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Ow TW, Sukocheva O, Bampton P, Iyngkaran G, Rayner CK, Tse E. Improving Concordance Between Clinicians With Australian Guidelines for Bowel Cancer Prevention Using a Digital Application: Randomized Controlled Crossover Study. JMIR Cancer 2024; 10:e46625. [PMID: 38238256 PMCID: PMC10921317 DOI: 10.2196/46625] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 11/28/2023] [Accepted: 01/18/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Australia's bowel cancer prevention guidelines, following a recent revision, are among the most complex in the world. Detailed decision tables outline screening or surveillance recommendations for 230 case scenarios alongside cessation recommendations for older patients. While these guidelines can help better allocate limited colonoscopy resources, their increasing complexity may limit their adoption and potential benefits. Therefore, tools to support clinicians in navigating these guidelines could be essential for national bowel cancer prevention efforts. Digital applications (DAs) represent a potentially inexpensive and scalable solution but are yet to be tested for this purpose. OBJECTIVE This study aims to assess whether a DA could increase clinician adherence to Australia's new colorectal cancer screening and surveillance guidelines and determine whether improved usability correlates with greater conformance to guidelines. METHODS As part of a randomized controlled crossover study, we created a clinical vignette quiz to evaluate the efficacy of a DA in comparison with the standard resource (SR) for making screening and surveillance decisions. Briefings were provided to study participants, which were tailored to their level of familiarity with the guidelines. We measured the adherence of clinicians according to their number of guideline-concordant responses to the scenarios in the quiz using either the DA or the SR. The maximum score was 18, with higher scores indicating improved adherence. We also tested the DA's usability using the System Usability Scale. RESULTS Of 117 participants, 80 were included in the final analysis. Using the SR, the adherence of participants was rated a median (IQR) score of 10 (7.75-13) out of 18. The participants' adherence improved by 40% (relative risk 1.4, P<.001) when using the DA, reaching a median (IQR) score of 14 (12-17) out of 18. The DA was rated highly for usability with a median (IQR) score of 90 (72.5-95) and ranked in the 96th percentile of systems. There was a moderate correlation between the usability of the DA and better adherence (rs=0.4; P<.001). No differences between the adherence of specialists and nonspecialists were found, either with the SR (10 vs 9; P=.47) or with the DA (13 vs 15; P=.24). There was no significant association between participants who were less adherent with the DA (n=17) and their age (P=.06), experience with decision support tools (P=.51), or academic involvement with a university (P=.39). CONCLUSIONS DAs can significantly improve the adoption of complex Australian bowel cancer prevention guidelines. As screening and surveillance guidelines become increasingly complex and personalized, these tools will be crucial to help clinicians accurately determine the most appropriate recommendations for their patients. Additional research to understand why some practitioners perform worse with DAs is required. Further improvements in application usability may optimize guideline concordance further.
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Affiliation(s)
- Tsai-Wing Ow
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Olga Sukocheva
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter Bampton
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Guruparan Iyngkaran
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Australia
| | - Christopher K Rayner
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Edmund Tse
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
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Ow TW, Angelica B, Burn S, Chu M, Lee SZ, Lin R, Tran V, Iyngkaran G, Bampton P, Sukocheva O, Tse E, Rayner CK. Comparing the resource implications of old and new colorectal adenoma surveillance guidelines in Australia. Intern Med J 2024; 54:250-257. [PMID: 37287100 DOI: 10.1111/imj.16149] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/30/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND The latest update to the Australian adenoma surveillance guideline in 2018 introduced a novel risk stratification system with updated surveillance recommendations. The resource implications of adopting this new system are unclear. AIMS To quanitfy the resource demands of adopting new over old adenoma surveillance guidelines. METHODS We studied data from 2443 patients undergoing colonoscopies, in which a clinically significant lesion was identified in their latest, or previous procedure(s) across five Australian hospitals. We excluded procedures with inflammatory bowel disease, new or prior history of colorectal cancer or resection, inadequate bowel preparation and incomplete procedures. Old and new Australian surveillance intervals were calculated according to the number, size and histological characteristics of lesions identified. We used these data to compare the rate of procedures according to each guideline. RESULTS Based on the procedures for 766 patients, the new surveillance guidelines significantly increased the number of procedures allocated an interval of 1 year (relative risk (RR): 1.57, P = 0.009) and 10 years (RR: 3.83, P < 0.00001) and reduced those allocated to half a year (RR: 0.08, P = 0.00219), 3 years (RR: 0.51, P < 0.00001) and 5 years (RR: 0.59, P < 0.00001). Overall, this reduced the relative number of surveillance procedures by 21% over 10 years (25.92 vs 32.78 procedures/100 patient-years), which increased to 22% after excluding patients 75 or older at the time of surveillance (19.9 vs 25.65 procedures/100 patient-years). CONCLUSION The adoption of the latest Australian adenoma surveillance guidelines can reduce demand for surveillance colonoscopy by more than a fifth (21-22%) over 10 years.
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Affiliation(s)
- Tsai-Wing Ow
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Bianca Angelica
- Department of Gastroenterology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Sophie Burn
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Matthew Chu
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Shawn Z Lee
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Richard Lin
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vy Tran
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Guru Iyngkaran
- Department of Gastroenterology and Hepatology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter Bampton
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Olga Sukocheva
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Edmund Tse
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Chris K Rayner
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Ow TW, Tse E, Iyngkaran G, Macrae F. The basis and implications of diverging approaches to colorectal adenoma surveillance in the West. Intern Med J 2023; 53:635-639. [PMID: 37005714 DOI: 10.1111/imj.16029] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/02/2022] [Indexed: 04/04/2023]
Abstract
Algorithms for the surveillance of colorectal adenomas have recently undergone revision in Australia and abroad. Despite a shared evidence base, significant differences are observed and optimal intervals for surveillance remain controversial. We sought to explore their differences in relation to current evidence, practical aspects and how we may improve our own approach to adenoma surveillance in Australia.
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Affiliation(s)
- Tsai-Wing Ow
- Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Edmund Tse
- Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Guru Iyngkaran
- Gastroenterology and Hepatology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Finlay Macrae
- Gastroenterology and Hepatology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Ow TW, Sukocheva OA, Tran V, Lin R, Lee SZ, Chu M, Angelica B, Rayner CK, Tse E, Iyngkaran G, Bampton PA. Quality of colonoscopy performed by medical or surgical specialists and trainees in five Australian hospitals. World J Gastrointest Endosc 2022; 14:672-683. [PMID: 36438878 PMCID: PMC9693691 DOI: 10.4253/wjge.v14.i11.672] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/19/2022] [Accepted: 10/31/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ensuring colonoscopy procedure quality is vital to the success of screening and surveillance programmes for bowel cancer in Australia. However, the data on the performance of quality metrics, through adequate adenoma detection, bowel preparation, and procedure completion rates, in the Australian public sector is limited. Understanding these can inform quality improvement to further strengthen our capacity for prevention and early detection of colorectal cancer.
AIM To determine the quality of colonoscopy in Australian teaching hospitals and their association with proceduralist specialty, trainee involvement, and location.
METHODS We retrospectively evaluated 2443 consecutive colonoscopy procedure reports from 1 January to 1 April, 2018 from five public teaching tertiary hospitals in Australia (median 60 years old, 49% male). Data for bowel preparation quality, procedure completion rates, and detection rates of clinically significant adenomas, conventional adenomas, and serrated lesions was collected and compared to national criteria for quality in colonoscopy. Participating hospital, proceduralist specialty, and trainee involvement indicators were used for stratification. Data was analysed using Chi-squared tests of independence, Mann-Whitney U, One-way ANOVA, and multivariate binary logistic regression.
RESULTS Fifty-two point two percent (n = 1276) and 43.3% (n = 1057) were performed by medical and surgical proceduralists respectively, whilst 29.8% (n = 728) involved a trainee. Inadequate bowel preparation affected 7.3% of all procedures. The procedure completion rate was 95.1%, which increased to 97.5% after adjustment for bowel preparation quality. The pooled cancer, adenoma, and serrated lesion detection rates for all five hospitals were 3.5%, 40%, and 5.9% respectively. Assessed hospitals varied significantly by patient age (P < 0.001), work-force composition (P < 0.001), adequacy of bowel preparation (P < 0.001), and adenoma detection rate (P < 0.001). Two hospitals (40%) did not meet all national criteria for quality, due to a procedure completion rate of 94.5% or serrated lesion detection rate of 2.6%. Although lower than the other hospitals, the difference was not significant. Compared with surgical specialists, procedures performed by medical specialists involved older patients [65 years (inter-quartile range, IQR 58-73) vs 64 years (IQR 56-71); P = 0.04] and were associated with a higher adenoma detection rate [odds ratio (OR) 1.53; confidence interval: 1.21-1.94; P < 0.001]. Procedures involving trainee proceduralists were not associated with differences in the detection of cancer, adenoma, or serrated lesions, compared with specialists, or according to their medical or surgical background. On multivariate analysis, cancer detection was positively associated with patient age (OR 1.04; P < 0.001) and negatively associated with medical compared to surgical proceduralists (OR 0.54; P = 0.04). Conventional adenoma detection rates were independently associated with increasing patient age (OR 1.04; P < 0.001), positively associated with medical compared to surgical proceduralists (OR 1.41; P = 0.002) and negatively associated with male gender (OR 0.53; P < 0.001).
CONCLUSION Significant differences in the quality of colonoscopy in Australia exist, even when national benchmarks are achieved. The role of possible contributing factors, like procedural specialty and patient gender need further evaluation.
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Affiliation(s)
- Tsai-Wing Ow
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park 5042, SA, Australia
| | - Olga A Sukocheva
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
| | - Vy Tran
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
| | - Richard Lin
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
| | - Shawn Zhenhui Lee
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South 5011, SA, Australia
| | - Matthew Chu
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South 5011, SA, Australia
| | - Bianca Angelica
- Department of Gastroenterology, Royal Darwin Hospital, Darwin 0810, NT, Australia
| | - Christopher K Rayner
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
| | - Edmund Tse
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
| | - Guru Iyngkaran
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Parkville 3050, VIC, Australia
| | - Peter A Bampton
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
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Ow TW, Fatourou E, Rabinowich L, van den Boom BP, Nair S, Patel VC, Hogan B, McPhail M, Roberts LN, Bernal W. Prevalence of bleeding and thrombosis in critically ill patients with chronic liver disease. Thromb Haemost 2021; 122:1006-1016. [PMID: 34638152 DOI: 10.1055/a-1667-7293] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Haemorrhage and venous thromboembolism (VTE) are recognised complications of chronic liver disease (CLD), but their prevalence and risk factors in critically ill patients is uncertain. PATIENTS AND METHODS We studied a retrospective cohort of patients with CLD non-electively admitted to a specialist intensive care unit determining the prevalence and timing of major bleeding and VTE (early, present on admission/diagnosed within 48h; later diagnosed >48h post ICU admission). Associations with baseline clinical and laboratory characteristics, multi-organ failure (MOF), blood product administration and mortality were explored. Odds ratios (OR) and 95% CIs were calculated using logistic regression. RESULTS Of 623 patients with median age 52, bleeding (>48 hours after admission) occurred in 87 (14%) patients. Bleeding was associated with greater illness severity and increased mortality. Gastrointestinal bleeding accounted for 72% of events, secondary to portal hypertension in >90%. Procedure-related bleeding was uncommon. VTE occurred in 125 (20%) patients: Early VTE in 80 (13%) and involving the portal vein (PVT) in 85%. Later VTE affected 45 (7.2%) patients. Hepatocellular Carcinoma (HCC) and non-alcoholic liver disease were independently associated with early VTE (OR 2.79, (95% CI 1.5 -5.2) and 2.32, (1.4 -3.9) respectively), and HCC, sepsis and cryoprecipitate use with late VTE (OR 2.45, (1.11-5.43), 2.26 (1.2-4.3) and 2.60 (1.3-5.1). CONCLUSION VTE was prevalent on admission to critical care and less commonly developed later. Bleeding was associated with MOF and increased mortality. Severe MOF was not associated with an increased rate of VTE which was linked with HCC, and specific etiologies of CLD.
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Affiliation(s)
- Tsai-Wing Ow
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Evangelia Fatourou
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Liane Rabinowich
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Bente Pernille van den Boom
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.,2. Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, Netherlands
| | - Shirjit Nair
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Vishal C Patel
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.,School of Immunology and Microbial Sciences, King's College London Faculty of Life Sciences and Medicine, London, United Kingdom of Great Britain and Northern Ireland.,Institute of Hepatology, Foundation for Liver Research, London, United Kingdom of Great Britain and Northern Ireland
| | - Brian Hogan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Mark McPhail
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.,School of Immunology and Microbial Sciences, King's College London Faculty of Life Sciences and Medicine, London, United Kingdom of Great Britain and Northern Ireland
| | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - William Bernal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.,School of Immunology and Microbial Sciences, King's College London Faculty of Life Sciences and Medicine, London, United Kingdom of Great Britain and Northern Ireland
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Ow TW, Ralton L, Tse E. Saving costs through a coordinated care model for patients with hepatocellular cancer. Intern Med J 2017; 47:1005-1011. [DOI: 10.1111/imj.13465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Tsai-Wing Ow
- Department of Gastroenterology and Hepatology; Royal Adelaide Hospital; Adelaide South Australia Australia
- Liver Intensive Therapy Unit; King's College Hospital; London UK
| | - Lucy Ralton
- Department of Gastroenterology and Hepatology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Edmund Tse
- Department of Gastroenterology and Hepatology; Royal Adelaide Hospital; Adelaide South Australia Australia
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Huynh DK, Toscano L, Phan VA, Ow TW, Schoeman M, Nguyen NQ. Ultrathin disposable gastroscope for screening and surveillance of gastroesophageal varices in patients with liver cirrhosis: a prospective comparative study. Gastrointest Endosc 2017; 85:1212-1217. [PMID: 27894929 DOI: 10.1016/j.gie.2016.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 08/19/2016] [Accepted: 11/16/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS This study aims to evaluate the role of unsedated, ultrathin disposable gastroscopy (TDG) against conventional gastroscopy (CG) in the screening and surveillance of gastroesophageal varices (GEVs) in patients with liver cirrhosis. METHOD Forty-eight patients (56.4 ± 1.3 years; 38 male, 10 female) with liver cirrhosis referred for screening (n = 12) or surveillance (n = 36) of GEVs were prospectively enrolled. Unsedated gastroscopy was initially performed with TDG, followed by CG with conscious sedation. The 2 gastroscopies were performed by different endoscopists blinded to the results of the previous examination. Video recordings of both gastroscopies were validated by an independent investigator in a random, blinded fashion. Endpoints were accuracy and interobserver agreement of detecting GEVs, safety, and potential cost saving. RESULTS CG identified GEVs in 26 (54%) patients, 10 of whom (21%) had high-risk esophageal varices (HREV). Compared with CG, TDG had an accuracy of 92% for the detection of all GEVs, which increased to 100% for high-risk GEVs. The interobserver agreement for detecting all GEVs on TDG was 88% (κ = 0.74). This increased to 94% (κ = 0.82) for high-risk GEVs. There were no serious adverse events. CONCLUSIONS Unsedated TDG is safe and has high diagnostic accuracy and interobserver reliability for the detection of GEVs. The use of clinic-based TDG would allow immediate determination of a follow-up plan, making it attractive for variceal screening and surveillance programs. (Clinical trial (ANZCTR) registration number: ACTRN12616001103459.).
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Affiliation(s)
- Dep K Huynh
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Leanne Toscano
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vinh-An Phan
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Tsai-Wing Ow
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mark Schoeman
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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