Lisbeth Selby

Receipt of preventive health services by IBD patients is significantly lower than by primary care patients

Background: Persons with chronic diseases often do not receive preventive care at the same rate as the general population. Reasons for this are not clear. We conducted a cross‐sectional survey of patients with inflammatory bowel disease (IBD) and controls to assess receipt of 10 preventive health services. Methods: From March through October 2006, IBD outpatients and primary care outpatients at the University of Kentucky (UK) were surveyed by trained clinicians, using chart data to augment patient response. A second sample of IBD patients from the University of Chicago was studied with a self‐administered survey. Results: One hundred and seventeen IBD subjects were enrolled at UK, 125 IBD subjects were enrolled at UCH, and 100 control subjects were recruited from UK primary care clinics. The overall age‐/sex‐adjusted screening rate, as measured by the screening index, was significantly lower in UK IBD subjects than in UK controls (75.1% versus 83.9%, P = 0.0002). The UCH data showed a 67% overall age‐/sex‐adjusted screening rate. After adjusting for insurance status, the difference in screening rates was still lower for IBD patients than for controls (71% versus 78%; P = 0.022). Neither disease type nor disease control rating predicted screening rate. Conclusions: Our data suggest IBD patients do not receive preventive services at the same rate as general medical patients. Preventive care is a facet of global IBD management that deserves further study.

Gastroduodenal Crohn's Disease Is Associated With NOD2/CARD15Gene Polymorphisms, Particularly L1007PHomozygosity

Limited data exist on the specific association between gastroduodenal Crohns disease (GDCD) and NOD2/CARD15gene polymorphisms. The aim of this study was to assess the association between NOD2polymorphisms and GDCD, and to assess the specific association between each of the 3 major allelic variants G908R, L1007P, and R702Wand the clinical features of Crohns disease. We retrospectively reviewed the records of 202 patients with confirmed Crohns disease and complete data was performed. Seventy-one patients (35%) had at least 1 allelic variant: 55 had 1 variant, 4 were homozygous for L1007fs, 2 homozygous for R702W, and 10 were compound heterozygous. Eighteen patients with confirmed GDCD were identified; 10 (56%) had wild type, 4 (22%) had 1 variant, and 4 (22%) had 2 allelic variants (2 were L1007Phomozygous and 2 compound heterozygous). Compared to patients without gastroduodenal involvement, those with GDCD were more likely to have 2 allelic variants (22% vs. 6%; odds ratio [OR] 2.7; 95% confidence interval [CI] 1.6–7.3) and to be homozygous for L1007P(11% vs. 1%; OR 5.2; 95% CI 2.5–9.4). G908Rheterozygosity was associated with ileal involvement (OR 1.4; 95% CI 1.1–2.9) and smoking habits (OR 2.4; 95% CI 1.2–3.8), whereas L1007Phomozygosity was associated with GDCD (OR 5.8; 95% CI 2.6–10.8). L1007Pvariation was associated with younger age at diagnosis as well. There was no specific association between R702Whomo- or heterozygosity and any of the characteristics examined. In conclusion, GDCD is associated with double dose of the NOD2/CARD15gene variants, particularly L1007Phomozygosity. There is evidence of specific variant-phenotype associations. G908Rheterozygosity is associated with ileal involvement and smoking, whereas L1007Phomozygosity is strongly associated with GDCD and younger age at diagnosis.

The association of bullous pemphigoid and ulcerative colitis.

Bullous pemphigoid (BP) is an uncommon blistering skin disease, mainly affecting the elderly and often described in association with other autoimmune disorders (1–5). It has rarely been reported in association with IBD (2, 6–8). We report two patients with ulcerative colitis (UC) who developed BP at an age younger than that of the typical BP patient. Given the rarity of BP and the immune dysregulation common to both UC and BP, namely, a Th2 antibody response, we postulate a casual association of these disorders. Furthermore, BP could be considered an extraintestinal manifestation of IBD.

How to avoid common pitfalls with bowel preparation agents

a e s e w s c t t n f t r r Colonoscopy is the driving force of our specialty, and gastroenterologists are obliged to perform a high-quality colonoscopy to ensure the future of conventional colonoscopy. In addition, quality colonoscopy protects against colorectal cancer incidence and mortality. The quality of examination during colonoscopy can be impaired by imperfect bowel preparation. Steps to improve patient understanding of and compliance with bowel preparation could significantly improve the outcomes of colonoscopy in clinical practice. In this month’s edition of the Fellows’ Corner, Dr. Freddy Caldera and Dr. Lisbeth Selby shed light on various bowel preparation regimens and on the different steps that gastroenterologists should follow to improve patient compliance and tolerability of different colonic cleansing regimens.

Split dosing bowel preparation: patients' willingness and lack of interference with travel.

To the Editor: The American College of Gastroenterology in its latest colorectal cancer screening guidelines recommended split dosing of bowel preparation for screening colonoscopy, as it provides superior bowel cleansing compared with traditional dosing.1 With this regimen, the patient ingests half of the laxative the day before the procedure and the remainder on the day of the procedure. In 7 prospective randomized studies, split dosing was superior to traditional dosing in the quality of bowel cleansing.2–8 In addition, when using PEG-based solutions, split dosing makes the bowel regimen more tolerable for patients which increases adherence.6 In a recent small survey, gastroenterologists were reluctant to incorporate split dosing into their practices due to a belief that their patients would not be willing to wake up early to take the remainder of the split dose regimen and that it would interfere with patients’ travel.9 However, a survey of 300 people who were scheduled for an esophagogastroduodenoscopy or were the drivers of patients undergoing a colonoscopy revealed that 85% of both groups indicated that they would be willing to use a split dose regimen before an early morning colonoscopy. This study also showed that 78% of patients who used a split dose regimen for colonoscopy awoke and took the second dose at the appropriate time.10 Another study evaluating the satisfaction and inconvenience of bowel prep regimens found that a significantly higher percentage of patients in the split dose regimen reported no or minimal difficulty completing the bowel prep compared with prior day dosing (81.3% vs. 55.7%). In addition, there was no significant difference in the number of patients whose travel was affected by stopping for a bowel movement between the 2 groups.11 We conducted an observational 2phase survey study between September 2010 and April 2011 to determine if patients were willing to undergo split dosing, if they were concerned it would affect their travel on the day of the procedure, and if an interruption actually occurred. During the first phase of our study, we interviewed 100 consecutive patients reporting for an outpatient colonoscopy who had used prior day dosing bowel preparation. The consequences of adequate and inadequate preparations were described to patients, and they were told that split dose regimens could increase their likelihood of an adequate preparation. Then they were asked about their willingness to wake up 5 hours before the procedure to complete a split dose regimen. For the second phase of the study, we interviewed 150 consecutive patients who had undergone split dosing with 2-L PEG-ELS+ascorbic acid (MoviPrep; Salix Pharmaceuticals Inc.) before a colonoscopy. Completing the bowel preparation within 5 hours of their scheduled procedure was an inclusion criterion. Patients were asked about their willingness to repeat a split dosing regimen in the future. We asked if they were worried about a bowel movement interrupting their travel to the procedure location and if an interruption occurred. In both phases, all patients were given conscious sedation and no one refused to participate in the study. In the first phase where patients used the conventional previous day regimen, 88% of patients were scheduled for a colonoscopy before noon. Eighty-two percent of the total 100 patients indicated that they would have preferred to use split dosing if given the option before their procedure. Of those patients, 62% claim they would have taken the second dose at 1:00 or 2:00 AM. The most common reasons given for not wanting to use split dosing were refusal to wake this early and extended travel time on day of procedure. Those who reported a lengthy travel time all drove at least an hour for their procedure. In the second phase where patients used a split dose bowel prep, 71% of patients were scheduled for a colonoscopy before noon. The majority of patients (88.6%) indicated they were willing to repeat split dosing for their next colonoscopy. Interestingly, we found that 50.6% of patients were worried that split dosing would interrupt their travel plans on the day of the procedure but only 4% were actually affected by needing to find a restroom during the journey. Only 2.6% of patients were late for their appointment due to travel interruptions. Most patients (86%) in phase 2 traveled <1 hour for their procedure. The quality of patients’ preparation in both phases was assessed by the Aronchick scale and shown in Table 1. The efficacy of split dosing has been established by the previously mentioned studies, and the American College of Gastroenterology recommends it as the preferred regimen for screening colonoscopy. This observational study demonstrates that the patients surveyed prefer split dosing and would choose to repeat this regimen in the future. This study adds to the literature on this topic as few previous studies demonstrate the willingness of patients undergoing colonoscopy to repeat split dosing.12 Potential limitations of this study include a lack of randomization and that most patients in phase 2 traveled less than an hour for their procedure. However, the results are still applicable for practice settings where most patients come from within this distance. Gastroenterologists can assuage patients who are concerned about split dosing interfering with travel plans as few patients are affected. The benefits of split dosing addressed in this study and others should significantly reduce apprehension of providers to implement it with all of their patients. This study may also contribute to further research toward designating split dosing as the new standard-of-care bowel regimen.

S1098 Suboptimal Utilization of Antiplatelet Therapy in the Setting of Treated Peptic Ulcer Disease Bleeding Post Coronary Artery Stenting

tion or outpatient, hemorrhagic recidive and Rockall score). Our outcomes were mortality directly related to the hemorrhage (in-hospital), mortality up 30 days and length of stay in hospitalized patients. For statistical analysis we used the Chi-square test and t Student test, with p<0.05 as significant differences. Results: 832 patients (532 male, 300 female), with median age 69 years; admission in weekdays 610 patients (73.1%) and weekend/holydays 222 patients (26.6%). The groups A and B are similar (Table) Mortality in-hospital 24 patients (2.88%)(6 patients admitted weekend/holidays vs 18 patients in weekdays, p=1), and total mortality 41 patients (4.92%) (9 patients admitted in weekend/holydays vs 32 patients in weekdays, p=0.588); length stay of hospitalized patients 5.4 ± 4.7 days (5.4 ± 4.4 in group A vs 5.5 ± 5.9 in group B, p=0.873). Conclusions: In our hospital does not exist weekend effect on patients with NVUGIH

MedSurv: a software application for creating, conducting and managing medical surveys and questionnaires

Background and solution MedSurv is a system designed for the rapid creation and maintenance of research surveys and questionnaires that does not require programmer intervention. MedSurv is built with medical surveys in mind and utilizes a groupbased permission control with additional security features to help ensure compliance with applicable healthcare regulations. MedSurv is designed as a module for DotNetNuke [1], an open source portal and content management system built with ASP.Net technology, and therefore can be deployed and managed as intranet, extranet, and web sites. At the same time, all data is stored at the researchers institution to guarantee the required data privacy. Thanks to its built-in support for user authentication and user roles, there is no need to create such functionality from scratch. However, a group-based permissions system is added to MedSurv to support sufficient granularity for access control. Although from the data access point of view data storage acts as a relational table, MedSurv uses a solution that we call virtual tables. The premise behind such a solution is that the structure of the tables is itself stored in a set of relational tables within the database, essentially creating a miniature database within the database. This additional layer is transparent to the user and removes the need for any programming or database knowledge. At the same time it gives the user the flexibility of changing the survey at runtime. Unlike a traditional structure that may require database developers involvement each time a survey is added or changed, with virtual tables there is very low developer and database administration need after launch. MedSurv allows for creating complex medical surveys and is, in particular, used to develop questionnaires for research driven data collection in the Department of Gastroenterology.

Crohn's disease, infliximab treatment and IgA nephropathy

IgA nephropathy is one of the most common glomerular lesions worldwide, with a reported prevalence of 25–50 cases/100,000. Much like IBD, it classically affects the young. However, it has rarely been associated with Crohns disease. Only 6 cases have been reported. We report a case of IgA nephropathy which developed in a 38 year-old Caucasian male who had a 19 year history of fistulizing Crohns ileocolitis and perianal disease. The patient has had prior ileal resection and numerous perianal surgeries. About 2 years before the presentation of IgA nephropathy, he was placed on a regimen of infliximab infusions every 8 weeks and 6-mercaptopurine. His bowel disease was under good control when he presented with fatigue followed shortly by gross hematuria. Initially his creatinine was normal and there was no proteinuria. However, he soon developed significant proteinuria, 2.4 gm/24h, and renal insufficiency with a peak creatinine of 2.8 several months after the onset of hematuria. Renal biopsy revealed a moderately increased mesangial matrix with immunostaining against IgA showing 3–4 + mesangial deposition. There was also 4+ mesangial staining for C3. Overall the findings were felt typical for IgA nephropathy. The patient was started on a regimen of glucocorticoids, ACE inhibitors and fish oil. His creatinine and proteinuria progressively improved over the course of 6 months. During this treatment his gastrointestinal symptoms have remained quiescent. The pathogenesis of IgA nephropathy is incompletely understood but a key feature is the glomerular deposition of circulating immune complexes and activation of complement via the alternative pathway. The IgA is mainly polymeric IgA1, which is often of mucosal origin. This plus the fact that IgA nephropathy has been reported with various gastrointestinal disorders such as celiac sprue and dermatitis herpetiformis has led to speculation that IgA nephropathy is a disease of the mucosal immune system. As in Crohns disease, antibodies to various dietary and microbial antigens have been reported in IgA nephropathy. Finally, it is possible that infliximab and the resulting generation of antibodies to infliximab (ATI) may have contributed to the development of this patients renal disease.