Markus B. Frenz

Infliximab use in Crohn's disease:impact on health care resources in the UK

Objective To quantify the impact of infliximab therapy on health care resource utilization in the UK. Methods A retrospective audit was undertaken at seven centres in the UK, which reviewed patient notes for a period of 6 months before and 6 months after an initial infliximab infusion. Details of hospital admissions, outpatient visits, operations, diagnostic procedures, drug usage, and overall efficacy were collected. Results were compared for the two 6 month study periods. Results A total of 205 patients (62% female, median age 33 years) with moderate/severe Crohns disease were audited. The majority of patients had chronic active disease (62%) and most received one infusion initially (72%). Clinicians rated 74% of responses as good to excellent and patients 72%. Most patients had concomitant immunosuppression (pre: 75%, post: 75%). Approximately half of the patients (45%) stopped taking steroids, with a further 34% having a dosage reduction. A fall of 1093 inpatient days was seen (1435 vs. 342) in the 6 months following infliximab administration. There were seven fewer operations, 33 fewer examinations under anaesthetic, and 99 fewer diagnostic procedures. Outpatient visits were similar pre- versus post- (555 vs. 534). The total reduction in direct costs amounted to an estimated £591 006. Three hundred and fifty-three infliximab infusions were administered at an estimated cost of £562 719. Thus, there was a net reduction of £28 287 or £137.98 per patient. Conclusions Infliximab appears to be a potentially cost effective treatment for selected patients based on the reduced number of inpatient stays, examinations under anaesthetic, and diagnostic procedures over a 6 month period.

Propofol sedation for upper gastrointestinal endoscopy in patients with liver cirrhosis as an alternative to midazolam to avoid acute deterioration of minimal encephalopathy: a randomized, controlled study.

Objective. Midazolam sedation for upper gastrointestinal (GI) endoscopy exacerbates minimal hepatic encephalopathy (HE) in patients with liver cirrhosis, therefore an alternative drug regimen for these patients is warranted. The aim of this randomized, controlled study was to assess whether the use of the short-acting propofol as a sedative for GI endoscopy could prevent the exacerbation of minimal HE in patients with liver cirrhosis. Material and methods. The study comprised patients with liver cirrhosis without clinical HE who had undergone upper GI endoscopy for therapeutic purposes (intended variceal band ligation). Sixty patients were randomly assigned into two groups to receive propofol (n=40) or midazolam (n=20) for upper GI endoscopy. The study groups were matched for age, gender and Child-Pugh score. All patients completed number connecting tests (NCTs), as well as a porto-systemic encephalopathy (PSE) syndrome test before and at 2 h after completion of the endoscopic procedure. Time needed to fulfill the tests was documented. Baseline results of the psychomotor test batteries were compared with the post-interventional evaluations. Data were also compared with the results of a healthy control group (n=20) that did not undergo endoscopic sedation. Recovery time and quality (score system) were evaluated. Results. The differences in the NCT times before and after sedation (median delta NCT, midazolam group, 11 s (95% CI, −1.2 to 16.1 s) versus the propofol group, −9.5 s (95% CI, −15.7 to −4.6 s), p=0.002) and in the PSE scores (median delta PSE, midazolam group, −1 (95% CI, −1.5 to 0.2) versus the propofol group, 1 (95% CI, 0.5 to 1.5), p=0.0009) differed significantly between the two groups. In addition, the recovery time and quality in patients receiving propofol were significantly improved compared with in the midazolam group (7.8±2.9 min versus 18.4±6.7 min, 6.1±1.1 versus 8.2±1.3, both p<0.001). Conclusions. The study demonstrates that propofol sedation for upper GI endoscopy does not cause acute deterioration of minimal hepatic encephalopathy and is associated with improved recovery in patients with liver cirrhosis. Propofol should be recommended for these patients as an alternative to midazolam.

Comparison between prospective and retrospective evaluation of Crohn's disease activity index.

The Crohns disease activity index (CDAI) is the most widely used measure of clinical disease activity in patients entered into clinical trials. The prospective nature of the CDAI calculation precludes its use as a clinical assessment tool. We compared the retrospective evaluation of the CDAI with the prospective evaluation in a heterogenous patient population of 100 patients with Crohns disease. The correlation between the two assessment methods was good with an r-value of 0.84 (p < 0,0001). There was a tendency of patients with a high retrospective CDAI to have a lower prospective CDAI which is explained by intention to treat. This study shows that a retrospective assisted evaluation of the CDAI is as accurate as the traditional prospective evaluation.

Endoscopic pancreatic duct stenting for relief of pancreatic cancer pain.

Introduction Little is known about the effects of endoscopic pancreatic duct (PD) decompression in patients with ‘obstructive type’ pain from pancreatic carcinoma. Methods Twenty patients with unresectable carcinoma of the pancreas, PD obstruction and postprandial epigastric pain were enrolled. The pain intensity, opioid dose and quality-of-life index were documented pre-treatment and at 4-weekly intervals. PD stenting was attempted in all patients. PD stent change was performed if biliary stents had to be changed or intense pain relapsed. Results Endoscopic PD drainage was successful in 19/20 patients by placement of a 7 F (n=9) or 10 F (n=10) plastic stent. Median follow-up was 16 weeks. Two patients were alive at the end of follow-up. Eleven patients received gemcitabine chemotherapy. The pre-interventional pain score was 6.7±0.9 points and decreased to 3.1±1.4 points at 4 weeks (P<0.001). It remained lowered significantly at 8/12 weeks and at the final visit (4.2±1.5 points, n=13). The mean pre-stenting fentanyl dose was 85.5±34.7 μg/h, and it was decreased to 57.9±39.1 μg/h after 4 weeks (P<0.01), 60.5±38.9 μg/h after 8 weeks and 64.1±39.8 μg/h (P<0.01 versus pre-treatment) after 12 weeks but increased to 82.7±41.3 μg/h (NS) at the final visit. The quality-of-life index improved 4 weeks after stenting (from 4.8±1 to 6.2±1.5 points, P<0.01) but was lowered to 5.5±2.3 points at 12 weeks (NS). The response was independent of stent diameter and chemotherapy. Conclusion PD stenting achieved significant pain relief and short-term improvement of the quality of life in the majority of patients with PD obstruction due to pancreatic carcinoma.

Making the diagnosis of coeliac disease: is there a role for push enteroscopy?

• Coeliac disease is one of the most common genetically based diseases. • Increasing numbers of patients are identified based on serological screening. • Histological confirmation of the characteristic small bowel changes with partial or total villous atrophy remain the gold standard for making a diagnosis. • Gastro-duodenoscopy with four-quadrant biopsies from the descending duodenum is adequate in most patients to make a histological diagnosis. • Push enteroscopy with jejunal biopsies can play a valuable role in diagnosing coeliac disease in patients with positive endomysial antibodies, but non-conclusive initial duodenal biopsies. Coeliac disease is one of the most common genetically based diseases. The wide clinical spectrum of the disease and the availability of highly specific antibody testing have led to an increased number of patients undergoing gastroscopy with distal duodenal biopsies. Histological confirmation of the characteristic small bowel changes with partial or total villous atrophy remain the gold standard for making a diagnosis. Patients with positive antibodies but initially negative or uncertain biopsies pose a particular diagnostic dilemma. Due to the patchiness of the histological changes, push enteroscopy with jejunal biopsies can play a valuable role in this group of patients. Similarly, patients with refractory coeliac disease can benefit from push enteroscopy with jejunal biopsies.