Esther A. Torres

Inflammatory bowel disease characteristics among African Americans, Hispanics, and non-Hispanic Whites: characterization of a large North American cohort.

OBJECTIVES:Inflammatory bowel disease (IBD), comprising primarily of Crohns disease (CD) and ulcerative colitis (UC), is increasingly prevalent in racial and ethnic minorities. This study was undertaken to characterize racial differences in disease phenotype in a predominantly adult population.METHODS:Phenotype data on 830 non-Hispanic white, 127 non-Hispanic African American, and 169 Hispanic IBD patients, recruited from six academic centers, were abstracted from medical records and compiled in the NIDDK-IBD Genetics Consortium repository. We characterized racial differences in family history, disease location and behavior, surgical history, and extraintestinal manifestations (EIMs) using standardized definitions.RESULTS:African American CD patients were more likely than whites to develop esophagogastroduodenal CD (OR = 2.8; 95% CI: 1.4–5.5), colorectal disease (OR = 1.9; 95% CI: 1.1–3.4), perianal disease (OR = 1.7; 95% CI: 1.03–2.8), but less likely to have ileal involvement (OR = 0.55; 95% CI: 0.32–0.96). They were also at higher risk for uveitis (OR = 5.5; 95% CI: 2.3–13.0) and sacroiliitis (OR = 4.0; 95% CI: 1.55–10.1). Hispanics had higher prevalence of perianal CD (OR = 2.9; 95% CI: 1.8–4.6) and erythema nodosum (3.3; 95% CI: 1.7–6.4). Among UC patients, Hispanics had more proximal disease extent. Both African American and Hispanic CD patients, but not UC patients, had lower prevalences of family history of IBD than their white counterparts.CONCLUSIONS:There are racial differences in IBD family history, disease location, and EIMs that may reflect underlying genetic variations and have important implications for diagnosis and management of disease. These findings underscore the need for further studies in minority populations.

Long-Range LD Can Confound Genome Scans in Admixed Populations

A.L.P. is supported by a Ruth Kirschstein National Research Service Award from the NIH. N.P. is supported by a K-01 career development award from the NIH. D.R. is supported by a Burroughs Wellcome Career Development Award in the Biomedical Sciences. This research was also supported by U-01 award HG004168 from the NIH (D.R. and N.P.), by NIDDK grant PO1DK46763 (J.I.R.), and by the Board of Governors Chair in Medical Genetics at Cedars-Sinai Medical Center (J.I.R.). Genotyping of the Puerto Rican samples was supported in part by grant M01-RR00425 to the Cedars-Sinai GCRC genotyping core (K.D.T.) and by NIH grant DK62413 (K.D.T).

Assessment of reliability and validity of IBD phenotyping within the National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK) IBD Genetics Consortium (IBDGC).

Background: The NIDDK IBD Genetics Consortium (IBDGC) collects DNA and phenotypic data from inflammatory bowel disease (IBD) subjects to provide a resource for genetic studies. No previous studies have been performed on the reliability and validity of phenotypic determinations in either Crohns disease (CD) or ulcerative colitis (UC) using primary records. Our aim was to determine the reliability and validity of these phenotypic assessments. Methods: The de‐identified records of 30 IBD patients were reviewed by 2 phenotypers per center using a standard protocol for phenotypic assessment. Each phenotyper evaluated 10 charts on 2 occasions 5 months apart. Reliability was expressed as the kappa (&kgr;) statistic. Performance characteristics were determined by comparison to a consensus‐derived “gold standard” and by generation of receiver operating characteristic (ROC) curves. Results: Agreement for diagnosis was excellent (&kgr; = 0.82; 95% confidence interval [CI]: 0.71–0.92). Agreement for CD location was good for jejunal, ileal, colorectal, and perianal disease with &kgr; between 0.60 and 0.74 but was fair for esophagogastroduodenal (&kgr; = 0.36). Agreement for UC extent (&kgr; = 0.67; 95% CI: 0.48–0.85), and CD behavior (&kgr; = 0.67; 95% CI: 0.49–0.83) were very good. Area under the ROC curves was greater than 0.84 for diagnosis, CD behavior, UC extent, and ileal and colonic CD location. Conclusions: IBD phenotype classification using a standard protocol exhibited very good to excellent inter‐ and intrarater agreement and validity. This study highlights the importance of standard protocols in generating reliable and valid phenotypic assessments. The data will facilitate estimates of phenotyping misclassification rates that should be considered when making inferences from IBD genotype–phenotype studies.

Phenotypic and Genotypic Characteristics of Inflammatory Bowel Disease in French Canadians: Comparison With a Large North American Repository

OBJECTIVES:Phenotype characteristics of inflammatory bowel disease (IBD) may differ significantly among ethnic subpopulations. The aim of this study was to characterize the IBD phenotype in French Canadians, the most prominent founder population in North America.METHODS:Using well-characterized phenotype data in the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)-IBD Genetics Consortium repository on patients with IBD, we compared phenotypic characteristics of 202 French Canadians with those of 1,287 other Caucasian patients. These included diagnosis, anatomical location, disease behavior, extraintestinal manifestations, surgical history, and family history of IBD.RESULTS:French-Canadian patients with Crohns disease (CD) were less likely to have stricturing disease (11 vs. 21%, P=0.005; odds ratio (OR): 0.45, 95% confidence interval (95% CI): 0.24–0.85). Using a stringent definition of ethnicity (three out of four grandparents being French Canadians, as opposed to self-report, n=148), French Canadians had a tendency toward developing fistulizing CD (37 vs. 28%, P=0.07), and there was an increased prevalence of sacroiliitis among those with IBD (4 vs. 2%, P=0.045). Among French Canadians, the numbers of current smokers in CD (40 vs. 25%, P=0.006) and former smokers in ulcerative colitis (UC) (35 vs. 20%, P=0.03) were significantly higher. The prevalence of one of the three main variants of nucleotide-binding oligomerization domain containing 2 (NOD2) single-nucleotide polymorphisms (SNPs) among French-Canadian CD patients was 43.2%. The 3020insC SNP correlated with small bowel disease in French Canadians (75 vs. 0%, P=0.006).CONCLUSIONS:French Canadians show an IBD phenotype profile distinct from other Caucasian IBD populations, with an accentuated association between smoking status and IBD. This unique profile may have implications regarding the need for a different approach to the management of IBD in this population.

Iron-deficiency anemia as presentation of pouchitis.

Goals This study sought to describe the percentage and cause of anemia in patients who underwent ileal pouch with anal anastomosis (IPAA) for ulcerative colitis (UC), and to compare the distribution of complications in patients with and without anemia, especially pouchitis, after IPAA. Background IPAA is the surgical procedure of choice for UC. Complications include pouchitis (40%), strictures (30%), small bowel obstruction (10%), pelvic sepsis (<5%), and urinary and sexual dysfunctions (<5%). Few studies have described the prevalence of anemia after IPAA, but no conclusive findings have been reported. Study Patients who had undergone IPAA for UC were recruited from the UPR Inflammatory Bowel Disease Clinic and the Gastroenterology Research Unit. Demographic and medical data were obtained. Anemia was diagnosed using standard hematologic criteria. Serum iron, ferritin, transferrin, folate, vitamin B12, erythropoietin, total iron-binding capacity, reticulocyte count, peripheral smear, and bone marrow aspirate were evaluated in patients with anemia. Data analysis was performed with EPI Info version 6.4d. Results Iron-deficiency anemia was identified in 55.5% (10/18) of patients and pouchitis was found in 77% (14/18). All 10 patients with anemia had pouchitis, whereas only 4 of the 8 without anemia had pouchitis. In half of the anemic patients, pouchitis was asymptomatic. Conclusions Iron-deficiency anemia may be a clinical presenting sign of pouchitis. Hemoglobin levels may be considered as surveillance tools for pouchitis in patients with IPAA.

Inflammatory Bowel Disease in Hispanics: The University of Puerto Rico IBD Registry

A registry of patients with inflammatory bowel diseases, ulcerative colitis (UC) and Crohns disease (CD), was created at the University of Puerto Rico in 1995. Subjects with a documented diagnosis of IBD by clinical, radiologic, endoscopic, and/or pathologic criteria were recruited from the IBD clinics, support groups, and community practices, and demographic and medical data was collected. All entries from 1995 to 2009 were analyzed for demographics, family history, disease extent, extraintestinal manifestations, surgery, and smoking history. Results were described using summary statistics. 635 Hispanics living in Puerto Rico, 299 with UC and 336 with CD, were included. Mean ages were 40.3 for UC and 30.9 for CD. Over half (56%) of UC and 41% of CD were females. Family history was present in 19.3% of UC and 17.5% of CD. Surgery for IBD had been performed in 31.9% of UC and 51.2% of the CD patients. Over one-fourth of the patients reported extraintestinal manifestations, most frequently arthropathies. Our findings contribute to the limited epidemiologic and clinical data on Hispanics with IBD.

Serum vitamin D and colonic vitamin D receptor in inflammatory bowel disease

AIM To determine serum vitamin D levels and colonic vitamin D receptor (VDR) expression in inflammatory bowel disease (IBD) and non-IBD patients and correlate these with histopathology. METHODS Puerto Rican IBD (n = 10) and non-IBD (n = 10) patients ≥ 21 years old scheduled for colonoscopy were recruited. Each patient completed a questionnaire and provided a serum sample and a colonic biopsy of normal-appearing mucosa. For IBD patients, an additional biopsy was collected from visually diseased mucosa. Serum vitamin D levels were measured by ultra-performance liquid chromatography and mass spectrometry. Hematoxylin and eosin stained tissue sections from colonic biopsies were classified histologically as normal or colitis (active/inactive), and scored for the degree of inflammation present (0-3, inactive/absent to severe). Tissue sections from colonic biopsies were also stained by immunohistochemistry for VDR, for which representative diagnostic areas were photographed and scored for staining intensity using a 4-point scale. RESULTS The IBD cohort was significantly younger (40.40 ± 5.27, P < 0.05) than the non-IBD cohort (56.70 ± 1.64) with a higher prevalence of vitamin D deficiency (40% vs 20%, respectively) and insufficiency (70% vs 50%, respectively). Histologic inflammation was significantly higher in visually diseased mucosa from IBD patients (1.95 ± 0.25) than in normal-appearing mucosa from control patients (0.25 ± 0.08, P < 0.01) and from IBD patients (0.65 ± 0.36, P < 0.05) and correlated inversely with VDR expression in visually diseased colonic tissue from IBD patients (r = -0.44, P < 0.05) and from IBD patients with Crohns disease (r = -0.69, P < 0.05), but not in normal-appearing colonic tissue from control patients or IBD patients. Control and IBD patient serum vitamin D levels correlated positively with VDR expression in normal colon from control and IBD patients (r = 0.38, P < 0.05) and with patient age (r = 0.54, P < 0.01). CONCLUSION Levels of serum vitamin D correlate positively with colonic VDR expression in visually normal mucosa whereas inflammation correlates negatively with colonic VDR expression in visually diseased mucosa in Puerto Rican patients.

Immunohistochemical expression of SP-NK-1R-EGFR pathway and VDR in colonic inflammation and neoplasia

AIM To determine the expression of neurokinin-1 receptor (NK-1R), phosphorylated epidermal growth factor receptor (pEGFR), cyclooxygenase-2 (Cox-2), and vitamin D receptor (VDR) in normal, inflammatory bowel disease (IBD), and colorectal neoplasia tissues from Puerto Ricans. METHODS Tissues from patients with IBD, colitis-associated colorectal cancer (CAC), sporadic dysplasia, and sporadic colorectal cancer (CRC), as well as normal controls, were identified at several centers in Puerto Rico. Archival formalin-fixed, paraffin-embedded tissues were de-identified and processed by immunohistochemistry for NK-1R, pEGFR, Cox-2, and VDR. Pictures of representative areas of each tissues diagnosis were taken and scored by three observers using a 4-point scale that assessed intensity of staining. Tissues with CAC were further analyzed by photographing representative areas of IBD and the different grades of dysplasia, in addition to the areas of cancer, within each tissue. Differences in the average age between the five patient groups were assessed with one-way analysis of variance and Tukey-Kramer multiple comparisons test. The mean scores for normal tissues and tissues with IBD, dysplasia, CRC, and CAC were calculated and statistically compared using one-way analysis of variance and Dunnetts multiple comparisons test. Correlations between protein expression patterns were analyzed with the Pearsons product-moment correlation coefficient. Data are presented as mean ± SE. RESULTS On average, patients with IBD were younger (34.60 ± 5.81) than normal (63.20 ± 6.13, P < 0.01), sporadic dysplasia (68.80 ± 4.42, P < 0.01), sporadic cancer (74.80 ± 4.91, P < 0.001), and CAC (57.50 ± 5.11, P < 0.05) patients. NK-1R in cancer tissue (sporadic CRC, 1.73 ± 0.34; CAC, 1.57 ± 0.53) and sporadic dysplasia (2.00 ± 0.45) were higher than in normal tissues (0.73 ± 0.19). pEGFR was significantly increased in sporadic CRC (1.53 ± 0.43) and CAC (2.25 ± 0.47) when compared to normal tissue (0.07 ± 0.25, P < 0.05, P < 0.001, respectively). Cox-2 was significantly increased in sporadic colorectal cancer (2.20 ± 0.23 vs 0.80 ± 0.37 for normal tissues, P < 0.05). In comparison to normal (2.80 ± 0.13) and CAC (2.50 ± 0.33) tissues, VDR was significantly decreased in sporadic dysplasia (0.00 ± 0.00, P < 0.001 vs normal, P < 0.001 vs CAC) and sporadic CRC (0.47 ± 0.23, P < 0.001 vs normal, P < 0.001 vs CAC). VDR levels negatively correlated with NK-1R (r = -0.48) and pEGFR (r = -0.56) in normal, IBD, sporadic dysplasia and sporadic CRC tissue, but not in CAC. CONCLUSION Immunohistochemical NK-1R and pEGFR positivity with VDR negativity can be used to identify areas of sporadic colorectal neoplasia. VDR immunoreactivity can distinguish CAC from sporadic cancer.

Evaluation of the rating form for inflammatory bowel diseases patients concerns (RFIPC) spanish translation in Puerto Ricans with IBD

Health related quality of Life (HRQL) can be measured in patients with IBD using disease-specific instruments such as the RFIPC. The RFIPC measures concerns over impact of disease, sexual intimacy, complications and body stigma, using 25 questions on a visual analogue scale of 100. There is no Spanish translation of the RFIPC. A general instrument, the Short Form-36 (Medical Outcomes Trust), is available in Spanish. Aim: We evaluated the reliability and validity of a Spanish translation of the RFIPC using the SF-36 in Puerto Ricans with IBD. Methods: The RFIPC was translated from English into Spanish using back-translation. The Spanish translation was done by two bilingual Puerto Rican physicians and translated back into English by two independent English-speaking bilingual scientists. The back-translations were compared to the original by a third English speaking physician. After informed consent, 30 consecutive patients from the IBD clinics received the RFIPC and SF-36. A second RFIPC was completed two weeks later. The RFIPC’s were compared for test-retest reliability to determine consistency over time and internal consistency. The RFIPC was compared with the SF-36 for validity. The relationship between overall RFIPC sumscore and SF-36 subscales’ scores was evaluated using Spearman’s correlation. Two-sided p values were calculated. The protocol was approved by the IRB. Results: Test-retest reliability using Spearman’s correlation was 0.82 (p,.0001) and internal consistency measured with Cronbach’s alpha was 0.87. When subscale individual items were analyzed for internal consistency, Cronbach’s alpha ranged from 0.75 to 0.81. There were significant correlations between the RFIPC and SF-36 subscales for role limitations due to physical and emotional problems (r 52.60 and r 52.62, p,.001). A bordeline significant correlation between the physical functioning SF-36 subscale and RFIPC was found (r 52.33, p5.08). Conclusions:The Spanish translation of the RFIPC is a reliable and valid instrument for measuring HRQL in patients with IBD. Its application will be important in the management of Hispanic populations with IBD. 796

977 Gene-Environment Interactions: IBD Risk Loci and Hygene-Related Childhood Environmental Factors in the Puerto Rico IBD Population

G A A b st ra ct s and wild type allele carrying patients (n=15), simultaneously. Expression of CSF2RB was determined by flowcytometry and confirmed by qPCR. ROS production upon stimulation of cells with fMLP with or without prior priming with GMCSF or GCSF was measured by flowcytometry. Uptake and killing of E. Coli were measured using fluorescence spectophotometry. CSF2RB signaling was studied after stimulation with GMCSF and IL5. Results: Membrane expression of CSF2RB is similar between patients bearing either T or C allele (n=10; 323±40 and 323±54 MFI). GMCSF-primed ROS production was greatly diminished in C allele patients compared to T allele patients (n=10, 221±41 MFI vs 464±52 MFI, p= 0.002), wereas GCSF-primed ROS production was unaffected (210±30 vs 225±20 MFI, p= 0.79). indicating a specific GMCSF receptor signaling defect. E.Coli uptake was not different, whereas a trend towards diminished killing was observed in C allele patients (171±28 vs 280±86 CFU). In C-allele patients, GMCSF stimulation induced less activation of STAT3 (n=5, 1.8±0.8 vs 3.5±1.1 vs); AKT (11±5 vs 23±13) and ERK (30±20 vs 40±10) in C-allele carriers. IL5 activated lower STAT5 (n=4, 0.2± 0.1 vs 0.5±0.2) and AKT signaling (0.03±0.06 vs 0.7±0.04). Conclusion: We show a specific defect in CSFR2B signaling in patients carrying the NCF4 risk allele. The CSFR2B receptor is used by both GMCSF and IL5, and both cytokines induce reduced signaling in C-allele patients. In contrast, priming of PMN by GCSF, which signals through a different receptor, was normal. Thus, the NCF4 risk allele confers a defect in CSFR2B signaling, and may identify a subset of CD patients whose inflammation is influenced by impaired innate immunity induced by neutrophils. GM-CSF treatment, which is beneficial for some patients, may be limited by NCF4 genetic background of patients.