BACKGROUND: Defective cell-mediated immunity increases the risk of human papillomavirus-associated anal dysplasia and cancer. There is limited information on anal canal disease in patients with IBD.
OBJECTIVE: The purpose of this study was to assess anal/vaginal human papillomavirus and anal dysplasia prevalence in patients with IBD.
DESIGN: Patients had an anal examination before routine colonoscopy.
SETTINGS: The study was conducted at a tertiary IBD referral center.
PATIENTS: We studied a convenience sample of sexually active male and female patients with IBD who were not on biological therapy.
INTERVENTION: Anal examination, anal and vaginal human papillomavirus testing, anal cytology, and high-resolution anoscopy/biopsy were carried out.
MAIN OUTCOME MEASURES: Anal and vaginal human papillomavirus types, anal cytology, and biopsy grade were measured.
RESULTS: Twenty-five male and 21 female evaluable participants, 31 with Crohn's disease, 14 with ulcerative colitis, and 1 with indeterminate colitis, were predominantly white (91.3%), treatment experienced (76.1%), an average age of 38.1 years (range, 22.0-66.0 y), and had an average length of IBD diagnosis of 9.3 years (range, 1.0-33.0 y). Eighteen (39.1%) had an abnormal perianal examination and 3 (6.5%) had an abnormal digital examination. Forty-one (89.1%) had anal human papillomavirus, 16 with a single type and 25 with multiple types (range, 2-5 types). Human papillomavirus type 16 was most common (65.2%), followed by human papillomavirus types 11 and 45 (37.0% each). Nineteen of 21 (90.5%) women had vaginal human papillomavirus. Overall, 21 (45.7%) had abnormal anal cytology. Thirty three (71.7%) had ≥1 anal biopsy (9 had multiple), with dysplasia diagnosed in 28 (60.9%) and high-grade and low-grade squamous intraepithelial lesions diagnosed in 4 (8.7%) and 24 (43.5%).
LIMITATIONS: No control group was included, and no detailed sexual history was taken.
CONCLUSIONS: A high prevalence of anal and vaginal human papillomavirus and anal dysplasia was demonstrated in the study population outcomes. See Video Abstract at http://links.lww.com/DCR/A379.
Oncology (1), Immune System Diseases (1) Colitis (1), Ulcerative Colitis (1), Papillomavirus Infections (1), more mentions
An adhesive small bowel obstruction (ASBO) is generally caused by postoperative adhesions and is more frequently associated with colorectal surgeries than other procedures. We compared the outcomes of operative and conservative management of ASBO after primary colorectal cancer surgery.We retrospectively reviewed 5060 patients who underwent curative surgery for primary colorectal cancer; 388 of these patients (7.7%) were readmitted with a diagnosis of SBO. We analyzed the clinical course of these patients with reference to the cause of their surgery.Of the 388 SBO patients analyzed, 170 were diagnosed with ASBO. Their 3-, 5-, and 7-year recurrence-free survival rates were 86.1%, 72.8%, and 61.5%, respectively. The median follow-up period was 59.2 months. Repeated conservative management for ASBO without surgical management led to higher recurrence rates: 21.0% after the first admission, 41.7% after the second, 60.0% after the third, and 100% after the fourth (P = .006). Surgical management was needed for 19.2%, 22.2%, 50%, and 66.7% of patients admitted with ASBO on the first to fourth hospitalizations, respectively. Repeated hospitalization for obstruction led to a greater possibility of surgical management (P = .001). Of 27 patients with surgical management at the first admission, 6 (17.6%) were readmitted with a diagnosis of SBO, but there were no further episodes of SBO in the surgically managed patients.Patients who undergo operative management for ASBO have a reduced risk of recurrence requiring hospitalization, whereas those with repeated conservative management have an increased risk of recurrence and require operative management. Operative management should be considered for recurrent SBO.
Oncology (3) Colorectal Neoplasms (4), Intestinal Obstruction (1), more mentions
BACKGROUND: Patients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where nonoperative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed nonoperatively to evaluate variability in nonoperative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered.
METHODS: Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in nonoperative patients, rates of adverse outcomes were identified, and hospitals were ranked by performance with and then without including nonoperative cases.
RESULTS: Two thousand ninety-one patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of nonoperative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS pilot, nonoperative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with four hospitals changing by three or more positions.
CONCLUSION: This study identifies a gap in performance evaluation when nonoperative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating nonoperative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include nonoperative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation.
LEVEL OF EVIDENCE: Care management, level IV; Epidemiologic, level III.
Appendicitis (4), Cholecystitis (3), Acute Cholecystitis (1), more mentions
Objective To determine if circulating concentrations of vitamin D are causally associated with risk of cancer.Design Mendelian randomisation study.Setting Large genetic epidemiology networks (the Genetic Associations and Mechanisms in Oncology (GAME-ON), the Genetic and Epidemiology of Colorectal Cancer Consortium (GECCO), and the Prostate Cancer Association Group to Investigate Cancer Associated Alterations in the Genome (PRACTICAL) consortiums, and the MR-Base platform).Participants 70 563 cases of cancer (22 898 prostate cancer, 15 748 breast cancer, 12 537 lung cancer, 11 488 colorectal cancer, 4369 ovarian cancer, 1896 pancreatic cancer, and 1627 neuroblastoma) and 84 418 controls.Exposures Four single nucleotide polymorphisms (rs2282679, rs10741657, rs12785878 and rs6013897) associated with vitamin D were used to define a multi-polymorphism score for circulating 25-hydroxyvitamin D (25(OH)D) concentrations.Main outcomes measures The primary outcomes were the risk of incident colorectal, breast, prostate, ovarian, lung, and pancreatic cancer and neuroblastoma, which was evaluated with an inverse variance weighted average of the associations with specific polymorphisms and a likelihood based approach. Secondary outcomes based on cancer subtypes by sex, anatomic location, stage, and histology were also examined.Results There was little evidence that the multi-polymorphism score of 25(OH)D was associated with risk of any of the seven cancers or their subtypes. Specifically, the odds ratios per 25 nmol/L increase in genetically determined 25(OH)D concentrations were 0.92 (95% confidence interval 0.76 to 1.10) for colorectal cancer, 1.05 (0.89 to 1.24) for breast cancer, 0.89 (0.77 to 1.02) for prostate cancer, and 1.03 (0.87 to 1.23) for lung cancer. The results were consistent with the two different analytical approaches, and the study was powered to detect relative effect sizes of moderate magnitude (for example, 1.20-1.50 per 25 nmol/L decrease in 25(OH)D for most primary cancer outcomes. The Mendelian randomisation assumptions did not seem to be violated.Conclusions There is little evidence for a linear causal association between circulating vitamin D concentration and risk of various types of cancer, though the existence of causal clinically relevant effects of low magnitude cannot be ruled out. These results, in combination with previous literature, provide evidence that population-wide screening for vitamin D deficiency and subsequent widespread vitamin D supplementation should not currently be recommended as a strategy for primary cancer prevention.
The aim of this study was to investigate the association between urinary incontinence (UI) and peptic ulcer (PU) and how this is related to psychological stress in Korean women by analyzing the data from the Korea National Health and Nutrition Examination Survey IV (KNHANES).A nationally representative sample of data on 7475 Korean women ≥19 years of age from the KNHANES 2008 to 2010 was included. Physician-diagnosed UI and PU were assessed using questionnaires and surveys. Psychological stress was assessed through a questionnaire using a 4-point Likert scale. Data were analyzed using logistic regression to determine the association between UI and PU according to the level of psychological stress perception.PU was found in 1.41% of the total population. Breaking this down by the existence of UI, PU was found in 3.5% of the population with UI, and 1.4% of the population without UI, which showed a significant difference. A statistically significant trend for increasing prevalence of UI and PU with increasing psychological stress perception levels was found among the study population. Multivariable logistic regression analyses for PU showed that UI was significantly associated with a higher probability of PU in an adjusted model, which means that members of the population with UI were more likely to have PU than those without UI. A higher level of psychological stress perception was also significantly associated with increased odds of PU in the adjusted model.UI could potentiate the development of PU through increasing levels of psychological stress perception.
Urology (3) Peptic Ulcer (3), Urinary Incontinence (3), more mentions
DescriptorName: Anti-Inflammatory Agents, Non-Steroidal. DescriptorName: Arthralgia. DescriptorName: Diarrhea. DescriptorName: Female. DescriptorName: Humans. DescriptorName: IntestinalDiseases. DescriptorName: Long Term Adverse Effects. DescriptorName: Mefenamic Acid. DescriptorName: Middle Aged. DescriptorName: Migraine Disorders. DescriptorName: Time Factors. AbstractText: Mefenamic acid-induced enteropathy may be an under-recognized condition because few reported cases and no review of literature to comprehensively describe all reported cases ...
Pain Management (1), Blood Disorders and Hematology (1), Anti-Obesity and Weight Loss (1) Diarrhea (3), Atrophy (2), Arthralgia (1), more mentions
BACKGROUND: Decision-making for pulse generator implantation for sacral nerve stimulation in the management of fecal incontinence is based on the results of a test phase. Its duration is still a matter of debate.
OBJECTIVE: The purpose of this study was to determine whether an early positive response during the test phase could predict implantation of a permanent sacral nerve pulse generator.
DESIGN: This was a short-term observational cohort study. A positive response was defined as a >50% decrease of fecal leaks compared with baseline. A multivariate logistic regression was computed to predict pulse generator implantation after the first week of the test phase.
SETTINGS: The study was conducted in 3 national referral centers.
PATIENTS: From January 2006 to December 2012, 144 patients with fecal incontinence enrolled in a prospectively maintained database completed a 2- to 3-week bowel diary, at baseline and during test phase.
MAIN OUTCOME MEASURES: The primary outcome was the clinical decision to implant a pulse generator. The primary predictor was a calculated score including the number of leak episodes, bowel movements, and urgencies and the time to defer defecation expressed in minutes during the first screening test week.
RESULTS: After the first, second and third week of the test phase, 81 (56%) of 144, 96 (67%) of 144, and 93 (70%) of 131 patients had a positive test. A permanent pulse generator was implanted in 114. Time to defer defecation increased during the 3 weeks of screening. Urgencies were unchanged. The computed score was predictive of a permanent pulse generator implantation (Se = 72.6% (95% CI, 59.8-83.1); Sp = 100% (95% CI, 78.2-100); c-index = 0.86 (95% CI, 0.78-0.94)).
LIMITATIONS: No cost analysis or projection based on our proposal to reduce the test phase has been made.
CONCLUSIONS: Permanent pulse generator implantation can be safely proposed early (1-week screening) to fast responders. Nonetheless, permanent implantation may be decided as well in patients exhibiting a delayed response. Whether a rapid response to sacral nerve stimulation could be predictive of a long-term response remains to be determined. See Video Abstract at http://links.lww.com/DCR/A452.
BACKGROUND: Approximately half of Crohn's patients require intestinal resection, and many need repeat resections.
OBJECTIVE: The purpose of this study was to evaluate the increased risk of clinical anastomotic leak in patients with a history of previous intestinal resection undergoing repeat resection with anastomosis for Crohn's disease.
DESIGN: This was a retrospective analysis of prospectively collected departmental data with 100% capture.
SETTINGS: The study was conducted at the department of colorectal surgery in a tertiary care teaching hospital between July 2007 and March 2016.
PATIENTS: A cohort of consecutive patients with Crohn's disease who were treated with intestinal resection and anastomosis, excluding patients with proximal fecal diversion, were included. The cohort was divided into 2 groups, those with no previous resection compared with those with previous resection.
MAIN OUTCOME MEASURES: Clinical anastomotic leak within 30 days of surgery was measured.
RESULTS: Of the 206 patients who met criteria, 83 patients had previous intestinal resection (40%). The 2 groups were similar in terms of patient factors, immune-suppressing medication use, and procedural factors. Overall, 20 clinical anastomotic leaks were identified (10% leak rate). There were 6 leaks (5%) detected in patients with no previous intestinal resection and 14 leaks (17%) detected in patients with a history of previous intestinal resection (p < 0.005). The OR of anastomotic leak in patients with Crohn's disease with previous resection compared with no previous resection was 3.5 (95% CI, 1.3-9.4). Patients with 1 previous resection (n = 53) had a leak rate of 13%, whereas patients with ≥2 previous resections (n = 30) had a leak rate of 23%. The number of previous resections correlated with increasing risk for clinical anastomotic leak (correlation coefficient = 0.998).
LIMITATIONS: This was a retrospective study with limited data to perform a multivariate analysis.
CONCLUSIONS: Repeat intestinal resection in patients with Crohn's disease is associated with an increased rate of anastomotic leakage when compared with initial resection despite similar patient, medication, and procedural factors. See Video Abstract at http://links.lww.com/DCR/A459.
Immune System Diseases (5) Anastomotic Leak (8), Crohn Disease (1), more mentions
BACKGROUND: Tumour stroma has important roles in the development of colorectal cancer (CRC) metastasis. We aimed to clarify the roles of microRNAs (miRNAs) and their target genes in CRC stroma in the development of liver metastasis.
METHODS: Tumour stroma was isolated from formalin-fixed, paraffin-embedded tissues of primary CRCs with or without liver metastasis by laser capture microdissection, and miRNA expression was analysed using TaqMan miRNA arrays.
RESULTS: Hierarchical clustering classified 16 CRCs into two groups according to the existence of synchronous liver metastasis. Combinatory target prediction identified tenascin C as a predicted target of miR-198, one of the top 10 miRNAs downregulated in tumour stroma of CRCs with synchronous liver metastasis. Immunohistochemical analysis of tenascin C in 139 primary CRCs revealed that a high staining intensity was correlated with synchronous liver metastasis (P<0.001). Univariate and multivariate analyses revealed that the tenascin C staining intensity was an independent prognostic factor to predict postoperative overall survival (P=0.005; n=139) and liver metastasis-free survival (P=0.001; n=128).
CONCLUSIONS: Alterations of miRNAs in CRC stroma appear to form a metastasis-permissive environment that can elevate tenascin C to promote liver metastasis. Tenascin C in primary CRC stroma has the potential to be a novel biomarker to predict postoperative prognosis.
PURPOSE: To evaluate the effective dose and patterns of recurrence after stereotactic body radiation therapy (SBRT) for hepatic metastases that arise from colorectal cancer.
METHODS AND MATERIALS: A cohort of 70 patients with 103 colorectal liver metastases were treated with SBRT at a single institution. The prescribed doses were 45 to 60 Gy in 3 to 4 fractions, but these were modified according to the tolerance of the adjacent normal tissue. To allow for dose comparisons, a biological equivalent dose was calculated.
RESULTS: The median follow-up period was 34.2 months (range, 5.3-121.8 months). The 2-year overall survival and progression-free survival rates were 75% and 35%, respectively. In subgroups, the 2-year local control rates for biological equivalent dose ≤80 Gy (group 1), 100 to 112 Gy (group 2), and ≥132 Gy (group 3) were 52%, 83%, and 89%, respectively. Cox proportional hazards model revealed a significant difference between groups (hazard ratio 0.44, P=.03 for group 2; hazard ratio 0.17, P=.17 for group 3; P=.01 for total). The major pattern of failure was a new liver metastasis out of the SBRT field. There was no grade ≥3 toxicity.
CONCLUSIONS: Stereotactic body radiation therapy of liver metastases derived from colorectal cancer offers a locally effective treatment without significant complications. Longer local control can be expected if higher doses are used. Further studies will be needed to compare the efficacies of SBRT with those of surgical resection or radiofrequency ablation.
BACKGROUND: The existing scores reflecting the patient's nutritional and inflammatory status do not include all biomarkers and have been poorly studied in colorectal cancers.
OBJECTIVE: The purpose of this study was to assess a new prognostic tool, the Naples prognostic score, comparing it with the prognostic nutritional index, controlling nutritional status score, and systemic inflammation score.
DESIGN: This was an analysis of patients undergoing surgery for colorectal cancer.
SETTINGS: The study was conducted at a university hospital.
PATIENTS: A total of 562 patients who underwent surgery for colorectal cancer in July 2004 through June 2014 and 468 patients undergoing potentially curative surgery were included. MaxStat analysis dichotomized neutrophil:lymphocyte ratio, lymphocyte:monocyte ratio, prognostic nutritional index, and the controlling nutritional status score. The Naples prognostic scores were divided into 3 groups (group 0, 1, and 2). The receiver operating characteristic curve for censored survival data compared the prognostic performance of the scoring systems.
MAIN OUTCOME MEASURES: Overall survival and complication rates in all patients, as well as recurrence and disease-free survival rates in radically resected patients, were measured.
RESULTS: The Naples prognostic score correlated positively with the other scoring systems (p < 0.001) and worsened with advanced tumor stages (p < 0.001). Patients with the worst Naples prognostic score experienced more postoperative complications (all patients, p = 0.010; radically resected patients, p = 0.026). Compared with group 0, patients in groups 1 and 2 had worse overall (group 1, HR = 2.90; group 2, HR = 8.01; p < 0.001) and disease-free survival rates (group 1, HR = 2.57; group 2, HR = 6.95; p < 0.001). Only the Naples prognostic score was an independent significant predictor of overall (HR = 2.0; p = 0.03) and disease-free survival rates (HR = 2.6; p = 0.01). The receiver operating characteristic curve analysis showed that the Naples prognostic score had the best prognostic performance and discriminatory power for overall (p = 0.02) and disease-free survival (p = 0.04).
LIMITATIONS: This is a single-center study, and its validity needs additional external validation.
CONCLUSIONS: The Naples prognostic score is a simple tool strongly associated with long-term outcome in patients undergoing surgery for colorectal cancer. See Video Abstract at http://links.lww.com/DCR/A469.
Before the 2010 devastating earthquake and cholera outbreak, Haiti's public health laboratory systems were weak and services were limited. There was no national laboratory strategic plan and only minimal coordination across the laboratory network. Laboratory capacity was further weakened by the destruction of over 25 laboratories and testing sites at the departmental and peripheral levels and the loss of life among the laboratory health-care workers. However, since 2010, tremendous progress has been made in building stronger laboratory infrastructure and training a qualified public health laboratory workforce across the country, allowing for decentralization of access to quality-assured services. Major achievements include development and implementation of a national laboratory strategic plan with a formalized and strengthened laboratory network; introduction of automation of testing to ensure better quality of results and diversify the menu of tests to effectively respond to outbreaks; expansion of molecular testing for tuberculosis, human immunodeficiency virus, malaria, diarrheal and respiratory diseases; establishment of laboratory-based surveillance of epidemic-prone diseases; and improvement of the overall quality of testing. Nonetheless, the progress and gains made remain fragile and require the full ownership and continuous investment from the Haitian government to sustain these successes and achievements.
Cardiovascular Diseases (2), Immune System Diseases (1) Cholera (3), Tuberculosis (2), Malaria (2), more mentions
BACKGROUND AND OBJECTIVES: Diarrhea is a common complication of enteral nutrition (EN), which affects recovery and prolongs the length of hospital stay (LOHS). To investigate the effect of fiber and probiotics in reducing diarrhea associated with EN in postoperative patients with gastric cancer (GC), the authors designed this prospective randomized-controlled trial.
METHODS AND STUDY DESIGN: This study included 120 patients with GC, and the patients were classified into 3 groups via random picking of envelopes: fiber-free nutrition formula (FF group, n = 40), fiber-enriched nutrition formula (FE group, n = 40), and fiber- and probiotic-enriched nutrition formula (FEP group, n = 40). All patients were given EN formulas for 7 consecutive days after surgery.
RESULTS: The number of diarrhea cases was higher in the FF group than in the FE group (P = .007). The FEP group had a lower number of diarrhea cases compared with the FE group (P = .003). Patients in the FE group had a significantly shorter first flatus time than the FF group (P = .002). However, no significant difference was observed between the FE group and FEP group (P = .30). Intestinal disorders were similar between the FE group and FF group (P = .38). The FEP group had a lower number of intestinal disorder cases than the FF group (P = .03). LOHS in the FE and FEP groups was shorter than that in the FF group (P = .004; P < .001). However, no significant difference was observed between the FE and FEP groups (P = .28). In addition, no significant difference was observed between the 3 groups in terms of total lymphocyte count, albumin, prealbumin, and transferrin levels on day 7 of enteral feeding.
CONCLUSIONS: The combination of fiber and probiotics was significantly effective in treating diarrhea that is associated with EN in postoperative patients with GC.
BACKGROUND: Clinical guidelines are generated to preserve high-quality evidence-based care. Data on the implementation of guidelines into clinical practice are scarce, despite that guideline adherence prevents over- and undertreatment and correlates with survival. Therefore, we investigated guideline adherence for the systemic treatment in high-risk stage II and stage III colon cancer and metastatic colorectal cancer.
PATIENTS AND METHODS: In all Dutch hospitals (n = 88) 1 medical oncologist involved in colorectal cancer care was approached to participate. An online survey was conducted regarding the local standard of care for adjuvant chemotherapy in high-risk stage II and stage III colon cancer and first-line treatment regimens in metastatic colorectal cancer. Frequency tables were provided for categorical variables and compared for differences in guideline adherence according to hospital type (academic/teaching/regional).
RESULTS: The overall response rate was 70% (62 of 88). Reported guideline adherence was at least 60% of all presented settings. For high-risk stage II and stage III colon cancer, treatment strategies agreed with national guidelines in 66% and 84% of hospitals, and overtreatment patterns were identified in 28% and 13%, respectively. Targeted therapy was not routinely administered as first-line treatment in metastatic colorectal cancer (range from 63% to 71% in different settings). No differences in guideline adherence were observed among different hospital types.
CONCLUSION: Guideline adherence as reported by medical oncologists in The Netherlands is suboptimal. Possible explanations include unawareness or disagreement with the guidelines, or local financial restrictions. Our results recommend additional support of guideline implementation and monitoring in clinical practice, and investigating underlying causes in case of nonadherence.
Oncology (9) Colorectal Neoplasms (7), Colonic Neoplasms (3), more mentions
BACKGROUND: The optimal timing for performing appendectomy in adults remains controversial.
METHOD: A one-year retrospective review of adult patients with acute appendicitis who underwent appendectomy. The cohort was divided by time-to-intervention into two groups: patients who underwent appendectomy within 8 h (group 1), and those who had surgery after 8 h (group 2). Outcome measures including perioperative morbidity and mortality, post-operative length of stay, and the 30-day readmission rate were compared between the two groups.
RESULTS: A total of 116 patients who underwent appendectomy met the inclusion criteria: 75 patients (65%) in group 1, and 41 (35%) in group 2. There were no differences between group 1 & 2 in perioperative complications (6.7% vs. 9.8%, P = 0.483), postoperative length of stay (median [IQR]; 19.5 [11.5-40.5] vs. 20.0 [11.25-58.5] hours, P = 0.632), or 30-day readmission rate (2.7% vs. 4.9%, P = 0.543). There were no deaths in either group.
CONCLUSION: Delayed appendectomy performed more than 8 h was not associated with increased perioperative complications, postoperative length of stay, 30-day readmission rate, or mortality.
SUMMARY: This is a retrospective analysis of patients presenting with acute appendicitis. Outcome measures including mortality and morbidity (complications), 30-day readmission rate, and postoperative length of stay were compared in patients who underwent early appendectomy (within 8 h from time of arrival, to emergency department, to skin incision), and those who underwent delayed appendectomy (after 8 h). No reported mortality. No differences were observed between the two groups regarding complications, 30-day readmission rates, or postoperative length of stay.
INTRODUCTION: Several European studies suggest that some patients with appendicitis can be treated safely with antibiotics. A portion of patients eventually undergo appendectomy within a year, with 10%-15% failing to respond in the initial period and a similar additional proportion with suspected recurrent episodes requiring appendectomy. Nearly all patients with appendicitis in the USA are still treated with surgery. A rigorous comparative effectiveness trial in the USA that is sufficiently large and pragmatic to incorporate usual variations in care and measures the patient experience is needed to determine whether antibiotics are as good as appendectomy.
OBJECTIVES: The Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial for acute appendicitis aims to determine whether the antibiotic treatment strategy is non-inferior to appendectomy.
METHODS/ANALYSIS: CODA is a randomised, pragmatic non-inferiority trial that aims to recruit 1552 English-speaking and Spanish-speaking adults with imaging-confirmed appendicitis. Participants are randomised to appendectomy or 10 days of antibiotics (including an option for complete outpatient therapy). A total of 500 patients who decline randomisation but consent to follow-up will be included in a parallel observational cohort. The primary analytic outcome is quality of life (measured by the EuroQol five dimension index) at 4 weeks. Clinical adverse events, rate of eventual appendectomy, decisional regret, return to work/school, work productivity and healthcare utilisation will be compared. Planned exploratory analyses will identify subpopulations that may have a differential risk of eventual appendectomy in the antibiotic treatment arm.
ETHICS AND DISSEMINATION: This trial was approved by the University of Washington's Human Subjects Division. Results from this trial will be presented in international conferences and published in peer-reviewed journals.
TRIAL REGISTRATION NUMBER: NCT02800785.
BACKGROUND: Postoperative recurrence (POR) of Crohn's disease (CD) is common. Guidelines on POR management have recently been issued, but clinical practice may vary.
AIMS: To examine the current clinical practice of POR management in the USA METHODS: A web-based survey was sent to all members of the American Gastroenterological Association and the American College of Gastroenterology. The survey consisted of multiple-choice questions with clinical scenarios to assess how participants manage POR.
RESULTS: A total of 189 responses were received from practices in 34 states. 44% of participants were from academic settings. The median number of CD patients seen each month was 20-30 patients per participant. The majority of participants considered smoking, prior intestinal surgery, penetrating disease, perianal fistula, early disease onset, and long extent of disease as high-risk factors for POR. To diagnose and grade endoscopic recurrence, 57% of participants used an endoscopic scoring system; 86% defined clinical recurrence using a combination of symptoms and endoscopic findings; and 79% of participants routinely performed colonoscopy after surgery. In high-risk patients, 65% offered medical prophylaxis-most often biologics and/or immunomodulators-immediately after surgery, while 34% offered medical prophylaxis regardless of the patient's risk of POR. 64% of participants never stopped medical prophylaxis once initiated.
CONCLUSIONS: Most gastroenterologists routinely perform colonoscopy to guide POR management. The majority of these providers continue medical prophylaxis indefinitely regardless of subsequent endoscopic findings. Further research is needed to determine the risks and benefits of continuing versus deescalating therapy in patients with potentially surgically induced remission.
Immune System Diseases (2) Inflammatory Bowel Diseases (1), Fistula (1), more mentions
BACKGROUND: Prior studies have shown poor compliance with quality measures for IBD at academic and private practices. We sought to provide focused interventions to improve compliance and documentation with the IBD measures.
METHODS: Two centers, academic practice (AP) and private practice (PP), initially reviewed their compliance with eight established IBD quality measures in consecutive charts. A multi-faceted intervention was developed to improve awareness and documentation of these measures. The initial data and the quality measures were reviewed at a group meeting. Following this, a handout summarizing the measures was placed in each exam room. The AP added a new screen to the EHR that summarized the relevant IBD history, while the PP added a new template that was filled out and imported into the charts. Three months after this intervention, charts were reviewed for compliance with the measures.
RESULTS: The intervention cohort consisted of 768 patients (AP = 569/PP = 199) compared to the initial cohort of 566 patients (AP = 367/PP = 199). Improvement was seen throughout all measures compared to the initial cohort. The AP reported compliance with all relevant measures in 21% and the PP in 60% compared to 7 and 10% in the initial cohort. PP had ≥ 75% compliance with every measure, of which only assessment for bone loss and pneumococcal vaccination was under 80%. In contrast, the AP compliance ranged from 35 to 100% with assessment for bone loss, influenza, and pneumococcal vaccination scoring lowest.
CONCLUSION: Our study demonstrates that focused low-cost interventions can significantly improve compliance with IBD quality measures in different practice settings.
Muscular and Skeletal Diseases (2) Inflammatory Bowel Diseases (2), Ulcerative Colitis (1), Human Influenza (1), more mentions
Intestinal microbiome dysbiosis has been consistently described in patients with IBD. In the last decades, Escherichia coli, and the adherent-invasive E coli (AIEC) pathotype in particular, has been implicated in the pathogenesis of IBD. Since the discovery of AIEC, two decades ago, progress has been made in unravelling these bacteria characteristics and its interaction with the gut immune system. The mechanisms of adhesion of AIEC to intestinal epithelial cells (via FimH and cell adhesion molecule 6) and its ability to escape autophagy when inside macrophages are reviewed here. We also explore the existing data on the prevalence of AIEC in patients with Crohn's disease and UC, and the association between the presence of AIEC and disease location, activity and postoperative recurrence. Finally, we highlight potential therapeutic strategies targeting AIEC colonisation of gut mucosa, including the use of phage therapy, bacteriocins and antiadhesive molecules. These strategies may open new avenues for the prevention and treatment of IBD in the future.
Immune System Diseases (1) Inflammatory Bowel Diseases (2), Ulcerative Colitis (1), more mentions
BACKGROUND & AIMS: Inflammatory bowel disease (IBD) is a chronic disease usually diagnosed after the appearance of gastrointestinal symptoms. Little is known about IBD progression during its early and even preclinical phases. We aimed to determine the number of new incidental diagnoses of IBD in an older population, and evaluate disease progression from its early stages.
METHODS: We performed a retrospective analysis of 31,005 colonoscopies performed during colorectal cancer screening of patients with positive results from fecal immunochemical tests, at 11 centers in the Basque Country (Spain) from 2009 through 2014. We collected clinical and laboratory data from all asymptomatic individuals suspected to have IBD during screening colonoscopies, with histologic confirmation.
RESULTS: Colonoscopy screening led to 79 new diagnoses of ulcerative colitis, 24 of Crohn's disease, and 7 of unclassified colitis (average patient age, 57 years old; interquartile range, 52-62 years; 57% male). Eleven patients had symptoms before colonoscopy and were excluded from the analysis. Among those patients were asymptomatic at diagnosis, 36% developed symptoms after a follow-up period of 25 months (interquartile range, 10.5-42 months), mostly rectal bleeding and diarrhea. Treatment was prescribed for 81 patients (88%) and 2 cases required surgery.
CONCLUSION: We analyzed data from a large cohort of patients with IBD diagnosed at early or even preclinical stages, from an older population. New incidental diagnoses of IBD were made in 0.35% of individuals undergoing a population-based screening colonoscopy-most were classified as ulcerative colitis. Approximately one-third of patients developed symptoms during the follow-up period.
Oncology (1), Immune System Diseases (1) Ulcerative Colitis (3), Inflammatory Bowel Diseases (2), Colorectal Neoplasms (1), more mentions