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Barnes A, Ooi SYJ, Lynch KD, Parthasarathy N, Bishara M, Gounder M, Grafton R, Leach P, Bampton P, Sechi A, Ng W, Connor S, van Langenberg D, Mountifield R, Andrews JM. Proactive Metabolite Testing in Patients on Thiopurine May Yield Long-Term Clinical Benefits in Inflammatory Bowel Disease. Dig Dis Sci 2023; 68:889-896. [PMID: 35687221 PMCID: PMC10011286 DOI: 10.1007/s10620-022-07556-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/04/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The thiopurine medications are well established in the treatment of inflammatory bowel disease (IBD). There is significant variation in levels of toxic and therapeutic metabolites. Current data from small or short-term studies support therapeutic drug monitoring (TDM) in assessing azathioprine (AZA) and 6-mercaptopurine (6MP). TDM of thiopurines involves measurement and interpretation of metabolites 6-TGN and 6-MMPR. AIMS This study aimed to assess long-cterm outcomes of patients on thiopurines following therapeutic drug monitoring. METHODS A multicenter retrospective observational study of outcomes post thiopurine TDM was conducted. Demographics, disease characteristics, physician global assessment, IBD therapy at baseline TDM and again at 12 months were collected. Clinical outcomes were analyzed according to TDM result, and indication for TDM including proactive and other indications. RESULTS The study included 541 patients. Only 39% of patients had appropriate dosing of thiopurines. AZA/6MP TDM informed a management change in 61.9%, and enabled 88.8% of the cohort to continue AZA/6MP following TDM. At 12 months following TDM the majority (74.1%) of the cohort remained on AZA/6MP. Clinical remission was higher at 12-months following thiopurines TDM (68%) compared to baseline (37%), including proactive TDM. Post TDM, 13.0% of patients were identified as shunters and commenced on thiopurine-allopurinol co-therapy. CONCLUSION Thiopurine TDM resulted in a change in management for the majority of patients. Post TDM significantly more patients were in remission. TDM allowed the identification of non-adherence and shunters who, without intervention, would not reach therapeutic drug levels. Proactive TDM allowed identification and management of inappropriate dosing, and was associated with increased levels of clinical remission.
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Affiliation(s)
- Alex Barnes
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital Adelaide, Adelaide, Australia.
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia.
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Soong-Yuan J Ooi
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital Adelaide, Adelaide, Australia
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Kate D Lynch
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital Adelaide, Adelaide, Australia
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Nina Parthasarathy
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Australia
| | - Maria Bishara
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Australia
| | - Michael Gounder
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
- South Western Sydney Clinical School, Faculty of Medicine, University of NSW, Sydney, Australia
| | - Rachel Grafton
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital Adelaide, Adelaide, Australia
| | - Peta Leach
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
| | - Peter Bampton
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
| | - Alexandra Sechi
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
| | - Watson Ng
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
- South Western Sydney Clinical School, Faculty of Medicine, University of NSW, Sydney, Australia
| | - Susan Connor
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
- South Western Sydney Clinical School, Faculty of Medicine, University of NSW, Sydney, Australia
| | - Daniel van Langenberg
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Réme Mountifield
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital Adelaide, Adelaide, Australia
- School of Medicine, University of Adelaide, Adelaide, Australia
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Krishnaprasad K, Walsh A, Begun J, Bell S, Carter D, Grafton R, Sechi A, Sewell K, McMahon A, Connor S, Radford-Smith G, Andrews JM. Crohn's Colitis Care (CCCare): bespoke cloud-based clinical management software for inflammatory bowel disease. Scand J Gastroenterol 2020; 55:1419-1426. [PMID: 33161791 DOI: 10.1080/00365521.2020.1839960] [Citation(s) in RCA: 5] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Adherence to evidence-based management is variable in inflammatory bowel disease (IBD), which leads to worse patient outcomes and higher healthcare utilization. Solutions include electronic systems to enhance care, but these have often been limited by lack of clinician design input, poor usability, and low perceived value. A cloud-based IBD-specific clinical management software - 'Crohn's Colitis Care' (CCCare) was developed by Australia and New Zealand Inflammatory Bowel Disease Consortium clinicians and software developers to improve this. METHODS CCCare captures patient-reported disease activity and medical assessment, medication monitoring, cancer screening, preventative health, and facilitates communication with the IBD team and referring doctor. De-identified longitudinal data are stored separately in a clinical quality registry for research. CCCare was tested for feasibility and usability in routine clinical settings at two large Australian hospitals. Users' experience was evaluated with System Usability Scale (SUS). Value to clinicians and patients was assessed by qualitative feedback. Security was assessed by penetration testing. RESULTS Users (n = 13; doctors, nurses, patients) reported good usability and learnability (mean SUS score 75 (range 50-95), sub-scores were 77 (50-94) and 68 (38-100), respectively). Patients reported better communication with clinical team and greater ability to track disease. Clinicians highlighted structured management plans, medication adherence, and centralised data repository as positive features. Penetration testing was passed successfully. CONCLUSIONS Initial evaluation demonstrates CCCare is usable, secure, and valued in clinical use. It is designed to measure outcomes of clinical care, including efficacy, quality, cost, and complications for individuals, and to audit these at hospital and national level.
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Affiliation(s)
- Krupa Krishnaprasad
- Gut Health, QIMR Berghofer Medical Research Institute, Brisbane, Australia.,Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Alissa Walsh
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Jakob Begun
- Department of Gastroenterology, Mater Hospital, Brisbane, Australia
| | - Sally Bell
- Department of Gastroenterology, Monash Health, Melbourne, Australia
| | - David Carter
- Stratos Technology Partners, Christchurch, New Zealand
| | - Rachel Grafton
- Department of Gastroenterology, Royal Adelaide Hospital & University of Adelaide, Adelaide, Australia
| | - Alexandra Sechi
- Department of Gastroenterology, Liverpool Hospital, University of NSW & Ingham Institute of Applied Medical Research, Liverpool, Australia
| | - Karen Sewell
- Department of Gastroenterology, Mater Hospital, Brisbane, Australia
| | - Anna McMahon
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Susan Connor
- Department of Gastroenterology, Liverpool Hospital, University of NSW & Ingham Institute of Applied Medical Research, Liverpool, Australia
| | - Graham Radford-Smith
- Gut Health, QIMR Berghofer Medical Research Institute, Brisbane, Australia.,Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Australia.,University of Queensland School of Medicine, Brisbane, Australia
| | - Jane M Andrews
- Department of Gastroenterology, Royal Adelaide Hospital & University of Adelaide, Adelaide, Australia
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3
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Kaazan P, Tan Z, Bednarz J, Hughes J, Grafton R, Andrews JM. Infliximab-related weight gain in inflammatory bowel disease: associations and financial impacts. Intern Med J 2020; 50:1134-1138. [PMID: 32929820 DOI: 10.1111/imj.14987] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/25/2020] [Accepted: 04/26/2020] [Indexed: 11/26/2022]
Abstract
Association between tumour necrosis alpha inhibitors and weight gain has been reported. We examined weight change in our cohort of inflammatory bowel disease patients treated with infliximab (IFX) for over 12 months, its associations and financial implications. Two-thirds of patients gained weight during the course of therapy. The mean change in weight after 12 months of IFX therapy was 3.3 (±6.5) kg.
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Affiliation(s)
- Patricia Kaazan
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Division of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Zhi Tan
- Division of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jana Bednarz
- Division of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Julie Hughes
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rachel Grafton
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jane M Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Division of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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4
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Liu J, Andrews JM, Sammour T, Bryant RV, Grafton R, Simpson E, Putrus E, Nixon C. Benefits of Exclusive Enteral Nutrition in Adults With Complex Active Crohn’s Disease: A Case Series of 13 Consecutive Patients. Crohn's & Colitis 360 2019. [DOI: 10.1093/crocol/otz044] [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 and Aims
Immunosuppressive therapy is routine for adults with complex active Crohn’s disease (CD), however carries risks, particularly in the setting of sepsis. Exclusive enteral nutrition (EEN) is widely used in paediatric CD, yet efficacy data in adults are sparse. This study evaluated outcomes of EEN in adults with complex active CD.
Methods
Between December 2016 and June 2018, 13 patients with complex active CD (range 20–74 years) managed at a single hospital received 2 or more weeks of EEN. Patients were offered EEN based on either malnutrition, contraindication to immunosuppression, or CD refractory to multiple therapies. Subjective and objective outcomes were recorded at 2 and 6 weeks and compared with baseline data.
Results
Nine of 13 patients experienced subjective improvement in wellbeing. Objective improvements included nine CRP decrements (median = 87.7 mg/L, IQR = 70.6 mg/L), nine serum albumin increments (median = 7 g/L, IQR = 4 g/L), and six gained weight (median = 3.6 kg, IQR = 3.0 kg). All five patients with complex abscess resolved without surgery. One ileocolic fistula and one enterocutaneous fistula achieved resolution without surgery. One of two perianal fistulae cases resolved without surgery. Seven of 10 patients initially thought to need surgery avoided it due to disease resolution. Only one of the three patients who proceeded to surgery sustained a post-operative complication. There were no EEN-associated complications.
Conclusions
In complex active CD, our real-world data show that EEN improves wellbeing, decreases inflammatory markers, leads to healthy weight gain, reduces need for surgical intervention, and reduces postoperative complications.
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Affiliation(s)
- Jianliang Liu
- Faculty of Health and Medical Sciences, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Jane M Andrews
- Faculty of Health and Medical Sciences, The University of Adelaide Medical School, Adelaide, South Australia, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Faculty of Health and Medical Sciences, The University of Adelaide Medical School, Adelaide, South Australia, Australia
- Department of Surgery, Colorectal Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Robert V Bryant
- Faculty of Health and Medical Sciences, The University of Adelaide Medical School, Adelaide, South Australia, Australia
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Rachel Grafton
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eliza Simpson
- Department of Clinical Dietetics, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Emma Putrus
- Department of Clinical Dietetics, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Claire Nixon
- Department of Clinical Dietetics, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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5
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Roberts RL, Wallace MC, Seinen ML, van Bodegraven AA, Krishnaprasad K, Jones GT, van Rij AM, Baird A, Lawrance IC, Prosser R, Bampton P, Grafton R, Simms LA, Studd C, Bell SJ, Kennedy MA, Halliwell J, Gearry RB, Radford-Smith G, Andrews JM, McHugh PC, Barclay ML. Nonsynonymous Polymorphism in Guanine Monophosphate Synthetase Is a Risk Factor for Unfavorable Thiopurine Metabolite Ratios in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2018; 24:2606-2612. [PMID: 29788244 DOI: 10.1093/ibd/izy163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 01/03/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Up to 20% of patients with inflammatory bowel disease (IBD) who are refractory to thiopurine therapy preferentially produce 6-methylmercaptopurine (6-MMP) at the expense of 6-thioguanine nucleotides (6-TGN), resulting in a high 6-MMP:6-TGN ratio (>20). The objective of this study was to evaluate whether genetic variability in guanine monophosphate synthetase (GMPS) contributes to preferential 6-MMP metabolizer phenotype. METHODS Exome sequencing was performed in a cohort of IBD patients with 6-MMP:6-TGN ratios of >100 to identify nonsynonymous single nucleotide polymorphisms (nsSNPs). In vitro assays were performed to measure GMPS activity associated with these nsSNPs. Frequency of the nsSNPs was measured in a cohort of 530 Caucasian IBD patients. RESULTS Two nsSNPs in GMPS (rs747629729, rs61750370) were detected in 11 patients with very high 6-MMP:6-TGN ratios. The 2 nsSNPs were predicted to be damaging by in silico analysis. In vitro assays demonstrated that both nsSNPs resulted in a significant reduction in GMPS activity (P < 0.05). The SNP rs61750370 was significantly associated with 6-MMP:6-TGN ratios ≥100 (odds ratio, 5.64; 95% confidence interval, 1.01-25.12; P < 0.031) in a subset of 264 Caucasian IBD patients. CONCLUSIONS The GMPS SNP rs61750370 may be a reliable risk factor for extreme 6MMP preferential metabolism.
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Affiliation(s)
- Rebecca L Roberts
- Department of Surgical Sciences (Dunedin), University of Otago, Otago, New Zealand
| | - Mary C Wallace
- Department of Surgical Sciences (Dunedin), University of Otago, Otago, New Zealand
| | - Margien L Seinen
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands.,Department of Internal Medicine, Gastroenterology and Geriatrics, Atrium-ORBIS Medical Center, Heerlen-Sittard, the Netherlands
| | - Adriaan A van Bodegraven
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands.,Department of Internal Medicine, Gastroenterology and Geriatrics, Atrium-ORBIS Medical Center, Heerlen-Sittard, the Netherlands
| | | | - Gregory T Jones
- Department of Surgical Sciences (Dunedin), University of Otago, Otago, New Zealand
| | - Andre M van Rij
- Department of Surgical Sciences (Dunedin), University of Otago, Otago, New Zealand
| | - Angela Baird
- Centre for Inflammatory Bowel Disease, Saint John of God Hospital, Subiaco, WA, Australia
| | - Ian C Lawrance
- Centre for Inflammatory Bowel Disease, Saint John of God Hospital, Subiaco, WA, Australia.,Harry Perkins Institute of Medical Research, School of Medicine and Pharmacology, University of Western Australia, Murdoch, WA, Australia
| | - Ruth Prosser
- Flinders Medical Centre, Flinders University of South Australia, Bedford Park, South Australia, Australia
| | - Peter Bampton
- Flinders Medical Centre, Flinders University of South Australia, Bedford Park, South Australia, Australia
| | - Rachel Grafton
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Lisa A Simms
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Corrie Studd
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Sally J Bell
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Martin A Kennedy
- Department of Pathology, University of Otago Christchurch, Christchurch, New Zealand
| | - Jacob Halliwell
- Centre for Biomarker Research, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Richard B Gearry
- Department of Gastroenterology, Christchurch Hospital, Christchurch, New Zealand
| | - Graham Radford-Smith
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jane M Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Patrick C McHugh
- Centre for Biomarker Research, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Murray L Barclay
- Department of Gastroenterology, Christchurch Hospital, Christchurch, New Zealand
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6
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Doecke JD, Hartnell F, Bampton P, Bell S, Mahy G, Grover Z, Lewindon P, Jones LV, Sewell K, Krishnaprasad K, Prosser R, Marr D, Fischer J, R Thomas G, Tehan JV, Ding NS, Cooke SE, Moss K, Sechi A, De Cruz P, Grafton R, Connor SJ, Lawrance IC, Gearry RB, Andrews JM, Radford-Smith GL. Infliximab vs. adalimumab in Crohn's disease: results from 327 patients in an Australian and New Zealand observational cohort study. Aliment Pharmacol Ther 2017; 45:542-552. [PMID: 27995633 DOI: 10.1111/apt.13880] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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: 06/03/2016] [Revised: 06/19/2016] [Accepted: 11/06/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Maintenance anti-tumour necrosis factor-α (anti-TNFα) treatment for Crohn's disease is the standard of care for patients with an inadequate response to corticosteroids and immunomodulators. AIM To compare the efficacy and safety of infliximab and adalimumab in clinical practice and assess the value of concomitant immunomodulator therapy. METHODS We performed an observational cohort study in consecutive patients with Crohn's disease qualifying for anti-TNFα treatment in Australia and New Zealand between 2007 and 2011. Demographic and clinical data were prospectively recorded to identify independent factors associated with induction and maintenance of response to infliximab or adalimumab, or to either anti-TNFα therapy. RESULTS Three hundred and twenty-seven patients (183 infliximab, 144 adalimumab) successfully applied for treatment. Eighty-nine percent responded in all groups and median maintenance of response was similar for the two agents. Concomitant immunomodulator with infliximab, but not adalimumab, demonstrated a significantly longer response overall (P = 0.002), and significantly fewer disease and treatment-related complications (P = 0.017). Corticosteroids at baseline, and/or in the preceding 12 months, were associated with a 9-13 times greater risk of disease flare during maintenance treatment as compared to no corticosteroids (P < 0.0001). Maintenance of response was similar in the anti-TNF naïve and anti-TNF experienced subgroups. CONCLUSIONS In this large, real-life study, we demonstrate infliximab and adalimumab to have similar response characteristics. However, infliximab requires concomitant immunomodulator to achieve optimal maintenance of response comparable to adalimumab monotherapy. The results of this study will assist clinicians in further optimising patient care in their day-to-day clinical practice.
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Affiliation(s)
- J D Doecke
- Parkville, Vic., Australia.,Brisbane, Qld, Australia
| | | | | | - S Bell
- Melbourne, Vic., Australia
| | - G Mahy
- Townsville, Qld, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - K Moss
- Bedford Park, SA, Australia
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7
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Bryant RV, Ooi S, Schultz CG, Goess C, Grafton R, Hughes J, Lim A, Bartholomeusz FD, Andrews JM. Low muscle mass and sarcopenia: common and predictive of osteopenia in inflammatory bowel disease. Aliment Pharmacol Ther 2015; 41:895-906. [PMID: 25753216 DOI: 10.1111/apt.13156] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [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: 11/03/2014] [Revised: 11/20/2014] [Accepted: 02/15/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Body composition is poorly studied in inflammatory bowel disease (IBD). Sarcopenia describes a loss of muscle mass and strength. AIM To assess the prevalence of low lean mass (LM), sarcopenia and associated morbidity in an adult IBD cohort. METHODS Cross-sectional data were gathered on pre-menopausal 18- to 50-year-old patients with IBD. Whole-body dual-energy X-ray absorptiometry, anthropometric assessment and grip strength were performed. Low LM was defined as ≥1 s.d. below the population mean for appendicular skeletal muscle index [ASMI (kg)/height (m)²], and sarcopenia as both ASMI and grip strength ≥1 s.d. below population mean. Multivariate regression analyses were performed. RESULTS Of 137 participants (median age 31 years, BMI 24.8 kg/m(2) ), 56% were male and 69% had Crohn's disease (CD). Low LM and sarcopenia were observed in 21% and 12% of patients, respectively, and osteopenia/osteoporosis in 38% of patients (mean lumbar spine t-score -0.3 ± s.d. 1.1). Grip strength predicted low LM and sarcopenia better than did body mass index (BMI) (OR 4.8 vs. OR 0.7 for low-LM, P < 0.05 both). Normal BMI was falsely reassuring in 72% and 76% of patients with low ASMI and sarcopenia, respectively. Low LM and sarcopenia (OR = 3.6, P = 0.03; OR = 6.3, P = 0.02; respectively), but not BMI nor fat mass, predicted osteopenia/osteoporosis. CONCLUSIONS Low lean mass and sarcopenia are common in patients with IBD, and important to recognise as they predict osteopenia/osteoporosis. Grip strength testing should be incorporated into routine clinical practice to detect low lean mass deficits, which may go unrecognised using BMI alone.
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Affiliation(s)
- R V Bryant
- Inflammatory Bowel Disease Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia; School of Medicine, University of Adelaide, Adelaide, SA, Australia
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8
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Lim AH, Grafton R, Hetzel DJ, Andrews JM. Clinical audit: recent practice in caring for patients with acute severe colitis compared with published guidelines--is there a problem? Intern Med J 2014; 43:803-9. [PMID: 23176535 DOI: 10.1111/imj.12042] [Citation(s) in RCA: 3] [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] [Received: 08/09/2012] [Accepted: 10/28/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND Acute severe colitis (ASC) is a serious condition with possible outcomes of emergency colectomy and mortality. Validated guidelines exist to help avoid these. AIMS To examine local adherence to guidelines and identify (a) opportunities to improve care and (b) possible barriers to adherence. METHODS Retrospective, hospital-wide audit of all patients with ASC during a 2-year period (2009-2010) at a major metropolitan hospital. Cases were identified by an electronic search of all discharges with International Classification of Diseases-10 codes for colitis, colectomy, ulcerative colitis or Crohn disease. RESULTS Twenty-six patients had 30 ASC admissions (14 female). Most admissions were under gastroenterology (25), 4 (13%) were under general medicine and 1 was under general surgery. Only 8 patients' (26%) management (all under gastroenterology) included all major details: blood investigations, Clostridium difficile test, abdominal X-ray, colonic examination and venous thromboembolism prophylaxis. Only one patient had formal severity scoring on admission, and seven patients (24%) had descriptive severity recorded. On day 3, nine patients (30%) had some recorded severity assessment; however, no formal criteria were used. Four had colectomy, three during first admission and one on re-admission. Of these patients, three received cyclosporine prior to colectomy. The mean duration of admission was 10 days (standard deviation 10.54, range 1-61). CONCLUSION Opportunities to optimise care exist including formal severity assessments on days 1 and 3, better deep vein thrombosis/pulmonary embolism prophylaxis and prompt colonic examination. Admission under teams other than gastroenterology appeared to be a barrier to better care. Despite the low rate of ideal management, the colectomy rate was acceptably low at 20%.
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Affiliation(s)
- A H Lim
- University of Adelaide, Adelaide, South Australia, Australia.
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9
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Lawrance IC, Murray K, Batman B, Gearry RB, Grafton R, Krishnaprasad K, Andrews JM, Prosser R, Bampton PA, Cooke SE, Mahy G, Radford-Smith G, Croft A, Hanigan K. Crohn's disease and smoking: is it ever too late to quit? J Crohns Colitis 2013; 7:e665-71. [PMID: 23790611 DOI: 10.1016/j.crohns.2013.05.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/22/2013] [Accepted: 05/22/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Smoking increases CD risk. The aim was to determine if smoking cessation at, prior to, or following, CD diagnosis affects medication use, disease phenotypic progression and/or surgery. METHODS Data on CD patients with disease for ≥5 yrs were collected retrospectively including the Montreal classification, smoking history, CD-related abdominal surgeries, family history, medication use and disease behaviour at diagnosis and the time when the disease behaviour changed. RESULTS 1115 patients were included across six sites (mean follow-up-16.6 yrs). More non-smokers were male (p=0.047) with A1 (p<0.0001), L4 (p=0.028) and perianal (p=0.03) disease. Non-smokers more frequently received anti-TNF agents (p=0.049). (p=0.017: OR 2.5 95%CI 1.18-5.16) and those who ceased smoking prior to diagnosis (p=0.045: OR 2.3 95%CI 1.02-5.21) progressed to complicated (B2/B3) disease as compared to those quitting at diagnosis. Patients with uncomplicated terminal ileal disease at diagnosis more frequently developed B2/B3 disease than isolated colonic CD (p<0.0001). B2/B3 disease was more frequent with perianal disease (p<0.0001) and if i.v. steroids (p=0.004) or immunosuppressants (p<0.0001) were used. 49.3% (558/1115) of patients required at least one intestinal surgery. More smokers had a 2nd surgical resection than patients who quit at, or before, the 1st resection and non-smokers (p=0.044: HR=1.39 95%CI 1.01-1.91). Patients smoking >3 cigarettes/day had an increased risk of developing B2/B3 disease (p=0.012: OR 3.8 95%CI 1.27-11.17). CONCLUSION Progression to B2/B3 disease and surgery is reduced by smoking cessation. All CD patients regardless of when they were diagnosed, or how many surgeries, should be strongly encouraged to cease smoking.
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Affiliation(s)
- Ian C Lawrance
- Centre for Inflammatory Bowel Diseases, Fremantle Hospital, WA, Australia; University Department of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, WA, Australia.
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Phan VAH, van Langenberg DR, Grafton R, Andrews JM. A dedicated inflammatory bowel disease service quantitatively and qualitatively improves outcomes in less than 18 months: a prospective cohort study in a large metropolitan centre. Frontline Gastroenterol 2012; 3:137-142. [PMID: 28839654 PMCID: PMC5517272 DOI: 10.1136/flgastro-2011-100086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [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: 11/08/2011] [Accepted: 03/08/2012] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Maintaining high efficacy and quality of care in inflammatory bowel disease (IBD) management is a priority. The authors examined whether the introduction of a formal IBD Service (IBDS) positively influenced outcomes for their patients. METHODS In 2007-2008, all IBD patients attending the Royal Adelaide Hospital were surveyed regarding clinical/demographic data, IBD knowledge, quality of life, mental health and satisfaction. Survey responders were re-surveyed ≥15 months later. RESULTS 162 responded to survey 1 and 81 again responded to survey 2. Within the responders, 61% had Crohn's disease and 48% were men. Compared with survey 1, the proportions of patients with improved knowledge, adherence, satisfaction with care, QoL (≥5 points), anxiety and depression scores were 63% (95% CI 51 to 73), 62% (95% CI 50 to 72), 65% (95% CI 54 to 76), 42% (95% CI 31 to 54), 52% (95% CI 40 to 63) and 43% (95% CI 32 to 55), respectively. When comparing survey 2 with survey 1, reductions in hospitalisation (48% vs 30%, p=0.02), courses of corticosteroids and opiates (mean 1.63 vs 0.91 and 1.00 vs 0.61, both p<0.05) and overall medications (5.63 vs 4.65, p<0.05), were seen. Fewer 2009 non-responders required hospitalisation (53% vs 21%, p<0.001), suggesting a `cohort' rather than `responder-specific' effect. CONCLUSIONS The introduction of an IBDS resulted in improved patient outcomes with significant reductions in negative markers for IBD morbidity including: hospitalisations, polypharmacy, steroid and opiate use. Despite increased costs in additional staff, these measures are likely to be cost effective.
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Affiliation(s)
- Vinh-An Huu Phan
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Daniel R van Langenberg
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia,Box Hill Hospital, Melbourne, Victoria, Australia
| | - Rachel Grafton
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia,School of Medicine, University of Adelaide & Department of Medicine, Adelaide, Australia
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Sack C, Phan VA, Grafton R, Holtmann G, van Langenberg DR, Brett K, Clark M, Andrews JM. A chronic care model significantly decreases costs and healthcare utilisation in patients with inflammatory bowel disease. J Crohns Colitis 2012; 6:302-10. [PMID: 22405166 DOI: 10.1016/j.crohns.2011.08.019] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [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: 06/01/2011] [Revised: 08/15/2011] [Accepted: 08/31/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Inflammatory bowel disease (IBD) is a chronic condition, yet the model of care is often reactive. We sought to examine whether a formal IBD service (IBDS) reduced inpatient healthcare utilisation or lowered costs for inpatient care. MATERIAL AND METHODS With protocols, routine nurse phone follow-up a help-line, more proactive care was delivered, with many symptoms and concerns dealt with prior to routine presentation. Over two five month periods before (2007/8) and after (2009/10) introducing a formal IBDS two discrete cohorts of admitted IBD patients were identified at a single centre. Each patient was assigned five contemporaneously admitted, age and gender matched controls. Inpatient healthcare utilisation was compared between patients and controls and disease-specific factors amongst the two IBD cohorts. RESULTS The initial audit captured 102 admitted IBD patients (510 controls, median age 44 years, 57% female); the second audit 95 patients (475 controls, median age 46 years, 45.3% female). In 2009/10, the number of admissions was lower in IBD patients than in controls (mean 1.53+/-1.03 vs. 2.54+/-2.35; p<0.0001). This contrasts with the first audit, where IBD patients had more admissions than controls. Following IBDS introduction, the mean total cost of inpatient care was lower for IBD patients than controls (US$12,857.48 (US$15,236.79) vs. US$ 30,467.78 (US$ 53,760.20), p=0.005). In addition, patients known to a specialist gastroenterologist (GE) and the IBD Service tended to have the lowest mean number of admissions (GE and IBDS 1.14 (+/-0.36) vs. no GE/IBDS 1.64 (+/-1.25)). CONCLUSIONS Healthcare utilisation and disease burden in IBD decreased significantly since introducing an IBDS. These data suggest that proactive management improved outcomes. Contact with a gastroenterologist and IBDS seemed to give best results.
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Affiliation(s)
- C Sack
- IBD Service, Department of Gastroenterology & Hepatology, Royal Adelaide Hospital, Australia
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Krishnaprasad K, Andrews JM, Lawrance IC, Florin T, Gearry RB, Leong RWL, Mahy G, Bampton P, Prosser R, Leach P, Chitti L, Cock C, Grafton R, Croft AR, Cooke S, Doecke JD, Radford-Smith GL. Inter-observer agreement for Crohn's disease sub-phenotypes using the Montreal Classification: How good are we? A multi-centre Australasian study. J Crohns Colitis 2012; 6:287-93. [PMID: 22405164 DOI: 10.1016/j.crohns.2011.08.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [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: 05/29/2011] [Revised: 08/21/2011] [Accepted: 08/21/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Crohn's disease (CD) exhibits significant clinical heterogeneity. Classification systems attempt to describe this; however, their utility and reliability depends on inter-observer agreement (IOA). We therefore sought to evaluate IOA using the Montreal Classification (MC). METHODS De-identified clinical records of 35 CD patients from 6 Australian IBD centres were presented to 13 expert practitioners from 8 Australia and New Zealand Inflammatory Bowel Disease Consortium (ANZIBDC) centres. Practitioners classified the cases using MC and forwarded data for central blinded analysis. IOA on smoking and medications was also tested. Kappa statistics, with pre-specified outcomes of κ>0.8 excellent; 0.61-0.8 good; 0.41-0.6 moderate and ≤0.4 poor, were used. RESULTS 97% of study cases had colonoscopy reports, however, only 31% had undergone a complete set of diagnostic investigations (colonoscopy, histology, SB imaging). At diagnosis, IOA was excellent for age, κ=0.84; good for disease location, κ=0.73; only moderate for upper GI disease (κ=0.57) and disease behaviour, κ=0.54; and good for the presence of perianal disease, κ=0.6. At last follow-up, IOA was good for location, κ=0.68; only moderate for upper GI disease (κ=0.43) and disease behaviour, κ=0.46; but excellent for the presence/absence of perianal disease, κ=0.88. IOA for immunosuppressant use ever and presence of stricture were both good (κ=0.79 and 0.64 respectively). CONCLUSION IOA using MC is generally good; however some areas are less consistent than others. Omissions and inaccuracies reduce the value of clinical data when comparing cohorts across different centres, and may impair the ability to translate genetic discoveries into clinical practice.
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Affiliation(s)
- Krupa Krishnaprasad
- Inflammatory Bowel Disease Research Group, Queensland Institute of Medical Research, Brisbane, Australia.
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de la Rocha AG, Robertson GA, Grafton R, Levitt M. Resection of a metastatic sternal carcinoma and reconstruction of the chest wall: a case report. Can J Surg 1984; 27:599-601. [PMID: 6388771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
A large metastatic squamous carcinoma of the anterior chest wall was managed by en-bloc resection of the thoracic wall. The extensive defect resulting from the resection was bridged with Marlex mesh superimposed on an omental flap that served as recipient to partial-thickness skin grafts. This composite reconstruction restored an efficient bellows action to the chest cage, manifested by the lack of anterior flailing and postoperative spirometry values, measured at the bedside, that were 75% of those obtained preoperatively. During the initial postoperative period, however, mechanical ventilatory assistance was required to treat an adult respiratory distress syndrome that together with mild anterior flailing made early extubation impossible.
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