[The right care in the right place]. / De juiste zorg op de juiste plek.

Older patients who experience a fall may be admitted to hospital without a strict medical necessity. An unexplained fall incident requires thorough history taking and, if necessary, further investigation into the cause of the fall. Possible underlying multimorbidity must also be examined to prevent recurrence and complications. Admission to hospital without medical necessity is undesirable, but often unavoidable due to a lack of alternatives for patients who can no longer care for themselves in an acute situation. Reducing this unnecessary health care consumption is only possible if the options for care outside the hospital are expanded. In addition to regional cooperation to gain insight into available home care and places to stay, the use of unlabeled beds in care homes for further assessment of care needs and triage could help resolve this issue. In this way we can work together to provide the right care in the right place.

Multidisciplinary decision-making and course of treatment in older patients with colorectal cancer: Effect of geriatrician input.

INTRODUCTION: We evaluated the effect of the inclusion of a geriatrician in the multidisciplinary cancer team (MDT) on decision-making for chemotherapy with curative intent in older patients with colorectal cancer. MATERIALS AND METHODS: We audited all patients aged 70 years and older with colorectal cancer discussed at MDT meetings between January 2010 and July 2018; selection was limited to those patients for whom guidelines recommended chemotherapy with curative intent as part of the primary treatment. We assessed how treatment decisions came about, and what the course of treatment was in the period before (2010-2013) and after (2014-2018) the geriatrician joined the MDT meetings. RESULTS: There were 157 patients included: 80 patients from 2010 to 2013 and 77 patients from 2014 to 2018. Age was mentioned significantly less often as the reason to withhold chemotherapy in the 2014-2018 cohort (10% vs 27% in 2010-2013, p = 0.04). Instead, patient preferences, physical condition, and comorbidities were the main reasons stated for withholding chemotherapy. Although a similar proportion of patients started chemotherapy in both cohorts, patients treated in 2014-2018 required many fewer treatment adaptations and were thus more likely to complete their treatments as planned. DISCUSSION: Over time and by incorporating a geriatrician's input, the multidisciplinary selection of older patients with colorectal cancer for chemotherapy with curative intent has improved. By basing decisions on an assessment of the patient's ability to tolerate treatment rather than using a more general parameter such as age, both overtreatment of not-so-fit patients and undertreatment of fit-but-old patients can be prevented.

Complete Endoscopic Healing Is Associated With Lower Relapse Risk After Anti-TNF Withdrawal in Inflammatory Bowel Disease.

BACKGROUND & AIMS: Discontinuation of anti-tumor necrosis factor-α treatment (anti-TNF) (infliximab and adalimumab) in patients with inflammatory bowel disease (IBD) is associated with a high relapse risk that may be influenced by endoscopic activity at the time of stopping. We assessed the relapse rate after anti-TNF withdrawal in patients with endoscopic healing and studied predictors of relapse including the depth of endoscopic healing. METHODS: This was a multicenter, prospective study in adult patients with Crohn's disease (CD), ulcerative colitis (UC), or IBD-unclassified (IBDU), with ≥6 months of corticosteroid-free clinical remission (confirmed at baseline) and endoscopic healing (Mayo <2/SES-CD <5 without large ulcers), who discontinued anti-TNF between 2018 and 2020 in the Netherlands. We performed Kaplan-Meier and Cox regression analyses to assess the relapse rate and evaluate potential predictors: partial (Mayo 1/SES-CD 3-4) versus complete (Mayo 0/SES-CD 0-2) endoscopic healing, anti-TNF trough levels, and immunomodulator and/or mesalamine use. RESULTS: Among 81 patients (CD: n = 41, 51%) with a median follow-up of 2.0 years (interquartile range, 1.6-2.1), 40 patients (49%) relapsed. Relapse rates in CD and UC/IBDU patients were comparable. At 12 months, 70% versus 35% of patients with partial versus complete endoscopic healing relapsed, respectively (adjusted hazard rate [aHR], 3.28; 95% confidence interval [CI], 1.43-7.50). Mesalamine use was associated with fewer relapses in UC/IBDU patients (aHR, 0.08; 95% CI, 0.01-0.67). Thirty patients restarted anti-TNF, and clinical remission was regained in 73% at 3 months. CONCLUSIONS: The relapse risk was high after anti-TNF withdrawal in IBD patients with endoscopic healing, but remission was regained in most cases after anti-TNF reintroduction. Complete endoscopic healing and mesalamine treatment in UC/IBDU patients decreased the risk of relapse.

Treatment of Perianal Fistulas in Crohn's Disease, Seton Versus Anti-TNF Versus Surgical Closure Following Anti-TNF [PISA]: A Randomised Controlled Trial.

BACKGROUND AND AIMS: Most patients with perianal Crohn's fistula receive medical treatment with anti-tumour necrosis factor [TNF], but the results of anti-TNF treatment have not been directly compared with chronic seton drainage or surgical closure. The aim of this study was to assess if chronic seton drainage for patients with perianal Crohn's disease fistulas would result in less re-interventions, compared with anti-TNF and compared with surgical closure. METHODS: This randomised trial was performed in 19 European centres. Patients with high perianal Crohn's fistulas with a single internal opening were randomly assigned to: i] chronic seton drainage for 1 year; ii] anti-TNF therapy for 1 year; and iii] surgical closure after 2 months under a short course anti-TNF. The primary outcome was the cumulative number of patients with fistula-related re-intervention[s] at 1.5 years. Patients declining randomisation due to a specific treatment preference were included in a parallel prospective PISA registry cohort. RESULTS: Between September 14, 2013 and November 20, 2017, 44 of the 126 planned patients were randomised. The study was stopped by the data safety monitoring board because of futility. Seton treatment was associated with the highest re-intervention rate [10/15, versus 6/15 anti-TNF and 3/14 surgical closure patients, p = 0.02]. No substantial differences in perianal disease activity and quality of life between the three treatment groups were observed. Interestingly, in the PISA prospective registry, inferiority of chronic seton treatment was not observed for any outcome measure. CONCLUSIONS: The results imply that chronic seton treatment should not be recommended as the sole treatment for perianal Crohn's fistulas.

Multimodal treatment of perianal fistulas in Crohn's disease: seton versus anti-TNF versus advancement plasty (PISA): study protocol for a randomized controlled trial.

BACKGROUND: Currently there is no guideline for the treatment of patients with Crohn's disease and high perianal fistulas. Most patients receive anti-TNF medication, but no long-term results of this expensive medication have been described, nor has its efficiency been compared to surgical strategies. With this study, we hope to provide treatment consensus for daily clinical practice with reduction in costs. METHODS/DESIGN: This is a multicentre, randomized controlled trial. Patients with Crohn's disease who are over 18 years of age, with newly diagnosed or recurrent active high perianal fistulas, with one internal opening and no anti-TNF usage in the past three months will be considered. Patients with proctitis, recto-vaginal fistulas or anal stenosis will be excluded. Prior to randomisation, an MRI and ileocolonoscopy are required. All treatment will start with seton placement and a course of antibiotics. Patients will then be randomised to: (1) chronic seton drainage (with oral 6-mercaptopurine (6MP)) for one year, (2) anti-TNF medication (with 6MP) for one year (seton removal after six weeks) or (3) advancement plasty after eight weeks of seton drainage (under four months anti-TNF and 6MP for one year). The primary outcome parameter is the number of patients needing fistula-related re-intervention(s). Secondary outcomes are the number of patients with closed fistulas (based on an evaluated MRI score) after 18 months, disease activity, quality of life and costs. DISCUSSION: The PISA trial is a multicentre, randomised controlled trial of patients with Crohn's disease and high perianal fistulas. With the comparison of three generally accepted treatment strategies, we will be able to comment on the efficiency of the various treatment strategies, with respect to several long-term outcome parameters. TRIAL REGISTRATION: Nederlands Trial Register identifier: NTR4137 (registered on 23 August 2013).

Long-term changes in physical capacity after colorectal cancer treatment.

Older patients with colorectal cancer are faced with the dilemma of choosing between the short-term risks of treatment and the long-term risks of insufficiently treated disease. In addition to treatment-related morbidity and mortality, patients may suffer from loss of physical capacity. The purpose of this review was to gather all available evidence regarding long-term changes in physical functioning and role functioning after colorectal cancer treatment, by performing a systematic Medline and Embase search. This search yielded 27 publications from 23 studies. In 16 studies addressing physical functioning after rectal cancer treatment, a median drop of 10% (range -26% to -5%) in the mean score for this item at three months. At six months, mean score was still 7% lower than baseline (range -18% to 0%) and at twelve months 5% lower (range -13% to +5%). For role functioning (i.e. ability to perform daily activities) after rectal cancer treatment, scores were -18% (range -39% to -2%), -8% (range -23% to +6%) and -5% (range -17% to +10%) respectively. Elderly patients experience the greatest and most persistent decline in self-care capacity (up to 61% at one year). This systematic review demonstrates that both physical functioning and role functioning are significantly affected by colorectal cancer surgery. Although initial losses are recovered partially during follow-up, there is a permanent loss in both aspects of physical capacity, in patients of all ages but especially in the elderly. This aspect should be included in patient counselling regarding surgery.

Diagnostic choices and clinical outcomes in octogenarians and nonagenarians with iron-deficiency anemia in the Netherlands.

OBJECTIVES: To evaluate current clinical practice for octogenarians with iron-deficiency anemia (IDA) by assessing referral patterns, diagnostic choices, clinical consequences of omission of endoscopy, and risks and benefits of IDA-related surgery. DESIGN: Chart review. SETTING: A regional hospital-based laboratory in the Netherlands between January 2008 and December 2010. PARTICIPANTS: All individuals aged 80 and older with newly ascertained IDA. MEASUREMENTS: IDA was defined as a hemoglobin level of 11.1 g/dL or less and a ferritin level of 25 µg/L or less. RESULTS: Four hundred seventy-one participants were newly diagnosed with IDA during the study period (median age 85.4), 276 of whom (59%) did not undergo any diagnostic procedures for IDA. A cause of anemia was identified during the initial examination in 50% of the 205 investigated participants, including nine (4%) upper and 37 (18%) lower gastrointestinal malignancies. Another 24 malignancies were identified during follow-up, of which 16 were in the gastrointestinal tract, primarily in participants for whom the initial diagnostic examination was limited or omitted. Perioperative mortality was 15% in individuals with colon cancer. Median survival for participants with colon cancer was 2.2 years, and the survival benefit of surgery over supportive care was not apparent until 1.3 years after ascertainment of IDA. CONCLUSION: The omission of endoscopy for IDA and the omission of surgery for colon cancer occur frequently in octogenarians and seem appropriate in the presence of significant comorbidity and in cases in which there is limited life expectancy. Further research is needed to determine which baseline factors should guide decision-making to optimize treatment outcomes and quality of life.

Clinical consequences of videocapsule endoscopy in GI bleeding and Crohn's disease.

BACKGROUND: Videocapsule endoscopy (VCE) has a high diagnostic yield in the analysis of GI bleeding and Crohn's disease. Little information is available on the impact of VCE findings on clinical care. OBJECTIVE: Assess the impact of VCE findings on clinical management and outcome. DESIGN: Retrospective descriptive study. SETTING: General hospital. PATIENTS: VCE was performed in 150 patients for GI bleeding (n = 97), Crohn's disease (n = 36), and miscellaneous reasons (n = 17). MAIN OUTCOME MEASUREMENTS: Clinical consequences were evaluated by using a questionnaire and were divided into change of management or unchanged management. Change of medication, endoscopic procedures, surgical procedures, other consequences, and avoidance of additional investigations were considered a change of management. For all patients, an assessment of the actual clinical condition and the most recent Hb level were registered. RESULTS: A definite diagnosis was established in 34%, a probable diagnosis in 34%, and no diagnosis in 32%. Management was changed in 38% of patients, increasing to 59% if a definite diagnosis was established at VCE. No relation between change of management and clinical improvement or increased Hb level could be established. LIMITATIONS: The start of ethinylestradiol/norethisterone in case of telangiectasia was considered a change of management, although controversy on the rationale of this treatment exists. A more detailed and objective evaluation of the clinical condition should be performed to assess the clinical outcome. CONCLUSIONS: VCE findings have a serious impact on clinical practice. VCE in particular leads to a change of management in 59% of the patients in whom a definite diagnosis is established.

Assessment of intestinal vascular malformations in patients with hereditary hemorrhagic teleangiectasia and anemia.

INTRODUCTION: Hereditary hemorrhagic teleangiectasia (HHT) is an autosomal dominant disorder with mucocutaneous teleangiectasia and visceral arteriovenous malformations. Mutations of endoglin and Activin A receptor like kinase-1 have different phenotypes, HHT1 and HHT2, respectively. The gastrointestinal tract is frequently affected, but limited information is available on the relationship with genotype. AIM: To determine whether different genotypes have different phenotypes with respect to intestinal teleangiectasia. METHODS: HHT patients, referred for anemia, underwent videocapsule endoscopy. Chart review was performed for information on genotype and HHT manifestations. RESULTS: Twenty-five patients were analyzed (men/women 13/9, mean age 49+/-15 years.), 14 HHT1, eight HHT2 and three without known mutation. Epistaxis occurred in 96% of patients. Gastroduodenoscopy revealed teleangiectasia in 7/12 (58%) HHT1 and 3/8 (38%) HHT2 patients. Videocapsule endoscopy found teleangiectasia in all HHT1 and 5/8 (63%) HHT2 patients. In 9/14 HHT1 patients, teleangiectasia were large. Teleangiectasia in the colon was restricted to 6/11 (55%) HHT1 patients. Hepatic arteriovenous malformations were present in 1/7 HHT1 and 5/6 HHT2 patients. CONCLUSION: Large teleangiectasia in small intestine and colon appear to occur predominantly in HHT1. Hepatic arteriovenous malformations are mainly found in HHT2. In HHT patients with unexplained anemia, videocapsule endoscopy should be considered to determine the size and extent of teleangiectasia and exclude other abnormalities.

Detection of small-bowel neuroendocrine tumors by video capsule endoscopy.

OBJECTIVES: Carcinoid tumors are the most common GI neuroendocrine tumors (NET). They often originate in the small intestine. The primary tumor is often difficult to locate, and resection in an early phase is recommended to prevent complications. This study evaluated the value of videocapsule endoscopy (VCE) in the detection of small-intestinal primary carcinoid tumor. DESIGN: Prospective descriptive study. SETTING: Tertiary referral center. PATIENTS: Twenty consecutive patients (13 men, 7 women; 60.5 +/- 9.3 years) with metastatic NET of unknown primary tumor. INTERVENTIONS: All patients underwent CT, enteroclysis, nuclear imaging, and VCE of the small bowel. RESULTS: CTs and enteroclysis did not detect a primary small-intestinal carcinoid tumor. Nuclear imaging demonstrated abnormalities in the abdominal area in 13 patients but was unable to relate this to an intestinal localization in any patient. VCE revealed a small-intestinal tumor in 9 patients. Three other patients showed external compression and erosions. At surgery, 5 patients had a small-intestinal carcinoid tumor, and, in 2 patients, a small-intestinal ischemic segment was present. LIMITATIONS: The number of false-positive VCE findings was not clear, because not all patients underwent surgery. The absence of abnormalities at VCE in patients with abnormalities at nuclear imaging might be related to the presence of carcinoid tumor restricted to the mesenterium or to a false-negative VCE. CONCLUSIONS: VCE had a high diagnostic yield of 45% for identification of primary small-intestinal carcinoid tumors. Although nuclear imaging had a comparable diagnostic yield, it could not differentiate between intestinal and mesenterial localization of the carcinoid.