ABSTRACT
As clinicians involved in the care of patients with disorders of gut-brain interaction (DGBIs), we-and many colleagues-have the impression that social media are adversely shaping the nature, presentation, and ability to manage these disorders, especially at the severe end of the DGBI clinical spectrum. We turned to the research literature to see if these clinical impressions were corroborated but found it virtually nonexistent. Social media have rapidly become a ubiquitous, pervasive part of the lives of most people on the planet. Although they bring many benefits, they are also replete with health misinformation, reinforcement of abnormal sick-role behavior, and undermining of the legitimacy of psychological care. We first set out four reasons for concern about social media and DGBIs, particularly severe DGBIs. These reasons stem from phenomena described in medical fields outside DGBIs, but there is no reason to think DGBIs should be exempt from such phenomena. We then present the results of a literature search, which yielded only eight disparate recent empirical studies. We review these studies, which, although not uninformative, reveal a field in its infancy. We set out implications, most urgently multidisciplinary research directly addressing the role of social media and evaluation of interventions to mitigate its ill effects. Gastroenterological clinicians involved in DGBI care and research need to collaborate with experts in social media research, which is a very rapidly evolving, specialized field. Although knowledge is at an early stage, there are implications for specialist practice, education and training, and DGBI service delivery.
ABSTRACT
There are wide-ranging probiotic choices in Australasia. We reviewed the efficacy of probiotics for the management of gastrointestinal (GI) conditions in adults and assessed relevance to clinical practice. The benefits of probiotics were inconsistent, with a strong consensus reached for only a few of the indications. As different species/strains and combinations differ in efficacy, results cannot be extrapolated from one to another. This review endorses specific probiotics for limited indications. Efficacy of most marketed probiotic formulations remains unstudied and unproven, warranting further research.
Subject(s)
Gastrointestinal Diseases , Probiotics , Probiotics/therapeutic use , Humans , Gastrointestinal Diseases/therapy , Treatment OutcomeABSTRACT
BACKGROUND: Patients with inflammatory bowel disease (IBD) are at increased risk of malignancy and infection compared to the general population. AIMS: We aim to identify risk factors for malignancy or serious infection in our IBD cohort. METHODS: Patients with IBD from a single tertiary referral centre were included. Demographic and clinical details, including immunosuppressant exposure, were collected and medical records retrospectively screened for adverse events, including malignancy or infection requiring hospitalisation. Logistic regression was used to evaluate risk factors for adverse events. RESULTS: Five hundred and forty-nine patients with IBD (340 Crohn disease (CD) and 209 ulcerative colitis (UC)) were studied. Forty-eight malignancies, including 39 (81.3%) non-melanoma skin cancers, 3 (6.3%) haematologic malignancies and 6 (15.4%) solid-organ malignancies, were identified, and 92 cases of serious infection were detected. IBD duration (odds ratio (OR) = 1.08; 95% confidence interval (CI) = 1.03-1.13) and ileocolonic CD (OR = 4.96; 95% CI = 1.13-21.71) were associated with increased odds of overall cancer. Compared with patients not previously exposed to the given class of immunosuppression assessed, the development of overall malignancy was not higher with thiopurine exposure (OR = 1.00; 95% CI = 0.50-2.24) or anti-tumour necrosis factor-alpha (TNF-α) exposure (OR = 0.78; 95% CI = 0.37-1.64). Similarly, compared with patients not exposed, infection risk was not affected by thiopurine (OR = 0.74; 95% CI = 0.46-1.20) or anti-TNF exposure (OR = 0.60; 95% CI = 0.38-0.95). CONCLUSIONS: Factors including ileocolonic CD and increasing IBD duration were associated with higher malignancy risk in this cohort. Compared with non-exposure, patients exposed to thiopurines were not at increased risk of malignancy or serious infection. Similarly, patients exposed to anti-TNF treatment did not experience increased rates of malignancy or serious infection compared to patients not exposed to this treatment.
Subject(s)
Colitis, Ulcerative , Crohn Disease , Inflammatory Bowel Diseases , Neoplasms , Purines , Sulfhydryl Compounds , Humans , Retrospective Studies , Tumor Necrosis Factor Inhibitors , Inflammatory Bowel Diseases/drug therapy , Neoplasms/epidemiology , Colitis, Ulcerative/epidemiology , Crohn Disease/drug therapy , Risk FactorsABSTRACT
BACKGROUND: Inflammatory bowel disease (IBD) is best managed by a multidisciplinary team within a dedicated IBD service. IBD nurses play an important role within this team. We aimed to evaluate the contribution of our comprehensive outpatient IBD nursing service on patient outcomes, quality of care, and healthcare costs. METHODS: We performed a retrospective review of all IBD nurse encounters with patients over a 12-month period from October 2020 to September 2021 at a tertiary IBD referral center. Each nurse encounter was classified with respect to its clinical context, activities, and outcomes. Descriptive statistics were used to characterize these encounters and an economic analysis was performed to estimate the cost savings to the hospital. RESULTS: A total of 2537 nurse encounters occurred with 682 patients; 41% of encounters were nurse-initiated contacts with patients and 34% were patient-initiated contacts with the nurse helpline (26% via email, 8% via telephone). Most encounters involved clinical assessments (66%), providing education, counseling or updates (47%), and reviewing investigation results (38%). A gastroenterologist was consulted for advice in 35% of contacts. An estimated 29 emergency department visits, 1925 outpatient clinic visits, and 137 general practitioner visits were avoided. After deducting costs incurred, a net estimated annual saving of up to AUD $570 838 was achieved. Nurses commonly facilitated faster access to investigations (29%), education provision (28%), delivery of biologic services (25%), and medication changes (19%). CONCLUSIONS: A comprehensive IBD nursing service is associated with improved patient outcomes and quality of care, and reduced healthcare costs. This study supports the expanding role of IBD nurses in a modern multidisciplinary IBD service and the need for greater funding and integration of IBD nurses into IBD services.
ABSTRACT
BACKGROUND: The Chicago classification primarily utilizes ten 5 mL liquid swallows in a supine position as the standard high-resolution esophageal manometry (HRM) protocol. HRM can be performed with varying volumes and consistencies and in an upright position. We aimed to determine the impact on HRM results by (1) position, (2) swallows of differing volume and consistency, and (3) perception of bolus passage. METHODS: HRM was performed in healthy volunteers (HV) with the following protocol of swallows: liquids 10 × 5 mL, 5 × 10 mL, and 3 × 10 mL multiple rapid swallows; applesauce 5 × 5 mL and 5 × 10 mL; and bread 5 × 2 × 2 cm and 5 × 4 × 4cm. HV rated difficulty of each swallow on a 5-point Likert scale. All HVs performed the protocol in supine position first and then in "semi-upright" (sitting 70 degrees in a bed) and "upright" (sitting in a chair) in a randomized order. KEY RESULTS: Thirty-seven HVs, median age 27 years, 64% female completed this study. Median distal contractile integral (DCI) and integrated relaxation pressure 4 s (IRP4) of 5 mL liquid swallows significantly differed (all p < 0.01) between position performed. Large volume swallows resulted in higher DCI and lower IRP4. IRP4 results were significantly increased for 2 × 2 cm pieces of bread compared to 5 mL water swallows. DCI results were higher for 2 × 2 cm pieces of bread compared to 5 mL water swallows. Distal latency was shorter in more upright positions. Among this cohort of HV, perceived difficulty of bolus passage was more likely to occur with solid boluses. CONCLUSIONS AND INFERENCES: The volume and consistency of a swallow and the position it is performed in, significantly alter HRM metrics. Interpretation of HRM studies should incorporate different normative values which are specific to the position and bolus type.
Subject(s)
Deglutition , Esophageal Motility Disorders , Humans , Female , Adult , Male , Esophagus , Manometry/methods , Sitting Position , WaterABSTRACT
BACKGROUND AND OBJECTIVES: The role of therapeutic drug monitoring for ustekinumab in the treatment of Crohn's disease has not been defined. This study aimed to explore the relationship of serum ustekinumab trough concentration (UTC) with clinical and biochemical disease outcomes in a real-world setting. METHODS: We performed a retrospective analysis of Crohn's disease patients treated at a single tertiary centre. Ustekinumab was given as a single intravenous induction dose, followed by maintenance subcutaneous injections every 4 to 8 weeks. Rates of clinical remission (Harvey-Bradshaw Index ≤ 4), biochemical remission (C-reactive protein < 5 mg/l and faecal calprotectin < 150 µg/g) and complete remission were assessed at baseline and at the time of UTC testing during maintenance therapy. The association between baseline variables and UTC was tested using linear regression. We also performed an external validation analysis of UTC cut-offs established in four previously published studies. RESULTS: This study included 43 patients. Compared to 8-weekly dosing, a 2.49- and 2.65-fold increase in UTC was associated with 6-weekly and 4-weekly dosing respectively. However, there was no significant difference in clinical, biochemical or complete remission among the dosing groups. An external validation of previously published optimal UTC cut-offs found low predictive value for our patient population. CONCLUSIONS: In this study, dosing interval was the only determinant significantly associated with a higher UTC for patients on maintenance ustekinumab therapy. While a higher UTC may be achieved with dose escalation, it was not associated with improved rates of clinical or biochemical response in our cohort.
Subject(s)
Crohn Disease , Ustekinumab , Humans , Adult , Ustekinumab/therapeutic use , Crohn Disease/drug therapy , Crohn Disease/metabolism , Retrospective Studies , Remission Induction , Administration, IntravenousABSTRACT
OBJECTIVE: Idiopathic megarectum is characterized by abnormal, pronounced rectal dilatation in the absence of identifiable organic pathology. Idiopathic megarectum is uncommon and under-recognized. This study aims to describe the clinical features and management of idiopathic megarectum. METHODS: A retrospective review was undertaken on patients diagnosed with idiopathic megarectum with or without idiopathic megacolon over a 14-year period until 2021. Patients were identified from the hospital's International Classification of Diseases codes, and pre-existing clinic patient databases. Patient demographics, disease characteristics, healthcare utilization and treatment history data were collected. RESULTS: Eight patients with idiopathic megarectum were identified; half of the patients were female, with the median age of symptom onset being 14â years (interquartile range [IQR] 9-24). The median rectal diameter measured was 11.5â cm (IQR 9.4-12.1). The most common presenting symptom was constipation, bloating and faecal incontinence. All patients required prior sustained periods of regular phosphate enemas and 88% were using ongoing oral aperients. Concomitant anxiety and or depression were found in 63% of patients and 25% were diagnosed with an intellectual disability. Healthcare utilization was high with a median of three emergency department presentations or ward admissions related to idiopathic megarectum per patient over the follow-up period; 38% of patients required surgical intervention during the period of follow-up. CONCLUSION: Idiopathic megarectum is uncommon and associated with significant physical and psychiatric morbidity and high healthcare utilization.
Subject(s)
Megacolon , Rectal Diseases , Humans , Adult , Female , Adolescent , Male , Rectum/surgery , Rectum/pathology , Constipation/complications , Megacolon/complications , Megacolon/pathology , Megacolon/surgery , Retrospective StudiesSubject(s)
Colonoscopy , Gastrointestinal Diseases , Female , Humans , Aged , Weight Loss , Habits , GastroscopyABSTRACT
BACKGROUNDS AND AIMS: Inflammatory bowel disease (IBD) affects a growing cohort of elderly patients. Our aim was to compare the quality of care received by elderly patients with IBD with a nonelderly adult IBD population using clinical markers including steroid-free clinical remission. METHOD: Retrospective audit of all consecutive patients attending a specialist IBD centre over a 1-year period aged >60 (elderly cohort [EC]) and 50 consecutive patients aged 30-45 years (control cohort [CC]). A follow-up survey was completed assessing current symptoms and perceptions of care. RESULTS: One hundred thirty-nine patients were evaluated (89 EC, 50 CC). Steroid-free clinical remission was observed less commonly in the EC (58, 64%) compared with the CC (40, 80%) (P < 0.05). Biologics such as infliximab (15% EC vs 36% CC; P < 0.01) and adalimumab (14% EC vs 30% CC; P = 0.02) were used less frequently in the EC, whilst vedolizumab (6% EC vs 6% CC; P = 1) and ustekinumab (3% EC vs 2% CC; P = 1) were used at a similar frequency. Patients in the EC were less likely to have specialist IBD nursing contact (P < 0.01), smoking screening (P < 0.011) or influenza vaccinations (P < 0.006). IBD nurse contact was associated with significantly greater provision of the preventative care measures. CONCLUSION: Elderly patients with IBD were less likely to experience steroid-free clinical remission or be prescribed biologics. Elderly patients were less likely to receive education with respect to preventative medicine. The models of care for the elderly need re-evaluation and greater incorporation with the multidisciplinary IBD team.
Subject(s)
Biological Products , Colitis, Ulcerative , Inflammatory Bowel Diseases , Adult , Aged , Humans , Colitis, Ulcerative/diagnosis , Retrospective Studies , Inflammatory Bowel Diseases/diagnosis , Inflammatory Bowel Diseases/drug therapy , Inflammatory Bowel Diseases/epidemiology , Infliximab/therapeutic use , Biological Products/therapeutic useSubject(s)
Inflammatory Bowel Diseases , Humans , Vaccination , Chronic Disease , Primary Health CareABSTRACT
BACKGROUND AND AIM: Refractory bowel symptoms in quiescent inflammatory bowel disease (IBD) are common but evidence for effective management is limited. We aimed to determine whether behavioral treatment, including pelvic floor muscle training, decreases the severity of functional bowel symptoms in patients with quiescent IBD. Secondary aims were to evaluate the treatment effect on quality of life, psychological well-being and pelvic floor muscle function. METHODS: This prospective study included IBD patients in remission with persistent symptoms of fecal incontinence or constipation who received up to six sessions of behavioral treatment at monthly intervals. The primary outcome was patient-rated symptom improvement on a 7-point Likert scale (1 = substantially worse, 7 = substantially better). Secondary outcomes included validated symptom scores, quality-of-life, psychological measures, and transperineal ultrasound assessment of pelvic floor muscle activity. RESULTS: Thirty-four patients (median age 38 years; 24 females; 18 ulcerative colitis, 13 Crohn's disease, 3 ileo-anal pouch) were included. Twenty-one of the 29 (72%) patients who completed treatment, or 21 of all 34 (62%) patients, reported moderate or substantial improvement (patient rating of 6 or 7). Symptom scores (p < .001), IBD-specific quality of life (p = .008) and illness perception scores (p = .003) significantly improved. General quality of life, and anxiety and depression scores, did not change significantly. Transperineal ultrasound pelvic floor measures did not correlate with patient-rating of symptom improvement. CONCLUSION: Significant symptomatic improvement occurred in a majority of patients with quiescent IBD. Behavioral treatment should be considered for patients with quiescent IBD and ongoing functional bowel symptoms of fecal incontinence, fecal urgency, or constipation.
Subject(s)
Fecal Incontinence , Inflammatory Bowel Diseases , Adult , Chronic Disease , Constipation/etiology , Constipation/therapy , Fecal Incontinence/etiology , Fecal Incontinence/therapy , Female , Humans , Inflammatory Bowel Diseases/complications , Inflammatory Bowel Diseases/therapy , Pelvic Floor/diagnostic imaging , Prospective Studies , Quality of LifeABSTRACT
BACKGROUND & AIMS: Functional gastrointestinal disorders are common and costly to the healthcare system. In the Multidisciplinary Treatment of Functional Gastrointestinal Disorders study, we demonstrated that multidisciplinary care resulted in superior clinical and cost outcomes, when compared with standard gastroenterologist-only care at end of treatment. In this study we evaluate the longer-term outcomes. METHODS: In a single-center, pragmatic trial patients with Rome IV criteria-defined functional gastrointestinal disorders were randomized 1:2 to a gastroenterologist-only standard care vs a multidisciplinary clinic comprising gastroenterologists, dietitians, gut hypnotherapists, psychiatrists, and biofeedback physiotherapists. Outcomes in this study were assessed 12 months after the end of treatment. Global symptom improvement was assessed by using a 5-point Likert scale. Symptoms, specific disorder status, psychological state, quality of life, and cost were additional outcomes. A modified intention-to-treat analysis was performed. RESULTS: Of 188 randomized patients, 143 (46 standard care, 97 multidisciplinary) formed the longer-term modified intention-to-treat analysis. Sixty-two percent of multidisciplinary clinic patients saw allied clinicians. Sixty-five percent (30/46) standard care versus 76% (74/97) multidisciplinary clinic patients achieved global symptom improvement 12 months after end of treatment (P = .17), whereas 20% (9/46) versus 37% (36/97) rated their symptoms as "5/5 much better" (P = .04). A ≥50-point reduction in Irritable Bowel Syndrome Severity Scoring System occurred in 38% versus 66% (P = .02), respectively, for irritable bowel syndrome patients. Anxiety and depression were greater in the standard care than multidisciplinary clinic (12 vs 10, P = .19), and quality of life was lower in standard care than the multidisciplinary clinic (0.75 vs 0.77, P =·.03). An incremental cost-effectivness ratio found that for every additional 3555AUD spent in the multidisciplinary clinic, a further quality-adjusted life year was gained. CONCLUSIONS: Twelve months after the completion of treatment, integrated multidisciplinary clinical care achieved a greater proportion of patients with improvement of symptoms, psychological state, quality of life, and cost, compared with gastroenterologist-only care. CLINICAL TRIALS: gov: number NCT03078634.
Subject(s)
Gastroenterologists , Gastrointestinal Diseases , Irritable Bowel Syndrome , Delivery of Health Care , Humans , Quality of LifeABSTRACT
The composition and function of the dynamic microbial community that constitutes the gut microbiome is continuously shaped by the host genome, mode of birth delivery, geography, life stage, antibiotic consumption, and diet. Diet is one of the most potent factors in determining microbiome integrity. Dietary factors in early life appear to substantially determine the risk of later health or disease; for example, exposure to ultra-processed foods in childhood or adolescence may increase the risk of the later development of inflammatory bowel disease or colorectal cancer, thought to be mediated by modulation of the gut microbiota. Dietary factors when gut diseases are established influence symptoms and disease activity, can form a risk factor for ongoing disease, or can be used as therapy to decrease disease activity. The characterization of dietary content is currently complex and imperfect, but tools are emerging to define precisely the nature of dietary composition. Similarly, the revolution in microbial analysis allows greater understanding of how diet influences microbial composition and function. Defining the interaction between diet, the gut microbiome, and gastrointestinal disease is leading to radical changes in our clinical approach to these disorders.
Subject(s)
Diet , Gastrointestinal Diseases , Gastrointestinal Microbiome , Diet/adverse effects , Gastrointestinal Diseases/epidemiology , HumansABSTRACT
BACKGROUND: Preventive health measures reduce treatment and disease-related complications including infections, osteoporosis, and malignancies in patients with inflammatory bowel disease (IBD). Although guidelines and quality measures for IBD care highlight the importance of preventive care, their uptake remains variable. This systematic review evaluates interventions aimed at improving the rates of provision and uptake of preventive health measures, including vaccinations, bone density assessment, skin cancer screening, cervical cancer screening, and smoking cessation counseling. METHODS: We searched PubMed, MEDLINE, EMBASE, and CENTRAL for full text articles published until March 2021. Studies were included if they evaluated interventions to improve the provision or uptake of 1 or more preventive health measures in adult IBD patients and if they reported pre- and postintervention outcomes. RESULTS: In all, 4655 studies were screened, and a total of 17 studies were included, including 1 randomized controlled trial, 1 cluster-controlled trial, and 15 prospective interventional studies. A variety of interventions were effective in improving the rates of adherence to preventive health measures. The most common interventions targeted gastroenterologists, including education, electronic medical records tools, and audit feedback. Other interventions targeted patients, such as education, questionnaires, and offering vaccine administration at clinic visits. Few interventions involved IBD nurses or primary care physicians. CONCLUSIONS: A range of interventions-targeted at gastroenterologists, patients, or both-were effective in improving the provision and uptake of preventive care. Future studies should involve randomized controlled trials evaluating multifaceted interventions that target barriers to adherence and involve IBD nurses and primary care physicians.
Subject(s)
Inflammatory Bowel Diseases , Uterine Cervical Neoplasms , Adult , Chronic Disease , Early Detection of Cancer , Female , Humans , Inflammatory Bowel Diseases/complications , Prospective Studies , Randomized Controlled Trials as TopicABSTRACT
BACKGROUND: Patients with gastrointestinal disorders are prone to heightened awareness of dietary intake. When diet-related thoughts or behaviors are excessive, they may lead to psychological distress, nutritional compromise, and impair medical treatment. Identification of disordered eating behavior and eating disorders is crucial for effective management, but data on their prevalence within this population remain scarce. We conducted a systematic review of the prevalence of disordered eating behavior and eating disorders in adults with gastrointestinal disorders. METHODS: MEDLINE, PubMed, and PsycInfo databases were searched up to June 2021. Studies examining disordered eating in adult patients with a primary gastrointestinal diagnosis were included. KEY RESULTS: A total of 17 studies met the inclusion criteria for the review. The range of gastrointestinal disorders examined included disorders of gut-brain interaction (DGBI), coeliac disease, and inflammatory bowel disease (IBD). The methods for examining disordered eating were highly variable. The prevalence of disordered eating ranged from 13-55%. The prevalence was higher in patients with disorders of gut-brain interaction (DGBI) than in those with organic gastrointestinal disorders. Factors associated with disordered eating included female sex, younger age, gastrointestinal symptom severity, anxiety and depression, and lower quality of life. CONCLUSIONS & INFERENCES: Disordered eating is highly prevalent in adult patients with gastrointestinal illness, particularly those with DGBI. Understanding whether a patient's primary underlying diagnosis is that of an eating disorder or gastroenterological disorder remains a challenge for clinicians. There is an unmet need to identify at-risk patients so that psychological intervention can be included in the therapeutic strategy.
Subject(s)
Celiac Disease/complications , Feeding and Eating Disorders/epidemiology , Adult , Celiac Disease/psychology , Eating/psychology , Feeding and Eating Disorders/complications , Female , Humans , Prevalence , Quality of LifeABSTRACT
The gut microbiota has a key role in the maintenance of good health, and in the pathogenesis of gastrointestinal diseases. These conditions include the inflammatory bowel diseases, colorectal cancer, coeliac disease and metabolic liver disease. Although the nature of the microbial disturbance in these conditions has not been fully characterised, this has not prevented the development of microbially based therapies. Microbial-changing therapies may address newly recognised pathophysiological contributors of disease and have the potential to replace or supplement standard therapies. Antibiotics play a role in initial Clostridiodes difficile disease and some specific inflammatory disorders. Probiotics have a more limited proven role. Faecal microbiota transplantation is of proven therapeutic benefit in recurrent C. difficile disease and ulcerative colitis. We review the current literature for microbiota-targeted therapies in gut disorders.
Subject(s)
Clostridioides difficile , Gastrointestinal Microbiome , Inflammatory Bowel Diseases , Microbiota , Probiotics , Fecal Microbiota Transplantation , Humans , Inflammatory Bowel Diseases/therapy , Probiotics/therapeutic useABSTRACT
BACKGROUND: Advances in inflammatory bowel disease (IBD) monitoring, greater number of available treatments and a shift towards tight disease control, IBD care has become more dynamic with regular follow ups. AIMS: We assessed the impacts of the COVID-19 pandemic on outpatient IBD patient care at a tertiary centre in Melbourne. More specifically, we assessed patient satisfaction with a telehealth model of care, failure to attend rates at IBD clinics and work absenteeism prior to and during the pandemic. METHODS: We conducted a retrospective, qualitative analysis to assess our aims through an online survey. We invited patients who attended an IBD outpatient clinic from April to June 2020 to participate. This study was conducted at a single, tertiary referral hospital in Melbourne. The key data points that we analysed were patient satisfaction with a telehealth model of care and the effect of telehealth clinics on work absenteeism. RESULTS: One hundred and nineteen (88.1%) patients were 'satisfied' or 'very satisfied' with the care received in the telehealth clinic. Eighty-four (60.4%) patients reported needing to take time off work to attend a face-to-face appointment, compared to 29 (20.9%) patients who needed to take time off work to attend telehealth appointments (P < 0.001). Clinic non-attendance rates were similar prior to and during the pandemic with rates of 11.4% and 10.4% respectively (P = 0.840). CONCLUSIONS: Patients report high levels of satisfaction with a telehealth model of care during the COVID-19 pandemic, with clinic attendance rates not being affected. Telehealth appointments significantly reduced work absenteeism when compared to traditional face-to-face clinics.