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Efficacy and Safety of Upadacitinib for Perianal Fistulizing Crohn's Disease: A Post Hoc Analysis of 3 Phase 3 Trials. 乌达帕替尼治疗肛周瘘性克罗恩病的疗效和安全性:对 3 项 3 期试验的事后分析。
IF 11.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Pub Date : 2024-09-24 DOI: 10.1016/j.cgh.2024.08.032
Jean-Frédéric Colombel, Ana P Lacerda, Peter M Irving, Remo Panaccione, Walter Reinisch, Florian Rieder, Adam Steinlauf, David Schwartz, Tian Feng, Elena Dubcenco, Samuel I Anyanwu, F Stephen Laroux, Colla Cunneen, Nick Powell

Background & aims: Efficacy of upadacitinib, an oral Janus kinase inhibitor, for moderate-to-severe Crohn's disease was demonstrated in phase 3 induction (U-EXCEL, U-EXCEED) and maintenance (U-ENDURE) trials; this post hoc analysis evaluated upadacitinib outcomes in patients with fistulizing disease in these studies.

Methods: Patients were randomized (2:1) to once daily upadacitinib 45 mg or placebo for 12 weeks. Upadacitinib 45 mg clinical responders were rerandomized (1:1:1) to upadacitinib 15 mg, upadacitinib 30 mg, or placebo for 52 weeks. In patients with fistulas (any and perianal), resolution of drainage, closure of external openings, clinical remission, endoscopic response, and safety were assessed.

Results: Of 1021 patients in U-EXCEL and U-EXCEED, 143 (14.0%) had any fistulas at baseline (66 draining); of these, most (n = 128) had perianal fistulas (56 draining). Greater proportions of patients receiving upadacitinib vs placebo achieved resolution of drainage of perianal fistulas at the end of induction (placebo: 5.6%, n/n = 1/18; upadacitinib 45 mg: 44.7%, n/n = 17/38; P = .003) and maintenance (placebo: 0%, n/n = 0/11; upadacitinib 15 mg: 28.6%, n/n = 4/14; P = .105; upadacitinib 30 mg: 23.1% n/n = 3/13; P = .223) and closure of perianal fistula external openings (for induction, placebo: 4.8%, n/n = 2/42; upadacitinib 45 mg: 22.1%, n/n = 19/86; P = .013; for maintenance, placebo: 0%, n/n = 0/30; upadacitinib 15 mg: 18.8%, n/n = 6/32; P = .024; upadacitinib 30 mg: 16.0%, n/n = 4/25; P = .037).

Conclusion: Patients with fistulizing disease (primarily perianal) treated with upadacitinib achieved higher rates of resolution of drainage, closure of external openings, clinical remission, and endoscopic response vs placebo.

Clinicaltrials: gov, Numbers: NCT03345849 (U-EXCEL), NCT03345836 (U-EXCEED), NCT03345823 (U-ENDURE).

背景与目的:口服Janus激酶抑制剂upadacitinib治疗中重度克罗恩病的疗效已在3期诱导(U-EXCEL、U-EXCEED)和维持(U-ENDURE)试验中得到证实;这项事后分析评估了这些研究中瘘管化疾病患者的upadacitinib疗效:患者被随机(2:1)分配至每日一次的达达替尼 45 毫克(UPA45)或安慰剂,为期 12 周。UPA45临床应答者被重新随机分组(1:1:1)至达帕替尼15毫克(UPA15)、30毫克(UPA30)或安慰剂,为期52周。对瘘管(任何瘘管和肛周瘘管)患者的引流恢复情况、外部开口闭合情况、临床缓解情况、内窥镜反应和安全性进行了评估:U-EXCEL和U-EXCEED的1021名患者中,143人(14.0%)在基线时有瘘管(66人引流通畅);其中大多数(128人)有肛周瘘管(56人引流通畅)。在诱导治疗(安慰剂,5.6%,n/N = 1/18;UPA45,44.7%,n/N = 17/38;P = .003)和维持治疗(安慰剂,0%,n/N = 0/11;UPA15,28.6%,n/N = 4/14;P = .结论:结论:与安慰剂相比,接受高达替尼治疗的瘘管病(主要是肛周瘘管病)患者的引流通畅率、外部开口闭合率、临床缓解率和内镜反应率都更高:U-excel (NCT03345849)、U-exceed (NCT03345836)、U-endure (NCT03345823)。
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引用次数: 0
Risk of Recurrence in Screen-Detected vs Non-Screen-Detected Colorectal Cancer Patients. 筛查与非筛查发现的结直肠癌患者的复发风险。
IF 11.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Pub Date : 2024-09-24 DOI: 10.1016/j.cgh.2024.08.033
Sanne J K F Pluimers, Pieter H A Wisse, Monique E van Leerdam, Evelien Dekker, Iris van Lansdorp-Vogelaar, Pieter J Tanis, Marloes A G Elferink, Caroline M den Hoed, Manon C W Spaander

Background and aims: Patients with screen-detected colorectal cancer (CRC) have a better stage-specific overall survival than non-screen-detected CRC. Currently, it is unknown if recurrence rates differ between screen-detected and non-screen-detected CRCs, and whether this could explain the observed difference in overall survival. Therefore, we aimed to assess the disease-free survival (DFS) rates in screen-detected and non-screen-detected CRCs and if recurrence affects overall survival.

Methods: Dutch CRC (stage I-III) patients, diagnosed by screening or not in the first 6 months of 2015, were included from the Netherlands Cancer Registry. DFS and survival data were retrieved and analyzed by Kaplan-Meier method. The association between mode of detection and recurrence and overall survival was evaluated with a Cox regression model.

Results: A total of 3725 CRC patients were included, 2073 (55.7%) non-screen detected and 1652 (44.3%) screen detected. Three-year DFS was significantly higher in screen-detected CRC compared with non-screen-detected CRC (87.8% vs 77.2%; P < .001). Stage-specific DFS rates for screen-detected vs non-screen-detected CRC were 94.7% vs 92.3% for stage I (P = .45), 84.3% vs 81.4% for stage II (P = .17), and 77.9% vs 66.7% for stage III (P < .001), respectively. Detection by screening was independently associated with a lower risk of recurrence (hazard ratio, 0.67; 95% confidence interval, 0.55-0.81; P < .001) when adjusted for age, sex, tumor location, stage and treatment. Recurrence independently predicted overall survival (hazard ratio, 15.90; 95% confidence interval, 13.28-19.04; P < .001).

Conclusion: DFS was significantly better in screen-detected compared with non-screen-detected CRCs independent of age, sex, tumor location, stage and treatment, and was associated with an overall survival benefit.

背景和目的:筛查出的结直肠癌(CRC)患者的特定阶段总生存期优于未筛查出的 CRC。目前,筛查出的 CRC 和未筛查出的 CRC 的复发率是否存在差异,以及这是否能解释观察到的总生存率差异,尚不得而知。因此,我们旨在评估筛查出的和未筛查出的 CRC 的无病生存率(DFS),以及复发是否会影响总生存率:方法:我们从荷兰癌症登记处纳入了 2015 年上半年通过筛查或未通过筛查确诊的荷兰 CRC(I-III 期)患者。检索了DFS和生存数据,并采用卡普兰-梅耶尔法进行了分析。采用Cox回归模型评估了检测方式与复发和总生存率之间的关系:结果:共纳入 3725 例 CRC 患者,其中 2073 例(55.7%)为未筛查出的 CRC,1652 例(44.3%)为筛查出的 CRC。筛查出的 CRC 三年无病生存率明显高于未筛查出的 CRC(87.8% 对 77.2.%,pConclusion):筛查出的 CRC 与未筛查出的 CRC 相比,无病生存期明显更长,不受年龄、性别、肿瘤位置、分期和治疗方法的影响,并且与总生存期获益相关。
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引用次数: 0
Cold Snare Resection in the Colorectum: When to Choose it, When to Avoid it, and How to Do it. 结直肠冷阱切除术:何时选择、何时避免以及如何操作。
IF 11.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Pub Date : 2024-09-23 DOI: 10.1016/j.cgh.2024.08.030
John J Guardiola, Joseph C Anderson, Tonya Kaltenbach, Heiko Pohl, Douglas K Rex

Cold snaring is now the preferred resection method for the majority of colorectal polyps encountered during colonoscopy. A key advantage of cold resection over resection utilizing electrocautery is a substantially lower risk of delayed hemorrhage. Cold snare resection is preferred for all lesions ≤10 mm and for nondysplastic sessile serrated lesions of any size but should be avoided when lesions have a significant risk of submucosal invasion or fibrosis. Cold snare resection can be considered for certain lesions 11-19 mm in size and some lateral spreading lesions ≥20 mm. This review discusses tips and techniques to optimize cold snare resection.

目前,冷吸法是结肠镜检查中遇到的大多数结肠息肉的首选切除方法。与使用电烧切除术相比,冷切除术的一个主要优势是延迟出血的风险大大降低。冷钳切除术适用于所有≤ 10 毫米的病变和任何大小的非增生性无柄锯齿状病变,但如果病变有粘膜下侵犯或纤维化的重大风险,则应避免使用冷钳切除术。对于某些 11-19 毫米大小的病变和某些≥ 20 毫米的侧向蔓延病变,可以考虑冷钳切除术。本综述将讨论优化冷钳切除术的技巧和技术。
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引用次数: 0
Culturally Sensitive and Inclusive IBD Care. 具有文化敏感性和包容性的 IBD 护理。
IF 11.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Pub Date : 2024-09-23 DOI: 10.1016/j.cgh.2024.06.052
Victor Chedid, Laura Targownik, Oriana M Damas, Sophie Balzora

As the prevalence of inflammatory bowel disease (IBD) increases within historically disadvantaged communities, it is imperative to better understand how intersectionality-defined as the complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism)-intersects and social determinants of health influence the patient's experiences within the medical system when navigating their disease. Culturally sensitive care is characterized by the ability to deliver patient-centered care that recognizes how the intersectionality of an individual's identities impacts their disease journey. An intentional consideration and sensitivity to this impact play important roles in providing an inclusive and welcoming space for historically disadvantaged individuals living with IBD and will help address health inequity in IBD. Cultural competence implies mastery of care that understands and respects values and beliefs across cultures, while cultural humility involves recognizing the complexity of cultural identity and engaging in an ongoing learning process from individual patient experiences. Heightening our patient care goals from cultural competence to cultural sensitivity allows healthcare professionals and the systems in which they practice to lead with cultural humility as they adopt a more inclusive and humble perspective when caring for patient groups with a diverse array of identities and cultures and to avoid maintaining the status quo of implicit and explicit biases that impede the delivery of quality IBD care. In this article, we review the literature on IBD care in historically disadvantaged communities, address culturally sensitive care, and propose a framework to incorporating cultural humility in IBD practices and research.

随着炎症性肠病(IBD)在历来处于不利地位的社区中发病率的增加,当务之急是更好地理解交叉性,即多种形式的歧视(如种族主义、性别歧视和阶级歧视)的影响如何以复杂、累积的方式与健康的社会决定因素交织在一起,影响患者在医疗系统中治疗疾病的经历。文化敏感性护理的特点是能够提供以患者为中心的护理,认识到个人身份的交叉性如何影响他们的疾病历程。对这种影响的有意考虑和敏感性在为历史上处于不利地位的 IBD 患者提供一个包容和欢迎的空间方面发挥着重要作用,并将有助于解决 IBD 患者的健康不平等问题。文化胜任力意味着在理解和尊重不同文化的价值观和信仰的基础上掌握护理技巧,而文化谦逊则包括认识到文化身份的复杂性,并从患者的个人经历中不断学习。将我们的患者护理目标从文化能力提升到文化敏感性,可使医疗保健专业人员及其所在的系统在护理具有不同身份和文化的患者群体时,采取更具包容性和谦逊的视角,以文化谦逊的态度进行领导,并避免维持阻碍提供优质 IBD 护理的隐性和显性偏见的现状。在本文中,我们将回顾有关历史上弱势社区 IBD 护理的文献,探讨文化敏感性护理,并提出将文化谦逊纳入 IBD 实践和研究的框架。
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引用次数: 0
Elsewhere in the AGA Journals 其他 AGA 期刊
IF 11.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Pub Date : 2024-09-23 DOI: 10.1016/S1542-3565(24)00736-5
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引用次数: 0
Blue Notes 蓝色音符
IF 11.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Pub Date : 2024-09-23 DOI: 10.1016/j.cgh.2024.07.018
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引用次数: 0
Interventions to Increase Follow-Up of Abnormal Stool-Based Colorectal Cancer Screening Tests in Safety Net Settings: A Systematic Review 在安全网环境中采取干预措施,加强对粪便异常结直肠癌筛查试验的随访:系统回顾
IF 11.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Pub Date : 2024-09-23 DOI: 10.1016/j.cgh.2024.07.001
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引用次数: 0
AGA Clinical Practice Update on Endoscopic Scoring Systems in Inflammatory Bowel Disease: Commentary 美国胃肠病协会关于炎症性肠病内窥镜评分系统的临床实践更新:评论。
IF 11.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Pub Date : 2024-09-20 DOI: 10.1016/j.cgh.2024.06.048

Description

Endoscopic scoring systems evaluate the severity of inflammation and provide objectivity, uniformity, and standardization of reporting of mucosal appearances in patients with inflammatory bowel disease; thus, they have been advised for assessing the efficacy of medical treatment and prognosis. This American Gastroenterological Association (AGA) Clinical Practice Update Expert Commentary aims to review the utilized endoscopic scoring systems and their role in assessing mucosal healing in inflammatory bowel disease and the practical challenges in their applications, as well as to discuss the future of endoscopic scoring systems.

Methods

This expert commentary was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology.

Results/Conclusion

This expert commentary incorporates essential studies in this field and reflects the authors’ expertise in the endoscopic evaluation of inflammatory bowel disease.
说明内镜评分系统可评估炎症的严重程度,并提供客观、统一和标准化的炎症性肠病患者粘膜外观报告,因此被建议用于评估药物治疗的疗效和预后。这篇美国胃肠病学会(AGA)临床实践更新专家评论旨在回顾已使用的内镜评分系统及其在评估炎症性肠病粘膜愈合中的作用和应用中的实际挑战,并讨论内镜评分系统的未来:本专家评论由AGA研究所临床实践更新委员会和AGA理事会委托并批准,目的是就对AGA成员具有高度临床重要性的主题提供及时指导,并经过了临床实践更新委员会的内部同行评审和《临床胃肠病学和肝病学》标准程序的外部同行评审:本专家评论纳入了该领域的重要研究,反映了作者在炎症性肠病内镜评估方面的专业知识。
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引用次数: 0
Redefining the Curve: Insights on Baseline Viral Load and HCC Risk in Chronic Hepatitis B. 重新定义曲线:对慢性乙型肝炎病毒载量基线和 HCC 风险的见解。
IF 11.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Pub Date : 2024-09-19 DOI: 10.1016/j.cgh.2024.08.031
Wukun Ge, Weiqin Chen, Peizhi Mao
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引用次数: 0
Personalized (N-of-1) Clinical Trials for Inflammatory Bowel Disease: Opportunities and Challenges. 炎症性肠病的个性化(N-of-1)临床试验:机遇与挑战。
IF 11.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Pub Date : 2024-09-18 DOI: 10.1016/j.cgh.2024.08.028
Sailish Honap, Guangyong Zou, Silvio Danese, Laurent Peyrin-Biroulet, Vipul Jairath

Background & aims: Heterogeneity of treatment effects in inflammatory bowel disease (IBD) means that many individuals or patient subgroups depart from the average for whom the outcomes from traditional randomized trials may not be applicable. The N-of-1 trial is a design in which a single patient is followed over time with the treatments being randomized from period to period with the intention of finding the most effective treatment for that patient. The aim was to investigate the utility of N-of-1 trials in IBD.

Methods: To identify relevant articles for this scoping review, a MEDLINE literature search was conducted through the PubMed platform for articles published in the English language using the search terms "inflammatory bowel disease," "Crohn's disease," "ulcerative colitis," "N-of-1 trials," "single case designs," and "personalized trials."

Results: N-of-1 trials have seen a resurgence across several medical disciplines, driven by a need for more personalized medicine and patient-centered health care; their use in IBD is scarce with only 3 trials identified. Studies involving multiple N-of-1 trials can generate robust evidence for each participant and average effect estimates. The N-of-1 trial may hold potential for studying patients with IBD that are excluded from or underrepresented by randomized trials, such as those with extraintestinal manifestations, pouchitis, and proctitis. Although methodologically sound and akin to the rigor of a randomized controlled trial, the crossover periods inherent to the study design can be perceived as burdensome by patients and researchers.

Conclusions: The N-of-1 trial design provides a patient-centered means of objectively determining individual response to therapy.

背景和目的:炎症性肠病治疗效果的异质性意味着许多个体或患者亚群偏离平均水平,传统随机试验的结果对他们可能不适用。N-of-1试验是一种对单个患者进行长期随访的设计,不同时期的治疗方法是随机的,目的是找到对该患者最有效的治疗方法。本研究旨在调查N-of-1试验在IBD中的实用性:为确定本范围综述的相关文章,我们在PubMed平台上使用 "炎症性肠病"、"克罗恩病"、"溃疡性结肠炎"、"N-of-1试验"、"单病例设计"、"个性化试验 "等检索词对MEDLINE上发表的英文文章进行了文献检索:在更多个性化医疗和以患者为中心的医疗保健需求的推动下,N-of-1试验在多个医学学科中再次兴起,但在IBD中的应用却很少,仅发现了三项试验。涉及多项N-of-1试验的研究可为每位参与者提供可靠的证据以及平均效应估计值。N-of-1试验可用于研究被随机试验排除在外或代表性不足的IBD患者,如肠道外表现、小袋炎和直肠炎患者。虽然从方法学上讲,N-of-1试验是合理的,而且类似于RCT试验的严谨性,但研究设计中固有的交叉期可能会被患者和研究人员视为负担:N-of-1试验设计提供了一种以患者为中心的方法,可以客观地确定个体对治疗的反应。
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引用次数: 0
期刊
Clinical Gastroenterology and Hepatology
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