Management of the Hospitalized Patient with Acute Colitis.

Acute severe ulcerative colitis is a rapidly progressive severe form of colitis that can occur in 20-30% patients with ulcerative colitis. Early recognition, hospitalization at centers with experience and expertise and multidisciplinary treatment is the cornerstone of appropriate management of this condition. After excluding infections and other differentials, patients should be started on parenteral corticosteroids to control inflammation. ASUC patients are at high risk for thromboembolic complications and hence DVT prophylaxis is ideally started as soon as possible in the emergency room and continued throughout hospitalization. Objective criteria should be applied to assess improvement and identify patients who are unlikely to improve without second line/rescue therapy as early as 72 hours on steroid therapy. Infliximab and cyclosporine are the most used options for second line therapy and should be administered under direction by gastroenterologists. Disease progression despite aggressive treatment or non-response to second line therapy, complications such as megacolon, perforation, hemorrhage can occur requiring colectomy as a salvage option in those patients.

The conundrum of indeterminate QuantiFERON-TB Gold results before anti-tumor necrosis factor initiation.

BACKGROUND: Tumor necrosis factor alpha (TNFα) is a key cytokine in both the pathogenesis of inflammatory bowel disease (IBD) and rheumatoid arthritis (RA) and the host defense against tuberculosis (TB). Consequently, anti-TNFα medications result in an increased risk of latent TB infection (LTBI) reactivation. Here, we sought to evaluate the factors affecting the results of QuantiFERON-TB Gold In-Tube (QFT-GIT) assay as a screening tool for LTBI. METHODS: We conducted an observational, retrospective study in patients with IBD and RA who underwent LTBI screening using QFT-GIT at UMass Memorial Medical Center between 2008 and 2016 prior to initiation of anti-TNF medications. RESULTS: We included 107 and 89 patients with IBD and RA, respectively. We found that a higher proportion of IBD patients had indeterminate QFT-GIT result compared to RA patients. Furthermore, we found that the majority of patients with indeterminate results were tested during an acute flare of IBD (88%) and while taking corticosteroids. Of all patients receiving ≥20 mg equivalent prednisone dose (n=32), 63% resulted in indeterminate QFT-GIT, compared to only 6% indeterminate testing in patients receiving <20 mg of equivalent prednisone dose (n=164, P<0.001). There was no correlation between indeterminate results and age, gender, disease duration, or distribution, or smoking status within each population. CONCLUSION: We observed that high-dose corticosteroids may affect QFT-GIT outcomes leading to a high proportion of indeterminate results. We propose that IBD patients should be tested prior to initiation of corticosteroids to avoid equivocal results and prevent potential delays in initiation of anti-TNF medications.

A retrospective analysis of adverse events in the elderly in a tertiary referral center in Mumbai (Bombay), India.

BACKGROUND: Adverse events (AEs) account for significant morbidity and mortality in elderly. Inappropriate medication usage has been regarded as an important factor contributing to AEs in them. Beers criteria are a set of standard criteria for guiding drug prescription in elderly. OBJECTIVE: To estimate the burden of AEs in the elderly in India and use of Beers criteria for assessing appropriateness of drug prescription in them. MATERIALS AND METHODS: Data on AEs collected by our tertiary referral center for the years 2005 and 2006 was analyzed. The term 'elderly individuals' was defined as those aged >or=58 years. An AE was defined as any untoward medical occurrence with a medicinal product in a patient or a clinical investigation, whether or not causally related. RESULTS: In 2005, 321 AEs were reported, and in 2006 there were 673. Of them, those in the elderly constituted 60 (18.9%) and 44 (11.8%) AEs in the 2 years, respectively. About 7 (11.6%) of the AEs in elderly in 2005 were due to medications not fulfilling Beers criteria but none in 2006. Two thirds of the AEs in both years were found to be due to antidiabetics, oral anticoagulants and antiplatelets and drugs with a narrow therapeutic index. Warfarin, digoxin and insulin accounted for a quarter of the AEs. CONCLUSIONS: Some commonly used medications account for a major proportion of AEs in elderly. Prospective studies of similar nature could further help us assess the burden of AEs in elderly.