Field and Laboratory Testing of Feeding Stimulants to Enhance Insecticide Efficacy Against Spotted-Wing Drosophila, Drosophila suzukii (Matsumura).

The invasive spotted-wing drosophila, Drosophila suzukii (Matsumura), is a key insect pest of berries globally, causing lost revenues and increased production costs associated with applications of insecticides. The insecticides utilized are commonly broad-spectrum pyrethroids, organophosphates, or carbamates in conventionally managed fields and spinosad in organically managed fields. Adoption of more selective insecticides has been limited due to their lower residual activity, and the requirement that some must be ingested to be effective. We investigated the use of feeding stimulants for D. suzukii as a method to improve longevity and efficacy in a range of insecticides. In laboratory bioassays, sugar increased the efficacy of all chemical classes tested; however, the inclusion of yeast only showed a benefit with malathion. Feeding stimulants had a limited effect in some cases under field conditions. Similarly, infestation in field plots and a semifield bioassay showed no significant decreases in infestation with the inclusion of feeding stimulants for the insecticides tested in these trials. We discuss the implications of these findings for managing D. suzukii in fruit crops to help ensure the harvest of marketable fruit.

Field Perimeter Trapping to Manage Rhagoletis mendax (Diptera: Tephritidae) in Wild Blueberry.

Rhagoletis mendax Curran (the blueberry maggot fly) is a major pest of wild blueberry. It is a direct pest of the fruit. Females lay eggs in fruit resulting in infestations of larvae unacceptable to most consumers. Three field perimeter interception tactics were tested for control of R. mendax in wild blueberry, Vaccinium angustifolium Aiton (Ericales: Ericaceae), between 2000 and 2010. We investigated field perimeter deployment of baited, insecticide-treated, green spheres (2000-2005), baited, yellow Trécé PHEROCON AM traps (2005 and 2006), and baited, Hopper Finder, sticky barrier tape (2008-2010). Only the Hopper Finder tape provided significant reduction in R. mendax adults and fruit infestation over the 3-yr field study. However, the reduction in fruit infestation compared with control plots was only 48.2 ± 7.3%, a level of reduction in damage that would be unsuitable for many commercial wild blueberry growers as a stand-alone tactic, but could be an important reduction as part of a multiple tactic IPM strategy. In addition, we constructed an agent-based computer simulation model to assess optimal trap placement between three patterns: 1) a single row of traps along field perimeter; 2) a double row of traps along the field perimeter at half the density of the single row; and 3) a grid of traps spread throughout the field but with the largest distance between traps. We found that the single row deployment pattern of traps was the best for reducing immigration of R. mendax adults into simulated fields.

Movement of Rhagoletis mendax (Diptera: Tephritidae) in Fruit-Bearing Wild Blueberry Fields. Part II.

During dispersal into fruit-bearing wild blueberry fields, blueberry maggot flies were highly active during all daylight hours as revealed by trap captures, although in one trial afternoon activity was greater than morning activity. Flies were not captured in traps at night, although observations in growth chambers showed that their activity at night, measured as displacement of position, was equal to daylight conditions. Flies were shown to fly at low altitude, just above the crop canopy, and screen fencing was shown to be effective at reducing colonization of plots, presumably due to their low height during flight. Over a 4-yr mark-capture study, colonization rate was shown to be low at 9.7 m/d, although a separate 2010 study showed higher rates at 14.1 and 28.0 m/d. Movement was shown to be nondirectional or random in the field, but a constrained random walk exhibiting direction into the field. Weed cover and high fruit density were associated with higher fly relative abundance, suggesting these field characteristics served as attractors slowing colonization rate into a field. Transect trap studies showed the temporal and spatial pattern of fly colonization into commercial wild blueberry fields, one of a slow wave that penetrates into the field interior as the season progresses. There is also an increase in fly abundance within-field edges and adjacent forest. The 'stacking' of flies along a field edge and slow movement rate into a field was shown through simulation to be a result of nondirectional short-distance dispersal of flies.

Temporal Dynamics of the Blueberry Maggot Fly (Diptera: Tephritidae) and its Primary Parasitoid, Biosteres melleus (Hymenoptera: Braconidae), in the Maine Wild Blueberry System.

Between 1998 and 2017, we conducted studies in wild blueberry, Vaccinium angustifolium Aiton (Ericales: Ericaceae), to elucidate the temporal dynamics of the blueberry maggot fly, Rhagoletis mendax Curran, and its parasitoid, Biosteres melleus (Gahan). A predictive model for the emergence of R. mendax was validated at two sites over 3 yr. A second predictive model for the major parasitoid, B. melleus, of R. mendax was constructed and suggests that the delay in emergence of the parasitoid relative to its host provides a period or 'biological window' of 9 d where insecticide sprays can be applied to manage R. mendax with a limited impact on the parasitoid. A 20-yr study on the parasitoid/host dynamics showed parasitism rates ranging from 0.5 to 28.2%. It appears that R. mendax populations in Maine wild blueberry are characterized by stable equilibrium dynamics, significantly affected by stochastic processes. There was a weak, but significant relationship between B. melleus density and R. mendax intrinsic rates of growth. Our data suggest that R. mendax population dynamics in wild blueberry is characterized by an unstable equilibrium tipping point of 7.9 maggots per liter of blueberries or an average of 10 flies per trap.

Dispersal From Overwintering Sites, Action Thresholds for Blueberry Maggot Fly (Diptera: Tephritidae), and Factors That Can Influence Variation in Predicted Fruit Infestation Levels in Maine Wild Blueberry: Part I.

Between 1996 and 2003 field studies were conducted in wild blueberry, Vaccinium angustifolium Aiton (Ericales: Ericaceae) to determine action thresholds for the blueberry maggot fly, Rhagoletis mendax Curran (Diptera: Tephritidae). Thresholds were based upon cumulative fly trap captures on baited Pherocon AM traps. The cumulative numbers of R. mendax flies captured over time was a significant predictor of infested fruit levels (maggots/liter blueberries). Fifty percent of the variance in fruit infestation is explained by fly captures. Based upon this relationship, the University of Maine Cooperative Extension has recommended action threshold of 10 cumulative fly captures/trap. However, this threshold is liberal in terms of risk as only 50% of the variance in fruit infestation is explained by fly captures. The dynamics of colonization rate and fly physiological status entering fruit-bearing fields might partially explain the variance in the action threshold. The majority of flies emerge from pruned fields or along forest scrub/shrub field edges, and it takes between 1 and 10 d (mean = 4.1 ± 0.9 d) for the populations to enter adjacent fruit-bearing fields. Flies dispersed from pruned fields at a decreasing rate the farther they dispersed. The rate of dispersal into fruit-bearing wild blueberry fields also depends upon the overwintering site quality. Sites with fruit exhibited both delayed colonization and lower colonization rates into fruit-bearing fields than adjacent pruned fields with no fruit. We also found that as the season progressed the proportion of flies capable of laying eggs varied greatly by location and year.

Population Dynamics of Spotted Wing Drosophila (Drosophila suzukii (Matsumura)) in Maine Wild Blueberry (Vaccinium angustifolium Aiton).

A long-term investigation of D. suzukii dynamics in wild blueberry fields from 2012-2018 demonstrates relative abundance is either still increasing or exhibiting periodicity seven years after the initial invasion. Relative abundance is determined by physiological date of first detection and air temperatures the previous winter. Date of first detection of flies does not determine date of fruit infestation. The level of fruit infestation is determined by year, fly pressure, and insecticide application frequency. Frequency of insecticide application is determined by production system. Non-crop wild fruit and predation influences fly pressure; increased wild fruit abundance results in increased fly pressure. Increased predation rate reduces fly pressure, but only at high abundance of flies, or when high levels of wild fruit are present along field edges. Male sex ratio might be declining over the seven years. Action thresholds were developed from samples of 92 fields from 2012-2017 that related cumulative adult male trap capture to the following week likelihood of fruit infestation. A two-parameter gamma density function describing this probability was used to develop a risk-based gradient action threshold system. The action thresholds were validated from 2016-2018 in 35 fields and were shown to work well in two of three years (2016 and 2017).

The Blueberry Gall Midge (Diptera: Cecidomyiidae): A Recent Pest of Wild Blueberry (Vaccinium angustifolium; Ericales: Ericaceae) and Its Impact on Potential Yield.

Blueberry gall midge, Dasineura oxycoccana (Johnson) (Diptera: Cecidomyiidae), is an emerging pest on wild blueberry, Vaccinium angustifolium Aiton (Ericales: Ericaceae). The purpose of this study was to document the population increase of blueberry gall midge on this crop in Maine since its discovery in 2003 until 2018. Dasineura oxycoccana appears to have three generations during the prune cycle in Maine wild blueberry, although this may vary among years. Prune fields have higher infestation rates than crop fields, most likely due to the greater abundance of susceptible leaf tissue. Production system does affect infestation rates. Fields managed under a high input system exhibit lower gall midge infestation than low or medium input fields. Field infestation rates in organic fields were intermediate to high input and low and medium input fields. In seven trials conducted between 2010 and 2017, D. oxycoccana infestation of stems resulted in significantly fewer flower-bud clusters developed at the end of the prune year in four of seven trials and significantly fewer viable flowers during bloom in the crop year in four of seven trials. Two of the seven trials resulted in significantly more flowers on infested stems than noninfested stems, evidence that in some years D. oxycoccana infestation may stimulate flower-bud production, resulting in an increase in potential yield. We provide an optimal sampling plan for D. oxycoccana infestation sampling and economic thresholds for three levels of production (yield levels) and three expected prices that growers might receive.

Spotted-Wing Drosophila (Diptera: Drosophilidae) Adult Movement, Activity, and Oviposition Behavior in Maine Wild Blueberry (Vaccinium angustifolium; Ericales: Ericaceae).

Over a period of 5 yr (2012-2016), we conducted laboratory and field studies on activity, movement, and response to trap placement of adult Drosophila suzukii (Matsumura) in wild blueberry, Vaccinium angustifolium Aiton, fields in Maine. When measuring temporal patterns in fruit infestation, we found that D. suzukii females are most active in the morning and that they are 10 times more likely to lay eggs in blueberries at the top of the plant canopy compared with berries located in the lower part of the bush. Flies were found to be more abundant in fruit-bearing (crop) fields compared with pruned (vegetative) fields based on trap capture of adults. They are also most abundant along edges of fields compared with interiors. Trap efficiency is significantly better in traps 1.2 m above the ground and above the crop canopy of this low-growing crop plant than within the crop canopy. Three experiments involving the marking of laboratory-reared flies with fluorescent marker, their release, and capture with traps along a grid in fields suggest that: 1) fluorescent markers do not affect the distance moved of marked flies, 2) dispersal rates are not different between sexes, 3) there is little difference in the dispersal pattern through pruned fields and fruit-bearing fields, and 4) flies disperse at a low rate of 0.1-30 m per day, with an average of 5 m per day, but that long-distance dispersal over 1-2 km is feasible based on statistical model extrapolation.

Long-Term Benefit of Golimumab for Patients with Moderately to Severely Active Ulcerative Colitis: Results from the PURSUIT-Maintenance Extension.

BACKGROUND AND AIMS: To evaluate the safety and efficacy of 3 additional years of subcutaneous golimumab maintenance in patients with moderately to severely active ulcerative colitis. METHODS: The PURSUIT-maintenance long-term extension enrolled patients who had completed placebo or golimumab 50 mg or 100 mg treatment every 4 weeks [q4w] through Week 52 and evaluations at Week 54 [n = 666]; treatment continued through Week 212. Patients receiving placebo were discontinued after study unblinding. Efficacy endpoints, golimumab concentrations, and anti-drug antibodies were summarized as observed for golimumab-induction responders who continued golimumab therapy during the long-term extension. Observations relating to safety were summarized for all treated patients. RESULTS: Overall, 63% of patients who were receiving golimumab at the beginning of the extension remained on treatment through the end of the study. Among all treated patients in the extension, rates of adverse events of special interest [e.g. tuberculosis, demyelination, and malignancy] were infrequent. Nine deaths occurred during the extension [1 placebo, 1 golimumab 50 mg, and 7 golimumab 100 mg]. Serum golimumab concentrations were dose-proportional and were maintained over time. During the extension through Week 228, anti-drug antibody rates with golimumab 50 mg and 100 mg were 4.4% and 3.7%, respectively. Among golimumab-induction responders, 99.3% had no disease or mild disease activity as per the Physician's Global Assessment, 92.5% were corticosteroid-free, and 76.1% had an Inflammatory Bowel Disease Questionnaire score of ≥170 at Week 216. CONCLUSIONS: Subcutaneous golimumab treatment of moderately to severely active ulcerative colitis for up to 3 additional years during the extension maintained clinical benefit with no new safety signals observed.ClinicalTrials.gov number NCT00488631.

Pupation Behavior and Predation on Drosophila suzukii (Diptera: Drosophilidae) Pupae in Maine Wild Blueberry Fields.

Drosophila suzukii (Matsumura; Diptera: Drosophilidae) is an invasive vinegar fly and pest of soft fruits in North America, including wild blueberries (Vaccinium angustifolium Aiton) in Maine. Despite its presence in the continental United States for 9 yr, little is known about its natural enemy complex. Here we report the results of a 3-yr study designed to identify naturally-occurring predators in Maine's wild blueberry fields. Experiments were conducted to determine pupation site and pupation depth to understand D. suzukii's predation vulnerability. Predation rates in the field of fully-exposed, caged, and buried pupae were measured. Pitfall traps were deployed to identify the potential predator assemblage, and laboratory experiments were conducted to determine how many pupae were consumed by commonly occurring ground beetle species (Carabidae) and field crickets (Gryllus pennsylvanicus Burmeister). The most commonly collected predators were ants, ground beetles, harvestmen, and field crickets. Significantly more pupae were found to occur in the soil compared to blueberry fruit, with most pupae in the top 0.5 cm layer of soil. Pupal predation rates in the field were high, with higher rates of predation on exposed pupae compared to buried pupae. Laboratory studies revealed that ground beetles and field crickets are likely predators of D. suzukii pupae.

Maintenance of Efficacy and Continuing Safety of Golimumab for Active Ulcerative Colitis: PURSUIT-SC Maintenance Study Extension Through 1 Year.

OBJECTIVES: The safety and efficacy of subcutaneous golimumab through 2 years of maintenance therapy was evaluated in patients with moderate-to-severe ulcerative colitis (UC). METHODS: Patients completing treatment through week 52 (placebo, golimumab 50, 100, every-4-weeks (q4w)) and evaluations at week 54 were eligible for this long-term extension (LTE) trial. Patients receiving placebo or golimumab 50 mg with worsening disease during the LTE could receive golimumab 100 mg. Efficacy assessments included the Mayo physician's global assessment (PGA) subscore, inflammatory bowel disease questionnaire (IBDQ), and corticosteroid use. Patients who were randomized to golimumab at PURSUIT-Maintenance baseline and continued receiving golimumab during the LTE were analyzed for efficacy (using intention-to-treat and "as observed" analyses; N=195) and safety (N=200). Patients treated with golimumab at any time from induction baseline through week 104 (N=1240) constituted the overall safety population. RESULTS: Baseline demographics and disease characteristics of patients entering the LTE receiving golimumab were similar to those of all patients randomized to golimumab maintenance at baseline. At week 104, 80.5% (157/195) of patients had a PGA=0/1 (range weeks 56-104: 80.5-91.8%) and 56.4% (110/195) had a PGA=0 (weeks 56-104: range: 53.8-58.5%). Through week 104, 86% of patients maintained inactive or mild disease activity. Among 174 corticosteroid-free patients at week 54, 88.5% remained corticosteroid-free at week 104. At week 104, 62.2% (120/193) had an IBDQ score ≥170. Tuberculosis, opportunistic infection, and malignancy rates were low, and the overall safety profile was similar to that reported through week 54. Two non-melanoma skin cancers, one metastatic colon cancer, and two deaths (biventricular heart dysfunction, sepsis) occurred between weeks 54 and 104. CONCLUSION: Subcutaneous golimumab q4w through 2 years maintained clinical benefit and reduced corticosteroid use among patients who did well in the maintenance study. No new safety signals were observed.

Multistate Comparison of Attractants for Monitoring Drosophila suzukii (Diptera: Drosophilidae) in Blueberries and Caneberries.

Drosophila suzukii Matsumara, also referred to as the spotted wing drosophila, has recently expanded its global range with significant consequences for its primary host crops: blueberries, blackberries, raspberries, cherries, and strawberries. D. suzukii populations can increase quickly, and their infestation is difficult to predict and prevent. The development of effective tools to detect D. suzukii presence in new areas, to time the beginning of activity within a crop, to track seasonal activity patterns, and to gauge the effectiveness of management efforts has been a key research goal. We compared the efficiency, selectivity, and relationship to fruit infestation of a range of commonly used homemade baits and a synthetic formulated lure across a wide range of environments in 10 locations throughout the United States. Several homemade baits were more efficient than apple cider vinegar, a commonly used standard, and a commercially formulated lure was, in some configurations and environments, comparable with the most effective homemade attractant as well as potentially more selective. All alternative attractants also captured flies between 1 and 2 wk earlier than apple cider vinegar, and detected the presence of D. suzukii prior to the development of fruit infestation. Over half the Drosophila spp. flies captured in traps baited with any of the attractants were not D. suzukii, which may complicate their adoption by nonexpert users. The alternative D. suzukii attractants tested are improvement on apple cider vinegar and may be useful in the development of future synthetic lures.

Subcutaneous golimumab maintains clinical response in patients with moderate-to-severe ulcerative colitis.

BACKGROUND & AIMS: Subcutaneous golimumab, a fully human monoclonal antibody to tumor necrosis factor-α (TNFα), was evaluated as maintenance therapy in TNFα antagonist-naive adults with moderate-to-severe active ulcerative colitis, despite conventional therapy, who responded to golimumab induction therapy. METHODS: We performed a phase 3, double-blind trial of patients who completed golimumab induction trials (Program of Ulcerative Colitis Research Studies Utilizing an Investigational Treatment, eg, PURSUIT). Patients who responded to induction therapy with golimumab (n = 464) were assigned randomly to groups given placebo or injections of 50 or 100 mg golimumab every 4 weeks through week 52. Patients who responded to placebo in the induction study continued to receive placebo. Nonresponders in the induction study received 100 mg golimumab. The primary end point was clinical response maintained through week 54; secondary end points included clinical remission and mucosal healing at both weeks 30 and 54. RESULTS: Clinical response was maintained through week 54 in 47.0% of patients receiving 50 mg golimumab, 49.7% of patients receiving 100 mg golimumab, and 31.2% of patients receiving placebo (P = .010 and P < .001, respectively). At weeks 30 and 54, a higher percentage of patients who received 100 mg golimumab were in clinical remission and had mucosal healing (27.8% and 42.4%) than patients given placebo (15.6% and 26.6%; P = .004 and P = .002, respectively) or 50 mg golimumab (23.2% and 41.7%, respectively). Percentages of serious adverse events were 7.7%, 8.4%, and 14.3% among patients given placebo, 50 mg, or 100 mg golimumab, respectively; percentages of serious infections were 1.9%, 3.2%, and 3.2%, respectively. Among all patients given golimumab in the study, 3 died (from sepsis, tuberculosis, and cardiac failure, all in patients who received 100 mg golimumab) and 4 developed active tuberculosis. CONCLUSIONS: Golimumab (50 mg or 100 mg) maintained clinical response through week 54 in patients who responded to induction therapy with golimumab and had moderate-to-severe active ulcerative colitis; patients who received 100 mg golimumab had clinical remission and mucosal healing at weeks 30 and 54. Safety was consistent with that reported for other TNFα antagonists and golimumab in other approved indications. ClinicalTrials.gov number: NCT00488631.

Subcutaneous golimumab induces clinical response and remission in patients with moderate-to-severe ulcerative colitis.

BACKGROUND & AIMS: Little is known about the efficacy of golimumab, a fully human monoclonal antibody to tumor necrosis factor (TNF) -α, for treatment of ulcerative colitis (UC). We evaluated subcutaneous golimumab induction therapy in TNF-α antagonist-naïve patients with moderate-to-severe UC despite conventional treatment. METHODS: We integrated double-blind phase 2 dose-finding and phase 3 dose-confirmation trials in a study of 1064 adults with UC (Mayo score: 6-12; endoscopic subscore ≥ 2; 774 patients in phase 3). Patients were randomly assigned to groups given golimumab doses of 100 mg and then 50 mg (phase 2 only), 200 mg and then 100 mg, or 400 mg and then 200 mg, 2 weeks apart. The phase 3 primary end point was week-6 clinical response. Secondary end points included week-6 clinical remission, mucosal healing, and Inflammatory Bowel Disease Questionnaire (IBDQ) score change. RESULTS: In phase 2, median changes from baseline in the Mayo score were -1.0, -3.0, -2.0, and -3.0, in the groups given placebo, 100 mg/50 mg, 200/100 mg, and 400/200 mg golimumab, respectively. In phase 3, rates of clinical response at week 6 were 51.0% and 54.9% among patients given 200 mg/100 mg and 400 mg/200 mg golimumab, respectively, vs 30.3% among those given placebo (both, P ≤ .0001). Rates of clinical remission and mucosal healing and mean changes in IBDQ scores were significantly greater in both golimumab groups vs the placebo group (P ≤ .0014, all comparisons). Rates of serious adverse events were 6.1% and 3.0%, and rates of serious infection were 1.8% and 0.5%, in the placebo and golimumab groups, respectively. One patient in the 400 mg/200 mg group died as a result of surgical complications of an ischiorectal abscess. CONCLUSIONS: Treatment with subcutaneous golimumab induces clinical response, remission, and mucosal healing, and increases quality of life in larger percentages of patients with active UC than placebo. ClinicalTrials.gov Number: NCT00487539.

Assessment and management of low bone density in inflammatory bowel disease and performance of professional society guidelines.

BACKGROUND: Inflammatory bowel disease (IBD) patients have increased prevalence of osteoporosis, leading to guideline recommendations for bone mineral density (BMD) testing. The study aim was to identify predictors of BMD testing and treatment and assess guideline effectiveness to identify IBD patients with osteoporosis. METHODS: Records of all IBD patients at seven medical facilities were reviewed for clinical data and BMD testing from January 1996 through October 2006. RESULTS: A total of 2035 patients had 317 bone density tests performed. Osteopenia was found in 48% of patients, osteoporosis in 26%. Among patients meeting guideline criteria for BMD testing and ≥1 year of follow-up, 23.3% underwent testing. The strongest predictors of testing were menopause (adjusted hazard ratio [AHR] 3.02) and receiving care at a tertiary center (AHR 2.56). Testing rates were low in patients with age ≥60 years, ulcerative colitis, and a history of inpatient IBD treatment. Osteoporotic patients received calcium/vitamin D and bisphosphonates in 59% and 75% of cases, respectively. Osteoporotic males had a 37% rate of hypogonadism. Guideline criteria do not distinguish patients with osteoporosis. The criteria had a sensitivity, specificity, positive predictive value, and negative predictive value of 84%, 23%, 27%, and 81% for osteoporosis in the tested population, respectively. CONCLUSIONS: Osteoporosis is highly prevalent in the IBD population, but BMD testing and osteoporosis treatments are underutilized. Male hypogonadism is common in osteoporotic IBD patients. Guidelines do not identify IBD patients with osteoporosis.

Predictors of pouchitis after ileal pouch-anal anastomosis: a retrospective review.

PURPOSE: The primary end point of this study was to determine the risk factors that predict chronic pouchitis in those patients having ileal pouch-anal anastomosis. METHODS: A total of 237 patients with ulcerative colitis and undergoing ileal pouch-anal anastomosis by one surgeon at Oregon Health & Science University from 1993 to 2003 were evaluated. Data were gathered via retrospective chart reviews and by a questionnaire administered by telephone in 2004. Patients were excluded if there was less than one-year follow-up documented in the chart or they could not be contacted by telephone (n = 62), postoperative diagnosis of Crohn's disease (n = 3), failed ileoanal procedure (n = 1), and one-stage ileal pouch-anal anastomosis (n = 3), leaving 167 patients for evaluation. Patients were defined as having chronic pouchitis (> 3 episodes of pouchitis) or no pouchitis (< or = 3 episodes of pouchitis). Potential risk factors included number of operations used to perform ileal pouch-anal anastomosis, fulminant ulcerative colitis with two-stage operation, duration of diverting ileostomy after pouch formation, primary sclerosing cholangitis, other extraintestinal manifestations of ulcerative colitis, preoperative liver function tests, duration of ulcerative colitis, and the occurrence of postoperative complications. Initial univariate analysis was performed on all risk factors. Multivariate analysis was performed on all univariate risk factors with P values < 0.2. RESULTS: The prevalence of chronic pouchitis in our population was 46 percent. The following variables were identified during univariate analysis and entered into a multivariate model: preoperative serum albumin (P = 0.07), PSC (P = 0.126), duration of diverting ileostomy (P = 0.111), fulminant ulcerative colitis with two-stage operation, (P = 0.051), the presence of postoperative complications (P = 0.031), and the type of postoperative complications (anastomotic complications, P = 0.013). Patients who did not undergo diverting ileostomy at the time of their ileal pouch-anal anastomosis trended toward a lower likelihood of developing chronic pouchitis (P = 0.06). Multivariate analysis showed that patients with postoperative complications (53 percent, P = 0.042), specifically anastomotic complications, were more likely to develop chronic pouchitis (P = 0.005). Eight percent of patients had primary sclerosing cholangitis and 11 percent of patients had at least one extraintestinal manifestation of ulcerative colitis. Patients with primary sclerosing cholangitis were not more likely to develop chronic pouchitis (P = 0.168). Patients with extraintestinal manifestations also were not more likely to develop chronic pouchitis (P = 0.273). CONCLUSIONS: Chronic pouchitis is a frequent complication after ileal pouch-anal anastomosis. In this study patients with primary sclerosing cholangitis or other extraintestinal manifestations of ulcerative colitis were not more likely to develop chronic pouchitis. Patients with postoperative complications, specifically anastomotic complications after ileal pouch-anal anastomosis, were more likely to develop chronic pouchitis and may benefit from early strategies to prevent pouchitis.

Five-year colon surveillance after screening colonoscopy.

BACKGROUND & AIMS: Outcomes of colon surveillance after colorectal cancer screening with colonoscopy are uncertain. We conducted a prospective study to measure incidence of advanced neoplasia in patients within 5.5 years of screening colonoscopy. METHODS: Three thousand one hundred twenty-one asymptomatic subjects, age 50 to 75 years, had screening colonoscopy between 1994 and 1997 in the Department of Veterans Affairs. One thousand one hundred seventy-one subjects with neoplasia and 501 neoplasia-free controls were assigned to colonoscopic surveillance over 5 years. Cohorts were defined by baseline findings. Relative risks for advanced neoplasia within 5.5 years were calculated. Advanced neoplasia was defined as tubular adenoma greater than > or =10 mm, adenoma with villous histology, adenoma with high-grade dysplasia, or invasive cancer. RESULTS: Eight hundred ninety-five (76.4%) patients with neoplasia and 298 subjects (59.5%) without neoplasia at baseline had colonoscopy within 5.5 years; 2.4% of patients with no neoplasia had interval advanced neoplasia. The relative risk in patients with baseline neoplasia was 1.92 (95% CI: 0.83-4.42) with 1 or 2 tubular adenomas <10 mm, 5.01 (95% CI: 2.10-11.96) with 3 or more tubular adenomas <10 mm, 6.40 (95% CI: 2.74-14.94) with tubular adenoma > or =10 mm, 6.05 (95% CI: 2.48-14.71) for villous adenoma, and 6.87 (95% CI: 2.61-18.07) for adenoma with high-grade dysplasia. CONCLUSIONS: There is a strong association between results of baseline screening colonoscopy and rate of serious incident lesions during 5.5 years of surveillance. Patients with 1 or 2 tubular adenomas less than 10 mm represent a low-risk group compared with other patients with colon neoplasia.

Surveillance and management of dysplasia in ulcerative colitis.

BACKGROUND: Recently updated practice guidelines give specific recommendations on surveillance and management of dysplasia in patients with ulcerative colitis. Previous studies of gastroenterologists in the United States and the United Kingdom demonstrated inconsistent surveillance techniques and limited understanding of the implications of dysplasia. OBJECTIVES: To demonstrate current surveillance practices and management of dysplasia among U.S. gastroenterologists. DESIGN: An 18-item questionnaire was mailed to 1000 gastroenterologists in the United States who were randomly selected from an American Gastroenterological Association mailing list. SETTING: United States. RESULTS: A total of 334 questionnaires were returned, and 312 were analyzed: 25% of respondents were in academic practice and 75% were in private practice. The majority were in practice more than 10 years. Nearly 80% begin surveillance colonoscopy at 8 to 10 years of disease duration for patients with pancolitis, and 54% report sending at least 31 biopsy specimens. Sixty percent of respondents did not recommend immediate colectomy for a confirmed finding of low-grade dysplasia, instead opting for repeat colonoscopy in 3 to 12 months. Physicians who took fewer biopsy specimens were more likely to recommend continued surveillance for low-grade dysplasia compared with those who took a greater number of biopsy specimens. LIMITATIONS: Limitations included the response rate of 33% and the potential for recall bias. CONCLUSIONS: Most U.S. gastroenterologists are practicing surveillance in patients with ulcerative colitis in accordance with published guidelines. There is widespread variation in the management of dysplasia and raised lesions, and the majority of U.S. gastroenterologists do not recommend immediate colectomy for a finding of low-grade dysplasia.

Vicious circles in inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease can present with a bewildering array of disease manifestations whose overall impact on patient health is difficult to disentangle. The multitude of disease complications and therapeutic side effects result in conflicting ideas on how to best manage a patient. The aim of the study is to test the usefulness of influence diagrams in resolving conflicts centered on managing complex disease processes. METHODS: The influences of a disease process and the ensuing medical interventions on the health of a patient with inflammatory bowel disease are modeled by an influence diagram. Patient health is the focal point of multiple influences affecting its overall strength. Any downstream influence represents the focal point of other preceding upstream influences. The mathematics underlying the influence diagram is similar to that of a decision tree. Its formalism allows one to consider additive and inhibitory influences and include in the same analysis qualitatively different types of parameters, such as diagnoses, complications, side effects, and therapeutic outcomes. RESULTS: Three exemplary cases are presented to illustrate the potential use of influence diagrams. In all three case scenarios, Crohn's disease resulted in disease manifestations that seemingly interfered with its own therapy. The presence of negative feedback loops rendered the management of each case particularly challenging. The analyses by influence diagrams revealed subtle interactions among the multiple influences and their joint contributions to the patient's overall health that would have been difficult to appreciate by verbal reasoning alone. CONCLUSION: Influence diagrams represent a decision tool that is particularly suited to improve decision-making in inflammatory bowel disease. They highlight key factors of a complex disease process and help to assess their quantitative interactions.