1
|
Ernest-Suarez K, Murguía-Favela LE, Novak KL, Panaccione R, Constantinescu C, Seow CH. Normal Infant Immunologic Assessment and Uneventful Live Rotavirus Vaccination Despite Continuous Tofacitinib Exposure In Utero and During Breastfeeding. Crohns Colitis 360 2024; 6:otae006. [PMID: 38317692 PMCID: PMC10841763 DOI: 10.1093/crocol/otae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Indexed: 02/07/2024] Open
Abstract
Background Janus kinase (JAK) inhibitors are effective for the treatment of inflammatory bowel disease (IBD). However, this class of medications is not recommended during pregnancy or breastfeeding based on animal data suggesting teratogenesis and recent reports of transmammary transfer after maternal ingestion, raising concerns for immune system development in babies exposed to these drugs. Methods We present the case of a patient with IBD treated with a JAK inhibitor who decided to continue the medication throughout her pregnancy and during breastfeeding. This is the first reported case of a detailed immunologic profile in a baby exposed to tofacitinib in utero and during lactation. Results A 30-year-old female with ulcerative colitis with previous exposure to vedolizumab and infliximab achieved complete remission with tofacitinib therapy. The patient became pregnant after 5 months of JAK inhibitor therapy and decided to continue tofacitinib during pregnancy and while breastfeeding. The patient delivered a healthy offspring with no congenital malformations, a normal detailed immunologic profile, and subsequent safe provision of the live oral rotavirus vaccine. Conclusions This case highlights the importance of individualized counseling for patients of childbearing age who are candidates for JAK inhibition. Those who are pregnant or breastfeeding with refractory disease may have limited medical therapeutic options. Ongoing effective therapy for IBD resulted in complete disease remission in the mother and favorable outcomes in the infant. Further, an in-depth infant immunological assessment can lead to specific vaccination recommendations in exposed infants.
Collapse
Affiliation(s)
- Kenneth Ernest-Suarez
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Luis E Murguía-Favela
- Section of Hematology/Immunology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cora Constantinescu
- Section of Infectious Diseases, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
2
|
St-Pierre J, Delisle M, Kheirkhahrahimabadi H, Goodsall TM, Bryant RV, Christensen B, Vaughan R, Al-Ani A, Ingram RJM, Heatherington J, Carter D, Lu C, Ma C, Novak KL. Bedside Intestinal Ultrasound Performed in an Inflammatory Bowel Disease Urgent Assessment Clinic Improves Clinical Decision-Making and Resource Utilization. Crohns Colitis 360 2023; 5:otad050. [PMID: 37809033 PMCID: PMC10558199 DOI: 10.1093/crocol/otad050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Indexed: 10/10/2023] Open
Abstract
Background Patients with inflammatory bowel disease (IBD) require accessible, timely, and noninvasive strategies to monitor disease. The aim was to assess the integration of intestinal ultrasound (IUS) on decision-making and endoscopy utilization in a standardized care pathway. Methods This prospective, multicenter, international, observational cohort study included patients seen within a centralized model for IBD care was conducted during the COVID pandemic. Patients were evaluated with IUS alone or in combination with an in-clinic, unsedated sigmoidoscopy. Demographic, clinical, laboratory, and imaging data, clinical decisions, and need for urgent endoscopy, hospitalization, and surgeries were recorded. Results Of the 158 patients included, the majority had an established diagnosis of Crohn's disease (n = 123, 78%), and 47% (n = 75) of patients were on biologic therapy. IUS identified active inflammation in 65% (n = 102) of patients, and strictures in 14% (n = 22). Fecal calprotectin levels correlated with inflammation detected on IUS (median of 50 μg/g [Q1-Q3: 26-107 μg/g] without inflammation and 270 μg/g [Q1-Q3: 61-556 μg/g] with inflammation; p = 0.0271). In the majority of patients, clinical assessment with IUS led to an acute change in IBD-specific medications (57%, n = 90) and avoided or delayed the need for urgent endoscopy (85%, n = 134). Four patients were referred for urgent surgical consultation. Conclusions Point-of-care IUS used in a flare clinic pathway is a useful strategy to improve effective IBD care delivery and to assist in therapeutic management decisions, in many cases avoiding the acute need for endoscopy.
Collapse
Affiliation(s)
- Joëlle St-Pierre
- IBD Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Maxime Delisle
- IBD Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | | | - Thomas M Goodsall
- IBD Service, Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- School of Medicine, Faculty of Health Science, University of Adelaide, Adelaide, South Australia, Australia
| | - Robert V Bryant
- IBD Service, Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- School of Medicine, Faculty of Health Science, University of Adelaide, Adelaide, South Australia, Australia
| | - Britt Christensen
- Department of Gastroenterology, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Rose Vaughan
- Department of Gastroenterology, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Aysha Al-Ani
- Department of Gastroenterology, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Richard J M Ingram
- IBD Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Joan Heatherington
- IBD Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cathy Lu
- IBD Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Christopher Ma
- IBD Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Kerri L Novak
- IBD Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| |
Collapse
|
3
|
Lei Y, Halasz J, Novak KL, Congly SE. Intermittent Proton Pump Inhibitor Therapy in Low-Risk Non-Variceal Upper Gastrointestinal Bleeding May Be Significantly Cost-Saving. Medicines (Basel) 2023; 10:44. [PMID: 37505065 PMCID: PMC10384205 DOI: 10.3390/medicines10070044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND High-dose proton pump inhibitor (PPI) therapy, given either intermittently or continuously for non-variceal upper gastrointestinal bleeding (NV-UGIB), is efficacious. Using intermittent PPI for low-risk patients may be cost-saving. Our objective was to estimate the annual cost savings if all low-risk NV-UGIB patients received intermittent PPI therapy. METHODS Patients who presented to hospital in Calgary, Alberta, who received a PPI for NV-UGIB from July 2015 to March 2017 were identified using ICD-10 codes. Patients were stratified into no endoscopy, high-risk, and low-risk lesion groups and further subdivided into no PPI, oral PPI, intermittent intravenous (IV), and continuous IV subgroups. Average length of stay (LOS) in each subgroup and costs were calculated. RESULTS We identified 4141 patients with NV-UGIBs, (median age 61, 57.4% male). One-thousand two-hundred and thirty-one low-risk patients received continuous IV PPI, with an average LOS of 6.8 days (95% CI 6.2-7.3) versus 4.9 days (95% CI 3.9-5.9) for intermittent IV patients. If continuous IV PPI patients instead received intermittent IV PPI, 3852 patient days and CAD 11,714,390 (2017 CAD)/year could be saved. CONCLUSIONS Using real-world administrative data, we demonstrate that a sizable portion of low-risk patients with NV-UGIB who were given continuous IV PPI if switched to intermittent IV therapy could generate significant potential cost savings.
Collapse
Affiliation(s)
- Yang Lei
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Jennifer Halasz
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB T2N 4Z6, Canada
| |
Collapse
|
4
|
Hamilton P, Buhler K, MacDonald JK, Kaplan GG, Seow CH, Lu C, Novak KL, Andrews CN, Singh S, Jairath V, Panaccione R, Ma C. Meta-analysis: Placebo rates in microscopic colitis randomised trials and applications for future drug development using a historical control arm. Aliment Pharmacol Ther 2023; 57:837-850. [PMID: 36825479 DOI: 10.1111/apt.17433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/05/2023] [Accepted: 02/11/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Effective medical therapies for patients with microscopic colitis (MC) who fail budesonide are lacking. However, conducting randomised controlled trials (RCTs) in MC has been challenging due to small sample sizes. Understanding placebo responses can help inform more efficient future trials. AIMS The aim of this study is to estimate clinical and histologic placebo response rates and to determine factors associated with placebo response in MC. METHODS EMBASE, MEDLINE, and CENTRAL were searched until 7 January 2022, to identify placebo-controlled RCTs in adult patients with MC. Clinical and histologic response in the placebo arms were pooled using random-effects models. Stratified analyses based on disease- and trial-level characteristics, leave-one-out meta-analysis, and cumulative meta-analysis were performed. RESULTS Twelve RCTs enrolling a total of 391 patients (placebo n = 163) with MC were included. Pooled clinical and histologic placebo response rates were 24.4% (95% CI: 12.4%-38.4%), I2 = 60.8%, p < 0.01, and 19.9% (95% CI: 5.3%-39.0%), I2 = 66.4%, p = 0.01 (tests for heterogeneity), respectively. Clinical response to placebo was numerically higher in patients with lymphocytic compared to collagenous colitis (39.9% vs. 19.8%, p = 0.08). Heterogeneity in clinical response to placebo was significantly reduced when the Miehlke 2014 RCT was excluded in the leave-one-out meta-analysis or when a more stringent secondary definition of response based on the Hjortswang criteria was applied. CONCLUSIONS Approximately one-quarter of patients in MC trials respond to placebo, although with substantial heterogeneity, reflecting the need for standardised outcome definitions and study designs for MC. This analysis also serves to inform future MC trials that may consider incorporating an external, historical placebo control arm, rather than directly randomising patients to placebo.
Collapse
Affiliation(s)
- Patrick Hamilton
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Katherine Buhler
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Gilaad G Kaplan
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Lu
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher N Andrews
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Vipul Jairath
- Alimentiv Inc., London, Ontario, Canada
- Division of Gastroenterology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Remo Panaccione
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alimentiv Inc., London, Ontario, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
5
|
Hudson AS, Huynh HQ, Novak KL, Ma H, Kuc A, Kim J, Almeida P, Carroll MW, Wine E, Isaac DM. Pediatric Patient and Caregiver Satisfaction With the Use of Transabdominal Bowel Ultrasound in the Assessment of Inflammatory Bowel Diseases. J Pediatr Gastroenterol Nutr 2023; 76:33-37. [PMID: 36123762 DOI: 10.1097/mpg.0000000000003618] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Transabdominal bowel ultrasound (TABUS) is emerging as an attractive, noninvasive tool in inflammatory bowel disease (IBD). Patient and caregiver experience with TABUS is not well described. We aimed to determine pediatric patient and caregiver satisfaction with TABUS and the impact of IBD severity, gender, age, and a history of anxiety on satisfaction. METHODS Pediatric patients (0-18 years old) with suspected IBD prospectively underwent baseline TABUS, magnetic resonance enterography (MRE), blood work, stool studies, and endoscopy. Patients and their caregiver each completed a cross-sectional satisfaction questionnaire (5-point Likert scale) after the baseline investigations. RESULTS There were 54 patients included (67% male). The majority were completely satisfied and strongly agree TABUS was better tolerated than other investigations, regardless of disease severity ( P > 0.05). Patients with higher Simple Endoscopic Score for Crohn Disease (SES-CD) scores felt that TABUS increased their understanding of their IBD ( P < 0.05) and disease location ( P < 0.05). Patients with Crohn disease had similar responses to those with ulcerative colitis, but more strongly agreed that TABUS was better than MRE and endoscopy ( P < 0.05). Those with anxiety did not have an increased level of worry about potential ultrasound findings ( P > 0.05). CONCLUSIONS Pediatric patients and their caregivers were highly satisfied with TABUS, preferring it to other modalities. It did not lead to increased worry, and was particularly important in those with severe IBD. These findings support wider implementation of this well tolerated and preferred monitoring tool in pediatrics.
Collapse
Affiliation(s)
- Alexandra S Hudson
- From the Edmonton Pediatric IBD Clinic (EPIC), Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Hien Q Huynh
- From the Edmonton Pediatric IBD Clinic (EPIC), Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Kerri L Novak
- the Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Henry Ma
- From the Edmonton Pediatric IBD Clinic (EPIC), Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Anna Kuc
- From the Edmonton Pediatric IBD Clinic (EPIC), Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Justin Kim
- From the Edmonton Pediatric IBD Clinic (EPIC), Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Patricia Almeida
- From the Edmonton Pediatric IBD Clinic (EPIC), Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Matthew W Carroll
- From the Edmonton Pediatric IBD Clinic (EPIC), Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Eytan Wine
- From the Edmonton Pediatric IBD Clinic (EPIC), Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Daniela M Isaac
- From the Edmonton Pediatric IBD Clinic (EPIC), Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
6
|
Al-Ani AH, Vaughan R, Christensen B, Bryant RV, Novak KL. Treat to transmural healing: how to incorporate intestinal ultrasound into the treatment of inflammatory bowel disease. Br J Radiol 2022; 95:20211174. [PMID: 35766939 PMCID: PMC10996947 DOI: 10.1259/bjr.20211174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Intestinal ultrasound (IUS) is emerging as a key tool to achieving the therapeutic target of transmural healing in inflammatory bowel disease (IBD). IUS is a non-invasive, radiation-free, imaging modality comparable to MRI, CT and ileocolonoscopy (IC). With the appropriate training and equipment, IUS can be an easily repeatable bedside test for IBD diagnosis and disease monitoring, including treatment response. Core to successful high quality IUS employment are appropriate training and expert techniques; however, the training pathway will not be explored in this review. Given the increasing shift towards objective assessment for tight disease control, gastroenterologist-led IUS should be incorporated into the armamentarium of imaging modalities alongside radiologists, to enhance our diagnostic and monitoring toolbox. This comprehensive review aims to outline the current literature around IUS and propose the placement of IUS in a treat-to-target algorithm in IBD. Ultimately, IUS facilitates timely management decisions to optimise patient care with potential to revolutionise patient outcomes, moving towards transmural healing as the holy grail of therapy in IBD.
Collapse
Affiliation(s)
- Aysha H Al-Ani
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Rose Vaughan
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Britt Christensen
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Robert V Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, Australia
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Kerri L Novak
- Department of Gastroenterology, The University of Calgary, Alberta, Australia
| |
Collapse
|
7
|
Lu C, Ma C, Ingram RJM, Chan M, Kheirkhahrahimabadi H, Martin ML, Seow CH, Kaplan GG, Heatherington J, Devlin SM, Panaccione R, Novak KL. Innovative Care for Inflammatory Bowel Disease Patients during the COVID-19 Pandemic: Use of Bedside Intestinal Ultrasound to Optimize Management. J Can Assoc Gastroenterol 2022; 6:e1-e6. [PMID: 36785574 PMCID: PMC8992330 DOI: 10.1093/jcag/gwac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The COVID-19 pandemic caused by SARS-CoV-2 has reduced access to endoscopy and imaging. Safe alternatives, available at the bedside, are needed for accurate, non-invasive strategies to evaluate disease activity. The aim of this study is to establish the impact of clinic-based bedside intestinal ultrasound (IUS) on decision making, reduction in reliance on endoscopy and short-term healthcare utilization. Methods We conducted a prospective observational evaluation during the COVID-19 pandemic, of the impact of a regional comprehensive care pathway to manage IBD patients consecutively recruited with acute symptoms, or suspected new diagnosis of IBD. Clinic-based access to sigmoidoscopy and bedside intestinal ultrasound were evaluated, used to direct clinical care and avoid hospitalization or hospital-based endoscopy. Results A total of 72 patients were seen between March 15 and June 30, 2020. Of these, 57% (41/72) were female, 64% had Crohn's disease (46/72) with 14% (10/72) presenting with symptoms requiring investigation, of which 5 new cases of IBD were identified (50%). Immediate access to ultrasound and sigmoidoscopy led to meaningful changes in management in 80.5% (58/72) of patients. Active inflammation was detected by IUS alone (72.5%, 29/40) or in combination with in-clinic sigmoidoscopy (78%, 18/23) or sigmoidoscopy alone (78% 7/9). Six patients were referred to colorectal surgery for urgent surgical intervention including two patients admitted directly. Conclusion Implementation of IUS as part of a clinical care pathway during the COVID-19 pandemic is a useful strategy to enhance care delivery and improve clinical decisions, while sparing other important acute care resources.
Collapse
Affiliation(s)
| | | | - Richard J M Ingram
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada
| | - Melissa Chan
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada
| | - Hengameh Kheirkhahrahimabadi
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada,Department of Medicine, Division of Rheumatology, University of Calgary, Alberta, Canada
| | - Marie-Louise Martin
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada
| | - Cynthia H Seow
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Joan Heatherington
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada
| | - Shane M Devlin
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada
| | - Remo Panaccione
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada
| | - Kerri L Novak
- Correspondence: Kerri L. Novak, MD, MSc, Clinical Associate Professor, Division of Gastroenterology and Hepatology, University of Calgary, Teaching Research Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta, Canada T2N 4Z6, e-mail:
| |
Collapse
|
8
|
Cooper J, Markovinovic A, Coward S, Shaheen AM, Swain M, Panaccione R, Ma C, Novak KL, Kaplan GG. A211 INCIDENCE OF PRIMARY SCLEROSING CHOLANGITIS: A META-ANALYSIS OF POPULATION-BASED STUDIES. J Can Assoc Gastroenterol 2022. [PMCID: PMC8859279 DOI: 10.1093/jcag/gwab049.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Primary sclerosing cholangitis (PSC) is a chronic liver disease associated with significant morbidity, mortality and healthcare utilization. Understanding the incidence of PSC is important in defining the burden of disease and planning for allocation of healthcare resources. Aims To conduct a systematic review and meta-analysis of population-based studies of the incidence of PSC and to assess temporal trends of incidence overtime. Methods Medline and Embase (from inception to May 10, 2021) were systematically searched to identify studies via the following inclusion criteria: 1) original articles, 2) population-based study of defined geographic area, 3) reported the incidence of PSC or provided data to calculate the incidence of PSC. Studies that assessed specific populations (e.g., pediatric-only, IBD-only) or reported less than 1 year of data were excluded. Abstracts and full texts were reviewed for inclusion and data was extracted independently in duplicate by two individuals (JC, AM). Meta-analyses were performed to calculate overall and country-specific incidence rates (per 100,000 persons) with 95% confidence intervals (CI). Meta-regression calculated the Average Annual Percentage Change (AAPC) of PSC incidence rates overtime. Results The initial search returned 3,958 abstracts. After duplicates were removed, abstracts (3,443) were screened, and full texts were reviewed (317), 17 studies met the criteria for inclusion and underwent data extraction. Meta-analysis included 6 studies with annual data contributing to the calculation of AAPC. Studies originated from 10 countries from North America, Europe, and Oceania; however, no population-based studies were published in Asia, Africa, or Latin America (Figure 1). Overall, the incidence rates of PSC was 0.82 per 100,000 (95% CI: 0.62, 1.02) (Figure 1). Incidence rates of PSC were significantly increasing overtime (AAPC: 4.56%; 95% CI: 0.45, 8.68). Conclusions The incidence of PSC is low at 0.82 per 100,000 but has been significantly increasing over time. Future studies on the incidence of PSC should be directed at Asia, Africa of Latin America to assess the global epidemiology of PSC. ![]()
Figure 1: Pooled incidence rate estimates of PSC per 100,000 person-years at risk. Funding Agencies None
Collapse
Affiliation(s)
- J Cooper
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - A Markovinovic
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - S Coward
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - A M Shaheen
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - M Swain
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - R Panaccione
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - C Ma
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - K L Novak
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - G G Kaplan
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
9
|
St-Pierre J, Frolkis A, Seow C, Oshiomogho J, Bindra G, Heatherington J, Kaplan GG, Panaccione R, Novak KL, Nasser Y, Jijon H. A97 DEVELOPMENT OF PREDICTION MODELS FOR THE TRIAGING OF REFERRALS OF INDIVIDUALS WITH SUSPECTED INFLAMMATORY BOWEL DISEASE TO IMPROVE PROMPT ACCESS TO CARE. J Can Assoc Gastroenterol 2022. [PMCID: PMC8859190 DOI: 10.1093/jcag/gwab049.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The negative impact of a delayed inflammatory bowel disease (IBD) diagnosis has been well established. We created a clinical pathway referred to as the “High-Risk IBD clinic” within a centralized referral program in a tertiary referral centre, in order to improve access to subspecialist care for individuals suspected but not yet diagnosed with IBD. Despite the creation of this specialized clinic, wait times continue to be above the recommended benchmarks established by the Canadian Association of Gastroenterology (CAG). Aims The purpose of our study was to create predictive models to identify factors associated with an IBD diagnosis in order to improve triage of referrals of individuals with features highly suggestive of IBD. We hypothesized that features suggestive of IBD could be used to create discriminating prediction models between IBD and IBS. Methods We conducted a retrospective cohort study of referrals to the High-Risk IBD clinic from February 2014 to December 2018. Referral information, investigations, endoscopic findings and final diagnosis were obtained from 316 consented individuals. Information required included symptoms (e.g. diarrhea, abdominal pain, rectal bleeding), risk factors (e.g. family history, rheumatological disease) and investigations (e.g. hemoglobin, CRP, abdominal imaging). Univariate logistic regression was performed to explore the association between factors included in the referral form, and a diagnosis of Crohn’s disease (CD) and ulcerative colitis (UC). For creation of predictive models, any variable with a p-value of <0.1 in univariate logistic regression was selected for entry into the multivariate model for CD and UC. Results For UC, the predictive model included weight loss, the presence of rectal bleeding and abdominal pain. Using these criteria, the sensitivity and specificity of the model were 62.5% and 74.1%, respectively. The negative predictive value (NPV) was high at 94.2%. For CD, the predictive model included male gender, elevated CRP, presence of anemia and presence of weight loss. The sensitivity and specificity of this model were 61.7% and 71.2%, respectively. As for UC, the NPV was also high (89.2%). For IBS, the most common diagnosis encountered in patients referred to the HR-IBD clinic, the model included absence of weight loss, presence of abdominal pain and female gender. The sensitivity and specificity were 71.6% and 64.0%, respectively. The positive predictive value was 60.6% and NPV was 74.5%. Conclusions We established predictive tools associated with a final diagnosis of IBD and IBS as a means to expedite the care of individuals with undiagnosed IBD. Funding Agencies CCC
Collapse
Affiliation(s)
- J St-Pierre
- Medicine, University of Calgary, Calgary, AB, Canada
| | - A Frolkis
- University of Calgary, Calgary, AB, Canada
| | - C Seow
- Medicine, University of Calgary, Calgary, AB, Canada
| | - J Oshiomogho
- Medicine, University of Calgary, Calgary, AB, Canada
| | - G Bindra
- Medicine, University of Calgary, Calgary, AB, Canada
| | | | - G G Kaplan
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | | | - K L Novak
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - Y Nasser
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - H Jijon
- University of Calgary, Calgary, AB, Canada
| |
Collapse
|
10
|
Chhibba T, Guizzetti L, Seow CH, Lu C, Novak KL, Ananthakrishnan AN, Bernstein CN, Kaplan GG, Panaccione R, Ma C. Frequency of Opioid Prescription at Emergency Department Discharge in Patients with Inflammatory Bowel Disease: A Nationwide Analysis. Clin Gastroenterol Hepatol 2021; 19:2064-2071.e1. [PMID: 32683099 DOI: 10.1016/j.cgh.2020.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) frequently experience chronic pain. Patients will often seek out care in the emergency department (ED) where short-term opioid use may be associated with potential treatment-related complications. We aimed to assess the rate and factors associated with opioid prescription in IBD patients discharged from the ED. METHODS We conducted a cross-sectional analysis of data collected in the US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006-2017. We determined the proportion of adult patients (≥18 years) with IBD prescribed an opioid in ED or at ED discharge. Logistic regression was used to evaluate predictors of opioid prescription. Time-trend analysis was performed to evaluate temporal patterns in opioid use. All analyses were adjusted for complex survey design. RESULTS We identified ∼965,000 weighted discharges from the ED for patients with IBD. In total, 51.9% [95% CI: 42.2% -61.6%] of visits resulted in opioid administration in ED and 35.3% [95% CI: 26.5% -45.2%] of IBD-related ED discharges were associated with an opioid prescription. IBD patients with moderate/severe pain (adjusted odds ratio aOR 5.06 [95% CI: 1.72 -14.90], p < 0.01) were more likely to receive opioids whereas older age (aOR 0.73 per decade [95% CI: 0.55 -0.98], p = 0.04) were less likely. In temporal analysis, a trend towards decreasing opioid use in ED and opioid prescriptions at discharge was observed in 2015-2017. CONCLUSIONS More than one third of IBD patients are prescribed an opioid at discharge from ED, highlighting a potential gap in care for accessing effective pain management solutions in this population.
Collapse
Affiliation(s)
- Tarun Chhibba
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Leonardo Guizzetti
- Alimentiv (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alimentiv (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada.
| |
Collapse
|
11
|
Delisle M, Wilkens R, Novak KL. Keeping It Simple: Using Intestinal Ultrasound to Assess Ulcerative Colitis with a Novel UC-Ultrasound Index. J Crohns Colitis 2021; 15:1250-1252. [PMID: 34224568 DOI: 10.1093/ecco-jcc/jjab066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Maxime Delisle
- Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada
| | - Rune Wilkens
- Division of Medicine, Gastro Unit, Hvidovre Hospital, Copenhagen, Denmark.,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Denmark
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada
| |
Collapse
|
12
|
Halasz JB, Burak KW, Dowling SK, Murray B, Williams J, Misra T, Veldhuyzen van Zanten SJ, Kaplan GG, Swain M, Novak KL. Do Low-Risk Patients With Dyspepsia Need a Gastroscopy? Use of Gastroscopy for Otherwise Healthy Patients With Dyspepsia. J Can Assoc Gastroenterol 2021; 5:32-38. [PMID: 35118225 PMCID: PMC8806042 DOI: 10.1093/jcag/gwab017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/09/2021] [Indexed: 12/16/2022] Open
Abstract
Background Choosing Wisely Canada (CWC) recommends not to perform gastroscopy for dyspepsia in otherwise healthy adults less than 55 years of age (2014). The aim of this study was to evaluate the use of gastroscopy in a young, healthy population with uncomplicated dyspepsia. Methods A retrospective review of gastroscopies completed during 3-month periods in 2015, 2016, and 2017 identified all patients undergoing gastroscopy for the primary indication of dyspepsia. Low-risk patients for dyspepsia were defined as adults, aged 18 to 54 years without alarm symptoms, comorbidities and/or abnormal imaging findings or laboratory values. Gastroscopy and pathology reports were reviewed to identify clinically actionable findings. Clinical outcomes were followed to December 31, 2018 including gastroenterology referrals, emergency room visitation and hospitalization. Results Among 1358 patients having a gastroscopy for dyspepsia, 480 (35%) were low-risk patients. Sixteen patients 3.3% (16/480) had a clinically actionable result found on gastroscopy or biopsy. No malignant lesions were detected. Low-risk patients were followed up for an average of 2.75 years, 8% (39/480) visited the emergency department (ED), 1% (3/480) of patients were admitted to hospital and 12% (59/480) of patients were re-referred for a dyspepsia-related concern. Interpretation A high rate of low yield, high cost, invasive endoscopic investigations were performed in this population of otherwise healthy patients under age 55 years. These data suggest limited uptake of current recommendations against the routine use of gastroscopy to investigate dyspepsia.
Collapse
Affiliation(s)
- Jennifer B Halasz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kelly W Burak
- Department of Medicine, Division of Gastroenterology Hepatology, University of Calgary, Calgary, Alberta, Canada
- Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary, Calgary, Alberta, Canada
| | - Shawn K Dowling
- Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenna Murray
- Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Williams
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Tarun Misra
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | | | - Gilaad G Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Mark Swain
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
13
|
Wilkens R, Novak KL, Maaser C, Panaccione R, Kucharzik T. Relevance of monitoring transmural disease activity in patients with Crohn's disease: current status and future perspectives. Therap Adv Gastroenterol 2021; 14:17562848211006672. [PMID: 33948115 PMCID: PMC8053830 DOI: 10.1177/17562848211006672] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/11/2021] [Indexed: 02/04/2023] Open
Abstract
Treatment targets of inflammatory bowel diseases (IBD), ulcerative colitis (UC) and Crohn's disease (CD) have evolved over the last decade. Goals of therapy consisting of symptom control and steroid sparing have shifted to control of disease activity with endoscopic remission being an important endpoint. Unfortunately, this requires ileocolonoscopy, an invasive procedure. Biomarkers [C-reactive protein (CRP) and fecal calprotectin (FCP)] have emerged as surrogates for endoscopic remission and disease activity, but also have limitations. Despite this evolution, we must not lose sight that CD involves transmural inflammation, not fully appreciated with ileocolonoscopy. Therefore, transmural assessment of disease activity by cross-sectional imaging, in particular with magnetic resonance enterography (MRE) and intestinal ultrasonography (IUS), is vital to fully understand disease control. Bowel-wall thickness (BWT) is the cornerstone in assessment of transmural inflammation and BWT normalization, with or without bloodflow normalization, the key element demonstrating resolution of transmural inflammation, namely transmural healing (TH) or transmural remission (TR). In small studies, achievement of TR has been associated with improved long-term clinical outcomes, including reduced hospitalization, surgery, escalation of treatment, and a decrease in clinical relapse over endoscopic remission alone. This review will focus on the existing literature investigating the concept of TR or residual transmural disease and its relation to other existing treatment targets. Current data suggest that TR may be the next logical step in the evolution of treatment targets.
Collapse
Affiliation(s)
- Rune Wilkens
- Gastrounit, Division of Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Copenhagen, Denmark
- Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Denmark
| | - Kerri L. Novak
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Christian Maaser
- Inflammatory Bowel Disease Outpatient Unit, Department of Geriatric Medicine, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Remo Panaccione
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Torsten Kucharzik
- Department of Gastroenterology, University Teaching Hospital Lueneburg, Bögelstraße 1, Lueneburg 21339, Germany
| |
Collapse
|
14
|
Novak KL, Nylund K, Maaser C, Petersen F, Kucharzik T, Lu C, Allocca M, Maconi G, de Voogd F, Christensen B, Vaughan R, Palmela C, Carter D, Wilkens R. Expert Consensus on Optimal Acquisition and Development of the International Bowel Ultrasound Segmental Activity Score [IBUS-SAS]: A Reliability and Inter-rater Variability Study on Intestinal Ultrasonography in Crohn's Disease. J Crohns Colitis 2021; 15:609-616. [PMID: 33098642 PMCID: PMC8023841 DOI: 10.1093/ecco-jcc/jjaa216] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Intestinal ultrasound [IUS] is an accurate, patient-centreed monitoring tool that objectively evaluates Crohn's disease [CD] activity. However no current, widely accepted, reproducible activity index exists to facilitate consistent IUS identification of inflammatory activity. The aim of this study is to identify key parameters of CD inflammation on IUS, evaluate their reliability, and develop an IUS index reflecting segmental activity. METHODS There were three phases: [1] expert consensus Delphi method to derive measures of IUS activity; [2] an initial, multi-expert case acquisition and expert interpretation of 20 blinded cases, to measure inter-rater reliability for individual measures; [3] refinement of case acquisition and interpretation by 12 international experts, with 30 blinded case reads with reliability assessment and development of a segmental activity score. RESULTS Delphi consensus: 11 experts representing seven countries identified four key parameters including: [1] bowel wall thickness [BWT]; [2] bowel wall stratification; [3] hyperaemia of the wall [colour Doppler imaging]; and [4] inflammatory mesenteric fat. Blind read: each variable exhibited moderate to substantial reliability. Optimal, standardised image and cineloop acquisition were established. Second blind read and score development: intra-class correlation coefficient [ICC] for BWT was almost perfect at 0.96 [0.94-0.98]. All four parameters correlated with the global disease activity assessment and were included in the final International Bowel Ultrasound Segmental Activity Score with almost perfect ICC (0.97 [0.95-0.99, p <0.001]). CONCLUSIONS Using expert consensus and standardised approaches, identification of key activity measurements on IUS has been achieved and a segmental activity score has been proposed, demonstrating excellent reliability.
Collapse
Affiliation(s)
- Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Canada
| | - Kim Nylund
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Institute of Clinical Medicine, University in Bergen, Klinisk institutt 1, Bergen, Norway
| | - Christian Maaser
- Outpatient Department of Gastroenterology, Department of Geriatric Medicine, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Frauke Petersen
- Department of Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Torsten Kucharzik
- Department of Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Canada
| | - Mariangela Allocca
- Humanitas Clinical and Research Centre, Rozzano, Italy
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences. FBF- L.Sacco University Hospital, Milan. Italy
| | - Floris de Voogd
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Britt Christensen
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC Australia
| | - Rose Vaughan
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC Australia
| | - Carolina Palmela
- Division of Gastroenterology, Department of General Surgery, Hospital Beatriz Ângelo, Loures, Portugal
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Centre, Tel Hashomer, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rune Wilkens
- Gastrounit, Division of Medicine, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark
| |
Collapse
|
15
|
Goodsall TM, Jairath V, Feagan BG, Parker CE, Nguyen TM, Guizzetti L, Asthana AK, Begun J, Christensen B, Friedman AB, Kucharzik T, Lee A, Lewindon PJ, Maaser C, Novak KL, Rimola J, Taylor KM, Taylor SA, White LS, Wilkens R, Wilson SR, Wright EK, Bryant RV, Ma C. Standardisation of intestinal ultrasound scoring in clinical trials for luminal Crohn's disease. Aliment Pharmacol Ther 2021; 53:873-886. [PMID: 33641221 DOI: 10.1111/apt.16288] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/08/2020] [Accepted: 01/25/2021] [Indexed: 12/09/2022]
Abstract
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.
Collapse
|
16
|
Novak KL, Ma C, Kheirkhahrahimabadi H, heatherington J, Ingram R, Martin M, Panaccione R, Kaplan GG, Devlin S, Seow C, Chan M, Lu C. A173 INNOVATIVE CARE FOR INFLAMMATORY BOWEL DISEASE PATIENTS DURING THE COVID-19 PANDEMIC: USE OF BEDSIDE INTESTINAL ULTRASOUND TO OPTIMIZE MANAGEMENT. J Can Assoc Gastroenterol 2021. [PMCID: PMC7958805 DOI: 10.1093/jcag/gwab002.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background The COVID-19 pandemic has led to significant alterations in the ability to deliver outpatient care to patients with inflammatory bowel disease (IBD) including endoscopic evaluation. This has highlighted the need for alternative, accurate, non-invasive strategies to safely assess disease activity. Aims The aim of this study is to describe the impact of point of care intestinal ultrasound (IUS) in a university-based tertiary care IBD urgent access clinic. Methods We prospectively evaluated a comprehensive care pathway which incorporated outpatient sigmoidoscopy and intestinal ultrasound with the purpose of directing further ambulatory clinical care and avoiding hospitalization or hospital-based investigations including endoscopy during the COVID pandemic for patients with established IBD with symptoms suggestive of a disease flare, or those at high risk of a new diagnosis of IBD. Non-invasive markers C Reactive Protein (CRP) and fecal calprotectin (fCal) were collected where available. Patients were pre-screened for influenza-like illness, as COVID-19 testing was not available for this population during the study period. Substantial management changes were defined as addition of any medications, biologic switch/ optimization, and or referral for surgical consultation. Results Between March 15th and June 30th 2020, a total of 72 patients were seen in the urgent access clinic. All patients were seen within 7 days of referral. The majority were female 57% (41/72) and/ or had Crohn’s disease 65.5% (47/72) (Table 1). Of these, 84.7% (61/72) underwent a substantial management change based on features of active inflammation detected by either IUS alone (53% 38/72) sigmoidoscopy alone (12.5% 9/72) or combination IUS with in-clinic sigmoidoscopy (32% 23/72) in addition to CRP and fCal. Three new diagnoses of IBD were made: one colonic Crohn’s and 2 with ulcerative colitis. One pregnant patient avoided all acute care utilization. Five patients were referred to colorectal surgery for urgent resection including two patients admitted directly for emergent operations. No patients required visits to the emergency department. Furthermore, there have been no unscheduled hospitalizations occurred in this cohort since inception March 23, 2020 til November 15th 2020. Conclusions The implementation of IUS in a centralized, urgent access clinic pathway resulted in efficient and meaningful changes in IBD management while sparing the need for acute care services including ER visits, need for in-hospital endoscopy, and hospitalization. The pandemic highlights the utility of this patient-center tool and supports expansion of wider IUS adoption. Funding Agencies None
Collapse
Affiliation(s)
- K L Novak
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - C Ma
- University of Calgary, Calgary, AB, Canada
| | | | | | - R Ingram
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - M Martin
- Alberta Health Services, Calgary, AB, Canada
| | | | - G G Kaplan
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - S Devlin
- University of Calgary, Calgary, AB, Canada
| | - C Seow
- Medicine, University of Calgary, Calgary, AB, Canada
| | - M Chan
- Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - C Lu
- Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| |
Collapse
|
17
|
Cooper J, Koro K, Wilson S, Medellin A, Ma C, Novak KL, Seow C, Kaplan GG, Panaccione R, Lu C. A123 DEFINING CROHN’S DISEASE STRICTURES USING INTESTINAL ULTRASOUND COMPARED TO HISTOPATHOLOGY. J Can Assoc Gastroenterol 2021. [DOI: 10.1093/jcag/gwab002.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Fibrostenotic Crohn’s Disease (CD) is a challenging phenotype often leading to surgical resection. Diagnostic imaging is an invaluable tool to diagnose CD strictures. MRE (Magnetic Resonance Enterography) is the most widely used modality for evaluating strictures, but is limited by access and cost. The current definition of strictures is based only on MRE or CT (computed tomography). Strictures are defined as increased bowel wall thickness (BWT), narrowed luminal apposition, and pre-stenotic dilation > 3cm according to CONSTRICT MR/CT expert consensus criteria. However, this definition has not been studied in intestinal US (IUS). IUS is a cost-effective, easily repeatable, and well-tolerated tool shown to have equal accuracy to MRE in diagnosing and monitoring CD.
Aims
The objective of this study was to assess the utility of identifying strictures with IUS using CONSTRICT definition.
Methods
In this retrospective pilot study, 30 of 80 CD patients who underwent small bowel resection (gold standard for stricture diagnosis) between 2015–2019 with IUS within 6 months prior to surgery were randomly identified for chart review. IUS was performed in a fasted state without oral contrast. Data extracted included confirmed stricture on resection specimens defined as having fibrosis and prestenotic dilation. Fistulizing disease was excluded. Student’s t-tests, sensitivities, specificities, positive (PNV) and negative predictive values (NPV) were calculated for IUS in detecting strictures.
Results
Of the 30 CD patients evaluated, 20 patients had fibrostenosis on pathology and IUS reports. Only 40% (8/20) met CONSTRICT criteria for stricture diagnosis on IUS, despite having a stricture on pathology. All patients had elevated BWT and luminal narrowing, but 60% (12/20) did not have prestenotic dilation > 3cm. Mean dilation was 2.9 cm (SD 1.38) and was significantly different from the mean stricture diameter of 1.3cm (SD 0.59 cm, p=0.0001, 95% CI: 0.9–2.2). Mean BWT was 8.7 mm (SD: 2.5, range 5–15) where normal is < 3mm, and mean luminal apposition was 2.3 mm (SD 1.2, range 0.2–5.8mm). IUS has a sensitivity of 95.2% (95% CI: 76.2 - 99.9%), specificity of 66.7% (95% CI: 29.9 - 92.5%), PPV of 87.0% (95% CI: 72.5–94.4), and NPV of 85.7% (95% CI 45.6–97.7%) in detecting strictures when compared to gold standard.
Conclusions
CONSTRICT criteria for diagnosing fibrostenotic CD on CT/MR may not be applicable to IUS. In this study, only 40% of patients met criteria despite having histologic confirmed strictures. Thus, perhaps additional criteria of stricture diameter < 50% of prestenotic dilation size is most appropriate for IUS. This pilot study provides the initial data to delineate an IUS stricture definition for future validation and to inform both clinical practice and trial design.
Funding Agencies
None
Collapse
Affiliation(s)
- J Cooper
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - K Koro
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - S Wilson
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - A Medellin
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - C Ma
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - K L Novak
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - C Seow
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - G G Kaplan
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - R Panaccione
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - C Lu
- Internal Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
18
|
Veldhuyzen Van Zanten S, Jelinski S, Kaplan GG, Reeb L, Morrin L, pow J, McLarty J, Metha A, Novak KL, Burak KW, Greenaway M. A79 PROVINCIAL DATA IN ALBERTA REVEAL A CLEAR NEED TO ADDRESS OVERPRESCRIBING OF PROTON PUMP INHIBITORS. J Can Assoc Gastroenterol 2021. [DOI: 10.1093/jcag/gwab002.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Proton pump inhibitors (PPIs) are among the most commonly prescribed drugs in Canada. They are effective for several upper GI-disorders, have a very favorable safety profile and therefore there are few barriers to prescribing. Concern about overuse of PPIs has been growing. Many patients do not need long term treatment. Patients starting PPI should receive short term therapy (e.g. 8 weeks) and if they respond the need for long term therapy needs to be determined. The usual starting dose is once a day for most indications. Evidence suggests a lack of ongoing indication for PPI in 40–55% of primary care patients.There are economic implications of overuse of PPIs. Public drug spending on PPIs in Canada totaled $288.3 million of $13.5 billion spent in 2017.
Aims
To analyze prescribing data for all PPI prescriptions in Alberta for the years 2017–18 and 2018–19 and 2019–2020, to document number of prescriptions >60 days, the number of new versus repeat prescriptions, proportion of new prescriptions at a greater than 1x daily dose, the proportion of prescriptions written by primary care physicians and to estimate the number of prescriptions targetted for deprescribing.
Methods
Data were obtained anonymously from the Pharmaceutical Information Network (PIN) database from community based pharmacies in Alberta. PPIs were identified using DIN numbers. Prescribed dose and duration were obtained, as well as data on repeat prescriptions. The number of prescriptions that could be targeted for deprescribing was also estimated.
Results
The results are shown in table 1. More than 10% of the population receives a prescription each year. Of these 25–31% were new prescriptions and 69–75% were refills. The percentage of patients who were prescribed PPIs for more than 60 days was 26–28%. Furthermore, 23% of all prescriptions had a defined daily dosage greater than the recommended standard dose of once a day therapy for most indications.75% of all prescriptions are written by family physicians.
Conclusions
Prescription rates of PPIs are very high in Alberta and 75% of patients are on longer term therapy. There likely is significant overprescribing of PPIs, estimated to be up to 40% of patients filling PPI prescriptions in Alberta. This represents a significant avoidable medication and system burden and patient costs. The starting dose of new prescriptions is also high, despite the fact that for most indications the daily dose should be 1x a day. A 20% reduction in prescribing would save at least $ 9 million in Alberta. A deprescribing project has been initiated by the Digestive Health Strategic Clinical Network, a multi-stakeholder network, which addresses important GI issues in Alberta.
Funding Agencies
None
Collapse
Affiliation(s)
| | - S Jelinski
- Alberta Health Services, Calgary, AB, Canada
| | - G G Kaplan
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - L Reeb
- Alberta Health Services, Calgary, AB, Canada
| | - L Morrin
- Alberta Health Services, Calgary, AB, Canada
| | - j pow
- Alberta Health Services, Calgary, AB, Canada
| | - j McLarty
- University of Alberta, Edmonton, AB, Canada
| | - A Metha
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - K L Novak
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - K W Burak
- Liver Unit, Univ Calgary, Calgary, AB, Canada
| | - m Greenaway
- Alberta Health Services, Calgary, AB, Canada
| |
Collapse
|
19
|
Ma C, Congly SE, Novak KL, Belletrutti PJ, Raman M, Woo M, Andrews CN, Nasser Y. Epidemiologic Burden and Treatment of Chronic Symptomatic Functional Bowel Disorders in the United States: A Nationwide Analysis. Gastroenterology 2021; 160:88-98.e4. [PMID: 33010247 PMCID: PMC7527275 DOI: 10.1053/j.gastro.2020.09.041] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/10/2020] [Accepted: 09/24/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Functional bowel disorders (FBDs) are the most common gastrointestinal problems managed by physicians. We aimed to assess the burden of chronic symptomatic FBDs on ambulatory care delivery in the United States and evaluate patterns of treatment. METHODS Data from the National Ambulatory Medical Care Survey were used to estimate annual rates and associated costs of ambulatory visits for symptomatic irritable bowel syndrome, chronic functional abdominal pain, constipation, or diarrhea. The weighted proportion of visits associated with pharmacologic and nonpharmacologic (stress/mental health, exercise, diet counseling) interventions were calculated, and predictors of treatment strategy were evaluated in multivariable multinomial logistic regression. RESULTS From 2007-2015, approximately 36.9 million (95% CI, 31.4-42.4) weighted visits in patients of non-federally employed physicians for chronic symptomatic FBDs were sampled. There was an annual weighted average of 2.7 million (95% CI, 2.3-3.2) visits for symptomatic irritable bowel syndrome/chronic abdominal pain, 1.0 million (95% CI, 0.8-1.2) visits for chronic constipation, and 0.7 million (95% CI, 0.5-0.8) visits for chronic diarrhea. Pharmacologic therapies were prescribed in 49.7% (95% CI, 44.7-54.8) of visits compared to nonpharmacologic interventions in 19.8% (95% CI, 16.0-24.2) of visits (P < .001). Combination treatment strategies were more likely to be implemented by primary care physicians and in patients with depression or obesity. The direct annual cost of ambulatory clinic visits alone for chronic symptomatic FBDs is approximately US$358 million (95% CI, 233-482 million). CONCLUSIONS The management of chronic symptomatic FBDs is associated with considerable health care resource use and cost. There may be an opportunity to improve comprehensive FBD management because fewer than 1 in 5 ambulatory visits include nonpharmacologic treatment strategies.
Collapse
Affiliation(s)
- Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul J Belletrutti
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maitreyi Raman
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Woo
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher N Andrews
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yasmin Nasser
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
20
|
Seow CH, Leung Y, Novak KL. Towards Routine Non-invasive Monitoring of Disease Activity Using Gastrointestinal Ultrasound and Faecal Calprotectin in Pregnant Women With IBD. J Crohns Colitis 2020; 14:1790-1791. [PMID: 32544230 DOI: 10.1093/ecco-jcc/jjaa122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- C H Seow
- Department of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Y Leung
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - K L Novak
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
21
|
Ma C, Smith M, Guizzetti L, Panaccione R, Kaplan GG, Novak KL, Lu C, Khanna R, Feagan BG, Singh S, Jairath V, Ananthakrishnan AN. Assessing National Trends and Disparities in Ambulatory, Emergency Department, and Inpatient Visits for Inflammatory Bowel Disease in the United States (2005-2016). Clin Gastroenterol Hepatol 2020; 18:2500-2509.e1. [PMID: 31988046 PMCID: PMC8011653 DOI: 10.1016/j.cgh.2020.01.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/23/2019] [Accepted: 01/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel diseases (IBDs) require repeated health care encounters, although the focus of care differs when patients are seen in ambulatory, emergency department (ED), or inpatient settings. We examined contemporary trends and disparities in IBD-related health care visits. METHODS We used data from the National Ambulatory Medical Care Survey, the Nationwide Emergency Department Sample, and the National Inpatient Sample to estimate the total number of annual IBD-related visits from 2005 through 2016. We performed logistic regression analyses to test temporal linear trends. Slope and differences in distributions of patient demographics were compared across time and treatment settings. RESULTS From 2005 through 2016, approximately 2.2 million IBD-related ambulatory visits (95 CI, 1.9-2.5) occurred annually on average, increasing by 70.3% from the time period of 2005 to 2007 through the time period of 2008 to 2010, and decreasing by 19.8% from the time period of 2011 to 2013 through the time period of 2014 to 2016. An average of 115,934 IBD-related ED visits (95% CI, 113,758-118,111) and 89,111 IBD-related hospital discharges (95% CI, 87,416-90,807) occurred annually. Significant increases in the rate of IBD-related ED visits (3.2 visits/10,000 encounters; P < .0001) and hospital discharges (6.0 discharges/10,000 encounters; P < .0001) were observed from 2005 through 2016. The proportion of patients paying with private insurance decreased from 2005 through 2016, among all care settings. A greater proportion of young patients, patients with Crohn's disease, non-white patients, and patients with Medicare or Medicaid used hospital-based vs ambulatory services. CONCLUSIONS In an analysis of data from 3 large databases, we found that although IBD-related ambulatory visits stabilized to decreased from 2005 through 2016, rates of ED use and admission to the hospital have continued to increase with changes in patient demographics, over time and among care settings.
Collapse
Affiliation(s)
- Christopher Ma
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada; Robarts Clinical Trials, Inc, London, Ontario, Canada.
| | - Matthew Smith
- Department of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Remo Panaccione
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G. Kaplan
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L. Novak
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Lu
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Reena Khanna
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Brian G. Feagan
- Robarts Clinical Trials, Inc., London, Ontario, Canada,Division of Gastroenterology, Western University, London, Ontario, Canada,Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California, United States
| | - Vipul Jairath
- Robarts Clinical Trials, Inc., London, Ontario, Canada,Division of Gastroenterology, Western University, London, Ontario, Canada,Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | | |
Collapse
|
22
|
Wright EK, Wang I, Wong D, Bell SJ, Connell WR, Thompson AJ, Novak KL, Kamm MA. Accuracy of point-of-care intestinal ultrasound for Crohn's disease. Australas J Ultrasound Med 2020; 23:176-182. [PMID: 34760597 DOI: 10.1002/ajum.12218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Point-of-care ultrasound (POCUS), performed by a gastroenterologist, provides safe and convenient imaging allowing for immediate clinical decision in Crohn's disease. The minimum training required to gain competency, its accuracy and clinical utility requires evaluation. Methods In this pilot study, Crohn's disease activity and extent were assessed using POCUS (performed by a single gastroenterologist following the completion of 200 supervised scans), magnetic resonance enterography (MRE) and ileo-colonoscopy. The presence of complications was assessed by POCUS and MRE. Accuracy of POCUS was analysed with respect to MRE and ileo-colonoscopy. Agreement between modalities was assessed using kappa coefficient. Results Forty-two patients had a POCUS paired with MRE. Thirty-eight patients had a POCUS paired with ileo-colonoscopy. When compared to MRE, POCUS was accurate in the assessment of disease activity (sensitivity 87.5%, specificity 61.1%, ROC 0.74), extent (sensitivity 77.8%, specificity 83.3%, ROC 0.81) and complications (sensitivity 85.7%, specificity 94.3%, ROC 0.90). Agreement between POCUS and MRE was moderate (kappa estimates 0.50, P < 0.001, 0.61, P < 0.001 and 0.76, P < 0.001) for disease activity, extent and complications, respectively. When compared to ileo-colonoscopy, POCUS was accurate in the assessment of disease activity (sensitivity 72%, specificity 86%, ROC 0.79) and extent (sensitivity 85.7%, specificity 86%, ROC 0.86). For POCUS and ileo-colonoscopy, kappa estimates were 0.55, P < 0.001 for disease activity and 0.62, P < 0.001 for disease extent. Conclusion POCUS performed by a gastroenterologist after completion of limited training is accurate for assessing Crohn's disease activity, extent and the presence of complications.
Collapse
Affiliation(s)
- Emily K Wright
- Department of Gastroenterology St Vincent's Hospital Victoria Pde Fitzroy Victoria Fitzroy 3065 Australia.,The University of Melbourne Grattan Street Melbourne Victoria Parkville Victoria 3010 Australia
| | - Ian Wang
- Department of Gastroenterology St Vincent's Hospital Victoria Pde Fitzroy Victoria Fitzroy 3065 Australia
| | - Darren Wong
- Department of Gastroenterology St Vincent's Hospital Victoria Pde Fitzroy Victoria Fitzroy 3065 Australia.,The University of Melbourne Grattan Street Melbourne Victoria Parkville Victoria 3010 Australia
| | - Sally J Bell
- Department of Gastroenterology St Vincent's Hospital Victoria Pde Fitzroy Victoria Fitzroy 3065 Australia
| | - William R Connell
- Department of Gastroenterology St Vincent's Hospital Victoria Pde Fitzroy Victoria Fitzroy 3065 Australia
| | - Alexander J Thompson
- Department of Gastroenterology St Vincent's Hospital Victoria Pde Fitzroy Victoria Fitzroy 3065 Australia.,The University of Melbourne Grattan Street Melbourne Victoria Parkville Victoria 3010 Australia
| | - Kerri L Novak
- Division of Gastroenterology University of Calgary University Drive NW Calgary Alberta T2N 1N4 Canada
| | - Michael A Kamm
- Department of Gastroenterology St Vincent's Hospital Victoria Pde Fitzroy Victoria Fitzroy 3065 Australia.,The University of Melbourne Grattan Street Melbourne Victoria Parkville Victoria 3010 Australia
| |
Collapse
|
23
|
Novak KL, Halasz J, Andrews C, Johnston C, Schoombee W, Tanyingoh D, Kaplan GG, van Zanten SV, Swain M. Nurse-Led, Shared Medical Appointments for Common Gastrointestinal Conditions-Improving Outcomes Through Collaboration With Primary Care in the Medical Home: A Prospective Observational Study. J Can Assoc Gastroenterol 2020; 3:59-66. [PMID: 32328544 PMCID: PMC7165260 DOI: 10.1093/jcag/gwy061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/19/2018] [Indexed: 12/16/2022] Open
Abstract
Background Gastroesophageal reflux disease (GERD), dyspepsia and irritable bowel syndrome (IBS) are common gastrointestinal disorders accounting for a significant demand for specialty care. The aim of this study was to evaluate safety, access and outcomes of patients assessed by a nurse-led, shared medical appointment. Methods This prospective observational study utilized a sample of 770 patients referred to a gastroenterology Central Access and Triage for routine GERD, dyspepsia or IBS from 2011 to 2014. Patient demographics, clinical indication, frequency and outcomes of endoscopy, quality of life, wait times and long-term outcomes (>2 years) were compared between 411 patients assigned to a nurse-led, shared medical appointment and 359 patients assigned to clinic for a gastroenterology physician consultation. Results The nurse-led, shared medical appointment pathway compared with usual care pathway had shorter median wait times (12.6 weeks versus 137.1 weeks, P < 0.0001), fewer endoscopic exams (50.9% versus 76.3%, P < 0.0001), less gastroenterology re-referrals (4.6% versus 15.6%, P < 0.0001), and reduced visits to the emergency department (6.1% versus 12.0%, P = 0.004). After two years of follow-up, outcomes were no different between the pathways. Conclusions Patients with GERD, IBS or dyspepsia who attend the nurse-led, shared medical appointment have improved access to care and reduced resource utilization without increased risk of significant gastrointestinal outcomes after two years of follow-up.
Collapse
Affiliation(s)
| | - Jennifer Halasz
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Andrews
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Divine Tanyingoh
- Division of Gastroenterology and Hepatology and Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology and Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Mark Swain
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
24
|
Stach J, Coward S, Charette JH, Jelinski S, van Zanten S, Morrin L, Kroeker K, Baumgart D, Seow C, Panaccione R, Novak KL, Kaplan GG. A63 HOSPITALIZATION RATES FOR INFLAMMATORY BOWEL DISEASE VARY GEOGRAPHICALLY IN SOUTHERN ALBERTA: A POPULATION-BASED COHORT STUDY. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Hospitalization rates for patients with inflammatory bowel disease (IBD) are decreasing throughout Canada; however, this may vary across Canadian jurisdictions. Access to gastroenterologists is limited in many parts of Canada, resulting in care by non-gastroenterologists, and variation in outcomes.
Aims
To assess trends of hospitalization rates in three regions in Southern Alberta: Calgary zone, a metropolitan city; Chinook region: local gastroenterologists; and Palliser region: no local gastroenterologists.
Methods
The Alberta IBD Surveillance Cohort is a population-based database consisting of an algorithmically defined prevalent IBD population for Alberta. IBD patients in Southern Alberta were identified by 3-digit postal code and their hospitalizations from the Discharge Administrative Database were extracted (2002 to 2015). IBD patients were stratified by the number of IBD prevalent patients: Calgary Zone (n=9625 in 2015), Palliser region (n=1419), and Chinook region (n=727). Age- and sex- standardized hospitalization rates, per 100 prevalent IBD patients, were calculated for each year. Average Annual Percentage Change (AAPC with associated 95% confidence intervals (CI)) were calculated using the log-linear regression. Rate ratios of standardized hospitalization rates between Calgary, Chinook, and Palliser were calculated.
Results
From 2002 to 2015 the average hospitalization rate (per 100 prevalent population) was: 27.6 in Calgary, 30.2 in Chinook, and 37.4 in Palliser (Table 1). The AAPCs across these regions were significantly decreasing (Figure 1). By 2011–2015 hospitalization rates fell to 23, 26.3, and 30.2 in Calgary, Chinook, and Palliser, respectively (Table 1). Calgary and Chinook had significantly lower hospitalization rates compared to Palliser (Calgary: 0.72, 95% CI: 0.70, 0.75; Chinook: 0.80, 95% CI: 0.76, 0.84) (Table 1).
Conclusions
Hospitalization rates for patients with IBD are decreasing, which may be explained by advances in therapeutic modalities and increased expertise of gastroenterologists. The lack of access to a local gastroenterologist in Palliser may account for higher hospitalization rates for patients with IBD. Future studies are needed.
Funding Agencies
CIHRDHSCN (Digestive Health Strategic Clinical Network), AHS (Alberta Health Services)
Collapse
Affiliation(s)
- J Stach
- University of Calgary, Calgary, AB, Canada
| | - S Coward
- University of Calgary, Calgary, AB, Canada
| | - J H Charette
- Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - S Jelinski
- Alberta Health Services, Calgary, AB, Canada
| | | | - L Morrin
- Alberta Health Services, Calgary, AB, Canada
| | - K Kroeker
- University of Alberta, Edmonton, AB, Canada
| | - D Baumgart
- University of Alberta, Edmonton, AB, Canada
| | - C Seow
- Medicine, University of Calgary, Calgary, AB, Canada
| | | | - K L Novak
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - G G Kaplan
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
25
|
Hansen T, Baraty B, Lu C, Tanyingoh D, Maaser C, Novak KL. A248 WHAT IS THE MINIMUM TRAINING STANDARD FOR POINT OF CARE INTESTINAL ULTRASOUND? A SINGLE CENTER, PROSPECTIVE, OBSERVATIONAL STUDY TO DEFINE TRAINING STANDARDS. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Higher demands for colonoscopy and magnetic resonance imaging (MRI) for long term disease monitoring can be expected as the prevalence of IBD continues to rise in Canada. As resources are perpetually constrained, timely access to effective monitoring strategies important to direct care are increasingly compromised. Intestinal ultrasound provides a cost-effective solution to these challenges. Intestinal ultrasound (IUS) is a patient-centered, accurate modality used during clinic by non-radiologists to enhance clinical decision making. Minimum IUS training standards have yet to be established.
Aims
The aim of this study is to report a single operator IUS performance characteristics after completion of 4 weeks of training with 100 completed supervised scans.
Methods
A single center, prospective, observational study over 4 years utilizing a convenience sample of patients presenting to the inflammatory bowel disease (IBD) clinic at the University of Calgary. A single operator compared IUS to gold standard (either colonoscopy, or alternative cross-sectional imaging) with sensitivity, specificity, positive and negative predictive value calculated for each year. Joinpoint regression was performed to analyze the trend for sensitivity and specificity over the study period.
Results
A total of 235 IUS were performed on 235 individuals diagnosed with IBD between 2013 and 2016. There were individuals with 26 ulcerative colitis and 209 persons diagnosed with Crohn’s disease. There was a non-significant increase in sensitivity and specificity point estimates over the 4 year period (Table 1). The sensitivity, specificity, positive predictive value, and accuracy of IUS in 2016 were 100% (95% CI: 81%-100%), 92% (95% CI: 62%-100%), 94% (95% CI: 72%-99%) and 97% (95% CI: 8%-100%) respectively.
Conclusions
IUS provision by a gastroenterologist having completed 100 supervised scans during training within an expert center is sufficient, resulting in high accuracy. Although there is some improvement over time, the trend towards improvement over time is not significant. This study provides evidence to inform IUS training programs with a minimum training standard benchmark, imperative with expanding demand and development of new expert centers.
Funding Agencies
None
Collapse
Affiliation(s)
- T Hansen
- University of Calgary, Calgary, AB, Canada
| | - B Baraty
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - C Lu
- Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - D Tanyingoh
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - C Maaser
- Hospital Luneberg, Luneberg, Germany
| | - K L Novak
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| |
Collapse
|
26
|
Chhibba T, Panaccione R, Seow C, Lu C, Novak KL, Kaplan GG, Ma C. A215 PATIENTS WITH INFLAMMATORY BOWEL DISEASE ARE FREQUENTLY PRESCRIBED OPIOID ANALGESICS WHEN DISCHARGED FROM THE EMERGENCY DEPARTMENT. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Patients with inflammatory bowel disease (IBD) suffer a substantial burden of morbidity related to chronic abdominal pain and are susceptible to opioid dependence and abuse that is associated with increased rates of depression, hospitalization, and mortality. While opioid prescription and renewal by a single provider minimizes the long-term risk of misuse, many patients with IBD will seek out care in the emergency department (ED) where short-term, ‘to-go’ use of narcotic analgesia is associated with potential treatment-related complications.
Aims
To assess rates of opioid prescription in IBD patients presenting to the ED and to assess factors associated with opioid use.
Methods
This is a retrospective analysis of cross-sectional data collected in the United States National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006–2015. We compared a study population of adult IBD patients (International Classification of Diseases ICD-9 555.X, 556.X) ≥18 years discharged from the ED to a control group of patients presenting with non-specific abdominal pain (ICD-9 789.0, 564.1, 536.8). The proportion of patients given opioids in ED and at ED discharge were calculated with relative standard error (RSE), and national level estimates were produced using survey weights. Univariable and multivariable logistic regression was used to evaluate predictors of opioid prescription at discharge, expressed as odds ratios (OR) with 95% confidence intervals (CI).
Results
A total of 767,577 IBD patients were compared to 71,359,257 patients with non-specific abdominal pain. A total of 37.3% (RSE 4.7%) of IBD patients compared to 24.7% (RSE 0.8%) of controls (p<0.01) received an opioid prescription on ED discharge. 49.1% (RSE 5.6%) of IBD patients compared to 37.2% (RSE 0.8%) of patients with non-specific abdominal pain (p=0.02) received an opioid while in ED. Significant predictors of narcotic prescription at discharge in multivariable analysis included: age <50 (OR 6.83 [95% CI: 1.21, 38.48], p=0.03), non-white race (OR 4.73 [95% CI: 1.46, 15.39], p=0.01), and narcotic use in the ED (OR 5.27 [95% CI: 1.96, 14.21], p<0.01).
Conclusions
Nearly 40% of IBD patients were prescribed an opioid at discharge from the ED. This rate is significantly higher than for patients who present with non-specific abdominal pain and younger, non-white IBD patients were disproportionately more likely to receive an opioid prescription. Given the risks associated with on-demand narcotic use in IBD patients, our data highlight a potential gap in care for accessing comprehensive pain management solutions.
Funding Agencies
None
Collapse
Affiliation(s)
- T Chhibba
- University of Calgary, Calgary, AB, Canada
| | | | - C Seow
- University of Calgary, Calgary, AB, Canada
| | - C Lu
- University of Calgary, Calgary, AB, Canada
| | - K L Novak
- University of Calgary, Calgary, AB, Canada
| | - G G Kaplan
- University of Calgary, Calgary, AB, Canada
| | - C Ma
- University of Calgary, Calgary, AB, Canada
| |
Collapse
|
27
|
Charette JH, Stach J, Tanyingoh D, Coward S, Jelinski S, Lang E, van Zanten S, Morrin L, Reeb L, Grigat D, Hair H, Novak KL, Kaplan GG. A5 ADMISSION AND RE-ADMISSION FOR UPPER GASTROINTESTINAL BLEEDING ARE MORE COMMON IN REGIONS UNDERREPRESENTED BY GASTROENTEROLOGISTS: A POPULATION BASED COHORT STUDY. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Lack of access to gastroenterologists may influence outcomes for upper gastrointestinal bleeding (UGIB).
Aims
To evaluate admission and re-admissions for patients with UGIB across the five health zones in Alberta that vary by access to local gastroenterologists.
Methods
Administrative databases identified all patients presenting to an emergency department with an UGIB who were admitted to hospital in Alberta from 2010 to 2015 (n = 17143). Admissions were stratified based the patients’ residence: Calgary, Edmonton, South, Central and North. Log-linear regression assessed an Average Annual Percentage Change (AAPC) in the incidence of UGIB hospitalizations with associated 95% confidence intervals (CI). Endoscopy and readmission to hospital within 30 days of discharge was evaluated.
Results
The per capita number of gastroenterologists was highest in Calgary (3.9 per 100,000) and Edmonton (3.8) as compared to Central (0.84), South (0.66), and North (0.41). Incidence of hospital admission for UGIB decreased in Alberta (AAPC=-6.9%; 95%CI: -8.4,-5.4); though rates for UGIB in Calgary and Edmonton was less common than non-metropolitan zones (Figure 1). Patients living in Calgary and Edmonton had lower 30-day hospital readmission rate (4.30% and 4.84%) as compared to North (11.95%), Central (10.74%), and South (8.24%) (Table 1). Patients in Calgary and Edmonton underwent endoscopic evaluation more frequently (79.6% and 76.1%) than the North, Central, and South (68.41%, 66.3%, and 71.36%).
Conclusions
Patients presenting to emergency departments with UGIB were more likely to be admitted to hospital and subsequently be re-admitted within 30-days of discharge in regions underrepresented by gastroenterologists. Improving access to local gastroenterologists in may reduce the burden of hospitalizations for an UGIB.
Funding Agencies
Partnership for Research and Innovation in the Health System (PRIHS) funded by Alberta Health Services and Alberta Innovates
Collapse
Affiliation(s)
- J H Charette
- Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - J Stach
- Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - D Tanyingoh
- Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - S Coward
- University of Calgary, Calgary, AB, Canada
| | - S Jelinski
- Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - E Lang
- Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | | | - L Morrin
- Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - L Reeb
- Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - D Grigat
- Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - H Hair
- Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - K L Novak
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - G G Kaplan
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
28
|
Ma C, Almutairdi A, Tanyingoh D, Seow CH, Novak KL, Lu C, Panaccione R, Kaplan GG, Kotze PG. Reduction in surgical stoma rates in Crohn's disease: a population-based time trend analysis. Colorectal Dis 2019; 21:1279-1287. [PMID: 31206974 DOI: 10.1111/codi.14731] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/10/2019] [Indexed: 12/12/2022]
Abstract
AIM Trends in surgical rates for Crohn's disease (CD) in the biological era are controversial. We aim to assess modern trends in the formation rates of surgical stomas. METHOD Population-based surveillance in the Calgary Health Zone (CHZ), Canada, was conducted between 1 April 2002 and 31 March 2011, using the Discharge Abstract Database to identify adult patients with CD admitted to hospital and treated with surgical stoma formation (n = 545). Annual stoma incidence was calculated by dividing the number of incident stomas by the prevalence of CD in the CHZ. Time trend analysis of the stoma-formation rate was performed, expressed as annual percentage change (APC) with 95% CI. Stoma-formation rates were stratified according to procedure (emergency vs elective) and duration of stoma [temporary (reversed within 2 years of formation) vs permanent]. RESULTS The overall rate of stoma formation between 2002 and 2011 showed a downwards trend, of a mean of 5.2% (95% CI: -8.5 to -1.8) per year, from a rate of 2.30 stomas/100 person-years (PY) in 2002 to 1.51 stomas/100 PY in 2011. The rate of emergency stoma formation decreased significantly from 2002 to 2011 (mean APC = -9.4%; 95% CI: -15.6 to -2.8), while the rate of elective ostomies essentially showed no change (mean APC = -0.9%; 95% CI: -5.3 to 3.8). The rate of temporary stoma formation decreased significantly, by 4.6% (95% CI: -7.3 to -1.8) per year, while permanent stoma formation was stable (APC = 1.0%; 95% CI: -4.0 to +6.3). CONCLUSION A reduction in the overall rate of stoma formation in CD has been driven by fewer emergency stomas, although rates of permanent stoma have remained stable.
Collapse
Affiliation(s)
- C Ma
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada.,Robarts Clinical Trials, Inc., London, Ontario, Canada
| | - A Almutairdi
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - D Tanyingoh
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - C H Seow
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - K L Novak
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - C Lu
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - R Panaccione
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - G G Kaplan
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - P G Kotze
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada.,Inflammatory Bowel Disease Outpatient Clinics, Colorectal Surgery Unit, Catholic University of Paraná, Curitiba, Brazil
| |
Collapse
|
29
|
Lu C, Dufour A, Ueno A, Jijon H, Prowse K, Novak KL, Panaccione R, Hirota SA. A13 PROTEINS AND FIBROSTENOTIC CROHN’S DISEASE; WHO SHOWED UP TO THE PARTY? J Can Assoc Gastroenterol 2019. [DOI: 10.1093/jcag/gwz006.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- C Lu
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - A Dufour
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - A Ueno
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - H Jijon
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - K Prowse
- McMaster University, Hamilton, AB, Canada
| | - K L Novak
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - R Panaccione
- Gastroenterology, University of Calgary, Calgary AB, AB, Canada
| | - S A Hirota
- Physiology & Pharmacology, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
30
|
Mazurek MS, Belletrutti PJ, Heather GS, Swain M, Novak KL. A22 ROUTINE GASTROINTESTINAL REFERRAL WAIT LIST REDUCTION VIA AN ENHANCED PRIMARY CARE PATHWAY. J Can Assoc Gastroenterol 2019. [DOI: 10.1093/jcag/gwz006.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M S Mazurek
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - P J Belletrutti
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - G S Heather
- Alberta Health Services, Calgary, AB, Canada
| | - M Swain
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - K L Novak
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
31
|
Panaccione N, Novak KL, Seow C, Devlin S, Lu C, Heatherington J, Kaplan GG, Panaccione R. A122 COMBINATION BIOLOGIC THERAPY IN INFLAMMATORY BOWEL DISEASE: THE CALGARY EXPERIENCE. J Can Assoc Gastroenterol 2019. [DOI: 10.1093/jcag/gwz006.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - K L Novak
- University of Calgary, Calgary, AB, Canada
| | - C Seow
- University of Calgary, Calgary, AB, Canada
| | - S Devlin
- University of Calgary, Calgary, AB, Canada
| | - C Lu
- University of Calgary, Calgary, AB, Canada
| | | | - G G Kaplan
- University of Calgary, Calgary, AB, Canada
| | | |
Collapse
|
32
|
Leung Y, Shim HH, Wilkens R, Tanyingoh D, Afshar EE, Sharifi N, Pauls M, Novak KL, Kaplan GG, Panaccione R, Wilson SR, Seow CH. The Role of Bowel Ultrasound in Detecting Subclinical Inflammation in Pregnant Women with Crohn's Disease. J Can Assoc Gastroenterol 2018; 2:153-160. [PMID: 31616856 PMCID: PMC6785691 DOI: 10.1093/jcag/gwy062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 10/05/2018] [Indexed: 12/16/2022] Open
Abstract
Background and Aims Maintaining disease remission improves outcomes for pregnant women with Crohn’s disease (CD). As symptoms may correlate poorly with disease activity in the gravid state, we investigated the utility of bowel sonography during pregnancy to assess disease activity. Methods We conducted a prospective observational cohort study of pregnant women with CD undergoing bowel sonography between July 1, 2012, and December 1, 2016. Clinically active disease was defined using standardized clinical indices (Harvey Bradshaw Index >4 for active disease). Sonographic findings were graded as inactive (normal, mild) or active (moderate, severe) by expert radiologists. Results There were 91 pregnancies in 82 CD patients. Symptoms were present in 12 pregnancies; however, eight (67%) had sonographic findings of inactive disease, and escalation of therapy was not initiated. Conversely, sonographically active disease in seven asymptomatic pregnancies resulted in four women escalating therapy. The remaining three women declined escalation of therapy, one had a miscarriage, and the other two women had persistently active disease on sonography and endoscopy at one-year postpartum. Conclusions Bowel ultrasound may detect subclinical inflammation in asymptomatic pregnant women with CD and stratify CD activity in symptomatic patients. Therefore, bowel sonography should be considered as a useful adjunct for the assessment of the pregnant woman with Crohn’s disease.
Collapse
Affiliation(s)
- Yvette Leung
- Division of Gastroenterology and Hepatology, Department of Medicine, University of British Columbia, British Columbia, Canada.,Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Hang Hock Shim
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada.,Department of Gastroenterology and Hepatology, Singapore General Hospital, Bukit Merah, Singapore
| | - Rune Wilkens
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Hospital, Silkeborg, Denmark.,Department of Radiology and Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | | | - Elnaz Ehteshami Afshar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Nastaran Sharifi
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Mehrnoosh Pauls
- Department of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Stephanie R Wilson
- Department of Radiology and Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
| |
Collapse
|
33
|
Shim HH, Ma C, Kotze PG, Seow CH, Al-Farhan H, Al-Darmaki AK, Pang JXQ, Fedorak RN, Devlin SM, Dieleman LA, Kaplan GG, Novak KL, Kroeker KI, Halloran BP, Panaccione R. Preoperative Ustekinumab Treatment Is Not Associated With Increased Postoperative Complications in Crohn's Disease: A Canadian Multi-Centre Observational Cohort Study. J Can Assoc Gastroenterol 2018; 1:115-123. [PMID: 31294352 PMCID: PMC6507292 DOI: 10.1093/jcag/gwy013] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Ustekinumab (UST), an anti-IL12/23 inhibitor is indicated for moderate-to-severe Crohn's disease (CD). However, it is unclear if patients treated with UST are at increased risk for postoperative complications. AIM To evaluate the postoperative safety outcomes in UST-treated CD patients. METHODS A multicentre cohort study of UST-treated CD patients at two tertiary care centres (University of Calgary, University of Alberta, Canada) undergoing abdominal surgery between 2009 and 2016 was performed. Postoperative outcomes were compared against a control cohort of anti-TNF-treated patients over the same time-period. The primary outcome was occurrence of postoperative complications up to six months postoperatively, stratified by timing (early <30 days vs. late complications ≥30 days). RESULTS Twenty UST-treated patients and 40 anti-TNF-treated patients were included with a median preoperative treatment exposure of 6.5 months and 18 months, respectively (p=0.01). Bowel obstruction was the most common surgical indication in both cohorts. UST-treated patients were more likely to require an ostomy (70.0% vs. 12.5%, p<0.001) and be on combination therapy with either systemic corticosteroids or concurrent immunomodulators (azathioprine or methotrexate) (25.0% vs. 2.5%, p=0.01). Despite the increased concomitant use of immunosuppression in the UST-treated cohort, there were no significant differences in early or late postoperative wound infections (1/20 in UST-cohort, 2/40 in anti-TNF cohort, p=1.00), anastomotic leak (0/20 in UST-cohort, 3/40 in anti-TNF cohort, p=0.54), or postoperative ileus/obstruction (3/20 in UST-cohort, 4/40 in anti-TNF cohort, p=0.67). CONCLUSIONS CD patients receiving preoperative UST did not experience an increase in postoperative complications, despite increased use of concurrent immunosuppression.
Collapse
Affiliation(s)
- Hang Hock Shim
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Paulo G Kotze
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
- Inflammatory Bowel Disease Outpatient Clinics, Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Heba Al-Farhan
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Ahmed K Al-Darmaki
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Jack X Q Pang
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Richard N Fedorak
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Shane M Devlin
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | | | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Karen I Kroeker
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | | | - Remo Panaccione
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| |
Collapse
|
34
|
Kotze PG, Ma C, Almutairdi A, Al-Darmaki A, Devlin SM, Kaplan GG, Seow CH, Novak KL, Lu C, Ferraz JGP, Stewart MJ, Buresi M, Jijon H, Mathivanan M, Heatherington J, Martin ML, Panaccione R. Real-world clinical, endoscopic and radiographic efficacy of vedolizumab for the treatment of inflammatory bowel disease. Aliment Pharmacol Ther 2018; 48:626-637. [PMID: 30063077 DOI: 10.1111/apt.14919] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 05/08/2018] [Accepted: 07/03/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Vedolizumab is an α4β7 integrin antagonist with proven efficacy for inducing and maintaining clinical response and remission in Crohn's disease (CD) and ulcerative colitis (UC). AIM To evaluate clinical and objective response and remission rates with vedolizumab in a large, real world cohort. METHODS A retrospective cohort study of adult CD and UC patients receiving vedolizumab between 2012 and 2017 was conducted. PRIMARY OUTCOME clinical or objective response and remission at 3, 6 and 12 months after induction. Clinical remission was defined by complete, steroid-free absence of symptoms. Objective remission was defined by endoscopic mucosal healing or normalisation of radiographic appearance on contrast-enhanced ultrasound or CT/MR enterography. RESULTS The study included 222 vedolizumab patients (122 CD, 100 UC). In CD, clinical remission at 3, 6 and 12 months was achieved in 19.8% (22/111), 22.1% (21/95) and 22.1% (15/68) of patients, respectively. Objective remission occurred in 11.5% (6/52), 21.2% (14/66), and 18.9% (7/37) of patients at 3, 6 and 12 months, respectively. In UC, clinical remission at 3, 6, and 12 months was 51.0% (51/100), 61.8% (55/89) and 61.9% (39/63), respectively. Endoscopic remission occurred in 27.5% (11/40), 41.0% (16/39) and 47.8% (22/46) of patients at 3, 6 and 12 months, respectively. In multivariable analysis, patients with UC as compared to CD, and those with milder disease activity were more likely to achieve objectively defined remission at both 6 and 12 months. CONCLUSIONS Vedolizumab was effective for induction and maintenance of clinical and objective remission, both in Crohn's disease and ulcerative colitis.
Collapse
Affiliation(s)
- Paulo G Kotze
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Inflammatory Bowel Disease Outpatient Clinics, Catholic University of Paraná (PUCPR), Curitiba, PR, Brazil
| | - Christopher Ma
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Robarts Clinical Trials Inc., Western University, London, ON, Canada
| | - Abdulelah Almutairdi
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ahmed Al-Darmaki
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shane M Devlin
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gilaad G Kaplan
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cynthia H Seow
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kerri L Novak
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cathy Lu
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jose G P Ferraz
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael J Stewart
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michelle Buresi
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Humberto Jijon
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Meena Mathivanan
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Joan Heatherington
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marie-Louise Martin
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Remo Panaccione
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
35
|
Calabrese E, Kucharzik T, Maaser C, Maconi G, Strobel D, Wilson SR, Zorzi F, Novak KL, Bruining DH, Iacucci M, Watanabe M, Lolli E, Chiaramonte C, Hanauer SB, Panaccione R, Pallone F, Ghosh S, Monteleone G. Real-time Interobserver Agreement in Bowel Ultrasonography for Diagnostic Assessment in Patients With Crohn's Disease: An International Multicenter Study. Inflamm Bowel Dis 2018; 24:2001-2006. [PMID: 29718450 DOI: 10.1093/ibd/izy091] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND The unavailability of standardized parameters in bowel ultrasonography (US) commonly used in Crohn's disease (CD) and the shortage of skilled ultrasonographers are 2 limiting factors in the use of this imaging modality around the world. The aim of this study is to evaluate interobserver agreement among experienced sonographers in the evaluation of bowel US parameters in order to improve standardization in imaging reporting and interpretation. METHODS Fifteen patients with an established diagnosis of CD underwent blinded bowel US performed by 6 experienced sonographers. Prior to the evaluation, the sonographers and clinical and radiological IBD experts met to formally define the US parameters. Interobserver agreement was tested with the Quatto method (s). RESULTS All operators agreed on the presence/absence of CD lesions and distinguished absence of/mild activity or moderate/severe lesions in all patients. S values were moderate for bowel wall thickness (s = 0.48, P = n.s.), bowel wall pattern (s = 0.41, P = n.s.), vascularization (s = 0.52, P = n.s.), and presence of lymphnodes (s = 0.61, P = n.s.). Agreement was substantial for lesion location (s = 0.68, P = n.s.), fistula (s = 0.74, P = n.s.), phlegmon (s = 0.78, P = 0.04), and was almost perfect for abscess (s = 0.95, P = 0.02). Poor agreement was observed for mesenteric adipose tissue alteration, lesion extent, stenosis, and prestenotic dilation. CONCLUSIONS In this study, the majority of the US parameters used in CD showed moderate/substantial agreement. The development of shared US imaging interpretation patterns among sonographers will lead to improved comparability of US results among centers and facilitate the development of multicenter studies and the spread of bowel US training, thereby allowing a wider adoption of this useful technique.
Collapse
Affiliation(s)
- Emma Calabrese
- Gastroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata," Italy
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Staedtisches Klinikum Lueneburg, Lueneburg, Germany
| | - Christian Maaser
- Ambulanzzentrum Gastroenterologie am Klinikum Lüneburg, Lüneburg, Germany
| | - Giovanni Maconi
- Department of Clinical Sciences, L. Sacco University Hospital, Milan, Italy
| | | | - Stephanie R Wilson
- Department of Radiology and **Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Canada.,Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Francesca Zorzi
- Gastroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata," Italy
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - David H Bruining
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Japan
| | - Marietta Iacucci
- Institute of Translational of Medicine, University of Birmingham, Birmingham, UK
| | - Mamoru Watanabe
- Northwestern University Feinberg School of Medicine, Digestive Disease Center, Chicago, Illinois, USA
| | - Elisabetta Lolli
- Gastroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata," Italy
| | - Carlo Chiaramonte
- Gastroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata," Italy
| | - Stephen B Hanauer
- Northwestern University Feinberg School of Medicine, Digestive Disease Center, Chicago, Illinois, USA
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Francesco Pallone
- Gastroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata," Italy
| | - Subrata Ghosh
- Institute of Translational of Medicine, University of Birmingham, Birmingham, UK
| | - Giovanni Monteleone
- Gastroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata," Italy
| |
Collapse
|
36
|
Bryant RV, Friedman AB, Wright EK, Taylor KM, Begun J, Maconi G, Maaser C, Novak KL, Kucharzik T, Atkinson NSS, Asthana A, Gibson PR. Gastrointestinal ultrasound in inflammatory bowel disease: an underused resource with potential paradigm-changing application. Gut 2018; 67:973-985. [PMID: 29437914 DOI: 10.1136/gutjnl-2017-315655] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 12/20/2022]
Abstract
Evolution of treatment targets in IBD has increased the need for objective monitoring of disease activity to guide therapeutic strategy. Although mucosal healing is the current target of therapy in IBD, endoscopy is invasive, expensive and unappealing to patients. GI ultrasound (GIUS) represents a non-invasive modality to assess disease activity in IBD. It is accurate, cost-effective and reproducible. GIUS can be performed at the point of care without specific patient preparation so as to facilitate clinical decision-making. As compared with ileocolonoscopy and other imaging modalities (CT and MRI), GIUS is accurate in diagnosing IBD, detecting complications of disease including fistulae, strictures and abscesses, monitoring disease activity and detecting postoperative disease recurrence. International groups increasingly recognise GIUS as a valuable tool with paradigm-changing application in the management of IBD; however, uptake outside parts of continental Europe has been slow and GIUS is underused in many countries. The aim of this review is to present a pragmatic guide to the positioning of GIUS in IBD clinical practice, providing evidence for use, algorithms for integration into practice, training pathways and a strategic implementation framework.
Collapse
Affiliation(s)
- Robert Venning Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, Australia.,Faculty of Health Sciences, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Antony B Friedman
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Emily Kate Wright
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Kirstin M Taylor
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Jakob Begun
- Department of Gastroenterology, Mater Hospital, Brisbane, Australia.,Mater Research Institute, University of Queensland, Brisbane, Australia
| | - Giovanni Maconi
- Department of Gastroenterology, Luigi Sacco University Hospital, Milan, Italy
| | - Christian Maaser
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Kerri L Novak
- Division of Gastroenterology, University of Calgary, Calgary, Canada
| | - Torsten Kucharzik
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | | | - Anil Asthana
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| |
Collapse
|
37
|
Ma C, Fedorak R, Kaplan GG, Dieleman LA, Devlin S, Stern N, Kroeker KI, Seow C, Leung Y, Novak KL, Halloran BP, Huang V, Wong K, Ghosh S, Panaccione R. A108 USTEKINUMAB IS EFFECTIVE FOR INDUCING CLINICAL, ENDOSCOPIC, AND RADIOGRAPHIC RESPONSE IN REFRACTORY MODERATE-TO-SEVERE CROHN’S DISEASE: A MULTICENTRE COHORT STUDY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- C Ma
- University of Calgary, Calgary, AB, Canada
| | - R Fedorak
- University of Alberta, Edmonton, AB, Canada
| | - G G Kaplan
- University of Calgary, Calgary, AB, Canada
| | | | - S Devlin
- University of Calgary, Calgary, AB, Canada
| | - N Stern
- University of Alberta, Edmonton, AB, Canada
| | | | - C Seow
- University of Calgary, Calgary, AB, Canada
| | - Y Leung
- University of Calgary, Calgary, AB, Canada
| | - K L Novak
- University of Calgary, Calgary, AB, Canada
| | | | - V Huang
- University of Alberta, Edmonton, AB, Canada
| | - K Wong
- University of Alberta, Edmonton, AB, Canada
| | - S Ghosh
- University of Birmingham, Birmingham, United Kingdom
| | | |
Collapse
|
38
|
Shim H, Ma C, Al-Farhan H, Aldarmaki AK, Pang J, Seow C, Fedorak R, Devlin S, Dieleman LA, Kaplan GG, Novak KL, Kroeker KI, Halloran BP, Panaccione R. A107 POSTOPERATIVE OUTCOMES AMONG USTEKINUMAB TREATED CROHN’S DISEASE PATIENTS: A MULTICENTRE CANADIAN PROVINCIAL EXPERIENCE. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- H Shim
- Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - C Ma
- University of Calgary, Calgary, AB, Canada
| | - H Al-Farhan
- Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - A K Aldarmaki
- Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - J Pang
- University of Calgary, Calgary, AB, Canada
| | - C Seow
- Medicine, University of Calgary, Calgary, AB, Canada
| | - R Fedorak
- Los Alamos National Laboratory, Edmonton, AB, Canada
| | - S Devlin
- University of Calgary, Calgary, AB, Canada
| | - L A Dieleman
- Medicine, University of Alberta, Edmonton, AB, Canada
| | - G G Kaplan
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - K L Novak
- Gastroenterology, University of Calgary, Calgary AB, Canada
| | - K I Kroeker
- Medicine, University of Alberta, Edmonton, AB, Canada
| | - B P Halloran
- Medicine, Divison of Gastroenterology, University Of Alberta, Edmonton, AB, Canada
| | | |
Collapse
|
39
|
Mazurek MS, Belletrutti PJ, Halasz J, Heather GS, Swain M, Novak KL. A230 NOT ALL PATIENTS WITH GASTROINTESTINAL COMPLAINTS REQUIRE SPECIALIST CARE: TWO YEAR OUTCOMES FROM AN ENHANCED PRIMARY CARE PATHWAY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- M S Mazurek
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - P J Belletrutti
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - J Halasz
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - G S Heather
- Alberta Healther Services, Calgary, AB, Canada
| | - M Swain
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - K L Novak
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
40
|
Ma C, Fedorak R, Kaplan GG, Dieleman LA, Devlin S, Stern N, Kroeker KI, Seow C, Leung Y, Novak KL, Halloran BP, Huang V, Wong K, Ghosh S, Panaccione R. A106 USTEKINUMAB IS EFFECTIVE FOR MAINTAINING CLINICAL RESPONSE IN REFRACTORY MODERATE-TO-SEVERE CROHN’S DISEASE: A MULTICENTRE COHORT STUDY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- C Ma
- University of Calgary, Calgary, AB, Canada
| | - R Fedorak
- University of Alberta, Edmonton, AB, Canada
| | - G G Kaplan
- University of Calgary, Calgary, AB, Canada
| | | | - S Devlin
- University of Calgary, Calgary, AB, Canada
| | - N Stern
- University of Alberta, Edmonton, AB, Canada
| | | | - C Seow
- University of Calgary, Calgary, AB, Canada
| | - Y Leung
- University of Calgary, Calgary, AB, Canada
| | - K L Novak
- University of Calgary, Calgary, AB, Canada
| | | | - V Huang
- University of Alberta, Edmonton, AB, Canada
| | - K Wong
- University of Alberta, Edmonton, AB, Canada
| | - S Ghosh
- University of Calgary, Calgary, AB, Canada
| | | |
Collapse
|
41
|
Ma C, Kotze P, Almutairdi A, Al-Darmaki A, Devlin S, Kaplan GG, Seow C, Novak KL, Lu C, Ferraz J, Stewart MJ, Buresi MC, Mathivanan M, Heatherington J, Martin M, Panaccione R. A116 LOSS OF RESPONSE TO VEDOLIZUMAB MAINTENANCE THERAPY IN CROHN`S DISEASE. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- C Ma
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - P Kotze
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - A Almutairdi
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - A Al-Darmaki
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - S Devlin
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - G G Kaplan
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - C Seow
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - K L Novak
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - C Lu
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - J Ferraz
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - M J Stewart
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - M c Buresi
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - M Mathivanan
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - J Heatherington
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - M Martin
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - R Panaccione
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
42
|
Mazurek MS, Novak KL, Heather VC, Heather GS, Swain M, Belletrutti PJ. A231 URGENT PRIORITY ENDOSCOPY PATHWAY IN A HIGH VOLUME CENTRAL ACCESS MODEL: OPTIMIZING GASTROENTEROLGY CARE FOR THE SICKEST PATIENTS. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M S Mazurek
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - K L Novak
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - V C Heather
- Alberta Health Services, Calgary, AB, Canada
| | - G S Heather
- Alberta Health Services, Calgary, AB, Canada
| | - M Swain
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - P J Belletrutti
- Gastroenterology, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
43
|
Kotze P, Ma C, Almutairdi A, Al-Darmaki A, Devlin S, Kaplan GG, Seow C, Novak KL, Lu C, Ferraz J, Stewart MJ, Buresi MC, Mathivanan M, Heatherington J, Martin M, Panaccione R. A115 CLINICAL, RADIOGRAPHIC, AND ENDOSCOPIC REMISSION WITH VEDOLIZUMAB TREATMENT IN CROHN’S DISEASE. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- P Kotze
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - C Ma
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - A Almutairdi
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - A Al-Darmaki
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - S Devlin
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - G G Kaplan
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - C Seow
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - K L Novak
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - C Lu
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - J Ferraz
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - M J Stewart
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - M c Buresi
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - M Mathivanan
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - J Heatherington
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - M Martin
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - R Panaccione
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
44
|
Iacucci M, Kaplan GG, Panaccione R, Akinola O, Lethebe BC, Lowerison M, Leung Y, Novak KL, Seow CH, Urbanski S, Minoo P, Gui X, Ghosh S. A Randomized Trial Comparing High Definition Colonoscopy Alone With High Definition Dye Spraying and Electronic Virtual Chromoendoscopy for Detection of Colonic Neoplastic Lesions During IBD Surveillance Colonoscopy. Am J Gastroenterol 2018; 113:225-234. [PMID: 29134964 DOI: 10.1038/ajg.2017.417] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 09/12/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Dye spraying chromoendoscopy (DCE) is recommended for the detection of colonic neoplastic lesions in inflammatory bowel disease (IBD). The majority of neoplastic lesions are visible endoscopically and therefore targeted biopsies are appropriate for surveillance colonoscopy. To compare three different techniques for surveillance colonoscopy to detect colonic neoplastic lesions in IBD patients: high definition (HD), (DCE), or virtual chromoendoscopy (VCE) using iSCAN image enhanced colonoscopy. METHODS A randomized non-inferiority trial was conducted to determine the detection rates of neoplastic lesions in IBD patients with longstanding colitis. Patients with inactive disease were enrolled into three arms of the study. Endoscopic neoplastic lesions were classified by the Paris classification and Kudo pit pattern, then histologically classified by the Vienna classification. RESULTS A total of 270 patients (55% men; age range 20-77 years, median age 49 years) were assessed by HD (n=90), VCE (n=90), or DCE (n=90). Neoplastic lesion detection rates in the VCE arm was non-inferior to the DCE arm. HD was non-inferior to either DCE or VCE for detection of all neoplastic lesions. In the lesions detected, location at right colon and the Kudo pit pattern were predictive of neoplastic lesions (OR 6.52 (1.98-22.5 and OR 21.50 (8.65-60.10), respectively). CONCLUSIONS In this randomized trial, VCE or HD-WLE is not inferior to dye spraying colonoscopy for detection of colonic neoplastic lesions during surveillance colonoscopy. In fact, in this study HD-WLE alone was sufficient for detection of dysplasia, adenocarcinoma or all neoplastic lesions.
Collapse
Affiliation(s)
- Marietta Iacucci
- Inflammatory Bowel Disease Clinic Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Canada.,Division of Gastroenterology & Institute of Translational Medicine, NIHR Biomedical Research Center, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Gilaad G Kaplan
- Inflammatory Bowel Disease Clinic Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Remo Panaccione
- Inflammatory Bowel Disease Clinic Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Oluseyi Akinola
- Inflammatory Bowel Disease Clinic Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Brendan Cord Lethebe
- Department of Community Health Sciences, Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Mark Lowerison
- Department of Community Health Sciences, Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Yvette Leung
- Inflammatory Bowel Disease Clinic Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Kerri L Novak
- Inflammatory Bowel Disease Clinic Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Cynthia H Seow
- Inflammatory Bowel Disease Clinic Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Canada.,Department of Community Health Sciences, Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Stefan Urbanski
- Department of Pathology, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Parham Minoo
- Department of Pathology, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Xianyong Gui
- Department of Pathology, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Subrata Ghosh
- Inflammatory Bowel Disease Clinic Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Canada.,Division of Gastroenterology & Institute of Translational Medicine, NIHR Biomedical Research Center, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| |
Collapse
|
45
|
Ma C, Fedorak RN, Kaplan GG, Dieleman LA, Devlin SM, Stern N, Kroeker KI, Seow CH, Leung Y, Novak KL, Halloran BP, Huang VW, Wong K, Blustein PK, Ghosh S, Panaccione R. Clinical, endoscopic and radiographic outcomes with ustekinumab in medically-refractory Crohn's disease: real world experience from a multicentre cohort. Aliment Pharmacol Ther 2017; 45:1232-1243. [PMID: 28252210 DOI: 10.1111/apt.14016] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 12/22/2016] [Accepted: 02/07/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ustekinumab is a monoclonal antibody targeting interleukins-12 and -23, with efficacy in Crohn's disease (CD) demonstrated in clinical trials. AIM To assess the real-world clinical, endoscopic and radiographic response and remission outcomes achieved with ustekinumab in medically-refractory CD. METHODS A retrospective multicentre cohort study was performed on CD patients receiving ustekinumab between 2011 and 2016. The primary outcome was achievement of clinical and objective steroid-free response and remission at 3, 6 and 12 months. Clinical response and remission were defined by reduction in Harvey Bradshaw Index (HBI) of ≥3 points and an HBI ≤4 points respectively. Objective response was defined by improvement in endoscopic or radiographic CD, as assessed by ileocolonoscopy, contrast-enhanced ultrasound or CT/MR enterography. Objective remission was defined by endoscopic mucosal healing or complete resolution of inflammatory parameters on radiographic assessment. RESULTS A total of 167 CD patients were treated with ustekinumab. 95.2% (159/167) previously failed anti-TNF therapy. Median follow-up was 45.6 weeks (IQR: 24.4-88.9). At 3 months, clinical response was achieved in 38.9% (65/167) and remission in 15.0% (25/167) of patients. At 6 months, clinical response was achieved in 60.3% (91/151) and remission in 25.2% (38/151) of patients. At 12 months, clinical response was achieved in 59.5% (66/111) and remission in 27.9% (31/111) of patients. Endoscopic or radiographic response was demonstrated in 54.5% (67/123) at 6 months and 55.8% (48/86) of patients at 12 months. CONCLUSIONS Ustekinumab is an effective therapeutic option for inducing and maintaining clinical, endoscopic and radiographic response in patients with Crohn's disease failing anti-TNF therapy.
Collapse
Affiliation(s)
- C Ma
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - R N Fedorak
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - G G Kaplan
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - L A Dieleman
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - S M Devlin
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - N Stern
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - K I Kroeker
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - C H Seow
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Y Leung
- Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
| | - K L Novak
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - B P Halloran
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - V W Huang
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - K Wong
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - P K Blustein
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - S Ghosh
- University of Birmingham, Birmingham, UK
| | - R Panaccione
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
46
|
Gasia MF, Ghosh S, Panaccione R, Ferraz JG, Kaplan GG, Leung Y, Novak KL, Seow CH, Iacucci M. Targeted Biopsies Identify Larger Proportions of Patients With Colonic Neoplasia Undergoing High-Definition Colonoscopy, Dye Chromoendoscopy, or Electronic Virtual Chromoendoscopy. Clin Gastroenterol Hepatol 2016; 14:704-12.e4. [PMID: 26804384 DOI: 10.1016/j.cgh.2015.12.047] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 12/05/2015] [Accepted: 12/30/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is unclear what are the best and most appropriate endoscopic procedures for detecting colonic neoplasia in patients with long-term colonic inflammatory bowel disease (IBD). Dye chromoendoscopy (DCE) is the standard used in IBD surveillance colonoscopies. However, studies are needed to determine the optimal endoscopic technique for detecting dysplastic lesions. We investigated current practices used in surveillance colonoscopies by IBD gastroenterologists at a single tertiary center. We also determined the rate of neoplasia detection among different surveillance endoscopic techniques in an analysis of random or targeted biopsies. METHODS We collected data on 454 patients with IBD (54.5% male; mean age, 50 y; mean disease duration, 14.5 y; 55.9% with ulcerative colitis, 42.7% with Crohn's disease, and 1.3% with indeterminate colitis) who underwent surveillance colonoscopy from April 2011 through March 2014 at the University of Calgary in Canada. Subjects were examined using white-light standard-definition endoscopy (WLE), high-definition (HD) colonoscopy, virtual electronic chromoendoscopy (VCE), or DCE; random or targeted biopsy specimens were collected. Endoscopic and histologic descriptions with suspected neoplasia were recorded. Rates of neoplasia detection by the different endoscopic procedures were compared using chi-square analysis. RESULTS Of the patients analyzed, 27.7% had WLE endoscopy with random collection of biopsy specimens, 27.3% had HD colonoscopy with random collection of biopsy specimens, 14.1% had VCE with random collection of biopsy specimens, 0.9% had DCE with random collection of biopsy specimens, 12.8% had HD colonoscopy with collection of targeted biopsy specimens, 11.9% had VCE with collection of targeted biopsy specimens, and 5.3% had DCE with collection of targeted biopsy specimens. Neoplastic lesions were detected in 8.2% of the procedures performed in the random biopsy group (95% confidence interval, 5.6-11.7) and 19.1% of procedures in the targeted biopsy group (95% confidence interval, 13.4-26.5) (P < .001). Neoplasias were detected in similar proportions of patients by HD colonoscopy, VCE, or DCE, with targeted biopsy collection. CONCLUSIONS In a large cohort of IBD patients undergoing surveillance colonoscopy, targeted biopsies identified greater proportions of subjects with neoplasia than random biopsies. Targeted collection of biopsy specimens appears to be sufficient for detecting colonic neoplasia in patients undergoing HD colonoscopy, DCE, or VCE, but not WLE.
Collapse
Affiliation(s)
- Miriam F Gasia
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Subrata Ghosh
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Jose G Ferraz
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Yvette Leung
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Marietta Iacucci
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada.
| |
Collapse
|
47
|
Novak KL, Jacob D, Kaplan GG, Boyce E, Ghosh S, Ma I, Lu C, Wilson S, Panaccione R. Point of Care Ultrasound Accurately Distinguishes Inflammatory from Noninflammatory Disease in Patients Presenting with Abdominal Pain and Diarrhea. Can J Gastroenterol Hepatol 2016; 2016:4023065. [PMID: 27446838 PMCID: PMC4904691 DOI: 10.1155/2016/4023065] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 09/29/2015] [Indexed: 12/15/2022] Open
Abstract
Background. Approaches to distinguish inflammatory bowel disease (IBD) from noninflammatory disease that are noninvasive, accurate, and readily available are desirable. Such approaches may decrease time to diagnosis and better utilize limited endoscopic resources. The aim of this study was to evaluate the diagnostic accuracy for gastroenterologist performed point of care ultrasound (POCUS) in the detection of luminal inflammation relative to gold standard ileocolonoscopy. Methods. A prospective, single-center study was conducted on convenience sample of patients presenting with symptoms of diarrhea and/or abdominal pain. Patients were offered POCUS prior to having ileocolonoscopy. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% confidence intervals (CI), as well as likelihood ratios, were calculated. Results. Fifty-eight patients were included in this study. The overall sensitivity, specificity, PPV, and NPV were 80%, 97.8%, 88.9%, and 95.7%, respectively, with positive and negative likelihood ratios (LR) of 36.8 and 0.20. Conclusion. POCUS can accurately be performed at the bedside to detect transmural inflammation of the intestine. This noninvasive approach may serve to expedite diagnosis, improve allocation of endoscopic resources, and facilitate initiation of appropriate medical therapy.
Collapse
Affiliation(s)
- Kerri L. Novak
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Deepti Jacob
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Gilaad G. Kaplan
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
- Department of Community Health Sciences, Calgary, AB, Canada T2N 2T9
| | - Emma Boyce
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Subrata Ghosh
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Irene Ma
- Division of General Internal Medicine, Calgary, AB, Canada T2N 2T9
| | - Cathy Lu
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada T2N 2T9
| | - Stephanie Wilson
- Diagnostic Imaging, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Remo Panaccione
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
| |
Collapse
|
48
|
Novak KL, Jacob D, Kaplan G, Boyce E, Ghosh S, Ma I, Lu C, Wilson S, Panaccione R. Point-of-care ultrasound accurately distinguishes inflammatory from noninflammatory disease in patients presenting with abdominal pain and diarrhea. Can J Gastroenterol Hepatol 2015:17208. [PMID: 26523457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
|
49
|
Singh S, Al-Darmaki A, Frolkis AD, Seow CH, Leung Y, Novak KL, Ghosh S, Eksteen B, Panaccione R, Kaplan GG. Postoperative Mortality Among Patients With Inflammatory Bowel Diseases: A Systematic Review and Meta-analysis of Population-Based Studies. Gastroenterology 2015; 149:928-37. [PMID: 26055136 DOI: 10.1053/j.gastro.2015.06.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 05/02/2015] [Accepted: 06/01/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS There have been varying reports of mortality after intestinal resection for the inflammatory bowel diseases (IBDs). We performed a systematic review and meta-analysis of population-based studies to determine postoperative mortality after intestinal resection in patients with IBD. METHODS We searched Medline, EMBASE, and PubMed, from 1990 through 2015, to identify 18 articles and 3 abstracts reporting postoperative mortality among patients with IBD. The studies included 67,057 patients with ulcerative colitis (UC) and 75,971 patients with Crohn's disease (CD), from 15 countries. Mortality estimates stratified by emergent and elective surgeries were pooled separately for CD and UC using a random-effects model. To assess changes over time, the start year of the study was included as a continuous variable in a meta-regression model. RESULTS In patients with UC, postoperative mortality was significantly lower among patients who underwent elective (0.7%; 95% confidence interval [CI], 0.6%-0.9%) vs emergent surgery (5.3%; 95% CI, 3.8%-7.4%). In patients with CD, postoperative mortality was significantly lower among patients who underwent elective (0.6%; 95% CI, 0.2%-1.7%) vs emergent surgery (3.6%; 95% CI, 1.8%-6.9%). Postoperative mortality did not differ for elective (P = .78) or emergent (P = .31) surgeries when patients with UC were compared with patients with CD. Postoperative mortality decreased significantly over time for patients with CD (P < .05) but not UC (P = .21). CONCLUSIONS Based on a systematic review and meta-analysis, postoperative mortality was high after emergent, but not elective, intestinal resection in patients with UC or CD. Optimization of management strategies and more effective therapies are necessary to avoid emergent surgeries.
Collapse
Affiliation(s)
- Sunny Singh
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Ahmed Al-Darmaki
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra D Frolkis
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Yvette Leung
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Subrata Ghosh
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Bertus Eksteen
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
50
|
Wilkens R, Novak KL, Lebeuf-Taylor E, Wilson SR. Impact of intestinal ultrasound on classification and management of Crohn disease patients with inconclusive colonoscopy. Can J Gastroenterol Hepatol 2015:16943. [PMID: 26301329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
|