Prashant R. Mudireddy

Risk of New or Recurrent Cancer in Patients With Inflammatory Bowel Disease and Previous Cancer Exposed to Immunosuppressive and Anti-Tumor Necrosis Factor Agents

BACKGROUND & AIMSnOur understanding of malignancy associated with immunosuppression in patients with inflammatory bowel disease (IBD) comes from studies of individuals with no history of cancer. We investigated whether patients with IBD and a history of cancer who were subsequently immunosuppressed have an increased risk of developing incident cancer.nnnMETHODSnWe performed a retrospective analysis of data from 333 patients with IBD treated at 8 academic medical centers who developed cancer and subsequently received treatment with anti-tumor necrosis factor (TNF), anti-TNF with an antimetabolite (thiopurines, methotrexate), antimetabolites, or no subsequent exposure to immunosuppressive agents (controls). We collected data on their primary outcomes of incident cancers (new or recurrent). Hazard ratios (HRs) were calculated by using Cox proportional hazards and Kaplan-Meier survival curves; study groups were compared by using the log-rank test.nnnRESULTSnDuring the follow-up period, 90 patients (27%) developed an incident cancer. Patient characteristics between groups differed, but matching was not possible because of the relatively small sample sizes. There was no difference in time to incident cancer (Pxa0= .14) or type of incident cancer (Pxa0= .61) among the 4 groups. After adjusting for recurrence risk for type of prior cancer, there was no difference in risk of incident cancer (HR for anti-TNF, 0.32; 95% confidence interval [CI], 0.09-1.09; HR for anti-TNF with an antimetabolite, 0.64; 95% CI, 0.26-1.59; HR for an antimetabolite, 1.08; 95% CI, 0.54-2.15) or time to subsequent cancer between study arms (Pxa0= .22).nnnCONCLUSIONnOn the basis of a retrospective study, in patients with IBD and a history of cancer, exposure to an anti-TNF agent or an antimetabolite after cancer was not associated with an increased risk of incident cancer, compared with patients who did not receive immunosuppression. Larger, matched, prospective studies are needed to confirm these findings.

Pointing towards colonoscopy: sharp foreign body removal via colonoscopy

Removal of sharp foreign bodies via upper endoscopy is common; however, management in the setting of distal migration is not well-documented. We report two cases of objects beyond the ligament of Treitz, including successful extraction of a 4.4 cm sewing pin from the cecum using hot biopsy forceps with a protector hood to shield colonic mucosa, and in a separate case, a 3.4 cm glass shard from the ascending colon using a Roth Net retriever. We demonstrate that monitoring with serial radiographs and examination may allow for supervised passage of sharp objects into the colon, where removal can be performed safely via colonoscopy.

A prospective pilot comparison of wet and dry heparinized suction for EUS-guided liver biopsy (with videos)

BACKGROUND AND AIMSnAs EUS-guided liver biopsy sampling (EUS-LB) becomes more widely used, further studies have investigated ways to improve tissue yields. Use of a heparin-primed needle may lead to less clotting of blood within the needle, improve tissue recovery, and decrease fragmentation. The purpose of this study was to prospectively evaluate wet suction using a heparin-primed needle for EUS-LB.nnnMETHODSnThis was a prospective crossover study evaluating wet suction for EUS-LB in parenchymal liver disease. The primary outcome was specimen adequacy, defined by an aggregate specimen lengthxa0≥15xa0mm andxa0≥5 complete portal tracts (CPTs). Secondary outcomes included number of CPTs, length of the longest piece, aggregate specimen length, and number of small (≤4xa0mm), medium (5-8xa0mm), and large (≥9xa0mm) fragments. Adverse events were tracked at 7 and 30 days.nnnRESULTSnOne hundred twenty biopsy specimens were collected from 40 participants (3 specimens per patient). Specimen adequacy occurred in 39 wet heparin (98%), 37 dry heparin (93%), and 30 dry needle biopsy samples (80%; 95% confidence interval [CI], .14-.18; Pxa0= .01). There was no difference between dry needle techniques. Length of the longest piece was 8.9xa0mm for wet heparin and 5.8xa0mm for dry techniques (95% CI, .33-1.53; Pxa0=xa0.003). Aggregate specimen length was 49.2xa0mm for wet heparin and 23.9xa0mm for dry heparin (95% CI, -46.34 to 44.94; Pxa0= .003). Mean CPT count was 7.0 for wet heparin versus 4.0 for dry (95% CI, .74-6.26; Pxa0= .01). There were more medium (2.0 vs 1.0; 95% CI, .06-1.24; Pxa0= .03) and large (1.0 versus 0.0; 95% CI, .33-1.53; Pxa0= .003) fragments with wet suction with no difference in small fragments between groups.nnnCONCLUSIONSnThe use of wet suction EUS-LB demonstrated improved tissue adequacy compared with dry needle techniques. (Clinical trial registration number: NCT03103997.).

Tu1247 Unplanned Hospital Readmission: Rates and Causes in Patients With Inflammatory Bowel Disease: A Critical Analysis

Patients complete Functional Assessment of Chronic Illness Therapy-Fatigue score (FACITCF) as well as psychological scores (Beck for depression, Stai for anxiety, Epworth for sleep disturbances and IBDQ-9 for quality of life) and IBD activity scores. Biological parameters (Interleukin 5, 8, 12, complete blood count, ferritin, C-reactive protein, erythrocyte sedimentation rate and micronutrients) were tested by appropriate blood tests. Results: A total of 219 were studied and at the end of the study 177 patients (mean age, 39 ± 12 years, 28% ulcerative colitis and 72% crohns disease) were included for the analysis. The median Fatigue score (38, range (1-52)) was lower that than in general population. Twenty-eight (16%) patients had moderate-to-severe fatigue determined as fatigue score of 22 or lower. In the univariate analysis, fatigue differed significatively with gender, type of IBD, Harvey and Mayo score, articular disease, body mass Index (BMI), psychological tests, thiopurine and biological treatment. All these variables were included in the multivariate analysis. Female gender (β-6.61, p<0.001), BMI (β -0.61, p<0.001) and higher depression (β-0.43, p<0.001) and anxiety (β -0.18, p<0.001) scores were predictors of increased fatigue. IBDQ9 (β0.51, p<0.001) was independently related to lower fatigue. Conclusion: Fatigue was prevalent in our IBD patients and was related to high levels of anxiety and depression and low quality of life. None of the biological factors evaluated including pro-inflammatory interleukins or micronutrient deficiencies was associated with fatigue.

Sa1138 Patients With Inflammatory Bowel Disease and a History of Cancer: The Risk of Cancer Following Exposure to Immunosuppression

Back ground: The calcineurin inhibitor (CNI) tacrolimus (TAC) has been reported to be effective for induction and maintenance of remission in patients with refractory ulcerative colitis (UC). However, CNI has nephrotoxic potential leading to acute and chronic renal damage in some cases. To date, little is known about the influence of long term administration of oral TAC on renal function in patients with UC. Aim: The aim of our study was to evaluate the incidence and the severity of renal function impairment in UC patient who received TAC treatment. Methods: In this retrospective study, the medical charts of 71 adult patients with steroid-refractory UC treated with TAC between 2012 and 2014 in a single Japanese center were analyzed. In principle, TAC was orally administrated as a 2 week-induction (target trough levels 10-15ng/ml) followed by a maintenance therapy (target trough levels 5-10ng/ml). Estimated glomerular filtration rate (eGFR) was evaluated during the treatment. Acute kidney injury (AKI) was defined by the RIFLE (Risk of renal dysfunction, Injury to the kidney, Failure of function, Loss of function and End-stage kidney disease) consensus criteria using the maximal change in serum creatinine (Scr) and eGFR during the TAC treatment compared with baseline value before treatment. Results: The mean duration of TAC administration was 210 days. At 12weeks, TAC produced a clinical response in 54 patients (76.1%) and remission was achieved in 29 of those 54 (40.8%). The AKI rate during TAC treatment was 46.5% (33 of 71 patients). RIFLE class R (Scr increase > 1.5 times or eGFR decrease > 25%) accounted for 27 patients (38.0%), and RIFLE class I (Scr increase > 2 times or eGFR decrease > 50%) for six (8.5%). The AKI rate was 76.8% (10/13) in patients who had been administrated TAC for more than 1 year and 37.5% (18/48) in patients with TAC treatment within 6 months (p=0.006). After withdrawal of TAC, renal function impairment (eGFR decrease > 25%) was still observed in 10 patients (14.1%). Conclusions: Oral TAC therapy appears to be effective for patients with refractory UC. However, renal function impairment was frequently observed during this treatment. Thus, careful monitoring of renal function must be required to avoid irreversible chronic renal damage during long-term administration of TAC.

The History of Medical Therapy of Ulcerative Colitis

Ulcerative colitis is a chronic inflammatory bowel disease of unknown etiology that affects the colon. There has been an increased knowledge in the understanding of ulcerative colitis in the last 100 years. But there are several examples in the medical literature to suggest that a diarrheal disease similar to ulcerative colitis had been described many centuries ago.

Contrast and Comparison of Mesalamine Derivatives in the Treatment of Ulcerative Colitis

Mesalamine (called mesalazine in Europe) or 5-aminosalicylic acid is the recommended first-line agent for both induction and maintenance of remission in patients with mild to moderately severe ulcerative colitis. Mesalamine is available as both oral and topical formulations. Topical preparations are preferred for distal and left-sided colitis, while oral agents are used for more extensive disease. Sulfasalazine was the first mesalamine-containing drug used in the treatment of ulcerative colitis. It was developed by Dr. Nana Svartz in the 1940s for the treatment of rheumatoid arthritis, but she noticed that it improved colitis symptoms in patients with ulcerative colitis. Later randomized controlled studies established its efficacy in the treatment of ulcerative colitis