Sandra M. Quezada

Association of age at diagnosis and Crohn's disease phenotype

BACKGROUND fifteen percent of patients with Crohns disease (CD) are elderly; they are less likely to have complications and more likely to have colonic disease. OBJECTIVE to compare disease behaviour in patients with CD based on age at diagnosis. DESIGN cross-sectional study. SETTING tertiary referral centre. SUBJECTS patients with confirmed CD. METHODS behaviour was characterised according to the Montreal classification. Patients with either stricturing or penetrating disease were classified as having complicated disease. Age at diagnosis was categorised as <17, 17-40, 41-59 and ≥ 60 years. Logistic regression analysis was performed to examine the association between advanced age ≥ 60 and complicated disease. RESULTS a total of 467 patients were evaluated between 2004 and 2010. Increasing age of diagnosis was negatively associated with complicated disease and positively associated with colonic disease. As age of diagnosis increased, disease duration (P < 0.001), family history of Inflammatory bowel disease (IBD) (P = 0.015) and perianal disease decreased (P < 0.0015). After adjustment for confounding variables, the association between age at diagnosis and complicated disease was no longer significant (OR: 0.60, 95% CI: 0.21-1.65). CONCLUSIONS patients diagnosed with CD ≥ 60 were more likely to have colonic disease and non-complicated disease. However, the association between age at diagnosis and complicated disease did not persist after adjustment for confounding variables.

Anti-TNF therapy is associated with decreased imaging and radiation exposure in patients with Crohn's disease.

Background:Diagnostic imaging is frequently used in Crohns disease (CD) for diagnosis, evaluation of complications, and determination of response to treatment. Patients with CD are at risk for high radiation exposure in their lifetime. The aim of our study was to compare the effective dose of radiation in CD patients the year prior to and the year after initiation of anti-tumor necrosis factor (anti-TNF) agents or corticosteroids. Methods:We conducted a retrospective review of 99 CD patients initiated on anti-TNF therapy or corticosteroids between 2004 and 2009 in a tertiary care center. Results:Sixty-five patients were initiated on anti-TNF agents and 34 were initiated on corticosteroids. The anti-TNF cohort was significantly younger at diagnosis and at the time of initiation of anti-TNF or steroid therapy. The anti-TNF group had significantly more stricturing, penetrating, and perianal disease than the corticosteroid group. The anti-TNF cohort had a significant reduction in number of radiologic exams (5.5 vs. 3.7, P < 0.01) as well as a significant reduction in the cumulative radiation dose (28.1 vs. 15.0 mSv, P < 0.01) the year after initiation of therapy. This reduction was largely attributable to decreased use of computed tomography (CT) scans. In contrast, there was no significant change in radiation exposure in the corticosteroid cohort. Logistic regression analysis showed a strong trend toward higher exposure in patients with complicated disease behavior (stricturing or penetrating phenotype) (odds ratio [OR] 2.87, 95% confidence interval [CI] 0.98–8.38). Conclusions:Initiation of anti-TNF therapy for treatment of CD is associated with a significant reduction in diagnostic radiation exposure. Conversely, steroid treatment does not reduce diagnostic radiation exposure.

Cigarette smoking adversely affects disease activity and disease-specific quality of life in patients with Crohn’s disease at a tertiary referral center

Purpose Smoking has a negative impact on disease activity in Crohn’s disease (CD). Smoking may also affect the quality of life, but this has not been evaluated using validated measures over time. We assessed the relationship between smoking and disease-specific quality of life over time in a tertiary referral inflammatory bowel disease cohort. Patients and methods Retrospective cohort study from July 2004 to July 2009 in patients with CD identified from the University of Maryland, Baltimore, Institutional Review Board-approved University of Maryland School of Medicine Inflammatory Bowel Disease Program database. Smoking status was classified as current, former, and never. Age was categorized as <40 years, 40–59 years, and ≥60 years. Index visit disease activity and quality of life was measured with the Harvey–Bradshaw index, and the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). Repeated measures linear regression was used to assess the association between smoking and quality of life over time after adjustment for confounding variables. Results A total of 608 patients were included, of whom 42% were male; 80% were Caucasian; 22% were current smokers; 24% were former smokers; and 54% were never smokers. Over time, adjusted Harvey–Bradshaw index scores declined in all patients, but current smokers had consistently higher scores. After adjustment for sex, age, and disease duration, never smokers had higher mean SIBDQ scores at index visit compared to former and current smokers (P<0.0001); all increased over time but SIBDQ scores for never smokers remained consistently highest. Conclusion Smoking has a negative impact on disease activity and quality of life in patients with CD. Prospects of improved disease activity and quality of life should be proposed as an additional incentive to encourage smoking cessation in patients with CD.

Complementary and Alternative Medicine.

Abstract:Inflammatory bowel disease is a complex, chronic, multifactorial inflammatory disorder of the digestive tract. Standard therapies include immunosuppressive and biological treatments, but there is increasing interest in the potential benefit of complementary and alternative medicine for the treatment of inflammatory bowel disease. Given the high prevalence of use of complementary and alternative medicine among inflammatory bowel disease patients, gastroenterologists must remain knowledgeable regarding the risks and benefits of these treatment options. This article reviews the updated scientific data on the use of biologically based complementary and alternative therapies for the treatment of inflammatory bowel disease.

Telemedicine for Chronic Digestive Diseases: A Systematic Qualitative Review

According to 2004 statistics from the National Digestive Diseases Information Clearinghouse, digestive diseases affect 60-70 million people in the United States, resulting in 105 million ambulatory visits and 13.5 million hospitalizations. The cost burden associated with these diseases is high. It is estimated that direct and indirect medical costs related to digestive diseases are

Telemedicine for Patients with Inflammatory Bowel Disease (Tele-IBD)

98 billion and

Age Modifies the Association Between Depressive Symptoms and Adherence to Self-Testing With Telemedicine in Patients With Inflammatory Bowel Disease

44 billion, respectively. Chronic digestive diseases make up a significant proportion of these disorders, including but not limited to celiac disease, chronic constipation, chronic pancreatitis, cirrhosis, Crohn’s disease, gastroesophageal reflux disease, irritable bowel syndrome, ulcerative colitis, and viral hepatitis. Telemedicine has been used successfully in chronic conditions such as asthma, diabetes, and congestive heart failure. In patients with asthma, telemedicine improves symptoms, decreases use of quick relief inhalers, improves adherence with self-action plans, improves quality of life and patient knowledge, and decreases urgent care visits (Joshi et al, 2005). In diabetes, telemedicine reduces glycosylated hemoglobin levels (Quinn et al, 2009). Telemedicine improves quality of life, and decreases hospitalizations and costs in congestive heart failure (Roth et al, 2004). Telemedicine has proven to be a feasible and well accepted method of treatment delivery in the field of gastroenterology as well. A systematic review of scientific publications was performed in order to identify all studies conducted examining the application of telemedicine in digestive diseases. Database searches in MEDLINE, the Cochrane Controlled Trials Register, and Web of Science Conference Proceedings Citation Index were done with the following search terms: telemedicine, gastroenterology, inflammatory bowel disease, ulcerative colitis, Crohn’s disease, gastroesophageal reflux disease, hepatitis C, hepatitis B, chronic liver disease, cirrhosis, constipation, irritable bowel syndrome, microscopic colitis, celiac disease and chronic pancreatitis. This search yielded telemedicine studies conducted in one of three disease states: inflammatory bowel disease with a specific focus in ulcerative colitis, irritable bowel syndrome, and chronic viral hepatitis C. In this chapter, we will review the use of telemedicine for these chronic digestive diseases and the effect of telemedicine on access to care, disease activity, education, and quality of life.

Mimicking Abdominal Tuberculosis: Abdominal Abscess Caused by Lawsonella clevelandensis in Inflammatory Bowel Disease

Background: Depression is common in patients with inflammatory bowel disease (IBD) and contributes to poor quality of life (QoL). The use of information technology for the remote management of patients with IBD is growing, but little is known about its impact on depressive symptoms (DS) and QoL. We aimed to evaluate the impact of telemedicine on DS and generic QoL in IBD patients. Methods: We analyzed data from the Telemedicine for Patients with IBD (TELE-IBD) study. During this 12-month clinical trial, patients were randomized to receive text message-based telemedicine weekly (TELE-IBD W), every other week (TELE-IBD EOW), or to standard care. Depressive symptoms and QoL were assessed over time with the Mental Health Inventory 5 (MHI-5) and the Short Form 12 (SF-12), respectively. We compared the change in MHI-5 and SF-12 (with separate physical (PCS) and mental component summary (MCS) scores) between the study arms. Results: A total of 217 participants were included in this analysis. After 1 year, there was no significant difference in the change in MHI-5 (TELE-IBD W +3.0 vs TELE-IBD EOW +0.7 vs standard care +3.4; P = 0.70), MCS (TELE-IBD W +1.4 vs TELE-IBD EOW +1.0 vs standard care +2.5; P = 0.89), and PCS scores (TELE-IBD W +0.4 vs TELE-IBD EOW +0.6 vs standard care +3.7; P = 0.06) between the groups. Conclusions: Text message-based telemedicine does not improve DS or QoL when compared with standard care in IBD patients treated at tertiary referral centers. Further studies are needed to determine whether telemedicine improves DS or QoL in settings with few resources.

Experience with Telemedicine Systems in Chronic Illness: What Can We Learn

Background Depression is common in patients with inflammatory bowel disease (IBD) and is known to be associated with poor adherence in the usual care setting. In the last decade, there has been an increase in the use of information technology (IT) for the delivery of IBD care, but the association between depressive symptoms (DS) and adherence to self-testing in this context is not known. We aimed to investigate this association among IBD patients managed via a text messaging-based telemedicine system. Methods This was a prospective study of participants in the 2 intervention arms of the Telemedicine for Patients with IBD (TELE-IBD) trial. Depressive symptoms were measured at baseline, and then participants received periodic text messages to initiate IBD-specific self-testing. Treatment plans were similarly conveyed, and adherence to self-testing was evaluated at the end of 1 year. Regression analyses were performed, and age-stratified models were constructed to evaluate for effect modification. Results Of the 193 study participants, 48% had DS at baseline. Overall, there was no significant association between DS and adherence to self-testing. However, upon stratification by age, adherence increased with depressive symptoms in those that were 40 years and younger (P = 0.02), but there was no association between depressive symptoms and adherence in the older group (P = 0.53). Conclusions Younger IBD patients with DS have high adherence when managed in a text messaging-based telemedicine program. Telemedicine interventions have the potential to improve health outcomes in this demographic-a group that is often thought to be difficult to manage due to nonadherence.

What About Alternative Therapies I Can Try? Dietary Supplements, Probiotics, Prebiotics, and Alternative Therapies in IBD

38-year-old male immigrant from the Caribbean Awith a history of medically refractory ulcerative colitis and recent completion of a total proctocolectomy with ileal pouch–anal anastomosis, presented with abdominal pain, swelling, and fever. Physical examination showed a firm and tender mass in the right lower quadrant (RLQ), and laboratory results were significant for a white blood cell count of 18.8 10/L. Computed tomography of the abdomen showed a 7.3 3.9 6.2 cm RLQ intra-abdominal mass, and an overlying 5.3 4 cm anterior abdominal wall mass, suspicious for abscesses (Figure A). Broad-spectrum antibiotics were initiated, and the subcutaneous abscess was drained. On diagnostic laparoscopy, a walled-off abscess was seen in the RLQ, and a computed tomography–guided percutaneous drain was placed (Figure B). Microbiologic evaluation of fluid from the abscess showed acid-fast bacilli on smear (Figure C), and antitubercular treatment was started for suspected abdominal tuberculosis. There was no organism growth from cultures, and Mycobacterium tuberculosis complex DNA was not detected by polymerase chain reaction. 16S Ribosomal RNA gene sequence analysis eventually led to the identification of a novel pathogen known as Lawsonella clevelandensis. Antibiotic therapy was switched to amoxicillin clavulanate, with subsequent clinical improvement and resolution of the abscess.