Justin L. Sewell

Systematic review: proton‐pump inhibitor failure in gastro‐oesophageal reflux disease – where next?

Proton‐pump inhibitor failure has become a common clinical dilemma in gastrointestinal clinics and has been increasingly encountered at the primary care level as well. Underlying mechanisms are diverse and may overlap. Most patients who have proton‐pump inhibitor failure are likely to originate from the non‐erosive reflux disease phenotype. Currently, available diagnostic modalities provide limited clues to the exact underlying cause. Treatment relies primarily on escalating dosing of proton‐pump inhibitors. However, new insights into the pathophysiology of proton‐pump inhibitor failure are likely to provide alternative therapeutic options.

The effect of a therapeutic trial of high-dose rabeprazole on symptom response of patients with non-cardiac chest pain: a randomized, double-blind, placebo-controlled, crossover trial

Background : Empirical trial with high‐dose omeprazole has been shown to be a sensitive tool for diagnosing patients with gastro‐oesophageal reflux disease‐related non‐cardiac chest pain.

Meta-analysis: antibiotic therapy for small intestinal bacterial overgrowth

Small intestinal bacterial overgrowth (SIBO) is an under‐recognised diagnosis with important clinical implications when untreated. However, the optimal treatment regimen remains unclear.

Hospitalizations are increasing among minority patients with Crohn's disease and ulcerative colitis.

Background: Rates of inflammatory bowel disease (IBD) appear to be increasing among nonwhite populations outside the United States, but national data describing the incidence and prevalence of IBD are not available for minority patients. The aim of this study was to examine time trends of hospital discharge among minority patients with IBD. Methods: Nationally representative data describing hospital discharges were obtained from the National Hospital Discharge Survey for the years 1994 to 2006. Race‐specific annual proportions of hospitalizations including a discharge diagnosis of ulcerative colitis and Crohns disease were calculated. Trends in proportions were assessed for statistical significance using the extended Mantel–Haenszel χ‐square test for trend. Results: The proportion of hospitalizations including a discharge diagnosis of IBD increased significantly from 1994 to 2006 among the total population and among Asian, black, and white patients separately. Increases were statistically significant when analysis was performed for Crohns disease and ulcerative colitis combined and separately. Marked increases were seen among Asians. Conclusions: The proportion of hospitalizations including a discharge diagnosis of IBD increased significantly among minority and nonminority patients from 1994 through 2006. The causes underlying these changes are not certain and should be further investigated. Inflamm Bowel Dis 2009

Systematic review: The role of race and socioeconomic factors on IBD healthcare delivery and effectiveness.

Background:Race and socioeconomic status (SES) significantly affect the content and delivery of healthcare for multiple chronic disease states. Inflammatory bowel disease (IBD) is a set of complex, chronic diseases with the potential for significant morbidity if the content or delivery of healthcare is suboptimal. However, the literature related to race, SES, and IBD remains fragmented. Methods:Using guidelines published by the Centre for Reviews and Dissemination, we performed a systematic review of the worlds literature to identify studies related to: 1) IBD, 2) race/ethnicity, 3) SES, 4) healthcare delivery, and 5) healthcare effectiveness. Results:We identified 40 studies that met inclusion criteria. Twenty-four studies (60%) assessed the role of SES and 21 (53%) evaluated race. Topics addressed by these studies included: 1) Utilization of Medical and Surgical Therapy; 2) Adherence to Medical Therapy; 3) Clinical Outcomes; 4) Healthcare Access and Utilization; 5) Disease Perception and Knowledge; and 6) Employment/Insurance. We identified race- and SES-based disparities in the content of medical and surgical healthcare, utilization of inpatient and ambulatory medical care, adherence to medical therapy, and disease perceptions and knowledge. Several studies also identified race- and SES-based disparities in outcomes for IBD, including in-hospital mortality rates and health-related quality of life. Conclusions:Race- and SES-based disparities in the delivery and effectiveness of healthcare for patients with IBD exist in numerous domains, yet studies remain limited in their scope and breadth. Concerted, prospective, multicenter efforts are needed to address underlying causes for disparities and to identify methods of reducing and eliminating disparities.

Hepatocellular carcinoma after sustained virologic response in hepatitis C patients without cirrhosis on a pretreatment liver biopsy.

Among hepatitis C patients, lack of cirrhosis and sustained virologic response (SVR) reduce the risk of hepatocellular carcinoma (HCC). Japanese studies document multiple cases of HCC among these patients, but only one case has been reported outside of Asia. We identified five patients with hepatitis C in our university-based hepatology practice who developed HCC despite SVR and lack of cirrhosis on their pretreatment liver biopsy. At the time of HCC diagnosis, two remained noncirrhotic, one had clearly progressed to cirrhosis, and two lacked repeat histology. We present these patients in a case series format and discuss several important implications of their cases. Physicians often base screening and treatment decisions on an initial liver biopsy performed years earlier. As fibrosis may advance, and because SVR and lack of cirrhosis do not fully protect against HCC, future study should further evaluate the risk of HCC among hepatitis C patients after sustained virologic response.

Urgent colonoscopy in patients with lower GI bleeding: a systematic review and meta-analysis

BACKGROUND AND AIMS Lower GI bleeding (LGIB) is a common cause of morbidity and mortality. Colonoscopy is indicated in all hospitalized patients with LGIB, yet the time frame for performing colonoscopy remains unclear. Prior studies of outcomes in urgent versus elective colonoscopy have yielded conflicting results and were often underpowered. Our study objective was to compare several outcomes between urgent and elective colonoscopy in patients hospitalized for LGIB. METHODS Systematic review and meta-analysis were performed on studies that compared urgent and elective colonoscopy in patients with LGIB. Pooled rates were calculated for specific outcomes, and rate ratios were determined for selected comparison groups. RESULTS Twelve studies met inclusion criteria, with a total sample size of 10,172 patients in the urgent colonoscopy arm and 14,224 patients in the elective colonoscopy arm. Urgent colonoscopy was associated with increased use of endoscopic therapeutic intervention (RR, 1.70; 95% CI, 1.08-2.67). There were no significant differences in bleeding source localization (RR, 1.08; 95% CI, .92-1.25), adverse event rates (RR, 1.05; 95% CI, .65-1.71), rebleeding rates (RR, 1.14; 95% CI, .74-1.78), transfusion requirement (RR, 1.02; 95% CI, .73-1.41), or mortality (RR, 1.17; 95% CI, .45-3.02). CONCLUSIONS Urgent colonoscopy appears to be safe and well tolerated, but there is no clear evidence that it alters important clinical outcomes.

Preconsultation Exchange for Ambulatory Hepatology Consultations

BACKGROUND Preconsultation exchange is an emerging model of specialty care proposed by the American College of Physicians that seeks to answer a clinical question without a formal patient visit to the specialty clinic. This form of specialty care has been little studied. We sought to determine the appropriateness of preconsultation exchange for ambulatory hepatology consultations within our urban health care system. METHODS Retrospective study of referrals for ambulatory hepatology consultation in the safety net health care system of San Francisco, Calif from January 2007 through April 2010. RESULTS Of the 500 referrals reviewed, 87 were excluded as repeat requests. The most common reasons for referral were hepatitis B (34.9%) and hepatitis C (32.0%). Fifty-six referrals (13.6%) were appropriate for preconsultation exchange, and 190 (46.0%) were inappropriate for preconsultation exchange. One hundred sixty-seven (40.4%) referrals did not include enough information to determine appropriateness for preconsultation exchange. Most of these (83.8%) were made for hepatitis B or hepatitis C, despite the presence of explicit referral guidelines. Midlevel providers were more likely than physicians to provide enough information to determine appropriateness for preconsultation exchange. CONCLUSION In our urban health care system, preconsultation exchange appears to be an appropriate form of specialty care for some ambulatory hepatology consultations. Communication between primary care provider and specialist appears to be an important barrier to broader implementation of preconsultation exchange. Optimizing the preconsultation exchange is critical to improve the primary-specialty care interface, and to build a true Patient-Centered Medical Home Neighborhood.

The Effects of Race and Socioeconomic Status on Immunomodulator and Anti-Tumor Necrosis Factor Use among Ambulatory Patients With Inflammatory Bowel Disease in the United States

Objectives:Health-care disparities exist for patients of minority race and low socioeconomic status (SES) in many chronic disease states, but little is known regarding health-care disparities for patients with inflammatory bowel disease (IBD). Using nationally representative data, we sought to determine whether use of immunomodulators and anti-tumor necrosis factor (TNF) agents differed by race/ethnicity and SES among ambulatory patients with IBD.Methods:We used data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 1998 to 2010. We identified visits associated with IBD and the medications associated with those visits. Race/ethnicity and SES were characterized. The frequency of immunomodulator and anti-TNF use over time was assessed. We performed analyses accounting for the surveys complex multistage probability sampling design. Associations between race/ethnicity, SES and IBD medication use were identified.Results:A total of 26,400,000 visits for patients with IBD occurred in the United States from 1998 to 2010. Seventy-six per cent of visits were for whites, 9% were for blacks, 7% were for Hispanics, and 2% were for Asians. Sixty-one per cent of visits were privately insured, whereas 7% had Medicaid coverage. From 1998 to 2010, the proportion of visits associated with immunomodulators increased from 6 to 13%, whereas the proportion associated with anti-TNF agents increased from <1 to 14%. In adjusted analyses, visits with Medicaid were three times more likely to be associated with immunomodulators than visits with private insurance, but there were no race/ethnicity-based differences in immunomodulator use. There were no race/ethnicity- or SES-based differences in anti-TNF therapy.Conclusions:Using nationally representative data over a 13-year time period, we found no evidence of disparities in medical therapy for IBD among visits with minority race/ethnicity or low SES.

Assessment of delivery methods used in the informed consent process at a safety-net hospital

BACKGROUND Informed consent is legally and ethically required before a patient undergoes an endoscopic procedure, yet current literature suggests that patient comprehension of key components of informed consent is poor. OBJECTIVE To evaluate specific aspects of and patient satisfaction with the informed consent process in patients who attended an endoscopy education class versus gastroenterology clinic. DESIGN Prospective survey that examined all components of the informed consent process. SETTING Safety-net hospital. PATIENTS Outpatients undergoing endoscopy. INTERVENTION Endoscopy education class versus gastroenterology clinic. MAIN OUTCOME MEASUREMENTS Patient recall of the components of and satisfaction with the informed consent process. RESULTS A total of 301 patients completed the survey, 52.0% of whom attended and were consented in an endoscopy education class. Patients who attended an endoscopy education class reported that a greater number of individual components of the informed consent process were explained to them as compared with patients who were consented in clinic. In multivariate analysis, patients who attended an education class were more likely to recall having had the alternatives (odds ratio [OR] 4.8; 95% confidence interval [CI], 2.0-11.8), details of the procedure (OR 3.0; 95% CI, 1.3-6.8), and what to expect after the procedure (OR 3.0; 95% CI, 1.5-5.6) explained to them by a provider. These patients were more likely to know they could refuse the procedure (OR 4.1; 95% CI, 1.0-16.8), compared with patients consented in the gastroenterology clinic. LIMITATIONS Non-randomized trial. CONCLUSION Patients from a diverse, urban population who attended a multilingual endoscopy education class reported having more elements of the informed consent process explained to them compared with patients who were consented in gastroenterology clinic.