Christina Tofani

4-Liter Split-Dose Polyethylene Glycol Is Superior to Other Bowel Preparations, Based on Systematic Review and Meta-analysis

BACKGROUND & AIMS Adequate bowel cleansing is an important determinant of the efficacy of screening colonoscopy. Polyethylene glycol (PEG)-based solutions are used commonly in bowel preparation, but their poor palatability and large volumes (4 L) influence compliance. Adjunct therapies, such as bisacodyl, split-dose regimens, and lower-volume regimens have been tested. We performed a meta-analysis to determine whether a 4-L split dose of PEG is better than others for bowel cleansing before colonoscopy. METHODS We searched MEDLINE, the Cochrane Central Register of Controlled Trials and Database, recent abstracts from major conference proceedings, references from selected reviews and randomized trials (http://clinicaltrials.gov), and Google Scholar, through September 2011, for high-quality, randomized trials that compared 4-L split-dose PEG without adjunct therapy with other bowel preparation methods. Nine of 2477 trials considered were used in the analysis. We calculated pooled estimates of bowel preparation quality (primary outcome: excellent or good), preparation compliance, favorable overall experiences, willingness to repeat same preparation, and side effects. We calculated pooled estimates of odds ratios by fixed- and random-effects models. We also assessed heterogeneity among studies and publication bias. RESULTS The overall pooled odds ratio for excellent or good bowel preparation quality for 4-L split-dose PEG was 3.46, compared with other methods (95% confidence interval, 2.45-4.89; P < .01). Although there was significant heterogeneity in results among studies, 7 of 9 reported a significant benefit from the 4-L split-dose PEG preparation. There were no significant differences between PEG and others in preparation compliance, favorable overall experience, willingness to repeat the same preparation, abdominal cramping, nausea, or sleep disturbance. There was no significant publication bias based on funnel plot. CONCLUSIONS A meta-analysis showed that 4-L split-dose PEG is better than other bowel preparation methods for colonoscopy. Significant heterogeneity among studies might result from differences in patient demographics and protocols. A 4-L split dose of PEG should be considered the standard with which new bowel preparation methods are compared.

Endoscopic retrograde cholangiopancreatography in the pediatric population is safe and efficacious

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly being used in the evaluation and management of biliary and pancreatic disorders in children. The aim of this study was to review the pediatric ERCP experience of a large academic referral center affiliated with a tertiary care childrens hospital. Methods: This is a retrospective review of medical records, endoscopic and operative reports, and radiography of those patients ages 0 to 21 years who underwent ERCP for any indication between 1993 and 2011 at a tertiary referral center affiliated with a large urban pediatric hospital. ERCP technical success was defined as cannulation of the desired duct. Serious adverse events included bleeding, perforation, pancreatitis, or death. Results: Four hundred twenty-nine ERCPs were performed on 296 patients. The mean age was 14.9 ± 4.8 years (3 months–21 years); 51.1% were boys. Patients with a history of previous liver transplant comprised 13.1% (56) of all ERCPs. Abnormal liver chemistries or suspected choledocholithiasis accounted for half of the indications. A therapeutic intervention was performed in 64.1%. Technical success was achieved in 95.2% of ERCPs. Serious adverse events occurred in 7.7%. Conclusions: Pediatric ERCP is highly efficacious in the pediatric population, with the rates of technical success and use of therapeutic interventions mirroring those in adults. There is a low overall rate of serious adverse events. The overall efficacy and safety support the performance of pediatric ERCP by experienced endoscopists at high-volume centers.

Infections in IBD Patients on Immunomodulators, Corticosteroids, and Anti-TNF therapy: Is Elderly Age a Predictor?

Background: Inflammatory bowel disease (IBD) therapy, including immunomodulatory (IMM), corticosteroids (CS), and TNF inhibitors (TNFI), is known to increase the infectious risk when used in to treat many diseases. No recent studies have analyzed the incidence of infections in elderly patients on these therapies. We aim to analyze the effect of immunosuppressant use and age on infectious complications in IBD patients. Methods: A retrospective cohort study was conducted of patients at a tertiary care center with Crohns disease (CD), ulcerative colitis (UC), or IBD, comparing infection risk in patients ≥65 years old to those < 65 years old. Chi-square and Wilcoxon Rank Sum statistics were performed. Infection rate ratio (IRRs) were evaluated. Results: 292 patients were assessed. 83% of patients < 65years old and 72% of patients ≥65years old were on immunosuppressant’s. Infections occurred in 41.4% patients. 7.8% of the cohort had ≥2 infections. The infection incidence rate per year of follow up in the younger and older cohorts were 0.106 and 0.170, respectively, with IRR of 1.60 (95% CI=1.16, 2.21) in the older. The IRR in elderly patients on CS compared to non-CS regimens was 3.28 (95% CI=1.62, 6.64). The IRR in elderly patients on IMM and CS, and on TNFI and CS were 10.58 (95% CI=1.27, 87.91) and 10.64 (95% CI=1.95, 58.10), respectively. Conclusions: Increasing age is associated with an increased risk for infections in IBD patients using immunosuppressive medications. CS had the highest IRR for infections compared to other therapies. Infectious risk is greatly increased when CS are added to IMM and TNFI. Correspondence to: Christina Tofani, MD, 132 S. 10th St., Main Building, Suite 480, Philadelphia, PA, USA, Tel: +1 215-662-4000; E-mail: christina.tofani@gmail.com