The inflammatory bowel disease disk application: A platform to assess patients' priorities and expectations from treatment

OBJECTIVE

Inflammatory bowel disease (IBD) significantly impacts on patients' well-being. Patients' preferences for treatment outcomes do not necessarily fit physicians' goals. We aimed to investigate patients' priorities and expectations from treatment.

METHODS

A questionnaire based on the IBD Disk application was distributed to patients through social media. Patient's preferences were assessed by grading the 10 IBD Disk items on a Likert-type scale from 1 to 10. A cluster analysis was used to classify patients into homogeneous subgroups according to their preferred items, using the K-means method.

RESULTS

Among the 224 patients, 69.2% had Crohn's disease (CD). Their mean age was (38.9 ± 14.9) years and 62.9% were female. More CD patients compared with those with ulcerative colitis were treated with biologics compared with those with ulcerative colitis (71.0% vs 39.1%, P < 0.001). Most IBD Disk items ranked high in patients' preferences for treatment outcomes. Their leading preference was reducing abdominal pain, which was more prominent in CD patients, followed by regulating defecation and energy. Least important were interpersonal interactions, sexual functions, and body image. Patients were categorized into three clusters. Cluster 3 patients gave lower scores to most items and were characterized by tertiary education (P = 0.001), higher income (P < 0.001), less active disease (P = 0.02), and higher prevalence of successful treatment (P = 0.04).

CONCLUSIONS

Patients' preferences for treatment outcomes are influenced by higher education, higher income, rural-dwelling, and disease activity. Better understanding of individual patient's preferences and the factors that affect them might bridge the gap between patients' and physicians' priorities to achieve better teamwork in controlling disease outcomes.

Diagnosis and Management of Achalasia: Updates of the Last Two Years

Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller's myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.

Gastroenterologists attitude in various clinical settings in the era of COVID-19 pandemic: An online Uni-National Israeli Survey

Coronavirus disease 2019 (COVID-19) pandemic has impacted our clinical practice. Many gastroenterologists have changed their attitudes toward various gastroenterological clinical settings. The aim of the present study is to explore the gastroenterologist's attitudes in several clinical settings encountered in the clinical practice.An online based survey was completed by 101 of 250 Israeli gastroenterologists (40.5%).Most of the participants were males (76.2%), and most of them were in the age range of 40 to 50 (37.6%). For all questionnaire components, the 2 most common chosen options were "I perform endoscopy with N95 mask, gloves and gown protection in a standard endoscopy room without preendoscopy severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) testing" and "Tend to postpone endoscopy until SARS-CoV-2 test is performed because of fear from being infected, or virus spreading in the endoscopy suite." Notably, 12 (11.9%) gastroenterologists were infected by Coronavirus disease 2019 during their work. Classifying the clinical settings to either elective and non-elective, most gastroenterologists (77.4%) chose the attitude of "I perform endoscopy with N95 mask, gloves and gown protection in a standard endoscopy room without SARS-COV-2 testing" in the nonelective settings as compared to 54.2% for the elective settings, (P < .00001), whereas 32.9% of the responders chose the attitude of "Tend to postpone endoscopy until SARS-COV-2 test is performed because of fear from being infected, or virus spreading in the endoscopy suite" in the elective settings (P < .00001).Gastroenterologists' attitude in various gastroenterological settings was based on the clinical indication. Further studies are needed to assess the long-term consequences of the different attitudes.

Post-Diverticulitis Colonoscopy Was Not Associated with Higher Colonic Adenoma and Carcinoma: A Multicenter Case-Control Study

Background and Objectives: Colonoscopy following an episode of acute diverticulitis is currently recommended to rule out underlying colon cancer. However, a number of studies have debated this recommendation. We aimed to explore whether patients with colonic diverticulosis who experienced an episode of acute diverticulitis had higher prevalence colonic pathologies, essentially colonic adenomas and colorectal carcinoma (CRC) on a follow-up colonoscopy. Materials and Methods: We performed a multicenter retrospective study that included patients with a diagnosis diverticulosis as the control group and allocated patients after diverticulitis according to computed tomography (CT) scan and clinical presentation that had performed colonoscopy within 6 months from the acute diverticulitis episode. We compared the detection rate of colonic pathologic findings in both groups. Results: Overall, 367 patients were included. Of them, 134 patients experienced an episode of diverticulitis vs. 233 patients who did not have diverticulitis. On univariate analysis, there was no difference between all pathological findings (CRC, colonic adenomas; OR (odds ratio) 1.51, p = 0.085), and even for each pathological findings alone, there was no difference (for colonic adenomas, p = 0.07; for CRC, p = 0.87). Further sub-analysis revealed that only male gender (OR 4.03, p = 0.004) and smoking (OR 8.67, p < 0.0001) correlated with colonic adenomas and CRC, while moderate to severe disease was not correlated with colonic pathological findings (OR 0.86, 95% CI (confidence interval) 0.4–1.82, p = 0.68). Conclusions: Post-diverticulitis screening colonoscopy has not found a higher rate of colonic pathological findings, especially colonic neoplasia. Decision to perform colonoscopy after acute diverticulitis should be individualized based on risk stratification of colonic neoplasia.

Serum Albumin to Creatinine Ratio as Predictor for 30-Day All-Cause Mortality in Patients with Clostridium Di!cile-Associated Diarrhea

BACKGROUND

Clostridium difficile-associated diarrhea (CDAD) is a significant cause of mortality and morbidity in hospitalized patients. Several scores have developed in order to assess the severity of CDAD.

OBJECTIVE

To determine the role of the serum albumin to creatinine ratio (sACR) in predicting the 30-day all-cause mortality of patients with CDAD in comparison with other known severity scores of CDAD.

METHODS

A retrospective study was conducted at Baruch-Padeh Medical Center from January 2014 to December 2019. Patients with CDAD were recruited from Internal Medicine Departments, Intensive Care Units, and Surgical Departments. Data on demographic characteristics, clinical signs, underlying conditions, and several risk factors for CD infection were collected. We compared between severity scores of CDAD, such as ATLAS, the CDAD severity score, and the sACR in predicting the 30-day all-cause mortality in hospitalized patients with CDAD.

RESULTS

116 patients with CDAD were included. The ATLAS, CDAD scores, and sACR were calculated for all patients. The mean age of the participants was 71.4±16.4 years. 57.7% were of female gender. Fifty-two (44.8%) died within 30 days. An ATLAS score of ≥8 points had a 3.6-fold higher risk of 30-day all-cause mortality in hospitalized patients with CDAD (HR 3.6, 95% CI 3.28-3.99, p=0.001), a CDAD score of ≥5 points (HR 1.1, 95% CI 0.91-1.42, p=0.05), and a sACR≤3.4 (HR 1.5, 95%CI 1.25-1.82, p=0.04).

CONCLUSION

In this study, it was found that a sACR≤3.4 could predict the 30-day all-cause mortality in patients with CDAD.

Urological management and surgical procedures in migrants from Sub-Saharan Africa with urogenital schistosomiasis

INTRODUCTION AND OBJECTIVES

An increasing number of urogenital schistosomiasis (UGS) is being diagnosed in Europe following the unprecedented migratory flux from Sub-Saharan Africa (SSA). This phenomenon represent a challenge for urologists working in a non-endemic area. The aim of this study is to describe the urological management and the surgical procedures of patients with UGS in a tertiary referral centre.

PATIENTS

All subjects from SAA diagnosed with UGS from January 2011 to November 2018 were enrolled retrospectively. Detailed data of patients with UGS undergoing to urological procedures were collected and analysed.

RESULTS

Thirty patients were diagnosed with UGS, among them 12 (42.8%) were submitted to surgery. The most common surgical procedure was trans urethral resection of bladder (TURB) for suspected lesions persisted after praziquantel treatment performed in 7cases (58%). Other surgical procedure were TURB and concomitant ureteroscopy with laser fragmentation for suspected bladder neoplasm with renal stone, endoscopic lithotripsy and percutaneous nephrolithotomy for bladder and renal stones, laparoscopic nephrectomy for end-stage kidney disease, placement of bilateral nephrostomy for hydroureteronephrosis, explorative testicular surgery for a suspected testicular torsion in one case each. Four patients (33%) were lost at the follow up.

CONCLUSION

An increasing number of migrants from SSA diagnosed with UGS has been observed. Some patients required a surgical intervention for suspected neoplastic lesions or end-stage organ damage. It was particularly difficult to perform a regular follow-up in several patients. Further multicentric studies are needed to reach a proper standard in diagnosis, treatment and follow-up of subjects with UGS.

Diagnostic approach to faecal incontinence: What test and when to perform?

Faecal incontinence (FI) is a debilitating common end result of several diseases affecting the quality of life and leading to patient disability, morbidity, and increased societal burden. Given the various causes of FI, it is important to assess and identify the underlying pathomechanisms. Several investigatory tools are available including high-resolution anorectal manometry, transrectal ultrasound, magnetic resonance imaging, and electromyography. This review article provides an overview on the causes and pathophysiology of FI and the author’s perspective of the stepwise investigation of patients with FI based on the available literature. Overall, high-resolution anorectal manometry should be the first investigatory tool for FI, followed by either transrectal ultrasound or magnetic resonance imaging for anal internal sphincter and external anal sphincter injury, respectively.

Nonattendance to gastroenterologist follow-up after discharge is associated with a thirty-days re-admission in patients with inflammatory bowel disease: a multicenter study

BACKGROUND

Inflammatory bowel disease (IBD) is a set of chronic inflammatory diseases associated with significant morbidity and high hospitalization rate. IBD patients are particularly prone to rehospitalization resulting in high medical cost and morbidity. The aim of this study was to assess laboratory and clinical predictors of readmission in patients who were hospitalized with IBD flare.

METHODS

A multicenter, retrospective, cross-sectional analysis included IBD patients who were admitted with disease exacerbation from January 1, 2019 to January 1, 2020 in three Israeli university hospitals (Nazareth Hospital, Galilee Medical Center and Hadassah Medical Organization).

RESULTS

Overall, a total of 176 hospitalizations for IBD flares were included. Seventeen patients were readmitted within 30 days after discharge (group A), as compared to 159 patients who were not (group B). The average age was 35.3±19.2 years in group A vs. 38.6±16 years in group B. Eight (47.1%) and 9 (52.9%) patients had Crohn's disease (CD) and ulcerative colitis (UC) in group A as compared to 102 (64.2%) and 57 (35.9%) in group B, respectively. On univariate analysis, only the attendance to gastroenterology clinic follow-up after discharge from hospitalization due to IBD flare was significantly protective factor to with 30-days readmission (OR=0.37, 95% CI: 0.13-1, P=0.05). There were no associations with the other assessed clinical and laboratory parameters and importantly IBD type (OR=1.99, 95% CI: 0.74-5.34, P=0.17). Notably, there was no effect of the day of discharge white blood counts, albumin and C reactive protein (CRP) values on readmission rates (odds ratio [OR]=1.07, 95% CI: 0.96-1.20, P=0.19, OR=0.86, 95% CI: 0.39-1.91, P=0.71 and OR=0.99, 95% CI: 0.97-1.01, P=0.59), respectively.

CONCLUSIONS

Attendance to out-patient gastroenterologist follow-up is the only significant protective parameter to 30-days readmission in patients with IBD. This finding highlights the vital need of adequate gastroenterological follow-up of these patients after hospital discharge. Further studies are warranted to precisely define timing and role of outpatient follow-up in reducing IBD readmissions.

Water vapor therapy (Rezūm) for lower urinary tract symptoms related to benign prostatic hyperplasia: early results from the first Italian multicentric study

Purpose

Rezūm is the latest developed minimally invasive treatment for benign prostatic hyperplasia (BPH). We aimed to carefully assess the functional outcomes of patients treated with Rezūm for BPH.

Methods

We prospectively followed 135 consecutive patients treated by Rezūm at 5 institutions from June 2019 to August 2020. The International Prostate Symptom Score (IPSS), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI SF), the Overactive Bladder Questionnaire-Short Form (OAB-q SF) score, the International Index of Erectile Function (IIEF-5) and questions 9 and 10 to assess ejaculatory dysfunction were recorded.

Election criteria were age > 18, no prior prostate interventions, IPSS ≥ 13, post-void residual ≤ 250 mL, prostate volume between 30 and 120 cc.

Results

The median operative time was 10.5 (IQR 8.7–15) min. All patients were dismissed few hours after surgery with indwelling urinary catheter that was removed after a median of 7 (IQR 7–10) days. A significantly decrease of IPSS from baseline at first (p = 0.001) and third (p < 0.0001) month after surgery was reported. No difference was reported in terms of ICIQ-UI SF score postoperatively. A mild reduction of the OAB-q SF score was reported at 1 month from surgery (p = 0.06) that turned significant at 3 months postoperatively (p < 0.0001). A slight but statistically significant increase of the IIEF-5 score was reported from baseline at 6 months (p = 0.04). Postoperatively, patients reported a significantly decrease of ejaculatory dysfunction after alpha-blocker interruption.

Conclusion

Rezūm treatment is a feasible minimally invasive option for patients with BPH symptoms and showed optimal early functional outcomes.