Management of inflammatory bowel disease Wright, Emily K; Ding, Nik S; Niewiadomski, Ola
Medical journal of Australia,
October 2018, Volume:
209, Issue:
7
Journal Article
Peer reviewed
Australia has one of the highest incidence rates of inflammatory bowel disease (IBD) in the world. Early diagnosis and treatment for IBD is critical. For Crohn disease, in particular, this may change ...the natural history of disease and reduce disability. Faecal calprotectin is a sensitive test that can be used by primary care physicians to assist in determining which patients with gastrointestinal symptoms may have IBD. This allows for prompt identification of patients who may benefit from endoscopy. Regular re-evaluation of disease status with strategies that can safely, readily and reliably detect the presence of inflammation with faecal biomarkers and imaging is important. To avoid the risks of cumulative radiation exposure, magnetic resonance imaging and/or intestinal ultrasound, rather than computed tomography scanning, should be performed when possible. Drug treatments for IBD now include five biological drugs listed by the Pharmaceutical Benefits Scheme: adalimumab, infliximab, golimumab, vedolizumab and ustekinumab. Such developments offer the possibility for improved disease control in selected patients.
Background
The gastrointestinal microbiota is the key antigenic drive in the inflammatory bowel diseases. Randomized controlled trials (RCTs) in ulcerative colitis have established fecal microbiota ...transplantation (FMT) as an effective therapy. We have conducted a systematic review to evaluate the efficacy of FMT in Crohn's disease.
Methods
A systematic literature search was performed through to August 2020 (MEDLINE; Embase). Studies were included if they reported FMT administration in patients with Crohn's disease, and reported on clinical outcomes.
Results
Fifteen studies published between 2014 and 2020, comprising 13 cohort studies and two RCTs, were included in the analysis. The majority of trials evaluated FMT for induction of remission, with follow‐up duration varying from 4 to 52 weeks. One RCT in 21 patients, of single‐dose FMT versus placebo, following steroid‐induced remission, showed a higher rate of steroid‐free clinical remission in the FMT group compared to the control group: 87.5% vs 44.4% at week 10 (P = 0.23). Another RCT, two‐dose FMT in 31 patients, showed an overall clinical remission rate of 36% at week 8, however, with no difference in clinical or endoscopic endpoints between FMT administered by gastroscopy and colonoscopy. Considering all studies, the clinical response rates in early follow up were higher following multiple FMT than with single FMT. FMT dose did not appear to influence clinical outcomes, nor did whether FMT was fresh or frozen. FMT delivered via upper gastrointestinal route demonstrated higher early efficacy rates of 75 to 100% compared with lower delivery route rates of 30% to 58%, but on follow up beyond 8 weeks, this difference was not maintained. Whether pre‐FMT antibiotic administration was beneficial was not able to be determined due to the limited number of patients receiving antibiotics and varying antibiotic regimens. No serious adverse events were reported.
Conclusions
Preliminary studies suggest that FMT may be an effective therapy in Crohn's disease. However large controlled trials are needed. No serious safety concerns have been identified.
Mindfulness meditation interventions-which train skills in monitoring present-moment experiences with a lens of acceptance-have shown promise for increasing positive emotions. Using a theory-based ...approach, we hypothesized that learning acceptance skills in mindfulness interventions helps people notice more positive experiences in daily life, and tested whether removing acceptance training from mindfulness interventions would eliminate intervention-related boosts in positive affect. In 2 randomized controlled trials (RCTs) of stressed community adults, mindfulness skills were dismantled into 2 structurally equivalent interventions: (a) training in both monitoring and acceptance (Monitor + Accept) and (b) training in monitoring only (Monitor Only) without acceptance training. Study 1 tested 8-week group-based Monitor + Accept and Monitor Only interventions compared with a no treatment control group. Study 2 tested 2-week smartphone-based Monitor + Accept and Monitor Only interventions compared with an active control training. In both studies, end-of-day and momentary positive affect and negative affect were measured in daily life for 3 days pre- and post-intervention using ambulatory assessments. As predicted, across 2 RCTs, Monitor + Accept training increased positive affect compared with both Monitor Only and control groups. In Study 1, this effect was observed in end-of-day positive affect. In Study 2, this effect was found in both end-of-day and momentary positive affect outcomes. In contrast, all active interventions in Studies 1 and 2 decreased negative affect. These studies provide the first experimental evidence that developing an orientation of acceptance toward present-moment experiences is a central mechanism of mindfulness interventions for boosting positive emotions in daily life.
Full text
Available for:
CEKLJ, FFLJ, NUK, ODKLJ, PEFLJ
The intestinal microbiota is involved in the pathogenesis of inflammatory bowel disease. A reduction in the diversity of the intestinal microbiota as well as specific taxonomic and functional shifts ...have been reported in Crohn's disease and may play a central role in the inflammatory process. The aim was to systematically review recent developments in the structural and functional changes observed in the gastrointestinal microbiome in patients with Crohn's Disease.
Seventy-two abstracts were included in this review. The effects of host genetics, disease phenotype, and inflammatory bowel disease treatment on the gastrointestinal microbiome in Crohn's disease were reviewed, and taxonomic shifts in patients with early and established disease were described. The relative abundance of Bacteroidetes is increased and Firmicutes decreased in Crohn's disease compared with healthy controls. Enterobacteriaceae, specifically Eschericia coli, is enriched in Crohn's disease. Faecalibacterium prausnitzii is found at lower abundance in Crohn's disease and in those with postoperative recurrence. Observed functional changes include major shifts in oxidative stress pathways, a decrease in butanoate and propanoate metabolism gene expression, lower levels of butyrate, and other short-chain fatty acids, decreased carbohydrate metabolism, and decreased amino acid biosynthesis.
Changes in microbial composition and function have been described, although a causative role remains to be established. Larger, prospective, and longitudinal studies are required with deep interrogation of the microbiome if causality is to be determined, and refined microbial manipulation is to emerge as a focused therapy.
QUESTION: Are plant traits more closely correlated with mean annual temperature, or with mean annual precipitation? LOCATION: Global. METHODS: We quantified the strength of the relationships between ...temperature and precipitation and 21 plant traits from 447,961 species‐site combinations worldwide. We used meta‐analysis to provide an overall answer to our question. RESULTS: Mean annual temperature was significantly more strongly correlated with plant traits than was mean annual precipitation. CONCLUSIONS: Our study provides support for some of the assumptions of classical vegetation theory, and points to many interesting directions for future research. The relatively low R² values for precipitation might reflect the weak link between mean annual precipitation and the availability of water to plants.
Objective: Mindfulness interventions have been shown to reduce stress; however, the mechanisms driving stress resilience effects are not known. Mindfulness interventions aim to teach individuals how ...to: (a) use attention to monitor present moment experiences; with (b) an attitude of acceptance and equanimity. A randomized controlled dismantling trial (RCT) was conducted to test the prediction that the removal of acceptance skills training would eliminate stress-reduction benefits of a mindfulness intervention. Method: This preregistered RCT randomly assigned stressed community adults to 1 of 3 conditions: (a) Monitor and Accept (MA) mindfulness training, a standard 8-week Mindfulness-Based Stress Reduction (MBSR) intervention that provided explicit instruction in developing both monitoring and acceptance skills; (b) Monitor Only (MO) mindfulness training, a well-matched 8-week MBSR intervention that taught monitoring skills only; or (c) No Treatment (NT) control. Stress and nonjudgment were measured using ecological momentary assessment (EMA) for 3 days at baseline and 3 days at postintervention. Results: Consistent with predictions, MA participants increased in nonjudgment and decreased in both stress ratings and the proportion of assessments that they reported experiencing feelings of stress in daily life, relative to both MO and NT participants. Conclusions: This RCT provides one of the first experimental tests of the mechanisms linking mindfulness interventions with stress resilience. These findings suggest that acceptance skills training may be a necessary active ingredient and support the value of integrating acceptance skills training into stress-reduction interventions.
Full text
Available for:
CEKLJ, FFLJ, NUK, ODKLJ, PEFLJ
To compare short-term patient-reported outcomes (PRO) of two contemporary matrix-associated autologous chondrocyte implantation (M-ACI) products for the treatment of large articular cartilage defects ...of the knee.
A retrospective, registry-based, matched-pair analysis was performed, comparing PRO of patients undergoing isolated M-ACI with either Spherox™, a spheroid-based ACI (Sb-ACI), or NOVOCART™ Inject, a hydrogel-based ACI product (Hb-ACI), for a focal full-thickness cartilage defect of the knee ≥4 cm
. Matching parameters included age, sex, body mass index, defect size, defect localization, symptom duration and previous surgeries. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) score were obtained up to the 24-month follow-up. The total KOOS response rate and percentage of patients attaining a substantial clinical benefit (SCB) in KOOS subscores were calculated.
A total of 45 patients per group were matched. The response rate after 24 months was not significantly different between the groups (Sb-ACI 64.4% vs. Hb-ACI 82.2%, p = 0.057). The number of patients with a SCB at 24 months was not significantly different in any KOOS subscore, despite significantly higher improvement of the total KOOS (14.8 ± 16.2 vs. 21.5 ± 15.4, p = 0.047) and KOOS pain in the Hb-ACI group (12.2 ± 18.6 vs. 20.6 ± 19.1, p = 0.037). The IKDC score in the Hb-ACI group was significantly higher at the 12- and 24-month follow-up (60.7 ± 20.2 vs. 70.9 ± 18.0, p = 0.013).
The response rate and number of patients achieving an SCB were not significantly different between patients treated with Sb-ACI or Hb-ACI. Both procedures can achieve favourable 2-year PRO. Hb-ACI was associated with better PRO between 1 and 2 years postoperatively; however, the clinical relevance of this benefit is yet to be proven.
III, Retrospective comparative study.
Background
In medically refractory Ulcerative Colitis (UC), proctocolectomy with ileoanal pouch procedure (IAPP) is the preferred continence‐preserving surgical option. Functional outcomes ...post‐surgery and long‐term complication rates in the biologic era remain ambiguous. This review primarily aims to provide an update on these outcomes. Secondarily, risk factors associated with chronic pouchitis and pouch failure are explored.
Methods
Two online databases (MEDLINE and EMBASE) were searched on 4 October 2022 for English studies from 2011‐present relating to long‐term outcomes of IAPP in inflammatory bowel disease (IBD) patients. Adult patients with 12 month follow‐up were included. Studies focused on 30‐day post‐operative outcomes, non‐IBD patients or studies including less than 30 patients were excluded.
Results
Following screening and full‐text review of 1094 studies, 49 were included. Median sample size was n = 282 (IQR: 116–519). Median incidences for chronic pouchitis and pouch failure were 17.1% (IQR: 12–23.6%) and 6.9% (IQR: 4.8–10.8%), respectively. Upon multivariate analysis, chronic pouchitis development was most significantly associated with pre‐operative steroid use, pancolitis and extra‐intestinal IBD manifestations, whilst pouch failure was most significantly associated with pre‐operative diagnosis of Crohn's disease (compared to UC), peri‐operative pelvic sepsis and anastomotic leak. Overall patient satisfaction was very high with four included studies reporting greater than 90% satisfaction rates.
Conclusion
Long‐term complications for IAPP were common. However, despite this, patient satisfaction post‐IAPP was high. Up‐to‐date knowledge of complication rates and their risk factors improves pre‐operative counselling, management planning and patient outcomes.
Long‐term complication rates and functional outcomes of ileoanal pouch procedures in the biologic era have not been well defined. This review primarily aims to provide an update on these outcomes. Secondarily, risk factors associated with chronic pouchitis and pouch failure are explored.
Background:
Anterior cruciate ligament (ACL) reinjury results in worse outcomes and increases the risk of posttraumatic osteoarthritis.
Purpose:
To identify the risk factors for both ipsilateral and ...contralateral ACL tears after primary ACL reconstruction (ACLR).
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Data from the Multicenter Orthopaedic Outcomes Network (MOON), a prospective longitudinal cohort, were used to identify risk factors for ACL retear. Subjects with primary ACLR, no history of contralateral knee surgery, and a minimum of 2-year follow-up data were included. Age, sex, Marx activity score, graft type, lateral meniscal tear, medial meniscal tear, sport played at index injury, and surgical facility were evaluated to determine their contribution to both ipsilateral retear and contralateral ACL tear.
Results:
A total of 2683 subjects with average age of 27 ± 11 years (1498 men; 56%) met all study inclusion/exclusion criteria. Overall there were 4.4% ipsilateral graft tears and 3.5% contralateral ACL tears. The odds of ipsilateral ACL retear were 5.2 times greater for an allograft (P < .01) compared with a bone–patellar tendon–bone (BTB) autograft; the odds of retear were not significantly different between BTB autograft and hamstring autograft (P = .12). The odds of an ipsilateral ACL retear decreased by 0.09 for every yearly increase in age (P < .01) and increased by 0.11 for every increased point on the Marx score (P < .01). These odds were not significantly influenced by sex, smoking status, sport played, medial or lateral meniscal tear, or consortium site (P > .05). The odds of a contralateral ACL tear decreased by 0.04 for every yearly increase in age (P = .04) and increased by 0.12 for every increased point on the Marx score (P < .01); these odds were not significantly different between sex, smoking status, sport played, graft type, medial meniscal tear, or lateral meniscal tear (P > .05).
Conclusion:
Younger age, higher activity level, and allograft graft type were predictors of increased odds of ipsilateral graft failure. Higher activity and younger age were found to be risk factors in contralateral ACL tears.
This trial compared surgery with physical therapy (followed by surgery as needed) in patients with a meniscal tear and mild-to-moderate knee osteoarthritis. Functional outcomes and pain were similar ...in the two groups at 6 months; 30% of the PT group crossed over to surgery.
Symptomatic, radiographically confirmed osteoarthritis of the knee affects more than 9 million people in the United States.
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Meniscal tears are also highly prevalent, with imaging evidence of a meniscal tear observed in 35% of persons older than 50 years of age; two thirds of these tears are asymptomatic.
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Meniscal damage is especially prevalent among persons with osteoarthritis
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,
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and is frequently treated surgically with arthroscopic partial meniscectomy. This procedure, in which the surgeon trims the torn meniscus back to a stable rim, is performed for a range of indications in more than 465,000 persons annually in the United States.
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