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Occupational mortality from inflammatory bowel disease in the United States 1991–1996
AJG – September, 2000
8 hospitalized patients failed to respond to have total colectomy. None of all 9 patients treated at ambulatory setting required hospitalization. Dramatic clinical, endoscopic and histological improvement occurred in 6 days in most of these patients and the improvement lasted 2 to 10 months. In all 8 Prednisone dependent patients who were followed for 5 months or longer after infliximab, Prednisone therapy was no longer required. No significant side effect related to infliximab was observed. We conclude that infliximab is an effective agent for inducing remission of patients with UC as it is for Crohn’s disease patients. Our observations strongly suggest that the treatment avoids surgical intervention in most of hospitalized UC patients and minimizes the number of UC patients for hospitalization. Large multicenter trials are warranted. 411 Intravenous Remicade outpatient treatment of Crohn’s disease: a personal experience Boris G. Chusid, Burton I. Korelitz*, Andrew Blank, Margarita Kaganovskaya. Lenox Hill Hospital and New York University School of Medicine, New York, N.Y., United States. Purpose: To treat and evaluate results of Remicade in Crohn’s disease patients not well controlled by 5 ASA and/or immunosuppressives but not requiring hospitalization. Methods: 35 Crohn’s disease patients (22 male and 13 female) received 94 intravenous Remicade infusions for 2 hours each over an 18 month period ending in May 2000. Patients were divided into groups with/without fistulas and short duration disease (⬍2 years)/long duration disease (⬎5 years). There were 1 patient with short-term disease with fistulas, 5 shortterm disease without fistulas, 11 long-term disease with fistulas and 14 long term disease and no fistulas. Major indication for Remicade infusion was primary bowel manifestations in 19 and fistulous disease in 12. Prior to infusion and 1 week after CDAI was calculated and the state of the fistula(s) noted; vital signs, and any adverse reactions were noted. Remicade was prepared from 15 to 60 minutes prior to infusion and non-PVC tubing was used. Preinfusion medications were continued. Average age was 43 and Crohn’s disease duration was 16 years. Patients selected were only those who had failed to respond to maintenance therapy with 5 ASAs and immunosuppressives. 4 patients were excluded because of incorrect diagnosis or fulminating disease. Results: Out of 31 Crohn’s disease patients 7 received three infusions (0, 2, and 6 weeks), 8 had 1 infusion, 1 had 2 infusions, 2 had 5 infusions, 1 had 9 infusions and 1 had 12 infusions. Mean CDAI fell from 233 to 141 after infusion 1, from 144 to 116 after infusion 2, remained stable at 125 after infusion 3, fell from 148 to 118 after the fourth, from 215 to 142 after the fifth and remained stable at 169 after the sixth. All patients receiving Remicade for fistulas (most commonly receiving 4 or more infusions) had fistulas close or drain much less but later infusions were required to maintain this status. Remicade was well tolerated, with transient headaches (3), depression (1), rash (2), non-cardiac chest pain (1), and a reversible anaphylactic reaction. Patients with short term disease and fistula required 3.00 infusions to maintain fistula closure/decrease drainage, long term disease with fistula required 3.73 infusions but 2 required 9 and 12 infusions, short term disease without fistula required 1.80 infusions, long term disease without fistula required 2.36 infusions. Conclusions: Intravenous Remicade is successful and safe on an outpatient basis in reversing moderate Crohn’s disease of short duration but requires reinfusions in long standing Crohn’s disease with/without fistulas for maintenance. It is equally effective for primary bowel inflammation and fistulizing disease. 412 Occupational mortality from inflammatory bowel disease in the United States 1991–1996 Claudia Cucino, Amnon Sonnenberg. Department of Veterans Affairs Medical Center and University of New Mexico, Albuquerque, New Mexico.
Abstracts
2531
Purpose: The occupational distribution of inflammatory bowel disease (IBD) may help to shed light on its yet unknown etiology. The US vital statistics offer the opportunity to study cause of death by occupation and industry. Methods: The numbers of deaths from Crohn’s disease and ulcerative colitis were retrieved from the computerized 1991–1996 data files of the National Center for Health Statistics. Deaths were grouped by gender, ethnicity, disease type, occupation, and industry. Mortality by occupation and industry were expressed as standardized mortality ratio (SMR), adjusted for gender and ethnicity. Results: Between 1991 and 1996, 2,399 subjects died from Crohn’s disease and 2,419 subjects died from ulcerative colitis. Significant correlations were found between the SMR values of ulcerative colitis and Crohn’s disease regarding their distribution by occupation, r ⫽ 0.36 (p ⬍ 0.05), as well as by industry, r ⫽ 0.37 (p ⬍ 0.01). IBD mortality by occupation was significantly reduced among janitors and cleaners (SMR: 61, 95% confidence interval: 25–98), farmers (62, 38 – 87), mining machine operators (30, 0 –72), laborers (56, 35–76) and homemakers (90, 81–100). A nonsignificant increase was found among sales persons (120, 97–142) and secretaries (130, 88 –172). IBD mortality by industry was significantly reduced in agricultural production of crops (68, 41–96), agricultural production of livestock (36, 1–72), mining (46, 9 – 82), grocery stores (57, 17–97), and work in private households (59, 28 –90). A non-significant increase was found in food production (129, 75–184), investment and insurance business (144, 81–208), and administration (128, 86 –171). Conclusions: Crohn’s disease and ulcerative colitis show a similar distribution. IBD mortality is low in occupations associated with manual work and farming and relatively high in sedentary occupations associated with indoors work. 413 At what age is it appropriate to stop screening flexible sigmoidoscopy? Joseph David MD, Frank Totta DO, Masud Shaukat MD, FACG, Francisco C Ramirez MD, FACG. VA Medical Center, Phoenix, Arizona. No formal recommendations exist as to age of cessation of colon cancer screening with flexible sigmoidoscopy. Purpose: To determine the relationship between age and presence of significant colonic pathology at time of screening flexible sigmoidoscopy. Methods: All screening flexible sigmoidoscopies performed at our institution between January 1 and December 31, 1999 were reviewed. Patients were stratified according to age and need for subsequent colonoscopy. Pathology reports for all patients who underwent polypectomy were then reviewed for presence of significant pathology defined as tubular adenoma, tubulovillous adenoma, or adenocarcinoma. No significant pathology (NSP) was defined as either not requiring colonoscopy after screening flexible sigmoidoscopy or normal colonoscopy. Results: Of 1281 total flexible sigmoidoscopies performed, 775 (60.5%) were for routine screening. Of these, 122 (15.7%) required subsequent colonoscopy. The rate of finding NSP in the different age groups are shown in the graph below. When age is plotted against NSP rates, a “U” shaped curve emerges. The nadir of this curve represents the point of most frequent significant pathology. Stopping screening at a point significantly far enough to the right of the nadir, so as not to exclude patients with significant pathology, appears optimal. Age 75 represents such a point, based on our data.
8 hospitalized patients failed to respond to have total colectomy. None of all 9 patients treated at ambulatory setting required hospitalization. Dramatic clinical, endoscopic and histological improvement occurred in 6 days in most of these patients and the improvement lasted 2 to 10 months. In all 8 Prednisone dependent patients who were followed for 5 months or longer after infliximab, Prednisone therapy was no longer required. No significant side effect related to infliximab was observed. We conclude that infliximab is an effective agent for inducing remission of patients with UC as it is for Crohn’s disease patients. Our observations strongly suggest that the treatment avoids surgical intervention in most of hospitalized UC patients and minimizes the number of UC patients for hospitalization. Large multicenter trials are warranted. 411 Intravenous Remicade outpatient treatment of Crohn’s disease: a personal experience Boris G. Chusid, Burton I. Korelitz*, Andrew Blank, Margarita Kaganovskaya. Lenox Hill Hospital and New York University School of Medicine, New York, N.Y., United States. Purpose: To treat and evaluate results of Remicade in Crohn’s disease patients not well controlled by 5 ASA and/or immunosuppressives but not requiring hospitalization. Methods: 35 Crohn’s disease patients (22 male and 13 female) received 94 intravenous Remicade infusions for 2 hours each over an 18 month period ending in May 2000. Patients were divided into groups with/without fistulas and short duration disease (⬍2 years)/long duration disease (⬎5 years). There were 1 patient with short-term disease with fistulas, 5 shortterm disease without fistulas, 11 long-term disease with fistulas and 14 long term disease and no fistulas. Major indication for Remicade infusion was primary bowel manifestations in 19 and fistulous disease in 12. Prior to infusion and 1 week after CDAI was calculated and the state of the fistula(s) noted; vital signs, and any adverse reactions were noted. Remicade was prepared from 15 to 60 minutes prior to infusion and non-PVC tubing was used. Preinfusion medications were continued. Average age was 43 and Crohn’s disease duration was 16 years. Patients selected were only those who had failed to respond to maintenance therapy with 5 ASAs and immunosuppressives. 4 patients were excluded because of incorrect diagnosis or fulminating disease. Results: Out of 31 Crohn’s disease patients 7 received three infusions (0, 2, and 6 weeks), 8 had 1 infusion, 1 had 2 infusions, 2 had 5 infusions, 1 had 9 infusions and 1 had 12 infusions. Mean CDAI fell from 233 to 141 after infusion 1, from 144 to 116 after infusion 2, remained stable at 125 after infusion 3, fell from 148 to 118 after the fourth, from 215 to 142 after the fifth and remained stable at 169 after the sixth. All patients receiving Remicade for fistulas (most commonly receiving 4 or more infusions) had fistulas close or drain much less but later infusions were required to maintain this status. Remicade was well tolerated, with transient headaches (3), depression (1), rash (2), non-cardiac chest pain (1), and a reversible anaphylactic reaction. Patients with short term disease and fistula required 3.00 infusions to maintain fistula closure/decrease drainage, long term disease with fistula required 3.73 infusions but 2 required 9 and 12 infusions, short term disease without fistula required 1.80 infusions, long term disease without fistula required 2.36 infusions. Conclusions: Intravenous Remicade is successful and safe on an outpatient basis in reversing moderate Crohn’s disease of short duration but requires reinfusions in long standing Crohn’s disease with/without fistulas for maintenance. It is equally effective for primary bowel inflammation and fistulizing disease. 412 Occupational mortality from inflammatory bowel disease in the United States 1991–1996 Claudia Cucino, Amnon Sonnenberg. Department of Veterans Affairs Medical Center and University of New Mexico, Albuquerque, New Mexico.
Abstracts
2531
Purpose: The occupational distribution of inflammatory bowel disease (IBD) may help to shed light on its yet unknown etiology. The US vital statistics offer the opportunity to study cause of death by occupation and industry. Methods: The numbers of deaths from Crohn’s disease and ulcerative colitis were retrieved from the computerized 1991–1996 data files of the National Center for Health Statistics. Deaths were grouped by gender, ethnicity, disease type, occupation, and industry. Mortality by occupation and industry were expressed as standardized mortality ratio (SMR), adjusted for gender and ethnicity. Results: Between 1991 and 1996, 2,399 subjects died from Crohn’s disease and 2,419 subjects died from ulcerative colitis. Significant correlations were found between the SMR values of ulcerative colitis and Crohn’s disease regarding their distribution by occupation, r ⫽ 0.36 (p ⬍ 0.05), as well as by industry, r ⫽ 0.37 (p ⬍ 0.01). IBD mortality by occupation was significantly reduced among janitors and cleaners (SMR: 61, 95% confidence interval: 25–98), farmers (62, 38 – 87), mining machine operators (30, 0 –72), laborers (56, 35–76) and homemakers (90, 81–100). A nonsignificant increase was found among sales persons (120, 97–142) and secretaries (130, 88 –172). IBD mortality by industry was significantly reduced in agricultural production of crops (68, 41–96), agricultural production of livestock (36, 1–72), mining (46, 9 – 82), grocery stores (57, 17–97), and work in private households (59, 28 –90). A non-significant increase was found in food production (129, 75–184), investment and insurance business (144, 81–208), and administration (128, 86 –171). Conclusions: Crohn’s disease and ulcerative colitis show a similar distribution. IBD mortality is low in occupations associated with manual work and farming and relatively high in sedentary occupations associated with indoors work. 413 At what age is it appropriate to stop screening flexible sigmoidoscopy? Joseph David MD, Frank Totta DO, Masud Shaukat MD, FACG, Francisco C Ramirez MD, FACG. VA Medical Center, Phoenix, Arizona. No formal recommendations exist as to age of cessation of colon cancer screening with flexible sigmoidoscopy. Purpose: To determine the relationship between age and presence of significant colonic pathology at time of screening flexible sigmoidoscopy. Methods: All screening flexible sigmoidoscopies performed at our institution between January 1 and December 31, 1999 were reviewed. Patients were stratified according to age and need for subsequent colonoscopy. Pathology reports for all patients who underwent polypectomy were then reviewed for presence of significant pathology defined as tubular adenoma, tubulovillous adenoma, or adenocarcinoma. No significant pathology (NSP) was defined as either not requiring colonoscopy after screening flexible sigmoidoscopy or normal colonoscopy. Results: Of 1281 total flexible sigmoidoscopies performed, 775 (60.5%) were for routine screening. Of these, 122 (15.7%) required subsequent colonoscopy. The rate of finding NSP in the different age groups are shown in the graph below. When age is plotted against NSP rates, a “U” shaped curve emerges. The nadir of this curve represents the point of most frequent significant pathology. Stopping screening at a point significantly far enough to the right of the nadir, so as not to exclude patients with significant pathology, appears optimal. Age 75 represents such a point, based on our data.