Philip N. Okafor

Increased Risk of Pneumocystis Jiroveci Pneumonia among Patients with Inflammatory Bowel Disease

Objectives:Patients with inflammatory bowel disease (IBD) may be at increased risk for pneumocystis jiroveci pneumonia (PCP). Our aims were (1) to determine the incidence and relative risk of PCP in IBD and (2) to describe medication exposures in patients with IBD with PCP. Methods:We performed a retrospective cohort study and a case series using administrative data from IMS Health Inc, LifeLink Health Plan Claims Database. In the cohort, patients with IBD were matched to 4 individuals with no IBD claims. PCP risk was evaluated by incidence rate ratio and adjusted Cox proportional hazards modeling. The demographics and medication histories of the 38 cases of PCP in patients with IBD were extracted. Results:The cohort included 50,932 patients with Crohn’s disease, 56,403 patients with ulcerative colitis, and 1269 patients with unspecified IBD; matched to 434,416 individuals without IBD. The crude incidence of PCP was higher in the IBD cohort (10.6/100,000) than in the non-IBD cohort (3.0/100,000). In the adjusted analyses, PCP risk was higher in the IBD versus non-IBD cohort (hazard ratio, 2.96; 95% confidence interval, 1.75–4.29), with the greatest risk in Crohn’s disease compared with non-IBD (hazard ratio, 4.01; 95% confidence interval, 1.88–8.56). In the IBD case series of PCP cases (n = 38), the median age was 49 (interquartile range, 43–57). A total of 20 individuals (53%) were on corticosteroids alone or in combination with other immunosuppression. Conclusions:Although the overall incidence of PCP is low, patients with IBD are at increased risk. Patients with IBD with PCP are predominantly on corticosteroids alone or in combination before PCP diagnosis.

Pneumocystis jiroveci pneumonia in inflammatory bowel disease: when should prophylaxis be considered?

Background: The incidence of inflammatory bowel disease (IBD) has increased over the past several decades with a corresponding increase in the number of patients on combination immunosuppressive therapy including corticosteroids, anti-metabolites and biologic agents. The exact incidence of pneumocystis jiroveci pneumonia (PJP) in IBD patients is unknown but there has been an increase in the number of reports of PJP in IBD patients on combination immunosuppressive therapy. Methods: We evaluated the published literature describing PJP infections in IBD patients, as well as other non-HIV cohorts and identified risk factors for PJP infection in this group of patients. Prophylaxis and treatment regimens were reviewed. Results: Corticosteroid therapy, lymphopenia (total lymphocyte count < 600 cells/mm3), and age greater than 55 years appear to be risk factors for developing pneumocystis jiroveci pneumonia. In addition, PJP mortality is greater in the non-HIV cohort in contrast to the HIV population. No evidence-based guidelines for primary PJP prophylaxis exist to direct practice for gastroenterology providers. Conclusions: Better surveillance and reporting of opportunistic infections including PJP are needed to elucidate risk factors for acquisition of infection. Gastroenterology providers should continue to evaluate the need for PJP prophylaxis on a case-by-case basis to recognize patients who may benefit from primary PJP prophylaxis. In particular, older patients on corticosteroids, multiple immunosuppressive agents, and patients with lymphopenia should be considered for prophylaxis.

Effect of vagotomy during Roux-en-Y gastric bypass surgery on weight loss outcomes

BACKGROUND During Roux-en-Y gastric bypasses (RYGB), some surgeons elect to perform a vagotomy to reduce symptoms of gastro-oesophageal reflux (GER). Routine vagotomy during RYGB may independently affect weight loss and metabolic outcomes following bariatric surgery. We aimed to determine whether vagotomy augments percent excess weight loss in obese patients after RYGB. METHODS We examined the effect of vagotomy in 1278 patients undergoing RYGB at our institution from 2003 to 2009. Weight and percent excess weight loss (%EWL) were modelled at three months and annually up to five years using a longitudinal linear mixed model controlling for differences in age, gender, initial body mass index (BMI), ideal body weight, and presence of vagotomy. RESULTS Vagotomy was performed on 40.3% of our cohort. Vagotomy patients had significantly lower initial BMI (46.4±6.2 vs. 48.3±7.7kg/m(2), p<0.001), but there were no other significant differences at baseline. The strongest predictor of %EWL over time was initial BMI, with lower BMI patients exhibiting greater %EWL (p<0.001). Age and gender effects were also significant, with younger patients (p<0.04) and males (p<0.002) attaining greater %EWL. Vagotomy had no effect on %EWL in either simple or multiple regression models. CONCLUSION Our series suggest that vagotomy does not augment %EWL when performed with RYGB.

Cost-effectiveness of nonmelanoma skin cancer screening in Crohn's disease patients.

Background:Several studies have demonstrated an increased risk of nonmelanoma skin cancer (NMSC) in patients with inflammatory bowel disease, with the greatest risk in patients with Crohns disease (CD). We investigated the cost-effectiveness of NMSC screening in patients with CD. Methods:A mathematical model was used to compare lifetime costs, life expectancies, and benefits of NMSC screening in a hypothetical cohort of 100,000 patients with CD. Strategies studied include: (1) Treat NMSC cases as they present and follow affected patients annually; (2) Screen patients with CD annually once they turn 50 years old, treat NMSC cases as they present and follow affected patients annually; (3) Screen patients with CD annually once they start receiving thiopurines, treat NMSC cases as they present and follow affected patients annually; (4) Screen patients with CD annually when they turn 50 years old or start receiving thiopurines, treat NMSC cases as they present, and follow affected patients annually; (5) Screen all patients with CD annually. These strategies were then studied on a biennial basis, accounting for 10 competing strategies. Results:Screening all patients with CD annually proved the most cost-effective strategy with an average lifetime cost of more than

Determinants of Palliative Care Utilization Among Patients Hospitalized With Metastatic Gastrointestinal Malignancies

333,000, a quality-adjusted life expectancy of about 26 QALYs (95% confidence interval: 22–29), ICER of

Pneumocystis jiroveci pneumonia in patients with inflammatory bowel disease: a survey of prophylaxis patterns among gastroenterology providers.

3263/QALY, and led to early detection of about 94% of incident NMSC cases. The next best strategy was screening all CD patients biennially with an average lifetime cost of more than

African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients

328,000 with 24.5 QALYs (95% confidence interval: 21–25). Only 47% of new NMSC cases were detected early with this strategy. Conclusion:At a willingness-to-pay threshold of

Secondary analysis of large databases for hepatology research

50,000, screening all patients with CD annually for NMSC proved the most cost-effective strategy.

Endoscopic ultrasound for rectal cancer staging: A population-based study of utilization, impact on treatment patterns, and survival: Endoscopic ultrasound and rectal cancer outcomes

Background: Gastrointestinal tract cancers account for a significant proportion of the national cancer burden. Aim: We sought to explore patient- and hospital-level determinants of palliative care utilization among patients hospitalized with metastatic gastrointestinal tract cancers using a national database. Methods: An analysis of the 2012 National Inpatient Sample was performed. International Classification of Diseases, Ninth Revision codes were used to identify hospital discharges associated with metastatic digestive tract cancers and patient/hospital covariates for inclusion in a logistic regression model. Total charges and length of stay were analyzed in a linear regression model. Results: Compared to males, females were more likely to receive inpatient palliative care (adjusted odds ratio [OR] 1.12, P = .002). No difference was seen between white and Asian patients (adjusted OR 1.2, P = .11) or Native Americans patients (adjusted OR 1.4, P = .22). However, relative to white patients, African Americans (adjusted OR 1.13, P = .02) and Hispanics (adjusted OR 1.25, P = .001) had significantly higher odds of inpatient palliative care. Medicare patients were least likely to receive palliative care compared to those with Medicaid or commercial payers. Length of stay during these hospitalizations was longer in African Americans (P = .0001), Asians (P = .0001), and Native Americans (P = .03) compared to white patients. No difference was seen when total charges were compared between white and African American patients (P = .08). Conversely, total charges were higher in Hispanics (P = .005) and Asians (P = .001) relative to white patients. Conclusion: Gender and racial differences exist in utilization of inpatient palliative care among patients hospitalized with metastatic gastrointestinal tract cancers.

Rising Incidence of Intestinal Infections in Inflammatory Bowel Disease: A Nationwide Analysis

Background:The use of combination immunosuppressive agents is associated with reports of pneumocystis jiroveci pneumonia (PJP). The aim of this study was to determine practice patterns among gastroenterology providers for PJP prophylaxis in patients with inflammatory bowel disease (IBD) on immunosuppressive therapy. Methods:An internet-based survey of 14 questions was sent through e-mail to a random sampling of 4000 gastroenterologists, nurse practitioners, and physician assistants between November 2011 and February 2012. Three reminder e-mails were sent to providers who had not completed the survey. Results;The invitation e-mail that contained the link to the survey was clicked by 504 providers and the completed surveys were returned by 123 of them (78% physicians, 11% nurse practitioners, 11% physician assistants). The response rate was 24.4%. Seventy-nine percent of the respondents had managed >25 patients with IBD in the past year, with as much as one-third of all respondents managing >100 patients. Eight percent of the respondents reported patients who had developed PJP on immunosuppressive therapy, 11% reported initiating PJP prophylaxis, mostly for patients on triple immunosuppressive therapy. Prescription of PJP prophylaxis was not significantly associated with the number of years in practice or the number of IBD patients treated. However, providers with patients that had developed PJP were 7.4 times more likely to prescribe prophylaxis (P = 0.01). In addition, providers in academic centers were 4 times more likely to initiate PJP prophylaxis than those in nonacademic centers (P = 0.03). The most common reasons for not prescribing PJP prophylaxis included the absence of guidelines on the benefits of prophylaxis, lack of personal experience with PJP, and the lack of knowledge on the need for prophylaxis in patients with IBD on combination immunosuppressive therapy. Conclusions:The lack of guidelines seems to influence the decision on not to prescribe PJP prophylaxis in patients with IBD. Additional studies are needed to determine PJP risk factors and risks and benefits of prophylaxis.