Lawrence F. Borges

Risk Factors for Rehospitalization Within 90 Days in Patients with Inflammatory Bowel Disease.

Background:Care of patients with inflammatory bowel disease (IBD) poses a significant burden to the health-care system. Repeat hospitalization in subgroups of IBD patients seems to be a large part of this issue; however, there are limited data examining the characteristics of these patients. The aim of this study was to characterize admission patterns in patients with IBD at a tertiary-care center and to identify preventable risk factors of 90-day readmission after an index IBD admission. Methods:Retrospective analysis was performed extracting data from an electronic medical record over a 2-year period. Results:Three hundred fifty-six patients were admitted at least once during the 2-year study period for an unplanned IBD-related reason. Of these, 48.9% were admitted once, 38.2% were admitted 2 to 4 times, and 12.9% were admitted 5 or more times during the study period. Patients with any admission within 90 days before index were excluded; n = 33. One hundred two patients had experienced a readmission by 90 days after index admission. Numerous demographic and medical factors were examined for association with readmission. The final Cox model included 3 variables: depression (HR = 1.99, 1.33–3.00), chronic pain (HR = 1.88, 1.14–3.10), and steroid use in the previous 6 months (HR = 1.33, 0.92–2.04). Conclusions:Our findings suggest that patients with depression and chronic pain are at greatest risk for a readmission within 90 days after an initial IBD admission. Disease activity, represented by steroid use in the previous 6 months, was not related to readmission. Addressing these problems in the outpatient setting may reduce future hospitalizations.

Trends in Narcotic and Corticosteroid Prescriptions in Patients with Inflammatory Bowel Disease in the United States Ambulatory Care Setting from 2003 to 2011

Background/Hypothesis: Before the availability of biological therapies, corticosteroids and narcotics were frequently used in patients with inflammatory bowel disease (IBD) because of a paucity of disease-modifying therapies. The increased accessibility to effective biologicals for IBD over the last decade should be leading to less use of corticosteroids and narcotic medications. This study aims to examine trends in prescriptions of corticosteroids and narcotics to patients with IBD in the United States during the period 2003 to 2011. Methods: Data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were used to examine visits of patients with IBD. Trends in corticosteroid and narcotic prescriptions were explored, and predictors of use were assessed using survey-weighted chi-square tests. Results: From 2003 to 2011, a total of 1119 patients with IBD had visits recorded in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey databases. Although biological prescriptions significantly increased from 3.3% in 2003 to 2005 to 15.9% in 2009 to 2011 (P = 0.004), there was no significant decrease in corticosteroid or narcotic prescriptions during this same time frame. Patients with IBD were less likely to receive narcotics (odds ratio = 0.38) when seeing a medical specialist compared with primary care physicians or surgeons. Conclusions: Despite the availability of more effective biological therapies, prescriptions for corticosteroids and narcotics did not decline in patients with IBD visiting U.S. ambulatory clinics and emergency departments from 2003 to 2011.

Dual pH Probes Without Proximal Esophageal and Pharyngeal Impedance May Be Deficient in Diagnosing LPR

BACKGROUND Laryngopharyngeal reflux (LPR) is commonly treated with empiric acid suppression. More evidence points to pepsin in the pathophysiology of LPR. Previous studies have evaluated esophageal impedance in patients who had previously failed high dose proton pump inhibitor (PPI) using older catheters without proximal esophageal (just under the upper esophageal sphincter) and pharyngeal impedance sensors. The aim of this study was to compare what traditional diagnostic tools, used for esophageal reflux, would detect and diagnose compared with what a combined hypopharyngeal-esophageal MII catheter with dual pH (HEMII-pH) can detect in the esophagus and pharynx in patients with suspected LPR. METHODS Forty-two subjects with presumed LPR were referred for HEMII-pH testing. The number of distal and proximal esophageal impedance events, number of pharyngeal impedance events, symptom correlation, and event acidity were recorded. Previous normative values (>1 pharyngeal impedance events every 24 hours) were used to designate what was pathological LPR on HEMII-pH. RESULTS Forty-two total subjects had pharyngeal impedance sensor data recorded. Twelve (28.6%) of the subjects were tested while taking high-dose PPI therapy. The mean number of proximal esophageal events was 23.3. The mean number of pharyngeal impedance events was 10. Thirty-four subjects (81%) tested positive for pharyngeal reflux. All patients who tested positive using traditional proximal impedance criteria also tested positive using pharyngeal criteria. Of patients who tested negative using traditional criteria, 72% were positive based on pharyngeal criteria. CONCLUSIONS HEMII-pH catheters should be considered in patients with LPR symptoms. Traditional criteria used for diagnosing esophageal reflux may not translate into LPR.

Abnormal Bolus Reflux Is Associated With Poor Pulmonary Outcome in Patients With Idiopathic Pulmonary Fibrosis

Background/Aims Gastroesophageal reflux (GER) is postulated to play a role in idiopathic pulmonary fibrosis (IPF). However, the value of objective GER measures in predicting IPF disease progression is unclear. We aim to evaluate the association between objective GER measures on multichannel intraluminal impedance and pH (MII-pH) testing and development of poor pulmonary outcomes within 1 year in pre-lung transplant IPF patients. Methods This was a retrospective cohort study of adults with IPF who underwent pre-lung transplant evaluation with MII-pH off proton pump inhibitors (PPI) at a tertiary care center from June 2008 to November 2015. Patients were followed for 1 year from time of MII-pH for poor pulmonary outcomes, defined by hospitalization for respiratory exacerbation or death. Univariate, multivariate and time-to-event analyses were performed to assess associations between baseline GER parameters on MII-pH and poor outcomes. Results Eighty-four subjects (mean age 61.1 years, 64.3% male) were included. Subjects with increased bolus exposure time (BET) had a higher incidence of 1-year poor pulmonary outcome vs normal BET (45.7% vs 15.2%, P = 0.006). Increased BET remained an independent predictor of poor outcome after controlling for age, gender, body mass index, smoking, lung disease severity, and PPI use (OR, 4.18; P = 0.030). Increased BET was also predictive of decreased time to poor pulmonary outcome (hazard ratio [HR], 4.88; P = 0.007). Subgroup analyses showed that increased BET remained independently associated with time to pulmonary hospitalization (HR, 4.00; P = 0.020), with a trend for 1-year mortality (HR, 2.19; P = 0.380). Conclusion Increased BET on MII-pH is an independent predictor of poor pulmonary outcome over 1 year in IPF patients.

Persistent Symptoms After Antireflux Surgery and Their Management

At the end of this chapter, the reader will understand the prevalence of persistent symptoms following antireflux surgery, the most common symptoms reported, and the pre-operative risk factors that may predict the development of symptoms. The reader will also understand how to approach the work-up of persistent symptoms in an algorithmic fashion, and the common treatments to consider.

Sa1247 Risk Factors for Re-Hospitalization Within 90 Days in Patients With Inflammatory Bowel Disease Are Not Related to Disease Activity

Background: Previous studies have demonstrated that the care of inflammatory bowel disease (IBD) patients poses a significant burden to the healthcare system. More than one and a half million people in the United States suffer from ulcerative colitis (UC) and Crohns disease (CD) and these patients require more frequent hospital admissions than non-IBD patients, and have an increased average length of stay. Moreover, hospital care for IBD patients has been shown to be twice as expensive as that for non-IBD controls. Repeat hospitalization in subgroups of IBD patients appears to be a large part of this issue, however there is only limited literature examining the characteristics of IBD patients that are associated frequent hospital use. Aims: To characterize admission patterns in patients with IBD at a tertiary care referral center, and identify preventable causes of 90-day readmission after an index IBD admission. Methods: Data was gathered retrospectively from a tertiary-care IBD referral center. Study subjects included all patients age 18 or older with a known diagnosis of IBD, who were admitted at least once between January 1st, 2011 and December 31st, 2012 for a non-elective, IBD-related reason. Hospital billing records were searched using the Research Patient Data Registry. Univariate analysis was performed. A cox proportional hazards model was developed with covariates felt a priori to be related to readmission. Forward selection was performed. Results: 356 patients were admitted at least once during the 2-year study period for an unplanned, IBD-related reason. 208 (58.4%) had CD and 148 (41.6%) had UC. The mean age at time of index admission was 41.7 years (SD +/17). Women accounted for 62% (n = 220). 125 patients had experienced a re-admission by 90 days and no patients were censored prior to 90 days. The initial model contained 19 covariates. Depression and steroid use in the prior 6 months (a marker of active disease) were forced in. After forward selection the final model included four variables, depression (HR=2.06, 1.42-2.98), chronic pain (HR=1.87,1.19-2.94) etoh use (HR=2.43, 1.21-5.29) and Remicade use (HR=1.15, 0.76-1.72).The proportional hazard assumption was then tested on using Martingale residuals for each of the four variables in the final model and all resulted in non-significant p-value. Conclusions: These findings suggests that patients with depression, chronic pain, and who drink alcohol are at greatest risk for a re-admission within 90 days after an initial IBD admission. Disease activity, represented by steroid use in the prior 6 months, was not related to re-admission. Our study identified that comorbid psychiatric disease, chronic pain, and substance abuse are associated with repeat hospitalization. Addressing these problems in the outpatient setting may reduce future hospitalizations in IBD patients. Table 1: Cox Proportional Hazard Model for 90-day Readmission