Mast cell activation and nutritional disorders in patients with hypermobility

PURPOSE OF REVIEW

Individuals with joint hypermobility disorders are increasingly referred to gastroenterology services for support with the investigation and management of gastrointestinal complaints. Individuals can present with a myriad of complex coexisting diagnoses, the inter-relationship of which is unclear. This review discusses the proposed association between hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD) with disorders of mast cell activation and provides an overview of gastrointestinal symptoms and nutritional outcomes in this patient cohort.

RECENT FINDINGS

It is unclear whether a true association between hEDS/HSD and mast cell activation disorders exists. There is a high prevalence of nonspecific gastrointestinal symptoms in individuals with hEDS/HSD and patients may be at risk of macro-nutrient and micro-nutrient deficiencies, although the current evidence base is limited.

SUMMARY

We advocate a pragmatic approach to the investigation and management of gastrointestinal symptoms in patients with hEDS/HSD. This centres on excluding organic pathology, discussing the overlap with disorders of gut-brain interactions, trialling evidence-based therapies targeting individual symptoms, and supporting nutritional deficiencies where present via the least invasive approach. Engagement with a broad multidisciplinary team is also important to support the holistic needs of this patient cohort.

Performance of Artificial Intelligence in Detecting Diabetic Macular Edema From Fundus Photography and Optical Coherence Tomography Images: A Systematic Review and Meta-analysis

BACKGROUND

Diabetic macular edema (DME) is the leading cause of vision loss in people with diabetes. Application of artificial intelligence (AI) in interpreting fundus photography (FP) and optical coherence tomography (OCT) images allows prompt detection and intervention.

PURPOSE

To evaluate the performance of AI in detecting DME from FP or OCT images and identify potential factors affecting model performances.

DATA SOURCES

We searched seven electronic libraries up to 12 February 2023.

STUDY SELECTION

We included studies using AI to detect DME from FP or OCT images.

DATA EXTRACTION

We extracted study characteristics and performance parameters.

DATA SYNTHESIS

Fifty-three studies were included in the meta-analysis. FP-based algorithms of 25 studies yielded pooled area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity of 0.964, 92.6%, and 91.1%, respectively. OCT-based algorithms of 28 studies yielded pooled AUROC, sensitivity, and specificity of 0.985, 95.9%, and 97.9%, respectively. Potential factors improving model performance included deep learning techniques, larger size, and more diversity in training data sets. Models demonstrated better performance when validated internally than externally, and those trained with multiple data sets showed better results upon external validation.

LIMITATIONS

Analyses were limited by unstandardized algorithm outcomes and insufficient data in patient demographics, OCT volumetric scans, and external validation.

CONCLUSIONS

This meta-analysis demonstrates satisfactory performance of AI in detecting DME from FP or OCT images. External validation is warranted for future studies to evaluate model generalizability. Further investigations may estimate optimal sample size, effect of class balance, patient demographics, and additional benefits of OCT volumetric scans.

The Blunt Liver and Spleen Trauma (BLAST) audit: national survey and prospective audit of children with blunt liver and spleen trauma in major trauma centres

PURPOSE

To compare the reported and observed management of UK children with blunt liver or spleen injury (BLSI) to the American Pediatric Surgical Association (APSA) 2019 BLSI guidance.

METHODS

UK Paediatric Major Trauma Centres (pMTCs) undertook 1 year of prospective data collection on children admitted to or discussed with those centres with BLSI and an online questionnaire was distributed to all consultants who care for children with BLSI in those centres.

RESULTS

All 21/21 (100%) pMTCs participated; 131 patients were included and 100/152 (65%) consultants responded to the survey. ICU care was reported and observed to be primarily determined using haemodynamic status or concomitant injuries rather than injury grade, in accordance with APSA guidance. Bed rest was reported to be determined by grade of injury by 63% of survey respondents and observed in a similar proportion of patients. Contrary to APSA guidance, follow-up radiological assessment of the injured spleen or liver was undertaken in 44% of patients before discharge and 32% after discharge, the majority of whom were asymptomatic.

CONCLUSIONS

UK management of BLSI differs from many aspects of APSA guidance. A shift towards using clinical features to determine ICU admission and readiness for discharge is demonstrated, in line with a strong evidence base. However, routine bed rest and re-imaging after BLSI is common, contrary to APSA guidance. This disparity may exist due to concern that evidence around the incidence, presentation and natural history of complications after conservatively managed BLSI, particularly bleeding from pseudoaneurysms, is weak.

Investigating the Relationship between Home Parenteral Support and Needs-Based Quality of Life in Patients with Chronic Intestinal Failure: A National Multi-Centre Longitudinal Cohort Study

Home parenteral support (HPS) is an essential but potentially burdensome treatment that can affect quality of life (QoL). The aims of this longitudinal study were to understand whether any changes in HPS over time were associated with QoL. The Parenteral Nutrition Impact Questionnaire (PNIQ) was used, and data were collected on HPS prescribed at three time points. Data were analysed using multi-level mixed regression models presented as effect size and were adjusted for confounders. Study recruited 572 participants from 15 sites. Of these, 201 and 145 completed surveys at second and third time-points, respectively. PNIQ score was out of 20 with a higher score indicating poorer QoL. Any reduction in HPS infusions per week was associated with an improved PNIQ score of -1.10 (95% CI -2.17, -0.02) unadjusted and -1.34 (95% CI -2.45, -0.24) adjusted. Per day change to the number of infusions per week was associated with a change in the PNIQ score of 0.32 (95% CI -0.15, 0.80) unadjusted and 0.34 (95% CI -0.17, 0.85) adjusted. This is the largest national study to demonstrate improvements in QoL associated with HPS reduction over time using an HPS-specific and patient-centric tool, adding unique data for use of therapies in intestinal failure.

1226 A MULTI-DISCIPLINARY APPROACH TO TRANSFORMING EYE CARE SERVICES FOR CARE HOME RESIDENTS

Introduction

Care home residents can have variable access to eye care services and treatments. We developed a collaborative approach between optometrists, care homes, and primary and secondary care to enable personalised patient-centred care.

Objective

To develop and evaluate an integrated model of eye care for care home residents.

Methods

Small scale plan-do-study-act (PDSA) service tests were completed in three care-homes in Southwark (2 residential, 1 nursing) between November 2021 to May 2022. Processes were compared to historical feedback and hospital-based ophthalmology clinic attendances (Mar 2019-2020). Hospital-like assessments were piloted at two care homes for feasibility and acceptability. Further piloting utilised usual domiciliary optometry-led assessment with multidisciplinary meeting access (including optometrist, GP, geriatrician, ophthalmologist and care home nurse) to reduce duplication of assessments and to evaluate MDM processes and referral rates.

Results

Examination was 100% successful at home (visual acuity and pressure measurement) compared to hospital outpatients (71.7% success visual acuity, 54.5% pressures). Examination was faster than in hospital settings (16 minutes vs 45 minutes-1 hour). Residents were away from usual activities for 32 minutes vs 6 hours for hospital visits including transport. Residents were less distressed with home-based assessments. Did-Not-Attend (DNA) rates reduced (26.7% to 0%), secondary care discharge rates improved (8.4% to 32%). Hospital eye service referral were indicated in 19% -23%, half of which were for consideration of cataract surgery. Alternative conservative plans were agreed at MDM for nursing home residents who were clinically too frail or would not have been able to comply with treatments avoiding 33% unnecessary referrals.

Conclusions

Home-based eye care assessments appear better tolerated and are more efficient for residents, health and care staff. Utilising an MDM for optometrists to discuss residents with ophthalmologists and wider MDT members enabled personalised patient-centred decision-making. Future work to test this borough wide is in progress.

Gastrointestinal symptoms and nutritional issues in patients with hypermobility disorders: assessment, diagnosis and management

Patients diagnosed with hypermobile Ehlers-Danlos syndrome and hypermobile spectrum disorders are increasingly presenting to secondary and tertiary care centres with gastrointestinal (GI) symptoms and nutritional issues. Due to the absence of specific guidance, these patients are investigated, diagnosed and managed heterogeneously, resulting in a growing concern that they are at increased risk of iatrogenic harm. This review aims to collate the evidence for the causes of GI symptoms, nutritional issues and associated conditions as well as the burden of polypharmacy in this group of patients. We also describe evidence-based strategies for management, with an emphasis on reducing the risk of iatrogenic harm and improving multidisciplinary team care.

Internet of things-Enabled technologies as an intervention for childhood obesity: A systematic review

Childhood obesity is one of the most serious public health challenges of the 21st century, with consequences lasting into adulthood. Internet of Things (IoT)-enabled devices have been studied and deployed for monitoring and tracking diet and physical activity of children and adolescents as well as a means of providing remote, ongoing support to children and their families. This review aimed to identify and understand current advances in the feasibility, system designs, and effectiveness of IoT-enabled devices to support weight management in children. We searched Medline, PubMed, Web of Science, Scopus, ProQuest Central and the IEEE Xplore Digital Library for studies published after 2010 using a combination of keywords and subject headings related to health activity tracking, weight management, youth and Internet of Things. The screening process and risk of bias assessment were conducted in accordance with a previously published protocol. Quantitative analysis was conducted for IoT-architecture related findings and qualitative analysis was conducted for effectiveness-related measures. Twenty-three full studies are included in this systematic review. The most used devices were smartphone/mobile apps (78.3%) and physical activity data (65.2%) from accelerometers (56.5%) were the most commonly tracked data. Only one study embarked on machine learning and deep learning methods in the service layer. Adherence to IoT-based approaches was low but game-based IoT solutions have shown better effectiveness and could play a pivotal role in childhood obesity interventions. Researcher-reported effectiveness measures vary greatly amongst studies, highlighting the importance for improved development and use of standardised digital health evaluation frameworks.

Impact of fast-track regulatory designations on strategic commercialization decisions for autologous cell therapies

Background: Regulatory authorities around the world have introduced incentives to improve the speed-to-market of innovative therapies. Aim & methods: To better understand the capacity and portfolio planning decisions of autologous cell therapies and particularly the impact of fast-tracking designations, this paper describes a mixed-integer linear programming approach for the optimization of capacity investment and portfolio selection decisions to maximize the net present value of a candidate portfolio of therapies under different regulatory programs. Results: The illustrative example shows that fast-track designations allow a 25% earlier breakeven, 42-86% higher net present value over a 20-year horizon with earlier upfront capital and reduce the portfolio's sensitivity to uncertainties. Conclusion: Fast-track designations are effective in providing commercialization incentives, but high capital risks given the compressed timeline should be better considered.

Impact of home parenteral nutrition on family members: A national multi-centre cross-sectional study

BACKGROUND & AIMS

Home parenteral nutrition (HPN) is a necessary treatment for patients with chronic, type 3, intestinal failure (IF). HPN often requires lifestyle adaptations, which are likely to affect quality of life (QoL) in both patients and family members. The aim of this study was to identify the level of burden on family members who are involved with HPN care and to understand specific factors that contribute to any burden.

METHODS

Patients over the age of 18 and receiving HPN were identified in IF clinics from multiple centres across the U.K. Eligible patients were asked to complete the parenteral nutrition impact questionnaire (PNIQ) to assess their QoL, while family members were asked to complete the burden scale for family caregivers (BSFC). Logistical regression was undertaken giving adjusted odds ratios (aOR).

RESULTS

678 participants completed the survey representing 339 patients with their appointed family member. Mean PNIQ score was 11.53 (S.D. 5.5), representing a moderate impact of HPN on patients' QoL. On the BSFC scale, 23% of family members reported a moderate to very severe subjective burden indicating an increased risk of psychosomatic symptoms. After adjusting for age and gender, predictors of BSFC included: family members self-reported health status using the EuroQol visual analogue scale (aOR 19.91, 95% CI 1.69, 233.99, p = 0.017) and support received by health services (aOR = 5.83, 95% CI = 1.93, 17.56, p = 0.002). Employment status, disease type, number of nights on HPN and length of time on HPN were not associated with BSFC.

CONCLUSIONS

Family members with a poor health status or lack of support by health service were more likely to have a moderate to very severe subjective burden. Tailored support from the multi-professional IF team may reduce the burden experienced by family members of people dependent on HPN.

Development of heart failure in long-term survivors of childhood cancer: results from the cvss study

Background

Long-term survivors of childhood cancer (CCS) are at increased risk for cardiovascular sequelae, including heart failure (HF) as the largest non-malignant contributor to excess death. Yet, little is known about the risk factors, mechanisms of cardiac dysfunction and prevalence of different stages of HF in these patients.

Purpose

To investigate the development and prevalence of HF phenotypes in CCS compared to the general population.

Methods

The CVSS study is a prospective single-center cohort study investigating cardiovascular sequelae of CCS. Patients were eligible for the study when they were diagnosed with a neoplasia according to the International Classification of Childhood Cancer (ICCC 3) at an age prior to 15 years between 1980 and 1990, survived more than five years after initial cancer diagnosis and received antineoplastic treatment. Between 2013 and 2016, study individuals underwent a comprehensive, standardized clinical investigation in the CVSS cohort study including echocardiographic examination. HF was categorized as stages A to D according to current HF guidelines of the American Heart Association (AHA). A population-based sample free of cancer (age- and sex matched) serves as control group.

Results

From 1,002 individuals, all CCS with history of chemo- or radiotherapy and no subsequent neoplasia (n=877) were included (mean age 34.2 (±5.5) years, 44.7% (N=392) female). Age at diagnosis was 6.28 years (±4.24) and the mean interval from the date of diagnosis of cancer to the date of completion of baseline examination 28.5±3.2 years. Based on echocardiographic examination, clinical data and biomarker assessment, 26.6% of CCS were diagnosed with HF stage A, 21.1% with HF stage B and 2.1% with symptomatic HF, i.e. HF stage C/D. Importantly, prevalence of different HF stages varied strongly by specific tumor history. Compared to the population, the prevalence ratio (PR) was 1.16 [95% confidence interval 1.02/1.31] for stage A HF and 1.91 [1.63/2.23] for the composite of stage B to D HF in an age- and sex-adjusted Poisson regression model. Multivariable linear regression with the systolic marker left ventricular ejection fraction as dependent variable and adjustment for tumor entities, age, sex, and cardiovascular risk factors (CVRF) revealed a lower EF in patients with history of bone tumors (β −6.0 [−8.1/−3.0]), soft tissue sarcoma (β −2.2 [−4.1/−0.35]), leukemia (β −0.84 [−1.8/0.08]) and renal tumors (β −1.8 [−4.0/0.27]) compared to the population. In contrast, the same model for the diastolic marker E/E', showed an association only with CVRF, but not with tumor entities.

Conclusion

The prevalence of stage B to D HF was significantly higher among long-term CCS in the 3rd to 5th age decade compared to the population and varied strongly by tumor entity. Systolic dysfunction was primarily associated with history of tumor entities, whereas diastolic dysfunction was associated with the higher burden of CVRF in CCS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study is funded by the Deutsche Forschungsgemeinschaft (DFG) (SP 1381/2-1&2, FA 1038/2-1&2, WI 3881/2-1&2)

Digital Technologies for Monitoring and Improving Treatment Adherence in Children and Adolescents With Asthma: Scoping Review of Randomized Controlled Trials

BACKGROUND

Inadequate pediatric asthma care has resulted in potentially avoidable unplanned hospital admissions and morbidity. A wide variety of digital technologies have been developed to monitor and support treatment adherence in children and adolescents with asthma. However, existing reviews need to be updated and expanded to provide an overview of the current state of research on these technologies and how they are being integrated into existing health care services and care pathways.

OBJECTIVE

This study aims to provide an overview of the current research landscape and knowledge gaps regarding the use of digital technologies to support the care of children and adolescents with asthma.

METHODS

This study was structured according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) and Population, Intervention, Comparator, Outcome, and Study frameworks. Five databases (PubMed, the Cochrane Central Register of Controlled Trials, Web of Science, Embase, and PsycINFO) were systematically searched for studies published in English from 2014 onward. Two reviewers independently screened the references and selected studies for inclusion based on the eligibility criteria. Data were systematically extracted per research question, which were synthesized in a descriptive analysis.

RESULTS

A wide variety of study characteristics, including the number and age of participants, study duration, and type of digital intervention, were identified. There was mixed evidence for the effectiveness of the interventions. Of the 10 studies that evaluated treatment adherence, 7 (70%) found improvements, but the evidence was inconsistent for asthma control (6/9, 67% of studies reported improvement or maintenance, but only 1 was significantly different between groups) and health outcome variables (5/9, 56% of studies found no evidence of effectiveness). The 6 studies that examined patient perceptions and assessments of acceptability and usability generally had positive findings.

CONCLUSIONS

A wide range of digital interventions are being developed and evaluated to support the monitoring and treatment adherence of children and adolescents with asthma. Meta-analyses are inhibited by the use of samples with a variety of overlapping age ranges; a theoretical framework for evaluating specific age groups would aid comparison between studies. Most studies found significant evidence for improved adherence to treatment or medications, but there was mixed evidence of the impact of the digital interventions on asthma control and other health outcomes. There are gaps in the literature relating to cost-effectiveness and integration with existing clinical care pathways. This study will be necessary to determine which digital interventions for children and young people with asthma are worth supporting and adopting in the clinical care pathways.

Machine Learning for Risk Group Identification and User Data Collection in a Herpes Simplex Virus Patient Registry: Algorithm Development and Validation Study

BACKGROUND

Researching people with herpes simplex virus (HSV) is challenging because of poor data quality, low user engagement, and concerns around stigma and anonymity.

OBJECTIVE

This project aimed to improve data collection for a real-world HSV registry by identifying predictors of HSV infection and selecting a limited number of relevant questions to ask new registry users to determine their level of HSV infection risk.

METHODS

The US National Health and Nutrition Examination Survey (NHANES, 2015-2016) database includes the confirmed HSV type 1 and type 2 (HSV-1 and HSV-2, respectively) status of American participants (14-49 years) and a wealth of demographic and health-related data. The questionnaires and data sets from this survey were used to form two data sets: one for HSV-1 and one for HSV-2. These data sets were used to train and test a model that used a random forest algorithm (devised using Python) to minimize the number of anonymous lifestyle-based questions needed to identify risk groups for HSV.

RESULTS

The model selected a reduced number of questions from the NHANES questionnaire that predicted HSV infection risk with high accuracy scores of 0.91 and 0.96 and high recall scores of 0.88 and 0.98 for the HSV-1 and HSV-2 data sets, respectively. The number of questions was reduced from 150 to an average of 40, depending on age and gender. The model, therefore, provided high predictability of risk of infection with minimal required input.

CONCLUSIONS

This machine learning algorithm can be used in a real-world evidence registry to collect relevant lifestyle data and identify individuals' levels of risk of HSV infection. A limitation is the absence of real user data and integration with electronic medical records, which would enable model learning and improvement. Future work will explore model adjustments, anonymization options, explicit permissions, and a standardized data schema that meet the General Data Protection Regulation, Health Insurance Portability and Accountability Act, and third-party interface connectivity requirements.

Distributed Ledger Infrastructure to Verify Adverse Event Reporting (DeLIVER): Proposal for a Proof-of-Concept Study

Background

Adverse drug event reporting is critical for ensuring patient safety; however, numbers of reports have been declining. There is a need for a more user-friendly reporting system and for a means of verifying reports that have been filed.

Objective

This project has 2 main objectives: (1) to identify the perceived benefits and barriers in the current reporting of adverse events by patients and health care providers and (2) to develop a distributed ledger infrastructure and user interface to collect and collate adverse event reports to create a comprehensive and interoperable database.

Methods

A review of the literature will be conducted to identify the strengths and limitations of the current UK adverse event reporting system (the Yellow Card System). If insufficient information is found in this review, a survey will be created to collect data from system users. The results of these investigations will be incorporated into the development of a mobile and web app for adverse event reporting. A digital infrastructure will be built using distributed ledger technology to provide a means of linking reports with existing pharmaceutical tracking systems.

Results

The key outputs of this project will be the development of a digital infrastructure, including a backend distributed ledger system and an app-based user interface.

Conclusions

This infrastructure is expected to improve the accuracy and efficiency of adverse event reporting systems by enabling the monitoring of specific medicines or medical devices over their life course while protecting patients’ personal health data.

International Registered Report Identifier (IRRID)

PRR1-10.2196/28616

377 Global Recruitment for The RESECT Study (Transurethral Resection and Single-Instillation Intravesical Chemotherapy Evaluation in Bladder Cancer Treatment): An International Observational Cohort Study Aiming to Improve the Quality of Surgery for Non-Muscle Invasive Bladder Cancer

Introduction

Non-muscle invasive bladder cancer (NMIBC) can be curatively treated with ‘good quality’ transurethral resection of the bladder tumour (TURBT). However, despite evidence-based international guidelines, there is anecdotal evidence that practice varies widely, and this may affect oncological outcomes. Launching in 2020, RESECT aims to measure and report variation in TURBT quality globally, and determine if outcome reporting improves outcomes.

Method

RESECT was advertised internationally through social media, mailing lists, websites, and in person. Collaborators at each registered site will collect data about current practice and the experience of local TURBT surgeons. The primary outcome is the rate of achievement of key TURBT quality indicators.

Results

As of August 27, 508 collaborators have registered to participate. Collaborators represent 321 centres from 54 countries, with the highest number from the United Kingdom (54.5%), Spain (5.9%), and Argentina (3.7%). 51.2% are trainees, 29.9% consultants, and 17.5% medical students. Based on current registrations, patient recruitment will far exceed initial projections and considerably improve statistical power.

Conclusions

RESECT has attracted a large number of collaborators globally and from all training levels. Therefore, the RESECT study has the potential to improve the quality of TURBT surgery across the world.

Colonic Gene Expression and Fecal Microbiota in Diarrhea-predominant Irritable Bowel Syndrome: Increased Toll-like Receptor 4 but Minimal Inflammation and no Response to Mesalazine

Background/Aims

Diarrhea-predominant irritable bowel syndrome (IBS-D) has been previously associated with evidence of immune activation and altered microbiota. Our aim is to assess the effect of the anti-inflammatory agent, mesalazine, on inflammatory gene expression and microbiota composition in IBS-D.

Methods

We studied a subset of patients (n = 43) from a previously published 12-week radomized placebo-controlled trial of mesalazine. Mucosal biopsies were assessed by immunohistochemistry and reverse transcription-polymerase chain reaction for a range of markers of inflammation, altered permeability, and sensory receptors including Toll-like receptors (TLRs) at randomization after treatment. All biopsy data were compared to 21 healthy controls. Patient’s stool microbiota composition was analysed through 16S ribosomal RNA sequencing.

Results

We found no evidence of increased immune activation compared to healthy controls. However, we did find increased expression of receptors in both sensory pathways and innate immune response including TLR4. Higher TLR4 expression was associated with greater urgency. TLR4 expression correlated strongly with the expression of the receptors bradykinin receptor B2, chemerin chemokine-like receptor 1, and transient receptor potential cation channel, subfamily A, member 1 as well as TLR4’s downstream adaptor myeloid differentiation factor 88. Mesalazine had minimal effect on either gene expression or microbiota composition.

Conclusions

Biopsies from a well-characterized IBS-D cohort showed no substantial inflammation. Mesalazine has little effect on gene expression and its previous reported effect on fecal microbiota associated with much greater inflammation found in inflammatory bowel diseases is likely secondary to reduced inflammation. Increased expression of TLR4 and correlated receptors in IBS may mediate a general increase in sensitivity to external stimuli, particularly those that signal via the TLR system.

Comparison between centralized and decentralized supply chains of autologous chimeric antigen receptor T-cell therapies: a UK case study based on discrete event simulation

BACKGROUND AIMS

Decentralized, or distributed, manufacturing that takes place close to the point of care has been a manufacturing paradigm of heightened interest within the cell therapy domain because of the product's being living cell material as well as the need for a highly monitored and temperature-controlled supply chain that has the potential to benefit from close proximity between manufacturing and application.

METHODS

To compare the operational feasibility and cost implications of manufacturing autologous chimeric antigen receptor T (CAR T)-cell products between centralized and decentralized schemes, a discrete event simulation model was built using ExtendSIM 9 for simulating the patient-to-patient supply chain, from the collection of patient cells to the final administration of CAR T therapy in hospitals. Simulations were carried out for hypothetical systems in the UK using three demand levels-low (100 patients per annum), anticipated (200 patients per annum) and high (500 patients per annum)-to assess resource allocation, cost per treatment and system resilience to demand changes and to quantify the risks of mix-ups within the supply chain for the delivery of CAR T treatments.

RESULTS

The simulation results show that although centralized manufacturing offers better economies of scale, individual facilities in a decentralized system can spread facility costs across a greater number of treatments and better utilize resources at high demand levels (annual demand of 500 patients), allowing for an overall more comparable cost per treatment. In general, raw material and consumable costs have been shown to be one of the greatest cost drivers, and genetic modification-associated costs have been shown to account for over one third of raw material and consumable costs. Turnaround time per treatment for the decentralized scheme is shown to be consistently lower than its centralized counterpart, as there is no need for product freeze-thaw, packaging and transportation, although the time savings is shown to be insignificant in the UK case study because of its rather compact geographical setting with well-established transportation networks. In both schemes, sterility testing lies on the critical path for treatment delivery and is shown to be critical for treatment turnaround time reduction.

CONCLUSIONS

Considering both cost and treatment turnaround time, point-of-care manufacturing within the UK does not show great advantages over centralized manufacturing. However, further simulations using this model can be used to understand the feasibility of decentralized manufacturing in a larger geographical setting.

Pain Severity Correlates With Biopsy-Mediated Colonic Afferent Activation But Not Psychological Scores in Patients With IBS-D

INTRODUCTION

Despite heterogeneity, an increased prevalence of psychological comorbidity and an altered pronociceptive gut microenvironment have repeatedly emerged as causative pathophysiology in patients with irritable bowel syndrome (IBS). Our aim was to study these phenomena by comparing gut-related symptoms, psychological scores, and biopsy samples generated from a detailed diarrhea-predominant IBS patient (IBS-D) cohort before their entry into a previously reported clinical trial.

METHODS

Data were generated from 42 patients with IBS-D who completed a daily 2-week bowel symptom diary, the Hospital Anxiety and Depression score, and the Patient Health Questionnaire-12 Somatic Symptom score and underwent unprepared flexible sigmoidoscopy. Sigmoid mucosal biopsies were separately evaluated using immunohistochemistry and culture supernatants to determine cellularity, mediator levels, and ability to stimulate colonic afferent activity.

RESULTS

Pain severity scores significantly correlated with the daily duration of pain (r = 0.67, P < 0.00001), urgency (r = 0.57, P < 0.0005), and bloating (r = 0.39, P < 0.05), but not with psychological symptom scores for anxiety, depression, or somatization. Furthermore, pain severity scores from individual patients with IBS-D were significantly correlated (r = 0.40, P < 0.008) with stimulation of colonic afferent activation mediated by their biopsy supernatant, but not with biopsy cell counts nor measured mediator levels.

DISCUSSION

Peripheral pronociceptive changes in the bowel seem more important than psychological factors in determining pain severity within a tightly phenotyped cohort of patients with IBS-D. No individual mediator was identified as the cause of this pronociceptive change, suggesting that nerve targeting therapeutic approaches may be more successful than mediator-driven approaches for the treatment of pain in IBS-D.

Developing a Blockchain-Based Supply Chain System for Advanced Therapies: Protocol for a Feasibility Study

Background

Advanced therapies, including cell and gene therapies, have shown therapeutic promise in curing life-threatening diseases, such as leukemia and lymphoma. However, these therapies can be complicated and expensive to deliver due to their sensitivity to environment; troublesome tissue, cell, or genetic material sourcing; and complicated regulatory requirements.

Objective

This study aims to create a novel connected supply chain logistics and manufacturing management platform based on blockchain, with cell and gene therapy as a use case. Objectives are to define the requirements and perform feasibility evaluations on the use of blockchain for standardized manufacturing and establishment of a chain of custody for the needle-to-needle delivery of autologous cell and gene therapies. A way of lowering overall regulatory compliance costs for running a network of facilities operating similar or parallel processes will be evaluated by lowering the monitoring costs through publishing zero-knowledge proofs and product release by exception.

Methods

The study will use blockchain technologies to digitally connect and integrate supply chain with manufacturing to address the security, scheduling, and communication issues between advanced therapy treatment centers and manufacturing facilities in order to realize a transparent, secure, automated, and cost-effective solution to the delivery of these life-saving therapies. An agile software development methodology will be used to develop, implement, and evaluate the system. The system will adhere to the EU and US good manufacturing practices and regulatory requirements.

Results

This is a proposed study protocol, and upon acceptance, grant funding will be pursued for its execution in 2021.

Conclusions

The successful implementation of the integrated blockchain solution to supply chain and manufacturing of advanced therapies can push the industry standards toward a safer and more secure therapy delivery process.

International Registered Report Identifier (IRRID)

PRR1-10.2196/17005

Mobile Fitness and Weight Management Apps: Protocol for a Quality Evaluation

BACKGROUND

Obesity is a contributing factor for many noncommunicable diseases and a growing problem worldwide. Many mobile apps have been developed to help users improve their fitness and weight management behaviors. However, the speed at which apps are created and updated means that it is important to periodically assess their quality.

OBJECTIVE

The purpose of this study is to evaluate the quality of fitness and weight management mobile health apps using the Mobile Application Rating Scale (MARS). It will also describe the features of the included apps and compare the results to a previous evaluation conducted in 2015.

METHODS

Searches for "fitness," "weight," "exercise," "physical activity," "diet," "eat*," and "food" will be conducted in the Apple App Store and Google Play. Apps that have been updated over the past 5 years will be included. Two reviewers will rate the apps' quality using the MARS objective and subjective quality subscales. Interrater reliability will also be assessed. Features included in high-quality apps will be assessed, and changes in quality, features, and behavior change techniques made during the past 5 years will be described.

RESULTS

The results will be included in the evaluation paper, which we aim to publish in 2020.

CONCLUSIONS

This evaluation will assess the quality of currently available fitness and weight management apps.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/17685.

The Impact of Brexit on the Pharmaceutical Supply Chain of the United Kingdom: Scoping Review Protocol

Background

The continuing uncertainty around Brexit has caused concern in the pharmaceutical industry and among health care professionals and patients. The exact consequences of Brexit on the pharmaceutical supply chain in the United Kingdom will depend on whether a deal is reached and what it entails, but it is likely to be affected by the withdrawal of the United Kingdom from the European Union. Regulatory issues and delays in supply have the potential to negatively affect the ability of UK residents to receive an adequate and timely supply of necessary medicines.

Objective

The purpose of this protocol is to provide an overview and critical analysis of current perspectives on the effect of Brexit on the UK pharmaceutical supply chain.

Methods

The PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines will be used to structure this protocol. A systematic search of MEDLINE, EMBASE, PsycINFO, Healthcare Management Information Consortium (HMIC), Cochrane, Web of Science, Business Source Complete, EconLit, and Economist Intelligence Unit will be conducted, as well as a Google and Nexis.UK search for grey literature such as reports, opinion pieces, and press releases. Two reviewers will independently screen the titles and abstracts of identified references and select studies according to the eligibility criteria. Any discrepancies will then be discussed and resolved. One reviewer will extract data from the included studies into a standardized form, which will be validated by a second reviewer. Risk of bias will be assessed using the Cochrane Collaboration Risk of Bias tool for any randomized controlled trials; quality will be assessed using the relevant Critical Appraisal Skills Programme (CASP) checklists; and grey literature will be assessed using the Authority, Accuracy, Coverage, Objectivity, Date, Significance (AACODS) checklist. Outcomes include the agreement between sources on the potential, likelihood, and severity of the consequences of Brexit on the UK pharmaceutical supply chain.

Results

Results will be included in the scoping review, which will be published in 2020.

Conclusions

This scoping review will summarize the currently expected consequences of Brexit on the UK pharmaceutical supply chain.

International Registered Report Identifier (IRRID)

PRR1-10.2196/17684

Agile Requirements Engineering and Software Planning for a Digital Health Platform to Engage the Effects of Isolation Caused by Social Distancing: Case Study

Background

Social distancing and shielding measures have been put in place to reduce social interaction and slow the transmission of the coronavirus disease (COVID-19). For older people, self-isolation presents particular challenges for mental health and social relationships. As time progresses, continued social distancing could have a compounding impact on these concerns.

Objective

This project aims to provide a tool for older people and their families and peers to improve their well-being and health during and after regulated social distancing. First, we will evaluate the tool’s feasibility, acceptability, and usability to encourage positive nutrition, enhance physical activity, and enable virtual interaction while social distancing. Second, we will be implementing the app to provide an online community to assist families and peer groups in maintaining contact with older people using goal setting. Anonymized data from the app will be aggregated with other real-world data sources to develop a machine learning algorithm to improve the identification of patients with COVID-19 and track for real time use by health systems.

Methods

Development of this project is occurring at the time of publication, and therefore, a case study design was selected to provide a systematic means of capturing software engineering in progress. The app development framework for software design was based on agile methods. The evaluation of the app’s feasibility, acceptability and usability shall be conducted using Public Health England's guidance on evaluating digital health products, Bandura’s model of health promotion, the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework and the Nonadoption, Abandonment and Challenges to the Scale-up, Spread and Suitability (NASSS) framework.

Results

Making use of a pre-existing software framework for health behavior change, a proof of concept was developed, and a multistage app development and deployment for the solution was created. Grant submissions to fund the project and study execution have been sought at the time of publication, and prediscovery iteration of the solution has begun. Ethical approval for a feasibility study design is being sought.

Conclusions

This case study lays the foundations for future app development to combat mental and societal issues arising from social distancing measures. The app will be tested and evaluated in future studies to allow continuous improvement of the app. This novel contribution will provide an evidence-based exemplar for future app development in the space of social isolation and loneliness.

Massive Open Online Course Evaluation Methods: Systematic Review

BACKGROUND

Massive open online courses (MOOCs) have the potential to make a broader educational impact because many learners undertake these courses. Despite their reach, there is a lack of knowledge about which methods are used for evaluating these courses.

OBJECTIVE

The aim of this review was to identify current MOOC evaluation methods to inform future study designs.

METHODS

We systematically searched the following databases for studies published from January 2008 to October 2018: (1) Scopus, (2) Education Resources Information Center, (3) IEEE (Institute of Electrical and Electronic Engineers) Xplore, (4) PubMed, (5) Web of Science, (6) British Education Index, and (7) Google Scholar search engine. Two reviewers independently screened the abstracts and titles of the studies. Published studies in the English language that evaluated MOOCs were included. The study design of the evaluations, the underlying motivation for the evaluation studies, data collection, and data analysis methods were quantitatively and qualitatively analyzed. The quality of the included studies was appraised using the Cochrane Collaboration Risk of Bias Tool for randomized controlled trials (RCTs) and the National Institutes of Health-National Heart, Lung, and Blood Institute quality assessment tool for cohort observational studies and for before-after (pre-post) studies with no control group.

RESULTS

The initial search resulted in 3275 studies, and 33 eligible studies were included in this review. In total, 16 studies used a quantitative study design, 11 used a qualitative design, and 6 used a mixed methods study design. In all, 16 studies evaluated learner characteristics and behavior, and 20 studies evaluated learning outcomes and experiences. A total of 12 studies used 1 data source, 11 used 2 data sources, 7 used 3 data sources, 4 used 2 data sources, and 1 used 5 data sources. Overall, 3 studies used more than 3 data sources in their evaluation. In terms of the data analysis methods, quantitative methods were most prominent with descriptive and inferential statistics, which were the top 2 preferred methods. In all, 26 studies with a cross-sectional design had a low-quality assessment, whereas RCTs and quasi-experimental studies received a high-quality assessment.

CONCLUSIONS

The MOOC evaluation data collection and data analysis methods should be determined carefully on the basis of the aim of the evaluation. The MOOC evaluations are subject to bias, which could be reduced using pre-MOOC measures for comparison or by controlling for confounding variables. Future MOOC evaluations should consider using more diverse data sources and data analysis methods.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/12087.

Knowledge, Attitude and Preventive Practice on Dementia Care among Primary Health Professionals in Macao

The Macao Dementia Policy was recognized by Alzheimer Disease International as the 27th globally and one of the highest stage 5 to develop dementia friendly community and primary health professionals are in a pivotal position to enhance community-based dementia prevention and care quality. This study aimed to investigate the knowledge, attitude and preventive practice on dementia care among primary health professionals in Macao. A specially designed 30-item questionnaire was developed and validated for the study. The Content Validity Index (CVI) and Cronbach's α of the questionnaire were 0.973 and 0.808. The questionnaires were distributed to all 375 primary health professionals from 8 Health Centers throughout Macao and 234 valid questionnaires (62.4%) were returned. The score for dementia care knowledge was 87.02±14.01; attitude was 69.52±5.83; preventive practice was 77.88±13.18, of which doctors (79.89±13.77) was significantly higher (t=2.29, p=0.023) than nurses (75.91±12.33). There were positive relationships between preventive practice and attitude (r=0.163, p=0.014), and age (r=0.212, p=0.002), and a negative relationship between knowledge and age (r=-0.139, p=0.040). These findings have significant implications that most primary health professionals in Macao had sufficient knowledge, a positive attitude and appropriate preventive practice on dementia care. However, enhanced dementia education to improve knowledge and preventive practice was a strong agenda for the training for senior staff and nurses.

Application of Internet of Things in Cell-Based Therapy Delivery: Protocol for a Systematic Review

Background

Internet of Things (IoT), or Industry 4.0, represents a smart shift to more interconnected manufacturing processes where individual entities within the supply chain communicate with each other to achieve greater flexibility and responsiveness in general manufacturing and leaner manufacturing to reduce the cost of production. IoT has become instrumental in driving leaner manufacturing and more efficient systems in other industries such as transportation and logistics. Cell-based therapeutic products could potentially transform various diseases; however, the delivery of these products is complex and challenging.

Objective

This study aims to understand the applicability of IoT in cell-based product supply chains and delivery.

Methods

We will search Medline, EMBASE (OvidSP), Web of Science, Cochrane Library &amp; HEED, Scopus, ACM digital library, INSPEC, ScienceDirect, and the IEEE Xplore Digital Library for studies published after 2008 using a combination of keywords and subject headings related to IoT used in cell therapies. Additionally, a Google search to identify gray literature will be conducted. Two authors will independently screen the titles and abstracts identified from the search and accept or reject the studies according to the study inclusion criteria. Any discrepancies will then be discussed and resolved. The quality of the selected literature will be assessed using the Critical Appraisal Skills Programme systematic review checklist.

Results

Data from eligible publications will be abstracted into a predesigned form to map the current and future directions of the technologies, applications, benefits, and challenges in the implementation of IoT in regenerative medicine. This study will be published in a peer-reviewed journal in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This systematic review will be executed by June 2020, and the completed review will be published in a peer-reviewed journal to inform future developments in IoT application for the delivery of cell-based therapies.

Conclusions

This review paper will provide an overview of all technologies available in the area and inspect the current IoT applications in cell-based therapies to identify the benefits, challenges, and future directions of using IoT to allow safe and cost-effective delivery of cell-based therapies.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16935

Internet of Things-Enabled Technologies for Weight Management in Children and Adolescents: Protocol for a Systematic Review

Background

Childhood obesity is a serious global issue, leading to increased medical spending on obesity-related diseases such as cardiovascular diseases and diabetes. There is a need for health care services that link health behavior to risk factors, such as diet and physical activity, and that provide better advice and feedback to users, which Internet of Things–enabled technologies could facilitate.

Objective

The objective of the systematic review will be to identify available Internet of Things–enabled technologies for weight management of children and adolescents (users younger than 18 years). It will also aim to understand the use, effectiveness, and feasibility of these technologies.

Methods

We will search the Medline, PubMed, Web of Science, Scopus, ProQuest Central, and IEEE Xplore Digital Library databases for studies published after 2010, using a combination of keywords and subject headings related to health activity tracking, youth, and Internet of Things. In addition, a Google search to identify grey literature will be conducted. Two authors will independently screen the titles and abstracts identified from the search and accept or reject the studies according to the study inclusion criteria. Any discrepancies will then be discussed and resolved. The quality of the included studies will be assessed using the Critical Appraisal Skills Programme (CASP) checklists. Data from included studies will be extracted into a predesigned form to identify the types of devices or apps, Internet of Things applications, and health outcomes related to weight management.

Results

A preliminary search on Medline returned 484 results. The publication of the final systematic review is expected in mid-2020.

Conclusions

The effectiveness and feasibility of physical activity trackers and consumer wearables for different patient groups have been well reviewed, but there are currently no published reviews that look into these technologies in the wider Internet of Things context. This review aims to address this gap by examining Internet of Things–enabled technologies that are designed for youth weight management and thus inform further research and clinical studies to reduce childhood obesity.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16930

Mobile Apps for Health Behavior Change in Physical Activity, Diet, Drug and Alcohol Use, and Mental Health: Systematic Review

Background

With a growing focus on patient interaction with health management, mobile apps are increasingly used to deliver behavioral health interventions. The large variation in these mobile health apps—their target patient group, health behavior, and behavioral change strategies—has resulted in a large but incohesive body of literature.

Objective

This systematic review aimed to assess the effectiveness of mobile apps in improving health behaviors and outcomes and to examine the inclusion and effectiveness of behavior change techniques (BCTs) in mobile health apps.

Methods

PubMed, EMBASE, CINAHL, and Web of Science were systematically searched for articles published between 2014 and 2019 that evaluated mobile apps for health behavior change. Two authors independently screened and selected studies according to the eligibility criteria. Data were extracted and the risk of bias was assessed by one reviewer and validated by a second reviewer.

Results

A total of 52 randomized controlled trials met the inclusion criteria and were included in the analysis—37 studies focused on physical activity, diet, or a combination of both, 11 on drug and alcohol use, and 4 on mental health. Participant perceptions were generally positive—only one app was rated as less helpful and satisfactory than the control—and the studies that measured engagement and usability found relatively high study completion rates (mean 83%; n=18, N=39) and ease-of-use ratings (3 significantly better than control, 9/15 rated >70%). However, there was little evidence of changed behavior or health outcomes.

Conclusions

There was no strong evidence in support of the effectiveness of mobile apps in improving health behaviors or outcomes because few studies found significant differences between the app and control groups. Further research is needed to identify the BCTs that are most effective at promoting behavior change. Improved reporting is necessary to accurately evaluate the mobile health app effectiveness and risk of bias.

Development of an Innovative Real-World Evidence Registry for the Herpes Simplex Virus: Case Study

Background

Infection with the herpes simplex virus (HSV) is common but not well understood. Furthermore, there remains a social stigma surrounding HSV that can have psychosocial implications for those infected. Despite many patients infected with HSV experiencing mild-to-severe physical symptoms, only one subeffective treatment is available. A registry collecting real-world data reported by individuals potentially infected with HSV could help patients to better understand and manage their condition.

Objective

This study aimed to report on the development of a registry to collect real-world data reported by people who might be infected with HSV.

Methods

A case study design was selected as it provides a systematic and in-depth approach to investigating the planning phase of the registry. The case study followed seven stages: plan, design, prepare, collect, analyze, create, and share. We carried out semistructured interviews with experts, which were thematically analyzed and used to build use cases for the proposed registry. These use cases will be used to generate detailed models of how a real-world evidence registry might be perceived and used by different users.

Results

The following key themes were identified in the interviews: (1) stigma and anonymity, (2) selection bias, (3) understanding treatment and outcome gaps, (4) lifestyle factors, (5) individualized versus population-level data, and (6) severe complications of HSV. We developed use cases for different types of users of the registry, including individuals with HSV, members of the public, researchers, and clinicians.

Conclusions

This case study revealed key considerations and insights for the development of an appropriate registry to collect real-world data reported by people who might be infected with HSV. Further development and testing of the registry with different users is required. The registry must also be evaluated for the feasibility and effectiveness of collecting data to support symptom management. This registry has the potential to contribute to the development of vaccines and treatments and provide insights into the impact of HSV on other conditions.

Effectiveness of Conversational Agents (Virtual Assistants) in Health Care: Protocol for a Systematic Review

Background

Conversational agents (also known as chatbots) have evolved in recent decades to become multimodal, multifunctional platforms with potential to automate a diverse range of health-related activities supporting the general public, patients, and physicians. Multiple studies have reported the development of these agents, and recent systematic reviews have described the scope of use of conversational agents in health care. However, there is scarce research on the effectiveness of these systems; thus, their viability and applicability are unclear.

Objective

The objective of this systematic review is to assess the effectiveness of conversational agents in health care and to identify limitations, adverse events, and areas for future investigation of these agents.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols will be used to structure this protocol. The focus of the systematic review is guided by a population, intervention, comparator, and outcome framework. A systematic search of the PubMed (Medline), EMBASE, CINAHL, and Web of Science databases will be conducted. Two authors will independently screen the titles and abstracts of the identified references and select studies according to the eligibility criteria. Any discrepancies will then be discussed and resolved. Two reviewers will independently extract and validate data from the included studies into a standardized form and conduct quality appraisal.

Results

As of January 2020, we have begun a preliminary literature search and piloting of the study selection process.

Conclusions

This systematic review aims to clarify the effectiveness, limitations, and future applications of conversational agents in health care. Our findings may be useful to inform the future development of conversational agents and promote the personalization of patient care.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16934

Teaching Real-World Evidence: Protocol for a Systematic Review

Background

Real-world evidence (RWE) refers to observational health care data beyond clinical trial data. It holds the promise of transforming health care as a new form of evidence to support decision makers in making decisions when developing and regulating medicines. As the importance of RWE is recognized by industry and regulatory bodies, teaching RWE becomes an important matter to evaluate and refine in order to develop future researchers and stakeholders who can better integrate RWE into the routine development of medicine.

Objective

The aim of this review is to understand how RWE is currently being taught. From this landscape study, the insufficiencies of the current education of RWE can be identified and subsequently inform future education policies around RWE and its subfacets.

Methods

We will search MEDLINE, EMBASE, PsycINFO, Healthcare Management Information Consortium, Cochrane, and Web of Science for published studies using a combination of keywords and subject headings related to RWE and education. In addition, a Google search to identify grey literature will be conducted. Two authors will independently screen the titles and abstracts identified from the search and accept or reject the studies according to the study inclusion criteria; any discrepancies will be discussed and resolved. The quality of the included literature will be assessed using the Critical Appraisal Skills Programme systematic review checklist.

Results

Data from eligible publications will be abstracted into a predesigned form in order to better understand the current state of education of RWE and inform future RWE education directions and policies.

Conclusions

The subsequent systematic review will be published in a peer-reviewed journal.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16941

Mobile Apps for Health Behavior Change: Protocol for a Systematic Review

Background

The popularity and ubiquity of mobile apps have rapidly expanded in the past decade. With a growing focus on patient interaction with health management, mobile apps are increasingly used to monitor health and deliver behavioral interventions. The considerable variation in these mobile health apps, from their target patient group to their health behavior, and their behavioral change strategy, has resulted in a large but incohesive body of literature.

Objective

The purpose of this protocol is to provide an overview of the current landscape, theories behind, and effectiveness of mobile apps for health behavior change.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols will be used to structure this protocol. The focus of the systematic review is guided by a population, intervention, comparator, and outcome framework. A systematic search of Medline, EMBASE, CINAHL, and Web of Science will be conducted. Two authors will independently screen the titles and abstracts of identified references and select studies according to the eligibility criteria. Any discrepancies will then be discussed and resolved. One reviewer will extract data into a standardized form, which will be validated by a second reviewer. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias tool, and a descriptive analysis will summarize the effectiveness of all the apps.

Results

As of November 2019, the systematic review has been completed and is in peer review for publication.

Conclusions

This systematic review will summarize the current mobile app technologies and their effectiveness, usability, and coherence with behavior change theory. It will identify areas of improvement (where there is no evidence of efficacy) and help inform the development of more useful and engaging mobile health apps.

Trial Registration

PROSPERO CRD42019155604; https://tinyurl.com/sno4lcu

International Registered Report Identifier (IRRID)

PRR1-10.2196/16931

Increased fasting small-bowel water content in untreated coeliac disease and scleroderma as assessed by magnetic resonance imaging

Background and aims

The regular overnight migrating motor complex (MMC) ensures that the normal fasting small-bowel water content (SBWC) is minimised. We have applied our recently validated non-invasive magnetic resonance technique to assess SBWC in newly diagnosed coeliac disease (CD), scleroderma (SCD) and irritable bowel syndrome (IBS), conditions possibly associated with small intestinal bacterial overgrowth (SIBO).

Methods

A total of 20 CD and 15 SCD patients with gastrointestinal symptoms were compared to 20 healthy volunteers (HV) and 26 IBS with diarrhoea (IBS-D) patients, as previously reported. All underwent a fasting magnetic resonance imaging (MRI) scan on a 1.5 T Philips Achieva MRI scanner to assess fasting SBWC and colonic volumes. Stool and symptom diaries were completed for one week.

Results

Compared to HV, all patients had significantly increased stool frequency and Bristol stool form score. SBWC was significantly increased in CD (median 109 mL; interquartile range (IQR) 53-224 mL) compared to HV (median 53 mL; IQR 31-98 mL; p < 0.01) and IBS-D (median 42 mL; IQR 28-67 mL; p < 0.01). A variable increase in SBWC was also found in SCD (median 77 mL; IQR 39-158 mL), but this was not significant (p = 0.2). Colonic volumes were similar for all groups, being a median of 547 mL (IQR 442-786 mL) for CD, 511 mL (453-789 mL) for SCD, 612 mL (445-746 mL) for HV and 521 mL (428-757 mL) for IBS-D. When CD patients were subdivided according to the Marsh classification, the higher grades had larger colonic volumes.

Conclusion

Fasting SBWC as assessed by MRI is significantly increased in newly diagnosed CD and SCD but decreased in IBS-D. Future studies should test whether increased resting fluid predisposes to SIBO.