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BACKGROUND/AIMS: Robust management algorithms are required to reduce the residual risk of colectomy in acute severe ulcerative colitis (ASUC) refractory to standard infliximab salvage therapy. The aim of this study was to evaluate the performance and benefits of alternative ASUC management strategies using simulated prediction models of varying accuracy. METHODS: This was a simulation-based modeling study using a hypothetical cohort of 5,000 steroid-refractory ASUC patients receiving standard infliximab induction. Simulated predictive models were used to risk-stratify patients and escalate treatment in patients at high risk of failing standard infliximab induction. The main outcome of interest was colectomy by 3 months. RESULTS: The 3-month colectomy rate in the base scenario where all 5,000 patients received standard infliximab induction was 23%. The best-performing management strategy assigned high-risk patients to sequential Janus kinase inhibitor inhibition and mediumrisk patients to accelerated infliximab induction. Using a 90% area under the curve (AUC) prediction model and optimistic treatment efficacy assumptions, this strategy reduced the 3-month colectomy rate to 8% (65% residual risk reduction). Using an 80% AUC prediction model with only modest treatment efficacy assumptions, the 3-month colectomy rate was reduced to 15% (35% residual risk reduction). Overall management strategy efficacy was highly dependent on predictive model accuracy and underlying treatment efficacy assumptions. CONCLUSIONS: This is the first study to simulate predictive model-based management strategies in steroid-refractory ASUC and evaluate their effect on short-term colectomy rates. Future studies on predictive model development should incorporate simulation studies to better understand their expected benefit.

Background and Aim: Hepatitis C virus (HCV) is now a highly treatable condition. HCV is overrepresented in people with serious mental illness, largely as a consequence of substance misuse. People with serious mental illness are marginalized in terms of access to care. Strengthened community engagement to optimize population HCV management could feasibly reduce overall HCV seroprevalence, while likely reducing disease incidence. As such, we aimed to investigate the prevalence of HCVin a tertiary mental health service and, hence, identify barriers to care and opportunities to optimize community-based HCV management. Method(s): We retrospectively analyzed 4492 people admitted to a multisite mental health service between January 2017 and December 2018. We appraised patterns and rates of HCV screening using medical records, electronic pathology, and ICD-10 coding. Referral pathways were analyzed for people with serious mental illness and potentially treatable HCV. Intensified access to HCV care was prospectively provided to eligible, untreated people within community mental health services. Result(s): HCV seroprevalence was 6.2%, based on pooled serology together with HCV ICD-10 coding. In a sensitivity analysis, 19.1% (35/ 183) of those with identified HCV risk factors remained unscreened. We identified 209 people who required additional HCV work-up or treatment. Multiple opportunity losses were manifest in the care cascade, particularly through lack of referral to treatment (89, 42.6%) and failure to attend specialist outpatient clinics (52, 25.8%). Given this attrition, we identified 48 community-managed patients who were untreated or incompletely worked up for HCV. Of these, 10 people (20.8%) with longstanding mental health service integration achieved a sustained virological response at 12 weeks through bolstered community support. However, 22 people (45.8%) could not be engaged (Fig. 1). Conclusion(s): HCV screening and treatment should be prioritized in people wit

Background and Aim: The most commonly used diagnostic instrument to detect inflammation of an ileal pouch-anal anastomosis (IPAA) is the 18-point Pouchitis Disease Activity Index (PDAI). A total PDAI score of >= 7 or a modified PDAI (mPDAI) score of >= 5 is considered diagnostic for pouchitis. The consistency of scoring between endoscopists using the PDAI is poor, likely owing to the variable interrater reliability of the endoscopic components of the score; therefore, alternative scoring systems have been proposed.We aimed to assess the interrater reliability of endoscopic findings and compare the diagnostic utility of a simpler version of the PDAI. Method(s): We conducted a prospective, observational study at a single tertiary center. Consecutive patients with an IPAA were recruited. Clinical, endoscopic, and histological data were collected. Pouchoscopies occurred a median of 37 days after clinical review and were reviewed by two experienced gastroenterologists, while biopsies were reviewed by a single pathologist, all of whom were blinded to the clinical history. We assessed the interrater reliability and diagnostic performance of three disease activity scores: the traditional PDAI; a proposed alternative score combined with clinical PDAI; and a simplified PDAI (sPDAI), which uses only PDAI endoscopy items with at least high-moderate interrater reliability (Cohen's kappa >= 0.5). Interrater reliability was assessed by calculating observed agreement and Cohen's kappa coefficient. Diagnostic performance was analyzed using receiver operator characteristic (ROC) analysis. Result(s): A total of 35 patients (mean age, 52 years; 72% male) underwent a pouchoscopy. All had a J pouch. The mean age of the pouches was 12.8 years (1-27). Seven patients had a normal pouch, 13 had antibiotic-responsive pouchitis, eight had antibiotic-dependent pouchitis, three had antibiotic-refractory pouchitis, and three had Crohn's disease of the pouch. Of the PDAI endoscopic components, onl

Background and Aim: Patients with ileal pouch-anal anastomosis (IPAA) often require a pouchoscopy to investigate symptoms of increased frequency, urgency, and abdominal cramps, which are not specific to pouchitis. Fecal calprotectin (FC) testing has the potential to be an alternative non-invasive tool for the assessment of pouch activity.We aimed to assess the utility of FC testing in the assessment of inflammatory complications of the pouch. Method(s): We conducted a prospective observational study at a single center between October 2018 and November 2019. Consecutive symptomatic patients with IPAA referred from clinic were recruited. At recruitment, clinical data, as well as FC and serum C-reactive protein (CRP) levels, were measured. Pouchoscopy was performed after a median of 35 days. Histopathological examination of biopsies of the pre-pouch ileum, pouch body, and cuff was performed by a single pathologist blinded to the clinical history. A diagnosis of pouchitis was defined as Pouchitis Disease Activity Index (PDAI) score >= 7. Associations were assessed by correlation and regression analyses, and area under the curve (AUC) for receiver operator characteristic analysis was used to analyze diagnostic performance of CRP and FC. Result(s): Of 40 patients, 34 had complete data (mean age, 52.4 years; 72% male). Seven had a normal pouch, 13 had antibiotic-responsive pouchitis, eight had antibiotic-dependent pouchitis, three had antibiotic-refractory pouchitis, and three had Crohn's disease of the pouch. Two-thirds had active pouchitis. Median FC level was higher in 20 patients with pouchitis (442 mug/g; interquartile range [IQR], 345- 590) compared with 11 with isolated cuffitis and/or pre-pouch ileitis without pouchitis (167 mug/g; IQR, 75-320; P = 0.03) and nine without pouchitis or cuffitis/pre-pouch ileitis (66 mug/g; IQR, 44-120; P < 0.001). No patients had isolated pouchitis without cuffitis or ileitis. After multivariate adjustment for presence of cuffitis (n

Background/purpose of the study: Little is known about all-cause liver disease in people with serious mental illness (SMI), despite heightened risk factors. We, therefore, prospectively assessed liver disease by etiology and severity in a cross-sectional cohort of people with SMI at a tertiary health service. Method(s): We recruited 255 people with SMI between August 2019 and March 2020. Liver disease data were derived from structured interview, medical records, biochemical and BBV serological analyses, and vibration-controlled transient elastography (VCTE). Steatosis was determined using a threshold of >= 248 db/m via the controlled attenuation parameter (CAP) on VCTE. Liver disease prevalence was assessed descriptively, and predictors of metabolic-dysfunction associated fatty liver disease (MAFLD) analyzed using linear regression and multivariable analysis. Best fit modeling of non-invasive screening tests for MAFLD was also assessed. Result(s): Valid VCTE was obtained for 252 (98.9%) participants. Median age was 40 years (IQR 31-49) with male predominance (65.9%). Hepatitis C Virus (HCV) seroprevalence was 14.7% (37/252), with four new viremic cases identified. Hepatic steatosis was diagnosed in 61.5% (155/252) of participants, with MAFLD criteria met in 59.9% (151/252) of cases. Clozapine and paliperidone were associated with hepatic steatosis (CAP + 23.3 db/m, p 0.013 and CAP + 25.5, p 0.037, respectively). Advanced liver disease, defined by LSM >= 8.2 kPa, was identified in 26 individuals (10.3%). MAFLD compared to no MAFLD was associated with more advanced liver disease (5.3 kPa, 4.3-6.5 versus 4.9 kPa, 3.9-5.6, p < 0.001). Conclusion(s): Liver disease is common in people with SMI and should be screened for as part of standard physical health assessment. Graphic abstract: [Figure not available: see fulltext.].Copyright © 2021, Asian Pacific Association for the Study of the Liver.

BACKGROUND AND AIMS: In symptomatic patients with ileoanal pouches, pouchoscopy is needed for accurate diagnosis, but is invasive. We aimed to assess the utility of non-invasive gastrointestinal ultrasound and faecal calprotectin in ileoanal pouch patients. METHOD(S): Patients with an ileoanal pouch were consecutively enrolled in this cross-sectional study from clinics in Victoria, Australia. The pouchitis disease activity index was used as a reference standard. Video-recorded pouchoscopies were reviewed by three gastroenterologists. Pouch, pre-pouch and cuff biopsies were reviewed by a single pathologist. Ultrasound was performed by a single gastroenterologist transabdominally and transperineally. Faecal calprotectin was measured from morning stool samples. All examiners were blinded to patients' clinical history. RESULT(S): 44 participants had a pouchoscopy, of whom 43 had a faecal calprotectin and 42 had an ultrasound. 17 had pouchitis, 15 had pre-pouch ileitis, and 16 had cuffitis. Pouch wall thickness of <3 mm was 88% sensitive at excluding pouchitis, and pouch wall thickness of >=4 mm was 87% specific at diagnosing pouchitis. Transabdominal ultrasound had good utility (area-under-the-curve 0.78) in diagnosing moderate-severe pre-pouch ileitis. Transperineal ultrasound had good utility for the diagnosis of pouchitis (area-under-the-curve 0.79). Faecal calprotectin differentiated inflammatory from non-inflammatory pouch disorders such as irritable pouch syndrome with an area-under-the-curve of 0.90. Faecal calprotectin <100 microg/g ruled out inflammatory pouch disorders with a sensitivity of 94%. CONCLUSION(S): Faecal calprotectin and ultrasound are accurate and complementary tests to diagnose and localise inflammation of the ileoanal pouch. Prospective studies are needed to validate proposed sonographic indices and calprotectin levels.Copyright © The Author(s) 2021. Published by Oxford University Press on behalf of European Crohn's and Colitis Organisation. Al

BACKGROUND: People with serious mental illness (SMI) are underserved from a hepatitis C Virus (HCV) screening and treatment perspective. AIMS: To examine the HCV care cascade in people with SMI and to pilot a supported HCV treatment integration program. METHOD(S): HCV prevalence was retrospectively analysed from 4,492 consecutive individuals admitted to a tertiary hospital mental health service between January 2017 and December 2018. Sub-cohort analysis of screening patterns and predictors of seropositive infection was performed. Referral pathways and community care integration were analysed for HCV positive individuals, and a prospective community-based 'identify and treat' HCV program was assessed. RESULT(S): Screening for HCV had been performed in 18.6% (835/4,492) of the cohort. Seroprevalence was 4.6% (207/4,492). HCV seropositivity was associated with age >40-years (OR = 9.30, CI 3.69-23.45, p <0.01), injecting drug use (IDU) (OR = 24.26, CI 8.99-65.43, p <0.01), and previous incarceration (OR = 12.26, 4.51-33.31, p <0.01). In a cohort of treatment-eligible individuals, 43.3% (90/208) had neither been referred to specialist services or general practitioners for HCV management. Amongst those referred to specialist services, 64.7% (57/88) did not attend scheduled follow-up, and 48.3% (15/31) of attendees were lost to follow-up. Through an intensified community access program, 10 people were successfully treated for HCV, though 22 could not be engaged. CONCLUSION(S): People with SMI are underserved by traditional models of HCV healthcare. Intensified community-based support can partially bolster the treatment cascade, though investment in innovative screening and management strategies are required to achieve healthcare parity. This article is protected by copyright. All rights reserved.

BACKGROUND AND AIMS: Currently-used endoscopic items for the assessment of pouchitis and cuffitis have deficiencies in reliability and validation. We assessed the reliability and accuracy of new endoscopic items for pouchitis and of the Ulcerative Colitis Endoscopic Index of Severity (UCIS) for cuffitis. METHOD(S): Three new endoscopic items were assessed and included in the Monash pouchitis endoscopic subscore: bleeding (absent/contact/spontaneous); erosions (absent/<10/>=10); and ulceration (absent/<10%/>=10%). Three raters evaluated 44 pouchoscopy videos in duplicates, in random order. Intra- and inter-rater reliability of all endoscopic items and UCEIS were assessed. Clinical and histologic pouchitis disease activity index (PDAI) subscores were also assessed and faecal calprotectin measured. RESULT(S): All three Monash endoscopic items had substantial intra-rater reliability with an intraclass correlation coefficients (ICCs) > 0.61(95% CI >0.61), compared with only ulcers from the currently-used PDAI endoscopic subscore, but inter-rater reliability was only substantial for ulceration and no better than those of the currently-used endoscopic items. The Monash endoscopic subscore had a strong positive correlation with the reference standard global endoscopic lesion severity r=0.80 (95% CI 0.80-0.80) and the reference standard PDAI endoscopic subscore r=0.70 (95% CI 0.67-0.73), which was higher than the correlation observed for the currently-used PDAI endoscopic subscore. The UCEIS had substantial intra-rater reliability, but only fair inter-rater reliability and poor diagnostic performance for cuffitis. CONCLUSION(S): The Monash endoscopic items and endoscopic subscore they generate have enhanced overall performance compared with the currently-used PDAI items and subscore. Further validation and responsiveness to change in disease state are indicated.Copyright © The Author(s) 2021. Published by Oxford University Press on behalf of European Crohn's and Colitis Orga

BACKGROUND AND AIM: Marked elevations of alanine aminotransferase (ALT) are caused by a limited number of underlying pathologies, including hepatic ischemia, drugs/toxins, viral hepatitis, and-rarely-autoimmune hepatitis. The aim of this study was to determine the relative incidence of pathologies resulting in ALT greater than 1000 IU/L and factors predicting clinical outcomes in an Australian cohort. METHODS: A retrospective cohort study of all adult patients with ALT levels greater than 1000 IU/L between January 2013 and December 2015 was conducted at a large teaching hospital network in Australia. Multivariable logistic regression analysis was used to determine predictors of etiology and mortality. RESULTS: There were 287 patients identified with ALT levels greater than 1000 IU/L. The most common causes were ischemia (44%), drugs/toxins (19%), biliary obstruction (16%), and viral hepatitis (7%). Independent predictors of a diagnosis of ischemic hepatitis included (adjusted odds ratio; 95% confidence interval): hypotension (29.2; 8.2-104.7), chronic obstructive pulmonary disease (COPD) (20.2; 2.8-145.3), coronary artery disease (12.9; 1.7-98.9), congestive cardiac failure (7.8; 1.2-49.2), diabetes mellitus (7.4; 1.6-33.9), metabolic acidosis (6.2; 2.0-19.4), gamma-glutamyltransferase < 135 IU/L (5.1; 1.5-17.6), and albumin <34 g/L (3.4; 1.1-11.0). Independent risk factors for all-cause 28-day mortality included: septic shock (14.7; 4.3-50.7), metabolic acidosis (7.3; 2.5-21.3), history of COPD (5.4; 1.6-17.8), cardiogenic shock (4.3; 1.6-11.7), prothrombin time ≥ 20 s (3.7; 1.5-9.2), and age ≥ 65 years (3.0; 1.3-7.2). CONCLUSIONS: Ischemic hepatitis was the most common cause of ALT levels greater than 1000 IU/L and was associated with high mortality.

Background and Aim: With increasing cost pressures exerted on the Australian health care system, there is a growing need to justify and optimally allocate resources, especially for chronic conditions such as Crohn's disease (CD). Perianal Crohn's disease (pCD), affecting up to a quarter of patients with CD, is a particularly difficult phenotype to treat, requiring early aggressive treatment with a combination of highcost biological agents and frequent surgical procedures. Yet there are no Australian data assessing the cost of this treatment algorithm. We aimed to compare the costs of treating pCD and non-perianal CD. Method(s): We conducted a retrospective cohort study comparing the health care cost of treating patients with pCD and non-perianal CD with a biological agent at a large multicampus tertiary center in Australia. The groups were age- and sex-matched and consisted of 46 patients in each arm (with 11 in total lost to follow-up). The total direct health care costs for each patient were calculated over 1 year to gather a cross-sectional cohort cost and were compared between groups, with the use of the Wilcoxon rank test with continuity correction to assess significance. Result(s): The pCD and CD groups were similar in terms of age (median, 36.6 vs 34.8 years, P = 0.84), sex (59% vs 67% male, P = 0.50), and disease duration (median, 8.1 vs 6.4 years, P = 0.58). The pCD and CD cohorts were similar in their annual total treatment cost (mean, $25 793 vs $24 550 per patient, P = 0.78). The major cost driver in both groups was medications, at 76.12% of total cost in the pCD group and 84.80% in the CD group (mean per patient, $19 969 in pCD and $20 818 in CD, P = 0.82) (Fig. 1). Biological agents and their administration were the major contributor to these medication costs (pCD, 97.49%; CD, 97.25% of total medication cost). Surgery made up 16% and 3.3% of the total cost in pCD and CD, respectively. The mean surgical cost was significantly higher in the pCD group (pC

BACKGROUND: The extent to which disease activity impacts patient-reported outcomes (PRO) is unclear. AIMS: To examine the relationship between disease activity and PRO. METHODS: Adult inflammatory bowel disease (IBD) patients attending a tertiary clinic from May to June 2015 were included. Assessment of disease activity (Simple Clinical Colitis Activity Index (SCCAI), Harvey Bradshaw Index (HBI)), IBD knowledge (CCKNOW), medication adherence (MMAS8), psychological distress (Hospital Anxiety and Depression Scale (HADS)), work productivity (WPAI) and quality of life (IBDQ) was performed to investigate any correlations between disease activity and PRO. RESULTS: A total of 81 participants was included: 49% female, 57% Crohn disease (CD), 38% ulcerative colitis (UC) and 5% IBD-unclassified, with a median age of 34 years. At least mild levels of depression were present in 21 of 81 (26%) of patients; 37 of 81 (46%) expressed some level of anxiety. A moderate-to-strong correlation was found between disease activity and depression in UC (r = 0.84, P = 0.002) but not in CD (r = 0.53, P = 0.29). Disease activity correlated with: overall work impairment due to health (r = 0.85, P = 0.001), health-related impairment while working (r = 0.76, P = 0.02) and percentage of activity impaired due to health (r = 0.83, P = 0.002) in UC only. CONCLUSIONS: Disease activity significantly affects mood and work productivity in patients with UC. Monitoring patients' ability to function and work, rather than minimising disease activity alone, should become a routine part of IBD care.

BACKGROUND: Electronic health (eHealth) decision support tools have the potential to: facilitate inflammatory bowel disease (IBD) self-management, reduce health care utilisation and alleviate the pressure on overburdened outpatient clinics. The purpose of this study was to explore the perspectives of key stakeholders on the potential use of a decision support tool for IBD patients. METHODS: A qualitative study using focus group methodology was conducted at a tertiary IBD centre in Melbourne, Australia in February 2015. Key stakeholders, including physicians, nurses and patients, were included in the study. Two independent reviewers undertook inductive coding and generated themes. RESULTS: In total, 31 participants were included in the study (including 16 males; 11 physicians; 6 nurses). An eHealth decision support tool was thought to be beneficial to facilitate IBD self-management. Four themes emerged: (i) Framework for the decision support tool - the tool should be an adjunct to current models of care and facilitate shared decision-making and patient engagement; (ii) Target population - stable patients with mild to moderate disease; (iii) Functionalities of the intervention - a web-based platform encompassing patient-reported outcomes, objective markers of disease and clinical algorithms based on international guidelines; and (iv) Design and Implementation - patients should be involved in the design. CONCLUSIONS: eHealth interventions are thought to be an important strategy to facilitate self-management for patients with IBD. A multi-stage iterative approach should be adopted in the design and implementation process of eHealth interventions. Patient perspectives need to be sought prior to and throughout the development of an eHealth decision support tools for IBD.