Update on the Natural Course of Fistulizing Perianal Crohn's Disease in a Population-Based Cohort.

BACKGROUND: This study sought to re-estimate the cumulative incidence of perianal or rectovaginal fistulas and the associated proctectomy rate in the prebiologic era vs the biologic era using a population-based cohort of Crohn's disease (CD) patients. METHODS: The medical records of 414 residents of Olmsted County, Minnesota, who were diagnosed with CD between 1970 and 2010 were reviewed. The cumulative incidence of perianal or rectovaginal fistulas from time of CD diagnosis and the cumulative rate of proctectomy from date of first perianal or rectovaginal fistula diagnosis were estimated using the Kaplan-Meier method. RESULTS: Eighty-five patients (20.5%) diagnosed with CD between 1970 and 2010 had at least 1 perianal or rectovaginal fistula episode between January 1, 1970, and June 30, 2016. The cumulative incidence of perianal or rectovaginal fistulas was 18% after 10 years, 23% after 20 years, and 24% after 30-40 years from CD diagnosis. The cumulative incidence of perianal or rectovaginal fistulas was significantly lower in patients diagnosed in 1998 or after than in patients diagnosed before 1998 (P = 0.03, log-rank). Among 85 patients developing perianal or rectovaginal fistulas, 16 patients (18.8%) underwent proctectomy for the treatment of perianal or rectovaginal fistulas during follow-up. CONCLUSIONS: In a population-based inception cohort of CD, one-fifth of patients were diagnosed with at least 1 perianal or rectovaginal fistula. The cumulative probability of perianal or rectovaginal fistulizing disease has decreased over time.

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.

Clinical predictors of recurrent Clostridium difficile infection in out-patients.

BACKGROUND: Clostridium difficile infection (CDI) recurs in 20-30% of patients. AIM: To describe the predictors of recurrence in out-patients with CDI. METHODS: Out-patient cases of CDI in Olmsted County, MN residents diagnosed between 28 June 2007 and 25 June 2010 were identified. Recurrent CDI was defined as recurrence of diarrhoea with a positive C. difficile PCR test from 15 to 56 days after the initial diagnosis with interim resolution of symptoms. Patients who had two positive tests within 14 days were excluded. Cox proportional hazard models were used to assess the association of clinical variables with time to recurrence of CDI. RESULTS: The cohort included 520 out-patients; 104 had recurrent CDI (cumulative incidence of 17.5% by 30 days). Univariate analysis identified increasing age and antibiotic use to be associated with recurrent CDI. Severe CDI, peripheral leucocyte count and change in serum creatinine >1.5-fold were not. In a multiple variable model, concomitant antibiotic use was associated with risk of recurrent CDI (HR = 5.4, 95% CI 1.6-17.5, P = 0.005), while age (HR per 10 year increase = 1.1, 95% CI 0.9-1.3, P = 0.22); peripheral leucocyte count >15 × 10(9) /L (HR = 1.0, 95% CI 0.5-2.1, P = 0.92); and change in serum creatinine greater than 1.5-fold (HR = 0.8, 95% CI 0.4-1.5, P = 0.44) were not. CONCLUSIONS: Antibiotic use was independently associated with a dramatic risk of recurrent Clostridium difficile infection in an out-patient cohort. It is important to avoid unnecessary systemic antibiotics in patients with Clostridium difficile infection, and patients with ongoing antibiotic use should be monitored closely for recurrent infection.

Single-port and four-port laparoscopic cholecystectomy: difference in outcomes.

AIM: Patients prefer minimally invasive procedures with fast recovery, minimal pain and good cosmesis. Single-port cholecystectomy may decrease the need for narcotic pain medication and thus shorten recovery. Outcome-based evidence for this procedure is still being assembled. METHODS: Single-port cholecystectomy patients were matched based on age and gender with control patients undergoing four-port cholecystectomy during the same time. The primary endpoint was in hospital use of narcotic pain medication, measured by morphine equivalents. Secondary endpoints were operative time and length of stay. Statistical analysis was done by Student's t-test. RESULTS: Fifty patients (36 women, 14 men) underwent single port cholecystectomy between 11/2009-7/2012 and 50 patients underwent traditional cholecystectomy during the same time period. All patients were matched within 10 years of age. Morbidity was 4% for the single port group, 0% for the traditional cholecystectomy. There were no conversions to open cholecystectomy. The single-port group required a median of 29.0 mg (range, 8.7-180 mg) morphine equivalents of pain medication and the control group required a median of 33.2 mg (range, 0-185.7 mg) morphine equivalents (P=0.04). Single port cholecystectomy operative times were longer (median, 85 vs. 77 minutes, P=0.03). CONCLUSION: In this small study, there is a statistically significant difference in narcotic use during the initial hospital stay was measured between the two groups. After the initial ten cases, the operative time for single-port cholecystectomy approximated the standard four-port cholecystectomy. Prospective randomized controlled trials are necessary to investigate differences in outcomes between the two approaches.

Analysis of heart rate and heart rate variation during cardiac CT examinations.

RATIONALE AND OBJECTIVES: We sought to examine heart rate and heart rate variability during cardiac computed tomography (CT). MATERIALS AND METHODS: Ninety patients (59.0 +/- 13.5 years) underwent coronary CT angiography (CTA), with 52 patients also undergoing coronary artery calcium scanning (CAC). Forty-two patients with heart rate greater than 70 bpm were pretreated with oral beta-blockers (in five patients, use of beta-blocker was not known). Sixty-four patients were given sublingual nitroglycerin. Mean heart rate and percentage of beats outside a +/-5 bpm region about the mean were compared between baseline (free breathing), prescan hyperventilation, and scan acquisition (breath-hold). RESULTS: Mean scan acquisition time was 13.1 +/- 1.5 seconds for CAC scanning and 14.2 +/- 2.9 seconds for coronary CTA. Mean heart rate during scan acquisition was significantly lower than at baseline (CAC 58.2 +/- 8.5 bpm; CTA 59.2 +/- 8.8 bpm; baseline 62.8 +/- 8.9 bpm; P < .001). The percentage of beats outside a +/-5 bpm about the mean were not different between baseline and CTA scanning (3.5% versus 3.3%, P = .87). The injection of contrast had no significant effect on heart rate (58.2 bpm versus 59.2 bpm, P = .24) or percentage of beats outside a +/-5 bpm about the mean (3.0% versus 3.3%, P = .64). No significant difference was found between gender and age groups (P > .05). CONCLUSIONS: Breath-holding during cardiac CT scan acquisition significantly lowers the mean heart rate by approximately 4 bpm, but heart rate variability is the same or less compared with normal breathing.

Risk factors for colorectal neoplasia in inflammatory bowel disease: a nested case-control study from Copenhagen county, Denmark and Olmsted county, Minnesota.

OBJECTIVES: Population-based data on risk factors and protective factors for colorectal dysplasia and cancer in patients with inflammatory bowel disease (IBD) are sparse. We conducted a nested case-control study of such factors in two well-described IBD cohorts from Copenhagen County, Denmark and Olmsted County, Minnesota. METHODS: Forty-three neoplasia cases were matched on six criteria to 1-3 controls (N = 102). Medical records were scrutinized for demographic and clinical data. For each variable, the odds of neoplasia were estimated using conditional logistic regression. RESULTS: Primary sclerosing cholangitis (PSC) (odds ratio [OR] 6.9, 95% confidence interval [CI] 1.2-40), percentage of disease course with clinically active disease (OR [per 5% increase] 1.2, 95% CI 0.996-1.4), and >or=1 yr of continuous symptoms (OR 3.2, 95% CI 1.2-8.6) were associated with neoplasia, whereas a borderline association with median number of small-bowel x-rays (OR 1.3, 95% CI 0.96-1.6) was observed. We did not observe a protective effect of frequency of physician visits (OR 1.4, 95% CI 0.96-2.0), number of colonoscopies (OR 1.4, 95% CI 1.0-2.1), cumulative dose of sulfasalazine (OR [per 1,000 g] 1.1, 95% CI 1.0-1.3) and mesalamine (OR [per 1,000 g] 1.3, 95% CI 0.9-1.9), or partial intestinal resections (OR 1.5, 95% CI 0.3-7.1). CONCLUSIONS: Subgroups of IBD patients-those with PSC, severe long-standing disease, and exposure to x-ray-were at greater risk of colorectal neoplasia. The protective effect of close follow-up, colonoscopy, and treatment with 5-aminosalicylates was questionable.

Comparison of the VERSANT HCV RNA qualitative assay (transcription-mediated amplification) and the COBAS AMPLICOR hepatitis C virus test, version 2.0, in patients undergoing interferon-ribavirin therapy.

Hepatitis C virus (HCV)-infected patients were tested for the presence of HCV RNA using two qualitative assays at various time points during interferon-ribavirin therapy. Among patients treated for 48 weeks, transcription-mediated amplification and the COBAS AMPLICOR Hepatitis C Virus Test results at Week 24 predicted subsequent virologic non-response or virologic relapse in 12/15 (80%) and 8/15 (53%) patients, respectively.