Adam C. Ehrlich

Are your patients taking their medicine? Validation of a new adherence scale in patients with inflammatory bowel disease and comparison with physician perception of adherence.

Background: To date no adherence survey has been validated in IBD. The aim was to administer an improved medication adherence survey to IBD patients, to validate the scale in IBD, and to compare the results to perceived adherence by the gastroenterologists. Methods: IBD patients were given the Morisky Medication Adherence Scale (MMAS‐8). To validate the scale, prescription claim information, calculated as continuous single‐interval medication availability (CSA) and mean possession ratio (MPR), was correlated to the MMAS‐8 scale. Nonpersistence or low adherence was defined as a CSA or MPR < 0.8. Treating gastroenterologists, blinded to the instrument, then assessed adherence in these patients. Results: Of 110 IBD patients in the study, MMAS‐8 identified 54 patients as low adherers (LAs) to their IBD medication and 56 patients as medium or high adherers (MHAs). Eighty‐five percent of LAs had nonpersistent fill rates, as per CSA, compared with 11% of MHAs. Physicians correctly classified 95% of patients who were MHAs but only 33% of LAs. Underestimation of adherence only occurred in 5% of patients, whereas overestimation occurred in 67% (P < 0.0001). In a linear regression analysis, CSA was significantly correlated with disease activity score (P < 0.001). Conclusions: LAs are a challenge to identify. This study demonstrates that the MMAS‐8 scale is a valid instrument for assessing medication adherence in IBD. This is the first adherence scale to be validated in IBD. (Inflamm Bowel Dis 2011)

Current practice and perception of screening for medication adherence in inflammatory bowel disease.

Background Adherence to medication in inflammatory bowel disease (IBD) improves outcomes. Current practices of screening for adherence to IBD medications are unknown. The goal of this study was to determine current practice and perception of screening for medication adherence among US-based gastroenterologists. Methods A survey was mailed electronically to gastroenterologists whose electronic-mail address was listed in the American College of Gastroenterology database. Physicians who cared for IBD patients were invited to answer. Results About 6830 surveys were sent to gastroenterologists nationwide, and 395 physicians who cared for IBD patients completed the survey. The true response rate is unknown, as the number of physicians caring for IBD patients in the database is unknown. About 77% (n=303) of physicians who responded stated they screen for adherence to medication. Of the 77% of physicians who screened for adherence, only 19% (n=58) use accepted measures of screening for adherence (pill counts, prescription refill rates, or adherence surveys). The remaining 81% used patient interview to screen for adherence, a measure considered least accepted to determine adherence, as it overestimates adherence. The average number of IBD patients observed in 1 week had no statistical significance in predilection for screening (P=0.82). Private practice physicians (P=0.05), younger physicians (P=0.03), and physicians with fewer years of experience (P=0.02) all were more likely to screen. About 95% of responders thought determining a low adherer to medicine was important because an intervention can increase adherence. Conclusions The majority of gastroenterologists surveyed recognize that adherence to medication is important and improves outcomes. The majority of physicians in this study are screening for nonadherence in IBD, but are not using accepted measures for adherence detection. If this study truly reflects the majority of physicians nationwide, changing the way physicians screen for adherence, may detect more low adherers to medication.

Administrative Database Research Overestimates the Rate of Interval Colon Cancer.

Goals: Our study reexamines the prevalence of interval colorectal cancer (I-CRC) by manually reviewing CRC cases at a single institution. Background: In 2% to 8% of patients with CRC, diagnosis occurs during the interval 6 to 36 months after a cancer-free colonoscopy. Rates are often determined by linking the date of colonoscopy with cancer registry information. Study: We examined all colonoscopies from 1993 to 2011. These examinations were linked with Pennsylvania Cancer Registry data. Matched charts were manually reviewed. We determined whether the CRC was “prevalent” or, for patients with a previous colonoscopy, whether they were interval or noninterval based on time from last colonoscopy. For interval cases, we identified “administrative errors” that could falsely increase the number of reported I-CRC. Results: Over the study period, 43,661 colonoscopies were performed, with 1147 (2.6%) positive for CRC after excluding cases (n=52) in which patients had IBD, previous surgery, or nonadenocarcinoma malignancy. Prevalent CRCs totaled 1062 (92.6%). Noninterval CRCs (diagnosed over 36 mo from index colonoscopy) were present in 40 (3.5%). There remained 45 (3.9%) potential I-CRC cases. However, after manual review, 21 cases were found to be administrative errors. Therefore, the accurate proportion of colonoscopies that found an I-CRC was 2.1% (95% confidence interval, 1.5%-3.2%). Conclusions: The prevalence of I-CRC at our institution before adjustment was comparable with previously reported rates. This proportion was 47% lower after adjusting for administrative errors placing our figure at the lower end of reported I-CRC incidence. Reported rates of I-CRC may be falsely elevated due to errors unique to merging administrative databases.

Chronic Abdominal Wall Pain: An Under-Recognized Diagnosis Leading to Unnecessary Testing.

Chronic abdominal wall pain (CAWP) refers to a condition wherein pain originates from the abdominal wall itself rather than the underlying viscera. According to various estimates, 10% to 30% of patients with chronic abdominal pain are eventually diagnosed with CAWP, usually after expensive testing has failed to uncover another etiology. The most common cause of CAWP is anterior cutaneous nerve entrapment syndrome. The diagnosis of CAWP is made using an oft-forgotten physical examination finding known as Carnett’s sign, where focal abdominal tenderness is either the same or worsened during contraction of the abdominal musculature. CAWP can be confirmed by response to trigger point injection of local anesthetic. Once diagnosis is made, treatment ranges from conservative management to trigger point injection and in refractory cases, even surgery. This review provides an overview of CAWP, discusses the cost and implications of a missed diagnosis, compares somatic versus visceral innervation, describes the pathophysiology of nerve entrapment, and reviews the evidence behind available treatment modalities.

Genetic Associations of Obesity: The Fat-Mass and Obesity-Associated ( FTO) Gene

Obesity is a global epidemic and contributes to a myriad of medical conditions including cardiovascular disease, diabetes, and cancer.1 As with many other diseases, there is an increasing body of literature that links genetics to obesity. For example, several genes expressed in the hypothalamic region are involved in the regulation of appetite.2, 3 To date, the strongest genome-wide association, as it relates to obesity, is located in introns 1 and 2 of the fat-mass and obesity-associated (FTO) gene located on chromosome 16q12.2. This relationship was first identified in a series of studies in 2007.4, 5 Recently, several single-nucleotide polymorphisms (SNPs) of the FTO gene have been implicated in the risk of obesity and its complications. In this brief review, we will discuss new insights into the pathophysiological mechanism by which the FTO gene affects obesity and some clinical implications of its SNP variants.

Su1263 Clostridium difficile Infection Remains an Independent Risk Factor for Mortality and Colectomy in Hospitalized Patients With Ulcerative Colitis

Background: Severe flares of ulcerative colitis (UC) requiring hospitalization are frequently associated with Clostridium difficile infection (CDI). Previous studies suggest an increase risk of colectomy (OR=2.5) and mortality (OR=4.7) in hospitalized patients with IBD and concomitant CDI (Inflamm Bowel Dis 2011; 17 and Gut 2008; 57). Over the past 5 years the utilization of vancomycin for CDI and biologics for UC has increased substantially. This study aimed to re-assess the relationship between UC and CDI using more recent data to identify whether outcomes have improved. Methods: We utilized the Nationwide Inpatient Sample, a database that collects discharge data from more than 7 million admissions annually from participating community hospitals. This data set represents 20 percent of the discharges from these hospitals. We identified patients hospitalized for the period 2007-2011. We restricted our analysis to patients aged 18 to 80, admitted under urgent or emergent conditions, with a diagnosis of ulcerative colitis with or without CDI, as indicated by ICD-9 coding. Rates of in-hospital mortality and colectomy were similarly ascertained. The study sample was weighted and analyzed using the Complex Samples Module of SPSS 22.0. Results: After weighting, 307,898 hospitalizations for UC were identified. Mean age was 51 ± 17.5 years; 53% female. There were 19,090 (6.2%) with concomitant CDI. The rate of colectomy in patients hospitalized with UC and CDI was 2.5%, compared with 0.6% in those without concomitant CDI (univariate odds ratio (OR) for colectomy 4.7, 95% CI= 4.2-5.1). In multivariate logistic regression, when adjusting for age, race, and gender, the OR remained highly significant at 5.1 (95% CI=4.5-5.8, p<0.001). The mortality rate in patients hospitalized with UC and CDI was 10.3%, compared with 1.5% in those without CDI (univariate OR for death 7.4 (95% CI=7.0-7.8, p<0.001). In multivariate logistic regression, when correcting for age, race, and gender, the OR similarly remained highly significant at 7.1 (95% CI=6.7-7.6, p<0.001). Conclusion: In this large, nationwide sample of patients hospitalized with ulcerative colitis, infection with CDI remains a highly significant independent risk factor for in-hospital mortality and colectomy. Our results are similar to previous reports indicating that there has been little change in outcomes despite advances in therapy for both diseases.

Measurement of Fractional Exhaled Nitric Oxide as a Marker of Disease Activity in Inflammatory Bowel Disease.

BACKGROUND AND AIMS Definitive diagnosis of IBD requires endoscopic and pathologic confirmation. These tools are also used to classify disease activity. Our aim was to determine if the fractional exhaled nitric oxide (FeNO) could be utilized to screen for IBD and assess for disease activity. METHODS We matched weighted IBD cases and controls from the 2009-2010 NHANES dataset. All subjects underwent measurement of FeNO using standardized techniques. We assessed for potential confounders for FeNO measurement including age, height, and asthma. For IBD subjects, we used the presence of diarrhea, fatigue, and weight loss as a proxy for IBD activity. Laboratory parameters examined to estimate disease activity included anemia (≤ 10 g/dl), iron deficiency (ferritin ≤ 20 ng/ml), hypoalbuminemia (≤ 3.2 g/dl), and CRP (≥ 1.1 mg/dl). RESULTS The weighted sample represented 199,414,901 subjects. The weighted prevalence of IBD was 2,084,895 (1.0%). IBD subjects had nearly the same FeNO level as those without IBD (17.0 ± 16.2 vs. 16.7 ± 14.5 ppb). The odds of a FeNO > 25 ppb was half (OR=0.501; 95% CI 0.497-0.504) for subjects with IBD compared to those without IBD after controlling for confounders. The AUROC curve for FeNO was 0.47 (0.35-0.59). FeNO levels were not higher in patients with laboratory values suggestive of active disease. FeNO levels were higher in IBD patients with diarrhea, rectal urgency, and fatigue but were lower in those with unintentional weight loss. CONCLUSION Measurement of FeNO does not appear to be useful to screen for IBD or assess disease activity.

Sa1076 Abdominal Diameter Index Is a Stronger Predictor of Barrett's Esophagus Than BMI or Waist-to-Hip Ratio

Background: Abdominal obesity is associated with the development of gastroesophageal reflux disease (GERD) and, subsequently, Barretts esophagus (BE). Increased body mass index (BMI) and waist-to-hip ratio (WHR) have individually been associated with BE; however, other anthropometric measurements exist and may be more accurate. Abdominal diameter index (ADI, sagittal abdominal diameter divided by thigh circumference) was previously shown to be a more accurate predictor of incident cardiovascular disease compared to other body measurements. Our aim was to examine whether ADI was a more accurate predictor of prevalent BE compared to other anthropometric measurements. Methods: We conducted a case-control study of patients presenting to our institution from October 2013November 2014. Our study population was consecutive Caucasian men with a known history of BE confirmed by endoscopy and histology. We recruited Caucasian male control patients who underwent endoscopy for any reason and who did not have evidence of BE by history or endoscopy. Prior to endoscopy or outpatient visit both groups completed a questionnaire about demographics, smoking status, and medication use and underwent a series of body measurements including height, weight, waist circumference, hip circumference, thigh circumference, and sagittal abdominal diameter using standardized measuring tools. BMI, WHR, and ADI were calculated, and the data was analyzed using SPSS 22.0. Results: A total of 31 BE patients and 42 control patients were recruited. The BE cohort were older (mean age 62.5 vs. 53.2 yrs, p=0.009) and had a higher rate of hiatal hernia (74.2% vs. 19.0%, p<0.001) and proton pump inhibitor use (90.3% vs. 69.0%, p=0.03). The mean ADI for patients with BE was 0.65 ± 0.07 and without BE was 0.59 ± 0.08 (p= 0.01). In univariate analysis, an ADI≥0.60 vs. <0.60 conferred an increased risk of BE (OR= 3.8, 95% CI=1.42-10.10). When controlling for age, history of tobacco use, and BMI, an ADI≥0.60 remained a significant independent risk factor for BE (OR=3.0, 95% CI=1.078.55). Of note, BMI was not a significant predictor of BE. Similarly, WHR was not associated with BE in either univariate or multivariate analysis. The predictive value of ADI was analyzed using a receiver-operator characteristic (ROC) curve and was a more powerful predictor of BE than WHR or BMI (AUROC=0.72 vs. 0.60 vs. 0.52, respectively). Using a cut-point ADI value of 0.60, ADI had a sensitivity of 77.4% and a specificity of 64.3% for the presence of BE. Conclusion: ADI appears to be a more powerful predictor of the presence of BE than BMI and WHR. ADI may be a better measure of central obesity than WHR. In the future, physicians may be able to use ADI to help risk-stratify those patients that should undergo screening for Barretts esophagus.