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Gauss A, Geiss T, Hinz U, Schaefert R, Zwickel P, Zawierucha A, Stremmel W, Klute L. Quality of Life Is Related to Fecal Calprotectin Concentrations in Colonic Crohn Disease and Ulcerative Colitis, but not in Ileal Crohn Disease. Medicine (Baltimore) 2016; 95:e3477. [PMID: 27100452 PMCID: PMC4845856 DOI: 10.1097/md.0000000000003477] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
To formulate therapy goals, we aimed to define the relationship between fecal calprotectin and health-related quality of life in inflammatory bowel diseases (IBDs). This retrospective single-center cross-sectional study included ambulatory IBD patients who had completed standardized questionnaires comprising items of health-related quality of life (Short Inflammatory Bowel Disease Questionnaire) and clinical disease activity scores, and who had provided stool samples for calprotectin determination within 30 days of questionnaire completion. Correlation analyses were performed between the indicated parameters. Post hoc analysis was conducted, taking into account only data from patients with fecal calprotectin concentrations measured within 3 days of questionnaire completion. One hundred ninety-seven patients with Crohn disease and 111 patients with ulcerative colitis were enrolled in the study. Lower fecal calprotectin concentrations were associated with better health-related quality of life. The correlations were weak, but stronger if only fecal calprotectin concentrations measured within 3 days of questionnaire completion were included (results for 3 days; Crohn disease: n = 86, rS = -0.419, P < 0.001; ulcerative colitis: n = 43, rS = -0.432, P = 0.004). In Crohn disease, a significant correlation between fecal calprotectin concentration and health-related quality of life was found in patients with colonic involvement (n = 59, rS = -0.470, P < 0.001), but not in patients with purely ileal disease (n = 27, rS = -0.268, P = 0.18). Correlations between fecal calprotectin concentrations and clinical disease activity were also only weak to moderate. Owing to its moderate correlation with fecal calprotectin concentrations in IBD patients with colonic involvement, health-related quality of life should be used in combination with other markers for IBD management. This is even more important in isolated ileal Crohn disease, where no significant correlation between fecal calprotectin concentration and health-related quality of life was found. Especially for use in research studies, care should be taken to keep the time between clinical evaluation of IBD patients and the determination of fecal calprotectin concentrations as short as possible.
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Affiliation(s)
- Annika Gauss
- From the Department of Gastroenterology and Hepatology (AG, TG, PZ, AZ, WS, LK), University of Heidelberg, Heidelberg, Germany; Unit for Documentation and Statistics of the Department of Surgery (UH), University of Heidelberg, Heidelberg, Germany; and Department of General Internal Medicine and Psychosomatics (RS), University of Heidelberg, Heidelberg, Germany
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Aberrant Motility in Unaffected Small Bowel is Linked to Inflammatory Burden and Patient Symptoms in Crohn's Disease. Inflamm Bowel Dis 2016; 22:424-32. [PMID: 26509756 DOI: 10.1097/mib.0000000000000601] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Inflammation-related enteric dysmotility has been postulated as a cause for abdominal symptoms in Crohn's disease (CD). We investigated the relationship between magnetic resonance imaging-quantified small bowel (SB) motility, inflammatory activity, and patient symptom burden. METHODS The Harvey-Bradshaw index (HBI) and fecal calprotectin were prospectively measured in 53 patients with CD (median age, 35; range, 18-78 years) the day before magnetic resonance enterography, which included a dynamic (cine), breath-hold motility sequence, repeated to encompass the whole SB volume. A validated registration-based motility quantitation technique produced motility maps, and regions of interest were drawn to include all morphologically normal SB (i.e., excluding diseased bowel). Global SB motility was correlated with calprotectin, HBI, and symptom components (well-being, pain, and diarrhea). Adjustment for age, sex, smoking, and surgical history was made using multivariate linear regression. RESULTS Median calprotectin was 336 (range, 0-1280). Median HBI, motility mean, and motility variance were 3 (range, 0-16), 0.33 (0.18-0.51), and 0.01 (0.0014-0.034), respectively. Motility variance was significantly negatively correlated with calprotectin (rho = -0.33, P = 0.015), total HBI (rho = -0.45, P < 0.001), well-being (rho = -0.4, P = 0.003), pain (rho = -0.27, P = 0.05), and diarrhea (rho = -0.4, P = 0.0025). The associations remained highly significant after adjusting for covariates. There was no association between mean motility and calprotectin or HBI (P > 0.05). CONCLUSIONS Reduced motility variance in morphologically normal SB is associated with patient symptoms and fecal calprotectin levels, supporting the hypothesis that inflammation-related enteric dysmotility may explain refractory abdominal symptoms in CD.
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Grimstad T, Norheim KB. Utmattelse ved inflammatorisk tarmsykdom. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1721-1724. [DOI: 10.4045/tidsskr.16.0134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Barreiro-de Acosta M, Vallejo N, de la Iglesia D, Uribarri L, Bastón I, Ferreiro-Iglesias R, Lorenzo A, Domínguez-Muñoz JE. Evaluation of the Risk of Relapse in Ulcerative Colitis According to the Degree of Mucosal Healing (Mayo 0 vs 1): A Longitudinal Cohort Study. J Crohns Colitis 2016; 10:13-9. [PMID: 26351390 DOI: 10.1093/ecco-jcc/jjv158] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 08/24/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Mucosal healing in ulcerative colitis (UC) has become a common endpoint in most clinical trials and a relevant therapeutic goal in clinical practice. Despite important differences between endoscopic Mayo scores 0 and 1, both scores are considered as mucosal healing in most important trials. The aim of the present study was to evaluate the risk of relapse in UC patients according to the degree of mucosal healing (endoscopic Mayo scores of 0 and 1). METHODS A prospective longitudinal cohort study was designed. All UC patients who presented with mucosal healing at colonoscopy were consecutively included. Mucosal healing was defined as an endoscopic Mayo score of 0 or 1. Clinical relapse was defined as the need for therapy to induce remission, any treatment escalation, hospitalization or colectomy. All clinical relapses were evaluated at months 6 and 12 after study entry. Results were subjected to unconditional stepwise logistic and Kaplan-Meier regression analysis. RESULTS One hundred and eighty-seven consecutive UC patients (126 [67.3%] with Mayo score 0 and 61 [32.7%] with Mayo score 1) were included. Of patients with Mayo scores 0 and 1, 9.4 and 36.6% respectively presented a relapse during the first 6 months of follow-up (p < 0.001). The only factor independently associated with UC relapses in the multivariate analysis was an endoscopic Mayo score of 1 (odds ratio 6.27, 95% confidence interval 2.73-14.40, p < 0.001). CONCLUSIONS Patients with an endoscopic Mayo score of 1 have a higher risk of relapse than those with a score of 0. The concept of mucosal healing should be limited to patients with an endoscopic Mayo score of 0.
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Affiliation(s)
- Manuel Barreiro-de Acosta
- FIENAD, Department of Gastroenterology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - Nicolau Vallejo
- FIENAD, Department of Gastroenterology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - Daniel de la Iglesia
- FIENAD, Department of Gastroenterology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - Laura Uribarri
- FIENAD, Department of Gastroenterology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - Iria Bastón
- FIENAD, Department of Gastroenterology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - Rocío Ferreiro-Iglesias
- FIENAD, Department of Gastroenterology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - Aurelio Lorenzo
- FIENAD, Department of Gastroenterology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - J Enrique Domínguez-Muñoz
- FIENAD, Department of Gastroenterology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
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Wang CD, Guo XX. Goal of treatment of inflammatory bowel disease: Deep remission and therapeutic strategies. Shijie Huaren Xiaohua Zazhi 2015; 23:3824-3830. [DOI: 10.11569/wcjd.v23.i24.3824] [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] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a non-specific chronic inflammatory disorder of the gut. Although itsetiologyremains unclear, it maybe involves the interactions among genetic factors, environmental factors and inappropriate immune response. Conventional therapies for IBD include aminosalicylates, corticosteroids, immunosuppressants, and anti-tumor necrosis factor agents. Increasing recognition of the concept of quality of life has led to the evolution of treatment goals in IBD from clinical response and remission toward deep remission. This paper highlights the definition and importance of deep remission, and the current strategies to achieve deep remission.
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Theede K, Kiszka-Kanowitz M, Nordgaard-Lassen I, Mertz Nielsen A. The Impact of Endoscopic Inflammation and Mucosal Healing on Health-related Quality of Life in Ulcerative Colitis Patients. J Crohns Colitis 2015; 9:625-32. [PMID: 25956537 DOI: 10.1093/ecco-jcc/jjv081] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/30/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Health-related quality of life [HRQoL] is impaired in ulcerative colitis and is correlated to clinical disease activity. The recent shift towards more objective treatment goals like mucosal healing generates a need for evaluating the association between endoscopic disease activity, mucosal healing and HRQoL. METHODS In this cross-sectional study, patients with either active or inactive ulcerative colitis underwent sigmoidoscopy. Clinical disease activity was assessed by the Simple Clinical Colitis Activity Index [SCCAI], endoscopic inflammation by the Mayo Endoscopic Subscore [MES], and HRQoL by the Short Inflammatory Bowel Disease Questionnaire [SIBDQ] and Short Health Scale [SHS]. RESULTS A total of 110 patients, 71% with active disease, had a median SCCAI score of 3 and a median MES score of 1. Patients in clinical remission had a mean SIBDQ of 60 and SHS of 6. HRQoL decreased significantly with increasing clinical (SIBDQ [χ(2) = 61.8, p < 0.0001] and SHS [χ(2) = 63.4, p < 0.0001]) and endoscopic disease activity (SIBDQ [χ(2) = 33.1, p < 0.0001] and SHS [χ(2) = 40.3, p < 0.0001]). Mucosal healing was associated with a higher HRQoL than active inflammation (59/46, p < 0.0001 [SIBDQ] and 7/20, p < 0.0001 [SHS]). Decreased HRQoL was observed with more extensive disease. Linear regression revealed strong association between SIBDQ and SHS. CONCLUSIONS Not only clinical disease activity but also endoscopic inflammation and disease extent were associated with decreased HRQoL. Patients with mucosal healing had significant higher HRQoL, emphasising the importance of this treatment goal. Both SHS and SIBDQ are easy to use and to implement, and were strongly correlated.
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Affiliation(s)
- Klaus Theede
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Denmark
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D'Haens G, Löwenberg M, Samaan MA, Franchimont D, Ponsioen C, van den Brink GR, Fockens P, Bossuyt P, Amininejad L, Rajamannar G, Lensink EM, Van Gossum AM. Safety and Feasibility of Using the Second-Generation Pillcam Colon Capsule to Assess Active Colonic Crohn's Disease. Clin Gastroenterol Hepatol 2015; 13:1480-6.e3. [PMID: 25804331 DOI: 10.1016/j.cgh.2015.01.031] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 01/24/2014] [Accepted: 01/30/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The second-generation Pillcam Colon Capsule Endoscope (PCCE-2; Given Imaging Ltd, Yoqneam, Israel) is an ingestible capsule for visualization of the colon. We performed a multicenter pilot study to assess its safety and feasibility in evaluating the severity of Crohn's disease (CD). METHODS In a prospective study, 40 patients with active colonic CD underwent PCCE-2 and optical colonoscopy procedures. Using both techniques, we generated values for the Crohn's Disease Endoscopic Index of Severity (CDEIS), the Simple Endoscopic Score for CD, and global evaluation of lesion severity. In the first stage of the study, we calculated the correlation between PCCE-2 and optical colonoscopy scores. In the second stage, we performed interobserver agreement analysis for a random subset of 20 PCCE-2 recordings, graded in duplicate by 2 independent readers. RESULTS There was substantial agreement between PCCE-2 and optical colonoscopy in the measurement of the CDEIS (intraclass correlation coefficient [ICC], 0.65; 95% confidence interval [CI], 0.43-0.80). There was substantial interobserver agreement between 2 independent PCCE-2 readers for the CDEIS (ICC, 0.67; 95% CI, 0.35-0.86) and the Simple Endoscopic Score for CD (ICC, 0.66; 95% CI, 0.32-0.85). However, the PCCE-2 scoring systematically underestimated the severity of disease compared with optical colonoscopy; based on our results, PCCE-2 detected colonic ulcerations with 86% sensitivity and 40% specificity. No adverse events were observed and PCCE-2 was better tolerated than colonoscopy. CONCLUSIONS PCCE-2 is feasible, safe, and well tolerated for the assessment of mucosal CD activity in selected populations. Larger studies are needed to assess its operating characteristics further. European clinical trials database number: 2014-003854-15.
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Affiliation(s)
- Geert D'Haens
- Inflammatory Bowel Disease Unit, Academic Medical Centre, Amsterdam, The Netherlands; Robarts Clinical Trials, Inc, Amsterdam, The Netherlands and London, Ontario, Canada.
| | - Mark Löwenberg
- Inflammatory Bowel Disease Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - Mark A Samaan
- Inflammatory Bowel Disease Unit, Academic Medical Centre, Amsterdam, The Netherlands; Robarts Clinical Trials, Inc, Amsterdam, The Netherlands and London, Ontario, Canada
| | | | - Cyriel Ponsioen
- Inflammatory Bowel Disease Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - Gijs R van den Brink
- Inflammatory Bowel Disease Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - Paul Fockens
- Inflammatory Bowel Disease Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - Peter Bossuyt
- Department of Gastroenterology, Imelda Ziekenhuis, Bonheiden, Belgium
| | - Leila Amininejad
- Department of Gastroenterology, Hospital Erasme, Brussels, Belgium
| | - Gopalan Rajamannar
- Robarts Clinical Trials, Inc, Amsterdam, The Netherlands and London, Ontario, Canada
| | - Elsemieke M Lensink
- Inflammatory Bowel Disease Unit, Academic Medical Centre, Amsterdam, The Netherlands
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Expressions of E-cadherin, p120ctn, β-catenin and NF-κB in ulcerative colitis. ACTA ACUST UNITED AC 2015; 35:368-373. [PMID: 26072075 DOI: 10.1007/s11596-015-1439-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 04/01/2015] [Indexed: 01/05/2023]
Abstract
This study was aimed to investigate the expressions of E-cadherin, p120ctn, β-catenin and NF-κB in ulcerative colitis (UC) tissues and the implications of their expressions in the pathogenesis of UC. The expressions of E-cadherin, p120ctn, β-catenin and NF-κB were detected by immunohistochemistry, and those of p120ctn and NF-κB by Western blotting in 23 cases of UC and 17 cases of normal colonic tissues. The relationship between the expression of E-cadherin or NF-κB and that of p120ctn was analyzed by Spearman rank correlation analysis. The results showed that in UC and normal colonic groups, the abnormal expression rate of E-cadherin, p120ctn, β-catenin, and NF-κB was 52.2% vs. 0 (P<0.05), 73.9% vs. 23.5% (P<0.05), 65.2% vs. 17.6% (P<0.05) and 78.4% vs. 23.5% (P<0.05), respectively. p120ctn expression was positively correlated with E-cadherin expression (r=0.404, P<0.05), but negatively with nuclear NF-κB expression (r= - 0.347, P<0.05). Western blotting showed that as compared with the normal controls, the p120ctn protein level was significantly decreased (P<0.05), whereas the NF-κB protein level was increased (P<0.05) in UC tissues. It was concluded that in the colonic tissues of UC patients, the expressions of E-cadherin, p120ctn and β-catenin are decreased, suggesting the mucosal barrier is impaired in UC. Moreover, NF-κB is increased and activated in the UC tissues, resulting in the inflammation in UC. p120ctn may influence the UC development through modulating intercellular adhesion and inflammatory response.
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Abstract
Crohn's disease is associated with substantially impaired health-related quality of life (HRQoL). Even in the absence of active disease, patients with Crohn's disease report lower HRQoL, poorer function, and greater concerns, than those without disease. Achievement of disease remission in Crohn's disease, whether by pharmacological or surgical means, is associated with improved HRQoL, although the durability of the improvement seen after intestinal resection is uncertain because of the high rate of postoperative disease recurrence. This review focuses on the available literature on HRQoL in patients with Crohn's disease with an emphasis on the effects of intestinal resection and immunomodulatory therapy.
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Mawe GM. Colitis-induced neuroplasticity disrupts motility in the inflamed and post-inflamed colon. J Clin Invest 2015; 125:949-55. [PMID: 25729851 DOI: 10.1172/jci76306] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Effective colonic motility involves an intricate pattern of excitatory and inhibitory neuromuscular signals that arise from the enteric neural circuitry of the colon. Recent investigations have demonstrated that inflammation leads to a variety of changes in the physiological properties of the neurons in this circuitry, including hyperexcitability of neurons at the afferent end of the peristaltic reflex, synaptic facilitation, and attenuated inhibitory neuromuscular transmission. Furthermore, links have been established between these changes and disrupted motor activity in the colon, and we now know that some of these changes persist long after recovery from inflammation. It is highly likely that inflammation-induced neuroplasticity, which is not detectable by clinical diagnostics, contributes to disrupted motility in active and quiescent inflammatory bowel disease and in functional gastrointestinal disorders.
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Herrera-deGuise C, Casellas F, Robles V, Navarro E, Borruel N. Predictive value of early restoration of quality of life in Crohn's disease patients receiving antitumor necrosis factor agents. J Gastroenterol Hepatol 2015; 30:286-91. [PMID: 25302652 DOI: 10.1111/jgh.12803] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIM Crohn's disease (CD) impairs patients' health-related quality of life (HRQoL), therefore a goal of treatment is to improve their health. Recently, a more ambitious therapeutic target has been proposed, to reestablish patients' HRQoL to normal standards. There is no information on long-term prognostic value of restoring the health of patients with CD. Our aim was to determine if early restoration of HRQoL with antitumor necrosis factor (anti-TNF) agents is associated with long-term clinical remission. METHODS Retrospective longitudinal study in patients with active CD treated with anti-TNF agents. Patients completed the Inflammatory Bowel Disease Questionnaire (IBDQ)-36 at baseline and weeks 2, 6, 14, 28, and 52. Early restoration of health was defined as an IBDQ-36 score > 209 at week 14, and long-term clinical remission as a Cohn's disease activity index (CDAI) score < 150 maintained through week 52. RESULTS Ninety-four patients were included. Sixty-three patients maintained long-term remission, with 47 (75%) of them achieving early restoration of HRQoL. Of the 31 patients who did not maintain long-term remission, only 4 (13%) restored their HRQoL early (P < 0.01). There was a strong negative correlation between the IBDQ-36 at week 14 and CDAI values at week 52 (rs = - 0.64, P < 0.01). Ninety-two percent of patients with early restoration of HRQoL maintained long-term remission versus 37% who did not restore their HRQoL (P < 0.01). To predict long-term remission, the cutoff point of 209 of the early IBDQ-36 had an area under the receiver operating characteristic (AUROC) curve of 0.87. CONCLUSION Achieving early restoration of HRQoL with anti-TNF agents is associated with sustained long-term remission. This could be a therapeutic goal of treatment in clinical trials and daily practice.
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Affiliation(s)
- Claudia Herrera-deGuise
- Unitat Atenció Crohn-Colitis (UACC), Hospital Universitari Vall d'Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
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Levesque BG, Sandborn WJ, Ruel J, Feagan BG, Sands BE, Colombel JF. Converging goals of treatment of inflammatory bowel disease from clinical trials and practice. Gastroenterology 2015; 148:37-51.e1. [PMID: 25127678 DOI: 10.1053/j.gastro.2014.08.003] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 08/02/2014] [Accepted: 08/05/2014] [Indexed: 12/21/2022]
Abstract
It is important to have clear goals for treating inflammatory bowel disease in clinical practice and in research. Conventional end points for trials in ulcerative colitis and Crohn's disease have been based on composite indices, such as the Mayo Clinic Score and the Crohn's Disease Activity Index; these indices incorporate symptoms, signs, and findings from laboratory tests and sometimes endoscopic assessments. Although definitions of clinical response and remission have been based on these indices for regulatory purposes, they are difficult to apply to practice because they are complex and not intuitive to clinicians. This has caused a disconnect between clinical trials and practice. Recently, the use of composite indices in trials has been reevaluated in Food and Drug Administration-sponsored Gastroenterology Regulatory Endpoints and the Advancement of Therapeutics workshops due to concerns about the validity of the indices. Alternative measures of outcome and definitions of response are being developed. Patient-reported outcomes are psychometric instruments created and defined by patients to quantify symptoms. A combination of end points, comprising patient-reported outcomes and objective evaluation of inflammation by endoscopy, offers a clinically meaningful and scientifically valid alternative to existing composite indices. Unlike composite indices, response definitions based on endoscopy and patient-reported outcomes can be readily applied in practice. This convergence of outcome assessment in clinical trials and practice could expedite implementation of "treat-to-target" algorithms, in which therapy is progressively intensified until a specific treatment goal is reached. This approach could improve patient care by reducing rates of disease-related complications, surgery, and hospitalization.
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Affiliation(s)
- Barrett G Levesque
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California.
| | - Joannie Ruel
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brian G Feagan
- Robarts Clinical Trials, Robarts Research Institute, Department of Medicine, Western University, London, Ontario, Canada
| | - Bruce E Sands
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean-Frederic Colombel
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
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Sun JJ, Zhai XF. Relationship between psychosocial factors and quality of life in patients with inflammatory bowel disease. Shijie Huaren Xiaohua Zazhi 2014; 22:4695-4700. [DOI: 10.11569/wcjd.v22.i30.4695] [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] [Indexed: 02/07/2023] Open
Abstract
AIM: To analyze psychosocial factors affecting quality of life in patients with inflammatory bowel disease (IBD).
METHODS: Both outpatients and inpatients treated in the Affiliated Hospital and Second Affiliated Hospital of Nantong University from October 2012 to March 2014 were included. A survey of general information was conducted. Disease activity index was adopted as the standard to determine the disease stage. Patients' anxiety and depression were assessed using self-rating anxiety scale and self-rating depression scale, respectively. A survey of the quality of life was carried out using the medical outcomes study short-form 36 (SF-36). The relationship between quality of life and psychosocial factors was then analyzed statistically.
RESULTS: This study included 90 cases of IBD, including 48 cases of ulcerative colitis and 42 cases of Crohn's disease. There were 42 males and 48 females, and their average age was 51.31 ± 14.97 years. According to the score of disease activity index, 54 patients were in remission stage and 36 patients were in active stage. Fifteen patients suffered from anxiety and 36 patients from depression, accounting for 16.67% and 40.00%, respectively, which were considerably higher than the normal levels. IBD patients' quality of life was significantly worse compared with healthy people, and the quality of life in the active stage was considerably lower than that in the remission stage. Disease activity index, anxiety and depression were negatively correlated with patients' quality of life.
CONCLUSION: The quality of life in patients with IBD worsens considerably, which negatively correlates with disease activity, anxiety and depression.
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Abstract
The gastrointestinal tract is innervated by several distinct populations of neurons, whose cell bodies either reside within (intrinsic) or outside (extrinsic) the gastrointestinal wall. Normally, most individuals are unaware of the continuous, complicated functions of these neurons. However, for patients with gastrointestinal disorders, such as IBD and IBS, altered gastrointestinal motility, discomfort and pain are common, debilitating symptoms. Although bouts of intestinal inflammation underlie the symptoms associated with IBD, increasing preclinical and clinical evidence indicates that infection and inflammation are also key risk factors for the development of other gastrointestinal disorders. Notably, a strong correlation exists between prior exposure to gut infection and symptom occurrence in IBS. This Review discusses the evidence for neuroplasticity (structural, synaptic or intrinsic changes that alter neuronal function) affecting gastrointestinal function. Such changes are evident during inflammation and, in many cases, long after healing of the damaged tissues, when the nervous system fails to reset back to normal. Neuroplasticity within distinct populations of neurons has a fundamental role in the aberrant motility, secretion and sensation associated with common clinical gastrointestinal disorders. To find appropriate therapeutic treatments for these disorders, the extent and time course of neuroplasticity must be fully appreciated.
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A systematic review of measurement of endoscopic disease activity and mucosal healing in Crohn's disease: recommendations for clinical trial design. Inflamm Bowel Dis 2014; 20:1850-61. [PMID: 25029615 DOI: 10.1097/mib.0000000000000131] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic idiopathic inflammatory disorder of the gastrointestinal tract. Recently, mucosal healing has been proposed as a goal of therapy because clinical symptoms are subjective. Evaluative indices that measure endoscopic disease activity are required to define mucosal healing for clinical trials. The primary objective of this systematic review was to assess the existing evaluative indices that measure disease activity in CD and evaluate their role as outcome measures in clinical trials. METHODS A systematic literature review was performed using MEDLINE (Ovid), EMBASE (Ovid), PubMed, the Cochrane Library (CENTRAL), and DDW abstracts to identify randomized controlled trials and controlled clinical trials that used a relevant evaluative index from inception to February 2013. The data obtained from these trials were reviewed and summarized. RESULTS The initial literature searches identified 2300 citations. After duplicates were removed, 1454 studies remained. After application of the apriori inclusion and exclusion criteria, 109 articles were included and 3 were identified with handsearches. In total, 9 evaluative indices for CD were identified and reviewed. The Crohn's Disease Endoscopic Index of Severity (CDEIS) and the Simple Endoscopic Score in Crohn's Disease (SES-CD) are indices with the most extensively described operating properties. CONCLUSIONS Both the endoscopic evaluative instrument selected and the definition chosen for mucosal healing affect the validity of assessing endoscopic disease activity during a clinical trial for CD. Currently, the CDEIS and SES-CD have the most data regarding operating properties; however, further validation is required.
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Marchetti M, Liberato NL. Biological therapies in Crohn's disease: are they cost-effective? A critical appraisal of model-based analyses. Expert Rev Pharmacoecon Outcomes Res 2014; 14:815-24. [PMID: 25262931 DOI: 10.1586/14737167.2014.957682] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In refractory Crohn's disease, anti-TNF and anti-α 4 integrin agents are used for ameliorating disease activity but impose high costs to health-care systems. The authors systematically reviewed cost-effectiveness analyses based on decision models: most of the studies were judged to have a good quality, but a large portion assessed health and costs in a short time horizon, usually disregarding fistulizing disease and not considering safety. Infliximab induction followed by on-demand retreatment consistently proved to have a good cost per quality-adjusted life year, while maintenance treatment never satisfied commonly accepted cost-utility thresholds. Challenges in cost-effectiveness analysis include the lack of a standard model structure, a large variability in the costs of surgery and poor data on indirect costs. As clinical practice is moving to mucosal healing as a robust response marker, personalized schedules of anti-TNF therapies might prove cost-effective even in the perspective of the health-care system in the near future.
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Affiliation(s)
- Monia Marchetti
- Hematology Unit, Azienda Sanitaria Locale, Ospedale "Cardinal Massaia", Asti, Italy
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Burisch J, Weimers P, Pedersen N, Cukovic-Cavka S, Vucelic B, Kaimakliotis I, Duricova D, Bortlik M, Shonová O, Vind I, Avnstrøm S, Thorsgaard N, Krabbe S, Andersen V, Dahlerup JF, Kjeldsen J, Salupere R, Olsen J, Nielsen KR, Manninen P, Collin P, Katsanos KH, Tsianos EV, Ladefoged K, Lakatos L, Ragnarsson G, Björnsson E, Bailey Y, O'Morain C, Schwartz D, Odes S, Valpiani D, Boni MC, Jonaitis L, Kupcinskas L, Turcan S, Barros L, Magro F, Lazar D, Goldis A, Nikulina I, Belousova E, Fernandez A, Sanroman L, Almer S, Zhulina Y, Halfvarson J, Arebi N, Diggory T, Sebastian S, Lakatos PL, Langholz E, Munkholm P. Health-related quality of life improves during one year of medical and surgical treatment in a European population-based inception cohort of patients with inflammatory bowel disease--an ECCO-EpiCom study. J Crohns Colitis 2014; 8:1030-42. [PMID: 24560877 DOI: 10.1016/j.crohns.2014.01.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/06/2014] [Accepted: 01/31/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Health-related quality of life (HRQoL) is impaired in patients with Inflammatory Bowel Disease (IBD). The aim was prospectively to assess and validate the pattern of HRQoL in an unselected, population-based inception cohort of IBD patients from Eastern and Western Europe. METHODS The EpiCom inception cohort consists of 1560 IBD patients from 31 European centres covering a background population of approximately 10.1 million. Patients answered the disease specific Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and generic Short Form 12 (SF-12) questionnaire at diagnosis and after one year of follow-up. RESULTS In total, 1079 patients were included in this study. Crohn's disease (CD) patients mean SIBDQ scores improved from 45.3 to 55.3 in Eastern Europe and from 44.9 to 53.6 in Western Europe. SIBDQ scores for ulcerative colitis (UC) patients improved from 44.9 to 57.4 and from 48.8 to 55.7, respectively. UC patients needing surgery or biologicals had lower SIBDQ scores before and after compared to the rest, while biological therapy improved SIBDQ scores in CD. CD and UC patients in both regions improved all SF-12 scores. Only Eastern European UC patients achieved SF-12 summary scores equal to or above the normal population. CONCLUSION Medical and surgical treatment improved HRQoL during the first year of disease. The majority of IBD patients in both Eastern and Western Europe reported a positive perception of disease-specific but not generic HRQoL. Biological therapy improved HRQoL in CD patients, while UC patients in need of surgery or biological therapy experienced lower perceptions of HRQoL than the rest.
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Affiliation(s)
- J Burisch
- Digestive Disease Centre, Medical Section, Herlev University Hospital, Copenhagen, Denmark.
| | - P Weimers
- Digestive Disease Centre, Medical Section, Herlev University Hospital, Copenhagen, Denmark
| | - N Pedersen
- Digestive Disease Centre, Medical Section, Herlev University Hospital, Copenhagen, Denmark
| | - S Cukovic-Cavka
- Division of Gastroenterology and Hepatology, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - B Vucelic
- Division of Gastroenterology and Hepatology, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - D Duricova
- IBD Center ISCARE, Charles University, Prague, Czech Republic
| | - M Bortlik
- IBD Center ISCARE, Charles University, Prague, Czech Republic
| | - O Shonová
- Gastroenterology Department, Hospital České Budějovice, České Budějovice, Czech Republic
| | - I Vind
- Department of Medicine, Amager Hospital, Amager, Denmark
| | - S Avnstrøm
- Department of Medicine, Amager Hospital, Amager, Denmark
| | - N Thorsgaard
- Department of Medicine, Herning Central Hospital, Herning, Denmark
| | - S Krabbe
- Medical Department, Viborg Regional Hospital, Viborg, Denmark
| | - V Andersen
- Medical Department, Viborg Regional Hospital, Viborg, Denmark; Medical Department, Hospital of Southern Jutland, Aabenraa, Denmark; Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - J F Dahlerup
- Department of Medicine V, Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - J Kjeldsen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark
| | - R Salupere
- Division of Endocrinology and Gastroenterology, Tartu University Hospital, Tartu, Estonia
| | - J Olsen
- Medical Department, The National Hospital of the Faroe Islands, Torshavn, Faroe Islands
| | - K R Nielsen
- Medical Department, The National Hospital of the Faroe Islands, Torshavn, Faroe Islands
| | - P Manninen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - P Collin
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - K H Katsanos
- 1st Division of Internal Medicine and Division of Gastroenterology, Medical School, University of Ioannina, Ioannina, Greece
| | - E V Tsianos
- 1st Division of Internal Medicine and Division of Gastroenterology, Medical School, University of Ioannina, Ioannina, Greece
| | - K Ladefoged
- Medical Department, Dronning Ingrids Hospital, Nuuk, Greenland
| | - L Lakatos
- Department of Medicine, Csolnoky F. Province Hospital, Veszprem, Hungary
| | - G Ragnarsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, The National University Hospital, Reykjavik, Iceland
| | - E Björnsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, The National University Hospital, Reykjavik, Iceland
| | - Y Bailey
- Department of Gastroenterology, Adelaide and Meath Hospital, TCD, Dublin, Ireland
| | - C O'Morain
- Department of Gastroenterology, Adelaide and Meath Hospital, TCD, Dublin, Ireland
| | - D Schwartz
- Department of Gastroenterology and Hepatology, Soroka Medical Center and Ben Gurion University of the Negev, Beer Sheva, Israel; Department of Gastroenterology and Hepatology, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - S Odes
- Department of Gastroenterology and Hepatology, Soroka Medical Center and Ben Gurion University of the Negev, Beer Sheva, Israel; Department of Gastroenterology and Hepatology, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - D Valpiani
- U.O. Gastroenterologia ed Endoscopia Digestiva, Ospedale Morgagni - Pierantoni, Forlì, Italy; On behalf of the EpiCom Northern Italy centre based in Crema & Cremona, Firenze, Forlì, Padova and Reggio Emilia, Italy
| | - M C Boni
- U.O. Medicina 3° e Gastroenterologia, Azienda Ospedaliera Arcispedale S. Maria Nuova, Reggio Emilia, Italy; On behalf of the EpiCom Northern Italy centre based in Crema & Cremona, Firenze, Forlì, Padova and Reggio Emilia, Italy
| | - L Jonaitis
- Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - L Kupcinskas
- Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - S Turcan
- Department of Gastroenterology, State University of Medicine and Pharmacy of the Republic of Moldova, Chisinau, Republic of Moldova
| | - L Barros
- Hospital de Vale de Sousa, Porto, Portugal
| | - F Magro
- Department of Gastroenterology, Hospital São João, Porto, Portugal; Institute of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal; IBMC - Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal
| | - D Lazar
- Clinic of Gastroenterology, University of Medicine 'Victor Babes', Timisoara, Romania
| | - A Goldis
- Clinic of Gastroenterology, University of Medicine 'Victor Babes', Timisoara, Romania
| | - I Nikulina
- Department of Gastroenterology, Moscow Regional Research Clinical Institute, Moscow, Russian Federation
| | - E Belousova
- Department of Gastroenterology, Moscow Regional Research Clinical Institute, Moscow, Russian Federation
| | - A Fernandez
- Gastroenterology Department, POVISA Hospital, Vigo, Spain
| | - L Sanroman
- Gastroenterology Department, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - S Almer
- Division of Gastroenterology and Hepatology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Gastroenterology/UHL, County Council of Östergötland, Linköping, Sweden
| | - Y Zhulina
- Department of Medicine, Division of Gastroenterology, Örebro University Hospital, Örebro, Sweden
| | - J Halfvarson
- Department of Medicine, Division of Gastroenterology, Örebro University Hospital, Örebro, Sweden; School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - N Arebi
- St. Mark's Hospital, Imperial College London, London, UK
| | - T Diggory
- Hull and East Yorkshire NHS Trust & Hull and York Medical School, Hull Royal Infirmary, Hull, UK; Hull and York Medical School, Hull Royal Infirmary, Hull, UK
| | - S Sebastian
- Hull and East Yorkshire NHS Trust & Hull and York Medical School, Hull Royal Infirmary, Hull, UK; Hull and York Medical School, Hull Royal Infirmary, Hull, UK
| | - P L Lakatos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - E Langholz
- Department of Medical Gastroenterology, Gentofte Hospital, Copenhagen, Denmark
| | - P Munkholm
- Digestive Disease Centre, Medical Section, Herlev University Hospital, Copenhagen, Denmark
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D'Haens GR, Sartor RB, Silverberg MS, Petersson J, Rutgeerts P. Future directions in inflammatory bowel disease management. J Crohns Colitis 2014; 8:726-34. [PMID: 24742736 DOI: 10.1016/j.crohns.2014.02.025] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/26/2014] [Accepted: 02/26/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Clinical management of inflammatory bowel diseases (IBD), new treatment modalities and the potential impact of personalised medicine remain topics of intense interest as our understanding of the pathophysiology of IBD expands. METHODS Potential future strategies for IBD management are discussed, based on recent preclinical and clinical research. RESULTS A top-down approach to medical therapy is increasingly being adopted for patients with risk factors for severe inflammation or an unfavourable disease course in an attempt to halt the inflammatory process as early as possible, prevent complications and induce mucosal healing. In the future, biological therapies for IBD are likely to be used more selectively based on personalised benefit/risk assessment, determined through reliable biomarkers and tissue signatures, and will probably be optimised throughout the course of treatment. Biologics with different mechanisms of action will be available; when one drug fails, patients will be able to switch to another and even combination biologics may become a reality. The role of biotherapeutic products that are similar to currently licensed biologics in terms of quality, safety and efficacy - i.e. biosimilars - is at an early stage and requires further experience. Other therapeutic strategies may involve manipulation of the microbiome using antibiotics, probiotics, prebiotics, diet and combinations of all these approaches. Faecal microbiota transplantation is also a potential option in IBD although controlled data are lacking. CONCLUSIONS The future of classifying, prognosticating and managing IBD involves an outcomes-based approach to identify biomarkers reflecting various biological processes that can be matched with clinically important endpoints.
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Affiliation(s)
- Geert R D'Haens
- Department of Gastroenterology, Academic Medical Centre, University of Amsterdam, The Netherlands.
| | - R Balfour Sartor
- Division of Gastroenterology and Hepatology, Multidisciplinary IBD Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Mark S Silverberg
- Mount Sinai Hospital, University of Toronto, ON, Canada; The Zane Cohen Centre for Digestive Diseases, University of Toronto, ON, Canada
| | - Joel Petersson
- Global Medical Affairs Gastroenterology, AbbVie, Rungis, France
| | - Paul Rutgeerts
- Division of Gastroenterology, Department of Internal Medicine, Catholic University of Leuven, Leuven, Belgium
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Cohen BL, Zoëga H, Shah SA, LeLeiko N, Lidofsky S, Bright R, Flowers N, Law M, Moniz H, Merrick M, Sands BE. Fatigue is highly associated with poor health-related quality of life, disability and depression in newly-diagnosed patients with inflammatory bowel disease, independent of disease activity. Aliment Pharmacol Ther 2014; 39:811-22. [PMID: 24612278 PMCID: PMC4670472 DOI: 10.1111/apt.12659] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 05/06/2013] [Accepted: 01/24/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fatigue is common in Crohn's disease (CD) and ulcerative colitis (UC). Data on fatigue in newly diagnosed patients are unavailable. AIM To report prevalence of fatigue in newly diagnosed CD and UC patients and examine its association with health-related quality of life (HRQOL), depression and disability. METHODS The Ocean State Crohn's and Colitis Area Registry (OSCCAR) is a statewide cohort of newly diagnosed inflammatory bowel disease patients in Rhode Island. Fatigue was assessed using the Functional Assessment of Chronic Illness Therapy-Fatigue Scale. Patients were administered instruments measuring HRQOL, overall disability and work impairment, and depression. RESULTS Fatigue was prevalent in 26.4% of 220 subjects. Cohen's d effect sizes for fatigue were large: Short-Form 36 Health Survey mental health component (CD 1.5, UC 1.4) and physical health component (CD 1.4, UC 1.4), EuroQol-5D valuation of current health state (CD 1.2, UC 1.0), Inflammatory Bowel Disease Questionnaire (CD 1.9, UC 1.6) and Patient Health Questionnaire depression scale (CD 1.8, UC 1.7). Fatigued patients reported more work impairment (Score difference: CD 29.5%, UC 23.8%) and activity impairment (score difference: CD 32.3%, UC 25.7%) on the Work Productivity and Activity Impairment Questionnaire. Fatigue's association with all scores remained highly significant despite controlling for disease activity. CONCLUSIONS Fatigue is strongly associated with poor HRQOL, disability and depression similarly in CD and UC even when controlling for disease activity. Fatigue's association with a wide range of patient-reported outcome measures suggests that monitoring fatigue is a simple way to screen for overall disruption in patient life.
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Affiliation(s)
- B L Cohen
- Division of Gastroenterology, Icahn School of Medicine at Mount SinaiNew York, NY, USA
| | - H Zoëga
- Division of Gastroenterology, Icahn School of Medicine at Mount SinaiNew York, NY, USA,Faculty of Medicine, Center of Public Health Sciences, University of IcelandReykjavik, Iceland
| | - S A Shah
- The Warren Alpert Medical School of Brown University, Gastroenterology Associates, Inc.Providence, RI, USA
| | - N LeLeiko
- Division of Pediatric Gastroenterology, Nutrition, and Liver Disease, Warren Alpert Medical School of Brown University, Hasbro Children's Hospital/Rhode Island HospitalProvidence, RI, USA
| | - S Lidofsky
- The Warren Alpert Medical School of Brown University, Gastroenterology Associates, Inc.Providence, RI, USA
| | - R Bright
- Division of Gastroenterology, Rhode Island HospitalProvidence, RI, USA
| | - N Flowers
- Centers for Disease Control and PreventionAtlanta, GA, USA
| | - M Law
- Division of Gastroenterology, Rhode Island HospitalProvidence, RI, USA
| | - H Moniz
- Division of Gastroenterology, Rhode Island HospitalProvidence, RI, USA
| | - M Merrick
- Crohn's & Colitis Foundation of AmericaNew York, NY, USA
| | - B E Sands
- Division of Gastroenterology, Icahn School of Medicine at Mount SinaiNew York, NY, USA
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Mosli M, Al Beshir M, Al-Judaibi B, Al-Ameel T, Saleem A, Bessissow T, Ghosh S, Almadi M. Advances in the diagnosis and management of inflammatory bowel disease: challenges and uncertainties. Saudi J Gastroenterol 2014; 20:81-101. [PMID: 24705146 PMCID: PMC3987157 DOI: 10.4103/1319-3767.129473] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 12/30/2013] [Indexed: 12/14/2022] Open
Abstract
Over the past two decades, several advances have been made in the management of patients with inflammatory bowel disease (IBD) from both evaluative and therapeutic perspectives. This review discusses the medical advancements that have recently been made as the standard of care for managing patients with ulcerative colitis (UC) and Crohn's Disease (CD) and to identify the challenges associated with implementing their use in clinical practice. A comprehensive literature search of the major databases (PubMed and Embase) was conducted for all recent scientific papers (1990-2013) giving the recent updates on the management of IBD and the data were extracted. The reported advancements in managing IBD range from diagnostic and evaluative tools, such as genetic tests, biochemical surrogate markers of activity, endoscopic techniques, and radiological modalities, to therapeutic advances, which encompass medical, endoscopic, and surgical interventions. There are limited studies addressing the cost-effectiveness and the impact that these advances have had on medical practice. The majority of the advances developed for managing IBD, while considered instrumental by some IBD experts in improving patient care, have questionable applications due to constraints of cost, lack of availability, and most importantly, insufficient evidence that supports their role in improving important long-term health-related outcomes.
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Affiliation(s)
- Mahmoud Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Mohammad Al Beshir
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, King Fahd Specialist Hospital, Dammam, Saudi Arabia
| | - Bandar Al-Judaibi
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Turki Al-Ameel
- Department of Medicine, King Fahd Specialist Hospital, Dammam, Saudi Arabia
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Abdulaziz Saleem
- Department of Surgery, McGill University and McGill University Health Centre, Montreal, Canada
- Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Talat Bessissow
- Department of Medicine, McGill University and McGill University Health Centre, Montreal, Canada
| | - Subrata Ghosh
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Majid Almadi
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
- Department of Medicine, McGill University and McGill University Health Centre, Montreal, Canada
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Mazzuoli S, Guglielmi FW, Antonelli E, Salemme M, Bassotti G, Villanacci V. Definition and evaluation of mucosal healing in clinical practice. Dig Liver Dis 2013; 45:969-77. [PMID: 23932331 DOI: 10.1016/j.dld.2013.06.010] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 05/21/2013] [Accepted: 06/26/2013] [Indexed: 12/11/2022]
Abstract
Since the introduction of biological therapy, endoscopic and histological remission, i.e. mucosal healing, has become an important therapeutic goal in Crohn's Disease and Ulcerative Colitis. Mucosal healing is associated with lower rates of hospitalization and surgery, although its role in preventing progression and changing the natural history of the disease has not been clearly demonstrated. A precise definition of mucosal healing has not yet been established, although the concept used in clinical trials is the "complete absence of all inflammatory and ulcerative lesions in all segments of gut" at endoscopy. This definition does not include mucosal improvement and does not distinguish among grades of mucosal healing. In both Crohn's Disease and Ulcerative Colitis trials, several qualitative and quantitative numeric endoscopic indices have been proposed to measure and distinguish endoscopic changes. In addition, the microscopic features associated with inflammatory bowel diseases are considerably modified by the course of the disease and the treatments adopted. However, it is not yet clear whether microscopic healing should be a primary endpoint in clinical trials. In this paper we discuss endoscopic and histological findings and the limitations of the endoscopic and histological indices as a basis for a standardised diagnosis of mucosal healing.
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Affiliation(s)
- Silvia Mazzuoli
- Gastroenterology and Artificial Nutrition Department, "San Nicola Pellegrino" Hospital Trani, BT, Italy
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Optimising monitoring in the management of Crohn's disease: a physician's perspective. J Crohns Colitis 2013; 7:653-69. [PMID: 23562672 DOI: 10.1016/j.crohns.2013.02.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 02/05/2013] [Indexed: 02/08/2023]
Abstract
Management of Crohn's disease has traditionally placed high value on subjective symptom assessment; however, it is increasingly appreciated that patient symptoms and objective parameters of inflammation can be disconnected. Therefore, strategies that objectively monitor inflammatory activity should be utilised throughout the disease course to optimise patient management. Initially, a thorough assessment of the severity, location and extent of disease is needed to ensure a correct diagnosis, identify any complications, help assess prognosis and select appropriate therapy. During follow-up, clinical decision-making should be driven by disease activity monitoring, with the aim of optimising treatment for tight disease control. However, few data exist to guide the choice of monitoring tools and the frequency of their use. Furthermore, adaption of monitoring strategies for symptomatic, asymptomatic and post-operative patients has not been well defined. The Annual excHangE on the ADvances in Inflammatory Bowel Disease (IBD Ahead) 2011 educational programme, which included approximately 600 gastroenterologists from 36 countries, has developed practice recommendations for the optimal monitoring of Crohn's disease based on evidence and/or expert opinion. These recommendations address the need to incorporate different modalities of disease assessment (symptom and endoscopic assessment, measurement of biomarkers of inflammatory activity and cross-sectional imaging) into robust monitoring. Furthermore, the importance of measuring and recording parameters in a standardised fashion to enable longitudinal evaluation of disease activity is highlighted.
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Graff LA, Clara I, Walker JR, Lix L, Carr R, Miller N, Rogala L, Bernstein CN. Changes in fatigue over 2 years are associated with activity of inflammatory bowel disease and psychological factors. Clin Gastroenterol Hepatol 2013; 11:1140-6. [PMID: 23602816 DOI: 10.1016/j.cgh.2013.03.031] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 03/24/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Cross-sectional studies have identified high levels of fatigue in patients with active or quiescent inflammatory bowel disease (IBD), but there has been little attention to the long-term effects of fatigue in these patients. We performed a longitudinal study of fatigue in patients with IBD to determine its course and contributing factors. METHODS Data were obtained from participants in the Manitoba IBD Cohort Study (N = 312; 51% with Crohn's disease), a longitudinal population-based study. Symptomatic disease activity was measured every 6 months for 2 years to characterize long-term disease patterns as active, fluctuating, or inactive, based on the validated Manitoba IBD Index. We collected data concurrently on fatigue (Multidimensional Fatigue Inventory), psychological function, and laboratory biomarkers at the point of study entry and 1 and 2 years later. RESULTS Of the study participants, 26% had consistently inactive, 29% had fluctuating, and 45% had consistently active disease over the 2-year time period. Mean levels of fatigue were strongly associated with disease activity; participants with consistently inactive disease had the lowest level of fatigue at each time point. Multivariate analyses indicated fatigue levels increased over time regardless of disease pattern (P < .001). Adjusting for disease activity, disease type and age, sex (female; P < .001), and psychological variables of distress (P < .001), reduced psychological well-being (P = .002) and poor sleep quality (P < .001) were associated independently with increases in fatigue over time. CONCLUSIONS Fatigue can increase over time in patients with IBD, even when their disease is in remission. Psychological factors are useful targets for intervention to reduce fatigue.
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Affiliation(s)
- Lesley A Graff
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada.
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Stewart MJ, Garg SK, Seow CH, Storr M. Interventions for induction and maintenance of mucosal healing in Crohn's disease. Hippokratia 2012. [DOI: 10.1002/14651858.cd010141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Michael J Stewart
- Dalhousie University; Department of Medicine; 9th Floor Victoria Building Victoria General Hospital Site 1276 South Park Street Halifax Nova Scotia, Canada B3H 2Y9
| | - Sushil K Garg
- University of Minnesota; Department of Surgery; 420 Delaware Street SE Mayo Mail Code 195 Minneapolis USA 55455
| | - Cynthia H Seow
- University of Calgary; Departments of Medicine & Community Health Sciences; TRW Building Rm 6D18 3280 Hospital Drive NW Calgary Alberta Canada T2N 4Z6
| | - Martin Storr
- University of Munich; Department of Medicine; Marchioninistr 15 Munich Germany 81377
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