Eric J. Vargas

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.

Silent Crohn's Disease: Asymptomatic Patients with Elevated C-reactive Protein Are at Risk for Subsequent Hospitalization.

Background:Patient-reported Crohns disease (CD) symptoms and endoscopic evaluation have historically guided routine care, but the risk of complications in asymptomatic patients with elevated C-reactive protein (CRP) is unknown. Methods:We conducted a prospective observational cohort study of patients with CD from a tertiary care center. Subjects with short inflammatory bowel disease questionnaire scores ≥50, Harvey–Bradshaw CD scores ⩽4, and same-day CRP measurement were eligible for inclusion. The primary outcome was disease-related hospitalization up to 24 months after the qualifying clinic visit. We assessed the relationship between CRP elevation and subsequent hospitalization. Results:There were 351 asymptomatic patients with CD (median age 40 yr; 50.4% female) who met inclusion criteria, and CRP was elevated in 19.7% of these individuals (n = 69). At 24 months, 16.8% (n = 59) of the study population had been hospitalized for CD-related complications. Significantly, more patients with an elevated CRP were hospitalized (33.3% versus 12.8%, P < 0.0001) compared with those with a normal CRP and were hospitalized at increased rate (P < 0.001) on Kaplan–Meier analysis. CRP elevation was significantly and independently associated with increased risk of hospitalization (adjusted hazard ratio 2.12; 95% confidence interval, 1.13–3.98; P = 0.02) in multivariable survival analysis. Conclusions:Asymptomatic patients with CD with elevated CRP are at a nearly 2-fold higher risk for hospitalization over the subsequent 2 years compared with asymptomatic patients with CD without CRP elevation.

Silent Crohn's Disease Predicts Increased Bowel Damage During Multiyear Follow-up: The Consequences of Under-reporting Active Inflammation

Background:Patients with Crohns disease (CD) in clinical remission with elevated C-reactive protein (CRP) have been labeled “silent CD” and have increased 2-year hospitalization rates when compared with asymptomatic patients with no biochemical evidence of inflammation. The risk of cumulative bowel damage in patients with silent CD is unknown. Methods:Observational study of patients with CD prospectively followed in a tertiary referral natural history registry. Consecutive patients with CD in clinical remission (Harvey–Bradshaw Index ⩽ 4) with good quality of life (short inflammatory bowel disease questionnaire score ≥ 50), and same day CRP measurement at first encounter, followed for a minimum of 4 years formed the study population. Disease trajectory was determined using change in Lémann Index as a measure of bowel damage. Results:A total of 185 patients with CD (median age 42 years; 51.4% men) were included in the study. CRP elevation was observed in 43 (23%) patients (Silent CD cohort). Majority of them showed worsening disease trajectories based on change in Lémann Index when compared with asymptomatic patients with normal CRP (65% versus 36%, P < 0.0001). Multinomial logistic regression analysis demonstrated that elevated CRP was independently associated with 7-fold higher odds (odds ratio = 6.93, P < 0.0001) of having worse disease trajectories when compared with stable disease trajectories. Conclusions:Two-thirds of patients with CD in clinical remission, while demonstrating elevated CRP, will develop bowel damage over the ensuing years, despite feeling well. These patients with silent CD are an “at-risk” group who warrant further investigation to prevent development of disease-related complications.

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.