Introduction

Glucagon-like-peptide-1 receptors agonists (GLP1-RA) are approved for treatment of diabetes mellitus (DM) and weight reduction.

Aims & Methods

We aimed to investigate the association between GLP1-RA use and poor preparation of colon.
Methods: A multicenter, retrospective study was conducted, including all colonoscopies performed across seven gastroenterology departments from 2016 to 2022. Patients who had undergone colon surgery or had conditions such as Parkinson's disease, cerebrovascular accidents (CVA), scleroderma, amyloidosis, gastroparesis, or those taking narcotic or anti-cholinergic drugs, as well as those with incomplete preparation data, were excluded from the study. The rates of "poor preparation" were collected.

Results

4,104 patients treated with GLP-1 receptor agonists (GLP-1 RA) (age 60 ± 0.2 years, 55.6% females) to 294,643 patients not treated with GLP1 RA (age 56.06 ± 13 years, 52.6% females), these patients were undergoing their first colonoscopy. The study found that 409 (10%) of GLP1 RA patients had poor colonic preparation, compared to 16,811 (5.7%) of patients not treated with GLP1 RA. Subgroup analysis revealed that 173 (8.3%) non-diabetic patients treated with GLP1 RA had poor colonic preparation, compared to 14,810 (5.4%) non-diabetic patients not treated with GLP1 RA (p<0.001). Among diabetic patients, 236 (11.7%) treated with GLP1 RA had poor colonic preparation, compared to 2,001 (9.7%) diabetic patients not treated with GLP1 RA (p=0.004). Multivariate analysis showed that both diabetes mellitus (DM) and treatment with GLP-1 RA were independent risk factors for poor colonic preparation, with odds ratios of 1.7 (p<0.001) and 1.3 (p<0.001), respectively.

Conclusion

GLP-1 RA among diabetes and non-diabetic have an impact on colonic preparation, indicating that these patients may require special consideration and tailored recommendations for their colonoscopy preparation. To establish the most effective approach for these patients, prospective studies are needed.

Introduction

Celiac disease (CeD) is a chronic, immune-mediated, systemic disorder characterized by inflammation of the small intestine and antibody formation in response to gluten ingestion. A gluten-free diet (GFD) has major limitations but is the only current treatment for CeD.

Aims & Methods

This US prospective observational study (Virtual Celiac Symptoms Study, NCT05309330) was conducted from July 25, 2022 to March 04, 2023 and aimed to assess experience with a GFD and celiac-related symptoms in patients with CeD. Eligible participants were aged ≥12 years, had a CeD diagnosis for ≥1 year confirmed via self-reported biopsy and serology (or serology only for participants diagnosed at age <18 years), were on a GFD for ≥6 months and reported CeD-related symptoms in the past 3 months. Participants were recruited with the assistance of the Celiac Disease Foundation via digital advertisements and data were collected using an electronic patient-reported outcomes platform. Study participants were followed up for 12 weeks and CeD-related symptoms and gluten exposure were assessed daily. Quality of life and healthcare resource utilization were also assessed. This analysis focuses on the adult participants’ perception of their disease experience at study initiation.

Results

The baseline questionnaires were completed by 338 adult participants. The median age was 37 years (range 18–71), 88% were female and 99% were White. CeD-related symptoms were reported by 58% of participants in the past week. When questioned about occurrence of CeD symptoms, 23% reported “Chronic/ongoing CeD symptoms even when I don't think I've been exposed to gluten”, 37% reported “CeD symptoms only while I am exposed to gluten or within a few days after exposure to gluten” and 36% reported “Chronic/ongoing CeD symptoms, but they are worse when I get exposed to gluten”. The most commonly reported symptoms were bloating (83%), tiredness (81%), abdominal pain (77%) and diarrhea (71%). All participants were following a GFD; 21% reported “never eating gluten accidentally or on purpose” and 71% reported “rarely eating gluten accidentally”. In total, 84% of participants reported that they were likely/extremely likely to experience CeD symptoms after gluten exposure. Symptom intensity was described as moderate or severe by 71% of participants, and 11% reported hospitalization or emergency department care due to CeD in the past year.

Conclusion

Despite high levels of reported adherence to a GFD, many patients still report CeD-related symptoms, especially in response to perceived gluten exposure. Symptoms were often reported as severe and over 10% reported a CeD-related hospitalization or emergency department visit in the past year. This ongoing study highlights the requirement for further understanding of persistent/recurrent symptoms and an unmet need for additional treatments for patients with CeD on a GFD.

Disclosure

LMM and DAL are employees of Takeda Development Center Americas, Inc. and receive stock or stock options. JRM, SSe and SSu are employees of Analysis Group, Inc., which received research support from Takeda Development Center Americas, Inc. MG is an employee of the Celiac Disease Foundation, which received financial support from Takeda Development Center Americas, Inc. EL and DA serve as consultants for Takeda Pharmaceuticals.
Funding statement: This study was sponsored by Takeda Development Center Americas, Inc. Medical writing support was provided by Christina Nikolakopoulou, PhD, of Oxford PharmaGenesis, Oxford, UK and was funded by Takeda Pharmaceuticals.

Introduction

There are no prediction models for a diagnosis of inflammatory bowel disease (IBD) in primary care. Our aim was to develop an IBD risk prediction tool to reduce the length of time patients have undiagnosed IBD symptoms and improve IBD clinical outcomes.

Aims & Methods

We developed and internally validated a risk prediction tool for the diagnosis of IBD, ulcerative colitis (UC) and Crohn’s disease (CD).
A population-based retrospective open cohort study using Clinical Practice Research Datalink (CPRD) database was undertaken between 1st January 2010 and 31st December 2019 of all the patients aged 18 years or older. Patients were followed from first presentation with lower gastrointestinal (GI) symptoms potentially related to IBD to IBD diagnosis. Candidate predictors were chosen based on clinical and substantive knowledge. Cox proportional hazards regression with backward elimination was used for model development of IBD, UC and CD risk prediction models. The predictive performance of the models was assessed using discrimination (C-statistic). Internal validation using 1000 bootstrap sampling repetitions was used to estimate the optimism-corrected measures of predictive performance.

Results

Of 2,056,398 patients with lower GI symptoms: 11,192 patients had an IBD diagnosis (7033 UC (62.8%) and 4138 CD (37.0%)). The final IBD model included demographic factors (age, sex, ethnicity, smoking, index of multiple deprivation, body mass index, Charlson comorbidity index, loperamide use) co-existing conditions (anxiety, depression, irritable bowel syndrome (IBS), haemorrhoids), extraintestinal (EIM) manifestations (mouth ulcers, ophthalmic, primary sclerosing cholangitis, dermatological), laboratory investigations (low haemoglobin (Hb), low Mean Corpuscular volume (MCV), low albumin, low ferritin, raised C-reactive protein (CRP), raised Erythrocyte Sedimentation Rate (ESR), raised calprotectin level). The UC model included all above except mouth ulcers, IBS, ophthalmic EIM. Depression and ferritin were excluded in the CD model though low vitamin B12 level was included. The risk score for each patient was the sum of individual risk factors. In the development dataset, models showed moderate discrimination. For the IBD prediction tool: C-statistic 0.71 (95% CI 0.70-0.71),UC prediction tool: C-statistic 0.70 (95% CI 0.69-0.70) and CD prediction tool: C-statistic 0.75 (95% CI 0.74-0.76). The C-statistics of the models showed that the IBD, UC and CD prediction tools reliably differentiated patients with and without IBD,UC and CD respectively.

Conclusion

A risk score of patient demographics, symptoms and investigations performs well for IBD,UC and CD and may help in prioritising suspected IBD referrals in symptomatic subjects in primary care.

Disclosure

No conflict of interest to declare

Introduction

Irritable bowel syndrome (IBS) is a bothersome condition with long term pain and bowel symptoms and the most common cause of referral to gastroenterologists in the United Kingdom. Despite this, IBS is poorly understood as a clinical entity. Furthermore, IBS has numerous comorbidities but the full spectrum of these and how they relate to IBS has not been studied.

Aims & Methods

Using clustering analysis on the UK Biobank dataset, an adult cohort (age > 40 years), we aimed to define the top co-morbidities associated with IBS and develop a machine learning model to predict IBS. Co-morbidities in patients based on ICD-10 Summary Diagnosis codes 2 years prior to and 2 years following diagnosis with IBS were assessed and clusters defined. These were compared with a control group of non-IBS patients. Several machine learning algorithms (K-Means, Linear Discriminant Analysis, Gaussian Mixture Models) were compared for accuracy.

Results

Amongst 18000 total adults (aged over 40), 8168 patients coded for IBS, 75% of whom were female. The top ten comorbidities (Table 1) found in IBS patients included diverticular disease, hypertension, hernia, haemorrhoids, osteoarthritis, asthma, gastro-oesophageal reflux disease without oesophagitis, history of psychoactive substance abuse, hypercholesterolaemia, and cholelithiasis. K-Means achieved the highest accuracy (83%) for predicting IBS based on the co-morbidity profile.

Conclusion

Most clusters identified contained obesity, hypercholesterolemia, and hypertension, indicating a possible link with metabolic syndrome. Asthma and allergies suggest a possible cohort of IBS patients with atopy. Further research is needed to establish these links. In clinical practice, this could help both in predicting development of IBS, and also identify the cohorts of IBS on which certain therapies are more likely to work.

References

Drossman, D. A., Camilleri, M., Mayer, E. A., & Whitehead, W. E. (2002). AGA technical review on irritable bowel syndrome. Gastroenterology, 123(6), 2108-2131. doi:10.1053/gast.2002.37095
Snyder, N. (2023, 10 Feb 2023). Irritable bowel syndrome. BMJ Best Practice. Retrieved from https://bestpractice.bmj.com/topics/en-gb/122
Staller, K., Olén, O., Söderling, J., Roelstraete, B., Törnblom, H., Khalili, H., . . . Ludvigsson, J. F. (2021). Diagnostic yield of endoscopy in irritable bowel syndrome: A nationwide prevalence study 1987-2016. Eur J Intern Med, 94, 85-92. doi:10.1016/j.ejim.2021.08.001

Introduction

ESPGHAN aims to develop evidence-based guidelines and practice recommendations in pediatric gastroenterology, hepatology, and nutrition (PGHN). The Quality of Care Task Force of ESPGHAN was set up to evaluate the implementation of such standards in routine practice. Here, we report the findings of our first initiative on documentation of anthropometric measurements in routine clinical practice in paediatric hospitals across Europe.

Aims & Methods

Pediatric hospitals from 28 European countries provided pseudonymized data through an online survey. Standards of nutritional care and anthropometric measurements were collected in the first survey using a questionnaire composed through consensus from members of the Quality of Care group. Hospitals reviewed medical notes of eight current and eight discharged patients, retrospectively, to retrieve additional data on anthropometric assessment and documentation in clinical routine. Differences between perceived (as estimated by physicians) compared with actual reports of anthropometric measurements in discharge letters were obtained by using the Friedman paired test. The second survey is ongoing and relates to diagnostic work-up and management of celiac disease.

Results

By 04/2023, 109 hospitals participated (68% academic, 62% certified for PGHN training, 92% with at least one pediatric gastroenterologist). Of these, 9% had no nutritionist/dietician available. Lack of standard policy for weight and height assessments was reported in 15% of hospitals, and absent training for nursing staff on anthropometric measurements in 15%. A wall-mounted stadiometer to measure standing height was unavailable in 10%, equipment for sitting weight in 33%. Measuring infant length was performed in 50% of hospitals by one but not two healthcare professionals. 14% routinely used measuring tape instead of a rigid length measuring board. When we compared physician-reported estimates (0 – 100%) against collected data from patient notes on documentation of weight, height, weight percentiles, and height percentiles, physicians overestimated performance for most items in both patients with PGHN-disorders and other diseases (Table 1).

Table 1: Anthropometrics routinely reported in discharge letter, perceived (as estimated by physicians) compared with actual reports

Conclusion

The survey identified several gaps in fundamental aspects of nutritional care of pediatric patients, including reporting of anthropometric data. The long-term Quality of Care initiative will survey two topics per year on PGHN with re-assessment after providing educational material and feedback for benchmarking. To assess improvement over time, the surveys will be repeated after one to three years. Hospitals in Europe caring for PGHN patients are invited to join this initiative.

Introduction

Initial reports suggested a high mortality associated with peri-operative COVID-19 infection resulting in delayed surgery and a global change in surgical pathways. The impact of COVID-19 variants and vaccinations on surgical outcomes is yet to be described.

Aims & Methods

We aimed to define the risk of COVID-19 infection in the 30 days following surgery and the associated mortality. With the approval of NHS England we identified all registered adult patients in an OpenSAFELY-TPP primary care general practice within England whilst having an abdominal, obstetric, orthopaedic, thoracic or vascular procedure defined using OPCS codes between 01/02/2020 and 01/03/2022.COVID vaccinations and COVID waves were defined. Crude 30 day risks were calculated using Kaplan Meier curves. A competing risks Cox proportional survival analysis was used to adjust the cumulative risk of COVID-19 infection by the competing risk of death and subsequent non COVID-19 emergency readmissions.
Primary care records managed by the GP software provider TPP were linked to ONS death data, Hospital Episodes Statistics, and Second Generation Surveillance System Public Health England test data through OpenSAFELY. All data were linked, stored and analysed securely within the OpenSAFELY platform: https://opensafely.org/. Data include pseudonymised data such as coded diagnoses, medications and physiological parameters. No free text data are included. All code is shared openly for review and re-use under MIT open license https://github.com/opensafely/PostOpCovid. Detailed pseudonymised patient data is potentially re-identifiable and therefore not shared.
This study was approved by the Health Research Authority [REC reference 21/EE/0278] by the East of England Research Ethics Committee.

Results

We identified 1,213,890 patients within the study period who underwent at least one surgical procedure. Following surgery 11,950 (0.9%) patients developed COVID-19 infection within 30 days. Post-operative COVID infections were greatest in wave 4 with 2.5% of patients having a post-operative infection. Adjusting for all factors post-operative COVID infection risk was 4.9 (aHR 4.88 95% CI 4.65-5.12) fold greater in the fourth wave compared to the first wave.
Within 90 days of surgery there were 820 (0.06%) deaths. A recent COVID infection increased crude morality to 1.42%, and a post-operative COVID infection increased crude mortality to 1.82%. The risk of death reduced following a first and second vaccination (aHR 0.11 95% CI 0.09-0.13). A recent COVID infection (7-42 days prior to admission) increased mortality 4 fold (aHR 3.84 95% CI 3.31-4.45) and a post-operative COVID infection increased mortality 8 fold (aHR 8.49 95% CI 7.6-9.48) compared to those without a COVID-19 infection. This increased 90 day mortality risk was highest in the second wave following a post-operative COVID infection, but then decreased to the non-covid baseline for both emergency and elective procedures in the 3^rd and 4^th waves.

Conclusion

The risk of post-operative COVID infection is low but has increased as strains have been become more transmissible. The absolute risk of death following peri-operative COVID-19 infection is greater than those who have not had infection however this risk has become attenuated during the latter waves of the pandemic.

Acknowledgements: We are very grateful for all the support received from the TPP Technical Operations team throughout this work, and for generous assistance from the information governance and database teams at NHS England and the NHS England Transformation Directorate.

Disclosure

None to declare

Introduction

Many CD patients experience clinically „silent“ disease with active inflammation leading to complications and disability. Invasive and resource consuming procedures such as endoscopy, MR enterography and CT imaging have long been the mainstay of monitoring disease activity in CD. Intestinal ultrasound (IUS) is becoming an established non-invasive alternative for everyday point-of-care management of patients with CD. The most important ultrasound parameters associated with active CD include bowel wall thickness (BWT), bowel wall stratification (BWS), color-doppler signal (CDS) and the presence of mesenteric fat (i-fat). Several ultrasound scoring systems using some of these parameteres have been proposed in order to facilitate monitoring of CD patients as well as standardise reporting of intestinal ultrasound findings.

Aims & Methods

The study aim was to compare performance of IBUS-SAS (International Bowel Ultrasound Segmental Activity Score), BUSS (Bowel Ultrasound Score), Simple-US (Simple Ultrasound Score), and SUS-CD (Simple Ultrasound score for Crohn's disease) in detecting disease activity in CD patients. A single center retrospective analysis of stored IUS images and corresponding CD patient charts with endoscopy findings at the time of the ultrasound has been performed. Endoscopic activity was defined as SES-CD>3. After assessment of normal distribution using Kolmogorov-Smirnov and Shapiro-Wilk tests continuous variables were reported as median and interquartile ranges (IQR) or as mean ± standard deviation, whereas categorical variables were reported as frequencies with percentages. ROC curve analyses were conducted in order to determine AUCs and predictive cut-off value scores, with endoscopy serving as the reference standard. The Z statistic and Hanley & McNeil methodology were used to compare ROC curves. P values less than 0.05 were considered statistically significant.

Results

A total of 83 patients were included, 45.8% female with a mean age 41 years and median disease duration of 8 years. Endoscopic disease activity was present in 55 (66.3%) patients. Isolated ileal disease was present in 48.2%. Stricturing and penetrating disease phenotype was present in 41% and 39.8% of patients respectively. The results for ROC analyses, cut-off values for remission, sensitivity and specificity of four different IUS scores are shown in table 1. Statistically significant differences among scores haven't been observed.

Table 1. Comparison of intestinal ultrasound scores for detecting active Crohn's disease

Conclusion

All IUS scores performed well for detecting CD endoscopic activity which shows IUS can reduce the number of endoscopies in the CD patient population without sacrificing accuracy. We found no significant difference in the sensitivity and specificity of different scores in out patient cohort, hence clinicans can rely on the IUS score they are comfortable with using. Our cut-off values are in line with published data further confirming method robustness.

References

1. Dragoni G, Gottin M, Innocenti T, Lynch EN, Bagnoli S, Macrì G, Bonanomi AG, Orlandini B, Rogai F, Milani S, Galli A, Milla M, Biagini MR. "Correlation of ultrasound scores with endoscopic activity in Crohn's disease: a prospective exploratory study". J Crohns Colitis. 2023 Apr 6:jjad068. doi: 10.1093/ecco-jcc/jjad068.
2. Wang L, Xu C, Zhang Y, Jiang W, Ma J, Zhang H. External validation and comparison of simple ultrasound activity score and international bowel ultrasound segmental activity score for Crohn's disease. Scand J Gastroenterol. 2023 Feb 23:1-7. doi: 10.1080/00365521.2023.2181038. Epub ahead of print. PMID: 36825305.