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Mukhtar MS, Mosli MH. Selecting first-line advanced therapy for ulcerative colitis: A clinical application of personalized medicine. Saudi J Gastroenterol 2024; 30:126-137. [PMID: 38597333 DOI: 10.4103/sjg.sjg_427_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/13/2024] [Indexed: 04/11/2024] Open
Abstract
Ulcerative colitis (UC) is a chronic autoimmune inflammatory disease that affects the colon, leading to symptoms of bloody diarrhea, abdominal cramps, and urgency. The treatment of UC has evolved over the past few decades from locally active anti-inflammatory compounds to more selective therapies that target specific arrays of the immune system. The challenge of selecting the first advanced therapy became apparent in this rapidly expanding landscape of medications. No current investigational tools, such as genetic, immunologic, or biological markers, can guide the identification of the safest and most effective therapeutic option for each patient. Hence, physicians must carefully assess patient/disease characteristics and match them with the most suitable drug through a clinically driven assessment. In this paper, we outline patient and drug characteristics that play a role in selecting first-line advanced therapies for UC and propose an algorithm for selection.
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Affiliation(s)
- Mariam S Mukhtar
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Inflammatory Bowel Disease Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mahmoud H Mosli
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Inflammatory Bowel Disease Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
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Mosli MH, Alghamdi MK, Bokhary OA, Alzahrani MA, Takieddin SZ, Galai TA, Alsahafi MA, Saadah OI. Inflammatory bowel disease in the elderly: A focus on disease characteristics and treatment patterns. Saudi J Gastroenterol 2023; 29:212-218. [PMID: 36722525 PMCID: PMC10445499 DOI: 10.4103/sjg.sjg_503_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/18/2022] [Accepted: 12/18/2022] [Indexed: 02/02/2023] Open
Abstract
Background As the population ages, the number of elderly inflammatory bowel disease (IBD) patients is expected to increase. The clinical features and therapeutic options for young and old patients may differ, as elderly IBD patients are likely to have different comorbidities and disease characteristics. The goal of this study was to examine the clinical aspects and therapeutic choices for elderly Saudi IBD patients. Methods We conducted a retrospective study aimed at describing the demographic, clinical, and management characteristics of IBD in elderly patients (≥60 years) who followed up at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. The data was extracted from the KAUH inflammatory bowel disease information system (IBDIS) registry. The primary outcome was to describe disease characteristics in accordance with the Montréal classification and the secondary outcomes were to describe treatment patterns and identify significant clinical associations. Results Our data were collected from 76 patients who fulfilled the study inclusion criteria. Females outnumbered males (53.9% vs 46.1%) and the mean age was 51.5 ± 9.7 years. Essential hypertension (26.3%) was the most common comorbidity followed by diabetes mellitus (23.6%), and malignant neoplasms (9.21%). More than half of the patients with Crohn's disease (CD) had disease onset after forty years of age. The most common form of disease distribution was ileocolonic disease (64.7%). Less than 17% of patients had a penetrating disease phenotype. About 88 percent of patients with UC presented >40 years of age. Approximately, half of the cohort had left-sided ulcerative colitis (UC) (48%), followed by pancolitis (40%). The most prescribed medication class for IBD was 5-aminosalicylic acid (5-ASA) derivatives (56.58%) followed by corticosteroids and immunosuppressive drugs. Conclusions In Saudi Arabia, age-specific concerns including comorbidities and polypharmacy remain the major challenges in the management of elderly IBD patients.
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Affiliation(s)
- Mahmoud H. Mosli
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Maha K. Alghamdi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Omar A. Bokhary
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Siba Z. Takieddin
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Tala A. Galai
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Majid A. Alsahafi
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Omar I. Saadah
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Alsahafi MA, Alajhar NA, Almahyawi AO, Alsulami HH, Alghamdi WA, Alharbi LA, Alsulami AS, Aljehani JT, Alkhowaiter SS, Mosli MH. The prevalence and risk factors for hiatal hernia among patients undergoing endoscopy: A retrospective analysis. Saudi Med J 2023; 44:509-512. [PMID: 37182923 PMCID: PMC10187740 DOI: 10.15537/smj.2023.44.5.20220903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/09/2023] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES To determine the prevalence of hiatal hernia (HH) and its association with age, gender, and body mass index (BMI). METHODS We retrospectively included patients who underwent esophagogastroduodenoscopy (EGD) at an academic tertiary care hospital. Data were collected on the presence of HH as well as patient demographics including age, gender, and BMI. Univariate and multivariate analysis were done to determine risk factors for HH. RESULTS A total of 2805 patients were included in this study. The mean age was 48.6 (±18.6) years and males constituted 28.8% of the study population. The mean BMI was 29.7 (±8.6) kg/m². The prevalence of HH was 29.8% among all patients and 48.6% among those who underwent EGD for gastroesophageal reflux disease-related indications. There was no significant association between HH and female gender (OR 1.04, 95%CI: 0.88 -1.26, p=0.53), older age (OR 0.77, 95%CI: 0.72 - 1.06, p=0.19) or BMI (OR 1.07, 95%CI: 0.9 - 1.2, p=0.39). CONCLUSION The prevalence of HH was 28.9% based on this large endoscopy-based population. We found no association between HH and gender, age, or BMI.
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Affiliation(s)
- Majid A. Alsahafi
- From the Division of Gastroenterology, Department of Medicine (Alsahafi, Alajhar, Almahyawi, Alsulami, Alghamdi, Alharbi, Alsulami, Aljehanil, Mosli), Faculty of Medicine, King Abdulaziz University, Jeddah; and from the Division of Gastroenterology, Department of Medicine (Alkhowaiter), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
| | - Najla A. Alajhar
- From the Division of Gastroenterology, Department of Medicine (Alsahafi, Alajhar, Almahyawi, Alsulami, Alghamdi, Alharbi, Alsulami, Aljehanil, Mosli), Faculty of Medicine, King Abdulaziz University, Jeddah; and from the Division of Gastroenterology, Department of Medicine (Alkhowaiter), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
| | - Amjad O. Almahyawi
- From the Division of Gastroenterology, Department of Medicine (Alsahafi, Alajhar, Almahyawi, Alsulami, Alghamdi, Alharbi, Alsulami, Aljehanil, Mosli), Faculty of Medicine, King Abdulaziz University, Jeddah; and from the Division of Gastroenterology, Department of Medicine (Alkhowaiter), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
| | - Hadeel H. Alsulami
- From the Division of Gastroenterology, Department of Medicine (Alsahafi, Alajhar, Almahyawi, Alsulami, Alghamdi, Alharbi, Alsulami, Aljehanil, Mosli), Faculty of Medicine, King Abdulaziz University, Jeddah; and from the Division of Gastroenterology, Department of Medicine (Alkhowaiter), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
| | - Wejdan A. Alghamdi
- From the Division of Gastroenterology, Department of Medicine (Alsahafi, Alajhar, Almahyawi, Alsulami, Alghamdi, Alharbi, Alsulami, Aljehanil, Mosli), Faculty of Medicine, King Abdulaziz University, Jeddah; and from the Division of Gastroenterology, Department of Medicine (Alkhowaiter), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
| | - Lama A. Alharbi
- From the Division of Gastroenterology, Department of Medicine (Alsahafi, Alajhar, Almahyawi, Alsulami, Alghamdi, Alharbi, Alsulami, Aljehanil, Mosli), Faculty of Medicine, King Abdulaziz University, Jeddah; and from the Division of Gastroenterology, Department of Medicine (Alkhowaiter), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
| | - Afnan S. Alsulami
- From the Division of Gastroenterology, Department of Medicine (Alsahafi, Alajhar, Almahyawi, Alsulami, Alghamdi, Alharbi, Alsulami, Aljehanil, Mosli), Faculty of Medicine, King Abdulaziz University, Jeddah; and from the Division of Gastroenterology, Department of Medicine (Alkhowaiter), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
| | - Jumana T. Aljehani
- From the Division of Gastroenterology, Department of Medicine (Alsahafi, Alajhar, Almahyawi, Alsulami, Alghamdi, Alharbi, Alsulami, Aljehanil, Mosli), Faculty of Medicine, King Abdulaziz University, Jeddah; and from the Division of Gastroenterology, Department of Medicine (Alkhowaiter), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
| | - Saad S. Alkhowaiter
- From the Division of Gastroenterology, Department of Medicine (Alsahafi, Alajhar, Almahyawi, Alsulami, Alghamdi, Alharbi, Alsulami, Aljehanil, Mosli), Faculty of Medicine, King Abdulaziz University, Jeddah; and from the Division of Gastroenterology, Department of Medicine (Alkhowaiter), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
| | - Mahmoud H. Mosli
- From the Division of Gastroenterology, Department of Medicine (Alsahafi, Alajhar, Almahyawi, Alsulami, Alghamdi, Alharbi, Alsulami, Aljehanil, Mosli), Faculty of Medicine, King Abdulaziz University, Jeddah; and from the Division of Gastroenterology, Department of Medicine (Alkhowaiter), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
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Mosli MH, Alsahafi M, Alsanea MN, Alhasani F, Ahmed M, Saadah O. Multimorbidity among inflammatory bowel disease patients in a tertiary care center: a retrospective study. BMC Gastroenterol 2022; 22:487. [DOI: 10.1186/s12876-022-02578-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 11/14/2022] [Indexed: 11/28/2022] Open
Abstract
Abstract
Background and objectives
Inflammatory bowel disease (IBD) is a chronic systemic inflammatory condition that debilitate the quality of life. Multimorbidity, a concept only beginning to emerge in IBD, is defined as two or more comorbidities present in the same individual. Notably, we used the term multimorbidity to refer to two or more comorbidities excluding IBD. Multimorbidity is linked to decreased quality of life, poorer disease outcomes, increased hospitalizations, healthcare costs and polypharmacy complications. We aim to estimate the prevalence of multimorbidity and to explore its effect on IBD patients.
Methods
We retrospectively reviewed all IBD patients registered in a validated web-based registry since February 2018. Data on patient demographics, comorbidities, IBD and extraintestinal complications were obtained. We analyzed the date using univariate, bivariate and multivariable analysis.
Results
Among 767 IBD patients, 54.6% had Crohn’s disease (CD), 41.9% had ulcerative colitis (UC) and 3.5% had IBD unclassified. The median age at diagnosis was 22 years (IQR: 15–29). Males compromised 50.2% of patients. According to the Montréal IBD classification, most UC patients had moderate UC (47.8%) while most CD patients had non-stricturing non-penetrating CD (49.8%). Overall, 10.3% IBD patients had multimorbidity and 23.9% had at least one comorbidity. The most common comorbidity was diabetes mellitus (4.9%) followed by essential hypertension (4%) and iron deficiency anemia (3%). Female gender (P = 0.008) and UC (P = 0.005) were more likely to have multimorbidity. Multimorbid IBD patients were more likely to develop thrombosis than non-multimorbid peers (16.7% vs. 1.6%; P < 0.001). Higher age at diagnosis (OR = 1.04, 95%CI: 1.01–1.07) and having a history of thrombosis (OR = 7.82, 95% CI: 2.67–22.92) are associated with increased risk of multimorbidity.
Conclusion
Multimorbidity is not uncommon among IBD patients, especially females diagnosed with UC. Our findings indicate that future studies are needed to explore the effects of multimorbidity on IBD patients.
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Mosli MH, Almudaiheem HY, AlAmeel T, Bakkari SA, Alharbi OR, Alenzi KA, Khardaly AM, AlMolaiki MA, Al-Omari BA, Albarakati RG, Al-Jedai AH, Saadah OI, Almadi MA, Al-Bawardy B. Saudi Arabia consensus guidance for the diagnosis and management of adults with inflammatory bowel disease. Saudi J Gastroenterol 2022; 29:361671. [PMID: 36412460 PMCID: PMC10540981 DOI: 10.4103/sjg.sjg_277_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/23/2022] [Accepted: 09/05/2022] [Indexed: 02/10/2023] Open
Abstract
Optimal management of inflammatory bowel disease (IBD) relies on a clear understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This article provides concise guidelines for the management of IBD in adults, based on the most up-to-date information at the time of writing and will be regularly updated. These guidelines were developed by the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacy. After an extensive literature review, 78 evidence-and expert opinion-based recommendations for diagnosing and treating ulcerative colitis and Crohn's disease in adults were proposed and further refined by a voting process. The consensus guidelines include the finally agreed on statements with their level of evidence covering different aspects of IBD diagnosis and treatment.
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Affiliation(s)
- Mahmoud H. Mosli
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | | | - Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Shakir A. Bakkari
- Division of Gastroenterology, King Saud Medical City, Riyadh, Saudi Arabia
| | - Othman R. Alharbi
- Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Khalidah A. Alenzi
- Regional Drug Information and Pharmacovigilance Center, Ministry of Health, Tabuk, Saudi Arabia
| | | | - Maha A. AlMolaiki
- Department of Pharmaceutical Care, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Bedor A. Al-Omari
- Pharmaceutical Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Rayan G. Albarakati
- Department of Obstetrics and Gynecology, Majmaah University, Riyadh, Saudi Arabia
| | - Ahmed H. Al-Jedai
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | - Omar I. Saadah
- Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Majid A. Almadi
- Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Badr Al-Bawardy
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
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Malibary NH, Ezzat MA, Mogharbel AM, Kouzaba KA, Alkadi AA, Malki UH, Gharib SM, Altowairqi FM, Saadah OI, Mosli MH. Factors Affecting Ulcerative Colitis Flare-Ups: Associations With Smoking Habits and Other Patient Characteristics. Cureus 2021; 13:e19834. [PMID: 34824952 PMCID: PMC8610210 DOI: 10.7759/cureus.19834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 12/03/2022] Open
Abstract
Background and study aims Currently, there are no studies conducted in the Kingdom of Saudi Arabia (KSA) that have assessed the relationship between ulcerative colitis (UC) flare-ups and smoking. The present study aims to assess the risk of UC flare-ups and evaluate the relationship between UC flare-ups and smoking in adult patients following up at King Abdulaziz University Hospital in Jeddah, KSA. Patients and methods This was a retrospective study involving patients with confirmed UC between January 2015 and December 2020. Various information was examined, including demographic, clinical, endoscopic, radiologic, and laboratory data. Descriptive statistics were used for summarizing findings and a logistic regression analysis was applied to test for possible associations. Results Eighty-nine patients with UC were included in the study. Almost half (48.3%) had recurrent UC flare-ups during follow-up. A non-significant relationship was found between recurrent UC flares and all types of smoking habits (cigarette smoking, P = 0.15; shisha smoking, P = 0.88; and vape smoking, P = 0.09). Participants who were underweight (P = 0.041), had family history of UC (P = 0.013), depression (P = 0.033), fecal incontinence (P = 0.003), iron deficiency anemia (P = 0.009), or a malignancy (P = 0.039) had a significantly higher probability of experiencing recurrent flares. Binary logistic regressions revealed that family history of UC (OR = 5.3, P = 0.007) and fecal incontinence (OR = 4.7, P = 0.006) were associated significantly with recurrent flares. Conclusion There was no clear association between smoking and recurrent UC flares identified in this cohort. Of the variables considered, UC patients with fecal incontinence or family history of UC were at the highest risk of developing recurrent flares.
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Affiliation(s)
- Nadim H Malibary
- Visceral and General Surgery, Hautepierre Hospital, Strasbourg, FRA.,Surgery, King Abdulaziz University Hospital, Jeddah, SAU
| | | | | | | | | | - Usama H Malki
- Medicine, King Abdulaziz University Hospital, Jeddah, SAU
| | | | | | - Omar I Saadah
- Pediatric Gastroenterology, King Abdulaziz University Hospital, Jeddah, SAU
| | - Mahmoud H Mosli
- Gastroenterology, King Abdulaziz University Hospital, Jeddah, SAU
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Mosli MH, Alamri AA, Saadah OI. Work and School Absenteeism in Inflammatory Bowel Disease Patients in Jeddah, Saudi Arabia: A Cross-Sectional Study. Saudi J Med Med Sci 2021; 9:159-166. [PMID: 34084107 PMCID: PMC8152386 DOI: 10.4103/sjmms.sjmms_79_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 08/01/2020] [Accepted: 11/03/2020] [Indexed: 12/29/2022]
Abstract
Background: Inflammatory bowel disease (IBD), which can have a considerable effect on quality of life, productivity and performance, is typically diagnosed during periods of life in which patients have academic and career-related responsibilities. Objective: The objective of the study was to determine the effect of IBD symptoms on work and school absenteeism in patients from Saudi Arabia. Patients and Methods: This cross-sectional survey included patients diagnosed with IBD, aged >8–60 years, at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. The validated 32-question IBD quality-of-life questionnaire was used to elicit information regarding quality of life and another 9-question validated questionnaire was used to assess work and school absenteeism. A logistic regression analysis was used to identify possible determinants of absenteeism. Results: A total of 123 IBD patients were included, with a 1:1 male-to-female ratio. The median age at presentation was 26 years (range: 8–59 years), 56.9% had Crohn's disease, and 43.1% had ulcerative colitis. Further, 58 (47.2%) were employed, 49 (39.8%) were students and 16 (13%) were unemployed. Forty-seven (43.9%) participants reported absenteeism: 26 were employees (55.3%) and 21 were students (44.7%). A binary logistic regression analysis identified IBD subtype (P = 0.006) and the presence of perianal disease (P = 0.028) as clinical predictors for absenteeism from school or work. A feeling of abdominal pain (P = 0.015), fatigue (P = 0.015) and difficulty taking part in social engagements (P < 0.001) were also significantly associated with absenteeism. Conclusions: A sizeable proportion of the participants reported absenteeism owing to the effects of IBD. IBD subtype, perianal disease, presence of ongoing abdominal pain, fatigue and difficulty in social engagement were strongly associated with nonattendance.
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Affiliation(s)
- Mahmoud H Mosli
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Inflammatory Bowel Disease Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdullah A Alamri
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Omar I Saadah
- Inflammatory Bowel Disease Research Group, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Pediatrics, Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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Abusharifah O, Bokhary RY, Mosli MH, Saadah OI. Solitary rectal ulcer syndrome in children and adolescents: a descriptive clinicopathologic study. Int J Clin Exp Pathol 2021; 14:399-407. [PMID: 33936361 PMCID: PMC8085826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/02/2020] [Indexed: 06/12/2023]
Abstract
Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder of the rectum. While benign, it can cause concern for patients and affect quality of life. Reported studies on SRUS worldwide are scarce. The aim of this study is to describe the clinicopathologic characteristics of SRUS in a cohort of children based in Saudi Arabia. In this study, children with a confirmed diagnosis of SRUS at King Abdulaziz University Hospital (KAUH) were included, during the period November 2003 to November 2017. Data were collected from hospital medical records. The study comprised twenty-one patients: 17 males (81%) and 4 females (19%); the median age was 11.4 years (range, 5.43-17.9 years). The most common presenting symptoms were rectal bleeding in 21 patients (100%), passage of mucus in 16 (76.1%), abdominal pain in 14 (66.6%), constipation in 13 (61.9%), straining in 9 (42.9%), and rectal prolapse in 5 (23.8%). The most common finding at initial colonoscopy was a single ulcer in 7 patients (33.3%), multiple ulcers in 6 (28.5%), polypoid lesions in 5 (23.8%), and hyperemic mucosa in 3 (14.2%). All patients received medical treatment and 14 (81%) continued to manifest one or more of the symptoms following treatment, which required subsequent modification of the treatment course. None of the patients required surgery. In conclusion, the study found rectal bleeding to be the most common presentation, with a single ulcer being the most prevalent lesion in endoscopy. Treatment response was variable, but almost half of patients reported relief of symptoms following treatment.
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Affiliation(s)
- Ohood Abusharifah
- Pediatric Gastroenterology Unit, Department of Pediatrics, Faculty of Medicine, King Abdulaziz UniversityJeddah, Saudi Arabia
- Departemnt of Pediatrics, Maternity and Children HospitalAbha, Saudi Arabia
| | - Rana Y Bokhary
- The Department of Pathology, Faculty of Medicine, King Abdulaziz UniversityJeddah, Saudi Arabia
| | - Mahmoud H Mosli
- The Department of Internal Medicine, Faculty of Medicine, King Abdulaziz UniversityJeddah, Saudi Arabia
| | - Omar I Saadah
- Pediatric Gastroenterology Unit, Department of Pediatrics, Faculty of Medicine, King Abdulaziz UniversityJeddah, Saudi Arabia
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Saadah OI, Annese V, Mosli MH. Prevalence and Predictors of Reduced Bone Density in Child and Adolescent Patients With Crohn's Disease. J Clin Densitom 2021; 24:252-258. [PMID: 32553268 DOI: 10.1016/j.jocd.2020.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/28/2020] [Accepted: 05/05/2020] [Indexed: 11/28/2022]
Abstract
Reduced bone mineral density (BMD) has broadly been found to be associated with inflammatory bowel disease across a number of geographical locations and cultures. We aimed to estimate the prevalence of reduced BMD and identify clinical predictors in a cohort of Crohn's disease patients (CD) in Saudi Arabia. We conducted a retrospective study involving children and adolescents with CD between 2013 and 2018. BMD was evaluated using dual-energy X-ray absorptiometry scans of the spine and body. A multivariate analysis was performed for the detection of predictors of low BMD. Sixty-four patients were enrolled. The median age was 16 years (range, 8-19 years) and 55% of patients were males. Total body BMD scanning identified 25 patients (39%) with osteoporosis. Twenty patients (31.3%) were found to have z scores consistent with osteopenia. A multivariate regression analysis identified a low weight-for-age z score (B coefficient = 0.347, 95% confidence interval [CI] = 0.211-0.482, p < 0.001 for Spine BMD and B coefficient = 0.321, 95% CI = 0.170-0.472, p < 0.001 for total body BMD), a low height-for-age z score (B coefficient = 0.187, 95% CI = 0.035-0.338, p = 0.017 for spine BMD and B coefficient = 0.0.258, 95% CI = 0.089-0.427, p = 0.004 for total body BMD), a low 25-hyroxyvitamin D level (B coefficient = 0.026, 95% CI = 0.013-0.038, p < 0.001 for spine BMD and B coefficient = 0.016, 95% CI = 0.002-0.031, p = 0.026 for total body BMD), and a higher number of corticosteroid induction courses (B coefficient = -0.567, 95% CI = -0.923 to -0.212, p = 0.003 for spine BMD and B coefficient = -0.566, 95% CI = 0.963-0.169, p = 0.007 for total body BMD) as predictors of low BMD. In the spine BMD analysis, older age at the time of presentation was identified as a significant predictor for low bone density (B coefficient = 0.254, 95% CI = 0.141-0.368, p < 0.001). In conclusion, Saudi Arabian children and adolescents with CD have a high prevalence rate of low bone density compared to Western populations. Several clinical characteristics are identified as significant predictors for low BMD.
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Affiliation(s)
- Omar I Saadah
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia; Inflammatory Bowel Disease Research Group, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Vito Annese
- Valiant Clinic & American Hospital, Dubai, United Arab Emirates
| | - Mahmoud H Mosli
- Inflammatory Bowel Disease Research Group, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Alharbi O, Almadi MA, Azzam N, Aljebreen AM, AlAmeel T, Schreiber S, Mosli MH. Clinical characteristics, natural history, and outcomes of Crohn's-related intra-abdominal collections. Saudi J Gastroenterol 2021; 27:79-84. [PMID: 33723092 PMCID: PMC8183360 DOI: 10.4103/sjg.sjg_89_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Intra-abdominal collections in the form of abscesses or matted bowel loops, called phlegmons, might occur in patients with Crohn's disease (CD). The clinical characteristics and management of such conditions are not well described. We aim to characterize CD-related intra-abdominal collections clinically, and identify predictors of need for surgical interventions and the time to surgery. METHODS We utilized the Saudi Inflammatory Bowel Disease Information System (IBDIS) database to identify all patients treated for radiologically proven intra-abdominal abscesses or phlegmons since inception. Demographics, clinical data, clinical course, and treatment outcomes were recorded. Logistic regression analysis and survival analysis were used to identify predictors of surgical resection and differences in time to surgery between patient subgroups, respectively. RESULTS A total of 734 patients with a diagnosis of CD were screened and 75 patients were identified. The mean age was 25.6 ± 9.9 years and 51% were males. Nearly 60% of patients had abscesses larger than 3 cm while 13% had smaller abscesses and 36% had phlegmons. On presentation, the most commonly reported symptom was abdominal pain (99%) followed by weight loss (27%). About 89% of patients were treated with antibiotics during hospitalization for an average of 2.7 weeks. Steroids were prescribed for 52% of patients and tumor necrosis factor alpha (TNF-alpha) antagonists for 17%. Surgical resection was required for 33 patients (44% of the cohort) while 51% were managed with antibiotics and/or percutaneous drainage. The most common surgical intervention was ileocecal resection (45%). Although patients who underwent follow-up imaging were more likely to require early surgical intervention (P = 0.04), no statistically significant predictor of surgery could be identified from this cohort. Time to surgery varied numerically according to abscess size (HR = 1.18, 95% CI = 0.62-2.27, P = 0.61). CONCLUSIONS Although the majority of patients with CD-related intra-abdominal collections underwent surgical resection in this cohort, no obvious predictors of surgical intervention could be identified. The decision to perform early surgery appeared to be influenced by the findings observed on cross-sectional imaging during the follow-up of these collections.
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Affiliation(s)
- Othman Alharbi
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia,Address for correspondence: Dr. Othman Alharbi, Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail:
| | - Majid A. Almadi
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Nahla Azzam
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdulrahman M. Aljebreen
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia
| | - Stefan Schreiber
- Department of Internal Medicine, Institute of Clinical Molecular Biology, Christian-Albrechts-University, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Mahmoud H. Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
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Mosli MH, Bukhari LM, Khoja AA, Ashour NA, Aljahdali HR, Khoja OA, Alhejaili FF, Saadah OI. Inflammatory bowel disease and restless leg syndrome. Neurosciences (Riyadh) 2020; 25:301-307. [PMID: 33130811 PMCID: PMC8015615 DOI: 10.17712/nsj.2020.4.20200021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives: Inflammatory bowel disease (IBD) has been associated with restless leg syndrome (RLS). This study aims to explore the prevalence, clinical predictors, and severity of RLS in IBD patients compared to controls. Methods: We conducted a case-control study between January and December of 2019 comparing IBD patients with controls. Assessment of RLS was performed using the previously validated diagnostic restless leg syndrome questionnaire (RLSQ). Logistic regression analyses were applied to investigate associations between patient demographics and clinical features and RLS diagnosis. Results: A total of 218 IBD patients and 211 healthy controls were incorporated after excluding 6 patients with positional discomfort and 4 patients with habitual foot tapping. The mean age was 30.2±11.7 and 64% were females. The prevalence of RLS was 16/218 (7.34%) and 17/211 (8.06%) among cases and controls, respectively. Based on the RLSQ severity score, 6/16 (37.5%), 4/16 (25%) and 1/16 (6.3%) of the IBD patients with RLS had mild, moderate and severe RLS; respectively. The odds of IBD were lower among patients with confirmed RLS (OR=0.90, 95% CI=0.44-1.84, p = 0.78). In the logistic regression analysis, only vitamin B12 deficiency (OR=10.20, 95% CI=1.40-74.10, p = 0.022) was associated with RLS diagnosis among IBD patients. Conclusion: No difference was found in the prevalence of RLS between IBD patients and non-IBD controls. Vitamin B12 deficiency was associated with RLS diagnosis among patients with IBD.
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Affiliation(s)
- Mahmoud H Mosli
- Department of Medicine, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia. E-mail:
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Almahdi FB, Hashim AH, Albaba EAM, Salih ON, Alkasam RJ, Mosli MH, Alsulaimani AF. The Impact of the Pharmaceutical Care Management Model of Hepatitis C Medications on the Cost at Health Insurance Level. Value Health Reg Issues 2020; 21:230-237. [PMID: 32334165 DOI: 10.1016/j.vhri.2020.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/16/2019] [Accepted: 01/06/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the impact of adopting a pharmaceutical care model on clinical outcomes, patient satisfaction, and cost at a health payer level. METHODS All patients with hepatitis C virus (HCV) who were insured by Bupa Arabia, with a direct-acting antivirals prior authorization drug request between April 2015 and October 2018 were included in this retrospective quasi-experimental study. The clinical outcome was the achievement of a sustained virologic response at least 12 weeks from end of treatment. Economic and patients' satisfaction outcomes were included in this study. The differences in cost of treatment was analyzed by using the paired t test. Stata statistical software package (StataCorp, College Station, TX) was used for data analysis. RESULTS A total of 371 patients were enrolled in this program of which 74% (n = 273) required clinical intervention. Among those, HCV treatment was modified for 64%. The overall cure rate was 97% among 267 patients for which sustained virologic responses were available. The results of the paired t test show that there was a 38% reduction in the mean direct cost of medications before and after intervention (95% confidence interval, 33%-43%; P<.001) and the calculated patients' satisfaction was 98%. CONCLUSIONS A structured pharmaceutical care program for HCV patients can guide the use of specialty medications to achieve optimal clinical outcomes, with lower expenditures and high patients' satisfaction. We can conclude that healthcare insurance can play a key role in managing specialty pharmaceuticals like HCV medications. Because this is a preliminary study, further studies are needed in an experimental design to strengthen the evidence behind the effectiveness of such a program.
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Affiliation(s)
- Fadia B Almahdi
- Pharmaceutical Care and Management Unit, Bupa Arabia, Jeddah, Saudi Arabia.
| | | | | | - Ohoud N Salih
- Pharmaceutical Care and Management Unit, Bupa Arabia, Jeddah, Saudi Arabia
| | - Reem J Alkasam
- Pharmaceutical Care and Management Unit, Bupa Arabia, Jeddah, Saudi Arabia
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Alshehri KA, Alharbi AA, Yaghmoor BE, Salman AK, Alaydarous SA, Abdalwassie LK, Mosli MH, Marzouki HZ. Awareness of the first aid management of foreign body aspiration among students: A cross-sectional study. J Educ Health Promot 2019; 8:220. [PMID: 31867384 PMCID: PMC6905279 DOI: 10.4103/jehp.jehp_306_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/12/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Pediatric foreign body aspiration (FBA) is a life-threatening condition responsible for many deaths every year, especially among children younger than 2 years. OBJECTIVE This study aimed to determine the level of knowledge among students in Jeddah, Saudi Arabia. SUBJECTS AND METHODS This observational, cross-sectional study was conducted between December and January 2018 at Jeddah, Saudi Arabia via a paper-based questionnaire survey of male and female high school and middle school students. The Chi-square test was used to compare frequencies, and the independent t-test was used to compare means. RESULTS A total of 671 students participated in this survey. The second item, "It is possible for a child to choke on a small toy" had the highest rate of correct responses among both males and females (93.2% vs. 94%, respectively). The eighth item "Sudden cough is a sign of choking among children" had the lowest rate of correct responses among males (40.8%) and females (33%). Most female participants (74.2%) knew that batteries are the most dangerous items a child can swallow, which requires immediate medical attention (item 14), while only 56.2% of male participants knew that (P < 0.001). The only significant predictor on linear regression analysis was "Having treated anyone with FBA" (coefficient = -0.24, P = 0.03). CONCLUSIONS There is inadequate knowledge regarding FBA among middle and high school students, as is the case among mothers. Moreover, only a small percentage of participants had any first aid training.
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Affiliation(s)
- Khalid A. Alshehri
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed A. Alharbi
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bassam E. Yaghmoor
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Anas K. Salman
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Shahad A. Alaydarous
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Lujain K. Abdalwassie
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mahmoud H. Mosli
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hani Z. Marzouki
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Mosli MH, Albeshri MA, Alsolami AA, Addas FA, Qazli AM, Alsahafi M, Jawa H, Alkhaldy A, Qari Y. Arabic translation and psychometric testing of the self-screening malnutrition universal screening tool in inflammatory bowel disease patients. Saudi Med J 2019; 40:828-835. [PMID: 31423521 PMCID: PMC6718852 DOI: 10.15537/smj.2019.8.24427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To translate and validate the malnutrition universal screening tool (MUST) for use in Arabic-speaking outpatients with inflammatory bowel disease (IBD). METHODS We translated the MUST into Arabic by using the Brislin back-translation method. This methodological study was performed between August 2016 and November 2017 on 143 outpatients with IBD at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. The patients must completed the self-administered (PSA) Arabic version of the MUST. Then, the health-care practitioners (HCPs) administered the Arabic MUST and performed standard patient clinical assessment. The nutrition risk was defined as low (MUST score=0), medium (MUST score=1), or high (MUST score greater than 1). The chance-corrected proportional agreement between the scores from the PSA and HCP-administered Arabic MUST was evaluated using Cohen's kappa coefficient. Internal consistency was evaluated using Cronbach's alpha statistic. RESULTS The overall agreement between the PSA and HCP-administered Arabic MUST was almost perfect (agreement=95.9%, expected agreement=72.4%, kappa=0.85, p less than 0.0001). The calculated Cronbach's alpha statistic for MUST scores in 15/143 (10%) patients was 0.79. The calculated Pearson's correlation coefficient between PSA and HCP-administered MUST scores was 0.93 (p less than 0.0001). CONCLUSIONS The PSA and HCP-administered Arabic MUST showed perfect agreement in outpatients with IBD.
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Affiliation(s)
- Mahmoud H Mosli
- Department of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia. E-mail.
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Al Mahdi FB, Hashim AH, Albaba EAM, Salih ON, Alkasam RJ, Mosli MH, Alsulaimani AF. The impact of the pharmaceutical care management model of hepatitis C medications on the cost at the health insurance level. J Adv Res 2019. [DOI: 10.1016/j.jare.2019.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
BACKGROUND This study describes the epidemiology and clinical features of hepatocellular carcinoma (HCC), and it investigates any association between Child-Pugh's classification and HCC. MATERIALS AND METHODS A retrospective chart review was performed for HCC cases diagnosed between 2008 and 2014 at King Abdulaziz University Hospital. We documented the age at cancer diagnosis, gender, occupation, ethnic origin, HCC etiology, Child-Pugh scores, tumor characteristics, alpha-fetoprotein (AFP), and alkaline phosphatase (ALP) levels at diagnosis, and treatment administered. The Chi-square test was used to determine differences between categorical variables. RESULTS We included 128 patients. Hepatitis B and C viral infections were documented in 24.2% and 33.6% of the patients, respectively. Patients with tumors >5 cm were more likely to have Child's Class C disease, whereas those with tumors ≤2 cm were more likely to have Child's Class A (P < 0.001). Similarly, patients with bilobular or metastatic tumors were more likely to have Child's Class C disease (P = 0.001 and 0.002, respectively). No difference in Child-Pugh score was found between patients with single or multiple tumors (P = 0.480). Furthermore, patients who were both hepatitis B and C positive were more likely to have Child's Class C disease (P = 0.018). Likewise, those who had abnormal AFP and ALP levels ≥1000 ng/mL were more likely to have Child-Pugh's Class C liver disease (P = 0.021 in both cases). CONCLUSION Hepatitis C and B infections were the main risk factors associated with HCC.
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Affiliation(s)
- Y A Qari
- Department of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - M H Mosli
- Department of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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AlAmeel T, Mosli MH. Combination Therapy With Adalimumab and Thiopurines in Inflammatory Bowel Disease: Is It a Case of Nepotism in Pharmacology? J Crohns Colitis 2018; 12:503-504. [PMID: 29220429 DOI: 10.1093/ecco-jcc/jjx166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital-Dammam, Saudi Arabia
| | - Mahmoud H Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Mohammed Vashist N, Samaan M, Mosli MH, Parker CE, MacDonald JK, Nelson SA, Zou GY, Feagan BG, Khanna R, Jairath V. Endoscopic scoring indices for evaluation of disease activity in ulcerative colitis. Cochrane Database Syst Rev 2018; 1:CD011450. [PMID: 29338066 PMCID: PMC6491285 DOI: 10.1002/14651858.cd011450.pub2] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Endoscopic assessment of mucosal disease activity is routinely used to determine eligibility and response to therapy in clinical trials of ulcerative colitis. The operating properties of the existing endoscopic scoring indices are unclear. OBJECTIVES A systematic review was undertaken to evaluate the development and operating characteristics of endoscopic scoring indices for the evaluation of ulcerative colitis. SEARCH METHODS We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2016. We also searched references and conference proceedings (Digestive Disease Week, United European Gastroenterology Week, European Crohn's and Colitis Organization). SELECTION CRITERIA Any study design (e.g. randomized controlled trials, cohort studies, case series) that evaluated endoscopic indices for evaluation of ulcerative colitis disease activity were considered for inclusion. Eligible participants were adult patients (> 16 years), diagnosed with ulcerative colitis using conventional clinical, radiologic and endoscopic criteria. DATA COLLECTION AND ANALYSIS Two authors independently reviewed the studies identified from the literature search. These authors also independently extracted and recorded data on the number of patients enrolled; number of patients per treatment arm; patient characteristics including age and gender distribution; endoscopic index; and outcomes such as reliability (intra-rater and inter-rater), validity (content, construct, criterion), responsiveness and feasibility. Any disagreements regarding study inclusion or data extraction were resolved by discussion and consensus with a third author. Risk of bias was assessed by determining whether assessors were blinded to clinical information and whether assessors scored the endoscopic index independently. We also assessed the methodological quality of the validation studies using the COSMIN checklist MAIN RESULTS: A total of 23 reports of 20 studies met the pre-defined inclusion criteria and were included in the review. Of the 20 included validation studies, 19 endoscopic scoring indices were assessed, including the Azzolini Classification, Baron Score, Blackstone Endoscopic Interpretation, Chinese Grading System of Ulcerative Colitis, Endoscopic Activty Index, Jeroen Score, Magnifying Colonoscopy Grade, Matts Score, Mayo Clinic Endoscopic Subscore, Modified Baron Score, Modified Mayo Clinic Endoscopic Subscore, Osada Score, Rachmilewtiz Endoscopic Score, St. Mark's Index, Ulcerative Colitis Colonoscopic Index of Serverity (UCCIS), endoscopic component of the Ulcerative Colitis Disease Activity Index (UCDAI), Ulcerative Colitis Endoscopic Index of Severity (UCEIS), Witts Sigmoidoscopic Score and Watson Grade. The individuals who performed the endoscopic scoring were blinded to clinical and/or histologic information in ten of the included studies, not blinded to clinical and/or histologic information in one of the included studies, and it was unclear whether blinding occurred in the remaining nine included studies. Independent observation was confirmed in four of the included studies, unclear in five of the included studies, and non-applicable (since inter-rater reliability was not assessed) in the remaining eleven included studies. The methodological quality (COSMIN checklist) of most of the included studies was rated as 'good' or 'excellent'. One study that assessed responsiveness was rated as 'fair'. The inter-rater reliability of nine endoscopic scoring indices including the Baron Score, Blackstone Endoscopic Interpretation, Endoscopic Activity Index, Matts Score, Mayo Clinic Endoscopic Subscore, Osada Score, UCCIS, UCEIS, Watson Grade was assessed in seven studies, with estimates of correlation, ƙ, ranging from 0.44 to 0.97. The iIntra-rater reliability of seven endoscopic scoring indices including the Baron Score, Blackstone Endoscopic Interpretation, Matts Score, Mayo Clinic Endoscopic Subscore, Osada Score, UCCIS and UCEIS was assessed in three studies, with estimates of correlation, ƙ, ranging from 0.41 to 0.86. No studies assessed content validity. Three studies evaluated the criterion validity of three endoscopic scoring indices including the Rachmilewitz Endoscopic Score, Magnifying Colonoscopy Grade and the UCCIS. These indices were correlated with objective markers of disease activity including albumin, blood leukocytes, C-reactive protein, fecal calprotectin, hemoglobin, mucosal interleukin-8 concentration and platelet count. Correlation estimates ranged from r = -0.19 to 0.83. Thirteen endoscopic scoring indices were tested for construct validity in 13 studies. Estimates of correlation between the endoscopic scoring indices and other measures of disease activity ranged from r = 0.27 to 0.93. Two studies explored the responsiveness of four endoscopic scoring indices including the Mayo Endoscopic Subscore, Modified Baron Score, Modified Mayo Endoscopic Subscore and UCEIS. One study concluded that the Modified Baron Score, Modified Mayo Endoscopic Subscore and UCEIS had similar responsiveness for detecting disease change in ulcerative colitis. The other included study concluded that the UCEIS may be the most accurate endoscopic scoring tool. None of the included studies formally assessed feasibility. AUTHORS' CONCLUSIONS While the UCEIS, UCCIS and Mayo Clinic Endoscopic Subscore have undergone extensive validation, none of these instruments have been fully validated and only two studies assessed responsiveness. Further research on the operating properties of these indices is needed given the lack of a fully-validated endoscopic scoring instrument for the evaluation of disease activity in ulcerative colitis.
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Affiliation(s)
| | - Mark Samaan
- Academic Medical CenterMeibergdreef 9 ‐ C2‐112AmsterdamNetherlands1105 AZ
| | - Mahmoud H Mosli
- King Abdulaziz UniversityKing Abdulaziz University HospitalJeddahSaudi Arabia
| | - Claire E Parker
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
| | - John K MacDonald
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
| | | | - GY Zou
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
| | - Brian G Feagan
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
| | - Reena Khanna
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
| | - Vipul Jairath
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
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Khanna R, Mosli MH, Lam MCW, Fu N, Bressler B, Rosenfeld G, MacDonald JK, Levesque BG, Feagan BG. Vedolizumab for induction and maintenance of remission in Crohn’s disease. Hippokratia 2017. [DOI: 10.1002/14651858.cd011615.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Reena Khanna
- University of Western Ontario; Department of Medicine; London ON Canada
- Robarts Clinical Trials; London ON Canada
| | - Mahmoud H Mosli
- King Abdulaziz University; King Abdulaziz University Hospital; Jeddah Saudi Arabia
| | - Mindy CW Lam
- University of British Columbia; Division of Gastroenterology; Vancouver BC Canada
| | - Nancy Fu
- University of British Columbia; Department of Medicine; Vancouver BC Canada
| | - Brian Bressler
- University of British Columbia; Division of Gastroenterology; Vancouver BC Canada
| | - Greg Rosenfeld
- University of British Columbia; Division of Gastroenterology; Vancouver BC Canada
| | - John K MacDonald
- University of Western Ontario; Department of Medicine; London ON Canada
- Robarts Clinical Trials; Cochrane IBD Group; 100 Dundas Street, Suite 200 London ON Canada N6A 5B6
| | | | - Brian G Feagan
- Robarts Clinical Trials; Cochrane IBD Group; 100 Dundas Street, Suite 200 London ON Canada N6A 5B6
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Jairath V, Zou GY, Parker CE, MacDonald JK, AlAmeel T, Al Beshir M, Almadi MA, Al‐Taweel T, Atkinson NSS, Biswas S, Chapman T, Dulai PS, Glaire MA, Hoekman DR, Koutsoumpas A, Minas E, Mosli MH, Samaan M, Khanna R, Travis S, D'Haens G, Sandborn WJ, Feagan BG. Placebo response and remission rates in randomised trials of induction and maintenance therapy for ulcerative colitis. Cochrane Database Syst Rev 2017; 9:CD011572. [PMID: 28886205 PMCID: PMC6483671 DOI: 10.1002/14651858.cd011572.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND It is important to minimize placebo rates in randomised controlled trials (RCTs) to efficiently detect treatment differences between interventions. Historically, high placebo rates have been observed in clinical trials of ulcerative colitis (UC). A better understanding of factors influencing placebo rates may lead to more informed clinical trial design. OBJECTIVES A systematic review and meta-analysis was conducted to evaluate placebo response and remission rates in RCTs evaluating UC treatments in adult patients. SEARCH METHODS Electronic databases (i.e. MEDLINE, EMBASE, and CENTRAL) were searched from inception to 1 March 2017 with no language restrictions applied. Reference lists and conference proceedings of major gastroenterology meetings were also handsearched to identify additional studies. SELECTION CRITERIA Placebo-controlled RCTs of adult patients with UC treated with corticosteroids, aminosalicylates, immunosuppressives or biologics were eligible, provided enrolment and outcome assessment was conducted using the Ulcerative Colitis Disease Activity Index (UCDAI) or the Mayo Clinic Score. The minimum trial duration was two weeks for induction trials and four months maintenance trials. DATA COLLECTION AND ANALYSIS Pairs of authors independently determined study eligibility and extracted data with any disagreements resolved through consensus. Outcomes of interest included the proportion of patients with clinical response and remission. Trial characteristics such as the design, participant demographics and disease history, interventions, and enrolment and assessment criteria were also recorded. The methodological quality of the included studies was evaluated using the Cochrane risk of bias tool. Pooled placebo response and remission rates and 95% confidence intervals (95% CI) were calculated using a binomial normal model for proportions. Induction of remission and maintenance studies were pooled separately. The impact of study-level characteristics on placebo response and remission rates was investigated using mixed-effects meta-regression analyses with logits of event rates as the outcome variables. An assessment of pooled placebo rates over time was conducted using a cumulative meta-analysis based on date of publication. Publication bias was examined using funnel plots. MAIN RESULTS The screening process identified 61 included studies which encompass 58 induction phases (5111 patients randomised to placebo) and 12 maintenance phases (1579 patients randomised to placebo). For induction trials, the pooled estimate of placebo response was 33% (95% CI 30% to 36%) while the pooled estimate of placebo remission was 12% (95% CI 9% to 15%). For maintenance trials, the pooled estimate of placebo response was 23% (95% CI 19% to 28%) while the pooled estimate of placebo remission was 17% (95% CI 10% to 27%).Studies enrolling patients with more active disease confirmed objectively by endoscopy were associated with significantly lower placebo remission and response rates than trials enrolling patients with less active disease (27% versus 4%, OR 2.60, 95% CI 1.25 to 5.42, P = 0.01 for UCDAI endoscopy sub score ≥1 versus ≥ 2 for remission; and 27% versus 4%, OR 1.70, 95% CI 1.02 to 2.82, P = 0.02 for UCDAI endoscopy sub score greater than or equal to one versus greater than or equal to two for response). With respect to drug class, the lowest placebo response and remission rates were observed in trials evaluating corticosteroids (23%; 95% CI 19 to 29%, and 5%; 95% CI 2 to 11%, respectively). Trials of biologics had the highest placebo response rate (35%; 95% CI 30 to 41%), while trials evaluating aminosalicylates had the highest placebo remission rate (18%; 95% CI 12 to 24%). Disease duration of greater than five years prior to enrolment was associated with a significantly lower placebo response rate compared to disease duration of less than or equal to five years (29% versus 47%, respectively; OR 0.54, 95% CI 0.32 to 0.92, P = 0.02). The requirement of a minimum rectal bleeding score for study eligibility was associated with an increased placebo response rate compared to studies that did not use rectal bleeding for trial eligibility (37% versus 32%, respectively; OR 1.70, 95% CI 1.02 to 2.82, P = 0.02). Finally, the time point of primary outcome assessment was found to be significantly associated with placebo remission rates such that every one week increment in endpoint assessment was associated with a 6% increase in the placebo remission rate (OR 1.06, 95% CI 1.02 to 1.10, P = 0.01).Cumulative meta-analysis indicated a consistent increase in the placebo response rate from 1987 to 2007 (from 13% to 33%), although rates have remained constant from 2008 to 2015 (32% to 34%). Similarly, placebo remission rates increased from 1987 to 2007 (5% to 14%) but have remained constant from 2008 to 2015 (12 to 14%). On meta-regression, there were no statistically significant differences between the 1987-2007 and 2008-2015 point estimates for both response (P = 0.81) and remission (P = 0.32). AUTHORS' CONCLUSIONS Placebo response and remission rates vary according to endoscopic disease severity and rectal bleeding score at trial entry, class of agent, disease duration, and the time point at which the primary outcome was measured. These observations have important implications for the design and conduct of future clinical trials in UC and will help researchers design trials, determine required sample sizes and also provide useful information about trial design features which should be considered when planning new trials.
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Affiliation(s)
| | | | | | | | - Turki AlAmeel
- King Fahad Specialist Hospital‐DammamDepartment of MedicineP.O Box 15215DammamSaudi Arabia31444
| | - Mohammad Al Beshir
- King Fahad Specialist Hospital‐DammamDepartment of MedicineP.O Box 15215DammamSaudi Arabia31444
| | | | | | | | - Sujata Biswas
- Wellcome Trust Centre for Human GeneticsTranslational Gastroenterology UnitRoosevelt DriveOxfordUKOX3 7BN
| | - Thomas Chapman
- John Radcliffe HospitalTranslational Gastroenterology UnitHeadley WayOxfordUKOX3 9DU
| | | | | | - Daniël R Hoekman
- Academic Medical CenterMeibergdreef 9AmsterdamNetherlands1105 AZ
| | | | | | - Mahmoud H Mosli
- King Abdulaziz UniversityKing Abdulaziz University HospitalJeddahSaudi Arabia
| | - Mark Samaan
- Academic Medical CenterMeibergdreef 9AmsterdamNetherlands1105 AZ
| | | | - Simon Travis
- University of OxfordTranslational Gastroenterology Unit, Nuffield Department of MedicineOxfordUK
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21
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Mosli MH, Parker CE, Nelson SA, Baker KA, MacDonald JK, Zou GY, Feagan BG, Khanna R, Levesque BG, Jairath V. Histologic scoring indices for evaluation of disease activity in ulcerative colitis. Cochrane Database Syst Rev 2017; 5:CD011256. [PMID: 28542712 PMCID: PMC6481362 DOI: 10.1002/14651858.cd011256.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Disease activity can be determined using clinical, endoscopic or histologic criteria in patients with ulcerative colitis (UC). Persistent disease activity is associated with poor outcomes. Histologic disease activity has been shown to be associated with relapse, colectomy and colorectal cancer. The ability to objectively evaluate microscopic disease activity using histology is important for both clinical practice and clinical trials. However, the operating properties of the currently available histologic indices remain unclear. OBJECTIVES A systematic review was undertaken to identify and evaluate the development and operating characteristics of histologic disease activity indices used to assess disease activity in people with ulcerative colitis. SEARCH METHODS We searched MEDLINE, EMBASE, PubMed, CENTRAL and the Cochrane IBD Review Group Specialized Trials Register from inception to 2 December 2016 for applicable studies. There were no language or document type restrictions. SELECTION CRITERIA Any study design (e.g. randomized controlled trials, cohort studies, case series) that evaluated a histologic index in patients with UC were considered for inclusion. Eligible patients were adults (> 18 years), diagnosed with UC using conventional clinical, radiographic, endoscopic and histologic criteria. DATA COLLECTION AND ANALYSIS Two authors (MHM and CEP) independently reviewed the titles and abstracts of the studies identified from the literature search. A standardized form was used to assess eligibility of trials for inclusion and for data extraction.Two authors (MHM and CEP) independently extracted and recorded data, which included the number of patients enrolled, number of patients per treatment arm, patient characteristics including age and gender distribution, and the name of the histologic index. Outcomes (i.e. intra-rater reliability, inter-rater reliability, internal consistency, content validity, criterion validity, construct validity, responsiveness, and feasibility) were recorded for each trial. MAIN RESULTS In total, 126 reports describing 30 scoring indices were identified through the screening process. Eleven of the 30 scoring indices have undergone some form of index validation. Intra-rater reliability was assessed for eight scoring indices. Inter-rater reliability was evaluated for all 11 of the scoring indices. Three of the indices underwent content validation. Two of the included scoring indices assessed criterion validity. Six of the included scoring indices explored content validity. Two of the included scoring indices were tested for responsiveness. AUTHORS' CONCLUSIONS The Nancy Index and the Robarts Histopathology Index have undergone the most validation in that four operating properties including reliability, content validity, construct validity (hypothesis testing) and criterion validity have been tested. However, none of the currently available histologic scoring indices have been fully validated. In order to determine the optimal endpoint for histologic healing in UC, more research is required. The optimal index would need to be fully validated.
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Affiliation(s)
- Mahmoud H Mosli
- King Abdulaziz UniversityKing Abdulaziz University HospitalJeddahSaudi Arabia
- Robarts Research InstituteRobarts Clinical TrialsP.O. Box 5015100 Perth DriveLondonONCanadaN6A 5K8
| | - Claire E Parker
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
| | | | - Kenneth A Baker
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
| | - John K MacDonald
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
| | - GY Zou
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
| | - Brian G Feagan
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
| | - Reena Khanna
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
| | | | - Vipul Jairath
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
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22
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Jairath V, Zou G, Parker CE, MacDonald JK, Mosli MH, AlAmeel T, Al Beshir M, AlMadi M, Al-Taweel T, Atkinson NSS, Biswas S, Chapman TP, Dulai PS, Glaire MA, Hoekman D, Kherad O, Koutsoumpas A, Minas E, Restellini S, Samaan MA, Khanna R, Levesque BG, D'Haens G, Sandborn WJ, Feagan BG. Systematic review with meta-analysis: placebo rates in induction and maintenance trials of Crohn's disease. Aliment Pharmacol Ther 2017; 45:1021-1042. [PMID: 28164348 DOI: 10.1111/apt.13973] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/08/2016] [Accepted: 01/16/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Minimising placebo response is essential for drug development. AIM To conduct a meta-analysis to determine placebo response and remission rates in trials and identify the factors affecting these rates. METHODS MEDLINE, EMBASE and CENTRAL were searched from inception to April 2014 for placebo-controlled trials of pharmacological interventions for Crohn's disease. Placebo response and remission rates for induction and maintenance trials were pooled by random-effects and mixed-effects meta-regression models to evaluate effects of study-level characteristics on these rates. RESULTS In 100 studies containing 67 induction and 40 maintenance phases and 7638 participants, pooled placebo remission and response rates for induction trials were 18% [95% confidence interval (CI) 16-21%] and 28% (95% CI 24-32%), respectively. Corresponding values for maintenance trials were 32% (95% CI 25-39%) and 26% (95% CI 19-35%), respectively. For remission, trials enrolling patients with more severe disease activity, longer disease duration and more study centres were associated with lower placebo rates, whereas more study visits and longer study duration was associated with higher placebo rates. For response, findings were opposite such that trials enrolling patients with less severe disease activity and longer study duration were associated with lower placebo rates. Placebo rates varied by drug class and route of administration, with the highest placebo response rates observed for biologics. CONCLUSIONS Placebo rates vary according to whether trials are designed for induction or maintenance and the factors influencing them differ for the endpoints of remission and response. These findings have important implications for clinical trial design in Crohn's disease.
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Affiliation(s)
| | | | | | | | - M H Mosli
- London, ON, Canada.,Jeddah, Saudi Arabia
| | | | | | | | | | | | | | | | - P S Dulai
- London, ON, Canada.,La Jolla, CA, USA
| | | | | | | | | | | | | | | | | | | | - G D'Haens
- London, ON, Canada.,Amsterdam, The Netherlands
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23
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Gazzaz F, Mosli MH, Jawa H, Sibiany A. Detection of human papillomavirus infection by molecular tests and its relation to colonic polyps and colorectal cancer. Saudi Med J 2017; 37:256-61. [PMID: 26905346 PMCID: PMC4800888 DOI: 10.15537/smj.2016.3.13514] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objectives: To prospectively examine the association between human papilloma virus (HPV) colonization of the colonic mucosa and the development of colorectal polyps (CRPs), and colorectal cancer (CRC) in Saudi Arabia. Methods: A case control study was performed between January 2013 and December 2014. All eligible patients underwent standard diagnostic colonoscopy. Patients with polyps or colorectal cancer were considered cases, while those with any other endoscopic findings were controls. Biopsy samples from polyps and tumors, and/or from normal colonic mucosa were acquired. Human papilloma virus colonization was detected using a hybrid capture technique of samples taken from both normal tissue, and CRPs and CRC. The association between HPV and CRPs/CRC was evaluated. Results: A total of 132 patients were recruited. The mean age was 53 (±15.9) years. Sixty patients had endoscopically detectable CRPs/CRC, and 72 had either inflammation or normal endoscopic evaluations. Only 4 (0.8%) of the 132 samples that were collected and analyzed were positive for the HPV gene. Statistical analysis did not identify any significant association between HPV colonization and the presence of CRPs/CRC. The only significant predictor of detecting CRPs/CRC on colonoscopy was symptomatic presentation (odds ratio=11.072, 95% confidence interval 4.7-26.2, p<0.001). Conclusion: Human papilloma virus colonic colonization is rare in Saudi Arabia. An association between HPV colonization and CRP/CRC development could not be identified in this cohort of patients.
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Affiliation(s)
- Faten Gazzaz
- Department of Microbiology, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia. E-mail.
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24
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Mosli MH, Feagan BG, Zou G, Sandborn WJ, D'Haens G, Khanna R, Shackelton LM, Walker CW, Nelson S, Vandervoort MK, Frisbie V, Samaan MA, Jairath V, Driman DK, Geboes K, Valasek MA, Pai RK, Lauwers GY, Riddell R, Stitt LW, Levesque BG. Development and validation of a histological index for UC. Gut 2017; 66:50-58. [PMID: 26475633 DOI: 10.1136/gutjnl-2015-310393] [Citation(s) in RCA: 222] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 09/15/2015] [Accepted: 09/22/2015] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Although the Geboes score (GS) and modified Riley score (MRS) are commonly used to evaluate histological disease activity in UC, their operating properties are unknown. Accordingly, we developed an alternative instrument. DESIGN Four pathologists scored 48 UC colon biopsies using the GS, MRS and a visual analogue scale global rating. Intra-rater and inter-rater reliability for each index and individual index items were measured using intraclass correlation coefficients (ICCs). Items with high reliability were used to develop the Robarts histopathology index (RHI). The responsiveness/validity of the RHI and multiple histological, endoscopic and clinical outcome measures were evaluated by analyses of change scores, standardised effect size (SES) and Guyatt's responsiveness statistic (GRS) using data from a clinical trial of an effective therapy. RESULTS Inter-rater ICCs (95% CIs) for the total GS and MRS scores were 0.79 (0.63 to 0.87) and 0.80 (0.69 to 0.87). The correlation estimates between change scores in RHI and change score in GS and MRS were 0.75 (0.67 to 0.82) and 0.84 (0.79 to 0.88), respectively. The SES and GRS estimates for GS, MRS and RHI were: 1.87 (1.54 to 2.20) and 1.23 (0.97 to 1.50), 1.29 (1.02 to 1.56) and 0.88 (0.65 to 1.12), and 1.05 (0.79 to 1.30) and 0.88 (0.64 to 1.12), respectively. CONCLUSIONS The RHI is a new histopathological index with favourable operating properties.
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Affiliation(s)
- Mahmoud H Mosli
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Department of Medicine, University of Western Ontario, London, Ontario, Canada.,Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Brian G Feagan
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Department of Medicine, University of Western Ontario, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Guangyong Zou
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - William J Sandborn
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Geert D'Haens
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Reena Khanna
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Lisa M Shackelton
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Christopher W Walker
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Sigrid Nelson
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Margaret K Vandervoort
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Valerie Frisbie
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Mark A Samaan
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Vipul Jairath
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - David K Driman
- Department of Pathology, University of Western Ontario, London, Ontario, Canada
| | - Karel Geboes
- Department of Pathology, University Hospital of KU Leuven and UZ Gent, Leuven, Belgium
| | - Mark A Valasek
- Department of Pathology, University of California, San Diego, USA
| | - Rish K Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, USA
| | - Gregory Y Lauwers
- Massachusetss General Hospital, Boston, USA.,Department of Pathology, Harvard Medical School, Boston, USA
| | - Robert Riddell
- Department of Pathology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Larry W Stitt
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Barrett G Levesque
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
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25
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Jairath V, Zou G, Parker CE, Macdonald JK, Mosli MH, Khanna R, Shackelton LM, Vandervoort MK, AlAmeel T, Al Beshir M, AlMadi M, Al-Taweel T, Atkinson NSS, Biswas S, Chapman TP, Dulai PS, Glaire MA, Hoekman D, Koutsoumpas A, Minas E, Samaan MA, Travis S, D’Haens G, Levesque BG, Sandborn WJ, Feagan BG. Systematic Review and Meta-analysis: Placebo Rates in Induction and Maintenance Trials of Ulcerative Colitis. J Crohns Colitis 2016; 10:607-18. [PMID: 26746169 PMCID: PMC4957452 DOI: 10.1093/ecco-jcc/jjw004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Minimisation of the placebo responses in randomised controlled trials [RCTs] is essential for efficient evaluation of new interventions. Placebo rates have been high in ulcerative colitis [UC] clinical trials, and factors influencing this are poorly understood. We quantify placebo response and remission rates in UC RCTs and identify trial design factors influencing them. METHODS MEDLINE, EMBASE, and the Cochrane Library were searched from inception through April 2014 for placebo-controlled trials in adult patients with UC of a biological agent, corticosteroid, immunosuppressant, or aminosalicylate. Data were independently doubly extracted. Quality was assessed using the Cochrane risk of bias tool. RESULTS In all, 51 trials [48 induction and 10 maintenance phases] were identified. Placebo response and remission rates were pooled according to random-effects models, and mixed-effects meta-regression models were used to evaluate effects of study-level characteristics on these rates. Pooled estimates of placebo remission and response rates for induction trials were 10% (95% confidence interval [CI] 7-13%) and 33% [95% CI 29-37%], respectively. Corresponding values for maintenance trials were 19% [95% CI 11-30%] and 22% [95% CI 17-28%]. Trials enrolling patients with more active disease confirmed by endoscopy [endoscopy subscore ≥ 2] were associated with lower placebo rates. Conversely, placebo rates increased with increasing trial duration and number of study visits. CONCLUSIONS Objective assessment of greater disease activity at trial entry by endoscopy lowered placebo rates, whereas increasing trial duration and more interactions with healthcare providers increased placebo rates. These findings have important implications for design and conduct of clinical trials.
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Affiliation(s)
- Vipul Jairath
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK,Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Guangyong Zou
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
| | - Claire E. Parker
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - John K. Macdonald
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Mahmoud H. Mosli
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada,Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Reena Khanna
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Lisa M. Shackelton
- Robarts Research Institute, University of Western Ontario, London, ON, Canada
| | | | - Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Mohammad Al Beshir
- Department of Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Majid AlMadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Talal Al-Taweel
- Haya Al-Habeeb Gastroenterology Center, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Nathan S. S. Atkinson
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK
| | - Sujata Biswas
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK
| | - Thomas P. Chapman
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK
| | - Parambir S. Dulai
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Mark A. Glaire
- Division of Medical Sciences, University of Oxford, Oxford, UK
| | - Daniel Hoekman
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Andreas Koutsoumpas
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK
| | - Elizabeth Minas
- Department of Geratology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Mark A. Samaan
- Department of Gastroenterology, Guy’s and St Thomas’ Hospital NHS Trust, London, UK
| | - Simon Travis
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK
| | - Geert D’Haens
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Barrett G. Levesque
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - William J. Sandborn
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brian G. Feagan
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada
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26
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Khanna R, Jairath V, Vande Casteele N, Mosli MH, Zou G, Parker CE, Levesque BG, Sandborn WJ, D'Haens G, Feagan BG. Efficient Early Drug Development for Ulcerative Colitis. Gastroenterology 2016; 150:1056-1060. [PMID: 27018491 DOI: 10.1053/j.gastro.2016.03.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Reena Khanna
- University of Western Ontario, London, Ontario, Canada
| | - Vipul Jairath
- University of Western Ontario, London, Ontario, Canada and University of Oxford, Oxford, UK
| | - Niels Vande Casteele
- University of Western Ontario, London, Ontario, Canada and Katholieke Universiteit Leuven, Leuven, Belgium
| | - Mahmoud H Mosli
- University of Western Ontario, London, Ontario, Canada and King Abdulaziz University, Jeddah, Saudi Arabia
| | - Guangyong Zou
- University of Western Ontario, London, Ontario, Canada
| | | | - Barrett G Levesque
- University of Western Ontario, London, Ontario, Canada and University of California San Diego, La Jolla, California
| | - William J Sandborn
- University of Western Ontario, London, Ontario, Canada and University of California San Diego, La Jolla, California
| | - Geert D'Haens
- University of Western Ontario, London, Ontario, Canada and Academic Medical Centre, Amsterdam, The Netherlands
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27
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Abstract
BACKGROUND Inflammatory bowel diseases (IBD) are a group of heterogeneous conditions, characterized by immune-mediated inflammation of the gastrointestinal tract. Traditionally, medical management of these disorders has been based on use of systemic immunosuppressives. The development of new drugs that selectively inhibit leukocyte trafficking to the gut has the potential to reduce inflammation and minimize systemic toxicities. KEY MESSAGES In this article, we review the immunology of the gut and the mechanism of action these emerging therapies for IBD. Natalizumab, a monoclonal antibody to the α4 integrin, was approved for the treatment of multiple sclerosis and showed promise in Crohn's disease (CD), however it is encumbered by the risk of progressive multifocal leukoencephalopathy. Vedolizumab inhibits the α4β7 integrin to induce clinical remission in patients with both ulcerative colitis and CD. Long-term safety data on this agent is not yet available. We also review agents in the pipeline. Finally, we discuss the positioning of therapies and potential alterations to therapeutic algorithms as new medications emerge. CONCLUSIONS New therapies are emerging for IBD; however, long-term data are pending. The positioning of these agents in algorithms will evolve.
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Affiliation(s)
- Reena Khanna
- Department of Medicine, University of Western Ontario, London, Ont., Canada
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28
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Mosli MH, Feagan BG, Zou G, Sandborn WJ, D'Haens G, Khanna R, Behling C, Kaplan K, Driman DK, Shackelton LM, Baker KA, MacDonald JK, Vandervoort MK, Samaan MA, Geboes K, Valasek MA, Pai R, Langner C, Riddell R, Harpaz N, Sewitch M, Peterson M, Stitt LW, Levesque BG. Reproducibility of histological assessments of disease activity in UC. Gut 2015; 64:1765-73. [PMID: 25360036 DOI: 10.1136/gutjnl-2014-307536] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 10/07/2014] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Histopathology is potentially an important outcome measure in UC. Multiple histological disease activity (HA) indices, including the Geboes score (GS) and modified Riley score (MRS), have been developed; however, the operating properties of these instruments are not clearly defined. We assessed the reproducibility of existing measures of HA. DESIGN Five experienced pathologists with GI pathology fellowship training and expertise in IBD evaluated, on three separate occasions at least two weeks apart, 49 UC colon biopsies and scored the GS, MRS and a global rating of histological severity using a 100 mm visual analogue scale (VAS). The reproducibility of each grading system and for individual instrument items was quantified by estimates of intraclass correlation coefficients (ICCs) based on two-way random effects models. Uncertainty of estimates was quantified by 95% two-sided CIs obtained using the non-parametric cluster bootstrap method. Biopsies responsible for the greatest disagreement based on the ICC estimates were identified. A consensus process was used to determine the most common sources of measurement disagreement. Recommendations for minimising disagreement were subsequently generated. RESULTS Intrarater ICCs (95% CIs) for the total GS, MRS and VAS scores were 0.82 (0.73 to 0.88), 0.71 (0.63 to 0.80) and 0.79 (0.72 to 0.85), respectively. Corresponding inter-rater ICCs were substantially lower: 0.56 (0.39 to 0.67), 0.48 (0.35 to 0.66) and 0.61 (0.47 to 0.72). Correlation between the GS and VAS was 0.62 and between the MRS and VAS was 0.61. CONCLUSIONS Although 'substantial' to 'almost perfect' ICCs for intrarater agreement were found in the assessment of HA in UC, ICCs for inter-rater agreement were considerably lower. According to the consensus process results, standardisation of item definitions and modification of the existing indices is required to create an optimal UC histological instrument.
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Affiliation(s)
- Mahmoud H Mosli
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada Department of Medicine, Western University, London, Ontario, Canada Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia Department of Epidemiology, Biostatistics and Occupational Medicine, McGill University, Montreal, Canada
| | - Brian G Feagan
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada Department of Medicine, Western University, London, Ontario, Canada Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Guangyong Zou
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - William J Sandborn
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Geert D'Haens
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Reena Khanna
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada Department of Medicine, Western University, London, Ontario, Canada
| | - Cynthia Behling
- Pacific Rim Pathology Medical Corporation, San Diego, California, USA
| | - Keith Kaplan
- Carolinas Medical Center, Charlotte, North Carolina, USA
| | - David K Driman
- Department of Pathology, Western University, London, Ontario, Canada
| | - Lisa M Shackelton
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Kenneth A Baker
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada
| | - John K MacDonald
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Margaret K Vandervoort
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Mark A Samaan
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Karel Geboes
- Department of Pathology, University Hospital of KU Leuven and UZ Gent, Leuven, Belgium
| | - Mark A Valasek
- Department of Pathology, University of California, San Diego, California, USA
| | - Rish Pai
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cord Langner
- Department of Pathology, Medical University of Graz, Graz, Austria
| | - Robert Riddell
- Department of Pathology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Noam Harpaz
- Department of Pathology, Mount Sinai Hospital, New York, New York, USA
| | - Maida Sewitch
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Michael Peterson
- Department of Pathology, Western Washington Pathology and Multicare Health System, Tacoma, Washington, USA
| | - Larry W Stitt
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Barrett G Levesque
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
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Abstract
BACKGROUND Ulcerative colitis (UC) is a chronic inflammatory disorder of the colon that has a relapsing-remitting course. Health related quality of life (HRQL) is significantly lower in patients with UC than the general population due to the negative effects of the disease on physical, psychological and social well-being. Randomized controlled trials (RCTs) evaluating medical interventions for UC have traditionally used clinical disease activity indices that focus on symptoms to define primary outcomes such as clinical remission or improvement. However, this approach does not evaluate benefits that are highly relevant to patients such as HRQL OBJECTIVES: The primary objective was to assess the impact of biologic therapy on the HRQL of UC patients. SEARCH METHODS We searched PubMed, MEDLINE, EMBASE and CENTRAL from inception to September, 2015. Conference abstracts and reference lists were also searched. SELECTION CRITERIA RCTs that compared biologics to placebo in UC patients and reported on HRQL using the Inflammatory Bowel Disease Questionnaire (IBDQ), or the SF-36 or EQ-5D to measure HRQL were included. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for inclusion, extracted data and assessed study quality using the Cochrane risk of bias tool. The primary outcome was improvement in HRQL. For dichotomous outcomes we calculated the risk ratio (RR) and 95% confidence interval (CI). For continuous outcomes we calculated the mean difference (MD) and 95% CI. The overall quality of the evidence supporting the primary outcome was assessed using GRADE. MAIN RESULTS Nine RCTs (n = 4143) were included. Biologics included rituximab (one small study), interferon-ß-1a (one study), vedolizumab (one study), and the tumor necrosis factor-alpha (TNF-α) antagonists infliximab (two studies), adalimumab (three studies), and golimumab (one study). Risk of bias was low in eight studies. The rituximab study was judged to be at high risk of bias due to attrition bias. The studies comparing interferon-ß-1a and rituximab to placebo found no clear evidence of a difference in the proportion of patients who experienced an improvement in HRQL at 8 or 12 weeks respectively. The proportion of patients with a clinically meaningful improvement in HRQL at 6 or 52 weeks was significantly higher in vedolizumab patients compared to placebo. At 6 weeks 37% (83/225) of vedolizumab patients had an improvement in IBDQ score of at least 16 points from baseline compared to 23% (34/149) of placebo patients (RR 1.62, 95% CI 1.15 to 2.27; 1 study). At 52 weeks, 64% (157/247) of vedolizumab patients had an improvement in IBDQ score of at least 16 points from baseline compared to 38% (48/126) of placebo patients (RR 1.62, 95% CI 1.15 to 2.27; 1 study). A GRADE analysis indicated that the overall quality of the evidence supporting these outcomes was moderate due to sparse data (< 400 events). Patients who received maintenance vedolizumab every eight weeks had significantly higher mean SF-36 scores than placebo patients at 52 weeks (MD 3.40, 95% CI 1.56 to 5.24, 1 study 248 patients). This difference appears to be clinically meaningful as the lower boundary for a clinically meaningful change in SF-36 is three points. A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was moderate due to sparse data (< 400 events). Adalimumab patients had significantly higher mean IBDQ scores than placebo patients at weeks 8 (MD 9.00, 95% CI 2.65 to 15.35; 1 study, 494 patients) and 52 (MD 8.00, 95% CI 0.68 to 15.32; 1 study, 494 patients). However, these differences may not be clinically meaningful as the lower boundary for a clinically meaningful change in IBDQ is 16 points. A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was moderate due to sparse data (< 400 events). Golimumab patients who received a dose of 200/100 mg (MD 12.20, 95% CI 6.52 to 17.88; 504 patients) or 400/200 mg (MD 12.10, 95% CI 6.40 to 17.80; 508 patients) had significantly higher mean IBDQ scores than placebo patients at week 6. Although a GRADE analysis indicated that the overall quality of the evidence supporting these outcomes was high, the difference in IBDQ scores may not be clinically meaningful. Infliximab patients had significantly higher mean IBDQ scores at week 6 or 8 than placebo patients (MD 18,58, 95% CI 13.19 to 23.97; 2 studies, 529 patients). This difference in HRQL is clinically meaningful. A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was high. The proportion of patients with a clinically meaningful improvement in HRQL at eight weeks was significantly higher in infliximab patients compared to placebo. Sixty-nine per cent (333/484) of infliximab patients had an improvement in IBDQ score of > 16 points from baseline compared to 50% of placebo patients (RR 1.39, 95% CI 1.21 to 1.60; 1 study). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was high. Similar results were found between infliximab and placebo when HRQL was measured using the SF-36 instrument. One small study (n = 43) found no difference in HRQL between infliximab and placebo when measured by the EQ-5D. Pooled analyses of TNF-α antagonists showed a benefit in HRQL favouring TNF-α over placebo. AUTHORS' CONCLUSIONS These results suggest that biologics have the potential to improve HRQL in UC patients. High quality evidence suggests that infliximab provides a clinically meaningful improvement in HRQL in UC patients receiving induction therapy. Moderate quality evidence suggests that vedolizumab provides a clinically meaningful improvement in HRQL in UC patients receiving maintenance therapy. These findings are important since there is a paucity of effective drugs for the treatment of UC that have the potential to both decrease disease activity and improve HRQL. More research is needed to assess the long-term effect of biologic therapy on HRQL in patients with UC. More research is needed to assess the impact of golimumab and adalimumab on HRQL in UC patients. Trials involving direct head to head comparisons of biologics would help determine which biologics provide optimum benefit for HRQL.
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Affiliation(s)
- Katie LeBlanc
- Robarts Research InstituteRobarts Clinical TrialsP.O. Box 5015100 Perth DriveLondonONCanadaN6A 5K8
| | - Mahmoud H Mosli
- King Abdulaziz UniversityKing Abdulaziz University HospitalJeddahSaudi Arabia
| | - Claire E Parker
- Robarts Research InstituteRobarts Clinical TrialsP.O. Box 5015100 Perth DriveLondonONCanadaN6A 5K8
| | - John K MacDonald
- Robarts Research InstituteRobarts Clinical TrialsP.O. Box 5015100 Perth DriveLondonONCanadaN6A 5K8
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Khanna R, Mosli MH, Feagan BG. Targeting Leukocyte Trafficking in Inflammatory Bowel Disease: What Is the Clinical Evidence? Dig Dis 2015; 33 Suppl 1:95-104. [PMID: 26368918 DOI: 10.1159/000437103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Since the cause of inflammatory bowel disease (IBD) is unknown, therapy has traditionally been based on the empiric use of anti-inflammatory drugs. However, the recent identification of specific mechanisms that regulate cellular migration into inflamed intestinal tissue has provided novel targets for drug development. In this article, we discuss these mechanisms and review emerging safety and efficacy data regarding use of selective inhibitors of leukocyte trafficking for the treatment of IBD.
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Abstract
INTRODUCTION Crohn's disease (CD) is an idiopathic inflammatory disorder of the gastrointestinal tract traditionally treated by the step-wise use of corticosteroids, antimetabolites and TNF-α antagonists. However, recent evidence indicates that the early introduction of drug combinations might be a superior strategy to step-care. AREAS COVERED In this article, we review existing literature regarding the efficacy and safety of combination drug therapy for the management of CD. Five major databases: MEDLINE, EMBASE, PubMed, the Cochrane Library (CENTRAL) and DDW abstracts were electronically searched from inception to February 2015 for any relevant studies. EXPERT OPINION Existing data strongly support the use of combination therapy for CD. The benefit of this approach appears to outweigh any associated risks. Until the role of gut selective therapies are better established, combination therapy should be considered the standard treatment approach for CD.
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Affiliation(s)
- Mahmoud H Mosli
- a 1 University of Western Ontario, Robarts Research Institute, Robarts Clinical Trials, Department of Medicine , 100 Perth Dr., London, ON N6A 5K8, Canada .,b 2 King Abdulaziz University, King Abdulaziz University Hospital, Department of Medicine , Jeddah , Saudi Arabia.,c 3 Department of Medicine, King Abdulaziz University , Jeddah , Saudi Arabia
| | - Brian G Feagan
- a 1 University of Western Ontario, Robarts Research Institute, Robarts Clinical Trials, Department of Medicine , 100 Perth Dr., London, ON N6A 5K8, Canada
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Mosli MH, Al-Harbi O, Feagan BG, Almadi MA. A Saudi Gastroenterology association position statement on the use of tumor necrosis factor-alfa antagonists for the treatment of inflammatory bowel disease. Saudi J Gastroenterol 2015; 21:185-97. [PMID: 26228361 PMCID: PMC4542416 DOI: 10.4103/1319-3767.161635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 04/29/2015] [Indexed: 12/16/2022] Open
Abstract
The objective of this position statement from the Saudi Gastroenterology Association is to guide gastroenterologists on the use of tumor necrosis factor-alfa (TNF-α) antagonists for the treatment of the idiopathic inflammatory bowel diseases, Crohn's disease, and ulcerative colitis. In this article, we summarize the relevant literature regarding the safety and efficacy of TNF-α antagonists, highlight relevant safety concerns specific to the environment in Saudi Arabia, and provide specific recommendations for the use of these agents.
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Affiliation(s)
- Mahmoud H. Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Othman Al-Harbi
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Brian G. Feagan
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Majid A. Almadi
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
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Khanna R, Mosli MH, Lam MCW, Fu N, Bressler B, Rosenfeld G, MacDonald JK, Levesque BG, Feagan BG. Vedolizumab for induction and maintenance of remission in Crohn’s disease. Hippokratia 2015. [DOI: 10.1002/14651858.cd011615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Reena Khanna
- Robarts Research Institute; Robarts Clinical Trials; P.O. Box 5015 100 Perth Drive London ON Canada N6A 5K8
| | - Mahmoud H Mosli
- Robarts Research Institute; Robarts Clinical Trials; P.O. Box 5015 100 Perth Drive London ON Canada N6A 5K8
- London Health Sciences Centre, University Hospital; London ON Canada
- King Abdulaziz University; King Abdulaziz University Hospital; Jeddah Saudi Arabia
| | - Mindy CW Lam
- University of British Columbia; Division of Gastroenterology; Vancouver BC Canada
| | - Nancy Fu
- University of British Columbia; Department of Medicine; Vancouver BC Canada
| | - Brian Bressler
- University of British Columbia; Division of Gastroenterology; Vancouver BC Canada
| | - Greg Rosenfeld
- University of British Columbia; Division of Gastroenterology; Vancouver BC Canada
| | - John K MacDonald
- Robarts Research Institute; Robarts Clinical Trials; P.O. Box 5015 100 Perth Drive London ON Canada N6A 5K8
| | - Barrett G Levesque
- University of California San Diego; Division of Gastroenterology; 9500 Gilman Drive La Jolla California USA 92093
| | - Brian G Feagan
- Robarts Research Institute; Robarts Clinical Trials; P.O. Box 5015 100 Perth Drive London ON Canada N6A 5K8
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Almadi MA, Mosli MH, Bohlega MS, Al Essa MA, AlDohan MS, Alabdallatif TA, AlSagri TY, Algahtani FA, Mandil A. Effect of public knowledge, attitudes, and behavior on willingness to undergo colorectal cancer screening using the health belief model. Saudi J Gastroenterol 2015; 21:71-7. [PMID: 25843192 PMCID: PMC4392578 DOI: 10.4103/1319-3767.153814] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND/AIMS Success of colorectal cancer (CRC) screening is dependent in part on the proportion of uptake by the targeted population. We aimed in this study to identify factors that were associated with willingness to undergo CRC screening based on the health belief model (HBM). PATIENTS AND METHODS This was a cross-sectional study among citizens of Riyadh, Saudi Arabia. Demographic data collected included gender, age, education, marital status, employment status, a history of CRC in the family or knowing a friend with CRC, as well as income. A questionnaire was developed in Arabic based on the HBM and included enquiries on knowledge about CRC symptoms and risk factors, types of CRC screening tests, perceived risk of CRC, previously undergoing CRC screening, intent to undergo CRC screening, perceived barriers to CRC screening, perceived severity of CRC, as well as attitudes toward CRC and its screening. RESULTS Five hundred participants were included. The mean age was 41.0 years (SD 10.7). Males were 50% and only 6.7% of those between 50 and 55 years of age had undergone CRC screening. Of those surveyed, 70.7% were willing to undergo CRC screening. Also, 70.5% thought that CRC is curable, 73.3% believed it was preventable, whereas 56.7% thought it was a fatal disease. Neither gender, level of education, occupation, income, marital status, nor general knowledge about CRC was found to be associated with the willingness to undergo CRC screening. Recognizing that colonoscopy was a screening test (OR 1.55, 95% CI; 1.04-2.29) was associated with a strong desire to undergo CRC screening while choosing a stool-based test was associated with not willing to undergo CRC screening (OR 0.59, 95%CI; 0.38-0.91). CONCLUSION We found that the majority of those interviewed were willing to undergo CRC screening and identified a number of barriers as well as potential areas that could be targeted in the promotion of CRC screening uptake if such a national program were to be implemented.
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Affiliation(s)
- Majid A. Almadi
- Division of Gastroenterology, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia,Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada,Address for correspondence: Dr. Majid Abdulrahman Almadi, Division of Gastroenterology, King Saud University Medical City, King Saud University, Riyadh, P. O. Box 2925 (59), Riyadh 11461, Saudi Arabia. E-mail:
| | - Mahmoud H. Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohamed S. Bohlega
- College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Mohanned A. Al Essa
- College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed S. AlDohan
- College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Turki A. Alabdallatif
- College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Turki Y. AlSagri
- College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Faleh A. Algahtani
- College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Ahmed Mandil
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia (seconded from High Institute of Public Health, University of Alexandria, Egypt
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Mosli MH, Al-Ahwal MS. Does the increasing trend of colorectal cancer incidence in jeddah reflect a rise in the Kingdom of Saudi Arabia? Asian Pac J Cancer Prev 2014; 13:6285-8. [PMID: 23464446 DOI: 10.7314/apjcp.2012.13.12.6285] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to outline the trend in the incidence of colorectal cancer (CRC) in the city of Jeddah, Kingdom of Saudi Arabia (KSA), for comparison with previously published national CRC data. MATERIALS AND METHODS A retrospective data analysis was performed on all cases of CRC diagnosed between January 2000 and December 2006 amongst Saudi patients in Jeddah using data retrieved from the Saudi Cancer Registry (SCR). Descriptive analysis was performed and results were compared to national CRC data from the SCR. RESULTS In Jeddah, 644 cases of CRC were diagnosed during the time period, accounting for 15% of all CRC cases in KSA. Males were more commonly affected than females (58% versus 42%). The male preponderance of CRC was similar to that observed at a national level. In Jeddah, the incidence was higher among those >45 years (77.0%), and the mean age at diagnosis was 57 years. At diagnosis, 10% of patients presented with localized disease; 25% presented with distant metastasis and the remaining patients had various stages of regional extension. Adenocarcinomas accounted for 72% of cases. Statistical analysis did not reveal any clinically significant differences between cases diagnosed in Jeddah and those diagnosed throughout KSA. CONCLUSIONS The increased trend in the incidence of CRC in Jeddah between 2000 and 2006 mirrors the recent trend in KSA. This highlights the magnitude of this healthcare hazard, not only in Jeddah, but also across the country and supports the need for preventive measures and early detection of the disease.
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Affiliation(s)
- Mahmoud H Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
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Mosli MH, Sandborn WJ, Kim RB, Khanna R, Al-Judaibi B, Feagan BG. Toward a personalized medicine approach to the management of inflammatory bowel disease. Am J Gastroenterol 2014; 109:994-1004. [PMID: 24842338 DOI: 10.1038/ajg.2014.110] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 03/30/2014] [Indexed: 12/11/2022]
Abstract
The medical management of inflammatory bowel disease (IBD) is evolving toward a personalized medicine-based model. Modern therapeutic algorithms that feature use of tumor necrosis factor (TNF) antagonists in combination with immunosuppressive are highly effective when initiated in high-risk patients early in the course of disease. Defined targets that guide intensification of therapy are critical interventions. In this model, therapy is optimized through appropriate pretreatment testing, therapeutic drug monitoring, and patient-based monitoring strategies. This review discusses the current application of personalized medicine to the management of IBD.
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Affiliation(s)
- Mahmoud H Mosli
- 1] Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada [2] Robarts Clinical Trials, Robarts Research Institute, London, Ontario, Canada [3] Department of Medicine, Division of Gastroenterology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - William J Sandborn
- 1] Robarts Clinical Trials, Robarts Research Institute, London, Ontario, Canada [2] Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Richard B Kim
- Department of Medicine, Division of Clinical Pharmacology, Western University, London, Ontario, Canada
| | - Reena Khanna
- 1] Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada [2] Robarts Clinical Trials, Robarts Research Institute, London, Ontario, Canada
| | - Bandar Al-Judaibi
- 1] Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada [2] Department of Medicine, Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Brian G Feagan
- 1] Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada [2] Robarts Clinical Trials, Robarts Research Institute, London, Ontario, Canada
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Mosli MH, Rivera-Nieves J, Feagan BG. T-Cell Trafficking and Anti-Adhesion Strategies in Inflammatory Bowel Disease: Current and Future Prospects. Drugs 2014; 74:297-311. [DOI: 10.1007/s40265-013-0176-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Mosli MH, Aljudaibi B, Al-Madi M. Saudi Gastroenterology Association position statement on safety issues associated with the use of domperidone. Saudi J Gastroenterol 2014; 20:267-9. [PMID: 25253360 PMCID: PMC4196340 DOI: 10.4103/1319-3767.141683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Mahmoud H. Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia E-mail: ,Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Bandar Aljudaibi
- Department of Medicine, University of Western Ontario, London, Ontario, Canada,Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Majid Al-Madi
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
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Khanna R, Mosli MH, Feagan BG. Challenging question: is treating inflammatory bowel disease an art or strictly an evidence-based matter? Dig Dis 2013; 31:213-7. [PMID: 24030228 DOI: 10.1159/000353371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Although evidence-based medicine (EBM) is the gold standard for clinical practice, misconceptions among health care providers regarding EBM are common. The medical management of inflammatory bowel diseases (IBD) has advanced substantially over the last 20 years as a direct result of the wealth of new evidence generated by randomized controlled trials. Integrating EBM and traditional clinical skills results in optimal care tailored to the individual patient. This article addresses the role of EBM in the management of IBD and dispels some of the common misconceptions about the use of EBM in practice.
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Affiliation(s)
- Reena Khanna
- Robarts Clinical Trials, Robarts Research Institute, Department of Medicine, University of Western Ontario, London, Ont., Canada
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Abstract
INTRODUCTION Crohn's disease (CD) is a chronic inflammatory disorder of unknown aetiology. Currently, approved therapies that include prednisone, anti-metabolites and TNF antagonists, are often ineffective and frequently cause adverse effects. As a result, patients with CD can develop serious complications that adversely affect quality of life. Consequently, new treatment options are needed. AREAS COVERED This review discusses the potential role of vedolizumab, a humanised monoclonal antibody that selectively blocks lymphocyte trafficking to the gut, for the treatment of CD. All randomised placebo-controlled trials that evaluated vedolizumab for the treatment of CD were reviewed and safety and efficacy data evaluated. EXPERT OPINION Vedolizumab is an effective and well-tolerated drug that is an important advance for the treatment of CD.
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Affiliation(s)
- Mahmoud H Mosli
- University of Western Ontario, Robarts Research Institute, Department of Medicine, Robarts Clinical Trials, 100 Perth Dr., London, ON N6A 5K8, Canada
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Abstract
BACKGROUND AND OBJECTIVES Colorectal cancer (CRC) is a major health problem in the Kingdom of Saudi Arabia (KSA). Our aim was to characterize the epidemiology of CRC in the Saudi population. DESIGN AND SETTING Retrospective analysis of all cases of CRC recorded in the Saudi Cancer Registry (SCR) between January 2001 and December 2006 amongst Saudi citizens in KSA. PATIENTS AND METHODS Data were retrieved from the database of the SCR. Descriptive statistics was performed using SPSS. RESULTS A total of 4,201 cases of CRC were registered in the SCR. The incidence of CRC increased between 2001 and 2006. The mean age of patients at the time of diagnosis was 58 years; most patients were above 45 years of age (n=3322; 79.1%). At the time of diagnosis, 977 patients (23.0%) presented with localized disease and 1,018 (24.0%) had distant metastasis. The most frequent pathological variant was adenocarcinoma (73%), with grade 2 (moderately differentiated) being the most common grade among all variants (61%). For all cancer grades, the frequency of CRC was significantly higher among patients >45 years (P=0.004), who presented with more advanced disease (stages III and IV) (P=0.012). Based on logistic regression, age >45 years was associated with advanced regional presentation (P=0.001). Tumor grade was associated with advanced regional presentation and metastasis. CONCLUSION There was an increase in the incidence of CRC between 2001 and 2006. The age at the time of diagnosis was low when compared with reports from developed countries. A nationwide approach is needed to encourage and illustrate the importance of screening programs.
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Mosli MH, Aljudaibi B, Almadi M, Marotta P. The safety and efficacy of gastric fundal variceal obliteration using N-butyl-2-cyanoacrylate; the experience of a single canadian tertiary care centre. Saudi J Gastroenterol 2013; 19:152-9. [PMID: 23828744 PMCID: PMC3745656 DOI: 10.4103/1319-3767.114508] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIM Bleeding from Gastric Varices (GV) is not only life threatening, but also leads to many hospitalizations, contributes to morbidity and is resource intensive. GV are difficult to diagnose and their treatment can be challenging due to their location and complex structure. To assess the safety and efficacy of endoscopic gastric fundal variceal gluing using periodic endoscopic injections of N-butyl-2-cyanoacylate (NBCA) and to assess the utility of endoscopic ultrasound (EUS) in assessing for the eradication of GV post-NBCA treatment. MATERIALS AND METHODS Analysis of prospectively collected data of a cohort of patients with GV who underwent periodic endoscopic variceal gluing from 2005 to 2011. Outcomes included success of GV obliteration, incidence of rebleeding, complications from the procedure, and analysis of factors that might predict GV rebleeding. The success of GV eradication was assessed by both EUS and direct endoscopy. RESULTS The cohort consisted of 29 consecutive patients that had undergone NBCA injection for GV. The mean age was 60.8 years standard deviations (SD 13.3, range 20-81). The average follow-up was 28 months (SD 19.61, range 1-64) and the most common cause for GV was alcoholic liver cirrhosis (34.48%). A total of 91 sessions of NBCA injections were carried out for 29 patients (average of 3.14 sessions/patient, SD 1.79, range 1-8) with a total of 124 injections applied (average of 4.28 injections/patient, SD 3.09, range 1-13). 24 patients were treated for previously documented GV bleeding while five were treated for primary prevention. Overall, 79% of patients were free of rebleeding once three sessions of histoacryl ® injection were completed. None of the patients treated for primary prevention developed bleeding during follow-up. 11 of the 24 patients (46%) with previous bleeding however had rebleeding. 4/11 (36%) patients had GV rebleeding while awaiting scheduled additional NBCA sessions. 19/29 (60%) patients had complete eradication of GV, 11/19 (58%) documented by endoscopic assessment alone, 4/19 (21%) by EUS alone and 4/19 (21%) by both techniques. Two of the 11 (18%) patients that had rebleeding had recurrence of GV bleeding after documented eradication by EUS compared to 5/11 (45%) patients documented eradication by endoscopic assessment and 2/11 (18%) patients that had rebleeding after documented eradication by both modalities. Twenty five patients in total had documented residual GV by EUS (14, 56%), direct endoscopic assessment (18, 72%) or both modalities (9, 36%), two of which developed recurrent bleeding (13%). No immediate or long-term complications of NBCA injection occurred, nor any related endoscopic complications were reported in any of these cases during the time of follow-up. CONCLUSION NBCA injection of GV is a safe and successful therapeutic intervention. A minimum of three endoscopic sessions is required to significantly decrease the risk of bleeding/rebleeding. In this small sample of patients, neither EUS nor direct endoscopic assessment was reliable in predicting the recurrence of GV bleeding.
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Affiliation(s)
- Mahmoud H. Mosli
- Department of Medicine, University of Western Ontario, London, Canada,Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bandar Aljudaibi
- Department of Medicine, University of Western Ontario, London, Canada,Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - 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, Québec, Canada,
| | - Paul Marotta
- Department of Medicine, University of Western Ontario, London, Canada,Address for correspondence: Dr. Paul Marotta, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada. E-mail:
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