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In this randomized trial involving adults with Crohn's disease in whom anti–tumor necrosis factor therapy had failed, ustekinumab, an antibody against interleukin-12 and 23, was associated with increased response rates, as compared with placebo. Crohn's disease is a chronic inflammatory bowel disease. 1 One third of patients do not have a response to initial treatment with tumor necrosis factor (TNF) antagonists (primary nonresponse) 2 – 6 ; another one third have a transient response 2 , 4 , 6 and require dose escalation or a switch to another therapy (secondary nonresponse). 7 , 8 Patients with primary nonresponse are unlikely to benefit from another TNF antagonist. Patients with secondary nonresponse who switch to a second TNF antagonist are less likely to have a response than are patients who have not received a TNF antagonist. 4 , 6 These represent difficult clinical problems. Preclinical studies . . .

In this randomized trial comparing infliximab, azathioprine, and combination therapy in adults with moderate-to-severe Crohn's disease, infliximab and combination therapy were superior to azathioprine. Adverse events were similar in the three groups. In this randomized trial comparing infliximab, azathioprine, and combination therapy in adults with moderate-to-severe Crohn's disease, infliximab and combination therapy were superior to azathioprine. Crohn's disease is a chronic inflammatory disorder of the gastrointestinal tract that is defined by relapsing and remitting episodes, with progression over time to complications of stricture, fistulas, or abscesses. 1 Symptoms of mild-to-moderate disease are treated with mesalamine, budesonide, or systemic corticosteroids. 2 , 3 The therapeutic benefit of corticosteroids is frequently offset by side effects of prolonged exposure. 4 In addition, systemic corticosteroids and budesonide are not effective for maintenance therapy. 5 – 7 Azathioprine and 6-mercaptopurine are frequently prescribed for patients in whom first-line therapies fail — in particular, those who are dependent on or do not have a response to systemic corticosteroids. . . .

Prolonged antibiotic use is limited by several adverse effects, one of which is Clostridium difficile infection (CDI). The aim of this study was to determine the incidence of CDI in patients receiving chronic antibiotic treatment for Crohn's disease (CD).MethodsWe conducted a retrospective review of 100 patients with CD for which ≥6 months of outpatient antibiotic therapy was prescribed. Data were collected regarding demographics, CD phenotype, treatment history, and CDI. The incidence of CDI in our patient population was calculated and compared with historical controls.Results100 patients were studied—60% of men, mean age 23.9 years at CD diagnosis. Eighty-two percent had disease involving the ileum, and 33% had disease involving the colon. The mean duration of antibiotic therapy was 39.6 months (range, 6–217 months). The most commonly prescribed classes of antibiotics were fluoroquinolones (84%), penicillins (57%), and cephalosporins (32%). Forty-nine percent of patients were treated with concomitant thiopurines, 45% with budesonide, and 41% with biologics. The overall incidence of CDI was 2%. This incidence of CDI was lower than previously reported for non-CD patients receiving chronic antibiotics for continuous-flow left ventricular assist device infections (12.5%) and orthopedic prosthesis infections (22.2%).ConclusionsThe incidence of CDI is rare in patients receiving chronic antibiotic treatment for CD, and it seems significantly lower than for non-CD populations reported in the literature.

Ulcerative Colitis is a chronic inflammatory bowel disease with evidence of immune activation 1 . Approximately 15 percent of patients with ulcerative colitis have a severe attack requiring hospitalization for intravenous corticosteroid therapy at some time during their illness 2 . This treatment leads to remission in only 60 percent of patients, and patients who do not have a response usually require total colectomy 3 , 4 . Cyclosporine selectively inhibits immune responses mediated by T lymphocytes and has proved effective in patients with chronic corticosteroid-resistant Crohn's disease 5 . In an uncontrolled study approximately 80 percent of patients with severe ulcerative colitis refractory to . . .

Intestinal stenosis is a frequent complication of Crohn's disease, often leading to repeated bowel obstruction and surgery. The prevalence of small bowel stenosis has ranged from 20% to 40% and from 7% to 15% in patients with colonic disease. Although balloon dilation is the initial preferred approach, many patients eventually restenose and require surgical resection or stricturoplasty. Infliximab, a chimeric IgG1 kappa monoclonal antibody against TNF-alpha, has been effective in the treatment of enteric as well as fistulous complications of Crohn's disease. Repeated systemic administration has been successful for active inflammatory disease yet has been reported to be ineffective in the treatment of strictures. Although the TREAT registry has shown systemic infliximab to be safe in the long term, there is concern regarding infectious as well as neoplastic complications.MethodsThis report describes 3 patients refractory to all medical therapy including systemic infliximab.ResultsIn all 3 patients, dilation of a colonic stricture was accomplished by injection of infliximab, via the sclerotherapy technique, into the distal and medial portions of the stricture.ConclusionsInfliximab was shown to be effective in the treatment of strictures in 3 patients.

The American College of Gastroenterology (ACG) and American Gastroenterology Association (AGA) have both recently issued guidelines (the \"Guidelines\") regarding the diagnosis and management of osteoporosis in patients with inflammatory bowel disease (IBD). The objective of this study was to determine the yield of implementing the Guidelines' recommendations in a prospective cohort of IBD patients and identify the prevalence of bone loss, risk factors, and potential influence on management. One hundred consecutive IBD patients who fulfilled the Guidelines' criteria underwent dual energy X-ray absorptiometry scanning (DEXA) scanning of the lumbar vertebrae and bilateral hips. Demographic data, risk factor information, and changes in therapy based on screening were collected and analyzed. Indications for screening were history of prolonged past or concurrent steroid use (92%), postmenopausal status (7%), and history of low trauma fracture (7%). Forty-four percent of patients had osteopenia of either the lumbar spine or the hips, 12% had osteoporosis of either the spine or hips, and 44% had normal bone density. In a univariate analysis, factors predicting a greater likelihood of osteoporosis (but not osteopenia) were a diagnosis of Crohn's disease (vs. ulcerative colitis), low body mass index in women, and postmenopausal status. Specific therapies based on DEXA findings were initiated in 69% of patients: oral calcium and vitamin D supplementation in 69% and an oral bisphoshphonate in 20%. Implementation of the Guidelines led to the detection of osteopenia or osteoporosis and initiation of specific therapies in a majority of patients who met the Guidelines' criteria for DEXA screening.

OBJECTIVESFew studies have examined the role of non-Clostridium difficile enteric infections in flares of inflammatory bowel disease (IBD). Our objective was to investigate enteric infection detected by multiplex PCR stool testing in patients with IBD.MethodsWe performed a cross-sectional analysis of 9403 patients who underwent 13,231 stool tests with a gastrointestinal pathogen PCR panel during a diarrheal illness from March 2015 to May 2017. Our primary outcome was the presence of an infection. Secondary outcomes included endoscopic and histologic predictors of infection, and IBD outcomes following testing.ResultsA total of 277 patients with Crohn’s disease (CD), 300 patients with ulcerative colitis (UC), and 8826 patients without IBD underwent 454, 503, and 12,275 tests, respectively. Compared to patients without IBD, patients with IBD were less likely to test positive (CD 18.1%, UC 16.1%, no IBD 26.6%, p < 0.001). Compared to patients without IBD, CD had a higher prevalence of norovirus (p = 0.05) and Campylobacter (p = 0.043), whereas UC had a lower prevalence of norovirus (p = 0.001) and a higher prevalence of Campylobacter (p = 0.013), Plesiomonas (p = 0.049), and Escherichia coli species (p < 0.001). Of 77 patients who underwent endoscopy, there were no major endoscopic or histologic predictors of a positive test. Patients who tested negative were more likely to have IBD therapy escalated (p = 0.004). Enteric infection did not impact IBD outcomes following testing (log-rank 0.224).ConclusionsNon-Clostridium difficile enteric infections were identified in 17% of symptomatic patients with IBD. Endoscopic and histologic findings may not differentiate flare from infection. Norovirus and E.coli may play an important role in flare of IBD.