Short and long-term follow-up and clinical outcomes in patients with celiac disease in a large private practice setting.

BACKGROUND: Celiac disease (CD) is caused by an immune response to gluten and treatment is adherence to a gluten-free diet. Guidelines from studies in large academic settings recommend registered dietitian (RD) referrals at time of diagnosis and periodic testing for micronutrient deficiencies. There is limited data to guide follow-up parameters in a large, community-based practice. The purpose of this study was to evaluate guideline adherence in this setting. METHODS: This retrospective study conducted in 2019 assessed CD care based on follow-up rates, micronutrient testing, symptoms, and serology results in cohorts with and without RD referrals. Patients in this study were followed at Rockford Gastroenterology Associates (RGA): a large, private GI practice. Patients were included if they had a diagnosis of CD from 1/2014 through 12/2018, based on positive serology and/or duodenal biopsy. Patient data was collected by chart review and analyzed through Microsoft Excel. Fisher's exact and Chi-square tests were used for the statistical analysis and were calculated through the Statistical Product and Service Solutions (SPSS) software. RESULTS: 320 patients were initially reviewed and a cohort of 126 patients met inclusion criteria. 69.8% had a RD referral. 65.9% had at least one lab test order for any of the 6 micronutrients. Of 63 patients tested for iron, 11 were iron deficient (8 with RD referral). Of 64 patients tested for vitamin D, 21 were deficient (17 with referral). 80.2% attended at least one follow-up appointment, but 34.9% had only one follow-up visit over a mean follow up duration of 5.82 months. 79 patients had follow-up data for symptoms or serology and were separated into 4 categories (with vs. without RD referral): (1) asymptomatic and negative serology (32% vs. 26%), (2) symptomatic and negative serology (28% vs. 16%), (3) asymptomatic and positive serology (27% vs. 32%), (4) symptomatic and positive serology (13% vs. 26%). Category 1 yielded a fisher exact test value of 2.62 (p = 0.466). CONCLUSIONS: RD referral, micronutrient testing, and close follow-up are important parameters that affect outcomes in patients with CD. Rates for dietitian referral, some micronutrient testing and follow-up visits were higher than 50%, though results from this study were not statistically significant. Further standardization of follow-up testing and monitoring for CD will help minimize discrepancies between community-based and large, academic GI practices.

Outcomes of symptom screening and universal COVID-19 reverse transcriptase polymerase chain reaction testing before endoscopy in a community-based ambulatory surgery center.

BACKGROUND AND AIMS: Elective endoscopy resumed in our outpatient ambulatory center after instituting the preprocedure policy of a confirmed negative coronavirus disease 2019 (COVID-19) reverse transcriptase polymerase chain reaction (RT-PCR) status performed 72 hours before a scheduled procedure as mandated by the state of Illinois. In addition, all patients were required to contemporaneously complete the American Society for Gastrointestinal Endoscopy (ASGE) COVID-19 risk screening questionnaire published April 28, 2020 as outlined in the ASGE guidance document for reopening GI endoscopy during the COVID-19 pandemic. The aim of our study is to report the outcomes of 1000 patients who successfully completed the clinical aspects of the ASGE COVID-19 risk screening questionnaire and whose RT-PCR tests were valid for interpretation. METHODS: Data were retrospectively collected from patient medical records for demographics, symptom responses to the preprocedure ASGE COVID-19 risk screening questionnaire, and RT-PCR test results of patients scheduled to undergo an elective outpatient endoscopy at Rockford Gastroenterology Associates from May 22 through June 28, 2020. Descriptive statistics and standard calculation methods to determine both positive and negative predictive values were used for data analysis. RESULTS: Eight of 1000 patients included in the study tested positive for COVID-19. Three of 8 patients reported 1 or more symptoms on the ASGE COVID-19 risk screening questionnaire. One hundred nineteen additional patients reported symptoms on the ASGE COVID-19 risk screening questionnaire but tested negative for COVID-19. The positive and negative predictive values of the ASGE COVID-19 risk screening questionnaire were 2.46% and 99.43%, respectively. CONCLUSIONS: The low incidence of COVID-19 infection in a community-based ambulatory surgery center is supported by a positive RT-PCR test rate of .80%. Absence of symptoms on the ASGE COVID-19 risk screening questionnaire was highly predictive of a negative RT-PCR test (99.43% negative predictive value), whereas the positive predictive value was low (2.46%) in symptomatic patients. A positive RT-PCR test was invaluable in preventing 5 asymptomatic patients from undergoing endoscopy. Similarly, 119 symptomatic patients underwent endoscopic evaluation who would have otherwise been excluded without RT-PCR testing. Symptom-based screening alone should not be the primary preprocedural assessment tool in selecting patients for undergoing endoscopy during the COVID-19 pandemic.

Results of a Community-based, Randomized Study Comparing a Clear Liquid Diet With a Low-residue Diet Using a Magnesium Citrate Preparation for Screening and Surveillance Colonoscopies.

BACKGROUND: Current bowel preparations for colonoscopy include a clear liquid diet (CLD) along with consumption of a laxative. This dietary restriction along with large volume bowel preparations are barriers to compliance and willingness among patients in scheduling screening examinations. The aim of our study was to compare the efficacy and tolerability of a low-volume split dose magnesium citrate bowel preparation in patients on a low-residue diet (LRD) with those on a CLD. METHODS: In this single center, single blinded, randomized controlled trial, patients scheduled for outpatient colonoscopies were assigned to either a CLD or a LRD 1 day before the examination. Both groups received a split dose magnesium citrate preparation. The quality of the preparation was rated using the Boston Bowel Preparation Scale (BBPS). Patient satisfaction and side effects were evaluated using a questionnaire. RESULTS: We were unable to detect a significant difference in the BBPS scores between the LRD and CLD groups (P=0.581). A significantly higher percentage of patients in the LRD group rated the diet as easy compared with the CLD group (P<0.001). Satisfaction scores were significantly higher in the LRD group, compared with the CLD group (P<0.001). The side effect profiles of both arms were similar. CONCLUSIONS: There was no significant difference between LRD and CLD in patients using a magnesium citrate bowel preparation for screening and surveillance colonoscopies. Patient satisfaction scores were higher with a LRD compared with a CLD. We believe the LRD should be the recommended diet in patients using a standard bowel preparation for screening and surveillance colonoscopy.

Targeted Physician Education and Standardizing Documentation Improves Documented Reporting with Inflammatory Bowel Disease Quality Measures in a Large Academic and Private Practice.

BACKGROUND: Prior studies have shown poor compliance with quality measures for IBD at academic and private practices. We sought to provide focused interventions to improve compliance and documentation with the IBD measures. METHODS: Two centers, academic practice (AP) and private practice (PP), initially reviewed their compliance with eight established IBD quality measures in consecutive charts. A multi-faceted intervention was developed to improve awareness and documentation of these measures. The initial data and the quality measures were reviewed at a group meeting. Following this, a handout summarizing the measures was placed in each exam room. The AP added a new screen to the EHR that summarized the relevant IBD history, while the PP added a new template that was filled out and imported into the charts. Three months after this intervention, charts were reviewed for compliance with the measures. RESULTS: The intervention cohort consisted of 768 patients (AP = 569/PP = 199) compared to the initial cohort of 566 patients (AP = 367/PP = 199). Improvement was seen throughout all measures compared to the initial cohort. The AP reported compliance with all relevant measures in 21% and the PP in 60% compared to 7 and 10% in the initial cohort. PP had ≥ 75% compliance with every measure, of which only assessment for bone loss and pneumococcal vaccination was under 80%. In contrast, the AP compliance ranged from 35 to 100% with assessment for bone loss, influenza, and pneumococcal vaccination scoring lowest. CONCLUSION: Our study demonstrates that focused low-cost interventions can significantly improve compliance with IBD quality measures in different practice settings.

Poor Documentation of Inflammatory Bowel Disease Quality Measures in Academic, Community, and Private Practice.

BACKGROUND & AIMS: Quality measures are used to standardize health care and monitor quality of care. In 2011, the American Gastroenterological Association established quality measures for inflammatory bowel disease (IBD), but there has been limited documentation of compliance from different practice settings. METHODS: We reviewed charts from 367 consecutive patients with IBD seen at academic practices, 217 patients seen at community practices, and 199 patients seen at private practices for compliance with 8 outpatient measures. Records were assessed for IBD history, medications, comorbidities, and hospitalizations. We also determined the number of patient visits to gastroenterologists in the past year, whether patients had a primary care physician at the same institution, and whether they were seen by a specialist in IBD or in conjunction with a trainee, and reviewed physician demographics. A univariate and multivariate statistical analysis was performed to determine which factors were associated with compliance of all core measures. RESULTS: Screening for tobacco abuse was the most frequently assessed core measure (89.6% of patients; n = 701 of 783), followed by location of IBD (80.3%; n = 629 of 783), and assessment for corticosteroid-sparing therapy (70.8%; n = 275 of 388). The least-frequently evaluated measures were pneumococcal immunization (16.7% of patients; n = 131 of 783), bone loss (25%; n = 126 of 505), and influenza immunization (28.7%; n = 225 of 783). Only 5.8% of patients (46 of 783) had all applicable core measures documented (24 in academic practice, none in clinical practice, and 22 in private practice). In the multivariate model, year of graduation from fellowship (odds ratio [OR], 2.184; 95% confidence interval [CI], 1.522-3.134; P < .001), year of graduation from medical school (OR, 0.500; 95% CI, 0.352-0.709; P < .001), and total number of comorbidities (OR, 1.089; 95% CI, 1.016-1.168; P = .016) were associated with compliance with all core measures. CONCLUSIONS: We found poor documentation of IBD quality measures in academic, clinical, and private gastroenterology practices. Interventions are necessary to improve reporting of quality measures.

Anti-tumour necrosis factor therapy for ulcerative colitis: evidence to date.

Infliximab, the chimeric monoclonal antibody directed against tumour necrosis factor (TNF)-alpha, has profoundly changed therapy for Crohn's disease (CD). However, for ulcerative colitis (UC), before the publication of ACT 1 and ACT 2 (Active Ulcerative Colitis Trials 1 and 2), there were only a few open-label and controlled trials that evaluated the role of infliximab in the treatment of UC. Results from these earlier studies were equivocal and ambiguous. However, the ACT 1 and ACT 2 trials were large, randomised and placebo-controlled, and have shown that infliximab is significantly more efficacious than placebo in treating both corticosteroid-responsive and -refractory moderate to severe UC. Data from these two studies showed that in patients with moderate to severe UC, treatment with infliximab (5 and 10 mg/kg), compared with placebo, led to significantly higher rates of clinical response, clinical remission and mucosal healing. However, a significant proportion of patients who were receiving oral corticosteroids at the start of the trials, remained on corticosteroids despite infliximab therapy. Additionally, the safety profile of the drug was found to be similar to what has been reported in clinical studies of infliximab in patients with CD. On the basis of currently available data, we use infliximab as a remission-inducing agent in patients who have moderate to severe UC and are either refractory to or intolerant of mesalazine (5-ASA) products and immunomodulators. Moreover, infliximab seems to be a reasonable therapeutic modality for remission maintenance in those patients with UC in whom mesalazine products and immunomodulators have failed. Although data are limited, infliximab may be considered as a remission-inducing agent in patients with moderate to severe UC which is refractory to oral corticosteroids. However, the role of infliximab in the treatment of UC patients who are dependent on oral corticosteroids is still unclear and, therefore, should be considered only in patients who cannot be successfully transitioned to or are intolerant of oral immunomodulators. Furthermore, infliximab may be an alternative to ciclosporin (cyclosporin) in hospitalised patients with severe to moderately severe but not fulminant UC who do not respond to intravenous corticosteroids. At present, there is insufficient evidence to advocate using infliximab as a first-line agent for UC patients with mild or moderate to severe disease. Future randomised, controlled trials with clearly defined patient populations should further help to clarify the definitive role of infliximab in the therapeutic scheme for UC.

Therapy insight: drugs for gastrointestinal disorders in pregnant women.

The management and treatment of gastrointestinal ailments in pregnant women requires special attention and expertise, since the safety of the mother, fetus and neonate remains the primary focus. Nausea and vomiting during pregnancy is common, as is symptomatic gastroesophageal reflux disease. Peptic ulcer disease occurs less frequently and with fewer complications. Gastroenterologists and obstetricians should be familiar with safe treatment options for these conditions, because they can profoundly impair the quality of life of pregnant women. During pregnancy, constipation can develop de novo, or chronic constipation can increase in severity. Given the array of therapies for constipation, physicians must apprise themselves of drugs that are safe for both mother and fetus. Management of acute, self-limited diarrhea should focus on supportive therapy, dietary changes and maintenance of hydration. Treatment of chronic diarrhea should be considered in the context of therapy for the underlying disorder. Inflammatory bowel disease and irritable bowel syndrome present a unique therapeutic challenge--to control the disease while minimizing toxicity to the fetus and mother. Initiation and alteration of medical therapy for gastrointestinal disorders during pregnancy must be undertaken after discussion with the patient's obstetrician.

Heightened NTPDase-1/CD39 expression and angiogenesis in radiation proctitis.

Radiation proctitis is an inflammatory process associated with persistent and refractory lower gastrointestinal bleeding. Purinergic signaling regulates hemostasis, inflammation, and angiogenesis. For example, CD39, the vascular ectonucleotidase, blocks platelet activation and is required for angiogenesis. Whether CD39 expression is affected by radiation injury is unknown. The aim of this work was to study CD39 expression patterns after clinical radiation injury to the rectum. We prospectively enrolled eight patients with radiation proctitis and five gender-matched controls. Biopsies were taken from normal-appearing rectal mucosa of controls and from the normal sigmoid and abnormal rectum of patients. Expression patterns of CD39, P2Y2 receptor, CD31, CD61 integrin, and vascular endothelial growth factor receptor 2 were examined by immunostaining; levels of CD39 were further evaluated by Western blots. Chronic inflammatory lesions of radiation proctitis were associated with heightened levels of angiogenesis. Immunohistochemical stains showed increased vascular expression of CD39, as confirmed by Western blots. CD39 was co-localized with vascular endothelial markers CD31 and CD61 integrin, as well as expressed by stromal tissues. Development of neovasculature and associated CD39 expression in radiation proctitis may be associated with the chronic, refractory bleeding observed in this condition.

The Role of Antibiotics in Inflammatory Bowel Disease.

Broad-spectrum antibiotics are the mainstay of therapy for patients with Crohn's disease (CD) who present with localized peritonitis due to a microperforation bacterial overgrowth secondary to chronic strictures. They are essential adjuncts to drainage therapy for CD-associated abscesses and for complicated perineal disease. The lack of well-designed, placebo-controlled trials has led to much skepticism about the efficacy of antibiotics as primary therapy for CD. However, a careful review of the experience with antibiotics, including clinical observations and controlled trials, leads to the conclusion that antibiotics have a role as primary therapy in active uncomplicated CD. The efficacy of their response must be considered in well-defined subsets of patients. Ciprofloxacin and metronidazole, the two most widely studied antibiotics, are effective therapy for patients with active ileocolonic and colonic disease and have been shown to reduce recurrence rates after ileocolonic resection. The benefits of these drugs are less clear for patients with uncomplicated ileal disease. Additionally, ciprofloxacin and metronidazole may also serve as an adjunct to immunomodulator therapy. The role of antimycobacterial therapy in treatment of CD is an attractive alternative, and hopefully this therapy will be further clarified when results of ongoing trials become available. In toxic patients with fulminant ulcerative colitis (UC), with or without megacolon, broad-spectrum antibiotics should be a part of the treatment program. In less severely ill patients requiring hospitalization, antibiotics may be given to cover for the potential of a superimposed infection until the workup for infection, including Clostridium difficile is completed. There may be a subset of patients with severe nontoxic colitis with persistent fever and bandemia after steroid therapy who respond to antibiotics, but to date controlled trials have not shown efficacy in this group. Antibiotics should not be routinely used for mild to moderately ill patients with UC, although a trial of ciprofloxacin is not unreasonable prior to colectomy for otherwise refractory patients. The use of rifaximin in UC requires further evaluation in larger studies.