Publications by authors named "Robert V Bryant"

44 Publications

Food-related quality of life in adults with inflammatory bowel disease is associated with restrictive eating behaviour, disease activity and surgery: A prospective multicentre observational study.

J Hum Nutr Diet 2021 May 18. Epub 2021 May 18.

Inflammatory Bowel Disease Services, The Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South, SA, Australia.

Background: Measuring food-related quality of life (FRQoL) quantifies the psychosocial impact of eating and drinking. FRQoL and associated factors are not well explored in people with inflammatory bowel disease (IBD), despite IBD being a chronic disease affecting the digestive tract. The present study aimed to characterise and identify any patient or disease-related predictors of FRQoL in individuals with IBD.

Methods: Adults with a formal diagnosis of IBD were recruited to a prospective multicentre cross-sectional study between April 2018 and December 2019. Participants completed questionnaires measuring FRQoL (FRQoL-29), clinical disease activity (Harvey Bradshaw Index and Simple Clinical Colitis Activity Index), restrictive eating behaviour (Nine-Item Avoidant/Restrictive Food Intake Disorder Screen), mental health (Depression Anxiety Stress Scale-21) and other patient and disease-related variables. A multivariable regression was performed to identify factors associated with FRQoL.

Results: One hundred and eight participants completed the questionnaires (n = 39, Crohn's disease; n = 69, ulcerative colitis). The mean FRQoL was 79 (95% confidence interval = 75-84) (poor, 0; superior, 145). Poorer FRQoL was observed in those with restrictive eating behaviour associated with fear of a negative consequence from eating (p < 0.0001) and reduced appetite (p < 0.030). Greater FRQoL was observed in those with lower disease activity (p < 0.0001) and previous IBD surgery (p = 0.024). FRQoL was not associated either way by IBD phenotype, duration, or gender. The majority of participants obtained their dietary information from the internet (60%) or gastroenterologist (46%).

Conclusions: FRQoL in people with IBD is poorer in those with restrictive eating behaviours and clinically active disease. Interestingly, it was greater in those with previous IBD surgery. Further research is required to validate these associations and explore longitudinal effects of poor FRQoL on patient outcomes and potential strategies for prevention or management of impaired FRQoL in IBD.
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http://dx.doi.org/10.1111/jhn.12920DOI Listing
May 2021

Dialing Back M for Monoclonal: Successful De-escalation of Dose-Intensified Anti-tumor Necrosis Factor Therapy in Inflammatory Bowel Disease.

Dig Dis Sci 2021 Mar 25. Epub 2021 Mar 25.

IBD Service, Department of Gastroenterology, The Queen Elizabeth Hospital, 28 Woodville Rd,, Woodville South, SA, 5011, Australia.

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http://dx.doi.org/10.1007/s10620-021-06946-yDOI Listing
March 2021

Editorial: use of intestinal ultrasound in the scoring of Crohn's disease activity in clinical trials - is it ready for prime time yet? Authors' reply.

Aliment Pharmacol Ther 2021 04;53(8):948-949

Alimentiv Inc. (formerly Robarts Clinical Trials, Inc.), London, ON, Canada.

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http://dx.doi.org/10.1111/apt.16313DOI Listing
April 2021

Standardisation of intestinal ultrasound scoring in clinical trials for luminal Crohn's disease.

Aliment Pharmacol Ther 2021 04 28;53(8):873-886. Epub 2021 Feb 28.

Calgary, AB, Canada.

Background: Intestinal ultrasound (IUS) is a valuable tool for assessment of Crohn's disease (CD). However, there is no widely accepted luminal disease activity index.

Aims: To identify appropriate IUS protocols, indices, items, and scoring methods for measurement of luminal CD activity and integration of IUS in CD clinical trials.

Methods: An expert international panel of adult and paediatric gastroenterologists (n = 15) and radiologists (n = 3) rated the appropriateness of 120 statements derived from literature review and expert opinion (scale of 1-9) using modified RAND/UCLA methodology. Median panel scores of 1 to ≤3.5, >3.5 to <6.5 and ≥6.5 to 9 were considered inappropriate, uncertain and appropriate ratings respectively. The statement list and survey results were discussed prior to voting.

Results: A total of 91 statements were rated appropriate with agreement after two rounds of voting. Items considered appropriate measures of disease activity were bowel wall thickness (BWT), vascularity, stratification and mesenteric inflammatory fat. There was uncertainty if any of the existing IUS disease activity indices were appropriate for use in CD clinical trials. Appropriate trial applications for IUS included patient recruitment qualification when diseased segments cannot be adequately assessed by ileocolonoscopy and screening for exclusionary complications. At outcome assessment, remission endpoints including BWT and vascularity, with or without mesenteric inflammatory fat, were considered appropriate. Components of an ideal IUS disease activity index were identified based upon panel discussions.

Conclusions: The panel identified appropriate component items and applications of IUS for CD clinical trials. Empiric evidence, and development and validation of an IUS disease activity index are needed.
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http://dx.doi.org/10.1111/apt.16288DOI Listing
April 2021

An International Consensus to Standardize Integration of Histopathology in Ulcerative Colitis Clinical Trials.

Gastroenterology 2021 Jun 19;160(7):2291-2302. Epub 2021 Feb 19.

Alimentiv Inc (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada; Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.

Background & Aims: Histopathology is an emerging treatment target in ulcerative colitis (UC) clinical trials. Our aim was to provide guidance on standardizing biopsy collection protocols, identifying optimal evaluative indices, and defining thresholds for histologic response and remission after treatment.

Methods: An international, interdisciplinary expert panel of 19 gastroenterologists and gastrointestinal pathologists was assembled. A modified RAND/University of California, Los Angeles appropriateness methodology was used to address relevant issues. A total of 138 statements were derived from a systematic review of the literature and expert opinion. Each statement was anonymously rated as appropriate, uncertain, or inappropriate using a 9-point scale. Survey results were reviewed and discussed before a second round of voting.

Results: Histologic measurements collected using a uniform biopsy strategy are important for assessing disease activity and determining therapeutic efficacy in UC clinical trials. Multiple biopsy strategies were deemed acceptable, including segmental biopsies collected according to the endoscopic appearance. Biopsies should be scored for architectural change, lamina propria chronic inflammation, basal plasmacytosis, lamina propria and epithelial neutrophils, epithelial damage, and erosions/ulcerations. The Geboes score, Robarts Histopathology Index, and Nancy Index were considered appropriate for assessing histologic activity; use of the modified Riley score and Harpaz Index were uncertain. Histologic activity at baseline should be required for enrollment, recognizing this carries operational implications. Achievement of histologic improvement or remission was considered an appropriate and realistic therapeutic target. Current histologic indices require validation for pediatric populations.

Conclusions: These recommendations provide a framework for standardized implementation of histopathology in UC trials. Additional work is required to address operational considerations and areas of uncertainty.
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http://dx.doi.org/10.1053/j.gastro.2021.02.035DOI Listing
June 2021

The Adequacy of Habitual Dietary Fiber Intake in Individuals With Inflammatory Bowel Disease: A Systematic Review.

J Acad Nutr Diet 2021 Apr 20;121(4):688-708.e3. Epub 2021 Jan 20.

Background: Dietary fiber may influence disease course in individuals with inflammatory bowel disease (IBD), yet there is a paucity of understanding of habitual fiber intakes.

Objectives: To identify studies measuring fiber intakes of individuals with IBD, compare the adequacy of fiber intakes with that of control groups or respective national dietary guidelines, and examine factors associated with fiber consumption.

Methods: Five electronic databases-MEDLINE, CINAHL, SCOPUS, PROQUEST, and COCHRANE LIBRARY-were systematically searched, using search terms inflammatory bowel disease, Crohn's disease, ulcerative colitis, dietary intake, and fiber, until December 2019, with hand searching of reference lists. Primary studies were included if fiber intakes were measured in participants 18 years of age or older, with confirmed IBD, with or without comparison to a control.

Results: A total of 2105 publications were identified, and 26 met inclusion criteria. Total fiber intake of 4164 participants with IBD ranged broadly (9.9 ± 7.8 g/day to 21.0 ± 10.5 g/day). Most (18/26) used cross-sectional study design, with a large degree of heterogeneity in tools measuring fiber intake. Sixty-six percent of studies comparing participants with IBD with control groups found that participants with IBD consumed significantly less fiber than control subjects. Four studies reported that less than 10% to 21% of IBD participants met their national fiber recommendations. Data conflicted regarding an association between disease type, disease activity, or rate of relapse and fiber intake.

Conclusions: Individuals with IBD consume less fiber than healthy populations. Fiber intakes are inadequate compared with respective national fiber guidelines. Interpretation of factors associated with fiber intakes were limited by data quality and conflicting results. Future research is required into factors associated with fiber intake and whether increasing fiber intakes can influence disease course and behavior.
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http://dx.doi.org/10.1016/j.jand.2020.12.001DOI Listing
April 2021

Antibiotic resistance of Helicobacter pylori in Australia and New Zealand: A systematic review and meta-analysis.

J Gastroenterol Hepatol 2021 Jun 3;36(6):1450-1456. Epub 2021 Jan 3.

Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.

Objective: While the global prevalence of antibiotic-resistant Helicobacter pylori (H. pylori) is increasing, there is much regional variation, and local data are required to guide eradication therapy. We performed a systematic review and meta-analysis to determine rates of H. pylori antibiotic resistance in Australia and New Zealand.

Study Design: Random effects meta-analysis of data from 15 published studies and three published abstracts reporting prevalence of primary or secondary H. pylori antibiotic resistance in Australasia.

Data Sources: PubMed, EMBASE, MEDLINE, PROSPERO, and the Cochrane Library were searched until August, 2020.

Data Synthesis: Fifteen published studies and three published abstracts were identified; one study was excluded due to high risk of bias. Seventeen studies conducted between 1996 and 2013 were included in the final analysis, 12 reporting primary and five reporting secondary antibiotic resistance. Prevalence of primary resistance was clarithromycin 7.4% (95% confidence interval [CI], 5.3-9.7%), metronidazole 50.0% (95%CI, 23.9-56.1%), fluoroquinolones 3.7% (95%CI, 0.004-14.8%), and both amoxicillin and tetracycline <0.5%. Subgroup analysis (last 20 years) showed doubling of clarithromycin resistance to 16.1% (95%CI 11.2-21.7%) with other resistance stable. Prevalence of secondary resistance was high for all antibiotics, particularly clarithromycin 78.7% (95%CI, 64.1-90.1%) and metronidazole 68.3% (95%CI, 59.9-76.1%).

Conclusions: The outcomes reveal an increase in primary H. pylori clarithromycin resistance since the year 2000, while metronidazole resistance has remained stable and primary resistance to amoxicillin, tetracycline, and fluoroquinolones is low. Rates of secondary resistance to metronidazole and clarithromycin are high. The results highlight the need for contemporary local data on antibiotic resistance in Australia and New Zealand.
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http://dx.doi.org/10.1111/jgh.15352DOI Listing
June 2021

Physician and patient perceptions of fecal microbiota transplant for recurrent or refractory in the first 6 years of a central stool bank.

JGH Open 2020 Oct 6;4(5):950-957. Epub 2020 Aug 6.

Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia.

Background And Aim: Fecal microbiota transplantation (FMT) is a highly effective therapy for recurrent or refractory infection (rCDI). Despite inclusion in society guidelines, the uptake of FMT therapy has been variable. Physician and patient attitudes may be a barrier to evidence-based uptake of therapies; however, data assessing attitudes regarding FMT for rCDI are limited.

Methods: The South Australian FMT for CDI database prospectively recorded patient outcomes of FMT for CDI from August 2013 to January 2019. A total of 93 consecutive patients who underwent FMT for rCDI in South Australia were invited to participate in a 20-question survey regarding the patient experience of FMT. All gastroenterologists and infectious disease physicians practicing in South Australia were invited to participate in an online survey comprised of 22 questions that addressed referral experience, indications for referral, perceived risks, and regulation and funding.

Results: Fifty-four patients (54/93, 58%) returned the survey, of whom 52 (96%) would recommend FMT to others, and 51 (94%) were satisfied with treatment outcome. Fifty physicians returned the online survey (50/100, 50%), of whom 23 (46%) were concerned about disease transmission risk, and 15 (30%) believed that the risk of FMT would outweigh the benefit. Infectious diseases physicians and advanced trainees had significantly greater concern regarding the potential alteration of the microbiome than gastroenterology physicians and advanced trainees (8/17 (47%) 6/33 (18%); = 0.047).

Conclusion: Despite high levels of patient-reported satisfaction following FMT, physician-reported reservations exist and may present a barrier to uptake of this therapy.
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http://dx.doi.org/10.1002/jgh3.12396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7578309PMC
October 2020

Understanding attitudes, concerns, and health behaviors of patients with inflammatory bowel disease during the coronavirus disease 2019 pandemic.

J Gastroenterol Hepatol 2021 Jun 3;36(6):1550-1555. Epub 2020 Nov 3.

IBD Service, Department of Gastroenterology, The Queen Elizabeth Hospital.

Background And Aim: The coronavirus disease 2019 (COVID-19) pandemic has led to a rapid shift in care delivery models for patients with inflammatory bowel disease (IBD); however, little is known about patient perceptions during this period. We aimed to prospectively evaluate the attitudes, concerns, and health behavior of IBD patients during COVID-19.

Methods: An online survey was sent to patients from a tertiary IBD Service. The survey included demographic information and questions about the impact of COVID-19, levels of concern caused by COVID-19, perceived risk of IBD medications, medication cessation, and care delivery preferences.

Results: Of 97 respondents (39%), 95 (98%) reported concern about the impact of COVID-19 on their health, and 43% felt their risk of contracting COVID-19 was above average; 62% reported concern about medication-induced COVID-19 risk, and 11% stopped medications because of COVID-19. Patients considered all medications to increase the risk of COVID-19 susceptibility and severity; 45% preferred telehealth while 16% preferred face-to-face clinic reviews. Preference for IBD monitoring tools in decreasing order was blood testing, stool collection, gastrointestinal ultrasound, magnetic resonance enterography, and then colonoscopy.

Conclusions: Patients with IBD are demonstrated to experience concern related to their diagnosis and medications. The insights provided by the survey are informative for a possible "second-wave" of COVID-19 and routine care, including acceptance of telemedicine, preference for non-invasive investigations, and a need for dissemination of information and education.
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http://dx.doi.org/10.1111/jgh.15299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675463PMC
June 2021

Periprocedural Euglycemic Diabetic Ketoacidosis Associated With Sodium-Glucose Cotransporter 2 Inhibitor Therapy During Colonoscopy.

Diabetes Care 2020 11 17;43(11):e181-e184. Epub 2020 Sep 17.

Department of Endocrinology and Diabetes, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.

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http://dx.doi.org/10.2337/dc20-1244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576412PMC
November 2020

ABC of topical therapy in inflammatory bowel disease.

JGH Open 2020 Aug 26;4(4):556-557. Epub 2020 Apr 26.

IBD Service, Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia.

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http://dx.doi.org/10.1002/jgh3.12323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7411570PMC
August 2020

Practical management of inflammatory bowel disease patients during the COVID-19 pandemic: expert commentary from the Gastroenterological Society of Australia Inflammatory Bowel Disease faculty.

Intern Med J 2020 07;50(7):798-804

Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.

The COVID-19 pandemic, caused by the novel coronavirus SARS-CoV-2, has emerged as a public health emergency and challenged healthcare systems globally. In a minority of patients, SARS-CoV-2 manifests with a severe acute respiratory illness and currently there is insufficient data regarding the virulence of COVID-19 in inflammatory bowel disease patients taking immunosuppressive therapy. This review aims to summarise the current literature and provide guidance on the management of inflammatory bowel disease patients in the context of the COVID-19 pandemic in the Australasian setting.
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http://dx.doi.org/10.1111/imj.14889DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405147PMC
July 2020

Systematic Review: Gastrointestinal Ultrasound Scoring Indices for Inflammatory Bowel Disease.

J Crohns Colitis 2021 Jan;15(1):125-142

Department of Gastroenterology, Queen Elizabeth Hospital, Adelaide, SA, Australia.

Background And Aims: Serial measurements of luminal disease activity may facilitate inflammatory bowel disease management. Gastrointestinal ultrasound is an easily performed, non-invasive alternative to other assessment modes. However, its widespread use is limited by concerns regarding validity, reliability, and responsiveness. We systematically identified ultrasound scoring indices used to evaluate inflammatory bowel disease activity and examine their operating characteristics.

Methods: Electronic databases were searched from inception to June 14, 2019 using pre-defined terms. Studies that reported on gastrointestinal ultrasound index operating properties in an inflammatory bowel disease population were eligible for inclusion. Study characteristics, index components, and operating property data [ie, validity, reliability, responsiveness, sensitivity, specificity, accuracy, positive predictive value, and negative predictive value] were extracted. The QUADAS-2 tool was used to examine study-level risk of bias.

Results: Of the 2610 studies identified, 26 studies reporting on 21 ultrasound indices were included. The most common index components included bowel wall thickness, colour Doppler imaging, and bowel wall stratification. The correlation between ultrasound indices and references standards ranged r = 0.62-0.95 and k = 0.40-0.96. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive values ranged 39-100%, 63-100%, 73-100%, 57-100%, and 40-100%, respectively. Reliability and responsiveness data were limited. Most [92%, 24/26] studies received at least one unclear or high risk of bias rating.

Conclusions: Several gastrointestinal ultrasound indices for use in inflammatory bowel disease have been developed. Future research should focus on fully validating existing or novel gastrointestinal ultrasound scoring instruments for assessment of Crohn's disease and ulcerative colitis.
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http://dx.doi.org/10.1093/ecco-jcc/jjaa129DOI Listing
January 2021

Histological Healing in Ulcerative Colitis: Near Enough Is Not Good Enough.

J Crohns Colitis 2020 Oct;14(10):1341-1342

IBD Service, Department of Gastroenterology, Queen Elizabeth Hospital, Adelaide, SA, Australia.

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http://dx.doi.org/10.1093/ecco-jcc/jjaa095DOI Listing
October 2020

COVID-19 and implications for thiopurine use.

Med J Aust 2020 06 13;212(10):490-490.e1. Epub 2020 May 13.

Queen Elizabeth Hospital, Adelaide, SA.

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http://dx.doi.org/10.5694/mja2.50613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7272893PMC
June 2020

Faecal microbiota transplantation: indications, evidence and safety.

Aust Prescr 2020 04 1;43(2):36-38. Epub 2020 Apr 1.

Inflammatory Bowel Disease Service, Department of Gastroenterology, Queen Elizabeth Hospital, Adelaide.

The human gut contains many species of microorganisms, many of which have a role in maintaining good health. The gut microbiota can be affected by diet, diseases and drugs, especially antibiotics. Faecal microbiota transplantation involves transplanting faecal material from a healthy person to a patient, with the aim of treating disease. It is a recommended treatment option for patients with recurrent or refractory Clostridioides difficile as it has a cure rate over 90%. There is evidence that faecal microbiota transplantation can induce remission in ulcerative colitis, however maintenance of remission data are lacking. For other diseases it currently should not be used outside a clinical trial. Stool donors have to be healthy and are screened for a range of diseases. As faecal material is usually transplanted during colonoscopy, the recipient must have bowel preparation before the procedure. Adverse effects are mainly gastrointestinal and usually resolve in the week following transplantation. There are limited data on long-term safety.
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http://dx.doi.org/10.18773/austprescr.2020.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186269PMC
April 2020

Monitoring Inflammatory Bowel Disease in Pregnancy Using Gastrointestinal Ultrasonography.

J Crohns Colitis 2020 Oct;14(10):1405-1412

Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia.

Background And Aims: Inflammatory bowel disease [IBD] affects women during their childbearing years. Gastrointestinal ultrasonography [GIUS] accurately identifies disease activity in non-pregnant patients with IBD. The utility of GIUS in pregnancy has not been established. We aimed to determine the feasibility and accuracy of GIUS in the assessment of IBD during pregnancy progression.

Methods: A multicentre observational study of women with IBD undergoing GIUS during pregnancy. Clinicians assessed the adequacy of bowel views and disease activity in four colonic segments and the terminal ileum. Location[s] in which views were impeded by the uterus were documented. GIUS disease activity [bowel wall thickness >3 mm] was compared with biochemical disease activity [faecal calprotectin >100 μg/g].

Results: Ninety patients and 127 GIUS examinations were included [median gestation 19 weeks, range 4-33]. Adequate colonic views were obtained in 116/127 [91%] scans. Adequate ileal views were obtained in 62/67 [93%] scans <20 weeks and 30/51 [59%] scans at 20-26 weeks. There was a positive correlation between bowel wall thickness and calprotectin [r = 0.26, p = 0.03]. GIUS delivered a specificity of 83%, sensitivity of 74%, and negative predictive value of 90% compared with calprotectin.

Conclusions: GIUS is a feasible and accurate modality for monitoring IBD in pregnancy. Adequate GIUS views of the colon and terminal ileum can be obtained in the majority of patients up to 20 weeks of gestation. Beyond 20 weeks, GIUS provides good views of the colon but the terminal ileum becomes difficult to assess.
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http://dx.doi.org/10.1093/ecco-jcc/jjaa082DOI Listing
October 2020

Point-of-care gastrointestinal ultrasound in inflammatory bowel disease: An accurate alternative for disease monitoring.

JGH Open 2020 Apr 9;4(2):273-279. Epub 2019 Oct 9.

Gastroenterology Department Queen Elizabeth Hospital Adelaide South Australia Australia.

Background And Aim: Point-of-care ultrasound (POCUS) is a noninvasive alternative to ileocolonoscopy for monitoring disease activity in inflammatory bowel disease (IBD) but is underutilized in practice. Accuracy data are needed to engender clinician confidence in POCUS and increase uptake. The aim of this study was to evaluate the accuracy of POCUS compared to ileocolonoscopy in detecting active disease and extent in patients with IBD.

Methods: A prospective, blinded study was performed at a single tertiary center in South Australia between May 2017 and May 2018. Consecutive patients with a formal diagnosis of IBD who underwent both POCUS and ileocolonoscopy within 30 days of one another, performed to evaluate IBD disease activity, were eligible for participation. The accuracy of POCUS compared to ileocolonoscopy was assessed using sensitivity, specificity, and Cohen's kappa coefficient analyses.

Results: A total of 74 patients were included in the final analysis, 35 (47%) of whom had Crohn's disease and 39 (53%) ulcerative colitis; 37 subjects (50%) underwent a POCUS and ileocolonoscopy on the same day. POCUS demonstrated 91% sensitivity and 83% specificity for detecting endoscopically active IBD, correlating with a positive predictive value (PPV) of 89%, a negative predictive value (NPV) of 86%, and a kappa coefficient of 0.74 (88%). POCUS defined disease extent with 87% sensitivity and 81% specificity, correlating with a PPV of 85% and NPV of 83% and a kappa coefficient of 0.70 (85%).

Conclusion: POCUS is accurate in defining disease activity and extent in IBD compared to ileocolonoscopy. POCUS represents an appealing, noninvasive alternative to ileocolonoscopy for monitoring disease activity in IBD.
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http://dx.doi.org/10.1002/jgh3.12269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144799PMC
April 2020

Gastrointestinal ultrasound in inflammatory bowel disease care: Patient perceptions and impact on disease-related knowledge.

JGH Open 2020 Apr 9;4(2):267-272. Epub 2019 Oct 9.

IBD Service, Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia.

Background And Aim: Objective monitoring of disease activity is integral to therapeutic decision-making in inflammatory bowel disease (IBD). Data are sparse on patients' perspectives of tools used to monitor disease activity in IBD. To evaluate patients' perspectives of gastrointestinal ultrasound (GIUS) performed during routine IBD clinical care, along with its impact on IBD-specific knowledge.

Methods: Patients with a formal diagnosis of IBD who underwent GIUS at two tertiary IBD services between March 2017 and January 2019 participated in this prospective study. Participants completed a questionnaire measuring the acceptability, tolerability, and usefulness of GIUS using a visual analogue scale (VAS) from 0 (disagree) to 10 (strongly agree). Comparative acceptability of IBD monitoring tools and the impact of GIUS on IBD-specific knowledge was measured.

Results: A total of 121 participants completed the questionnaire, with a mean age of 42 years (range 17-78), 54 (45%) males, and 79 (65%) Crohn's disease patients. In the overall population, GIUS was scored as highly acceptable for monitoring IBD (mean 9.20 ± 1.37) compared to colonoscopy (7.94 ± 2.30), stool sampling (8.17 ± 1.96), blood sampling (8.87 ± 1.62), and imaging (8.67 ± 1.60);  < 0.01 for each comparison. GIUS caused little patient discomfort (1.88 ± 1.83), and 98 (81%) participants ranked GIUS as their preferred IBD monitoring tool. GIUS also improved patients' overall IBD-specific knowledge (VAS IBD-specific knowledge 7.96 ± 1.92), including their understanding of the need for medical therapy and disease extent.

Conclusion: GIUS is a highly acceptable and well-tolerated tool for monitoring disease activity in IBD patients. GIUS is preferred by patients and enhances IBD-specific knowledge.
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http://dx.doi.org/10.1002/jgh3.12268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144798PMC
April 2020

Exclusive enteral nutrition: An optimal care pathway for use in adult patients with active Crohn's disease.

JGH Open 2020 Apr 10;4(2):260-266. Epub 2019 Sep 10.

Department of Gastroenterology, The Queen Elizabeth Hospital Adelaide South Australia Australia.

Background And Aim: Exclusive enteral nutrition (EEN) is progressively being used as a therapeutic option for adults with Crohn's Disease (CD); however, there is no standardized approach to delivering this therapy. The aim of this study is to develop an optimal care pathway for using EEN in adults with CD. This will create a standard of care that can be used as a benchmark practice and will provide direction for future research.

Methods: A working group of 12 multidisciplinary inflammatory bowel disease specialists across Australia and New Zealand was convened to develop a practical, clinically focused care pathway for using EEN in adults with active CD. Six key areas were identified as part of the care pathway: clinical indications, nutrition assessment, EEN protocol, monitoring, accessing formula, and food reintroduction. Current literature was identified via systematic review, and quality of evidence was graded. Consensus expert opinion was used where literature gaps were identified.

Results: An optimal care pathway for using EEN in adults with CD was developed with six key consensus statements on how to use EEN in adults with active CD. These key statements identify clinical indications for use, nutrition assessment, enteral prescription and duration of therapy, monitoring criteria, food reintroduction, and the role of partial EEN. An accompanying patient resource was also developed.

Conclusion: EEN is recommended as a treatment option to induce remission in adults with active CD. The consensus statements developed are practical and are based on best available evidence and expert opinion to assist in developing a standardized approach to delivering EEN therapy.
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http://dx.doi.org/10.1002/jgh3.12256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144766PMC
April 2020

Systematic Review: Patient Perceptions of Monitoring Tools in Inflammatory Bowel Disease.

J Can Assoc Gastroenterol 2021 Apr 24;4(2):e31-e41. Epub 2020 Jan 24.

Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, Australia.

Background And Aims: Inflammatory bowel disease (IBD) is a lifelong disease requiring frequent assessment to guide treatment and prevent flares or progression. Multiple tools are available for clinicians to monitor disease activity; however, there are a paucity of data to inform which monitoring tools are most acceptable to patients. The review aims to describe the available evidence for patient preference, satisfaction, tolerance and/or acceptability of the available monitoring tools in adults with IBD.

Methods: Embase, Medline, Cochrane Central and Clinical Trials.gov were searched from January 1980 to April 2019 for all study types reporting on the perspectives of adults with confirmed IBD on monitoring tools, where two or more tools were compared. Outcome measures with summary and descriptive data were presented.

Results: In 10 studies evaluating 1846 participants, monitoring tools included venipuncture, stool collection, gastrointestinal ultrasound, computed tomography, magnetic resonance imaging, wireless capsule endoscopy, barium follow-through and endoscopy. Outcome domains were patient satisfaction, acceptability of monitoring tool and patient preference. Noninvasive investigations were preferable to endoscopy in nine studies. When assessed, gastrointestinal ultrasound was consistently associated with greater acceptability and satisfaction compared with endoscopy or other imaging modalities.

Conclusions: Adults with IBD preferred noninvasive investigations, in particular gastrointestinal ultrasound, as compared to endoscopy for monitoring disease activity. When assessing disease activity, patient perceptions should be considered in the selection of monitoring tools. Further research should address whether adpoting monitoring approaches considered more acceptable to patients results in greater satisfaction, adherence and ultimately more beneficial clinical outcomes.
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http://dx.doi.org/10.1093/jcag/gwaa001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023822PMC
April 2021

Editorial: faecal microbiota transplantation-the silver bullet for severe and fulminant Clostridioides difficile infection?

Aliment Pharmacol Ther 2020 01;51(1):180-181

Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, SA, Australia.

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http://dx.doi.org/10.1111/apt.15584DOI Listing
January 2020

Uncovering the cause of ulcerative colitis.

JGH Open 2019 Aug 6;3(4):274-276. Epub 2019 Aug 6.

School of Medicine University of Adelaide Adelaide South Australia Australia.

The cause of ulcerative colitis still remains unclear. The most popular hypothesis is that colitis develops because of a complex interaction of genetic, microbial, environmental, and immunologic factors. This editorial summarizes the widely accepted hypothesis and comments on a variation of this hypothesis promoted by Dr Roediger.
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http://dx.doi.org/10.1002/jgh3.12216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684508PMC
August 2019

Interfering with leukocyte trafficking in Crohn's disease.

Best Pract Res Clin Gastroenterol 2019 Feb - Apr;38-39:101617. Epub 2019 May 28.

Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK. Electronic address:

The discovery of gut-specific leukocytes and the ability to modulate their function has been a groundbreaking development in the treatment of inflammatory bowel disease. Drugs target the interaction between lymphocytes and endothelial cells via integrins and their ligand cellular adhesion molecules. Safety, efficacy and sustainability of effect are key to this drug class, notwithstanding the association of natalizumab with fatal polyoma virus infection. Vedolizumab (2014) now licensed for the treatment of Crohn's disease around the world provides gut-specific immunosuppression. Targets for modulators of leukocyte trafficking include (examples in brackets) ICAM-1 (alicaforsen, efalizumab); MAdCAM-1 (PF-00547 659); α4 and related receptors (abrilumab, etrolizumab, natalizumab, vedolizumab); chemokine receptor CCR9 (vercirnon); and sphingosine 1-phosphate receptors (etrasimod, fingolimod, ozanimod). Oral and subcutaneous therapies are in development. The safety, efficacy and practice points of licensed drugs are discussed, in addition to initial results from therapeutic trials.
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http://dx.doi.org/10.1016/j.bpg.2019.05.004DOI Listing
November 2019

Editorial: assessing histological disease activity in Crohn's disease-a call for standardisation of mucosal biopsy location.

Aliment Pharmacol Ther 2019 07;50(1):103-104

IBD Service, Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, Australia.

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http://dx.doi.org/10.1111/apt.15284DOI Listing
July 2019

Faecal microbiota transplantation in Australia: bogged down in regulatory uncertainty.

Intern Med J 2019 02;49(2):148-151

Inflammatory Bowel Disease Service, Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.

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http://dx.doi.org/10.1111/imj.14212DOI Listing
February 2019

Effect of Fecal Microbiota Transplantation on 8-Week Remission in Patients With Ulcerative Colitis: A Randomized Clinical Trial.

JAMA 2019 01;321(2):156-164

Centre for Nutrition and Gastrointestinal Disease, Adelaide Medical School, University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.

Importance: High-intensity, aerobically prepared fecal microbiota transplantation (FMT) has demonstrated efficacy in treating active ulcerative colitis (UC). FMT protocols involving anaerobic stool processing methods may enhance microbial viability and allow efficacy with a lower treatment intensity.

Objective: To assess the efficacy of a short duration of FMT therapy to induce remission in UC using anaerobically prepared stool.

Design, Setting, And Participants: A total of 73 adults with mild to moderately active UC were enrolled in a multicenter, randomized, double-blind clinical trial in 3 Australian tertiary referral centers between June 2013 and June 2016, with 12-month follow-up until June 2017.

Interventions: Patients were randomized to receive either anaerobically prepared pooled donor FMT (n = 38) or autologous FMT (n = 35) via colonoscopy followed by 2 enemas over 7 days. Open-label therapy was offered to autologous FMT participants at 8 weeks and they were followed up for 12 months.

Main Outcomes And Measures: The primary outcome was steroid-free remission of UC, defined as a total Mayo score of ≤2 with an endoscopic Mayo score of 1 or less at week 8. Total Mayo score ranges from 0 to 12 (0 = no disease and 12 = most severe disease). Steroid-free remission of UC was reassessed at 12 months. Secondary clinical outcomes included adverse events.

Results: Among 73 patients who were randomized (mean age, 39 years; women, 33 [45%]), 69 (95%) completed the trial. The primary outcome was achieved in 12 of the 38 participants (32%) receiving pooled donor FMT compared with 3 of the 35 (9%) receiving autologous FMT (difference, 23% [95% CI, 4%-42%]; odds ratio, 5.0 [95% CI, 1.2-20.1]; P = .03). Five of the 12 participants (42%) who achieved the primary end point at week 8 following donor FMT maintained remission at 12 months. There were 3 serious adverse events in the donor FMT group and 2 in the autologous FMT group.

Conclusions And Relevance: In this preliminary study of adults with mild to moderate UC, 1-week treatment with anaerobically prepared donor FMT compared with autologous FMT resulted in a higher likelihood of remission at 8 weeks. Further research is needed to assess longer-term maintenance of remission and safety.

Trial Registration: anzctr.org.au Identifier: ACTRN12613000236796.
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http://dx.doi.org/10.1001/jama.2018.20046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439766PMC
January 2019

Development, Validation, and Comparative Assessment of an International Scoring System to Determine Risk of Upper Gastrointestinal Bleeding.

Clin Gastroenterol Hepatol 2019 05 27;17(6):1121-1129.e2. Epub 2018 Sep 27.

Department of Medicine, Western University, London, Canada; Division of Epidemiology and Biostatistics, Western University, London, Canada. Electronic address:

Background & Aims: The Glasgow-Blatchford score (GBS) and pre-endoscopy Rockall score (pRS) are used in determining prognoses of patients with acute upper gastrointestinal bleeding, but neither predicts outcomes of patients with a high level of accuracy. A scoring system is needed to identify patients at risk of adverse outcomes and patients at low risk of harm.

Methods: We pooled data from 5 data sets in Canada, the United Kingdom, and Australia on 12,711 patients with acute upper gastrointestinal bleeding. The GBS and pRS were calculated for each patient. We performed multivariable logistic regression modeling of data from 10,639 cases to develop the new scoring system Canada - United Kingdom - Adelaide (CANUKA). We performed area under the receiver operating characteristic analyses to test the ability of CANUKA to identify patients who died or had rebleeding within 30 days, surgical or radiologic intervention to control bleeding, need for therapeutic endoscopy, and transfusion-a poor outcome was defined as 1 or more of these outcomes. Patients at low risk of a poor outcome (safe for management as an outpatient) were identified based on lack of transfusion, rebleeding, therapeutic endoscopy, interventional radiology or surgery, or death. We validated in 2072 patients from a separate cohort compiled from 2 datasets.

Results: In the development data set there was no difference between GBS and pRS in identifying patients who died without 30 days of bleeding (area under the receiver operating characteristic curve [AUROC], 0.67; 95% CI, 0.62-0.72 for GBS; AUROC, 0.70; 95% CI, 0.66-0.74 for pRS; P = .21). The GBS was superior to the pRS in identifying patients with rebleeding, hemostatic interventions, and transfusions. In the validation data set, CANUKA had higher accuracy than the GBS in identifying patients who died within 30 days of bleeding (AUROC, 0.77 vs 0.74; P = .047), but there was no significant difference in the accuracy of these scoring systems in identifying patients who required hemostatic intervention. The GBS more accurately identified patients who required therapeutic endoscopy (AUROC, 0.78; 95% CI, 0.76-0.81 for GBS; AUROC, 0.77; 95% CI, 0.74-0.79 for CANUKA; P = .47). For patients classified as low-risk patients by CANUKA (score ≤1), 96.3% were safely discharged, whereas 16 patients with a GBS ≤1 had an adverse outcome (a 95.3% probability of safe discharge).

Conclusions: In an international validation analysis of the GBS and pRS for patients with acute upper gastrointestinal bleeding, we found the GBS to more accurately identify those who later required hemostatic interventions and transfusions; the scoring systems identified 30-day mortality or rebleeding with equal levels of accuracy. We developed a scoring system (CANUKA) that had similar performance to the GBS in predicting patient outcomes and it more accurately identifies patients at low risk for adverse outcomes.
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http://dx.doi.org/10.1016/j.cgh.2018.09.039DOI Listing
May 2019
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