Angiotensin Receptor Blocker-Related Sprue-like Enteropathy: Review of Food and Drug Administration Adverse Event Reporting System

BACKGROUND

Sprue-like enteropathy (SE) related to olmesartan use was first reported in 2012. In 2017, the manufacturer of Benicar paid $300 million for 2300 claims for olmesartan-related SE.

OBJECTIVE

A study in 2019 suggested that SE was related to olmesartan and with the possibility of angiotensin receptor blocker (ARB) class effect. To further characterize this condition, our group examined reports of ARB-related SE to Food and Drug Administration Adverse Event Reporting System (FAERS).

METHODS

All reports of ARB-related SE from January 2017 to December 2021 were downloaded from the FAERS database. Gastrointestinal adverse events including SE were reviewed. Reporter categories included physicians, pharmacists, other health care professionals, consumers, and attorneys.

RESULTS

A total of 106 590 reports of ARB-related adverse effects were analyzed. Sprue-like enteropathy was identified in 4337 cases (4.1% of total reports). Of these, 4240 cases (98.0%) of ARB-related SE were reported in patients using products with olmesartan, and 97 cases of SE were reported for all other ARBs (eprosartan, losartan, telmisartan, irbesartan, valsartan, and candesartan). Reports of olmesartan-related SE increased rapidly in 2017, continued at a high rate in 2018 and 2019, and essentially stopped in 2020 and 2021.

CONCLUSIONS AND RELEVANCE

Reports to FAERS for ARB-related SE are mostly related to olmesartan. There was a steep decline in reports of olmesartan-related SE following the lawsuit with potential of lawyer interference. There are reports of SE related to ARBs other than olmesartan, with increased physician awareness and the potential to discover a class effect with future studies.

A Summary of the Rare Reports of Osteonecrosis of the Jaw Associated With Tumor Necrosis-α Inhibitors in the United States Food and Drug Administration's Adverse Event Reporting System Database

PURPOSE

Recent case reports highlight an association between osteonecrosis of the jaw (ONJ) and antitumor necrosis factor (anti-TNF) medications. Our study reviewed and described reports of anti-TNF associated ONJ reported to the United States of America's Food and Drug Administration Adverse Event Reporting System to explore this potential adverse drug reaction further.

METHODS

Using the Food and Drug Administration Adverse Event Reporting System database, we identified reported cases of ONJ between 2010 and 2021. Cases were included in our study if they reported any prior or concomitant anti-TNF medication use. Additionally, only adults (age 18+) and reports from health-care professionals were included. Cases lacking subject age or gender were excluded. After duplicates were removed, a dataset was created and demographics were described including age, gender, and indication for use. Naranjo scoring was conducted to assess adverse drug reaction probability. Subject demographics were then separately described for cases without reported denosumab or bisphosphonate therapy history and compared to those with reported history or concomitant denosumab or bisphosphonate therapy.

RESULTS

Over twenty thousand cases of ONJ were reported. Forty-four potential cases (0.22%) of anti-TNF medication-associated ONJ were identified and reviewed. Of these, female gender comprised 77.3% (35 cases) and there was an average age of 61.3 years ± 13.7 years. Twenty cases (45.5%) had no prior/concomitant bisphosphonate or denosumab therapy. Of these, 55% (11 cases) were female and the average age was 54.5 ± 17.3 years. Rheumatoid arthritis was the most frequent indication for use (5 cases, 25%) followed by inflammatory bowel disease (IBD) and psoriatic arthritis (4 cases each, 20%) in this cohort.

CONCLUSIONS

Twenty potential cases of anti-TNF-associated ONJ without prior or concomitant medications known to be associated with ONJ were identified and described. Interestingly, male gender was more frequent and subjects were younger in these cases compared to those with prior/concomitant bisphosphonates or denosumab therapy. Naranjo scoring indicated a probable interaction for three cases. Further studies are needed to clarify the association of ONJ and anti-TNF therapy, including investigating potential mechanisms and reporting future cases with sufficient detail to assess possible confounding factors.

Medication-induced osteonecrosis of the jaw: a review of cases from the Food and Drug Administration Adverse Event Reporting System (FAERS)

BACKGROUND

Osteonecrosis of the jaw (ONJ) is a rare but serious adverse drug reaction (ADR) commonly associated with bisphosphonate and denosumab therapy. Prior research utilized an online, public FDA Adverse Event Reporting System (FAERS) Database to explore this ADR. This data identified and described several novel medications associated with ONJ. Our study aims to build upon the prior findings, reporting trends of medication induced ONJ over time and identifying newly described medications.

METHODS

We searched the FAERS database for all reported cases of medication related osteonecrosis of the jaw (MRONJ) from 2010 to 2021. Cases lacking patient age or gender were excluded. Only adults (18 +) and reports from Healthcare Professions were included. Duplicate cases were removed. The top 20 medications were identified and described for April 2010-December 2014 and April 2015-January 2021.

RESULTS

Nineteen thousand six hundred sixty-eight cases of ONJ were reported to the FAERS database from 2010-2021. 8,908 cases met inclusion criteria. 3,132 cases were from 2010-2014 and 5,776 cases from 2015-2021. Within the cases from 2010-2014, 64.7% were female and 35.3% were male, and the average age was 66.1 ± 11.1 years. Between 2015-2021, 64.3% were female and 35.7% were male, and the average age was 69.2 ± 11.5 years. Review of the 2010-2014 data identified several medications and drug classes associated with ONJ not previously described. They include lenalidomide, corticosteroids (prednisolone and dexamethasone), docetaxel and paclitaxel, letrozole, methotrexate, imatinib, and teriparatide. Novel drugs and classes described between 2015-2021 include palbociclib, pomalidomide, radium 223, nivolumab, and cabozantinib.

DISCUSSION

While stricter inclusion criteria and removal of duplicate cases led to fewer overall identified cases of MRONJ when compared to prior research, our data represents a more reliable analysis of MRONJ reports to the FAERS database. Denosumab was the most frequently reported medication associated with ONJ. While unable to imply incidence rates from our data due to the nature of the FAERS database, our findings provide further description of the various medications associated with ONJ and elucidate patient demographics associated with the ADR. Additionally, our study identifies cases of several newly described drugs and drug classes that have not been previously described in literature.

A Case Report of Diffuse Alveolar Hemorrhage Coexisting With Immunoglobulin A (IgA) Nephropathy

Immunoglobulin A (IgA) nephropathy is the most common cause of primary glomerulonephritis worldwide. IgA vasculitis (formerly known as Henoch-Schonlein purpura) typically presents with IgA nephropathy on renal biopsy in addition to extrarenal symptoms like purpura, abdominal pain, and arthritis. Diffuse alveolar hemorrhage (DAH) is the most common pulmonary complication, but this is rarely seen. In this case report, we describe a 35-year-old male with chronic untreated hepatitis B infection who presented with pulmonary-renal syndrome. He was found to have clinical findings of DAH and concomitant IgA nephropathy on renal biopsy, without having any other typical manifestations of IgA vasculitis. This shows that IgA nephropathy should be considered in the differential diagnosis of DAH and emphasizes the importance of a renal biopsy in patients presenting with pulmonary-renal syndrome.

Cost Analysis of Implementing an Exercise Program for Fall and Fracture Prevention in Older Adults on Proton Pump Inhibitor Therapy

Purpose

Falls have significant financial impact. Proton pump inhibitor (PPI) therapy is associated with an increased risk of falls and fractures. Exercise programs have been shown to decrease risk of falls in the elderly population and are recommended by the U.S. Preventive Services Task Force for patients over age 65 to reduce falls. Our study aimed to explore the potential financial benefit of implementing three different Centers for Disease Control and Prevention-recommended exercise-based interventions for fall prevention (Tai Chi, Stepping On, and Otago Exercise Program) in ≥65-year-old patients on PPI therapy.

Methods

A Markov model was developed to predict the financial implications of fall-related outcomes in the study population. Net cost of the intervention was deducted from the financial savings predicted for fall avoidance relative to the fall reduction conferred by the intervention. Sensitivity analysis was performed on a range of odds ratios between falling and PPI use.

Results

Exercise-based interventions were found to offer financial savings when fall reduction rates exceeded 5%, irrespective of variable odds ratios between PPI use and fall rate. Hypothetical implementation of an exercise-based intervention for PPI users ≥65 years of age was estimated to result in annual fall- and fracture-related savings ranging from $10,317.35 to $18,766.28 per individual. Findings suggested an estimated annual reduction in U.S. health care costs of $18 billion to $85 billion.

Conclusions

Implementing an exercise-based fall prevention program for elderly PPI users represents a possible strategy to mitigate health care costs in the United States. Future prospective studies are recommended.

Mesenteric Panniculitis, Sclerosing Mesenteritis and Mesenteric Lipodystrophy: Descriptive Review of a Rare Condition

Mesenteric panniculitis (MP) is the preferred nomenclature for a continuum of inflammatory diseases of the mesentery. The diagnosis of MP is often based on the appearance of a mass-like structure at the root of the mesentery. Characteristic histology includes focal fat necrosis, chronic inflammation, and sometimes mesenteric fibrosis. At present, robust literature related to diagnosis and management of MP are limited. MP is postulated to be an immune-mediated chronic inflammatory and/or a paraneoplastic disease. A personal or family history of other autoimmune diseases is commonly apparent. Several inciting events have been identified that possibly act as triggers in the development of the disease. Trauma, abdominal surgery, infection, and various cancers have been associated with mesenteric panniculitis. There are several diagnostic and histologic criteria that aid in making the diagnosis of MP. The differential diagnosis for a mesenteric mass includes neoplastic disease, and a biopsy may be indicated to rule out other conditions. While cases of MP with a short duration of symptoms, or spontaneously regression may occur, some patients experience prolonged periods of pain, fever, and alterations in bowel habit, causing significant morbidity. A variety of medical therapies have been suggested for MP. Only two, thalidomide and low-dose naltrexone, have been prospectively evaluated. For patients with chronic MP, good responses to prolonged corticosteroid treatment have been reported. Novel therapies include thalidomide and low-dose naltrexone. Hormonal and immunomodulatory therapies are also used based on small case series, but these treatments may have significant side effects. Surgical intervention is not curative and is avoided except for relief of focal bowel obstruction secondary to fibrotic forms of the disease.

State of the art review: coronary artery disease in patients with inflammatory bowel disease: mechanisms, prevalence, and outcomes

Extraintestinal disease manifestations of inflammatory bowel disease (IBD), such as arthritis and uveitis, have been well described in the medical literature. However, there has been growing evidence suggesting an association between IBD and both coronary artery disease (CAD) and acute myocardial infarctions (AMI). In this critical review, the pathogenesis of proatherogenic inflammatory markers (CD40-CD40L, IL-6, and TNF-α) are summarised along with clinical evidence that supports the association of these makers with CAD. Moreover, clinical data are examined that suggest an increased risk of AMI and CAD in IBD patients along with recent analyses of in-hospital and post-MI outcomes of AMI in IBD patients. This comprehensive review summarises and expands upon our understanding of the growing association between both CAD and AMI in IBD patients that potentially identifies IBD as a risk factor for developing CAD.

Menstrual Cycle Variation in MRI-Based Quantification of Intraluminal Gas in Women With and Without Dysmenorrhea

Women frequently report increased bloating, flatulence, and pain during the perimenstrual period. However, it is unknown whether women have more intraluminal gas during menses. To evaluate whether pain-free women or women with dysmenorrhea have different amounts of intraluminal bowel gas during the menses, we utilized magnetic resonance imaging (MRI) to determine colonic gas volumes throughout the menstrual cycle. To avoid dietary influence, the participants were instructed to avoid gas-producing foods before their scheduled MRI. We verified the measurement repeatability across the reviewers and obtained an intraclass correlation coefficient of 0.92. There were no significant differences in intraluminal gas volume between menses and non-menses scans (p = 0.679). Even among the women with dysmenorrhea, there was no significant difference in the intraluminal gas volume between menses and non-menses (p = 0.753). During menstruation, the participants with dysmenorrhea had less intraluminal gas than participants without dysmenorrhea (p = 0.044). However, the correlation between the bowel gas volume and the pain symptoms were not significant (p > 0.05). Although increased bowel symptoms and bloating are reported in the women with dysmenorrhea during menses, our results do not support the hypothesis that increased intraluminal gas is a contributing factor. Although dietary treatment has been shown in other studies to improve menstrual pain, the mechanism responsible for abdominal symptoms requires further investigation. Our findings demonstrate that the intraluminal bowel gas volume measurements are feasible and are unaffected by menses under a controlled diet. The method described might prove helpful in future mechanistic studies in clarifying the role of intraluminal bowel gas in other conditions.

Bevacizumab and gastrointestinal perforations: a review from the FDA Adverse Event Reporting System (FAERS) database

BACKGROUND

Bevacizumab is used in the treatment of advanced malignancies and has a "black box" warning for gastrointestinal perforations. Despite this known side effect, there are no large descriptive series of patients who experience bevacizumab-induced gastrointestinal perforations.

AIM

To review and describe post-market cases of bevacizumab-induced gastrointestinal perforation reported by healthcare professionals to the United States Food and Drug Association Adverse Event Reporting System (FAERS) database.

METHODS

In total, 74 025 cases of bevacizumab-induced adverse drug reaction were reported to FAERS from January 1 2004 to July 6 2021. We identified 2874 cases of bevacizumab-induced gastrointestinal perforation. A total of 1375 cases were determined to contain complete patient demographic data after the removal of duplicates and were reviewed. Subgroup analysis was completed on gastro-oesophageal perforations given the lack of prior data.

RESULTS

The average patient age was 61.9 ± 11.4 years. A total of 698 cases included descriptive locations of perforations with most occurring in the large intestine (385 cases, 55.2% of specifically described cases). Colorectal cancer was the most common indication for bevacizumab (691 cases, 50.3%) followed by ovarian cancer (197 cases, 14.3%) and non-small cell lung cancer (182 cases, 13.2%). Death was reported in 554 patients (40.3% of cases). Sixty-two cases of gastro-oesophageal perforation were identified.

CONCLUSIONS

This is the largest collective descriptive study of bevacizumab-induced gastrointestinal perforations, and sheds light on this often fatal complication. We additionally identified and described a rare subgroup of patients experiencing bevacizumab-induced gastro-oesophageal perforation not previously described.

Complications and Management of Eptifibatide-Induced Thrombocytopenia

BACKGROUND

Eptifibatide is used in acute coronary syndromes to reversibly block platelet aggregation by inhibiting the platelet glycoprotein IIb/IIIa receptor. A serious adverse effect of eptifibatide is a profound drop in platelet count, termed eptifibatide-induced thrombocytopenia (EIT).

OBJECTIVE

To provide insight into the types of complications and management of EIT.

METHODS

Cases of EIT submitted to the Food and Drug Administration adverse event reporting system were evaluated. Data analyses included management of EIT, complications of thrombocytopenia, initial platelets, and platelet nadir following eptifibatide.

RESULTS

103 cases of EIT were reported from January 2010 to 2019; 57 cases met the Naranjo scale and were included. Only 37 of those cases contained information on how EIT was managed. Eptifibatide administration was withheld in all 37 of those cases. Platelet transfusions were administered in 20 cases (54%). Two cases were managed with steroids (5.4%), and 1 case used intravenous immunoglobulin G to reverse EIT (2%). The median initial platelet count prior to administration of eptifibatide was 207 000 cells/mm³ (SD = 69 000; n = 27), and median platelet nadir was 9000 cells/mm³ (SD = 19 000; n = 35) The majority of complications of EIT included bleeding events (16/28, 57%). Delayed procedures, prolonged stay, allergic reactions, and thrombosis were each reported in 3 patients (10.75%).

CONCLUSION AND RELEVANCE

Most cases of EIT were managed by withholding eptifibatide with platelet transfusion if necessary. The majority of complications included bleeding. However, significant procedure delays, prolonged hospital stay, thrombosis, and allergic reactions were also reported.

445. Correlative Factors for State to State Differences in the Prevalence and Case Fatality Rates of SARS-CoV-2, COVID-19 Infections in the United States of America

Background

Individual States of the USA have ethnic, economic, community health and education differences that influence the prevalence and outcomes of COVID-19 infection. We hypothesized that Statewide differences in the prevalence and fatality rates of COVID-19 infections are dependent on factors that may be determined by mathematical modeling.

Methods

Two separate statistical regression models were developed using COVID-19 case prevalence and case fatality rates functioning as dependent variables. We obtained data from the prevalence and deaths from COVID-19 cases for each state in the USA that was posted at 4 PM Central Standard Time on April 29, 2020 from the Worldometer website. Publicly available databases were utilized to obtain data for the independent variables in the model.

Results

Models are represented as follows:

Statewide COVID-19 Prevalence Model

Log (Statewide COVID_19 case prevalence) = 1.847* (100–250 individuals/mile2) +3.0025*(250+ individuals/mile2) + 1.021* (% African American population) +1.029* (% Hispanic American population +2.164 *(% adults aged 85+)

Model results are shown in Table 1.

Statewide COVID-19 Case Fatality Rate Model

Log (Statewide COVID_19 case fatality rate) =2.194* (100–250 individuals/mile2) +2.758* (250+ individuals/mile2) +1.031* (% African American population) + 1.032* (% Hispanic American population) + 0.942 (% Native American population)+ 1.108 (% Asian American population) + 2.275 (% adults aged 85+)

Model results are shown in Table 2.

Table 1: COVID-19 Statewide Prevalence Model

Table 2: COVID-19 Statewide Case Fatality Model

Conclusion

Higher State population density (See Figure 1 and Figure 2) and higher State populations of elderly persons correspond to increased prevalence and case-fatality rates of COVID-19 infections. Statewide data also shows health disparities for COVID-19 infections in Hispanic Americans, African Americans, and Asian Americans. Paradoxically, States with larger populations of Native Americans who have known poor outcomes from COVID-19 infection demonstrate a decrease in case-fatality rates, suggesting a large effect of healthcare inequality in this population.

Figure 1: ANOVA one-way analysis of the association between COVID-19 prevalence and population density

Figure 2: ANOVA one-way analysis of the association between COVID-19 death prevalence and population density

Disclosures

Eli D. Ehrenpreis, MD, FACG, AGAF, E2Bio Consultants (Board Member, Chief Executive Officer)E2Bio Life Sciences (Shareholder, Chief Executive Officer)Level Ex, Inc. (Consultant)

Prevalence of Bloodstream Infections in Children With Short-Bowel Syndrome With a Central Line Presenting to Emergency Department With Fever

BACKGROUND

Children with short-bowel syndrome (SBS) have significant morbidity and mortality from bloodstream infections (BSIs). We studied the prevalence of BSI in children with SBS and identified possible predictors of BSI.

METHODS

This retrospective cohort study included patients with SBS who presented to Holtz Children's Hospital from April 1, 2009, to June 30, 2014, with fever or reported fever. Data including vital signs, white blood cell (WBC) count, C-reactive protein (CRP) levels, and blood and urine cultures were reviewed. We calculated the prevalence of BSI and its confidence level. We also assessed the odds of BSI with increases in WBC and CRP values.

RESULTS

A total of 246 encounters were evaluated. The adjusted calculated prevalence rate for BSI in children with SBS and fever was 55% (95% CI, 42.3%-65.4%). There were 114 gram-negative infections (72.6%), 46 gram-positive infections (29.3%), and 17 fungal infections (10.8%). Using the regression model, each additional 10 units above 20 mg/L CRP increased the odds of BSI by 26%. There was no association between WBC count and the presence of BSI.

CONCLUSION

Children with fever and SBS are at high risk for BSI with gram-positive and gram-negative organisms as well as fungus. WBC count at presentation is a poor predictor of BSI. Though elevated CRP increased the odds of BSI, its low negative predictive value made it a poor predictor of BSI in these patients. Children with SBS and fever should be treated urgently with broad-spectrum antibiotics.

The waiting game: laparoscopic repair of dual Morgagni and paraesophageal hernias in an elderly, infirm patient

Morgagni hernias are congenital diaphragmatic disruptions that occur when intra-abdominal organs herniate posterior to the sternum. It is very rare to concomitantly diagnose a paraesophageal hernia (PEH) in a patient with a Morgagni hernia. Here, we describe an elderly female patient presenting with severe chest pain subsequently diagnosed with a non-strangulated Morgagni hernia as well as PEH. She underwent successful robotic laparoscopic surgical repair of the hernias with resolution of her symptoms. This case demonstrates the need for early surgical intervention of Morgagni hernias to prevent sequelae, such as strangulation, and the rising benefits of laparoscopic repairs in adult patients.

The Mesentery, Systemic Inflammation, and Crohn's Disease

Initially thought to be a structure that only provided support to the abdominal contents, the mesentery has now gained special attention in the scientific community. The new approach of studying the mesentery as an individual organ has highlighted its importance in the development of local and systemic inflammatory diseases and its potential role in Crohn's disease. Its topographical relationship with the intestine in the setting of active inflammation and "creeping fat" is possibly one of the most important arguments for including the mesentery as an important factor in the pathogenesis of Crohn's disease. In this review, we discuss the importance of the mesentery from the anatomical and embryological standpoints. We also will summarize data on mesenteric inflammation in patients with Crohn's disease. The significance of the mesentery in systemic inflammatory syndromes will be discussed, and we provide an overview of primary inflammatory disorders of the mesentery. Finally, we discuss surgical approaches for patients requiring resection for Crohn's disease that incorporate mesenteric factors, pointing out recent data suggesting that these have the potential for improving outcomes and reducing disease recurrence. 10.1093/ibd/izy201_video1izy201.video15794169491001.

Patients with newly diagnosed cervical cancer should be screened for anal human papilloma virus and anal dysplasia: Results of a pilot study using a STELLA computer simulation and economic model

BACKGROUND

Women with cervical cancer often have anal human papillomavirus (HPV) infection and anal dysplasia. However, effectiveness of anal HPV screening is unknown.

METHODS

A dynamic model was constructed using STELLA. Populations are represented as "stocks" that change according to model rates. Initial anal cytology in new cervical cancer patients, dysplasia progression and regression, cost of treating high-grade squamous intraepithelial lesions (HSIL), and lifetime costs for anal cancer care were extrapolated from the literature. Local costs of anal HPV testing and cytology were obtained. Outcomes included anal cancer rates, anal cancer deaths, screening costs and cancer care.

RESULTS

Benefits in the screened group included reduction in anal cancers after three years and anal cancer deaths after four years. After 10 years, predicted costs per anal cancer prevented and anal cancer deaths were $168,796 and $210,057 and were $98,631 and $210,057 at 20 years. Predicted costs per quality of life year saved at 10 and 20 years were $9785 and $1687. Sensitivity analysis demonstrated cost-effectiveness of screening for a variety of cure rates HSIL with electrocautery.

CONCLUSION

Screening for anal HPV and treatment of anal HSIL in patients with cervical cancer is cost-effective, prevents anal cancer and reduces anal cancer deaths.

Hospital costs, length of stay and prevalence of hip and knee arthroplasty in patients with inflammatory bowel disease

AIM

To examined the prevalence of hip and knee arthroplasty in patients with inflammatory bowel disease (IBD) by comparing the diagnostic codes for these procedures in patients with IBD and a control group of patients.

METHODS

The National Inpatient Sample database (NIS) is part of the Healthcare Cost and Utilization Project (HCUP), the largest publicly available inpatient healthcare database in the United States. The NIS samples about 20% of discharges from all community hospitals participating in HCUP, representative of more than 95% of the United States population, with approximately 7000000 hospitalizations reported annually. NIS contains data on diagnoses, procedures, demographics, length of stay (LOS), co-morbidities and outcomes. ICD-9-CM diagnostic codes for primary hospitalizations for arthroplasty of the hip or knee with a co-diagnosis of IBD [combining both Crohn’s disease (CD) and ulcerative colitis (UC)] were used to identify study subjects for cost and LOS analysis for NIS from 1999-2012. Statistical analysis: 1: 2 propensity score matching between IBD vs a control group based on following factors: Patient age, gender, race, total co-morbidities, # of procedures, admission type, insurance, income quartiles, and hospital bed size, location and hospital teaching status. Categorical variables were reported as frequency and compared by χ² tests or Fisher’s exact tests. Individual 1:3 matching was also performed for patients carrying diagnostic codes for CD and for patients with the diagnostic code for UC. After matching, continuous variables were rcompared with Wilcoxon signed rank or Paired T-tests. Binary outcomes were compared with the McNemar’s test. This process was performed for the diagnosis of hip or knee arthroplasty and IBD (CD and UC combined). Prevalence of the primary or secondary diagnostic codes for these procedures in patients with IBD was determined from NIS 2007.

RESULTS

Costs and mortality were similar for patients with IBD and controls, but LOS was significantly longer for hip arthroplasties patients with IBD, (3.85 +/-2.59 d vs 3.68 +/-2.54 d, respectively, P = 0.009). Costs, LOS and survival from the procedures was similar in patients with CD and UC compared to matched controls. These results are shown in Tables 1-10. The prevalence of hip arthroplasty in patients with IBD was 0.5% in 2007, (170/33783 total patients with diagnostic codes for IBD) and was 0.66% in matched controls (P = 0.0012). The prevalence of knee arthroplasty in patients with IBD was 1.36, (292/21202 IBD patients) and was 2.22% in matched controls (P < 0.0001).

CONCLUSION

Costs and mortality rates for hip and knee arthroplasties are the same in patients with IBD and the general population, while a statistical but non-relevant increase in LOS is seen for hip arthroplasties in patients with IBD. Compared to the general population, arthroplasties of the hip and knee are less prevalent in hospitalized patients with IBD.

Domperidone is Commonly Prescribed With QT-Interacting Drugs: Review of a Community-based Practice and a Postmarketing Adverse Drug Event Reporting Database

INTRODUCTION

Domperidone, a peripheral D2 dopamine receptor antagonist, has efficacy for treatment of nausea, dyspepsia, and gastroparesis. Domperidone prolongs the QT interval (QTc), and may cause life-threatening arrhythmias.

METHODS

Electronic medical records for all patients receiving domperidone in the NorthShore University HealthSystem from January 1, 2008 to December 1, 2013 were reviewed. All concomitant medications were noted. The coadministration of QT-interacting medications was determined. Electrocardiogram (EKG) evaluation before and during domperidone therapy was noted. A query of the FDA Adverse Event Reporting System (FAERS) database was also performed. Individual reports from the FAERS Web site from January 2008 to June 2014 were downloaded and analyzed. The database was queried for all reports of adverse events with domperidone. Coadministration of QT-interacting medications was noted. Cardiac events that potentially were related to prolongation of the QTc were examined.

RESULTS

In total, 108 of 155 patients (69.7%) were coprescribed QT-interacting drugs along with domperidone. Fifty-nine of 155 patients (38.1%) underwent a baseline EKG and 9 (15.3%) had prolongation of the QTc at initiation. Forty patients (25.8%) had a follow-up EKG and 13 (32.5%) had prolongation of the QTc. All 13 were coprescribed QT-interacting medications. On the FAERS, 221 nonfatal cardiac events were reported in domperidone patients; of these, 162 (73.3%) occurred in patients receiving QT-interacting medications. Coprescription occurred in 53 of 151 deaths (35.1%) and in 16 of 61 cardiac arrests (26.2%).

CONCLUSIONS

Coprescribing of QT-prolonging medications and inconsistent EKG monitoring occur in patients receiving domperidone, placing these patients at risk for arrhythmias.

Clinical significance of mesenteric panniculitis-like abnormalities on abdominal computerized tomography in patients with malignant neoplasms

AIM

To clarify the association of malignancy with mesenteric panniculitis-like changes on computed tomography (CT).

METHODS

All abdominal CT scans performed at NorthShore University HealthSystem showing mesenteric panniculitis from January 2005 to August 2010 were identified in the Radnet (RadNet Corporation, Los Angeles, CA) database. Patients with a new or known diagnosis of a malignancy were included for this analysis. Longitudinal clinical histories were obtained from electronic medical records.

RESULTS

In total, 147794 abdominal CT scans were performed during the study period. Three hundred and fifty-nine patients had mesenteric panniculitis (MP)-like abnormalities on their abdominal CT. Of these patients, 81 patients (22.6%) had a known history of cancer at the time of their CT scan. Nineteen (5.3%) had a new diagnosis of cancer in concurrence with their CT, but the majority of these (14/19, 74%) were undergoing CT as part of a malignancy evaluation. Lymphomas were the most common cancers associated with MP-like findings on CT (36 cases, 36%), with follicular lymphoma being the most frequent subtype (17/36). A variety of solid tumors, most commonly prostate (7) and renal cell cancers (6) also were seen. CT follow up was obtained in 56 patients. Findings in the mesentery were unchanged in 45 (80%), worsened in 6 (11%), and improved in 5 patients (9%). Positron emission tomography (PET) scans performed in 44 patients only showed a positive uptake in the mesenteric mass in 2 patients (5%).

CONCLUSION

A new diagnosis of cancer is uncommon in patients with CT findings suggestive of MP. MP-like mesenteric abnormalities on CT generally remain stable in patients with associated malignancies. PET scanning is not recommended in the evaluation of patients with mesenteric panniculitis-like findings on CT.

Effect of the Diagnosis of Inflammatory Bowel Disease on Risk-Adjusted Mortality in Hospitalized Patients with Acute Myocardial Infarction, Congestive Heart Failure and Pneumonia

Introduction

Measurement of mortality in patients with acute myocardial infarction (AMI), congestive heart failure (CHF) and pneumonia (PN) is a high priority since these are common reasons for hospitalization. However, mortality in patients with inflammatory bowel disease (IBD) that are hospitalized for these common medical conditions is unknown.

Methods

A retrospective review of the 2005–2011 National Inpatient Sample (NIS), (approximately a 20% sample of discharges from community hospitals) was performed. A dataset for all patients with ICD-9-CM codes for primary diagnosis of acute myocardial infarction, pneumonia or congestive heart failure with a co-diagnosis of IBD, Crohn’s disease (CD) or ulcerative colitis (UC). 1:3 propensity score matching between patients with co-diagnosed disease vs. controls was performed. Continuous variables were compared between IBD and controls. Categorical variables were reported as frequency (percentage) and analyzed by Chi-square tests or Fisher’s exact test for co-diagnosed disease vs. control comparisons. Propensity scores were computed through multivariable logistic regression accounting for demographic and hospital factors. In-hospital mortality between the groups was compared.

Results

Patients with IBD, CD and UC had improved survival after AMI compared to controls. 94/2280 (4.1%) of patients with IBD and AMI died, compared to 251/5460 (5.5%) of controls, p = 0.01. This represents a 25% improved survival in IBD patients that were hospitalized with AMI. There was a 34% improved survival in patients with CD and AMI. There was a trend toward worsening survival in patients with IBD and CHF. Patients with CD and PN had improved survival compared to controls. 87/3362 (2.59%) patients with CD and PN died, compared to 428/10076 (4.25%) of controls, p < .0001. This represents a 39% improved survival in patients with CD that are hospitalized for PN.

Conclusion

IBD confers a survival benefit for patients hospitalized with AMI. A diagnosis of CD benefits survival in patients that are hospitalized with PN.

How drugs are developed and approved by the FDA: current process and future directions

OBJECTIVES

This article provides an overview of FDA's regulatory processes for drug development and approval, and the estimated costs associated with the development of a drug, and also examines the issues and challenges facing the FDA in the near future.

METHODS

A literature search was performed using MEDLINE to summarize the current FDA drug approval processes and future directions. MEDLINE was further utilized to search for all cost analysis studies performed to evaluate the pharmaceutical industry R&D productivity and drug development cost estimates.

RESULTS

While the drug approval process remains at high risk and spans over multiple years, the FDA drug review and approval process has improved, with the median approval time for new molecular drugs been reduced from 19 months to 10 months. The overall cost to development of a drug remains quite high and has been estimated to range from $868M to $1,241M USD. Several new laws have been enacted, including the FDA Safety and Innovation Act (FDASIA) of 2013, which is designed to improve the drug approval process and enhance access to new medicines.

CONCLUSIONS

The FDA's improved processes for drug approval and post-market surveillance have achieved the goal of providing patients with timely access to effective drugs while minimizing the risk of drug-related harm. The FDA drug approval process is not without controversy, as a number of well-known gastroenterology drugs have been withdrawn from the US market over the past few years. With the approval of the new FDASIA law, the FDA will continue to improve their processes and, working together with the ACG through the FDA-Related Matters Committee, continue to develop safe and effective drugs for our patients.

Infectious complications of TNF-α inhibitor monotherapy versus combination therapy with immunomodulators in inflammatory bowel disease: analysis of the Food and Drug Administration Adverse Event Reporting System

BACKGROUND & AIM

Incremental increase in the risk of serious infections with combinations of tumor necrosis factor-alpha (TNF-α) inhibitors and immunomodulators compared to monotherapy with these agents in inflammatory bowel disease (IBD) is unclear. Our aim was to analyze whether there is such an incremental increase in the odds of serious infections.

METHODS

The FDA Adverse Event Reporting System (2003 - June 2011) was queried for 'Primary Suspect' reports of various infections with TNF-α inhibitors, systemic corticosteroids and immunomodulators with usage indication of IBD. Odds ratios (ORs) were calculated for baseline odds of infections as well as serious infections (requiring hospitalization and/or death) with monotherapy and combination therapy (compared to 5-Aminosalicylates) as well as incremental increase in odds for dual or triple combination therapy (compared to monotherapy or dual combination therapy respectively) using Fisher's exact test with SPSS 20 (IBM Co. Armonk, NY, USA).

RESULTS

TNF-α inhibitor (OR 1.95; CI, 1.06-3.59) and immunomodulator (OR 9.99; CI, 1.28-78.16) monotherapy as well as in combination augmented baseline odds of serious infection for IBD patients. No incremental increase in the odds with combination therapy was seen when an immunomodulator was added to a TNF-α inhibitor (OR 0.37; CI, 0.05-2.80) and when both were used with a systemic corticosteroid (OR 0.91; CI, 0.50-1.66). Variations in these were seen for the individual infection subtypes.

CONCLUSIONS

TNF-α inhibitor and immunomodulator monotherapy increase the baseline odds of acquiring a serious infection. Combination therapy with these drugs does not further increase the odds of serious infections compared to monotherapy.

Clinical and endoscopic features of angiosarcoma of the colon: two case reports and a review of the literature

BACKGROUND

Angiosarcoma of the gastrointestinal tract is an extremely rare tumor. We present two cases of angiosarcoma of the colon. One patient developed syncope and anemia and the other had rectal bleeding.

DISCUSSION

Endoscopic findings of the colon were different; the first case demonstrated a reddened colonic fold without an obvious mass and the other had an ulcerated friable mass. Both of the tumors had positive immunohistochemical stains for CD31 and CD34 (one was also positive for CD117). Surgery was not performed in either case. Treatment included chemotherapy with imatinib for the first patient and paclitaxel for the second. Prognosis for this tumor is generally poor; in our cases, one patient was still alive after 5 months of follow-up and the other died within 2 months of diagnosis. After presenting our cases, we reviewed the current literature on angiosarcoma of the colon.

Neurological events with tumour necrosis factor alpha inhibitors reported to the Food and Drug Administration Adverse Event Reporting System

BACKGROUND

The association between inhibition of tumour necrosis factor alpha (TNF-α) and new onset of neurological adverse events (AEs) is unclear.

AIMS

To evaluate neurological AEs with TNF-α inhibitors reported to the Food and Drug Administration Adverse Event Reporting System (FAERS) utilising a standardised scoring tool for drug-induced AEs.

METHODS

A search of FAERS for neurological AEs (January 1, 2000 to December 31, 2009) reported with infliximab, adalimumab, certolizumab and etanercept was performed. Full-text reports were accessed using the Freedom of Information Act and scored using Naranjo score, while accounting for temporal association, previous conclusive reports of the neurological AE with any TNF-α inhibitor, and alternate explanations including underlying disease, concomitant medications and comorbidities, such as diabetes mellitus.

RESULTS

There were 772 reports. Most were in patients who had rheumatoid arthritis (393, 50.9%) followed by inflammatory bowel disease (140, 18.1%). No significant differences in age or gender were seen between IBD patients compared with rheumatological diseases (P = 0.584 and P = 0.055 respectively). Etanercept was reported most (327, 42.4%) followed by infliximab (276, 35.8%) (P = 0.008). Peripheral neuropathy was the most common neurological AE (296 reports, 38.3%) followed by central nervous system and/or spinal cord demyelination (153 reports, 19.8%). Majority (551, 71.4%) of the reports were of 'possible' AE with the remaining 'probable' AE and none identified as 'definite' AE.

CONCLUSION

While several neurological AEs have been described, definite association between de novo development of these AEs and exposure to TNF-α inhibitors was not established using the Naranjo score.

Hospitalizations for vaccine preventable pneumonias in patients with inflammatory bowel disease: a 6-year analysis of the Nationwide Inpatient Sample

Background

Pneumonias are among the most common causes of hospitalization among inflammatory bowel disease (IBD) patients. Guidelines published in 2004 advocate vaccination against Streptococcus pneumoniae and influenza virus. We sought to examine trends in hospitalizations for vaccine preventable pneumonias among IBD patients since the availability of published guidelines, and to identify whether Haemophilus influenzae is a causative organism for pneumonia hospitalizations among IBD patients.

Methods

This cross-sectional study on the Nationwide Inpatient Sample was used to identify admissions for pneumonias in patients with IBD between 2004 and 2009. A multivariate logistic regression analysis was performed comparing IBD patients to controls, accounting for potential confounders.

Results

There were more admissions for S. pneumoniae pneumonia than influenza virus or H. influenzae (787, 393, and 183 respectively). Crohn’s disease (CD) as well as ulcerative colitis (UC) patients did not demonstrate increased adjusted odds of hospitalization for S. pneumoniae pneumonia (1.08; confidence interval [CI] 0.99–1.17 compared to 0.93; CI 0.82–1.06 respectively). Increased adjusted odds for hospitalization for pneumonias due to influenza virus were seen among UC patients in the bottom quartile of income (1.86; CI 1.46–2.37). Adjusted odds for H. influenzae pneumonia admission in patients with UC and CD patients were increased compared to controls (1.42; CI 1.13–1.79 and 1.28; CI 1.06–1.54, respectively).

Conclusion

The study identified lowest income UC patients as having higher adjusted odds, and these patients should be targeted for influenza virus vaccination. Additionally, H. influenzae may be another vaccine preventable cause for pneumonia among IBD patients.

Increased risk of osteoporosis-related fractures in patients with irritable bowel syndrome

We sought to determine whether patients with irritable bowel syndrome (IBS) have an increased risk of osteoporosis and related fractures using the Nationwide Emergency Department Sample (NEDS). Patients with IBS had increased adjusted odds of osteoporosis and osteoporotic fractures compared to the non-IBS control group, controlling for known risk factors for osteoporosis. Screening measures to identify osteoporosis in this group are advised.

INTRODUCTION

Ulcerative colitis, Crohn's disease, and celiac disease have well-described augmented risk of osteoporosis and related fractures. We sought to determine whether IBS also indicates an increased risk of osteoporosis and related fractures.

METHODS

The 2008 NEDS database was used to determine the adjusted odds of osteoporosis and related fractures in IBS patients. Only fractures (pathologic wrist (733.12), vertebrae (733.13), and femur fractures (733.14), traumatic wrist (813.x), vertebrae (805.x-806.x), and hip fractures (820.x-821.x)) with a secondary diagnosis of osteoporosis (733.0x) were included in the analysis. A multivariate logistic regression analysis was performed, controlling for known risk factors for osteoporosis and related fractures.

RESULTS

We identified 317,857 ED visits in patients with a diagnosis of IBS. Of these, 17,752 carried a diagnosis of osteoporosis and 694 IBS patients had a concurrent diagnosis of a pathologic fracture of the wrist, hip, or vertebrae. A total of 1,503 IBS patients had a concurrent diagnosis of a traumatic fracture of the wrist, hip, or vertebra. Overall, patients with IBS had an increased adjusted odds of osteoporosis (odds ratio (OR) 4.28, 95% confidence interval (CI) 4.21-4.35) and osteoporotic fractures (OR 2.36, CI 2.26-2.47) compared to the non-IBS control group. The highest adjusted odds of fracture was seen at the wrist (OR 2.41, CI 2.10-2.77 compared to controls).

CONCLUSIONS

IBS patients are at an increased risk of osteoporosis and related fractures. Screening measures to identify osteoporosis and prevent fractures are advised.

Ischemic colitis with type I interferons used in the treatment of hepatitis C and multiple sclerosis: an evaluation from the food and drug administration adverse event reporting system and review of the literature

OBJECTIVE

To better characterize the association between type I interferons and ischemic colitis (IC) in patients with the hepatitis C virus (HCV) and multiple sclerosis (MS), by analyzing reports submitted to the Food and Drug Administration (FDA) Adverse Event Reporting System (AERS) and the published literature.

DATA SOURCES

A total of 2,562,390 reports of adverse events between January 2003 and June 2011 were downloaded from the FDA AERS. A literature review was performed on PubMed (January 1966-August 2012) using the MeSH terms interferon or interferon alfa or interferon beta and ischemic colitis separated by the Boolean operator "and" between the first 3 terms and the last term. Additional literature was identified by conducting a hand search of the reference list of the published literature identified in the initial search.

STUDY SELECTION AND DATA EXTRACTION

Cases were restricted to those with an indication of HCV or MS, a primary suspect drug of a type I interferon, and a reaction of IC. Full-length reports were requested and organized by type of interferon, age, sex, concomitant drugs, and comorbidities. The Naranjo probability scale was used to define cases as definite, probable, possible, or doubtful drug-induced adverse events.

DATA SYNTHESIS

Type I interferons, including interferon alfa (IFN-α) and interferon beta (IFN-β), are approved for the treatment of HCV and MS. IFN-α has been shown to induce IC, but a relationship between type I interferons and IC has not been clarified in the medical literature. Fifty-six primary suspect reports of type I interferons associated with IC in patients with HCV or MS were identified from the FDA AERS. Seventeen cases were reported with IFN-α and 39 cases were reported with IFN-β. The majority of the cases were in females (80%) and those between the ages of 50 and 65 years (52%). The Naranjo probability scale identified 13 probable and 4 possible cases of IFN-α-induced IC, and 19 probable and 20 possible cases of IFN-β-induced IC. In the literature, 11 cases of IFN-α-induced IC were reported, while there were no reports with IFN-β.

CONCLUSIONS

Our study suggests a possible association between treatment with type I interferons and the development of IC. Further research to determine the mechanism of this association is warranted.

Simulated comparison of topical and oral formulations of 5-aminosalicylate for the treatment of ulcerative colitis

BACKGROUND

5-Aminosalicylate (5-ASA) formulations are approved for the treatment of ulcerative colitis (UC). Determination of the colonic pharmacokinetics of 5-ASA is challenging. A dynamic model of 5-ASA colonic amounts after oral delayed-release 5-ASA (Asacol), oral extended delayed-release 5-ASA (Lialda), 5-ASA enema (Rowasa), foam and suppositories (Canasa) was developed to determine the colonic kinetics of these agents.

METHODS

We created a model with Stella software. Colonic 5-ASA in the right, transverse, descending, sigmoid colon, and rectum were estimated for adults after recommended doses of the above formulations. Simulations of active mild/moderate UC and in remission were performed and compared using Student's t-test for differences in means.

RESULTS

For UC in remission, the highest amounts of 5-ASA were from Asacol in the right and transverse colon (P < 0.01), Lialda in the descending and sigmoid colon (P < 0.01), and Rowasa in the rectum (P < 0.01). For active UC, sigmoid amounts were highest with foam (P < 0.01), and rectal amounts highest with Rowasa (P < 0.01). Differences in rectosigmoid amounts of 5-ASA from enemas and suppositories for UC in remission occurred based on the relationship between the timing of administration relative to the daily bowel movement (P < 0.01).

CONCLUSIONS

Compared to Asacol, Lialda results in higher 5-ASA amounts in the left colon. Asacol with Rowasa provides highest 5-ASA amounts across the entire colon. Higher 5-ASA amounts from topical formulations occur when the insertion occurs soon after the daily bowel movement. This model provides a rationale for further investigation.

Suboptimal reporting of adverse medical events to the FDA Adverse Events Reporting System by nurse practitioners and physician assistants

OBJECTIVES

The Adverse Events Reporting System (AERS) of the FDA is used to identify toxicities of drugs that are on the market. Nurse practitioners (NP) and physician assistants (PA), having an increasing role in the delivery of medical care, are also needed to participate in post-marketing pharmacovigilance. This study was performed to assess awareness and use of the AERS in voluntary reporting of drug toxicities by NPs and PAs.

METHODS

A cluster sample survey was issued at the Principles of Gastroenterology for the Nurse Practitioner and Physician Assistant course in August 2010. The survey assessed familiarity with the AERS, the number of adverse events seen and the frequency of reports sent to the AERS. NP and PA responses were compared using the two-tailed Fisher's exact.

RESULTS

Of the 92 respondents, 67 (72%) were NPs and 24 (26%) PAs. Of the 50 (54%) respondents that reported being familiar with the AERS system, 20 (40%) incorrectly identified the methods to report using the AERS. Overall reporting of adverse events was low, particularly in respondents seeing 5-12 adverse events per year.

CONCLUSION

The study suggests that improved education regarding the importance of using AERS for pharmacovigilance is suggested for NPs and PAs. Due to the small size of the study, these data should be viewed as preliminary, pending a larger confirmatory study.

Renal risks of sodium phosphate tablets for colonoscopy preparation: a review of adverse drug reactions reported to the US Food and Drug Administration

AIM

Sodium-phosphate-containing colonoscopy preparations cause renal failure by the development of calcium phosphate nephropathy. Although Fleet's Phospho-Soda has been removed from the US market, sodium phosphate tablets sold as OsmoPrep and Visicol remain available. Our aim was to analyse renal risks of the sodium phosphate tablets.

METHOD

We conducted a retrospective study using the US Food and Drug Administration Adverse Event Reporting System, a voluntary reporting system available for public access. Renal adverse events were identified using search terms including renal impairment, increased blood urea nitrogen, increased creatinine, renal failure, acute renal failure, chronic renal failure, acute phosphate nephropathy, nephrocalcinosis, renal tubular necrosis, haemodialysis, nephropathy toxic, dialysis, peritoneal dialysis, renal injury, renal tubular disorder, decreased glomerular filtration rate and decreased creatinine clearance. Patient age, gender and body weight were compared with data for the general population in the National Health and Nutrition Examination Survey (NHANES).

RESULTS

In total 2,097,223 files were extracted from the US Food and Drug Administration website for 2004-2008 and the first 9 months of 2009. Of these, 178 patients on tablet preparations (71% women) were identified, with increasing numbers of renal adverse drug reactions reported from tablet preparations each year. The mean weight for women with renal complications from tablet preparations was 68.57 ± 1.78 kg, significantly lower than the national average weight of 74 ± 0.5 kg for the same age group (P = 0.003) in NHANES.

CONCLUSION

Renal adverse drug reactions from sodium phosphate tablets are more common in women with a mean body weight lower than the national average weight.

Lower body weight and female gender: Hyperphosphatemia risk factors after sodium phosphate preparations

Casais et al have reported an inverse correlation between serum phosphate and body weight after administration of sodium phosphate at a dose of 60 g. Our group has already described the relationship between body weight and hyperphosphatemia with these preparations, although our study was not quoted by Casais. We performed a pharmacokinetic study involving 13 volunteers who were divided into two groups on the basis of body weight: group I consisting of seven women with a median weight of 60 kg and group IIconsisting of five men and one woman with a median weight of 119.2 kg. Group I developed higher peak phosphate levels and maintained these levels above the subjects in Group II for a prolonged time period despite adequate hydration being ensured with frequent monitoring of weight, fluid intake and total body weight. Our study demonstrated that adequate hydration does not protect against the secondary effects of hyperphosphatemia. In the study by Casais et al, 66% of the study subjects were women, the correlation between serum phosphate and gender in their data also appears to be important. Women are at higher risk of acute phosphate nephropathy due to a diminished volume of distribution of the high dose of ingested phosphate. Decreased volume of distribution in women is due to diminished body weight. This is further compounded by decreased creatinine clearance in females.

A dynamic model of once-daily 5-aminosalicylic acid predicts clinical efficacy

New once daily mesalamine formulations may improve adherence to medication usage. Response to Asacol and other forms of 5-aminosalicyclic acid (5-ASA) is better correlated with tissue concentrations and best predicted by concentrations of the drug within the lumen of the colon. Our group used computer simulation to predict colonic 5-ASA levels after Asacol administration. In our study, the model simulated Asacol distribution in the healthy colon, and during quiescent and active ulcerative colitis. An Asacol dosage of 800 mg, three times a day, was compared to 2400 mg given once a day. Under ideal conditions, the predicted maximum drug in the total colon and individual colonic segments over 100 d differed by less than 3% between single and multiple doses. Despite changes in motility and defection rates, the predicted maximum and average 5-ASA concentrations in the total colon and individual colonic segments differed by less than 10% between dosing regimens. Asymmetric distribution of 5-ASA in the colon was influenced by frequency of bowel movements and colonic transit rate. In active colitis, sigmoid 5-ASA concentration becomes negligible. Our model supports once daily administration of Asacol as standard treatment for ulcerative colitis.

Increased serum phosphate levels and calcium fluxes are seen in smaller individuals after a single dose of sodium phosphate colon cleansing solution: a pharmacokinetic analysis

BACKGROUND

Sodium phosphate containing colonoscopy preparations may cause electrolyte disturbances and calcium-phosphate nephropathy. Decreased body weight is an unexplored risk factor for complications with sodium phosphate ingestion.

AIM

To perform a pharmacokinetic analysis of a single dose of Fleet Phospho-Soda in smaller and larger individuals.

METHODS

Seven subjects weighing <55 kg (Group I) and six weighing >100 kg (Group II) consumed 45 mL Fleet Phospho-Soda. Serum electrolytes were measured. Hydration was closely maintained by monitoring weight, fluid intake and total body water.

RESULTS

Marked increases in serum phosphate were seen in Group I compared to Group II. For example, mean serum phosphate at 120 min was 7.8 +/- 0.5 mg/dL in Group I and 5.1 +/- 0.8 mg/dL in Group II (P < 0.001). Normalized area under the phosphate vs. time curve for Group I was 1120 +/- 190 mg/dL*min and 685 +/- 136 mg/dL*min for Group II (P < 0.001). Twelve-hour urine calcium was lower in Group I (16.4 +/- 7.6 mg) than in Group II (39.2 +/- 7.8 mg, P < 0.001).

CONCLUSIONS

Increased serum phosphate occurs in smaller individuals after ingestion of sodium phosphate preparations, even with strict attention to fluid intake. Smaller body weight poses a potential risk for calcium-phosphate nephropathy.

A dynamic model of colonic concentrations of delayed-release 5-aminosalicylic acid (Asacol)

BACKGROUND

5-ASA in a pH sensitive tablet (Asacol) is administered as three doses/day to treat ulcerative colitis. Once daily dosing may improve patient adherence. Simulation of colonic levels of 5-ASA can be used to compare dosing regimens.

AIM

To create a dynamic model of colonic concentrations of delayed-release 5-aminosalicylic acid (Asacol).

METHODS

Using published data, we created a computer model with STELLA software to simulate amounts of colonic 5-ASA in the total colon, right, transverse, descending and sigmoid/rectum after daily and three time/day Asacol.

RESULTS

The model predicted similar total and regional amounts of 5-ASA with both regimens. Distribution of 5-ASA was 38% in the right colon, 33% in the transverse colon and 14% each in the descending and sigmoid/rectal colon. Simulated increases in colonic motility and defecation rate exaggerated this 5-ASA distribution, resulting in negligible amounts of 5-ASA in the sigmoid/rectal region.

CONCLUSIONS

This computer model suggests that Asacol can be administered as a single daily dose. The model supports experimental and clinical observations that alternate dose or route of administration may be necessary to achieve adequate 5-ASA amounts in the distal colon during acute exacerbations of ulcerative colitis. This simulation cannot account for all sources of variability in the clinical setting, but provides a rationale for further investigation.

Normal Positron Emission Tomography-Computerized Tomogram in a Patient with Apparent Mesenteric Panniculitis: Biopsy Is Still the Answer

Mesenteric panniculitis (also known as sclerosing mesenteritis) is a chronic inflammatory disease of the mesenteric connective tissue. It is known to have a wide spectrum of clinical and radiological presentations. In general, biopsy is recommended for diagnosis; however, a recent study proposed that a negative positron emission tomography- computerized tomography (PET-CT) scan is accurate in differentiating benign and neoplastic mesenteric processes [Br J Radiol 2006;79:37–43]. The following case report questions the accuracy of PET-CT in this setting and confirms the requirement for biopsy to rule out the presence of mesenteric lymphoma.

Pharmacotherapy for fecal incontinence: a review

Fecal incontinence is a common clinical problem that often is frustrating to the patient and treating physician. Nonsurgical management for fecal incontinence includes dietary manipulation, Kegel exercises, perianal skin care, and biofeedback therapy. Pharmacotherapies often are used to assist in management of fecal incontinence. A variety of pharmacotherapies have been utilized for the management of fecal incontinence; limited data from randomized, placebo-controlled trials are available. This is a review of the existing literature on clinical trials of several classes of drugs and other medical therapies that may be beneficial for patients with fecal incontinence. The information in this article was obtained by a MEDLINE search for all clinical trials of drug therapy for fecal incontinence. These treatments and the existing data on their use are summarized. Treatments reviewed include stool bulking agents, with an emphasis on the most promising effect obtained with calcium polycarbophil, constipating agents, including loperamide, codeine, amitriptyline, atropine, and diphenoxylate agents injected into the anal sphincter, drugs to enhance anal sphincter function, including topical phenylepherine and oral sodium valproate, and trials of fecal disimpaction. A new classification to easily remember the treatment categories for this condition, based on the "ABCs of treatment for fecal incontinence," has been introduced into the structure of this review.

Irritable bowel syndrome. 10% to 20% of older adults have symptoms consistent with diagnosis

Although irritable bowel syndrome (IBS) is a common disorder, IBS is traditionally considered to be a condition that primarily affects young and middle-aged adults. However, increasing evidence suggests that prevalence of IBS in older adults may be similar to that in younger adults; therefore, the diagnosis should be considered when a geriatric patient presents with unexplained abdominal symptoms. Because incidences of other conditions with similar symptoms are higher in the geriatric population, use of certain diagnostic tests (eg, colonoscopy) is warranted in this patient population. In addition, because older adults are more likely than younger adults to suffer from comorbid conditions, polypharmacy is common in this patient population, and this should be considered when diagnosing and treating these patients.

Accuracy and reliability of the endoscopic classification of chronic radiation-induced proctopathy using a novel grading method

GOALS

To assess a novel grading method of radiation proctitis for intraobserver and interobserver agreement among endoscopists.

BACKGROUND

There are no established criteria for the endoscopic classification of chronic radiation-induced proctopathy. We introduce a classification system based on telangiectasia density and vascular coalescence. Accuracy and reproducibility of this system were examined.

STUDY

A total of 131 endoscopic images of the rectum in 74 consecutive patients undergoing lower endoscopy who had received pelvic radiation therapy were analyzed. Each image was duplicated, reversed, and rotated 90 degrees for a total of 262 images. These were shown in random order to 13 endoscopist evaluators (6 attending physicians, 7 gastroenterology fellows) using an online computer testing program. Each image was scored from grade 0 to 3 using criteria from the rectal telangiectasia density (RTD) classification we developed. Kappa (kappa) statistics and percent agreement were used to quantify the reproducibility and level of agreement.

RESULTS

Intraobserver agreement: The mean (SD) for kappa among the 13 raters was 0.58 (0.09); 95% confidence interval [CI] = 0.527-0.636. Interobserver agreement: The estimated kappa across all 13 raters was 0.518 (95% CI = 0.506-0.530). For the 7 trainees, kappa was 0.547 (95% CI = 0.523-0.571). For the 6 attending physicians, the kappa was 0.481 (95% CI = 0.453-0.509). As another indicator of agreement, all 13 evaluators agreed on 30 (22.9%) of images, differed by no more than 1 grade on 60 (45.8%) images, no more than 2 grades on 33 (25.2%) of images, and no more than 3 grades on 8 of the images (6.1%); 73% of patients referred for bleeding control were RTD grade 2 or 3.

CONCLUSIONS

The RTD grading scale for radiation proctopathy is reproducible among endoscopists. Hematochezia is associated with high RTD grade.