The Emerging Adult with Inflammatory Bowel Disease: Challenges and Recommendations for the Adult Gastroenterologist

Incidence of pediatric inflammatory bowel disease (IBD) is rising. Adult gastroenterologists are seeing increasing numbers of young adults with IBD, a subpopulation with unique needs and challenges that can impair their readiness to thrive in an adult healthcare system. Most adult gastroenterologists might not have the training or resources to address these needs. “Emerging adulthood” is a useful developmental lens through which this group can be studied. With complex disease phenotype and specific concerns of medication side effects and reproductive health, compounded by challenges of geographical and social flux and lack of adequate health insurance, emerging adults with IBD (EAI) are at risk of disrupted care with lack of continuity. Lessons learned from structured healthcare transition process from pediatric to adult services can be applied towards challenges in ongoing care of this population in the adult healthcare system. This paper provides an overview of the challenges in caring for the post transition EAI from the perspective of adult gastroenterologists and offers a checklist of provider and patient skills that enable effective care. This paper discusses the system-based challenges in care provision and search for meaningful patient-oriented outcomes and presents a conceptual model of determinants of continuity of care in this unique population

Posttransplant Lymphoproliferative Disorder of the Small Bowel as an Unexpected Cause of Iron Deficiency Anemia Decades after Heart Transplantation.

Although rare, gastrointestinal posttransplant lymphoproliferative disorder (PTLD) can lead to abdominal pain or gastrointestinal bleeding in patients with a history of solid-organ transplantation. We describe a case of isolated gastrointestinal PTLD in a patient who presented with acute on chronic iron deficiency anemia 26 years after heart transplant. A comprehensive endoscopic evaluation with video capsule endoscopy and small bowel enteroscopy revealed a large cratered ulceration in the small bowel with abnormal mucosal changes, which led to the diagnosis of PTLD

Serum 25-hydroxyvitamin D levels are not associated with adverse outcomes in Clostridium difficile infection

<em>Clostridium difficile</em> infection (CDI) is a significant source of healthcare-associated morbidity and mortality. This study investigated whether serum 25-hydroxyvitamin D is associated with adverse outcomes from CDI. Patients with CDI were prospectively enrolled. Charts were reviewed and serum 25-hydroxyvitamin D was measured. The primary outcome was a composite definition of severe disease: fever (temperature &gt;38°C), acute organ dysfunction, or serum white blood cell count &gt;15,000 cells/μL within 24-48 hours of diagnosis; lack of response to therapy by day 5; and intensive care unit admission; colectomy; or death within 30 days. Sixty-seven patients were included in the final analysis. Mean (±SD) serum 25- hydroxyvitamin D was 26.1 (±18.54) ng/mL. Severe disease, which occurred in 26 (39%) participants, was not associated with serum 25-hydroxyvitamin D [odds ratio (OR) 1.00; 95% confidence interval (CI) 0.96-1.04]. In the adjusted model for severe disease only serum albumin (OR 0.12; 95%CI 0.02-0.64) and diagnosis by detection of stool toxin (OR 5.87; 95%CI 1.09-31.7) remained independent predictors. We conclude that serum 25-hydroxyvitamin D is not associated with the development of severe disease in patients with CDI

Probability of <i>Clostridium difficile</i> Infection in Medicare Beneficiaries in the United States 1991–2007, by Smoking Status and Region of Residence.

<p>Footnotes:</p>a<p>Predicted marginal probabilities from survey-weighted, fully adjusted model. Covariates were year of birth (centered), sex, race, ethnicity, body mass index, alcohol use, marital status, education, total assets, heart disease, chronic lung disease, diabetes mellitus, stroke, end-stage renal disease, depression, Crohn disease, ulcerative colitis, irritable bowel disease, celiac disease, number of medical visits, number of infection-related visits.</p>b<p>Difference in CDI probability compared to never smokers.</p

Rate of <i>Clostridium difficile</i> Infection in Medicare Beneficiaries in the United States 1991–2007, by Smoking Status.

<p>Footnotes:</p>a<p>Number of individuals with <i>C. difficile</i>/100,000 person-years, survey-weighted to the reference population.</p>b<p>Unstable rates due to small numbers.</p

Procalcitonin levels associate with severity of Clostridium difficile infection.

Clostridium difficile infection (CDI) is a major cause of morbidity and biomarkers that predict severity of illness are needed. Procalcitonin (PCT), a serum biomarker with specificity for bacterial infections, has been little studied in CDI. We hypothesized that PCT associated with CDI severity.Serum PCT levels were measured for 69 cases of CDI. Chart review was performed to evaluate the presence of severity markers and concurrent acute bacterial infection (CABI). We defined the binary variables clinical score as having fever (T >38°C), acute organ dysfunction (AOD), and/or WBC >15,000 cells/mm(3) and expanded score, which included the clinical score plus the following: ICU admission, no response to therapy, colectomy, and/or death.In univariate analysis log10 PCT associated with clinical score (OR 3.13, 95% CI 1.69-5.81, P<.001) and expanded score (OR 3.33, 95% CI 1.77-6.23, P<.001). In a multivariable model including the covariates log10 PCT, enzyme immunoassay for toxin A/B, ribotype 027, age, weighted Charlson-Deyo comorbidity index, CABI, and extended care facility residence, log10 PCT associated with clinical score (OR 3.09, 95% CI 1.5-6.35, P = .002) and expanded score (OR 3.06, 95% CI 1.49-6.26, P = .002). PCT >0.2 ng/mL was 81% sensitive/73% specific for a positive clinical score and had a negative predictive value of 90%.An elevated PCT level associated with the presence of CDI severity markers and CDI was unlikely to be severe with a serum PCT level below 0.2 ng/mL. The extent to which PCT changes during CDI therapy or predicts recurrent CDI remains to be quantified

Odds ratios for predictors of CDI severity scores based on multiple logistic regression.

1<p>ng/mL,</p>2<p>true/false,</p>3<p>years,</p>4<p>weighted comorbidity score.</p

Percent of patients with a CDI severity marker.

<p>This bar graph illustrates that having ≥seven stools per day had a much higher prevalence than other severity markers in our cohort. (<i>WBC</i>: white blood cell; <i>AOD</i>: acute organ dysfunction; <i>ICU</i>: intensive care unit).</p