Impact of Care in an Interdisciplinary Inflammatory Bowel Disease Specialty Clinic on Outcomes in Patients Insured with Medicaid.

BACKGROUND: Inflammatory bowel disease (IBD) patients are known to benefit from care delivered in a specialized, interdisciplinary setting. We aimed to evaluate the impact of this model on health outcomes, quality metrics, and health care resource utilization (HRU) in IBD patients insured with Medicaid. MATERIALS AND METHODS: In July 2017, IBD patients at our tertiary hospital were transitioned from a fellows' general gastroenterology (GI) clinic to a fellows' interdisciplinary IBD clinic. IBD patients were included if they were insured with Medicaid, had at least 1 visit in the general GI clinic between July 1, 2016 and June 30, 2017, and at least 1 visit between July 1, 2017 and June 30, 2018 in the IBD clinic. Characteristics related to patients' IBD course, overall health care maintenance, and HRU were compared. RESULTS: A total of 170 patients (51% male, mean age 39 y) were included. After the transition to the IBD clinic, use of corticosteroids (37% vs. 25%; P =0.004) and combination therapy were significantly lower (55% vs. 38%; P =0.0004), although use of high-dose biologics numerically increased (58.5% vs. 67%; P =0.05). Posttransition, patients showed significantly lower levels of mean C-reactive protein ( P =0.04). After the transition, patients attended significantly fewer outpatient GI visits ( P =0.0008) but were more often seen by other health care specialists ( P =0.0003), and experienced a numeric decrease in HRU with fewer emergency department visits, hospitalizations, and surgeries. CONCLUSIONS: Care in an interdisciplinary, IBD specialty setting is associated with significantly decreased corticosteroid use, decreased C-reactive protein levels, and improved access to ancillary services in Medicaid patients.

Diagnostic performance of endoscopic ultrasound for detection of pancreatic malignancy following an indeterminate multidetector CT scan: a systemic review and meta-analysis.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis in part due to delayed diagnosis. Even with advances in cross-sectional imaging, small pancreatic malignancies can be missed. We sought to determine the performance of endoscopic ultrasound (EUS) in those without an obvious mass on multi-detector CT scan (MDCT), but with clinical suspicion for pancreatic malignancy. METHODS: Multiple databases were systematically searched to identify studies that assessed the diagnostic performance of EUS after negative or inconclusive pancreatic protocol MDCT for detection of pancreatic malignancy when clinically suspected. A total of four studies met the inclusion criteria. The point estimates in each study were compared to the summary pooled estimates of sensitivity and specificity with the aid of forest plots. Funnel plots and Egger's test were employed to evaluate possible publication bias. RESULTS: EUS-guided fine needle aspiration was performed in all studies. EUS was performed in 206 subjects with a clinical suspicion of a pancreatic mass but with an indeterminate MDCT. A pancreatic mass (mean size 21 ± 1.2 mm) was identified in 70% (n = 144) of the subjects, and 42.2% (n = 87) were diagnosed with PDAC. The pooled estimates of EUS for diagnosing pancreatic malignancy in the setting of an indeterminate MDCT were a sensitivity of 85% (95% CI 69-94%), specificity of 58% (95% CI 40-74%), positive predictive value of 77% (69-84%), negative predictive value of 66% (95% CI 53-77%), and an accuracy of 75% (95% CI 67-82). The summary area under the ROC curve was 0.80 (95% CI 0.52-0.89). The funnel plots and Egger's test did not show a significant publication bias. CONCLUSIONS: The yield of EUS is comparatively higher for the diagnosis of a pancreatic malignancy in patients with suspected cancer, but a non-diagnostic MDCT. Importantly, the majority of the lesions missed on CT represent PDAC, in which early diagnosis is essential.

Safety of endoscopic interventions in patients with thrombocytopenia.

BACKGROUND: The risk of endoscopic interventions in thrombocytopenia has received little attention in the medical literature. OBJECTIVE: The aim of this study was to assess the safety of endoscopic interventions including evaluation of GI bleeding (GIB) in patients with thrombocytopenia. DESIGN AND SETTING: Retrospective study, tertiary oncology center. PATIENTS AND INTERVENTION: Review of consecutive endoscopies with preprocedure platelet counts (PCs) of 75 × 10(3)/µL or lower. MAIN OUTCOME MEASUREMENTS: Risk of bleeding with routine endoscopic interventions and transfusion requirement after evaluation of GIB. RESULTS: A total of 617 (351 upper, 266 lower [90 colonoscopies]) endoscopies were performed in 395 patients. Forceps-biopsy specimens were obtained in 398 endoscopies (mean ± standard deviation [SD] PC: 38.21 ± 11.7 × 10(3)/µL) and 45 polypectomies were performed in 17 endoscopies (mean ± SD PC: 39.65 ± 8.53 × 10(3)/µL). The risk of bleeding was 1.5% (6 of 398 endoscopies) at the biopsy site and 4% (2 of 45 polypectomies) at the polypectomy site. Active GIB (mean ± SD PC: 32.85 ± 4.0 × 10(3)/µL) was observed in 68 (11% of 617) endoscopies and intervention (mean ± SD PC: 33.68 ± 4.6 × 10(3)/µL) was performed in 41 procedures. Together, angiodysplasias and ulcers were the most common etiology (51.2% of 41). Hemostasis was achieved in 39 (95.1% of 41) procedures. Comparison of blood transfusions ± 3 days of successful therapy showed a 52% reduction (P < .001). By multivariate analysis, a higher aggregate blood transfusion 3 days preceding endoscopy (odds ratio 1.32; 95% confidence interval, 1.16-1.50; P < .001) predicted endoscopic findings of active GIB. LIMITATIONS: Retrospective design, single center. CONCLUSIONS: In the largest endoscopic experience reported in thrombocytopenic patients (Common Terminology Criteria for Adverse Events grade 3 or lower), bleeding caused by standard forceps biopsy and polypectomy (≤10 mm) was minor and easily controlled. Endoscopic therapy for GIB is safe and significantly reduces the packed red blood cell requirement and should be considered in patients with thrombocytopenia in the setting of an appropriate transfusion strategy.

Endoscopic sonography and sonographically guided fine-needle aspiration biopsy in the diagnosis of unusual pancreatic metastases from synovial sarcoma.

Pancreatic metastases are commonly solitary solid lesions frequently derived from primary renal cell carcinoma, lung cancer, or melanoma. Very few case reports have described cystic-appearing metastases in the pancreas and even fewer have reported a combination of cystic and solid metastatic lesions. Synovial sarcoma is a rare and aggressive soft tissue neoplasm, frequently metastasizing to the lungs and bones. We present a case of primary synovial sarcoma with multiple solid and cystic-appearing pancreatic metastases diagnosed by endoscopic ultrasound and sonographically guided fine-needle aspiration.

The Cost of Crohn's Disease: Varied Health Care Expenditure Patterns Across Distinct Disease Trajectories.

BACKGROUND: Patients with Crohn's disease (CD) encompass a heterogeneous disease spectrum, with variable health care utilization and expenditure patterns. Lémann Index (LI) is a metric that quantifies cumulative bowel damage and has shown utility in delineating distinct disease phenotypes. We aimed to characterize the financial burden from all medical care in CD cohort in relation to the variations in LI-based disease phenotypes. METHODS: CD patients with 5-year (y) follow-up from a prospective registry were included. LI was calculated from first (LI1) and last (LI2) clinical encounters. Change in score (LI2-LI1) or Delta LI (DLI) was used for association analysis with health care expenditures. RESULTS: A total of 243 patients with CD formed the study population (median age, 44 years; 58% women; median disease duration 12 years). DLI was used to define disease trajectories: DLI <0 (indicating improving bowel damage); DLI = 0 (stable); DLI >0 (worsening); which comprised 15.6%, 30.9%, and 53.5% of the cohort, respectively. Patients with DLI >0 had significantly higher CD-related surgeries, health care utilization, medication (steroids and biologics) use as well as higher median 5 years total and stratified charges compared with the other groups. Total 5-year expenditure was $56 million; 67% of which was related to hospitalization. Total expense showed independent positive correlation with LI2 (P = 0.001) and DLI (P = 0.001), and negative correlation with age (P = 0.029) and 5-year quality of life score (P = 0.024). CONCLUSIONS: The financial burden of CD is significantly associated with worsening bowel damage. Further research should focus on the prediction and management of the costliest/sickest patients with CD.

Silent Crohn's Disease Predicts Increased Bowel Damage During Multiyear Follow-up: The Consequences of Under-reporting Active Inflammation.

BACKGROUND: Patients with Crohn's disease (CD) in clinical remission with elevated C-reactive protein (CRP) have been labeled "silent CD" and have increased 2-year hospitalization rates when compared with asymptomatic patients with no biochemical evidence of inflammation. The risk of cumulative bowel damage in patients with silent CD is unknown. METHODS: Observational study of patients with CD prospectively followed in a tertiary referral natural history registry. Consecutive patients with CD in clinical remission (Harvey-Bradshaw Index ≤ 4) with good quality of life (short inflammatory bowel disease questionnaire score ≥ 50), and same day CRP measurement at first encounter, followed for a minimum of 4 years formed the study population. Disease trajectory was determined using change in Lémann Index as a measure of bowel damage. RESULTS: A total of 185 patients with CD (median age 42 years; 51.4% men) were included in the study. CRP elevation was observed in 43 (23%) patients (Silent CD cohort). Majority of them showed worsening disease trajectories based on change in Lémann Index when compared with asymptomatic patients with normal CRP (65% versus 36%, P < 0.0001). Multinomial logistic regression analysis demonstrated that elevated CRP was independently associated with 7-fold higher odds (odds ratio = 6.93, P < 0.0001) of having worse disease trajectories when compared with stable disease trajectories. CONCLUSIONS: Two-thirds of patients with CD in clinical remission, while demonstrating elevated CRP, will develop bowel damage over the ensuing years, despite feeling well. These patients with silent CD are an "at-risk" group who warrant further investigation to prevent development of disease-related complications.

Management of Refractory Noninsulinoma Pancreatogenous Hypoglycemia Syndrome with Gastric Bypass Reversal: A Case Report and Review of the Literature.

Background. Roux-en-Y gastric bypass (RYGB) is a commonly performed, effective bariatric procedure; however, rarely, complications such as postprandial hypoglycemia due to noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) may ensue. Management of refractory NIPHS is challenging. We report a case that was successfully treated with RYGB reversal. Case Report. A 58-year-old male with history of RYGB nine months earlier for morbid obesity presented for evaluation of postprandial, hypoglycemic seizures. Testing for insulin level, insulin antibodies, oral hypoglycemic agents, pituitary axis hormone levels, and cortisol stimulation was unrevealing. Computed tomography (CT) scan of the abdomen was unremarkable. A 72-hour fast was completed without hypoglycemia. Mixed meal testing demonstrated endogenous hyperinsulinemic hypoglycemia (EHH) and selective arterial calcium stimulation testing (SACST) was positive. Strict dietary modifications, maximal medical therapy, gastrostomy tube feeding, and stomal reduction failed to alleviate symptoms. Ultimately, he underwent laparoscopic reversal of RYGB. Now, 9 months after reversal, he has markedly reduced hypoglycemia burden. Discussion. Hyperfunctioning islets secondary to exaggerated incretin response and altered intestinal nutrient delivery are hypothesized to be causative in NIPHS. For refractory cases, there is increasing skepticism about the safety and efficacy of pancreatic resection. RYGB reversal may be successful.

Renal outcomes of bariatric surgery in obese adults with diabetic kidney disease.

Obesity is a pandemic with several significant adverse health outcomes. Chronic kidney disease has been an overlooked consequence of obesity. Among diabetics, obesity is known to amplify the risk for kidney disease. Although bariatric surgery promises significant and sustained weight reduction with favorable impact on metabolic parameters such as glycemic control, hypertension and dyslipidemia, its impact on the renal complications of diabetes is poorly understood. This paper aims to comprehensively evaluate the evidence in the published literature on the impact of bariatric surgery on renal outcomes in obese adults with diabetic kidney disease. While many observational studies have demonstrated significant reduction in proteinuria after bariatric surgery, there is paucity of data regarding changes in renal filtration function such as doubling of serum creatinine or progression to end stage kidney disease. No randomized controlled trials comparing medical vs. surgical therapy in obese adults with diabetic kidney disease exist, hence assessing the metabolic benefits vs. the surgical risks is important before recommending bariatric surgery to this growing patient population. Future studies require a collaborative effort between bariatric surgeons and nephrologists to measure long-term effects of bariatric surgery on renal outcomes incorporating evolving markers of kidney injury to advance this field.