The prevalence of Clostridium difficile infection in pediatric and adult patients with inflammatory bowel disease.

OBJECTIVES: Adults with inflammatory bowel disease (IBD) have a high prevalence of Clostridium difficile infection (CDI). CDI in children with IBD may differ from adults. We aim to compare the prevalence of CDI in hospitalized pediatric and adult IBD patients and patients without IBD. METHODS: The rates of CDI per 1,000 IBD and non-IBD hospitalizations between 1993 and 2012 were examined using the Maryland Health Services Cost Review Commission database. Age, sex and calendar year adjusted incidence rate ratios comparing CDI in pediatrics and adults by type of IBD and with patients without IBD were calculated. p values for trend identifying changes in rates over time were calculated. RESULTS: Among children, the rate of CDI was over 12 times greater in IBD than non-IBD hospitalizations (p < 0.0001) and among adults, the rate of CDI was four times greater in IBD than non-IBD hospitalizations (p < 0.0001). In adults, CDI was significantly higher in ulcerative colitis (UC) than Crohn's disease (60.4 per 1,000 vs. 19.8 per 1,000, p < 0.0001) but in children there was no difference in CDI in UC compared with Crohn's disease (32 per 1,000 vs. 27 per 1,000, p = 0.45). The prevalence of CDI increased in pediatric and adult IBD patients, and patients without IBD, between 1993 and 2012 (p for trend <0.0001). CONCLUSIONS: CDI was more common in adult patients with UC, and no difference was found between CDI and IBD type in pediatrics. There may be different risk factors for CDI during hospitalization between adults and children with IBD.

Endoscopic and clinical responses to anti-tubercular therapy can differentiate intestinal tuberculosis from Crohn's disease.

BACKGROUND: Differentiation between intestinal tuberculosis and Crohn's disease is difficult and may require therapeutic trial with anti-tubercular therapy in tuberculosis-endemic regions. AIM: To evaluate the role of therapeutic trial with anti-tubercular therapy in patients with diagnostic confusion between intestinal tuberculosis and Crohn's disease. METHODS: We performed retrospective-comparative (n = 288: 131 patients who received anti-tubercular therapy before being diagnosed as Crohn's disease and 157 intestinal tuberculosis patients) and prospective-validation study (n = 55 patients with diagnostic confusion of intestinal tuberculosis/Crohn's disease). Outcomes assessed were global symptomatic response and endoscopic mucosal healing. RESULTS: In the derivation cohort, among those eventually diagnosed as Crohn's disease, global symptomatic response with anti-tubercular therapy was seen in 38% at 3 months and in 37% who completed 6 months of anti-tubercular therapy. Ninety-four per cent of intestinal tuberculosis patients showed global symptomatic response by 3 months. Endoscopic mucosal healing was seen in only 5% of patients with Crohn's disease compared with 100% of intestinal tuberculosis patients. In the validation cohort, all the patients with intestinal tuberculosis had symptomatic response and endoscopic mucosal healing after 6 months of anti-tubercular therapy. Among the patients with an eventual diagnosis of Crohn's disease, symptomatic response was seen in 64% at 2 months and in 31% who completed 6 months of anti-tubercular therapy, none had mucosal healing. CONCLUSIONS: Disproportionately lower mucosal healing rate despite an overall symptom response with 6 months of anti-tubercular therapy in patients with Crohn's disease suggests a need for repeat colonoscopy for diagnosing Crohn's disease. Patients with intestinal tuberculosis showing significant symptomatic response after 2-3 months of anti-tubercular therapy, suggest that symptom persistence after a therapeutic trial of 3 months of anti-tubercular therapy may indicate the diagnosis of Crohn's disease.

The Wand vs. traditional injection: a comparison of pain related behaviors.

PURPOSE: The purpose of this study was to evaluate the efficacy of a computerized anesthesia delivery system (e.g., Wand) compared to a traditional anesthesia administration, with respect to reducing disruptive pain related behavior during injections. METHODS: Subjects consisted of 62 patients between the ages of 5 and 13 requiring local anesthesia for dental restorations in the maxilla. Patients were randomly assigned to either the Wand or the traditional anesthetic delivery system. A palatal approach to the anterior and middle superior alveolar nerves and the anterior superior alveolar nerve was used with the Wand injections. Buccal infiltration and palatal injections were used for the traditional method. Pain behavior was observed and coded. Pain ratings were obtained. Subjects also rated their satisfaction with treatment. RESULTS: Results of chi-square tests found that the Wand injections produced significantly fewer patients who exhibited disruptive behavior during the initial 15 seconds of an injection when compared with those who received a traditional palatal injection. Wand patients were significantly less likely to cry, to exhibit disruptive body movements, and to require physical restraint. In contrast, there were no significant differences in disruptive behavior when comparing the Wand with the traditional buccal injection. Pain ratings showed no statistical difference between the Wand and the traditional injections. CONCLUSION: Wand injections can deliver proper anesthesia, utilizing one palatal injection site, while significantly reducing the likelihood of disruptive behaviors during the initial moments of an injection.

Lower regional and temporal ultraviolet exposure is associated with increased rates and severity of inflammatory bowel disease hospitalisation.

BACKGROUND: In the northern hemisphere, the incidence of inflammatory bowel diseases (IBD) has a north-south gradient, suggesting a link between ultraviolet (UV) exposure or vitamin D status and the pathogenesis of IBD. AIM: To test the association of UV exposure with the rates and severity of IBD hospitalisation. METHODS: We conducted a retrospective nationwide analysis of 649 932 Crohn's disease (CD), 384 267 ulcerative colitis (UC), and 288 894 297 non-IBD hospitalisations in the US between 1998 and 2010. Mean UV exposure was assigned to each hospitalisation using surface measures from the National Oceanic and Atmospheric Administration. Relative rates across UV exposures were estimated for IBD hospitalisations, prolonged hospitalisations, bowel surgeries and deaths. RESULTS: Among IBD patients, lower UV exposures had increased hospitalisation rates for CD (217.8 vs. 182.5 per 100 000 overall hospitalisations with low and very high UV, respectively; P trend <0.001) and UC (123.2 vs. 113.8 per 100 000; P trend = 0.033). Low UV groups had greater relative rates of prolonged hospitalisations [CD: 1.13, 95% confidence interval (CI) 1.07-1.19; UC: 1.21, 95% CI 1.13-1.30], bowel surgeries (CD: 1.24, 95% CI 1.16-1.32; UC: 1.21, 95% CI 1.09-1.33), and CD deaths (CD: 1.76, 95% CI 1.14-2.71; UC: 1.24, 95% CI 0.92-1.67). Among non-IBD patients, low UV was associated with prolonged hospitalisations (1.09; 95% CI 1.07-1.11) and deaths (1.13; 95% CI 1.09-1.17), but not bowel surgeries (1.01; 95% CI 0.99-1.03). CONCLUSIONS: Lower ultraviolet exposure is associated with greater rates of hospitalisation, prolonged hospitalisation and the need for bowel surgery in IBD. This trend for bowel surgery was not seen with non-IBD encounters.

Systematic review with network meta-analysis: pharmacological prophylaxis against post-ERCP pancreatitis.

BACKGROUND: The efficacy of many pharmacological agents for preventing post-ERCP pancreatitis (PEP) has been evaluated in randomised controlled trials (RCTs), but it is unclear which agent(s) should be used in clinical practice. Network meta-analyses of RCTs are used to simultaneously compare several agents to determine their relative efficacy and identify priority agents for comparison in future RCTs. AIM: To evaluate pharmacological agents for the prevention of PEP by conducting a network meta-analysis of RCTs. METHODS: We searched MEDLINE, EMBASE and Cochrane Library databases for RCTs that evaluated the efficacy of agents for preventing PEP. RCTs were simultaneously analysed using random-effects network meta-analysis under the Bayesian framework to identify the best agents. The efficacy of agents was ordered according to the probability of being ranked as any of the top three best performing agents. RESULTS: The network meta-analysis included 99 RCTs evaluating 16 agents in 25 313 patients. Topical epinephrine (adrenaline) was the most efficacious agent with 85.9% probability of ranking among the top three agents, followed by nafamostat (51.4%), antibiotics (44.5%) and NSAIDs (42.8%). However, in a sensitivity analysis including only rectal NSAIDs, NSAIDs moved from fourth rank to second (58.1%). Patients receiving topical epinephrine, compared with placebo, had a 75% reduced risk of PEP (OR 0.25, 95% probability interval 0.06-0.66). CONCLUSIONS: Topical epinephrine and rectal NSAIDs are the most efficacious agents for preventing post-ERCP pancreatitis, based on existing RCTs. Combinations of these agents, which act on different steps in the pathogenesis of post-ERCP pancreatitis, should be evaluated in future trials.

Screening differences and risk of cervical cancer in inflammatory bowel disease.

BACKGROUND: Cervical cancer risk is high among immune suppressed women. AIM: To evaluate inflammatory bowel disease (IBD) with medications and risk of cervical cancer. METHODS: Members of Kaiser Permanente Northern California (KPNC), 15-68 years from 1996 to 2006 with IBD were compared with age-matched women without IBD. Cervical cancer was ascertained using the KPNC Cancer Registry. IBD medications of interest were aminosalicylates (ASA), corticosteroids, immune modulators and infliximab. Odds of cervical cancer were analysed with adjusted logistic regression. The prevalence of Pap smear testing was compared using a log binomial model. RESULTS: Ten cervical cancer cases occurred among 1165 women with IBD and 72 cancers among 12 124 controls. The adjusted odds ratio (OR) of IBD with risk of cervical cancer was 1.45 [95% confidence interval (CI) 0.74-2.84]. Medication ORs were 1.65 for ASA, 2.79 for corticosteroids and 3.45 for immune modulators (all P > 0.05). No cancer case used infliximab. The adjusted absolute increase in Pap smears among IBD women compared to women without IBD was 4% (95% CI 2-5%). CONCLUSIONS: Although a trend of elevated risk for cervical cancer with IBD and IBD medications was observed, it was not statistically significant. Regular cervical cancer screening for women with IBD is recommended.