Absence of an Association Between Enteric Parasites in the Manifestations and Pathogenesis of HIV Enteropathy in Gay Men

49 gay men confirmed to be infected with the human immunodeficiency virus (HIV) and 9 HIV seronegative gay men participated in a pilot study comparing clinical status and enteric parasite load with gastrointestinal structure, function and symptomatology. Cases included 16/49 (33%) men who were CDC stage II, 7/49 (14%) who were CDC stage III, and 26/49 (53%) who were CDC stage IV. The mean CD4-lymphocyte count was 476 +/- 199 (SD)/microliter. The prevalence of enteric parasitic flora was similar in HIV seropositive patients and controls. Seven cases had enteric infection with pathogenic agents including 3 patients with Entamoeba histolytica, and 4 patients with Giardia lamblia, one of whom also had cryptosporidiosis. Other cases were most frequently colonized with Blastocystis hominis (44%) and Endolimax nana (41%) regardless of the HIV clinical status. HIV seropositive patients with enteric parasitic colonization tended to have lower mean levels of serum IgA than cases without parasites. Duodenal morphometric mucosal changes demonstrated a significant decrease in the mean villous height (p < 0.01) with no elongation of the crypt depth in HIV-infected patients with and without diarrhea compared to controls. Despite gastrointestinal symptoms including diarrhea and weight loss being more prevalent in HIV infected individuals than controls, no correlations were found between the presence of particular enteric parasites, gastrointestinal symptomatology, the clinical HIV status of the CD4-lymphocyte count, the malabsorption of D-xylose or morphometric changes in the duodenum.(ABSTRACT TRUNCATED AT 250 WORDS)

A randomized, double-blind, placebo-controlled trial of CDP571, a humanized monoclonal antibody to tumour necrosis factor-alpha, in patients with corticosteroid-dependent Crohn's disease

AIM

To evaluate CDP571, a humanized monoclonal antibody to tumour necrosis factor-alpha, for the treatment of corticosteroid-dependent Crohn's disease.

METHODS

Patients with corticosteroid-dependent Crohn's disease (use of prednisolone 15-40 mg/day or budesonide 9 mg/day for at least 8 weeks, a previous failed attempt to discontinue corticosteroids within 8 weeks, and Crohn's Disease Activity Index score 150 points or less) were enrolled in a 16-week, randomized, double-blind, placebo-controlled trial. The patients received intravenous CDP571 (20 mg/kg at week 0 and 10 mg/kg at week 8) or placebo. Corticosteroid therapy was decreased following a predefined schedule. The primary efficacy end-point was the percentage of patients with corticosteroid-sparing [i.e. no disease flare (Crohn's Disease Activity Index score > or =220 points) and no longer requiring corticosteroid therapy] at week 10. The major secondary efficacy end-point was corticosteroid-sparing at week 16.

RESULTS

Seventy-one patients received treatment. Corticosteroid-sparing was achieved by 19 of 39 (48.7%) CDP571 patients and 13 of 42 (40.6%) placebo patients (P = 0.452) at week 10, and by 18 of 39 (46.2%) CDP571 patients and seven of 32 (21.9%) placebo patients (P = 0.032) at week 16. CDP571 therapy was well-tolerated and the incidence of serious adverse events was similar to placebo.

CONCLUSIONS

The CDP571 was effective for corticosteroid-sparing at week 16 but not week 10, and was well-tolerated in patients with corticosteroid-dependent Crohn's disease.

Intestinal permeability is increased in a proportion of spouses of patients with Crohn's disease

OBJECTIVE

Increased small intestinal permeability has been found in patients with Crohn's disease and in a proportion of their healthy relatives. This may reflect a shared environment or shared genes. The finding of abnormal permeability in the healthy spouses of patients would favor an environmental cause for this observation.

METHODS

The healthy spouses of patients with Crohn's disease attending three gastroenterology clinics were invited to participate. Eligible subjects consumed a 350-ml solution containing lactulose, mannitol, and sucrose before bedtime. All overnight urine was collected, assayed by high performance liquid chromatography, and the ratio of fractional excretion of lactulose to mannitol was calculated as an index of permeability. The results were compared with those of a previously determined control group.

RESULTS

Sixty spouses completed the study. Increased permeability was present in eight (13.3%, 95% CI = 6.0-24.6%). The presence of increased permeability was not related to age, gender, duration of cohabitation, alcohol use, nonsteroidal anti-inflammatory drug use or to disease activity in the patient with Crohn's disease. There was a nonsignificant trend for abnormal permeability to occur in those spouses cohabiting with the patient with Crohn's disease at the time of disease diagnosis (p = 0.128).

CONCLUSIONS

Small intestinal permeability is increased in a proportion of healthy spouses of patients with Crohn's disease. The presence of abnormal permeability studies in patients with Crohn's disease and a proportion of their healthy close contacts suggests that this phenomenon is caused by environmental factors.

Giant cell myocarditis, in a patient with Crohn's disease, treated with etanercept--a tumour necrosis factor-alpha antagonist

Cardiac disease in association with inflammatory bowel disease (IBD) is uncommon. Reports include pericarditis, pericardial effusion, myocarditis, myocardial infarction, endocarditis and arrythmias. Myocardial inflammation related to IBD may be due to a drug hypersensitivity reaction or micronutrient deficiency, or may be secondary to the underlying IBD as an extraintestinal manifestation. In this setting, myocarditis usually presents as congestive heart failure and/or refractory arrhythmia. Prognosis varies among reported cases, including complete recovery, remission with recurrence and fatal disease. Treatment of myocarditis has included aminosalicylates and immunosuppressive medications. Recently, newer therapies for IBD have been developed, such as tumour necrosis factor-alpha (TNF-a) antagonists. The present report describes a case of a 46-year-old man with clinical and endoscopic evidence of moderately active colonic Crohn's disease who developed congestive heart failure due to giant cell myocarditis. Little clinical improvement occurred with immunosuppressive therapy. Only after the addition of etanercept, a TNF-a p75 receptor antagonist, did complete clinical resolution occur. These authors conclude that the use of TNF-a antagonists may be considered in the treatment of life-threatening extraintestinal manifestations of inflammatory bowel disease.

Medical management of inflammatory bowel disease: old and new perspectives

The treatment of inflammatory bowel disease is a continually evolving area and a major focus of the current literature in gastroenterology. As further information is gained in the areas of etiology, pathophysiology, and natural history of the disease, new agents are developed, and management strategies are revised. The contribution of this year's clinically based literature is reviewed in this summary and incorporated into specific management strategies.

Attitudes toward smoking and smoking behaviors of patients with Crohn's disease

OBJECTIVE

To examine the smoking behaviors of people with Crohn's disease. In active smokers, we measured their willingness to quit, their degree of nicotine dependence, and the proportion that made a quit attempt within 6 months to determine if they were refractory to smoking cessation in comparison to the general population. We also examined factors that were important in their decision to smoke.

METHODS

We conducted a cross-sectional survey of out-patients, supplemented by telephone interviews and a 6-month follow-up questionnaire of active smokers. Measures included disease activity, current smoking behaviors, intentions (stage of change), Fagerstrom Test for Nicotine Dependence, and factors related to their decision to smoke (decisional balance).

RESULTS

The questionnaire was completed by 115 patients (78% response rate). Forty percent were active smokers. Of active smokers, 59% were considering quitting within the next 6 months, and of these, 15% were planning on quitting within the next 30 days. Those with moderate disease activity were more likely to be considering quitting than those with mild or severe activity. Nicotine dependence was rated as high in 33% and as moderate in 43%. Factors unrelated to Crohn's disease were more important in their decision to smoke than were Crohn's disease-related factors. After 6 months, 23% had made an attempt to quit and this attempt was strongly associated with their stated intentions at the baseline questionnaire. Two of three patients who had recently quit at baseline had resumed smoking.

CONCLUSION

When compared to similar data for the general population, patients with Crohn's disease are no more refractory to smoking cessation.

Attitudes toward smoking and smoking behaviors of patients with Crohn's disease

OBJECTIVE

To examine the smoking behaviors of people with Crohn's disease. In active smokers, we measured their willingness to quit, their degree of nicotine dependence, and the proportion that made a quit attempt within 6 months to determine if they were refractory to smoking cessation in comparison to the general population. We also examined factors that were important in their decision to smoke.

METHODS

We conducted a cross-sectional survey of out-patients, supplemented by telephone interviews and a 6-month follow-up questionnaire of active smokers. Measures included disease activity, current smoking behaviors, intentions (stage of change), Fagerstrom Test for Nicotine Dependence, and factors related to their decision to smoke (decisional balance).

RESULTS

The questionnaire was completed by 115 patients (78% response rate). Forty percent were active smokers. Of active smokers, 59% were considering quitting within the next 6 months, and of these, 15% were planning on quitting within the next 30 days. Those with moderate disease activity were more likely to be considering quitting than those with mild or severe activity. Nicotine dependence was rated as high in 33% and as moderate in 43%. Factors unrelated to Crohn's disease were more important in their decision to smoke than were Crohn's disease-related factors. After 6 months, 23% had made an attempt to quit and this attempt was strongly associated with their stated intentions at the baseline questionnaire. Two of three patients who had recently quit at baseline had resumed smoking.

CONCLUSION

When compared to similar data for the general population, patients with Crohn's disease are no more refractory to smoking cessation.

An engineered human antibody to TNF (CDP571) for active Crohn's disease: a randomized double-blind placebo-controlled trial

BACKGROUND & AIMS

We evaluated CDP571, a humanized antibody to tumor necrosis factor, for the treatment of active Crohn's disease.

METHODS

One hundred sixty-nine patients with moderate-to-severe Crohn's disease were enrolled in a 24-week placebo-controlled trial. Patients were initially randomized to a single dose of 10 or 20 mg/kg CDP571 or placebo to assess dose response. Patients were then retreated with 10 mg/kg CDP571 or placebo every 8 or 12 weeks to assess subsequent dosing intervals. The primary endpoint was clinical response at week 2, defined as a decrease in the Crohn's Disease Activity Index score > or = 70 points.

RESULTS

At week 2, clinical response occurred in 45% of CDP571-treated patients compared with 27% of patients in the placebo group (P = 0.023). Patients appeared to benefit from retreatment with CDP571 over 24 weeks, but not all of the results for secondary endpoints were statistically significant. The frequency of severe or serious adverse events was similar among all groups.

CONCLUSIONS

CDP571 at an initial dose of 10 or 20 mg/kg is safe and effective for treatment of patients with moderate-to-severe Crohn's disease. Preliminary evidence suggests that retreatment with 10 mg/kg CDP571 at dose intervals of 8 or 12 weeks may also be beneficial, but additional studies are needed.

Prevention of relapse of Crohn's disease

Until a cure for Crohn's disease(s) is found, strategies that prolong the time spent in remission offer the greatest hope for reducing the morbidity and significant social costs associated with the disease. Medical therapy to date has been disappointing, and the search for a safe, effective therapy that could be offered at low cost continues. The aminosalicylates, so effective in ulcerative colitis, have shown, at best, minimal efficacy in maintaining remission in Crohn's disease. Conventional corticosteroids are not effective, and any reduction in time to relapse for budesonide-treated patients is measured in weeks not months. Azathioprine, 6-mercaptopurine, and methotrexate are effective in maintaining remission, but all three have significant side effects. Antibiotics may have a role to play. Biological therapy may be considered, but the issues of cost and long-term safety require evaluation. Future studies should segregate patients into two groups, those with a medically induced remission and patients whose concern is the prevention of postoperative recurrence.

Quality of life rapidly improves with budesonide therapy for active Crohn's disease. Canadian Inflammatory Bowel Disease Study Group

Our aims were to assess the impact on health-related quality of life (HRQOL) of a controlled ileal release (CIR) formulation of budesonide in active Crohn's disease (CD) and further define the role of HRQOL, using the Inflammatory Bowel Disease Questionnaire (IBDQ), in assessing outcome in CD. A randomized trial was conducted in 258 patients with active ileal or ileocecal CD. Budesonide CIR 1.5 mg, 4.5 mg, 7.5 mg, or placebo was given b.i.d. for 8 weeks. IBDQ score changes were compared among groups. Correlations for IBDQ and Crohn's Disease Activity Index (CDAI) scores were calculated. Mean IBDQ scores improved significantly over placebo by 2 weeks in budesonide 15 mg (155+/-38; p = 0.006) and 9 mg groups (157+/-33; p = 0.0002). Bowel, systemic, social, and emotional subscores were also significantly better (p < 0.002) at 2 and 8 weeks in the 9 mg group. Improved HRQOL scores correlated well with decreased CDAI (-0.8 < r < -0.4). Average per item change in IBDQ at remission was 1.17 to 1.48. Prior surgery (p < 0.005) or current smoker (p < 0.05) status predicted poorer initial HRQOL but not response. Budesonide CIR 9 or 15 mg/day rapidly and significantly improved HRQOL in active CD.

Defining the role of fiberoptic sigmoidoscopy in the investigation of patients presenting with bright red rectal bleeding

OBJECTIVE

This study was done to determine whether sigmoidoscopy could theoretically constitute sufficient investigation for some patients with bright red rectal bleeding.

METHODS

One hundred and forty-three patients undergoing investigative colonoscopy for bright red rectal bleeding and whose source of bleeding was identified were studied. The investigation took place in a large urban hospital over an 11-month period. Data obtained included changes in stool pattern, characteristics of the bleeding, lesions identified, and the distance of the lesion from the anus.

RESULTS

In patients younger than 55 yr, all serious lesions except for one malignancy in a patient with massive bleeding lay within 60 cm of the anus and theoretically within reach of the fiberoptic sigmoidoscope. The mixing of red blood with stool was commonly due to distal lesions, especially hemorrhoids.

CONCLUSIONS

In young persons with bright red rectal bleeding, fiberoptic sigmoidoscopy may prove to constitute appropriate initial investigation.

Helping patients with Crohn's disease quit smoking

Smoking is not only a risk factor for Crohn's disease, but ongoing smoking is associated with a poorer disease course. Therefore, smoking cessation should be an important treatment strategy for Crohn's disease patients who smoke tobacco. Recent improvements in understanding how people quit smoking and the development of pharmacological interventions, such as nicotine patches and bupropion, have improved cessation rates. In this article, we first briefly review the evidence supporting the adverse effects of smoking on the disease course. We next review the current understanding of how people change addictive behaviors, such as smoking. We then describe how the gastroenterologist can aid the patient with Crohn's disease to quit smoking, including appropriate and brief counseling strategies and the use of adjunctive treatments. Given the improvements in smoking cessation strategies, all patients with Crohn's disease should be strongly advised to quit smoking and be aided in doing so.

A simple classification of Crohn's disease: report of the Working Party for the World Congresses of Gastroenterology, Vienna 1998

Crohn's disease is a heterogeneous entity. Previous attempts of classification have been based primarily on anatomic location and behavior of disease. However, no uniform definition of patient subgroups has yet achieved broad acceptance. The aim of this international Working Party was to develop a simple classification of Crohn's disease based on objective variables. Eight outcome-related variables relevant to Crohn's disease were identified and stepwise evaluated in 413 consecutive cases, a database survey, and by clinical considerations. Allocation of variables was conducted with well-defined Crohn's disease populations from Europe and North America. Cross-table analyses were performed by chi-square testing. Three variables were finally elected: Age at Diagnosis [below 40 years (A1), equal to or above 40 years (A2)], Location [terminal ileum (L1), colon (L2), ileocolon (L3), upper gastrointestinal (L4)], and Behavior [nonstricturing nonpenetrating (B1), stricturing (B2), penetrating (B3)]. The allocation of patients to these 24 subgroups proved feasible and resulted in specific disease clusters. Cross-table analyses revealed associations between Age at Diagnosis and Location, and between Behavior and Location (all p < 0.001). The Vienna classification of Crohn's disease provides distinct definitions to categorize Crohn's patients into 24 subgroups. Operational guidelines should be used for the characterization of patients in clinical trials as well as for correlation of particular phenotypes with putative biologic markers or environmental factors.

A simple classification of Crohn's disease: report of the Working Party for the World Congresses of Gastroenterology, Vienna 1998

Crohn's disease is a heterogeneous entity. Previous attempts of classification have been based primarily on anatomic location and behavior of disease. However, no uniform definition of patient subgroups has yet achieved broad acceptance. The aim of this international Working Party was to develop a simple classification of Crohn's disease based on objective variables. Eight outcome-related variables relevant to Crohn's disease were identified and stepwise evaluated in 413 consecutive cases, a database survey, and by clinical considerations. Allocation of variables was conducted with well-defined Crohn's disease populations from Europe and North America. Cross-table analyses were performed by chi-square testing. Three variables were finally elected: Age at Diagnosis [below 40 years (A1), equal to or above 40 years (A2)], Location [terminal ileum (L1), colon (L2), ileocolon (L3), upper gastrointestinal (L4)], and Behavior [nonstricturing nonpenetrating (B1), stricturing (B2), penetrating (B3)]. The allocation of patients to these 24 subgroups proved feasible and resulted in specific disease clusters. Cross-table analyses revealed associations between Age at Diagnosis and Location, and between Behavior and Location (all p < 0.001). The Vienna classification of Crohn's disease provides distinct definitions to categorize Crohn's patients into 24 subgroups. Operational guidelines should be used for the characterization of patients in clinical trials as well as for correlation of particular phenotypes with putative biologic markers or environmental factors.

Azathioprine for maintaining remission of Crohn's disease

OBJECTIVES

To assess the effectiveness of azathioprine in maintaining remission of quiescent Crohn's disease.

SEARCH STRATEGY

Pertinent studies were selected using the MEDLINE data base (1966 - May 1998), the Cochrane Controlled Trials Register, the Inflammatory Bowel Disease Trials Register, as well as abstracts from major gastrointestinal research meetings and references from published articles and reviews.

SELECTION CRITERIA

Five randomized, double-blind, placebo-controlled trials of azathioprine therapy were identified. Two of these trials consisted solely of patients with quiescent Crohn's disease. Three trials had multiple therapeutic arms for both induction of remission and maintenance of remission.

DATA COLLECTION AND ANALYSIS

Data were extracted by three independent observers (GRM, GF, LRS) based on the intention to treat principle. Peto odds ratios for the overall maintenance of remission, steroid sparing, and withdrawals due to adverse effects were calculated, and from these, 95% confidence intervals were derived. Numbers needed to treat or harm (NNT, NNH respectively) for the maintenance of remission, steroid sparing, and withdrawals due to adverse effects were also determined.

MAIN RESULTS

Azathioprine had a positive effect on maintaining remission. The Peto odds ratio for maintenance of remission was 2.16 (CI 1.35 - 3.47) with an NNT of 7. A higher dose improved response. A steroid sparing effect was noted, with a Peto odds ratio of 5.22 (CI 1.06 - 25.68) and NNT of 3 for quiescent disease. The Peto odds ratio for withdrawals due to adverse events was 4.36 (CI 1.63 - 11.67), the NNH (Number Needed to Harm) was 19.

REVIEWER'S CONCLUSIONS

Azathioprine is effective in maintaining remission. There is evidence for a steroid sparing effect.

Gastric cancer and other endoscopic diagnoses in patients with benign dyspepsia

BACKGROUND

It has been suggested that endoscopy could be replaced with non-invasive assessment of helicobacter status in the initial work up of young dyspeptic patients without sinister symptoms.

AIMS

To determine the incidence of gastro-oesophageal malignancy in young dyspeptic patients.

METHODS

The Alberta Endoscopy Project captured clinical and demographic data on all endoscopies performed from April 1993 to February 1996 at four major adult hospitals in Alberta. The endoscopic and histological diagnosis in a subgroup of patients under 45 years of age without alarm symptoms that had undergone gastroscopy was reviewed. In addition, a random list of 200 patients was generated and their medical records reviewed in order to assess the proportion with symptoms suitable for a non-invasive management strategy.

RESULTS

Gastroscopy was performed in 7004 patients under 45 years. In 3634 patients (56% female) alarm type symptoms were absent; 78.9% of patients had symptoms amenable to a non-invasive initial approach, giving a corrected sample size of 2867 patients (correction factor 0.789). Three gastric cancers, one case of moderate dysplasia, 10 biopsy proved cases of Barrett's oesophagus, and 19 oesophageal strictures/rings were detected within this sample. The corrected prevalence of gastric cancer in this select population was 1.05 per thousand patients.

DISCUSSION

Endoscopy yielded three gastric cancers in this sample of under 45 year old dyspeptic patients without sinister symptoms. While initial non-invasive screening with one-week triple therapy for helicobacter positive individuals is unlikely to have a detrimental outcome the physician is advised to consider endoscopy in patients with persisting, recurrent, or sinister symptoms.

Lack of effect of intravenous administration on time to respond to azathioprine for steroid-treated Crohn's disease. North American Azathioprine Study Group

BACKGROUND & AIMS

Azathioprine is effective for Crohn's disease but acts slowly. A loading dose may decrease the time to response.

METHODS

A placebo-controlled study was conducted in patients with active Crohn's disease despite prednisone treatment. Patients were randomized to a 36-hour infusion of azathioprine, 40 mg/kg (51 patients), or placebo (45 patients) followed by oral azathioprine, 2 mg/kg, for 16 weeks. Prednisone was tapered over 5 weeks. The primary outcome measure was complete remission at week 8, defined by discontinuation of prednisone and a Crohn's Disease Activity Index of </=150 points. Erythrocyte concentrations of the azathioprine active metabolite, 6-thioguanine nucleotide, were measured.

RESULTS

At week 8, 13 patients (25%) were in complete remission in the azathioprine-loaded group compared with 11 patients (24%) in the placebo group. The frequency of complete remission did not increase after 8 weeks in either group. Both groups achieved steady state of 6-thioguanine nucleotide by week 2, and no differences were found in mean concentrations between the groups. There were no significant differences in the frequency of adverse events between the groups.

CONCLUSIONS

A loading dose does not decrease the time to response in patients with steroid-treated Crohn's disease beginning azathioprine therapy. Steady state of erythrocyte 6-thioguanine nucleotide and complete response occurred earlier than previously reported.

Survey of current practices among members of CAG in the follow-up of patients diagnosed with gastric ulcer

INTRODUCTION

Guidelines recommend a policy of endoscopic follow-up of all gastric ulcers until healing. Analysis of data from the Alberta Endoscopy Project indicates that fewer than 50% of patients diagnosed with benign gastric ulcer had undergone a repeat procedure. The practice and attitudes of physician members of the Canadian Association of Gastroenterology (CAG) on the follow-up of such patients were assessed.

METHODS

A self-administered questionnaire was mailed to members of CAG. Respondents were asked to indicate their practice setting and to estimate the proportion of gastric ulcer patients in whom they perform follow-up endoscopy. They were also asked to indicate factors influencing this choice, including the role of Helicobacter pylori.

RESULTS

Fifty-seven per cent of 220 respondents indicated that they perform repeat endoscopy in 95% to 100% of individuals with benign gastric ulcer. The most common reasons influencing this choice were to ensure healing (86.3%) and to confirm the benign nature of the lesion (79.5%). Nonsteroidal anti-inflammatory drug (NSAID) use (83.2%) and patient ill health (62.9%) were the most common reasons for not repeating the endoscopy. Twenty per cent of individuals indicated that H pylori had influenced a change in their practice.

DISCUSSION

Physicians vary widely in their follow-up of benign gastric ulcer. Studies on the occurrence of gastric cancer in this setting are not unanimous in their conclusions. Subgroups of patients with NSAID exposure and successfully eradicated H pylori infection may have a lower risk of malignancy. Studies to confirm this are warranted, and modified guidelines may be appropriate.

Intestinal permeability and postheparin plasma diamine oxidase activity in the prediction of Crohn's disease relapse

A method of detecting presymptomatic relapse of Crohn's disease could allow for the selective use of maintenance or intensified medical therapy in those with an increased risk of relapse. The aim of this study was to evaluate three potential laboratory markers of relapse: intestinal and gastroduodenal permeability and plasma diamine oxidase activity. Intestinal permeability (lactulose/mannitol test), gastroduodenal permeability (urinary sucrose excretion), and postheparin plasma diamine oxidase activity were serially measured in 61 adults with Crohn's disease in remission (CDAI <150) for at least 30 days. Subjects were followed periodically for clinical relapse (CDAI >150 and increased by at least 100 points or the need for steroids or surgery). Fourteen patients (23%) relapsed. A cut-off of 0.030 for the lactulose/mannitol ratio was defined. Those with ratios above the cutoff had a 7.0 times greater risk of relapse (p<0.001). Three subjects who went from a normal ratio to an abnormal ratio relapsed, whereas none of 32 subjects with a repeatedly normal ratio relapsed. Sucrose excretion and plasma diamine oxidase activity did not predict relapse. Serial testing of intestinal permeability, but not of gastroduodenal permeability or plasma diamine oxidase activity, was useful in predicting relapse in asymptomatic patients.

Intestinal permeability before and after ibuprofen in families of children with Crohn's disease

BACKGROUND

Members of a subset of first-degree relatives of adults with Crohn's disease have been shown to have an increased baseline intestinal permeability and/or an exaggerated increase in intestinal permeability after the administration of acetylsalicylic acid.

PURPOSE

To determine intestinal permeability in unaffected first-degree relatives of children with Crohn's disease before and after the administration of an ibuprofen challenge.

METHODS

Lactulose-mannitol ratios, a measure of intestinal permeability, were determined in 14 healthy control families (41 subjects) and 14 families with a child with Crohn's disease (36 relatives, 14 probands) before and after ingestion of ibuprofen. An upper reference limit was defined using the control group as mean +/- 2 SD.

RESULTS

The proportion of healthy, first-degree relatives with an exaggerated response to ibuprofen (20%, 95% CI 7% to 33%) was significantly higher than controls (P = 0.003). The exaggerated response was more common among siblings than among parents of pediatric probands.

CONCLUSIONS

Members of a subset of first-degree relatives of children with Crohn's disease have an exaggerated increase in intestinal permeability after ibuprofen ingestion. These findings are compatible with there being a genetic link between abnormalities of intestinal permeability and Crohn's disease.

The utility of endoscopy in the management of patients with gastroesophageal reflux symptoms

OBJECTIVE

The utility of endoscopy in the management of patients with symptoms of gastroesophageal reflux disease (GERD) is unclear. The purpose of this prospective study was to assess the impact of endoscopy on the subsequent management of patients with uncomplicated reflux symptoms.

METHODS

A total of 742 patients underwent endoscopy for symptoms of GERD. Endoscopists recorded the therapy before endoscopy, the findings of endoscopy, and the treatment recommendations after endoscopy.

RESULTS

There was no difference in pre-endoscopy therapy or grade of esophagitis in subjects undergoing endoscopy for failed therapy versus GERD symptoms alone. After endoscopy, the most common strategy for patients taking omeprazole was to maintain or increase the dose. For those taking an H2 blocker before endoscopy, the most common outcome was to switch the patient to omeprazole, independent of the grade of esophagitis.

CONCLUSIONS

Most patients undergoing endoscopy for symptoms of GERD were switched to omeprazole regardless of the endoscopic findings. No esophageal cancer was identified and the incidence of Barrett's esophagus was low. It appears that endoscopy itself did not change the management of patients receiving H2-blocker therapy. A trial of a proton pump inhibitor before endoscopy should be considered.

Increased intestinal permeability is associated with the development of multiple organ dysfunction syndrome in critically ill ICU patients

We conducted a prospective, observational cohort study designed to compare intestinal permeability (IP) and development of multiple organ dysfunction syndrome (MODS) in a subset of critically ill patients in an intensive care unit (ICU). All patients with an expected ICU stay of 72 h or more were entered into the study, and IP was determined on a daily basis whenever possible from the urinary fractional excretion of orally administered lactulose and mannitol (LMR). Forty-seven consecutive patients were studied, and 28 developed MODS either at the time of admission or during their ICU course. These patients, as a group, had significantly worse IP at admission than did a non-MODS cohort (LnLMR: -2.10 +/- 1.10 versus -3.26 +/- 0.83). Those patients who developed MODS following admission also had a significantly greater admission IP than did the non-MODS group (-2.51 +/- 0.85). Differences in IP between cohorts could not be explained by differences in the incidence of systemic inflammatory response syndrome (SIRS)/sepsis or shock. With multivariate regression analysis, the only parameter present on admission that was predictive of subsequent MODS was IP. Differences in IP and the severity of organ dysfunction were also present (MODS severity mild: -3.01 +/- 0.72; moderate: -1.97 +/- 0.69; and severe: -1.12 +/- 0.96). Patients who developed MODS had a persistently abnormal IP during their ICU stay, and a significantly delayed improvement in their IP compared with the non-MODS cohort. We conclude that the development of MODS is associated with an abnormal and severe derangement of IP that is detectable prior to the onset of the syndrome. This observation lends credence to the premise that gastrointestinal (GI) dysfunction may be causally associated with the development of MODS in the critically ill patient.

Does medical antireflux therapy improve asthma in asthmatics with gastroesophageal reflux?: a critical review of the literature

OBJECTIVE

Identify and critically review the peer-reviewed, English-language studies of the effects of medical antireflux therapy in asthmatics with gastroesophageal reflux (GER).

DESIGN

Using the 1966 to 1996 MEDLINE database, asthma was combined with GER to identify all studies of the effects of medical antireflux therapy on asthma control. The articles' bibliographies were also reviewed. Studies were graded according to Sackett's criteria and grouped by levels of evidence.

RESULTS

A total of 242 citations were found; 171 were published in English. Twelve studies of the effects of medical antireflux therapy on asthma control, with a total of 326 treated patients, were identified. Eight studies were placebo-controlled, three were open studies, and one used an untreated control. Eight studies treated 20 or fewer patients. Reflux symptoms either did not improve or the effects of antireflux therapy on them were not reported in four studies. The combined data from the controlled medical antireflux studies showed that: (1) asthma symptoms improved in 69% of the subjects; (2) asthma medication use was reduced in 62% of the subjects; (3) evening peak expiratory flow (PEF), but not PEF at other times, improved in 26% of the subjects; and (4) spirometry did not improve in any of the placebo-controlled antireflux studies.

CONCLUSIONS

Analysis of the combined data suggests that medical antireflux therapy improves asthma symptoms, may reduce asthma medication use, but has minimal or no effect on lung function.

Oral contraceptive use and smoking are risk factors for relapse in Crohn's disease. The Canadian Mesalamine for Remission of Crohn's Disease Study Group

BACKGROUND & AIMS

Lifestyle factors have been shown to influence prognosis in Crohn's disease. The purpose of this study was to prospectively assess the effects of smoking and oral contraceptive use on clinical relapse rates.

METHODS

Placebo-treated patients formed a prospective cohort, followed up for 48 weeks or until relapse. The influence of smoking and the use of oral contraceptives on relapse risk was examined by life-table analysis (log rank tests) and Cox proportional hazards modeling, taking into account demographic and disease characteristics.

RESULTS

Of 152 patients, 61 (40%) had a relapse. Univariate analysis showed unfavorable outcomes for women (P = 0.05), current smokers (P = 0.005), and use of oral contraceptives (P = 0.001). Recent surgery was associated with a decreased risk of relapse (P = 0.02). The Cox model retained current smoking vs. never smoking (hazard ratio, 2.1; 95% confidence interval, 1.1-4.2), oral contraceptive use (hazard ratio, 3.0; 95% confidence interval, 1.5-5.9), and medical compared with surgical induction of remission (hazard ratio, 2.1; 95% confidence interval, 1.0-4.2) as predictors of relapse. Ex-smokers did not have an increased risk. Finally, sex, age, time in remission, disease location, and disease duration were not significant predictors.

CONCLUSIONS

Oral contraceptive use and smoking are associated with an increased risk of relapse in patients with Crohn's disease.

The case against routine post-operative therapy for prevention of recurrence in Crohn's disease

Crohn's disease is inevitably characterized by episodes of relapse followed by remission. The majority of patients will require at least one resection, unfortunately many will have, at some time in the future, further recurrences requiring additional surgery. Faced with this clinical situation, the physician or surgeon may respond to the therapeutic imperative, i.e., it is better to do something rather than to do nothing at all (i.e., treat the patient). Because of these factors, various authors have suggested that the aminosalicylates or, in certain cases, azathioprine, should be prescribed following resection. From a health system point of view, the case for maintenance therapy must be reviewed against several criteria. First, the therapy to be prescribed must be safe for patients over the long term. For the most part, the safety profile of mesalamine has been well established. There is also increasing evidence for the safety of azathioprine when used in chronic inflammatory diseases such as rheumatoid arthritis. Second, there must be objective evidence of efficacy as assessed by randomized controlled, double-blind trials. To date, several trials have been performed, unfortunately, the most recent have only been reported in abstract form. The results of the trials have been contradictory with a mixture of positive and negative findings. There is a lack of consistency for both the dose response and preferred disease site, the use of placebos, the evaluation of outcome and the statistical analysis. Third, the cost-benefit ratio must favour the therapy. Calculation of the number to reat (NNT) to prevent one recurrence is often helpful. Finally, compliance in a group of patients who often decide on surgery so that they can stop taking medication must be considered. A variety of criteria have been developed to assist in making choices regarding prophylaxis. The first relates to the ease of treating the patient with recurrence. Some patients will respond promptly to conventional therapy and enter remission. Unfortunately, this is not the case for the majority of patients. We lack predictors of response. The second concerns the issue as to whether or not the condition to be prevented, recurrence, is a "serious" event. There would be little discussion of that issue at an IBD meeting! The third considers the possibility of adverse events related to the prophylaxis. Again, there does not appear to be concern related to safety. It is the final criterion regarding effectiveness that balances the argument against a routine recommendation for post-operative maintenance therapy.

Review article: treatment of Clostridium difficile infection

AIM

A systematic review of controlled trials of therapy of Clostridium difficile intestinal infection using methodology described by the Cochrane Collaboration.

METHODS

Trials were identified by searching computer databases over the years 1978-1996. Trials were included if they were (a) prospective randomized, controlled trials and (b) included patients with symptomatic disease. The primary end-point was clinical resolution of diarrhoea. Secondary end-points were clinical relapse and stool clearance of C. difficile and C. difficile toxin.

RESULTS

Nine trials (469 patients) satisfying the inclusion criteria were identified. Two trials were placebo controlled. Six trials compared vancomycin to other antibiotics (fusidic acid, bacitracin, teicoplanin and metronidazole). For clinical resolution response rates ranged from 21 (placebo) to 100% (vancomycin). On pooling the trials, no antibiotic showed clear therapeutic superiority. Rates of clinical relapse ranged from 5 to 42%. Only one trial showed significant advantage of one antibiotic over another for prevention of relapse (teicoplanin vs. fusidic acid).

CONCLUSION

The published data are limited, and further studies are required.

Pulmonary function abnormalities in patients with ulcerative colitis

OBJECTIVES

We hypothesized that abnormalities in pulmonary function are present in subjects with ulcerative colitis (UC). Our primary objectives were (1) to determine the frequency of pulmonary abnormalities in a sample of subjects with UC, and (2) to compare UC subjects with abnormal pulmonary function tests (PFT) with those who have normal PFT in terms of smoking behavior and history of preexisting pulmonary disease.

METHODS

We selected 100 consecutive UC subjects from the index of subjects currently attending the University of Calgary clinics. Sixty-six were eligible. Fifty-five (83%) agreed to participate.

RESULTS

PFT abnormalities were found in 30 (55%) subjects. Abnormal PFT could not be predicted by current or past smoking status, family history of respiratory diseases, occupational history, or current medication status.

CONCLUSIONS

(1) PFT abnormalities were detected in half of the subjects. (2) Smoking status was not predictive of these abnormalities.

5-Aminosalicylates, sulfasalazine, steroid use, and complications in patients with ulcerative colitis

OBJECTIVES

The choice between sulfasalazine and 5-aminosalicylate (5-ASA) drugs in the management of patients with ulcerative colitis often depends on idiosyncrasies of drug tolerance and control of the disease in individual patients. We sought to evaluate whether there were population differences in the effect of 5-ASA and sulfasalazine on the occurrence of clinically recognized adverse events. We also attempted to determine whether there were differences in the use of concomitant steroids and in the rates of hospitalization.

METHODS

We reviewed a large computerized database drawn from general practices in the United Kingdom. There we found records of 2894 patients in whom general practitioners had diagnosed ulcerative colitis, and who were receiving ongoing medical therapy specific to ulcerative colitis. The period of data availability ran from the beginning of 1990 to the latter part of 1993. The average duration of observation was 2.1 yr per patient. Patient histories were categorized into distinct periods according to the dose of 5-ASAs and sulfasalazine, steroids, and immunosuppressants, and were further separated according to the activity of ulcerative colitis. Within these categories, we examined the initiation and discontinuation of steroids, incidence of new hospitalizations for ulcerative colitis, and clinical mention of adverse events.

RESULTS

New clinical mentions of hepatic, pancreatic, renal, and hematological events other than anemia were similar among the 5-ASAs and were very infrequent overall. Hospitalizations for ulcerative colitis occurred with similar frequency (about 15 hospitalizations per 100 patients per year) among users of those drugs. Patients receiving sulfasalazine had lower rates of initiation of prednisolone than did patients receiving 5-ASA, but sulfasalazine was used proportionately less often in patients who had been recently hospitalized, and it may be that sulfasalazine patients were somewhat less sick, overall, than were 5-ASA-using patients. The choice of drug did not affect discontinuation rates for prednisolone among established users.

CONCLUSIONS

In the United Kingdom, during the period of this study, serious adverse reactions to drugs were not an important aspect of the management of patients with ulcerative colitis. Renal and pancreatic complications of sulfasalazine and 5-ASA therapy were extremely rare. Sulfasalazine and 5-ASA drugs have similar steroid-sparing properties. Disease-specific hospitalizations are approximately 100 times more common in ulcerative colitis patients than are serious adverse drug effects. Considerations of drug efficacy should therefore dominate the choice between therapeutic agents.

Endoscopists' opinions of indications for upper gastrointestinal endoscopy

OBJECTIVE

To determine whether endoscopists and general internists agreed with the characterization of appropriateness for endoscopy of various clinical scenarios, as previously reported by the RAND Corporation.

DESIGN

Mail survey.

STUDY SAMPLE

All endoscopists in western Canada and a random sample of general internists who did not perform endoscopy.

METHODS

Questionnaires were sent to 179 endoscopists in western Canada who were asked to rate the 53 scenarios for endoscopy on a nine-point scale ranging from most appropriate to most inappropriate. A similar questionnaire was sent to 39 general internists practising in the province of Alberta.

RESULTS

Response rate was 72% of endoscopists (n = 128) and 64% of general internists (n = 25). Among the endoscopists, there was agreement with the RAND classification for 32 scenarios. All 18 indications previously thought to be appropriate were considered to be appropriate. However, endoscopists agreed with only six of 16 equivocal and eight of 19 indications considered inappropriate. Discrepancies were reviewed by five experienced endoscopists and most appeared to be related to a concern regarding possible malignancy linked in part with the definition of failure to respond to medical therapy; and to a refusal to request a barium meal before endoscopy. Among general internists, there was agreement with RAND in 26 scenarios. When the appropriateness rankings of endoscopists and general internists were compared, there was agreement in 40 of 53 scenarios. Significant discrepancies in ratings were identified in scenarios in which barium studies were described as being normal, known or not done.

CONCLUSIONS

The equivocal and inappropriate ratings developed by the RAND Corporation are not uniformly accepted by the endoscopy community or general internists. Use of the RAND indications for assessing quality assurance can be challenged.

Maintenance therapy for inflammatory bowel disease: what really works

The propensity of inflammatory bowel disease sufferers to experience recurrent episodes or disease flares is well documented. Until a cure can be found, strategies to lengthen the period of remission offer the greatest opportunity to reduce morbidity and enhance patient quality of life. Therapies that have been shown in randomized, controlled, double-blind clinical trials to either lengthen the time of remission or improve the odds of staying in remission during a set time interval are required.

A randomized, placebo-controlled, double-blind trial of mesalamine in the maintenance of remission of Crohn's disease. The Canadian Mesalamine for Remission of Crohn's Disease Study Group

BACKGROUND & AIMS

The efficacy of mesalamine for the maintenance of remission in patients with Crohn's disease is controversial. The aim of this study was to conduct a double-blind, placebo-controlled study of mesalamine (750 mg four times a day for 48 weeks) in maintaining remission in 293 patients with Crohn's disease. Patients were stratified according to the method of induction of remission (medical or surgical).

METHODS

Patients were assessed at weeks 4, 12, 24, 36, and 48. Relapse was defined as a Crohn's Disease Activity Index of >150 (+60 points over baseline).

RESULTS

Of the 293 patients, 246 (84%) returned for at least 4 weeks of follow-up and were included in the final analysis. Thirty of the 118 (25%) who received mesalamine had a relapse compared with 47 of 128 (36%) receiving placebo (P = 0.056). Among those with relapse, the time to relapse was 119 days for the mesalamine-treated patients compared with 109 days for placebo-treated patients (P = NS). However, 25% of mesalamine-treated patients had relapsed by 249 days of follow-up compared with 154 days for placebo-treated patients. Subgroup analysis showed that patients with ileocecal-colonic disease or patients who were women had fewer relapses on mesalamine therapy than placebo-treated patients (21% vs. 41%, P = 0.018; and 19% vs. 41%, P = 0.003, respectively).

CONCLUSIONS

Mesalamine treatment reduced relapse compared with placebo treatment, although conventional statistical significance was not achieved.

HIV-associated non-Hodgkin's lymphoma of the gastrointestinal tract

OBJECTIVE

To determine the number of HIV-associated non-Hodgkin's lymphoma (NHL) of the gastrointestinal tract (GI) in a population of HIV-infected patients from a distinct geographic region (southern Alberta, Canada), from 1983 to 1995. The type and location of NHL within the GI tract as well it's affect on survival was examined. Patients with GI HIV-associated NHL were compared to patients with extraintestinal HIV-associated NHL.

METHODS

The Southern Alberta HIV Clinic in Calgary (SAC) serves all of southern Alberta which has an estimated population of one million. SAC provided primary care for 1086 patients from January 1983 to August 1995. Data were obtained by reviewing the clinic's data base and patient's charts.

RESULTS

Over a 12-yr period, 13 cases of NHL of the GI tract and 26 cases of extraintestinal NHL were diagnosed in the 1086 HIV-infected patients. HIV-associated GI NHL occurred in individuals of similar age, sex, HIV risk factors, incidence of preceding AIDS-defining illnesses and CD4 count compared to those with extraintestinal NHL. The most common presentations of GI NHL were; abdominal pain (77%), abdominal tenderness (77%), weight loss (77%), and GI bleeding (38%). The most common sites of GI involvement were the large bowel (46%), ileum (39%), and stomach (23%). Those with GI NHL survived longer (1.96 +/- 0.50 yr vs 0.95 +/- 0.20 yr, p < 0.05) and were more likely to respond to therapy (72.7% vs 33.3%, p < 0.03) than those with extraintestinal NHL.

CONCLUSIONS

This study suggests that; 1) the GI tract is common site of involvement in HIV-associated NHL, 2) HIV-associated GI NHL occurs in similar individuals as HIV-associated extraintestinal NHL, 3) those with HIV-associated GI NHL survive longer and are more likely to respond therapy than those with extraintestinal HIV-associated NHL.

Is the Mayo model for predicting survival useful after the introduction of ursodeoxycholic acid treatment for primary biliary cirrhosis?

Treatment of patients with primary biliary cirrhosis (PBC) using ursodeoxycholic acid (UDCA) leads to a reduction in serum bilirubin. The first objective of this study was to assess the performance of certain prognostic indicators for PBC after the introduction of treatment with UDCA. Serum bilirubin is an important prognostic indicator for PBC and an important component of the Mayo model for grading patients into risk categories. In an analysis of patients enrolled in the Canadian multicenter trial, the Mayo score was calculated before and after treatment with UDCA. After treatment, the Mayo score continued to divide patients with PBC into groups with varying risk. In addition, the serum bilirubin alone was shown to do the same even after the introduction of treatment with UDCA. A second objective was to establish whether UDCA had an effect on long-term (2- to 6-year) survival in patients with PBC.

Intestinal permeability changes in response to acetylsalicylic acid in relatives of patients with Crohn's disease

BACKGROUND & AIMS

Presence of a familial intestinal permeability defect in Crohn's disease remains controversial despite numerous studies. The purpose of this study was to determine whether detection of a permeability defect in first-degree relatives of patients with Crohn's disease can be enhanced using an acetylsalicylic acid provocation test.

METHODS

Lactulose-mannitol ratio, a measure of intestinal permeability, and total sucrose excretion, a measure of gastroduodenal permeability, were determined before and after ingestion of acetylsalicylic acid in healthy controls, in patients with Crohn's disease, and in the first-degree relatives of patients with Crohn's disease. Subjects were classified as hyperresponders if their results were above the mean of + 2SD of the controls.

RESULTS

First-degree relatives had a 110% increase in intestinal permeability after acetylsalicylic acid compared with an increase of 57% in controls (P = 0.001). Thirty-five percent of relatives were classified as hyperresponders. There was no significant difference in the change in sucrose excretion between relatives and controls (259% vs 198%; P < 0.05).

CONCLUSIONS

First-degree relatives of patients with Crohn's disease have an exaggerated increase in intestinal but not gastroduodenal permeability in response to acetylsalicylic acid. This study supports a familial permeability defect in Crohn's disease, which may not be present in all families.

Zidovudine absorption and small intestinal function in HIV seropositive patients

Zidovudine absorption was evaluated in HIV seropositive patients with (n = 15) and without diarrhoea (n = 20) in a standardised prospective pharmacokinetic study using single oral 200 mg doses. Zidovudine was rapidly absorbed with large peak variation (Cmax: 1.10 +/- 0.43 mg/L). There were no significant associations between pharmacokinetic parameters and presence of diarrhoea, CD4 counts, red blood cell folate concentrations, stool cultures/leucocytes or the lactulose/mannitol absorption test. Mean diarrhoea AUC (mg/L.h) was 1.13 +/- 0.30 and 1.07 +/- 0.36 in non-diarrhoeal patients. Antidiarrhoeals increased AUC and Cmax values in a small, non statistically significant subset of diarrhoea patients. Although zidovudine absorption varies significantly, our data do not support dosage individualisation based on any of the above parameters.

Oral budesonide as maintenance treatment for Crohn's disease: a placebo-controlled, dose-ranging study. Canadian Inflammatory Bowel Disease Study Group

BACKGROUND & AIMS

Budesonide is a corticosteroid with high topical anti-inflammatory activity and low systemic activity due to rapid hepatic metabolism. The efficacy and safety of an oral controlled-release preparation of budesonide for maintenance of remission was evaluated in patients with ileal or ileocecal Crohn's disease.

METHODS

In a double-blind, multicenter trial, 105 patients were randomly assigned to receive placebo or budesonide at doses of 3 or 6 mg daily for 1 year. The primary outcome measure was relapse defined by a Crohn's Disease Activity Index score of > 150 and a minimum increase of 60 points.

RESULTS

Patients receiving 6 mg of budesonide had a median time to relapse or discontinuation of therapy of 178 days compared with 124 days in those receiving 3 mg of budesonide and 39 days in those receiving placebo. However, at 1 year, the rate of relapse in the group receiving 6 mg of budesonide was similar to the rates in the 3-mg and placebo groups. Basal plasma cortisol levels and incidence of corticosteroid-associated effects were similar in the three groups.

CONCLUSIONS

Oral controlled-release budesonide (6 mg/day) was well tolerated and prolonged remission in Crohn's disease of the ileum and proximal colon, but this effect was not sustained at 1-year follow-up.

Meta-analysis of the role of oral contraceptive agents in inflammatory bowel disease

Numerous epidemiological studies have been performed to determine factors that might contribute to the development of inflammatory bowel disease. Although the role of oral contraceptive agents in Crohn's disease (CD) and ulcerative colitis (UC) have been assessed, most studies were of small sample size and characterised by low statistical precision. A meta-analysis was performed to increase the statistical power and to investigate the association between the use of oral contraceptives and the development of CD and UC. The study was based on a search of a Medline database from 1975 to October 1993 and a review of reference lists from published articles, reviews, symposia proceedings, and abstracts from major gastrointestinal meetings. All studies specifically designed to evaluate this association were selected. The combined results of nine studies--two cohort studies (30,379 unexposed and 30,673 exposed patients) and seven case-control studies (482 CD, 237 UC, and 3198 controls)--which satisfied our selection criteria were evaluated. The pooled relative risk (adjusted for smoking) associated with oral contraceptive use was 1.44 (1.12, 1.86) for CD and 1.29 (0.94, 1.77) for UC. These results suggest modest associations between the use of oral contraceptives and the development of CD and UC. As these associations are weak, non-causal explanations for the findings cannot be eliminated.

Perioperative blood transfusion does not prevent recurrence in Crohn's disease. A pooled analysis

The effect of perioperative blood transfusion on the recurrence of Crohn's disease is controversial. Various studies have suggested that perioperative blood transfusions reduce the risk of recurrence; others have failed to find a protective effect. Since all the studies are based on relatively small numbers, we performed a pooled analysis. We contacted the senior authors of seven previously published studies and asked for the original data. Four authors provided their data. The pooled database included 622 patients with a primary and complete resection of macroscopic disease. Recurrence was defined as the need for repeat surgery for disease control. Kaplan-Meier life table analysis was performed. Of the study sample, 366 cases (59%) were female. Disease distribution was as follows: small bowel (47%), small/large bowel (35%), and large bowel only (18%). Three hundred thirty-one patients (53%) received blood in the perioperative period. Mean follow-up was 72.8 months. For the overall sample, the 5-year recurrence rates were 26.9% for the transfused group and 25.2% for the nontransfused (p = 0.456). When the data were stratified by age, gender, disease location, and length of resection, no difference in 5-year recurrence rates between transfused and nontransfused cases could be detected. In this pooled analysis of four retrospective studies on the effect of blood transfusions on the risk of recurrence in Crohn's disease, we were unable to document a protective effect.

General practitioners' assessment of and interest in alternative medicine in Canada

Canadian physicians' opinions about alternative medicine have, as yet, not been assessed. The objectives of this pilot study were to assess general practitioners': (1) desired involvement in alternative medicine; (2) perceived demand for alternative medicine; and (3) beliefs about the efficacy of different alternative approaches. The study design was a cross-sectional survey of 400 randomly selected Alberta and Ontario general practitioners. Of the 384 eligible physicians, 200 (52%) completed the questionnaire. Seventy-three percent of physicians felt that they should have some knowledge about the most important alternative treatments. However, with respect to other issues, physicians desired less involvement with alternative medicine. Sixty-five percent perceived a demand for alternative medicine from their patients, in particular chiropractic. Alternative medicine was perceived to be needed most for musculoskeletal problems and chronic pain or illness. Chiropractic, hypnosis and acupuncture (for chronic pain) were believed to be most efficacious, while homeopathy and reflexology were considered to be least efficacious. Undergraduate, graduate clinical and continuing medical education will need to address alternative treatments in order to provide physicians with up-to-date and relevant information.

Azathioprine and 6-mercaptopurine in Crohn disease. A meta-analysis

PURPOSE

To assess the effectiveness of azathioprine and 6-mercaptopurine in inducing remission of active Crohn disease and the effectiveness of azathioprine in maintaining remission of quiescent disease.

DATA SOURCES

Pertinent studies were selected from the MEDLINE database (1966 to May 1994), abstracts from major gastrointestinal meetings, and references from published articles and reviews.

STUDY SELECTION

Nine randomized, placebo-controlled trials of azathioprine or 6-mercaptopurine therapy were identified: Four addressed active disease, two addressed quiescent disease, and three had multiple therapeutic arms.

DATA EXTRACTION

Data were extracted by three independent observers on the basis of the intention-to-treat principle and were analyzed with logistic regression. Each study was given a quality score on the basis of predetermined criteria.

DATA SYNTHESIS

Compared with placebo, azathioprine or 6-mercaptopurine therapy had an odds ratio of response of 3.09 (95% CI, 2.45 to 3.91) in patients with active Crohn disease. When the single trial that used 6-mercaptopurine in active disease was excluded from the analysis, the odds ratio of response was 1.45 (CI, 1.12 to 1.87). No trials of quiescent disease used 6-mercaptopurine; the odds ratio of response in these trials of quiescent disease was 2.27 (CI, 1.76 to 2.93). For active disease, continuation of therapy for at least 17 weeks improved response (P = 0.03). For quiescent disease, a higher dose improved response (P = 0.008). Increased cumulative dose improved response in both groups (P < 0.001 for active disease and P = 0.01 for quiescent disease). A steroid-sparing effect was seen in active disease (odds ratio, 3.69 (CI, 2.12 to 6.42) and in quiescent disease (odds ratio, 4.64 [CI, 1.00 to 21.54]). Fistulae improved with therapy (odds ratio, 4.44 [CI, 1.50 to 13.20]). Adverse events requiring withdrawal from a trial, primarily allergy, leukopenia, pancreatitis, and nausea, were increased with therapy (odds ratio, 5.26 [CI, 2.20 to 12.60]).

CONCLUSIONS

Azathioprine and 6-mercaptopurine are effective in treating active Crohn disease and in maintaining remission. Cumulative dose was an important factor in predicting response. Adverse effects were more common among patients receiving therapy.

Alternative medicine and general practitioners. Opinions and behaviour

OBJECTIVE

To describe general practitioners' opinions and behaviour regarding alternative medicine.

DESIGN

Cross-sectional survey of a random sample of Ontario and Alberta general practitioners.

SETTING

General practices in Ontario and Alberta.

PARTICIPANTS

A questionnaire was mailed to 400 general practitioners. Of the 384 eligible physicians, 200 completed the questionnaire.

MAIN OUTCOME MEASURES

Reported beliefs and practices concerning alternative medicine.

RESULTS

Acupuncture, chiropractic, and hypnosis were considered most useful and reflexology, naturopathy, and homeopathy least useful. Results showed 56% of general practitioners believed that alternative medicine has ideas and methods from which conventional medicine could benefit, 54% referred to alternative practitioners, and 16% practised some form of alternative medicine. Province of practice, place of graduation, training in alternative approaches, number of alternative approaches perceived useful, and attitude toward alternative medicine were clearly related to referring to alternative practitioners. Sex, age, type of practice, training in alternative medicine, referring to alternative practitioners, number of alternative approaches perceived useful, and attitude toward alternative medicine were related to practicing alternative medicine.

CONCLUSION

Although acceptance and integration of alternative medicine extend only to certain approaches, alternative medicine cannot be discounted in general practice. A study encompassing all Canadian provinces could help in planning medical education and developing policies to guide physician behaviour.

Meta-analysis of enteral nutrition as a primary treatment of active Crohn's disease

BACKGROUND/AIMS

The efficacy of enteral nutrition as primary therapy of active Crohn's disease is controversial. The aim of the study was to compare by meta-analysis the likelihood of clinical response to liquid diet therapy vs. corticosteroids and to assess the importance of formula composition to efficacy.

METHODS

Randomized controlled trials comparing exclusive enteral nutrition with corticosteroids and elemental with nonelemental formulas were identified through a combination of computerized and hand-searching techniques. Rates of clinical remission of active Crohn's disease, based on the intention-to-treat principle, were extracted from the studies by two independent reviewers. Odds ratios for likelihood of clinical response were calculated.

RESULTS

In eight trials comprising 413 patients, enteral nutrition was inferior to corticosteroids (pooled odds ratio, 0.35; 95% confidence interval, 0.23-0.53). In five trials comprising 134 patients, there was no difference in the efficacy of elemental versus nonelemental formulas (pooled odds ratio, 0.87; 95% confidence interval, 0.41-1.83).

CONCLUSIONS

Corticosteroids are more effective than enteral nutrition in the treatment of active Crohn's disease. Limited sample size precludes definitive conclusions about the importance of formula composition in the efficacy of enteral nutrition; however, data analyzed in this study do not support an advantage to elemental feedings compared with a polymeric formulation.