Crohn's disease: does race matter? The Mid-Atlantic Crohn's Disease Study Group.

OBJECTIVE: The severity of Crohn's disease (CD) has been reported to be greater in blacks than in whites. This possible disparity may be due, in part, to differences between these groups in health care utilization and accessibility. To explore these issues, we conducted a multicenter survey of patients with CD. METHODS: One-hundred and forty-five blacks with CD, recruited from four teaching hospitals and five private practices, and identified by medical record review or ICD-9 code, were enrolled and matched to 407 whites with CD (by age, gender, and practice type [teaching vs. private practice setting]). Participants were interviewed regarding medical history, health status, personal health care practices during the preceding 5 yr, and beliefs regarding health care in the general population. RESULTS: Blacks and whites were similar with respect to age of CD onset, lag in time to diagnosis, and number of gastrointestinal (GI)-related hospitalizations and surgeries. Medication usage patterns were also similar in the two groups. Quality of life, measured by SF-36, was lower in all categories for blacks, compared with whites. Blacks were more likely to have had to stop work (p<0.01) and have lost more work days (p<0.01) than were whites. Whites were more likely to have health insurance and be able to identify a regular provider than were blacks. Blacks were more likely to report the following: receiving Medicaid; difficulty affording health care; delaying appointments due to financial concerns; difficulty traveling to their provider's office; and experiencing unreasonable delays at their provider's office. After adjusting for potential confounding variables, we found no differences between the groups, except for the number of days of work lost because of CD. CONCLUSIONS: These data suggest that black and white patients have similar reported disease presentations and course, and contrast with prior reports suggesting a more severe disease course among black patients. Although the disease itself appears similar, there were numerous reported differences between the races in health care utilization practices and in disease impact upon daily activities. We suggest that apparent disparities in CD according to race are actually due to social and economic factors, and not to the disease itself.

Oral mesalamine (Asacol) for mildly to moderately active ulcerative colitis. A multicenter study.

OBJECTIVE: To evaluate the efficacy and safety of a pH-sensitive, polymer-coated oral preparation of mesalamine in patients with mildly to moderately active ulcerative colitis. DESIGN: A multicenter, double-blind, placebo-controlled randomized trial. SETTING: Five university-based medical centers, one inflammatory bowel disease center, and three private practice sites. PATIENTS: A total of 158 patients with newly or previously diagnosed active ulcerative colitis. INTERVENTION: A pH-sensitive, polymer-coated oral preparation of mesalamine (5-aminosalicylic acid) was used at 1.6 and 2.4 g/d for 6 weeks. MEASUREMENTS: Efficacy was measured by scores for stool frequency, rectal bleeding, patient's functional assessment, sigmoidoscopic findings, and physician's global assessment. Stringent criteria for disease activity were established prospectively. RESULTS: The analysis of protocol-compliant patients showed a significant improvement at 3 weeks in patients taking 2.4 g/d of mesalamine compared with patients taking placebo (32% versus 9%; P = 0.003). At 6 weeks, both the 1.6 g/d (43%) and 2.4 g/d (49%) doses were significantly superior to placebo (23%) (P = 0.03 and P = 0.003, respectively). In addition, more patients worsened in the placebo group compared with the 2.4 g/d group (50% versus 19%; P = 0.003); however, there was no statistically significant difference in worsening between the 1.6 g/d mesalamine group and the placebo group. The oral mesalamine tablet was well tolerated, and no clinically significant changes were observed in hematologic, hepatic, or renal laboratory profiles. CONCLUSION: Colon-targeted oral mesalamine at 2.4 g/d is effective therapy for mildly to moderately active ulcerative colitis. It is well tolerated and should provide a viable therapeutic alternative to sulfasalazine.

Potential economic impact of applying DRG-based prospective payment categories to inflammatory bowel disease patients.

New incentives regarding delivery of inpatient care by physicians and administrators have resulted from Medicare's DRG-based prospective reimbursement system. As these payment systems become widely adopted by other third-party payors, implications for adequate hospital reimbursement and quality inpatient care will intensify. This study of inflammatory bowel disease inpatients examines discharge data for 300 patients comprising 507 admissions from 1983 to 1987 at a large tertiary center hospital. While only 10.8% of these discharges were Medicare patients, all discharges were assigned a diagnosis-related-group reimbursement to derive a theoretical monetary loss or gain for the hospital. Overall hospital losses averaged $127.24 per case for this patient population, in which the medical and pediatric cases were adequately reimbursed, and the surgical admissions represented greater losses. The average length of stay for all patients decreased from 11.9 to 7.4 days over the study period, mostly a result of reductions in surgical hospital stays. We conclude that reimbursement for medical and pediatric discharges under DRG 179 appear adequate for this hospital, while surgical inflammatory bowel disease reimbursement is not. These data will be useful for comparison of future trends of inpatient utilization for inflammatory bowel disease patients as prospective reimbursement practices become more widespread.

Pulmonary vasculitis complicating ulcerative colitis.

Pulmonary vasculitis is an infrequent complication of ulcerative colitis. The patient reported herein had biopsy-proven pulmonary vasculitis on two occasions, associated with flares in ulcerative colitis. The diagnosis of this entity is best made by open lung biopsy. Corticosteroid therapy appears to be a rational first step in the management of this condition.

Chronic granulomatous disease of childhood presenting as gastric outlet obstruction.

A case of chronic granulomatous disease of childhood was first diagnosed when a 20-month-old infant developed gastric outlet obstruction. Because of the unusual clinical presentation and negative gastric mucosal biopsies, the diagnosis was delayed. A subsequent full thickness biopsy of the stomach wall which led to a correct diagnosis showed a granulomatous infiltrate in the muscularis propria. Characteristic yellow pigment-laden macrophages were seen in the gastric mucosa and pyloric lymph node. Early recognition of this chronic disorder is important not only for proper management but genetic counseling as well.

Fiberoptic colonoscopic examination in surgical patients with colorectal cancer.

A diagnostic and surveillance program using colonscopy in patients with colorectal cancer was established at North Carolina Memorial Hospital. The records of all patients who had preoperative or postoperative colonoscopic examination between 1976 and 1979 were reviewed. Fifty-five patients had colonscopic examination preoperatively. No additional disease was found in 39. In 15 patients, unsuspected additional disease was detected, and one patient had a suspected polyp ruled out by colonoscopic examination. One of these patients was found to have a synchronous primary cancer, not demonstrated by barium enema. Surgical treatment was modified in nine (16%) of these 55 patients by the preoperative colonoscopic findings. Sixty patients had colonoscopy six months to six years postoperatively. No additional disease was found in 47. Adenomatous polyps were found in eight. Two patients had recurrent cancer proved by colonoscopy, and three had a second primary cancer detected only by colonoscopy. Treatment was directly influenced by colonoscopy in eight (13.3%) of these 60 patients. These studies had a favorable cost/benefit ratio in patients with colorectal cancer and support a program of preoperative colonoscopy in patients with colorectal cancer and reexamination within two to three years after operation.

National Cooperative Crohn's Disease Study: results of drug treatment.

The response of active and quiescent Crohn's disease to prednisone, sulfasalazine, or azathioprine has been studied in 569 patients in a placebo-controlled, randomized, multicenter cooperative trial. The response of active symptomatic disease to prednisone or sulfasalazine was significantly better than to placebo. Response to azathioprine was better than to placebo, but the difference did not reach conventional levels of statistical significance. Patients with colonic involvement were especially responsive to sulfasalazine, and those with small bowel involvement were especially responsive to prednisone. Patients' drug therapy immediately before entry to the study significantly affected subsequent response. For patients with quiescent disease, none of the drugs was superior to placebo in prophylaxis against flare-up or recurrence. There is less than a 5% risk that a clinically significant prophylactic effect of any of the drug regimens was missed.

Correlations between clinical, blood leukocyte, and skin test data in the National Cooperative Crohn's Disease Study.

Peripheral blood leukocyte counts, percentages of lymphocytes and granulocytes, serum albumin levels, and results of skin tests with five antigens were examined in patients randomized in the National Cooperative Crohn's Disease Study. Inspection for differences from normal and correlations with a variety of variables showed no unusual characteristics except for a high incidence of anergy (31%) at randomization, and ranging up to 47.5% after treatment.

Intestinal function and morphology in strongyloidiasis.

Divergent available information on the capability of Strongyloides stercoralis to cause malabsorption prompted a long-term observation in which the nutritional state of the subjects was carefully defined. In spite of moderate to severe symptoms, well nourished patients, even with segmental jejunitis, did not show malabsorption. All patients presenting this parasitic infection with concomitant malnutrition showed absorptive defects. Abnormal absorption persisted in spite of parasitic cure when malnutrition was not immediately corrected, and disappeared with correction of the malnutrition even if parasitic infection was allowed to continue. The present experience indicates that the malabsorption syndrome seen in some cases of S. stercoralis infection is secondary to the concomitant malnutrition and not to the parasite per se.