Claudia Ramos-Rivers

Association of Vitamin D Level With Clinical Status in Inflammatory Bowel Disease: A 5-Year Longitudinal Study.

OBJECTIVES:Emerging data suggest that vitamin D has a significant role in inflammatory bowel disease (IBD). Prospective data evaluating the association of vitamin D serum status and disease course are lacking. We sought to determine the relationship between vitamin D status and clinical course of IBD over a multiyear time period.METHODS:IBD patients with up to 5-year follow-up from a longitudinal IBD natural history registry were included. Patients were categorized according to their mean serum 25-OH vitamin D level. IBD clinical status was approximated with patterns of medication use, health-care utilization, biochemical markers of inflammation (C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)), pain and clinical disease activity scores, and health-related quality of life.RESULTS:A total of 965 IBD patients (61.9% Crohn’s disease, 38.1% ulcerative colitis) formed the study population (mean age 44 years, 52.3% female). Among them, 29.9% had low mean vitamin D levels. Over the 5-year study period, subjects with low mean vitamin D required significantly more steroids, biologics, narcotics, computed tomography scans, emergency department visits, hospital admissions, and surgery compared with subjects with normal mean vitamin D levels (P<0.05). Moreover, subjects with low vitamin D levels had worse pain, disease activity scores, and quality of life (P<0.05). Finally, subjects who received vitamin D supplements had a significant reduction in their health-care utilization.CONCLUSIONS:Low vitamin D levels are common in IBD patients and are associated with higher morbidity and disease severity, signifying the potential importance of vitamin D monitoring and treatment.

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.

The Influence of Anti-tumor Necrosis Factor Agents on Hemoglobin Levels of Patients with Inflammatory Bowel Disease.

Background:Anti–tumor necrosis factor (TNF) agents are an important component of inflammatory bowel disease (IBD) treatment, but data on their influence on anemia, a frequent complication of IBD, are limited. The aim of this study was to evaluate the effect of anti-TNF agents on hemoglobin (Hb) levels in a large IBD cohort. Methods:Prospectively collected demographic, clinical, laboratory, and treatment data from IBD patients who started anti-TNF treatment at a tertiary referral center during the years 2010 to 2012 were analyzed. Follow-up data including disease activity scores (Harvey–Bradshaw index or ulcerative colitis activity index), quality of life scores (short IBD questionnaire) completed at each visit, and laboratory data were analyzed. Data from the year of anti-TNF initiation (yr 0) to the following year (yr 1) were compared. Results:A total of 430 IBD patients (324 with Crohns disease, 51.6% females) started anti-TNF treatment. The prevalence of anemia and median Hb levels did not change between years 0 and 1. Median short IBD questionnaire was significantly improved at year 1 (P = 0.002). IBD patients with anemia had significantly higher median Hb levels at year 1 compared with year 0 (P = 0.0009). Hematopoietic response (increase of Hb ≥2 g/dL) was observed in only 33.6% of the 134 anemic IBD patients, despite iron replacement being administered in 126 anemic patients (oral, 77%). Improvement in Hb levels was independently significantly correlated with change of C-reactive protein levels (P = 0.04) and immunomodulator use (P = 0.03). Conclusions:Anemia remains a significant manifestation of IBD 1 year after treatment with anti-TNF agents.

Five-Year Period Prevalence and Characteristics of Anemia in a Large US Inflammatory Bowel Disease Cohort.

Background: Anemia is a common manifestation of inflammatory bowel disease (IBD), but its prevalence in the United States is not well defined. Aim of this study was to determine the prevalence and characteristics of anemia in IBD patients who were followed in a US referral center. Materials and Methods: Demographic, clinical, laboratory, and treatment data from a prospective, consented longitudinal IBD registry between the years 2009 and 2013 were analyzed. Disease activity was evaluated using Harvey-Bradshaw index in Crohn’s disease (CD) and ulcerative colitis (UC) activity index in UC as well as C-reactive protein and erythrocyte sedimentation rate. Anemia was defined based on the World Health Organization criteria. Results: A total of 1821 IBD patients (1077 with CD, 744 with UC, median age 43.8 y, 51.9% female) were included. The 5-year period prevalence of anemia in IBD patients was 50.1%, (CD: 53.3% vs. UC: 44.7%, P=0.001). In multivariate logistic regression analysis, anemia was associated with surgery for IBD [odds ratio (OR)=2.77; 95% confidence interval (CI), 2.21-3.48; P<0.0001], female gender (OR=1.29; 95% CI, 1.04-1.61; P=0.02), C-reactive protein (OR=1.26; 95% CI, 1.16-1.37; P<0.0001), erythrocyte sedimentation rate (OR=1.02; 95% CI, 1.01-1.03; P=0.0002), and use of biologics (OR=2.00; 95% CI, 1.58-2.52; P=0.0001) or immunomodulators (OR=1.51; 95% CI, 1.21-1.87; P=0.0003). Iron replacement therapy was administered to 46.8% of the anemic patients. Conclusion: Anemia has a high period prevalence in IBD patients followed at a tertiary center. Anemia is more common in CD than in UC, is associated with disease activity, and in current practice is undertreated.

Multiyear Patterns of Serum Inflammatory Biomarkers and Risk of Colorectal Neoplasia in Patients with Ulcerative Colitis.

Background:Patients with ulcerative colitis (UC) are at increased risk of colorectal neoplasia (CRN) presumably because of chronic inflammation. Data on the relationship between long-term serum inflammatory biomarkers and the development of CRN in UC are limited. Methods:We performed a 5-year study (2009–2013) of demographic, clinical, laboratory, and treatment data of patients with UC from an inflammatory bowel disease registry in relation to the development of CRN. Disease activity was evaluated by UC activity index and by serum biomarkers such as C-reactive protein (CRP), erythrocyte sedimentation rate, hemoglobin, platelets, and albumin levels. A score based on the combination of median CRP and median albumin levels (0: both normal, 1: one of them abnormal, 2: both abnormal) was also evaluated. Results:A total of 773 patients with UC (median age 46 yr, 46.4% women) were included. Fifty-five patients (7.1%) developed CRN. Patients with UC and CRN had significantly higher median CRP, erythrocyte sedimentation rate, and platelets and lower hemoglobin and albumin levels compared with those without CRN. The prevalence of a CRP-albumin score (1 or 2) was significantly higher in the CRN group (40.0% or 30.9% versus 14.2% or 6.0%, respectively, P < 0.0001). In the multivariate logistic regression analysis, CRN was associated with male gender (P = 0.01), disease duration (P = 0.04), extensive colitis (P = 0.03), concomitant primary sclerosing cholangitis (P = 0.0003), median albumin levels (P = 0.03), and an increased CRP-albumin score (score 1 or 2) (P = 0.0002). Conclusions:Long-term serum inflammatory markers including the CRP-albumin score are associated with increased risk of CRN in patients with UC.

Quality of Sleep and Coexistent Psychopathology Have Significant Impact on Fatigue Burden in Patients With Inflammatory Bowel Disease

Background: Fatigue is common in inflammatory bowel disease (IBD) patients and is associated with factors such as psychopathology, sleep quality, and disease activity. Goal: To investigate the combined role of all the above factors in the burden of fatigue among IBD patients. Study: We conducted an observational study of adult patients enrolled in an IBD clinical research registry at a tertiary care clinic. Fatigue burden was defined by Item 1 of the Short-form IBD Questionnaire (SIBDQ), which is scored on a 7-point Likert scale. Crohn’s disease (CD) and ulcerative colitis (UC) disease activity were measured with the Harvey-Bradshaw Index or the UC Activity Index, respectively. Labs were obtained to assess anemia, vitamin deficiencies, and inflammatory markers. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Use of psychotropic medications and narcotics was used as proxy measure of psychopathology and pain. Results: Among 685 IBD patients enrolled in the registry, 631 (238 UC, 393 CD) had a complete SIBDQ. High fatigue burden was found in 57.5% of patients (64.4% CD, 46.2% UC). Fatigue burden was significantly associated with sleep disturbance (PSQI), SIBDQ, and disease activity. CD patients had more fatigue burden than UC patients. Multivariate regression showed that poor quality of life, sleep disturbance, and being on a psychotropic medication are significantly associated with fatigue burden for both UC and CD. Conclusion: Because fatigue is common in IBD patients, these findings suggest that attention to quality of sleep and psychopathology is as important as medical disease management.

Low Rates of Dermatologic Care and Skin Cancer Screening Among Inflammatory Bowel Disease Patients

BackgroundDermatologic manifestations of inflammatory bowel disease (IBD) are common, and certain IBD medications increase the risk of skin cancer.AimsTo define the rates of care and factors associated with dermatologic utilization with a focus on skin cancer screening.MethodsWe utilized a prospective, natural history IBD research registry to evaluate all outpatient healthcare encounters from 2010 to 2016. Gastrointestinal, dermatologic and primary care visits per individual were identified. We calculated the proportion of patients obtaining care, categorized primary indications for dermatologic visits, determined the incidence of melanoma and non-melanoma skin cancers, and used logistic regression to determine factors associated with dermatology utilization.ResultsOf the 2127 IBD patients included, 452 (21.3%) utilized dermatology over the study period, and 55 (2.6%) had a total body skin examination at least once. The 452 patients incurred 1633 dermatology clinic visits, 278 dermatologic procedures, and 1108 dermatology telephone encounters. The most frequent indication was contact dermatitis or dermatitis. Factors associated with dermatology use were family history of skin cancer, employment, systemic steroids, longer disease duration, emergency room use, and the number of IBD-related clinic visits. Between 8.3 and 11% of IBD patients recommended for skin cancer screening visited dermatology each year, and the resulting incidence of non-melanoma skin cancer was 35.4/10,000 [95% CI 23.3–51.5] and melanoma was 6.56/10,000 [95% CI 2.1–15.3].ConclusionsLess than one in ten IBD patients obtain dermatologic care. Given the increased risk of skin cancers among IBD patients, an emphasis on education, prevention, and screening merits attention.

Lasting Impact of Clostridium difficile Infection in Inflammatory Bowel Disease: A Propensity Score Matched Analysis.

Background: Patients with inflammatory bowel disease are at an increased risk of Clostridium difficile infection (CDI), but the impact of CDI on disease severity is unclear. The aim of this study was to determine the effect of CDI on long-term disease outcome in a matched cohort of patients with inflammatory bowel disease. Methods: Patients who tested positive for infection formed the CDI-positive group. We generated a 1:2 propensity matched case to control cohort based on risk factors for CDI in the year before infection. Health care utilization data (emergency department use, hospitalizations, and telephone encounters), medications, laboratories, disease activity, and quality-of-life metrics were compared by CDI status. Results: A total of 198 patients (66 CDI and 132 matched controls) were included (56.6% women; 60.1% Crohns disease, and 39.9% ulcerative colitis). In the year of infection, having CDI was significantly associated with more steroid and antibiotic exposure, elevated C-reactive protein or erythrocyte sedimentation rate, low vitamin D, increased disease activity, worse quality of life, and increased health care utilization (all P < 0.01). During the next year after infection, patients with CDI continued to have increased exposure to CDI-targeted antibiotics (P < 0.001) and other antibiotics (P = 0.02). They also continued to have more clinic visits (P = 0.02), telephone encounters (P = 0.001), and increased health care financial charges (P = 0.001). Conclusions: CDI in inflammatory bowel disease is significantly associated with markers of disease severity, increased health care utilization and poor quality of life during the year of infection, and a 5-fold increase in health care charges in the year after infection (see Video Abstract, Supplemental Digital Content, http://links.lww.com/IBD/B658).

Ileocecal Anastomosis Type Significantly Influences Long-Term Functional Status, Quality of Life, and Healthcare Utilization in Postoperative Crohn's Disease Patients Independent of Inflammation Recurrence.

Objectives:Anastomotic reconstruction following intestinal resection in Crohn’s disease (CD) may employ side-to-side anastomosis (STSA; anti-peristaltic orientation) or end-to-end anastomosis (ETEA). Our aim was to determine the impact of these two anastomotic techniques on long-term clinical status in postoperative CD patients.Methods:We performed a comparative effectiveness study of prospectively collected observational data from consented CD patients undergoing their first or second ileocolonic bowel resection and re-anastomosis between 2008 and 2012, in order to assess the association between anastomosis type and 2-year postoperative quality of life (QoL), healthcare utilization, disease clinical or endoscopic recurrence, use of medications, and need for repeat resection.Results:One hundred and twenty eight postoperative CD patients (60 STSA and 68 ETEA) were evaluated. At 2 years postoperatively, STSA patients had higher rates of emergency department visits (33.3% vs. 14.7%; P=0.01), hospitalizations (30% vs. 11.8%; P=0.01), and abdominal computed tomography scans (50% vs. 13.2%; P<0.001) with lower QoL (mean short inflammatory bowel disease questionnaire 47.9 vs. 53.4; P=0.007). There was no difference among the two groups in the 30 day surgical complications and 2-year patterns of disease activity, CD medication requirement, endoscopic recurrence, and need for new surgical management (all P > 0.05).Conclusions:At 2 years postoperatively, CD patients with ETEA demonstrated better QoL and less healthcare utilization compared with STSA, despite having similar patterns of disease recurrence and CD treatment. These findings suggest that surgical reconstruction of the bowel as an intact tube (ETEA) contribute to improved functional and clinical status in patients with CD.

The Association Between Sustained Poor Quality of Life and Future Opioid Use in Inflammatory Bowel Disease

Abstract Background Inflammatory bowel disease (IBD) is associated with poor quality of life and disability. The short inflammatory bowel disease questionnaire (SIBDQ) is validated to determine patients quality of life at single time points, or improvement over time. Few studies have evaluated if sustained poor quality of life is associated with future healthcare utilization patterns. Methods We analyzed patients from a prospective IBD natural history registry with 4 consecutive years of follow-up. SIBDQ was measured at outpatient visits. Healthcare utilization data were temporally organized into a 2-year observation period, and 2-year follow-up period. Mean SIBDQ score <50 during the first 2 years was categorized as having “poor quality of life”. Primary outcomes of interest were measures of unplanned healthcare utilization and opioid use. Results From a total of 447 participants (56.1% female, 66.1% Crohn’s disease, 34.9% ulcerative colitis), 215 (48.1%) were classified as having poor quality of life. Poor quality of life was significantly associated with Crohn’s disease (P < 0.01), history of IBD related surgery, and tobacco use (all P < 0.01). In the follow-up period, the same patients with poor quality of life were more likely to have abnormal biomarkers of inflammation, more telephone calls and office visits, experience unplanned care, and be exposed to opiates (all P < 0.05). After multivariable analysis, poor quality of life remained an independent predictor of future opiate use (odds ratio: 2.2, P = 0.003) and decreased time to first opiate prescription (hazard ratio: 1.67, P = 0.019) in the follow-up period. Conclusions IBD patients with sustained poor quality of life are at an increased risk of opiate use and decreased time to opiate exposure. Routine measurement of quality of life in the outpatient setting may provide insight into those at risk for narcotic use and healthcare utilization.