INTRODUCTION: The American Gastroenterology Association (AGA) Bridges to Excellence (BTE) Inflammatory Bowel Disease (IBD) Care Recognition program encourages clinicians to develop a superior quality of care in the management of IBD. The compliance to AGA quality metrics has been historically low in general gastroenterology (GI) clinics. We evaluated adherence to BTE measures in the care of IBD patients seen at a tertiary care hospital gastroenterology fellows' clinic, and developed a provider-friendly template to further increase compliance. METHODS: Patients with diagnosis of IBD (Crohn's disease (CD), Ulcerative Colitis (UC), or indeterminate colitis (IC)) were identified in the gastroenterology continuity clinic using ICD-9 and ICD-10 codes at the University of Oklahoma Health Sciences Center, Gastroenterology fellow's clinic. Baseline patient characteristics and 8 BTE measures were recorded. Based on compliance with quality metrics, a simple, provider-friendly template was added to GI initial and return clinic notes. Overall adherence to BTE measures and average scores as per the AGA 100 point scale were evaluated and compared pre- and post-intervention. RESULTS: 50 patients were seen in GI fellows' clinic over 6-month period in the pre-intervention phase, and 35 were seen in the post-intervention phase. Baseline characteristics for both groups were similar. Overall adherence to BTE measures was 54%, and average BTE score was 58.8 (3 star) in the pre-intervention phase. Overall adherence to BTE measures was 42.4%, and average BTE score was 53 (3 star) (P > 0.05) in the post-intervention phase. On sub-group analysis, it was found that only half of the patients had had the intervention implemented for their care (18/35). Sub-group analysis of patients where template was implemented, adherence to BTE measures was 98.4% and average BTE score was 98.5 (5 star) (P = 0.02). When compared to the group of patients where template was not used, the overall adherence was 42.4%, and average BTE score of 53 (3 star). This was found to be statistically insignificant when compared to pre-intervention group (P = 0.60). CONCLUSION: The care for IBD patients continues to be a multi-disciplinary, complex approach. Using template increased compliance to vaccination and tobacco screening/counselling in our cohort. Using a provider-friendly template may improve compliance with AGA quality metrics for the care of IBD patients in outpatient settings.

Primary hepatic actinomycosis is rare, with less than 100 cases reported in English literature. Most of these cases are cryptogenic. We describe a 35-year-old woman who presented with a retained common bile duct stent for 6 years and found to have a hepatic mass with altered perfusion and enhancement, and minimal degree of washout on enhanced cross-sectional imaging. Fine-needle aspiration revealed presence of filamentous bacteria morphologically consistent with Actinomyces species. This report is a demonstration of a rare instance in which a retained biliary stent led to primary hepatic actinomycosis.

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Background: Patients with medically-refractory ulcerative colitis or advanced neoplasia are often offered an ileal-pouch-anal anastomosis to restore bowel continuity. However, up to 50% of patients can suffer from inflammatory conditions of the pouch, some of which require biological therapy to treat. The aim of this study was to determine the efficacy of each biological agent for the treatment of inflammatory conditions of the pouch. Materials and Methods:A comprehensive literature search was performed in the major databases from inception through February 11, 2020, for studies assessing the efficacy of biologics in chronic antibiotic-refractory pouchitis (CARP) and Crohn's disease (CD) of the pouch. Both prospective and retrospective studies were included. The primary outcomes of interest were complete and partial responses were defined within each study. χ 2 test was used to compare variables.Results: Thirty-four studies were included in the systematic review and meta-analysis. Sixteen studies (N = 247) evaluated the use of infliximab (IFX), showing complete response in 50.7% and partial response in 28.1% for CARP, and complete response in 66.7% and partial response in 20% for CD of the pouch. Seven studies (n = 107) assessed the efficacy of adalimumab. For CARP, 33.3% of patients had a complete response, and 38.1% had a partial response, whereas for CD of the pouch, 47.7% experienced a complete response, and 24.6% had a partial response. Three studies (n = 78) reported outcomes with the use of ustekinumab, showing 50% complete response and 3.8% partial response for CARP. For the CD of the pouch, 5.8% had a complete response and 78.8% had a partial response. Seven studies (n = 151) reported the efficacy of vedolizumab, showing 28.4% complete response and 43.2% partial response in patients with CARP, whereas 63% of patients experienced partial response in CD of the pouch. IFX had higher rates of complete response in CARP compared with adalimumab (P = 0.04) and compared with vedolizumab (P = 0.005), but not compared with ustekinumab (P = 0.95). There were no new safety signals reported in any of the studies.Conclusions: Biologics are safe and efficacious in the treatment of chronic, refractory inflammatory conditions of the pouch. IFX seems to be more efficacious than adalimumab and vedolizumab for CARP. Further prospective, head-to-head evaluations are needed to compare biological therapies in the treatment of CARP and CD of the pouch.

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