Interventions for treating iron deficiency anaemia in inflammatory bowel disease
The Cochrane database of systematic reviews. 2021;1:Cd013529
BACKGROUND Inflammatory bowel disease affects approximately seven million people globally. Iron deficiency anaemia can occur as a common systemic manifestation, with a prevalence of up to 90%, which can significantly affect quality of life, both during periods of active disease or in remission. It is important that iron deficiency anaemia is treated effectively and not be assumed to be a normal finding of inflammatory bowel disease. The various routes of iron administration, doses and preparations present varying advantages and disadvantages, and a significant proportion of people experience adverse effects with current therapies. Currently, no consensus has been reached amongst physicians as to which treatment path is most beneficial. OBJECTIVES The primary objective was to evaluate the efficacy and safety of the interventions for the treatment of iron deficiency anaemia in people with inflammatory bowel disease. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two other databases on 21st November 2019. We also contacted experts in the field and searched references of trials for any additional trials. SELECTION CRITERIA Randomised controlled trials investigating the effectiveness and safety of iron administration interventions compared to other iron administration interventions or placebo in the treatment of iron deficiency anaemia in inflammatory bowel disease. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors. DATA COLLECTION AND ANALYSIS Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We expressed dichotomous and continuous outcomes as risk ratios and mean differences with 95% confidence intervals. We assessed the certainty of the evidence using the GRADE methodology. MAIN RESULTS We included 11 studies (1670 randomised participants) that met the inclusion criteria. The studies compared intravenous iron sucrose vs oral iron sulphate (2 studies); oral iron sulphate vs oral iron hydroxide polymaltose complex (1 study); oral iron fumarate vs intravenous iron sucrose (1 study); intravenous ferric carboxymaltose vs intravenous iron sucrose (1 study); erythropoietin injection + intravenous iron sucrose vs intravenous iron sucrose + injection placebo (1 study); oral ferric maltol vs oral placebo (1 study); oral ferric maltol vs intravenous ferric carboxymaltose (1 study); intravenous ferric carboxymaltose vs oral iron sulphate (1 study); intravenous iron isomaltoside vs oral iron sulphate (1 study); erythropoietin injection vs oral placebo (1 study). All studies compared participants with CD and UC together, as well as considering a range of disease activity states. The primary outcome of number of responders, when defined, was stated to be an increase in haemoglobin of 20 g/L in all but two studies in which an increase in 10g/L was used. In one study comparing intravenous ferric carboxymaltose and intravenous iron sucrose, moderate-certainty evidence was found that intravenous ferric carboxymaltose was probably superior to intravenous iron sucrose, although there were responders in both groups (150/244 versus 118/239, RR 1.25, 95% CI 1.06 to 1.46, number needed to treat for an additional beneficial outcome (NNTB) = 9). In one study comparing oral ferric maltol to placebo, there was low-certainty evidence of superiority of the iron (36/64 versus 0/64, RR 73.00, 95% CI 4.58 to 1164.36). There were no other direct comparisons that found any difference in the primary outcomes, although certainty was low and very low for all outcomes, due to imprecision from sparse data and risk of bias varying between moderate and high risk. The reporting of secondary outcomes was inconsistent. The most common was the occurrence of serious adverse events or those requiring withdrawal of therapy. In no comparisons was there a difference seen between any of the intervention agents being studied, although the certainty was very low for all comparisons made, due to risk of bias and significant imprecision due to the low numbers of events. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes were reported in any of the studies. An analysis of all intravenous iron preparations to all oral iron preparations showed that intravenous administration may lead to more responders (368/554 versus 205/373, RR 1.17, 95% CI 1.05 to 1.31, NNTB = 11, low-certainty due to risk of bias and inconsistency). Withdrawals due to adverse events may be greater in oral iron preparations vs intravenous (15/554 versus 31/373, RR 0.39, 95% CI 0.20 to 0.74, low-certainty due to risk of bias, inconsistency and imprecision). AUTHORS' CONCLUSIONS Intravenous ferric carboxymaltose probably leads to more people having resolution of IDA (iron deficiency anaemia) than intravenous iron sucrose. Oral ferric maltol may lead to more people having resolution of IDA than placebo. We are unable to draw conclusions on which of the other treatments is most effective in IDA with IBD (inflammatory bowel disease) due to low numbers of studies in each comparison area and clinical heterogeneity within the studies. Therefore, there are no other conclusions regarding the treatments that can be made and certainty of all findings are low or very low. Overall, intravenous iron delivery probably leads to greater response in patients compared with oral iron, with a NNTB (number needed to treat) of 11. Whilst no serious adverse events were specifically elicited with any of the treatments studied, the numbers of reported events were low and the certainty of these findings very low for all comparisons, so no conclusions can be drawn. There may be more withdrawals due to such events when oral is compared with intravenous iron delivery. Other outcomes were poorly reported and once again no conclusions can be made as to the impact of IDA on any of these outcomes. Given the widespread use of many of these treatments in practice and the only guideline that exists recommending the use of intravenous iron in favour of oral iron, research to investigate this key issue is clearly needed. Considering the current ongoing trials identified in this review, these are more focussed on the impact in specific patient groups (young people) or on other symptoms (such as fatigue). Therefore, there is a need for studies to be performed to fill this evidence gap.
Granulocyte and monocyte apheresis as an adjunctive therapy to induce and maintain clinical remission in ulcerative colitis: a systematic review and meta-analysis
BMJ open. 2021;11(5):e042374
OBJECTIVE The goal of treatment in ulcerative colitis (UC) is to induce and maintain remission. The addition of granulocyte and monocyte apheresis (GMA) to conventional therapy may be a promising therapeutic alternative. In this meta-analysis, we aimed to assess the efficacy and safety profile of GMA as an adjunctive therapy. DESIGN Systematic review and meta-analysis. METHODS We searched four databases (MEDLINE, Embase, Web of Science and Cochrane Central Register of Controlled Trials) for randomised or minimised controlled trials which discussed the impact of additional GMA therapy on clinical remission induction and clinical remission maintenance compared with conventional therapy alone. Primary outcomes were clinical remission induction and maintenance, secondary outcomes were adverse events (AEs) and steroid-sparing effect. ORs with 95% CIs were calculated. Trial Sequential Analyses were performed to adjusts for the risk of random errors in meta-analyses. RESULTS A total of 11 studies were eligible for meta-analysis. GMA was clearly demonstrated to induce and maintain clinical remission more effectively than conventional therapy alone (598 patients: OR: 1.93, 95% CI 1.28 to 2.91, p=0.002, I(2)=0.0% for induction; 71 patients: OR: 8.34, 95% CI 2.64 to 26.32, p<0.001, I(2)=0.0% for maintenance). There was no statistically significant difference in the number of AEs (OR: 0.27, 95% CI 0.05 to 1.50, p=0.135, I(2)=84.2%). CONCLUSION GMA appears to be more effective as an adjunctive treatment in inducing and maintaining remission in patients with UC than conventional therapy alone. PROSPERO REGISTRATION NUMBER CRD42019134050.
The role of refined nursing combined with targeted nursing in patients with digestive tract hemorrhages complicated by liver cirrhosis
American journal of translational research. 2021;13(5):5336-5342
OBJECTIVE To explore the effect of refined nursing combined with targeted nursing on patients with gastrointestinal bleeding complicated by liver cirrhosis. METHODS 128 patients with gastrointestinal bleeding and liver cirrhosis admitted to our hospital from April 2018 to April 2019 were recruited as the study cohort and were randomly divided into a control group and an experimental group with 64 patients in each group. The patients in the control group underwent conventional nursing, and the experimental group underwent refined nursing combined with targeted nursing. The two groups' clinical efficacy, complication rates, psychological states, prognoses, quality of life, and nursing satisfaction were statistically analyzed. RESULTS The clinical curative effect, prognosis complication rate, psychological state scores, quality of life scores, and nursing satisfaction in the experimental group were significantly better than they were in the control group (P<0.05). CONCLUSION Refined nursing combined with targeted nursing has a more significant clinical effect than the conventional nursing mode due to its strengths in improving patients' prognoses, psychological states, and quality of life, and reducing the incidence of complications, improving the patients' nursing satisfaction, and establishing good doctor-patient relationships.
High pooled performance of convolutional neural networks in computer-aided diagnosis of GI ulcers and/or hemorrhage on wireless capsule endoscopy images: a systematic review and meta-analysis
Gastrointest Endosc. 2020
BACKGROUND AND AIMS Diagnosis of gastrointestinal (GI) ulcers and/or hemorrhage by wireless capsule endoscopy (WCE) is limited by the physician-dependent, tedious, time-consuming process of image and/ or video classification. Computer-aided diagnosis (CAD) by convolutional neural networks (CNN) based machine learning may help reduce this burden. Our aim was to conduct a meta-analysis and appraise the reported data. METHODS Multiple databases were searched (from inception to November 2019) and studies that reported on the performance of CNN in the diagnosis of GI ulcerations and/ or hemorrhage on WCE were selected. Random effects model was used to calculate the pooled rates. In cases where multiple 2X2 contingency tables were provided for different thresholds, we assumed the data tables as independent from each other. Heterogeneity was assessed by I(2)% and 95% prediction intervals. RESULTS Nine studies were included in our final analysis that evaluated the performance of CNN based CAD of GI ulcers and/ or hemorrhage by WCE. The pooled accuracy was 95.4% (95% CI, 94.3-96.3), sensitivity was 95.5% (95% CI, 94-96.5), specificity was 95.8% (95% CI, 94.7-96.6), positive predictive value was 95.8% (95% CI, 90.5-98.2) and negative predictive value was 96.8% (95% CI, 94.9-98.1). I(2)% heterogeneity was negligible except for the pooled positive predictive value. CONCLUSIONS Based on our meta-analysis, CNN based CAD of GI ulcerations and/ or hemorrhage on WCE achieves high-level performance. The quality of evidence is robust and therefore CNN based CAD has the potential to become the first-choice of machine learning to optimize WCE image/video reading.
Genetic polymorphisms associated with upper gastrointestinal bleeding: a systematic review
The pharmacogenomics journal. 2020
Non-variceal upper gastrointestinal bleeding (non-variceal UGIB) is a frequent and severe adverse drug reaction. Idiosyncratic responses due to genetic susceptibility to non-variceal UGIB has been suggested. A systematic review was conducted to assess the association between genetic polymorphisms and non-variceal UGIB. Twenty-one publications and 7134 participants were included. Thirteen studies evaluated genetic polymorphism in patients exposed to non-steroidal anti-inflammatory drugs, low-dose aspirin, and warfarin. Eight studies present at least one methodological problem. Only six studies clearly defined that the outcome evaluated was non-variceal UGIB. Genetic polymorphisms involved in platelet activation and aggregation, angiogenesis, inflammatory process, and drug metabolism were associated with risk of non-variceal UGIB (NOS3, COX-1; COX-2; PLA2G7; GP1BA; GRS; IL1RN; F13A1; CDKN2B-AS1; DPP6; TBXA2R; TNF-alpha; VKORC1; CYP2C9; and AGT). Further well-designed studies are needed (e.g., clear restriction to non-variceal UGIB; proper selection of participants; and adjustment of confounding factors) to provide strong evidence for pharmacogenetic and personalized medicine.
Comparison in the diagnostic yield between "Pillcam SB3" capsule endoscopy and "OMOM Smart Capsule 2" in small bowel bleeding. A randomized head-to-head study
Digestive diseases (Basel, Switzerland). 2020
Introduction Capsule endoscopy is the first-line tool for diagnosis of small bowel bleeding. There are some studies that have compared different types of capsule endoscopy. OMOM capsule endoscopy is one of the newest in the market, and has not been compared to other types of capsule endoscopy. The objective of this study was to compare the diagnostic yield of the Pillcam SB3 and OMOM capsule endoscopy in small bowel bleeding. Material and methods This is a prospective, comparative, randomized and blinded study. Patients with suspected small bowel bleeding were included. All the patients were given both types of capsules endoscopy in random order. Diagnostic yield and functionality between the two types of capsule endoscopy were analyzed. Results We included 44 patients, 54.5% female with a median of 63.5 years old. Battery time was significantly longer with SB3 (816.5 vs. 700.5 minutes, p<0.001) and the download time was shorter with the OMOM (33 vs. 132 minutes, p<0.001). Both capsule endoscopies presented one failure. The cause of the bleeding was identified in 39 SB3 (88.6%) and in 34 OMOM CE (77.3%) (p=0.256). P2 lesions were observed in 32 SB3 (72.7%) and in 29 OMOM (65.9%) (p=0.784). The agreement between both capsule endoscopies for P2 lesions was moderate (κ=0.628). Conclusions Pillcam SB3 and OMOM devices are safe procedures and have a similar diagnostic yield. Significant differences were observed in the battery life and download time with both capsule endoscopies.
Diagnostic accuracy of computerized tomography (CT) angiography in detecting non-variceal gastrointestinal bleeding (NVGIB): a sistematic review
Minerva gastroenterologica e dietologica. 2020
INTRODUCTION The American Society for Gastrointestinal Endoscopy (ASGE) has produced numerous algorithms for the management of gastrointestinal bleeding (GIB) in which endoscopy plays a major role. The aim of this Systematic Review was to evaluate the diagnostic accuracy of computerized tomography (CT) angiography in detecting non-variceal gastrointestinal bleeding (NVGIB). METHODS Studies were identified on PubMed, Web of Science and Scopus databases from 2009 to 2019. The search performed included the following terms: "digestive" and "bleeding" as well as "acute bleeding gastrointestinal" or "acute bleeding digestive". Studies were included if enrolled adult patients and included measures of diagnostic accuracy (sensibility and specificity) of CT angiography in detecting GIB. Studies on variceal bleeding were excluded. First, a bivariate diagnostic randomeffects meta-analysis was fitted through REML (Restricted maximum likelihood approach) method, with the estimation of pooled sensitivity, specificity and SROC curve. Then, an univariate model was fitted for the 11 studies, with the estimation of pooled Diagnostic Odds Ratio and Cochrane's Q for heterogeneity. RESULTS Eleven studies were eligible for inclusion criteria and so included in the analysis. The pooled sensitivity is 85% [75%, 92%], the pooled specificity 93% [89%, 96%]. The pooled DOR is 94.35 [37.91, 234.82]. Q for heterogeneity is not significant (p=0.377). CONCLUSIONS CT angiography showed a good sensibility and specificity in detecting NVGIB. Therefore, it would be useful to consider CT angiography use also in the suspicion of NVGIB, especially when endoscopy is not immediately available and there are signs and symptoms of bleeding in progress.
Perforated and bleeding peptic ulcer: WSES guidelines
World journal of emergency surgery : WJES. 2020;15:3
Background: Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods: The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions: The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
Quality Evaluation of the Non-Variceal Upper Gastrointestinal Bleeding Guidelines/Consensuses via AGREE II Tools
Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2019;29(10):977-985
Non-variceal upper gastrointestinal bleeding (NUGIB) is a common disease in clinical practice; and many related guidelines/consensuses have been published. The authors assessed the methodological quality of the NUGIB guidelines/ consensuses published in English, in order to uncover which guidelines/consensuses are of better quality in methodology and the deficiency in the area. Appraisal of guidelines for research and evaluation instrument tools were adopted to assess the quality of the guidelines/consensuses. Each guideline/consensus was assessed independently by three researchers. Intra-class correlation (ICC) among researchers was retrieved to reflect reliability. Eight guidelines/consensuses regarding the management of NUGIB published in English were obtained. The ICCs among the evaluators were all above 0.75, indicating satisfactory reliability. Quality evaluation of the obtained guidelines via the AGREE II tools showed that the overall quality of the included guidelines/consensuses was moderate in all domains. A few guidelines/consensuses were better developed in scientific and methodological aspects than the others. The grades of recommendations with the guidelines/consensuses, according to a brief and preliminary scheme, were of practical value. Moreover, the recommendations regarding the pharmacological treatments in the guidelines/consensuses above, are various according to the study. Overall, the quality of some NUGIB guidelines/consensuses were generally acceptable and applicable, those yet are with minor deficiencies. The others may be improved according to the AGREE II items, likely by evaluating the quality of the guidelines/consensuses when the guidelines/consensuses are updated.
Machine Learning to Predict Outcomes in Patients with Acute Gastrointestinal Bleeding: A Systematic Review
Digestive diseases and sciences. 2019
Risk stratification of patients with gastrointestinal bleeding (GIB) is recommended, but current risk assessment tools have variable performance. Machine learning (ML) has promise to improve risk assessment. We performed a systematic review to evaluate studies utilizing ML techniques for GIB. Bibliographic databases and conference abstracts were searched for studies with a population of overt GIB that used an ML algorithm with outcomes of mortality, rebleeding, hemostatic intervention, and/or hospital stay. Two independent reviewers screened titles and abstracts, reviewed full-text studies, and extracted data from included studies. Risk of bias was assessed with an adapted Quality in Prognosis Studies tool. Area under receiver operating characteristic curves (AUCs) were the primary assessment of performance with AUC ≥ 0.80 predefined as an acceptable threshold of good performance. Fourteen studies with 30 assessments of ML models met inclusion criteria. No study had low risk of bias. Median AUC reported in validation datasets for predefined outcomes of mortality, intervention, or rebleeding was 0.84 (range 0.40-0.98). AUCs were higher with artificial neural networks (median 0.93, range 0.78-0.98) than other ML models (0.81, range 0.40-0.92). ML performed better than clinical risk scores (Glasgow-Blatchford, Rockall, Child-Pugh, MELD) for mortality in upper GIB. Limitations include heterogeneity of ML models, inconsistent comparisons of ML models with clinical risk scores, and high risk of bias. ML generally provided good-excellent prognostic performance in patients with GIB, and artificial neural networks tended to outperform other ML models. ML was better than clinical risk scores for mortality in upper GIB.