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Predictors of Mortality Among Patients Admitted to Hospital for Ischemic Colitis: A Population-Based U.S. Study
(OR 1.24, 95% CI 0.95-1.62), red meat intake (OR 1.21, 95% CI 0.92-1.58) or physical activity (OR 1.07, CI 0.81-1.41). Conclusion: We found no association between dietary fiber, fat, red meat or physical activity and diverticulosis. This was a large cross sectional study which assessed diet and physical activity with validated measures and confirmed the presence or absence of diverticulosis by colonoscopy. Previous hypothesizes regarding diverticulosis risk factors and diet recommendations to patients should be reconsidered. 276 Persistence of Endoscopic and Histological Inflammation Are Risk Factors of Diverticulitis Recurrence After Attack of Acute Uncomplicated Colonic Diverticulitis Antonio Tursi, Walter Elisei, GianMarco Giorgetti, Piera Giuseppina Lecca, Alfredo Papa, Giovanni Brandimarte Background and Aim: Colonic diverticulitis shows an high recurrence rate, but the role of persisting inflammation after attack of uncomplicated diverticulitis on disease's recurrence is unknown. The aim of this study was to investigate the role of some not yet investigated factors as risk factors of diverticulitis recurrence, focusing our attention of the persisting endoscopic and histological inflammation after attack of uncomplicated diverticulitis on recurrence of the disease. Methods: A prospective cohort study was performed on 130 patients suffering from Acute Uncomplicated Diverticulitis (AUD) (81 Males, 49 Females, mean age 64.71 years, range 40-85). All patients had Computerized Tomography (CT) and endoscopic confirmed AUD. Recurrence of the disease was defined as return to our observation due abdominal pain associated with detection of increased fecal calprotectin. Severity of CT scan at entry was graduated as mild or severe, as well as severity of endoscopic inflammation at entry was graduated as mild, moderate and severe. Clinical, endoscopic and histological follow-up was performed after six, 12 and therefore every 12 months after diagnosis of AUD. Results: Diverticulitis recurred in 18/114 patients (15.79%): 15/114 (13.15%) patients showed recurrence of AUD, whilst 3/144 (1.75%) showed recurrence of diverticulitis but complicated. At the end of follow-up (2 years), persistence of endoscopic damage was detected in 31/114 (27.20%), and persistence of active inflammation was detected in 42/114 patients (36.84%). In multivariate analysis (see table 1), persistence of endoscopic and of histological inflammation after an attack of AUD were both predictors of diverticulitis recurrence (p=0.048 and p<0.001 respectively). Neither CT appearance at entry nor severity of the endoscopic appearance at entry reached statistical significance. Conclusions: In a prospective analysis, we found that persistence of endoscopic and histological inflammation after attack of AUD were identified as predictors of diverticulitis recurrence. Table 1. Predictive value of diverticulitis recurrence of different parameters assessed
274 Predictors of Mortality Among Patients Admitted to Hospital for Ischemic Colitis: A Population-Based U.S. Study Matthew D. Sadler, James N. Hubbard, Subrata Ghosh, Paul L. Beck, Chris Prusinkiewicz, Gilaad G. Kaplan AIMS: Ischemic colitis has been associated with significant mortality; however, few population-based studies have published outcomes for ischemic colitis in North America. We assessed in-hospital mortality and determined independent predictors of mortality in a nationally-representative sample of US hospitals. METHODS: We used the Nationwide Inpatient Sample to identify all patients with discharges for ischemic colitis (ICD-9 557.X) as a primary diagnosis between 1993 and 2008. We described in-hospital mortality and performed multivariate logistic regression analyses to determine independent predictors of mortality after adjusting for age, gender, insurance status, ethnicity, Charlson comorbidities, and interventions. RESULTS: From 1993-2008 we identified a total of 97,592 discharges of ischemic colitis. In-hospital mortality was 13.0% (95% CI: 12.7-13.3) and colectomy was performed on 14.2% (95% CI: 13.9-14.4) of patients with ischemic colitis. Chronic pulmonary disease [21.2% (95% CI: 20.9-21.5)], diabetes mellitus [15.2% (95% CI: 14.9-15.4)], congestive heart failure [CHF; 14.5% (95% CI: 14.2-14.8)], renal disease [8.7% (95% CI: 8.5-8.9)], peripheral vascular disease [8.4% (95% CI: 8.2-8.6)], and myocardial infarction [6.3% (95% CI: 6.1-6.4)] were the most commonly associated comorbidities in patients presenting with ischemic colitis. Mortality was associated with: older age 65-85 years [OR= 4.21 (3.38-5.26)] and 50-64 years [OR=2.29 (1.84-2.84)] versus 18-34 years; Medicaid [OR=2.03 (1.81-2.27)], self-pay (OR=1.78 (1.52-2.09)], and Medicare [OR=1.53 (1.421.65)] vs. private health insurance; and comorbidities such as liver disease [OR=3.18 (2.893.51)], metastatic solid tumor [OR=2.27 (1.95-2.63)], AIDS/HIV [OR=2.22 (1.22-4.02)], renal disease [OR=2.10 (1.97-2.23)], and CHF [OR=1.87 (1.78-1.97)]. Patients who underwent colonoscopy or sigmoidoscopy [OR=0.47 (0.43-0.51)] had lower mortality whereas colectomy [OR=2.38 (2.26-2.50)] was associated with increased mortality. Women had lower mortality than men [OR=0.84 (0.81-0.88)] and fewer women required colectomy [OR=0.70 (0.68-0.73)] despite representing a greater proportion of IC patients [68.88% (95% CI: 68.56-69.20)]. Lower mortality was observed in Asians (OR=0.49 (0.36-0.66)) and Hispanics (OR=0.80 (0.71-0.90) whereas African Americans (OR=1.13 (1.04-1.24) were associated with increased mortality, as compared to Caucasians. CONCLUSIONS: Ischemic colitis was associated with several common conditions and carried a high mortality rate, especially in older patients. Furthermore, colectomies were commonly performed on hospitalized patients with ischemic colitis, and these patients had worse mortality.
277 Adalimumab Levels Detected in Cord Blood and Infants Exposed in Utero Uma Mahadevan, Jocelyne K. Miller, Douglas C. Wolf Introduction: Adalimumab (ADA) and infliximab (IFX) are IgG1 antibodies against TNF-α and are FDA pregnancy category B. As IgG1 is actively transferred across the placenta during the third trimester, infants exposed to ADA and IFX may be born with high serum levels of drug. This has been demonstrated with IFX where newborn serum IFX levels were higher than maternal serum levels at birth and were present for up to 6 months from birth.(1) Our hypothesis is that ADA should also transfer actively across the placenta and result in detectable infant serum drug levels. Methods: Pregnant women with IBD receiving ADA were enrolled. On the day of birth, levels were measured in the mother, infant and cord blood. Levels were then measured in the infant until undetectable. Serum levels were measured by ELISA. The lower limit of quantification was 3.13 ng/mL in 10% serum, the concentration used in this assay. This study was approved by the institutional review board. Results: Five mothers were enrolled. All infants were born at a mean of 39 weeks gestation and 3407 gm weight. Three were delivered by cesarean section. One infant suffered from pulmonary edema but recovered fully. The table lists the time of last dose of ADA prior to delivery and the levels of ADA in mother, infant and cord blood on the day of birth. In all cases, the cord blood level of ADA was higher than the maternal level, supporting active transfer of ADA from the mother to the infant. Infant 2 had levels checked at 6 weeks from delivery: mother was 16.1 μg/ml and infant was 1.94 μg/ml. Infant 4 had levels checked at 1 month (1.93 μg/ml) and 2 months (0.93 μg/ml) from delivery. Conclusions: ADA actively crosses the placenta and can be detectable in the serum of infants exposed in utero for at least 3 months from birth. (1) Mahadevan U, Terdiman J, Church, J et al. Gastroenterol 2007;132:A-144. ADA levels on Day of Birth
275 Dietary Fiber is Not Associated With Diverticulosis Anne F. Peery, Patrick R. Barrett, Doyun Park, Albert J. Rogers, Trevor Locklear, Joseph A. Galanko, Christopher F. Martin, Robert S. Sandler Background: Inadequate dietary fiber is widely considered to be a major risk factor for the development of diverticulosis. Sedentary behavior and a diet high in red meat and fat have also been thought to predispose to diverticulosis. However, there is little hard evidence to support any of these associations. Using validated measures, we conducted a large cross sectional study to determine whether dietary fiber, fat, red meat or sedentary behavior were associated with diverticulosis confirmed by colonoscopy. Methods: We used the data from three colonoscopy-based studies conducted between 1998 and 2010 at the University of North Carolina Hospitals. Eligible participants were between the ages of 30 and 80 with satisfactory preparation for colonoscopy and a complete exam to the cecum. We excluded patients with a history of previous colon resection or a diagnosis of polyposis, colitis, or colon cancer. Telephone interviewers collected detailed information on demographics, diet, physical activity and co-morbidities one month after colonoscopy. Diet was assessed with a validated quantitative food-frequency questionnaire. Cases were defined as participants found to have any diverticula identified by screening colonoscopy. Controls were diverticulafree on colonoscopy. Results: There were 2378 participants, with 968 diverticulosis cases and 1410 diverticula-free controls. Among the cases, the mean age was 59 ± 9 years; 43% were men and 84% were Caucasian with a mean BMI of 28 ± 6. Among the controls, the mean age was 54 ± 9 years; 43% were men and 79% were Caucasian with a mean BMI of 27 ± 6. Diverticulosis was more common in older, Caucasian and higher BMI participants. After adjustment for potential confounders (age, race, BMI), we found no association between total fiber and diverticulosis (OR 0.96, 95% CI 0.73-1.25). No fiber type was protective: bean fiber (OR 1.00, 95% CI 0.77-1.30), fruit and vegetable fiber (OR 1.01, 95% CI 0.771.31), grain fiber (OR 0.83, 95%, CI 0.63-1.08). We found no association with fat intake
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Anxiety & Depression Score (HADS-A)) and stress levels (Perceived Stress Questionnaire: Recent, R-PSQ, General, G PSQ). Outcomes were assessed, using the Travis criteria (day 3) and colectomy rates at day 70, in relation to upper and lower tertiles of the anxiety and stress scores. In addition, the psychometric scores of the ASUC patients were compared to those of 27 outpatients with inactive UC. RESULTS: Patients with ASUC had higher stress levels (R-PSQ Index 0.52 [0.03] (mean [SEM]), G-PSQ 0.46 [0.03]) than in patients with inactive UC (0.35 [0.03], p= 0.001, 0.39 [0.02], p=0.046, respectively) but there was no difference in anxiety scores (HADS-A: 9.6[0.8], 8.4[0.7], p=0.9, respectively). However, in paitents with ASUC, there was a positive correlation between stress and anxiety scores (RPSQ, r2=0.27, p=0.0008; G-PSQ, r2= 0.14, p=0.02)). Although stress scores were similar, anxiety levels were higher in the 11 newly presenting ASUC patients (12 [1.4]) than in those previously diagnosed (8.6 [0.9], p=0.049). There was no difference in those responding to iv hydrocortisone (by Travis criteria) or in day 70 colectomy rates between patients who were highly (upper tertile) anxious (Travis response 8/13, colectomy rate 2/13) or highly (upper tertile) stressed (R-PSQ: Travis response 8/12, colectomy rate 6/13; G-PSQ Travis response 5/13, colectomy rate 4/13) compared to those less (lower tertile) anxious (5/ 13, 3/13, respectively) or stressed (lower tertile) (R-PSQ, 5/13, 1/13; G-PSQ 5/12, 1/13, respectively). CONCLUSION: Perceived stress levels are greater in patients with ASUC than in those in remission and anxiety scores are highest in patients newly presenting with UC, but neither stress nor anxiety influenced disease outcome.
274 Predictors of Mortality Among Patients Admitted to Hospital for Ischemic Colitis: A Population-Based U.S. Study Matthew D. Sadler, James N. Hubbard, Subrata Ghosh, Paul L. Beck, Chris Prusinkiewicz, Gilaad G. Kaplan AIMS: Ischemic colitis has been associated with significant mortality; however, few population-based studies have published outcomes for ischemic colitis in North America. We assessed in-hospital mortality and determined independent predictors of mortality in a nationally-representative sample of US hospitals. METHODS: We used the Nationwide Inpatient Sample to identify all patients with discharges for ischemic colitis (ICD-9 557.X) as a primary diagnosis between 1993 and 2008. We described in-hospital mortality and performed multivariate logistic regression analyses to determine independent predictors of mortality after adjusting for age, gender, insurance status, ethnicity, Charlson comorbidities, and interventions. RESULTS: From 1993-2008 we identified a total of 97,592 discharges of ischemic colitis. In-hospital mortality was 13.0% (95% CI: 12.7-13.3) and colectomy was performed on 14.2% (95% CI: 13.9-14.4) of patients with ischemic colitis. Chronic pulmonary disease [21.2% (95% CI: 20.9-21.5)], diabetes mellitus [15.2% (95% CI: 14.9-15.4)], congestive heart failure [CHF; 14.5% (95% CI: 14.2-14.8)], renal disease [8.7% (95% CI: 8.5-8.9)], peripheral vascular disease [8.4% (95% CI: 8.2-8.6)], and myocardial infarction [6.3% (95% CI: 6.1-6.4)] were the most commonly associated comorbidities in patients presenting with ischemic colitis. Mortality was associated with: older age 65-85 years [OR= 4.21 (3.38-5.26)] and 50-64 years [OR=2.29 (1.84-2.84)] versus 18-34 years; Medicaid [OR=2.03 (1.81-2.27)], self-pay (OR=1.78 (1.52-2.09)], and Medicare [OR=1.53 (1.421.65)] vs. private health insurance; and comorbidities such as liver disease [OR=3.18 (2.893.51)], metastatic solid tumor [OR=2.27 (1.95-2.63)], AIDS/HIV [OR=2.22 (1.22-4.02)], renal disease [OR=2.10 (1.97-2.23)], and CHF [OR=1.87 (1.78-1.97)]. Patients who underwent colonoscopy or sigmoidoscopy [OR=0.47 (0.43-0.51)] had lower mortality whereas colectomy [OR=2.38 (2.26-2.50)] was associated with increased mortality. Women had lower mortality than men [OR=0.84 (0.81-0.88)] and fewer women required colectomy [OR=0.70 (0.68-0.73)] despite representing a greater proportion of IC patients [68.88% (95% CI: 68.56-69.20)]. Lower mortality was observed in Asians (OR=0.49 (0.36-0.66)) and Hispanics (OR=0.80 (0.71-0.90) whereas African Americans (OR=1.13 (1.04-1.24) were associated with increased mortality, as compared to Caucasians. CONCLUSIONS: Ischemic colitis was associated with several common conditions and carried a high mortality rate, especially in older patients. Furthermore, colectomies were commonly performed on hospitalized patients with ischemic colitis, and these patients had worse mortality.
277 Adalimumab Levels Detected in Cord Blood and Infants Exposed in Utero Uma Mahadevan, Jocelyne K. Miller, Douglas C. Wolf Introduction: Adalimumab (ADA) and infliximab (IFX) are IgG1 antibodies against TNF-α and are FDA pregnancy category B. As IgG1 is actively transferred across the placenta during the third trimester, infants exposed to ADA and IFX may be born with high serum levels of drug. This has been demonstrated with IFX where newborn serum IFX levels were higher than maternal serum levels at birth and were present for up to 6 months from birth.(1) Our hypothesis is that ADA should also transfer actively across the placenta and result in detectable infant serum drug levels. Methods: Pregnant women with IBD receiving ADA were enrolled. On the day of birth, levels were measured in the mother, infant and cord blood. Levels were then measured in the infant until undetectable. Serum levels were measured by ELISA. The lower limit of quantification was 3.13 ng/mL in 10% serum, the concentration used in this assay. This study was approved by the institutional review board. Results: Five mothers were enrolled. All infants were born at a mean of 39 weeks gestation and 3407 gm weight. Three were delivered by cesarean section. One infant suffered from pulmonary edema but recovered fully. The table lists the time of last dose of ADA prior to delivery and the levels of ADA in mother, infant and cord blood on the day of birth. In all cases, the cord blood level of ADA was higher than the maternal level, supporting active transfer of ADA from the mother to the infant. Infant 2 had levels checked at 6 weeks from delivery: mother was 16.1 μg/ml and infant was 1.94 μg/ml. Infant 4 had levels checked at 1 month (1.93 μg/ml) and 2 months (0.93 μg/ml) from delivery. Conclusions: ADA actively crosses the placenta and can be detectable in the serum of infants exposed in utero for at least 3 months from birth. (1) Mahadevan U, Terdiman J, Church, J et al. Gastroenterol 2007;132:A-144. ADA levels on Day of Birth
275 Dietary Fiber is Not Associated With Diverticulosis Anne F. Peery, Patrick R. Barrett, Doyun Park, Albert J. Rogers, Trevor Locklear, Joseph A. Galanko, Christopher F. Martin, Robert S. Sandler Background: Inadequate dietary fiber is widely considered to be a major risk factor for the development of diverticulosis. Sedentary behavior and a diet high in red meat and fat have also been thought to predispose to diverticulosis. However, there is little hard evidence to support any of these associations. Using validated measures, we conducted a large cross sectional study to determine whether dietary fiber, fat, red meat or sedentary behavior were associated with diverticulosis confirmed by colonoscopy. Methods: We used the data from three colonoscopy-based studies conducted between 1998 and 2010 at the University of North Carolina Hospitals. Eligible participants were between the ages of 30 and 80 with satisfactory preparation for colonoscopy and a complete exam to the cecum. We excluded patients with a history of previous colon resection or a diagnosis of polyposis, colitis, or colon cancer. Telephone interviewers collected detailed information on demographics, diet, physical activity and co-morbidities one month after colonoscopy. Diet was assessed with a validated quantitative food-frequency questionnaire. Cases were defined as participants found to have any diverticula identified by screening colonoscopy. Controls were diverticulafree on colonoscopy. Results: There were 2378 participants, with 968 diverticulosis cases and 1410 diverticula-free controls. Among the cases, the mean age was 59 ± 9 years; 43% were men and 84% were Caucasian with a mean BMI of 28 ± 6. Among the controls, the mean age was 54 ± 9 years; 43% were men and 79% were Caucasian with a mean BMI of 27 ± 6. Diverticulosis was more common in older, Caucasian and higher BMI participants. After adjustment for potential confounders (age, race, BMI), we found no association between total fiber and diverticulosis (OR 0.96, 95% CI 0.73-1.25). No fiber type was protective: bean fiber (OR 1.00, 95% CI 0.77-1.30), fruit and vegetable fiber (OR 1.01, 95% CI 0.771.31), grain fiber (OR 0.83, 95%, CI 0.63-1.08). We found no association with fat intake
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Anxiety & Depression Score (HADS-A)) and stress levels (Perceived Stress Questionnaire: Recent, R-PSQ, General, G PSQ). Outcomes were assessed, using the Travis criteria (day 3) and colectomy rates at day 70, in relation to upper and lower tertiles of the anxiety and stress scores. In addition, the psychometric scores of the ASUC patients were compared to those of 27 outpatients with inactive UC. RESULTS: Patients with ASUC had higher stress levels (R-PSQ Index 0.52 [0.03] (mean [SEM]), G-PSQ 0.46 [0.03]) than in patients with inactive UC (0.35 [0.03], p= 0.001, 0.39 [0.02], p=0.046, respectively) but there was no difference in anxiety scores (HADS-A: 9.6[0.8], 8.4[0.7], p=0.9, respectively). However, in paitents with ASUC, there was a positive correlation between stress and anxiety scores (RPSQ, r2=0.27, p=0.0008; G-PSQ, r2= 0.14, p=0.02)). Although stress scores were similar, anxiety levels were higher in the 11 newly presenting ASUC patients (12 [1.4]) than in those previously diagnosed (8.6 [0.9], p=0.049). There was no difference in those responding to iv hydrocortisone (by Travis criteria) or in day 70 colectomy rates between patients who were highly (upper tertile) anxious (Travis response 8/13, colectomy rate 2/13) or highly (upper tertile) stressed (R-PSQ: Travis response 8/12, colectomy rate 6/13; G-PSQ Travis response 5/13, colectomy rate 4/13) compared to those less (lower tertile) anxious (5/ 13, 3/13, respectively) or stressed (lower tertile) (R-PSQ, 5/13, 1/13; G-PSQ 5/12, 1/13, respectively). CONCLUSION: Perceived stress levels are greater in patients with ASUC than in those in remission and anxiety scores are highest in patients newly presenting with UC, but neither stress nor anxiety influenced disease outcome.