Anwar Dudekula

Association Between Telephone Activity and Features of Patients With Inflammatory Bowel Disease

BACKGROUND & AIMS Telephone communication is common between healthcare providers and patients with inflammatory bowel disease (IBD). We analyzed telephone activity at an IBD care center to identify disease and patient characteristics associated with high levels of telephone activity and determine if call volume could identify individuals at risk for future visits to the emergency department (ED) or hospitalization. METHODS We performed a prospective observational study in which we categorized telephone calls received by nursing staff over 2 years at a tertiary care IBD clinic (2475 patients in 2009 and 3118 in 2010). We analyzed data on 21,979 ingoing and outgoing calls in 2009 and 32,667 calls in 2010 and assessed associations between clinical factors and logged telephone encounters, and between patterns of telephone encounters and future visits to the ED or hospitalization. RESULTS Telephone encounters occurred twice as frequently as office visits; 15% of the patients generated >10 telephone encounters per year and were responsible for half of all telephone encounters. A higher percentage of these high telephone encounter (HTE) patients were female, had Crohns disease, received steroid treatment, had increased levels of C-reactive protein and rates of erythrocyte sedimentation, had psychiatric comorbidities, and had chronic abdominal pain than patients with lower telephone encounters. The HTE patients were also more frequently seen in the ED or hospitalized over the same time period and in subsequent years. Forty-two percent of patients with >8 telephone encounters within 30 days were seen in the ED or hospitalized within the subsequent 12 months. CONCLUSIONS Based on an analysis of telephone records at an IBD clinic, 15% of patients account for half of all calls. These HTE patients are a heterogeneous group with refractory disease who are likely to visit the ED or be hospitalized.

Impact of Obesity on the Management and Clinical Course of Patients with Inflammatory Bowel Disease.

Background:Obesity has been linked with a proinflammatory state and the development of inflammatory diseases. Data on the clinical course and treatment of obese patients with inflammatory bowel disease (IBD) are limited. We used an institutional IBD registry to investigate the impact of obesity on IBD severity and treatment. Methods:This was a retrospective analysis of prospectively collected data for 3 years (2009–2011). Patients with IBD were categorized by body mass index (BMI). IBD-related quality of life, biochemical markers of inflammation, comorbidities, health care utilization, and treatment were characterized. Obesity was defined as a BMI ≥30 (type I: 30–34.9, type II: 35–39.9, and type III ≥40). Results:Among 1494 patients with IBD, 71.9% were above their ideal BMI and 31.5% were obese. Obesity was more common in ulcerative colitis compared with patients with Crohns disease (P = 0.04). Obese class II and class III patients were predominantly female. Obesity in IBD was associated with female gender (P < 0.0001), diabetes mellitus (P < 0.001), hypertension (P < 0.001), hyperlipidemia (P < 0.001), poor quality of life (P < 0.0001), and increased rates of C-reactive protein elevation (P = 0.008). In logistic regression analysis, quality of life and C-reactive protein elevation were not independently correlated with obesity. There was no association between increasing BMI and annual prednisone use, emergency department visits, hospitalization, and surgery. Obesity was associated with lower milligrams per kilogram doses of purine analogs and biologics. Conclusions:Obesity in IBD is not associated with increased health care utilization and IBD-related surgeries. Optimal regimens for drug dosing in obese patients with IBD have yet to be defined.

Weight Loss in Nonalcoholic Fatty Liver Disease Patients in an Ambulatory Care Setting Is Largely Unsuccessful but Correlates with Frequency of Clinic Visits

Background and Aims Nonalcoholic fatty liver disease (NALFD) is a leading cause of liver disease. Weight loss improves clinical features of NAFLD; however, maintenance of weight loss outside of investigational protocols is poor. The goals of this study were to characterize patterns and clinical predictors of long-term weight loss in ambulatory patients with NAFLD. Methods We retrospectively reviewed 924 non-cirrhotic patients with NAFLD presenting to a liver clinic from May 1st 2007 to April 30th 2013. Overweight and obese patients were counseled on lifestyle modifications for weight loss as per USPSTF guidelines. The primary outcome was percent weight change between the first and last recorded visits: % weight change  =  (weightinitial – weightfinal)/(weightinitial). Baseline BMI and percent BMI change were secondary measures. Predictors of weight loss were determined using logistic regression. Results The mean baseline BMI was 33.3±6.6 kg/m2, and the mean follow-up duration was 17.3±17.6 months. Most patients with NAFLD were in either overweight (26.1%) or class I obesity (30.5%) categories at baseline, while the prevalence of underweight and class III obesity was lower (0.2% and 15.4%, respectively). Overall, there was no change in mean weight or BMI during the follow-up period, and only 183 patients (19.8%) lost at least 5% body weight during the follow up period. Independent predictors of weight loss included number of clinic visits and baseline BMI, and patients with higher baseline BMI required more clinic visits to lose weight. Conclusions Weight loss is largely unsuccessful in NAFLD patients in the ambulatory care setting. Frequent clinical encounters are associated with weight reduction, especially among individuals with high baseline BMI. Future studies are required to define effective weight loss strategies in NAFLD patients.

Hospitalizations and testing in gastroparesis

Background and Aim:  Gastroparesis significantly impairs the quality of life in affected individuals and may lead to repeat hospitalizations due to refractory symptoms. We hypothesized that pain is a key reason for emergency encounters and diagnostic testing.

Admission hematocrit and rise in blood urea nitrogen at 24 h outperform other laboratory markers in predicting persistent organ failure and pancreatic necrosis in acute pancreatitis: A post hoc analysis of three large prospective databases

OBJECTIVES:Predicting severe acute pancreatitis (AP) remains a challenge. The present study compares admission blood urea nitrogen (BUN), hematocrit, and creatinine, as well as changes in their levels over 24 h, aiming to determine the most accurate laboratory test for predicting persistent organ failure and pancreatic necrosis.METHODS:Clinical data of 1,612 AP patients, enrolled prospectively in three independent cohorts (University of Pittsburgh, Brigham and Women’s Hospital, Dutch Pancreatitis Study Group), were abstracted. The predictive accuracy of the studied laboratories was measured using area under the receiver-operating characteristic curve (AUC) analysis. A pooled analysis was conducted to determine their impact on the risk for persistent organ failure and pancreatic necrosis. Finally, a classification tree was developed on the basis of the most accurate laboratory parameters.RESULTS:Admission hematocrit ≥44% and rise in BUN at 24 h were the most accurate in predicting persistent organ failure (AUC: 0.67 and 0.71, respectively) and pancreatic necrosis (0.66 and 0.67, respectively), outperforming the other laboratory parameters and the acute physiology and chronic health evaluation-II score. In a pooled analysis, admission hematocrit ≥44% and rise in BUN at 24 h were associated with an odds ratio of 3.54 and 5.84 for persistent organ failure, and 3.11 and 4.07, respectively, for pancreatic necrosis. In addition, the classification tree illustrated that when both admission hematocrit was ≥44% and BUN levels increased at 24 h, the rates of persistent organ failure and pancreatic necrosis reached 53.6% and 60.3%, respectively.CONCLUSIONS:Admission hematocrit ≥44% and rise in BUN at 24 h may be the optimal predictive tools in clinical practice among existing laboratory parameters and scoring systems.

Clinical outcomes of isolated renal failure compared to other forms of organ failure in patients with severe acute pancreatitis

AIM To assess differences in clinical outcomes of isolated renal failure (RF) compared to other forms of organ failure (OF) in patients with severe acute pancreatitis (SAP). METHODS Using a prospectively maintained database of patients with acute pancreatitis admitted to a tertiary medical center between 2003 and 2016, those with evidence of persistent OF were classified to renal, respiratory, cardiovascular, or multi-organ (2 or more organs). Data regarding demographics, comorbidities, etiology of acute pancreatitis, and clinical outcomes were prospectively recorded. Differences in clinical outcomes after development of isolated RF in comparison to other forms of OF were determined using independent t and Mann-Whitney U tests for continues variables, and χ2 test for discrete variables. RESULTS Among 500 patients with acute pancreatitis, 111 patients developed persistent OF: mean age was 54 years, and 75 (67.6%) were male. Forty-three patients had isolated OF: 17 (15.3%) renal, 25 (21.6%) respiratory, and 1 (0.9%) patient with cardiovascular failure. No differences in demographics, etiology of acute pancreatitis, systemic inflammatory response syndrome scores, or development of pancreatic necrosis were seen between patients with isolated RF vs isolated respiratory failure. Patients with isolated RF were less likely to require nutritional support (76.5% vs 96%, P = 0.001), ICU admission (58.8% vs 100%, P = 0.001), and had shorter mean ICU stay (2.4 d vs 15.7 d, P < 0.001), compared to isolated respiratory failure. None of the patients with isolated RF or isolated respiratory failure died. CONCLUSION Among patients with SAP per the Revised Atlanta Classification, approximately 15% develop isolated RF. This subgroup seems to have a less protracted clinical course compared to other forms of OF. Isolated RF might be weighed less than isolated respiratory failure in risk predictive modeling of acute pancreatitis.

Su1250 Inflammatory Bowel Disease and Selective Immunoglobulin a Deficiency

Introduction: The pathogenesis of inflammatory bowel disease (IBD) is related to an unchecked inflammatory response in the gut mediated by tumor necrosis factor alpha (TNFa). Infliximab, an anti-TNFa chimeric IgGmonoclonal antibody, is a staple therapy for moderateto-severe IBD. Recent literature describes obesity as a low-grade inflammatory state as adipose tissue releases cytokines including TNFa. The purpose of this study was to determine if there is greater failure rate of infliximab therapy in obese IBD patients given theoretical increased TNFa activity. Methods: A retrospective study was performed. 103 patients who received infliximab from 2006-2012 were identified. Patient were grouped based on BMI (group 1 BMI , 18.5, group 2 BMI 18.5-25, group 3 BMI 25-30, group 4 BMI . 40). Logistic regression was performed on outcomes of the impact of weight and body mass index on surgery and loss of clinical response within one year of initiation of infliximab. Linear regression was performed on the impact of weight and body mass index on length of time of durable response of infliximab. Results: 52 women and 51 men were evaluated. The average age of the patient population when diagnosed with IBD was 26.38 years old (STD +/12.9). The average age of initiation of infliximab therapy was 33.7 years old (STD +/-13.1) with mean disease duration of 11 years (STD +/-10.79). Average BMI was 23.76lbs/ in2 (STD +/-4.44) with average weight of 155.6lbs (STD +/-38.6lbs). Average duration of infliximab therapy was 17 months (STD +/-13.67). There were no patients in group 4 (BMI . 30) that required surgery or hospitalization for complications of IBD within 1 year of initiating infliximab. Among all groups, there was no statistical significance in surgical requirements for IBD complications at 1 year. There was no significant relationship between BMI and duration of infliximab treatment, though there was a trend towards shorter duration in patients with normal BMI. Finally, there was no significant difference in ESR and CRP at 1 month into infliximab treatment across all BMI groups. Conclusions: IBD and obesity are two separate inflammatory states with shared elevated TNFa activity. This study demonstrated no statistical difference in failure rates within anti-TNFa treatment with infliximab in patients with different BMIs as measured by hospitalization and surgery secondary to complications of IBD at 1 year of therapy initiation. This study would benefit from an increase the sample size to determine if there is significance in these outcomes.