A recent (short ~2:30) ImproveCareNow (ICN) Video explains how ImproveCareNow is a forward-thinking network and how it has the potential to lead to better outcomes for children with inflammatory bowel disease.
If you are part of ICN, this video may help explain to your patients what ICN is all about.
As more data emerges on fecal microbiota transplantation (FMT) for inflammatory bowel disease in well-designed trials, it is not clear if FMT will be effective. A summary of some recent abstracts is available at this link to Gastroenterology and Endoscopy News: Fecal Transplants for IBD Show Mixed Results in Trials
One trial with 53 patients with mild to moderate UC (27 randomized to FMT, 26 to placebo) once weekly for six weeks showed similar results in both groups with 7 FMT patients and 8 placebo recipients experiencing improvement of at least 30% in their Mayo scores. Dr. Lawrence Brandt said, “It may be that we need to look at the patient’s unique bacterial composition and determine which organisms need to be replaced and formulate FMT accordingly.”
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“Colonoscopy in children routinely includes the practice of obtaining multiple biopsy samples even in the absence of gross mucosal abnormalities.” This is the beginning of a recent report (JPGN 2014; 58: 773-78) which shows good agreement between endoscopic and histologic findings in a retrospective study of 390 colonoscopies.
Key findings:
The authors “believe our data support the use of a combination of endoscopic appearance and evidence-based risk stratification to…reduce the number of biopsies obtained.” “The symptom of abdominal pain as a primary indication for performing the procedure was an extremely strong negative predictor of histopathology. ”
Take-home message: If the colon appears normal and there is no prior evidence of IBD/along with reassuring laboratory studies, taking fewer biopsies is appropriate with colonoscopy in children.
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. Endoscopy decisions should be determined by your physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
An excerpt of a review of a recent study (Inflamm Bowel Dis. 2014;20:291-300.) from Healio Gastro, http://bit.ly/1njexRZ. This study was briefly referenced at the bottom of a previous blog post (UC SUCCESS | gutsandgrowth).
Mortality and malignancy, the most serious complications of pediatric inflammatory bowel disease, were relatively rare and linked most commonly with aggressive treatment rather than the condition itself, according to recent study data.
In a multinational retrospective study, researchers surveyed all pediatric gastroenterologists in 20 European countries and Israel on cancer and/or mortality among their pediatric patients with inflammatory bowel disease (PIBD) from 2006 to 2011.
Among 44 children diagnosed with IBD (median age at diagnosis, 10 years; 26 boys), 18 cases of cancer were identified and/or 31 patients died. Twelve cancer patients had Crohn’s disease, and 19 patients who died had ulcerative colitis (UC). The most common cancers were hematopoietic tumors (n=11). Mortality was attributed to infections (n=14) and other causes, including cancer (n=5), uncontrollable disease activity related to IBD (n=4) and procedural complications (n=3).
“Cancer and mortality in PIBD are rare, but cumulative rates are not insignificant,” the researchers wrote. “…. At least six lymphomas were likely treatment-associated by virtue of their phenotype.”
Researchers said that aggressive therapy with immunosuppressants and biologics has become common among PIBD patients because their disease is often more severe than that found in adults with IBD…
“Nine out of 19 patients with UC died because of an infectious complication. These fatalities may have been prevented by earlier surgical intervention when intensified medical treatment is ineffective.”
Bottomline: Making a colectomy decision is quite difficult when medical therapies may be effective. Recent guidelines using PUCAI scores may assist physicians in identifying medical failures more quickly.
Recent links from AGA for FMT (fecal microbiota transplantation) for Clostridium difficile –excellent resource:
Also, summary of recent abstracts from ACG regarding FMT for C difficile, IBS, and IBD: http://t.co/7LFnDYq5V5
Some previous blog posts on this topic:
5. Inflamm Bowel Dis 2013; 19: 2927-36. This reference is another article that tries to help discuss the risks and benefits of biologic therapy for pediatric inflammatory bowel disease. After reviewing the potential risks, the authors provide their “Option Grid” (Page 2932). The authors state, “in summary, the adult literature supports the concept of the early use of combination therapy…the risks associated with anti-TNF therapy are really not significantly different as compared with thiopurine therapy and perhaps in some cases safer. Therefore, we should be moving closer to the idea of using anti-TNF therapy early, with or without an immunomodulator. In the sickest patients, combination therapy probably adds benefit, and then once in remission, consideration can be given for stopping one of the medications, more likely the thiopurine.
6. Gut 2013; 62: 689-94. Risk of ischemic heart disease in patients with inflammatory bowel disease: a nationwide Danish cohort study. From 1997 to 2009, the authors compared 28,833 IBD persons to >4.5 million persons without IBD who were matched for age, gender, socioeconomic status, and calendar year. With a mean follow-up of 13 years, they identified a 59% higher incidence rate of ischemic heart disease in patients with IBD. Long-term use of immunosuppressive medications, such as azathioprine and anti-tumor necrosis factor-alpha agents, was not associated with an increased risk of ischemic heart disease.
7. Gastroenterol 2013; 145: 1459-63. AGA Guideline for Use of Thiopurines, Methotrexate, and Ant-TNF-alpha Biologic Drugs for the Induction and Maintenance of Remission in Inflammatory Crohn’s Disease. This reference was previously noted in blog (with a link) AGA Guidelines for the Use of Thiopurines and Anti … – gutsandgrowt. The print version does have a nice algorithm (pg 1463). The accompanying technical review: Gastroenterol 2013; 145: 1464-78.
8. BMJ 2013;347:f6633. Free full-text BMJ article PDF. (Thanks to Mike Hart for this reference) From the abstract: During 3 421 972 person years of follow-up, we documented 284 cases of Crohn’s disease and 363 cases of ulcerative colitis. The risk of Crohn’s disease was inversely associated with physical activity (P for trend 0.02). Compared with women in the lowest fifth of physical activity, the multivariate adjusted hazard ratio of Crohn’s disease among women in the highest fifth of physical activity was 0.64 (95% confidence interval 0.44 to 0.94). Active women with at least 27 metabolic equivalent task (MET) hours per week of physical activity had a 44% reduction (hazard ratio 0.56, 95% confidence interval 0.37 to 0.84) in risk of developing Crohn’s disease compared with sedentary women with ❤ MET h/wk. Physical activity was not associated with risk of ulcerative colitis (P for trend 0.46). The absolute risk of ulcerative colitis and Crohn’s disease among women in the highest fifth of physical activity was 8 and 6 events per 100 000 person years compared with 11 and 16 events per 100 000 person years among women in the lowest fifth of physical activity, respectively. Age, smoking, body mass index, and cohort did not significantly modify the association between physical activity and risk of ulcerative colitis or Crohn’s disease (all P for interaction >0.35). Conclusion In two large prospective cohorts of US women, physical activity was inversely associated with risk of Crohn’s disease but not of ulcerative colitis.
Comment: While physical activity may directly reduce the risk of Crohn’s disease, it could also be an epiphenomenon of another unmeasured variable (eg. dietary habits) that modifies this risk.
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Understanding IBD Therapy Risks -A Good Link | gutsandgrowth Provides link to useful 6-minute internet video for families.
“Resentment is like drinking poison and then hoping it will kill your enemies.” –Nelson Mandela
A brief review on Fecal Microbiota Transplantation (FMT) (Gastroenterol 2013; 145: 946-53) made a few points that I was not familiar with and reiterated many other important aspects.
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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
In cooperation with ImproveCareNow, EmpoweredByKids.com, which was started by a group of parents, developed ‘The Book of Hope.’ This book “contains stories of hope and inspiration from parents and patients of Inflammatory Bowel Disease. These are encouraging stories to let families know someone else has been there too and you are not alone.”
You can download a copy of the IBD Book of Hope here.
I read through the downloaded version. In my view, the general theme was of perseverance. Given some of the difficulties shared in the book, this book might be best when someone is hospitalized and/or very sick rather than at the onset of diagnosis.
What do you think?
Additional family resource:
Free Self Management Handbook endorsed by ImproveCareNow:
https://improvecarenow.org/patients/self-management-handbook
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Many recent reports have provided conflicting data with regard to Clostridium difficile infection (CDI) epidemiology. Some of the newest data needs to be interpreted with caution due to the adoption of PCR technology. Previously, CDI was difficult to culture and identify. The problem now is proving causation when C diff is identified.
J Pediatr 2013; 163: 699-705. This study, using an administrative database, analyzed 33,095 first pediatric hospitalizations for malignancy from 43 pediatric hospitals between 1999 and 2011. A total of 1736 admissions with CDI were identified; 380 were considered hospital-acquired. The authors noted an apparent decrease in CDI incidence between 2006-2010. Exposure to chemotherapy, proton pump inhibitors and certain antibiotics were independent risk factors for hospital-acquired CDI.
JPGN 2013; 57: 487-88. New-onset patients with IBD cases were retrospectively reviewed from 2010-2012. 10 cases (8.1%) of 124 were positive for CDI within the first two months of diagnosis. Only 42% of the total 290 new IBD cases had documented testing for CDI. The prevalence of CDI without obvious preceding antibiotic exposure was 2.4%.
JPGN 2013; 57: 293-97. Between 2006-2012, stool samples were prospectively obtained from children with IBD (UC, n=76, Crohn, n=69) and controls with other noninflammatory GI conditions (n=51).
Key points:
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According to consumer advice guru, Clark Howard, clean bathrooms are a necessity for businesses and now there are mobile apps (eg. SitorSquat) to help people find them. For patients with GI disorders, this app may be very helpful as well.
Here’s the link from Clark Howard:
Clark Howard: Valued workers translate into a company’s success …
An excerpt:
“Now USA Today reports that dirty bathrooms can hurt business in some very direct ways. Nearly 50 percent of restaurant patrons who experience a dirty bathroom will tell friends. Almost three in 10 restaurant patrons won’t give a place a second chance if they encounter a dirty bathroom. And if you’re a restaurant owner, remember, this is the era of the smartphone where customers are taking pictures of your dirty bathroom and sharing it on social media.
Of course, when you gotta go, you gotta go. That’s why several different smartphone apps like SitorSquat have been developed (for both Android and iOS), pointing you to the nearest clean bathrooms.”
For IBD patients, sometimes taking your own toilet can be helpful, here’s a link to portable products:
gutsandgrowth 