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White I, Karki C, Geransar P, Leisle L, Junker S, Fleshner P. Impact of Seton Use on Clinical, Patient-Reported, and Healthcare Resource Utilization Outcomes in Complex Crohn's Perianal Fistulas: A Systematic Literature Review. Inflamm Bowel Dis 2024:izae186. [PMID: 39298676 DOI: 10.1093/ibd/izae186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Optimal treatment strategies for seton use in patients with Crohn's perianal fistulas (CPF) remain elusive. This systematic literature review aimed to summarize clinical, patient-reported, and healthcare resource utilization (HCRU) outcomes associated with seton use for symptomatic relief and treatment of complex CPF. METHODS Electronic databases (MEDLINE, Embase, EBM Reviews, EconLit) were searched. Titles, abstracts, and relevant full texts were screened by 2 reviewers for inclusion using prespecified PICOS-T criteria. Articles published in English between January 1, 1980 and September 6, 2021 were included; animal/in vitro studies and case reports with <5 patients were excluded. Outcomes of interest included rates of complete response/remission and fistula recurrence in patients receiving seton with/without infliximab or biologics. Data were summarized using descriptive statistics. RESULTS Overall, 56 studies were included (full texts: n = 43; congress abstracts: n = 13). CPF and clinical outcome definitions were heterogeneous. Rates (range) of complete response/remission varied widely (seton: 13%-75%; seton + infliximab: 23%-100%; seton + biologics: 23%-59%) as did rates for fistula recurrence (seton: 4%-68%; seton + infliximab: 0%-50%; seton + biologics: 0%-17%). Rates of fistula-related reintervention, new fistula or abscess formation, and abscess recurrence were also varied; more consistency was observed regarding the use of patient-reported outcomes. Few studies reported outcomes from pediatric/adolescent patients or HCRU. CONCLUSIONS Optimal use of seton in patients with CPF remains unclear. International standardization of definitions for CPF and related clinical outcomes are required to permit data comparability and identify the most effective treatment strategies involving seton use in CPF.
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Affiliation(s)
- Ian White
- Department of Surgery, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chitra Karki
- Takeda Pharmaceuticals USA, Inc., Cambridge, MA, USA
| | - Parnia Geransar
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - Lilia Leisle
- Ingress-Health HWM GmbH, an affiliate of Cytel, Inc., Real World & Advanced Analytics, Berlin, Germany
| | - Sophia Junker
- Ingress-Health HWM GmbH, an affiliate of Cytel, Inc., Real World & Advanced Analytics, Berlin, Germany
| | - Phillip Fleshner
- Cedars-Sinai Medical Center, Division of Colon and Rectal Surgery, Los Angeles, CA, USA
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Vuyyuru SK, Solitano V, Singh S, Hanzel J, Macdonald JK, Danese S, Peyrin Biroulet L, Ma C, Jairath V. Scoring Indices for Perianal Fistulising Crohn's Disease: A Systematic Review. J Crohns Colitis 2024; 18:836-850. [PMID: 38126903 DOI: 10.1093/ecco-jcc/jjad214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/20/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND AIMS In this systematic review we summarise existing scoring indices for assessing disease activity and quality of life in perianal fistulising Crohn's disease [PFCD], and highlight gaps in the literature. METHODS MEDLINE, EMBASE, and CENTRAL were searched from August 24, 2022, to identify studies evaluating clinical, radiological, or patient-reported outcome measures [PROMS] in PFCD. The primary objective was to identify all available scoring indices and describe the operating properties of these indices. RESULTS A total of 53 studies reported on the use of one clinical index [Perianal Disease Activity Index: PDAI], three PROMs, and 10 radiological indices; 25 studies evaluated the operating properties of these indices. The PDAI demonstrated content validity, construct validity, and responsiveness but criterion validity or reliability were not assessed. The Van Assche Index [VAI], modified VAI, and the Magnetic Resonance Index for Assessing Fistulas in Patients with CD [MAGNIFI-CD] were the most studied radiological indices. These indices demonstrated responsiveness and reliability. The VAI and MAGNIFI-CD demonstrated construct validity; criterion and content validity and feasibility have not been assessed. Among the three PROMs, the Crohn's Anal Fistula Quality of Life index demonstrated content and construct validity, inter-observer reliability, and responsiveness; criterion validity, intra-observer reliability, and feasibility have not been assessed for this index. CONCLUSIONS There are no fully valid, reliable, and responsive clinical disease or radiological indices for PFCD. Although the radiological indices demonstrated responsiveness and reliability, well-defined cut-offs for response and remission are lacking. Future research should focus on establishing standardised definitions and thresholds for outcomes.
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Affiliation(s)
- Sudheer K Vuyyuru
- Department of Medicine, Division of Gastroenterology, Schulich school of Medicine, Western University, London, ON, Canada
- Alimentiv Inc., 100 Dundas street, London, ON, Canada
| | - Virginia Solitano
- Department of Medicine, Division of Gastroenterology, Schulich school of Medicine, Western University, London, ON, Canada
- Alimentiv Inc., 100 Dundas street, London, ON, Canada
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Jurij Hanzel
- Alimentiv Inc., 100 Dundas street, London, ON, Canada
- Faculty of Medicine, University of Ljubljana, Department of Gastroenterology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Laurent Peyrin Biroulet
- Department of Gastroenterology, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- Inserm, NGERE, University of Lorraine, Nancy, France
- INFINY Institute, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- FHU-CURE, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- Groupe Hospitalier Privé Ambroise Paré - Hartmann, Paris IBD Center, Neuilly sur Seine, France
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC, Canada
| | - Christopher Ma
- Alimentiv Inc., 100 Dundas street, London, ON, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, Schulich school of Medicine, Western University, London, ON, Canada
- Alimentiv Inc., 100 Dundas street, London, ON, Canada
- Department of Epidemiology and Biostatistics and Robarts Research Institute, Western University, London, ON, Canada
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Wong C, van Oostrom J, Pittet V, Bossuyt P, Hanzel J, Samaan M, Tripathi M, Czuber-Dochan W, Burisch J, Leone S, Saldaña R, Baert F, Kopylov U, Jaghult S, Adamina M, Gecse K, Arebi N. Baseline Data and Measurement Instruments Reported in Observational Studies in Inflammatory Bowel Disease: Results from a Systematic Review. J Crohns Colitis 2024; 18:875-884. [PMID: 38214470 DOI: 10.1093/ecco-jcc/jjae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/04/2023] [Accepted: 01/11/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Heterogeneity in demographic and outcomes data with corresponding measurement instruments [MIs] creates barriers to data pooling and analysis. Several core outcome sets have been developed in inflammatory bowel disease [IBD] to homogenize outcomes data. A parallel Minimum Data Set [MDS] for baseline characteristics is lacking. We conducted a systematic review to develop the first MDS. METHODS A systematic review was made of observational studies from three databases [2000-2021]. Titles and abstracts were screened, full-text articles were reviewed, and data were extracted by two reviewers. Baseline data were grouped into ten domains: demographics, clinical features, disease behaviour/complications, biomarkers, endoscopy, histology, radiology, healthcare utilization and patient-reported data. Frequency of baseline data and MIs within respective domains are reported. RESULTS From 315 included studies [600 552 subjects], most originated from Europe [196; 62%] and North America [59; 19%], and were published between 2011 and 2021 [251; 80%]. The most frequent domains were demographics [311; 98.7%] and clinical [289; 91.7%]; 224 [71.1%] studies reported on the triad of sex [306; 97.1%], age [289; 91.7%], and disease phenotype [231; 73.3%]. Few included baseline data for radiology [19; 6%], healthcare utilization [19; 6%], and histology [17; 5.4%]. Ethnicity [19; 6%], race [17; 5.4%], and alcohol/drug consumption [6; 1.9%] were the least reported demographics. From 25 MIs for clinical disease activity, the Harvey-Bradshaw Index [n = 53] and Mayo score [n = 37] were most frequently used. CONCLUSIONS Substantial variability exists in baseline population data reporting. These findings will inform a future consensus for MDS in IBD to enhance data harmonization and credibility of real-world evidence.
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Affiliation(s)
- Charlotte Wong
- Department of Inflammatory Bowel Disease, St Mark's National Bowel Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Joep van Oostrom
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Valerie Pittet
- Center for Primary Care and Public Health-University of Lausanne, Department of Epidemiology and Health Systems, Lausanne, Switzerland
| | - Peter Bossuyt
- Department of Gastroenterology, Imelda General Hospital and Imelda Clinical Research Centre, Bonheiden, Belgium
| | - Jurij Hanzel
- Faculty of Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Mark Samaan
- Inflammatory Bowel Diseases Unit, Guy's and St Thomas' Hospital, London, UK
| | - Monika Tripathi
- Department of Histopathology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Wladyslawa Czuber-Dochan
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Johan Burisch
- Department of Gastroenterology, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Salvatore Leone
- European Federation of Crohn's and Colitis Associations [EFCCA], Brussels, Belgium
| | - Roberto Saldaña
- European Federation of Crohn's and Colitis Associations [EFCCA], Brussels, Belgium
- Confederation of Patients with Crohn's Disease and Ulcerative Colitis, Madrid, Spain
| | - Filip Baert
- Department of Gastroenterology, AZ Delta, Roeselare, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel, Israel
| | - Susanna Jaghult
- Department of Clinical Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Krisztina Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Naila Arebi
- Department of Inflammatory Bowel Disease, St Mark's National Bowel Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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Lee MJ, Lee E, Bradburn M, Hind D, Strong EB, Din F, Wysocki AP, Lund J, Moffatt C, Morton J, Senapati A, Jones H, Brown SR. Research and practice priorities in pilonidal sinus disease: a consensus from the PITSTOP study. Colorectal Dis 2024. [PMID: 38671581 DOI: 10.1111/codi.16946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/01/2024] [Indexed: 04/28/2024]
Abstract
AIM Pilonidal sinus disease is a common condition treated by colorectal surgeons. There is a lack of literature in the field to guide optimal management of this condition. As part of the PITSTOP study, we aimed to identify policy and research priorities to provide direction to the field. METHOD Patients and surgeons were invited to participate. A 'So what, now what' exercise was conducted, informed by data from PITSTOP. This generated statements for research and practice priorities. A three-round online Delphi study was conducted, ranking statements based on policy and research separately. Statements were rated 1 (not important) to 9 (important). Statements that were rated 7-9 by more than 70% of participants were entered into the consensus meeting. Personalized voting feedback was shown between rounds. A face-to-face meeting was held to discuss statements, and participants were asked to rank statements using a weighted choice vote. RESULTS Twenty-two people participated in the focus group, generating 14 research and 19 policy statements. Statements were voted on by 56 participants in round 1, 53 in round 2 and 51 in round 3. A total of 15 policy statements and 19 research statements were discussed in the consensus round. Key policy statements addressed treatment strategies and intensity, surgeon training opportunities, need for classification and the impact of treatment on return to work. Research recommendations included design of future trials, methodology considerations and research questions. CONCLUSION This study has identified research and policy priorities in pilonidal sinus disease which are relevant to patients and clinicians. These should inform practice and future research.
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Affiliation(s)
- Matthew J Lee
- Department of Oncology and Metabolism, School of Clinical Medicine, University of Sheffield, Sheffield, UK
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ellen Lee
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emily B Strong
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Farhat Din
- Academic Coloproctology, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | | | - Jon Lund
- Royal Derby Hospital, University Hospitals of Derby and Burton, Derby, UK
| | | | - Jonathan Morton
- Addenbrookes Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Asha Senapati
- St Mark's Hospital, London, UK
- Queen Alexandra Hospital, Portsmouth, UK
| | - Helen Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Steven R Brown
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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5
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Wu T, Yu Y, Huang Q, Chen X, Yang L, Liu S, Guo X. Current status and implementation strategies of patient education in core outcome set development. PATIENT EDUCATION AND COUNSELING 2024; 118:108027. [PMID: 37918218 DOI: 10.1016/j.pec.2023.108027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 10/13/2023] [Accepted: 10/15/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE Patient participation is essential for Core Outcome Set (COS) development studies. Patient education during participation may help patients better express their views in COS studies. This study aimed to investigate the current status of patient participation and the specified educational information in COS studies. METHODS We conducted a systematic review of COS development studies. Information on patient participation in COS research, and especially details of patient education, was analyzed. RESULTS In total, 146 COS development studies were included in this review. Of these, 125 studies (85.6%) mentioned patient participation. Most studies did not provide explicit information on patient participation. Some studies mentioned recruiting patients, but ultimately, none of them responded. Six studies reported conducting patient education through workshops, creating patient forums, or providing videos and slides. However, these studies did not provide details on education. Twenty-three studies used the plain language to explain patient outcomes. CONCLUSION COS developers are increasingly focusing on patient participation. However, only a few COS studies have explicitly reported conducting measures related to patient education. Further patient education is necessary when they participate in the development of a new Core Outcome Set. PRACTICE IMPLICATION This article provides implementation strategies related to patient education for future COS development studies.
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Affiliation(s)
- Tongtong Wu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yan Yu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qian Huang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xueyin Chen
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Lihong Yang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Shaonan Liu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China.
| | - Xinfeng Guo
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China.
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Fierens L, Carney N, Novacek G, van der Woude CJ, Siegmund B, Casellas F, Borruel N, Huberts AS, Sonnenberg E, Gerold N, Primas C, Hedin CRH, Stamm T, Julsgaard M, Fiorino G, Simona R, Zini MLL, Gross E, Sander C, Arijs I, Vakouftsi VR, Koltai T, Charlafti I, Ferrante M. A Core Outcome Set for inflammatory bowel diseases: development and recommendations for implementation in clinical practice through an international multi-stakeholder consensus process. J Crohns Colitis 2023:jjad195. [PMID: 38019894 DOI: 10.1093/ecco-jcc/jjad195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND AND AIMS Standardising health outcome measurements supports delivery of care, enables data-driven learning systems, and secondary data use for research. As part of the Health Outcomes Observatory initiative and building on existing knowledge, a core outcome set (COS) for inflammatory bowel diseases (IBD) was defined through an international modified Delphi method. METHODS Stakeholders rated 90 variables on a 9-point importance scale twice, allowing score modification based on feedback displayed per stakeholder group. Two consecutive consensus meetings were held to discuss results and formulate recommendations for measurement in clinical practice. Variables scoring 7 or higher by ≥80% of the participants, or based on consensus meeting agreement, were included in the final set. RESULTS In total, 136 stakeholders (45 IBD patients (advocates), 74 healthcare professionals/researchers, 13 industry representatives and 4 regulators), from 20 different countries participated. The final set includes 18 case-mix variables, 3 biomarkers (haemoglobin to detect anaemia, C-reactive protein and faecal calprotectin to detect inflammation) for completeness and 28 outcomes (including 16 patient-reported outcomes (PROs) and 1 patient-reported experience). The PRO-2 and IBD-Control questionnaires were recommended to collect disease-specific PROs at every contact with an IBD practitioner, and the Subjective Health Experience model questionnaire, PROMIS Global Health and Self-Efficacy short form to collect generic PROs annually. CONCLUSIONS A COS for IBD, including a recommendation for use in clinical practice, was defined. Implementation of this set will start in Vienna, Berlin, Barcelona, Leuven and Rotterdam, empowering patients to better manage their care. Additional centres will follow worldwide.
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Affiliation(s)
- Liselotte Fierens
- Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Nicholas Carney
- Personalised Healthcare and Patient Access, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Gottfried Novacek
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | | | - Britta Siegmund
- Division of Gastroenterology, Infectiology and Rheumatology, Charité - Universitätsmedizin Berlin CBF, Berlin, Germany
| | - Francesc Casellas
- Crohn-Colitis Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Natalia Borruel
- Crohn-Colitis Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Anouk S Huberts
- Quality and patientcare, Erasmus Medisch Centrum, Rotterdam, The Netherlands
| | - Elena Sonnenberg
- Division of Gastroenterology, Infectiology and Rheumatology, Charité Universitätsmedizin Berlin CBF, Berlin, Germany
| | - Nathalie Gerold
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Christian Primas
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Charlotte R H Hedin
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden and Gastroenterology unit, Department of Gastroenterology, Dermatovenereology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Tanja Stamm
- Institute for Outcomes Research, Center for Medical Data Science, Medical University of Vienna, Vienna, Austria and Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Mette Julsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark and Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease [PREDICT], Aalborg University, Copenhagen, Denmark
| | - Gionata Fiorino
- Department of Gastroenterology and Digestive Endoscopy, San Raffaele Hospital Milan, Milan, Italy and IBD Unit, AO San Camillo-Forlanini, Rome, Italy
| | - Radice Simona
- Department of Gastroenterology and Digestive Endoscopy, San Raffaele Hospital Milan, Milan, Italy
| | | | - Evelyn Gross
- Österreichische Morbus Crohn / Colitis ulcerosa Vereinigung (ÖMCCV), Vienna, Austria
| | - Cornelia Sander
- Referat Wissenschaft, Deutsche Morbus Crohn/Colitis ulcerosa Vereinigung, DCCV e.V., Berlin, Germany
| | - Ingrid Arijs
- Laboratorium voor Translationele Genetica (VIB-KU Leuven), KU Leuven, Leuven, Belgium
| | | | | | - Iliàs Charlafti
- Global Medical Affairs, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Marc Ferrante
- Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium and Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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7
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Karki C, Athavale A, Abilash V, Hantsbarger G, Geransar P, Lee K, Milicevic S, Perovic M, Raven L, Sajak-Szczerba M, Silber A, Yoon A, Tozer P. Multi-national observational study to assess quality of life and treatment preferences in patients with Crohn's perianal fistulas. World J Gastrointest Surg 2023; 15:2537-2552. [PMID: 38111766 PMCID: PMC10725550 DOI: 10.4240/wjgs.v15.i11.2537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/27/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Patients with Crohn's disease (CD) are at risk of developing complications such as perianal fistulas. Patients with Crohn's perianal fistulas (CPF) are affected by fecal incontinence (FI), bleeding, pain, swelling, and purulent perianal discharge, and generally face a higher treatment burden than patients with CD without CPF. AIM To gain insights into the burden of illness/quality of life in patients with CPF and their treatment preferences and satisfaction. METHODS This cross-sectional observational study was conducted in patients with CD aged 21-90 years via a web-enabled questionnaire in seven countries (April-August 2021). Patients were recruited into three cohorts: Cohort 1 included patients without perianal fistulas; cohort 2 included patients with perianal fistulas without fistula-related surgery; and cohort 3 included patients with perianal fistulas and fistula-related surgery. Validated patient-reported outcome measures were used to assess quality of life. Drivers of treatment preferences were measured using a discrete choice experiment (DCE). RESULTS In total, 929 patients were recruited (cohort 1, n = 620; cohort 2, n = 174; cohort 3, n = 135). Short Inflammatory Bowel Disease Questionnaire scores were worse for patients with CPF (cohorts 2 and 3) than for those with CD without CPF (cohort 1): Mean score 3.8 and 3.7 vs 4.1, respectively, (P < 0.001). Similarly, mean Revised FI and FI Quality of Life scores were worse for patients with CPF than for those with CD without CPF. Quality of Life with Anal Fistula scores were similar in patients with CPF with or without CPF-related surgery (cohorts 2 and 3): Mean score 41 and 42, respectively. In the DCE, postoperative discomfort and fistula healing rate were the most important treatment attributes influencing treatment choice: Mean relative importance 35.7 and 24.7, respectively. CONCLUSION The burden of illness in CD is significantly higher for patients with CPF and patients rate lower postoperative discomfort and higher healing rates as the most desirable treatment attributes.
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Affiliation(s)
- Chitra Karki
- Global Evidence and Outcomes-Gastroenterology, Takeda Pharmaceuticals United States, Inc, Cambridge, MA 02139, United States
| | - Amod Athavale
- Trinity Partners, LLC, Waltham, MA 02451-7528, United States
| | - Vijay Abilash
- Trinity Partners, LLC, Waltham, MA 02451-7528, United States
| | - Gary Hantsbarger
- Observational Research, Takeda Pharmaceuticals United States, Inc, Cambridge, MA 02139, United States
| | - Parnia Geransar
- Medical Affairs, Takeda Pharmaceuticals International Co., Opfikon 8152, Zurich, Switzerland
| | - Kate Lee
- Research and Patient Programs, Crohn’s and Colitis Canada, 600-60 St. Clair Avenue East, Toronto M4T 1N5, Ontario, Canada
| | - Slobodan Milicevic
- Medical Affairs, Takeda Pharmaceuticals International Co., Opfikon 8152, Zurich, Switzerland
| | - Marko Perovic
- Treasurer, European Federation of Crohn’s & Ulcerative Colitis Associations, Brussels B 1000, Belgium
| | - Leanne Raven
- Crohn’s and Colitis Australia, Camberwell South, VIC 3124, Australia
| | | | - Abigail Silber
- Trinity Partners, LLC, Waltham, MA 02451-7528, United States
| | - Annabelle Yoon
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo 103-8668, Japan
| | - Phil Tozer
- Department of Colorectal Surgery, St Mark’s Hospital and Academic Institute, London HA1 3UJ, United Kingdom
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8
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Lee MJ. 'Optimum' strategy and outcome in Crohn's anal fistula. Colorectal Dis 2023; 25:495-496. [PMID: 36350257 DOI: 10.1111/codi.16389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 09/26/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Matthew J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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9
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Lamidi S, Coe PO, Bordeianou LG, Hart AL, Hind D, Lindsay JO, Lobo AJ, Myrelid P, Raine T, Sebastian S, Fearnhead NS, Lee MJ, Adams K, Almer S, Ananthakrishnan A, Bethune RM, Block M, Brown SR, Cirocco WC, Cooney R, Davies RJ, Atici SD, Dhar A, Din S, Drobne D, Espin‐Basany E, Evans JP, Fleshner PR, Folkesson J, Fraser A, Graf W, Hahnloser D, Hager J, Hancock L, Hanzel J, Hargest R, Hedin CRH, Hill J, Ihle C, Jongen J, Kader R, Karmiris K, Katsanos KH, Keller DS, Kopylov U, Koutrabakis IE, Lamb CA, Landerholm K, Lee GC, Litta F, Limdi JK, Lopes EW, Madoff RD, Martin ST, Martin‐Perez B, Michalopoulos G, Millan M, Münch A, Nakov R, Noor NM, Oresland T, Paquette IM, Pellino G, Perra T, Porcu A, Roslani AC, Samaan MA, Sebepos‐Rogers GM, Segal JP, de Silva SD, Söderholm AM, Spinelli A, Speight RA, Steinhagen RM, Stenström P, Tsimogiannis KE, Varma MG, Verma AM, Verstockt B, Warden C, Yassin NA, Zawadzki A, Carr P, Devlin B, Avery MSP, Gecse KB, Goren I, Hellström PM, Kotze PG, McWhirter D, Naik AS, Sammour T, Selinger CP, Stein SL, Torres J, Wexner SD, Younge LC. Development of a core descriptor set for Crohn's anal fistula. Colorectal Dis 2022; 25:695-706. [PMID: 36461766 DOI: 10.1111/codi.16440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/21/2022] [Accepted: 11/08/2022] [Indexed: 12/04/2022]
Abstract
AIM Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research. METHOD Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting. RESULTS One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life. CONCLUSION The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.
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Affiliation(s)
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- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
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10
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Wong C, van Oostrom J, Bossuyt P, Pittet V, Hanzel J, Samaan M, Tripathi M, Czuber-Dochan W, Burisch J, Leone S, Saldaña R, Baert F, Kopylov U, Jaghult S, Adamina M, Gecse K, Arebi N. A Narrative Systematic Review and Categorisation of Outcomes in Inflammatory Bowel Disease to Inform a Core Outcome Set for Real-world Evidence. J Crohns Colitis 2022; 16:1511-1522. [PMID: 35512352 DOI: 10.1093/ecco-jcc/jjac057] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/01/2022] [Accepted: 04/08/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Heterogeneity exists in reported outcomes and outcome measurement instruments [OMI] from observational studies. A core outcome set [COS] for observational and real-world evidence [RWE] in inflammatory bowel disease [IBD] will facilitate pooling large datasets. This systematic review describes and classifies clinical and patient-reported outcomes, for COS development. METHODS The systematic review of MEDLINE, EMBASE, and CINAHL databases identified observational studies published between 2000 and 2021 using the population exposure outcome [PEO] framework. Studies meeting eligibility criteria were included. After titles and abstracts screening, full-text articles were extracted by two independent reviewers. Primary and secondary outcomes with corresponding OMI were extracted and categorised in accordance with OMERACT Filter 2.1 framework. The frequency of outcomes and OMIs are described. RESULTS From 5854 studies, 315 were included: 129 [41%] Crohn's disease [CD], 60 [19%] ulcerative colitis [UC], and 126 [40%] inflammatory bowel disease [IBD] studies with 600 552 participants. Totals of 1632 outcomes and 1929 OMI were extracted mainly from medical therapy [181; 72%], surgical [34; 11%], and endoscopic [6; 2%] studies. Clinical and medical therapy-related safety were frequent outcome domains recorded in 194 and 100 studies. Medical therapy-related adverse events [n = 74] and need for surgery [n = 71] were the commonest outcomes. The most frequently reported OMI were patient or event numbers [n = 914], Harvey-Bradshaw Index [n = 45], and Montreal classification [n = 42]. CONCLUSIONS There is substantial variability in outcomes reporting and OMI types. Categorised outcomes and OMI from this review will inform a Delphi consensus on a COS for future RWE in IBD. Data collection standardisation may enhance the quality of RWE applied to decision-making.
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Affiliation(s)
- Charlotte Wong
- Department of Inflammatory Bowel Disease, St Mark's Hospital, London, UK
| | - Joep van Oostrom
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Peter Bossuyt
- Department of Gastroenterology, Imelda General Hospital and Imelda Clinical Research Centre, Bonheiden, Belgium
| | - Valerie Pittet
- Center for Primary Care and Public Health, University of Lausanne, Department of Epidemiology and Health Systems, Lausanne, Switzerland
| | - Jurij Hanzel
- Department of Gastroenterology, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Mark Samaan
- Inflammatory Bowel Diseases Unit, Guy's and St Thomas' Hospital, London, UK
| | - Monika Tripathi
- Department of Histopathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Wladyslawa Czuber-Dochan
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Johan Burisch
- Department of Gastroenterology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Salvatore Leone
- European Federation of Crohn's and Ulcerative Colitis Associations, Brussels, Belgium
| | - Roberto Saldaña
- European Federation of Crohn's and Ulcerative Colitis Associations, Brussels, Belgium.,Confederation of Patients with Crohn's Disease and Ulcerative Colitis, Madrid, Spain
| | - Filip Baert
- Department of Gastroenterology, AZ Delta, Roeselare, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
| | - Susanna Jaghult
- Stockholm Gastro Center, Karolinska Institutet, Stockholm, Sweden
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Krisztina Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Naila Arebi
- Department of Inflammatory Bowel Disease, St Mark's Hospital, London, UK.,Imperial College London, London, UK
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11
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Hanzel J, Bossuyt P, Pittet V, Samaan M, Tripathi M, Czuber-Dochan W, Burisch J, Leone S, Saldaña R, Baert F, Kopylov U, Jäghult S, Adamina M, Arebi N, Gecse K. Development of a Core Outcome Set for Real-World Data in Inflammatory Bowel Disease: A European Crohn's and Colitis Organisation (ECCO) Position Paper. J Crohns Colitis 2022; 17:311-317. [PMID: 36190188 DOI: 10.1093/ecco-jcc/jjac136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The utility of real-world data is dependent on the quality and homogeneity of reporting. We aimed to develop a core outcome set for real-world studies in adult patients with inflammatory bowel disease (IBD). METHODS Candidate outcomes and outcome measures were identified and categorised in a systematic review. An international panel including patients, dietitians, epidemiologists, gastroenterologists, nurses, pathologists, radiologists and surgeons participated in a modified Delphi consensus process. A consensus meeting was held to ratify the final core outcome set. RESULTS A total of 26 panellists from 13 countries participated in the consensus process. A total of 271 items (130 outcomes, 141 outcome measures) in nine study domains were included in the first-round survey. Panellists agreed that real-world studies on disease activity should report clinical, endoscopic and biomarker disease activity. A disease-specific clinical index (Harvey-Bradshaw Index, Partial Mayo Score, Simple Clinical Colitis Activity Index) should be used, rather than physician global assessment. In ulcerative colitis (UC), either the UC Endoscopic Index of Severity or the Mayo Endoscopic Score can be used, but there was no consensus on an endoscopic index for Crohn's disease, nor was there consensus on the use of the presence of ulcers. There was consensus on using faecal calprotectin and C-reactive protein. There was no consensus on the use of histology in real-world studies. CONCLUSIONS A core outcome set for real-world studies in IBD has been developed based on international multidisciplinary consensus. Its adoption will facilitate synthesis in the generation of real-world evidence.
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Affiliation(s)
- Jurij Hanzel
- Department of Gastroenterology, University Medical Center Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Bossuyt
- Department of Gastroenterology, Imelda General Hospital and Imelda Clinical Research Centre, Bonheiden, Belgium
| | - Valerie Pittet
- Center for Primary Care and Public Health, University of Lausanne, Department of Epidemiology and Health Systems, Lausanne, Switzerland
| | - Mark Samaan
- Inflammatory Bowel Diseases Unit, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Monika Tripathi
- Department of Histopathology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Wladyslawa Czuber-Dochan
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Johan Burisch
- Department of Gastroenterology, Medical Division, Hvidovre Hospital, University of Copenhagen, Denmark.,Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Salvatore Leone
- European Federation of Crohn's and Colitis Associations (EFCCA), Milan, Italy
| | - Roberto Saldaña
- Confederation of Patients with Crohn's Disease and Ulcerative Colitis, Madrid, Spain
| | - Filip Baert
- Department of Gastroenterology, AZ Delta, Roeselare, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
| | | | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland.,Department of Biomedical Engineering, Faculty of Medicine, University of Basel, Allschwil, Switzerland
| | - Naila Arebi
- Department of Inflammatory Bowel Disease, St Mark's Hospital, Harrow, London, United Kingdom
| | - Krisztina Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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12
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Bouchard D, Pigot F, de Parades V, Staumont G, Abramowitz L, Siproudhis L, Bouchard D, Pigot F, de Parades V, Staumont G, Abramowitz L, Siproudhis L, Tracanelli L, Fathallah N, Babin-Pigot E, Ferry M, Bouguen G, Laharie D, Cotte E, Panis Y, Peyrin-Biroulet L, Roblin X, Zerbib P. Management of perianal fistulas in Crohn’s disease: a 2021 update of the French National Society of Coloproctology consensus. Tech Coloproctol 2022; 26:805-811. [DOI: 10.1007/s10151-022-02678-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 07/29/2022] [Indexed: 11/28/2022]
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13
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Tozer PJ. Gleaning insight from the PISA trials. Lancet Gastroenterol Hepatol 2022; 7:587-588. [DOI: 10.1016/s2468-1253(22)00162-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022]
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14
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Lamidi S, Williams KM, Hind D, Peckham-Cooper A, Miller AS, Smith AM, Saha A, Macutkiewicz C, Griffiths EA, Catena F, Coccolini F, Toogood G, Tierney GM, Boyd-Carson H, Sartelli M, Blencowe NS, Lockwood S, Coe PO, Lee MJ, Barreto SG, Drake T, Gachabayov M, Hill J, Ioannidis O, Lostoridis E, Mehraj A, Negoi I, Pata F, Steenkamp C, Ahmed S, Alin V, Al-Rashedy M, Atici SD, Bains L, Bandyopadhyay SK, Baraket O, Bates T, Beral D, Brown L, Buonomo L, Burke D, Caravaglios G, Ceresoli M, Chapman SJ, Cillara N, Clarke R, Colak E, Daniels S, Demetrashvili Z, Di Carlo I, Duff S, Dziakova J, Elliott JA, El Zalabany T, Engledow A, Ewnte B, Fraga GP, George R, Giuffrida M, Glasbey J, Isik A, Kechagias A, Kenington C, Kessel B, Khokha V, Kong V, Laloë P, Litvin A, Lostoridis E, Marinis A, Martínez-Pérez A, Menzies D, Mills R, Monzon BI, Morgan R, Neri V, Nita GE, Perra T, Perrone G, Porcu A, Poskus T, Premnath S, Sall I, Sarma DR, Slavchev M, Spence G, Tarasconi A, Tolonen M, Toro A, Venn ML, Vimalachandran D, Wheldon L, Zakaria AD. Defining core patient descriptors for perforated peptic ulcer research: international Delphi. Br J Surg 2022; 109:603-609. [PMID: 35467718 DOI: 10.1093/bjs/znac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/09/2022] [Accepted: 03/08/2022] [Indexed: 10/13/2023]
Abstract
BACKGROUND Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research. METHODS Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings. RESULTS Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history. CONCLUSION This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.
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15
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Geldof J, Iqbal N, LeBlanc JF, Anandabaskaran S, Sawyer R, Buskens C, Bemelman W, Gecse K, Lundby L, Lightner AL, Danese S, Spinelli A, Carvello M, Faiz O, Warusavitarne J, Lung P, De Looze D, D'Hoore A, Vermeire S, Hart A, Tozer P. Classifying perianal fistulising Crohn's disease: an expert consensus to guide decision-making in daily practice and clinical trials. Lancet Gastroenterol Hepatol 2022; 7:576-584. [DOI: 10.1016/s2468-1253(22)00007-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 12/14/2022]
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16
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Schwartz DA, Peyrin-Biroulet L, Lasch K, Adsul S, Danese S. Efficacy and Safety of 2 Vedolizumab Intravenous Regimens for Perianal Fistulizing Crohn's Disease: ENTERPRISE Study. Clin Gastroenterol Hepatol 2022; 20:1059-1067.e9. [PMID: 34597729 DOI: 10.1016/j.cgh.2021.09.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/17/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Fistulizing Crohn's disease (CD) is challenging to treat. We report results from ENTERPRISE, a randomized, double-blind, phase 4 trial evaluating 2 vedolizumab intravenous dosing regimens in patients with fistulizing CD. METHODS Patients with moderately to severely active CD and 1-3 active perianal fistulae (identified on magnetic resonance imaging [MRI]) received vedolizumab 300 mg intravenously at weeks 0, 2, 6, 14, and 22 (VDZ) or the same regimen plus an additional vedolizumab dose at week 10 (VDZ + wk10). Reduction from baseline in draining perianal fistulae and disease activity, MRI assessments, health-related quality of life (HRQoL), and safety were evaluated. Enrollment was stopped prematurely because of recruitment challenges; analyses are descriptive. RESULTS Of 32 patients with ≥1 active fistulae at baseline per MRI and postbaseline fistulae healing assessment, 28 (14 per dosing regimen) had ≥1 draining fistulae at baseline (assessed by gentle finger compression during clinical exam). Rapid and sustained fistula closure was observed; 53.6% (VDZ, 64.3%; VDZ + wk10, 42.9%) and 42.9% (VDZ, 50.0%; VDZ + wk10, 35.7%) of patients achieved ≥50% decrease in draining fistulae and 100% fistulae closure, respectively, at week 30. Mean (standard deviation) CD and Perianal Disease Activity Index scores decreased by 51.1 (78.3) and 4.1 (3.3), respectively, at week 30. HRQoL improved throughout the study. No new safety signals were observed. CONCLUSIONS Sustained improvements in fistulizing CD were seen with both vedolizumab regimens. An additional dose at week 10 does not appear to alter treatment outcomes. Safety profile was consistent with other vedolizumab studies. CLINICALTRIALS gov no: NCT02630966; EudraCT: 2015-000852-12.
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Affiliation(s)
- David A Schwartz
- Inflammatory Bowel Disease Center, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, Nancy, France; Inserm U1256 NGERE, Lorraine University, Nancy, France
| | - Karen Lasch
- Takeda Pharmaceuticals USA Inc, Lexington, Massachusetts
| | - Shashi Adsul
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - Silvio Danese
- IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milano, Italy
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17
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Queiroz NSF, Garcia KS, Miranda EF, Kotze PG. Patient-Reported Outcomes Measures in Perianal Fistulizing Crohn's Disease. Rev Recent Clin Trials 2022; 17:RRCT-EPUB-122860. [PMID: 35469573 DOI: 10.2174/1574887117666220425125424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 06/14/2023]
Abstract
Perianal fistulizing Crohn's disease (PFCD) is a disabling complication of Crohn's disease (CD) that can significantly impact on patients' quality of life (QoL) and often requires multidisciplinary care. Clinical trials assessing the efficacy of medical and surgical interventions for fistulas usually evaluate outcomes such as closure of fistula tracts or radiologic healing. However, these traditional outcome assessments fail in capturing the impact of the disease from patients' perspectives. In this context, regulatory authorities have increasingly encouraged the inclusion of validated patient-reported outcomes (PRO) that assess disease activity and reveal how a patient functions and feels. This recent trend towards patient-centered care aims to ensure that improvements in efficacy outcomes are accompanied by meaningful benefits to patients. The aim of this review is to discuss currently available PRO measures (PROMS) for the assessment of PFCD to provide to physicians appropriate tools aiming to optimize patient care and disseminate the use of these instruments in clinical practice.
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Affiliation(s)
| | - Karoline Soares Garcia
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Eron Fabio Miranda
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
- Health Sciences Postgraduate Program, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
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18
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Aiyegbusi OL, di Ruffano LF, Retzer A, Newsome PN, Buckley CD, Calvert MJ. Outcome selection for tissue-agnostic drug trials for immune-mediated inflammatory diseases: a systematic review of core outcome sets and regulatory guidance. Trials 2022; 23:42. [PMID: 35033186 PMCID: PMC8761289 DOI: 10.1186/s13063-022-06000-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/04/2022] [Indexed: 12/24/2022] Open
Abstract
Background Tissue-agnostic drug development provides a paradigm shift in precision medicine and requires innovative trial designs. However, outcome selection for such trials can prove challenging. The objectives of this review were to:
Identify and map core outcome sets (COS), across 11 immune-mediated inflammatory diseases (IMIDs) in order to facilitate the selection of relevant outcomes across the conditions for innovative trials of tissue-agnostic drug therapies. Compare outcomes or endpoints recommended by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) to identify and highlight similarities and differences.
Methods The Core Outcome Measures in Effectiveness Trials (COMET), International Consortium for Health Outcomes Measurement (ICHOM), FDA and EMA databases were searched from inception to 28th December 2019. Two reviewers independently screened titles and abstracts of retrieved entries and conducted the subsequent full text screening. Hand searching of the reference lists and citation searching of the selected publications was conducted. The methodological quality of the included peer-reviewed articles was independently assessed by the reviewers based on the items of the COS–Standards for Development recommendations (COS–STAD) checklist. Core outcomes from the included publications were extracted and mapped across studies and conditions. Regulatory guidance from FDA and EMA, where available for clinical trials for the IMIDs, were obtained from their databases and recommendations on outcomes to measure directly compared. Results Forty-four COS publications were included in the final analysis. Outcomes such as disease activity, pain, fatigue, quality of life, physical function, work limitation/productivity, steroid use and biomarkers were recommended across majority of the conditions. There were significant similarities and differences in FDA and EMA recommendations. The only instance where either regulatory body directly referenced a COS was for jSLE—both referenced the Paediatric Rheumatology International Trials Organization (PRINTO) COS. Conclusions The findings from this systematic review provide valuable information to inform outcome selection in tissue-agnostic trials for IMIDs. There is a need for increased collaboration between regulators and COS developers and inclusion of regulators as key stakeholders in COS development to enhance the quality of COS. Trial registration Not registered. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06000-w.
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Affiliation(s)
- Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, B15 2TT, Birmingham, UK. .,National Institute for Health Research (NIHR) Applied Research Centre West Midlands, and National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK. .,National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK. .,Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK.
| | - Lavinia Ferrante di Ruffano
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, B15 2TT, Birmingham, UK
| | - Ameeta Retzer
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, B15 2TT, Birmingham, UK
| | - Philip N Newsome
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, B15 2TT, Birmingham, UK.,National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK.,Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Christopher D Buckley
- National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK.,The Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK.,Rheumatology Research Group, Institute for Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Melanie J Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, B15 2TT, Birmingham, UK.,National Institute for Health Research (NIHR) Applied Research Centre West Midlands, and National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK.,Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
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19
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Zhu P, Sun JF, Gu YF, Chen HJ, Xu MM, Li YR, Yang BL. Combined therapy with early initiation of infliximab following drainage of perianal fistulising Crohn's disease: a retrospective cohort study. BMC Gastroenterol 2022; 22:15. [PMID: 35012467 PMCID: PMC8751033 DOI: 10.1186/s12876-021-02078-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/21/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Recent studies have confirmed that combined surgery and anti-TNF therapy could improve outcomes in patients with perianal fistulising Crohn's disease (PFCD). However, the optimal timing for infliximab infusion after surgical intervention is uncertain. We aimed to determine the long-term efficacy of early initiation of infliximab following surgery among PFCD patients. METHODS We performed a retrospective cohort study of PFCD patients who received combined infliximab and surgical treatment between 2010 and 2018 at a tertiary referral hospital. Patients were grouped according to the time interval between surgery and infliximab infusion, with < 6 weeks into early infliximab induction group and > 6 weeks into delayed infliximab induction group. The primary outcome was to compare surgical re-intervention between early and delayed infliximab induction groups. The secondary outcomes were fistula healing and predictors associated with these outcomes of early infliximab induction approach. RESULTS One hundred and seventeen patients were included (73 in early infliximab induction, 44 in delayed infliximab induction). The median interval between surgery and infliximab initiation was 9.0 (IQR 5.5-17.0) days in early infliximab induction group and 188.0 (IQR 102.25-455.75) days in delayed infliximab induction group. After followed-up for a median of 36 months, 61.6% of patients in early infliximab induction group and 65.9% in delayed infliximab induction group attained fistula healing (p = 0.643). The cumulative re-intervention rate was 23%, 32%, 34% in early infliximab induction group and 16%, 25%, 25% in delayed infliximab induction group, at 1, 2, and 3 years respectively (p = 0.235). Presence of abscess at baseline (HR = 5.283; 95% CI, 1.61-17.335; p = 0.006) and infliximab maintenance therapy > 3 infusions (HR = 3.691; 95% CI, 1.233-11.051; p = 0.02) were associated with re-intervention in early infliximab induction group. Presence of abscess at baseline also negatively influenced fistula healing (HR = 3.429, 95% CI, 1.216-9.668; p = 0.02). CONCLUSION Although no clear benefit was shown compared with delayed infliximab induction group, early initiation of infliximab after surgery could achieve promising results for PFCD patients. Before infliximab infusion, durable drainage is required for patients with concomitant abscess or prolonged infliximab maintenance therapy.
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Affiliation(s)
- Ping Zhu
- Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - Jin-Fang Sun
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education, School of Public Health, Southeast University, Nanjing, Jiangsu, China
| | - Yun-Fei Gu
- Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - Hong-Jin Chen
- Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - Min-Min Xu
- Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - You-Ran Li
- Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - Bo-Lin Yang
- Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, Jiangsu, China.
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20
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Adegbola SO, Sarafian M, Sahnan K, Pechlivanis A, Phillips RKS, Warusavitarne J, Faiz O, Haddow J, Knowles C, Tozer P, Holmes E, Hart A. Lack of anti-TNF drugs levels in fistula tissue - a reason for nonresponse in Crohn's perianal fistulating disease? Eur J Gastroenterol Hepatol 2022; 34:18-26. [PMID: 33522723 DOI: 10.1097/meg.0000000000002032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Anti-TNF therapy is recommended as treatment for patients with Crohn´s perianal fistulas. However, a significant proportion of patients have a sub-optimal response to anti-TNF therapy. Higher serum levels of anti-TNF agents have been associated with improved outcomes in perianal Crohn's disease. Currently, it is unknown whether anti-TNF agent levels can be detected in tissue from fistula tracts themselves and whether this is associated with response. AIMS AND METHODS We undertook a pilot study to measure fistula tissue levels of anti-TNF medication (infliximab and adalimumab). We used a previously validated targeted proteomic technique, employing ultraperformance liquid chromatography-mass spectrometry, to detect/quantify anti-TNF drugs. Biopsies were obtained from fistula tracts of patients with Crohn's disease on maintenance treatment; with idiopathic (cryptoglandular) fistula tissues used as negative controls as well as positive controls (by spiking the latter tissues with anti-TNF drugs). RESULTS Tissue was sampled from the fistula tracts of seven patients with Crohn's perianal disease (five patients were on adalimumab and two patients were on infliximab). The anti-TNF drugs, infliximab and adalimumab, were not detected in fistula samples from any of the Crohn's patients despite detection in 'spiked' positive control samples. CONCLUSION Absence of detection of the anti-TNF drugs in fistula tissue raises the question on the role of tissue penetrance of anti-TNF drugs in response to therapy. Further work is required in a larger number of patients to validate the findings observed and investigate if any correlation exists between tissue and serum levels of anti-TNF and clinical outcome. SUMMARY Predicting response in Crohn's fistula patients on biologic therapy is difficult with no reliable biomarkers. This pilot study uses targeted proteomics to investigate the potential role of tissue drug levels in acting as a biomarker of treatment response.
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Affiliation(s)
- Samuel O Adegbola
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | - Magali Sarafian
- Computational Systems Division, Imperial College London, South Kensington Campus
| | - Kapil Sahnan
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | | | - Robin K S Phillips
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | - Janindra Warusavitarne
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | - Omar Faiz
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | - James Haddow
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Charles Knowles
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Phil Tozer
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | - Elaine Holmes
- Computational Systems Division, Imperial College London, South Kensington Campus
| | - Ailsa Hart
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
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21
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Tabari A, Kaplan JL, Huh SY, Moran CJ, Gee MS. Clinical characteristics and MRI-based phenotypes of perianal abscess formation in children with fistulizing Crohn's Disease. Front Pediatr 2022; 10:1045583. [PMID: 36507146 PMCID: PMC9731150 DOI: 10.3389/fped.2022.1045583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/18/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The aim of this study was to explore potential correlation of the MR imaging features and clinical characteristics with formation of perianal abscess in children with Crohn's perianal fistulas (CPF). METHODS From 2010 to 2020, pediatric patients with CPF diagnosis on their first pelvic MRI were identified retrospectively. All patients were divided into two groups based on the presence or absence of perianal abscess. Baseline clinical and MRI characteristics were recorded for each patient. All the statistical calculations were performed using R (version 3.6.3). RESULTS A total of 60 patients [F:M 17:43, median age 14 years (IQR 10-15), ranging 3-18 years] were included in this study. Forty-four abscesses were identified in 36/60 children (mean volume 3 ± 8.6 ml, median 0.3 ml). In 24/60 patients with perianal disease, no abscess was detected on the MRI. Ten patients (28%) showed perianal abscess on pelvic MRI at the initial diagnosis. The rate of active disease on colonoscopy (visible ulcerations/aphthous ulcers) was similar in both groups (95% vs. 94%). With regards to disease location, the majority of patients (40/60, 66.6%) in both groups had ileocolonic CD. All patients without abscess had a single perianal fistula (n = 24; 3 simple and 21 complex fistulae), however, patients with perianal abscess tended to have >1 fistulous tracts (n = 50 fistulas; all complex, 27 single, 10 double and 1 triple). Intersphincteric fistula was the most common fistula type in both groups (79% and 66%, p = 0.1). The total length of fistula (3.8 ± 1.7 vs. 2.8 ± 0.8 cm, p = 0.006) and presence of multiple external openings (n = 25 vs. 7, p = 0.019) were significantly higher in patients with abscesses, and fistula length >3.3 cm showed 80% specificity and 83% PPV for the presence of perianal abscess. Fistulas were symptomatic (pain, bleeding or drainage) at similar rates in both groups (68% and 70%, p = 0.1). CONCLUSION Pediatric patients with CPF who develop perianal abscess have a distinct imaging phenotype defined by longer fistula length (>3.3 cm), multiple skin openings and multiple fistulous tracts (≥2) on MRI. Patients who have these features but does not have an abscess on imaging may merit more aggressive treatment (and close monitoring) to prevent the development of an abscess.
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Affiliation(s)
- Azadeh Tabari
- Division of Pediatric Imaging, Department of Radiology, MassGeneral Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jess L Kaplan
- Harvard Medical School, Boston, MA, USA.,Division of Pediatric Gastroenterology, MassGeneral Hospital for Children, Boston, MA, USA
| | - Susanna Y Huh
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA.,Takeda Pharmaceuticals International Co, Cambridge, MA, USA
| | - Christopher J Moran
- Harvard Medical School, Boston, MA, USA.,Division of Pediatric Gastroenterology, MassGeneral Hospital for Children, Boston, MA, USA
| | - Michael S Gee
- Division of Pediatric Imaging, Department of Radiology, MassGeneral Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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22
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Razanskaite V, Kallis C, Young B, Williamson PR, Bodger K. Heterogeneity in outcome assessment for inflammatory bowel disease in routine clinical practice: a mixed-methods study in a sample of English hospitals. BMJ Open 2021; 11:e056413. [PMID: 35679143 PMCID: PMC8719195 DOI: 10.1136/bmjopen-2021-056413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Knowledge of the extent of variation in outcome assessment for inflammatory bowel disease (IBD) in routine practice is limited. We aimed to describe and quantify variation in outcome coverage and to explore patient, clinician and practitioner factors associated with it. DESIGN Prospective exploratory mixed-methods study. SETTING IBD clinics at six hospitals in North West England with differing electronic health record (EHR) systems. METHODS Mixed-methods study comprising: (a) structured observations of outcomes elicited during consultations (102 patients consulting 24 clinicians); (b) retrospective analysis of outcomes recorded in the EHR (909 consultations; 127 clinicians) and (c) semistructured interviews with the 24 observed clinicians. We determined whether specific outcome 'sets' were elicited or recorded, including: (1) a minimum set of symptom pairs ('PRO-2'); (2) symptom sets from disease activity indices and (3) a reference list of 37 symptoms, signs and impacts. Factors associated with variation were explored in univariate and multivariate binary logistic regression analyses and from clinician interviews. RESULTS PRO-2 coverage was not invariable (elicited during 81% of observed consultations; recorded in 56% of EHR) and infrequent for complete activity indices (all domains from Harvey-Bradshaw Index: elicited, 18%; recorded, 5%). The median number of outcomes from the reference list elicited per consultation was 12 (13-fold variation) and recorded in EHR was 7 (>20-fold variation). Symptom quantification (PRO-2) seldom adhered closely to standardised descriptors and an explicit timeframe was defined rarely. PRO-2 recording in EHR was associated with a diagnosis of ulcerative colitis (OR: 2.09 (95% CI 1.15 to 3.80)) and nurse-led consultations (OR: 6.98 (95% CI 3.28 to 14.83)) and a three-way model suggested 26% of total variability lay between clinicians, 17% between patients but the remainder was unexplained. Most clinicians expressed preference for individualised health status evaluations versus standardised outcome assessments. CONCLUSIONS There was little evidence for standardised assessment and recording of IBD outcomes and substantial intra-clinician and inter-clinician variation from one consultation to another. Nurses demonstrated a greater tendency to standardised practice.
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Affiliation(s)
- Violeta Razanskaite
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Constantinos Kallis
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Bridget Young
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Paula R Williamson
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Keith Bodger
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
- Digestive Diseases Unit, Aintree University Hospital, Liverpool, UK
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23
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Adegbola SO, Dibley L, Sahnan K, Wade T, Verjee A, Sawyer R, Mannick S, McCluskey D, Bassett P, Yassin N, Warusavitarne J, Faiz O, Phillips R, Tozer PJ, Norton C, Hart AL. Development and initial psychometric validation of a patient-reported outcome measure for Crohn's perianal fistula: the Crohn's Anal Fistula Quality of Life (CAF-QoL) scale. Gut 2021; 70:1649-1656. [PMID: 33272978 PMCID: PMC8355881 DOI: 10.1136/gutjnl-2019-320553] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 08/22/2020] [Accepted: 10/29/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Crohn's perianal fistulas are challenging for patients and clinicians. Many do not respond to available treatments and despite recommendations by a global consensus, there are currently no specific patient-derived quality of life tools to measure response to treatment. We present a new validated patient-reported outcome measure (PROM) for this complicated disease phenotype. METHODS A draft questionnaire was generated using unstructured qualitative patient interviews on the experience of living with Crohn's perianal fistula, a nationwide multidisciplinary consensus exercise, a systematic review of outcomes assessing medical/surgical/combined treatment and a patient and public involvement day. Psychometric properties were assessed including construct validity (by comparison with the Hospital Anxiety and Depression Scale (HADS) and the UK Inflammatory Bowel Disease Questionnaire (UK-IBDQ)), and reliability and responsiveness was assessed by test-retest analysis. RESULTS Data from 211 patients contributed to development of a final 28-item questionnaire. The Crohn's Anal Fistula Quality of Life (CAF-QoL) demonstrated good internal consistency (Cronbach's alpha 0.88), excellent stability (intraclass correlation 0.98) and good responsiveness and construct validity, with positive correlation with the UK-IBDQ and HADS. CONCLUSION The CAF-QoL scale is ready for use as a PROM in research and clinical practice. It complements objective clinical evaluation of fistula by capturing impact on the patient.
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Affiliation(s)
- Samuel O Adegbola
- Surgery and Cancer, Imperial College London, London, UK .,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Lesley Dibley
- Faculty of Education, Health and Human Sciences, University of Greenwich, London, UK
| | - Kapil Sahnan
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Tiffany Wade
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Azmina Verjee
- CAF-QoL Patient and Public Involvement Team, London, UK
| | - Rachel Sawyer
- CAF-QoL Patient and Public Involvement Team, London, UK
| | | | | | - Paul Bassett
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Nuha Yassin
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Janindra Warusavitarne
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Omar Faiz
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Robin Phillips
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Phil J Tozer
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Ailsa L Hart
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
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24
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Rectovaginal fistula in Crohn's disease treatment: a low long-term success rate and a high definitive stoma risk after a conservative surgical approach. Tech Coloproctol 2021; 25:1143-1149. [PMID: 34436729 DOI: 10.1007/s10151-021-02506-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 08/11/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Management of rectovaginal fistula (RVF) in Crohn's disease (CD) is challenging. Available studies are heterogeneous and retrospective, with short-term follow-up. The aim of this study was to assess the overall long-term medico-surgical treatment results in women with RVF due to CD. METHODS A retrospective study was conducted on consecutive patients operated on for RVF in CD from September 1996 to November 2019 at a tertiary teaching hospital. All surgeries were classified as preliminary, closure, or salvage procedures. Primary outcome was fistula remission defined as the combination of fistula closure and no stoma, at least 6 months since last procedure. RESULTS Thirty-two patients (median age 34 [range 21-55] years), with a median follow-up of 11.3 years (0-23.7) after first surgery, were included. Altogether, 138 procedures were performed; 36 (26%) preliminary, 80 (58%) closure, and 13 (9%) salvage procedures. RVF remission was obtained in 7/32 patients (22%). At the end of follow-up, a stoma was present in 13/32 patients (41%). The percentage of time on biologics was 86% for patients in remission, versus 36% for the others (p = 0.0057). After univariate analysis, only anti-TNF-α was significantly related to successful closure techniques (p = 0.007). CONCLUSIONS The RVF remission rate in CD was low in the long term. However, patients underwent a succession of interventions, and the stoma rate was high. Combination of biologics with surgical management was crucial.
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25
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Vollebregt PF, Vander Mijnsbrugge GJ, Molenaar CBH, Felt‐Bersma RJF. Efficacy of Permacol injection for perianal fistulas in a tertiary referral population: poor outcome in patients with complex fistulas. Colorectal Dis 2021; 23:2119-2126. [PMID: 33955138 PMCID: PMC8453864 DOI: 10.1111/codi.15696] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/13/2021] [Accepted: 04/10/2021] [Indexed: 12/17/2022]
Abstract
AIM Injection of Permacol collagen paste can be used as a sphincter-sparing treatment for perianal fistulas. In a tertiary referral population we aimed to evaluate the efficacy of Permacol injection and the clinical and fistula-related factors associated with recurrence. METHOD This was a retrospective analysis of consecutive patients with perianal fistulas treated with Permacol injection at a specialist centre between June 2015 and April 2019. Endoanal ultrasonography was systematically reanalysed, blinded to treatment outcome. Rectovaginal, anovaginal and Crohn's disease fistulas were excluded. Healed fistulas were defined as absent anal symptoms and a closed external opening on physical examination at a minimum follow-up of 6 months. Regression analyses were performed to identify factors associated with unhealed fistulas. RESULTS A total of 90 patients (51 men; median age 45 years) were analysed. Seventy-two (80.0%) patients had complex perianal fistulas (greater than one-third sphincter involvement or multiple tracts). After a single Permacol injection, fistulas were healed in 20 (22.2%) patients at 3 months follow-up and in 18 (20.0%) patients at a median follow-up of 30 months (interquartile range 17-37). Eight (11.1%) patients with unhealed fistulas had significant improvement in their symptoms. Complex fistulas were significantly associated with unhealed status [OR 3.53 (95% CI 1.12-11.09); p = 0.031]. Twenty patients underwent subsequent Permacol injections, which were successful in six (30.0%) patients after one (n = 3) or two (n = 3) additional injections. CONCLUSION This largest study to date in patients with mainly complex perianal fistulas, demonstrated that the efficacy of a single Permacol injection was only 20%. Complex fistulas were associated with a poor outcome.
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Affiliation(s)
- Paul F. Vollebregt
- Department of Gastroenterology and HepatologyAmsterdam UMCAmsterdam Gastroenterology Endocrinology MetabolismVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | | | | | - Richelle J. F. Felt‐Bersma
- Department of Gastroenterology and HepatologyAmsterdam UMCAmsterdam Gastroenterology Endocrinology MetabolismVrije Universiteit AmsterdamAmsterdamThe Netherlands,Proctos KliniekBilthovenThe Netherlands
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26
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Vasudevan A, Bruining DH, Loftus EV, Faubion W, Ehman EC, Raffals L. Approach to medical therapy in perianal Crohn's disease. World J Gastroenterol 2021; 27:3693-3704. [PMID: 34321838 PMCID: PMC8291021 DOI: 10.3748/wjg.v27.i25.3693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/13/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
Perianal Crohn's disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and medical interventions. Anti-tumor necrosis factor (anti-TNF) therapy, including infliximab and adalimumab, remain preferred medical therapies for perianal Crohn's disease. Infliximab has been shown to be efficacious in improving fistula closure rates in randomized controlled trials. Clinicians can be faced with a number of questions relating to the optimal use of anti-TNF therapy in perianal Crohn's disease. Specific issues include evaluation for the presence of perianal sepsis, the treatment target of therapy, the ideal time to commence treatment, whether additional medical therapy should be used in conjunction with anti-TNF therapy, and the duration of treatment. This article will discuss key studies which can assist clinicians in addressing these matters when they are considering or have already commenced anti-TNF therapy for the treatment of perianal Crohn's disease. It will also discuss current evidence regarding the use of vedolizumab and ustekinumab in patients who are failing to achieve a response to anti-TNF therapy for perianal Crohn's disease. Lastly, new therapies such as local injection of mesenchymal stem cell therapy will be discussed.
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Affiliation(s)
- Abhinav Vasudevan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - Edward V Loftus Jr
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - William Faubion
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - Eric C Ehman
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
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27
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Abstract
PURPOSE OF REVIEW Multiple new medications with novel mechanisms of action are now available to treat Crohn's disease (CD). However, they have varying effectiveness in the management of perianal CD. Identifying the most appropriate therapy and optimizing it is essential to maximize effectiveness of therapy. Additionally, the management of perianal CD requires imaging of the perianal area to identify the fistula anatomy and local complications such as abscesses that require surgical drainage. Initial surgical assessment is key to drain abscesses and allow fistula healing with medical therapy. RECENT FINDINGS Although anti-tumor necrosis factor (TNFs) remain the most effective medications to treat perianal CD, real-world data suggests that ustekinumab may be a 2nd-line option in patients nonresponsive to an anti-TNF or having contraindications. Mesenchymal stem cells are an emerging therapeutic approach that is currently in Phase 3 trials in the United States and poised to play a major role in the treatment algorithm. SUMMARY The management of perianal CD requires a multidisciplinary approach with a combination of initial imaging and surgical assessment to adequately control local sepsis, optimization of biological therapy with adjunct antibiotics or immunomodulators, and close clinical follow-up with imaging to evaluate response to therapy and guide further surgical management options.
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28
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Patients Undergoing Ileoanal Pouch Surgery Experience a Constellation of Symptoms and Consequences Representing a Unique Syndrome: A Report from the Patient-Reported Outcomes After Pouch Surgery (PROPS) Delphi Consensus Study. Dis Colon Rectum 2021; 64:861-870. [PMID: 33938531 DOI: 10.1097/dcr.0000000000002099] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Functional outcomes after ileoanal pouch creation have been studied; however, there is great variability in how relevant outcomes are defined and reported. More importantly, the perspective of patients has not been represented in deciding which outcomes should be the focus of research. OBJECTIVE The primary aim was to create a patient-centered definition of core symptoms that should be included in future studies of pouch function. DESIGN This was a Delphi consensus study. SETTING Three rounds of surveys were used to select high-priority items. Survey voting was followed by a series of online patient consultation meetings used to clarify voting trends. A final online consensus meeting with representation from all 3 expert panels was held to finalize a consensus statement. PATIENTS Expert stakeholders were chosen to correlate with the clinical scenario of the multidisciplinary team that cares for pouch patients, including patients, colorectal surgeons, and gastroenterologists or other clinicians. MAIN OUTCOME MEASURES A consensus statement was the main outcome. RESULTS patients, 62 colorectal surgeons, and 48 gastroenterologists or nurse specialists completed all 3 Delphi rounds. Fifty-three patients participated in online focus groups. One hundred sixty-one stakeholders participated in the final consensus meeting. On conclusion of the consensus meeting, 7 bowel symptoms and 7 consequences of undergoing ileoanal pouch surgery were included in the final consensus statement. LIMITATIONS The study was limited by online recruitment bias. CONCLUSIONS This study is the first to identify key functional outcomes after pouch surgery with direct input from a large panel of ileoanal pouch patients. The inclusion of patients in all stages of the consensus process allowed for a true patient-centered approach in defining the core domains that should be focused on in future studies of pouch function. See Video Abstract at http://links.lww.com/DCR/B571. LOS PACIENTES SOMETIDOS A CIRUGA DE RESERVORIO ILEOANAL EXPERIMENTAN UNA CONSTELACIN DE SNTOMAS Y CONSECUENCIAS QUE REPRESENTAN UN SNDROME UNICO Un Informe de los Resultados Reportados por los Pacientes Posterior a la Cirugía de Reservorio (PROPS) Estudio de Consenso DelphiANTECEDENTES:Los resultados funcionales después de la creación del reservorio ileoanal han sido estudiados; sin embargo, existe una gran variabilidad en la forma en que se definen y reportan los resultados relevantes. Más importante aún, la perspectiva de los pacientes no se ha representado a la hora de decidir qué resultados deberían ser el foco de investigación.OBJETIVO:El objetivo principal era crear en el paciente una definición centrada de los síntomas principales que debería incluirse en los estudios futuros de la función del reservorio.DISEÑO:Estudio de consenso Delphi.ENTORNO CLINICO:Se emplearon tres rondas de encuestas para seleccionar elementos de alta prioridad. La votación de la encuesta fue seguida por una serie de reuniones de consulta de pacientes en línea que se utilizan para aclarar las tendencias de votación. Se realizo una reunión de consenso final en línea con representación de los tres paneles de expertos para finalizar una declaración de consenso.PACIENTES:Se eligieron partes interesadas expertas para correlacionar con el escenario clínico del equipo multidisciplinario que atiende a los pacientes con reservorio: pacientes, cirujanos colorrectales, gastroenterólogos / otros médicos.PRINCIPALES MEDIDAS DE VALORACION:Declaración de consenso.RESULTADOS:Ciento noventa y cinco pacientes, 62 cirujanos colorrectales y 48 gastroenterólogos / enfermeras especialistas completaron las tres rondas Delphi. 53 pacientes participaron en grupos focales en línea. 161 interesados participaron en la reunión de consenso final. Al concluir la reunión de consenso, siete síntomas intestinales y siete consecuencias de someterse a una cirugía de reservorio ileoanal se incluyeron en la declaración de consenso final.LIMITACIONES:Sesgo de reclutamiento en línea.CONCLUSIONES:Este estudio es el primero en identificar resultados funcionales claves después de la cirugía de reservorio con información directa de un gran panel de pacientes con reservorio ileoanal. La inclusión de pacientes en todas las etapas del proceso de consenso permitió un verdadero enfoque centrado en el paciente para definir los dominios principales en los que debería centrarse los estudios futuros de la función del reservorio. Consulte Video Resumen en http://links.lww.com/DCR/B571.
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Cavallaro PM, Fearnhead NS, Bissett IP, Brar MS, Cataldo TE, Clarke R, Denoya P, Elder AL, Gecse KB, Hendren S, Holubar S, Jeganathan N, Myrelid P, Norton BA, Wexner SD, Wilson L, Zaghiyan K, Bordeianou L. Patients Undergoing Ileoanal Pouch Surgery Experience a Constellation of Symptoms and Consequences Representing a Unique Syndrome: A Report From the Patient-Reported Outcomes After Pouch Surgery (PROPS) Delphi Consensus Study. Ann Surg 2021; 274:138-145. [PMID: 33914449 PMCID: PMC8968673 DOI: 10.1097/sla.0000000000004829] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The primary aim was to create a patient-centered definition of core symptoms that should be included in future studies of pouch function. BACKGROUND Functional outcomes after ileoanal pouch creation have been studied; however, there is great variability in how relevant outcomes are defined and reported. More importantly, the perspective of patients has not been represented in deciding which outcomes should be the focus of research. METHODS Expert stakeholders were chosen to correlate with the clinical scenario of the multidisciplinary team that cares for pouch patients: patients, colorectal surgeons, gastroenterologists/other clinicians. Three rounds of surveys were employed to select high-priority items. Survey voting was followed by a series of online patient consultation meetings used to clarify voting trends. A final online consensus meeting with representation from all 3 expert panels was held to finalize a consensus statement. RESULTS One hundred ninety-five patients, 62 colorectal surgeons, and 48 gastroenterologists/nurse specialists completed all 3 Delphi rounds. Fifty-three patients participated in online focus groups. One hundred sixty-one stakeholders participated in the final consensus meeting. On conclusion of the consensus meeting, 7 bowel symptoms and 7 consequences of undergoing ileoanal pouch surgery were included in the final consensus statement. CONCLUSIONS This study is the first to identify key functional outcomes after pouch surgery with direct input from a large panel of ileoanal pouch patients. The inclusion of patients in all stages of the consensus process allowed for a true patient-centered approach in defining the core domains that should be focused on in future studies of pouch function.
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Affiliation(s)
- Paul M. Cavallaro
- Department of General Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicola S. Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Ian P. Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mantaj S. Brar
- Division of General Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas E. Cataldo
- Division of Colon and Rectum Surgery, Beth Israel-Deaconess Health Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Paula Denoya
- Division of Colon and Rectal Surgery, Department of Surgery, Stony Brook University Hospital. Stony Brook, New York
| | | | - Krisztina B. Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Samantha Hendren
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nimalan Jeganathan
- Department of Surgery, Division of Colon and Rectal Surgery, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Pär Myrelid
- Department of Surgery, County Council of Östergötland, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Beth-Anne Norton
- Crohn’s and Colitis Center, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Steven D. Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Lauren Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Liliana Bordeianou
- Massachusetts General Hospital Colorectal Surgery and Crohn’s Colitis Centers, Department of Gastrointestinal Surgery and Surgical Oncology, Boston, Massachusetts
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Gu B, De Gregorio M, Pipicella JL, Vande Casteele N, Andrews JM, Begun J, Connell W, D'Souza B, Gholamrezaei A, Hart A, Liew D, Radford-Smith G, Rimola J, Sutherland T, Toong C, Woods R, Wu Y, Xuan W, Williams AJ, Ng W, Ding NS, Connor S. Prospective randomised controlled trial of adults with perianal fistulising Crohn's disease and optimised therapeutic infliximab levels: PROACTIVE trial study protocol. BMJ Open 2021; 11:e043921. [PMID: 34210720 PMCID: PMC8252869 DOI: 10.1136/bmjopen-2020-043921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Perianal fistulising Crohn's disease (pfCD) can be somewhat treatment refractory. Higher infliximab trough levels (TLIs) may improve fistula healing rates; however, it remains unclear whether escalating infliximab therapy to meet higher TLI targets using proactive, or routine, therapeutic drug monitoring (TDM) improves outcomes. This randomised controlled trial aimed to assess whether infliximab therapy targeting higher TLIs guided by proactive TDM improves outcomes compared with standard therapy. METHODS AND ANALYSIS Patients with active pfCD will be randomised 1:1 to either the proactive TDM arm or standard dosing arm and followed up for 54 weeks. Patients in the proactive TDM arm will have infliximab dosing optimised to target higher TLIs. The targets will be TLI ≥ 25 µg/mL at week 2, ≥ 20 µg/mL at week 6 and ≥ 10 µg/mL during maintenance therapy. The primary objective will be fistula healing at week 32. Secondary objectives will include fistula healing, fistula closure, radiological fistula healing, patient-reported outcomes and economic costs up to 54 weeks. Patients in the standard dosing arm will receive conventional infliximab dosing not guided by TLIs (5 mg/kg at weeks 0, 2 and 6, and 5 mg/kg 8 weekly thereafter). Patients aged 18-80 years with pfCD with single or multiple externally draining complex perianal fistulas who are relatively naïve to infliximab treatment will be included. Patients with diverting ileostomies or colostomies and pregnant or breast feeding will be excluded. Fifty-eight patients per arm will be required to detect a 25% difference in the primary outcome measure, with 138 patients needed to account for an estimated 6.1% primary non-response rate and 10% dropout rate. ETHICS AND DISSEMINATION Results will be presented in peer-reviewed journals and international conferences. Ethics approval has been granted by the South Western Sydney Local Health District Human Research Ethics Committee in Australia. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12621000023853); Pre-results.
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Affiliation(s)
- Bonita Gu
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Michael De Gregorio
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Joseph Louis Pipicella
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Niels Vande Casteele
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Jane M Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jakob Begun
- Immunity, Infection, and Inflammation Program, Mater Research Institute, Brisbane, Queensland, Australia
- Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - William Connell
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Basil D'Souza
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Ali Gholamrezaei
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Ailsa Hart
- Inflammatory Bowel Diseases Unit, St Mark's Hospital, Harrow, UK
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Graham Radford-Smith
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jordi Rimola
- Inflammatory Bowel Disease Unit, Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Tom Sutherland
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Medical Imaging Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Catherine Toong
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Immunology, NSW Health Pathology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Rodney Woods
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Yang Wu
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Wei Xuan
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Astrid-Jane Williams
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Watson Ng
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Nik Sheng Ding
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Susan Connor
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
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Langbroek GB, Wolkerstorfer A, Horbach SER, Spuls PI, Kelly KM, Robertson SJ, van Raath MI, Al-Niaimi F, Kono T, Boixeda P, Laubach HJ, Badawi AM, Troilius Rubin A, Haedersdal M, Manuskiatti W, van der Horst CMAM, Ubbink DT. Development of a core outcome domain set for clinical research on capillary malformations (the COSCAM project). J Eur Acad Dermatol Venereol 2021; 35:1888-1895. [PMID: 34014582 PMCID: PMC8453952 DOI: 10.1111/jdv.17376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/21/2021] [Indexed: 01/19/2023]
Abstract
Background Due to a large variety in treatment outcomes reported in therapeutic trials and lacking patient‐relevant outcomes, it is hard to adequately compare and improve current therapies for patients with capillary malformations (CMs). The Core Outcome Set for Capillary Malformations (COSCAM) project aims to develop a core outcome set (COS) for use in future CM trials, in which we will first develop a core outcome (sub)domain set (CDS). Here, we describe the methods for the development of a CDS and present the results of the first development stage. Methods The COSCAM project is carried out according to the recommendations of the Cochrane Skin Core OUtcomes Set INitiative (CS‐COUSIN) and the Core Outcome Measures in Effectiveness Trials (COMET) initiative. During the first stage, we identified all potentially relevant outcome subdomains based on a systematic review, two focus group sessions and input from patient representatives of Dutch patient organizations and the COSCAM‐founding group. In stage two, we will present the subdomains in a three‐round e‐Delphi study and online consensus meeting, in which CM patients, parents/caregivers and CM experts worldwide rate the importance of the proposed subdomains, hereby finalizing the core outcome (sub)domains of the CDS. Results A total of 67 potential outcome subdomains were included; sixteen were previously used in the literature, 20 were proposed by Dutch patients and their parents/caregivers (n = 13) in focus group sessions and 38 were suggested by the experts of the COSCAM‐founding group. Seven were excluded because of overlap. Conclusion The final CDS may serve as a minimum standard in future CM trials, thereby facilitating adequate comparison of treatment outcomes. After this CDS development, we will select appropriate outcome measurement instruments to measure the core outcome subdomains.
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Affiliation(s)
- G B Langbroek
- Department of Surgery, Amsterdam University Medical Center (UMC) Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Wolkerstorfer
- Department of Dermatology, Amsterdam University Medical Center UMC, Amsterdam Public Health, Immunity and Infections, University of Amsterdam, Amsterdam, The Netherlands
| | - S E R Horbach
- Department of Plastic-, Reconstructive- and Hand Surgery, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - P I Spuls
- Department of Dermatology, Amsterdam University Medical Center UMC, Amsterdam Public Health, Immunity and Infections, University of Amsterdam, Amsterdam, The Netherlands
| | - K M Kelly
- Department of Dermatology, University of California Irvine, Irvine, CA, USA
| | - S J Robertson
- Department of Dermatology and Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - M I van Raath
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
| | - F Al-Niaimi
- Private Dermatological Practice, London, UK.,Department of Dermatology, University of Aalborg, Aalborg, Denmark
| | - T Kono
- Department of Plastic Surgery, Tokai University School of Medicine, Shimokasuya Isehara Kanagawa, Kanagawa, Japan
| | - P Boixeda
- Department of Dermatology, Hospital Ramon y Cajal, Madrid, Spain
| | - H J Laubach
- Department of Dermatology, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - A M Badawi
- Department of Dermatology, Szeged University, Szeged, Hungary.,Department of Medical Laser Applications, National Institute of Laser Enhanced Sciences, Cairo University, Giza, Egypt
| | - A Troilius Rubin
- Department of Dermatology, Skåne University Hospital, Malmö, Sweden
| | - M Haedersdal
- Department of Dermatology, University of Copenhagen, Bispebjerg Hospital, Copenhagen NV, Denmark
| | - W Manuskiatti
- Department of Dermatology, Siriraj Skin Laser Center Department of Dermatology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - C M A M van der Horst
- Department of Plastic-, Reconstructive- and Hand Surgery, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - D T Ubbink
- Department of Surgery, Amsterdam University Medical Center (UMC) Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Tyrell S, Coates E, Brown SR, Lee MJ. A systematic review of the quality of reporting of interventions in the surgical treatment of Crohn's anal fistula: an assessment using the TIDiER and Blencowe frameworks. Tech Coloproctol 2021; 25:359-369. [PMID: 33599902 PMCID: PMC8016786 DOI: 10.1007/s10151-020-02359-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/10/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Crohn's anal fistula is a challenging condition, and may require multiple surgical procedures. To replicate successful procedures, these must be adequately reported in the literature. The aim of this study was to review the quality of reporting of components of surgical interventions for Crohn's anal fistula. METHODS A systematic review was conducted. It was registered with PROSPERO (CRD:42019135157). The Medline and EMBASE databases were searched for studies reporting interventions intended to close fistula in patients with Crohn's disease, published between 1999 and August 2019. Abstracts and full texts were screened for inclusion by two reviewers. Dual extraction of data was performed to compare reporting to the TIDiER and Blencowe frameworks for reporting of interventions. RESULTS Initial searches identified 207 unique studies; 38 full texts were screened for inclusion and 33 were included. The most common study design was retrospective cohort (17/33), and the most frequently reported interventions were anal fistula plug (n = 8) and fibrin glue (n = 6). No studies showed coverage of all domains of TIDieR. Reporting was poor among domains related to who provided an intervention, where it was provided, and how it was tailored. Reporting of domains in the Blencowe framework was poor; the majority of studies did not report the component steps of procedures or efforts to standardise them. CONCLUSIONS This study demonstrates that reporting on technical aspects of interventions for Crohn's anal fistula is poor. Surgeons should aim to improve reporting to allow accurate reproduction of techniques both in clinical practice and in clinical trials.
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Affiliation(s)
- S Tyrell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - E Coates
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steven R Brown
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - M J Lee
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, S10 2RX, UK.
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Abstract
BACKGROUND Pilonidal sinus is a hole in the natal cleft which may cause severe pain and become infected. The evidence base for management of pilonidal sinus is said to be poor quality, poorly focused and rapidly proliferating. We undertook a systematic mapping review to provide a broad overview of the field and support the identification of research priorities. METHODS We searched MEDLINE, CINAHL, and EMBASE from inception to 22nd Nov 2020 for primary research studies focused on the management of pilonidal sinus. We extracted data on study design and categorised studies under five major headings ('non-surgical treatment', 'surgical treatment', 'aftercare' and 'other'), producing frequency counts for different study designs. Gaps in research were identified from published systematic reviews and tabulated. RESULTS We identified 983 eligible studies, of which 36 were systematic reviews and/or meta-analyses; 121 were randomised controlled trials), and 826 observational studies of various design. The majority of studies evaluated surgical techniques (n = 665), or adjuvant medical interventions (n = 98). The literature on wound care has developed most recently, and the evidence base includes 30% randomised controlled trials. Gaps analysis highlighted comparison of surgical techniques including flaps, laser depilation, and wound care interventions as potential areas for randomised controlled trials. CONCLUSIONS This mapping review summarises eight decades of research on the management of pilonidal sinus. Further research is needed to identify front-running interventions, understand variation in practice and patient values, and to prioritise future research.
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Amiot A, Bouguen G, Bonnaud G, Bouhnik Y, Hagege H, Peyrin-Biroulet L. Clinical guidelines for the management of inflammatory bowel disease: Update of a French national consensus. Dig Liver Dis 2021; 53:35-43. [PMID: 33160886 DOI: 10.1016/j.dld.2020.10.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND New treatments and therapeutic approaches repeatedly emerged in the field of inflammatory bowel disease. AIM to update the French treatment algorithms for Crohn's disease (CD) and ulcerative colitis (UC). METHODS A formal consensus method was used to determine changes to the treatment algorithms for various situations of CD and UC. Thirty-seven experts voted on questions that had been drafted by the steering committee ahead of time. Consensus was defined as at least 66% of experts agreeing on a response. RESULTS Anti-TNF were reinforced as a first-line therapy rather than the use of immunosuppressant alone. Vedolizumab for UC, ustekinumab for CD took place as second-line maintenance therapy and potentially as a first-line therapy in the setting of unrestricted reimbursement for vedolizumab. Tofacitinib was recommended by the experts in case of vedolizumab failure for UC. Algorithms for complicated CD with abscess, intestinal and complex anal fistula were updated according to recent prospective cohort studies. CONCLUSION The changes incorporated to the algorithms provide up-to-date and easy-to-use guidelines to treat patients with IBD.
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Affiliation(s)
- Aurélien Amiot
- Department of Gastroenterology, Henri Mondor University Hospital, APHP, EC2M3-EA7375, Paris Est-Creteil University, Creteil, France.
| | - Guillaume Bouguen
- CHU and University of Rennes, INSERM, CIC1414, Institut NUMECAN (Nutrition Metabolism and Cancer), F-35000 Rennes, France
| | | | - Yoram Bouhnik
- CHU Paris Nord-Val de Seine, Beaujon Hospital, Department of Gastroenterology, IBD and nutritive support, Clichy, France
| | - Hervé Hagege
- Intercommunal Hospital of Créteil, Department of Gastroenterology, Créteil, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, Vandoeuvre-lès-Nancy, France; Inserm U1256 NGERE, Lorraine University, Vandoeuvre-lès-Nancy, France
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Adegbola SO, Dibley L, Sahnan K, Wade T, Verjee A, Sawyer R, Mannick S, McCluskey D, Yassin N, Phillips RKS, Tozer PJ, Norton C, Hart AL. Burden of disease and adaptation to life in patients with Crohn's perianal fistula: a qualitative exploration. Health Qual Life Outcomes 2020; 18:370. [PMID: 33218361 PMCID: PMC7678264 DOI: 10.1186/s12955-020-01622-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/06/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Perianal fistulas are a challenging manifestation of Crohn's disease. Best medical and surgical therapy results in only about a third of patients remaining in remission at one year on maintenance treatment and sustained healing is often elusive. There is little published data on patient perspective of living with the condition or coping strategies in the face of non-curative/non-definitive treatment. We aimed to understand the experience of living with perianal fistula(s) and their impact on quality of life and routine functioning. METHODS This exploratory qualitative study used purposive sampling to recruit participants with current / previous diagnosis of Crohn's anal fistulas, from national IBD / bowel disease charities. The "standards for reporting qualitative research" (SRQR) recommendations were followed. Unstructured individual face-to-face interviews were audio recorded, transcribed and analysed thematically. Early themes were reviewed by the study team including patient advocates, clinicians and qualitative researchers. RESULTS Twelve interviews were conducted, achieving apparent data saturation. Three broad themes were uncovered: Burden of symptoms; Burden of treatment; and Impact on emotional, physical and social well-being. Each included several sub-themes, with considerable interplay between these. The impact of perianal fistula(s) on patients with CD is intense and wide reaching, negatively affecting intimate, close and social relationships. Fistulas cause losses in life and work-related opportunities, and treatments can be difficult to tolerate. CONCLUSION Crohn's perianal fistulas exert a heavy negative physical and emotional impact on patients. These findings will inform development of a patient reported outcome measure to assess treatment effectiveness and quality of life for patients living with this challenging condition.
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Affiliation(s)
- Samuel O Adegbola
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Watford Road, Harrow, HA1 3UJ, Middlesex, UK.
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Praed Street, London, W2 1NY, UK.
| | - Lesley Dibley
- Faculty of Education, Health and Human Sciences, University of Greenwich, London, UK
| | - Kapil Sahnan
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Watford Road, Harrow, HA1 3UJ, Middlesex, UK
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Praed Street, London, W2 1NY, UK
| | - Tiffany Wade
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, London, UK
| | | | | | | | | | - Nuha Yassin
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Watford Road, Harrow, HA1 3UJ, Middlesex, UK
| | - Robin K S Phillips
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Watford Road, Harrow, HA1 3UJ, Middlesex, UK
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Praed Street, London, W2 1NY, UK
| | - Philip J Tozer
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Watford Road, Harrow, HA1 3UJ, Middlesex, UK
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Praed Street, London, W2 1NY, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, London, UK
| | - Ailsa L Hart
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Watford Road, Harrow, HA1 3UJ, Middlesex, UK
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Praed Street, London, W2 1NY, UK
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Limdi JK. Indian Journal of Gastroenterology September-October 2020. Indian J Gastroenterol 2020; 39:415-418. [PMID: 33226569 DOI: 10.1007/s12664-020-01120-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Jimmy K Limdi
- Section of Inflammatory Bowel Diseases, Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK. .,Manchester Academic Health Sciences, University of Manchester, Manchester, UK. .,Manchester Metropolitan University, Manchester, UK.
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Fearnhead NS, Blackwell S, Raine T. More Tribulations Than Trials in Research on Fistulating Perianal Crohn's Disease. J Crohns Colitis 2020; 14:1031-1032. [PMID: 32894297 DOI: 10.1093/ecco-jcc/jjaa148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Nicola S Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Adegbola SO, Sahnan K, Twum-Barima C, Iqbal N, Reza L, Lung P, Warusavitarne J, Tozer P, Hart A. Current review of the management of fistulising perianal Crohn's disease. Frontline Gastroenterol 2020; 12:515-523. [PMID: 34712470 PMCID: PMC8515276 DOI: 10.1136/flgastro-2020-101489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 02/04/2023] Open
Abstract
Perianal manifestations of Crohn's disease constitute a distinct disease phenotype commonly affecting patients and conferring an increased risk of disability and disease burden. Much research has gone into management of fistulising manifestations, with biological therapy changing the landscape of treatment. In this article, we discuss the up-to-date surgical and medical management of perianal fistulas, highlighting current consensus management guidelines and the evidence behind them, as well as future directions in management.
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Affiliation(s)
- Samuel O Adegbola
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kapil Sahnan
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Charlene Twum-Barima
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nusrat Iqbal
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lillian Reza
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Phillip Lung
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - Janindra Warusavitarne
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Phil Tozer
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ailsa Hart
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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39
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Lee MJ, Coe PO, O'Donoghue R, Peirson M, Saha A. Variation in descriptors of patient characteristics in randomized clinical trials of peptic ulcer repair: a systematic review. Br J Surg 2020; 107:1570-1579. [PMID: 32671830 DOI: 10.1002/bjs.11771] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/02/2020] [Accepted: 05/14/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND The ability to compare findings across surgical research is important. Inadequate description of participants, interventions or outcomes could lead to bias and inaccurate assessment of findings. The aim of this study was to assess consistency of description of participants using studies comparing laparoscopic and open repair of peptic ulcer as an example. METHODS This systematic review is reported in line with the PRISMA checklist. Searches of MEDLINE and Embase databases were performed to identify studies comparing laparoscopic and open repair of perforated peptic ulcer in adults, published in the English language. Manuscripts were dual-screened for eligibility. Full texts were retrieved and dual-screened for inclusion. Data extracted from studies included descriptors of participants in studies from tables and text. Descriptors were categorized into conceptual domains by the research team, and coverage of each domain by study was tabulated. RESULTS Searches identified 2018 studies. After screening, 37 full texts were retrieved and 23 studies were included in the final synthesis. A total of 76 unique descriptors were identified. These were classified into demographics (11 descriptors), vital signs (9 descriptors), disease-specific characteristics (10 descriptors), presentation and pathway factors (4 descriptors), risk factors (8 descriptors), laboratory tests (14 descriptors) and baseline health (28 descriptors). The number of descriptors in a single study ranged from three to 31. All studies reported at least one demographic descriptor. Laboratory tests was the least frequently described domain. CONCLUSION Study participants are described inconsistently in studies of a single example surgical condition.
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Affiliation(s)
- M J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - P O Coe
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - M Peirson
- Department of General Surgery, Ysbyty Gwynedd Hospital, Bangor, UK
| | - A Saha
- Department of General Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
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41
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Young AE, Brookes ST, Avery KN, Davies A, Metcalfe C, Blazeby JM. A systematic review of core outcome set development studies demonstrates difficulties in defining unique outcomes. J Clin Epidemiol 2019; 115:14-24. [DOI: 10.1016/j.jclinepi.2019.06.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/31/2019] [Accepted: 06/26/2019] [Indexed: 12/20/2022]
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42
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Lee M, Hind D, Brown S. Methodology in core outcome sets. Colorectal Dis 2019; 21:1211. [PMID: 31254418 DOI: 10.1111/codi.14744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 05/28/2019] [Indexed: 02/08/2023]
Affiliation(s)
- M Lee
- Northern General Hospital, Sheffield, UK
| | - D Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - S Brown
- Northern General Hospital, Sheffield, UK
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43
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Dellon ES, Gupta SK. A Conceptual Approach to Understanding Treatment Response in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2019; 17:2149-2160. [PMID: 30710696 PMCID: PMC6667323 DOI: 10.1016/j.cgh.2019.01.030] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/15/2019] [Accepted: 01/20/2019] [Indexed: 02/07/2023]
Abstract
While the diagnosis and initial treatment of eosinophilic esophagitis are becoming more standardized, there are still major gaps in knowledge related to measuring treatment response. One such question centers on how to measure treatment response and what treatment endpoints should be. This impacts not only patient care and engagement in decision-making, but also the field of drug development. In addition, studies so far have use a myriad of treatment endpoints including over a dozen histologic endpoint criteria. This review will discuss the various stakeholders involved in assessment of treatment endpoints of a complex condition, including patients, practitioners and regulatory agencies, and the care settings in which treatment response is assessed, including routine clinical care, clinical trials, and observational studies. Potential parameters or treatment endpoints such as histology, symptoms, patient-reported outcomes, endoscopy, and biomarkers are discussed along with associated challenges and opportunities. A framework on how to define treatment outcomes is discussed and a conceptual approach treatment response is proposed. This takes into account histology, symptoms, and endoscopic findings and harnesses existing, validated tools. It includes definitions of nonresponse, complete normalization, and a graded response category between these 2 extremes, and also permits flexibility and latitude for modifications as newer knowledge emerges. In addition, ways to position the pediatric population in these endeavors are discussed as are future research directions.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, University of Illinois College of Medicine, Peoria, IL
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44
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El-Hussuna A, Myrelid P, Holubar SD, Kotze PG, Mackenzie G, Pellino G, Winter D, Davies J, Negoi I, Grewal P, Gallo G, Sahnan K, Rubio-Perez I, Clerc D, Demartines N, Glasbey J, Regueiro M, Sherif AE, Neary P, Pata F, Silverberg M, Clermont S, Chadi SA, Emile S, Buchs N, Millan M, Minaya-Bravo A, Elfeki H, De Simone V, Shalaby M, Gutierrez C, Ozen C, Yalçınkaya A, Rivadeneira D, Sturiale A, Yassin N, Spinelli A, Warusavitarne J, Ioannidis A, Wexner S, Mayol J. Biological Treatment and the Potential Risk of Adverse Postoperative Outcome in Patients With Inflammatory Bowel Disease: An Open-Source Expert Panel Review of the Current Literature and Future Perspectives. CROHN'S & COLITIS 360 2019; 1. [DOI: 10.1093/crocol/otz021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2023] Open
Abstract
AbstractBackgroundThere is widespread concern that treatment with biologic agents may be associated with suboptimal postoperative outcome after surgery for inflammatory bowel diseases (IBD).AimWe aimed to search and analyze the literature regarding the potential association of biologic treatment on adverse postoperative outcome in patients with IBD. We used the subject as a case in point for surgical research. The aim was not to conduct a new systematic review.MethodThis is an updated narrative review written in a collaborative method by authors invited through Twitter via the following hashtags (#OpenSourceResearch and #SoMe4Surgery). The manuscript was presented as slides on Twitter to allow discussion of each section of the paper sequentially. A Google document was created, which was shared across social media, and comments and edits were verified by the primary author to ensure accuracy and consistency.ResultsForty-one collaborators responded to the invitation, and a total of 106 studies were identified that investigated the potential association of preoperative biological treatment on postoperative outcome in patients with IBD. Most of these studies were retrospective observational cohorts: 3 were prospective, 4 experimental, and 3 population-based studies. These studies were previously analyzed in 10 systematic/narrative reviews and 14 meta-analyses. Type of biologic agents, dose, drug concentration, antidrug antibodies, interval between last dose, and types of surgery varied widely among the studies. Adjustment for confounders and bias control ranged from good to very poor. Only 10 studies reported postoperative outcome according to Clavien–Dindo classification.ConclusionAlthough a large number of studies investigated the potential effect of biological treatment on postoperative outcomes, many reported divergent results. There is a need for randomized controlled trials. Future studies should focus on the avoiding the weakness of prior studies we identified. Seeking collaborators and sharing information via Twitter was integral to widening the contributors/authors and peer review for this article and was an effective method of collaboration.
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Affiliation(s)
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Stefan D Holubar
- Director of Research, Department of Colon & Rectal Surgery, Cleveland, OH
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | | | - Gianluca Pellino
- Department of Surgery, Università della Campania Luigi Vanvitelli, Aversa, Italy
| | - Des Winter
- Centre for Colorectal Disease, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
| | - Justin Davies
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Ionut Negoi
- Carol Davila University of Medicine and Pharmacy Bucharest, Romania
| | - Perbinder Grewal
- Department of Cardiovascular, University Hospital Southampton, UK
| | - Gaetano Gallo
- Department of General Surgery, “Magna Graecia” University, Catanzaro, Italy
| | - Kapil Sahnan
- Imperial College Faculty of Medicine, Department of Surgery and St Marks Hospital, London, UK
| | - Ines Rubio-Perez
- General and Digestive Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Daniel Clerc
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - James Glasbey
- Academic Department of Surgery, University of Birmingham Heritage Building, UK
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH
| | - Ahmed E Sherif
- Department of Clinical Surgery, University of Edinburgh, UK
| | - Peter Neary
- South East Cancer Governance Lead, University Hospital Waterford/Cork, Ireland
| | - Francesco Pata
- Department of Surgery, Sant’Antonio Abate Hospital, Gallarate, Italy
| | - Mark Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, University of Toronto, ON, Canada
| | | | - Sami A Chadi
- Division of General Surgery, University Health Network, Toronto, Ontario, Canada
| | - Sameh Emile
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Nicolas Buchs
- Department of Surgery, University Hospitals of Geneva, Switzerland
| | - Monica Millan
- Department of Surgery, Joan XXIII University Hospital, Tarragona, Spain
| | | | - Hossam Elfeki
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Veronica De Simone
- Proctology Unit, Catholic University, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Mostafa Shalaby
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Celestino Gutierrez
- Department of Suregry, Centre Hospitalier de Redon Ille-et-Vilaine Bretagne-France
| | - Cihan Ozen
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | - David Rivadeneira
- Colorectal Surgery & Surgical Services, Northwell Health in Huntington, NY, USA
| | - Alssandro Sturiale
- Proctological and Perineal Surgical Unit, Cisanello University Hospital, Pisa, Italy
| | - Nuha Yassin
- Department of surgery, Royal Wolverhampton Hoaspital, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Humanitas University, Milan, Italy
| | | | - Argyrios Ioannidis
- Department of General, Laparoscopic and Robotic Surgery, Athens Medical Center
| | - Steven Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
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Currie AC, Bright T, Thompson SK, Smith L, Devitt PG, Watson DI. Acceptable outcomes after fundoplication-different views are held by patients, GPs, and surgeons. Dis Esophagus 2019; 32:5479249. [PMID: 31323089 DOI: 10.1093/dote/doz025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Antireflux surgery aims to improve quality of life. However, whether patients and clinicians agree on what this means, and what is an acceptable outcome following fundoplication, is unknown. This study used clinical scenarios pertinent to laparoscopic fundoplication for gastroesophageal reflux to define acceptable outcomes from the perspective of patients, surgeons, and general practitioners (GPs). Patients who had previously undergone a laparoscopic fundoplication, general practitioners, and esophagogastric surgeons were invited to rank 11 clinical scenarios of outcomes following laparoscopic fundoplication for acceptability. Clinicopathological and practice variables were collated for patients and clinicians, respectively. GPs and esophagogastric surgeons additionally were asked to estimate postfundoplication outcome probabilities. Descriptive and multivariate statistical analyses were undertaken to examine for associations with acceptability. Reponses were received from 331 patients (36.4% response rate), 93 GPs (13.4% response), and 60 surgeons (36.4% response). Bloating and inability to belch was less acceptable and dysphagia requiring intervention more acceptable to patients compared to clinicians. On regression analysis, female patients found bloating to be less acceptable (OR: 0.51 [95%CI: 0.29-0.91]; P = 0.022), but dysphagia more acceptable (OR: 1.93 [95%CI: 1.17-3.21]; P = 0.011). Postfundoplication estimation of reflux resolution was higher and that of bloating was lower for GPs compared to esophagogastric surgeons. Patients and clinicians have different appreciations of an acceptable outcome following antireflux surgery. Female patients are more concerned about wind-related side effects than male patients. The opposite holds true for dysphagia. Surgeons and GPs differ in their estimation of event probability for patient recovery following antireflux surgery, and this might explain their differing considerations of acceptable outcomes.
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Affiliation(s)
- Andrew C Currie
- Discipline of Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
| | - Tim Bright
- Discipline of Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
| | - Sarah K Thompson
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia
| | - Lorelle Smith
- Discipline of Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia.,Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter G Devitt
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia
| | - David I Watson
- Discipline of Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
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46
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Ratto C, Grossi U, Litta F, Di Tanna GL, Parello A, De Simone V, Tozer P, DE Zimmerman D, Maeda Y. Contemporary surgical practice in the management of anal fistula: results from an international survey. Tech Coloproctol 2019; 23:729-741. [PMID: 31368010 PMCID: PMC6736896 DOI: 10.1007/s10151-019-02051-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/19/2019] [Indexed: 12/22/2022]
Abstract
Background Management of anal fistula (AF) remains challenging with many controversies. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons. Methods An online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. An invitation was extended to others via social media. The survey had 74 questions exploring diagnostic and surgical techniques. Results In March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Respondents were mostly colorectal surgeons (84%) at consultant level (84%), age ≥ 40 years (64%), practicing in academic (53%) or teaching (30%) hospitals, from the USA (36%) and Europe (34%). About 80% considered fistulotomy as the gold standard treatment for simple fistulas. Endorectal advancement flap was performed using partial- (42%) or full-thickness (44%) flaps. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. Geographic and demographic differences were found in both the diagnostic and therapeutic approaches to AF. Declared rates of recurrence and fecal incontinence with these techniques were variable and did not correlate with surgeons’ experience. Only 1–4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn’s disease. Conclusions Profound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers. Electronic supplementary material The online version of this article (10.1007/s10151-019-02051-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Ratto
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - U Grossi
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy. .,National Bowel Research Centre, Queen Mary University of London, London, UK.
| | - F Litta
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - G L Di Tanna
- Statistics Division, The George Institute for Global Health, UNSW, Sydney, Australia
| | - A Parello
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - V De Simone
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - P Tozer
- Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK.,Imperial College London, London, UK
| | - D DE Zimmerman
- Department of Surgery, ETZ (Elisabeth-TweeSteden Hospital), Tilburg, The Netherlands
| | - Y Maeda
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
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Rencz F, Stalmeier PFM, Péntek M, Brodszky V, Ruzsa G, Gönczi L, Palatka K, Herszényi L, Schäfer E, Banai J, Rutka M, Gulácsi L, Lakatos PL. Patient and general population values for luminal and perianal fistulising Crohn's disease health states. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:91-100. [PMID: 31102158 PMCID: PMC6544586 DOI: 10.1007/s10198-019-01065-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/13/2019] [Indexed: 05/04/2023]
Abstract
BACKGROUND In patients with Crohn's disease (CD), luminal disease activity paralleled by perianal fistulas may seriously impair health-related quality of life (HRQoL). Health utility values are not available from patients with CD that reflect the health loss associated with both luminal and perianal CD. OBJECTIVE To generate utilities for luminal and concomitant perianal fistulising CD health states directly from patients and from members of the general public. METHODS A cross-sectional survey was undertaken enrolling CD patients and a convenience sample of members of the general population. Respondents were asked to evaluate four common CD heath states [severe luminal disease (sCD), mild luminal disease (mCD), severe luminal disease with active perianal fistulas (sPFCD), and mild luminal disease with active perianal fistulas (mPFCD)] by 10-year time trade-off (TTO). In addition, patients assessed their current HRQoL by the TTO method. RESULTS Responses of 206 patients (40.8% with perianal fistulas) and 221 members of the general population were analysed. Mean ± SD utilities among patients for sPFCD, sCD, mPFCD and mCD states were 0.69 ± 0.33, 0.73 ± 0.31, 0.80 ± 0.29 and 0.87 ± 0.26. Corresponding values in the general public were: 0.59 ± 0.31, 0.65 ± 0.29, 0.80 ± 0.26 and 0.88 ± 0.25. Patients with active perianal fistulas, previous non-resection surgeries, and higher pain intensity scores valued their current health as worse (p < 0.05). CONCLUSIONS TTO is a feasible method to assess HRQoL in patients with perianal fistulising disease, often not captured by health status questionnaires. Utilities from this study are intended to support the optimization of treatment-related decision making in patients with luminal disease paralleled by active perianal fistulas.
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Affiliation(s)
- Fanni Rencz
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary.
- Premium Postdoctoral Research Program, Hungarian Academy of Sciences, Nádor u. 7, 1051, Budapest, Hungary.
| | - Peep F M Stalmeier
- Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Márta Péntek
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Valentin Brodszky
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Gábor Ruzsa
- Doctoral School of Psychology, Institute of Psychology, Eötvös Loránd University of Sciences, Izabella u. 46, 1064, Budapest, Hungary
- Department of Statistics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Lóránt Gönczi
- 1st Department of Medicine, Semmelweis University, Korányi Sándor u. 2/a, 1083, Budapest, Hungary
| | - Károly Palatka
- Division of Gastroenterology, Department of Internal Medicine, University of Debrecen, Nagyerdei krt. 98, 4032, Debrecen, Hungary
| | - László Herszényi
- Medical Centre, Hungarian Defence Forces, Podmaniczky u. 109-111, 1062, Budapest, Hungary
| | - Eszter Schäfer
- Medical Centre, Hungarian Defence Forces, Podmaniczky u. 109-111, 1062, Budapest, Hungary
| | - János Banai
- Medical Centre, Hungarian Defence Forces, Podmaniczky u. 109-111, 1062, Budapest, Hungary
| | - Mariann Rutka
- 1st Department of Internal Medicine, University of Szeged, Korányi fasor 8-10, 6720, Szeged, Hungary
| | - László Gulácsi
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Peter L Lakatos
- 1st Department of Medicine, Semmelweis University, Korányi Sándor u. 2/a, 1083, Budapest, Hungary
- Division of Gastroenterology, McGill University, MUHC, Montreal General Hospital, 1650 Ave. Cedar, D16.173.1, Montreal, QC, H3G 1A4, Canada
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Lopez N, Ramamoorthy S, Sandborn WJ. Recent advances in the management of perianal fistulizing Crohn's disease: lessons for the clinic. Expert Rev Gastroenterol Hepatol 2019; 13:563-577. [PMID: 31023087 PMCID: PMC6545251 DOI: 10.1080/17474124.2019.1608818] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Managing fistulizing perianal disease is among the most challenging aspects of treating patients with Crohn's disease. Perianal fistulas are indicative of poor long-term prognosis. They are commonly associated with significant morbidities and can have detrimental effects on quality of life. While durable fistula closure is ideal, it is uncommon. In optimal circumstances, reported long-term fistula healing rates are only slightly higher than 50% and recurrence is common. Achieving these results requires a combined medical and surgical approach, highlighting the importance of a highly skilled and collaborative multidisciplinary team. In recent years, advances in imaging, biologic therapies and surgical techniques have lent to growing enthusiasm amongst treatment teams, however the most advantageous approach is yet to be determined. Areas covered: Here we review current management approaches, incorporating recent guidelines and novel therapies. Additionally, we discuss recently published and ongoing studies that will likely impact practice in the coming years. Expert opinion: Investing in concerted collaborative multi-institutional efforts will be necessary to better define optimal timing and dosing of medical therapy, as well as to identify ideal timing and approach of surgical interventions. Standardizing outcome measures can facilitate these efforts. Clearly, experienced multidisciplinary teams will be paramount in this process.
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Affiliation(s)
- Nicole Lopez
- Division of Colon and Rectal Surgery, University of California San Diego, California, USA
| | - Sonia Ramamoorthy
- Division of Colon and Rectal Surgery, University of California San Diego, California, USA
| | - Willam J. Sandborn
- Inflammatory Bowel Disease Center, University of California San Diego, California, USA,Division of Gastroenterology, University of California San Diego, California, USA
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49
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Catt H, Hughes D, Kirkham JJ, Bodger K. Systematic review: outcomes and adverse events from randomised trials in Crohn's disease. Aliment Pharmacol Ther 2019; 49:978-996. [PMID: 30828852 PMCID: PMC6492112 DOI: 10.1111/apt.15174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/03/2018] [Accepted: 01/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The suitability of disease activity indices has been challenged, with growing interest in objective measures of inflammation. AIM To undertake a systematic review of efficacy and safety outcomes in placebo-controlled randomised controlled trials (RCTs) of patients with Crohn's disease. METHODS MEDLINE, EMBASE, CINAHL and Cochrane Library were searched until November 2015, for RCTs of adult Crohn's disease patients treated with medical or surgical therapies. Data on efficacy and safety outcomes, end-point definitions, and measurement instruments were extracted and stratified by publication date (pre-2009 and 2009 onwards). RESULTS One hundred and eighty-one RCTs (110 induction and 71 maintenance) were identified, including 23 850 patients. About 92.3% reported clinical efficacy endpoints. The Crohn's Disease Activity Index (CDAI) dominated, defining clinical response or remission in 63.5% of trials (35 definitions of response or remission). CDAI < 150 was the commonest endpoint, but reporting reduced between periods (46.4%-41.1%), whilst use of CDAI100 increased (16.8%-30.4%). Fistula studies most commonly reported fistula closure (9, 90.0%). Reporting of biomarker, endoscopy and histology endpoints increased overall (33.3%-40.6%, 14.4%-30.4% and 3.2%-12.5%, respectively), but were heterogeneous and rarely reported in fistula trials. Patient-reported outcome measures were reported in 41.4% of trials and safety endpoints in 35.4%. Many of the common adverse events relate to disease exacerbation or treatment failure. CONCLUSIONS Trial endpoints vary across studies, over time and are distinct in fistula studies. Despite growth in reporting of objective measures of inflammation and in patient-reported outcome measures, there is a lack of standardisation. This confirms the need for a core outcome set for comparative effectiveness research in Crohn's disease.
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Affiliation(s)
- Heather Catt
- Department of BiostatisticsUniversity of LiverpoolLiverpoolUK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines EvaluationBangor UniversityBangorUK
| | | | - Keith Bodger
- Department of BiostatisticsUniversity of LiverpoolLiverpoolUK,Digestive Diseases CentreAintree University Hospital NHS TrustLiverpoolUK
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50
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De Meyer D, Kottner J, Beele H, Schmitt J, Lange T, Van Hecke A, Verhaeghe S, Beeckman D. Delphi procedure in core outcome set development: rating scale and consensus criteria determined outcome selection. J Clin Epidemiol 2019; 111:23-31. [PMID: 30922885 DOI: 10.1016/j.jclinepi.2019.03.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/04/2019] [Accepted: 03/19/2019] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The objective of this study was to compare two different rating scales within one Delphi study for defining consensus in core outcome set development and to explore the influence of consensus criteria on the outcome selection. STUDY DESIGN AND SETTING Randomized controlled parallel group trial with 1:1 allocation within the first Delphi round of the Core Outcome Set in the Incontinence-Associated Dermatitis project. Outcomes were rated on a three-point or nine-point Likert scale. Decisions about which outcomes to retain were determined by commonly used consensus criteria (i.e., [combinations of] proportions with restricted ranges, central tendency within a specific range, and decrease in variance). RESULTS Fifty-seven participants (group 1 = 28, group 2 = 29) rated 58 outcomes. The use of the nine-point scale resulted in almost twice as many outcomes being rated as "critical" compared with the three-point scale (24 vs. 13). Stricter criteria and combining criteria led to less outcomes being identified as "critical". CONCLUSION The format of rating scales in Delphi studies for core outcome set development and the definition of the consensus criteria influence outcome selection. The use of the nine-point scale might be recommended to inform the consensus process for a subsequent rating or face-to-face meeting. The three-point scale might be preferred when determining final consensus.
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Affiliation(s)
- Dorien De Meyer
- Department of Public Health and Primary Care, Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery, Ghent University, Ghent, Belgium
| | - Jan Kottner
- Department of Public Health and Primary Care, Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery, Ghent University, Ghent, Belgium; Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin, Berlin, Germany
| | - Hilde Beele
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, Medizinische Fakultät Carl Gustav Carus TU Dresden, Dresden, Germany
| | - Toni Lange
- Center for Evidence-Based Healthcare, Medizinische Fakultät Carl Gustav Carus TU Dresden, Dresden, Germany
| | - Ann Van Hecke
- Department of Public Health and Primary Care, Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery, Ghent University, Ghent, Belgium; Nursing Department, Ghent University Hospital, Ghent, Belgium
| | - Sofie Verhaeghe
- Department of Public Health and Primary Care, Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery, Ghent University, Ghent, Belgium; Department Health Care, VIVES University College, Roeselare, Belgium
| | - Dimitri Beeckman
- Department of Public Health and Primary Care, Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery, Ghent University, Ghent, Belgium; Faculty of Medicine & Health Sciences, School of Nursing and Midwifery, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland; School of Health Sciences, Örebro University, Örebro, Sweden.
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