bluuebunny/crossref_metadata_2025 huggingface dataset:
708 History of Clostridium difficile Infection Predicts Late Colectomy in Patients With Acute Ulcerative Colitis
Authors: Paknikar Raghavendra , Dwadasi Sujaata , Goens Donald , Zafer Maryam , Pekow Joel , Micic Dejan
Published: October 2019

INTRODUCTION:

Studies have identified a significant prevalence of enteric pathogens (EP), most prominently clostridium difficile (CD), in patients with Ulcerative Colitis (UC). The clinical role of these EPs remains debatable, as in patients with UC they often can represent the sole reason for acute presentation, asymptomatic carrier status, or a comorbid presentation with UC. We aimed to study the prevalence of testable EPs in hospitalized UC patients and assess the impact of these pathogens on colectomy outcomes.

METHODS:

We designed a retrospective study including patients >18 years old with an admission for UC at a single academic center between 1/1/2013 and 4/1/2018. Cases were identified using the ICD-9 code 556.X and ICD-10 code K51.X and separately verified. Clinical variables of interest and laboratory values were obtained via chart review or extracted from the electronic medical record. Logistic regression was performed in order to identify predictors of in-hospital and 90 day colectomy. Statistical analysis was conducted using JMP ® 13.1.0.

RESULTS:

262 patients admitted with UC were reviewed. Our study identified 48/251 (19.1%) patients with positive CD testing. 11/91 (12.1%) patients had Non-CD EPs and only 1/91 (1.1%) patient was positive in both tests. The identified infections are outlined in Table 1. We also identified 31/261 (11.9%) who had a positive CD test in 8 weeks prior to admission. Basic demographic and clinical variables are listed in Table 2. History of CD infection in the past 8 weeks before admission predicted Colectomy at 90 days in univariate analysis (P-value = 0.0015). Multivariate logistic regression model with all covariates in Table 2 (excluding non-CD EP status and in-hospital CD infection status) revealed an area under curve = 0.80. History of CD infection in the past 8 weeks remained the only significant predictor within this model of late colectomy at 90 days (P-value = 0.0063, OR = 10.53, 95% CI 1.95-57.0).

CONCLUSION:

Prior to admission diagnosis of CD infection is a strong predictor of late colectomy at 90 days in hospitalized patients with UC. Multiple explanations are possible including outpatient management of CD delaying initiation of inpatient management of acute UC flares. Conversely, accumulated adverse effects of gut dysbiosis from EPs may occur over weeks before leading to adverse outcomes. Future work is needed to optimally characterize the pathogenicity of both CD and non-CD EPs in UC patients via current testing and treatment strategies.
718 The Experience of and Access to Rapid Infliximab Infusions at an Academic Tertiary Medical Center
Authors: Pusateri Antoinette , Patel Nisha , Hatcher Ashley , Lehman Joy , Afzali Anita
Published: October 2019

INTRODUCTION:

Infliximab (IFX) induces and maintains remission in patients with inflammatory bowel disease (IBD) and rheumatologic disease (RD). It is time-intensive, which places great burden on patients and health systems. Rapid infusions (RI) reduce infusion time from 2 hours to 1 hour, theoretically can alleviate this burden and enhance access to care defined by effectiveness (safety), availability (capacity) and utilization (patient characteristics). We aimed to describe the RI experience at our center, with the hypothesis that RI enhance access to care for all patients regardless of indication for IFX.

METHODS:

All patients treated with IFX for IBD or RD at our outpatient infusion center from February 2016 to August 2017 were included. Demographic and clinical information including IFX indication, history of infusion reaction, use of pre-medication, number of standard and RI were collected.

RESULTS:

There were 348 patients, 212 (60.92%) were female, 193 (55.5%) had IBD and 143 (41.1%) had RD. In terms of safety, 21 (6%) had a history of infusion reaction, 7.8% with IBD and 3.5% with RD (P = 0.1127). 33.6% were premedicated for infusions. For only RD, a lower number receiving RI received pre-medications (P = 0.0002). The history of infusion reaction was 5.7% in the RI group and 6.3% in the standard infusion group (P = 1.000). Only 2 patients required switch back to standard infusion after reaction with RI. In terms of capacity, 40% of patients were converted to RI during the study period. This resulted in a 16.1% decrease in average daily infusion time and 9.8% increase in average daily available scheduled chair time or an additional 261.2 (±19.7) minutes per day (P = 0.72). In terms of patient characteristics, a larger number of RD patients received RI versus IBD patients (P = 0.0261). Only for the RD group a lower number of patients receiving RI were female (P = 0.0491). For patients with RD and IBD, a lower number of patients receiving RI versus standard infusions were on public insurance (P = 0.011 and P = 0.0151) and patients receiving RI had been on IFX for a longer period of time (P = 0.0002, P < 0.0001).

CONCLUSION:

RI were safe and increased available chair time. There were differences in patient characteristics: females with RD and public insurance patients were less likely to receive RI. Future directions include creation of a prospective registry and patient quality of life surveys to understand if implicit bias against disease, gender, socioeconomic status, or other factors impact access to RI.
721 Risk Factors for Recurrence vs. Reinfection of Clostridioides difficile Infection in Inflammatory Bowel Disease: Single Center Retrospective Study
Authors: Dickson Zachary , Hunold Thomas , Baray Merwise , Hays R. Ann
Published: October 2019

INTRODUCTION:

Patients with inflammatory bowel disease (IBD) are at greater risk for development of Clostridioides difficile infection (CDI) than the general population, ulcerative colitis (UC) more so than Crohn's disease (CD). Although the data regarding risk factors for development of CDI in IBD patients is conflicting, a 2019 meta-analysis suggested recent antibiotics, colonic involvement in CD, and biologic therapy to be significant risk factors. This study investigated the role of these risk factors and the use of proton pump inhibitors (PPI), opiates, and steroids in the development of recurrence vs reinfection of CDI in IBD patients.

METHODS:

A retrospective cohort of patients age 18-75 with a history of IBD diagnosed with CDI from January 1, 2012–December 31, 2016. Recurrence defined as CDI diagnosis within 3 months of the index CDI. Reinfection defined as second episode of CDI between 3 months to 3 years of the index CDI. Patient demographics, antibiotics used to treat index CDI, presence of colonic involvement, and use of PPIs, opiates, biologics, and steroids at the time of second CDI were recorded. Data was analyzed with Fisher's exact test and student t-tests using SAS 9.4 software.

RESULTS:

A total of 121 IBD patients with CDI were identified: 60 with Crohn's and 61 with UC. 59.5% of IBD patients had either recurrent CDI or CDI reinfection. Recurrent CDI occurred in 32.7% of UC patients and 23.3% of Crohn's patients. CDI reinfection was observed in 36.6% of Crohn's patients and 26.2% of UC patients. Colonic involvement was documented in 100% (n = 14) of Crohn's patients with CDI recurrence and 81.8% (n = 18) of Crohn's patients with CDI reinfection. CDI recurrence and reinfection were not associated with gender, race, or the use of steroids, biologics, PPIs, opiates, or antibiotics.

CONCLUSION:

Compared to Crohn's patients, there was a greater proportion of UC patients who experienced recurrent CDI. Additionally, colonic involvement occurring in all Crohn's patients in this cohort with recurrent CDI suggests that the extent of colonic disease may predispose to recurrent CDI. Further investigation examining the incidence of recurrent CDI in Crohn's patients without colonic involvement is warranted. This study suggests that therapy with biologics, opiates, PPIs, and steroids are not risk factors for the development of CDI in IBD patients.
727 Clinical Epidemiology of Inflammatory Bowel Disease in Los Angeles County: A Study of a Predominantly Latino Population
Authors: Zhornitskiy Alex , Fung Brian M. , Tabibian James H.
Published: October 2019

INTRODUCTION:

The body of research pertaining to the epidemiology, features, and treatment of inflammatory bowel disease (IBD) continues to grow; however, relatively little remains known about IBD in minority populations. Hispanics and Blacks have been understudied in most population studies, often comprising <2% of the sample size. This disproportion limits the ability to formulate reliable conclusions regarding ethnoracial influences on incidence, phenotype, severity of disease, and outcomes in these minority groups. To help address this void, we initiated a population-based study of the clinical epidemiology of IBD in Los Angeles County Department of Health Services (LADHS), the second largest municipal healthcare system in the United States. The ethnoracial makeup of the county is comprised predominantly of Latino patients, which provides a unique opportunity to evaluate IBD in a population that has not been well-studied to date.

METHODS:

We conducted a retrospective cohort study of all biopsy-proven cases of IBD diagnosed between November 2015 and June 2018 at Olive View-UCLA Medical Center, one of three hospitals comprising LADHS. Patient and disease-related data such as age, gender, ethnicity, presenting symptoms and laboratory values, and complications, were collected using a standardized data collection tool and tabulated.

RESULTS:

One hundred and twenty-six cases of IBD were found, of which 42 were new diagnoses, suggesting an incidence and prevalence of 160 and 481 per 100,000 person-years, respectively. Among these 126 patients, 79% were Latino, with the average age of diagnosis at 36.4 years. 54% of patients were female. The most common diagnosis was ulcerative colitis (43%), with Crohn's and indeterminate colitis making up 29% and 28% of patients, respectively. The most common presenting symptoms were bloody diarrhea and abdominal pain, both of which occurred more frequently in patients diagnosed with Crohn's disease.

CONCLUSION:

Both the prevalence and incidence in this predominantly Hispanic cohort are significantly higher than reported rates for IBD by the Center of Disease Control (CDC), Furthermore, this cohort appears to have unique clinical characteristics, with UC more common in females, Crohn's disease more common in males, and a large proportion of patients having indeterminate colitis. Further evaluation is needed to better understand the characteristics, etiopathogenesis, and outcomes of IBD, as well as reduce healthcare disparities in this historically understudied population.
729 The Impact of Anemia on Venous Thromboembolism and Short Term Outcomes Among Hospitalized Patients With Inflammatory Bowel Disease
Authors: Wade Francis , Mohammed Kahee , Schroeder Katie S.
Published: October 2019

INTRODUCTION:

Inflammatory bowel disease (IBD) patients have increased venous thromboembolism (VTE) risk and commonly have iron deficiency anemia (IDA) and anemia of chronic inflammation (ACI). Anemia can signal increased inflammation and disease severity in IBD patients. Pro-inflammatory diseases, like IBD, and IDA have been independently associated with VTE. VTE chemoprophylaxis is sometimes withheld in hospitalized IBD patients with minor rectal bleeding or severe disease due to safety concerns. This study aimed to assess the impact of anemia on VTE, in-hospital mortality, and length of hospital stay in hospitalized IBD patients.

METHODS:

Using the Nationwide Inpatient Sample database, a cross-sectional analysis was performed of hospitalized IBD patients between 2008 and 2014 aged ≥18 years stratified by VTE diagnosis based on ICD-9 code. Multivariate hierarchical logistic regression analyses were performed to evaluate the impact of IDA and ACI on VTE and short-term outcomes.

RESULTS:

Of 434,834 hospitalized IBD patients, 2.8% had diagnosis of VTE. Characteristics of hospitalized IBD patients are described (Table 1). ACI and IDA were independently associated with VTE in IBD patients. In a subgroup analysis using a multivariate hierarchical logistic regression model, IBD patients with IDA had higher odds of VTE (OR, 1.35; 95% CI, 1.27–1.43), deep vein thrombosis (OR, 1.36; 95% CI, 1.27–1.46), and pulmonary embolism (OR, 1.40; 95% CI, 1.27–1.54). IBD patients with ACI also had higher odds of VTE (OR, 1.28; 95% CI, 1.20–1.37) and deep vein thrombosis (OR, 1.42; 95% CI, 1.32–1.53), but not pulmonary embolism (OR, 0.94; 95% CI, 0.83–1.05). Higher odds of in-hospital mortality were seen in IBD patients with IDA (OR, 2.03; 95% CI, 1.82–2.28) and ACI (OR, 1.43; 95% CI, 1.30-1.58). Prolonged hospitalization was also more common in IBD patients with IDA (OR, 1.36; 95% CI, 1.33-1.40) and ACI (OR, 1.54; 95% CI, 1.49-1.59) (Table 2).

CONCLUSION:

The presence of anemia due to IDA and ACI independently predicts the occurrence of VTE, prolonged hospitalization, and in-hospital mortality in hospitalized IBD patients. Higher odds of in-hospital mortality and prolonged hospitalization suggests increased disease severity among hospitalized IBD patients with anemia. Providers should adhere to VTE chemoprophylaxis guidelines for hospitalized IBD patients, including those with severe disease or minor rectal bleeding, to mitigate VTE risk.
732 Laboratory Parameters Related to Monitoring in Patients With Ulcerative Colitis Treated With Tofacitinib for up to 3 Years in the OCTAVE Open-Label, Long-Term Extension Study
Authors: Melmed Gil Y. , Chang Shannon , Kulisek Nicole , Fan Haiyun , Lawendy Nervin , Maller Eric , Soonasra Arif , Irving Peter M.
Published: October 2019

INTRODUCTION:

Tofacitinib is an oral, small molecule JAK inhibitor for the treatment of ulcerative colitis (UC). Monitoring of liver enzymes, lipids, absolute neutrophil count (ANC), absolute lymphocyte count (ALC), and hemoglobin (Hg) is recommended in patients (pts) with UC treated with tofacitinib.
1

METHODS:

Changes in laboratory parameters (liver enzymes, lipids, ANC, ALC, and Hg) from baseline at Month 36 were investigated in pts with moderately to severely active UC treated with tofacitinib in OCTAVE Open, an ongoing Phase 3, open-label, long-term extension (OLE) study (NCT01470612; data as of Sep 2018, database not locked). Pts who completed or demonstrated treatment failure in the OCTAVE Sustain maintenance study, or those who were non-responders after completing OCTAVE Induction 1 or 2, were eligible for the OLE study. Pts in remission at the end of OCTAVE Sustain were assigned to tofacitinib 5 mg twice daily (BID); all other pts were assigned to tofacitinib 10 mg BID in the OLE study. The proportions of pts with laboratory values meeting protocol criteria for discontinuation (Table 1), with investigator-defined hyperlipidemia treatment-emergent adverse events (TEAEs), and with a change in lipid-lowering agent (LLA), were evaluated.

RESULTS:

For pts treated with tofacitinib 5 and 10 mg BID, changes from OLE study baseline in liver enzymes, lipids, ANC, ALC, and Hg at Month 36 and the proportion of pts meeting protocol criteria for discontinuation are presented in the Table 1. Hyperlipidemia TEAEs were experienced by 1.7% and 1.2% of pts treated with tofacitinib 5 and 10 mg BID, respectively. Furthermore, 8.0% and 6.6% of pts treated with tofacitinib 5 and 10 mg BID, respectively, had a new LLA added, and 2.3% and 1.7% of pts treated with tofacitinib 5 and 10 mg BID, respectively, had their LLA dose increased.

CONCLUSION:

No major changes from OLE study baseline were observed in the laboratory parameters recommended for monitoring in pts treated with tofacitinib up to Month 36. In addition, the proportions of pts meeting protocol criteria for discontinuation for liver enzymes, ANC, ALC, or Hg, with hyperlipidemia TEAEs or with a change in LLA, were evaluated and were low in both tofacitinib treatment groups. Due to the dose assignment in the OLE study, the pt populations in the treatment arms differ in terms of their baseline remission status.
737 Economic Burden of Biologic Treatment in Patients With Inflammatory Bowel Disease in the U.S.
Authors: Bornheimer Rebecca , Hass Steve , Nag Arpita , Oster Gerry
Published: October 2019

INTRODUCTION:

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is a chronic relapsing condition. IBD treatment has shifted from symptom management with corticosteroids to biologics aimed at achieving clinical remission. Patients refractory to first-line biologics are candidates for second and third-line agents. In this study, we explore the economic burden of IBD in the USA among patients initiating treatment with a biologic, and we examine whether this differs in relation to receipt of additional biologics during follow-up.

METHODS:

Using the IQVIATM Real-World Data Adjudicated Claims Database – US, we identified adults (≥18 years) with CD or UC and evidence of receipt of ≥1 IBD-related biologic from January 1, 2011 through December 31, 2017. Date of therapy initiation was designated the index date. Persons with <12 months of continuous data prior to index date or previous receipt of a biologic were excluded. Biologic use was examined from index date to date of IBD-related surgery, receipt of another biologic or end of study period, whichever came first. Total healthcare, outpatient and inpatient costs, prior to index date and during follow-up, were examined using Kaplan–Meier Sample Average methods and least-squares means.

RESULTS:

A total of 8071 patients with CD and 4832 with UC were identified. Of the patients with CD, 1028 received ≥1 additional biologic during follow-up (Multiple Biologic Cohort), while 7043 did not (Single Biologic Cohort). Corresponding counts for patients with UC were 843 and 3989, respectively. While total healthcare costs were similar for Multiple and Single Biologic Cohorts in the 12 months preceding the index date, mean (SD) total quarterly healthcare costs over 20 quarters post index date were significantly higher for the former group (CD: US$13,262 [15,463] vs US$10,902 [12,798]; P < 0.001; UC: US$14,313 [16,967] vs US$11,433 [13,387]; P < 0.001; Multiple and Single Biologic Cohorts respectively; Figures 1 and 2). Mean total quarterly inpatient and outpatient costs for patients with CD and UC post index date were also significantly higher in the Multiple compared with the Single Biologic Cohort.

CONCLUSION:

The level of healthcare utilization and costs post index date were significantly higher for patients with IBD who received more than one biologic during follow-up compared to those who did not.
758 The Hidden Burden of Faecal Incontinence in Active and Quiescent Ulcerative Colitis: An Underestimated Problem?
Authors: Nigam Gaurav B. , Limdi Jimmy K. , Hamdy Shaheen , Vasant Dipesh H.
Published: October 2019

INTRODUCTION:

Despite advances in Ulcerative Colitis (UC) therapies, many patients suffer refractory defecatory symptoms in the absence of active inflammation. For this group, treatment is challenging, with a paucity of research and limited therapeutic options. In this prospective, ongoing study, we aim to determine the prevalence of faecal incontinence (FI) in patients with quiescent UC.

METHODS:

In a cross-sectional study, consecutive patients with UC attending Inflammatory Bowel Disease (IBD) clinics completed a series of validated questionnaires; including an IBD-specific FI questionnaire (ICIQ-IBD questionnaire), Hospital Anxiety and Depression Scale (HADS), the Rome IV diagnostic questionnaire, and the IBD-control questionnaire. Participants were requested to return a Faecal Calprotectin (FCP) within 2 weeks of completing questionnaires. Quiescent UC was defined as IBD-control 8 score ≥13 and IBD-control-VAS ≥85, and/or FCP levels ≤250 (where available, FCP data were used in preference to IBD-control to classify UC activity). Data were compared between active and quiescent groups using chi-square and non-parametric tests.

RESULTS:

Overall, n = 97 UC patients (n = 50 males, mean age 48 (range 18-82) participated. ICIQ-IBD data revealed that most patients experience FI (84/97 (87%) during 'relapses'. Interestingly, 58/97 (60%) reported FI when in 'remission', and this group had higher median HADS depression (P = 0.0002), poorer QoL scores (P < 0.0001), and trend towards higher HADS anxiety (P = 0.09) scores, compared to those without FI. Disease activity data (IBD-control and/or FCP) were available for all patients, and based on these 61/97 (63%) had quiescent UC. The prevalence of FI based on ICIQ-IBD did not differ between those with active (22/36, 61%) and quiescent UC (36/61, 59%), P = NS. In those with FI on ICIQ-IBD, median IBD-FI symptom scores, IBD-FI QoL scores and HADS (anxiety: P = 0.47, depression: P = 0.18) id not differ between disease activity groups. However, within the quiescent group, patients that met the more stringent Rome IV criteria for FI (n = 13) had higher median IBD-FI symptom scores (P = 0.007) and HADS-depression scores (P = 0.05), a trend to worse IBD-FI QoL (P = 0.07), but similar HADS-anxiety (P = 0.68).

CONCLUSION:

This is one of the first studies to identify that FI affects most patients with UC, regardless of disease activity, with a detrimental impact on patients' psychological wellbeing and QoL. FI be screened for in IBD clinics. There is an urgent need for further research in this area.
759 A UK National Survey of Therapeutic Drug Monitoring With Anti-TNF Medications in IBD
Authors: Nayeemuddin Shadab , Nigam Gaurav B. , Kontopantelis Evangelos , Hayee Bu , Limdi Jimmy K.
Published: October 2019

INTRODUCTION:

A growing body of evidence supports use of therapeutic drug monitoring (TDM) in improving efficacy and cost-effectiveness of anti-TNF therapy in patients with inflammatory bowel disease (IBD). Existing and evolving knowledge of TDM in clinical practice is less well understood. Our objective was to assess attitudes and barriers to TDM use with anti-TNF's in the UK.

METHODS:

A 17-question survey was distributed to members of the British Society of Gastroenterology. Information on clinician characteristics, demographics, use and barriers towards implementing TDM with anti-TNF's was collected. Logistic regression was used to predict factors influencing TDM use.

RESULTS:

243 respondents participated (51.6% male) of which 237 respondents met inclusion criteria; treating >5 IBD patients and at least 1 with an anti-TNF per month. Of the total respondents, 45% were Consultant Gastroenterologists (GI), 40% IBD Nurse Specialists (CNS) and 15% GI Specialist Registrars (SPR). Of these 237 respondents, TDM was used by 95.7% for secondary loss of response; 71.4% for primary non-response and 53.6% used TDM proactively. Barriers for TDM use were time lag in receiving results (27.1%), lack of awareness of guidelines (15.6%), and cost (11.9%). Clinicians working at a teaching hospital were more likely to use TDM compared to a district hospital (OR 2.6, 95% CI 0.71-9.8). IBD CNS and GI SPR used TDM more often, when compared to Consultant GI (OR 2.6, 95% CI 0.69-10 & OR 1.5, 95% CI 0.3-7.2 respectively). Clinicians practising for >20 years were more likely to check TDM than less experienced clinicians (OR 4.1, 95% CI 0.4-41.8). Clinicians with large volume IBD practice (>50% IBD patients per month) were more likely to check TDM than those seeing fewer IBD patients (OR 45.6, 95% CI 7.5-275). Proactive TDM was more likely to be used by clinicians working in a tertiary care setting (OR 2.25, 95% CI 0.84-6.05), IBD CNS (OR 1.2, 95% CI 0.6-2.1), clinicians managing large volume IBD practice (OR 10.8, 95% CI 1.2-90) and clinicians with 5-9 years of experience in practice (OR 2.6 & CI 1.04-6.42).

CONCLUSION:

Significant barriers to TDM implementation in the UK are time lag from test to result, lack of awareness of current guidelines and evolving knowledge, cost and less experience. Validation of point of care testing, lower cost assays, and wider dissemination of current evolving paradigms with updated recommendations may further optimise treatment with anti-TNF therapies.
760 Disease Location Is Associated With Non-Alcoholic Fatty Liver Disease in Patients With Crohn's Disease
Authors: Ritaccio Gabrielle , Abutaleb Ameer , George Lauren A. , Salas Samuel , Cross Raymond K. , Sakiani Sasan , Shetty Kirti , Wong Uni
Published: October 2019

INTRODUCTION:

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disorder in western countries and an increasing cause of end stage liver disease and hepatocellular carcinoma (HCC). While patients with inflammatory bowel disease (IBD) are traditionally viewed as underweight and malnourished, increasingly effective therapies have led to similar rates of obesity in these patients when compared to the average population. The aims of this study were to 1) characterize rates of NAFLD in a large cohort of patients with IBD and 2) identify IBD-related predictors of NAFLD.

METHODS:

We conducted a single-center retrospective chart review of patients referred to our IBD program from 2007-2017. NAFLD was defined as imaging or biopsy findings of hepatic steatosis without coexisting liver disease or significant alcohol use. Relevant patient demographic and clinical data was collected within one year of NAFLD diagnosis. Comparisons between NAFLD rates in various groups were made using chi squared tests and one-way ANOVA tests.

RESULTS:

1673 unique patients presented to our IBD program between the years 2007-2017. While patients were receiving care at our program, 237 (14%) had imaging or biopsy findings of hepatic steatosis. Of those 237 patients, 28 were excluded from analysis due to concurrent diagnosis of hepatitis C (n = 7) or B virus infection (n = 1), HIV infection (n = 2), significant alcohol use (n = 10), methotrexate-related liver injury (n = 2), sarcoidosis of the liver (n = 1), or primary sclerosing cholangitis (n = 5). As expected, increasing BMI was associated with higher NAFLD rates (P = 0.05). NAFLD rates were also significantly different between different types of IBD (P = 0.02). 63% of NAFLD patients had Crohn's disease (n = 132/209) and 19% had ulcerative colitis (n = 39/209). In patients with Crohn's, disease location in the proximal colon and rectum was positively associated with NAFLD (P = 0.02 and 0.02 respectively). NAFLD rates were not significantly different between types of Crohn's disease phenotypes including inflammatory, obstructing, and perforating (P = 0.77).

CONCLUSION:

NAFLD rates among patients with Crohn's disease are high. Disease location in the proximal colon and rectum was associated with NAFLD while disease behavior was not. Further research is needed to determine mechanisms driving development NAFLD in patients with Crohn's disease.
768 Association Between Hepatocellular Carcinoma and Inflammatory Bowel Disease: 5-Year Nationwide Analysis in the Unites States
Authors: Shah Hardikkumar , Botros Youssef , Baddoura Walid
Published: October 2019

INTRODUCTION:

Hepatocellular Carcinoma (HCC) commonly occurs in patients with Cirrhosis and Hepatitis B. Inflammatory Bowel Disease (IBD) is well known to be associated with intestinal malignancy like colon cancer and extra intestinal malignancy such as Cholangiocarcinoma. There are few case reports showing increased risk of HCC among patients with IBD, but larger studies are lacking so we aim to study association between HCC and IBD in a nationwide database.

METHODS:

We performed data analysis on Nationwide readmissions Database (NRD) from year 2010 through 2014. We compared hospitalized adult patients with IBD and HCC with patients with IBD alone. Patients with liver disease and primary sclerosing cholangitis were excluded from analysis. Univariate analysis was done for categorical data using chi-square or fisher's exact test while continuous data were analyzed using t-test. Multivariate logistic regression analysis was performed to look for factors associated with HCC in patients with IBD and factors associated with mortality.

RESULTS:

There were total of 939224 weighted admissions with IBD and 350(180 Ulcerative Colitis, 170 Crohn's Disease) admissions with both IBD + HCC. In Univariate Analysis, male gender, age more than 50, higher CCI (Charlson's Comorbidity Index) were significantly more in IBD+HCC group. Mean total Charges (58177 USD vs 44201 USD, P < 0.001) and in hospital mortality (3.2% vs 1.4%, P < 0.0001) were significantly higher in IBD + HCC group (Table 1). Multivariate analysis showed that significantly more patients with IBD + HCC group were male (Odds Ratio (OR) 2.9, P < 0.0001) but significantly less patients in IBD + HCC group were having diabetes (OR 0.51, P 0.0002). Among IBD patients, male gender (OR 1.15, P 0.001), age more than 50 (OR 11, P 0.0001), renal failure (OR 3.3, P 0.001) and higher CCI (OR 3.1, P 0.0001) were associated with higher in hospital mortality in multivariate analysis.

CONCLUSION:

HCC does co-exist in about 0.04% patients with IBD. There is no clear pathophysiology of developing HCC among patients with IBD. One theory is development of HCC due to IBD itself altering gut microbiome and causing passage of harmful bacteria to portal circulation which causes abnormal expression of cell adhesion molecules in liver causing immune mediated damage to liver. Another mechanism is development of HCC due to immunomodulating effect of medications like Azathioprine in treatment of IBD. There is need of more research to find factors associated HCC development among IBD patients.
771 No Increase in Odds for Infection or Malignancy When Treating to Disease Severity in Elderly IBD Patients
Authors: Nadhem Omar , Spataro Joseph , Gaidos Jill
Published: October 2019

INTRODUCTION:

The prevalence of inflammatory bowel disease (IBD) in the elderly population is increasing. Current studies suggest that the use of immunosuppressive therapies in this population leads to a higher risk of complications, particularly an increase in infections. However, many studies show prolonged steroid use and ongoing active inflammation in elderly patients, suggesting undertreatment of their IBD. The aims of this study were to assess for an increase in infections or malignancy among an elderly Veteran population of IBD patients with treatment based on disease severity and disease activity.

METHODS:

After obtaining IRB approval, we performed a retrospective chart review of all VA IBD patients seen in the outpatient Gastroenterology Clinics at the Hunter Holmes McGuire VA Medical Center from January 1, 1999 through March 27, 2019. Data collected included demographic data, details of the IBD history, medication use, and any history of infection or malignancy after IBD diagnosis. Breslow-Day test was used to determine the Odds Ratios between elderly (diagnosed at 60 years or older) and non-elderly cohorts for each outcome based on medication use.

RESULTS:

153 Veterans with IBD were included: 126 (82.4%) male, 80 (52.3%) had UC, and 132 (86.3%) diagnosed <60 years of age (Table 1). At enrollment, most non-elderly subjects were treated with 5-ASAs (49%) then biologics (44%) compared to 62% of elderly subjects on 5-ASA and 38% on biologics. At one year of follow-up, there was no difference in the odds of developing infection or malignancy for elderly compared to non-elderly IBD patients with any IBD therapy (Table 2).

CONCLUSION:

In this single-center retrospective study, we found no increase in infections or malignancy in elderly IBD patients regardless of IBD therapy. Our elderly cohort is small, so our study may have been underpowered, however data collection is ongoing.
773 The Natural Course of Inflammatory Bowel Disease After Bariatric Surgery
Authors: Singh Amandeep , Aminian Ali , Nan Lan , Shen Bo , Schauer Philip , Regueiro Miguel
Published: October 2019

INTRODUCTION:

Approximately 32–52% of inflammatory bowel disease (Crohn's disease [CD] and ulcerative colitis [UC]) patients have obesity or are overweight. Bariatric surgery (BS) is a recommended and widely used approach to address severe obesity and its related comorbidities. However, data on the effect of BS on IBD are equivocal. We aimed to assess the course of IBD after BS.

METHODS:

Using ICD-9 codes all IBD patients who underwent BS (Roux-en-Y gastric bypass [RYGB], sleeve gastrectomy [SG] or gastric band/balloon [GB]) at a major referral center between January 2000-June 2018 were identified. Data on baseline demographics, co-morbidities and concomitant medications was collected. Laboratory data, endoscopic data (Mayo score for UC and Simple Endoscopy score [SES] for CD), patient reported outcomes (PROs) and medications at baseline and 6-12 months after BS were collected. We also assessed exacerbation of IBD, hospitalization and adverse events after BS.

RESULTS:

A total of 58 IBD patients (46.6% CD and 53.4% UC) underwent BS (79.3% GS, 15.5% RYGB and 5.2% GB) during the study period. Our cohort consisted of 74% females and 81% were Caucasians. At the time of BS, mean age was 47.8 ± 12.2 years, mean BMI was 43.5 ± 7, and 36.2% were active smokers. Compared to baseline, 6 months after BS, a decrease in WBC (8.6 ± 3 vs. 7.2 ± 2), CRP (0.7 vs. 0.6), aspartate aminotransferase (34.1 ± 28 vs. 23.5 ± 10) and alanine aminotransferase (34.4 ± 28 vs. 20.2 ± 11) and an increase in vitamin D (25.5 ± 15 vs. 20.2 ± 11) (P < 0.05 for all) was noted. Beside the significant decrease in BMI (43.5 ± 7 vs. 36.3 ± 7) and HbA1C (5.6 vs. 5.2), extraintestinal manifestation of IBD also improved (50% vs. 5.2%) (P < 0.05 for all). There was no differences in PROs, IBD therapy, and endoscopy scores (Table 1). Five patients (8.6%) had IBD exacerbation (all after GS) of which two had active disease at the time of BS, only two required hospitalization and intravenous steroids, but none of the patients required any further surgery or intervention.

CONCLUSION:

To date, our study is the largest on the natural course of IBD after bariatric surgery. A significant improvement in BMI, HbA1c, liver enzymes and IBD-related extraintestinal manifestations were noted after bariatric procedures. Longer follow-up is required, but based on these results; bariatric surgery for obesity appears to be safe in IBD patients.
776 Accelerated Infliximab Infusion Protocol for Inflammatory Bowel Disease: A Safety and Cost-Effectiveness Study in an Asian Tertiary Center
Authors: Lim Chong Teik , Ong Wan Chee , Shim Hang Hock , Chan Elaine , Lim Teong Guan , Loy Kia Lan , Chan Webber
Published: October 2019

INTRODUCTION:

The recommended infusion time for infliximab for inflammatory bowel disease (IBD) is 2 hours or more. Time spent on receiving infliximab infusions in the hospital disrupts school and work activities. Significant nursing time is also spent which increases healthcare costs. Shortening infliximab infusion to over 1 hour has been shown to be safe and has the potential to decrease time spent in hospital. This study aims to determine the safety and effectiveness of this accelerated infliximab infusion protocol in patients with IBD in Southeast Asia.

METHODS:

We conducted a retrospective study on patients with Crohn's disease (CD) and ulcerative colitis (UC), who received infliximab from September 2018 to May 2019 at Singapore General Hospital. Patients on stable maintenance infliximab were offered the accelerated protocol if they had tolerated ≥4 infliximab infusions without reactions. The need for pre-medications was determined by the prescribing physician. Primary endpoint was infusion-related reaction rate and secondary endpoints were cost and time saved per infusion.

RESULTS:

A total of 187 infusions were administered to 57 patients (53 CD, 4 UC). The mean age was 52.0 ± 17.0 years and 61.4% of the subjects were male. Out of the 57 patients, 22 of them received the accelerated infusion protocol with a total of 86 1-h infusions. Three reactions (1 immediate, 2 delayed) were observed during the 1-h infusions and were reverted back to the standard 2-h infusion subsequently. However, this was not found to be statistically significant after adjustment for age, sex, administration of pre-medications or types of disease. The median time spent per infusion in the hospital for the accelerated infusion protocol was significantly reduced compared to for the standard infusion (138 ± 26 minutes vs. 216 ± 26 minutes; P < 0.05). This improvement amounts to an estimate of 65 minutes returned to the patient for normal activities outside of the hospital per infusion. There was also a reduction in nursing time and cost (S$ 42.9 per infusion and 46.4% relative cost reduction) to the hospital.

CONCLUSION:

The accelerated infliximab infusion protocol is safe in our cohort of IBD patients. It also results in a decrease in in-hospital time for patients and improves the efficiency of healthcare delivery.
781 Dietary Practices and Beliefs of Patients With Inactive Ulcerative Colitis: A Prospective Study From the United Kingdom
Authors: Crooks Benjamin J. , McLaughlin John , Limdi Jimmy K.
Published: October 2019

INTRODUCTION:

An epidemiological association implicating diet in inflammatory bowel disease (IBD) risk or protection is widely accepted and patients often make links to diet. Recent studies have explored dietary habits in the general IBD population but few studies have specifically addressed this in active or inactive disease.
1
We aim to describe the dietary practices of patients with inactive ulcerative colitis (UC) and the information resources which guide these beliefs.

METHODS:

We developed a questionnaire assessing demographics, dietary beliefs and habits in patients with inactive UC (defined as a PRO2 score ≤ 1 (rectal bleeding sub score = 0)). This is being prospectively administered to 200 consecutive patients with UC. We report an interim analysis of our findings.

RESULTS:

Data from 47 patients; mean age 53.7 years, 60% male and 89% Caucasian, are available so far. Mean disease duration was 10.6 years. Disease extent was 17% E1, 49% E2 and 30% E3. Mean CRP was 3.5. 68% of patients reported no relapse in the last year. 40% considered diet to be an initiating factor for their UC and this was based on their own experience (95%), a gastroenterologist's advice (26%) and the internet (26%). 49% of patients felt that diet had triggered a relapse of their disease, the most commonly reported triggers being spicy foods (57%), alcohol (39%), fatty foods (30%) and coffee (30%). 64% of patients avoided certain foods to prevent relapse. Spicy and fatty foods were most frequently avoided (70%) followed by alcohol (50%), carbonated drinks (47%), coffee (43%), milk products (37%) and sweet foods (37%). 21% of patients consumed specific foods or nutritional supplements to prevent UC relapse, most commonly turmeric in 40% of these patients. 57% reported being able to find specific dietary advice for UC, most commonly on the internet.

CONCLUSION:

A significant proportion of patients with inactive UC have strong beliefs pertaining to diet and specific dietary triggers. A high prevalence of dietary restriction may put these patients at risk of nutritional deficiency and impact upon quality of life. More data and mechanistic explanations are needed to understand the complicated relationship between dietary components and gut inflammation. A larger dataset will be presented at conference proceedings.
782 Pathological Findings of Resected Inflow Limbs in Patients With Pouches for Ulcerative Colitis
Authors: Plietz Michael , Rubin Peter , Polydorides Alexandros , Mui Alex , Kayal Maia , Hao Yansheng , Bauer Joel
Published: October 2019

INTRODUCTION:

Approximately 30% of ulcerative colitis (UC) patients require surgery during their disease course. Patients will commonly undergo total proctocolectomies with subsequent creation of a “pouch,” such as a J-pouch (pelvic pouch with ileal pouch-anal anastomosis) or a Kock pouch. A small portion of patients undergoing “pouch” procedures for UC will develop severe symptoms related to the inflow limb of the pouch requiring operative intervention. A clear understanding has not been established as to the pathological mechanism by which these pouch inflow problems develop and what pathologic entity they belong.

METHODS:

Methods: A retrospective chart review was conducted at a single tertiary medical center. A database was created of all patients who underwent subsequent pouch-related surgical procedures between 2006 and 2018. Patients with requiring operative intervention of the inflow limb were identified among this cohort. Operative and pathological data were collected.

RESULTS:

178 patients were identified who underwent procedures yielding a surgical pathologic specimen related to their pouch. 15 of these procedures reported significant pathology of the inflow limb to the original pouch (9 J-pouches and 6 Kock pouches), occurring on average of 19.6 years after the creation of the original pouch. The most common diagnosis requiring reoperation was obstruction due to stricture formation (n = 11). Reoperations for inflow limb pathology included pouch excision (n = 3), inflow limb resection with ileo-pouch anastomosis (n = 9), stricturoplasty (n = 1), and bypass of the inflow limb (n = 1). In addition, 3 patients required a temporary, diverting loop ileostomy as part of their reoperation. The pathologic findings of the inflow limb were consistent with Crohn's ileitis in 6 patients (40%). 3 other patients (20%) were diagnosed with Crohn's disease and had diagnostic findings suspicious of Crohn's on inflow limb pathology. Remaining patients (n = 6) were found to have chronic, nonspecific enteritis/serositis. There was one case of poorly differentiated adenocarcinoma.

CONCLUSION:

A small proportion of patients who have undergone a “pouch” procedure require eventual surgery for a problem with the inflow limb of the pouch. These patients were found to have a high rate of Crohn's disease of the inflow limb and overall change in diagnosis to Crohn's disease.
786 Efficacy of Vedolizumab in Older IBD Patients Based on Prior Biologic Exposure
Authors: Patel Devin B. , Cohen Erica , Ha Christina
Published: October 2019

INTRODUCTION:

Evaluating the safety and efficacy of therapeutics for older patients with moderate to severe IBD is challenging as they are often excluded from clinical trials. Medication recommendations have primarily focused on risks of adverse effects, thus vedolizumab has emerged as the preferred first line therapy for these patients. However, there is a paucity of data regarding its clinical and endoscopic efficacy for the older population compared to other biologics. The aim of this study was to characterize the response rates and adverse effects to vedolizumab in older IBD patients based on prior medication and/or biologic exposure.

METHODS:

A retrospective cohort study of 55 consecutive older IBD patients, >60 years, treated at a tertiary care referral center from 1/2016 to 12/2018 with exposure to vedolizumab during the study period was performed. The primary outcome of interest was clinical response rates (defined as >50% improvement in abdominal pain and stool frequency) to vedolizumab induction in biologic-exposed vs biologic-naïve older patients. The secondary outcome was to compare adverse effects to vedolizumab in biologic-exposed vs biologic-naïve older patients within 1 year of initiation of therapy.

RESULTS:

Patients with prior biologic exposure were younger in age (69.1 ± 6.2 vs 74.6 ± 8.4 yrs, P = 0.01) and more likely to have also been treated with immunomodulators (76.2%) than naïve (30.8%) patients, P = 0.006. More bio-exposed patients had stricturing disease (60.0% vs 0%, P = 0.04) and were treated with combination therapy at induction (29.3% vs 0%, P = 0.05) compared to bio-naïve patients (Table 1). There were no differences in clinical response to induction (P = 0.76), vedolizumab dose escalation (P = 1.0), steroid use after induction (P = 0.36), and adverse effects (P = 1.0) between bio-exposed and naïve older patients (Figure 1). The addition of immunomodulators did not yield better outcomes for the older bio-exposed patients 50.0% combination therapy vs 55.2% monotherapy response rates, P = 1.0.

CONCLUSION:

These results suggest similar efficacy and safety of vedolizumab for older IBD patients regardless of prior biologic exposure based on clinical symptom assessment. Combination therapy did not add incremental benefit for this higher-risk age group or complications associated with additive immunosuppression. Further studies are needed to determine appropriate positioning of vedolizumab prior to or after anti-TNF agents or ustekinumab.
800 Indirect Treatment Comparison of the 1-year Efficacy for Ustekinumab Versus Other Advanced Therapies in Moderate to Severe Ulcerative Colitis
Authors: Welty Margaux , Mesana Laura , Padhiar Amie , Naessens Dominik , Diels Joris , Van Sanden Suzy , Pacou Maud
Published: October 2019

INTRODUCTION:

In the absence of head-to-head comparisons, indirect treatment comparisons (ITC) on the relative efficacy of ustekinumab (UST) vs other therapies were performed, comparing 1-year response and remission of therapies in non-biologic failure (NBF) & biologic failure (BF) patients with moderate-severe UC, in order to inform clinical and HTA decision-making.

METHODS:

Randomised controlled trials reporting induction & maintenance efficacy of anti-TNFs (infliximab [IFX], adalimumab [ADA], golimumab [GOL]), vedolizumab (VDZ), tofacitinib (TOF) or UST were identified by a systematic literature review through MEDLINE, MEDLINE IN PROCESS, Embase & Cochrane up to the 28th March 2019. Analyses were conducted for clinical response (decrease in baseline total Mayo score ≥30% & ≥3 points, decrease in rectal bleeding subscore (RBS) ≥ 1, or RBS 0 or 1) & clinical remission (total Mayo score ≤2 points, no individual subscore >1 [definitions with RBS of 0 were also included]) by population. To mimic an ITT-based approach, maintenance data from trials with re-randomised response designs were re-calculated to correspond to treat-through arms. For trials with only short-term PBO rates or missing data for PBO non-responders, end of 1-year PBO-to-PBO rates were externally imputed. UST efficacy was calculated for patients starting the ∼6 mg/kg IV regimen. Bayesian ITCs were conducted to obtain posterior distribution probabilities for UST to perform better than its comparators by population. In the NBF population, maintenance doses were pooled as no dose-response was apparent.

RESULTS:

Six trials were included in the NBF population ITC, & four included in the BF ITC. For the NBF group, UST given as a 1-year regimen showed higher probabilities of both clinical response & remission vs all treatments, with Bayesian probabilities of UST being better than active therapies ranging between 91% (VDZ) to 100% (ADA) for response & 82% (VDZ) to 99% (ADA) for remission, respectively. In the BF group, UST was also shown to be the most effective treatment for response and remission (for the Q8W dose), however the effect sizes were smaller compared to the NBF population.

CONCLUSION:

ITC Results indicate a higher likelihood of response & remission at 1 year on UST in NBF population vs comparators, especially vs anti-TNFs. In BF patients, a higher likelihood of response to UST vs most comparators was observed as well, though results were more uncertain due to smaller sample sizes & data limitations.