Background Women with inflammatory bowel disease (IBD) with poor IBD-specific reproductive knowledge experience more childlessness and fear of IBD medications in pregnancy. The Pregnancy in IBD Decision Aid (PIDA), developed by an international multidisciplinary team, offers personalized online decision support regarding pregnancy in IBD. Aims Assess the impact of PIDA on quality of reproductive decision-making and pregnancy-related knowledge among preconception (PC) and pregnant patients with IBD, and evaluate acceptability to patients and clinicians. Methods PC and pregnant patients with IBD aged 18–45 completed questionnaires pre- and post-PIDA to assess quality of decision-making (Decisional Conflict Scale (DCS); Decision Self-Efficacy Scale (DSES) and IBD-in-pregnancy knowledge (Crohn's and Colitis Pregnancy Knowledge Score (CCPKnow)). Paired t test assessed for differences pre- and post-PIDA. Patients and clinicians completed acceptability surveys. Results DCS and DSES were completed by 74 patients (42 Crohn’s disease, 32 ulcerative colitis); 41 PC and 33 pregnant. DCS improved significantly post-PIDA in PC patients regarding pregnancy planning (t(40) = 4.83, p < 0.0001, Cohen’s dz = 0.75) and in pregnant patients regarding medication management (t(32) = 2.37, p = 0.0242, dz = 0.41). DSES for PC patients improved significantly post-PIDA (t(40) = -3.56, p = 0.001, dz = -0.56). CCPKnow improved significantly post-PIDA in PC (t(42) = 4.93, p < 0.0001, dz = -0.75) and pregnant patients (t(32) = 5.1, p < 0.0001, dz = -0.89). PIDA was deemed optimal for length, readability, and content amount and considered highly useful by patients (n = 73) and clinicians (n = 14). Conclusions Patients using PIDA developed an improved quality of reproductive decision-making and IBD-in-pregnancy knowledge. PIDA is an accessible tool that can empower women with IBD to make values-congruent, evidence-based decisions regarding pregnancy and may reduce voluntary childlessness.
BACKGROUND Colorectal cancer (CRC) is a major health problem. There is minimal consensus of the appropriate approach to manage patients with positive immunochemical fecal occult blood test (iFOBT), following a recent colonoscopy. AIM To determine the prevalence of advanced neoplasia in patients with a positive iFOBT after a recent colonoscopy, and clinical and endoscopic predictors for advanced neoplasia. METHODS The study recruited iFOBT positive patients who underwent colonoscopy between July 2015 to March 2020. Data collected included demographics, clinical characteristics, previous and current colonoscopy findings. Primary outcome was the prevalence of CRC and advanced neoplasia in a patient with positive iFOBT and previous colonoscopy. Secondary outcomes included identifying any clinical and endoscopic predictors for advanced neoplasia. RESULTS The study included 1051 patients (male 53.6%; median age 63). Forty-two (4.0%) patients were diagnosed with CRC, 513 (48.8%) with adenoma/sessile serrated lesion (A-SSL) and 257 (24.5%) with advanced A-SSL (AA-SSL). A previous colonoscopy had been performed in 319 (30.3%). In this cohort, four (1.3%) were diagnosed with CRC, 146 (45.8%) with A-SSL and 56 (17.6%) with AA-SSL. Among those who had a colonoscopy within 4 years, none had CRC and 7 had AA-SSL. Of the 732 patients with no prior colonoscopy, there were 38 CRCs (5.2%). Independent predictors for advanced neoplasia were male [odds ratio (OR) = 1.80; 95% confidence interval (CI): 1.35-2.40; P < 0.001), age (OR = 1.04; 95%CI: 1.02-1.06; P < 0.001) and no previous colonoscopy (OR = 2.07; 95%CI: 1.49-2.87; P < 0.001). CONCLUSION A previous colonoscopy, irrespective of its result, was associated with low prevalence of advanced neoplasia, and if performed within four years of a positive iFOBT result, was protective against CRC.
Ménétrier’s disease (MD) is a rare gastropathy characterised by giant rugal folds which can present with nausea, vomiting, abdominal pain and protein losing gastropathy. We report a 21-year-old woman with comorbid MD and ulcerative colitis (UC). Management was complicated by limited treatment options for MD, significant symptom burden, worsening nutrition and difficulty determining which disease was the predominant cause of symptoms. Since age 18 the patient experienced recurrent UC flares characterised by diarrhoea, persistent vomiting and corticosteroid dependence. Endoscopic assessment demonstrated concurrent MD and active UC. Octreotide and cetuximab were trialled given persistent hypoalbuminaemia and suspicion for MD associated protein-losing gastropathy. UC management comprised dose-optimised infliximab and methotrexate. Repeat endoscopic assessment demonstrated improvement in UC without corresponding improvement in symptoms or hypoalbuminaemia. Nasojejunal feeding and parenteral nutrition failed to significantly improve nutritional status and accordingly the patient proceeded to radical total gastrectomy. Postoperatively, MD-associated symptoms and hypoalbuminemia resolved completely.
Background Women with inflammatory bowel disease (IBD) with poor IBD-specific reproductive knowledge experience more voluntary childlessness. Poor knowledge is associated with fear of IBD medications in pregnancy; this must be addressed as active IBD at preconception (PC) correlates with worse intrapartum disease and poor fetal outcomes. The Pregnancy IBD Decision Aid (PIDA), developed by an international multidisciplinary team following International Patient Decision Aids Standards, is an interactive online tool that offers personalised decision support on fertility, pregnancy, and medications in IBD (Fig). Aims To assess PIDA’s impact on knowledge and quality of decision-making among PC and pregnant patients with IBD, and to evaluate its feasibility as a tool for patients and clinicians. Methods PC and pregnant women aged 18–45 with IBD, recruited in Canada and Australia, completed questionnaires pre and post PIDA to assess quality of decision-making (Decisional Conflict Scale, DCS; Self-Efficacy Score, SES) and IBD in pregnancy knowledge (Crohn’s and Colitis Pregnancy Knowledge Score, CCPKnow). DCS assesses if a decision is informed, aligned with personal values, and would be implemented. SES measures belief in one’s ability to make informed decisions. Patients and clinicians (gastroenterology, obstetrics, primary care) also completed feasibility surveys. Paired t-test assessed for differences pre and post PIDA. Results DCS and SES were completed by 74 patients (42 Crohn’s disease, 32 ulcerative colitis); 41 PC and 33 pregnant. DCS improved significantly post PIDA (effect size 0.44, p<0.0001); this was observed in PC patients regarding pregnancy planning with IBD, and in pregnant patients regarding peripartum IBD medication management. SES of PC but not pregnant patients improved significantly post PIDA (effect size 0.32 vs 0.24, p=0.0001 vs 0.0525). In both cohorts, CCPKnow improved significantly post PIDA (n=76, effect size 0.66, p<0.0001). Patients (n=73) assessed PIDA feasibility. Mean scores for length (3.05±0.44), readability (3.09±0.5), and content amount (2.91±0.81) were perceived as appropriate (1=limited, 5=excessive). Perceived usefulness of PIDA was high among all patients (4.09±0.93; 5=most useful). Clinicians (n=14) believed PIDA had appropriate length, readability, and content amount, and deemed PIDA useful to patients (4.6±0.8) and themselves (4.8±0.8) for clinical practice. Conclusions PIDA improved knowledge and quality of decision-making in PC and pregnant patients with IBD. Patients developed a strengthened belief in their ability to make informed, effective decisions, and both patients and clinicians found PIDA feasible. PIDA is an accessible tool that can empower women with IBD to make evidence-based decisions about pregnancy and may ultimately reduce voluntary childlessness. Funding Agencies Mount Sinai Hospital Resident Research Grant; Gastroenterological Society of Australia Rose Amarant Grant; Women and Children’s Health Research Institute (WCHRI); Clinical/Community Research Integration Support Program (CRISP); Merck Better Care, Healthy Communities Funding Program
Background Vedolizumab (VDZ) is a gut-specific α4β7 integrin antagonist that has demonstrated efficacy for induction and maintenance of remission in moderate to severe ulcerative colitis (UC). The aim of this study was to assess the rates of histological remission (HR) in a real-world setting and to identify predictors for histological remission. Methods Retrospective cohort study of all UC patients (≥18 years) initiated on VDZ from 2016 to 2020 was completed. Clinical, biochemical, endoscopic and histologic data were collected. All patients received standard induction therapy with VDZ 300 mg IV at Weeks 0, 2, and 6 and maintained on an 8-weekly regimen. Dose was escalated to a every 4-weekly regimen as per physician’s discretion. A 52-week follow-up was completed on all patients. Endoscopic assessment was carried out between 24 and 52 weeks after commencing VDZ. Histological activity was graded as per Nancy index and histological remission was defined as Nancy grade 0. Endoscopic remission was defined as Mayo endoscopic score = 0. Clinical remission was defined as SCCAI ≤ 5. Results A total of 51 patients [55% female, median age 48 years (IQR 35–60)] were included. 16/51 (34%) were anti-TNF exposed. In 30/51 (59%) patients VDZ was combined with steroids at induction and by week 12 steroids were completely tapered in 14/30 (46.7%) patients. At weeks 12, 24 and 52, 89.6%, 87% and 97.5% of patients, respectively, were in clinical remission. 19/37 (51.3%) patients were in endoscopic remission at end of follow up. Median Nancy score prior to commencing VDZ was 3 (IQR: 2–4) and the median Nancy score at end of follow up was 1 (IQR: 0–2). 19/37 (51.3%) patients achieved HR; 3 patients who were in HR at the time of commencement of VDZ remained in HR at the end of follow up. Median baseline faeces calprotectin (FC) was 320 mcg/g (IQR 45–1000) and was similar in patients who achieved HR and those who did not. Median FC at 12 weeks was 155 mcg/g (45–720) and was significantly lower in patients who achieved HR when compared to patients who did not achieve histological remission (45 vs 420, p 0.028). FC at week 12 predicted histological remission (AUC =0.8667). FC ≥ 200mcg/g at week 12 predicted failure to achieve HR with sensitivity 70%, specificity 100%, PPV 100%, NPV 75%, accuracy 84%. Conclusion Vedolizumab is effective in achieving histological remission and FC ≥ 200 mcg/g at week 12 accurately predicts failure to achieve HR in patients treated with VDZ.
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