Optimizing Intravenous Access for Long-Term Parenteral Nutrition.

PURPOSE OF REVIEW: Securing safe and effective intravenous (IV) access is of utmost importance for administering parenteral nutrition (PN). Sustaining this access can indeed pose challenges, especially when dealing with the risk of complications associated with long-term PN. This review emphasizes best practices to optimize intravenous access and reviews the current evidence-based recommendations and consensus guidelines. RECENT FINDINGS: An individualized approach when selecting central venous catheters (CVC) is recommended, considering the estimated duration of need for IV access and the number of lumens needed. Established and novel approaches to minimize complications, including infection and thrombosis, are recognized. These include placement and positioning of the catheter tip under sonographic guidance and the use of antimicrobial lock therapies. Moreover, when possible, salvaging CVCs can reduce the risk of vascular access loss. CVC selection for patients requiring PN depends on several factors. Carefully reviewing an individual patient's clinical characteristics and discussing options is important. Given the increased infection risk, CVC lumens should be minimized. For long-term PN beyond 6 months, using CVCs with skin barriers and larger diameters should be considered.

Osteonecrosis in Inflammatory Bowel Disease: Clinical Features, Risk Factor Analysis, and Outcomes.

BACKGROUND: Avascular necrosis (AVN) is a known adverse event associated with corticosteroid (CS) usage. Inflammatory bowel disease (IBD) is often treated with a CS for induction of remission. We sought to describe clinical features and outcomes of IBD patients with AVN. METHODS: In this retrospective, single-center, case-control study, patients with IBD who had a diagnosis of osteonecrosis, aseptic necrosis, or AVN from 1976 to 2009 were included, and each was matched with up to 2 controls (IBD but no AVN) on age, sex, IBD subtype, geographic area of residence, and date of IBD diagnosis. We abstracted risk factor data from the medical records. Conditional logistic regression was performed accounting for minor differences in age and date of first IBD visit to assess the relationship between putative risk factors and AVN, expressed as odds ratio and 95% confidence interval. RESULTS: Eighty-five patients were diagnosed with IBD-AVN and were matched with 163 controls. The mean age at AVN diagnosis was 47.5 years. AVN was diagnosed a median of 12.2 years after IBD diagnosis, and the control group was followed for a median of 15 years after IBD diagnosis to ensure that they did not have AVN. Ten percent of patients with AVN did not have any CS exposure. History of arthropathy or estrogen use in Crohn's disease and use of CS, osteoporosis, and history of arthropathy in ulcerative colitis were significantly associated with AVN. CONCLUSIONS: Most patients with IBD-AVN had multifocal involvement. Most had received CS, but many patients had other risk factors including arthropathy.

This single-center, case-control study of inflammatory bowel disease patients with osteonecrosis showed that while corticosteroid use was likely a risk factor, especially among ulcerative colitis patients, other risk factors included estrogen use among Crohn's disease patients, arthropathy, and osteoporosis.

Outcomes of Endoscopic Therapy for Luminal Strictures in Crohn's Disease.

Backgrounds: We sought to describe the outcomes of endoscopic therapy of luminal strictures in patients with Crohn's disease (CD) at a large tertiary referral center. Methods: All patients who had undergone endoscopic dilation of CD strictures between January 1, 1990 and November 30, 2013 were identified. Demographics, disease characteristics including medication use and history of surgeries, details of endoscopic procedures, and long-term outcomes were analyzed. A successful procedure was defined as ability of the endoscope to pass through the stricture after dilation or effacement of the dilating balloon under fluoroscopy. Kaplan-Meier and Cox proportional hazards analysis were used. Results: For this study 286 index procedures for CD-related stricture dilation were performed in 273 patients (53.8% women) with median age of 45.9 years (range, 14.9-92.2). The most common stricture locations were ileocolonic anastomosis (36.4%) and colon (13.9%). One hundred fourteen (41.8%) patients had a second dilation. The cumulative probability of need for a second dilation following the index procedure was 33.6% at 1 year (95% CI, 25.9%-38.7%), 53.9% at 3 years (45.9%-61.2%), and 60.2% at 5 years (51.4%-67.5%). Six adverse events occurred after the first procedure: 4 perforations, 1 patient with bleeding, and 1 patient with abdominal pain requiring hospitalization. A total of 82 (30%) patients required surgery for their stricture. Conclusions: In a large cohort, endoscopic stricture dilation in CD was safe and effective. About 33% of patients required a second dilation at 1 year after the initial dilation; younger age and smaller inner diameter of the index stricture predicted need for a second dilation. 10.1093/ibd/izy049_video1izy049.video15794820307001.

Pilot Study Comparing 2 Oral Rehydration Solutions in Patients With Short Bowel Syndrome Receiving Home Parenteral Nutrition: A Prospective Double-Blind Randomized Controlled Trial.

BACKGROUND: Short bowel syndrome (SBS) is a common indication for home parenteral nutrition (HPN). Oral rehydration solutions (ORSs) have the ability to supplement or reduce HPN dependence. However, ORSs have suffered from poor taste profiles, making long-term consumption and compliance unlikely. The goal of the current study was to assess the taste and compliance of 2 ORSs among patients with SBS requiring HPN. METHODS: All participants with SBS receiving HPN with anticipated duration >3 months were offered enrollment: 31 participants met inclusion criteria; 3 declined enrollment; and 28 were randomized to receive a modified World Health Organization ORS (group A) or a commercially available ORS (DripDrop; group B). RESULTS: Six participants dropped out shortly after randomization (3 in each group) due to poor taste or intolerance. An additional 3 (1 in group A and 2 in group B) discontinued the ORS before the end of the study at 6 months. At the end of the study, 19 remained. The mean taste rating given by the participants was, on a scale of 1-10, 7.3 ± 1.9 for group A and 7.6 ± 1.6 for group B ( P = .61). The mean number of days that ORSs were consumed each week was 6.0 ± 1.3 for group A and 6.6 ± 1 days for group B ( P = .06). CONCLUSION: Taste rating was not different for both ORSs; however, a significant number of participants did not complete the study.

Publication Rates of Abstracts Presented at the Society of General Internal Medicine Annual Meeting.

BACKGROUND: Abstracts accepted at scientific meetings are often not subsequently published. Data on publication rates are largely from subspecialty and surgical studies. OBJECTIVE: The aims of this study were to 1) determine publication rates of abstracts presented at a general internal medicine meeting; 2) describe research activity among academic general internists; 3) identify factors associated with publication and with the impact factor of the journal of publication; and 4) evaluate for publication bias. DESIGN: Retrospective cohort study. PARTICIPANTS: All scientific abstracts presented at the Society of General Internal Medicine 2009 Annual Meeting. MAIN MEASURES: Publication rates were determined by searching for full-text publications in MEDLINE. Data were abstracted regarding authors' institution, research topic category, number of study sites, sample size, study design, statistical significance (p value and confidence interval) in abstract and publication, journal of publication, publication date, and journal impact factor. KEY RESULTS: Of the 578 abstracts analyzed, 274 (47.4%) were subsequently published as a full article in a peer-reviewed journal indexed in MEDLINE. In a multivariable model adjusting for institution site, research topic, number of study sites, study design, sample size, and abstract results, publication rates for academic general internists were highest in the areas of medical education (52.5%, OR 5.05, 95% CI 1.57-17.25, reference group Veterans Affairs (VA)-based research, publication rate 36.7%), mental health/substance use (67.7%, OR 4.16, 95% CI 1.39-13.06), and aging/geriatrics/end of life (65.7%, OR 3.31, 95% CI 1.15-9.94, p = 0.01 across topics). Publication rates were higher for multicenter studies than single-institution studies (52.4% vs. 40.4%, OR 1.66, 95% CI 1.10-2.52, p = 0.04 across categories). Randomized controlled trials had higher publication rates than other study designs (66.7% vs. 45.9%, OR 2.72, 95% CI 1.30-5.94, p = 0.03 across study designs). Studies with positive results did not predict higher publication rates than negative studies (OR 0.89, 95% CI 0.6-1.31, p = 0.21). CONCLUSIONS: This study demonstrated that 47.4% of abstracts presented at a general internal medicine national conference were subsequently published in a peer-reviewed journal indexed in MEDLINE.

Do patients receiving hemodialysis regret starting dialysis? A survey of affected patients
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AIMS: End-stage renal disease (ESRD) is associated with high morbidity and mortality. A prior study showed that many Canadian patients regretted their decision to start dialysis. We sought to determine if US patients also regretted dialysis. MATERIALS AND METHODS: We surveyed hemodialysis patients within 55 miles of Rochester, MN, with a 25-question survey about their perceptions of their health, preparedness for dialysis, advance care planning, and regrets about starting dialysis. Surveys were administered in person at the patients' usual dialysis session from July 1 through December 1, 2014; responses were captured electronically. RESULTS: Of the 198 eligible patients, 128 participated (70% men); 80% received dialysis for more than 1 year; 38% reported their health and 58% described their quality of life as "good" or "very good"; 51% had started dialysis in the hospital; and 68% agreed they were prepared for what to expect. Only 35% of patients reported being offered supportive care without dialysis. Most patients (82%) recalled a discussion about prognosis. Only 43% completed an advance directive, but 72% thought it was at least "very important" to plan for the end of life. Nine (7%) reported regretting the decision to start dialysis. CONCLUSIONS: Most of our patients were optimistic about their health and prognosis. Few regretted the decision to start dialysis.
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Prevention of Subsequent Catheter-Related Bloodstream Infection Using Catheter Locks in High-Risk Patients Receiving Home Parenteral Nutrition.

INTRODUCTION: Catheter-related bloodstream infection (CRBSI) is a serious complication in patients receiving home parenteral nutrition (HPN). Antibiotic lock therapy (ALT) and ethanol lock therapy (ELT) can be used to prevent CRBSI episodes in high-risk patients. METHODS: Following institutional review board approval, all patients enrolled in the Mayo Clinic HPN program from January 1, 2006, to December 31, 2013, with catheter locking were eligible to be included. Patients without research authorization and <18 years old at the initiation of HPN were excluded. Total number of infections before and after ALT or ELT were estimated in all patients. RESULTS: A total of 63 patients were enrolled during the study period. Of 59 eligible patients, 29 (49%) were female, and 30 (51%) were male. The median duration of HPN was 3.66 (interquartile range, 0.75-8.19) years. The mean age ± SD at initiation of HPN was 49.89 ± 14.07 years. A total of 51 patients were instilled with ALT, and 8 patients were instilled with ELT during their course of HPN. A total of 313 CRBSI episodes occurred in these patients, 264 before locking and 49 after locking ( P < .001). Rate of infection per 1000 catheter days was 10.97 ± 25.92 before locking and 1.09 ± 2.53 after locking ( P < .001). DISCUSSION: The major findings of the present study reveal that ALT or ELT can reduce the overall rate of infections per 1000 catheter days. ALT or ELT can be used in appropriate clinical setting for patients receiving HPN.

Hyperglycemia During Home Parenteral Nutrition Administration in Patients Without Diabetes.

BACKGROUND: Parenteral nutrition (PN) is a life-sustaining therapy in appropriate clinical settings. In the hospital setting, some nondiabetic patients develop hyperglycemia and subsequently require long-term insulin while receiving PN. Whether similar hyperglycemia is seen in the outpatient setting is unclear. METHODS: We studied patients enrolled in the Mayo Clinic Home Parenteral Nutrition (HPN) program between January 1, 2010, and December 31, 2012. Patients were excluded if they had diabetes mellitus type 2 (DM2), had previously received HPN, had taken corticosteroids, or were at risk for refeeding syndrome. RESULTS: Of 144 enrolled patients, 93 met inclusion criteria with 39 patients requiring the addition of insulin to HPN. The mean age of the insulin-requiring group (IR) was higher than that of the non-insulin-requiring group (NIR) (60.74 ± 13.62 years vs 48.97 ± 17.62 years, P < .001). There were 17 (44%) men in the IR group and 26 (48%) men in the NIR group. Mean blood glucose at baseline before starting the infusion was 131.82 ± 49.55 mg/dL in IR patients and 106.16 ± 59.01 mg/dL in NIR patients ( P = .03). In the stepwise multivariate analysis for assessing the risk for developing hyperglycemia, HR for age was 1.020 (1.010-1.031), P < .001. CONCLUSIONS: Hyperglycemia is a common finding with the use of PN in both the hospital and ambulatory setting in patients without a previous diagnosis of DM2. Age was the most significant predictor of the requirement of insulin in the present study. When hyperglycemia is managed appropriately with insulin therapy, the long-term complications can be minimized.

Catheter Salvage After Catheter-Related Bloodstream Infection During Home Parenteral Nutrition.

BACKGROUND: Catheter-related bloodstream infection (CRBSI) is a common complication in patients receiving home parenteral nutrition (HPN). Data regarding catheter salvage after a CRBSI episode are limited. We aimed to determine the incidence of CRBSI and rates of catheter salvage in adult patients receiving HPN. MATERIALS AND METHODS: We retrospectively searched our prospectively maintained HPN database for the records of all adult patients receiving HPN from January 1, 1990, to December 31, 2013, at our tertiary referral center. Data abstracted from the medical records included demographics, diseases, treatments, and outcomes. The incidence of CRBSI and rates of catheter salvage were determined. RESULTS: Of 1040 patients identified, 620 (59.6%) were men. The median total duration on HPN was 124.5 days (interquartile range, 49.0-345.5 days). Mean (SD) age at HPN initiation was 53.3 (15.3) years. During the study period, 465 CRBSIs developed in 187 patients (18%). The rate of CRBSI was 0.64/1000 catheter days. Overall, 70% of catheters were salvaged (retained despite CRBSI) during the study period: 78% of infections with coagulase-negative staphylococci, 87% with methicillin-sensitive Staphylococcus aureus, and 27% with methicillin-resistant S aureus. The percentage of catheters salvaged was 63% from 1990 to 1994, 63% from 1995 to 1999, 61% from 2000 to 2004, 72% from 2005 to 2009, and 76% from 2010 to 2013. CONCLUSION: Catheter salvage is possible after a CRBSI episode. Since most episodes of CRBSI are caused by skin commensals, effective treatment without removal of the central venous catheter is possible in most cases.

Prevalence and Contents of Advance Directives of Patients with ESRD Receiving Dialysis.

BACKGROUND AND OBJECTIVES: ESRD requiring dialysis is associated with increased morbidity and mortality rates, including increased rates of cognitive impairment, compared with the general population. About one quarter of patients receiving dialysis choose to discontinue dialysis at the end of life. Advance directives are intended to give providers and surrogates instruction on managing medical decision making, including end of life situations. The prevalence of advance directives is low among patients receiving dialysis. Little is known about the contents of advance directives among these patients with advance directives. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We retrospectively reviewed the medical records of all patients receiving maintenance in-center hemodialysis at a tertiary academic medical center between January 1, 2007 and January 1, 2012. We collected demographic data, the prevalence of advance directives, and a content analysis of these advance directives. We specifically examined the advance directives for instructions on management of interventions at end of life, including dialysis. RESULTS: Among 808 patients (mean age of 68.6 years old; men =61.2%), 49% had advance directives, of which only 10.6% mentioned dialysis and only 3% specifically addressed dialysis management at end of life. Patients who had advance directives were more likely to be older (74.5 versus 65.4 years old; P<0.001) and have died during the study period (64.4% versus 46.6%; P<0.001) than patients who did not have advance directives. Notably, for patients receiving dialysis who had advance directives, more of the advance directives addressed cardiopulmonary resuscitation (44.2%), mechanical ventilation (37.1%), artificial nutrition and hydration (34.3%), and pain management (43.4%) than dialysis (10.6%). CONCLUSIONS: Although one-half of the patients receiving dialysis in our study had advance directives, end of life management of dialysis was rarely addressed. Future research should focus on improving discernment and documentation of end of life values, goals, and preferences, such as dialysis-specific advance directives, among these patients.

Accuracy of Intravenous Electrocardiography Confirmation of Peripherally Inserted Central Catheter for Parenteral Nutrition.

BACKGROUND: Parenteral nutrition (PN) is a life-saving therapy for patients with intestinal failure. Safe delivery of hyperosmotic solution requires a central venous catheter (CVC) with tip in the lower superior vena cava (SVC) or at the SVC-right atrium (RA) junction. To reduce cost and delay in use of CVC, new techniques such as intravascular electrocardiogram (ECG) are being used for tip confirmation in place of chest x-ray (CXR). The present study assessed for accuracy of ECG confirmation in home PN (HPN). METHODS: Records for all patients consulted for HPN from December 17, 2014, to June 16, 2015, were reviewed for patient demographics, diagnosis leading to HPN initiation, and ECG and CXR confirmation. CXRs were subsequently reviewed by a radiologist to reassess location of the CVC tip and identify those that should be adjusted. RESULTS: Seventy-three patients were eligible, and after assessment for research authorization and postplacement CXR, 17 patients (30% male) with an age of 54 ± 14 years were reviewed. In all patients, postplacement intravascular ECG reading stated tip in the SVC. However, based on CXR, the location of the catheter tip was satisfactory (low SVC or SVC-RA junction) in 10 of 17 patients (59%). CONCLUSION: Due to the high osmolality of PN, CVC tip location is of paramount importance. After radiology review of CXR, we noted that 7 of 17 (41%) peripherally inserted central catheter lines were in an unsatisfactory position despite ECG confirmation. With current data available, intravenous ECG confirmation should not be used as the sole source of tip confirmation in patients receiving HPN.

Prevalence and Contents of Advance Directives in Patients Receiving Home Parenteral Nutrition.

BACKGROUND: Ethical issues may arise with patients who receive home parenteral nutrition (HPN) and have a change in their overall health status. We sought to determine the extent of advance care planning and the use of advance directives (ADs) by patients receiving HPN. MATERIALS AND METHODS: Retrospective review of the medical records of adult patients newly started on HPN at the Mayo Clinic, Rochester, Minnesota, between January 1, 2003, and December 31, 2012, to determine the prevalence and contents of their ADs. RESULTS: A total of 537 patients met the inclusion criteria. Mean (SD) age at commencement of HPN was 52.8 (15.2) years, and 39% (n = 210) were men. Overall, 159 patients (30%) had ADs. Many mentioned specific life-prolonging treatments: cardiopulmonary resuscitation (44 [28%]), mechanical ventilation (43 [27%]), and hemodialysis (19 [12%]). Almost half mentioned pain control (78 [49%]), comfort measures (65 [41%]), and end-of-life management of HPN (76 [48%]). Many also contained general statements about end-of-life care (no "heroic measures"). The proportion specifically addressing end-of-life management of HPN (48%) was much higher than that previously reported in other populations with other life-supporting care such as cardiac devices. The primary diagnosis or the indication for HPN was not correlated with whether or not the patient had an AD (P = .07 and .46, respectively). CONCLUSION: Although almost one-third of the patients had an AD, less than half specifically mentioned HPN in it, which suggests that such patients should be encouraged to execute an AD that specifically addresses end-of-life management of HPN.

Acute Effects of a Glucagon-Like Peptide 2 Analogue, Teduglutide, on Gastrointestinal Motor Function and Permeability in Adult Patients With Short Bowel Syndrome on Home Parenteral Nutrition.

BACKGROUND: Glucagon-like peptide 2 (GLP-2) agonists decrease the need for parenteral nutrition (PN) in short bowel syndrome (SBS); mechanisms evaluated to date have focused on the intestinotrophic effect of GLP-2 agonists such as increased absorptive capacity of the remnant intestine and increased citrulline levels. Other mechanisms may also play a role in effects of GLP-2 agonists. AIM: To measure effects of a GLP-2 agonist, teduglutide (TED), compared with placebo (PLA) on gastric emptying (GE), overall gut transit, fluid balance, intestinal monosaccharide absorption, and permeability in patients with SBS on home PN (HPN). MATERIALS AND METHODS: In 8 adults with SBS on HPN, we compared daily subcutaneous TED (0.05 mg/kg) and PLA (crossover design, each treatment 7 days with a 14-day washout) on gut transit, intestinal absorption, and permeability after oral mannitol (200 mg) and lactulose (1 g), as well as stool weight and urine volume over 8 hours. Analysis used the paired t test. RESULTS: Of 8 patients, 4 were men, with a mean ± SD age of 54 ± 1 years, body mass index of 25 ± 4 kg/m2, residual small intestine of 63 ± 12 cm, and 25% ± 15% of residual colon. The overall gut transit (% emptied at 6 hours) was 53.4% ± 15% for TED vs 62.4% ± 15.2% for PLA (P = .075), with no effect on GE (P = .74). TED increased urine mannitol excretion at 0-2 hours (16.2 ± 3.6 mg TED vs 11.3 ± 2.2 mg PLA, P = .20) and 0-8 hours (32.7 ± 5.9 mg PLA vs 48.8 ± 8.9 mg TED, P = .17). There were no differences in urine lactulose excretion or lactulose/mannitol ratio (0.024 ± 0.005 TED vs 0.021 ± 0.005 PLA). Over 8 hours, TED (vs PLA) numerically reduced stool weight (mean ± SEM, 77 ± 18 g TED vs 106 ± 43 g PLA, P = .42) and increased urine volume (408.9 ± 52.2 mL TED vs 365.7 ± 57.3 mL PLA, P = .34). CONCLUSION: Seven-day TED treatment in 8 participants suggests beneficial effects on fluid balance and monosaccharide absorption, and it retarded overall gut transit with no effects on GE or mucosal permeability. Larger, longer, mechanistic studies of TED in SBS are warranted. This trial was registered at clinicaltrials.gov as NCT02099084.

Hidradenitis Suppurativa in Patients With Inflammatory Bowel Disease: A Population-Based Cohort Study in Olmsted County, Minnesota.

BACKGROUND & AIMS: Patients with inflammatory bowel disease (IBD) may be at higher risk for hidradenitis suppurativa (HS). We studied the risk and clinical characteristics of HS in a population-based cohort of patients with IBD. METHODS: We identified all cases of HS (confirmed by biopsy and/or dermatologic evaluation) in a population-based inception cohort of Olmsted County, Minnesota, residents diagnosed with IBD between 1970 and 2004 and followed up through August 2013. We estimated the incidence rate ratio of HS in patients with IBD compared with the general population, and described the clinical characteristics, risk factors, and management of HS. RESULTS: In 679 IBD patients followed up over a median of 19.8 years, we identified 8 patients with HS (mean age, 44.4 ± 8.3 y; 7 women; 6 obese). Compared with the general population, the incidence rate ratio of HS in IBD was 8.9 (95% confidence interval, 3.6-17.5). The 10- and 30-year cumulative incidence of HS was 0.85% and 1.55%, respectively. Five patients had Crohn's disease, 4 of whom had perianal disease; of 3 patients with ulcerative colitis, 2 had undergone ileal pouch-anal anastomosis. Axillae, groin, and thighs were the most common sites of involvement. Six patients had Hurley stage 2 disease (recurrent abscesses with sinus tracts and scarring, involving widely separated areas), and required a combination of antibiotics and surgery; none of the patients were treated with anti-tumor necrosis factor-α agents. CONCLUSIONS: In this population-based study, patients with IBD were approximately 9 times more likely to develop HS than the general population, with a female predisposition.

Blenderized Tube Feeding Use in Adult Home Enteral Nutrition Patients: A Cross-Sectional Study.

BACKGROUND: Use of long-term enteral nutrition (EN) has increased dramatically in the United States. It has been the authors' experience that most home EN (HEN) patients use blenderized tube feeding (BTF) in addition to commercial EN. There are limited resources available for patients interested in BTF, and studies evaluating safety and effectiveness are limited. METHODS: The authors conducted a prospective cross-sectional study (n = 54). INCLUSION CRITERIA: age >18 years, follow-up in HEN clinic, prescribed commercial EN. Participants were provided the survey at HEN follow-up appointments after receiving HEN for at least 3 weeks. RESULTS: Median age (range) was 60.5 (22-87) years with 42.6% females (n = 23). BTF was used by 55.5% of patients (n = 30). Most (57%; n = 31) received HEN for >6 months. BTF use was a median of 4 (1-7) days per week. Most common reasons for using BTF were as follows: it is more natural (43%), like eating what their family does (33%), and tolerate BTF better (30%). In patients who use BTF, 80% reported maintaining goal body weight. BTF resulted in significantly less reported nausea, vomiting, bloating, diarrhea, and constipation compared with commercial EN. CONCLUSIONS: This is the first study to evaluate BTF use in an adult HEN population. More than 50% of our patients used and approximately 80% expressed a desire to use BTF if provided with adequate information. With new connection tube changes coming in the near future, adequate adapters for BTF need to be developed.

Effect of Medications on Risk of Cancer in Patients With Inflammatory Bowel Diseases: A Population-Based Cohort Study from Olmsted County, Minnesota.

OBJECTIVES: To estimate the overall risk of cancer in a population-based cohort of patients with inflammatory bowel disease (IBD) and how IBD-related medications modify this risk. METHODS: We identified all incident cancers (excluding nonmelanoma skin cancer) after IBD diagnosis in a cohort of 839 patients diagnosed as having IBD from January 1, 1940, through December 31, 2004, in Olmsted County, Minnesota, and followed up for a median 18 years through December 31, 2011 (122 patients taking biologic agents at last follow-up). We calculated standardized incidence ratios (SIRs) with 95% CIs of all cancers and compared cancer risk in patients treated with immunomodulators (IMMs) and biologics with that of patients not exposed to these medications, using an incidence rate ratio (IRR). RESULTS: One hundred nine patients developed 135 cancers. The 10-year cumulative probability of cancer was 3.8%. Patients with Crohn disease (SIR, 1.6; 95% CI, 1.2-2.1) but not ulcerative colitis (SIR, 1.1; 95% CI, 0.8-1.4) had an increased overall risk of cancer compared with the general population. Patients treated with IMMs (relative to IMM-naive patients) had an increased risk of melanoma (IRR, 5.3; 95% CI, 1.1-24.8) (and a numerically higher risk of hematologic malignant tumors [IRR, 4.2; 95% CI, 0.9-19.2]), although this risk returned to baseline on discontinuation of IMM treatment. Patients treated with biologics (relative to biologic-naive patients) had a numerically higher risk of hematologic malignant tumors (IRR, 5.3; 95% CI, 0.7-40.5). There was no significant increase in the risk of gastrointestinal malignancies in patients with IBD compared with the general population. CONCLUSIONS: We observed an increased risk of melanoma in IMM-treated patients with IBD, and this risk returned to baseline after discontinued use of the medications.

Association Between Study Quality and Publication Rates of Medical Education Abstracts Presented at the Society of General Internal Medicine Annual Meeting.

BACKGROUND: Studies reveal that 44.5% of abstracts presented at national meetings are subsequently published in indexed journals, with lower rates for abstracts of medical education scholarship. OBJECTIVE: We sought to determine whether the quality of medical education abstracts is associated with subsequent publication in indexed journals, and to compare the quality of medical education abstracts presented as scientific abstracts versus innovations in medical education (IME). DESIGN: Retrospective cohort study. PARTICIPANTS: Medical education abstracts presented at the Society of General Internal Medicine (SGIM) 2009 annual meeting. MAIN MEASURES: Publication rates were measured using database searches for full-text publications through December 2013. Quality was assessed using the validated Medical Education Research Study Quality Instrument (MERSQI). KEY RESULTS: Overall, 64 (44%) medical education abstracts presented at the 2009 SGIM annual meeting were subsequently published in indexed medical journals. The MERSQI demonstrated good inter-rater reliability (intraclass correlation range, 0.77-1.00) for grading the quality of medical education abstracts. MERSQI scores were higher for published versus unpublished abstracts (9.59 vs. 8.81, p = 0.03). Abstracts with a MERSQI score of 10 or greater were more likely to be published (OR 3.18, 95% CI 1.47-6.89, p = 0.003). ). MERSQI scores were higher for scientific versus IME abstracts (9.88 vs. 8.31, p < 0.001). Publication rates were higher for scientific abstracts (42 [66%] vs. 37 [46%], p = 0.02) and oral presentations (15 [23%] vs. 6 [8%], p = 0.01). CONCLUSIONS: The publication rate of medical education abstracts presented at the 2009 SGIM annual meeting was similar to reported publication rates for biomedical research abstracts, but higher than publication rates reported for medical education abstracts. MERSQI scores were associated with higher abstract publication rates, suggesting that attention to measures of quality--such as sampling, instrument validity, and data analysis--may improve the likelihood that medical education abstracts will be published.

A population-based study of incidence, risk factors, clinical spectrum, and outcomes of ischemic colitis.

BACKGROUND & AIMS: Little is known about progression of ischemic colitis (IC) among unselected patients. We aimed to estimate the incidence, risk factors, and natural history of IC in a population-based cohort in Olmsted County, Minnesota. METHODS: We performed a retrospective population-based cohort and nested case-control study of IC. Each IC case was matched to 2 controls from the same population on the basis of sex, age, and closest registration number. Conditional logistic regression, the Kaplan-Meier method, and proportional hazards regression were used to assess comorbidities, estimate survival, and identify characteristics associated with survival, respectively. RESULTS: Four hundred forty-five county residents (median age, 71.6 years; 67% female) were diagnosed with IC from 1976 through 2009 and were matched with 890 controls. The age-adjusted and sex-adjusted incidence rates of IC nearly quadrupled from 6.1 cases/100,000 person-years in 1976-1980 to 22.9/100,000 in 2005-2009. The odds for IC were significantly higher among subjects with atherosclerotic diseases; odds ratios ranged from 2.6 for individuals with coronary disease to 7.9 for individuals with peripheral vascular disease. Of IC cases, 59% survived for 5 years (95% confidence interval, 54%-64%), compared with 90% of controls (95% confidence interval, 88%-92%). Age >40 years, male sex, right-sided colon involvement, concomitant small bowel involvement, and chronic obstructive pulmonary disease were all independently associated with mortality (P < .05). CONCLUSIONS: The incidence of IC increased during the past 3 decades in a population-based cohort in Minnesota. IC typically presents in older patients with multiple comorbidities and is associated with high in-hospital mortality (11.5%) and rates of surgery (17%).

Targeted Physician Education Positively Affects Delivery of Nutrition Therapy and Patient Outcomes: Results of a Prospective Clinical Trial.

BACKGROUND: Malnutrition is a continuing epidemic among hospitalized patients. We hypothesize that targeted physician education should help reduce caloric deficits and improve patient outcomes. MATERIALS AND METHODS: We performed a prospective trial of patients (n = 121) assigned to 1 of 2 trauma groups. The experimental group (EG) received targeted education consisting of strategies to increase delivery of early enteral nutrition. Strategies included early enteral access, avoidance of nil per os (NPO) and clear liquid diets (CLD), volume-based feeding, early resumption of feeds postprocedure, and charting caloric deficits. The control group (CG) did not receive targeted education but was allowed to practice in a standard ad hoc fashion. Both groups were provided with dietitian recommendations on a multidisciplinary nutrition team per standard practice. RESULTS: The EG received a higher percentage of measured goal calories (30.1 ± 18.5%, 22.1 ± 23.7%, P = .024) compared with the CG. Mean caloric deficit was not significantly different between groups (-6796 ± 4164 kcal vs -8817 ± 7087 kcal, P = .305). CLD days per patient (0.1 ± 0.5 vs 0.6 ± 0.9), length of stay in the intensive care unit (3.5 ± 5.5 vs 5.2 ± 6.8 days), and duration of mechanical ventilation (1.6 ± 3.7 vs 2.8 ± 5.0 days) were all reduced in the EG compared with the CG (P < .05). EG patients had fewer nosocomial infections (10.6% vs 23.6%) and less organ failure (10.6% vs 18.2%) than did the CG, but these differences did not reach statistical significance. CONCLUSION: Implementation of specific educational strategies succeeded in greater delivery of nutrition therapy, which favorably affected patient care and outcomes.