Development of a core descriptor set for Crohn's anal fistula

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.

A multi-centre audit of excess steroid use in 1176 patients with inflammatory bowel disease

BACKGROUND

Corticosteroids are central to inducing remission in inflammatory bowel disease (IBD) but are ineffective maintenance agents.

AIM

To benchmark steroid usage in British outpatients and assess factors associated with excess exposure.

METHODS

We recorded steroid use in unselected IBD outpatients. Cases meeting criteria for steroid dependency or excess were blind peer reviewed to determine whether steroid prescriptions were avoidable. Associations between steroid use and patient/institutional factors were analysed.

RESULTS

Of 1176 patients, 30% received steroids in the prior 12 months. 14.9% had steroid dependency or excess, which was more common in moderate/severe ulcerative colitis (UC) than Crohn's disease (CD) (42.6% vs 28.1%; P = .027). Steroid dependency or excess was deemed avoidable in 49.1%. The annual incidence of inappropriate steroid excess was 7.1%. Mixed-effects logistic regression analysis revealed independent predictors of inappropriate steroid excess. The odds ratio (OR, 95%CI) for moderate/severe compared to mild/quiescent disease activity was 4.59 (1.53-20.64) for UC and 4.60 (2.21-12.00) for CD. In CD, lower rates of inappropriate steroid excess were found in centres with an IBD multi-disciplinary team (OR 0.62 [0.46-0.91]), whilst dedicated IBD clinics protected against inappropriate steroid excess in UC (OR 0.64, 95% CI 0.21-0.94). The total number of GI trainees was associated with rates of inappropriate steroid excess.

CONCLUSIONS

Steroid dependency or excess occurred in 14.9% of British IBD patients (in 7.1% potentially avoidable). We demonstrated positive effects of service configurations (IBD multi-disciplinary team, dedicated IBD clinics). Routine recording of steroid dependency or excess is feasible and should be considered a quality metric.

The relationship between different information sources and disease-related patient knowledge and anxiety in patients with inflammatory bowel disease

BACKGROUND

Patient education forms a cornerstone of management of inflammatory bowel disease (IBD). The Internet has opened new avenues for information gathering.

AIM

To determine the relationship between different information sources and patient knowledge and anxiety in patients with IBD.

METHODS

The use of information sources in patients with IBD was examined via questionnaire. Anxiety was assessed with the hospital anxiety and depression scale and disease-related patient knowledge with the Crohn's and colitis knowledge score questionnaires. Associations between these outcomes and demographics, disease-related factors, and use of different information sources were analysed using linear regression analysis.

RESULTS

Of 307 patients (165 Crohn's disease, 142 ulcerative colitis) 60.6% were female. Participants used the hospital IBD team (82.3%), official leaflets (59.5%), and official websites (53.5%) most frequently in contrast to alternative health websites (9%). University education (P < 0.001), use of immunosuppressants (P = 0.025), Crohn's and Colitis UK membership (P = 0.001), frequent use of the hospital IBD team (P = 0.032), and frequent use of official information websites (P = 0.005) were associated with higher disease-related patient knowledge. Female sex (P = 0.004), clinically active disease (P < 0.001), frequent use of general practitioners (P = 0.014), alternative health websites (homoeopathy, nutritionists, etc.) (P = 0.004) and random links (P = 0.016) were independently associated with higher anxiety.

CONCLUSIONS

Different patient information sources are associated with better knowledge or worse anxiety levels. Face-to-face education and written information materials remain the first line of patient education. Patients should be guided towards official information websites and warned about the association between the use of alternative health websites or random links and anxiety.

Smoking prevalence and its influence on disease course and surgery in Crohn's disease and ulcerative colitis

BACKGROUND

Smoking demonstrates divergent effects in Crohn's disease (CD) and ulcerative colitis (UC). Smoking frequency is greater in CD and deleterious to its disease course. Conversely, UC is primarily a disease of nonsmokers and ex-smokers, with reports of disease amelioration in active smoking.

AIM

To determine the prevalence of smoking and its effects on disease progression and surgery in a well-characterised cohort of inflammatory bowel diseases (IBD) patients.

METHODS

Patients with smoking data of the Sydney IBD Cohort were included. Demographic, phenotypic, medical, surgical and hospitalisation data were analysed and reported on the basis of patient smoking status.

RESULTS

1203 IBD patients were identified comprising 626 CD and 557 UC with 6725 and 6672 patient-years of follow-up, respectively. CD patients were more likely to smoke than UC patients (19.2% vs. 10.2%, P < 0.001). A history of smoking in CD was associated with an increased proportional surgery rate (45.8% vs. 37.8%, P = 0.045), requirement for IBD-related hospitalisation (P = 0.009) and incidence of peripheral arthritis (29.8% vs. 22.0%, P = 0.027). Current smokers with UC demonstrated reduced corticosteroid utilisation (24.1% vs. 37.5%, P = 0.045), yet no reduction in the rates of colectomy (3.4% vs. 6.6%, P = 0.34) or hospital admission (P = 0.25) relative to nonsmokers. Ex-smokers with UC required proportionately greater immunosuppressive (36.2% vs. 26.3%, P = 0.041) and corticosteroid (43.7% vs. 34.5%, P = 0.078) therapies compared with current and never smokers.

CONCLUSIONS

This study confirms the detrimental effects of smoking in CD, yet failed to demonstrate substantial benefit from smoking in UC. These data should encourage all patients with IBD to quit smoking.

Reproduction in the patient with inflammatory bowel disease

Inflammatory bowel disease (IBD) often occurs in women of childbearing age and requires complex treatment decision. IBD can have profound influences on fertility, the course of a pregnancy, child birth and lactation. Many women with IBD remain voluntarily childless and patient knowledge of pregnancy related issues is generally poor, which can lead to negative views regarding IBD treatments. To achieve good clinical outcomes for mother and infant a balance has to be struck between the risks of any IBD treatment and the risks of untreated IBD. The advent of the biological age has brought another level of complexity. While more data demonstrating the safe use in pregnancy have recently emerged, effects on infants continue for up to 6 months with important implications on vaccination plans. This review discusses recent advances in the field of IBD and reproduction.

Probiotic VSL#3 prevents antibiotic-associated diarrhoea in a double-blind, randomized, placebo-controlled clinical trial

BACKGROUND

Antibiotic-associated diarrhoea (AAD) is a frequent complication of systemic antibiotic therapy and Clostridium difficile-associated diarrhoea (CDAD) is its most serious form due to associated morbidity and mortality.

AIM

This trial aimed to investigate whether the probiotic VSL#3 prevents AAD and CDAD in average-risk hospital patients.

METHODS

Adult hospital inpatients exposed to systemic antibiotics were recruited to this multicentre, randomized, double-blind, placebo-controlled trial. One sachet of VSL#3 or placebo was given twice daily for the length of the antibiotics course and for seven days thereafter. Primary outcomes were AAD and CDAD.

FINDINGS

Patients randomized to active (N = 117) and placebo (N = 112) groups were well-matched for baseline demographic patient data. No cases of CDAD were detected. The rate of AAD was significantly lower in the active group on per protocol analysis (0% active vs 11.4% placebo; P = 0.006). On intention-to-treat analysis the difference in AAD incidence (4.3% active vs 8.9% placebo; P = 0.19) was not significant.

CONCLUSIONS

VSL#3 is associated with a significant reduction in the incidence of AAD in average-risk hospital inpatients exposed to systemic antibiotics. As the incidence of CDAD has fallen sharply, no cases of CDAD were found. Probiotic administration as prophylaxis for CDAD may not be indicated in average-risk hospital patients.

Patients' knowledge of pregnancy-related issues in inflammatory bowel disease and validation of a novel assessment tool ('CCPKnow')

BACKGROUND

Inflammatory bowel diseases (IBD) require complex therapeutic decisions and life choices concerning pregnancy, but little is known about patient's knowledge of IBD and its treatment before and during pregnancy.

AIM

To develop a novel tool (Crohn's and Colitis Pregnancy Knowledge Score 'CCPKnow') to assess knowledge of pregnancy-related issues in IBD. The validated tool was then applied to determine knowledge in patients.

METHOD

Discriminate ability of 'CCPKnow' was validated in four groups with different levels of IBD knowledge. Reliability and readability were tested by Cronbach-α and Flesch-Kencaid. Construct validity was subsequently assessed against general IBD knowledge (CCKnow) in 145 women with IBD. Associations between patient factors and knowledge were studied.

RESULTS

Median CCPKnow scores differed significantly between the validation groups (P < 0.001). CCPKnow displayed excellent internal consistency, reliability (Cronbach-α 0.94), readability (reading age 9 years) and close correlation with CCKnow (Spearman's ρ 0.64; P < 0.001). Of 145 patients, 44.8% had poor, 27.6% adequate, 17.3% good and only 10.3% very good knowledge. Better knowledge was associated with Caucasian ethnicity, higher income, having a partner, having children, Crohn's and Colitis Association membership, longer disease duration and Crohn's disease.

CONCLUSIONS

Crohn's and Colitis Pregnancy Knowledge Score, a novel knowledge assessment tool of pregnancy and IBD, demonstrated excellent test characteristics. We found that nearly half of the women with IBD had poor knowledge, identifying a pressing need for better education.

Flexible sigmoidoscopy does not significantly increase polyp and cancer detection yield when used to supplement CT colonography

BACKGROUND AND AIMS

Flexible sigmoidoscopy (FS) increases polyp and carcinoma detection in addition to double contrast barium enema (DCBE). However, CT colonography (CTC) is now the preferred technique. Our aim was to explore whether FS increases polyp and carcinoma detection rates when used in addition to CTC.

METHODS

Patients who underwent FS and CTC between 2007 and 2009 were included and data were collected from patient records. Yields of polyp, adenoma and carcinoma detection were calculated for FS and CTC.

RESULTS

In a cohort of 294 patients, CTC detected 36 patients with carcinomas while FS detected 28. One rectal cancer not seen on CTC was diagnosed by FS. Polyps were seen by CTC in 66 and FS in 45 patients. In 5 patients FS found polyps that were not detected by CTC; 3 of which were small adenomas. FS detected extra adenomas or carcinomas in 1.36% (4/294). Adding FS to CTC neither increased the cancer nor the polyp detection yield significantly.

CONCLUSIONS

This first study investigating the use of FS in addition to CTC detected little additional pathology. The routine use of FS as a supplement to CTC for adenoma and carcinoma detection is of questionable utility.

Oesophageal stent insertion for palliation of dysphagia in a District General Hospital: experience from a case series of 137 patients

BACKGROUND

Endoscopic oesophageal stent insertion is a widely used procedure to alleviate dysphagia caused by malignant strictures of the oesophagus and gastric cardia. It can, however, be associated with significant complications, mortality and morbidity.

AIM AND METHOD

This retrospective case note study was undertaken to assess success rates, complications and mortality of oesophageal stenting when undertaken in a UK District General Hospital (DGH) setting. Patients who underwent oesophageal stenting for malignant disease from January 2000 to January 2006 were included.

RESULTS

Of the 137 patients studied, oesophageal adenocarcinoma was present in 57% of patients, squamous cell oesophageal carcinoma in 37% and gastric adenocarcinoma in 6%. Indications for stent insertion were: presence of non-resectable tumours (65%), co-morbidities that contraindicated surgery (25%), refusal by patients for surgery for potentially resectable disease (6%) and a need for enhanced oral nutrition prior to surgery (4%). Prior to stenting 86.4% of patients suffered from advanced dysphagia. A significant improvement in symptoms was seen in 94% of patients. Discharge from hospital was within 48 h in 45% of cases. Chest pain was experienced by 13.9% of patients and serious acute stent-related complications (perforation or bleeding) occurred in 5.8% of patients. Overall 41.6% of patients had at least one complication. Mortality was 4.4% at 7 days and 24.8% at 30 days.

CONCLUSION

Oesophageal stent insertion proved to be an effective palliation of dysphagia in group studied. It is a relatively safe procedure with a low rate of serious acute complications (5.8%) and can be done as a short stay in many patients.