Faculty Bibliography

Crohn disease is a chronic inflammatory condition that primarily affects the gastrointestinal tract. Typical manifestations include fever, weight loss, fatigue, and abdominal pain, and abdominal abscesses and fistulae are frequent complications. Abdominal actinomycosis is a subacute or indolent disease associated with Actinomyces spp. Symptoms can be very similar to those of Crohn disease, and fistulae are also common. Since ulcerations in the intestinal tract are thought to be caused by Actinomyces escaping from the gut lumen and establishing intra-abdominal infection, it seems likely that abdominal actinomycosis may occur in patients with inflammatory bowel disease. We report a case of abdominal actinomycosis in a woman with active Crohn disease.

BACKGROUND/AIMS/OBJECTIVE:Variation exists among anesthesia providers as to acceptable timing of NPO ("nothing by mouth") for elective colonoscopy procedures. There is a need to balance optimal colonic preparation, patient convenience, and scheduling efficiency with anesthesia safety concerns. We reviewed the evidence for the relationship between NPO timing and aspiration incidence and colonoscopy rescheduling. METHODS:We searched MEDLINE (1990-April 2015) for English language studies of any design and included them if at least one bowel preparation regimen was completed within 8 hours of colonoscopy. Study characteristics, patient characteristics, and outcomes were abstracted and verified by investigators. We determined risk of bias for each study and overall strength of evidence for primary and secondary outcomes. RESULTS:We included 28 randomized controlled trials (RCTs), 2 controlled clinical trials, and 10 observational reports. Six studies reported on aspiration; none found that shorter NPO status prior to colonoscopy increased aspiration risk, though studies were not designed to assess this outcome (low strength of evidence). One RCT found fewer rescheduled procedures following split-dose preparation but NPO status was not well-documented (insufficient evidence). CONCLUSIONS:Aspiration incidence requiring hospitalization during colonoscopy with moderate or deep sedation is very low. No study found that shorter NPO status prior to colonoscopy increased aspiration risk. We did not find direct evidence of the effect of NPO status on colonoscopy rescheduling.

AIM/OBJECTIVE:Inadequate bowel preparation continues to be a substantial problem for colonoscopy. The seven-point Bristol Stool Form Scale (BSFS) has been associated with delayed colonic transit in adults. We evaluated the utility of the BSFS to identify patients more likely to present with an inadequate preparation. METHOD/METHODS:Two large community-based academic medical centres in New Jersey, USA, studied a prospective cohort of 411 consecutive patients undergoing outpatient colonoscopy who were prescribed similar bowel preparations. The BSFS and several other study variables were collected by gastroenterology fellows during an outpatient visit prior to scheduling colonoscopy. All colonoscopy examinations were performed in the morning by a gastroenterologist who graded the adequacy of bowel preparation. Inadequate preparation was defined as one resulting in a repeat colonoscopy at a shorter time interval than would generally be recommended based solely on risk factors or pathological findings. The ability of study variables to discriminate those who did or did not have an adequate preparation was summarized by the c-statistic. The relationship between variables that provided some discrimination and the probability of an adequate preparation was modelled using logistic regression. RESULTS:The mean age of the study sample was 56 ± 8 (SD) years and 63% were women. Bowel preparation was adequate in 337 (82%) of the patients. The BSFS ratings ranged from 1 to 7. The score was <3 in 144 (35%) indicating lower gastrointestinal motility. There was a statistically significant association between the score and the probability of an adequate bowel preparation (odds ratio 1.4; 95% confidence interval 1.2-1.7; P < 0.001) and the c-statistic was 0.64 (0.58-0.70). CONCLUSION/CONCLUSIONS:Use of the BSFS may help identify patients for whom standard bowel preparation most probably will not be adequate.

BACKGROUND:Inflammatory bowel diseases (IBDs) are group of chronic inflammatory illnesses with a remitting and relapsing course that may result in appreciable morbidity and high medical costs secondary to repeated hospitalizations. The study's objectives were to identify the reasons for hospitalization among patients with inflammatory bowel diseases, and compare inpatient courses and readmission rates for IBD-related admissions versus non-IBD-related admissions. METHODS:A retrospective chart review was performed on all patients with IBD admitted to the Minneapolis VA Medical Center between September 2010 and September 2012. RESULTS:A total of 111 patients with IBD were admitted during the 2-year study period. IBD flares/complications accounted for 36.9 % of the index admissions. Atherothrombotic events comprised the second most common cause of admissions (14.4 %) in IBD patients. Patients with an index admission directly related to IBD were significantly younger and had developed IBD more recently. Unsurprisingly, the IBD admission group had significantly more gastrointestinal endoscopies and abdominal surgeries, and was more likely to be started on medication for IBD during the index stay. The median length of stay (LOS) for the index hospitalization for an IBD flare or complication was 4 (2-8) days compared with 2 (1-4) days for the other patients (P = 0.001). A smaller percentage of the group admitted for an IBD flare/complication had a shorter ICU stay compared with the other patients (9.8 % vs. 15.7 %, respectively); however, their ICU LOSs tended to be longer (4.5 vs. 2.0 days, respectively, P = 0.17). Compared to the other admission types, an insignificantly greater percentage of the group whose index admission was related to an IBD flare or complication had at least one readmission within 6 months of discharge (29 % versus 21 %; P = 0.35). The rate of admission was approximately 80 % greater in the group whose index admission was related to an IBD flare or complication compared to the other types of admission (rate ratio 1.8, 95 % confidence interval 0.96 to 3.4), although this difference did not reach statistical significance (P = 0.07). CONCLUSION/CONCLUSIONS:Identifying the reasons for the patients' index admission, IBD flares versus all other causes, may provide valuable information concerning admission care and the subsequent admission history.

OBJECTIVE:The objective of this study was to determine what proportion of veterans previously screened for colorectal cancer (CRC) using fecal immunochemical testing (FIT) would be willing to undergo a second round of FIT screening. METHODS:Patients in the Iowa City Veterans Affairs Health Care System (<65 years old, asymptomatic, average risk, overdue for CRC screening) who completed a mailed FIT (April 2011 to May 2012) were contacted 1 year later by telephone to collect demographic and recent CRC screening information, and were offered a second mailed FIT if eligible. RESULTS:Of 204 veterans who completed initial FIT testing, 159 were eligible to participate in a second round of FIT screening; 132 (83%) participated in the telephone survey, and 126 (79%) completed a second annual FIT, with 10 (8%) individuals testing positive. The majority of participants (67%) reported being more likely to take a yearly FIT than a colonoscopy every 10 years. Participants overwhelmingly reported that the FIT was easy to use and convenient (89%), and they were likely to complete a mailed FIT each year (97%). CONCLUSIONS:Those willing to take a mailed FIT seem satisfied with this method and willing to do it annually. Population-based or provider-based FIT mailing programs have the potential to increase CRC screening in overdue populations.

OBJECTIVES/OBJECTIVE:To examine the receipt of colonoscopy through the Veterans Health Administration (VA) or through Medicare by older veterans who are dually enrolled. STUDY DESIGN/METHODS:Retrospective cohort study. METHODS:The VA Outpatient Care Files and Medicare Enrollment Files were used to identify 1,060,523 patients 65 years and older in 15 of the 22 Veterans Integrated Service Networks nationally, who had 2 or more VA primary care visits in 2009 and who were simultaneously enrolled in Medicare. VA and Medicare files were used to identify the receipt of an outpatient colonoscopy. Patients were categorized as receiving care in community-based outpatient clinics (CBOCs) (n=601,337; 57%) or VA medical centers (n=459,186; 43%) based on where most patient-centered encounters occurred. Analyses used multinomial logistic regression to identify patient characteristics related to the odds of receiving a colonoscopy at the VA or through Medicare. RESULTS:Patients had a mean age of 76.9 (SD=7.0) years; 98% were male, 89% were white, and 21% resided in a rural location. Overall, 100,060 (9.4%) patients underwent outpatient colonoscopy either through the VA (n=33,600; 35.5%) or Medicare providers (n=65,716; 65.5%). The adjusted odds of receiving a colonoscopy from Medicare providers were higher (P<.001) for patients who were male, white, receiving primary care at CBOCs, and for residents of an urban location. The receipt of colonoscopy through the VA decreased dramatically by age; for example, the odds of colonoscopy by the VA in patients aged >85 years and 80 to 84 years, relative to patients aged 65 to 69 years, were 0.26 and 0.13, respectively. In contrast, the receipt of colonoscopy through Medicare did not decline as markedly with age. CONCLUSIONS:In a national analysis of the receipt of an outpatient colonoscopy by older veterans, more veterans received their colonoscopies through CMS than through the VA. The use of colonoscopy within the VA was found to be more concordant with age-related practice guidelines.

OBJECTIVES/OBJECTIVE:Despite vigorous infection control measures, Clostridium difficile continues to cause significant disease burden. Antibiotic stewardship programmes (ASPs) may prevent C. difficile infections by limiting exposure to certain antibiotics. Our objective was to perform a meta-analysis of published studies to assess the effect of ASPs on the risk of C. difficile infection in hospitalized adult patients. METHODS:Searches of PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature and two Cochrane databases were conducted to find all published studies on interventions related to antibiotic stewardship and C. difficile. Two investigators independently assessed study eligibility and extracted data. Risk of bias was assessed using the Downs and Black tool. Risk ratios were pooled using random effects models. Heterogeneity was evaluated using the I(2) statistic. RESULTS:The final search yielded 891 articles; 78 full articles were reviewed and 16 articles were identified for inclusion. Included articles used quasi-experimental (interrupted time series or before-after) or observational (case-control) study designs. When the results of all studies were pooled in a random effects model, a significant protective effect (pooled risk ratio 0.48; 95% CI: 0.38, 0.62) was observed between ASPs and C. difficile incidence. When stratified by intervention type, a significant effect was found for restrictive ASPs (complete removal of drug or prior approval requirement). Furthermore, ASPs were particularly effective in geriatric settings. CONCLUSIONS:Restrictive ASPs can be used to reduce the risk of C. difficile infection.