Timothy Dougherty

Search with caution: Internet sites target pediatric Crohn's patients with probiotics that often claim to be curative†

We read with interest the article by Marel et al, which revealed that alternative medicine Websites had lower content quality than institutional, pharmaceutical, and nonpharmaceutical commercial Websites as measured by the DISCERN instrument. Inaccuracies on these Websites would likely include information regarding probiotics, as these are among the most common alternative medical therapies. While these products are often used by pediatric Crohn’s disease (CD) patients, there are limited data demonstrating their effectiveness. Lactobacillus GG is the only probiotic that has been studied in children. However, there are conflicting data on the efficacy of Lactobacillus GG. Nevertheless, the potential for effectiveness of probiotics has encouraged its use by pediatric CD patients. This study evaluated the therapeutic claims, bacterial composition, and cost of probiotics marketed for pediatric patients with CD. Using the online search engine Google, ‘‘Crohn’s AND probiotic’’ was searched using Boolean logic. Data were retrieved from July 22, 2009 to July 24, 2009. The first 100 Websites were categorized as either commercial, academic, informational, or as blogs. Commercial Websites were defined as those marketing or selling a product. Academic Websites were defined as those containing scholarly journal articles or textbooks. Informational Websites were defined as sites containing information regarding CD and probiotics, but did not market or sell any products. A blog was defined as a personal chronological log. For each commercial Website, products that were marketed to pediatric patients were identified and the microbial composition was obtained. The first 100 Websites were reviewed. There were nine commercial Websites, 32 academic Websites, 36 informational Websites, and 22 blogs. One Website was not operational. Twenty different probiotics were advertised for sale. Five products were marketed specifically for children and three products were marketed to both children and adults. One product was marketed to adults only, 10 products did not mention a target population, and one product’s information could not be obtained. Of the five products marketed for pediatric use, three were advertised as curative and two were advertised as adjunctive therapy. One of the products advertised as curative claimed to have been clinically studied without providing references. The remaining products did not provide supporting data. The products contained between three and six microbes. None of the five products contained the studied bacteria Lactobacillus GG. Two of the products advertised as curative contained Lactobacillus acidophilus and Bifidobacterium bifidum. None of the other organisms in the advertised products were the same. The two products advertised as adjunctive therapy had six identical organisms. The cost of the products ranged from

P-093 Always Seen But Often Overlooked—Shortfalls in Skin Protective Practices Counseling for IBD Patients

174 to

P-037 Prevalence and Detection of Sporadic Adenomas in IBD Patients

299 annually. Two of the products’ cost could not be determined based on the provided information. This study found that probiotics marketed to pediatric patients with CD have limited supportive data. While future studies and clinical experience may justify probiotic use in CD patients, presently only Lactobacillus GG has been studied in pediatric patients. Nevertheless, multiple probiotics are available and marketed for the pediatric population with some claiming to be curative. Caution must be exercised when incorporating new products into pediatric medical regimens when there are limited data demonstrating clinical efficacy. Physicians must be knowledgeable of the therapeutic claims of products marketed for children and offer balanced information to pediatric CD patients.

P-103 Type of Inflammatory Bowel Disease Does Not Influence Rate of Cervical Dysplasia

Background:Patients with inflammatory bowel disease (IBD) have many unique health care needs. There is increasing evidence of an elevated baseline risk of skin cancer among individuals with IBD. This elevated risk may be related to the underlying disease, the use of certain immunomodulating medications, or the combination of the 2. It is recommended that individuals with IBD be counseled about preventative measures to reduce their risk of skin cancer. This study aims to examine physician counseling practices regarding skin cancer risk and prevention for IBD patients. Methods:A retrospective review was completed using an electronic medical record of consecutive IBD patients who presented for surveillance colonoscopy at an urban academic medical center during a 1-year period. Data regarding patient ethnicity, IBD type and extent, current treatment regimen, documentation of counseling regarding skin cancer and preventive practices, and colonoscopic findings were compiled in a database created with Microsoft Excel. Patient confidentiality was maintained. The study was approved by the university institutional review board. Statistical analysis was performed using Fishers exact test, with statistical significance set at P < 0.05. Results:There were 136 IBD patients included, 57 (41.9%) were male and 79 (58.1%) were female. Sixty-eight patients were Caucasian (50.0%), 34 (25.0%) African American, 8 (5.9%) Latino, 14 (10.3%) were of “other” ethnicity, and 12 (8.8%) were of unknown ethnicity. 78 had ulcerative colitis and 58 had Crohns disease. Of the 136 IBD patients, 46 (34%) were counseled on skin cancer preventative measures or referred to a dermatologist. Twenty-seven (39.7%) Caucasian and 8 (23.5%) African American patients were counseled. 28 (35.9%) ulcerative colitis patients and 18 (31.0%) Crohns patients were counseled. There was no statistically significant difference in the rate of skin protective counseling based on race/ethnicity (P = 0.2555) or disease type (P = 0.5869). Conclusions:Compared to the general population, IBD patients are at increased risk for the development of skin cancer. It is recommended that these patients receive counseling on skin protective practices. In this study only one-third of medical records showed documentation of counseling or dermatology referral. The shortfall in counseling or referral practices may be attributed to the complex nature of care required for IBD patients, decrease awareness or lack of clear documentation. While this study is limited due to size, the data should serve as a reminder to include counseling for skin protective in IBD patients. Efforts to increase awareness of health care providers and patients about skin cancer risks are important.

Acute Myopericarditis due to Hepatitis E Virus Infection: The First Reported Case in the Western Hemisphere

Background:Patients with Inflammatory Bowel Disease (IBD) are at risk for dysplasia and colorectal cancer (CRC) related to underlying chronic inflammation. Similar to the general population, individuals with IBD are at risk for sporadic adenomas that may also progress to CRC. Benchmark adenoma detection rates (ADR) in average-risk patients are 15% in women and 25% in men. ADR benchmarks have not yet been established for IBD patients. The frequency of surveillance colonoscopies may complicate the establishment of accurate ADR in IBD patients. This study evaluated the prevalence of sporadic adenomas in an average-risk population and in IBD patients at a university medical center. Methods:A retrospective medical record review of average-risk and IBD patients undergoing a colonoscopy at a university medical center during a 1-year period was conducted. Records of IBD patients were also examined to determine whether colonoscopies had been performed during the previous 5 years. Maintaining patient confidentiality, a database of demographic, clinical, colonoscopic, and pathologic information was created in Microsoft Excel. Statistical analysis was performed using Fishers Exact Test with significance set at P < 0.05. The study was approved by the university institutional review board. Results:There were 1523 patients who had an average-risk screening colonoscopy. There were 656 females and 867 males, with an average age of 57.9 years (95% confidence interval of 57.1–58.7). Six hundred thirty-three patients (41.6%) had an adenoma detected.There were 136 IBD patients had a surveillance colonoscopy. Among IBD patients, 29 (21.3%) had one or more procedures during the previous 5 years. There were 20 females and 9 males with an average age of 51.0 years (95% confidence interval 44.8–57.2). Sporadic adenomas were detected in 7 (24.1%) of these patients. There was no significant difference (P = 0.0848) in the ADR of average risk individuals and IBD patients. Conclusions:While IBD patients are at risk for IBD-related dysplasia, sporadic adenoma is also possible. The adenoma detection rate (ADR) benchmarks, a quality indicator for screening colonoscopies, are not yet available for IBD surveillance procedures. This study exposed a trend toward a lower incidence of adenoma in IBD patients compared to the general population. This might reflect a slightly younger population of IBD patients, an IBD-related alteration in neoplastic pathways, or an effect of IBD medications stabilizing the mucosa. However, the results of this study are limited due to small sample size and single institutional design. Further study is needed to determine the incidence of adenomas and to establish ADR benchmarks for quality procedures in IBD patients.

Buyer beware: therapeutic claims of probiotics marketed to Crohn's disease patients via the internet lack supporting data.

BACKGROUND: Women with inflammatory bowel disease (IBD) have been reported to have an increased risk for cervical dysplasia compared to the general population. Several studies have revealed more than a 4-fold increase in abnormal Pap smears in IBD women. Human papilloma virus (HPV) and medication-induced immunosuppression have been cited to be significant factors related to Pap smear irregularity. It is unclear if the type of IBD influences the development of cervical dysplasia. This study evaluated the rate of cervical dysplasia in women with Crohn’s disease and ulcerative colitis. METHODS: A retrospective medical records review of women cared for at a university IBD center during a 1.5 year period was conducted. There were no exclusion factors. Patient age, gender, disease type, medication regimen and Pap smear results were obtained. Pap smears were considered abnormal if there were HPV-associated changes or cervical dysplasia. A database was created using Microsoft Excel. Statistical significance was performed using Fischer Exact test, with significance set at P < 0.05. The study was approved by the university Institutional Review Board. RESULTS: Two hundred eight medical records of IBD women (mean age 43 years) were reviewed. One hundred eleven (53.4%) women had Crohn’s disease, 95 (45.7%) had ulcerative colitis and 2 (1.0%) had indeterminate colitis. One hundred seven (51.4%) women had Pap smears performed. Fifty-five of 111 (49.5%) women with Crohn’s disease, 51 of 95 (53.7%) women with ulcerative colitis and 1 of 2 (50%) women with indeterminate colitis had Pap smears. There was no significant difference (P = 0.578) in the rate of Pap smear performance based upon disease type. Sixteen of 55 (29.1%) women with Crohn’s disease and 14 of 51 (27.5%) women with ulcerative colitis had HPV positivity, HPV-associated changes or cervical dysplasia on Pap smear. There was no significant difference (P = 1.000) in the rate of abnormal Pap smears based upon disease type. CONCLUSIONS: Women with inflammatory bowel disease have an increased rate of abnormal Pap smears when compared to the general population. Studies have reported that the cervical abnormalities are likely related to HPV-induced changes. While HPV and immunosuppression from medications may be significant risk factors for the development of cervical dysplasia, it is uncertain if there are other contributing factors to the increase rate of irregular Pap smears in women with inflammatory bowel disease. This study revealed that women with IBD infrequently underwent recommended cervical cancer screening. There was no difference in the rate of screening between women with Crohn’s disease and ulcerative colitis. In addition, there was no difference in the frequency of abnormal Pap smears between women with Crohn’s disease and ulcerative colitis. Further research needs to be conducted to determine all of the factors that may have a significant role in cervical dysplasia in women with inflammatory bowel disease.