Edward L. Barnes

Impact of capsule endoscopy on management of inflammatory bowel disease: a single tertiary care center experience.

Background: Capsule endoscopy (CE) is performed to assess inflammatory bowel disease (IBD). We aimed to define the results of CE in subtypes of IBD and to determine whether CE results in management changes. Methods: A retrospective cohort study was performed of all CEs for IBD at a tertiary care center from 2003–2009. Descriptive statistics were used to compare IBD‐specific medications, surgeries, and imaging studies in the 3 months prior and 3 months after CE. Results: Of 907 CEs performed from 2003–2009, 128 were for an indication of symptomatic IBD and 124 capsules left the stomach (86 for Crohns disease [CD], 15 for indeterminate colitis [IC], 23 for pouchitis). Only 22.1% of CEs done for CD were normal, as compared to 53.3% for IC and 34.8% for pouchitis. Severe findings in CD consisted of multiple aphthae/ulcers (22.1%), stenosis (8.1%), and stenosis with immediate retention (17.4%). In CD, 61.6% had a change in medication in the 3 months after the CE, with 39.5% initiating a new IBD medication, most commonly budesonide or corticosteroids. In the 3 months following CE, 12.8% of patients with CD underwent surgery. Severe findings on CE in patients with CD, as compared to no/minimal findings, resulted in significant differences in medication changes (73.2% versus 51.1%, P = 0.04), addition of medications (58.5% versus 22.2%, P < 0.01), and surgeries (21.9% versus 4.4%, P = 0.01). Conclusions: CE results in management changes in the majority of cases of symptomatic IBD, regardless of the subtype of IBD. (Inflamm Bowel Dis 2011;)

Are patients with inflammatory bowel disease on chronic immunosuppressive therapy at increased risk of cervical high-grade dysplasia/cancer? A meta-analysis.

Background:Immunosuppression is a mainstay of therapy for both induction and maintenance of remission for inflammatory bowel disease (IBD). Women who are chronically immunosuppressed have been shown to be at higher risk of developing cervical high-grade dysplasia and/or carcinoma. There is contradictory data whether immunosuppressed patients with IBD have the same risk profile for cervical cancer as patients with solid organ transplant or HIV infection. Objective:To determine whether the risk of cervical high-grade dysplasia and/or cancer is higher in patients with IBD on immunosuppressive therapy compared with the rates in the general population. Methods:The studies were restricted to full-text retrospective cohort studies and case controls that had a high (6–9) Newcastle-Ottawa Score. Results:All pooled analyses were based on a random-effects model. Five cohort studies and 3 case–control studies of patients with IBD on any immunosuppression with cervical high-grade dysplasia/cancer (n = 995) were included in the meta-analysis. The total IBD population in these studies was 77,116. Patients with IBD had an increased risk of cervical high-grade dysplasia/cancer compared with healthy controls (odds ratio = 1.34, 95% confidence interval: 1.23–1.46). Heterogeneity was detected (I2 = 34.23, Q = 10.64, df = 7; P = 0.15). The source was found to be the type of study, as well as the odds ratio presented (crude versus adjusted). Conclusions:There is sufficient evidence to suggest an increased risk of cervical high-grade dysplasia/cancer in patients with IBD on immunosuppressive medications compared with the general population. Given this increased risk, increased screening intervals are indicated.

Narcotic use for inflammatory bowel disease and risk factors during hospitalization.

Background: Growing evidence demonstrates the adverse effects of narcotics in inflammatory bowel disease (IBD). We sought to study the relationship between narcotic use, objective measures of disease activity, and other associated factors in hospitalized patients with IBD. Methods: We performed a retrospective cohort study of all adult IBD patients admitted to a general medical or surgical ward service at a United States tertiary care center over a 1‐year period. We collected demographic and disease‐specific information, inpatient narcotic use, and disease activity measurements from endoscopic and radiologic reports. Bivariate comparisons were made between characteristics and narcotic use. Logistic regression was used to evaluate the independent effects of characteristics on narcotic use. Results: A total of 117 IBD patients were included. Narcotics were given to 70.1% of hospitalized patients. Factors significantly associated with any inpatient narcotic use: Crohns disease (CD); P ≤ 0.01, duration of IBD, P = 0.02, prior psychiatric diagnosis, P = 0.02, outpatient narcotic use, P ≤ 0.01, current smoking, P ≤ 0.01, prior IBD‐specific surgery, P < 0.02, and prior IBD / irritable bowel syndrome (IBS) diagnosis, P = 0.02. Narcotic use was not significantly associated with disease severity on computed tomography (CT) scan or endoscopy. On multivariate analysis, smoking (odds ratio [OR] 4.34, 95% confidence interval [CI] 1.21–15.6) and prior outpatient narcotic use (OR 5.41, 95% CI 1.54–19.0) were independently associated with inpatient narcotic use. Conclusions: A majority of patients with IBD are prescribed narcotics during hospitalization in spite of data on increased complications. Risk factors for narcotic use include CD and associated factors (disease duration, surgeries), substance abuse (outpatient narcotics and smoking), psychiatric diagnoses, and IBD‐IBS. (Inflamm Bowel Dis 2011;)

Depression Is Associated With More Aggressive Inflammatory Bowel Disease

Objectives:Depression is prevalent in inflammatory bowel disease (IBD) patients. The impact of depression on IBD is not well-studied. It is unknown how providers should assess depression.Methods:We used data from the Sinai–Helmsley Alliance for Research Excellence cohort, to assess methods of diagnosing depression and effects of baseline depression on disease activity at follow-up. A patient health questionnaire (PHQ-8) score ≥5 was consistent with mild depression. Relapse was defined as a modified Harvey–Bradshaw Index ≥5 or Simple Clinical Colitis Activity Index >2. We performed binomial regression to calculate adjusted risk ratios (RRs).Results:We included 2,798 Crohn’s disease (CD) patients with 22-month mean follow-up and 1,516 ulcerative colitis (UC) patients with 24-month mean follow-up. A total of 64% of CD patients and 45% of UC patients were in remission at baseline. By self-report, 20% of CD and 14% of UC patients were depressed. By PHQ-8, 38% of CD and 32% of UC patients were depressed (P<0.01). Adjusted for sex, remission, and disease activity, CD patients with baseline depression were at an increased risk for relapse (RR: 2.3; 95% confidence interval (CI): 1.9–2.8), surgery, or hospitalization (RR: 1.3 95% CI: 1.1–1.6) at follow-up. UC patients with baseline depression were also at increased risk for relapse (RR: 1.3; 95% CI: 0.9–1.7), surgery, or hospitalization (RR: 1.3; 95% CI: 1.1–1.5) at follow-up.Conclusions:Baseline depression is associated with a higher risk for aggressive IBD at follow-up. A single question is not a sensitive method of assessing depression. Providers should consider administering the PHQ-8 to capture those at greater risk for aggressive disease.

Modifiable Risk Factors for Hospital Readmission Among Patients with Inflammatory Bowel Disease in a Nationwide Database

Background: Previous studies suggest that disease activity alone does not reliably predict hospital readmission among patients with inflammatory bowel diseases (IBDs). Using a national database, we aimed to further describe the burden of readmissions for IBD and identify modifiable risk factors. Methods: We performed a retrospective cohort study using 2013 data from the Nationwide Readmission Database (NRD). Using International Classification of Diseases, ninth Revision, Clinical Modification (ICD-9-CM) codes, we identified adult patients with discharge diagnoses of ulcerative colitis or Crohns disease and ascertained diagnoses of anxiety, depression, chronic pain, tobacco use, and other comorbidities during index admission. Logistic regression was used to estimate factors associated with hospital readmission. Results: Among 52,498 hospitalizations of patients with IBD (63% Crohns disease and 37% ulcerative colitis), 12,407 (24%) were readmitted within 90 days of the index hospitalization, resulting in roughly

Hospitalizations for Acute Myocardial Infarction Are Decreased Among Patients with Inflammatory Bowel Disease Using a Nationwide Inpatient Database.

576 million in excess charges. In multivariable analysis of patients with Crohns disease, anxiety (odds ratio [OR] 1.31, 95% confidence interval [CI], 1.21–1.43), depression (OR 1.27, 95% CI, 1.07–1.50), chronic pain (OR 1.31, 95% CI, 1.18–1.46), and tobacco abuse (OR 1.13, 95% CI, 1.06–1.22) were associated with a significant increase in odds of readmission. Among patients with ulcerative colitis, anxiety (OR 1.28, 95% CI, 1.14–1.45), depression (OR 1.35, 95% CI, 1.07–1.70), and chronic pain (OR 1.44, 95% CI, 1.21–1.73) were associated with a significant increase in odds of readmission. Conclusions: Readmission occurs frequently in patients with IBD and is costly. Anxiety, depression, and chronic pain may represent targets for interventions to prevent 90-day hospital readmission in this population.

The risk of inflammatory bowel disease flares after fecal microbiota transplantation: Systematic review and meta-analysis

Background:Questions remain regarding the true prevalence of cardiovascular events such as myocardial infarction (MI) among patients with inflammatory bowel disease (IBD). Using the Nationwide Inpatient Sample (NIS), we aimed to compare the proportion of hospitalizations for acute MI among patients with IBD with that of the general population. Methods:This study used data from years 2000 to 2011 in Nationwide Inpatient Sample, the largest publicly available all-payer inpatient database in the United States. International Classification of Diseases, Ninth Revision, Clinical Modification discharge codes were used to identify adult patients with discharge diagnoses of IBD (ulcerative colitis or Crohns disease), acute MI, and multiple comorbid risk factors for cardiovascular disease. The independent effect of a diagnosis of IBD on risk of acute MI was examined using a multivariable logistic regression model controlling for multiple confounders. Data were analyzed using SAS survey procedures and weighted to reflect national estimates. Results:We identified 567,438 hospitalizations among patients with IBD and 78,121,000 hospitalizations among the general population. Patients with IBD were less likely to be hospitalized for acute MI than patients in the general population (1.3% versus 3.1%, P < 0.001). In adjusted analyses, the odds of hospitalization for acute MI among patients with IBD were decreased when compared with the general population (odds ratio, 0.51; 95% confidence interval, 0.50–0.52). Conclusions:Despite prior reports of a potentially increased risk of acute MI among patients with IBD, in a nationwide inpatient database, lower rates of acute MI were demonstrated in the IBD population when compared with the general population.

High Dietary Intake of Specific Fatty Acids Increases Risk of Flares in Patients With Ulcerative Colitis in Remission During Treatment With Aminosalicylates

ABSTRACT Several studies have suggested worsening in inflammatory bowel disease (IBD) activity following fecal microbiota transplantation (FMT). We aimed to assess the risk of worsening in IBD activity following FMT. An electronic search was conducted using MEDLINE (1946-June 2016), EMBASE (1954-June 2016) and Cochrane Central Register of Controlled Trials (2016). Studies in which FMT was provided to IBD patients for IBD management or (Clostridium difficile infection) CDI treatment were included. The primary outcome was the rate of worsening in IBD activity. Results: Twenty-nine studies with 514 FMT-treated IBD patients were included. Range of follow up was 4 weeks to 3 y. The pooled rate of IBD worsening was 14.9% (95% CI 10–21%). Heterogeneity was detected: I2 D 52.1%, Cochran Q test D 58.1, p D 0.01. A priori subgroup analyses were performed. Although not significant, the pooled rate of worsening in IBD activity following FMT for CDI (22.7% (95% CI: 13–36%)) was higher compared with FMT for IBD (11.1% (95% CI 7–17%)). Rates of worsening in IBD after lower GI FMT delivery revealed a higher rate of worsening in IBD activity (16.5% (95% CI: 11–24%)) compared with upper GI delivery (5.6% (95% CI: 2–16%)). Rates of worsening in high quality studies and randomized controls trials (RCTS) suggested a marginal risk of worsening in IBD activity (4.6%, (95% CI: 1.8–11%). Rates of IBD worsening are overall marginal across high quality RCTS. It is unknown if the FMT itself led to the worsening of IBD in this small fraction or if this represents alternative etiologies.

New Biomarkers for Diagnosing Inflammatory Bowel Disease and Assessing Treatment Outcomes.

BACKGROUND & AIMS: Dietary factors may have a significant role in relapse of disease among patients with ulcerative colitis (UC). However, the relationship between diet and UC is inadequately understood. We analyzed data from the diet’s role in exacerbations of mesalamine maintenance study to determine whether dietary factors affect the risk of disease flares in patients with UC. METHODS: We performed a prospective, multicenter, observational study of 412 patients, from 25 sites, with UC in remission during monotherapy with an aminosalicylate. Patients completed a validated food frequency questionnaire at enrollment and were followed for 12 months. We analyzed the relationship between diet and disease remission or flare for groups of macronutrients and micronutrients, and food groups previously associated with an increased risk of flare. RESULTS: Forty‐five patients (11%) had a UC relapse within 1 year of study enrollment. When analyzed in tertiles, increasing intake of multiple fatty acids was associated with increasing odds of relapse. In multivariable logistic regression analysis, only myristic acid (odds ratio, 3.01; 95% confidence interval, 1.17–7.74) maintained this dose–response relationship. Other foods previously implicated in flares of UC, such as processed meat, alcohol, and foods high in sulfur, were not associated with an increased risk of flare. CONCLUSIONS: In a prospective study of more than 400 patients with UC undergoing treatment with aminosalicylates, we associated high dietary intake of specific fatty acids, including myristic acid (commonly found in palm oil, coconut oil, and dairy fats) with an increased risk of flare. These findings can help design interventional studies to evaluate dietary factors in UC.

Use of blood based biomarkers in the evaluation of Crohn's disease and ulcerative colitis.

Abstract:Despite advances in our understanding of the pathophysiology underlying inflammatory bowel disease, there remains a significant need for biomarkers that can differentiate between Crohns disease and ulcerative colitis with high sensitivity and specificity, in a cost-efficient manner. As the focus on personalized approaches to the delivery of medical treatment increases, new biomarkers are being developed to predict an individuals response to therapy and their overall disease course. In this review, we will outline many of the existing and recently developed biomarkers, detailing their role in the assessment of patients with inflammatory bowel disease. We will identify opportunities for improvement in our biomarkers, including better differentiation between the subtypes of inflammatory bowel disease. We will also discuss new targets and strategies in biomarker development, including combining modalities to create biomarker signatures to improve the ability to predict disease courses and response to therapy among individual patients.