Ali Abbas

Risk of Lymphoma in Patients With Ulcerative Colitis Treated With Thiopurines: A Nationwide Retrospective Cohort Study

BACKGROUND & AIMSnThere is controversy over whether the treatment of patients with ulcerative colitis (UC) with thiopurines increases their risk of lymphoma. We evaluated the risk of lymphoma (ongoing, residual, and per year of therapy) among thiopurine-treated patients with UC.nnnMETHODSnWe obtained nationwide data from the Veterans Affairs (VA) health care system from 2001 to 2011. We performed a retrospective cohort study, analyzing data on 36,891 patients from their date of diagnosis of UC in the VA health care system to a diagnosis of lymphoma or October 1, 2011 (subjects followed up for a median of 6.7 years). Thiopurine exposure wasxa0assessed using the VA pharmacy database. Patients who developed lymphoma were identified based on ICD-9 codes and confirmed by manual chart review.nnnRESULTSnIn total, 4734 patients with UC (13%) were treated with thiopurines for a median of 1 year. Lymphoma developed in 119 patients who had not been treated with thiopurines, 18 who were treated with thiopurines, and 5 whoxa0had discontinued treatment with thiopurines. The incidence rates of lymphoma were 0.60 per 1000 person-years among patients who had not been treated with thiopurines, 2.31 among patients who were treated with thiopurines, and 0.28 among patients who had discontinued treatment with thiopurines. The incidence rates of lymphoma during the first year, second year, third year, fourth year, and >4 years of thiopurine therapy were 0.9, 1.6, 1.6, 5, and 8.9 per 1000 person-years, respectively. The age-, sex-, and race-adjusted hazard ratios of developing lymphoma were 4.2 (95% confidence interval, 2.5-6.8; P < .0001) while being treated withxa0thiopurines and 0.5 (95% confidence interval, 0.2-1.3; Pxa0= .17) after discontinuing treatment with thiopurines compared with patients who had not been treated with thiopurines.nnnCONCLUSIONSnBased on a retrospective, nationwide cohort study, patients with UC have a 4-fold increase in risk of lymphoma while being treated with thiopurines compared with patients who have not been treated with thiopurines. The risk increases gradually for successive years of therapy. Discontinuing thiopurine therapy reduces the risk of lymphoma.

The Incidence, Predictors and Outcomes of Gastrointestinal Bleeding in Patients with Left Ventricular Assist Device (LVAD).

ObjectivesTo evaluate rate, recurrence, and predictors of gastrointestinal bleeding (GIB) and impact of endoscopy in left ventricular assist device (LVAD) patients.MethodsThis is a cohort study of all patients who received the current-generation continuous-flow HeartMate II LVAD from 2005 to 2013 at our institution. Patients were followed up, and GIB events recorded until death, time of heart transplantation, or end of observation.ResultsLVAD was implanted in 112 patients (median age 67xa0years, 88xa0% male). A total of 44 patients (39xa0%) had 74 GIB events occurring at a rate of 42.9 per 100 p-y. Endoscopy was performed in 77xa0% of patients, and GIB source was identified in 57xa0% with upper GIB found in almost two-third of cases. Right ventricular dysfunction and post-LVAD ejection fraction >30xa0% were associated with higher GIB rates. Higher pulsatility index was associated with lower GIB rates. Re-bleeding occurred in 19 (43xa0%) patients at a rate of 62.5 per 100 p-y and was not affected by endoscopic therapy at the index endoscopy.ConclusionsGIB in LVAD patients is common, occurring primarily in the upper GI tract. Upper endoscopy is the preferred strategy though lower endoscopy is also recommended for a full workup. Endoscopy can identify GIB lesions in about 50xa0% of patients, but re-bleeding is common. Right ventricular dysfunction and post-LVAD ejection fraction >30xa0% are associated with higher GIB rates. Higher pulsatility index is associated with lower GIB rates. Reduction in pump speed is a potential strategy for managing and preventing GIB.

Racial disparities in clinical presentation, surgical treatment and in-hospital outcomes of women with breast cancer: analysis of nationwide inpatient sample database.

To examine racial/ethnic disparities in stage of disease and comorbidity (pre-treatment), surgical treatment allocation (breast-conserving surgery versus mastectomy), and in-hospital outcomes after surgery (post-treatment) among women with breast cancer. Nationwide inpatient sample is a nationwide clinical and administrative database compiled from 44 states representing 95xa0% of all hospital discharges in the Unites States. Discharges of adult women who underwent surgery for breast cancer from 2005 to 2009 were identified. Information about patients and hospitals characteristics was obtained. Multivariate logistic regression analyses were used to examine the risk adjusted association between race/ethnicity and the aforementioned outcomes (pre-treatment, treatment, and post-treatment). We identified 75,100 patient discharges. Compared to Whites, African-Americans (1.17, pxa0<xa00.001), and Hispanics (1.20, pxa0<xa00.001) were more likely to present with regional or metastatic disease. Similarly, African-American (1.58, pxa0<xa00.001) and Hispanics (1.11, p 0.003) were more likely to have comorbidity. Compared to Whites, African-Americans (0.71, pxa0<xa00.001), and Hispanics (0.77, pxa0<xa00.001) were less likely to receive mastectomy. Compared to Whites, African-Americans were more likely to develop post-operative complications (1.35, pxa0<xa00.001) and in-hospital mortality (1.87, p 0.13). Other racial groups showed no statistically significant difference compared to Whites. After controlling for potential confounders, we found racial/ethnic disparities in stage, comorbidity, surgical treatment allocation, and in-hospital outcomes among women with breast cancer. Future researches should examine the underlying factors of these disparities.

Risk of Melanoma and Non-Melanoma Skin Cancer in Ulcerative Colitis Patients Treated With Thiopurines: A Nationwide Retrospective Cohort

OBJECTIVES:There are limited data on the risk of non-melanoma skin cancer (NMSC) and melanoma skin cancer (MSC) among thiopurine-treated patients with ulcerative colitis (UC). Our aim was to investigate the risk while on, by cumulative years, and after stopping thiopurine therapy.METHODS:Nationwide data were obtained from the Veterans Affairs (VA) health-care system during 2001–2011. We performed a retrospective cohort study evaluating patients with UC. Cox regression was used to investigate the association between thiopurines use and time to NMSC while adjusting for demographics, ultraviolet radiation exposure, and VA visiting frequency. A matched nested case–control study was conducted to investigate the association between thiopurine use and MSC.RESULTS:We included 14,527 patients with UC in the analysis, with a median follow-up of 8.1 years. A total of 3,346 (23%) patients used thiopurines for a median duration of 1.6 years. We identified 421 NMSC and 45 MSC cases. The adjusted hazard ratios of developing NMSC while on and after stopping thiopurines were 2.1 (P<0.0001) and 0.7 (P=0.07), respectively, as compared with unexposed patients. The incidence rate of NMSC among those who never used thiopurines was 3.7 compared with 5.8, 7.9, 8.3, 7.8, and 13.6 per 1,000 person-years for the 1st, 2nd, 3th, 4th, and 5th year of thiopurine use, respectively. No statistically significant association was observed between thiopurine use and MSC, odds ratio 0.8 (P=0.6).CONCLUSIONS:In this predominantly white male nationwide cohort, there was a twofold increase in the risk of NMSC while on thiopurines. The incidence rate of NMSC significantly increased with subsequent years of cumulative exposure to thiopurines. Stopping thiopurines reduced the risk of NMSC to pre-exposure levels irrespective of the prior exposure duration.

Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy

BACKGROUND & AIMS: In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM. METHODS: We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non‐HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months. RESULTS: POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non‐HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non‐HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non‐HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups. CONCLUSIONS: POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.

Early corticosteroids requirement after the diagnosis of ulcerative colitis diagnosis can predict a more severe long-term course of the disease - a nationwide study of 1035 patients.

There are limited data regarding clinical outcomes in ulcerative colitis (UC) patients who require early corticosteroids (CS) use.

Comprehensive Analysis of Adverse Events Associated with per Oral Endoscopic Myotomy in 1826 Patients: An International Multicenter Study

Objectives:The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM.Methods:Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case–control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders).Results:A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs.Conclusions:This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.

Prevalence of Corticosteroids Use and Disease Course After Initial Steroid Exposure in Ulcerative Colitis

AbstractBackgroundLimited nationwide data currently exists regarding corticosteroid (CS) use and long-term outcome after CS initiation in ulcerative colitis (UC).nAimsThe purpose of this study was to assess CS use prevalence and long-term outcomes after the index CS exposure. Our outcomes of interest were CS use level (reintroduction, dependency, and refractoriness), thiopurine use, and colectomy.MethodsNationwide data was obtained from the Veterans Affairs (VA) healthcare system for the period 2001–2011. Patients with UC were included if they had been diagnosed in the VA system and if they had filled CS for the first time during the observation period. A retrospective cohort design and time-to-event survival analysis was used to track outcomes of interest.ResultsA total of 1,038 newly-diagnosed patients with UC were identified. The prevalence of CS use over the observation period was 45xa0%. Four hundred sixty-four CS users with median follow-up of 3.4xa0years were included. Among the included patients, 65xa0% required CS reintroduction, 38xa0% were classified as CS dependent, and 11xa0% were classified as CS refractory mostly within 2xa0years after the index CS course. Respectively, 8.6 and 38xa0% had colectomy and received thiopurine. Colectomy and thiopurine use rates varied significantly according to CS use level.ConclusionsApproximately half of newly-diagnosed patients with UC required CS. Among CS users, one third of the patients had a sustained response after the initial CS course while two-thirds required further CS therapy. We observed a trend towards higher than previously reported thiopurine use accompanied by marked reduction in colectomy rates.

Epidemiology of Metastatic Hepatocellular Carcinoma, A Nationwide Perspective

BackgroundHepatocellular carcinoma (HCC) is the most common primary tumor of the liver.AimsThe aim of this study was to describe the prevalence, trends, and predictors of metastatic HCC on a national scale.MethodsWe used two nationwide datasets for our study: the University Health Consortium (UHC) and the Nationwide Inpatient Sample (NIS) databases. We included adults with a primary diagnosis of HCC from 2000 to 2011. We collected information regarding demographics, insurance, HCC risk factors, liver decompensation, and the sites and frequencies of metastases. Multivariable regression analysis was used to examine predictors of metastatic HCC. Trend analysis was performed to examine the change in metastatic HCC prevalence over time.ResultsWe included 25,671 and 26,054 HCC patients from UHC and NIS, respectively. Prevalence of metastatic HCC was 18xa0% with lung being the most frequent site (31xa0%). Compared with Caucasian, African American ethnicity was an independent predictor of metastasis in both the NIS [OR 1.13 (1.02–1.25)] and UHC [OR 1.4 (1.3–1.6)] databases. Lack of long-term insurance was associated with significantly higher prevalence of metastasis in both the NIS [OR 1.6 (1.4–1.9)] and UHC [OR 1.9 (1.6–2.2)] databases. There has been an increased prevalence of metastatic HCC over the last decade with an annual percentage change of +1.25 and +1.60xa0% (pxa0=xa00.03 and pxa0=xa00.08) for the NIS and UHC databases, respectively.ConclusionsMetastasis is not rare among HCC patients and is rising in prevalence over the last decade. Lungs were the most common metastatic site. Ethnicity and insurance status are independent predictors of metastasis.

United States Women Receive More Curative Treatment for Hepatocellular Carcinoma Than Men

AbstractBackgroundPrevious database studies have found gender disparities favoring men in rates of liver transplantation, which resolve in cohorts examining only patients with hepatocellular carcinoma (HCC).nAimsOur study aims to use two large, multicenter United States (US) databases to assess for gender disparity in HCC treatment regardless of transplant listing status.nMethodsWe performed a retrospective database analysis of inpatient admission data from the University Health Consortium (UHC) and the Nationwide Inpatient Sample (NIS), over a 9- and 10-year period, respectively. Adults with a primary discharge diagnosis of HCC, identified using the International Classification of Diseases 9th Edition (ICD-9) code, were included. Series of univariate and multivariate analyses were performed to examine gender disparities in metastasis, liver decompensation, treatment type, and inpatient mortality after controlling for other possible predictors.ResultsWe included 26,054 discharges from the NIS database and 25,671 patients from the UHC database in the analysis. Women with HCC appear to present less often with decompensated liver disease (ORxa0=xa00.79, pxa0<xa00.001). Furthermore they are more likely to receive invasive HCC treatment, with significantly higher rates of resection across race and diagnoses (ORxa0=xa01.34 and 1.44, pxa0<xa00.001). Univariate analyses show that US women have lower unadjusted rates of transplant; however, the disparity resolves after controlling for other clinical and demographic factors.ConclusionsUS women more often receive invasive treatment for HCC (especially resection) than US men with no observed disparity in transplantation rates when adjusted for pre-treatment variables.