Role for structured telephone clinics in paediatric gastroenterology: reflections, lessons and patient feedback

Background: Telephone clinics have been established within our department to try and improve communication with families, limit waiting times and help face-to-face clinics run more efficiently. As part of the ongoing care needs for our patients and families it was felt important to determine if telephone clinics were meeting the needs of the young person and family as well as those of the health professional. Objective: To assess the effects of a structured consultant delivered telephone clinic. Method: Data were collected regarding patients who had a consultant telephone appointment between July 2016 and March 2017. Data collected include demographics and appointment reason. An evaluation questionnaire was sent to all parent/carer(s). Results: 25 clinics comprising 194 contacts, including 34 duplicate contacts. 120 questionnaires sent. 7/160 (4.3%) were new patients. The main contact reason was biopsy results after endoscopy (93/180; 52%). Failure to attend rate was significantly lower at 18/194 (9.2%) compared with failure to attend rate of 52/240 (21.6%) for a traditional clinic (p<0.001). 40/120 (33%) returned completed questionnaires, 25/40 (68.4%) reported the reason for appointment was test results. Travel time and school attendance were identified as main advantages. Mean parental rating score for the service was 8/10 with 21/40 (54%) scoring the service as 10/10. Conclusion: The initial results of this audit are promising. Structured telephone appointments have a key role in delivering patient care in paediatric gastroenterology and have benefits to health professional, parent/carer and patients. These clinics have now been widely adopted by all members of our department

An automated identification and analysis of ontological terms in gastrointestinal diseases and nutrition-related literature provides useful insights

With an unprecedented growth in the biomedical literature, keeping up to date with the new developments presents an immense challenge. Publications are often studied in isolation of the established literature, with interpretation being subjective and often introducing human bias. With ontology-driven annotation of biomedical data gaining popularity in recent years and online databases offering metatags with rich textual information, it is now possible to automatically text-mine ontological terms and complement the laborious task of manual management, interpretation, and analysis of the accumulated literature with downstream statistical analysis. In this paper, we have formulated an automated workflow through which we have identified ontological information, including nutrition-related terms in PubMed abstracts (from 1991 to 2016) for two main types of Inflammatory Bowel Diseases: Crohn’s Disease and Ulcerative Colitis; and two other gastrointestinal (GI) diseases, namely, Coeliac Disease and Irritable Bowel Syndrome. Our analysis reveals unique clustering patterns as well as spatial and temporal trends inherent to the considered GI diseases in terms of literature that has been accumulated so far. Although automated interpretation cannot replace human judgement, the developed workflow shows promising results and can be a useful tool in systematic literature reviews. The workflow is available at https://github.com/KociOrges/pytag

Take-home messages from 20 years progress in dietary therapy of inflammatory bowel disease

Background: A significant body of literature has interrogated the critical role of diet in the development and management of inflammatory bowel disease (IBD). Summary: This review provides a summary and critical appraisal of the literature in this area, focussing on four distinct themes: nutritional epidemiology, animal and in vitro experiments, enteral nutrition, and food-based dietary therapies. Key Messages: Nutritional epidemiology and data from experiments in animals indicate that a western-type diet pattern is associated with increased risk of IBD onset. However, these findings have not been consistently replicated in the dietary management of IBD. Exclusive enteral nutrition (EEN) is the only dietary therapy with reproducible evidence of efficacy in the management of active Crohn’s disease (CD). Use of EEN may also be useful for improving perioperative outcomes in CD, and as an adjuvant therapy to biologic therapy. Several dietary therapies for CD and ulcerative colitis have been proposed in the literature, but replication in well-controlled studies is needed before their routine use enters the clinical setting. Precision nutritional therapy might be an attractive therapeutic paradigm in a heterogenous disease like IBD. However, no recommendations for personalised dietary therapy can currently be made, and it is imperative we unravel the complex interplay between diet and gut inflammation before we are able to do so. Undoubtedly, diet is of critical importance in the development and management of IBD. However, the exact mechanism by which diet causes gut inflammation is still elusive, and dietary guidance is difficult to formulate.</p

Take-home messages from 20 years progress in dietary therapy of inflammatory bowel disease

Background: A significant body of literature has interrogated the critical role of diet in the development and management of inflammatory bowel disease (IBD). Summary: This review provides a summary and critical appraisal of the literature in this area, focussing on four distinct themes: nutritional epidemiology, animal and in vitro experiments, enteral nutrition, and food-based dietary therapies. Key Messages: Nutritional epidemiology and data from experiments in animals indicate that a western-type diet pattern is associated with increased risk of IBD onset. However, these findings have not been consistently replicated in the dietary management of IBD. Exclusive enteral nutrition (EEN) is the only dietary therapy with reproducible evidence of efficacy in the management of active Crohn’s disease (CD). Use of EEN may also be useful for improving perioperative outcomes in CD, and as an adjuvant therapy to biologic therapy. Several dietary therapies for CD and ulcerative colitis have been proposed in the literature, but replication in well-controlled studies is needed before their routine use enters the clinical setting. Precision nutritional therapy might be an attractive therapeutic paradigm in a heterogenous disease like IBD. However, no recommendations for personalised dietary therapy can currently be made, and it is imperative we unravel the complex interplay between diet and gut inflammation before we are able to do so. Undoubtedly, diet is of critical importance in the development and management of IBD. However, the exact mechanism by which diet causes gut inflammation is still elusive, and dietary guidance is difficult to formulate.</p

Dietary treatment of Crohn’s disease: perceptions of families with children treated by exclusive enteral nutrition, a questionnaire survey

Background: Diet is strongly associated with the aetiology of Crohn’s Disease (CD) and exclusive enteral nutrition (EEN) is the primary induction treatment in paediatric CD. This study explored opinions around the use of EEN and alternative novel, solid food-based diets (SFDs) expressed by paediatric patients with CD, previously treated with EEN and their parents. Methods: This anonymous questionnaire surveyed families of CD patients treated with EEN over 1 year. Two questionnaire forms were completed; one asking the patients’ opinions and another referring to their main carer. This questionnaire explored participants’ demographic characteristics; acceptability of a repeat EEN course to treat a future flare (EEN repeat); their opinion on how difficult EEN would be compared to an example SFD; and their intention to participate in a future clinical trial assessing the therapeutic efficacy of an SFD in CD. Results: Forty-one families of CD patients were approached with 29 sending replies (71%). Most of our participants were positive on completing another EEN course, however the majority would choose an SFD alternative (Patients: 66, Parents:72%). Both patients and their parents rated EEN to be more difficult to adhere to compared to an example SFD (p &lt; 0.05), and their ratings were strongly correlated (EEN:r = 0.83, SFD:r = 0.75, p &lt; 0.001). The majority of our respondents would agree to participate in a clinical trial assessing an SFD’s effectiveness (Patients:79, Parents:72%) for the management of active CD. Conclusions: While patients with CD and their families would accept an EEN repeat, the majority would prefer an SFD alternative. CD families surveyed are supportive of the development of solid food-based dietary treatments

Spanish Artifacts from Santa Elena

This volume contains Parts I and 2 of a three-part presentation of the artifacts relating to the sixteenth century Spanish occupation of the colonial capital of La Florida at Santa Elena, located on Parris Island, South Carolina from 1566 to 1587. Part 1, by Stanley South, with contributions by Eugene Lyon, Richard Polhemus, William Radisch and Carl Steen, comprises the Spanish non-ceramic artifacts. Part 2, by Russell Skowronek, Richard Johnson and Stanley South, examines the Spanish imported ceramics. Part 3, incomplete at this writing, by Chester Depratter, deals with the Spanish-contemporary Indian pottery. This third part will be published as a separate volume at a later date. The entire artifact inventory of the artifacts from Santa Elena is presented in this three-part volume, being those recovered from a number of expeditions to the site between 1979 and 1985. For comparative use the appendices contain the tabulated artifact inventory resulting from these expeditions. Synthesizing tables from these data are presented in the text. This information should prove useful to students of sixteenth century Spanish colonial history, particularly historical archaeologists involved in excavating sites of this period wherever they may be.https://scholarcommons.sc.edu/archanth_anthro_studies/1008/thumbnail.jp

An investigation of the genetic determinants of succeptibility and disease behavoir in early onset Inflammatory Bowel Disease in Scottish children.

A series of investigations examining the importance of genetic factors in the development of the inflammatory bowel diseases (IBD) namely Crohn’s disease (CD), Ulcerative Colitis (UC) and Indeterminate Colitis (IC) has been undertaken in Scottish children. This has been performed by collection of clinical details and DNA from children with IBD, then analysing the contribution of various candidate genes to both disease susceptibility and disease phenotype. In order to carry out these studies the presenting features of a large cohort of children from across Scotland with IBD diagnosed at less than 16 years were collected, both by examination of hospital case records and by patient interview and questionnaire. For each patient a detailed analysis was made of disease phenotype at presentation including detailed examination of disease location, disease behaviour and growth parameters. A repository of clinical material (DNA, plasma and lymphocytes) was collected from children to accompany the detailed clinical parameters allowing genotype-phenotype analysis at a later stage. Additionally, DNA was also collected from parents where possible to facilitate family based association analysis of candidate genes by transmission disequilibrium testing. A previous DNA repository of healthy Scottish controls had been collected previously and the data generated was available for use in this study. The phenotypic data was collected using an established phenotypic classification (the Vienna classification) used in adult studies as well as a personally devised paediatric phenotypic classification designed for use in this thesis. Firstly, the contribution of the three common mutations within the NOD2/CARD15 gene (R702W, G908R and Leu1007finsC) was analysed in 247 children with IBD. The Leu1007finsC variant was associated with Crohn’s disease by case-control (p = 0.01) and TDT analysis (p = 0.006). Genotype phenotype analysis demonstrated NOD2/CARD15 variants were strongly associated with several markers of disease severity in CD most notably with an increased need for surgery on multifactorial analysis. Then to examine the further contribution of other mutations within the whole NOD2/CARD15 gene, the 12 exons of the gene were sequenced in 24 paediatric CD patients, to identify any additional SNPs that may have conferred an increased susceptibility to CD. Two mutations (V955I, M863V) identified in xii sequencing were genotyped in a large patient cohort, but were not found to confer increased disease susceptibility. Next, the contribution of IBD5 locus was analysed in 299 children with IBD studying 5 SNPs, including mutations in the proposed candidate genes OCTN 1 and 2. Allele frequencies of OCTN1/2 variants were significantly higher in IBD/CD cases (p<0.04). The homozygous mutant OCTN1/2 haplotype was increased in IBD and UC patients (p = 0.02 for both) compared to healthy controls. OCTN1/2 variants however were not independent of the background IBD5 risk haplotype in conferring disease susceptibility. Genotype- phenotype analysis demonstrated association of the risk haplotype with both lower weight and body mass index centiles at diagnosis as analysed by multifactorial analysis. The contribution of the 113 G/A mutation within the discs, large homolog 5 (DLG5) gene was examined in 296 children with IBD. TDT analysis demonstrated a significant association with IBD (p<0.05). Genotype-phenotype analysis demonstrated associations with higher social class, male sex and taller children. Finally, the Anti-Saccharomyces cerevisiae antibodies (ASCA) status of 301 IBD patients was determined. CD patients had a higher prevalence of ASCA antibodies compared to UC patients and healthy controls (p<0.001 for both). A positive ASCA antibody was more common in CD patients with markers of more severe disease and on multifactorial analysis in patients with CD involvement of the oral cavity (p = 0.001). In summary, the candidate genes examined thus far in children with IBD in Scotland have demonstrated a relatively minor contribution to disease susceptibility but have been demonstrated to be associated with specific disease phenotypes in patients with Crohn’s disease. The use of a novel paediatric phenotypic classification in this thesis has allowed description of these novel genotype-phenotype associations

The distinct features of microbial 'dysbiosis' of Crohn's disease do not occur to the same extent in their unaffected, genetically linked kindred

Background/Aims: Studying the gut microbiota in unaffected relatives of people with Crohn’s disease (CD) may advance our understanding of the role of bacteria in disease aetiology. Methods: Faecal microbiota composition (16S rRNA gene sequencing), genetic functional capacity (shotgun metagenomics) and faecal short chain fatty acids (SCFA) were compared in unaffected adult relatives of CD children (CDR, n = 17) and adult healthy controls, unrelated to CD patients (HUC, n = 14). The microbiota characteristics of 19 CD children were used as a benchmark of CD ‘dysbiosis’. Results: The CDR microbiota was less diverse (p = 0.044) than that of the HUC group. Local contribution of β-diversity analysis showed no difference in community structure between the CDR and HUC groups. Twenty one of 1,243 (1.8%) operational taxonomic units discriminated CDR from HUC. The metagenomic functional capacity (p = 0.207) and SCFA concentration or pattern were similar between CDR and HUC (p&#62;0.05 for all SCFA). None of the KEGG metabolic pathways were different between these two groups. Both of these groups (HUC and CDR) had a higher microbiota α-diversity (CDR, p = 0.026 and HUC, p&#60;0.001) with a community structure (β-diversity) distinct from that of children with CD. Conclusions: While some alterations were observed, a distinct microbial ‘dysbiosis’, characteristic of CD patients, was not observed in their unaffected, genetically linked kindred