CONCLUSIONS: The COVID-19 pandemic has led to restrictions in endoscopic volumes and endoscopy training, with high rates of anxiety and burnout among endoscopy trainees worldwide. Targeted measures by training programs to address these key issues are warranted to improve trainee well-being and support trainee education.

The Management Approach to the Adolescent IBD Patient: Health Maintenance and Medication Considerations.

PURPOSE OF REVIEW: Inflammatory bowel disease (IBD) is often diagnosed during adolescence and can have a deep impact on the physical, hormonal, developmental, and psychosocial changes associated with this life period. The purpose of this review is to address the particular manifestations of IBD (such as growth and pubertal delay), health maintenance issues, and treatment considerations in the adolescent. RECENT FINDINGS: The need for a multidisciplinary approach to recognize and address growth and pubertal delay, bone health, as well as the psychosocial impact of IBD on the adolescent has been increasingly recognized as an integral part of IBD care in this population. Vaccinations schedule, preventive health measures, and promoting compliance with care are particularly important during adolescence. Replacing nutrients deficits is also crucial: in particular, vitamin D has been shown to play a role in the gut immune system, and adequate vitamin D levels might promote IBD remission. Iron replacement should be done by intravenous route since oral iron is poorly absorbed in chronic inflammatory states. Finally, recent data have shed light on the increased risk of particular types of lymphoma in adolescent on thiopurines, whereas biologic therapies, in particular, anti-TNF, now are positioned as a preferred and effective steroid-sparing agents in moderate to severe IBD. Management of adolescents with IBD is not without significant challenges. An early implementation of steroid-sparing therapies, a multidisciplinary treatment approach, and a dynamic physician-patient relationship are essential to achieve remission, prevent disease-related complications but also optimize developmental, physical, and psychosocial health, and encourage compliance and transition to adult care.

MR Enterography of Inflammatory Bowel Disease with Endoscopic Correlation.

Crohn disease (CD) and ulcerative colitis (UC) are the two main forms of idiopathic inflammatory bowel disease (IBD). CD is a transmural chronic inflammatory disorder that can affect any part of the gastrointestinal tract in a discontinuous distribution. UC is a mucosal and submucosal chronic inflammatory disease that typically originates in the rectum and may extend proximally in a continuous manner. In treating patients with CD and UC, clinicians rely heavily on accurate diagnoses and disease staging. Magnetic resonance (MR) enterography used in conjunction with endoscopy and histopathologic analysis can help accurately diagnose and manage disease in the majority of patients. Endoscopy is more sensitive for detection of the early-manifesting mucosal abnormalities seen with IBD and enables histopathologic sampling. MR enterography yields more insightful information about the pathologic changes seen deep to the mucosal layer of the gastrointestinal tract wall and to those portions of the small bowel that are not accessible endoscopically. CD can be classified into active inflammatory, fistulizing and perforating, fibrostenotic, and reparative and regenerative phases of disease. Although CD has a progressive course, there is no stepwise progression between these disease phases, and various phases may exist at the same time. The endoscopic and MR enterographic features of UC can be broadly divided into two categories: acute phase and subacute-chronic phase. Understanding the endoscopic features of IBD and the pathologic processes that cause the MR enterographic findings of IBD can help improve the accuracy of disease characterization and thus optimize the medication and surgical therapies for these patients. ©RSNA, 2016.

Short- and long-term risk of colorectal adenoma recurrence among whites and blacks.

BACKGROUND: It is unclear whether the higher burden from colorectal cancer among blacks is due to an increased biological susceptibility. OBJECTIVE: To determine whether non-Hispanic blacks (blacks) have a higher risk of adenoma recurrence than non-Hispanic whites (whites) after removal of colorectal adenoma. DESIGN: Secondary analysis of the Polyp Prevention Trial (PPT) data. SETTING: United States. PATIENTS: Patients were 1668 self-identified whites and 153 blacks who completed the 4-year trial. Of these, 688 whites and 55 blacks enrolled in a posttrial, passive Polyp Prevention Trial Continued Follow-up Study (PPT-CFS) and underwent another colonoscopy. MAIN OUTCOME MEASUREMENTS: Recurrence and location of the adenoma and advanced adenoma by race-ethnicity during PPT and cumulative recurrence over a mean follow-up of 8.3 years (range, 4.9-12.4 years) among PPT-CFS enrollees. RESULTS: Blacks had similar risk of recurrence of adenoma (39.2% vs 39.4%; incidence risk ratio [RR] = .98; 95% CI, .80-1.20) and advanced adenoma (8.5% vs 6.4%; RR = 1.18; 95% CI, .68-2.05) as whites at the end of PPT. Recurrence risk did not differ by colon subsite. Among PPT-CFS enrollees, the cumulative recurrence rate over a maximal follow-up period of 12 years was similar for blacks and whites for adenoma (67.3% vs 67.0%; RR = 1.01; 95% CI, .84-1.21) and advanced adenoma (14.5% vs 16.9%; RR = 1.03; 95% CI, .60-1.79). LIMITATION: There were few blacks in the long-term follow-up study. CONCLUSIONS: Adenoma and advanced adenoma recurrence did not differ by race. Our study does not support more frequent surveillance colonoscopies for blacks with a personal history of adenoma as an intervention to reduce colorectal cancer disparity.