Alexandra Feathers

Systematic review with meta-analysis: enteral nutrition therapy for the induction of remission in paediatric Crohn's disease

Despite potential adverse‐events in a paediatric population, corticosteroids are used to induce remission in paediatric Crohns disease. Exclusive enteral nutrition also induces remission, but is infrequently used in the USA because corticosteroids are considered the superior therapy. New data have become available since the publication of the most recent meta‐analysis in 2007.

Inflammatory Bowel Disease: Predictors and Causes of Early and Late Hospital Readmissions

Background and Aims: The rate of hospital readmission after discharge has been studied extensively in chronic conditions such as hepatic cirrhosis, diabetes mellitus, chronic obstructive pulmonary disease, and heart failure. Causative factors associated with hospital readmission have not been adequately investigated in patients with inflammatory bowel disease (IBD). We studied the rate, causes, and factors that predict readmissions at 1 month, 3 months, and 1 year in patients with IBD. Methods: We performed a retrospective cohort study using the electronic medical record of a tertiary academic medical center, encompassing 3 large hospitals to identify patients discharged between January 2007 and December 2010 with a primary discharge diagnosis of either ulcerative colitis or Crohns disease. The index admission was defined as the first unplanned admission during this period. Readmission was defined as unplanned admission (because of any cause) occurring within 1 week, 1 month, 3 months, and 1 year from the index admission. To identify factors predictive of readmissions, we compared social, demographic, and clinical features at the index admission of patients with readmission and those with no readmissions. Multivariate logistic regression analyses were performed to identify variables associated with 1-month, 3-month, and 1-year readmissions. Results: A total of 439 index admissions with a primary discharge diagnosis of either ulcerative colitis or Crohns disease were eligible for inclusion in the study. These patients accounted for a total of 785 admissions to the health system during the study period. The unplanned readmission rates were 5% at 1 week, 14% at 1 month, 23.7% at 3 months, and 39.2% at 1 year. The most common reasons for readmissions were IBD exacerbations, infections, and abdominal pain. On multivariate analysis, receiving total parenteral nutrition (odds ratio [OR] = 2.3; 95% confidence interval [CI], 1.22–4.30) and intensive care unit stay during index admission (OR = 3.61; 95% CI, 1.38–9.46) predicted both early and late readmissions, whereas sex, race, insurer, and outside hospital transfers predicted 1-year readmission. Receiving steroids (OR = 0.52; 95% CI, 0.23–1.15) at index admission was protective against 1-month readmission; being discharged on biologics (OR = 0.44; 95% CI, 0.19–1.02) was protective against 3-month readmission. Conclusions: Both early and late hospital readmissions are common in patients with IBD. Because frequent readmissions are indicators of poor quality of care, future prospective studies using larger cohorts of patients are needed to identify modifiable factors in patient care before discharge to improve quality of care, prevent readmissions, and consequently reduce health care costs.

Escalation of Immunosuppressive Therapy for Inflammatory Bowel Disease Is Not Associated With Adverse Outcomes After Infection With Clostridium difficile

BACKGROUND Clostridium difficile infection (CDI) is common in patients with inflammatory bowel disease (IBD), often leading to diagnostic confusion and delays in IBD therapy escalation. This study sought to assess outcomes after CDI in IBD patients exposed to new or escalated immunosuppressive therapy. METHODS This multicenter retrospective cohort study included IBD patients with documented CDI at 4 academic medical centers. Data were abstracted from clinical databases at each institution. Outcomes at 30 and 90 days were compared between patients undergoing new or intensified immunosuppressive therapy and those without therapy escalation. Continuous variables were compared using t tests, and proportions using chi-square tests. Multivariable logistic regression was used to determine the association of individual variables with severe outcomes (including death, sepsis, and/or colectomy) within 90 days. Secondary outcomes included CDI recurrence, rehospitalization, worsening of IBD, and severe outcomes within 30 days. RESULTS A total of 207 adult patients with IBD and CDI were included, of whom 62 underwent escalation to biologic or corticosteroid therapy (median time to escalation, 13 days). Severe outcomes within 90 days occurred in 21 (15.6%) nonescalated and 1 (1.8%) therapy-escalated patients. Serum albumin <2.5 mg/dL, lactate >2.2 mg/dL, intensive care unit admission, hypotension, and comorbid disease were associated with severe outcomes. Likelihood of severe outcomes was decreased in patients undergoing escalation of IBD therapy after CDI (adjusted odds ratio [aOR], 0.12) and increased among patients aged >65 years (aOR, 4.55). CONCLUSIONS Therapy escalation for IBD within 90 days of CDI was not associated with worse clinical outcomes. Initiation of immunosuppression for active IBD may therefore be appropriate in carefully selected patients after treatment of CDI.

Letter: enteral nutrition therapy for the induction of remission in paediatric Crohn's disease—Authors’ reply

macol Ther 2017;46:645-656. 2. Dziechciarz P, Horvath A, Shamir R, Szajewska H. Meta-analysis: enteral nutrition in active Crohn’s disease in children. Aliment Pharmacol Ther. 2007;26:795-806. 3. Zachos M, Tondeur M, Griffiths AM. Enteral nutritional therapy for induction of remission in Crohn’s disease. Cochrane Database Syst Rev 2007;1:CD000542. 4. Tjellstrom B, Hogberg L, Stenhammar L, et al. Effect of exclusive enteral nutrition on gut microflora function in children with Crohn’s disease. Scand J Gastroenterol. 2012;47:1454-1459. 5. Esaki M, Matsumoto T, Hizawa K, et al. Preventive effect of nutritional therapy against postoperative recurrence of Crohn disease, with reference to findings determined by intra-operative enteroscopy. Scand J Gastroenterol. 2005;40:1431-1437.

Letter: reproducible evidence shows that exclusive enteral nutrition significantly reduces faecal calprotectin concentrations in children with active Crohn's disease-Authors' reply

EDITORS, We thank Drs. Logan and colleagues for taking an interest in our paper and raising an important point regarding data on faecal calprotectin. Only 1 study in our systematic review contained information regarding faecal calprotectin. Levine et al measured faecal calprotectin at baseline and at end of treatment in patients induced with exclusive enteral nutrition and corticosteroids. Among those induced with exclusive enteral nutrition, 22 of 72 had normalisation of faecal calprotectin. Only 3 of 23 treated with corticosteroids had normalisation of faecal calprotectin. Although the difference was not statistically significant, the trend was towards greater improvement in the exclusive enteral nutrition group (OR 2.93, [CI 95% 0.7910.90]). Because only 1 study met our inclusion criteria, we did not feel it met the threshold to be included in the final manuscript, but failed to update the abstract. We agree that the absence of statistical benefit does not imply an absence of benefit, but simply that the literature we reviewed was not mature enough to have enough studies with which to base any conclusions. Logan et al do provide data on improvement in faecal from studies which did not meet our inclusion criteria. We agree that biomarkers have taken on a large importance in the management of Crohn’s disease, and that future rigorous comparison studies of Crohn’s nutritional therapy should include biomarker and mucosal healing data as part of their design.