Discontinuation of Anti-Tumour Necrosis Factor Therapy in Patients with Perianal Fistulizing Crohn's Disease: Individual Participant Data Meta-Analysis of 309 Patients from 12 Studies

BACKGROUND

The risk of relapse after anti-tumour necrosis factor [TNF] therapy discontinuation in Crohn's disease patients with perianal fistulas [pCD] is unclear. We aimed to assess this risk.

METHODS

A systematic literature search was conducted to identify cohort studies on the incidence of relapse following anti-TNF discontinuation in pCD patients. Individual participant data were requested from the original study cohorts. Inclusion criteria were age ≥16 years, pCD as a (co)indication for start of anti-TNF therapy, more than three doses, and remission of luminal and pCD at anti-TNF discontinuation. The primary outcome was the cumulative incidence of CD relapse using Kaplan-Meier estimates. Secondary outcomes included response to re-treatment and risk factors associated with relapse as assessed by Cox regression analysis.

RESULTS

In total, 309 patients from 12 studies in ten countries were included. The median duration of anti-TNF treatment was 14 months [interquartile range 5.8-32.5]. Most patients were treated for pCD without active luminal disease [89%], received first-line anti-TNF therapy [87%], and continued immunomodulatory therapy following anti-TNF discontinuation [78%]. The overall cumulative incidence of relapse was 36% (95% confidence interval [CI] 25-48%) and 42% [95% CI 32-53%] at 1 and 2 years after anti-TNF discontinuation, respectively. Risk factors for relapse included smoking (hazard ratio [HR] 1.5 [1.0, 2.1]) and history of proctitis (HR 1.7 [1.1, 2.5]). The overall re-treatment response rate was 82%.

CONCLUSIONS

This individual participant data meta-analysis, on predominantly patients with pCD without active luminal disease and first-line anti-TNF therapy, shows that over half of patients remain in remission 2 years after anti-TNF discontinuation. Therefore, anti-TNF discontinuation may be considered in this subgroup.

Co-Administration of Proton Pump Inhibitors May Negatively Affect the Outcome in Inflammatory Bowel Disease Treated with Vedolizumab

Concomitant medications may alter the effect of biological therapy in inflammatory bowel disease. The aim was to investigate the effect of proton pump inhibitors on remission rates in patients with inflammatory bowel disease treated with the gut-selective vedolizumab. Patients from the Hungarian nationwide, multicenter vedolizumab cohort were selected for post hoc analysis. Primary outcomes were the assessment of clinical response and endoscopic and clinical remission at weeks 14 and 54. Secondary outcomes were the evaluation of the combined effect of concomitant steroid therapy and other factors, such as smoking, on remission. A total of 108 patients were identified with proton pump inhibitor data from 240 patients in the original cohort. Patients on steroids without proton pump inhibitors were more likely to have a clinical response at week 14 than patients on concomitant PPI (95% vs. 67%, p = 0.005). Non-smokers with IBD treated with VDZ were more likely to develop a clinical response at week 14 than smokers, particularly those not receiving PPI compared with patients on co-administered PPI therapy (81% vs. 53%, p = 0.041, and 92% vs. 74%, p = 0.029, respectively). We found that the use of PPIs in patients treated with VDZ may impair the achievement of response in certain subgroups. Unnecessary PPI prescriptions should be avoided.

Conception and reality: Outcome of SARS-CoV-2 infection and vaccination among Hungarian IBD patients on biologic treatments

Introduction

Inflammatory bowel disease potentially elevates the risk of infections, independently from age, while the disease activity and medical treatment(s) can also increase the risks. Nevertheless, it is necessary to clarify these preconceptions as well during the COVID-19 pandemic.

Methods

An observational, questionnaire based study was conducted in Hungary between February and August 2021. 2 questionnaires were completed. The first questionnaire surveyed the impact of the pandemic on patients with biologic treatments and assessed the severity and outcome of the infection, whereas the second one assessed vaccination rate and adverse events.

Results

472 patients participated in the study. 16.9 % of them acquired the infection and 6.3 % needed hospitalization. None of them required ICU care. Male sex elevated the risk of infection (p = 0.008), while glove (p = 0.02) and mask wearing (p = 0.005) was the most effective prevention strategy. Nevertheless, abstaining from community visits or workplace did not have an impact on the infection rate. Smoking, age, and disease type did not elevate the risk. UC patients had poorer condition during the infection (p = 0.003); furthermore, the disease activity could potentially worsen the course of infection (p = 0.072). The different biological treatments were equally safe; no difference was observed in the infection rate, course of COVID-19. Azathioprine and corticosteroids did not elevate the infection rate. 28 patients (35.0 %) suspended the ongoing biologic treatment, but it had no impact on the disease course. However, it resulted in changing the current treatment (p = 0.004). 9.8 % of the respondents were sceptic about being vaccinated, and 90 % got vaccinated. In one case, a serious flare-up occurred.

Discussion

Most patients acquired the infection at workplace. Biologic therapies had no effect on the COVID-19 infection, whereas male sex, an active disease, and UC could be larger threat than treatments. Vaccination was proved to be safe, and patient education is important to achieve mass vaccination of the population.

Cutting edge selection: learning from high reliability organisations for virtual recruitment in surgery during the COVID-19 pandemic

INTRODUCTION

National selection for higher surgical training (ST3+) recruitment in the UK is competitive. The process must prioritise patient safety while being credible, impartial and fair. During the COVID-19 pandemic, all face-to-face interviews were cancelled. Selection was based on a controversial isolated self-assessment score with no evidence checking taking place. From 2021, selection will take place entirely online. Although this has cost and time advantages, new challenges emerge.

METHODS

We review surgical selection as it transitions to an online format and suggest validated methods that could be adapted from High Reliability Organisations (HRO).

FINDINGS

Virtual selection methods include video interviewing, online examinations and aptitude testing. These tools have been used in business for many years, but their predictive value in surgery is largely unknown. In healthcare, the established online Multi-Specialty Recruitment Assessment (MSRA) examines generic professional capabilities. Its scope, however, is too limited to be used in isolation. Candidates and interviewers alike may have concerns about the technical aspects of virtual recruitment. The significance of human factors must not be overlooked in the online environment. Surgery can learn from HROs, such as aviation. Pilot and air traffic control selection is integral to ensuring safety. These organisations have already established digital selection methods for psychological aptitude, professional capabilities and manual dexterity.

CONCLUSION

National selection for higher surgical training (ST3+) can learn from HROs, using validated methods to prioritise patient safety while being acceptable to candidates, trainers and health service recruiters.

Prediction of Short- and Medium-term Efficacy of Biosimilar Infliximab Therapy. Do Trough Levels and Antidrug Antibody Levels or Clinical And Biochemical Markers Play the More Important Role?

BACKGROUND AND AIMS

Biosimilar infliximab CT-P13 received European Medicines Agency [EMA] approval in June 2013 for all indications of the originator product. In the present study, we aimed to evaluate the predictors of short- and medium-term clinical outcome in patients treated with the biosimilar infliximab at the participating inflammatory bowel disease [IBD] centres in Hungary.

METHODS

Demographic data were collected and a harmonised monitoring strategy was applied. Clinical and biochemical activities were evaluated at Weeks 14, 30, and 54. Trough level [TL] and anti-drug antibody [ADA] concentrations were measured by enzyme-linked immunosorbent assay [ELISA] [LT-005, Theradiag, France] at baseline at 14, 30 and 54 weeks and in two centres at Weeks 2 and 6.

RESULTS

A total of 291 consecutive IBD patients (184 Crohn's disease [CD] and 107 ulcerative colitis [UC]) were included. In UC, TLs at Week 2 predicted both clinical response and remission at Weeks 14 and 30 (clinical response/remission at Week 14: area under the curve [AUC] = 0.81, p < 0.001, cut-off: 11.5 μg/ml/AUC = 0.79, p < 0.001, cut-off: 15.3μg/ml; clinical response/remission at Week 30: AUC = 0.79, p = 0.002, cut-off: 11.5 μg/ml/AUC = 0.74, p = 0.006, cut-off: 14.5 μg/ml), whereas ADA positivity at Week 14 was inversely associated with clinical response at Week 30 [58.3% vs 84.8% ,p = 0.04]. Previous anti-tumour necrosis factor [TNF] exposure was inversely associated with short-term clinical remission [Week 2: 18.8% vs 47.8%, p = 0.03, at Week 6: 38.9% vs 69.7%, p = 0.013, at Week 14: 37.5% vs 2.5%, p = 0.06]. In CD, TLs at Week 2 predicted short-term [Week 14 response/remission, AUCTLweek2 = 0.715-0.721, p = 0.05/0.005] but not medium-term clinical efficacy. In addition, early ADA status by Week 14 [p = 0.04-0.05 for Weeks 14 and 30], early clinical response [p < 0.001 for Weeks 30/54] and normal C-reactive protein [CRP] at Week 14 [p = 0.005-0.0001] and previous anti-TNF exposure [p = 0.03-0.0001 for Weeks 14, 30, and 54] were associated with short-and medium-term clinical response and remission.

CONCLUSIONS

In UC, early TLs were predictive for short- and medium-term clinical efficacy, whereas in CD, Week 2 TLs were associated only with short-term clinical outcomes.

The sociodemographic profile, risk categories and prevalence of HIV infection among people attending a London same-day testing clinic, 2000-2001

The objectives were to determine the sociodemographic profile, risk category, and prevalence of HIV infection amongst people attending a confidential clinic providing counselling, medical advice and results of HIV antibody testing on the same day of consultation. Data were collected on all 1749 individuals attending the same-day HIV testing clinic at the Royal Free Hospital, London and proceeding to HIV testing between June 2000 and May 2001. One thousand, one hundred and forty-eight men and 601 women (mean age 33.3 years) were tested for HIV antibodies. The primary risk for HIV infection was heterosexual contact (69.9%; 1224/1749) and homosexual contact (27.7%; 485/1749). Fifty individuals tested HIV-positive (42 men and eight women). HIV seroprevalence was 2.8% (50/1749) and was highest among men who reported risk through homosexual contact (6.2%; 30/485). The rates for heterosexual men and women were 1.8% (12/648) and 1.4% (8/576), respectively, though they were highest among Black Caribbean (12%; 3/25) and Black African attendees from sub-Saharan African countries (11.2%; 18/160). Of the total number attending the clinic, more than half (56%; 981/1749) had previously been tested and received a negative test result. Of the fifty HIV antibody-positive individuals, 26%, (13) had previously received a negative result and had all reported risk through homosexual contact. Thirty of the HIV antibody-positive individuals were asymptomatic, 14 were symptomatic and three were diagnosed with an AIDS-defining condition. Half of all HIV-positive attendees (51.2%; 22/43) presented at the time of testing with CD4 cell counts below the normal range (>400x10(6)/l). The high HIV seroprevalence among homosexual men, some of whom had previously tested negative, suggests that HIV prevention strategies used within this group may need to be reassessed. The continuing high HIV seroprevalence among individuals from African countries suggests that this population require specific targeting for HIV risk reduction and information on the advantages of early diagnosis and treatment.

The challenges to intimacy and sexual relationships for gay men in HIV serodiscordant relationships: a pilot study

Human Immunodeficiency Virus (HIV) infection and disease progression create imbalance in long-term, HIV-serodiscordant, gay male relationships, particularly in sexual relations and issues of physical and emotional intimacy. Stage of disease progression and worldview of the couple both affect the relationship and its survival. To redress imbalance, partners employ a range of coping strategies and techniques. This article explores these issues in the context of HIV serodiscordant gay couples and how they preserve their relationships in the face of these unique challenges. For workers who provide psychotherapeutic and community support for people with HIV and for their partners, the results of this study may be helpful in recognizing stress factors for couples, and tailoring support services to the needs of both partners. Overall, this study provides a basis for further work examining the dynamics of serodiscordant relationships.

'I'm not picking up a heart-beat': experiences of sonographers giving bad news to women during ultrasound scans

This study explores the experiences of obstetric sonographers imparting diagnostic information which may be considered 'bad news' to expectant mothers. Semi-structured interviews were conducted with nine sonographers at two London Hospitals to elicit their experiences of giving bad news. Themes which emerged then formed the basis for a quantitative survey of 180 practising obstetric sonographers in England. Their perception of what constitutes 'bad news' was examined. It was found that sonographers were predominantly concerned with lack of time and the unpredictability of the patient's reaction when giving bad news. Staff working in settings where there was a clear protocol specifying how to proceed following disclosure of bad news experienced less stress than those working without such a protocol. These findings have implications for psychologists working with patients who suffer pregnancy loss who may consider provision of support and counselling skills training for sonographers.

Coping with the disfiguring effects of vitiligo: a preliminary investigation into the effects of cognitive-behavioural therapy

Vitiligo is a progressive condition involving a loss of pigmentation in the skin; it can be disfiguring and no effective treatment or cure exists. Although vitiligo's medical effects have been studied extensively, little attention has been paid to its psychological impact or to the effects of psychological state on the illness itself. To address these issues, the present study examined the effect of cognitive behavioural therapy on coping with vitiligo and adaptation to the negative effects on body image, quality of life and self-esteem in adult patients. The study also examined whether any psychological gains acquired from psychological therapy would influence the progression of the condition itself. Two matched groups of vitiligo patients were compared, one of which received cognitive-behavioural therapy over a period of 8 weeks, while the other received no changes to their treatment status. All patients were assessed on self-esteem, body image and quality of life, prior to, immediately following and 5 months following the end of therapy. The progression of the condition was assessed by photographing patients prior to the start of counselling and 5 months following counselling. Results suggest that patients can benefit from cognitive behavioural therapy in terms of coping and living with vitiligo. There is also preliminary evidence to suggest that psychological therapy may have a positive effect on the progression of the condition itself. Implications for incorporating psychological counselling into patient care and management are discussed.

Impact of life events on the onset of vitiligo in adults: preliminary evidence for a psychological dimension in aetiology

The present study retrospectively examines the role of stressful life events in the onset of vitiligo in adults. A matched clinical sample of patients with other forms of disfigurement or skin disease (dystrophic epidermolysis bullosa and naevi, not thought to be associated with stress) served as a control group. Newly diagnosed patients and matched controls were thus asked to complete the 12-month version of the Schedule of Recent Experience, a questionnaire which measures the frequency and number of stressful life events occurring over a specified period. The results suggest that such patients endure a significantly higher number of stressful life events than do controls, suggesting that psychological distress may have contributed to the onset of their condition. The implications of the results are discussed and suggestions made for future research.

Psychological distress among gay men supporting a lover or partner with AIDS: a pilot study

To date, there has been little research to examine how much psychological distress is caused to people providing care and support to a lover or partner with AIDS. This study aimed to determine the level of psychological distress experienced by a sample of gay men providing care and support to a lover or partner with AIDS. It was conducted as a cross-sectional questionnaire survey. A control group was not enlisted, thus the study was descriptive in nature. The experimental hypothesis proposed that providing care and support would result in a high level of psychological distress. Thirty-eight gay men, some of whom themselves were infected with HIV, who were the primary carer of a lover or partner with an AIDS diagnosis were assessed using a self-report questionnaire. The 28-item General Health Questionnaire was used as a measure of global psychological distress. In addition, Martin's (1988) Traumatic Stress Response Scale was used as a measure of psychological distress arising specifically from AIDS. The sample reported high levels of global and AIDS-specific psychological distress. The levels of distress reported were of such a degree to indicate that the majority of the sample were probably suffering from significant psychiatric problems. The results strongly suggest that providing care and support to a lover or partner with AIDS may have an adverse affect on the carer's own psychological health: however, because of the design of the study it is impossible to state this conclusively.

Nurses' knowledge of and attitudes towards sexuality and the relationship of these with nursing practice

Issues concerning sex and sexuality are relevant to nursing practice. The objective of this study was to determine the relationship between knowledge of and attitude towards sexuality, and nursing practice. Nursing practice in this case was defined as the discussion of sexuality with the patient, with particular reference to taking a sexual history on admission to the ward. A multi-choice questionnaire with sections establishing demographic details and nursing practice, and including the Sex, Knowledge and Attitude Test (SKAT), was administered to 357 registered general nurses (RGNs). Results show a relationship between knowledge and attitude but no relationship between either of these and the nursing practice scale. However, a slight but significant correlation between receiving teaching about sexual history taking and questioning patients about sexuality on admission suggests that nursing practice and knowledge are weakly related. There is evidence that factors other than those within the scope of this study influence all three independent variables, and these are discussed. The implications of the study suggest the need for an improvement in nurse education regarding sexuality at all stages of training.

HIV seroprevalence in a London same-day testing clinic

OBJECTIVES

To determine the prevalence of HIV infection among people attending a confidential, non-genitourinary medicine based testing clinic that provides HIV antibody test results on the day of consultation.

METHODS

Retrospective analysis of data collected on 2635 individuals attending the Same-Day HIV Testing Clinic at the Royal Free Hospital, London between March 1992 and February 1993.

RESULTS

A total of 1612 men and 1023 women were tested for HIV antibody. The primary risk for HIV infection was heterosexual (71.7%; 1889 out of 2635) and homosexual contact (24.5%; 646 out of 2635). Fifty-four individuals were given positive HIV test results (46 men, median age 34 years; eight women, median age 27 years). Overall HIV seroprevalence was 2.0% (95% confidence interval, 1.5-2.5). HIV seroprevalence was highest among homosexual men (6.5%; 41 out of 635) and injecting drug users (5.7%; four out of 70). The rates for heterosexual men and women were 0.2% (two out of 915) and 0.7% (seven out of 974), respectively. Of the 54 individuals who were HIV-antibody-positive, 44 were Centers for Disease Control and Prevention stage II/III, eight stage IV and one was tested at the time of seroconversion (stage I; data were not available for one patient). Of the total numbers attending this clinic 27% (702 out of 2635) had previously been tested and received a negative result. Of a total of 54 HIV-antibody-positive individuals, 40% (21) had previously received a negative test result.

CONCLUSIONS

The data suggest that seroprevalence amongst homosexual men attending a designated HIV testing clinic in London is lower than that reported by genitourinary clinic based testing sites. The large number of repeat testers who subsequently became infected with HIV suggests that there is a population requiring specific targetting for HIV risk reduction.

Knowledge about HIV and views about HIV testing among students at an inner London university

Undergraduate students at an inner London university were surveyed at the beginning of 1992 about their basic knowledge regarding HIV/AIDS, HIV transmission and views about the HIV antibody test. Although they demonstrated good knowledge about HIV/AIDS and routes of transmission, a proportion had had unprotected intercourse, but were deterred from seeking an HIV test for a number of reasons. Implications for promoting safer sex and increasing awareness about HIV testing sites on university campuses are discussed.

Talking to patients about sexual matters

Specific counselling skills that will assist nurses in discussing sexual matters with patients can be learned. The possession of such skills by nurses will enhance the nurse/patient relationship and encourage patients in the era of HIV/AIDS, to discuss their concerns about sexual issues more openly. This article describes the place of conversation about sexual matters with patients.

Social care services for patients with HIV at a London teaching hospital; an evaluation

OBJECTIVE

To investigate outpatients' use of, and satisfaction with social care services in an HIV unit.

DESIGN

Survey of patients with HIV infection using self administered questionnaire.

SETTING

Outpatient HIV clinics at the Royal Free Hospital, London, March-April 1991.

MAIN OUTCOME MEASURES

Patients' social circumstances, use or intended use of social care services and satisfaction with social care services.

RESULTS

The greatest demand was for counselling about coping with HIV (38% of respondents), available medical treatment (24%), counselling for the HIV test (33%), psychological support for emotional (24%) or relationship problems (16%), advice about housing (24%) and financial matters (20%). In general, the use of social care services by men and women was similar. Twice as many men, however, sought help with payment of domestic bills, compared with women. Women were more likely to seek advice about financial benefits, obtaining sterile injecting equipment and discuss sleep and relationship problems. Thirty eight percent of patients were unemployed. Overall, 84% thought the service was good or excellent. Although less than 40% of patients currently used any one service, 60% thought they would use these services in the future.

CONCLUSION

The greatest demand for social care services was for coping with HIV, housing and financial matters, and HIV test counselling. More than half the patients stated that they would probably need social care services in future.

Evaluation of an intensive HIV/AIDS counselling course in Zimbabwe

The anticipated increase in the number of people with HIV infection and AIDS in Zimbabwe, together with those who have associated worries, will place extra demands upon clinical and counselling services in the coming decade. To meet these demands, a wide range of health care staff will have to acquire specialist counselling skills. For this reason, an intensive 2 day HIV/AIDS counselling training course was run at the Family Counselling Unit, Harare, in February 1989. The structure, content and evaluation of the course are presented here. Overall, the course was positively evaluated by the 38 trainees. However, a number of trainees were critical about some of the teaching methods and the degree of emphasis given to some of the objectives. Our experiences may help others in establishing HIV/AIDS counselling courses elsewhere.

Increasing workload of an HIV/AIDS counselling service in a London teaching hospital, 1990-91

The number of new patients referred to the HIV/AIDS Counselling Unit at the Royal Free Hospital, London, increased from 926 in 1989-90 to 1450 in 1990-91. Follow-up contacts nearly doubled during the same period of time. Growing demand for HIV testing as well as the shift to the treatment of HIV as a chronic condition increased the workload of the HIV/AIDS counsellors.

Discussing safer sex in HIV counselling: assessing three communication formats

Although it is acknowledged that counselling can be an important factor in behaviour change, we lack information on how HIV counselling works in practice. Research is reported based on transcriptions of audio-tapes of counselling drawn from seven hospital centres in England and the USA. It is shown that communication occurs in the context of three different formats. Certain formats and conversational strategies used by counsellors produce far greater patient participation. Such participation may hold out the prospect of greater behavioural change than simply listening to information and advice.

Research into HIV and AIDS between 1981 and 1990: the epidemic curve

The main features of research into HIV and AIDS between 1981 and 1990 were examined using a database of medical, nursing and dental journals [compact disc read-only memory (CD-ROM) version of the Medline database (Silver Platter Information Services, London, UK)]. More than 30,000 papers on HIV and AIDS were indexed by Medline between 1981 and 1990. Of these, only 3% were concerned with African populations although a quarter of AIDS cases worldwide were reported from African countries during the decade. The number of papers on HIV/AIDS increased from 24 in 1982 to an estimated 8300 in 1990. Between 1983 and 1988 the number of indexed papers on HIV/AIDS increased at around 50-60% per year; between 1988 and 1989, however, the rate of growth fell to 6%. The percentage of papers discussing the aetiology of AIDS fell from 25 to 3% between 1983 and 1990. During the same period, papers concerned with HIV increased from 2 to 37% of the HIV/AIDS total. Research into drug therapy also accounted for an increasing proportion of indexed papers during the decade. The percentage of papers dealing with prevention and control rose to 18% in 1988, but had declined to 12% by 1990. Priorities for the 1990s should include a renewed interest in aetiology and a sustained emphasis on prevention. Furthermore, countries that have so far been neglected should be granted priority in future research.