The document discusses methods for achieving deep remission in treatment of inflammatory bowel disease (IBD). Deep remission means achieving both symptomatic and mucosal remission. Optimization of conventional therapy, early treatment, use of the Lemann score to assess damage, performance of double-balloon endoscopy, treatment using Traditional Chinese Medicine, and good communication between physicians and patients are needed to attain deep remission. Using these methods can help change the course of the disease, improve patient prognoses, and increase quality of life by minimizing complications and bowel damage.
Point-of-Care Ultrasound Diagnosis an Asset for IBD PatientsJason Jaramillo
An MD practicing at the Maimonides Medical Center in New York, Dr. Jason Jaramillo is part of a community private practice. Jason Jaramillo, MD, provides patient-centered ultrasound diagnostics through the handheld, bedside, Point-of-Care Ultrasound (POCUS) approach.
As reported in Gastroenterology & Endoscopy News, a 2021 University of Calgary study revealed the effectiveness of bedside POCUS in delivering meaningful, efficient care to inflammatory bowel disease (IBD) patients. The impetus was the COVID-19 pandemic and a need to restrict IBD patients’ routine endoscopy access, as well as hospitalization and visits to the emergency department.
Calgary physicians developed a centralized bedside intestinal ultrasound protocol that enabled them to accurately and objectively measure IBD progress in patients. Of the 72 patients evaluated as part of the study, more than 84 percent underwent intestinal ultrasound, sigmoidoscopy, or a combination of the two techniques, which led to detection of active inflammation and significant management changes.
Physicians referred a half dozen of these patents to colorectal surgery for complicated disease resection, and three new IBD diagnoses were made as well. With POCUS diagnosis in place, not a single IBD visited the ER across the duration of the study. In addition, 80 percent of patients avoided acute care in-hospital endoscopy. These results point to POCUS as a significant asset to gastroenterologists seeking to minimize patient time in ER and clinical settings.
Comparative Evaluation of the Effect of Doxycycline As An Adjunct to Non-Surg...QUESTJOURNAL
Background: The association between diabetes and periodontal disease has long been discussed with conflicting conclusions. Earlier studies demonstrating the relationship between diabetes and severity of periodontal disease has been equivocal. However, recent studies have clearly proven that diabetes increases the risk of periodontal disease progression. Less clear is the impact of periodontal disease on diabetes. It has been hypothesised that periodontal therapy may improve the metabolic control of diabetes. Aim: To determine the effect of doxycycline as an adjunct to non-surgical periodontal therapy in improving the metabolic control of poorly controlled type 2 diabetic subjects with chronic generalized periodontitis. Method: 30 poorly controlled type 2 diabetic subjects with chronic generalized periodontitis and receiving antidiabetic therapy were selected for the study. The subjects were randomly allotted to either of two treatment groups containing 15 subjects each: Group 1 (scaling and root planing(SRP)+ 15 days Doxycycline) or Group 2 (scaling and root planing(SRP). The Glycated haemoglobin (HbA1c) values, Gingival Index(GI), and Probing pocket depth of both the groups were assessed at baseline and after 3 months. Results: Both the treatment groups exhibited reductions in HbA1c, G I and Probing pocket depth compared to baseline over time. The amount of reduction in the glycated haemoglobin and gingival parameters was higher in Group I compared to group 2 after 3 months. Conclusion: Both treatments improved glycemic control in patients with type 2 diabetes; however, the reduction in HbA1c values reached statistical significance only in the group receiving doxycycline as an adjunct to scaling and root planing.
Bone marrow transplant (BMT) recipients often require parenteral nutrition (PN) to meet their nutrient needs. While general guidelines for the provision of PN support by nutrition support teams (NSTs) have been shown to decrease inappropriate PN use, recommendations for nutrition in BMT recipients are lacking. We reviewed the charts of patients status post BMT on PN to determine whether institutional guidelines for PN initiation and continuous supervision of NSTs could be applied in this population. With the Institutional Review Board (IRB) approval, charts of adult BMT recipients on PN between June 14, 2006 and June 30, 2007 were examined. Sixty-nine charts were reviewed. Indications for initiation of PN included severe mucositis, graft versus host disease (GVHD), and other transplant related side effects resulting in poor oral intake. Among 69 patients, 37 (54%) had severe mucositis, 12 (17%) had GVHD, 2 (3%) had both mucositis and GVHD, and 18 (26%) had other side effects. It was determined that all patients met the criteria for initiation of PN support, as outlined in the guidelines form. Comprehensive guidelines for initiating PN support, developed by NSTs can also be used for BMT recipients in order to optimize their nutritional status.
Point-of-Care Ultrasound Diagnosis an Asset for IBD PatientsJason Jaramillo
An MD practicing at the Maimonides Medical Center in New York, Dr. Jason Jaramillo is part of a community private practice. Jason Jaramillo, MD, provides patient-centered ultrasound diagnostics through the handheld, bedside, Point-of-Care Ultrasound (POCUS) approach.
As reported in Gastroenterology & Endoscopy News, a 2021 University of Calgary study revealed the effectiveness of bedside POCUS in delivering meaningful, efficient care to inflammatory bowel disease (IBD) patients. The impetus was the COVID-19 pandemic and a need to restrict IBD patients’ routine endoscopy access, as well as hospitalization and visits to the emergency department.
Calgary physicians developed a centralized bedside intestinal ultrasound protocol that enabled them to accurately and objectively measure IBD progress in patients. Of the 72 patients evaluated as part of the study, more than 84 percent underwent intestinal ultrasound, sigmoidoscopy, or a combination of the two techniques, which led to detection of active inflammation and significant management changes.
Physicians referred a half dozen of these patents to colorectal surgery for complicated disease resection, and three new IBD diagnoses were made as well. With POCUS diagnosis in place, not a single IBD visited the ER across the duration of the study. In addition, 80 percent of patients avoided acute care in-hospital endoscopy. These results point to POCUS as a significant asset to gastroenterologists seeking to minimize patient time in ER and clinical settings.
Comparative Evaluation of the Effect of Doxycycline As An Adjunct to Non-Surg...QUESTJOURNAL
Background: The association between diabetes and periodontal disease has long been discussed with conflicting conclusions. Earlier studies demonstrating the relationship between diabetes and severity of periodontal disease has been equivocal. However, recent studies have clearly proven that diabetes increases the risk of periodontal disease progression. Less clear is the impact of periodontal disease on diabetes. It has been hypothesised that periodontal therapy may improve the metabolic control of diabetes. Aim: To determine the effect of doxycycline as an adjunct to non-surgical periodontal therapy in improving the metabolic control of poorly controlled type 2 diabetic subjects with chronic generalized periodontitis. Method: 30 poorly controlled type 2 diabetic subjects with chronic generalized periodontitis and receiving antidiabetic therapy were selected for the study. The subjects were randomly allotted to either of two treatment groups containing 15 subjects each: Group 1 (scaling and root planing(SRP)+ 15 days Doxycycline) or Group 2 (scaling and root planing(SRP). The Glycated haemoglobin (HbA1c) values, Gingival Index(GI), and Probing pocket depth of both the groups were assessed at baseline and after 3 months. Results: Both the treatment groups exhibited reductions in HbA1c, G I and Probing pocket depth compared to baseline over time. The amount of reduction in the glycated haemoglobin and gingival parameters was higher in Group I compared to group 2 after 3 months. Conclusion: Both treatments improved glycemic control in patients with type 2 diabetes; however, the reduction in HbA1c values reached statistical significance only in the group receiving doxycycline as an adjunct to scaling and root planing.
Bone marrow transplant (BMT) recipients often require parenteral nutrition (PN) to meet their nutrient needs. While general guidelines for the provision of PN support by nutrition support teams (NSTs) have been shown to decrease inappropriate PN use, recommendations for nutrition in BMT recipients are lacking. We reviewed the charts of patients status post BMT on PN to determine whether institutional guidelines for PN initiation and continuous supervision of NSTs could be applied in this population. With the Institutional Review Board (IRB) approval, charts of adult BMT recipients on PN between June 14, 2006 and June 30, 2007 were examined. Sixty-nine charts were reviewed. Indications for initiation of PN included severe mucositis, graft versus host disease (GVHD), and other transplant related side effects resulting in poor oral intake. Among 69 patients, 37 (54%) had severe mucositis, 12 (17%) had GVHD, 2 (3%) had both mucositis and GVHD, and 18 (26%) had other side effects. It was determined that all patients met the criteria for initiation of PN support, as outlined in the guidelines form. Comprehensive guidelines for initiating PN support, developed by NSTs can also be used for BMT recipients in order to optimize their nutritional status.
ABSTRACT- The treatment of carbuncle is early administration of antibiotics and surgery. The commonest surgical approach is Saucerization and Incision & Drainage (I&D). Two cases are presented here, one underwent Saucerization and then primary split thickness skin grafting. Another un-derwent I&D for her carbuncle. They were followed up for 8 weeks to assess their outcome. Saucerization produced the shortest length of hospital stay while I&D resulted in shortest wound healing. As a new modality of treatment now-a-days two new modalities gaining popularity for better cosmetic purpose: primary split thickness skin grafting & transposition of local skin/musculocutaneous flap.
Keywords: carbuncle, surgery, good glycemic control
NUTRITIONAL THERAPY IN CRITICAL ILL PATIENTS
However, significant barriers can impede the enteral administration of nutrients, including gastroduodenal dysfunction reflected by high gastric residual volumes, and diarrhoea and constipation.
Possible solutions are suggested. In case of contraindication or failure of enteral nutrition, parenteral nutrition is indicated -----as a replacement or a supplement to failing enteral feeding.
The perfect timing of supplemental parenteral nutrition (early or late) remains uncertain, and parenteral nutrition should be carefully monitored
Correlation of Clinical Attachment Level (CAL) and C - Reactive Protein (CRP)...Dr. Anuj S Parihar
Periodontal disease, caused mainly by bacteria, is characterized by inflammation and destruction of the attachment apparatus of the teeth. Periodontitis is a multi-factorial disease with microbial dental plaque as the initiator of periodontal disease. Studies indicate that the periodontal lesion is not strictly a localized process but may lead to systemic alterations in the immune function. The present study intends to evaluate the correlation of clinical attachment level and C-reactive protein levels in
smoker and non-smoker patients with chronic generalized periodontitis. A total of fifty patients were included in the study, and they were divided into two group. Group A consisting of 25 patients who are smokers and they are having chronic generalized periodontitis, while Group B consist of 25 patients who are nonsmokers and having chronic generalized periodontitis. In the study clinical parameters we checked were Oral hygiene index – Simplified (OHI-S), Gingival Index (GI), Probing pocket depth (PPD) and Clinical Attachment level (CAL). Furthermore, CRP was evaluated as well between
Group-A (Smokers with chronic generalized periodontitis) and Group-B (Nonsmokers with chronic generalized periodontitis). The results showed higher OHI – S, PPD, CAL and CRP levels in Group - A (Smokers having chronic generalized periodontitis) than Group - B (Nonsmokers having chronic generalized periodontitis). GI score was higher in Group - B as compared to Group - A. Increased levels of clinical attachment level
(CAL) were seen in smokers suffering from chronic periodontitis. Significantly an increased level of C - reactive protein (CRP) was seen in smokers suffering from chronic periodontitis. Correlation between Clinical attachment level (CAL) and Creactive protein levels (CRP) was very strongly positive and significant. Suggesting, as value of CAL increases, CRP also increases.
RECENT ADVANCES IN THE MANAGEMENT OF INFLAMMATORY BOWEL DISEASEPARUL UNIVERSITY
Medical treatment for inflammatory bowel disease (IBD) has progressed significantly over the past decade to achieve and maintain clinical remission in patients & to overcome the side effects of existing drugs for IBD. Conventional therapy for IBD include the use of Amino salicylates, corticosteroids & Anti-microbials. Patients who fail to respond to the conventional therapy are treated with agents such as Calcineurin inhibitor (Cyclosporine), and Biologics like TNF-α inhibitors (Infliximab or Adalimumab) or Anti-cell adhesion molecules (Vedolizumab, natalizumab). These agents are targeted against pro-inflammatory cytokines such as Tumor Necrosis Factor-α (TNF-α), Interleukin-2 (IL-2) and Cell Surface Adhesion Molecules Integrin α4β7. In this review, we provide an overview on the recent advances in the treatment for IBD such as newer Biologics, Small Molecule drugs and Biosimilars effective for IBD and the role of other therapies like Probiotics, Prebiotics, Stem cell transplant and Faecal microbiota transplant and Microbiome targeting diet in the management of IBD
ABSTRACT- The treatment of carbuncle is early administration of antibiotics and surgery. The commonest surgical approach is Saucerization and Incision & Drainage (I&D). Two cases are presented here, one underwent Saucerization and then primary split thickness skin grafting. Another un-derwent I&D for her carbuncle. They were followed up for 8 weeks to assess their outcome. Saucerization produced the shortest length of hospital stay while I&D resulted in shortest wound healing. As a new modality of treatment now-a-days two new modalities gaining popularity for better cosmetic purpose: primary split thickness skin grafting & transposition of local skin/musculocutaneous flap.
Keywords: carbuncle, surgery, good glycemic control
NUTRITIONAL THERAPY IN CRITICAL ILL PATIENTS
However, significant barriers can impede the enteral administration of nutrients, including gastroduodenal dysfunction reflected by high gastric residual volumes, and diarrhoea and constipation.
Possible solutions are suggested. In case of contraindication or failure of enteral nutrition, parenteral nutrition is indicated -----as a replacement or a supplement to failing enteral feeding.
The perfect timing of supplemental parenteral nutrition (early or late) remains uncertain, and parenteral nutrition should be carefully monitored
Correlation of Clinical Attachment Level (CAL) and C - Reactive Protein (CRP)...Dr. Anuj S Parihar
Periodontal disease, caused mainly by bacteria, is characterized by inflammation and destruction of the attachment apparatus of the teeth. Periodontitis is a multi-factorial disease with microbial dental plaque as the initiator of periodontal disease. Studies indicate that the periodontal lesion is not strictly a localized process but may lead to systemic alterations in the immune function. The present study intends to evaluate the correlation of clinical attachment level and C-reactive protein levels in
smoker and non-smoker patients with chronic generalized periodontitis. A total of fifty patients were included in the study, and they were divided into two group. Group A consisting of 25 patients who are smokers and they are having chronic generalized periodontitis, while Group B consist of 25 patients who are nonsmokers and having chronic generalized periodontitis. In the study clinical parameters we checked were Oral hygiene index – Simplified (OHI-S), Gingival Index (GI), Probing pocket depth (PPD) and Clinical Attachment level (CAL). Furthermore, CRP was evaluated as well between
Group-A (Smokers with chronic generalized periodontitis) and Group-B (Nonsmokers with chronic generalized periodontitis). The results showed higher OHI – S, PPD, CAL and CRP levels in Group - A (Smokers having chronic generalized periodontitis) than Group - B (Nonsmokers having chronic generalized periodontitis). GI score was higher in Group - B as compared to Group - A. Increased levels of clinical attachment level
(CAL) were seen in smokers suffering from chronic periodontitis. Significantly an increased level of C - reactive protein (CRP) was seen in smokers suffering from chronic periodontitis. Correlation between Clinical attachment level (CAL) and Creactive protein levels (CRP) was very strongly positive and significant. Suggesting, as value of CAL increases, CRP also increases.
RECENT ADVANCES IN THE MANAGEMENT OF INFLAMMATORY BOWEL DISEASEPARUL UNIVERSITY
Medical treatment for inflammatory bowel disease (IBD) has progressed significantly over the past decade to achieve and maintain clinical remission in patients & to overcome the side effects of existing drugs for IBD. Conventional therapy for IBD include the use of Amino salicylates, corticosteroids & Anti-microbials. Patients who fail to respond to the conventional therapy are treated with agents such as Calcineurin inhibitor (Cyclosporine), and Biologics like TNF-α inhibitors (Infliximab or Adalimumab) or Anti-cell adhesion molecules (Vedolizumab, natalizumab). These agents are targeted against pro-inflammatory cytokines such as Tumor Necrosis Factor-α (TNF-α), Interleukin-2 (IL-2) and Cell Surface Adhesion Molecules Integrin α4β7. In this review, we provide an overview on the recent advances in the treatment for IBD such as newer Biologics, Small Molecule drugs and Biosimilars effective for IBD and the role of other therapies like Probiotics, Prebiotics, Stem cell transplant and Faecal microbiota transplant and Microbiome targeting diet in the management of IBD
Postpartum Meningitis by Enterococcus Faecalis Secondary to Neuraxial AnesthesiaAnonIshanvi
Meningitis is an infrequent and serious cause of postpartum fever that requires early diagnosis and treatment to prevent serious complications and to reduce the high mortality rate. Neuraxial anesthesia is a frequently used technique in obstetrics. Meningitis is a very rare complication of neuraxial an- esthesia and enterococcus....
Presentation by Sam Blamires, registered dietician and Senior Medical Affairs Advisor at Nutricia. Part of the PLAN Summer meeting 2016. A review of the latest evidence and guidelines on supporting nutrition in COPD, including the causes and consequences of malnutrition in COPD, the use of screening tools, the NICE guidelines on supplementation, and putting theory into practice.
A protocol for a trial of homeopathic treatment for irritable bowel syndromehome
Irritable bowel syndrome is a chronic condition with no known cure. Many sufferers seek
complementary and alternative medicine including homeopathic treatment. However there is much controversy as
to the effectiveness of homeopathic treatment. This three-armed study seeks to explore the effectiveness of
individualised homeopathic treatment plus usual care compared to both an attention control plus usual care and
usual care alone, for patients with irritable bowel syndrome.
Every Civilization having its own culture of treating diseases
260 AD around establishment of Jund-i-Shapur
Initially Prisoners from Roman Empire
After Roman Empire cracked down on Scientific Centers and Intellectuals
The AYUSH system of medicine mostly relies on
prevention of disease. The Unani System of Medicine has much more to
offer for prevention of the disease.
Six essentials of life which form the basics of the Unani
Preventive measures are:
•Air-----Quality of air
•Food and Drinks (Ma’akool wa Mashroob)---Dietary habits,
balanced diet etc
•Physical Rest and Movement (Harkat wa Sakoon Badni)….Exercise
etc
•Mental Rest and Movement (Harkat wa Sakoon Nafsani) ….
Thinking, stress etc
•Sleep and awakeness (Naum wa Yagza)----Sleep time, good sleep
•Retention and Evacuation (Ehtibas and Estefaragh)….What is to be
retained and evacuated from the body.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
Safalta Digital marketing institute in Noida, provide complete applications that encompass a huge range of virtual advertising and marketing additives, which includes search engine optimization, virtual communication advertising, pay-per-click on marketing, content material advertising, internet analytics, and greater. These university courses are designed for students who possess a comprehensive understanding of virtual marketing strategies and attributes.Safalta Digital Marketing Institute in Noida is a first choice for young individuals or students who are looking to start their careers in the field of digital advertising. The institute gives specialized courses designed and certification.
for beginners, providing thorough training in areas such as SEO, digital communication marketing, and PPC training in Noida. After finishing the program, students receive the certifications recognised by top different universitie, setting a strong foundation for a successful career in digital marketing.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
2. Han J et al. / Review
This paper explores the treatment changes that have developed with the evolution of the goals of IBD therapy
and discusses the treatment methods necessary to reach
the goal of deep remission.
However, translating these goals into everyday practice
requires the implantation of optimized treatment strategies and ongoing monitoring of treatment outcomes.12
In addition, precise definition of the goals themselves
is required, and the long-term benefits associated with
their achievement need to be studied. Furthermore, although effective treatments are available, there remain
many uncertainties about how best to use them.13
EVOLUTION OF TREATMENT GOALS
IN IBD
The evolution of treatment goals in patients with IBD
is potentially changing the course of the disease, the expectations of patients and healthcare professionals, and
the development of treatment plans. Twenty years ago,
treatment methods for IBD were based on the symptoms of the patient, and the point of view that early
treatment would lead to long-term maintenance of remission was put forward.7 This point of view has become the standard of treatment in the form of induction of remission and its subsequent maintenance. The
provision of personalized medicine is now becoming
possible through, for example, a better understanding
of pharmacogenetics and therapeutic drug monitoring.8 In the future, treatment will be increasingly determined and optimized according to biotypes based on
genetics, serology, proteomics, metabolomics, individual microbiology, etc.9 In addition, treatment goals have
evolved toward mucosal healing with establishment
and maintenance of deep remission. It is hoped that
achieving these goals will lead to improvements in clinical outcomes, including quality of life, and reductions
in disease-related complications and costs of surgery
and hospitalization. Future goals may include avoidance of corticosteroids, prevention of extraintestinal
complications, and decreased treatment costs.10
Changing treatment goals requires variations in treatment strategies. In conventional approaches, immunomodulators are used with a bottom-up strategy based
on clinical outcomes. At present, the aims include induction and maintenance of clinical remission, prevention of disease development and complications, optimization of surgical outcomes, and prevention of postoperative recurrence. Future approaches are likely to involve personalized treatments based on the patient's
prognosis as determined using biological predictors of
response. Future goals will be to increase therapeutic effects, decrease treatment costs, and prevent disease.
Optimization of conventional therapy
Corticosteroids and immunomodulators have been
used in the treatment of IBD for decades, and their effectiveness is highlighted by the fact that they are recommended by national and international guidelines.14
However, these agents also have some disadvantages.
Although corticosteroids are very effective, they are not
able to maintain remission, and their side effect profile
makes their long-term use inappropriate. In addition,
the slow action of immunomodulators may not be adequate to induce remission, and their long-term ability
to modify disease has recently been questioned.
Despite these shortcomings, corticosteroids and immunomodulators have been widely used in the treatment
of IBD for many years. However, high-quality evidence
to guide their precise use in terms of dosage, mode of
administration, and duration of therapy is limited.15
High-quality studies showing that corticosteroids effectively induced clinical remission in patients with IBD
were published more than 30 years ago, and the efficacy of corticosteroids in IBD has been confirmed in Cochrane systematic reviews of controlled studies.16 However, once remission has been achieved, the goal is to
maintain steroid-free remission. Despite inducing remission in most patients, a prolonged response to corticosteroids is observed in less than half of all patients.17
Importantly, corticosteroids are associated with substantial toxicity and should not be continued long-term.
Thus, corticosteroids alone are inadequate for achieving the proposed treatment goal of deep remission.
They should normally be supplemented and ultimately
replaced by immunomodulators early in the treatment
course.18
Early treatment
The clinical features of IBD have changed in recent
years, with a decreasing frequency of a purely inflammatory response and an increasing frequency of a penetrating disease leading to the need for surgery. Accordingly, to change the course of the disease, disease-modifying treatments must be prescribed early in the course
of IBD before complications occur.19
There is now increasing clinical evidence to support
the hypothesis that early treatment improves clinical
outcomes in patients with IBD. Recent studies have also demonstrated that early treatment with anti-TNF
therapy is associated with sustained steroid-free remission and complete mucosal healing.20
However, the identification of patients with early IBD
in clinical practice remains a challenge because no for-
HOW TO IMPROVE THE
MANAGEMENT OF IBD TO ACHIEVE
DEEP REMISSION
Advances in drug development have provided highly effective treatments to prevent bowel structure damage
in patients with IBD, making deep remission a realistic
goal.11 In fact, anti-TNF therapy achieved deep remission in a randomized placebo-controlled clinical study,
which also indicates that deep remission is closely associated with a significant increase in quality of life and a
significant decrease in the need for hospitalization.
JTCM | www. journaltcm. com
550
August 15, 2013 | Volume 33 | Issue 4 |
3. Han J et al. / Review
mal definition exists. An international consensus has
been established to develop a formal definition of early
IBD. The agreed-upon definition is a disease duration
of <18 months in the absence of the use of disease-modifying agents.21 General acceptance of such a
definition will help establish the widespread use of an
optimized treatment strategy.
the last 10 to 15 years.24,25 Satisfactory results and positive effects of both acupuncture and acupuncture combined with Chinese herbal medicine decoctions have
been reported.26
According to TCM theory, spleen "damp-heat", which
is present in many patients with mild to moderate
IBD, cannot strongly promote blood circulation, easily
resulting in "blood stasis". Combined wind and dampness is found to adversely interfere with "Yang Qi", inducing blood stagnation and resulting in thrombosis
and stagnant cold-dampness.27
The TCM treatment principles for IBD are regulation
of Qi activity, promotion and improvement of blood
circulation, and invigoration of the spleen. TCM therapy has shown definite effectiveness. At the same time,
because TCM methods involve a long-term treatment
course, they greatly contribute to achieving the aim of
deep remission. In addition, if patients have erosions
that are confined to the colon, even the left-sided colon and mainly ulcerative colitis, treatment comprising
enemas or Chinese medicine suppositories would be
adopted. Such treatments can not only directly reach
the erosions, but also have long-term effects. In TCM,
they are now regarded as important complementary
methods for patients with IBD.
New indices in IBD management
Several assessment tools are available for evaluating
IBD symptoms, including the CDAI and Harvey-Bradshaw index, but these are often not used routinely in
clinical practice. However, the Lemann score is clinically useful and can reflect both the extent and severity of
digestive damage.22 To assess the extent of damage, the
digestive tract is considered to be divided into segments: the upper tract comprises 3 segments, the small
bowel comprises up to 20 segments, the colon and rectum comprise 6 segments, and the anus is considered
to be 1 segment.
As a first step in assessing the severity of damage, each
segment is evaluated separately for strictures, penetrating lesions, and a history of surgery or other procedures. Each section is graded from no damage to the
most severe damage corresponding to resection, and
based on this evaluation, a score from 0 to 10 is attributed to each segment.
In the second step, the score per organ is calculated,
which is the sum of the scores in all segments in the organ. Thus, the score per organ would be 0 to 30 for
the upper tract, 0 to 200 for the small bowel, 0 to 60
for the colon/rectum, and 0 to 10 for the anus.
Finally, the scores obtained for each organ are summed
to give an overall score for the entire digestive tract.
The Lemann score is independent of the diagnostic
technique used and allows patients to be assessed at different clinical stages regardless of surgical history or
whether they have limited or extensive disease.
Good communication between physicians and
patients
Good communication between physician and patients
is a cornerstone of effective disease management.28 After diagnosis of IBD, patients are likely to feel great uncertainty about their future. They may be concerned
about the impact of the disease and its treatment on
their daily life, employment prospects, ability to have
children, and later need for hospitalization and surgery.
By proactively discussing these issues, physicians and
the patients can begin to build confidence and establish an open and long-lasting relationship of trust.
Clear communication regarding the benefits and risks
of alternative management strategies and therapeutic
options is essential throughout the physician-patient relationship. However, physicians must keep in mind
that the management goals that are important to the
patient and the benefits or risks assessed by the patient
may differ from their own. To help reconcile the two
perspectives, the physician must clearly communicate
issues such as the rationale for a long-term management plan, the impact of disease progression, steroid
dependence, common and rare potential complications
of surgery, etc. At every decision point, the potential
risk of the treatment (development of complications,
need for surgery, and nutritional problems) must be
carefully balanced against those of overtreatment (anti-TNF-induced toxicity and potential impact on quality of life).
Role of endoscopy in daily clinical practice
Endoscopy plays a key role in the monitoring of IBD.
It allows for assessment of the extent and severity of
the disease, aids treatment decisions, and detects signs
of progression.
Double-balloon endoscopy (DBE) allows for complete
examination of the small bowel, which is important for
determining the extent of mucosal healing.23 Furthermore, it may also be used for biopsies or therapeutic interventions (such as balloon dilatation of strictures)
during DBE. This means that DBE may offer an alternative to surgery for some patients. DBE has been successfully used to dilate strictures, while endoscopy does
not have this function.
Use of Traditional Chinese Medicine
Acupuncture, a popular procedure in Traditional Chinese Medicine (TCM), has a long history of medical
treatment in China and other Asian countries. It has
been increasingly performed as a complementary and
alternative medical therapy for patients with IBD in
JTCM | www. journaltcm. com
CONCLUSION
IBD is characterized by sustained inflammation that
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4. Han J et al. / Review
may affect any part of the gastrointestinal tract. Chronic uncontrolled inflammation can lead to the development of complications such as stenosis and fistulae, resulting in irreversible structural bowel damage that is
not amenable to medical therapy.29 Such damage is often associated with the need for surgical removal of
bowel segments. Even during clinical remission, subclinical inflammation may persist and is largely unrecognized, increasing the risk of complications. Treating
physicians must recognize the disconnect between
symptoms and the presence of inflammation, and periodic evaluation of disease activity should be routinely
conducted. It is hoped that complete control of inflammation, timely use of appropriate therapy, strict control of complications, and minimization of bowel damage will change the course of the disease, improve prognoses, and increase the quality of life of affected patients.
12
13
14
15
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