Chelle L. Wheat

Trends in Hospitalization for Diverticulitis and Diverticular Bleeding in the United States From 2000 to 2010

BACKGROUND & AIMS Most studies of trends in diverticular disease have focused on diverticulitis or on a composite outcome of diverticulitis and bleeding. We aimed to quantify and compare the prevalence of hospitalization for diverticular bleeding and diverticulitis overall and by sex and race. METHODS We analyzed data from the Nationwide Inpatient Sample from 2000 through 2010. We identified adult patients with a discharge diagnosis of diverticular bleeding or diverticulitis. By using yearly US intercensal data, we calculated age-, sex-, and race-specific rates, as well as age-adjusted prevalence rates. RESULTS The prevalence of hospitalizations per 100,000 persons for diverticular bleeding decreased over the 10-year period from 32.5 to 27.1 (-5.4; 95% confidence interval, -5.1 to -5.7). The prevalence of hospitalizations for diverticulitis peaked in 2008 (74.1/100,000 in 2000, 96.0/100,000 in 2008, and 91.9/100,000 in 2010). The prevalence of diverticulitis was higher in women than in men, whereas women and men had similar rates of diverticular bleeding. The prevalence of diverticular bleeding was highest in blacks (34.4/100,000 in 2010); whereas the prevalence of diverticulitis was highest in whites (75.5/100,000 in 2010). CONCLUSIONS Over the past 10 years, the prevalence of hospitalizations for diverticulitis increased and then plateaued, whereas that of diverticular bleeding decreased. The prevalence according to sex and race differed for diverticulitis and diverticular bleeding. These findings indicate different mechanisms of pathogenesis for these disorders.

Adherence to Competing Strategies for Colorectal Cancer Screening Over 3 Years.

Objectives:We have shown that, in a randomized trial comparing adherence to different colorectal cancer (CRC) screening strategies, participants assigned to either fecal occult blood testing (FOBT) or given a choice between FOBT and colonoscopy had significantly higher adherence than those assigned to colonoscopy during the first year. However, how adherence to screening changes over time is unknown.Methods:In this trial, 997 participants were cluster randomized to one of the three screening strategies: (i) FOBT, (ii) colonoscopy, or (iii) a choice between FOBT and colonoscopy. Research assistants helped participants to complete testing only in the first year. Adherence to screening was defined as completion of three FOBT cards in each of 3 years after enrollment or completion of colonoscopy within the first year of enrollment. The primary outcome was adherence to assigned strategy over 3 years. Additional outcomes included identification of sociodemographic factors associated with adherence.Results:Participants assigned to annual FOBT completed screening at a significantly lower rate over 3 years (14%) than those assigned to colonoscopy (38%, P<0.001) or choice (42%, P<0.001); however, completion of any screening test fell precipitously, indicating the strong effect of patient navigation. In multivariable logistic regression analysis, being randomized to the choice or colonoscopy group, Chinese language, homosexuality, being married/partnered, and having a non-nurse practitioner primary care provider were independently associated with greater adherence to screening (P<0.01).Conclusions:In a 3-year follow-up of a randomized trial comparing competing CRC screening strategies, participants offered a choice between FOBT and colonoscopy continued to have relatively high adherence, whereas adherence in the FOBT group fell significantly below that of the choice and colonoscopy groups. Patient navigation is crucial to achieving adherence to CRC screening, and FOBT is especially vulnerable because of the need for annual testing.

Worldwide Incidence of Colorectal Cancer, Leukemia, and Lymphoma in Inflammatory Bowel Disease: An Updated Systematic Review and Meta-Analysis

Background/Aims. Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer (CRC). In addition, there may be an association between leukemia and lymphoma and IBD. We conducted a systematic review and meta-analysis of the IBD literature to estimate the incidence of CRC, leukemia, and lymphoma in adult IBD patients. Methods. Studies were identified by a literature search of PubMed, Cochrane Library, Medline, Web of Science, Scopus, EMBASE, and ProQuest Dissertations and Theses. Pooled incidence rates (per 100,000 person-years [py]) were calculated through use of a random effects model, unless substantial heterogeneity prevented pooling of estimates. Several stratified analyses and metaregression were performed to explore potential study heterogeneity and bias. Results. Thirty-six articles fulfilled the inclusion criteria. For CRC, the pooled incidence rate in CD was 53.3/100,000 py (95% CI 46.3–60.3/100,000). The incidence of leukemia was 1.5/100,000 py (95% CI −0.06–3.0/100,000) in IBD, 0.3/100,000 py (95% CI −1.0–1.6/100,000) in CD, and 13.0/100,000 py (95% CI 5.8–20.3/100,000) in UC. For lymphoma, the pooled incidence rate in CD was 0.8/100,000 py (95% CI −0.4–2.1/100,000). Substantial heterogeneity prevented the pooling of other incidence estimates. Conclusion. The incidence of CRC, leukemia, and lymphoma in IBD is low.

Educational Needs of Patients with Inflammatory Bowel Disease (IBD) and Non-Adherence to Medical Therapy-A Qualitative Study

Objective: Patients with IBD are at risk for serious complications when their disease is poorly managed. Patient non-adherence to medical therapy contributes to suboptimal outcomes, but may be modified through improved education. The primary aim of this study is to identify educational needs, and barriers and factors associated with non-adherence among inflammatory bowel disease (IBD) patients. Methods: Eighteen IBD patients and ten IBD providers were recruited. Semi-structured interviews were conducted and a qualitative framework approach used to identify patient educational needs, barriers to obtaining information, and factors associated with non-adherence with medical therapy. Results: Prevention of IBD symptoms and factors contributing to development of IBD were the most frequently identified patient educational needs. Both providers and patients identified diet and nutrition, as well as access to general information about IBD, as important areas of education. Common barriers to obtaining or conveying information for patients and providers included: information oversaturation, ineffective provider communication skills, and lack of provider time. Factors that impact patient comprehension and decision making were also identified. Providers frequently believed that patient non-adherence is associated with lack of current symptoms or denial of their chronic condition. Conclusion: Our findings highlight several deficits in knowledge in IBD patients. We also identify factors associated with IBD patient comprehension, decision making, and non-adherence to therapy. These results can be used to develop targeted educational resources to improve adherence among IBD patients. We propose that patient self-management programs are potentially effective educational interventions that warrant further study in IBD.

Inflammatory Bowel Disease (IBD) pharmacotherapy and the risk of serious infection: a systematic review and network meta-analysis

BackgroundThe magnitude of risk of serious infections due to available medical therapies of inflammatory bowel disease (IBD) remains controversial. We conducted a systematic review and network meta-analysis of the existing IBD literature to estimate the risk of serious infection in adult IBD patients associated with available medical therapies.MethodsStudies were identified by a literature search of PubMed, Cochrane Library, Medline, Web of Science, Scopus, EMBASE, and ProQuest Dissertations and Theses. Randomized controlled trials comparing IBD medical therapies with no restrictions on language, country of origin, or publication date were included. A network meta-analysis was used to pool direct between treatment comparisons with indirect trial evidence while preserving randomization.ResultsThirty-nine articles fulfilled the inclusion criteria; one study was excluded from the analysis due to disconnectedness. We found no evidence of increased odds of serious infection in comparisons of the different treatment strategies against each other, including combination therapy with a biologic and immunomodulator compared to biologic monotherapy. Similar results were seen in the comparisons between the newer biologics (e.g. vedolizumab) and the anti-tumor necrosis factor agents.ConclusionsNo treatment strategy was found to confer a higher risk of serious infection than another, although wide confidence intervals indicate that a clinically significant difference cannot be excluded. These findings provide a better understanding of the risk of serious infection from IBD pharmacotherapy in the adult population.Prospero registrationThe protocol for this systematic review was registered on PROSPERO (CRD42014013497).

Oral and Parenteral Corticosteroid Therapy in Ulcerative Colitis

Over the past 50 years, the widespread use of corticosteroids in the management of active ulcerative colitis (UC) has resulted in a dramatic mortality reduction. In the 1930s, mortality from UC was estimated to be up to 75 %, and this has decreased to less than 1 % in the twenty-first century. Similarly to other drugs used to treat autoimmune inflammatory disorders, corticosteroids were first used in the treatment of rheumatoid arthritis and then applied to inflammatory bowel disease.