The management of Crohn’s disease involves immunosuppressive protocols in a step-up approach that progresses through a therapeutic pyramid with several tiers of medication. Medications at the top are considered more potent but present greater risk. A new top-down approach to therapy inverts this procedure, using top-tier drugs for initial treatment. A critical appraisal of the current literature relating to top-down therapy was performed to evaluate its merit. A literature search was conducted on PubMed, Ovid, and PubMed Central to identify studies of the efficacy of top-down therapy. Papers were appraised critically using the Scottish Intercollegiate Guidelines Network score to evaluate current evidence for the use of top-down therapy. Nineteen studies were identified, including six randomized controlled trials, thirteen cohort studies, and two cost-benefit studies. Early combined therapy involving both biologics and immunomodulators was found to be effective at improving patient outcomes; however, early biologics alone were not shown to have a clear benefit over step-up therapy. Likewise, the early use of immunomodulators alone showed inconsistent results with respect to efficacy in terms of both remission and surgical outcomes. Evidence for application in pediatric populations was also inconclusive. The cost-benefit analyses found that top-down therapy merits investigation, as it proved to be economical given current data. Top-down therapy has the potential of being a viable alternative to step-up therapy, but further studies are needed to determine the most appropriate patients to receive this treatment.

No abstract

No abstract

Background and aims: The Lothian Chronic Pain Service relocated from a university teaching hospital (Western General Hospital (WGH)) to a community centre (Leith Community Treatment Centre (LCTC)) in 2015. Transportation and geographical location were noted by staff to be potential challenges that could negatively impact on the patient experience. The objective of this study is to evaluate how relocating pain clinic from an urban-based hospital to a peripheral community centre on patient experience. Methods: An assessment and audit of the impact of the relocation on the Patient-Reported Experience Measure (PREM) of pain services was conducted. Using a nationally developed questionnaire, the patientreported experience from LCTC was prospectively collected in 2016 and was compared to historical data obtained from WGH in 2014 by National Health Service (NHS) Scotland. All patients attending Lothian Chronic Pain Service clinics were deemed eligible for the audit. Patient demographics were compared between the two data sets. The impact of patient deprivation on patient experience was investigated using the Scottish Index of Multiple Deprivation (SIMD16). Results: Data from 111 patients from LCTC were compared to 206 patients from WGH. Percentage of patients rating care as 'excellent' was found to be significantly greater at LCTC than WGH (0.0049). However, overall patient rating of care from LCTC was not significantly different from WGH data and ratings were higher at LCTC. No correlation was found between patient deprivation and PREM. Conclusion: There is no clear evidence that PREM was negatively affected by the move from a university teaching hospital to a community setting. As this only reported experiences of patients who attended the service, further studies may be warranted to investigate the impact of patient nonattendance.