bluuebunny/crossref_metadata_2025_split huggingface dataset:
812 Change in Medical Expenses Per Capita for Inflammatory Bowel Disease in Korea Over the Last Five Years
Authors: Jung Sung Hoon , Kang Sang-Bum , Kim Dae Bum 
Published: October 2019

INTRODUCTION:
As the incidence of IBD has increased, the overall cost of medical care also has been increasing. However, It is not clear whether the per-capita cost is increasing or not in the era of biologics. We aimed to estimate annual per-capita health care expenditures for IBD and analyze the trends by region and age in Korea overall the last five years.

METHODS:
We estimated IBD patient data and reimbursement information from the Korean Health Insurance Review & Assessment Service between 2013 and 2017. The data converted into the annual per capita healthcare expenditures were analyzed by region and age. For analysis of the results, the currency unit is KRW1000. (KRW1000 = USD0.9).

RESULTS:
The overall number of IBD patient has increased steadily (CD;16,138 & UC;31,026 in 2013 vs CD;20,231 & UC;40,939 in 2017), and the overall cost of medical care has also increased significantly. The annual per capita healthcare costs for CD and UC have also increased steadily since 2013 and nearly doubled in 2017(CD;3583.03 & UC;999.48 in 2013 vs CD;6134.04 & UC;1651.68 in 2017). The annual per capita healthcare costs for CD and UC in major cities including Seoul, where Tertiary referred hospitals are located, was higher than that for other regions (Figure 1). The annual per capita healthcare costs for CD in teens, 20s and 30s was higher than other decades and then decreased sharply, and that for UC in teens and 20s was high and then gradually decreased (Figure 2). Interestingly, the annual per capita healthcare costs for girls under the age of 10 in UC has increased dramatically.

CONCLUSION:
The health-care cost in IBD has been increasing not only on a whole scale but also on a per capita healthcare costs in Korea over the last five years. Consuming more medical costs at younger ages means that they are suffering from moderate-to-severe disease, which means that there is a large socio-economic loss. Given the increasing trend, government measures are needed to support medical expenses in the future, and it is thought that a sustained trend analysis is needed.
814 Characteristics of Microscopic Colitis (MC) in a Diverse Urban Healthcare Setting
Authors: Hong Simon , Patel Sneha , Panarelli Nicole , Brandt Lawrence 
Published: October 2019

INTRODUCTION:
MC is a chronic inflammatory condition of the colon characterized by watery, non-bloody diarrhea and is comprised of 2 subtypes: collagenous colitis (CC) and lymphocytic colitis (LC). Prior population-based studies of MC have been performed in regions such as Northern Europe and Olmsted County, MN which, in general, are racially homogenous. The purpose of our study is to describe the characteristics of patients (pts) with MC in a diverse, urban medical center in Bronx County, NY.

METHODS:
We retrospectively identified pts diagnosed with MC between January 2006 and June 2018 at our institution. Diagnosis was confirmed based on chart review of pts’ symptoms and histopathology. For each patient (pt), we recorded demographics, disease characteristics and co-morbidities. Our population characteristics were compared with those reported for pts with MC in Olmsted County, MN (Gentile et al. 2014).

RESULTS:
76 pts were included in our study. The median age at diagnosis was 61.5 years (range 31 to 89 years) and 55 (72.4%) were female. There was a slight predominance of CC over LC (52.6% vs. 47.4%), with a trend towards significance compared with pts in Olmsted County, where CC was less common than LC (42.9% vs 57.1%, P = 0.10) (Table 1). Pts in Bronx County had lower rates of smoking (27.5% vs 52.5%, P < 0.01), but similar rates of autoimmune disease (21.4% vs. 19.2%, P = 0.75) compared with pts in Olmsted County. Race/ethnicity was reported in 65 pts, of whom 34 (52%) were Caucasian, 7 (11%) were African-American (AA), and 24 (37%) were Hispanic. When comparing pts based on race/ethnicity, AA and Hispanic pts were younger (P = 0.02) and had lower socioeconomic status (SES) (P < 0.01) than Caucasian pts (Table 2). No statistically significant differences in sex or MC subtype were seen among the 3 racial/ethnic groups.

CONCLUSION:
The racially/ethnically mixed pt population with MC in our urban healthcare setting has more CC predominance and less smoking exposure compared with the predominantly Caucasian population in a previously described US cohort. Age at diagnosis, female predominance and rates of concurrent autoimmune disease are similar. AA and Hispanic pts have an earlier age at diagnosis and lower SES than Caucasian pts. Our findings suggest that a diverse population may have a different presentation of MC than previously described. Larger population-based studies in these communities are needed to confirm our findings.
816 The Prevalence and Clinical Associations of Sacroiliitis in Crohn’s Disease Using a Standardized Magnetic Resonance Scoring System
Authors: Levine Irving , Malik Fardina , Castillo Gabriel , Jaros Brian D. , Alaia Erin , Ream Justin , Scher Jose U. , Hudesman David P. , Axelrad Jordan E. 
Published: October 2019

INTRODUCTION:
Sacroiliitis (SI), an inflammatory arthropathy of the sacroiliac joints, has an established correlation with Inflammatory Bowel Disease (IBD). Yet SI often goes undiagnosed, and the clinical association between IBD disease activity and SI is not established. Patients with Crohn’s disease (CD) often receive magnetic resonance enterography (MRE), affording clinicians the opportunity to evaluate for the presence of sacroiliitis. We sought to identify the prevalence and disease characteristics associated with SI in CD using MRE.

METHODS:
All CD patients undergoing MRE for any reason between 2014-2018 at an IBD referral center were identified. A musculoskeletal radiologist reviewed all MRE exams for acute and chronic SI using standardized scoring. We analyzed demographics, IBD characteristics, clinical and endoscopic activity, and management between CD patients with and without SI.

RESULTS:
258 patients with CD underwent MRE during the study period. The mean age was 35 years old, 53% were male, and mean duration of CD at MRE was 9 years. Few reported back pain (8%) and 14% had previously seen a rheumatologist. Overall, 17% (n = 45) of patients had MR evidence of SI (Table 1). Female gender, back pain, and later age of CD diagnosis were associated with SI (P = 0.05, P < 0.001; P = 0.04 respectively; Table 2). Disease location and medication exposures were not associated with SI. Stricturing phenotype was associated with a lower rate of SI (7%) compared to inflammatory (48%) or penetrating phenotypes (45%). Disease activity, noted by clinical scores, endoscopic disease activity, or radiographic disease activity, were not associated with SI (Table 2). On multivariable analysis, only back pain was associated with SI (OR 3.01, 95% CI; P = 0.04).

CONCLUSION:
SI is a common comorbid condition in CD, but often underdiagnosed. With limited clinical clues and disease characteristics to suggest SI, physicians may utilize MRE for clinical activity to assess for SI. Data suggest targeted screening of patients with back pain.
819 Comparing Efficacy and Adverse Effects of Biological Agents in South Asian Inflammatory Bowel Disease Patients Living in the United States to Caucasian American Patients
Authors: Bodiwala Vimal , Marhsall Timothy , Seril Darren 
Published: October 2019

INTRODUCTION:
The aim of this study was to compare the efficacy and adverse effects of biological therapies in South Asian patients with Crohn’s disease (CD) and ulcerative colitis (UC) living in the United States with those of a Caucasian American cohort.

METHODS:
The efficacy, reasons for therapy discontinuation, and adverse effects of biological therapies in 73 South Asian patients (31 CD and 42 UC) who presented initially to our tertiary referral center from 2012 to 2016 and had subsequent follow-up were retrospectively compared with those of 408 consecutive Caucasian American patients (245 CD and 163 UC). The reasons for biologic therapy discontinuation were classified as: financial barrier, clinician judgment based on disease remission, primary non-response, secondary non-response, adverse effects, and patient preference. Adverse effects for biologic agents were classified as injection site reaction, infusion reactions, cytopenia, secondary infections, neurologic effects (including demyelinating disease or vestibular issues), cardiac effects (including heart failure), cutaneous effects, malignancy, and others.

RESULTS:
For both the South Asian and Caucasian American cohorts, adalimumab and infliximab were the most commonly prescribed biologic agents. Twenty-two out of 22 (100%) South Asian CD patients treated with adalimumab or infliximab had primary response. The Caucasian American CD cohort had a primary non-response rate of 16.5% to adalimumab and 12.1% to infliximab (Table 1). There was no statistical difference noted in the incidence of secondary non-response due to immunogenicity between South Asian and Caucasian American CD patients. Primary non-response, secondary non-response and adverse effects were the leading reasons for discontinuing biological therapy in both UC cohorts (Table 2). South Asian and Caucasian American CD patients experienced similar rates of adverse effects to anti-TNF therapy (Table 3). South Asian UC patients had a higher rate of primary non-response and a lower rate of adverse events with infliximab therapy compared to Caucasian American UC patients (Table 3).

CONCLUSION:
A cohort of South Asian IBD patients, mainly migrants, showed differing rates of response and adverse effects to biological therapies compared to a Caucasian American cohort. Of note, South Asian CD patients had higher rates of primary response to anti-TNF therapy than Caucasian American CD patients. These results provide insights into ethnic and racial variation in IBD therapeutics.
820 What Can Prealbumin/Albumin Ratio Tell You About Etiology of Hypoalbuminemia?
Authors: Lin Bixuan , Sherman Katherine , Berger William 
Published: October 2019

INTRODUCTION:
Hypoalbuminemia can be caused by either decreased albumin production (e.g. malnutrition, systemic inflammation, liver disease) or increased loss (e.g. protein-losing enteropathy, increased metabolism, wounds). Prealbumin is affected by the same factors as albumin, but its half-life of 2 days is a fraction of the 21-day half-life of albumin. Due to this difference in half-life, protein loss should disproportionately impact albumin level, while underproduction should impact both proteins more equally. Therefore, the prealbumin to albumin ratio (PAR) may present a quick, noninvasive, and cost-efficient tool to help elucidate causes of low albumin.

METHODS:
We performed a retrospective chart review of subjects seen at the CJ Zablocki VAMC in Milwaukee, WI, USA between 2012-2016 with albumin and prealbumin levels drawn within 1 week of each other. Chronic kidney disease patients were excluded as prealbumin clearance is impaired in this population. Prealbumin to albumin ratio (PAR) was defined for each category of hypoalbuminemia etiology (loss, underproduction, or mixed) as determined by chart review including notes by physicians and nutritionists, medical history, and labs reflecting nutrition and inflammation (ferritin, CRP, ESR, lymphocyte count). A validation set was then run against these proposed parameters.

RESULTS:
The definition (n = 36) and validation (n = 96) sets did not differ significantly in age, gender, or inpatient status. PAR separated by etiology (Figure 1) shows clear distinction between loss and underproduction. PAR differences are shown in Table 1. A linear progression model comparing PAR in protein loss only (n = 10) versus underproduction only (n = 21) provided a 97% prediction accuracy with r2 of 0.58 when PAR cut-off was set to 6.5.

CONCLUSION:
PAR is significantly higher among individuals with protein loss verses protein underproduction. PAR may be particularly useful as a screening tool for deciding whether to pursue PLE workup in a patient with unexplained hypoalbuminemia. Clinical utility of PAR needs to be further studied and is likely limited to patients with no more than 1 or 2 possible etiologies for hypoalbuminemia.
826 Biologic Use in Pediatric Patients Newly Diagnosed With Crohn’s Disease in the United States, 2010-2013 and 2014-2016
Authors: D'Haens Geert R. , Naegeli April , Mahoui Malika , Morton Stuart , Dong Yan , Hunter Theresa 
Published: October 2019

INTRODUCTION:
The purpose of this study is to characterize treatment patterns and sequences of biologic initiation in pediatric patients newly diagnosed with Crohn’s Disease (CD) in the United States in 2010-2013 and 2014-2016.

METHODS:
Pediatric (0-17 years) patients with ≥2 CD diagnosis codes (ICD-9: 555.x; ICD-10:K50.x) from October 1, 2010 to September 30, 2016 were included in this retrospective analysis of medical and pharmacy claims data from the IBM Marketscan Commercial and Medicaid Claims database. Patients were excluded if they were >18 years old, had an Ulcerative Colitis (UC) diagnosis, had a dual UC and CD diagnosis, or did not have treatment throughout the study period. Pathway visualization techniques and subgroups analyses were conducted for the 2 years post diagnosis to compare biologic use following first diagnosis during 2010-2013 and 2014-2016. Two-sample t test were conducted for continuous patient characteristics between 2010 -2013 and 2014-2016 diagnosis periods. Chi-square tests were used to compare categorical variables.

RESULTS:
A cohort of 940 CD patients were identified with 482 (51.3%) diagnosed with CD during 2010-13 and 458 (48.7%) diagnosed during 2014-16. The majority of patients during both time periods were male. Mean age at diagnosis was not statistically different during 2010-2013 and 2014-2016 (13.4 vs. 13.5 years; P = 0.75). In general, the majority of patients initiated conventional treatment (aminosalicylates, immunomodulators, and/or corticosteroids) at the time of diagnosis. However, there was a statistically significant increase in biologic use from 43.6% of patients in 2010-2013 to 59.8% of patients in 2014-2016 (P < 0.001). The median time to biologic treatment in the 2 years post diagnosis was 173.0 days for those diagnosed 2010-13 versus 76.5 days for those diagnosed during 2014-16 (P < 0.001). Infliximab was more frequently identified as the first-line biologic in the 2 years post diagnosis for those diagnosed 2010-13 and 2014-2016, yet rates of infliximab were low. However, pathway visualization Sankey diagrams illustrated limited switching from one biologic to another after initiation of biologic therapy during the 2 years post diagnosis for 2010-13 (Figure 1), with no predominant sequence identified. This trend remained for the 2014-16 cohort (Figure 2).

CONCLUSION:
Biologic use among pediatric CD patients has increased in recent years; however conventional treatment is still more common at the time of diagnosis.
827 Efficacy and Safety of Tofacitinib in Moderate-Severe Ulcerative Colitis: A Systematic Review and Meta-Analysis
Authors: Dhindsa Banreet , Dhaliwal Amaninder , Mashiana Harmeet , Choa Jacqueline , Sayles Harlan , Ohning Gordon , Hewlett Alexander , Young Renee , Eichele Derrick 
Published: October 2019

INTRODUCTION:
Tofacitinib was FDA approved in 2018 for use in patients with moderate to severe ulcerative colitis (UC). It is an oral inhibitor of Janus-kinase 1-3 and can be used in patients who are naïve or have failed other biological therapies. We conducted a systematic review and meta-analysis to assess the overall clinical response and remission of Tofacitinib in patients with moderate-severe UC.

METHODS:
We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Web of Science databases, Google Scholar and manual search of references (from inception through October 2018) to identify studies that reported use of Tofacitinib in moderate-severe UC patients. The primary outcome was to look at the clinical response and remission and secondary outcome was to look for adverse events. Clinical response was defined as an absolute decrease of Mayo-score by at least 3 points and a relative decrease by at least 30%-with an accompanying decrease in rectal bleeding sub score of at least 1 point or an absolute rectal bleeding sub score of 0 to 1. Clinical remission was defined as total Mayo score of 0 to 2, with no individual sub score exceeding 1. The meta-analysis was performed using Der Simonian and Laird random effect model.

RESULTS:
A total of 6 studies reporting on 1207 patients receiving 10 mg of Tofacitinib were included in our final meta- analysis. The mean age and follow up were 41.5 years and 15.4 months respectively. 497 patients and 627 patients (using 5/6 studies) were TNF inhibitors naïve and experienced respectively. The overall pooled clinical response and clinical remission of Tofacitinib in moderate-severe UC was 59.68% (95% CI = 55.3- 63.57, I2 = 31.92%) and 31.61% (95% CI = 20.78-43.52, I2 = 92.77%) respectively (Tables 1 and 2). The overall adverse events were 706, which mainly included infections with 22.73% [95% CI = 15.51- 30.83, I2 = 86.13%). The cumulative incidence of Herpes zoster was 0.6% (95% CI = 0.0-2.24, I2 = 67.21%). Significant heterogeneity was noted in the studies included in our meta-analysis.

CONCLUSION:
Based on the limited data included in our meta-analysis, Tofacitinib (10 mg) seems to have good overall clinical response rate of 59.68%. There was higher rate of infections noted in our meta-analysis. Overall low incidence of Herpes zoster could be due to short follow up (4/6 studies). Further multi-center studies are needed to assess long-term efficacy and safety of Tofacitinib in moderate-severe ulcerative colitis patients.
829 Appropriateness of Treatment Options in Mild to Moderate Ulcerative Colitis: A RAND Appropriateness Panel
Authors: Irving Peter M. , Melmed Gil Y. , Lightner Amy L. , Kotze Paulo , Ullman Thomas , Raffals Laura E. , Baidoo Leonard , Bressler Brian , Cheifetz Adam , Devlin Shane , Jones Jennifer , Kozuch Patricia , Sparrow Miles , Velayos Fernando , Siegel Corey A. 
Published: October 2019

INTRODUCTION:
Treatment options for patients with moderate-severe ulcerative colitis (UC) are increasing. The appropriateness of their use in mild-moderate UC is less clear, as is the role of surgical intervention. Our aim was to define the appropriateness of therapeutic options in a range of clinical scenarios in mild-moderate UC

METHODS:
We applied the RAND/UCLA Appropriateness Method to rate appropriateness of treatment choices in patients with mild-moderate UC; severe disease (likely to need hospitalization or surgery within 2 weeks) was excluded. A literature review was presented to the BRIDGe group, a panel of 13 IBD specialists, as well as 1 external IBD expert and 2 IBD surgical experts. 12 chapters were constructed including failed 5-ASA, steroid or thiopurine therapy, and primary/secondary non-response to biologics or tofacitinib. Scenarios were also divided by disease extent (proctitis vs more extensive) and activity (mild vs moderate) creating 260 scenarios in all. Panellists used a modified Delphi method to anonymously rate the appropriateness of a therapy on a 1-9 scale (1-3 not appropriate, 4-6 uncertain, 7-9 appropriate). Disagreement was assessed using a validated index (DI) and was defined as a DI > 1. The panellists then convened in person to discuss areas of disagreement, followed by a second round of rating. Scenarios rated a median of 7 or higher were deemed appropriate and those rated 3 or lower were deemed inappropriate. Scenarios rated 4-6 were considered uncertain, as were any with a DI > 1

RESULTS:
Appropriateness was agreed in 131 and inappropriateness in 47 scenarios. Greatest disagreement was around the use of thiopurines, but no scenario had a DI > 1. There were 82 scenarios were rated uncertain. Biologics and tofacitinib were more likely to be rated appropriate for treatment resistance and greater disease activity; disease extent less likely to influence decision making. Surgery was felt to be appropriate in 8 scenarios, generally in more extensive and active disease that had failed to respond to medical therapy. Surgery was felt to be inappropriate in 16 scenarios and was uncertain in 24

CONCLUSION:
Although there was little disagreement amongst an expert panel of IBD physicians and surgeons, there remained uncertainty about the use of medical and surgical therapy in nearly one third of situations in patients with mild-moderate UC. These results could be used to guide the design of clinical trials for these patient groups in order to guide best practice.
830 Can CD74 Predict Treatment Response to Anti-TNF Agents in Inflammatory Bowel Disease?
Authors: Farr Laura , Bucala Richard , Moonah Shannon 
Published: October 2019

INTRODUCTION:
Anti-TNF treatment, a game changer for inflammatory bowel disease (IBD) therapy, promotes mucosal healing in patients with IBD (1). By poorly understood mechanisms, a considerable amount of IBD patients either do not primarily respond or lose response to anti-TNF agents (2). A recent study identified a strong association between a polymorphism in the CD74 gene and anti-TNF failure in IBD patients (3). This led us to hypothesize that anti-TNF failure is more likely to occur in the setting of defective CD74 signaling.

METHODS:
To test this hypothesis, we used the common DSS-induced colitis mouse model that mimics key immunological and histopathological features of IBD in humans. We studied both normal wild-type (WT) and CD74 deficient mice. Mice were given alternating days of DSS and normal drinking water to allow for partial repair. Anti-TNF antibody at 10 mg/kg was injected one hour prior to oral DSS administration.

RESULTS:
We found that anti-TNF therapy did not protect CD74 deficient mice from DSS-induced body weight loss, colon shortening, and tissue damage measured by the histological score and FITC-dextran analysis compared to normal wild-type mice. We further assessed epithelial layer integrity by immunofluorescence staining for the Claudin-3 tight junction marker. In keeping with the severe intestinal damage observed, extensive loss of Claudin-3 was found in CD74 deficient mice after treatment with DSS. Also, myeloperoxidase (MPO) levels, a widely used marker of intestinal inflammation, was significantly higher in the colonic tissue of CD74 deficient mice.

CONCLUSION:
Thus, our findings support the hypothesis that an inferior response to anti-TNF drugs occurs with defective CD74 signaling, and provides a novel insight into the mechanism of treatment failure. Whether CD74 gene variants can be used to predict success in a personalized medicine approach to the management of IBD should be a focus of future research.