5930 W Greenway Rd #14A
Glendale AZ 85306
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License #: 6599
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Clinical disease activity, C-reactive protein normalisation and mucosal healing in Crohn's disease in the SONIC trial. - Gut
The Crohn's Disease Activity Index (CDAI) has been criticised due to heavy weighting on subjective clinical symptoms. C-reactive protein (CRP) and endoscopic lesions are objective measures of inflammation. We investigated the relationships between clinical disease activity, CRP normalisation and mucosal healing in Crohn's disease (CD).The Study of Biologic and Immunomodulator Naive Patients in CD trial compared infliximab to azathioprine and to infliximab plus azathioprine in 508 CD patients. Mucosal healing was defined as the absence of mucosal ulceration at the week 26 ileocolonoscopy in a patient who had evidence of ulceration at the baseline ileocolonoscopy.188 patients who had evaluable ileocolonoscopy with evidence of mucosal ulceration at baseline, CDAI scores and CRP values at baseline and week 26 were analysed. Seventy-two of 136 patients (53%) who had a CDAI<150 at week 26 achieved mucosal healing, and 38 of 90 patients (42%) achieved both CRP normalisation (CRP<0.8 mg/dL) and mucosal healing while in clinical remission. The positive predictive value (PPV) and negative predictive value (NPV) of CDAI to detect mucosal healing using 150 as a cut-off for CDAI were 65% and 53%, respectively. The PPV and NPV of CDAI to detect mucosal healing and CRP normalisation using 150 as a cut-off for CDAI were 79% and 42%, respectively.Half the patients under azathioprine and/or infliximab in clinical remission have endoscopic and/or CRP evidence of residual active CD, whereas other patients with endoscopic and CRP normalisation have persistent clinical symptoms. Clinical symptoms as scored by CDAI are not a reliable measure of the underlying inflammation.
Assessing discrepant findings between QF-PCR on uncultured prenatal samples and karyotyping on long-term culture. - Prenatal diagnosis
To assess the prevalence of discrepant results found between quantitative fluorescent polymerase chain reaction (QF-PCR) analysis on uncultured prenatal samples and karyotyping on long-term culture.Results of QF-PCR from 1932 amniotic fluid (AF) and 1132 chorionic villus (CV) samples collected from September 1999 to February 2008 were analyzed. Nature of discrepancies was categorized for normal or abnormal results from uncultured and cultured samples.A total of nine (0.8%) discrepant cases were found in the CV and six (0.3%) in AF samples. Three abnormal results involving trisomy 18 or mosaic trisomy 13 showed normal karyotype with one representing complete discordance. There were three QF-PCR reports with initial mosaic trisomy 21 and five cases involving sex chromosome aneuploidy showing complete trisomy 21 and 45,X, respectively, after long-term culture.CV (0.8%) and AF (0.3%) samples showed discrepant results after culturing and 40% of discrepancy involved the sex chromosomes. QF-PCR on long-term culture was concordant with karyotyping results meaning that QF-PCR is technically sound. Discrepant PCR findings in uncultured prenatal samples likely arose from mosaicism or preferential cell culture. Limitations in abnormal QF-PCR results may be discussed with couples before further action.Copyright (c) 2009 John Wiley & Sons, Ltd.
A pooled analysis of infections, malignancy, and mortality in infliximab- and immunomodulator-treated adult patients with inflammatory bowel disease. - The American journal of gastroenterology
The objective of this study was to analyze the safety of long-term infliximab treatment, with/without concomitant immunomodulators, across Crohn's disease (CD) and ulcerative colitis (UC) clinical trials.To maximize sample size, we pooled primary safety data across 10 CD or UC trials, including five randomized, controlled trials contributing data from patients who received intravenous infliximab 5 or 10 mg/kg (n=1,713; Â±azathioprine) or placebo (n=406; Â±azathioprine). Pooled incidences and 95% confidence intervals (CIs) were determined for mortality, infection, and malignancy. Standardized incidence ratios and 95% CIs were also determined for malignancies using the Surveillance, Epidemiology, and End Results database.We observed no increase in infections, serious infections, or malignancy with infliximab vs. placebo in these patients with inflammatory bowel disease (IBD). In patients with UC, but not CD, immunomodulator treatment (vs. treatment without immunomodulator) yielded a higher incidence (95% CI) of infections (120.07 (110.66, 130.08)/100 patient-years (pt-yrs) vs. 92.47 (84.54, 100.94)/100 pt-yrs). Among placebo-treated patients with CD, but not UC, those with immunomodulator use demonstrated a higher incidence (95% CI) of malignancy vs. no immunomodulator treatment (1.84 (0.22, 6.66)/100 pt-yrs vs. 0.00 (0.00, 0.00)/100 pt-yrs). Mortality and infection-related mortality appeared unaffected by infliximab or immunomodulator treatment.Infliximab treatment of IBD did not appear to affect incidences of infection, mortality, or malignancy. Relative to patients with no immunomodulator use, immunomodulator-treated UC patients demonstrated a higher incidence of infection and immunomodulator-plus-placebo-treated CD patients demonstrated a higher incidence of malignancy.
Effect of Misalignment between Hospital and Provincial Formularies on Medication Discrepancies at Discharge: PPITS (Proton Pump Inhibitor Therapeutic Substitution) Study. - The Canadian journal of hospital pharmacy
Medication discrepancies may occur on admission, transfer, or discharge from hospital. Therapeutic interchange within a drug class is a common practice in hospitals, and orders for specific proton pump inhibitors (PPIs) are often substituted with the hospital's formulary PPI through therapeutic interchange protocols. Rabeprazole is the PPI on the formulary of the British Columbia PharmaCare program. However, different PPIs may appear on the formularies of the province's hospitals. This misalignment and use of therapeutic interchange may lead to increased rates of medication discrepancies at the time of discharge.To evaluate the effect of formulary misalignment for PPIs between St Paul's Hospital in Vancouver and the British Columbia PharmaCare program and use of therapeutic interchange on the occurrence of medication discrepancies at discharge.A cohort chart review was performed to compare discharge discrepancy rates for PPI orders between 2 periods: June 2006 to June 2008, when the same PPI appeared on the hospital and provincial formularies, and July 2008 to July 2010, when the designated PPIs differed between the hospital and provincial formularies. Data for the first study period were used to establish the baseline discharge discrepancy rate, and data for the later period represented the discharge discrepancy rate in the presence of misalignment between the hospital and PharmaCare formularies.The discharge discrepancy rate for PPIs was 27.3% (24/88) when the 2 formularies were aligned and 49.1% (81/165) when the formularies were misaligned. This represents an absolute increase of 21.8 percentage points in the risk of discharge discrepancies (95% confidence interval 9.8-33.9 percentage points; p < 0.001) when the hospital and provincial formularies were misaligned and the hospital's therapeutic interchange protocol was used.Misalignment between the PPIs specified in the hospital and provincial formularies, combined with use of therapeutic interchange, was associated with a significant increase in medication discrepancies at discharge.
Utility of fecal and serum anti-Saccharomyces cerevisiae antibodies in the diagnosis of Crohn's disease-like condition of the pouch. - International journal of colorectal disease
Fecal antibodies against bacterial products may directly reflect the interaction between luminal bacteria and mucosal immunity, and assays for these antibodies may be clinically useful in the diagnosis and differential diagnosis of Crohn's disease-like (CDL) condition of the pouch.This study aims to evaluate stool and serum anti-Saccharomyces cerevisiae antibodies (ASCA) in normal and diseased pouches, to assess the correlation between ASCA levels and endoscopic disease activity, and to ascertain the diagnostic utility of ASCA for CDL of the pouch.One hundred eighty-nine patients with ileal pouches were prospectively enrolled and corresponding serum and pouch aspirate samples were collected. Fecal and serum ASCA levels were measured with enzyme-linked immunosorbent assay in a blinded fashion. Statistical analysis was then conducted using the signed rank test, Spearman correlation coefficients, and analysis of variance.Forty-three patients (22.8 %) had irritable pouch syndrome or normal pouches, 74 (39.2 %) had pouchitis/cuffitis, 52 (27.5 %) had CDL, 9 (4.8 %) had familial adenomatous polyposis, and 11 (5.8 %) had surgical complications of the pouch. Receiver operating characteristic curves to distinguish CDL from other categories of pouch dysfunction had an area under the curve (AUC) of 0.608 for fecal ASCA and an AUC of 0.517 for serum ASCA. Neither fecal nor serum ASCA correlated with endoscopic disease activity scores. There was a significant difference in the mean values of fecal ASCA between inflammatory and fistulizing CDL (0.27 vs. 0.03 ELISA units/ml, P < 0.05).Fecal ASCA appears to be better than serum ASCA in differentiating CDL from other pouch disorders, although this distinction may be of limited clinical utility.
Evaluation of endoscopic and imaging modalities in the diagnosis of structural disorders of the ileal pouch. - Inflammatory bowel diseases
Computerized tomography enterography (CTE), gastrograffin enema (GGE), magnetic resonance imaging (MRI), and pouch endoscopy (PES) have commonly been used to assess ileal pouch disorders. However, their diagnostic utility has not been systematically evaluated. The aims of this study were to compare these imaging techniques to each other and to optimize diagnosis of pouch disorders by using a combination of these diagnostic modalities.Clinical data of patients from the Pouchitis Clinic from 2003 to 2008 who had a PES and at least 1 additional imaging modalities (CTE, GGE, or MRI) used for evaluation of ileal pouch disorders were retrospectively evaluated. We analyzed the accuracy, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) with which these tests were able diagnose pouch inlet and distal small bowel and pouch outlet strictures, pouch fistulas, sinuses, and leaks. Subsequently, accuracy was recalculated by combining 2 imaging modalities to see if this could enhance accuracy.A total of 66 patients underwent evaluation with PES and 1 other imaging modality as follows: PES + CTE (n = 23), PES + GGE (n = 34), and PES + MRI (n = 26). The mean age was 41.5 +/- 14.5 years, with 28 being female (42.4%). Sixty patients (90.9%) had J pouches and 59 (89.4%) had a preoperative diagnosis of ulcerative colitis. Overall, CTE, GGE, MRI, and PES all had reasonable accuracy for the diagnosis of small bowel and inlet strictures (73.9%-95.4%), outlet strictures (87.9%-92.3%), fistula (76.9%-84.8%), sinus (68.0%-93.9%), and pouch leak (83-93.9%). CTE had the lowest accuracy for small bowel and inlet strictures (73.9%) and MRI had the lowest accuracy for pouch sinus (68.0%). Combining 2 imaging tests can increase the accuracy of diagnosis to 100% for strictures, fistulas, sinus, and pouch leaks.CTE, GGE, MRI, and PES offer complementary information on disorders of the pouch and the combination of these tests increases diagnostic accuracy for complex cases.
Safety and utility of ERCP during pregnancy. - Gastrointestinal endoscopy
ERCP is an important diagnostic and therapeutic tool in patients with biliary and pancreatic disease. Its utility and safety during pregnancy is largely unknown because it is not often required and because its use has been only infrequently reported in the published literature.Our purpose was to report the clinical experience with ERCP during pregnancy.Retrospective review, single academic center.All (consecutive) pregnant women who underwent ERCP at Parkland Memorial Hospital from 2000 to 2006.History, clinical data, hospital course, procedure-related complication rates and outcomes, and delivery and fetal outcomes were abstracted from medical records.During the study period, 68 ERCPs were performed on 65 pregnant women. The calculated ERCP rate was 1 per 1415 births. The common indications for ERCP in pregnancy were recurrent biliary colic, abnormal liver function tests, and dilated bile duct on US. ERCP was technically successful in all patients. The median fluoroscopy time was 1.45 minutes (range 0-7.2 minutes). There was no perforation, sedation-related adverse event, postsphincterotomy bleeding, cholangitis, or procedure-related maternal or fetal deaths. Post-ERCP pancreatitis was diagnosed in 11 patients (16%). None of these 11 patients had local or systemic complications. Fifty-nine patients had complete follow-up. Endoscopic therapy at the time of ERCP was undertaken in all patients. Furthermore, 9 patients (32.1%) underwent cholecystectomy in the first and second trimesters for either acute cholecystitis (6) or symptomatic gallstones (3). Term pregnancy was achieved in 53 patients (89.8%). Patients having ERCP in the first trimester had the lowest percentage of term pregnancy (73.3%) and the highest risk of preterm delivery (20.0%) and low-birth-weight newborns (21.4%). None of the 59 patients with long-term follow-up had spontaneous fetal loss, perinatal death, stillbirth, or fetal malformation.Retrospective review.ERCP can be performed safely during pregnancy. Further, ERCP performed in pregnancy leads to specific therapy in essentially all patients. However, ERCP may be associated with a higher rate of post-ERCP pancreatitis than in the general population.
Iatrogenic esophageal submucosal dissection after attempted diagnostic gastroscopy (with videos). - The Laryngoscope
Diagnostic esophagogastroduodenoscopy (EGD) is generally a very safe procedure. We report the first case of iatrogenic esophageal submucosal dissection after an attempted diagnostic gastroscopy in a patient with a small previously undiagnosed Zenker's diverticulum (ZD). After EGD, she developed severe dysphagia with the inability to swallow solids, liquids, and even her own saliva. On barium swallow study, there was a column of contrast below the upper esophageal sphincter, and this was misdiagnosed as a large ZD by the radiologist. The resultant stricture was successfully managed with endoscopic balloon dilatation under fluoroscopy with wire-guided cannulation. The ZD was treated with flexible endoscopic clip-assisted diverticulotomy. Iatrogenic submucosal dissection is a unique complication of upper endoscopy. Endoscopists, otolaryngologists, radiologists, and cardiothoracic surgeons should be aware of this condition and prepare to manage it appropriately. If the patient is stable and the possibility of perforation is small, conservative and supportive care can be tried first. A surgical gastrostomy tube can be placed for enteral feeding. In patients with ZD, ZD recognition and gentle manipulation is strongly recommended during esophageal intubation.
A comparison of self-perceived health status in inflammatory bowel disease and irritable bowel syndrome patients from a Canadian national population survey. - Canadian journal of gastroenterology = Journal canadien de gastroenterologie
To determine whether differences exist in perceptions of physical health, mental health and stress levels between patients with inflammatory bowel disease (IBD) and patients with irritable bowel syndrome (IBS).Data were obtained from the 2005 Canadian Community Health Survey, which had a sample size of 132,947 Canadians. Information on 4441 participants aged 19 years or older who reported that they had been diagnosed with Crohn's disease (n=474), ulcerative colitis (n=637) or IBS (n=3330) was analyzed regarding perceptions of their physical health, mental health, stress levels and activity levels.Overall, IBD patients reported being in fair to poor health (P<0.01) more often than IBS patients. In addition, IBS patients were more likely than IBD patients to report poor mental health status (P<0.01) and greater stress levels (P<0.01). In multivariate analyses, having IBS or IBD along with another chronic disease significantly increased the odds of reporting poorer health status.People with IBD were more likely to experience fair or poor general health. IBS patients reported higher levels of stress and poorer mental health than IBD patients. When IBS or IBD coexisted with another chronic condition, activity participation at home and at work was significantly more likely to be impaired.
Flexible endoscopic clip-assisted Zenker's diverticulotomy: the first case series (with videos). - The Laryngoscope
In treating Zenker's diverticulum (ZD), there are potential risks associated with performing flexible endoscopic diverticulotomy without suturing or stapling. We recently introduced flexible endoscopic clip-assisted diverticulotomy (ECD) in treating ZD by securing the septum prior to dissection.To evaluate the feasibility and safety of ECD for complete septum dissection.Case series at an academic center. Seven consecutive patients (mean age 71 y; range 48-91 y) with symptomatic ZD of various craniocaudal sizes based on radiographic measurements (mean 2.6 cm; range 0.8 cm-4.5 cm) were included. The mean depth of the septum was 1.73 cm (range 0.3 cm-3.1 cm). The mean duration of symptoms was 4.8 years (range 0.5-10 y).After endoclips were placed on either side of the cricopharyngeal bar, the septum was dissected between these two clips down to the inferior end of the diverticulum with a needle-knife. Procedures including "one-step ECD" (n = 1), "stepwise ECD" (n = 3), and "bottom ECD" (n = 2) were performed based on the septum depth of the ZD during endoscopy. ECD was not performed on one patient due to severe mucosal fragility of the esophageal inlet. Iatrogenic blunt dissection of the septum by the endoscopic hood occurred secondary to patient retching during the procedure. Main outcome measurements were symptom resolution and complications.All patients (n = 6) who underwent ECD had complete resolution of esophageal symptoms at a minimum 6-month follow-up. There were no procedural complications. The patient who did not undergo ECD developed an esophageal perforation. She was managed conservatively without surgical intervention. On follow-up, her dysphagia was completely resolved.ECD is feasible, safe, and effective for complete septum dissection. ECD and endoscopic stapler-assisted diverticulotomy are complimentary rather than competing strategies in approaching ZD. Study limitations include the case series design and limited follow-up period.
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5930 W Greenway Rd #14A Glendale, AZ 85306
5750 W. Thunderbird Rd Suite A-100
5555 W Thunderbird Rd
13980 N 67Th Ave Suite Number 1