bluuebunny/crossref_metadata_2025_split huggingface dataset:
653 Crohn's Disease Mortality and Ambient Air Pollution in New York City
Authors: Feathers Alexandra , Lovasi Gina , Beem Kade , Grigoryan Zoya , Datta Samit K. , Faleck David , Socci Thomas , Swaminath Arun 
Published: October 2019

INTRODUCTION:
Recent years have seen an increase in the prevalence of Crohn's Disease (CD), along with drastically rising modernization at a pace not seen before, and an accompanying decline in air quality. Air pollution has been shown to affect epithelial cell function and modulate immune responses, as well as change the composition of enteric microbiota. In epidemiologic studies, ambient air pollution has demonstrated a weakly positive relationship with incident CD cases, along with CD hospitalizations. However, to date, there are no data on the associated risk of CD-related death in relation to air pollution exposure.

METHODS:
We conducted an ecologic study comparing the number of CD deaths of individuals residing in given zip codes, with the level of air pollution from NO, NO2, SO2, and fine particulate matter (PM2.5). Cases consisted of any patients with CD mentioned on their death certificate who died in New York City between 1993-2010. Zip code was assigned by patient residence. Air pollution was measured by the New York Community Air Survey. We conducted Pearson correlations, and a Poisson regression with robust standard errors. Each component of pollution was modeled separately.

RESULTS:
There was a higher risk of CD-related death among individuals living in zip codes with higher levels of SO2 (IRR 1.16, Cl 95% 1.06-1.27). Zip codes with higher percentage of Black and Latino residents were associated with lower rates of CD-related death in the SO2 model (IRR .58 Cl 95% .34-.98, IRR .14 Cl 95% .06-.33). There was no significant association of either population density or area-based income with the CD-related death rate. NO, NO2, and PM2.5 were not associated with a higher risk of death.

CONCLUSION:
In New York City from 1993-2010, CD death rates were higher among individuals from neighborhoods with higher levels of SO2, and lower among those from neighborhoods with predominately Black or Latino residents. CD death rates were not associated with levels of NO, NO2, or PM2.5. These findings raise an important and timely public health issue regarding exposure of CD patients to environmental SO2, and suggest that this area of Crohn's Disease research needs further exploration.
654 Improving Inflammatory Bowel Disease Care: A Quality Improvement Project for Venous Thromboembolism Prophylaxis
Authors: Penninti Pranav , Patel Chirag , Coss Elizabeth 
Published: October 2019

INTRODUCTION:
Inflammatory Bowel Disease (IBD) patients admitted with a flare are 5-6x more likely to have a complication with venous thromboembolism (VTE). As a result, more emphasis is being placed on administering chemical prophylaxis to these patients. A 6-month retrospective chart review of patients hospitalized at our institution with an IBD flare without severe GI bleeding revealed that only 39% received chemical VTE prophylaxis. Herein, we designed a quality improvement project with an aim to improve this rate to over 75%.

METHODS:
Our initial Ishikawa diagram was used to map out the entire process from which a patient enters the emergency room until they are admitted to their hospital bed to analyze reasons DVT chemoprophylaxis was withheld. “Bleeding” was the most commonly documented reason. We then decided to target the patient population to hospitalized IBD flares without severe GI bleeding. The parameters we set for this included Hemoglobin <7 g/dL, tachycardia, and/or hypotension. Our main intervention was placing reminder sheets in each Internal Medicine team room with the aforementioned parameters for appropriate use of chemical prophylaxis. Further, a department-wide e-mail was sent to all of Internal Medicine with the reminder sheet attached and educational text.

RESULTS:
Over the 4 months post-intervention, VTE prophylaxis rates for hospitalized IBD flares without severe bleeding (n = 14) improved to 100%. Hospitalization related costs for a diagnosis of “DVT” or “PE” are reportedly ∼$10,000 & $20,000, respectively. The cost of Lovenox for a 5 day length of stay for an 80 kg man is $420. There is an estimated 7.6 to 41% risk of VTE amongst patients hospitalized for flares. At University Hospital, we averaged about 4 flares without severe bleeding/month. Using 25% risk for 48 patients per year, this could potentially lead to 12 VTE prevented/year. Taking all of this into account there is a potential 900% return on investment with savings of about $160,000/year.

CONCLUSION:
It does appear that our interventions helped us reach our goal to improve VTE prophylaxis rates in IBD flares. A weakness, however, is the low sample size of patients, but we do plan to continue collecting data over the next year. Further, education has been proven to be a weak intervention with poor sustainability in the world of QI. The main plan for sustainability remains to work with IT to implement “IBD flare without severe bleeding” as a check-mark for high-risk of VTE on the admission order set.
657 Ulceration of the Pre-Pouch Ileum in Patients With Ulcerative Colitis Following Proctocolectomy With Ileal Pouch-Anal Anastomosis: An Analysis of Pouchoscopies From 272 Patients
Authors: Ollech Jacob E. , Akyiama Shintaro , Rai Victoria , Cohen Russell D. , Hurst Roger D. , Hyman Neil H. , Dalal Sushila R. , Rubin David T. 
Published: October 2019

INTRODUCTION:
Colectomy is required in up to 30% of patients with ulcerative colitis (UC) due to medically refractory disease or development of dysplasia/cancer. In such cases, restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgery of choice. However, pouchitis may occur in up to 80% of patients and significantly impairs quality of life. Pouchitis usually spares the pre-pouch ileum, however, a subset of patients develops discrete ulcerations in the pre-pouch ileum despite a firm preoperative UC diagnosis. The prevalence of such findings and predictive factors have not been adequately studied. We report a large cohort of patients undergoing pouchoscopies and describe the prevalence of pre-pouch ileal ulcerations.

METHODS:
This is a retrospective single-center study of adult patients with UC who had a total proctocolectomy with IPAA and subsequently underwent pouchoscopy between January 2007 and August 2018. At our institution, pouchoscopies are performed using a standard operating protocol. These reports include detailed descriptions of the mucosa as well as high definition images of the different areas of the pouch, the pre-pouch ileum, the pouch inlet, forward view of the pouch, a retroverted view of the pouch, and the rectal cuff. Based on these images and descriptions, we characterized pouch phenotypes and ulcer locations. Patient demographic and clinical data were also assessed.

RESULTS:
We reviewed the pouchoscopies of 272 patients who underwent proctocolectomy with IPAA for a pre-operative diagnosis of UC. Characteristics of the patients included median age 39 years (IQR 30.2-50.7), median BMI 25 (IQR 22.5-28.6), 90% Caucasian, 59% men, 23% ex-smokers and 83% extensive colitis prior to colectomy. 18% of our patients had discrete ulcerations in their pre-pouch ileum. In a multivariate analysis including age, sex, BMI, disease extent, race, ex-smoking status, prior treatment with anti TNFs or immunomodulators, history of PSC and previous infection with C. diff, none of these factors were associated with pre-pouch ileal ulcers (Table 1).

CONCLUSION:
Despite a firm diagnosis of UC prior to colectomy, 18% of patients at our tertiary center were found to have discrete ulcers in their pre-pouch ileum. We did not identify predictive factors in this patient cohort, but the potential impact of these findings suggests that proactive post-operative monitoring may be helpful.
658 Epidemiology of Major Depressive Disorder, Anxiety Disorder, and Bipolar Disorder in Ulcerative Colitis in the United States Between 2014 and 2019: A Population-Based National Study
Authors: Chouhan Vijit , Mansoor Emad , Saleh Mohannad Abou , Katz Jeffry , Regueiro Miguel , Cooper Gregory S. 
Published: October 2019

INTRODUCTION:
Studies have shown that patients with ulcerative colitis (UC) are at an increased risk for developing various psychiatric illnesses including major depressive disorder (MDD), anxiety disorder, and bipolar disorder. However, these studies have been limited by a small sample size. We aimed to describe the epidemiology of psychiatric illness in UC through utilization of a large sample population.

METHODS:
We queried a commercial database (Explorys Inc, Cleveland, OH), an aggregate of electronic health record data from 26 major integrated US healthcare systems. We identified an aggregated patient cohort of eligible patients with a diagnosis of UC and depression, anxiety, and bipolar disorder between 2014 and 2019 based on the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT). We also identified patients with a diagnosis of depression, anxiety, or bipolar disorder without UC. We calculated the overall prevalence of depression, anxiety, and bipolar disorder in UC amongst various patient groups. We also performed univariate analyses to identify risk factors for psychiatric illness in UC.

RESULTS:
Of the total number of patients in the database with UC, 22,780 had depression, 28,480 had anxiety, and 5,140 had bipolar disorder, with prevalences of 17%, 23%, and 4%, respectively. Depression, anxiety, and bipolar disorder in UC were more prevalent than in individuals without UC. Within UC, psychiatric illness was more prevalent in elderly (age >65 years old), females, and Caucasians. Compared to patients with psychiatric illness without UC, patients with psychiatric illness and UC were more likely to have a history of alcohol abuse, tobacco use, substance use, personality disorder, and corticosteroid use.

CONCLUSION:
This is one of the largest studies to date to describe the epidemiology of psychiatric illness in UC. Individuals with UC were more likely to suffer from depression, anxiety, and bipolar disorder compared to their non-UC counterparts. Prevalence of psychiatric illness in UC was more common in elderly, females, and Caucasians. Psychiatric illness is under recognized in UC and should be screened for and treated accordingly.
661 Isolated Lymphoid Aggregates Identified in Non-Inflammatory Bowel Disease (IBD) Patients Are Associated With an Increased Incidence of IBD Development
Authors: Cholapranee Aurada , Sultan Keith , Pohanka Charles J. 
Published: October 2019

INTRODUCTION:
The Centers for Disease Control and Prevention reports an estimated incidence rate of IBD between 17.7-28.9 cases per 100,000 person years. While IBD is typically associated with visible mucosal abnormalities studies have shown that up to 40% of patients with suspected IBD and normal appearing mucosa have evidence of inflammation on biopsy. Lymphoid aggregates (LA) are often found on histopathology in cases of known or suspected IBD, along with more characteristic findings of chronic inflammation, crypt distortion/abscesses. However, the significance of isolated LA without other abnormal histopathology is unknown. We hypothesized that isolated LA may be a marker of future onset IBD.

METHODS:
We conducted a retrospective study using a patient database at the Endoscopy Center of Long Island, part of Northwell Health system. A database query was conducted of all colonoscopy reports for adults > 18 years of age during the years of 2006-2011. These reports were reviewed for associated histopathology reports describing LA. Patient were excluded if the histopathology reported any finding suggestive or diagnostic of IBD other than LA. Only patients with a followup colonoscopy were included in final analysis. Patient medical records were further used to exclude those with a documented IBD history or use of IBD medication. A diagnosis of IBD on follow up colonoscopy was determined by endoscopic and microscopic findings. The primary analysis used exact binomial methods to compute an exact 95% CI for IBD diagnosis incidence rate as compared to the CDC estimated IBD incidence rate.

RESULTS:
39,680 patients had colonoscopies during the study period. Of these, 767 patients had evidence of LA. 539 (1.36%) demonstrated isolated LA without other evidence of inflammation. Of these, 284 met the requirement of a follow up colonoscopy. 165 were excluded due to documented history of IBD, leaving 119 subjects for analysis. Of these, 5 developed IBD. The median time from initial colonoscopy to diagnosis of IBD was 6.29 years. The observed incidence of IBD in our study group was 654 cases per 100,000 person years, compared to the highest CDC estimated US incidence (P < 0.0001).

CONCLUSION:
We found that LA in patients is associated with an over twenty fold increased incidence of IBD, and may be an early sign of the disease. Some IBD therapies may be reasonable in select patients with isolated LA, and clinicians should not be hesitant to repeat colonoscopy in those with isolated LA and ongoing complaints.
668 Immune Checkpoint Inhibitor Related Colitis (ICI-Colitis) in Patients With Preexisting Inflammatory Bowel Disease or Microscopic Colitis
Authors: Sleiman Joseph , Shah Ravi , Wei Wei , Funchain Pauline , Philpott Jessica , Simons-Linares Roberto 
Published: October 2019

INTRODUCTION:
Immune checkpoint inhibitors (ICI) have shown efficacy in the treatment of a growing number of cancers resulting in increasing numbers of patients exposed. ICI-related colitis (ICI-colitis) is a common ICI-related adverse event and mimics inflammatory bowel disease (IBD). In this study, we report the rate of colitis in patients with cancer receiving ICI with pre-existing IBD or microscopic colitis (MC).

METHODS:
We retrospectively reviewed 1672 patients who underwent ICI therapy for cancer at a tertiary center since January 2011. We included patients who had a baseline IBD or MC diagnosis. Demographic data, clinical history of IBD, MC, cancer, ICI treatment, colitis events after ICI therapy and overall survival (OS) were analyzed. OS and time to colitis were estimated by Kaplan-Meier method.

RESULTS:
We identified 13 patients who had either IBD or MC. Among 11 IBD patients, 7 (64%) were on chronic therapy. ICIs were mostly PD-1/PD-L1 inhibitors monotherapy (10, 91%). Six (55%) patients developed colitis at a median of 17 (95% CI: 5-NA) weeks after ICI initiation. Imaging and endoscopy were done in 4 (66%) and 3 (50%) of cases, respectively. Ruling out C. difficile infection was performed in 2 (33%) of cases before starting steroid therapy, and laboratory testing (CRP and ESR) was done in 2 (33%) cases. No case had fecal calprotectin, lactoferrin or enteric PCR testing. 4 (80%) and 5 (100%) of 5 patients on steroid regimens had tapers over at least 6 or 4 weeks, respectively. ICIs were resumed in 2 cases. No case diagnosed as IBD flare was re-challenged with ICIs. In contrast, both patients with MC were on chronic treatment with 5-ASA and local steroid. One of the 2 patients with MC developed grade 1 ICI-colitis within 18 weeks and is still receiving ICI therapy. Median follow-up was 25 months (range: 18-29). Median OS was 12 (95% CI: 2-NA) months.

CONCLUSION:
In our cohort 50-55% of patients with preexisting inflammatory conditions of the intestines developed colitis while on ICIs. This proportion is higher than reported rates of ICI-induced colitis, which range from 0.5-20% in the general population, to 5.2-20% among patients with autoimmune disorders. Further studies require clarification of risk and identification of means to modify risk in order to allow these patients to benefit from cancer therapy.
673 The Peripartum Risk of Deep Vein Thrombosis and Pulmonary Embolism in Women With Inflammatory Bowel Disease: A Population-Based Cohort Analysis
Authors: Saxena Akriti , Dalal Rahul S. , Berera Shivali , Lichtenstein Gary R. 
Published: October 2019

INTRODUCTION:
Population-based adverse outcomes in the peripartum period are limited. Both Inflammatory Bowel Disease (IBD) and pregnancy are known risk factors for venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). The aim of our study was to determine whether the odds of VTE are higher in women with Ulcerative Colitis (UC) and Crohn's disease (CD) at the time of delivery, compared to pregnant patients without IBD.

METHODS:
We performed a population-based retrospective cohort study using the Healthcare Cost and Utilization Project (HCUP)'s Nationwide Inpatient Sample (NIS) between 2005 and 2014. ICD-9-CM diagnosis and procedure codes were used to identify unique obstetric hospitalizations associated with delivery of an infant, and VTE. We created national estimates using appropriate weights for each NIS admission. Multivariable logistic regression was used to evaluate the association of UC and CD with VTE, while adjusting for age, race, smoking, obesity, Charlson Comorbidity Index, chronic steroid use, income, primary insurance, hospital region, and hospital bed size.

RESULTS:
The cohort comprised of 39.8 million deliveries, including 19,167 in women with UC and 31,083 in women with CD. Table 1 depicts baseline characteristics of the cohort. Overall, IBD patients were more likely to be white, have private insurance, receive care at larger hospitals, have a cesarean section and use chronic steroids compared to non-IBD patients. There were 19 (0.1%) cases of VTE in UC patients, 18 (0.06%) in CD patients versus 11,935 (0.03%) in non-IBD patients. Unadjusted odds ratios [OR] were 4.0 for UC; 95% confidence interval [CI] 1.5-10.5, and 2.5 (95% CI, 0.9-6.8) for CD. After adjusting for confounders, the OR for developing VTE was 1.63 (95% CI 0.41-6.55) among UC patients and 2.11 (95% CI, 0.79-5.64) in CD patients. As seen in Table 2, the following variables were associated independently with an increased risk for VTE: age, higher comorbidity scores, inpatient cesarean delivery, obesity and smoking.

CONCLUSION:
Our study showed that patients with IBD were not at greater risk for VTE at the time of delivery compared with non-IBD, perhaps due to the lower absolute risk of VTE over time (0.06-0.1% in our study vs 1.5-2.1% in the 2005 NIS database). Improved awareness and practices surrounding DVT prophylaxis may also be contributing. This study was not able to differentiate between active versus quiescent disease.
679 Epidemiology and Impact of Pneumocystis jirovecii Pneumonia in Hospitalized Patients With Inflammatory Bowel Disease
Authors: Shah-Khan Sardar M. , Shah-Khan Musa , Kupec Justin T. 
Published: October 2019

INTRODUCTION:

Pneumocystis jirovecii pneumonia (PJP) is rare opportunistic infection that is most often associated with human immunodeficiency virus (HIV) but is also a reported complication in patients with inflammatory bowel disease (IBD). Treatment for IBD often include systemic corticosteroids and immunosuppressive agents that render these patients to opportunistic infections. Despite this, prophylaxis against PJP remains a topic of debate among providers with no clear consensus. Furthermore, data regarding the burden of PJP in patients with IBD and its impact on healthcare utilization remains limited. We aim to explore the epidemiology and impact of PJP on outcomes in hospitalized patients with IBD.

METHODS:
We queried the National Inpatient Sample (NIS) for all hospitalizations with a primary or secondary diagnosis of IBD [Crohn's disease (CD) or ulcerative colitis (UC)] with or without a diagnosis of PJP using the International Classification of Diseases 9th Edition Clinical Modification codes from 2003-2014. We conducted a retrospective analysis using SPSS (version 25.0). The primary outcome was in-hospital mortality and secondary outcomes included length of stay (LOS) and average total hospital charges. Associations were assessed using multivariable adjustment accounting for age, sex, income, region, hospital characteristics and the Elixhauser comorbidity index. Trend analysis was tested using Cochran Armitage trend test.

RESULTS:
From 2003-2014, there were a total of 840 hospitalizations for PJP in patients with IBD. The patients were primarily white (81%), aged between 41-60 (41.8%) and male (63.2%). Patients with PJP had a greater proportion of in-hospital mortality (10.8% vs 1.6%. P < 0.0001) and were more likely to die while hospitalized (OR 6.2, CI 4.8-7.9, P < 0.0001). PJP was associated with increased mean LOS (13 days vs. 6) and greater total hospital charges ($32,716.12 vs. $14,329.83). Patients with PJP had greater rates of comorbid HIV infection (36.4% vs. 0.30%) and comorbid HIV was associated with a significant risk of PJP infection (OR 232, CI 192-280, P < 0.0001). Cochran-Armitage test did not show a statistically significant increase in the disease incidence over the study period (P = 0.580).

CONCLUSION:
The incidence of PJP in hospitalized IBD patients is low and rates of disease remain stable. Disease is most likely related to comorbid HIV. Overall, PJP in IBD patients is associated with great mortality risk and significantly higher healthcare utilization costs.
686 Neither Obesity nor Hepatic Steatosis Are Associated With an Increased Prevalent or Incident Colonic Dysplasia in Patients With Inflammatory Bowel Disease and Concomitant Primary Sclerosing Cholangitis
Authors: Senter-Zapata Michael , McHenry Scott , Motowski Hayley , Ciorba Matthew A. , Deepak Parakkal 
Published: October 2019

INTRODUCTION:
A concomitant diagnosis of Primary Sclerosing Cholangitis (PSC) in patients with Inflammatory Bowel Disease (IBD) is associated with an increased risk of colonic dysplasia. Obesity and hepatic steatosis also have been associated with an increased risk of colonic dysplasia in non-IBD patients. Given the increasing prevalence of obesity in patients with IBD, we aimed to clarify if hepatic steatosis and obesity function as additional risk factors for PSC-associated colonic dysplasia.

METHODS:
This is a single-center, retrospective cohort study between 1/1/2013 through 12/1/2018. Adult patients with a clinical diagnosis of IBD and PSC that had undergone magnetic resonance cholangiopancreatography (MRCP) were included. Those with an alternative etiology of liver disease (e.g., chronic viral hepatitis, greater than moderate alcohol usage) were excluded. MRCP protocols had been modified to allow liver fat quantification by the MR-proton density fat fraction method. Hepatic steatosis was defined as >5.5% liver fat with obesity defined as body mass index (BMI) >30 kg/m2. Prevalent and incident colonic dysplasia were identified. The co-primary outcomes were the Odds Ratio (OR) for the association between hepatic steatosis or obesity and life-time prevalence of colonic dysplasia. Secondary outcomes included the analogous Hazards Ratio (HR) by a cox-proportional hazards model of colonic-dysplasia free-survival from the time of PSC diagnosis.

RESULTS:
112 PSC-IBD patients (80% Ulcerative Colitis, median age at enrollment 48 years, median age at PSC diagnosis 39 years, median BMI 27 kg/m2) had a life-time prevalence of colonic dysplasia in 24 (21%), hepatic steatosis in 22 (20%) and obesity in 23 (21%). Neither hepatic steatosis (OR, 0.8; 95% CI, 0.2-2.6; P = 0.78) nor obesity (OR, 1.1; 95% CI, 0.4–2.9; P = 0.90) were risk factors for the life-time prevalence of colonic dysplasia. Similarly, neither hepatic steatosis (HR, 0.9; 95% CI, 0.3-2.3; P = 0.78) nor obesity (HR, 1.0; 95% CI, 0.9–1.0; P = 0.37), were risk factors for dysplasia-free survival.

CONCLUSION:
We found that hepatic steatosis and obesity were not associated with increased lifetime prevalence for colonic dysplasia in patients with IBD-PSC. This may imply a different pathway for carcinogenesis in IBD-PSC compared to non-IBD patients.