RESUMO
BACKGROUND: Blocking of lymphocyte trafficking to bile ducts is a potential mechanism to alter the disease course of patients with primary sclerosing cholangitis (PSC). AIM: To describe the effect of the α4 ß7 integrin antibody, vedolizumab, on liver biochemistry and disease activity in patients with PSC and inflammatory bowel disease (IBD). METHODS: This is a retrospective multi-centre study of adult patients with a diagnosis of both IBD and PSC. The primary outcome was change in serum alkaline phosphatase level at weeks 14 and 30. Secondary outcomes included changes in other liver biochemistries and in clinical outcomes for the bowel disease. A safety analysis for adverse events was performed. RESULTS: Thirty-four patients (16 Crohn's disease, 18 ulcerative colitis) were included. Nine (26%) had a history of liver transplant. Median follow-up on vedolizumab was 9 months (IQR: 7-16). There was no overall change in serum alkaline phosphatase level with vedolizumab therapy (median 268 [IQR: 105-551] IU/L at baseline versus 249 [IQR: 183-634] IU/L, P = 0.99 at week 30). No significant changes in other liver biochemistries or the Mayo PSC Risk Score were demonstrated at week 30. Clinical remission was achieved at week 30 in 55% of Crohn's disease and 29% of ulcerative colitis patients. Seven (21%) patients ceased vedolizumab; six patients stopped therapy due to persistent IBD activity and one for worsening of liver biochemistries. CONCLUSION: Vedolizumab treatment in patients with PSC and IBD did not improve liver biochemistry but was associated with improvement in bowel disease and a favourable safety profile.
Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Colangite Esclerosante/complicações , Colangite Esclerosante/tratamento farmacológico , Doenças Inflamatórias Intestinais/complicações , Doenças Inflamatórias Intestinais/tratamento farmacológico , Fígado/efeitos dos fármacos , Adolescente , Adulto , Colangite Esclerosante/patologia , Progressão da Doença , Feminino , Humanos , Doenças Inflamatórias Intestinais/patologia , Fígado/química , Fígado/patologia , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Changes in behavior are necessary to apply genomic discoveries to practice. We prospectively studied medication changes made by providers representing eight different medicine specialty clinics whose patients had submitted to preemptive pharmacogenomic genotyping. An institutional clinical decision support (CDS) system provided pharmacogenomic results using traffic light alerts: green = genomically favorable, yellow = genomic caution, red = high risk. The influence of pharmacogenomic alerts on prescribing behaviors was the primary endpoint. In all, 2,279 outpatient encounters were analyzed. Independent of other potential prescribing mediators, medications with high pharmacogenomic risk were changed significantly more often than prescription drugs lacking pharmacogenomic information (odds ratio (OR) = 26.2 (9.0-75.3), P < 0.0001). Medications with cautionary pharmacogenomic information were also changed more frequently (OR = 2.4 (1.7-3.5), P < 0.0001). No pharmacogenomically high-risk medications were prescribed during the entire study when physicians consulted the CDS tool. Pharmacogenomic information improved prescribing in patterns aimed at reducing patient risk, demonstrating that enhanced prescription decision-making is achievable through clinical integration of genomic medicine.
Assuntos
Sistemas de Apoio a Decisões Clínicas/normas , Prescrições de Medicamentos/normas , Sistemas de Registro de Ordens Médicas/normas , Farmacogenética/normas , Papel do Médico , Sistemas Automatizados de Assistência Junto ao Leito/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Rotulagem de Medicamentos/métodos , Rotulagem de Medicamentos/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Farmacogenética/métodos , Estudos Prospectivos , Adulto JovemRESUMO
Despite growing clinical use of genomic information, patient perceptions of genomic-based care are poorly understood. We prospectively studied patient-physician pairs who participated in an institutional pharmacogenomic implementation program. Trust/privacy/empathy/medical decision-making (MDM)/personalized care dimensions were assessed through patient surveys after clinic visits at which physicians had access to preemptive pharmacogenomic results (Likert scale, 1 = minimum/5 = maximum; mean [SD]). From 2012-2015, 1,261 surveys were issued to 507 patients, with 792 (62.8%) returned. Privacy, empathy, MDM, and personalized care scores were significantly higher after visits when physicians considered pharmacogenomic results. Importantly, personalized care scores were significantly higher after physicians used pharmacogenomic information to guide medication changes (4.0 [1.4] vs. 3.0 [1.6]; P < 0.001) compared with prescribing visits without genomic guidance. Multivariable modeling controlling for clinical factors confirmed personalized care scores were more favorable after visits with genomic-influenced prescribing (odds ratio [OR] = 3.26; 95% confidence interval [CI] = (1.31-8.14); P < 0.05). Physicians seem to individualize care when utilizing pharmacogenomic results and this decision-making augmentation is perceived positively by patients.
Assuntos
Tomada de Decisão Clínica/métodos , Farmacogenética/métodos , Testes Farmacogenômicos/métodos , Relações Médico-Paciente , Padrões de Prática Médica , Medicina de Precisão/psicologia , Atitude Frente a Saúde , Sistemas de Apoio a Decisões Clínicas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Percepção Social , Estados UnidosRESUMO
BACKGROUND: Health-related quality of life (HRQL) is often diminished in patients with ulcerative colitis. AIM: To evaluate the effects of vedolizumab on HRQL in patients with ulcerative colitis. METHODS: Using maintenance phase data from the GEMINI 1 study, an analysis of covariance model was used to calculate mean differences between the vedolizumab and placebo groups in changes from baseline to week 52 for 3 HRQL instruments: The Inflammatory Bowel Disease Questionnaire (IBDQ), 36-Item Short Form Health Survey (SF-36), and EQ-5D. Proportions of patients meeting minimal clinically important difference (MCID) thresholds for changes on these instruments were compared between treatment groups for the overall population and for clinically important subgroups. Concordance between clinical remission and remission defined using IBDQ scores was examined. RESULTS: Compared with placebo-treated patients, vedolizumab-treated patients had greater improvements (152-201%) in IBDQ, EQ-5D visual analogue scale (VAS), and EQ-5D utility scores. Greater proportions (6.9-19.9%) of vedolizumab-treated patients than placebo-treated patients met MCID thresholds for all the instruments. Vedolizumab-treated patients with lower baseline disease activity and those without prior tumour necrosis factor (TNF) antagonist failure had greater HRQL improvements. Among 127 patients with clinical remission based on complete Mayo Clinic scores, >80% also had IBDQ remission; >70% of the 150 patients with IBDQ remission demonstrated clinical remission. CONCLUSIONS: Vedolizumab therapy was associated with significant improvements in HRQL measures compared with placebo. Benefits were greater in patients with lower disease activity and no prior TNF antagonist failure.
Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Colite Ulcerativa/tratamento farmacológico , Fármacos Gastrointestinais/uso terapêutico , Adulto , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Inquéritos e Questionários , Fator de Necrose Tumoral alfa/antagonistas & inibidoresRESUMO
OBJECTIVES: The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) program was initiated by the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD). It examined potential treatment targets for inflammatory bowel disease (IBD) to be used for a "treat-to-target" clinical management strategy using an evidence-based expert consensus process. METHODS: A Steering Committee of 28 IBD specialists developed recommendations based on a systematic literature review and expert opinion. Consensus was gained if ≥75% of participants scored the recommendation as 7-10 on a 10-point rating scale (where 10=agree completely). RESULTS: The group agreed upon 12 recommendations for ulcerative colitis (UC) and Crohn's disease (CD). The agreed target for UC was clinical/patient-reported outcome (PRO) remission (defined as resolution of rectal bleeding and diarrhea/altered bowel habit) and endoscopic remission (defined as a Mayo endoscopic subscore of 0-1). Histological remission was considered as an adjunctive goal. Clinical/PRO remission was also agreed upon as a target for CD and defined as resolution of abdominal pain and diarrhea/altered bowel habit; and endoscopic remission, defined as resolution of ulceration at ileocolonoscopy, or resolution of findings of inflammation on cross-sectional imaging in patients who cannot be adequately assessed with ileocolonoscopy. Biomarker remission (normal C-reactive protein (CRP) and calprotectin) was considered as an adjunctive target. CONCLUSIONS: Evidence- and consensus-based recommendations for selecting the goals for treat-to-target strategies in patients with IBD are made available. Prospective studies are needed to determine how these targets will change disease course and patients' quality of life.
Assuntos
Gerenciamento Clínico , Doenças Inflamatórias Intestinais/terapia , Guias de Prática Clínica como Assunto , Humanos , Indução de Remissão/métodosRESUMO
BACKGROUND: Treatments for Crohn's disease (CD) and ulcerative colitis (UC) are not uniformly effective, thus necessitating dose changes, switching, and augmentation and carry adverse event risk, often requiring discontinuation, which reduces treatment benefits. AIM: To assess continuity of and changes to initial CD and UC treatments, as well as costs associated with specific parameters defining suboptimal therapy. METHODS: Commercial US insurance claims (2006-2010) were retrospectively analysed. CD and UC patients receiving monotherapy with 5-aminosalicylates (5-ASAs), corticosteroids (CS), immunomodulators (IM) or biologics were included. Continuity of and changes to initial (index) therapy and associated costs (2011 US$) were assessed over 12 months following therapy initiation. Suboptimal therapy included discontinuation or switch (except for CS), dose escalation, augmentation, inadequate loading (biologics only), prolonged CS use (>3 months), surgery or hospitalisation. RESULTS: The study included 13,005 CD and 19,878 UC patients. Augmentation was a common index therapy change (~20% of 5-ASA initiators, ~40% of CS initiators, ≥40% of IM initiators and 26-55% of biologic initiators) in both CD and UC patients. Approximately 50% of CD and UC 5-ASA initiators discontinued/interrupted treatment. Approximately 80% of CD and UC patients had ≥1 suboptimal therapy marker. Mean all-cause total costs per CD patient were significantly higher in those with vs. without suboptimal therapy ($18,736 vs. $10,878; P < 0.001); in UC, the disparity was smaller ($12,679 vs. $9653; P < 0.001). CONCLUSIONS: Frequent dose and treatment changes were observed in all classes of initial UC and CD treatments. The economic impact of suboptimal therapy among UC and CD patients is substantial.
Assuntos
Anti-Inflamatórios/uso terapêutico , Colite Ulcerativa/tratamento farmacológico , Doença de Crohn/tratamento farmacológico , Fatores Imunológicos/uso terapêutico , Adolescente , Adulto , Anti-Inflamatórios/economia , Colite Ulcerativa/economia , Doença de Crohn/economia , Feminino , Glucocorticoides/economia , Glucocorticoides/uso terapêutico , Custos de Cuidados de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Fatores Imunológicos/economia , Masculino , Mesalamina/economia , Mesalamina/uso terapêutico , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Current approaches to the detection of colorectal neoplasia associated with inflammatory bowel disease (IBD-CRN) are suboptimal. AIM: To test the feasibility of using stool assay of exfoliated DNA markers to detect IBD-CRN. METHODS: This investigation comprised tissue and stool studies. In the tissue study, gene sequencing and methylation assays were performed on candidate genes using tissue DNA from 25 IBD-CRNs and from 25 IBD mucosae without CRN. Mutations on p53, APC, KRAS, BRAF or PIK3CA genes were insufficiently informative, but several aberrantly methylated genes were highly discriminant. In the stool study, we evaluated candidate methylated genes (vimentin, EYA4, BMP3, NDRG4) in a prospective blinded study on buffered stools from 19 cases with known IBD-CRN and 35 age- and sex-matched IBD controls without CRN. From stool-extracted DNA, target genes were assayed using quantitative allele-specific real-time target and signal amplification method. RESULTS: IBD-CRN cases included 17 with ulcerative colitis (UC) and two with Crohn's disease (CD); nine had cancer and 10 had dysplasia. Controls included 25 with UC and 10 with CD. Individually, BMP3, vimentin, EYA4 and NDRG4 markers showed high discrimination in stools with respective areas under the ROC curve of 0.91, 0.91, 0.85 and 0.84 for total IBD-CRN and of 0.97, 0.97, 0.95 and 0.85 for cancer. At 89% specificity, the combination of BMP3 and mNDRG4 detected 9/9 (100%) of CRC and 80% of dysplasia, 4/4 (100%) of high grade and 4/6 (67%) of low grade. CONCLUSION: These findings demonstrate the feasibility of stool DNA testing for non-invasive detection of colorectal neoplasia associated with inflammatory bowel disease.
Assuntos
Biomarcadores Tumorais/genética , Neoplasias Colorretais/diagnóstico , DNA de Neoplasias/análise , Fezes/química , Doenças Inflamatórias Intestinais/diagnóstico , Adulto , Idoso , Neoplasias Colorretais/genética , Feminino , Marcadores Genéticos/genética , Humanos , Doenças Inflamatórias Intestinais/genética , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos TestesAssuntos
Neoplasias Gastrointestinais/epidemiologia , Segunda Neoplasia Primária/epidemiologia , Sobreviventes , Adolescente , Adulto , Antineoplásicos/administração & dosagem , Antineoplásicos/efeitos adversos , Canadá/epidemiologia , Criança , Neoplasias Colorretais/epidemiologia , Humanos , Incidência , Compostos de Platina/administração & dosagem , Compostos de Platina/efeitos adversos , Vigilância da População , Procarbazina/administração & dosagem , Procarbazina/efeitos adversos , Radioterapia/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Recent studies have focused on the importance of mucosal healing in ulcerative colitis (UC). However, it was still unclear whether higher doses of delayed-release mesalazine (mesalamine) could provide additional benefit. AIM: To examine how two doses of delayed-release mesalazine (4.8 g/day and 2.4 g/day) from ASCEND I and II compare in their relative ability to heal colonic mucosa over time. METHODS: Primary data from two prospective 6-week, double-blind, randomised studies in patients with mildly to moderately active UC were pooled and analysed retrospectively. The mucosal healing analysis focuses on moderately active UC patients (n=391), comprising a majority of patients (84%). Additional analyses examined the relationship between mucosal healing and dose, clinical response to therapy and patient quality of life (Inflammatory Bowel Disease Questionnaire, IBDQ). RESULTS: At week 3, mucosal healing (endoscopy subscore of 0 or 1) was achieved in 65% of moderately active UC patients on 4.8 g/day and 58% of patients on 2.4 g/day (P=0.219). At week 6, this increased to 80% for 4.8 g/day and 68% for 2.4 g/day (P=0.012). Healing rates with the higher dose were also greater across all extents of disease and in patients with prior steroid use. At 6 weeks, clinical response to therapy and mucosal healing were found to be well correlated (kappa=0.694). Likewise, the change in IBDQ at week 6 showed a significant relationship with mucosal healing (P<0.0001). CONCLUSION: Mucosal healing rates in UC achieved at 6 weeks were statistically significantly higher with delayed-release mesalazine at 4.8 g/day vs. 2.4 g/day.
Assuntos
Anti-Inflamatórios não Esteroides/administração & dosagem , Colite Ulcerativa/tratamento farmacológico , Mesalamina/administração & dosagem , Administração Oral , Adolescente , Adulto , Idoso , Colonoscopia , Preparações de Ação Retardada , Relação Dose-Resposta a Droga , Métodos Epidemiológicos , Feminino , Humanos , Mucosa Intestinal/efeitos dos fármacos , Mucosa Intestinal/fisiologia , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Resultado do Tratamento , Cicatrização/efeitos dos fármacos , Adulto JovemRESUMO
Colorectal cancer is one of the most common cancers in the western world. Its early detection has been found to improve the prognosis of the patient, providing a wide window of opportunity for successful therapeutic interventions. However, current diagnostic techniques all have some limitations; there is a need to develop a better technique for routine screening purposes. We present a new methodology based on magnetic resonance spectroscopy of fecal extracts for the non-invasive detection of colorectal cancer. Five hundred twenty-three human subjects (412 with no colonic neoplasia and 111 with colorectal cancer, who were scheduled for colonoscopy or surgery) were recruited to donate a single sample of stool. One-dimensional (1)H magnetic resonance spectroscopy (MRS) experiments were performed on the supernatant of aqueous dispersions of the stool samples. Using a statistical classification strategy, several multivariate classifiers were developed. Applying the preprocessing, feature selection and classifier development stages of the Statistical Classification Strategy led to approximately 87% average balanced sensitivity and specificity for both training and monitoring sets, improving to approximately 92% when only crisp results, i.e. class assignment probabilities > or =75%, are considered. These results indicate that (1)H magnetic resonance spectroscopy of human fecal extracts, combined with appropriate data analysis methodology, has the potential to detect colorectal neoplasia accurately and reliably, and could be a useful addition to the current screening tools.
Assuntos
Biomarcadores Tumorais/análise , Neoplasias Colorretais/diagnóstico , Fezes/química , Ressonância Magnética Nuclear Biomolecular , Algoritmos , Neoplasias Colorretais/química , Neoplasias Colorretais/patologia , Humanos , Ressonância Magnética Nuclear Biomolecular/instrumentação , Ressonância Magnética Nuclear Biomolecular/métodos , Prognóstico , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Ulcerative colitis (UC) can be maintained in remission with 5-aminosalicylic acid (5-ASA) medications, but frequent non-adherence by patients who are feeling well has been associated with more frequent flares of colitis. AIM: To perform a systematic review of the published literature and unpublished randomized clinical trials (RCTs) regarding the impact of non-adherence with 5-ASA medications on the incidence of UC flares and costs of care. METHODS: A search of MEDLINE, EMBASE and the Cochrane databases was performed. Prospective studies of UC maintenance with 5-ASAs in adults were selected if they included data on adherence and disease flares. Studies using insurance claims data to estimate the impact of non-adherence on cost of care were included. Data from unpublished RCTs were obtained from the FDA with a request under the Freedom of Information Act. RESULTS: The relative risk for flare in non-adherent vs. adherent patients ranged from 3.65 to infinity. Data were obtained from six unpublished 5-ASA RCTs, but none measured the impact of adherence on disease activity. The comorbidity-adjusted annual costs of care in adherent patients were 12.5% less than in non-adherent patients, despite increased medication expenditures. CONCLUSIONS: A substantial proportion of UC flares and medical costs of UC are attributable to 5-ASA non-adherence. As non-adherence to 5-ASA medications is common, cost-effective strategies to improve adherence are needed. The impact of adherence on disease activity should be measured in RCTs of all inflammatory bowel disease treatments.
Assuntos
Anti-Inflamatórios não Esteroides/administração & dosagem , Colite Ulcerativa/tratamento farmacológico , Mesalamina/administração & dosagem , Cooperação do Paciente/estatística & dados numéricos , Adolescente , Adulto , Anti-Inflamatórios não Esteroides/economia , Colite Ulcerativa/economia , Colite Ulcerativa/psicologia , Análise Custo-Benefício , Progressão da Doença , Feminino , Humanos , Masculino , Mesalamina/economia , Pessoa de Meia-Idade , Cooperação do Paciente/psicologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Adulto JovemRESUMO
BACKGROUND: The usefulness of currently available colon imaging tests, including air contrast barium enema (ACBE), computed tomographic colonography (CTC), and colonoscopy, to detect colon polyps and cancers is uncertain. We aimed to assess the sensitivity of these three imaging tests. METHODS: Patients with faecal occult blood, haematochezia, iron-deficiency anaemia, or a family history of colon cancer underwent three separate colon-imaging studies--ACBE, followed 7-14 days later by CTC and colonoscopy on the same day. The primary outcome was detection of colonic polyps and cancers. Outcomes were assessed by building an aggregate view of the colon, taking into account results of all three tests. FINDINGS: 614 patients completed all three imaging tests. When analysed on a per-patient basis, for lesions 10 mm or larger in size (n=63), the sensitivity of ACBE was 48% (95% CI 35-61), CTC 59% (46-71, p=0.1083 for CTC vs ACBE), and colonoscopy 98% (91-100, p<0.0001 for colonoscopy vs CTC). For lesions 6-9 mm in size (n=116), sensitivity was 35% for ACBE (27-45), 51% for CTC (41-60, p=0.0080 for CTC vs ACBE), and 99% for colonoscopy (95-100, p<0.0001 for colonoscopy vs CTC). For lesions of 10 mm or larger in size, the specificity was greater for colonoscopy (0.996) than for either ACBE (0.90) or CTC (0.96) and declined for ACBE and CTC when smaller lesions were considered. INTERPRETATION: Colonoscopy was more sensitive than other tests, as currently undertaken, for detection of colonic polyps and cancers. These data have important implications for diagnostic use of colon imaging tests.
Assuntos
Sulfato de Bário , Colo/diagnóstico por imagem , Neoplasias do Colo/diagnóstico , Colonografia Tomográfica Computadorizada , Colonoscopia , Pólipos do Colo/diagnóstico , Enema , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumorradiografia , Sensibilidade e EspecificidadeRESUMO
PURPOSE: The Health Care Financing Administration's guidelines for billing and documentation by attending physicians have increased the amount of time that attending physicians spend documenting the services that they provide for patients. This study assessed the impact of these guidelines on attending physicians' teaching of housestaff on inpatient medical wards. METHOD: A survey of 92 housestaff from the department of medicine at one teaching hospital was conducted in 1998 to determine how attending physicians' billing and documentation requirements, clinic responsibilities, teaching styles, and inpatient census affected the quantity and quality of their teaching. The questionnaire included a rank-order analysis of factors affecting quantity and quality of attending physicians' teaching, as well as a five-point Likert scale assessing the quality of attending physicians' teaching. RESULTS: All housestaff responded. A total of 39% of housestaff perceived billing and documentation requirements to be the major detriment to quantity of teaching by attending physicians, and 30% perceived these requirements to be the major detriment to quality of teaching by attending physicians. Housestaff perceived more teaching and higher-quality teaching on services where attending physicians did not perform billing and documentation during teaching rounds. CONCLUSION: Billing and documentation requirements are a major detriment to the quantity of teaching on inpatient services, especially when faculty attempt to meet these requirements during teaching rounds.
Assuntos
Documentação , Hospitais de Ensino/organização & administração , Corpo Clínico Hospitalar/organização & administração , Ensino/organização & administração , Atitude do Pessoal de Saúde , Coleta de Dados , Educação Médica/organização & administração , Humanos , Fatores de Tempo , Carga de TrabalhoRESUMO
Anal fissure is a painful condition that is caused by anodermal tearing after the passage of hard stool. Severe cases result in involuntary internal anal sphincter spasm and have traditionally been treated surgically with a lateral sphincterotomy. Investigators have demonstrated that nitric oxide causes relaxation of the smooth muscle of the anal canal, so topical nitroglycerin ointment preparations have recently been studied as an efficacious alternative to surgery. Despite the fact that there are a number of trials examining topical nitroglycerin for the treatment of anal fissures, there remains no consensus about concentrations, compositions and applications necessary to obtain good results. This review summarises current literature regarding topical nitroglycerin pharmacotherapy for anal fissure.
Assuntos
Fissura Anal/tratamento farmacológico , Nitroglicerina/uso terapêutico , Vasodilatadores/uso terapêutico , Administração Tópica , Método Duplo-Cego , Feminino , Fissura Anal/fisiopatologia , Humanos , Masculino , Nitroglicerina/administração & dosagem , Pomadas , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento , Vasodilatadores/administração & dosagemRESUMO
Advances in computed tomography (CT) technology and computer capabilities have contributed to the development of a new imaging modality for colorectal lesions called CT colonography or virtual colonoscopy. Virtual colonoscopy is a rapid, minimally invasive scan of the cleansed and distended colon. Early work has demonstrated that this test is safe and well tolerated, and that it may be sensitive and specific enough to identify most significant precancerous or cancerous lesions. A number of technical and practical problems remain before virtual colonoscopy can be applied at a population level.
Assuntos
Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Interface Usuário-Computador , Humanos , Programas de Rastreamento , Sensibilidade e EspecificidadeRESUMO
Malabsorption syndromes often present diagnostic dilemmas to even the most experienced clinicians. Several malabsorption screening tests are available, but d-xylose testing is our initial screening method of choice. Recent innovations such as serum assays for antibodies associated with celiac sprue are improving the work-up of patients with suspected malabsorption. In addition, physicians are applying technological advances in imaging to determine the underlying pathologies responsible for the occurrence of malabsorption and maldigestion. Breath testing remains a controversial modality in the work-up of patients with malabsorption. Tubeless tests of pancreatic function are also the subject of debate due to a lack of sensitivity for diagnosing mild to moderate chronic pancreatic insufficiency. This review identifies and provides critical analysis of new developments in the field of malabsorption testing. The authors also provide a clinical algorithm for diagnosing malabsorption.
Assuntos
Síndromes de Malabsorção/diagnóstico , Kit de Reagentes para Diagnóstico , Algoritmos , Testes Respiratórios , Colangiopancreatografia Retrógrada Endoscópica , Diagnóstico Diferencial , Humanos , Síndromes de Malabsorção/etiologia , Anamnese , Xilose/análiseRESUMO
It is well established that smoking cigarettes is associated with Crohn's disease (CD) and that non-smoking is associated with ulcerative colitis (UC). Furthermore, there is convincing evidence that smoking cigarettes has a negative effect on the course of CD, and that smoking cigarettes may improve the disease severity or have a 'protective' effect in some patients with UC. Despite these well-described associations, the mechanism by which cigarette smoking affects CD and UC is not known. Researchers have studied the systemic effects, cellular and humoral immune effects, mucosal changes, and the intestinal permeability changes with inflammatory bowel disease (IBD) and smoking. To date, none of these studies adequately explains the observed clinical patterns. It has been assumed that nicotine is the active agent in these associations, but clinical trials of nicotine chewing gum and transdermal nicotine in UC have shown limited benefit, and have been complicated by significant side-effects. Topical delivery systems for nicotine therapy are currently under development and await future clinical trials.
Assuntos
Doenças Inflamatórias Intestinais/etiologia , Fumar/efeitos adversos , Comorbidade , Feminino , Humanos , Incidência , Doenças Inflamatórias Intestinais/diagnóstico , Doenças Inflamatórias Intestinais/epidemiologia , Masculino , Prognóstico , Fatores de Risco , Índice de Gravidade de Doença , Fumar/epidemiologia , Abandono do Hábito de FumarRESUMO
OBJECTIVE: We performed CT colonography in patients referred for conventional colonoscopy, interpreted the axial images, and used commercially available software to reconstruct endoluminal perspective views to differentiate polyps from folds. SUBJECTS AND METHODS: We prospectively examined 44 patients (27 men and 17 women; mean age, 58 years old) with CT colonography by interpreting the axial images and using three-dimensional rendering for problem solving only. The CT scans were interpreted by two radiologists who were unaware of patients' histories as revealed by colonoscopic findings. The findings on colonography were compared with those of conventional colonoscopy to determine sensitivity, specificity, time spent on interpretation, and confidence of interpretation. RESULTS: Colonoscopy showed normal findings in 28 patients and 22 polyps in the remaining 16 patients. Six polyps were 8 mm or larger, three were 5-7 mm, and 13 were 5 mm or smaller. The findings of the two observers revealed an overall sensitivity of 50% and 38%, respectively, and a specificity of 93% and 86%, respectively. Sensitivity for polyps larger than 8 mm was 83% and specificity was 100% for both observers. The average amount of time spent on interpretation was 28 min 30 sec (range, 14-65 min). Both observers used the endoluminal view for differentiating folds from polyps in 23 (52%) of 44 patients, which had only minimal impact on interpretation time. CONCLUSION: CT colonography can be performed and the images interpreted using currently available hardware and software by initially using the axial images to search for polyps of significant size. Endoluminal views should be used only when necessary to help distinguish normal folds from fixed raised lesions that are suggestive of polyps.