IDDF2023-ABS-0032 Active inflammatory bowel disease is associated with severe covid-19: a systematic review and meta-analysis

IDDF2023-ABS-0032 Figure 1 IDDF2023-ABS-0032 Figure 2 IDDF2023-ABS-0032 Figure 3 IDDF2023-ABS-0032 Figure 4COVID-19 outcomes in moderate-severe vs mild or quiescent IBD[Figure omitted. See PDF]ConclusionsPatients with IBD, particularly UC had an increased risk of developing severe COVID-19. Active IBD is associated with adverse COVID-19 outcomes, and the risk is increased with the disease activity of IBD.

POSSIBLE ROLE OF PEPTIDE EPITOPES OF COVID-19 BNT-162B2 MRNA VACCINE IN FOMENTING AUTOIMMUNITY: AN IN SILICO ANALYSIS

BackgroundFollowing the launch of the global COVID-19 vaccination campaign, there have been increased reports of autoimmune diseases developing de novo following vaccination. These cases include rheumatoid arthritis, autoimmune hepatitis, immune thrombotic thrombocytopenia, and connective tissue diseases. Nevertheless, COVID-19 vaccines are considered safe for patients with autoimmune diseases and are strongly recommended.ObjectivesThe aim of this in silico analysis is to investigate the presence of protein epitopes encoded by the BNT-162b2 mRNA vaccine, one of the most commonly administered COVID-19 vaccines, that could elicit an aberrant adaptive immune response in predisposed individuals.MethodsThe FASTA sequence of the protein encoded by the BNT-162b2 vaccine was retrieved from http://genome.ucsc.edu and used as a key input to the Immune Epitope Database and Analysis Resource (www.iedb.org). Linear peptides with 90% BLAST homology were selected, and T-cell, B-cell, and MHC ligand assays without MHC restriction were searched and evaluated. HLA-disease associations were screened on the HLA-SPREAD platform (https://hla-spread.igib.res.in) by selecting only positive markers.ResultsA total of 183 epitopes were found, corresponding to 178 SARS-CoV-2 and 5 SARS-CoV spike epitopes, respectively. Results were obtained from 22 T-cell assays, 398 B-cell assays, and 2 MHC ligand assays. Complementary receptors included 1080 T-cell receptors and 0 B-cell receptors.Specifically, the IEDB_epitope:1329790 (NATNVVIKVCEFQFCNDPFLGVYY) was shown to bind to HLA-DRB1*15:02 and HLA-DRB1*15:03 alleles, whereas the IEDB_epitope:1392457 (TKCTLKSFTVEKGIYQTSNFRVQPT) was reported to bind to HLA-DRB1*07:01, HLA-DRB1*03:01, HLA-DRB3*01:01, and HLA-DRB4*01:01 alleles. The HLA alleles detected were found to be positively associated with various immunological disorders (Table 1).Table 1.MHC-restricted epitopes of the BNT-162b2 vaccine and potentially associated immunological conditionsEpitopeAssayMHC moleculeAssociated disease (population)NATNVVIKVCEFQFCNDPFLGVYY + OX(C10)cellular MHC/mass spectrometry ligand presentationHLA-DRB1*15:02Takayasu arteritis (Japanese) Arthritis (Taiwanese) Scleroderma (Japanese) Colitis (Japanese)HLA-DRB1*15:03Systemic lupus erythematosus (Mexican American)TKCTLKSFTVEKGIYQTSNFRVQPT + SCM(K2)as aboveHLA-DRB1*07:01Allergy, hypersensitivity (Caucasian)HLA-DRB1*03:01Type 1 diabetes (African) Sarcoidosis, good prognosis (Finnish)HLA-DRB3*01:01Graves' disease (Caucasian) Thymoma (Caucasian) Sarcoidosis (Scandinavian) Autoimmune hepatitis (Caucasian)HLA-DRB4*01:01Vitiligo (Saudi Arabian)ConclusionSimilar to the SARS-CoV-2 spike protein, the protein product of the BNT-162b2 mRNA vaccine contains immunogenic epitopes that may trigger autoimmune phenomena in predisposed individuals. Genotyping for HLA alleles may help identify at-risk individuals. However, further research is needed to elucidate the underlying mechanisms and potential clinical implications.References[1]Vita R, Mahajan S, Overton JA et al. The Immune Epitope Database (IEDB): 2018 update. Nucleic Acids Res. 2019 Jan 8;47(D1):D339-D343. doi: 10.1093/nar/gky1006.[2]Dholakia D, Kalra A, Misir BR et al. HLA-SPREAD: a natural language processing based resource for curating HLA association from PubMed s. BMC Genomics 23, 10 (2022). https://doi.org/10.1186/s12864-021-08239-0[3]Parker R, Partridge T, Wormald C et al. Mapping the SARS-CoV-2 spike glycoprotein-derived peptidome presented by HLA class II on dendritic cells. Cell Rep. 2021 May 25;35(8):109179. doi: 10.1016/j.celrep.2021.109179.[4]Knierman MD, Lannan MB, Spindler LJ et al. The Human Leukocyte Antigen Class II Immunopeptidome of the SARS-CoV-2 Spike Glycoprotein. Cell Rep. 2020 Dec 1;33(9):108454. doi: 10.1016/j.celrep.2020.108454.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

THE NOVEL CORONAVIRUS INFECTION (COVID-19) CONCURRENT WITH PSEUDOMEMBRANOUS COLITIS IN THE EARLY POSTPARTUM PERIOD: A CLINICAL CASE.

Background: Women are most at risk for Clostridium difficile infection in the early postpartum period. Clostridium difficile-associated colitis may be mistaken for the intestinal form of COVID-19 during the ongoing novel coronavirus infection pandemic. Case report: The paper describes a clinical case of a female patient diagnosed with the novel coronavirus infection and Clostridium difficile-associated pseudomembranous colitis in the early postpartum period. It depicts the diagnosis and treatment of the identified concurrent pathology. It demonstrates data from of an endoscopic examination of the colon and spiral computed tomography of the chest and provides laboratory confirmation of the infectious etiology of comorbidity. There are data available in the literature on the high rate and recurrent course of pseudomembranous colitis in the early postpartum period. It is noted that timely C. difficile eradication and pathogenetic treatment for the novel coronavirus infection allow relief of clinical symptoms. Conclusion(s): The case of the novel coronavirus infection concurrent with Clostridium difficile-associated pseudomembranous colitis in the early postpartum period is of interest in connection with the need for differential diagnosis of the etiology of diarrheal syndrome, the precise identification of which determines the further tactics of patient management and the nature of anti-epidemic measures.Copyright © A group of authors, 2021.

Individual intensive nursing care plan for pseudomembranous colitis due to antibiotic treatment of COVID-19

In recent years, a number of complications have been observed as a result of uncontrolled antibiotic treatment. One of them is gastrointestinal dysbiosis. Not infrequently it is the cause of pseudomembranous colitis, a disease with a remarkably high associated mortality. It can be severe and requires serious medical care. This report presents a clinical case of a patient who developed the disease pseudomembranous colitis after antibiotic treatment for a Covid infection. The aim of the report is to define and present in a systematized manner the nursing care provided in the specific case. The daily analysis of the patient's condition allows to offer complex, adequate and individual nursing care, which, in addition to meeting her needs, also aims to alleviate her condition.

Gastrointestinal Manifestations of COVID-19 and Inflammatory Bowel Disease in the COVID-19 Era: Clinical Overview and Updated Guidelines

Aim: The aim of this chapter is to discuss the gastrointestinal (GI) manifestations of coronavirus (COVID-19) and inflammatory bowel disease (IBD) in the pandemic era. Methods: The author conducted a search of the scientific literature up to June 2021 including the following databases: PubMed, Cochrane library, Google Scholar, MedLine, EMBASE, and National trials registry, using the following keywords (IBD, inflammatory bowel disease, ulcerative colitis, Crohn's disease, COVID-19, SARS-CoV2, coronavirus). Results: This chapter explained the GI associated with COVID-19 including their pathophysiology and molecular pathways, methods of diagnosis, impact on the severity of the disease, and risk of associated mortality. The chapter also outlined the role of feco-oral infection, viral shedding, the gut-lung axis, and the effect of dysbiosis on COVID-19 infection. Moreover, this chapter discussed the IBD guidelines during the pandemic, including the European Crohn's and Colitis Organization (ECCO), American Gastroenterology Association (AGA), International Organization for the Study of Inflammatory Bowel Disease (IOIBD), and Asian Pacific Association of Gastroenterology (APAGE) guidelines, to delineate the agreements and disagreements between the different guidelines. Furthermore, it discussed the implementation of telemedicine, endoscopy regulations, and vaccination programs in IBD patients. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Factors influencing sonographer-led bowel ultrasound service

The aim of this study was to investigate factors influencing UK sonographers' practice of adult bowel ultrasound. A mixed-method online questionnaire was designed and shared on social media platforms in April 2021. Research restrictions due to COVID19 limited the sample size permitted. Convenience sampling recruited thirty UK sonographers performing adult abdominal ultrasound in their practice. Quantitative data were analysed using descriptive statistics, and qualitative data were analysed using inductive thematic analysis. Quantitative data revealed that 53% (n= 16) of the participants expressed a lack of confidence in scanning the bowel, while 77%, (n = 23) indicated a high level of interest in training in bowel ultrasound. Although 63.3% (n = 19) of the participants reported a high level of confidence in scanning the bowel for suspected appendicitis, the majority (70%, n = 21) expressed lack of confidence in examining the bowel for other pathologies like inflammatory bowel disease (IBD). Inductive thematic analysis of qualitative data revealed that the participants had varying opinions on this topic. Emerging themes included training opportunities, preference of other imaging modalities, management challenges, sonographers, and radiologists' influence. Qualitative results suggested that factors influencing sonographer evaluation of the bowel include advanced levels of training, a high degree of support from radiologists, regular bowel ultrasound lists, audits, and feedback from clinicians. Based on the findings of this study, most sonographers are not confident in practising bowel ultrasound beyond the evaluation of suspected appendicitis. Surveyed sonographers were interested in expanding their roles into other areas of bowel ultrasound like examining for Crohn's and ulcerative colitis. Sonographer role extension into this area of practice is limited by various factors like chronic shortage of sonographers, increasing workload, limited training, and the perception of diminishing support from radiologists. We recommend a future study that is not limited by a small sample size.

Multi-System Inflammatory Syndrome Presenting as Non-Specific Colitis: A Medical Diagnosis with a Surgical Presentation.

A 20-year-old woman with previous COVID-19 diagnosis presented with abdominal pain and colitis on CT scan. She was admitted in septic shock, with etiology of colitis unclear. After resuscitation, antibiotics, and steroids, she clinically deteriorated. Worsening Clostridioides difficile infection was most likely and she was taken to the operating room. Intraoperatively, only a segment of transverse colon appeared abnormal on gross and endoscopic evaluation. Total colectomy was deferred in favor of segmental resection. Given her unusual disease pattern and recent COVID-19 infection, diagnosis of MIS-C was considered. Steroids were continued and treatment broadened to include heparin and IVIG. The patient returned to the operating room for planned reexploration, endoscopy, and end colostomy. On hospital day three, the patient had an acute mental status change. Computed tomography demonstrated acute cerebral edema with brainstem herniation. The family chose comfort-care measures. Final pathology from the transverse colon demonstrated COVID-19-associated vasculitis.

Fulminant Clostridioides difficile Colitis With SARS-CoV-2 Infection.

Clostridioides difficile (C. difficile)and coronavirus disease 2019 (COVID-19) infections can have overlapping symptoms. Recently, the association and outcomes of coinfection have been studied. We present the case of an 83-year-old lady with Parkinson's disease (PD) who was admitted with pneumonia secondary to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. She was treated with empiric antibiotics ampicillin-sulbactam and azithromycin, along with antiviral therapy remdesivir and baricitinib, and dexamethasone. The patient developed severe C. difficile infection with a leukemoid reaction. She was treated with intravenous metronidazole and oral vancomycin without any improvement. Before she could receive a fecal microbiota transplant, her infection progressed to fulminant colitis, and she required emergent surgery. The patient developed several complications post-surgery and succumbed to the severe illness. Our patient's multiple comorbidities and an underlying COVID-19 infection predisposed her to severe illness. This case emphasizes the long-standing discussion on antibiotic stewardship and encourages a debate on the role of immunosuppressant antiviral medications and underlying PD in predisposing patients to a severe C. difficile infection.

COVID-19 vaccination in adults with inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) are not at increased risk of SARS-CoV-2 infection compared to the general population, and most are not at increased risk for severe disease. COVID-19 is nonetheless common, and vaccination is critical. Four safe and efficacious vaccines are now available for the prevention of COVID-19, with most data available for mRNA vaccines. Patients with IBD have a robust humoral response to vaccination with rates of seroconversion exceeding 95% following a two-dose mRNA vaccine series and 99% following a three-dose mRNA series, although those on certain therapies including anti-tumor necrosis factor α agents may have lower antibody concentrations and waning of antibodies over time. Additionally, rates of cell-mediated immune response, even in those patients with IBD who did not have evidence of humoral immunity, are high. Vaccines are safe and have not been associated with flares in disease activity. Gastroenterology providers should take an active role in ensuring patients with IBD are appropriately vaccinated against COVID-19.

Lactulose Works in the Large Bowel: But How Does It Improve Hepatic Encephalopathy in a Patient Without a Large Bowel?

Introduction: Lactulose is a non-absorbable disaccharide which acts in the large bowel, and is commonly used in the treatment of hepatic encephalopathy. We present an interesting case of altered mental status due to hepatic encephalopathy successfully managed with lactulose in a patient with history of total colectomy. Case Description/Methods: A 67-year-old male with non-alcoholic cirrhosis and inflammatory bowel disease (IBD) post total proctocolectomy with a continent ileostomy known as a Kock-pouch (K-pouch) presented to the hospital with flu like symptoms and altered mental status. He was subsequently found to be positive for COVID-19. At the time of initial evaluation, the patient was obtunded with an elevated ammonia level of 91 umol/L. Colorectal surgery was consulted as the patient was not able to empty his K-pouch. Recently, he complained of inability to catheterize and with bleeding from the stoma. Initial catheterization with a Water's tube yielded 400 cc of effluent. Nasogastric tube was placed through which he was receiving lactulose 30 mg q8 hours. The patient's mental status improved within 24 hours. The patient ultimately underwent flexible pouchoscopy with endoscopic dilation and placement of a 22 French mushroom catheter for decompression of the K-pouch. Discussion(s): Lactulose is a non-absorbable disaccharide composed of galactose and fructose. The small intestine does not have the enzymes required to breakdown lactulose so it reaches the large bowel in its original form. In the large bowel, it is metabolized by colonic bacteria into monosaccharides and then to volatile fatty acids, hydrogen and methane. Lactulose decreases both the production and absorption of ammonia mainly through the presence of gut bacteria. The question arises as to how lactulose decreased ammonia levels in this patient without a large bowel. One proposed mechanism is the translocation of bacteria normally found in the large bowel to the small intestine. Small Intestinal Bacterial Overgrowth (SIBO), is a condition causing an increased number of bacteria in the small intestine. Patients with IBD and structural abnormalities are at increased risk of developing SIBO. Lactulose is commonly used in the diagnosis through the administration of lactulose and subsequent measurements of hydrogen and methane gas in expired air. This condition, in our patient with history of ulcerative colitis and colectomy, is a proposed mechanism of the efficacy of lactulose in the treatment of hepatic encephalopathy.

Long-Term Outcomes of Treatment With and De-Escalation From a Combination of Vedolizumab and Another Biologic or Tofacitinib for Inflammatory Bowel Disease

Introduction: There are scant data on long-term outcomes of treatment of inflammatory bowel disease (IBD) with a combination of advanced therapies, including after de-escalation. Method(s): We identified patients with IBD at a tertiary center who began therapy with vedolizumab (VDZ) in combination with another advanced therapy (biologic or JAK inhibitor) between 2016 and 2020 and examined their outcomes through 6/1/22. We defined biochemical remission as CRP, 5 mg/L and calprotectin < 150 mcg/g, and endoscopic remission as Mayo endoscopic subscore 0 or simple endoscopic score for Crohn's disease (CD) 0. Short-term outcomes of this cohort were previously reported. Result(s): Fourteen patients with a median of 322 (IQR 251-322) weeks of follow up were identified. 10 had ulcerative colitis, 3 CD, and 1 indeterminate colitis. VDZ was combined with tofacitinib in 9 patients, ustekinumab in 3 and adalimumab in 2. Median time on combination therapy was 94 weeks (IQR 17-133). Eight patients achieved objective remission (3 biochemical, 5 endoscopic), 1 changed combination with subsequent endoscopic remission, 2 had primary non-response, 1 had secondary non-response, 1 stopped within 1 month due to reported adverse effect (paresthesia), and 1 lacked follow-up data. Eight patients de-escalated to a single agent, 4 at physician direction and 4 due to insurance denial. Before de-escalation, 6 had objective remission (2 biochemical, 4 endoscopic). After de-escalation, 3 patients maintained objective remission (2 biochemical, 1 endoscopic), 3 had disease flare, of which 1 required colectomy, and 2 lacked data. All 3 patients with disease flare had de-escalated following an insurance denial. Two patients remained on combination therapy through follow up: 1 has endoscopic remission after changing one drug of their combination and 1 has ongoing moderate endoscopic disease despite combination therapy. There were 2 infections requiring hospitalization (rotavirus, C. difficile), and 8 non-serious infections (5 mild SARS-COV-2, 1 peristomal cellulitis, 1 pneumonia, 1 sinus) while on combination therapy. Conclusion(s): In long-term follow up of this small cohort, there were no new signals on effectiveness or safety of combining advanced agents. De-escalation to a single agent was tolerated in half of patients with follow-up data;all patients who flared following de-escalation had adjusted therapy due to insurance denial. More data is needed to inform de-escalation decisions.

Knowledge About Preventive Health Guidelines for Inflammatory Bowel Diseases in Patients: A Quality Improvement Project

Introduction: Preventive care guidelines for patients with Inflammatory Bowel Disease (IBD) emphasize the need for a patient-centered interdisciplinary approach, with assessment and management of the patient's physical and mental health as well as the IBD. There is no data about compliance with current IBD preventive care guidelines in Puerto Rico. This study aims to evaluate current IBD preventive care in the clinic, and knowledge among patients and gastroenterologists about the preventive care guidelines. The 3-phase study includes retrospective medical record review, an anonymous online survey of gastroenterologists, and an anonymous survey of patients. We report the results of the patient survey. Method(s): Adult patients with an established diagnosis of at least 6 months of ulcerative colitis (UC), Crohn's disease (CD) or indeterminate colitis (IC), were recruited from the IBD Clinics and through IBDrelated social media. Questionnaires were filled in the clinic and online using Google forms. Statistical analysis was performed using descriptive statistics. Comparisons of proportions and means between groups was based on Fisher's exact and chi square tests. The study was approved by the MSC IRB. Result(s): 83 patients completed the survey, 42 from the clinics and 41 through social media. 60% had CD, 47.4% were diagnosed more than 10 years ago, 57.9% were younger than 38 years old and 68% were on immunosuppressants/biologics. 83.13% and 60.24% of patients knew that COVID and Influenza vaccines were indicated, respectively. However only 42.17%, 36.14%, 32.53% and 31.33% of patients knew about indications for HPV, pneumococcal, varicella and zoster vaccines, respectively. There was a significant difference about knowledge regarding screening for latent TB (p=0.019), anxiety and depression (p= 0.03) and smoking status (p=0.033) between CD and UC/IC patients, as shown in Table. Conclusion(s): Our study showed a significant lack of knowledge about IBD preventive care in patients. Strategies to improve patient education are needed. The results of the review of records from the clinic as well as the knowledge of gastroenterologists will point out other deficiencies in the healthcare system and help design methods to improve patient care. Another aspect that needs to be explored is access to preventive measures such as vaccines. (Table Presented).

Clostridium Difficillae Infection in Post-Covid Patients

Intro: The ongoing pandemic caused by the SARS-CoV-2 virus has brought many new insights into medicine. During the first months of the pandemic, when there were no comprehensive guidelines for precise antimicrobial therapy, empirical overuse of broad-spectrum antibiotics was observed. Which resulted in the development of clostidium infection in certain cases. In our report, we address 83 cases of clostridial colitis in post-covid patients from 3/2020 to 3/2021 and their specific therapy. Method(s): Retrospective analysis of risk factors for clostridial infection and therapy of clostridial colitis. Finding(s): In the period 3/2020-3/2021, 9617 patients were diagnosed with SARS-CoV-2 virus infection in our hospital, of which 1247 were hospitalized. In 83 cases, clostridial colitis occurred during or after the covid infection had resolved. Mortality in this group was 17%, which corresponds to 14 patients. Previous empirical administered antiobiotics in COVID-19 infection contributed to the development of clostridial colitis in case of 22 patients (27%) by clarithromycin, in 14 pacients (17%) by penicillins and by 3rd generation cephalosporins in 9 patients (11%). The average duration of therapy with broad-spectrum antibiotics was 15.63 days (+-8.99). Other risk factors we observed are: PPI use (25%), active malignant disease (10%), previous glucocorticoid therapy (22%). Vancomycin was used in clostridial infection therapy in 47% (39), metronidazole in 31% (25) and fidaxonicin in 7% (6). In the group, we observed recurrence of clostridium difficile infection in 14% of patients and FMT was performed in 6 patients. Conclusion(s): This study shows a higher percentage of clostridial infection in cases of long-term therapy with broad-spectrum antibiotics. It also points to the effect of specific antimicrobial therapy for infection caused by the bacterium Clostridium difficile and the possibility of using fecal bacteriotherapy.Copyright © 2023

Prevention of Venous Thromboembolism in IBD Patients May Not Be Associated With Prophylaxis Rates

Introduction: Patients with inflammatory bowel disease (IBD) harbor a higher risk of deep venous thrombosis and venous thromboembolism (VTE) compared to healthy individuals. Previous studies, including a large meta-analysis, estimate the risk of VTE incidence to be almost 2-3 times baseline. Guidelines, therefore, recommend VTE prophylaxis in most inpatients with IBD. While previous studies have demonstrated less than ideal adherence with these guidelines, we sought to determine the rate of VTE prophylaxis at an academic medical center. Method(s): A retrospective chart review of inpatients with Crohn's disease or ulcerative colitis admitted to a tertiary medical center in Bronx, NY from 1/2015 to 2/2020 was performed. All patients who were admitted with a primary gynecological or psychiatric disorder, COVID infection, or known hypercoagulable disorder were excluded. Orders for pharmacologic and mechanical VTE prophylaxis at any point during the patient's admission were ed. Using ICD10 codes, IBD patients with acute VTE variations were identified. Clinical and demographic variables were analyzed for their association with VTE prophylaxis. Two-sample t-tests and Fisher's exact tests were used as appropriate. A p-value < 0.05 was considered statistically significant. Result(s): A total of 1670 patients with IBD were identified among whom 1280 (76.7%) were prescribed either pharmacological or mechanical VTE prophylaxis during their hospital admission. 70 patients were excluded from the analysis of development of VTE because their diagnosis of VTE was prior to their admission date. Older age (p<.0001), higher BMI (p<.0001), female sex (p=.001), havingMedicare insurance (p<.0001) were associated with VTE prophylaxis ordering (see Table). There was a VTE incidence of 6.2% (n=98/1600) of the IBD patients in our cohort, with 3/388 patients (0.8%) not being prescribed prophylaxis and 95/1212 (7.8%) being prescribed prophylaxis (p< 0.001). Conclusion(s): Contrary to other studies, we show that VTE prophylaxis rates may not be associated with a reduction in VTE incidence during hospitalization. While bias by indication may be contributing to this finding with those at greatest risk more likely to receive prophylaxis, other factors may be involved. Further studies are warranted. (Table Presented).

Evaluation of Quality-of-Care Indicators Among Patients With Crohn's Disease and Ulcerative Colitis in the United States: 2019-2020

Introduction: Crohn's disease (CD) and ulcerative colitis (UC) can be difficult to manage and, due to a lack of meaningful quality measures, patient (pt) care may vary by provider. To understand where gaps in care may exist for these pts, this study assessed specific healthcare resource utilization (HRU) and medication metrics that may be potential quality of care (QOC) indicators. Method(s): Using a large commercial US claims database (2019-2020), pts with CD or UC were identified. Potential QOC indicators were selected based on clinical guidelines and recommendations from measures of quality organizations and included CD or UC prevalence;gastroenterologist (GE) and IBD-related non-GE outpatient visits;IBD-related emergency department visits or hospitalizations;excessive steroid use (prednisone equivalent >=10 mg/day for >=60 consecutive days or a single prescription of >=600 mg prednisone);excessive steroid users on corticosteroid (CS)-sparing therapy;excessive steroid users with central dual-energy X-ray absorptiometry (DEXA) or osteoporosis pharmacologic treatment;use of targeted immunomodulators (TIMs) and oral mesalamine (CD only);imaging assessments;and assessment of inflammatory biomarkers. National percentages of pts achieving each metric are reported. Result(s): In total, 41,555 CD and 52,507 UC pts were identified in 2019, resulting in a 0.3% and 0.4% prevalence, respectively (Table). Over a third of CD pts (39.8%) and almost half of UC pts (45.5%) did not visit a GE in 2019. Around 10% CD pts, and up to 6.4% of UC pts, had IBD-related ED visits or hospitalizations. 17.1% CD and 14.5% UC pts were excessive steroid users, yet < 9% CD and UC pts, received DEXA scans and/or bone treatments. A third of excessive steroid users with CD (34.5%), and over half (53.0%) of those with UC, did not receive CS-sparing therapy. The rate of TIM use was over two times higher in CD vs UC pts (CD: 44.3%;UC: 18.9%). Despite evidence that mesalamine is ineffective in CD, 18.7% of pts with CD were prescribed it. Inflammatory biomarker level testing rates were < 50% in both CD and UC. Similar outcomes were reported in 2020, with lower HRU, possibly due to COVID-19. Conclusion(s): This analysis of QOC indicators highlights various areas for improvement that may provide better treatment outcomes and reduce HRU for pts with CD and UC. Future research is needed to assess outcomes in pts that are not being routinely monitored. (Table Presented).

Pseudomembranous colitis in patients with COVID-19 (review)

AIM: to estimate the features of pseudomembranous colitis in patients with COVID-19, diagnostics, conservative treatment and surgery for complications. PATIENTS AND METHODS: a retrospective analysis of 396 patients with pseudomembranous colitis (PMC) in patients with new coronavirus infection was carried out for the period from March 2020 to November 2021. Among them there were 156 (39.3%) males, females - 240 (60.6%), moderate and severe forms of COVID-19 occurred in 97.48%. The diagnosis of PMC was established due to clinical picture, laboratory, instrumental methods (feces on Cl. difficile, colonoscopy, CT, US, laparoscopy). RESULT(S): the PMC rate in COVID-19 was 1.17%. All patients received antibiotics, 2 or 3 antibiotics - 44.6%, glu-cocorticoids were received by all patients. At 82.8%, PMC developed during the peak of COVID-19. To clarify the PMC, CT was performed in 33.8% of patients, colonoscopy - 33.08%, laparoscopy - in 37.1% (to exclude bowel perforation, peritonitis). Conservative treatment was effective in 88.8%, 76 (19.1%) patients had indications for surgery (perforation, peritonitis, toxic megacolon). Most often, with peritonitis without clear intraoperative confir-mation of perforation, laparoscopic lavage of the abdominal cavity was performed (60 patients - 78.9%, mortality - 15.0%), colon resection (n = 6 (7.9%), mortality - 66.6%), ileo-or colostomy (n = 8 (10.5%), mortality - 37.5%), colectomy (n = 2 (2.6%), mortality - 50.0%). The overall postoperative mortality rate was 22.4%, the incidence of surgical complications was 43.4%. In addition, in the postoperative period, pneumonia was in 76.3%, thrombosis and pulmonary embolism in 22.3% of patients. In general, the overall mortality in our patients with PMC was 11.4%, with conservative treatment - 8.8%. CONCLUSION(S): pseudomembranous colitis is a severe, life-threatening complication of COVID-19. In the overwhelm-ing majority of patients, conservative therapy was effective, but almost 1/5 of patients developed indications for surgery, the latter being accompanied by high mortality and a high morbidity rate. Progress in the treatment of PMC, apparently, is associated with early diagnosis, intensive conservative therapy, and in the case of indications for surgery, their implementation before decompensation of the patient's condition and the development of severe intra-abdominal complications and sepsis.Copyright © 2022, Association of Coloproctologists of Russia. All rights reserved.

A Rare Etiology for Ulcerative Colitis Flare

Introduction: Prior to colonoscopy, it is well understood that patients must undergo bowel cleansing. Based on the type of laxative, colonoscopy preparations fall into two categories - polymer-based formulas (PEG) and saline-based formulas (NaP). Both types of bowel preparations are deemed to be relatively safe and part of routine practice. However, we describe the rare case of an ulcerative colitis (UC) flare due to the bowel preparation formula. Case Description/Methods: A 29-year-old female with diagnosis of UC, presently in clinical and biochemical remission on oral mesalamine, contracted COVID-19 and had reactivation of UC symptoms. After being on budesonide tablets and rectal foam for two months, patient achieved clinical remission, and a surveillance colonoscopy was performed which revealed normal colon and terminal ileum except mild congestion in the cecum (Figure A). Pathology revealed unremarkable mucosa in the entire colon except for chronic active colitis in the cecum. Immediately following this colonoscopy, the patient started to experience another severe UC flare requiring hospitalization. The patient's laboratory work-up was normal except for an elevated fecal calprotectin (1710). Stool infectious work-up was negative and the patient denied any NSAID or antibiotic use. The patient underwent a repeat colonoscopy which revealed severe Mayo 3 pancolitis (Figure B) in comparison to a stable colonoscopy a few weeks prior. It was revealed that for her initial colonoscopy, she had used SUPREP bowel prep kit. On prior colonoscopies she had used MiraLAX bowel prep with no adverse effects. During hospitalization, the patient was started on biologic therapy with good effect. Discussion(s): There are no clear guidelines on appropriate bowel preparation formula for the inflammatory bowel disease (IBD) population. Sufficient literature exists to confirm that NaP can irritate the intestinal mucosal wall. Moreover, numerous animal experiments have employed dextran sodium sulfate for chemical induction of intestinal inflammation to mimic UC flares in humans [1]. Thus, it can be surmised that because SUPREP ingredients contain sodium sulfate, the potential for UC flare is higher. It is pertinent for practitioners to be aware of the possible rare adverse effects of saline-based formulas, especially when treating the IBD population.

QUASAR Induction Study 1 Cumulative Response to Guselkumab in Patients With Moderately to Severely Active Ulcerative Colitis

Introduction: Guselkumab (GUS), an IL-23p19 antagonist, had greater efficacy than placebo (PBO) in achieving clinical response and clinical remission atWeek (Wk) 12 in the randomized, controlled Phase 2b QUASAR Induction Study 1 (NCT04033445) in patients with moderately to severely active ulcerative colitis (UC).1 Patients who were not in clinical response at Wk 12 received GUS treatment through Wk 24. Here, we report GUS cumulative efficacy and safety results for Induction Study 1. Method(s): Eligible patients had moderately to severely active UC (modified Mayo score of 5 to 9 with a Mayo endoscopy subscore >=2) at baseline. Patients were randomized 1:1:1 to IV GUS 200mg, 400mg, or PBO at Wks 0, 4, and 8. Patients who were not in clinical response to IV induction at Wk 12 received GUS treatment (PBO IV->GUS 200mg IV;GUS 200mg IV->GUS 200mg SC;GUS 400mg IV->GUS 200mg SC) at Wks 12, 16, and 20 and were evaluated at Wk 24 (Figure). Matching IV or SC PBO was administered to maintain the blind. Result(s): Three hundred thirteen patients were randomized and treated at baseline. Demographic and disease characteristics at baseline were similar among the treatment groups, and approximately 50% had a prior inadequate response or intolerance to advanced UC therapy. AtWk 12, clinical response was achieved by 61.4% (62/101) and 60.7% (65/107) of patients randomized to GUS 200mg and GUS 400mg IV vs 27.6 % (29/105) of patients randomized to PBO IV (both p< 0.001). Of the patients in the GUS groups who were not in clinical response at Wk 12, 54.3% (19/35) in the GUS 200mg IV->200mg SC group and 50.0% (19/38) in the GUS 400mg IV->200mg SC group achieved clinical response at Wk 24. Clinical response atWk 12 or 24 was achieved by 80.2% of patients who were randomized to GUS 200mg IV and 78.5% of patients who were randomized to GUS 400mg IV. For patients who received PBO IV->GUS 200mg IV, clinical response at Wk 24 (65.2%) was similar toWk 12 clinical response following GUS 200mg IV induction (61.4%). The most frequent adverse events among all GUS-treated pts (n=274) were anemia (7.7%), headache (5.1%), worsening UC (4.4%), COVID-19 (3.6%), arthralgia (2.9%) and abdominal pain (2.6%) which are consistent with Wk 12 results. Conclusion(s): Overall, approximately 80% of patients randomized to receive GUS achieved clinical response at Wk 12 or 24. Continued treatment with SC GUS allowed 50-54.3% of IV GUS Wk 12 clinical nonresponders to achieve clinical response at Wk 24. No new safety concerns for GUS were identified. (Figure Presented).

Mucosa-Associated Lymphoid Tissue Lymphoma of the Rectum Incidentally Found in a Patient with Ulcerative Colitis

Introduction: Mucosa-associated lymphoid tissue (MALT) lymphomas are extra-nodal marginal zone B-cell lymphomas, most commonly found in the stomach, associated with Helicobacter pylori infections, and generally not linked with inflammatory bowel disease. Rectal MALT lymphoma is very uncommon and often associated with painful defecation, change in bowel habits, or rectal pressure/prolapse. Here, we present a rare case of an asymptomatic female with ulcerative colitis (UC) found to have benign-appearing rectal polyps during a routine screening colonoscopy. Case Description/Methods: The patient is a 56-year-old female with a history of left-sided UC, diagnosed in 1993, with one flare after receiving the 2nd dose of the Moderna COVID-19 vaccine, taking oral Olsalazine 500 mg twice daily, low-dose Prednisone, and mesalamine suppositories as needed presenting for screening colonoscopy. The patient was asymptomatic, citing regular non-bloody bowel movements and normal stool consistency. Colonoscopy revealed two 7 mm sessile, non-bleeding rectal polyps, surrounded by congested, erythematous, friable, and ulcerated mucosa in the rectosigmoid colon. Cold forceps biopsies were taken. Hematopathology evaluation of the routine colon biopsy samples revealed chronic nonspecific colitis while pathology of the rectal polyps showed marked lymphoplasmacytic infiltrate and extra-nodal marginal zone lymphoma of MALT. Ancillary studies, immunohistochemistry, and molecular studies for B-cell gene rearrangement confirmed extra-nodal marginal zone lymphoma of MALT with prominent plasmacytic differentiation. The patient was informed and close follow-up in Gastroenterology clinic was arranged. (Figure) Discussion: Rectal MALT lymphoma is rare with unclear management options. Treatments of UC include watchful waiting, surgical resection, endoscopic mucosal resection, radiation, and/or chemotherapy. Helicobacter pylori infections, though strongly linked with gastric MALT lymphoma, have not been shown to be strongly correlated with rectal MALT lymphoma. Given that patients with UC have chronic UCassociated colonic inflammation, lymphoma is often difficult to distinguish visually during colonoscopy, frequently masked by ulcerations and pseudo-polyps. In cases like these, more definitive treatments such as surgical resection could therefore be warranted. Long-term follow-up data is sparse and definitive management remains a clinical conundrum, thus these patients require reliable long-term multidisciplinary close follow-up. (Figure Presented).

Clostridium difficile Infection Rates During the Pandemic in New York Capital Area: A Single-Center Study.

Introduction Clostridioides difficile (C. difficile) colonizes the large intestine, rendering healthy individuals asymptomatic carriers of the disease. In certain instances, C. difficile infection (CDI) occurs. Antibiotic use remains the leading risk factor for CDI. During the coronavirus disease 2019 (COVID-19) pandemic, multiple risk and protective factors for and against CDI were identified, and as such multiple studies tried to analyze the pandemic's overall effect on CDI incidence rates, with contradictory results. Our study's aim is to further characterize the CDI incidence rates trends, but for a longer period of 22 months in the pandemic. Methods We included only adult (>18 years) patients, diagnosed with CDI during their hospitalization for the following period: January 1, 2018, to December 31, 2021. Incidence was calculated as cases per 10,000 patient days. The period identified as the COVID-19 pandemic period was the following: March 1, 2020, to December 31, 2021. All analyses were performed by an expert statistician using Minitab software (Minitab Inc., State College, Pennsylvania, United States). Results The mean CDI incidence rate per 10,000 patient-days was 6.86 +/-2.1. The 95% confidence interval for the CDI incidence rate prior to the pandemic was found at 5.67 +/-0.35 while the interval during the pandemic was calculated at 8.06 +/- 0.41 per 10,000 patient days. Those results reveal a statistically significant increase in CDI incidence rates during the COVID-19 era. Conclusion Multiple risk and protective factors for and against hospital-acquired infections (including CDI) have been identified during the unprecedented COVID-19 healthcare crisis. In the literature, there is high controversy regarding the trends of CDI incidence during the pandemic. The current study analyzed an almost two-year period into the pandemic, identifying an increase in CDI rates when compared to the pre-pandemic era.