Ruth Cawdron

Positron emission tomography in the investigation of pediatric inflammatory bowel disease

Background: Endoscopic and radiologic studies are frequently required in inflammatory bowel disease (IBD) to determine disease activity, extent of disease, and delineating disease type. Positron emission tomography (PET) using fluorine‐18‐fluoro‐deoxyglucose to identify metabolically active tissues may offer a simple noninvasive alternative to conventional studies in identification and localization of active intestinal inflammation in children with IBD. The aim of this study was to assess the value of PET in identifying active intestinal inflammation compared with conventional endoscopic and radiologic studies, including small bowel follow‐through and colonoscopy. Methods: Sixty‐five children were enrolled in the study. This included 55 children (mean age, 13.3 yr; range, 7‐18 yr; 20 girls) with newly diagnosed IBD (37) or symptoms suggestive of recurrent disease (18) and 10 children with recurrent abdominal pain (mean age, 12.7 yr; range, 8‐15 yr; 7 girls) who were studied with PET, and the results were compared with small bowel follow‐through with pneumocolon and/or colonoscopy. Thirty‐eight patients had Crohns disease (17 ileal, 12 ileocolic, 5 pancolonic, 3 left‐sided disease, 1 right‐sided disease), and 17 had ulcerative colitis (15 pan‐colitis, 2 left‐sided colitis). Mean time interval between PET and other studies was 30 ± 17.6 days. Results: PET correctly identified active inflammatory disease in 80% of children with IBD (81.5% with Crohns disease; 76.4% with ulcerative colitis) and correctly showed no evidence of inflammation in children with recurrent abdominal pain. Gluorine‐18‐fluoro‐deoxyglucose accumulated at sites that corresponded with active disease at colonoscopy in 83.8% of patients and with small bowel follow‐through with pneumocolon 75.0% of the time. Conclusion: This study suggests that PET offers a noninvasive tool for identifying and localizing active intestinal inflammation in children with IBD. PET may not be able to replace conventional studies; however, it may be useful when conventional studies cannot be performed or fail to be completed.

Alternative Medicine Use by Canadian Ambulatory Gastroenterology Patients: Secular Trend or Epidemic?

OBJECTIVES:To assess the prevalence and determinants of alternative medicine (AM) use in gastroenterology outpatients and those with inflammatory bowel disease (IBD).METHODS:An 80-item questionnaire, addressing symptoms, general health, quality of life, and AM use, was administered and analyzed using logistic regression.RESULTS:52.5% of 341 participants used AM in the previous year. Most commonly used were herbal medicine (45.2% of users; 95% CI 35.4–52.5%), chiropractor (40.7%; 95% CI 31.4–48.0%), and massage therapy (22.9%; 95% CI 15.9–29.1%). Reasons prompting AM use were ineffective medical therapy (39.5%; 95% CI 30.4–46.8%), a greater sense of self-control (29.1%; 95% CI 21.2–35.7%), agreement with personal beliefs (19.5%; 95% CI 13.1–25.4%), and conventional drug adverse-effects (17.3%; 95% CI 11.2–22.9%). AM use was predicted as follows: (1) higher education (odds ratio (OR) 2.10; 95% CI 1.22–3.60), (2) comorbid medical conditions (OR 1.80; 95% CI 1.08–3.00), 3) poor mental component summary score of the SF-12 health survey (OR 1.04; 95% CI 1.01–1.07), and (4) higher annual income (OR 1.17; 95% CI 1.001–1.36), but was not related to response to conventional medical therapy. AM practitioners had instructed 8.6% to change prescription medications. AM usage for gastrointestinal disease was greater in patients with IBD (44.6%vs 10.0%; p< 0.05), who were more likely to cite adverse drug effects as a reason for AM use (28.9 vs 14.4%; p= 0.03).CONCLUSIONS:AM was used by 52.5% of gastroenterology outpatients and its use was greater in those with a higher level of education, comorbid conditions, poorer mental health-related quality of life, and higher income. Drug-related side effects also led to increased AM use.

Low prevalence of Helicobacter pylori infection in Canadian children: A cross-sectional analysis

BACKGROUND The incidence and prevalence rates of childhood Helicobacter pylori infection vary greatly by nation, with infection rates of 8.9% to 72.8% reported in developed and developing countries, respectively. To date, few studies have assessed the prevalence of H pylori in Canadian children, with studies limited to Aboriginal communities and single tertiary care centres from Ontario and Quebec. OBJECTIVES To determine the prevalence of H pylori in consecutive children referred to three Canadian tertiary care academic centres for upper gastrointestinal (GI) endoscopy due to upper GI symptoms, and to determine the sensitivity and specificity of the carbon-13-labelled urea breath test, the rapid urease test and the H pylori stool monoclonal antigen test. RESULTS Two hundred four patients were recruited. The prevalence of H pylori was 7.1%. Of the H pylori-positive patients, 41.7% were male, with a mean age of 10.3 years. Ethnic minorities accounted for 42% of the H pylori-positive patients. Consistent with previous observations, the sensitivity and specificity of the carbon-13-labelled urea breath test were 1.0 and 0.98, respectively. The sensitivity and specificity of the rapid urease test were 1.0 and 0.99, respectively. Stool samples were collected from 34 patients from one centre, with a sensitivity and specificity of 1.0 and 0.68, respectively. No defining symptoms of H pylori infection were evident and no peptic ulcer disease was demonstrated. CONCLUSION H pylori infection rates in Canadian children with upper GI symptoms are low, and are lower than those reported for other developed countries. Further studies are required in Canada to determine the prevalence in the general population and specifically in the populations at risk.

Health information provided by retail health food outlets.

Alternative health practices have become increasingly popular in recent years. Many patients visit specific complementary practitioners, while others attempt to educate themselves, trusting advice from employees at local health food stores or the Internet. Thirty-two retail health food stores were surveyed on the nature of the information provided by their staff. A research assistant visited the stores and presented as the mother of a child in whom Crohns disease had been diagnosed. Seventy-two per cent (23 of 32) of store employees offered advice, such as to take nutritional and herbal supplements. Of the 23 stores where recommendations were made, 15 (65%) based their recommendation on a source of information. Fourteen of the 15 stores using information sources used the same reference book. This had a significant impact on the recommendations; the use of nutritional supplements was favoured. In conclusion, retail health food stores are not as inconsistent as hypothesized, although there are many variances in the types of supplements recommended for the same chronic disease.

Patient web-resource interest and internet readiness in pediatric inflammatory bowel disease.

Objective The internet has been touted as a cost-effective method of providing valuable patient education and support resources. However, little is known of the level of internet interest in or access to web-based resources of most chronically ill populations generally, and pediatric populations in particular. Web-based patient resources could be especially applicable to the pediatric inflammatory bowel disease (IBD) population given the potential appeal of an anonymous forum for this group. Methods Tertiary-care clinic patients aged 8–18 years and diagnosed with IBD were surveyed by mail. &khgr;2 and/or analysis of variance were used to compare demographic data from nonresponders and responders and for subgroup analyses. Results Of 162 eligible patients, 63 (38.9%) completed the survey. Responders did not differ significantly from nonresponders by age, sex, or distribution of disease. Overall, 98.4% of those surveyed had internet access, with 61.9% having access at school. Ninety-five percent had used the internet, while 91% expressed interest in visiting a pediatric IBD website for general IBD information (83%), for support (73%), to pose questions (78%) or read (73%) or respond (60%) to questions, or to chat with others (46%). Despite expressed interest, far fewer had ever used the internet as an IBD information (52.4%) or support (9.5%) resource. Similarly, although 15.8% anticipated visiting a pediatric IBD site weekly, only 1.5% had done so in the week of the survey. Conclusions Reported levels of interest in web-based patient resources are high among pediatric IBD patients, yet use may be infrequent.

Prospective comparison of small bowel meal with pneumocolon versus ileo-colonoscopy for the diagnosis of ileal Crohn's disease.

BACKGROUND AND AIMS:Both endoscopy and barium radiography are used routinely to diagnose terminal ileal (TI) Crohns disease (CD). A prospective study was undertaken to compare ileoscopy with biopsy to small bowel meal with pneumocolon (SBMP) in patients with suspected TI CD.METHODS:A cohort of outpatients investigated for diarrhea with features of TI disease underwent SBMP followed by colonoscopy with ileal intubation and biopsy within 21 days. All results were reported in a standardized, sequential format to assign SBMP TI diagnoses by the duty radiologist and by dual reading with consensus, ileoscopy by the attending endoscopist, and ileoscopy with biopsy by a blinded panel of endoscopists and pathologists. Reference standard TI diagnoses were determined by a consensus panel with full access to medical records.RESULTS:Among 120 subjects, the reference standard TI diagnosis was normal in 47 (39.1%), lymphoid nodular hyperplasia (LNH) in 24 (20.0%), CD in 48 (40.0%), and NSAID enteropathy in 1 (0.9%). Colonoscopy provided TI images and/or biopsies in 97 cases (80.8%), while SBMP provided TI images in 119 (99.1%). When ileoscopy with biopsy succeeded, its accuracy was similar to SBMP with dual reading (89.7% vs 89.9%, p = NS) but superior to SBMP if interpreted only by the duty radiologist (80.0%, p < 0.05). Biopsy improved the accuracy of ileoscopy, while dual reading improved that of SBMP.CONCLUSIONS:Both ileoscopy with biopsy and SBMP with dual reading are highly accurate for diagnosing TI CD. Choice of initial test should reflect local expertise and availability, and the likelihood of associated disease in the proximal small bowel or colon.

Use and misuse of cost-effectiveness terminology in the gastroenterology literature: a systematic review

OBJECTIVE:The increased popularity of economic analyses for evaluating medical interventions has given rise to concern about the rigor with which economic constructs and terminology are used. True cost-effectiveness analysis considers both the costs and outcomes of alternative interventions. A systematic review of the gastroenterology literature was undertaken to evaluate how appropriately cost-effectiveness is assessed.METHODS:A structured MEDLINE search identified all studies published in major gastroenterology journals between 1980 and 1998 that claimed in their abstracts to have assessed the cost-effectiveness of an intervention. Blinded copies of eligible studies were assessed by two independent reviewers who used standard criteria to evaluate the use of economic terminology and key economic constructs. Discrepancies were resolved by consensus. Studies met a “broad criterion” for appropriateness by evaluating both costs and effects and a “strict criterion” by demonstrating dominance of one strategy or considering both incremental costs and incremental effects.RESULTS:Of 110 eligible studies, 77 (70.0%) met the broad criterion and 62 (56.4%) met the strict criterion for appropriateness. This did not seem to vary with either journal impact factor or publication year. Only eight of 18 studies reporting an incremental cost-effectiveness ratio compared its value to an external standard. Few studies explicitly stated their analytic perspective, and a minority of those with time horizons longer than 1 yr had discounted future costs or effects.CONCLUSIONS:Although most studies seem to use cost-effectiveness terminology well, there remains room to improve the rigor with which economic terminology and constructs are applied.

Validation of a disease specific health-related quality of life (HRQOL) instrument for pediatric inflammatory bowel disease (IBD)

• G4006 VALIDATION OF A DISEASE SPECIFIC HEALTH-RELATED QUALITY OF LIFE (HRQOL) INSTRUMENT FOR PEDIATRIC INFLAMMATORY BOWEL DISEASE (IBD). S Forget ], R Cawdron 2, RM lssenman 2, N Gold 3, EJ Irvine 4. Division of Pediatric Gastroenterology 1, Montreal Childrens Hospital, Mc Gill University, Montreal, and Division of Pediatric Gastroenterology 2, School of Social Work 3 and Division of Gastroenterology 4, Mc Master University Medical Center, Hamilton, Canada.

Client satisfaction in support of service planning within a regulatory framework: Experience of a research hospital

Research Operations at UHN provide services to a large, complex client research community with varying needs. This requires complex coordination and continual refining of service and resource targets to meet client, government and external stakeholder requirements. The UHN Research Operations model focuses on six key enablers: client education, service team expertise, direct communication, process improvement, quality assurance, and, systems and tools. Service departments that have deployed these enablers experience improved client satisfaction.