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.

OBJECTIVES: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.METHODS: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; ±azathioprine) or placebo (n=406; ±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.RESULTS: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.CONCLUSIONS: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.

Endovascular revascularization procedures for PAD cost the health payer less compared with open surgery and primary amputation. While devices used to deliver contemporary endovascular therapy are more expensive, the reduction in bed days, ICU utilization, and related hospital resources results in a significantly lower mean total cost per admission for the initial treatment.

Small bowel obstruction (SBO) following intraperitoneal renal transplantation, either solitary or due to simultaneous pancreas-kidney transplantation, is a known complication. While SBO is most commonly due to adhesions, there have been documented cases of internal herniation following simultaneous pancreas-kidney transplantation with enteric drainage due to the formation of a mesenteric defect. We present a unique complication in which the transplant ureter has caused strangulation and necrosis of a length of small intestine. The transplant ureter was mistaken for a band adhesion and divided. Post-operative anuria signalled this difficult diagnosis. Subsequent re-look laparotomy and ureteric reimplantation with Boari flap were required. Therefore, it is important to consider the ureter as a cause of internal herniation in kidney transplant patients and recognize that a band adhesion within the pelvis may in fact be the transplant ureter, obstructing a loop of small intestine beneath its course.

BackgroundThe Cancer Council posits that the size of adenomas is a more robust marker of risk than histological characteristics. The purpose of our study is to assess the accuracy of estimation of polyp size at colonoscopy amongst different levels of endoscopists and compare this with histopathological size.MethodsA retrospective review of prospectively collected data was performed. Specimens were included if they were (i) from patients aged 18 years or older, (ii) polyp obtained at colonoscopy, (iii) measured in quantitative units and (iv) the largest eligible polyp per patient.ResultsA total of 92 patients were included. Our results demonstrate that the relationship between the histological size of a polyp and an endoscopist's estimate depended upon seniority level (P = 0.001). Senior consultants tended to overestimate lesion size (P < 0.001), fellows/junior consultants tended to underestimate size (P = 0.010), whilst registrars' estimates demonstrated no systematic difference from histological size (P = 0.518). The ratio of a senior consultant's estimate of polyp size to histological size was on average 74% with their estimates ranging from 31% to 173%. The corresponding estimates are 123% (32–470%) for fellows/junior consultants and 107% (35–334%) for registrars.ConclusionOur study demonstrates that senior consultants are more precise with more junior endoscopists having a great degree of variability in their practice. It is evident that there is a relationship between proceduralist experience and polyp size estimation. It is, therefore, important to consider the ways in which we can mitigate this learning curve and continue to develop technology to improve our accuracy.