Absence of Day 3 Steroid Response Predicts Colitis-Related Complications and Colectomy in Hospitalized Ulcerative Colitis Patients.

BACKGROUND AND AIMS: Rates and predictors of complications among hospitalized ulcerative colitis (UC) patients requiring high-dose corticosteroids have not been well-characterized, especially in the era of biologics. METHODS: We retrospectively studied consecutive UC admitted for a colitis flare requiring high-dose corticosteroids between April 2006 and December 2016. We evaluated rates and determinants of serious in-hospital complications (colitis-related complications, systemic complications, peri-operative complications and death) and colectomy. We performed multivariable logistic regression analysis to assess the independent association between day 3 steroid response and the risk of incurring in-hospital complications and colectomy. RESULTS: Of 427 consecutive admissions, serious in-hospital complications occurred in 87 cases (20%), while colitis-related complications occurred in 47 cases (11%). There were significantly fewer colitis-related complications during the 2012 to 2016 period as compared to the 2006 to 2011 period (7% versus 16%, P < 0.01), but significantly more systemic complications (16% versus 5%, P = 0.001). In-hospital colectomy occurred in 50 hospitalizations (12%). Day 3 steroid response was achieved in 167 hospitalizations (39%). Day 3 steroid nonresponse was significantly associated with colitis-related complications among males (adjusted odds ratio [aOR] 8.22, 95% confidence interval [CI] 1.77 to 38.17), but not among females (aOR 1.39, 95% CI 0.54 to 3.60). Older age, C. difficile infection and admission to a non-gastroenterology service were also associated with a higher risk of in-hospital complications. Day 3 steroid nonresponse was significantly associated with in-hospital colectomy (aOR 10.10, 95% CI 3.56 to 28.57). CONCLUSION: In our series of UC hospitalizations for a colitis flare, absence of day 3 steroid response was associated with an increased risk of colitis-related complications among males and of in-hospital colectomy. Clinicians should recognize the importance of early steroid response as a marker to guide the need for treatment optimization.

Tumor Necrosis Factor Inhibitors May Have Limited Efficacy for Complex Perianal Fistulas Without Luminal Crohn's Disease.

BACKGROUND: Complex perianal fistulas occurring in the absence of luminal inflammation (isolated perianal disease, IPD) may represent a specific phenotype of Crohn's disease (CD). AIM: We assessed the effectiveness of tumor necrosis factor (TNF)-antagonists in patients with IPD compared to those with perianal CD (PCD) with luminal inflammation. METHODS: Patients were identified through our institutional radiology database and were classified as PCD or IPD based on the presence or absence of luminal inflammation by ileocolonoscopy and abdominal enterography. Consecutive adults (> 17 years) with recurrent IPD who were treated with TNF antagonists were matched by age and gender to patients with complex PCD (1:2 ratio). Fistula remission was defined as an absence of fistula drainage. Surgery-free survival was assessed by Cox proportional hazard models. RESULTS: Twenty-two patients with IPD treated with a TNF antagonist were compared with 44 matched patients with PCD. A similar proportion of patients with IPD and PCD were treated with concomitant immunomodulators (55% vs. 66%) and underwent examinations under anesthesia prior to therapy (36% vs. 46%). Fistula remission at 3, 6, and 12 months was lower for the IPD cohort: 9.5% versus 34%; 19% versus 39%; and 19% versus 43%. Surgical intervention after initiating anti-TNF therapy was more common for patients with IPD (HR 3.99: 95% CI, 1.62-9.83; p = 0.0026). CONCLUSIONS: Fewer patients with IPD achieved fistula remission, and more required surgical intervention after anti-TNF therapy, suggesting that TNF antagonists may not be as effective in these patients.

Strategies to Optimize Anti-tumor Necrosis Factor Therapy for Perianal Fistulizing Crohn's Disease: A Systematic Review.

Tumor necrosis factor (TNF) antagonists are considered the cornerstone therapy for fistulizing perianal Crohn's disease (PCD), yet a substantial proportion of patients fail to achieve healing. Therefore, we reviewed the evidence for strategies to enhance the efficacy of TNF antagonists for PCD. A systematic search of electronic databases through July 2018 was performed to identify studies that assessed the effectiveness of TNF antagonists combined with another medical or surgical intervention for PCD; or assessed the association between anti-TNF serum concentrations and fistula healing. Twelve studies compared anti-TNF therapy alone versus a combined approach: four with surgery, three with antibiotics, and five with immunomodulators. Only two studies, both with antibiotics, were rated high quality. The addition of antibiotics to anti-TNF therapy resulted in significantly higher rates of fistula response and healing in one study, and a trend toward reduction in fistula drainage in the other. Three of four studies found higher rates of fistula healing when surgery was combined with TNF antagonists. In contrast, one of five studies found a trend toward higher rates of fistula healing in patients treated concomitantly with immunomodulators. Five observational studies assessed the association between anti-TNF concentration and fistula healing. Higher infliximab serum concentrations were consistently associated with fistula healing. In conclusion, few high-quality studies assessing strategies to optimize anti-TNF therapy for PCD exist. Although antibiotics, possibly surgery, and higher serum infliximab concentrations appear to improve fistula healing, future prospective studies are needed to determine the optimal treatment strategy.

Driving and Dementia: Workshop Module on Communicating Cessation to Drive.

BACKGROUND: For persons with dementia (PWD), driving becomes very dangerous. Physicians in Canada are legally responsible to report unfit drivers and then must disclose that decision to their patients. That difficult discussion is fraught with challenges: physicians want to maintain a healthy relationship; patients often lack insight into their cognitive loss and have very strong emotional reactions to the loss of their driving privileges. All of which may stifle the exchange of accurate information. The goal of this project was to develop a multimedia module that would provide strategies and support for health professionals having these difficult conversations. METHODS: Literature search was conducted of Embase and OVID MedLine on available driving and dementia tools, and on websites of online tools for communication strategies on driving cessation. A workshop module was developed with background material, communication strategies, links to resources and two videos demonstrating the "bad" then the "good" ways of managing this emotionally charged discussion. RESULTS: When the module was tested with internal medicine trainees, results demonstrated that confidence increased significantly (p < .001), and comfort and willingness in discussing the subject improved. CONCLUSION: This project demonstrated the positive impact of the module on improving health professionals' attitude and readiness to communicate driving cessation to PWD.