What to do when traditional rescue therapies fail in acute severe ulcerative colitis.

Acute severe ulcerative colitis (ASUC) is a medical emergency that affects approximately 25% of patients with ulcerative colitis at some point in time in their lives. Outcomes of ASUC are highly variable. Approximately 30% of patients do not respond to corticosteroids and up to 50% of patients do not respond to rescue therapy (infliximab or cyclosporin) and require emergency colectomy. Data are emerging on infliximab dosing strategies, use of cyclosporin as a bridge to slower acting biologic agents and Janus kinase inhibition as primary and sequential therapy. In this review, we outline contemporary approaches to clinical management of ASUC in the setting of failure to respond to traditional rescue therapies.

Acute severe ulcerative colitis management: unanswered questions and latest insights.

Acute severe ulcerative colitis (ASUC) is a distinctive ulcerative colitis flare presentation characterised by the presence of systemic inflammation as well as bloody diarrhoea, and occurs at least once in 25% of patients with ulcerative colitis during their disease course. Each episode carries a risk of complications, need for colectomy, and mortality. Little is known about ASUC pathogenesis, although impaired host-microbiota crosstalk involving pathobionts is suspected. In this Review, we discuss unanswered questions and results from the latest research on the medical-first-line, second-line, and potential third-line therapies-and surgical management of ASUC. We detail promising options for management, such as the use of enteral nutrition in combination with intravenous steroids, the ability to predict early failure of first-line or second-line therapies, and the emerging role of JAK inhibitors. An optimal framework to personalise therapy on the basis of multiomics tools is yet to be developed.

Factors Associated With Response to Rescue Therapy in Acute Severe Ulcerative Colitis.

BACKGROUND: Acute severe ulcerative colitis (ASUC) is a medical emergency for which colectomy is required in patients who do not respond to rescue therapy. While previous studies have predominantly focused on predicting outcome to first-line corticosteroid therapy, there is a need to understand the factors associated with response to rescue therapies in order to improve clinical outcomes. We reviewed the evidence regarding factors associated with response to rescue therapy in adults with ASUC and identified future directions for research. METHODS: A systematic search of the literature was conducted, and 2 reviewers independently assessed studies for inclusion. RESULTS: Of 3509 records screened, 101 completed studies were eligible for inclusion. We identified 42 clinical, hematological, biochemical, endoscopic, or pharmacological factors associated with response to rescue therapy. Older age (≥50 years), thiopurine experience, and cytomegalovirus or Clostridioides difficile infection were associated with a higher risk of nonresponse to rescue therapy. Biochemical factors associated with poorer response included an elevated C-reactive protein (CRP) ≥30mg/L on admission, hypoalbuminemia and an elevated ratio of CRP to albumin. Severe endoscopic findings, including a Mayo endoscopic score of 3 or Ulcerative Colitis Endoscopic Index of Severity ≥5, portended poorer outcomes. The role of fecal calprotectin and therapeutic value of measuring infliximab drug levels in ASUC remain to be defined. CONCLUSIONS: Response to rescue therapy can be predicted by several specific factors, which would aid clinical decision-making. Existing and emerging factors should be integrated within predictive and prognostic models to help improve clinical outcomes.

In this review, we summarize the clinical, hematological, biochemical, radiological, endoscopic, and drug-related factors that predict or are associated with response to rescue therapy in patients with acute severe ulcerative colitis. We also provide a clinical algorithm for clinicians.

Guideline-based intervention to reduce telemetry rates in a large tertiary centre.

BACKGROUND: Inappropriate cardiac telemetry use is associated with reduced patient flow and increased healthcare costs. AIM: To evaluate the outcomes of guideline-based application of cardiac telemetry. METHODS: Phase I involved a prospective audit (March to August 2011) of telemetry use at a tertiary hospital. Data were collected on indication for telemetry and clinical outcomes. Phase II prospectively included patients more than 18 years under general medicine requiring ward-based telemetry. As phase II occurred at a time remotely from phase I, an audit similar to phase I (phase II - baseline) was completed prior to a 3-month intervention (May to August 2015). The intervention consisted of a daily telemetry ward round and an admission form based on the American Heart Association guidelines (class I, telemetry indicated; class II, telemetry maybe indicated; class III, telemetry not indicated). Patient demographics, telemetry data, and clinical outcomes were studied. Primary endpoint was the percentage reduction of class III indications, while secondary endpoint included telemetry duration. RESULTS: In phase I (n = 200), 38% were admitted with a class III indication resulting in no change in clinical management. A total of 74 patients was included in phase II baseline (mean ± standard deviation (SD) age 73 years ± 14.9, 57% male), whilst 65 patients were included in the intervention (mean ± SD age 71 years ± 18.4, 35% male). Both groups had similar baseline characteristics. There was a reduction in class III admissions post-intervention from 38% to 11%, P < 0.001. Intervention was associated with a reduction in median telemetry duration (1.8 ± 1.8 vs 2.4 ± 2.5 days, P = 0.047); however, length of stay was similar in both groups (P > 0.05). CONCLUSION: Guideline-based telemetry admissions and a regular telemetry ward round are associated with a reduction in inappropriate telemetry use.

Outcomes of patients with appendicitis who present to an outer metropolitan hospital.

BACKGROUND: The present study investigates patients with acute appendicitis who presented to a hospital with no acute surgical service (group A) and compares the outcomes of these patients with those that presented to a tertiary centre with an acute surgical service within the same health network (group B). All group A patients were transferred to the group B hospital for appendicectomy. METHODS: During a 10-month period, 257 patients (80 in group A, 177 in group B) with acute appendicitis were analysed retrospectively. Demographics, emergency department parameters, time to waiting bay, time to surgery, operative time, complications, length of stay and the stage of appendicitis were all noted for each group. A comparison of each of these parameters was made between the two groups of patients. RESULTS: There were 80 patients in group A and 177 patients in group B. There was a significant difference between the two groups in the fields of length of stay in the emergency department (P = 0.003), bed availability (P = 0.038), time to waiting bay (P = 0.006) and time to surgery (P = 0.006). There was no significant difference in the total length of stay and complication rates between the two groups (P = 0.58 and 0.78, respectively). CONCLUSION: This study concludes that patients with acute appendicitis presenting to a hospital with no acute surgical services had a greater waiting period prior to surgery. However, this did not translate into greater complication rates or length of stay for these patients. We propose a prospective study to further analyse the outcomes in such patients.