Patient Perspectives on the Long-term Management of Celiac Disease.

GOAL: The aim of this study was to survey adults with celiac disease (CD) on the utility of specific aspects of follow-up and on information needs. BACKGROUND: Currently, the treatment for CD is strict gluten avoidance. Although this places the onus on the patient for disease management, patient perspectives on CD care have not been formally assessed. STUDY: The Manitoba Celiac Disease Cohort prospectively enrolled adults newly diagnosed with CD using serology and histology. At the 24-month study visits, participants rated the utility of aspects of CD care on a 5-point scale anchored by "not at all useful" and "very useful" and the helpfulness of information on CD-related topics on a 6-point scale anchored by "not at all helpful" and "very helpful." RESULTS: The online survey was completed by 149 of 211 cohort members [median age 40 (interquartile range 30 to 56) y; 68% female]. Adherence to a gluten-free diet was good. Most participants (87%) responded that they should be seen regularly for medical follow-up of CD, preferably every 6 (26%) or 12 months (48%). Blood tests were the most highly rated care component (rated scored ≥4/5 by 78% of respondents), followed by the opportunity to ask about vitamins and supplements (50%), symptom review (47%), and information on CD research (44%). Diet review was not considered helpful. CONCLUSIONS: Two years after diagnosis, most individuals with CD find regular specialist follow-up helpful, particularly for biochemical assessment of disease activity and its complications. Furthermore, information on research and long-term complications of CD is also valued.

Dose Augmentation of Tumor Necrosis Factor Inhibitors is Frequently Performed in Persons With Inflammatory Bowel Disease in the Absence of Objective Evidence of Active Inflammation.

BACKGROUND: Antitumor necrosis factor (anti-TNF) dose augmentation is frequently utilized in the management of inflammatory bowel disease (IBD), yet the extent to which clinicians assess for objective markers of inflammation before using the strategy is unknown. AIMS: To determine the incidence of anti-TNF dose augmentation and the frequency with which it is preceded by the objective assessment of IBD activity. MATERIALS AND METHODS: All 23 prescribers of anti-TNF for IBD in Manitoba facilitated chart review of their adult anti-TNF users from 2005 to 2016. Time from anti-TNF initiation to dose augmentation was recorded for all previously biologic-naïve patients. The practices of 11 of 23 prescribers were audited in greater detail and the biochemical, imaging, and endoscopic investigations conducted in the 90-day preceding dose augmentation extracted. RESULTS: A total of 838 patients met inclusion criteria; 70.4% had Crohn's disease, whereas 29.6% had ulcerative colitis or IBD unclassified. The median duration of follow-up was 22.6 [interquartile range (IQR), 10.3-43.2] months for adalimumab and 28.4 (IQR, 10.2-59.9) months for infliximab (P=0.01). The cumulative incidence of dose augmentation at 12 months was 32.9%. Dose augmentation occurred more often in ulcerative colitis than in Crohn's disease (hazard ratio, 1.83; IQR, 1.36-2.47). Overall, 70.7% of patients underwent some form of testing to assess the inflammatory burden before dose augmentation. Objective evidence of inflammation supporting dose augmentation was documented in only 24.7% of cases. CONCLUSIONS: One third of previously biologic-naïve patients had anti-TNF doses increased within the first 12 months of treatment. Dose augmentation frequently occurred in the absence of objective evidence of inflammatory disease activity.

Trends and Novel Research in Hospital Nutrition Care: A Narrative Review of Leading Clinical Nutrition Journals.

Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.

Serum immunoglobulin A levels and alcohol-induced liver disease.

Background: Recent data suggest intestinal immunity including immunoglobulin A (IgA) may contribute to the pathogenesis of alcohol-induced liver disease (ALD). Methods: We documented serum IgA levels in ALD patients and determined whether those with elevated levels of IgA (E-IgA) had similar, more, or less advanced disease and different rates of progression than those with normal levels of IgA (N-IgA). Standard liver function tests (bilirubin, international normalized ratio [INR], and albumin), model for end-stage liver disease (MELD), and Fibrosis-4 (FIB-4) scores were used as indicators of disease severity. Results: From the study centre's clinical database, we identified 175 adult patients with ALD, 107 (61%) with E-IgA and 68 (39%) with N-IgA. Gender distribution and mean age of the two cohorts were similar. E-IgA patients had biochemical evidence of more advanced liver disease (higher serum bilirubin and INR and lower albumin levels) than N-IgA patients (ps < .05). E-IgA patients also had significantly higher median MELD and FIB-4 scores (ps < .01). A higher percentage of E-IgA patients had FIB-4 values in keeping with advanced fibrosis or cirrhosis (55% versus 28%, p = .02). After mean follow-up periods of approximately 4 years, liver biochemistry and MELD and FIB-4 scores changed to similar extents in the two cohorts. Conclusions: Serum IgA levels were increased in approximately 70% of ALD patients. Although these patients had biochemical and non-invasive indicators of more advanced disease, elevations in serum IgA levels do not predict disease progression; therefore, IgA is unlikely to be of importance in the pathogenesis of ALD.

A Population-Based Study of Combination vs Monotherapy of Anti-TNF in Persons With IBD.

BACKGROUND: Few data exist about the utilization of combination therapy (anti-tumor necrosis factor [anti-TNF] plus immunosuppressives) in clinical practice. We assessed the prevalence and predictors of combination therapy use vs anti-TNF monotherapy in inflammatory bowel disease (IBD) in the Canadian province of Manitoba. METHODS: All 23 prescribers of anti-TNF medications for IBD in Manitoba facilitated chart review of their comprehensive lists of adult anti-TNF patients from 2005 to 2015. Subjects were stratified by year of first anti-TNF exposure. Patient, disease, and prescriber factors influencing combination therapy use were explored. RESULTS: A total of 774 patients met inclusion criteria. Seventy-one point one percent had Crohn's disease (CD), 28.3% had ulcerative colitis (UC), and 0.6% had IBD unclassified; 45.3% received combination therapy, with no difference between CD and UC. Crohn's disease subjects receiving combination therapy were more likely to have penetrating or perianal disease (56.9% vs 42.8%; P = 0.001) and less likely to have had previous IBD-related surgeries (36.2% vs 46.2%; P = 0.02). The median age at diagnosis and at anti-TNF initiation was lower among combination therapy users. Adalimumab users were as likely as infliximab users to receive combination therapy but persisted with treatment for a shorter time. The proportion of new anti-TNF users receiving combination therapy did not change over time (P = 0.43). There was substantial variation in combination therapy use between prescribers (P = 0.002). The most frequently encountered reasons for avoiding combination therapy were previous intolerance or ineffectiveness of immunosuppressive monotherapy. CONCLUSION: Use of combination therapy has remained unchanged over time despite the publication of high-quality data supporting its efficacy over anti-TNF monotherapy.

The Clinician's Guide to Proton Pump Inhibitor Related Adverse Events.

A substantial volume of literature exists linking proton pump inhibitor (PPI) use with a multitude of serious adverse events. There is uncertainty, however, over whether these associations are clinically important. Excessive concern about PPI-related adverse events may leave patients at risk of harm by leaving acid-related upper gastrointestinal disease untreated. Conversely, the risk of treatments may outweigh the benefits if any of the purported adverse events are directly caused by PPI use; this is of particular concern where indications for PPI use are not present. In this paper, we review the studies which have reported associations between adverse events and PPI use, discuss the proposed mechanisms of action, grade the confidence in whether these associations are truly causal, and provide advice regarding balancing the benefits of PPI use against their possible harms.

Serum immunoglobulin A levels and non-alcoholic fatty liver disease.

Background: Intestinal immunity, and immunoglobulin A (IgA) in particular, may play an important role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD). The aim of this study was to document the prevalence of elevated serum IgA levels in NAFLD patients and determine whether the severity and course of NAFLD differs in those with elevated (E-IgA) versus normal (N-IgA) levels. Methods: A retrospective review of a clinical database containing demographic, laboratory, and histologic findings of adult NAFLD patients was undertaken. Liver biochemistry, model for end stage-liver disease (MELD) and Fib-4 scores served to document disease severity and progression. Results: Of 941 NAFLD study subjects, 254 (27%) had E-IgA at presentation. E-IgA patients were older, and had lower serum albumin levels and higher MELD scores than N-IgA patients. The percent of E-IgA patients with Fib-4 scores >3.25 (suggestive of cirrhosis) was also higher (25% vs. 5.5%, p<0.001). E-IgA patients had higher METIVIR fibrosis scores (2.2 ± 1.4 vs. 1.0 ± 1.2, p<0.0001) than N-IgA patients. After mean follow-ups of 47 (E-IgA) and 41 (N-IgA) months, serum albumin levels remained lower, INR values were now more prolonged and MELD scores higher in E-IgA patients. Of the non-cirrhotic patients at baseline, a larger percent of E-IgA patients developed cirrhosis by Fib-4 testing at last visit (11% vs. 2.9%, p<0.001). Conclusions: Elevated serum IgA levels are common in NAFLD patients and when present, are associated with more advanced disease. Patients with elevated serum IgA levels are also more likely to progress to cirrhosis than those with normal levels.