Comparative Safety of Biologic Agents in Patients With Inflammatory Bowel Disease With Active or Recent Malignancy: A Multi-Center Cohort Study.

BACKGROUND & AIMS: Safety of biologic agents is a key consideration in patients with inflammatory bowel disease (IBD) and active or recent cancer. We compared the safety of tumor necrosis factor (TNF)-α antagonists vs non-TNF biologics in patients with IBD with active or recent cancer. METHODS: We conducted a multicenter retrospective cohort study of patients with IBD and either active cancer (cohort A) or recent prior cancer (within ≤5 years; cohort B) who were treated with TNFα antagonists or non-TNF biologics after their cancer diagnosis. Primary outcomes were progression-free survival (cohort A) or recurrence-free survival (cohort B). Safety was compared using inverse probability of treatment weighting with propensity scores. RESULTS: In cohort A, of 125 patients (483.8 person-years of follow-up evaluation) with active cancer (age, 54 ± 15 y, 75% solid-organ malignancy), 10 of 55 (incidence rate [IR] per 100 py, 4.4) and 9 of 40 (IR, 10.4) patients treated with TNFα antagonists and non-TNF biologics had cancer progression, respectively. There was no difference in the risk of progression-free survival between TNFα antagonists vs non-TNF biologics (hazard ratio, 0.76; 95% CI, 0.25-2.30). In cohort B, of 170 patients (513 person-years of follow-up evaluation) with recent prior cancer (age, 53 ± 15 y, 84% solid-organ malignancy; duration of remission, 19 ± 19 mo), 8 of 78 (IR, 3.4) and 5 of 66 (IR 3.7) patients treated with TNFα antagonists and non-TNF biologics had cancer recurrence, respectively. The risk of recurrence-free survival was similar between both groups (hazard ratio, 0.94; 95% CI, 0.24-3.77). CONCLUSIONS: In patients with IBD with active or recent cancer, TNFα antagonists and non-TNF biologics have comparable safety. The choice of biologic should be dictated by IBD disease severity in collaboration with an oncologist.

A Multicenter Study of Left Ventricular Assist Device-Related Gastrointestinal Bleeding.

INTRODUCTION: Continuous left ventricular assist devices (LVADs) offer hemodynamic support in advanced and decompensated heart failure but are often complicated by gastrointestinal bleeding (GIB) in medically fragile patients. METHODS: We performed a retrospective analysis of 475 consecutive patients who underwent LVAD implantation at the Massachusetts General Hospital and Tufts Medical Center from 2008 to 2019 and identified 128 patients with clinically significant GIB. Clinical characteristics of each bleeding event, including procedures and interventions, were recorded. We examined LVAD patients with overt and occult presentations to determine diagnostic endoscopic yield and analyzed predictors of recurrent GIB. RESULTS: We identified 128 unique patients with LVAD implantation complicated by GIB. No significant difference was observed based on study center, underlying cardiomyopathy, race/ethnicity, serum indices, and medications used. Overt bleeders presented more commonly during LVAD implantation admission ( P = 0.001) than occult bleeders. Occult bleed presentations had only 1 lower and no middle GI bleed source identified, despite similar workups to overt bleeds. Destination therapy (e.g., among nontransplant candidates) LVAD implantation (odds ratio 2.38, 95% confidence interval 1.05-5.58) and a history of GIB (odds ratio 3.85, 95% confidence interval 1.29-12.7) were independently associated with an increased risk of recurrent GIB-related hospitalization. DISCUSSION: Our findings confirm a high rate of GIB, especially in destination LVAD patients, and show a low diagnostic yield for colonoscopy and middle GI bleed assessments in LVAD patients with occult bleeds. Overt bleeding was more common and associated with vascular malformations. Although endoscopic interventions stopped active hemorrhage, GIB often recurred.

An Unusual Cause of Lower Gastrointestinal Bleeding: Cecal Dieulafoy's Lesion.

Colonic Dieulafoy's lesions are an exceptionally rare cause of lower gastrointestinal (GI) bleeding. These lesions are almost exclusively found in the upper GI tract based on previous reviews. We present a case of an 81-year-old man who presented with melena progressing to hematochezia and was found to have a cecal Dieulafoy's lesion on colonoscopy. Hemostasis with clipping was achieved and allowed for the resumption of anticoagulation. This case demonstrates the importance of considering this diagnosis in lower GI bleeding when evidence of more common causes may not be present, especially considering these lesions amenability to endoscopic therapy.

The fast track back to registered nurses employment.

The registered nurse (RN) workforce continues to decline. One method to attract experienced RNs into the workforce is through RN refresher courses. To determine if our RN refresher program is successful in returning RNs to the workforce, we sought to measure the: characteristics of RNs who participate in our program; relationship among participants' employment and demographics; effect of high fidelity human simulation (HFHS) on participants' learning, and; program's ability to meet participants' preparation for employment. Seventy-three participants were surveyed to measure their demographics and employment; they ranked the HFHS experience and program experience on their learning and employment. Thirty-four (47%) surveys were returned. Thirty-three participants (97%) were female (mean age=50.44 years, SD=6.2). Their mean years of RN licensure was 24.93 years (SD=8.8), and their mean time out of nursing practice was 13.30 years (SD=8.0). Twenty-six (76.5%) were employed, with 20 (60.6%) employed as RNs at acute care facilities. Employed participants were licensed for less years than non-employed participants (p=0.047). Employed participants ranked their HFHS experience highly (p=0.04) and the program highly (p=0.04) on benefiting their current employment. Our refresher program appears to be successful in helping RNs re-enter the nursing workforce.