Treat to transmural healing: how to incorporate intestinal ultrasound into the treatment of inflammatory bowel disease

Intestinal ultrasound (IUS) is emerging as a key tool to achieving the therapeutic target of transmural healing in inflammatory bowel disease (IBD). IUS is a non-invasive, radiation-free, imaging modality comparable to MRI, CT and ileocolonoscopy (IC). With the appropriate training and equipment, IUS can be an easily repeatable bedside test for IBD diagnosis and disease monitoring, including treatment response. Core to successful high quality IUS employment are appropriate training and expert techniques; however, the training pathway will not be explored in this review. Given the increasing shift towards objective assessment for tight disease control, gastroenterologist-led IUS should be incorporated into the armamentarium of imaging modalities alongside radiologists, to enhance our diagnostic and monitoring toolbox. This comprehensive review aims to outline the current literature around IUS and propose the placement of IUS in a treat-to-target algorithm in IBD. Ultimately, IUS facilitates timely management decisions to optimise patient care with potential to revolutionise patient outcomes, moving towards transmural healing as the holy grail of therapy in IBD.

Review article: latent tuberculosis in patients with inflammatory bowel diseases receiving immunosuppression-risks, screening, diagnosis and management

BACKGROUND

One quarter of the world's population has latent tuberculosis infection (LTBI). Systemic immunosuppression is a risk factor for LTBI reactivation and the development of active tuberculosis. Such reactivation carries a risk of significant morbidity and mortality. Despite the increasing global incidence of inflammatory bowel disease (IBD) and the use of immune-based therapies, current guidelines on the testing and treatment of LTBI in patients with IBD are haphazard with a paucity of evidence.

AIM

To review the screening, diagnostic practices and medical management of LTBI in patients with IBD.

METHODS

Published literature was reviewed, and recommendations for testing and treatment were synthesised by experts in both infectious diseases and IBD.

RESULTS

Screening for LTBI should be performed proactively and includes assessment of risk factors, an interferon-gamma releasing assay or tuberculin skin test and chest X-ray. LTBI treatment in patients with IBD is scenario-dependent, related to geographical endemicity, travel and other factors. Ideally, LTBI therapy should be used prior to immune suppression but can be applied concurrently where urgent IBD medical treatment is required. Management is best directed by a multidisciplinary team involving gastroenterologists, infectious diseases specialists and pharmacists. Ongoing surveillance is recommended during therapy. Newer LTBI therapies show promise, but medication interactions need to be considered. There are major gaps in evidence, particularly with specific newer therapeutic approaches to IBD.

CONCLUSIONS

Proactive screening for LTBI is essential in patients with IBD undergoing immune-suppressing therapy and several therapeutic strategies are available. Reporting of real-world experience is essential to refining current management recommendations.

Maternal Smoking during Pregnancy Is Associated with Offspring Hypodontia

Little is known about environmental risk factors for hypodontia. The objective of this study was to investigate the association between hypodontia and common environmental risk factors, such as maternal smoking and alcohol and caffeine consumption during pregnancy. Eighty-nine hypodontia cases with 1 or more missing permanent lateral incisors and/or 1 or more missing premolars were enrolled in this clinic-based case-control study. Some 253 controls with no missing teeth were frequency matched to cases by age and sex. Hypodontia was diagnosed using panoramic radiographs. Sociodemographic data were collected from both the participants and their mothers, with maternal self-reported active and passive smoking, as well as alcohol and caffeine consumption during pregnancy, assessed by a questionnaire. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated with logistic regression to assess the strength of association between risk factors and hypodontia. OR estimates were then adjusted for possible confounders, such as maternal age at delivery, sex and gestational age of the child, and household socioeconomic background. Significant associations were found between hypodontia and maternal cigarette use during pregnancy, as well as the number of cigarettes smoked per day. The consumption of 10 or more cigarettes per day during pregnancy was associated with greater odds of having a child with hypodontia (adjusted OR, 4.18; 95% CI, 1.48-11.80; P = 0.007). Observed associations between hypodontia, second-hand smoke, and alcohol and caffeine consumption were not statistically significant. Maternal smoking during pregnancy is associated with hypodontia. Larger samples and prospective observational study designs, however, are needed to investigate this association further.

Noise levels in dental school clinics

Prolonged exposure to noise is a little-investigated occupational hazard in dentistry. There is anecdotal evidence suggesting that noise levels in four student clinics at the School of Dentistry are higher than the current occupational noise level guidelines in New Zealand, Australia and the United Kingdom, which suggest that levels should not exceed 85 dB (A) over a duration of 8 hours. The objectives of this study were to (1) measure the noise levels in the student clinics, and (2) determine whether they exceed current guidelines for occupational noise levels.

METHOD

A noise level meter was used to measure the decibel recordings in dB (A), before and during clinical sessions. The types of procedures being carried out by the students were recorded.

RESULTS

127 background recordings and 126 activity recordings were made, with measured noise levels ranging from 50.2 to 77.6 dB (A) for background levels, and 51.4 to 98.0 dB (A) during activity, with means of 60.8 and 70.5 dB (A) respectively. Measurements made in one clinic (the 4SW clinic) were significantly higher than those made in the other clinics (P < 0.001), and one (clinic 2N) gave the lowest readings.

CONCLUSION

Noise levels recorded from the clinics at the Otago School of Dentistry exceed those specified in the current New Zealand Occupational Health and Safety guidelines, but they are intermittent rather than continuous.