Excessive Steroid Use Research Articles

Healthcare Utilization Patterns and Excessive Steroid Use in Late Adolescence Age and Young Adults With Crohn's Disease and Ulcerative Colitis.

Late adolescents and young adults (AYA) with inflammatory bowel disease (IBD) are a vulnerable population as they transition to adult healthcare. We aim to provide a real-world data on their healthcare utilization patterns and medication use through a large database. We performed a retrospective cohort study from January 1, 2012, to June 30, 2020, using OneFlorida Data-Trust, an electronic health record-based data repository representing over half of the Florida population. Outcomes of interest included demographics, healthcare utilization, medications, and disease severity. Chi-square tests and logistic regression were used to compare the rates of medication use, healthcare utilization, and disease severity by age groups. The number of patients who met our inclusion criteria was 10,578 with 2731 (25.8%) in the 17-25-year-old group. AYA patients had fewer ambulatory visits vs children (90% vs 95%; P value <.05). AYA patients were admitted more frequently from emergency facilities vs children (22.3% vs 10.9%; P value <.05). AYA patients received steroids more often than adults and younger patients (48.9% vs 45.3 vs 44.3% P value <.05, respectively). AYA patients received more narcotic (41.1% vs 22.3 % P value <.05) and antidepressant prescriptions (15.9% vs 9.5%; P value <.05) compared with children. With advancing age, a decrease in biologic use was noted (51% vs 40% vs 25.4% P value <.05, respectively). AYA patients with IBD have higher rates of hospital admissions from emergency department, fewer ambulatory health visits and they receive more steroids compared to children. Our study demonstrates the need for age-specific IBD programs for AYA patients.

S874 Evaluation of Quality-of-Care Indicators Among Patients With Crohn’s Disease and Ulcerative Colitis in the United States: 2019–2020

Introduction: Crohn’s disease (CD) and ulcerative colitis (UC) can be difficult to manage and, due to a lack of meaningful quality measures, patient (pt) care may vary by provider. To understand where gaps in care may exist for these pts, this study assessed specific healthcare resource utilization (HRU) and medication metrics that may be potential quality of care (QOC) indicators. Methods: Using a large commercial US claims database (2019–2020), pts with CD or UC were identified. Potential QOC indicators were selected based on clinical guidelines and recommendations from measures of quality organizations and included CD or UC prevalence; gastroenterologist (GE) and IBD-related non-GE outpatient visits; IBD-related emergency department visits or hospitalizations; excessive steroid use (prednisone equivalent ≥10 mg/day for ≥60 consecutive days or a single prescription of ≥600 mg prednisone); excessive steroid users on corticosteroid (CS)-sparing therapy; excessive steroid users with central dual-energy X-ray absorptiometry (DEXA) or osteoporosis pharmacologic treatment; use of targeted immunomodulators (TIMs) and oral mesalamine (CD only); imaging assessments; and assessment of inflammatory biomarkers. National percentages of pts achieving each metric are reported. Results: In total, 41,555 CD and 52,507 UC pts were identified in 2019, resulting in a 0.3% and 0.4% prevalence, respectively (Table). Over a third of CD pts (39.8%) and almost half of UC pts (45.5%) did not visit a GE in 2019. Around 10% CD pts, and up to 6.4% of UC pts, had IBD-related ED visits or hospitalizations. 17.1% CD and 14.5% UC pts were excessive steroid users, yet < 9% CD and UC pts, received DEXA scans and/or bone treatments. A third of excessive steroid users with CD (34.5%), and over half (53.0%) of those with UC, did not receive CS-sparing therapy. The rate of TIM use was over two times higher in CD vs UC pts (CD: 44.3%; UC: 18.9%). Despite evidence that mesalamine is ineffective in CD, 18.7% of pts with CD were prescribed it. Inflammatory biomarker level testing rates were < 50% in both CD and UC. Similar outcomes were reported in 2020, with lower HRU, possibly due to COVID-19. Conclusion: This analysis of QOC indicators highlights various areas for improvement that may provide better treatment outcomes and reduce HRU for pts with CD and UC. Future research is needed to assess outcomes in pts that are not being routinely monitored. Table 1. - Proportion of CD and UC patients achieving potential QOC metrics by year Indicator 2019 2020 CDN=41,555a UCN=52,507a CDN=39,025a UCN=47,940a Diagnosis Rate 0.3% 0.4% 0.3% 0.4% GE Outpatient Visits 60.2% 54.5% 57.5% 52.9% IBD-Related Non-GE Outpatient Visit 38.5% 43.8% 41.3% 45.6% IBD-related ED Visits 11.2% 4.7% 9.9% 4.5% IBD-related Hospitalizations 10.3% 6.4% 9.1% 5.9% Excessive Steroid Useb Corticosteroid-Sparing Therapyc,d DEXA or Bone Treatmentc,e,f 17.1%65.5%8.9% 14.5%47.0%7.9% 15.8%66.9%8.0% 14.5%49.4%6.9% Targeted Immunomodulator Use 44.3% 18.9% 48.4% 22.2% Oral Mesalamineg 18.7% N/A 17.0% N/A Imagingh 59.4% 64.2% 54.0% 58.0% Inflammatory Biomarkersi 49.8% 35.8% 49.9% 36.9% a) Sample size shown is based on continuous eligibility in medical benefit. Denominator for medication use outcomes focused on patients fully enrolled in both medical and pharmacy benefit, and thus were a subset of the larger population. b) Excessive steroid use was defined as doses ≥10 mg/day prednisone equivalent for ≥60 consecutive days or a single prescription of ≥600 mg prednisone. c) In excessive steroid users only. d) Treatments included thiopurine, methotrexate, or TIMs. e) All indicators were within the respective calendar year except DEXA/bone treatments that occurred during the prior calendar year. f) Defined as prescription osteoporosis treatment, excluding vitamin and mineral supplements. g) In patients with CD only. h) Including endoscopy, CT scan, MRI, or ultrasound. i) Including fecal calprotectin and c-reactive protein. CD, Crohn’s disease; CT, computed tomography; DEXA, dual-energy X-ray absorptiometry; ED, emergency department; GE, gastroenterologist; IBD, inflammatory bowel disease; TIM, targeted immunomodulator; UC, ulcerative colitis.

P492 Invasive fungal infection during COVID era at tertiary care hospital

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PMIntroductionInvasive fungal infection is a leading cause of morbidity and mortality in COVID patients as a secondary infection. Invasive fungal infections are often rapidly life-threatening and require specialist consultation for prompt diagnosis and therapy. The reporting of these invasive fungal infections (Mucormycosis, Aspergillosis, and candidiasis) is less than its occurrence.ObjectiveThis study was undertaken to diagnose invasive fungal infections in COVID patients during the first, second, and third COVID-19 pandemic waves by conventional methods.Materials and MethodsFrom March 2020 to December 2020 was considered the first wave pandemic, March 2021 to May 2021 was the second wave pandemic and December 2021 to February 2022 was considered the third wave pandemic era for this region. A total of 42, 168, and 87 samples were collected from patients clinically suspected to have invasive fungal infections during three pandemic waves from Covid indoor patients of RIMS, Ranchi. Among a total 24 were tissue samples, 13 BAL and 260 were nasal swabs/scrapes collected from suspected patients. KOH screening of all samples was done followed by culture on SDA media.ResultsA total of 83/297 (27.94%) cases were positive for KOH screening. In all, 91/297 (30.64%) samples showed culture positivity. A majority of growth was for Mucorales (48.2%), Aspergillus species (24.1%), Candida species (15%), and mixed growth (12.7%). Among Mucorales, Rhizopus was identified in 64% followed by Mucor (28%), Absidia (5%), and Rhizomucor (3%). Among Aspergillus species, majority were A. flavus (48%) followed by A. niger (37%), and A. fumigatus (15%). Maximum positivity for invasive fungal infections was observed during the second wave pandemic (62%) followed by the third wave (27%), and the first wave (11%) respectively.DiscussionMaximum cases were observed during and after the second wave COVID pandemic era due to excessive use of steroids during COVID treatment and cases were decreased during the third wave as compared with second wave timeframe due to the use of COVID vaccine, and many asymptomatic cases and home quarantine policy.ConclusionEarly diagnosis and treatment of invasive fungal infections with antifungal therapy and surgical debridement are necessary to reduce mortality and end-organ damage.

Physician education can minimize inappropriate steroid use in patients with inflammatory bowel disease: the ACTION study.

Epidemiological data on steroid use in South Korean patients with inflammatory bowel disease (IBD) are limited. We documented the steroid use patterns in these patients, and whether physician education on appropriate steroid use affected these patterns. ACTION was an observational cohort study conducted in adults (≥19 years) with IBD. A retrospective chart review was performed at baseline (cohort 1) and 1 year after physician training (cohort 2). Eligible cases with excessive or inappropriate steroid use were identified, along with any associated risk factors. Data were collected during May 2018-July 2019 from patients with Crohn's disease (CD) and ulcerative colitis (UC) in cohort 1 (n=1,685) and cohort 2 (n=1,649). At baseline, 155 patients (9.2%) had received steroids within the previous 12 months, 46 (29.7%) of whom had used steroids excessively, 16 (34.8%) of these having inappropriately used excessive steroids. Although steroid exposure was similar in cohort 1 (9.2%) and cohort 2 (9.7%), the latter comprised fewer excessive steroid users (20.0% vs. 29.7%). Severe disease was associated with excessive steroid use in cases with UC, but not with CD. Although, overall steroid use was relatively low in South Korean patients with IBD, one-third of steroid users used them excessively, and one-third among these used excessive steroids inappropriately. High disease activity was the main risk factor for excessive steroid use which may potentially be reduced by physician education, especially in cases with UC. Active screening to minimize excessive and inappropriate steroid use through physician education should be considered.

P498 Sources of excess steroid prescriptions and clinical adverse outcomes associated with steroid excess: The Leeds Steroids study

Abstract Background This retrospective study aims to determine steroid prescription practice across primary and secondary care, quantify the proportion of primary care prescriptions communicated to secondary care, and assess outcomes associated with excessive steroid use. Methods The study cohort consists of all patients attending IBD clinics under Leeds Teaching Hospitals from 1/1/2016 to 31/12/2017 with linked primary care records. Data were extracted from the hospital’s electronic health record. Steroid excess was defined based on ECCO guidelines. Cases with excess were reviewed to determine if escalation was implemented, appropriateness of escalation, timeliness of that (within 6 weeks of steroid course) and whether steroid excess was unavoidable. Results 2246 patients were included in the study (Mage: 47.26 y; 47.6% male; 46.4% CD, 46.8% UC; 36.2% of CD patients on thiopurines, 26.3% on biologics; 78.8% of UC patients on 5-ASA, 21.4% thiopurines, 5.6% biologics). During the study period 32.9% of patients were exposed to steroids (77.4% of steroid prescriptions issued for IBD, 27.5% of prescriptions for IBD originating from primary care). Significantly more prescriptions from secondary care were of appropriate dose and duration compared to primary care (84.7% vs 40.7%, p&amp;lt;0.001). Secondary care was made aware within six weeks of steroid initiation in 60.3% of steroid courses prescribed by primary care. 49.5% of patients flared after being prescribed steroids from primary care, compared to 39.1% from secondary care, p=0.003. Steroid excess was observed in 14.5% of patients and was related to IBD in 76% of them. In patients with steroid excess due to their IBD; excess was acted upon in 82.8% of patients (77.5% had treatment escalation). Escalation was considered appropriate in 98.9% of patients however, it was timely in 62.4% of patients and steroid excess was unavoidable in 47.6%. Patients with steroid excess due to IBD had significantly more hospital admissions for IBD (p&amp;lt;0.001), hospital admissions for infections (p=0.036) and more antibiotic courses prescribed by GP (p=0.023) compared to patients without steroid excess. Conclusion Steroid prescribing for IBD flares originating from primary care is common however, steroid dose and duration are frequently inappropriate, and more than one third of courses are not communicated to secondary care in a timely manner. A significantly higher amount of patients flare again after being prescribed steroids by primary care. Finally, over 50% of steroid excess is potentially avoidable and steroid excess is related to negative consequences such as IBD admissions, admissions for infections and antibiotic prescriptions.

Mucormycosis and diabetes in the times of COVID-19: A Mumbai-based observational study.

There is a significant increase in the number of mucormycosis cases in the setting of the coronavirus disease 2019 (COVID-19) pandemic. This study was undertaken to understand the clinical profile of such patients and the risk factors associated with increased mortality of this already deadly infection. A retrospective observational study was conducted by including microbiologically confirmed cases of mucormycosis with the background of COVID-19 infection (COVID-19-associated mucormycosis [CAM]). Data was segregated into those of survivors versus non-survivors and the two groups were analyzed for various risk factors. Early and late CAM were also compared. The case fatality rate was 21.73% (5/23 patients). Case fatality in early CAM was 33.3% versus 9.1% in late CAM. Rhino-orbital-cerebral mucormycosis (P = 0.01) and cranial nerve involvement (P = 0.0482) were associated with increased mortality. Diabetes and poor glycemic control were the common factors in all patients. Early CAM patients were more likely to have orbital or cerebral involvement (P = 0.0065). Patients having chronic liver disease had a higher risk of mortality (P = 0.0395). Sequential treatment or concurrent dual drug therapy with a combination of antifungal drugs was independently associated with better survival (P = 0.0395). The average duration of treatment with amphotericin-b required for cure by survivors was 29.05 ± 17.05 days. The average duration of treatment with isavuconazole/posaconazole for survivors was 50.32 ± 25.23 days. Early CAM had a higher case fatality rate. Patients had better recovery rates with sequential or dual antifungal treatment. The raised incidence and mortality in the COVID-19 pandemic is probably related to the COVID-19-induced immunosuppression with associated diabetes and excessive use of steroids.

Don't forget me in amidst of COVID-19 pandemic: A case series and review of literature on steroid associated psychiatric manifestations

There is a sudden upsurge in the use of steroids due to the ongoing COVID-19 pandemic, especially in patients with severe or critical COVID-19 infection. There are reports of excessive use of steroids, both in terms of use in patients who do not require the same and use in doses higher than the recommended. There are reports of the emergence of different adverse outcomes of excessive steroid use in the form of diabetes mellitus and a higher incidence of mucormycosis. However, little attention has been paid to the mental health impact of the use of steroids. This review attempts to evaluate the existing data in terms of incidence of psychiatric side effects of steroids, and the risk factors for steroid associated psychiatric manifestations. Additionally, an attempt is made to discuss the pathogenesis of steroid-associated psychiatric side effects and why it is likely that the incidence of psychiatric side effects may be more in patients with COVID-19 infection. There is a need to improve the awareness about the psychiatric side effects of steroids, both among the physicians and mental health professionals, as in any patient presenting with new-onset psychiatric symptoms while having COVID-19 infection or during the post-COVID-19 infection phase, a possibility of steroid associated side effect needs to be considered.

Clinico-Mycological Profile of Otomycosis in Chronic Suppurative Otitis Media Patients Attending a Tertiary Care Teaching Hospital

Chronic Suppurative Otitis Media (CSOM) is commonly encountered chronic inflammation of middle ear as well as the mastoid cavity due to dysfunction of Eustachian tube followed by microbial infection. Fungal infection in CSOM is now a major otolarynological problem in India not only in children but in adults too. Excessive use of steroids, antibiotics, cytotoxic chemotherapies and immunosuppressive diseases has increased the incidence of otomycosis in recent years. To define the aetiology of clinically diagnosed otomycosis. To isolate and identify fungal agents and their association with different factors(age, sex, predisposing factors). A total of 100 clinically diagnosed patients of CSOM with suspicion of otomycosis were included in the study. Patients where passing swab is difficult as with canal stenosis were excluded. Samples were taken using sterile swabs and studied for microbial profile. Male to female ratio in study was 1.6:1. The most common fungi isolated in CSOM cases was Aspergillus fumigatus followed by Aspergillus niger. Other fungus isolated were Aspergillus flavus, Penicillium species, Mucor species and Candida species. 04 samples showed mixed growth of Aspergillus species and Candida species. In our study we concluded that Aspergillus complex was most commonly isolated fungi in CSOM cases.

Abstract No. 471 Allergy testing for verification of contrast allergy prior to radiology procedures

Allergy to contrast material can limit the diagnostic and therapeutic options for patients, especially if the reaction to contrast media is listed as anaphylaxis (IgE-mediated allergic reactions). Many patients with physiologic response to contrast are labeled as being allergic to contrast because the patient or caregiver do not understand the differences between dose-related responses and allergy. Other patients with a history suggesting only a mild reaction may be at risk for anaphylaxis. Our goal is to provide appropriate documentation for the existences or lack of contrast allergy which facilitate best therapeutic and diagnostic options for the patient. Pre-procedure patients with written documentation of contrast allergy were, at the discretion of a licensed independent practitioner, referred to the Allergy and Immunology department for contrast media testing. Patients were tested using an established protocol. Based on reaction clinical history and skin testing patients were classified into four groups: Nonallergic (Negative skin testing, and negative clinical evaluation), predominantly histamine mediated reaction (Negative skin testing, clinical evaluation consistent with histamine mediated symptoms), allergic- like reaction (Negative skin testing, convincing clinical allergic-like reaction), and IgE- mediated allergic reaction (Positive skin testing and positive clinical history) Ten patients completed contrast allergy testing. Referral to allergy and immunology changed the management as follows: avoided steroids in 8/10 (80%) and avoided premedication completely in 6/10 (60%). The testing also confirmed IgE mediated reaction to contrast (Risk of anaphylactic reaction) in 1 patient (10%). Testing in this preliminary patient population suggests significant clinical benefit from referral to allergy and immunology for contrast media testing in patients with reported contrast allergy. Standardization of patient testing may reduce procedure cancellations, excessive use of steroids and potentially the risk of contrast induced anaphylaxis.

S2981 Emphysematous Gastritis: An Uncommon Cause of Acute Abdomen

INTRODUCTION: Emphysematous gastritis (EG) is defined as air within the gastric wall leading to inflammation and systemic compromise. It is often caused by gas-forming microorganisms. Malignancy, bowel obstruction, excessive steroid use, chemotherapy, nonsteroidal anti-inflammatory drugs, and perforated ulcers can all lead to EG. We report the case of a male who presented with peritonitis and septic shock in the setting of intramural air in the stomach. CASE DESCRIPTION/METHODS: An 83-year-old male with history of congestive heart failure, diabetes mellitus, hypertension, and hyperlipidemia presented with diffuse abdominal pain for 2 days. On presentation, the patient was tachycardic, tachypneic, and hypotensive. Initial Laboratory values are shown in table 1. Examination revealed a rigid abdomen with guarding and rebound tenderness. He was started on IV norepinephrine to maintain blood pressure. NG tube was placed which produced 1.5 L of dark fluid. CT angiogram of abdomen illustrated intraperitoneal free air and evidence of pneumatosis within the fundus and posterior wall of the body of the stomach (figure 1a, 1b, 1c). An emergent exploratory laparotomy was performed with wedge resection of the fundus. During the procedure, copious amounts of purulent material was noted which was cultured, revealing Candida glabrata. Postoperatively, the patient was transferred to the intensive care unit for further management. He remained hypotensive despite fluid resuscitation requiring vasopressors. Patient was started on fluconazole and piperacillin-tazobactam as antimicrobial therapy. His condition improved and was successfully extubated, and transferred to the surgical floors. He was later discharged to a nursing facility in stable condition. DISCUSSION: EG often presents with systemic compromise. The diagnosis requires a CT scan. Although a serious illness, conservative management is usually first attempted before considering surgical intervention. Vasopressors and fluid resuscitation are sometimes required to stabilize the patient hemodynamically. Appropriate antimicrobial therapy should be initiated with coverage of anaerobic organisms, gram negative organisms as well as candida species. If patients develop complications, such as peritonitis or fail conservative management, surgical intervention is warranted. Although rare, ED personnel should consider this condition in differentials of acute abdomen as prompt diagnosis and management can be lifesaving.Table 1.: Illustrating laboratory values on presentationFigure 1.: Figure 1a (coronal), 1b (sagittal) and 1c (axial): abdominal CT scan illustrating pneumatosis seen within the fundal portions and posterior wall of the body of the stomach (red arrows) with gastric distention.

Recent Updates on Corticosteroid Resistance in Asthma

Corticosteroids are one of the most effective medications available for a wide variety of inflammatory diseases, including rheumatoid arthritis, inflammatory bowel disease, autoimmune diseases, and chronic lung diseases such as asthma; however, 5–10% of asthma patients respond poorly to corticosteroids and require high doses, secondary immunosuppressants, such as calcineurin inhibitors and methotrexate, or disease-modifying biologics that can be toxic and/or expensive. Though steroid-resistant asthma affects a small percentage of patients, it consumes significant health resources and contributes to substantial morbidity and mortality. In addition, the side effects caused by excessive use of steroids dramatically impact patients’ quality of life. Recognition of patients who respond poorly to steroid therapy is important due to the persistent and considerable problems they face in managing their conditions, which bears a significant socioeconomic burden. Along with the recognition of such patients, elucidation of the molecular mechanisms of steroid resistance is equally important, so that administration of a high dosage of steroids, and the consequent adverse effects, can be avoided. This review provides an update on the mechanisms of steroid function and the possible new therapeutic modalities to treat steroid-resistant asthma.

A multi-centre audit of excess steroid use in 1176 patients with inflammatory bowel disease.

Corticosteroids are central to inducing remission in inflammatory bowel disease (IBD) but are ineffective maintenance agents. To benchmark steroid usage in British outpatients and assess factors associated with excess exposure. We recorded steroid use in unselected IBD outpatients. Cases meeting criteria for steroid dependency or excess were blind peer reviewed to determine whether steroid prescriptions were avoidable. Associations between steroid use and patient/institutional factors were analysed. Of 1176 patients, 30% received steroids in the prior 12months. 14.9% had steroid dependency or excess, which was more common in moderate/severe ulcerative colitis (UC) than Crohn's disease (CD) (42.6% vs 28.1%; P=.027). Steroid dependency or excess was deemed avoidable in 49.1%. The annual incidence of inappropriate steroid excess was 7.1%. Mixed-effects logistic regression analysis revealed independent predictors of inappropriate steroid excess. The odds ratio (OR, 95%CI) for moderate/severe compared to mild/quiescent disease activity was 4.59 (1.53-20.64) for UC and 4.60 (2.21-12.00) for CD. In CD, lower rates of inappropriate steroid excess were found in centres with an IBD multi-disciplinary team (OR 0.62 [0.46-0.91]), whilst dedicated IBD clinics protected against inappropriate steroid excess in UC (OR 0.64, 95% CI 0.21-0.94). The total number of GI trainees was associated with rates of inappropriate steroid excess. Steroid dependency or excess occurred in 14.9% of British IBD patients (in 7.1% potentially avoidable). We demonstrated positive effects of service configurations (IBD multi-disciplinary team, dedicated IBD clinics). Routine recording of steroid dependency or excess is feasible and should be considered a quality metric.

Establishment of a library of fragments for the rapid and reliable determination of anabolic steroids by liquid chromatography-quadrupole time of flight-mass spectrometry

Anabolic steroids have similar structures to testosterone, both of which promote the growth of muscle mass and increase strength. However, the side effects of anabolic steroid use may lead to heart attacks or strokes. Additionally, the excessive use of steroids inhibits the production of the sex hormones in the body via a negative feedback loop, which results in testicular atrophy in males and amenorrhea in females. Currently, the method of choice used to test for the presence of anabolic steroids is GC-MS. However, GC-MS methods require chemical derivatization of the steroid sample to ensure compatibility with the analytical method; therefore, analysis of many different samples is difficult and time consuming. Unlike GC-MS, the liquid chromatography-quadrupoletime of flight mass spectrometry (LC-Q-TOF-MS) method is suitable for many samples. Twenty-two different anabolic steroids were analyzed by LC-Q-TOF-MS with various collision energies (CE). Accurate mass spectral data were obtained using a Q-TOF-MS equipped with an electro-spray ionization source and operated in the positive MS/MS mode for several classes of steroids that are often the targets of testing. Based on the collected data, fragmentation pathways were carefully elucidated. The high selectivity and sensitivity of the LC-Q-TOF-MS instrument combined with these fragmentation pathways offers a new approach for the rapid and accurate screening of anabolic steroids. The obtained data from the 22 different anabolic steroids will be shared with the scientific community in order to establish a library to aid in the screening of illegal anabolic steroids.

A Study of Fungal Keratitis in North Africa: Exploring Risk Factors and Microbiological Features

A prospective case study of patients presenting with clinically suspected keratitis was conducted at Al-Rehma Hospital, Sirte, Libya between January 2008 and November 2010. A total of 32.9% patients were identified with fungal keratitis, Aspergillus and Fusarium together accounted for 89.28% of cases. Males had higher predisposition as compared with females. Trauma (78.5%) was the major cause, vegetative injury alone constituting 60.7% of cases. Other most common identifiable risk factors were history of diabetes mellitus (17.8%), contact lens (21.4%) and corticosteroids (3.57%). Fungal keratitis still possesses a significant threat for increased ocular morbidity. The overall knowledge of fungal keratitis with its clinical determinants and risk factors, would aid in general awareness and prevention of complications associated with it. Key-wordsFungal keratitis, Cornea, Vegetative trauma, Contact lens, Diabetes mellitus, Corticosteroid -------------------------------------------------IJLSSR----------------------------------------------INTRODUCTION Eye is one of the important organs of sensory perception. Normally it is kept free from microbial infections by the natural protective mechanisms. Breach of these protective barriers can predispose to ocular diseases leading to significant ocular morbidity. Keratitis as such is an inflammation of the cornea, due to infectious, physical or chemical causes, which can result in vision loss. Contact lens use is the main predisposing factor for infectious keratitis [1]. Eye is also vulnerable to infections with fungal members due to trauma and excessive steroid use with or without antibiotic. There has been increasing trends of infectious corneal blindness owing to higher incidences of direct ocular trauma added with personal and social factors like increased alcohol consumption, higher age, low socioeconomic status and lack of health education. Access this article online Quick Response Code: Website:

OC-080 Excess Steroid Use in IBD: Too Much, How Much and Why? Results From A Nationwide Audit

OC-080 Excess Steroid Use in IBD: Too Much, How Much and Why? Results From A Nationwide Audit

Mo1842 Excess Steroid Use in IBD: Too Much, How Much and Why? Results From a UK Nationwide Audit

Introduction Corticosteroids are the cornerstone of inducing remission in IBD but are limited in their ability to maintain remission, and associated with significant side effects. This is the first nationwide outpatient study of steroid use in IBD and factors affecting their use. Methods We audited consecutive IBD patients attending clinics at 11 centres over 3 months using a web-based assessment tool. Cases meeting criteria for steroid excess (SE) as defined by ECCO guidelines were blind peer reviewed and classified as non-IBD use, unavoidable and inappropriate steroid excess (ISE). Associations between steroid use and patient and institutional factors were analysed. Results Of 1177 patients [48% CD, 49% UC, 3% IBD-U] 79% were in remission/mild disease, 18.5% had moderate and 2.5% severe disease. In the previous 12 months, 30% had received steroids, 13.8% had SE. Peer review revealed that SE was inappropriate in 51.2% of these (8% non-IBD use; 40.7% unavoidable). Excess steroid exposure was more common in patients with active UC compared to active CD (41.6% vs 26.6%; p = 0.02). In multivariate analysis, disease activity was a significant predictor of SE/ISE. In addition, being established on anti-TNF agents protected against SE and ISE in CD. Exposure to thiopurine (SE + ISE) and starting anti-TNF therapy (ISE) were associated with excess steroid use in UC. CD patients from centres with an IBD MDT were less likely to have SE, similarly CD patients in centres with combined surgical clinics were less likely to experience SE and ISE. Care in centres with dedicated IBD clinics was associated with less SE and ISE in patients with UC. Centres with large numbers of GI trainees showed higher rates of SE in UC and SE and ISE in CD. (All of above independent predictors on multi-variate with significance p Conclusion We identified inappropriate excess steroid use in 7% of UK IBD patients. Risk factors for steroid exposure differed between UC and CD, likely reflecting inter alia , differences in access to biologic drugs. Our study is the first to demonstrate positive effects of service configurations (IBD MDT, dedicated IBD clinics, combined surgical clinics) on treatment outcomes even after correction for differences in disease severity. There was an association between ISE in Crohn’s and the number of GI trainees per centre suggesting possible gaps in training. Routine recording of excess steroid exposure is feasible and should be considered as a quality marker for outcomes of IBD services. Disclosure of Interest None Declared

DOP037. Excess steroid use in IBD: too much, how much, and why? Results from a UK nationwide audit

DOP037. Excess steroid use in IBD: too much, how much, and why? Results from a UK nationwide audit

Pro-Con Debate: Protracted Bacterial Bronchitis as a Cause of Chronic Cough in Children.

Pro: Children with chronic cough present a diagnostic challenge. Protracted bacterial bronchitis (PBB) is a chronic, persistent bacterial infection of conducting airways defined by the presence of cough for longer than 4 weeks that resolves with antimicrobial therapy and without an alternative diagnosis. The diagnosis is made by the findings of increased bronchial secretions and edema of the lower airways on flexible bronchoscopy and positive cultures on bronchoalveolar lavage. It is speculated that an initial respiratory insult such as viral infection disrupts normal surface morphology and ciliary function, which leads to chronic self-perpetuating inflammation with the formation of bacterial biofilms, leading to PBB. PBB is often misdiagnosed as asthma, leading to inappropriate and excessive use of steroids. The importance of timely diagnosis should be emphasized due to the potential that PBB may be a precursor to chronic suppurative lung disease or bronchiectasis if left untreated; however, every patient should be adequately assessed to exclude other causes of chronic cough. Con: Clinical criteria for the diagnosis of PBB are nonspecific and may not distinguish it from other known causes of chronic cough, including viral infections. Benefits from antibiotic therapy (particularly prolonged therapy) have not been demonstrated. Respiratory conditions are the most common reason for antibiotic prescriptions during ambulatory visits in the United States, and many of these prescriptions are inappropriate and/or unnecessary. The proposed diagnostic criteria and recommendations for the treatment of PBB will lead to unnecessary overuse of antibiotics.

Should we establish standards of care for management of elderly patients with inflammatory bowel disease?

lderly patients with inflammatory bowel disease (IBD) have poorer outcomes than their younger counterparts with increased inpatient mortality rates, infection rates, lymphoma rates (1), and intolerance to immunosuppressive agents or tumour necrosis factor inhibitors (TNFi) (2). These may lead to hesitancy in prescribing effective immunosup- pressive drugs and TNFi to elderly patients, especially in individuals with comorbid conditions. Overuse of corticosteroids, however, has significant deleterious effects in elderly patients including osteopor- osis, hypertension, diabetes, ocular complications, infections and postsurgical complications. Some elderly patients with IBD may also have very indolent disease and it is important not to overtreat them. Several studies, including the report by Stepaniuk et al (3) in the current issue of the Journal (pages 273-277), have clearly shown that elderly patients receive less TNFi and less immunosuppressive drugs than their younger counterparts with IBD (4). While whether such undertreatment contributes to poorer outcome and complications in elderly patients still requires robust evidence, it is also of concern that elderly patients may be treated and monitored less rigorously and objective end points, such as mucosal healing, may never be reached. Introduction of newer therapies, such as the integrin inhibitor vedol- izumab, may offer potentially certain safety advantages. TNFi may also be considered in this population as monotherapy rather than combination therapy in the presence of comorbid conditions such as chronic obstructive airways disease. Rapid control of more severe disease is essential to prevent increased morbidity and complications in elderly individuals. Several areas of management of IBD in elderly patients require specific attention (Box 1). These include establishment of diagnosis by robust exclusion of several conditions such as colon cancer, infections, especially Clostridium difficile, ischemic colitis, diverticular colitis and angiodysplasia. Monitoring by regular use of C-reactive protein, fecal calprotectin, complete blood count and liver function tests is necessary to avoid the necessity of frequent invasive investigations and avoid hematological or other complications. Transabdominal ultrasonography for distal ileal Crohn disease may be a very useful noninvasive monitor- ing modality because it is well tolerated. Endoscopic surveillance to detect dysplasia may be especially challenging in elderly patients due to the high prevalence of diverticular disease and polypoid lesions leading to difficulty in deciding on local endoscopic resection strategies (5) versus panproctocolectomy with potentially increased morbidity. It is also important to vaccinate elderly patients against common infective preventable diseases and be aware of the high incidence of herpes zoster. The use of steroid-sparing agents, such as azathioprine, methotrexate and TNFi, is important in elderly patients to avoid excessive use of steroids in moderate to severe IBD and ensure mucosal healing. Finally, inpatients need careful prophylaxis against thromboembolism, vigilance against nosocomial infections and surgery if required in a timely manner before advanced disease, poor nutrition and infections lead to postopera- tive complications and poor outcome including mortality. Elderly patients are often troubled by fecal incontinence after pouch surgery and a permanent ileostomy is often a preferred approach. However, elderly patients with adequate sphincter function may do well after pouch sur- gery. Multidisciplinary management of these elderly patients is espe- cially important given the comorbid conditions that are often present. While there are many guidelines and an increasing number of standards of care to optimize management of IBD, there are no specific guidelines for comprehensive management of elderly patients with IBD. This appears to be an omission that requires attention by national and international organizations. Many of the issues in the elderly population also require further generation of evidence because these patients form only a small fraction of patients in clinical trials. eDItorIal

Current Prospective of Aldose Reductase Inhibition in the Therapy of Allergic Airway Inflammation in Asthma

The prevalence of asthma and costs of its care have been continuously increasing, but novel therapeutic options to treat this inflammatory disease have not been brought to the US market. Current therapies such as inhaled steroids, long-acting beta-agonist bronchodilators, antihistamines and immunomodulators may control the symptoms of allergic asthma but fail to modify the underlying disease. Excessive use of steroids and other immunosuppresents alter the patient's quality of life, produce undesirable toxicities, and increase the risk of other pathologies such as diabetes. Hence novel therapeutic options to manage asthma are desirable. In the present review, we have discussed the role of the polyol pathway enzyme aldose reductase (AR) in the amplification of allergic airway inflammation. Recent studies have indicated that AR inhibition prevents the NF-κB-dependent generation of pro-inflammatory cytokines and chemokines in mouse models of allergic airway inflammation indicating the potential use of AR inhibition as a novel tool to control allergic responses. Since orally available AR inhibitors have already undergone phase III clinical trials for diabetic neuropathy and appear to have a manageable side effects profile, they could be readily developed as potential new drugs for the treatment of asthma and related complications.