Ron Reshef

Budesonide versus prednisone in the treatment of active Crohn's disease

BACKGROUND & AIMS Budesonide (BUD) is a potent steroid that undergoes extensive first-pass metabolism. BUD incorporated in a pH-dependent formulation has been proposed as an alternative treatment for Crohns disease (CD). The aim of this study was to compare the efficacy and safety of BUD and prednisone (PRED) in the treatment of active CD involving the terminal ileum and/or the colon. METHODS Patients with mild to moderately active CD were included in a randomized, double-blind, double-dummy controlled trial. Patients received either 9 mg BUD once daily for 8 weeks or 40 mg PRED once daily for the first 2 weeks tapered gradually to 5 mg/day by the end of the study. Disease activity, quality of life, and laboratory parameters were recorded. RESULTS One hundred patients received BUD, and 101 patients received PRED. By intention-to-treat analysis, treatment efficacy defined as Crohns Disease Activity Index of <150 at completion was 51% and 52.5% for the BUD and PRED groups, respectively. Twice as many responded to treatment with no side effects in the BUD compared with the PRED group (30% vs. 14%) (P = 0.006). Most of the decrease in CDAI scores occurred during the first 2 weeks. CONCLUSIONS BUD is as effective as PRED in the treatment of CD involving the terminal ileum and right colon. BUD has significantly fewer steroid-related adverse reactions.

Failure of Synbiotic 2000 to Prevent Postoperative Recurrence of Crohn's Disease

Complications of Crohn’s disease (CD) lead to surgery in about 70–90% of patients. The majority of patients suffer from relapse of the disease. Colonic bacteria are essential to the development of CD. Therefore, a rationale exists in trying to prevent relapse by manipulation of gut microflora. This is feasible by treatment with probiotics or antibiotics. Synbiotic 2000 is a cocktail containing 4 probiotic species and 4 prebiotics. It is rational to pursue that it could be effective in preventing postoperative disease. We sought to check weather treatment with Synbiotic 2000 could prevent postoperative recurrence in patients with CD. This was a prospective multicenter, randomized study. Patients were randomized to active treatment or placebo in a 2:1 ratio. Follow-up consisted of endoscopic, clinical, and laboratory parameters. Thirty patients were enrolled. No differences were found between the 2 treatment groups regarding gender, age at diagnosis, age at surgery, weight, smoking status, type of disease, length of the resected segment, or medical treatment prior to surgery. No difference in either endoscopic or clinical relapse rate was found between patients treated with once daily dose of Synbiotic 2000 or placebo. In our small study, Synbiotic 2000 had no effect on postoperative recurrence of patients with CD. Larger studies in patients with the inflammatory type of CD undergoing surgery, using higher doses of probiotics cocktail might prove effective.

The Impact of Endoscopic Ultrasonography on the Management of Suspected Pancreatic Cancer-a Comprehensive Longitudinal Continuous Evaluation

Objectives: Between 1997 and 2001, a single-center chart review demonstrated significant impact of endoscopic ultrasonography (EUS) in evaluating suspected pancreatic cancer (PCA). Repeating and comparing this review with that from 2001 to 2004 was performed to determine whether increased use of EUS results in more patients being accurately chosen for curative versus palliative procedures, and for surgical versus nonsurgical oncotherapy. Methods: The complete systematic review was made up of electronic files from the gastroenterology, oncology, and pathology departments of patients presenting with suspected PCA. Results were compared with those obtained in 1997-2001. Results: From 2001 to 2004, 72 patients had PCA. Seven tumor types were identified. Forty-seven percent (34/72) of patients with suspected PCA were preoperatively staged by EUS; 24% (17/72) of all patients underwent surgery. Comparatively, from 1997 to 2001, only 32% (20/62) of patients were evaluated by EUS (P = 0.056) and 45% (28/62) of all patients underwent surgery (P < 0.01). The EUS detected a tumor in 32 of 34 cases. The EUS-guided fine-needle aspiration cytology identified PCA in 14 of 18 cases. F-18-deoxyglucose-positron emission tomography and magnetic resonance imaging were not used. Endoscopic retrograde cholangiopancreatography was performed in 29% (21/72) of patients, with 15 stents inserted. Conclusions: Increased EUS use for diagnosing and staging PCA resulted in fewer patients undergoing futile surgery. The EUS plays a pivotal role in the management of patients with PCA.

The macrophage migration inhibition (MIF) assay as a marker of colorectal cancer

A specific macrophage migration inhibition assay, using patient lymphocytes incubated with a human colonic cancer extract, was studied in 92 patients with proven colorectal cancer and in 134 other individuals (20 normal controls, 80 patients with various nonmalignant gastrointestinal diseases, and 34 patients with extracolonic malignancies).A positive response was obtained in 78 of 92 colorectal cancer patients, but in none of the 20 normal controls. A positive response occurred in four of 34 patients with extracolonic malignancies and in approximately half of patients with colonic adenomas and in one third of patients with ulcerative colitis. The significance of positive results in these patients (with diseases considered premalignant) is unclear, and is being studied further. In patients with previous resection of colorectal cancers, positive responses were frequent during the first year following resection, and rare thereafter.The results suggest that this method may be useful as a clinical marker for colorectal cancer, and warrants further technical refinement and study of specific patient populations.

Satisfaction of the referring physician : A quality control study focusing on EUS

Introduction Utilization of endoscopic ultrasonography (EUS) is becoming more widespread. Largely in control of use of EUS, as a primary consumer of EUS, are the physicians who refer patients. This quality control study aimed to uncover remedial impediments to ideal utilization of EUS. Methods Two thousand patient EUS reports, all by one endoscopist, were screened. One hundred forty referring physicians were identified. One hundred of these physicians completed extensive feedback survey questionnaires. Results Overall satisfaction with EUS procedures was generally high. The level of satisfaction was comparable to satisfaction with gastroscopy procedures, both being significantly higher than for endoscopic retrograde cholongio-pancreatography. Sixty-nine percent of the physicians indicated their desire for more information regarding EUS, this being significantly higher among residents (vs. specialists). The open access system in current practice was seen as acceptable by less than half of physicians, both from the community and from within the hospital. Waiting time for EUS procedures and for biopsy results were rated as acceptable within the hospital, but more often as too long for outpatients. Conclusions Overall satisfaction with EUS procedures is high. More information should be brought to the referring physicians, in print and lectures. Improving communication and interacting with endoscopist-initiated feedback led to improved feelings of teamwork, uncovered remedial weak points in the EUS service, and was thus found to be valuable.

Cyclospora cayetanensis: a case report.

group, the NCCLS Area Committee mens, identifying organisms, measuring on Microbiology has submitted a new in vitro susceptibility patterns of organproject proposal on “Diagnostic Microisms to antimicrobial agents, and deterbiology for Limited Resources Laboramining the clinical significance of tories.” This consensus guideline would isolates. NCCLS is continually growing as an organization, both nationally and internationally. For further information about NCCLS, contact the executive offices online at www.nccls.org or by telephone at 610-688-0100.