Predictive Factors of Inactive Patient Participation in an Inflammatory Bowel Disease Learning Health System: A Longitudinal Cohort Study.

Patient participation is crucial to learning health systems that leverage patient data to improve care practices. Age, history of anxiety or depression, and frequency of clinic visits were associated with inactive participation in an inflammatory bowel disease learning health system.

Inflammatory Bowel Diseases-related Disability: Risk Factors, Outcomes, and Interventions.

The diagnosis of inflammatory bowel disease (IBD) is a life-changing moment for most adults. Biomedical advances over the past 2 decades have resulted in unprecedented growth of therapeutic options for IBD. However, due to the incurable nature of IBD, medical and surgical intervention alone may not be adequate to completely normalize health status and prevent long-term disability. In the biopsychosocial model of health and disease, a person's health and function result from complex physical, psychosocial, and environmental interactions. Adapting the World Health Organization definition, IBD-related disability encompasses limitations in educational and employment opportunities, exclusions in economic and social activities, and impairments in physical and psychosocial function. Although the concept of IBD-related disability is a long-term treatment end point in the updated Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II) treatment guideline, it has received limited attention in the literature. This review article explores an etiological framework of the physical and psychosocial aspects that contribute to IBD-related disability. We also explore the impact of IBD-related disability on the direct and indirect costs of IBD. Lastly, we present the available evidence for interventions with the potential to improve function and reduce IBD-related disability.

Increased Risks for Suicide, Self-Harm, Substance Use, and Psychiatric Disorders in Adults With Inflammatory Bowel Disease: A Nationwide Study in the United States From 2007 to 2017.

In an analysis of over 260 million emergency department visits across the United States from 2007 to 2017, inflammatory bowel disease conferred >10-fold risk for suicide deaths, self-harm, substance use, and psychiatric disorders, though the overall self-harm rates were low (<1% of all-cause inflammatory bowel disease emergency department visits; total 56 suicide deaths).

Correlations Between Gastrointestinal Symptoms and Endoscopic-Histologic Disease Activity in Adults with Ulcerative Colitis.

INTRODUCTION: Discordance between gastrointestinal (GI) symptoms and endoscopic inflammation in patients with ulcerative colitis (UC) is known. However, the correlations between symptoms and endoscopic and histologic (endo-histologic) mucosal healing and remains unknown. METHODS: We performed a secondary analysis of prospectively collected clinical, endoscopic, and histologic data on 254 colonoscopies from 179 unique adults at a tertiary referral center from 2014 to 2021. Spearman's rank was used to assess the correlation between patient reported outcomes and objective assessments of disease activity, as measured by validated instruments: Two-item patient-reported outcome measure (PRO-2) for stool frequency and rectal bleeding, the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) for endoscopic inflammation, and the Geboes score for histologic inflammation. The predictive value of objective assessments of inflammation and clinical symptoms was described using sensitivity, specificity, and positive/negative predictive value. RESULTS: One-quarter (28%, 72/254) of cases were in endo-histologic remission; of these, 25% (18/72) report GI symptoms (22% diarrhea; 6% rectal bleeding). Endo-histologically active disease had higher sensitivity (95% rectal bleeding; 87% diarrhea) and negative predictive value (94% rectal bleeding, 78% diarrhea) for clinically active disease compared to active disease on endoscopic (77%) or histologic assessment only (80%). The specificity of endo/histologic inflammation for GI symptoms was < 65%. PRO-2 was positively correlated with endoscopic disease activity (Spearman's rank 0.57, 95% CI 0.54-0.60, p < 0.0001) and histologic disease activity (Spearman's rank 0.49, 0.45-0.53, p < 0.0001). CONCLUSION: One-quarter of patients with ulcerative colitis in endo-histologic (deep) remission have gastrointestinal symptoms, more commonly with diarrhea than rectal bleeding. Endo-histologic inflammation has high sensitivity (≥ 87%) for diarrhea/rectal bleeding.

Prevalence and Correlations of Gastrointestinal Symptoms With Endoscopic and Histologic Mucosal Healing in Crohn's Disease.

To characterize the associations between clinical disease activity with endoscopic and histologic (endohistologic) mucosal healing in Crohn's disease, we performed a secondary analysis of prospectively collected data on 424 ileocolonoscopies from 258 unique adults at a tertiary referral center from 2014 to 2021. One-third of patients (34%, 25/73) in endoscopic-histologic remission reported gastrointestinal symptoms. The 2-item patient-reported outcome measure for abdominal pain and stool frequency correlated weakly with endoscopic (Simple Endoscopic Score for Crohn's Disease; r = 0.17, 95% CI 0.08-0.26, P = 0.0003) and histologic disease activity (Global Histologic Disease Activity Score; r = 0.14, 95% CI 0.03-0.24, P = 0.015). Overall, gastrointestinal symptoms correlate poorly with endohistologic disease activity.

Bidirectional Correlations Between Health Confidence and Inflammatory Bowel Disease Activity: A Nationwide Longitudinal Cohort Study.

Health confidence­an individual's belief in their ability and agency to affect disease outcomes­has bidirectional temporal correlations with inflammatory bowel disease activity. Low health confidence is associated with higher risks for future disease activity, and inflammatory bowel disease flares erode confidence.

Concordance and Discordance Between Patient-reported Remission, Patient-reported Outcomes, and Physician Global Assessment.

BACKGROUND: Although validated patient-reported outcome (PRO) measurements can categorize patients with inflammatory bowel disease (IBD) into clinical remission or active disease, patients may have different definitions of remission. The purpose of this study was to compare patient-defined remission to remission based on PRO measures and physician global assessment (PGA) and to understand the clinical and demographic factors associated with disagreements. METHODS: We retrospectively analyzed 3257 de-identified surveys from 2004 IBD patients who consented to participate in the Crohn's and Colitis Foundation's IBD Qorus Learning Health System between September 2019 and February 2021. We used logistic regression models with generalized estimating equations to analyze the clinical and demographic factors (eg, age, disease duration, health confidence) associated with discordance between patient-defined remission (yes/no) and PRO-defined remission for ulcerative colitis (UC; PRO2: stool frequency, rectal bleeding) and Crohn's disease (CD; PRO-3: average number of liquid stools, abdominal pain, well-being). RESULTS: Among patients with UC, overall concordance was 79% between patient self-report and PRO2-defined remission and 49% between patient self-report and PGA-defined remission. Among patients with CD, overall concordance was 69% between patient self-report and PRO3-defined remission and 54% between patient self-report and PGA-defined remission. Patients in PRO-defined remission were more likely to report active disease if they had IBD <5 years and low health confidence. Patients with PRO-defined active disease were more likely to report remission if they were not using prednisone and had high health confidence. CONCLUSION: Discordance exists between how remission is defined by patients, PRO measures, and PGA.

Discordance between patients' self-reported remission and remission defined based on patient-reported outcomes was observed in 31% of Crohn's disease visits and 21% of ulcerative colitis visits. Disease duration and health confidence were associated with discordance.

Cardiac Masses (from a 15-Year Experience With 389 Surgical Cases).

Cardiac masses are highly heterogeneous and vary widely in their clinical presentation, imaging features, and survival outcomes. Our understanding is limited by their rarity and the fact that few are confirmed based on surgical pathology. We set out to provide a comprehensive analysis of all cardiac masses resected at our institution from 1999 to 2015, including imaging methods and histopathologic findings. We found papillary fibroelastomas (PFEs) to be the most commonly resected benign cardiac masses, followed by myxomas. Patients with PFEs most frequently presented with cerebrovascular accidents and transient ischemic attacks, whereas those with myxomas were more likely to present with arrhythmias and palpitations. In contrast, primary malignant cardiac masses were much rarer; angiosarcoma was the predominant subtype with a poor prognosis. Renal cell carcinomas were the most commonly discovered primary cancer for metastatic cardiac masses, and calcified amorphous tumors were the most prevalent non-neoplastic masses. For the detection of cardiac masses, transthoracic echocardiography was the most frequently used but least sensitive of the imaging methods analyzed. Transesophageal echocardiography (TEE) was the most sensitive imaging method. Fluorodeoxyglucose Positron Emission Tomography had similar sensitivity to TEE but was the least frequently used imaging method. Computed tomography and magnetic resonance imaging performed well in detecting most masses; PFEs, for which TEE was the most sensitive, was the exception. In conclusion, we found that PFEs were the most commonly resected benign cardiac masses, and TEE was the most accurate imaging method for the detection of all surgically removed masses at our institution.

Dual Advanced Therapies and Novel Pharmacotherapies for Moderately to Severely Active Crohn's Disease.

Over the past 2 decades, there have been incredible advances in the pharmacotherapeutic options for the treatment of patients with moderately to severely active Crohn's disease. Despite the leaps and strides in safety, efficacy, and mechanistic specificity of treatment targets, a significant portion (up to ∼20-50%) of patients have refractory Crohn's disease ± concomitant rheumatologic disease/extraintestinal manifestations for which existing biologic and small molecule therapies are ineffective. In this review, we will explore the available evidence for the use of dual advanced therapies (combination of biologic and/or small molecule therapies) and novel pharmacotherapies in phase 2 to 3 clinical trials.

Impact of Comorbid Psychiatric Disorders on Healthcare Utilization in Patients with Inflammatory Bowel Disease: A Nationally Representative Cohort Study.

BACKGROUND AND AIMS: Patients with inflammatory bowel disease (IBD) frequently experience comorbid psychiatric disorders, which negatively impact quality of life. We characterized the longitudinal burden of hospitalization-related healthcare utilization in adults with IBD with and without comorbid anxiety, depression, or bipolar disorder. METHODS: In the 2017 Nationwide Readmissions Database (NRD), we identified 40,177 patients with IBD who were hospitalized between January 1, 2017 and June 30, 2017 and who were followed until December 31, 2017. In this cohort, we compared the annual burden (i.e., total days spent in hospital), costs, risk of readmission, inpatient mortality, and IBD-related surgery in patients with and without comorbid psychiatric disorders (anxiety, depression, or bipolar disorder). RESULTS: Of the 40,177 adults who were hospitalized for IBD, 25.7% had comorbid psychiatric disorders. Over a 10 month-long period of follow-up, patients with comorbid psychiatric disorders spent more days in the hospital (median, 7 days vs. 5 days, p < 0.01), experienced higher 30-day (31.3 vs. 25.4%; p < 0.01) and 90-day (42.6 vs. 35.3%, p < 0.01) readmission rates, and had higher hospitalization-related costs (median, $41,418 vs. $39,242, p < 0.01). However, they were less likely to undergo IBD-related procedures or surgeries. There were no differences in risk of mortality. On Cox proportional hazard analysis, the presence of comorbid psychiatric disorders was associated with a 16% higher risk of readmission (HR, 1.16; 95% CI, 1.13-1.20) and a 13% higher risk of severe IBD-related hospitalization (HR, 1.13; 95% CI, 1.08-1.16). CONCLUSIONS: In adults with IBD, comorbid psychiatric disorders were independently associated with a higher burden and cost of hospitalization, without an increase in the risk of IBD-related surgery or procedures. Population-based interventions aimed at treating psychiatric comorbidities may decrease the risk of unplanned healthcare utilization.

Analysis of Decreasing Adverse Events with Endoscopic Ultrasound in a New Advanced Endoscopy Program Over Time.

OBJECTIVE: New innovations and increasing utility of endoscopic ultrasound (EUS) are associated with rare but serious risks. We investigate the rates and risk factors for post-procedural complications over a four-year period at a new advanced endoscopy program. METHODS: We conducted a retrospective review of all adult patients who underwent upper EUS at an academic level-1 trauma center between April 2015 and November 2019. The primary outcome was the incidence of adverse events within 1 week of EUS. Secondary outcomes included emergency department visits and mortality within 30 days after EUS. Chi-square test, t test, and multivariable logistic regression were used to assess risk factors for post-procedural complications. RESULTS: A total of 968 EUS procedures were performed on 864 patients (54% female; 79% Caucasian; mean age 61 years). The overall incidence of post-procedural adverse event with EUS was 5.6%. The probability of an adverse event decreased by an average of 22% per year (p =0.01, OR 0.78). The risk for adverse events were 3.3% acute pancreatitis, 1.9% clinically significant bleeding, 0.3% bacteremia, 0.2% perforation, and 2.4% 30-day mortality. The adverse event rate was highest among low volume proceduralists (p =0.04). The 30-day mortality was more than threefolds among patients who had an adverse event within 7 days after EUS. CONCLUSION: The overall incidence of post-procedural adverse events at a new EUS program was 5.6%, with an average of 22% relative decrease in adverse events per year in the first 4 years.

Identifying and Predicting the Goals and Concerns Prioritised by Individuals with Inflammatory Bowel Disease.

BACKGROUND AND AIMS: In order to provide high-quality care, providers need to understand their patients' goals and concerns. This study aims to identify and predict the goals and concerns prioritised by patients with inflammatory bowel disease [IBD] in the outpatient setting. METHODS: Mixed-methods analysis was performed to identify the types, frequencies, and predictors of IBD patients' goals and concerns using 4873 surveys collected over 2016-2019 at 25 gastroenterology clinics across the USA participating in the Crohn's & Colitis Foundation's IBD Qorus Learning Health System. RESULTS: Patients with IBD most often prioritised goals and concerns related to symptoms/disease activity [50%] and clinical course/management [20%], whereas psychosocial/quality of life [12%] and medication [6%] concerns were less frequent. Females (odds ratio [OR] 22.1, 95% confidence interval [CI] 5.3-91.5) and patients in clinical remission [OR 2.2, 95% CI 1.2-4.1] were more likely to prioritise family planning. Patients >60 years old [OR 3.1, 95% CI 1.5-6.5] and patients with active disease [OR 3.2, 95% CI 1.4-7.6] were more often concerned about travelling. Smokers were more often concerned about nutrition [OR 4.2, 95% CI 1.9-9.2]. Surgery was more often a concern of patients with perianal Crohn's disease [OR 2.1, 95% CI 1.2-3.5], active disease [OR 1.9, 95% CI 1.1-3.4], and those with recent hospitalisations [OR 2.5, 95% CI 1.2-5.4]. CONCLUSIONS: IBD patients prioritised the remission of physical symptoms as treatment goals and they were less frequently concerned about medications and their side effects. Patients' demographics, IBD characteristics, and health care utilisation patterns can predict specific types of concerns/goals.

A Framework for Clinical Trials of Neurobiological Interventions That Target the Gut-Brain Axis in Inflammatory Bowel Disease.

A growing body of evidence from preclinical, translational, and clinical studies supports a bidirectional relationship within the gut-brain axis that contributes to neurobiological symptoms including anxiety, depression, fatigue, stress, and sleep disturbance. These symptoms have a significant impact on health-related quality of life and functional ability in individuals with inflammatory bowel disease. Clinical studies that generate high-quality evidence on pharmacological and nonpharmacological (eg, psychosocial, behavioral) interventions are needed to ultimately improve access to safe and effective therapies that have a meaningful impact on patients and to guide medical and regulatory decisions. This review outlines a framework for designing and conducting randomized controlled trials for interventions that target neurobiological symptoms in patients with inflammatory bowel disease based on the most recent guidance published within the past 5 years from policy makers, clinicians specialized in inflammatory bowel disease, patient-reported outcomes methodologists, health economists, patient advocates, industry representatives, ethicists, and clinical trial experts.

Health Confidence Is Associated With Disease Outcomes and Health Care Utilization in Inflammatory Bowel Disease: A Nationwide Cross-sectional Study.

BACKGROUND: We aimed to examine the associations between health confidence (one's belief on the degree of control on their health and disease), inflammatory bowel disease (IBD) outcomes, and health care utilization among adults with IBD. METHODS: In total, 17,205 surveys were analyzed from a cross-sectional sample of IBD patients at 23 gastroenterology (GI) practices participating in the Crohn's and Colitis Foundations' IBD Qorus Learning Health System. We used bivariate analyses and multivariable logistic regression to examine associations between health confidence and disease activity, opioid use, glucocorticoid use, well-being, and health care utilization. We used receiver operating curve analysis to determine a clinically relevant cutoff for health confidence (0-10 Likert scale). RESULTS: Health confidence was highly correlated with patients' well-being, symptomatic disease activity, opioid use, and glucocorticoid use (all P < .0001). Health confidence scores <8 had 69% sensitivity for emergency department (ED) visits and 66% for hospitalizations. In patients with inactive disease, patients with low health confidence (<8) were 10 times more likely to call/message the GI office >4 times/month (adjusted odds ratio [aOR], 10.3; 95% CI, 6.1-17.3; P < .0001), 3-4 times more likely to have an IBD-related ED visit (aOR, 4.0; 95% CI, 2.9, 5.4. P < .0001), or hospitalization (aOR, 3.0, 95% CI, 2.1, 4.1, P < .0001) compared with patients with high health confidence (≥8). CONCLUSIONS: In a large, national sample of adults with IBD, there were strong associations between patients' health confidence and multiple disease outcome measures. Health confidence scores <8 on a 0-10 Likert scale may be clinically useful to screen for patients who are at risk for ED visits and hospitalizations.

Direct-Acting Antiviral Therapy in Liver Transplant Patients With Hepatocellular Carcinoma and Hepatitis C.

Direct-acting antivirals (DAA) are highly effective for the treatment of hepatitis C (HCV), although there are limited data on the safety and efficacy of DAA therapy in hepatitis C-positive individuals awaiting liver transplantation for hepatocellular carcinoma (HCC). METHODS: We conducted a retrospective cohort study of HCV-positive patients who underwent liver transplantation for HCC at 3 liver transplant centers across the United States from 2014 to 2017 with follow-up to July 2018. Transplant recipients who received DAA before transplant were compared with those who did not (DAA naive) for posttransplant HCC recurrence rate, sustained virological response (SVR), allograft failure, and death using Kaplan-Meier analysis and Cox proportional hazard models. RESULTS: A total of 171 HCV-HCC transplant recipients (99 pretransplant DAA; 72 DAA naive controls) were included, with a median follow-up of 24 months. The overall posttransplant HCC recurrence rate was 9% (15/171). Pretransplant DAA was not associated with HCC recurrence (5% versus 14%; P = 0.07), graft failure (7% versus 3%; P = 0.21), or death (12% versus 19%; P = 0.19) as compared with DAA naive patients. SVR rates were significantly lower (P < 0.01) with pretransplant DAA (75%, 39/52) than posttransplant DAA (97%, 59/61) therapies. Those who received pretransplant DAA and those who did not were not statistically different in age, gender, alpha fetal protein levels, model for end-stage liver disease scores, or transplant wait time. CONCLUSIONS: Pretransplant DAA for HCV was not associated with an increased risk of posttransplant HCC recurrence, though pretransplant DAA had lower efficacy than posttransplant DAA in HCV-HCC transplant recipients.

P055 Sociodemographic Differences in Fecal Enteropathogen Testing Patterns in Adults Hospitalized for Inflammatory Bowel Disease Flares.

BACKGROUND: Adults with inflammatory bowel disease (IBD) have increased risks for gastrointestinal infections. Single-center studies in Michigan and New York report 17-31% positive enteropathogen tests in patients with symptomatic IBD. Population-based studies are lacking, particularly on factors that determine who undergo testing. Health inequities may exist in the care of patients with IBD where certain groups systematically experience social and/or economic disparities. We aim to assess sociodemographic and healthcare factors associated with enteropathogen testing of hospitalized IBD patients. METHODS: In this retrospective cohort study, we identified 770 patients with IBD who had 1,189 hospital admissions for primary symptoms consistent with IBD flares/enteric infections at 3 hospitals (tertiary referral teaching, community, and county) in the largest healthcare system in Rhode Island from January 2017-March 2019. Using modified Poisson regression to estimate relative risks (RR) and 95% Confidence Intervals (CIs), we assessed enteropathogen testing status as a function of sociodemographic and clinical characteristics in separate models. RESULTS: Patients with IBD hospitalized with symptoms consistent with IBD flares or enteric infections disproportionately had Crohn's disease (69% vs. 31% UC). Patients were 47 years old on average, 60% women, 79% non-Hispanic white, 13% Hispanic, and 7% non-Hispanic Black. Over half (55%) were privately insured, 42% publicly insured, and 2% uninsured. Over half (55%) of patients were treated with glucocorticoids within 1 week of hospitalization while 35% were on biologics. The top 5 primary symptoms for hospitalization were abdominal pain (63%), GI bleeding (8%), fever (8%), vomiting (7%), and diarrhea (7%). Enteropathogen testing (may be >1) was obtained in 46% of hospitalizations: 42% tested for C. difficile; 23 % tested for Salmonella spp., Shigella spp./enteroinvasive E. coli, Campylobacter spp., and Shiga toxin-producing organisms; and 15% had extensive testing for 22 enteropathogens (13 bacteria, 5 viruses, and 4 parasites). 10% of the tests were positive, most commonly for C. difficile (5%), E. coli spp (0.6%), Campylobacter spp (0.5%), Salmonella (0.3%), and Norovirus (0.3%). While gender differences in testing were not observed (female 45%, male 46%, F:M, RR 1.01, 95% CI 0.90,1.15), Hispanic patients were more likely to undergo enteropathogen testing than non-Hispanic white patients (58% vs 44%; RR 1.21, 95% CI 1.02-1.43). Relative to patients hospitalized at the tertiary referral teaching hospital, patients at the county hospital were 29% less likely (95% CI, 0.54-0.93) and those at the community hospital were 22% (95% CI 0.78-1.01) less likely to have enteropathogen testing. Enteropathogen testing occurred most frequently among the privately insured 48%, while uninsured were comparatively 20% less likely and publicly insured were 10% less likely to undergo testing, though neither comparison was statistically significant. CONCLUSION: Racial/ethnic (Hispanic vs non-Hispanic White) and healthcare settings (county vs tertiary referral teaching hospital) differences in enteropathogen testing patterns were observed in adults with IBD hospitalized primarily for GI symptoms at the state of Rhode Island's largest healthcare system. Further studies to assess health inequities, including sociodemographic and organizational differences, in the healthcare delivery in IBD are warranted.

Jejunal Diverticulosis Complicated by Diverticulitis and Small Bowel Obstruction.

Diverticular disease is common in the Western population and can cause considerable morbidity. The prevalence of colonic diverticulosis reaches 60% by the age of 60 years. Small bowel diverticulosis is much rarer and, when present, most commonly occurs in the duodenum. We herein report an elderly woman with jejunal diverticulosis complicated by diverticulitis and small bowel obstruction, who subsequently underwent small bowel resection and primary anastomosis. As demonstrated by this case, jejunal diverticulitis can cause serious complications and given the possibility of recurrence and serious complications, surgical options should be discussed early in the course of medical care.