Excisional haemorrhoidectomy in Crohn's disease - is it time to question an old dogma?

BACKGROUND: Haemorrhoidectomy in Crohn's disease is controversial due to fears over poor wound healing leading to proctectomy. We aim to review the available literature and establish the role of excisional haemorrhoidectomy in Crohn's disease. METHODS: A review of the current scientific literature was conducted using Medline, PubMed and the Cochrane Central Registry of Controlled Trials. Clinical trials from 2005 to present, reporting outcomes of excisional haemorrhoidectomy in Crohn's disease, were included. Review articles and case reports were excluded. RESULTS: A cohort of 67 patients across four studies was included in this review. There were no reported cases of proctectomy related to haemorrhoidectomy or poor wound healing. One patient (1.5%) had a non-healing wound post-operatively. Four (6%) cases of post-operative bleeding were identified, two (3%) patients were diagnosed with anal fissures and two (3%) were treated after developing perianal abscess post-procedure. There was one (1.5%) case of urinary retention, and one (1.5%) subject developed an anal stricture. CONCLUSION: The current available evidence suggests a role for excisional haemorrhoidectomy in Crohn's disease patients with well-controlled symptomatic disease, though further prospective analysis is certainly warranted. The preferred operation (open vs closed) remains unclear. FUTURE RECOMMENDATIONS: Further prospective trials are required to investigate the optimal approach to haemorrhoidectomy in Crohn's disease.

Long Covid at the crossroads: Comparisons and lessons from the treatment of patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).

Whilst parallels have been drawn between Long Covid and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), there is a well-documented history of negative stereotyping and marginalisation of patients with ME/CFS. A socio-politically oriented comparison of scientific, clinical and societal responses to Long Covid and ME/CFS is thus important to prevent similar harms arising among Long Covid patients. We identify four reasons for injustices in the treatment of ME/CFS patients, and discuss the risk of Long Covid following a similar trajectory. We conclude with policy and practice recommendations to help prevent such injustices arising again, including consideration of critical reflexivity in medical education.

The 'medically unexplained symptoms' syndrome concept and the cognitive-behavioural treatment model.

The American Psychiatric Association's, 2013 DSM-5 abandoned the use of the term 'medically unexplained symptoms' for non-neurological disorders. In the UK, treatments for various medical illnesses with unexplained aetiology, such as chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia, continue to fall under an MUS umbrella with cognitive behavioural therapy promoted as a primary therapeutic approach. In this editorial, we comment on whether the MUS concept is a viable diagnostic term, the credibility of the cognitive-behavioural MUS treatment model, the necessity of practitioner training and the validity of evidence of effectiveness in routine practice.

Myalgic encephalomyelitis/chronic fatigue syndrome and the biopsychosocial model: a review of patient harm and distress in the medical encounter.

Objective: Despite the growing evidence of physiological and cellular abnormalities in myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS), there has been a strong impetus to tackle the illness utilizing a biopsychosocial model. However, many sufferers of this disabling condition report distress and dissatisfaction following medical encounters. This review seeks to account for this discord.Methods: A narrative review methodology is employed to synthesize the evidence for potential iatrogenesis.Results: We identify seven potential modalities of iatrogenesis or harm reported by patients:difficulties in reaching an acceptable diagnosis;misdiagnosis, including of other medical and psychological conditions;difficulties in accessing the sick role, medical care and social support;high levels of patient dissatisfaction with the quality of medical care;negative responses to controversial therapies (cognitive behavioral therapy and graded exercise therapy);challenges to the patient narrative and experience;psychological harm (individual and collective distress).Conclusion: The biopsychosocial framework currently applied to ME/CFS is too narrow in focus and fails to adequately incorporate the patient narrative. Misdiagnosis, conflict, and harm are observable outcomes where doctors' and patients' perspectives remain incongruent. Biopsychosocial practices should be scrutinized for potential harms. Clinicians should consider adopting alternative patient-centred approaches.Implications for rehabilitationPatients with ME/CFS may report or experience one or more of the modalities of harms and distress identified in this review.It is important health and rehabilitation professionals seek to avoid and minimize harms when treating or assisting ME/CFS patients.There are conflicting models of ME/CFS; we highlight two divergent models, a biopsychosocial model and a biomedical model that is preferred by patients.The 'biopsychosocial framework' applied in clinical practice promotes treatments such as cognitive behavioral therapy and exercise therapy, however, the evidence for their success is contested and many patients reject the notion their illness is perpetuated by dysfunctional beliefs, personality traits, or behaviors.Health professionals may avoid conflict and harm causation in ME/CFS by adopting more concordant 'patient-centred' approaches that give greater prominence to the patient narrative and experience of illness.

Are ME/CFS Patient Organizations "Militant"? : Patient Protest in a Medical Controversy.

Myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS) is a contested illness category. This paper investigates the common claim that patients with ME/CFS-and by extension, ME/CFS patient organizations (POs)-exhibit "militant" social and political tendencies. The paper opens with a history of the protracted scientific disagreement over ME/CFS. We observe that ME/CFS POs, medical doctors, and medical researchers exhibit clear differences in opinion over how to conceptualize this illness. However, we identify a common trope in the discourse over ME/CFS: the claim of "militant" patient activism. Scrutinizing this charge, we find no compelling evidence that the vast majority of patients with ME/CFS, or the POs representing them, have adopted any such militant political policies or behaviours. Instead, we observe key strategic similarities between ME/CFS POs in the United Kingdom and the AIDs activist organizations of the mid-1980s in the United States which sought to engage scientists using the platform of public activism and via scientific publications. Finally, we explore the contours of disagreement between POs and the medical community by drawing on the concept of epistemic injustice. We find that widespread negative stereotyping of patients and the marginalization and exclusion of patient voices by medical authorities provides a better explanation for expressions of frustration among patients with ME/CFS.

Cognitive behavioural therapy in the treatment of chronic fatigue syndrome: A narrative review on efficacy and informed consent.

Cognitive behavioural therapy is increasingly promoted as a treatment for chronic fatigue syndrome. There is limited research on informed consent using cognitive behavioural therapy in chronic fatigue syndrome. We undertook a narrative review to explore efficacy and to identify the salient information that should be disclosed to patients. We found a complex theoretical model underlying the rationale for psychotherapy in chronic fatigue syndrome. Cognitive behavioural therapy may bring about changes in self-reported fatigue for some patients in the short term, however there is a lack of evidence for long-term benefit or for improving physical function and cognitive behavioural therapy may cause distress if inappropriately prescribed. Therapist effects and placebo effects are important outcome factors.

Further commentary on the PACE trial: Biased methods and unreliable outcomes.

Geraghty in the year 2016, outlines a range of controversies surrounding publication of results from the PACE trial and discusses a freedom of information case brought by a patient refused access to data from the trial. The PACE authors offer a response, writing 'Dr Geraghty's views are based on misunderstandings and misrepresentations of the PACE trial'. This article draws on expert commentaries to further detail the critical methodological failures and biases identified in the PACE trial, which undermine the reliability and credibility of the major findings to emerge from this trial.

'PACE-Gate': When clinical trial evidence meets open data access.

Science is not always plain sailing and sometimes the voyage is across an angry sea. A recent clinical trial of treatments for chronic fatigue syndrome (the PACE trial) has whipped up a storm of controversy. Patients claim the lead authors overstated the effectiveness of cognitive behavioural therapy and graded exercise therapy by lowering the thresholds they used to determine improvement. In this extraordinary case, patients discovered that the treatments tested had much lower efficacy after an information tribunal ordered the release of data from the PACE trial to a patient who had requested access using a freedom of information request.