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Fernandez C, Gajic Z, Esen E, Remzi F, Hudesman D, Adhikari S, McAdams-DeMarco M, Segev DL, Chodosh J, Dodson J, Shaukat A, Faye AS. Preoperative Risk Factors for Adverse Events in Adults Undergoing Bowel Resection for Inflammatory Bowel Disease: 15-Year Assessment of the American College of Surgeons National Surgical Quality Improvement Program. Am J Gastroenterol 2023; 118:2230-2241. [PMID: 37410929 PMCID: PMC10841104 DOI: 10.14309/ajg.0000000000002395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/13/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Older adults with inflammatory bowel disease (IBD) are at higher risk for postoperative complications as compared to their younger counterparts; however, factors contributing to this are unknown. We assessed risk factors associated with adverse IBD-related surgical outcomes, evaluated trends in emergency surgery, and explored differential risks by age. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified adults ≥18 years of age who underwent an IBD-related intestinal resection from 2005 to 2019. Our primary outcome included a 30-day composite of mortality, readmission, reoperation, and/or major postoperative complication. RESULTS Overall, 49,746 intestinal resections were performed with 9,390 (18.8%) occurring among older adults with IBD. Nearly 37% of older adults experienced an adverse outcome as compared to 28.1% among younger adults with IBD ( P < 0.01). Among all adults with IBD, the presence of preoperative sepsis (adjusted odds ratio [aOR], 2.08; 95% confidence interval [CI] 1.94-2.24), malnutrition (aOR, 1.22; 95% CI 1.14-1.31), dependent functional status (aOR, 6.92; 95% CI 4.36-11.57), and requiring emergency surgery (aOR, 1.50; 95% CI 1.38-1.64) increased the odds of an adverse postoperative outcome, with similar results observed when stratifying by age. Furthermore, 8.8% of surgeries among older adults were emergent, with no change observed over time ( P = 0.16). DISCUSSION Preoperative factors contributing to the risk of an adverse surgical outcome are similar between younger and older individuals with IBD, and include elements such as malnutrition and functional status. Incorporating these measures into surgical decision-making can reduce surgical delays in older individuals at low risk and help target interventions in those at high risk, transforming care for thousands of older adults with IBD.
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Affiliation(s)
- Cristina Fernandez
- Department of Medicine at New York University Langone Health, New York, NY, USA
| | - Zoran Gajic
- Department of Medicine at New York University Langone Health, New York, NY, USA
| | - Eren Esen
- Department of Surgery at New York University Langone Health, New York, NY, USA
| | - Feza Remzi
- Department of Surgery at New York University Langone Health, New York, NY, USA
| | - David Hudesman
- Inflammatory Bowel Disease Center at New York University Langone Health, Division of Gastroenterology and Hepatology, New York, NY, USA
| | - Samrachana Adhikari
- Department of Population Health at New York University Langone Health, New York, NY, USA
| | | | - Dorry L. Segev
- Department of Surgery at New York University Langone Health, New York, NY, USA
| | - Joshua Chodosh
- Department of Medicine at New York University Langone Health, Division of Geriatric Medicine and Palliative Care, New York, NY, USA
| | - John Dodson
- Department of Medicine at New York University Langone Health, Division of Cardiology, New York, NY, USA
| | - Aasma Shaukat
- Inflammatory Bowel Disease Center at New York University Langone Health, Division of Gastroenterology and Hepatology, New York, NY, USA
| | - Adam S. Faye
- Inflammatory Bowel Disease Center at New York University Langone Health, Division of Gastroenterology and Hepatology, New York, NY, USA
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van Linschoten RCA, Huberts AS, van Leeuwen N, Hazelzet JA, van der Woude J, West RL, van Noord D. Validity of the self-administered comorbidity questionnaire in patients with inflammatory bowel disease. Therap Adv Gastroenterol 2023; 16:17562848231202159. [PMID: 37877105 PMCID: PMC10591493 DOI: 10.1177/17562848231202159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/01/2023] [Indexed: 10/26/2023] Open
Abstract
Background The International Consortium for Health Outcomes Measurement has selected the self-administered comorbidity questionnaire (SCQ) to adjust case-mix when comparing outcomes of inflammatory bowel disease (IBD) treatment between healthcare providers. However, the SCQ has not been validated for use in IBD patients. Objectives We assessed the validity of the SCQ for measuring comorbidities in IBD patients. Design Cohort study. Methods We assessed the criterion validity of the SCQ for IBD patients by comparing patient-reported and clinician-reported comorbidities (as noted in the electronic health record) of the 13 diseases of the SCQ using Cohen's kappa. Construct validity was assessed using the Spearman correlation coefficient between the SCQ and the Charlson Comorbidity Index (CCI), clinician-reported SCQ, quality of life, IBD-related healthcare and productivity costs, prevalence of disability, and IBD disease activity. We assessed responsiveness by correlating changes in the SCQ with changes in healthcare costs, productivity costs, quality of life, and disease activity after 15 months. Results We included 613 patients. At least fair agreement (κ > 0.20) was found for most comorbidities, but the agreement was slight (κ < 0.20) for stomach disease [κ = 0.19, 95% CI (-0.03; 0.41)], blood disease [κ = 0.02, 95% CI (-0.06; 0.11)], and back pain [κ = 0.18, 95% CI (0.11; 0.25)]. Correlations were found between the SCQ and the clinician-reported SCQ [ρ = 0.60, 95% CI (0.55; 0.66)], CCI [ρ = 0.39, 95% CI (0.31; 0.45)], the prevalence of disability [ρ = 0.23, 95% CI (0.15; 0.32)], and quality of life [ρ = -0.30, 95% CI (-0.37; -0.22)], but not between the SCQ and healthcare or productivity costs or disease activity (|ρ| ⩽ 0.2). A change in the SCQ after 15 months was not correlated with a change in any of the outcomes. Conclusion The SCQ is a valid tool for measuring comorbidity in IBD patients, but face and content validity should be improved before being used to correct case-mix differences.
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Affiliation(s)
- Reinier Cornelis Anthonius van Linschoten
- Department of Gastroenterology & Hepatology, Franciscus Gasthuis & Vlietland, P.O Box 10900, Rotterdam 3004BA, Netherlands
- Department of Gastroenterology & Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Anouk Sjoukje Huberts
- Department of Quality and Patientcare, Erasmus MC, Rotterdam, Zuid-Holland, Netherlands
| | - Nikki van Leeuwen
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - Jan Antonius Hazelzet
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | | | - Rachel Louise West
- Department of Gastroenterology & Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
| | - Desirée van Noord
- Department of Gastroenterology & Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
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Abella MKIL, Lee AY, Kitamura RK, Ahn HJ, Woo RK. Disparities and Risk Factors for Surgical Complication in American Indians and Native Hawaiians. J Surg Res 2023; 288:99-107. [PMID: 36963299 DOI: 10.1016/j.jss.2023.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/25/2023] [Accepted: 02/18/2023] [Indexed: 03/26/2023]
Abstract
INTRODUCTION American Indian and Alaskan Natives (AIAN) and Native Hawaiian and Pacific Islanders (NHPI) research is limited, particularly in postoperative surgical outcomes. This study analyzes disparities in AIAN and NHPI surgical complications across all surgical types and identifies factors that contribute to postoperative complications. METHODS This retrospective cohort study examined all surgeries from 2011 to 2020 in the National Surgical Quality Improvement Program, queried by race. Multivariable models analyzed the association of race and ethnicity and 30-day postoperative complication. Next, multivariable models were used to identify preoperative variables associated with postoperative complications, specifically in AIAN and NHPI patients. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated. RESULTS AIAN patients were associated with higher odds of postoperative complication (AOR: 1.008 [CI: 1.005-1.011], P < 0.001) compared to non-Hispanic white patients. The comorbidities that were of higher incidence in AIAN patients, which also adversely contributed to postoperative complication, included dependent functional status, diabetes, congestive heart failure (CHF), open wounds, preoperative weight loss, bleeding disorders, preoperative transfusion, sepsis, hypoalbuminemia, along with an active smoking status and ASA ≥3. In NHPI patients, dependent functional status, CHF, renal failure, preoperative transfusion, open wounds, and sepsis were of higher incidence and significantly contributed to postoperative complication. CONCLUSIONS Surgical outcome disparities exist particularly in AIAN patients. Identification of modifiable patient risk factors may benefit perioperative care for AIAN and NHPI patients, which are historically understudied racial groups.
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Affiliation(s)
| | - Anson Y Lee
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Riley K Kitamura
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Queen's Medical Center, Honolulu, Hawaii
| | - Hyeong Jun Ahn
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Russell K Woo
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Kapi'olani Medical Center for Women and Children, Hawai'i Pacific Health, Honolulu, Hawaii
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Sousa P, Bertani L, Rodrigues C. Management of inflammatory bowel disease in the elderly: A review. Dig Liver Dis 2023; 55:1001-1009. [PMID: 36681569 DOI: 10.1016/j.dld.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/26/2022] [Accepted: 12/29/2022] [Indexed: 01/23/2023]
Abstract
The burden of Inflammatory Bowel Disease (IBD) is increasing worldwide, with a particular increase in the prevalence in the elderly population, due to the ageing of young-onset IBD as well as to the increasing incidence in elderly patients. Elderly IBD patients present specific challenges to the treating physician, as they have comorbidities, lower functional reserves, and higher risk of treatment-related complications. The diagnosis of IBD in the elderly may be difficult due to a more subtle disease presentation and to a wide range of differential diagnosis. Moreover, as these patients are often excluded from clinical trials, there is a lack of high-quality evidence to inform on the most appropriate management. Despite an increasing prevalence, the management of IBD in the elderly is still hindered by frequent misconceptions by physicians treating these patients. Due to a erroneous notion of a milder disease course and fear of adverse events, elderly IBD-patients are managed with frequent and continuous use of steroids and undertreated with effective medical therapies. In this review, we describe the principles of management of IBD in the elderly, which is a topic of increasing importance to IBD clinics, that will have to progressively adapt to care for an ageing population.
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Affiliation(s)
- Paula Sousa
- Department of Gastroenterology, Viseu Unit, Tondela-Viseu Hospital Centre, Viseu 3504-509, Portugal.
| | - Lorenzo Bertani
- Department of General Surgery and Gastroenterology, Tuscany North West ASL, Pontedera Hospital, Pontedera, Italy
| | - Cláudio Rodrigues
- Department of Gastroenterology, Viseu Unit, Tondela-Viseu Hospital Centre, Viseu 3504-509, Portugal
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Subhaharan D, Ramaswamy PK, Willmann L, Moattar H, Bhullar M, Ishaq N, Dorrington A, Shukla D, McIvor C, Edwards J, Mohsen W. Older adults with acute severe ulcerative colitis have similar steroid non-response and colectomy rates as younger adults. World J Gastroenterol 2023; 29:2469-2478. [PMID: 37179589 PMCID: PMC10167901 DOI: 10.3748/wjg.v29.i16.2469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/11/2023] [Accepted: 03/24/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND There is paucity of data on outcomes of acute severe ulcerative colitis (ASUC) in older adults (≥ 60 years of age). AIM To assess steroid non-response rates during the index admission for ASUC in older adults. Secondary outcomes were response to medical rescue therapy and colectomy rates; at index admission, 3 and 12 mo. METHODS This retrospective multicentre cohort study included ASUC admissions who received intravenous steroids between January 2013 and July 2020 at two tertiary hospitals. Electronic medical records were reviewed to collect clinical, biochemical, and endoscopic data. A modified Poisson regression model was used for analysis. RESULTS Of 226 ASUC episodes, 45 (19.9%) occurred in patients ≥ 60 years of age. Steroid non-response rates were comparable in older adults and patients < 60 years of age [19 (42.2%) vs 85 (47%), P = 0.618, crude risk ratio (RR) = 0.89 [95% confidence interval (CI): 0.61-1.30], adjusted RR = 0.99 (0.44-2.21). Rates of response to medical rescue therapy in older adults was comparable to the younger cohort [76.5% vs 85.7%, P = 0.46, crude RR = 0.89 (0.67-1.17)]. Index admission colectomy [13.3% vs 10.5%, P = 0.598, crude RR = 1.27 (0.53-2.99), adjusted RR = 1.43 (0.34-6.06)], colectomy at 3 mo [20% vs 16.6%, P = 0.66, crude RR = 1.18 (0.61-2.3), adjusted RR = 1.31 (0.32-0.53)] and colectomy at 12 mo [20% vs 23.2%, P = 0.682, crude RR = 0.85 (0.45-1.57), adjusted RR = 1.21 (0.29-4.97)], were similar between the two groups. CONCLUSION In older adults with ASUC, the steroid non-response rate, response to medical rescue therapy, and colectomy rate at index admission, 3 and 12 mo is similar to patients less than 60 years of age.
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Affiliation(s)
- Deloshaan Subhaharan
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | | | - Laura Willmann
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Hadi Moattar
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Maneesha Bhullar
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Naveed Ishaq
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Alexander Dorrington
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Dheeraj Shukla
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Carolyn McIvor
- Department of Gastroenterology, Logan Hospital, Logan 4131, Queensland, Australia
| | - John Edwards
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
| | - Waled Mohsen
- Department of Digestive Diseases, Gold Coast University Hospital, Gold Coast 4215, Queensland, Australia
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6
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Del Valle JP, Lee GC, Serrato JC, Feuerstein JD, Bordeianou LG, Hodin R, Kunitake H, Poylin V. Recurrence of Clostridium Difficile and Cytomegalovirus Infections in Patients with Ulcerative Colitis Who Undergo Ileal Pouch-Anal Anastomosis. Dig Dis Sci 2021; 66:4441-4447. [PMID: 33433814 DOI: 10.1007/s10620-020-06772-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Patients with ulcerative colitis (UC) are at increased risk for infections such as Clostridium difficile and cytomegalovirus (CMV) colitis due to chronic immunosuppression. These patients often undergo multiple surgeries putting them at risk for recurrence of the infection. However, rates of recurrence in this setting and outcomes are not well understood. AIM The aim of this study is to determine rates of recurrence of C difficile and CMV infection in patients undergoing multistage UC surgeries and effects of antibiotic prophylaxis on outcomes. METHODS All patients with UC who underwent IPAA between 2001 and 2017 (at two tertiary referral centers were identified. History of C. difficile or CMV colitis prior to any surgery and recurrence after IPAA was noted RESULTS: A total of 633 patients with UC who underwent IPAA were identified, of whom 8.1% patients had C. difficile and 2.7% had CMV infections. 9.8% of C. difficile and 5.9% of CMV patients recurred after IPAA. Rates of abdominal sepsis (14.7% vs. 12.7%), 90-day mortality (0% vs. 0.4%), pouchitis (36.8% vs. 45.0%), or return to stoma (7.4% vs. 5.4%) were similar between patients who did or did not have infections. In patients with C. difficile infection prior to first surgery, none of the patients who received prophylaxis had recurrent infection. CONCLUSIONS Rates of C. difficile and CMV infections remain high in patients undergoing surgery for UC, with substantial minority developing recurrent infection during subsequent surgical procedures. Antibiotic prophylaxis in patients with a history of C difficile may reduce the rate of recurrent infection.
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Affiliation(s)
- Jonathan Pastrana Del Valle
- Department of Surgery, Beth Israel Deaconess Medical Center, Beth Israel Deaconess Medical Center Suite 9B, 110 Francis Street, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Grace C Lee
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Jose Cataneo Serrato
- Department of Surgery, Beth Israel Deaconess Medical Center, Beth Israel Deaconess Medical Center Suite 9B, 110 Francis Street, Boston, MA, 02215, USA
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center Medicine, 330 Brookline Ave, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Liliana Grigorievna Bordeianou
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Richard Hodin
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Hiroko Kunitake
- Harvard Medical School, Boston, MA, USA
- Advocate Illinois Masonic Medical Center, 836 W Wellington Ave, Chicago, IL, 60657, USA
| | - Vitaliy Poylin
- Division of Gastrointestinal and Oncologic Surgery, Northwestern Medicine, Arkes Family Pavilion, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA.
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Shimodaira Y, Watanabe K, Iijima K. Clinical Course of Ulcerative Colitis Associated with an Age at Diagnosis: A Recent Japanese Database Survey. TOHOKU J EXP MED 2021; 255:33-39. [PMID: 34511579 DOI: 10.1620/tjem.255.33] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The onset age of ulcerative colitis has been increasing in several countries. Furthermore, the number of elderly patients with ulcerative colitis has been increasing in an aging society. We investigated the incidence of ulcerative colitis patients in Japan using a large-scale health insurance claims database to survey the ulcerative colitis incidence ratio and the clinical characteristics in late-onset ulcerative colitis patients. Newly diagnosed 2,791 ulcerative colitis between 2015 and 2018 was investigated. Medical treatment within 12 months of diagnosis was analyzed among 0-19, 20-39, 40-59 and 60-75 age groups. The mean age at diagnosis was 40.3 years (SD: 12.9), and the incidence ratio peaked in the 40's. Most of patients received 5-aminocylitic acid (91.7%), a subset of patients received prednisolone (20.1%), and a small number of patients took immunomodulator (6.8%), cytapheresis (3.3%), anti-TNFα therapy (4.3%), and colectomy (1.0%) within 12 months after diagnosis. All treatments except colectomy were most frequent in the 0-19 age group; however, colectomy was most frequent in 60-75 age group. The clinical course of ulcerative colitis that developed in adults did not differ significantly in terms of medical treatment within 12 months from the onset; meanwhile, the surgery rate was high in elderly patients. It is necessary to pay close attention to future trends regarding the aging of the onset age and the treatment, especially for late-onset ulcerative colitis patients.
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Affiliation(s)
- Yosuke Shimodaira
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine
| | - Kenta Watanabe
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine
| | - Katsunori Iijima
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine
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Ronaldson A, Elton L, Jayakumar S, Jieman A, Halvorsrud K, Bhui K. Severe mental illness and health service utilisation for nonpsychiatric medical disorders: A systematic review and meta-analysis. PLoS Med 2020; 17:e1003284. [PMID: 32925912 PMCID: PMC7489517 DOI: 10.1371/journal.pmed.1003284] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 08/10/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Psychiatric comorbidity is known to impact upon use of nonpsychiatric health services. The aim of this systematic review and meta-analysis was to assess the specific impact of severe mental illness (SMI) on the use of inpatient, emergency, and primary care services for nonpsychiatric medical disorders. METHODS AND FINDINGS PubMed, Web of Science, PsychINFO, EMBASE, and The Cochrane Library were searched for relevant studies up to October 2018. An updated search was carried out up to the end of February 2020. Studies were included if they assessed the impact of SMI on nonpsychiatric inpatient, emergency, and primary care service use in adults. Study designs eligible for review included observational cohort and case-control studies and randomised controlled trials. Random-effects meta-analyses of the effect of SMI on inpatient admissions, length of hospital stay, 30-day hospital readmission rates, and emergency department use were performed. This review protocol is registered in PROSPERO (CRD42019119516). Seventy-four studies were eligible for review. All were observational cohort or case-control studies carried out in high-income countries. Sample sizes ranged from 27 to 10,777,210. Study quality was assessed using the Newcastle-Ottawa Scale for observational studies. The majority of studies (n = 45) were deemed to be of good quality. Narrative analysis showed that SMI led to increases in use of inpatient, emergency, and primary care services. Meta-analyses revealed that patients with SMI were more likely to be admitted as nonpsychiatric inpatients (pooled odds ratio [OR] = 1.84, 95% confidence interval [CI] 1.21-2.80, p = 0.005, I2 = 100%), had hospital stays that were increased by 0.59 days (pooled standardised mean difference = 0.59 days, 95% CI 0.36-0.83, p < 0.001, I2 = 100%), were more likely to be readmitted to hospital within 30 days (pooled OR = 1.37, 95% CI 1.28-1.47, p < 0.001, I2 = 83%), and were more likely to attend the emergency department (pooled OR = 1.97, 95% CI 1.41-2.76, p < 0.001, I2 = 99%) compared to patients without SMI. Study limitations include considerable heterogeneity across studies, meaning that results of meta-analyses should be interpreted with caution, and the fact that it was not always possible to determine whether service use outcomes definitively excluded mental health treatment. CONCLUSIONS In this study, we found that SMI impacts significantly upon the use of nonpsychiatric health services. Illustrating and quantifying this helps to build a case for and guide the delivery of system-wide integration of mental and physical health services.
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Affiliation(s)
- Amy Ronaldson
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Lotte Elton
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Simone Jayakumar
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Anna Jieman
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Kristoffer Halvorsrud
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Kamaldeep Bhui
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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9
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Comorbidities in adolescents with inflammatory bowel disease: findings from a population-based cohort study. Pediatr Res 2020; 87:1256-1262. [PMID: 31801156 DOI: 10.1038/s41390-019-0702-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Inflammatory bowel diseases are associated with various immune- and non-immune-mediated conditions. We aimed to assess the association of inflammatory bowel diseases with comorbidities at late adolescence. METHODS Jewish Israeli adolescents who underwent a general health evaluation prior to enlistment to the Israeli Defense Forces from 2002 to 2016 were included. RESULTS Overall, 891 subjects (595 Crohn's disease, 296 ulcerative colitis, median age 17.1 years) and 1,141,841 controls were analyzed. Crohn's disease was associated with arthritis (odds ratio (OR) 4.7, 95% confidence interval (CI) 2.4-9.1), thyroid disease (OR 2.6, 95% CI 1.2-5.5), atopic dermatitis (OR 2, 95% CI 1.1-3.6), autoimmune hepatitis (OR 4.4, 95% CI 2.3-8.6), nephrolithiasis (OR 3.6, 95% CI 1.2-11.4), and pancreatitis (OR 41.8, 95% CI 17.2-101.9). Ulcerative colitis was associated with arthritis (OR 3.6, 95% CI 1.0-9.8), thyroid disease (OR 4.8, 95% CI 1.2-19.4), autoimmune hepatitis (OR 8, 95% CI 4-16.2), and pancreatitis (OR 51, 95% CI 16.1-158.9). Primary sclerosing cholangitis was associated with both diseases. Asthma, celiac, type 1 diabetes, psoriasis, and bone fractures were not more common in both diseases. Male predominance was noted for most associations. CONCLUSIONS At adolescence, both Crohn's disease and ulcerative colitis are associated with multiple comorbidities, not limited to autoimmune disorders.
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Abstract
OBJECTIVE Heart failure (HF) exerts deleterious effects on the gastrointestinal tract and the gut microbiome, yet its impact on inflammatory bowel disease (IBD) is unknown. This study was performed to evaluate the impact of HF on disease course and outcomes in patients with IBD. METHODS Using a large institutional database, we identified patients aged 18-65 years diagnosed with IBD and incident HF (IBD-HF), IBD without HF (IBD), and HF without IBD (HF). Patients were followed longitudinally, and IBD-related outcomes were compared between the IBD-HF and IBD cohorts using multivariable cox regression. General clinical outcomes were compared between all three cohorts using Kaplan-Meier survival analysis. RESULTS A total of 271, 2449, and 20,444 patients were included in the IBD-HF, IBD, and HF cohorts. Compared with IBD, IBD-HF had significantly higher risk of IBD-related hospitalization [hazard ratio (HR): 1.42; (95% confidence interval, CI: 1.2-1.69)], flare [HR 1.32 (1.09-1.58)], complication [HR 1.7 (1.33-2.17)], pancolitis [HR 1.55 (1.04-2.3)], and escalation to nonbiologic therapy. No significant difference was observed in the incidence of IBD-related surgery or Clostridium difficile infection. New biologic use was less frequent in IBD-HF [HR 0.52 (0.36-0.77)]. IBD-HF, compared with the other two groups, had reduced event-free survival for all-cause hospitalization (P < 0.001), emergency department visits (P = 001), and venous thromboembolism (P < 0.05). Mortality risk in IBD-HF was elevated compared to IBD but was similar to that within HF cohort. CONCLUSION Incident HF in patients with IBD is a predictor of adverse IBD-related and overall clinical outcomes.
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Preoperative factors associated with prolonged postoperative in-hospital length of stay in patients with Crohn's disease undergoing intestinal resection or strictureplasty. Int J Colorectal Dis 2019; 34:1925-1931. [PMID: 31659447 DOI: 10.1007/s00384-019-03418-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE To investigate factors that influence postoperative in-hospital length of stay (LOS) in patients with Crohn's disease (CD) undergoing bowel surgery. Furthermore, the study aimed to evaluate LOS as a surrogate for postoperative outcome. METHODS This is a multicentre retrospective cohort study. Inclusion criteria were adult patients with CD who underwent bowel surgery with either anastomosis or stricturoplasty. All timings of surgeries were included regardless of the method of access to the abdominal cavities. Patients with stoma were excluded. Demographic data, preoperative medications, previous operations for CD, preoperative sepsis, and operation were recorded. Primary outcome was LOS while secondary outcome variable was postoperative complications. RESULTS A total of 449 patients who underwent abdominal surgery for CD were included. Of the 449 patients, 265 were female (59%). Median age was 37 years (IQR = 20), median LOS was 7 days (IQR = 6). Patients with longer LOS had higher rates of re-laparotomy/re-laparoscopy (45/228 (19.7%) versus 9/219 (4.1%) p = 0.01). In multivariate analysis, age (OR = 1.024 [CI 95% 1.007-1.041], p = 0.005), preoperative intra-abdominal abscess (OR = 0.39 [CI 95% 0.185-0.821], p = 0.013), and previous laparotomy/laparoscopy (OR = 0.57 [CI 95% 0.334-0.918], p = 0.021) were associated with prolonged LOS. LOS correlated with postoperative complications after adjustment for age, gender, previous laparotomy/laparoscopy, and preoperative intra-abdominal abscesses (OR = 1.28 [CI 95% 1.199-1.366], p < 0.0001). CONCLUSION Age, preoperative intra-abdominal abscess, and previous laparotomy/laparoscopy significantly prolonged LOS. LOS correlated with postoperative complications and can therefore be used in epidemiological or register-based studies as a surrogate for postoperative outcome.
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LeBlanc JF, Wiseman D, Lakatos PL, Bessissow T. Elderly patients with inflammatory bowel disease: Updated review of the therapeutic landscape. World J Gastroenterol 2019; 25:4158-4171. [PMID: 31435170 PMCID: PMC6700701 DOI: 10.3748/wjg.v25.i30.4158] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
High-quality data remains scarce in terms of optimal management strategies in the elderly inflammatory bowel disease (IBD) population. Indeed, available trials have been mostly retrospective, of small sample size, likely owing to under-representation of such a population in the major randomized controlled trials. However, in the last five years, there has been a steady increase in the number of published trials, helping clarify the estimated benefits and toxicity of the existing IBD armamentarium. In the Everhov trial, prescription strategies were recorded over an average follow-up of 4.2 years. A minority of elderly IBD patients (1%-3%) were treated with biologics within the five years following diagnosis, whilst almost a quarter of these patients were receiving corticosteroid therapy at year five of follow-up, despite its multiple toxicities. The low use of biologic agents in real-life settings likely stems from limited data suggesting lower efficacy and higher toxicity. This minireview will aim to highlight current outcome measurements as it portends the elderly IBD patient, as well as summarize the available therapeutic strategies in view of a growing body of evidence.
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Affiliation(s)
- Jean-Frédéric LeBlanc
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Daniel Wiseman
- Department of Medicine, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Peter L Lakatos
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- 1st Department of Medicine, Semmelweis University, Budapest 1083, Hungary
| | - Talat Bessissow
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
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13
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Dietary Support in Elderly Patients with Inflammatory Bowel Disease. Nutrients 2019; 11:nu11061421. [PMID: 31238597 PMCID: PMC6627086 DOI: 10.3390/nu11061421] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/20/2019] [Accepted: 06/21/2019] [Indexed: 02/06/2023] Open
Abstract
Ageing of the human population has become a big challenge for health care systems worldwide. On the other hand, the number of elderly patients with inflammatory bowel disease (IBD) is also increasing. Considering the unique clinical characteristics of this subpopulation, including many comorbidities and polypharmacy, the current therapeutic guidelines for the management of IBD should be individualized and applied with caution. This is why the role of non-pharmacological treatments is of special significance. Since both IBD and older age are independent risk factors of nutritional deficiencies, appropriate dietary support should be an important part of the therapeutic approach. In this review paper we discuss the interrelations between IBD, older age, and malnutrition. We also present the current knowledge on the utility of different diets in the management of IBD. Considering the limited data on how to support IBD therapy by nutritional intervention, we focus on the Mediterranean and Dietary Approaches to Stop Hypertension diets, which seem to be the most beneficial in this patient group. We also discuss some new findings on their hypothetical anti-inflammatory influence on the course of IBD.
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Argollo M, Gilardi D, Peyrin-Biroulet C, Chabot JF, Peyrin-Biroulet L, Danese S. Comorbidities in inflammatory bowel disease: a call for action. Lancet Gastroenterol Hepatol 2019; 4:643-654. [PMID: 31171484 DOI: 10.1016/s2468-1253(19)30173-6] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic systemic inflammatory condition. Previously, the focus has been on extraintestinal manifestations of IBD, including arthritis, psoriasis, and uveitis. Although comorbidities have long been the subject of intensive research in other chronic inflammatory diseases such as rheumatoid arthritis, the concept of comorbidities is only beginning to emerge in IBD. Several comorbid conditions have been proposed to be related to IBD, including cardiovascular disease, neuropsychological disorders, and metabolic syndrome. Recognition of these conditions and their treatment could lead to better management of IBD. This Review aims to explore current knowledge regarding classic and emerging comorbidities related to IBD.
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Affiliation(s)
- Marjorie Argollo
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy; Universidade Federal de São Paulo, São Paulo, Brazil
| | - Daniela Gilardi
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy
| | | | - Jean-Francois Chabot
- Department of Pneumology, Nancy University Hospital, Lorraine University, Nancy, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, Nancy, France
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy.
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15
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Shrestha MP, Taleban S. Obesity Is Associated with Increased Risk of Colectomy in Inflammatory Bowel Disease Patients Hospitalized with Clostridium difficile Infection. Dig Dis Sci 2019; 64:1632-1639. [PMID: 30569334 DOI: 10.1007/s10620-018-5423-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obesity and inflammatory bowel disease (IBD) are associated with increased risk of Clostridium difficile infection (CDI). The effect of obesity on IBD course and development of complications is poorly understood. We performed this study to examine the effect of obesity on CDI-related morbidity and mortality in hospitalized patients with IBD. METHODS We used data from the National Inpatient Sample across five study years (2010-2014) to identify patients ≥ 18 years hospitalized with both CDI and IBD. We compared the outcomes of in-hospital mortality, partial or total colectomy, hospital length of stay, and hospital charges between obese and non-obese IBD-CDI patients. Analysis included univariate and multivariate linear and logistic regression analyses. RESULTS Of 304,298 hospitalized patients with IBD, 13,517 (4.4%) patients had CDI. Of these, 996 (7.4%) patients were obese. Obese IBD-CDI patients had a higher risk of colectomy (adjusted odds ratio, AOR 1.60, 95% CI 1.30-1.96; p < 0.001), longer hospital length of stay (difference 0.8 days, 95% CI 0.02-1.58; p = 0.04), and higher hospital charges (difference $11,051, 95% CI 1939-20,163; p = 0.02) than non-obese IBD-CDI patients, but no significant difference in mortality was found between the two groups. CONCLUSIONS Obesity is associated with a 60% increase in the risk of colectomy, longer hospital stay, and higher charges in IBD patients hospitalized with CDI. Further epidemiological and clinical studies are needed to confirm these findings.
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Affiliation(s)
- Manish P Shrestha
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Sasha Taleban
- Division of Gastroenterology, University of Arizona College of Medicine, 1501 N Campbell Ave, PO Box 24502B, Tucson, AZ, 85724, USA. .,Department of Medicine, Arizona Center of Aging, Tucson, AZ, USA.
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16
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Justiniano CF, Aquina CT, Becerra AZ, Xu Z, Boodry CI, Swanger AA, Monson JRT, Fleming FJ. Postoperative Mortality After Nonelective Surgery for Inflammatory Bowel Disease Patients in the Era of Biologics. Ann Surg 2019; 269:686-691. [PMID: 29232213 DOI: 10.1097/sla.0000000000002628] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of the study was to analyze recent trends in the rate of nonelective surgery and corresponding mortality for inflammatory bowel disease (IBD) patients since the rise of biologic use. BACKGROUND Modern biologic therapy has improved outcomes for IBD, but little is known about the impact on mortality rates after nonelective surgery. METHODS New York's Statewide Planning & Research Cooperative System was queried for hospital admissions for ulcerative colitis (UC) with concurrent colectomy and Crohn disease (CD) with concurrent small bowel resection or colectomy from 2000 to 2013. Mixed-effects analyses assessed patient, surgeon, and hospital-level factors and hospital-level variation associated with 30-day mortality after nonelective surgery. RESULTS Between 2000 to 2006 and 2007 to 2013, the number of unscheduled IBD-related admissions increased by 50% for UC and 41% for CD, but no change in the proportion of nonelective surgery cases was observed (UC=38% vs 38%; CD=45% vs 42%) among 15,837 intestinal resections (UC=5,297; CD=10,540). Nonelective surgery mortality rates between 2000 to 2006 and 2007 to 2013 were high and increased for UC (10.2% vs 15%) but decreased for CD (3.3% vs 2.2%). Nonelective surgery in 2007 to 2013 was associated with an 82% increased risk of 30-day mortality in UC cases (odds ratio: 1.82; confidence interval: 1.19-2.62). After controlling for patient-level factors, large hospital-level variation was observed with 23-fold difference in mortality for both UC and CD. CONCLUSIONS Although nonelective IBD surgery rates have remained stable, associated 30-day mortality for UC has doubled in recent years despite advances in medical management. Current clinical decision-making and care pathways must be further evaluated to improve outcomes in this high-risk population.
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Affiliation(s)
- Carla F Justiniano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | | | - Adan Z Becerra
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
- Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY
| | - Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Courtney I Boodry
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Alex A Swanger
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida, College of Medicine, Orlando, FL
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Vashishta R, Kendale SM. Relationship Between Preoperative Antidepressant and Antianxiety Medications and Postoperative Hospital Length of Stay. Anesth Analg 2019; 128:248-255. [DOI: 10.1213/ane.0000000000003910] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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18
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Higashiyama M, Sugita A, Koganei K, Wanatabe K, Yokoyama Y, Uchino M, Nagahori M, Naganuma M, Bamba S, Kato S, Takeuchi K, Omori T, Takagi T, Matsumoto S, Nagasaka M, Sagami S, Kitamura K, Katsurada T, Sugimoto K, Takatsu N, Saruta M, Sakurai T, Watanabe K, Nakamura S, Suzuki Y, Hokari R. Management of elderly ulcerative colitis in Japan. J Gastroenterol 2019; 54:571-586. [PMID: 31025187 PMCID: PMC6685935 DOI: 10.1007/s00535-019-01580-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/08/2019] [Indexed: 02/04/2023]
Abstract
Japan has the largest aging society, where many elderly people have intractable diseases including ulcerative colitis (UC). Along with the increasing total number of UC patients, the number of elderly UC patients has also been increasing and will continue to do so in the future. Although the clinical features and natural history of UC in the elderly have many similarities with UC in the non-elderly population, age-specific concerns including comorbidities, immunological dysfunction, and polypharmacy make the diagnosis and management of elderly UC challenging compared to UC in non-elderly patients. Based on increasing data related to elderly UC patients from Japan, as well as other countries, we reviewed the epidemiology, clinical course, differential diagnosis, management of comorbidities, surveillance, medical therapy, and surgery of UC in the elderly.
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Affiliation(s)
- Masaaki Higashiyama
- 0000 0004 0374 0880grid.416614.0Department of Internal Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513 Japan
| | - Akira Sugita
- 0000 0004 0377 5418grid.417366.1Inflammatory Bowel Disease Center, Yokohama Municipal Citizen’s Hospital, Yokohama, Kanagawa Japan
| | - Kazutaka Koganei
- 0000 0004 0377 5418grid.417366.1Inflammatory Bowel Disease Center, Yokohama Municipal Citizen’s Hospital, Yokohama, Kanagawa Japan
| | - Kenji Wanatabe
- 0000 0000 9142 153Xgrid.272264.7Department of Intestinal Inflammation Research, Hyogo College of Medicine, Nishinomiya, Hyogo Japan
| | - Yoko Yokoyama
- 0000 0000 9142 153Xgrid.272264.7Department of Intestinal Inflammation Research, Hyogo College of Medicine, Nishinomiya, Hyogo Japan
| | - Motoi Uchino
- 0000 0000 9142 153Xgrid.272264.7Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo Japan
| | - Masakazu Nagahori
- 0000 0001 1014 9130grid.265073.5Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Makoto Naganuma
- 0000 0004 1936 9959grid.26091.3cDivision of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shigeki Bamba
- 0000 0000 9747 6806grid.410827.8Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Shiga Japan
| | - Shingo Kato
- 0000 0001 2216 2631grid.410802.fDepartment of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Ken Takeuchi
- 0000 0000 9290 9879grid.265050.4Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Centre, Sakura, Chiba Japan
| | - Teppei Omori
- 0000 0001 0720 6587grid.410818.4Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Tomohisa Takagi
- 0000 0001 0667 4960grid.272458.eMolecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satohiro Matsumoto
- 0000000123090000grid.410804.9Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsuo Nagasaka
- 0000 0004 1761 798Xgrid.256115.4Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Aichi Japan
| | - Shintaro Sagami
- 0000 0004 1758 5965grid.415395.fCenter for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Kazuya Kitamura
- 0000 0004 0615 9100grid.412002.5Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Ishikawa Japan
| | - Takehiko Katsurada
- 0000 0001 2173 7691grid.39158.36Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido Japan
| | - Ken Sugimoto
- grid.505613.4First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka Japan
| | - Noritaka Takatsu
- grid.413918.6Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan
| | - Masayuki Saruta
- 0000 0001 0661 2073grid.411898.dDivision of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Toshiyuki Sakurai
- 0000 0001 0661 2073grid.411898.dDivision of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazuhiro Watanabe
- 0000 0001 2248 6943grid.69566.3aDepartment of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi Japan
| | - Shiro Nakamura
- 0000 0000 9142 153Xgrid.272264.7Department of Intestinal Inflammation Research, Hyogo College of Medicine, Nishinomiya, Hyogo Japan
| | - Yasuo Suzuki
- 0000 0000 9290 9879grid.265050.4Inflammatory Bowel Disease Center, Toho University Sakura Medical Centre, Sakura, Chiba Japan
| | - Ryota Hokari
- 0000 0004 0374 0880grid.416614.0Department of Internal Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513 Japan
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Abstract
PURPOSE OF REVIEW Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients undergoing colectomy to maintain intestinal continuity. Earlier studies have suggested that outcomes are worse in elderly patients who underwent IPAA. However, more recent reports have shown that IPAA outcomes in the elderly are comparable to younger patients. We review the recent medical literature regarding outcomes and treatments for common complications in elderly IPAA patients. RECENT FINDINGS Compared to younger patients, IPAA in the elderly is not associated with increased major surgical complications, but is associated with increased length of stay and re-admission rate for dehydration in older patients. Rates of fecal incontinence after IPAA were similar between younger and older patients. Sacral nerve stimulation has shown early promise as a possible treatment for fecal incontinence after IPAA, but more research is needed. Pouchitis is a common complication, and antibiotics remain first-line treatment options. Other treatment options include mesalamines, steroids, immunomodulators, and biologics. The efficacy of newer biologics such as vedolizumab and ustekinumab has been reported, but more data is needed. IPAA is safe in the elderly with high self-reported patient satisfaction. However, the elderly IPAA patient warrants special consideration regarding outcomes and management.
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Arnott I, Rogler G, Halfvarson J. The Management of Inflammatory Bowel Disease in Elderly: Current Evidence and Future Perspectives. Inflamm Intest Dis 2018; 2:189-199. [PMID: 30221146 DOI: 10.1159/000490053] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/10/2018] [Indexed: 12/11/2022] Open
Abstract
Data on the elderly population with inflammatory bowel disease (IBD) are scarce, as this population is normally excluded from clinical trials. With an ageing population and an overall increasing prevalence of IBD; the incidence of IBD in elderly is rising. Comorbidities, wide differential diagnosis and polypharmacy make the diagnosis and management of the disease in elderly more challenging compared to that in younger adults. The knowledge of specific requirements for the management and treatment of IBD in advanced age may help in the framing of the definition of the appropriate care of this patient group. This manuscript reviews the most recent knowledge in the epidemiology, diagnosis and management of IBD in this population.
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Affiliation(s)
- Ian Arnott
- Gastrointestinal Unit, Western General Hospital, Edinburgh, United Kingdom
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Zangenberg MS, Horesh N, Kopylov U, El-Hussuna A. Preoperative optimization of patients with inflammatory bowel disease undergoing gastrointestinal surgery: a systematic review. Int J Colorectal Dis 2017; 32:1663-1676. [PMID: 29051981 DOI: 10.1007/s00384-017-2915-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical management of inflammatory bowel disease (IBD) is a challenging task. The aim of preoperative optimization (PO) is to decrease the risk of complications and reduce the length of postoperative stay. The aim of this study was to review and grade the available evidence, attain clear recommendations, and point out potential future research. METHODS Studies were identified from electronic databases (PubMed, Embase, and Cochrane Library) and scanning reference lists in relevant papers. English-written studies examining PO in adult patients with IBD were included. Eight PO factors were investigated. RESULTS Management of IBD is a multidisciplinary task. Steroid withdrawal is recommended while steroid stress dose is not recommended. Thiopurines appear to be safe, but it may be prudent to plan the procedure remotely from the last dose of an anti-TNF agent. Nutritional risk screening is recommended to unveil and correct any malnutrition. Thrombosis prophylaxis prior to surgery is well supported by evidence while extended 4-week prophylaxis needs further research. Percutaneous ultrasound or CT-guided drainage for intra-abdominal abscesses is recommended, but it is unclear for how long supplementary antibiotics (ABs) should be used. Oral AB 24 h prior to open surgery might improve outcome if given as complementary to IV perioperative AB. Mechanical bowel preparation is not supported by evidence. Comorbidities must be treated accordingly prior to surgical intervention. Smoking cessation can be beneficial for wound healing. CONCLUSION Multimodel PO intervention in IBD patients is recommended.
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Affiliation(s)
| | - Nir Horesh
- Department of Surgery, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark.
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Surgical Rates for Crohn's Disease are Decreasing: A Population-Based Time Trend Analysis and Validation Study. Am J Gastroenterol 2017; 112:1840-1848. [PMID: 29087396 PMCID: PMC5729339 DOI: 10.1038/ajg.2017.394] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/10/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Temporal changes for intestinal resections for Crohn's disease (CD) are controversial. We validated administrative database codes for CD diagnosis and surgery in hospitalized patients and then evaluated temporal trends in CD surgical resection rates. METHODS First, we validated International Classification of Disease (ICD)-10-CM coding for CD diagnosis in hospitalized patients and Canadian Classification of Health Intervention coding for surgical resections. Second, we used these validated codes to conduct population-based surveillance between fiscal years 2002 and 2010 to identify adult CD patients undergoing intestinal resection (n=981). Annual surgical rate was calculated by dividing incident surgeries by estimated CD prevalence. Time trend analysis was performed and annual percent change (APC) with 95% confidence intervals (CI) in surgical resection rates were calculated using a generalized linear model assuming a Poisson distribution. RESULTS In the validation cohort, 101/104 (97.1%) patients undergoing surgery and 191/200 (95.5%) patients admitted without surgery were confirmed to have CD on chart review. Among the 116 administrative database codes for surgical resection, 97.4% were confirmed intestinal resections on chart review. From 2002 to 2010, the overall CD surgical resection rate was 3.8 resections per 100 person-years. During the study period, rate of surgery decreased by 3.5% per year (95% CI: -1.1%, -5.8%), driven by decreasing emergent operations (-10.1% per year (95% CI: -13.4%, -6.7%)) whereas elective surgeries increased by 3.7% per year (95% CI: 0.1%, 7.3%). CONCLUSIONS Overall surgical resection rates in CD are decreasing, but a paradigm shift has occurred whereby elective operations are now more commonly performed than emergent surgeries.
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Chronic comorbidities associated with inflammatory bowel disease: prevalence and impact on healthcare costs in Switzerland. Eur J Gastroenterol Hepatol 2017; 29:916-925. [PMID: 28471826 DOI: 10.1097/meg.0000000000000891] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Inflammatory bowel disease (IBD) was shown to be associated with a variety of chronic comorbidities. We aimed to evaluate the frequency of 21 chronic conditions and compared frequencies in IBD and non-IBD populations. Further, healthcare costs of those (additional) chronic conditions were calculated. PATIENTS AND METHODS A total of 4791 IBD patients, who were insured at Helsana Insurance Group in 2014, were compared with 1 114 638 individuals without IBD. Entropy balancing was performed to create balanced samples. Chronic conditions were identified by means of the updated Pharmacy-based Cost Group model. Multivariate log-transformed linear regression modeling was performed to estimate the effect of the morbidity status (non-IBD +none, +1, +2, and +3 or more chronic conditions) on the healthcare costs. RESULTS Overall, 78% of IBD patients had at least one comorbidity, with a median of three comorbidities. Largest differences between individuals with and without IBD were found for rheumatologic conditions, acid-related disorders, pain, bone diseases, migraines, cancer, and iron-deficiency anemia, whereas no significant differences between the two groups were found for diabetes, dementia, hyperlipidemia, glaucoma, gout, HIV, psychoses, and Parkinson's disease after adjustments for a variety of covariates. Each increase in the morbidity status led to increased healthcare costs; rheumatologic conditions, acid-related disorders, and pain as the most frequent comorbidities more than doubled total costs in IBD patients. CONCLUSION We found a considerably high prevalence of concomitant chronic diseases in IBD patients. This was associated with considerably higher healthcare costs, especially in the outpatient setting.
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Clinical Predictors of the Risk of Early Colectomy in Ulcerative Colitis: A Population-based Study. Inflamm Bowel Dis 2017; 23:1272-1277. [PMID: 28719540 DOI: 10.1097/mib.0000000000001211] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND A subset of patients with ulcerative colitis (UC) will require colectomy within a few years of diagnosis. Thus, our aim was to determine the clinical predictors of early colectomy among patients with UC who are hospitalized with an acute flare. METHODS Using population-based surveillance (1996-2009), all adults (≥18 years) hospitalized for UC within 3 years of diagnosis (n = 489) were identified. The primary outcome was a colectomy within 3 years of diagnosis. All medical charts were reviewed. A logistic regression model evaluated clinical variables that predicted colectomy within 3 years of diagnosis, and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported. RESULTS Among patients admitted to hospital with UC within 3 years of diagnosis, 57.7% underwent colectomy, with the odds of colectomy decreasing by 12% per year. Early colectomy was more likely among patients aged 35 to 64 years versus 18 to 34 years (OR 2.18 [95% CI, 1.27-3.74]), males (OR 2.03 [95% CI, 1.24-3.34]), those with pancolitis (OR 5.38 [95% CI, 3.20-9.06]), and living in rural areas (OR 2.81 [95% CI, 1.49-5.29]). Prescription of infliximab before hospitalization increased odds of surgery (OR 5.12 [95% CI, 1.36-19.30]). CONCLUSIONS Patients hospitalized for UC have a high risk of early colectomy. This is particularly true in middle-aged men, those living in rural areas, and those without response to infliximab.
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Ananthakrishnan AN, Donaldson T, Lasch K, Yajnik V. Management of Inflammatory Bowel Disease in the Elderly Patient: Challenges and Opportunities. Inflamm Bowel Dis 2017; 23:882-893. [PMID: 28375885 PMCID: PMC5687915 DOI: 10.1097/mib.0000000000001099] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The population of older patients with inflammatory bowel disease (IBD) continues to grow, partly reflecting the aging global population in general. The debilitating effects of IBD compound age-related decrements in health and functional capacity, and make the medical management of older patients with Crohn's disease and ulcerative colitis distinctly challenging to clinicians. Here, we review the recent literature describing the pharmacologic management of IBD in this population, with focus on the safety, tolerability, and efficacy of common treatment options, such as steroids, immunomodulators, tumor necrosis factor-α antagonists, and integrin antagonists; surgical interventions in older patients are also discussed. Few studies have systematically and prospectively evaluated the clinical challenges in the medical management of IBD in this patient population, leaving a limited evidence base to which clinicians can turn to for guidance. Treatment patterns may thus be suboptimal. For example, prolonged steroid use in the elderly was found to be common, causing significant morbidity from side effects in a particularly vulnerable population. Finally, within the context of a limited evidence base, we discuss common treatment scenarios to define the parameters within which physicians can individualize care for older patients with IBD. Overall, older patients with IBD are at higher risk of adverse events and less treatment responsiveness compared with younger patients, underscoring the need for future studies to fully characterize appropriate treatment courses for this population.
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Affiliation(s)
| | | | - Karen Lasch
- Takeda Pharmaceuticals USA, Inc., Deerfield, IL, USA
| | - Vijay Yajnik
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Kaplan GG, Ng SC. Globalisation of inflammatory bowel disease: perspectives from the evolution of inflammatory bowel disease in the UK and China. Lancet Gastroenterol Hepatol 2016; 1:307-316. [PMID: 28404201 DOI: 10.1016/s2468-1253(16)30077-2] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/20/2016] [Accepted: 07/28/2016] [Indexed: 02/07/2023]
Abstract
The UK and China provide unique historical perspectives on the evolution of the incidence of inflammatory bowel disease, which might provide insight into its pathogenesis. Historical records from the UK document the emergence of ulcerative colitis during the mid-1800s, which was later followed by the recognition of Crohn's disease in 1932. During the second half of the 20th century, the incidence of inflammatory bowel disease rose dramatically in high-income countries. Globalisation at the turn of the 21st century led to rapid economic development of newly industrialised countries such as China. In China, the modernisation of society was accompanied by the recognition of a sharp rise in the incidence of inflammatory bowel disease. The prevalence of inflammatory bowel disease is expected to continue to rise in high-income countries and is also likely to accelerate in the developing world. An understanding of the shared and different environmental determinants underpinning the pathogenesis of inflammatory bowel disease in western and eastern countries is essential to implement interventions that will blunt the rising global burden of inflammatory bowel disease.
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Affiliation(s)
- Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, LKS Institute of Health Science, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
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Raghu Subramanian C, Triadafilopoulos G. Care of inflammatory bowel disease patients in remission. Gastroenterol Rep (Oxf) 2016; 4:261-271. [PMID: 27899522 PMCID: PMC5193066 DOI: 10.1093/gastro/gow032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 08/21/2016] [Accepted: 09/04/2016] [Indexed: 12/11/2022] Open
Abstract
Inflammatory bowel disease (IBD) comprises two distinct conditions: ulcerative colitis and Crohn’s disease, both of which are chronic, relapsing disorders carrying significant morbidity, mortality and healthcare costs. With growing attention to coordinated healthcare for patients with chronic systemic diseases, this review focuses on the care of IBD patients in remission, their concerns, quality of life, follow-up, the role of primary care physicians and the IBD-specific aspects of long-term care. We did an extensive PubMed search for articles pertaining to IBD patients in remission and, along with the authors’ experience, formulated a comprehensive review. The difficulties faced by IBD patients in remission include but are not limited to education and employment concerns, psychosocial issues, problems related to health insurance, nutrition, fertility and infections. This review also addresses newer treatment modalities, the debatable effects of smoking on IBD and the importance of vaccination. IBD in remission can be a challenge due to its multifaceted nature; however, with a coordinated approach by gastroenterologists and other involved practitioners, several of these issues can be addressed.
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In-hospital weekend outcomes in patients diagnosed with bleeding gastroduodenal angiodysplasia: a population-based study, 2000 to 2011. Gastrointest Endosc 2016; 84:416-23. [PMID: 26972023 DOI: 10.1016/j.gie.2016.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 02/26/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS GI angiodysplastic (GIAD) lesions are an important cause of blood loss throughout the GI tract, particularly in elderly persons. The aim of this study was to determine whether mortality rates in patients with GIAD were higher for weekend compared with weekday hospital admissions. METHODS We performed a retrospective study using the National Inpatient Sample database from 2000 to 2011 including inpatients with an International Classification of Diseases, Ninth Revision, Clinical Modification code for gastrointestinal GIAD (code 537.82 or 537.83). We assessed rates of delayed endoscopy (examinations performed >24 hours after admission), intensive care unit (ICU) admissions, and in-hospital mortality rates. Bivariate and multivariate logistic regression analyses were performed to identify risk factors for mortality. RESULTS There were 85,971 discharges for GIAD between 2000 and 2011, of which 69,984 (81%) were weekday hospital admissions and 15,987 (19%) were weekend admissions. Patients with weekend versus weekday admissions were more likely to undergo delayed endoscopic examination (35% vs 26%, P ≤ .0001). Mortality rates were higher for patients with weekend admissions (2% vs 1%, P = .0002). The adjusted odds ratio (aOR) for inpatient mortality associated with weekend admissions was elevated (2.4; 95% confidence interval [CI], 1.5-3.9; P = .0005). Rates of delayed endoscopic examinations were lower in patients with higher socioeconomic status (aOR = 0.77; 95% CI, 0.68-0.88). ICU admission rates were higher for weekend compared with weekday admissions (8% vs 6%, P = .004). The presence of a delayed endoscopic examination was associated with an increased length of stay of 1.3 days (95% CI, 1.2-1.4 days). CONCLUSIONS Weekend admissions for angiodysplasia were associated with higher odds of mortality, ICU admissions, higher rates of delayed endoscopic procedures, longer lengths of stay, and higher hospital charges.
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Ahmed O, Nguyen GC. Therapeutic challenges of managing inflammatory bowel disease in the elderly patient. Expert Rev Gastroenterol Hepatol 2016; 10:1005-10. [PMID: 27087144 DOI: 10.1080/17474124.2016.1179579] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The rapid advancements in the management of inflammatory bowel disease (IBD) have given clinicians many new therapeutic options. The prevalence of IBD in the elderly is increasing, and the role of these therapeutic agents in the elderly population with IBD is still uncertain. AREAS COVERED In this review, we will highlight the challenges facing clinicians managing IBD in the elderly, the considerations to take when starting new medications, when to consider for surgical referral, the potential pitfalls to avoid, and the non-pharmacological management measures that clinicians should be aware of. Expert Commentary: The safety of prescribing new IBD medications in elderly patients must be taken into consideration. Managing comorbidities, polypharmacy, functional status and drug interactions can also be challenging and requires an individualized approach.
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Affiliation(s)
- Osman Ahmed
- a Mount Sinai Hospital Centre for Inflammatory Bowel Disease , University of Toronto , Toronto , Canada
| | - Geoffrey C Nguyen
- a Mount Sinai Hospital Centre for Inflammatory Bowel Disease , University of Toronto , Toronto , Canada
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John ES, Katz K, Saxena M, Chokhavatia S, Katz S. Management of Inflammatory Bowel Disease in the Elderly. ACTA ACUST UNITED AC 2016; 14:285-304. [PMID: 27387455 DOI: 10.1007/s11938-016-0099-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT A substantial and growing proportion of patients with inflammatory bowel disease (IBD) are elderly, and these patients require tailored treatment strategies. However, significant challenges exist in the management of this population due to the paucity of data. Establishing the initial diagnosis and assessing the etiology of future symptoms and flares can be challenging as several other prevalent diseases can masquerade as IBD, such as ischemic colitis, diverticular disease, and infectious colitis. Important pharmacologic considerations include reduced glomerular filtration rate and drug-drug interactions in the elderly. No drug therapy is absolutely contraindicated in this population; however, special risk and benefit assessments should be made. Older patients are more susceptible to side effects of steroids such as delirium, fractures, and cataracts. Budesonide can be an appropriate alternative for mild to moderate ulcerative colitis (UC) or Crohn's disease (CD) as it has limited systemic absorption. Pill size and quantity, nephrotoxicity, and difficulty of administration of rectal preparations should be considered with 5-aminosalicylic (5-ASA) therapy. Biologics are very effective, but modestly increase the risk of infection in a susceptible group. Based on their mechanisms, integrin receptor antagonists (e.g., vedolizumab) may reduce these risks. Use of antibiotics for anorectal or fistulizing CD or pouchitis in UC increases the risk of Clostridium difficile infection. Pre-existing comorbidities, functional status, and nutrition are important indicators of surgical outcomes. Morbidity and mortality are increased among IBD patients undergoing surgery, often due to postoperative complications or sepsis. Elderly adults with IBD, particularly UC, have very high rates of venous thromboembolism (VTE). Colonoscopy appears safe, but the optimal surveillance interval has not been well defined. Should the octogenarian, nonagenarian, and centurion undergo colonoscopy? The length of surveillance should likely account for the individual's overall life expectancy. Specific health maintenance should emphasize administering non-live vaccines to patients on thiopurines or biologics and regular skin exams for those on thiopurines. Smoking cessation is crucial to overall health and response to medical therapy, even among UC patients. This article will review management of IBD in the elderly.
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Affiliation(s)
- Elizabeth S John
- Department of Internal Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA. .,Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA.
| | - Kristina Katz
- Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Mark Saxena
- Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Sita Chokhavatia
- Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Seymour Katz
- New York University School of Medicine, 1000 Northern Blvd, Great Neck, NY, 11020, USA
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Jawitz OK, Wang Z, Boffa DJ, Detterbeck FC, Blasberg JD, Kim AW. The differential impact of preoperative comorbidity on perioperative outcomes following thoracoscopic and open lobectomies. Eur J Cardiothorac Surg 2016; 51:169-174. [DOI: 10.1093/ejcts/ezw239] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 05/25/2016] [Accepted: 06/06/2016] [Indexed: 11/13/2022] Open
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Anti-TNF Therapy Within 2 Years of Crohn's Disease Diagnosis Improves Patient Outcomes: A Retrospective Cohort Study. Inflamm Bowel Dis 2016; 22:870-9. [PMID: 26818419 DOI: 10.1097/mib.0000000000000679] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Although biological agents targeting tumor necrosis factor (TNF) alpha are effective in the management of Crohn's disease (CD), use of anti-TNF agents is often delayed until after failure of other treatment modalities, resulting in potentially long delays between diagnosis and initiation of infliximab or adalimumab. We aim to determine if early treatment with anti-TNF agents reduces the rate of surgical resection and clinical secondary loss of response in CD patients. METHODS A retrospective cohort study was conducted evaluating CD outpatients who were primary responders to anti-TNF therapy, on a maintenance regimen with infliximab or adalimumab from 2003 to 2014. Patients were stratified by time to first dose of anti-TNF therapy; early initiation was defined as starting anti-TNF therapy within 2 years of diagnosis. The primary outcome was occurrence of surgical resection or clinical secondary loss of response requiring dose escalation. Kaplan-Meier analysis was used to assess time to the primary outcomes. RESULTS One hundred ninety CD patients met inclusion criteria (100 infliximab, 90 adalimumab). Median follow-up duration was 154.4 weeks (inter quartile range, 106.4-227.8). Fifty-three patients (27.9%) had early initiation of anti-TNF therapy. Fewer patients in the early initiation group required surgery (5.7% versus 30.7%, P < 0.001) or experienced clinical secondary loss of response (45.3% versus 67.2%, P = 0.006). In Kaplan-Meier analysis, early initiation of anti-TNF therapy prolonged time to surgery (P = 0.001) and secondary loss of response (P = 0.006). CONCLUSIONS In CD patients, early initiation of infliximab or adalimumab within the first 2 years of diagnosis reduces the rate of surgery and secondary loss of response requiring dose escalation.
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Shi HY, Chan FKL, Leung WK, Li MKK, Leung CM, Sze SF, Ching JYL, Lo FH, Tsang SWC, Shan EHS, Mak LY, Lam BCY, Hui AJ, Wong SH, Wong MTL, Hung IFN, Hui YT, Chan YK, Chan KH, Loo CK, Tong RWH, Chow WH, Ng CKM, Lao WC, Harbord M, Wu JCY, Sung JJY, Ng SC. Natural History of Elderly-onset Ulcerative Colitis: Results from a Territory-wide Inflammatory Bowel Disease Registry. J Crohns Colitis 2016; 10:176-85. [PMID: 26512132 DOI: 10.1093/ecco-jcc/jjv194] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/07/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Data on the natural history of elderly-onset ulcerative colitis [UC] are limited. We aimed to investigate clinical features and outcomes of patients with elderly-onset UC. METHODS Patients with a confirmed diagnosis of UC between 1981 and 2013, from 13 hospitals within a territory-wide Hong Kong Inflammatory Bowel Disease Registry, were included. Clinical features and outcomes of elderly-onset patients, defined as age ≥ 60 years at diagnosis, were compared with those of non-elderly-onset disease [< 60 years at diagnosis]. RESULTS We identified 1225 patients, of whom 12.8% [157/1225; 56.1% male] had elderly-onset UC. Median duration of follow-up was 11 years [interquartile range, 6-16 years]. Age-specific incidence of elderly-onset UC increased from 0.1 per 100000 persons before 1991 to 1.3 per 100000 persons after 2010. There were more ex-smokers [32.2% vs. 12.2%, p < 0.001] and higher proportion of comorbidities [p < 0.001] in elderly-onset than non-elderly-onset patients. Disease extent, corticosteroids, immunosuppressants use, and colectomy rates were similar between the two groups. Elderly-onset disease was an independent risk factor for cytomegalovirus infection [odds ratio 2.9, 95% confidence interval 1.6-5.2, p < 0.001]. More elderly-onset patients had Clostridium difficile infection [11.0% vs. 5.4%, p = 0.007], hospitalisation for UC exacerbation [50.6% vs. 41.8%, p = 0.037], colorectal cancer [3.2% vs. 0.9%, p = 0.033], all-cause mortality [7.0% vs. 1.0%, p < 0.001], and UC-related mortality [1.9% vs. 0.2%, p = 0.017] than non-elderly-onset patients. CONCLUSIONS Elderly-onset UC patients are increasing in number. These patients have higher risk of opportunistic infections, hospitalisation, colorectal cancer, and mortality than non-elderly-onset patients. Management and therapeutic strategies in this special group need careful attention.
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Affiliation(s)
- Hai Yun Shi
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Wai Keung Leung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Michael K K Li
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong
| | - Chi Man Leung
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Shun Fung Sze
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Jessica Y L Ching
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Fu Hang Lo
- Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong
| | | | - Edwin H S Shan
- Department of Medicine and Geriatrics, Caritas Medical Center, Hong Kong
| | - Lai Yee Mak
- Department of Medicine, North District Hospital, Hong Kong
| | - Belsy C Y Lam
- Department of Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong
| | - Aric J Hui
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Sai Ho Wong
- Department of Medicine, Yan Chai Hospital, Hong Kong
| | - Marc T L Wong
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - Ivan F N Hung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Yee Tak Hui
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Yiu Kay Chan
- Department of Medicine and Geriatrics, Caritas Medical Center, Hong Kong
| | - Kam Hon Chan
- Department of Medicine, North District Hospital, Hong Kong
| | - Ching Kong Loo
- Department of Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong
| | - Raymond W H Tong
- Department of Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong
| | - Wai Hung Chow
- Department of Medicine, Yan Chai Hospital, Hong Kong
| | - Carmen K M Ng
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - Wai Cheung Lao
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Marcus Harbord
- Department of Gastroenterology, Chelsea and Westminster Hospital, London, UK
| | - Justin C Y Wu
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Joseph J Y Sung
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
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Abstract
BACKGROUND Hospitalization costs for ulcerative colitis (UC) following the introduction of infliximab have not been evaluated. OBJECTIVE To study predictors of costs for UC patients who were hospitalized for a flare or colectomy. METHODS Population-based surveillance identified adults (≥18 years of age) admitted to hospital for UC flare or colectomy between 2001 and 2009 in the Calgary Health Zone (Alberta). Medical charts were reviewed and patients stratified into three admission types: responsive to inpatient medical therapy (n=307); emergent colectomy (n=227); and elective colectomy (n=208). The annual median cost with interquartile range (IQR) was calculated. Linear regression determined the effect of admission type on hospital charges after adjusting for age, sex, smoking, comorbidities, disease extent, medication use (eg, infliximab) and year. The adjusted cost increase was presented as the percent increase with 95% CIs. Joinpoint analysis assessed for an inflection point in hospital cost after the introduction of infliximab. RESULTS Median hospitalization cost for UC flare, emergent colectomy and elective colectomy, respectively, were: $5,499 (IQR $3,374 to $8,904), $23,698 (IQR $17,981 to $32,385) and $14,316 (IQR $11,932 to $18,331). Adjusted hospitalization costs increased approximately 6.0% annually (95% CI 4.5% to 7.5%). Adjusted costs were higher for patients who underwent an elective colectomy (percent increase cost 179.8% [95% CI 151.6% to 211.1%]) or an emergent colectomy (percent increase cost 211.1% [95% CI 183.2% to 241.6%]) than medically responsive patients. Infliximab in hospital was an independent predictor of increased costs (percent increase cost 69.5% [95% CI 49.2% to 92.5%]). No inflection points were identified. CONCLUSION Hospitalization costs for UC increased due to colectomy and infliximab.
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Singh S, Al-Darmaki A, Frolkis AD, Seow CH, Leung Y, Novak KL, Ghosh S, Eksteen B, Panaccione R, Kaplan GG. Postoperative Mortality Among Patients With Inflammatory Bowel Diseases: A Systematic Review and Meta-analysis of Population-Based Studies. Gastroenterology 2015; 149:928-37. [PMID: 26055136 DOI: 10.1053/j.gastro.2015.06.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 05/02/2015] [Accepted: 06/01/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS There have been varying reports of mortality after intestinal resection for the inflammatory bowel diseases (IBDs). We performed a systematic review and meta-analysis of population-based studies to determine postoperative mortality after intestinal resection in patients with IBD. METHODS We searched Medline, EMBASE, and PubMed, from 1990 through 2015, to identify 18 articles and 3 abstracts reporting postoperative mortality among patients with IBD. The studies included 67,057 patients with ulcerative colitis (UC) and 75,971 patients with Crohn's disease (CD), from 15 countries. Mortality estimates stratified by emergent and elective surgeries were pooled separately for CD and UC using a random-effects model. To assess changes over time, the start year of the study was included as a continuous variable in a meta-regression model. RESULTS In patients with UC, postoperative mortality was significantly lower among patients who underwent elective (0.7%; 95% confidence interval [CI], 0.6%-0.9%) vs emergent surgery (5.3%; 95% CI, 3.8%-7.4%). In patients with CD, postoperative mortality was significantly lower among patients who underwent elective (0.6%; 95% CI, 0.2%-1.7%) vs emergent surgery (3.6%; 95% CI, 1.8%-6.9%). Postoperative mortality did not differ for elective (P = .78) or emergent (P = .31) surgeries when patients with UC were compared with patients with CD. Postoperative mortality decreased significantly over time for patients with CD (P < .05) but not UC (P = .21). CONCLUSIONS Based on a systematic review and meta-analysis, postoperative mortality was high after emergent, but not elective, intestinal resection in patients with UC or CD. Optimization of management strategies and more effective therapies are necessary to avoid emergent surgeries.
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Affiliation(s)
- Sunny Singh
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Ahmed Al-Darmaki
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra D Frolkis
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Yvette Leung
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Subrata Ghosh
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Bertus Eksteen
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada.
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Shabanzadeh DM, Sørensen LT. Alcohol Consumption Increases Post-Operative Infection but Not Mortality: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2015; 16:657-68. [PMID: 26244748 DOI: 10.1089/sur.2015.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Alcohol consumption causes multiple comorbidities with potentially negative outcome after operations. The aims are to study the association between alcohol consumption and post-operative non-surgical site infections and mortality and to determine the impact of peri-operative interventions. METHODS MEDLINE, Embase, and The Cochrane Library were searched systematically. Observational studies reporting patients with a defined amount of alcohol consumption and randomized controlled trials (RCTs) aimed at reducing outcomes were included. Meta-analyses were performed separately for observational studies and RCTs. RESULTS Thirteen observational studies and five RCTs were identified. Meta-analyses of observational studies showed more infections in those consuming more than two units of alcohol per day compared with drinking less in both unadjusted and adjusted data. No association between alcohol consumption and mortality was found. Meta-analyses of RCTs showed that interventions reduce infections but not mortality in patients with alcohol abuse. CONCLUSIONS Consumption of more than two units of alcohol per day increases post-operative non-surgical site infections. Alcohol-refraining interventions in patients with high daily alcohol consumption appear to reduce infections. The impact in patients with lesser intake is unknown. Further studies are needed.
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Affiliation(s)
| | - Lars Tue Sørensen
- Digestive Disease Center, Bispebjerg University Hospital , Copenhagen, Denmark
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Challenges in the Diagnosis and Management of Inflammatory Bowel Disease in the Elderly. ACTA ACUST UNITED AC 2015; 13:275-86. [DOI: 10.1007/s11938-015-0059-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Kaplan GG, Lim A, Seow CH, Moran GW, Ghosh S, Leung Y, Debruyn J, Nguyen GC, Hubbard J, Panaccione R. Colectomy is a risk factor for venous thromboembolism in ulcerative colitis. World J Gastroenterol 2015; 21:1251-1260. [PMID: 25632199 PMCID: PMC4306170 DOI: 10.3748/wjg.v21.i4.1251] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 08/05/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare venous thromboembolism (VTE) in hospitalized ulcerative colitis (UC) patients who respond to medical management to patients requiring colectomy.
METHODS: Population-based surveillance from 1997 to 2009 was used to identify all adults admitted to hospital for a flare of UC and those patients who underwent colectomy. All medical charts were reviewed to confirm the diagnosis and extract clinically relevant information. UC patients were stratified by: (1) responsive to inpatient medical therapy (n = 382); (2) medically refractory requiring emergent colectomy (n = 309); and (3) elective colectomy (n = 329). The primary outcome was the development of VTE during hospitalization or within 6 mo of discharge. Heparin prophylaxis to prevent VTE was assessed. Logistic regression analysis determined the effect of disease course (i.e., responsive to medical therapy, medically refractory, and elective colectomy) on VTE after adjusting for confounders including age, sex, smoking, disease activity, comorbidities, extent of disease, and IBD medications (i.e., corticosteroids, mesalamine, azathioprine, and infliximab). Point estimates were presented as odds ratios (OR) with 95%CI.
RESULTS: The prevalence of VTE among patients with UC who responded to medical therapy was 1.3% and only 16% of these patients received heparin prophylaxis. In contrast, VTE was higher among patients who underwent an emergent (8.7%) and elective (4.9%) colectomy, despite greater than 90% of patients receiving postoperative heparin prophylaxis. The most common site of VTE was intra-abdominal (45.8%) followed by lower extremity (19.6%). VTE was diagnosed after discharge from hospital in 16.7% of cases. Elective (adjusted OR = 3.69; 95%CI: 1.30-10.44) and emergent colectomy (adjusted OR = 5.28; 95%CI: 1.93-14.45) were significant risk factors for VTE as compared to medically responsive UC patients. Furthermore, the odds of a VTE significantly increased across time (adjusted OR = 1.10; 95%CI: 1.01-1.20). Age, sex, comorbidities, disease extent, disease activity, smoking, corticosteroids, mesalamine, azathioprine, and infliximab were not independently associated with the development of VTE.
CONCLUSION: VTE was associated with colectomy, particularly, among UC patients who failed medical management. VTE prophylaxis may not be sufficient to prevent VTE in patients undergoing colectomy.
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Characterization of inflammatory bowel disease in elderly patients: A review of epidemiology, current practices and outcomes of current management strategies. Can J Gastroenterol Hepatol 2015; 29:327-33. [PMID: 26069892 PMCID: PMC4578457 DOI: 10.1155/2015/136960] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The authors review and summarize the current literature regarding the epidemiology, clinical presentation and management of inflammatory bowel disease (IBD) in elderly patients. Among elderly patients, the incidence of ulcerative colitis (UC) is higher than that of Crohn disease (CD). Elderly patients with a new diagnosis of UC are more likely to be male and have left-sided colitis. Elderly patients with a new diagnosis of CD are more likely to be female and have colonic disease. Conversely, increasing age at diagnosis has been associated with a lower likelihood of having any of a family history of IBD, perianal disease in CD and extraintestinal manifestations. Although response to drug therapies appears to be similar in elderly patients and younger individuals, the elderly are more likely to receive 5-aminosalicylic acid agents, and less likely to receive immunomodulators and biologics. Corticosteroid use in the elderly is comparable with use in younger individuals. The rates of surgical intervention appear to be lower for elderly CD patients but not elderly UC patients. Elderly individuals with UC are more likely to need urgent colectomy, which is associated with an increased mortality rate. Elective surgery is associated with similar outcomes among the elderly and young patients with IBD. Therefore, the use of immunomodulators and biologics, and earlier consideration of elective surgery for medically refractory disease in elderly patients with IBD, should be emphasized and further evaluated to prevent complications of chronic corticosteroid(s) use and to prevent emergency surgery.
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Soon IS, deBruyn JCC, Hubbard J, Wrobel I, Sauve R, Sigalet DL, Kaplan GG. Rising post-colectomy complications in children with ulcerative colitis despite stable colectomy rates in United States. J Crohns Colitis 2014; 8:1417-26. [PMID: 24934481 DOI: 10.1016/j.crohns.2014.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/19/2014] [Accepted: 05/11/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS In children with ulcerative colitis, data on temporal colectomy trends and in-hospital post-colectomy complications are limited. Thus, we evaluated time trends in colectomy rates and post-colectomy complications in children with ulcerative colitis. METHODS We identified all children (≤18years) with a diagnosis code of ulcerative colitis (ICD-9: 556.X) and a procedure code of colectomy (ICD-9: 45.8 and 45.7) in the Kids' Inpatient Database for 1997, 2000, 2003, 2006 and 2009. The incidence of colectomies for pediatric ulcerative colitis was calculated and Poisson regression analysis was performed to evaluate the change in colectomy rates. In-hospital postoperative complication rates were assessed and predictors for postoperative complications were evaluated using multivariate logistic regression. RESULTS The annual colectomy rate in pediatric ulcerative colitis was 0.43 per 100,000person-years, which was stable throughout the study period (P>.05). Postoperative complications were experienced in 25%, with gastrointestinal (13%) and infectious (9.3%) being the most common. Postoperative complication rates increased significantly by an annual rate of 1.1% from 1997 to 2009 (P=.01). However, other independent predictors of postoperative complications were not identified. Patients with postoperative complications had significantly longer median length of stay (14.3days vs 8.2days; P<.001) and higher median hospital charges per patient (US $81,567 vs US $55,461; P<.001) compared to those without complications. CONCLUSION Colectomy rates across the United States in children with ulcerative colitis have remained stable between 1997 and 2009; however, in-hospital postoperative complication rates have increased.
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Affiliation(s)
- Ing Shian Soon
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - James Hubbard
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Iwona Wrobel
- Department of Paediatrics, University of Calgary, Calgary, Canada
| | - Reg Sauve
- Department of Community Health Sciences, University of Calgary, Calgary, Canada; Department of Paediatrics, University of Calgary, Calgary, Canada
| | - David L Sigalet
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Gilaad G Kaplan
- Department of Community Health Sciences, University of Calgary, Calgary, Canada; Department of Medicine, University of Calgary, Calgary, Canada.
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Negrón ME, Barkema HW, Rioux K, De Buck J, Checkley S, Proulx MC, Frolkis A, Beck PL, Dieleman LA, Panaccione R, Ghosh S, Kaplan GG. Clostridium difficile infection worsens the prognosis of ulcerative colitis. Can J Gastroenterol Hepatol 2014; 28:373-80. [PMID: 25157528 PMCID: PMC4144455 DOI: 10.1155/2014/914303] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The impact of Clostridium difficile infections among ulcerative colitis (UC) patients is well characterized. However, there is little knowledge regarding the association between C difficile infections and postoperative complications among UC patients. OBJECTIVE To determine whether C difficile infection is associated with undergoing an emergent colectomy and experiencing postoperative complications. METHODS The present population-based case-control study identified UC patients admitted to Calgary Health Zone hospitals for a flare between 2000 and 2009. C difficile toxin tests ordered in hospital or 90 days before hospital admission were provided by Calgary Laboratory Services (Calgary, Alberta). Hospital records were reviewed to confirm diagnoses and to extract clinical data. Multivariate logistic regression analyses were performed among individuals tested for C difficile to examine the association between C difficile infection and emergent colectomy and diagnosis of any postoperative complications and, secondarily, an infectious postoperative complication. Estimates were presented as adjusted ORs with 95% CIs. RESULTS C difficile was tested in 278 (58%) UC patients and 6.1% were positive. C difficile infection was associated with an increased risk for emergent colectomy (adjusted OR 3.39 [95% CI 1.02 to 11.23]). Additionally, a preoperative diagnosis of C difficile was significantly associated with the development of postoperative infectious complications (OR 4.76 [95% CI 1.10 to 20.63]). CONCLUSION C difficile diagnosis worsened the prognosis of UC by increasing the risk of colectomy and postoperative infectious complications following colectomy. Future studies are needed to explore whether early detection and aggressive management of C difficile infection will improve UC outcomes.
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Affiliation(s)
- María E Negrón
- Alberta Inflammatory Bowel Disease Consortium, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Production Animal Health, Faculty of Veterinary Medicine, University of Calgary, Calgary
| | - Herman W Barkema
- Alberta Inflammatory Bowel Disease Consortium, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Production Animal Health, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Community Health Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary
| | - Kevin Rioux
- Alberta Inflammatory Bowel Disease Consortium, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary
| | - Jeroen De Buck
- Alberta Inflammatory Bowel Disease Consortium, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Production Animal Health, Faculty of Veterinary Medicine, University of Calgary, Calgary
| | - Sylvia Checkley
- Department of Ecosystem and Public Health, Faculty of Veterinary Medicine, University of Calgary, Calgary
| | | | - Alexandra Frolkis
- Alberta Inflammatory Bowel Disease Consortium, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Community Health Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary
| | - Paul L Beck
- Alberta Inflammatory Bowel Disease Consortium, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary
| | - Levinus A Dieleman
- Alberta Inflammatory Bowel Disease Consortium, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Medicine, Faculty of Medicine, University of Alberta, Edmonton, Alberta
| | - Remo Panaccione
- Alberta Inflammatory Bowel Disease Consortium, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary
| | - Subrata Ghosh
- Alberta Inflammatory Bowel Disease Consortium, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary
| | - Gilaad G Kaplan
- Alberta Inflammatory Bowel Disease Consortium, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Community Health Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary
- Correspondence: Dr Gilaad Kaplan, Teaching Research and Wellness Centre, 6D56, 3280 Hospital Drive Northwest, Calgary, Alberta T2N 4N1. Telephone 403-592-5015, fax 403-592-5090, e-mail
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Allareddy V, Rampa S, Nalliah RP, Allareddy V. Longitudinal discharge trends and outcomes after hospitalization for mouth cellulitis and Ludwig angina. Oral Surg Oral Med Oral Pathol Oral Radiol 2014; 118:524-31. [PMID: 25216950 DOI: 10.1016/j.oooo.2014.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 05/06/2014] [Accepted: 06/03/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Objective is to provide longitudinal discharge trends and hospitalization outcomes in patients hospitalized because of mouth cellulitis or Ludwig angina. METHODS Nationwide Inpatient Sample for years 2004 to 2010 was used. All hospitalizations with primary diagnosis of cellulitis or Ludwig angina were selected. Discharge trends were examined. RESULTS A total of 29,228 hospitalizations occurred as a result of mouth cellulitis/Ludwig angina; 55% of all hospitalizations were male patients; 68% were aged 21 to 60 years. Non-whites comprised close to 40%. The uninsured comprised 22.3%. Ninety-nine patients died in hospitals. The total hospitalization charges across the entire United States over the study period was $772.57 million. Factors associated with increased hospitalization charges included, age, co-morbid burden, insurance status, race, teaching status of hospital, and geographic location. CONCLUSIONS Uninsured non-whites, those with high co-morbid burden, and those aged 21 to 60 years tended to be hospitalized consistently over the study period.
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Affiliation(s)
- Veerasathpurush Allareddy
- Associate Professor, Department of Orthodontics, College of Dentistry, The University of Iowa, Iowa City, IA.
| | - Sankeerth Rampa
- Graduate student, Texas A and M University Health Science Center School of Rural Public Health, College Station, TX
| | - Romesh P Nalliah
- Instructor, Department of Global Health, Harvard School of Dental Medicine, Boston, MA
| | - Veerajalandhar Allareddy
- Assistant Professor, Department of Pediatric Critical Care, Case Western Reserve University School of Medicine, Cleveland, OH
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Abstract
As the global population ages, the number of older people (≥65 years) living with IBD is expected to increase. IBD therapeutics have advanced considerably over the past few decades with the introduction of multiple steroid-sparing agents as well as numerous clinical trials that have tested new therapeutic targets. However, the current paradigms for IBD management might not be directly translatable to older patients with IBD. Age-related factors such as immunodeficiency relative to younger patients, comorbidity, polypharmacy and diminished physical reserve directly or indirectly affect the natural history of their disease. This Review highlights how these age-associated variables can affect older patients with IBD and also illustrates the multiple gaps in our current knowledge of IBD in the elderly.
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Affiliation(s)
- Christina Y Ha
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 Medical Plaza, Suite 365C, Los Angeles, CA 90095, USA
| | - Seymour Katz
- Division of Gastroenterology, NYU Langone Medical Center, 1000 Northern Boulevard, Great Neck, NY 11021, USA
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Abstract
This review describes the history of U.S. government funding for surveillance programs in inflammatory bowel diseases (IBD), provides current estimates of the incidence and prevalence of IBD in the United States, and enumerates a number of challenges faced by current and future IBD surveillance programs. A rationale for expanding the focus of IBD surveillance beyond counts of incidence and prevalence, to provide a greater understanding of the burden of IBD, disease etiology, and pathogenesis, is provided. Lessons learned from other countries are summarized, in addition to potential resources that may be used to optimize a new form of IBD surveillance in the United States. A consensus recommendation on the goals and available resources for a new model for disease surveillance are provided. This new model should focus on "surveillance of the burden of disease," including (1) natural history of disease and (2) outcomes and complications of the disease and/or treatments.
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Yarur AJ, Abreu MT, Salem MS, Deshpande AR, Sussman DA. The impact of Hispanic ethnicity and race on post-surgical complications in patients with inflammatory bowel disease. Dig Dis Sci 2014; 59:126-34. [PMID: 23483313 DOI: 10.1007/s10620-013-2603-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 02/07/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Surgery for inflammatory bowel disease (IBD) is common and represents a large portion of the cost of IBD treatment. There are multiple risk factors for post-operative complications after IBD surgery, but the role of ethnicity remains unclear. The aim of our study was to compare the rate of post-operative complications in Hispanic and non-Hispanic patients with equal access to health care. METHODS We designed a case-control study including patients enrolled in a health plan available to uninsured patients at Jackson Memorial Hospital (Miami, FL, USA) who had access to health care for at least 24 consecutive months prior to surgery. Sixty-seven Hispanic patients (cases) and 75 non-Hispanic patients (controls) met criteria and were compared with respect to demographics, type of surgery, disease phenotype, and laboratory markers. Primary outcome was the development of a medical or surgical complication. RESULTS A slight numerical increase in post-operative complications was seen in Hispanic patients; this did not reach statistical significance [1.06 (95 % CI 0.48-2.36; p = 0.88)]. Factors independently associated with post-operative complications included diagnosis of ulcerative colitis [OR 5.4 (95 % CI 1.67-20.58; p = 0.004)], pre-operative albumin levels <3 mg/dL [OR: 8.2 (95 % CI 2.3-35.5; p < 0.001)], smoking [OR 15.7 (95 % CI 4.2-72.35; p < 0.001)], and use of ≥20 mg of prednisone [OR 6.7 (95 % CI 2.15-24.62; p < 0.001)]. CONCLUSIONS In a group of patients with equal access to medical care and follow-up, Hispanics and non-Hispanics with IBD that underwent surgery had no significant differences in types of IBD surgeries or post-surgical outcomes.
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Affiliation(s)
- Andres J Yarur
- Division of Gastroenterology, Department of Medicine, University of Miami, Miller School of Medicine, 1120 NW 14th Street, Clinical Research Building 350 (D-49), Miami, FL, 33136, USA,
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Abstract
BACKGROUND Polypharmacy is of growing concern in the chronically ill, including individuals with inflammatory bowel disease (IBD). The authors aimed to describe the prevalence and predictors of non-IBD medication use and to compare drug use among individuals with and without IBD. METHODS This cross-sectional study included members of health plans included in the Thomson Reuters MarketScan databases with continuous enrollment during 2009 and 2010. Patients with IBD were identified through diagnosis codes and IBD medication dispensings and matched to 5 individuals without IBD. The prevalences of dispensed prescriptions for analgesics (narcotics, nonnarcotics), psychiatric medications (anxiolytics/sedatives/hypnotics, antidepressants), and broad drug classes defined by the Anatomic Therapeutic Classification system were estimated. Predictors of non-IBD medication use and comparisons of drug use by IBD status were evaluated using logistic regression. RESULTS The prevalence of medication use was higher among patients with IBD than matched members of the general population for nearly every drug class examined, including narcotic analgesics (48.1% versus 34.1%), nonnarcotic analgesics (12.8% versus 8.1%), anxiolytics/sedatives/hypnotics (25.8% versus 16.7%), and antidepressants (28.3% versus 19.4%). Medicaid insurance, middle age, gastrointestinal surgery, Crohn's disease, and increasing number of inpatient, and outpatient, and prescription events were significantly associated with analgesic and psychiatric medication use among patients with IBD. Psychiatric drug dispensings were more common among female IBD patients than male patients. CONCLUSIONS Patients with IBD have increased medication use, particularly of analgesic and psychiatric drugs. IBD care providers should be aware of polypharmacy and its potential for drug interactions.
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Maltenfort MG, Rasouli MR, Morrison TA, Parvizi J. Clostridium difficile colitis in patients undergoing lower-extremity arthroplasty: rare infection with major impact. Clin Orthop Relat Res 2013; 471:3178-85. [PMID: 23479237 PMCID: PMC3773117 DOI: 10.1007/s11999-013-2906-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The prevalence of Clostridium difficile colitis is reportedly increasing in surgical patients and can negatively impact their outcome. However, as yet there are no clear estimates of the C difficile infection colitis rate and its consequences among patients undergoing total joint arthroplasty (TJA). QUESTIONS/PURPOSES We asked: (1) What is the rate of C difficile colitis in TJA patients? (2) What are the risk factors of C difficile colitis in these patients? And (3) what is the effect of C difficile colitis on length of stay, in-hospital mortality, and estimated total charges? METHODS Using ICD-9-CM diagnosis and procedure codes, we queried the Nationwide Inpatient Sample database for patients undergoing TJA for the years 2002 to 2010. Demographic data, comorbidities, occurrence of C difficile colitis, length of hospital stay, mortality, and hospital charges were extracted. Logistic regression was performed to identify predictors of C difficile colitis and its impact on in-hospital mortality. RESULTS The incidence of C difficile remained less than 0.6% during the study period. Revision TJAs (odds ratio=6.9 and 4.4 for hip and knee, respectively) and number of comorbidities (odds ratio=1.5) increased risk of C difficile colitis. C difficile increased length of hospital stay by a week, hospital charges by USD 40,000, and in-hospital mortality to 4.66% from 0.24%. CONCLUSIONS Using lower and fewer doses of antibiotics in revision TJAs and among patients with many comorbidities may diminish risk of C difficile colitis and its consequent mortality. LEVEL OF EVIDENCE Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mitchell Gil Maltenfort
- The Rothman Institute of Orthopedics at Thomas Jefferson Hospital, 925 Chestnut Street, Philadelphia, PA 19107 USA
| | - Mohammad R. Rasouli
- The Rothman Institute of Orthopedics at Thomas Jefferson Hospital, 925 Chestnut Street, Philadelphia, PA 19107 USA
| | - Todd A. Morrison
- The Rothman Institute of Orthopedics at Thomas Jefferson Hospital, 925 Chestnut Street, Philadelphia, PA 19107 USA
| | - Javad Parvizi
- The Rothman Institute of Orthopedics at Thomas Jefferson Hospital, 925 Chestnut Street, Philadelphia, PA 19107 USA
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Abstract
BACKGROUND Although infections are a major cause of morbidity and mortality after total joint arthroplasty (TJA), little is known about nationwide epidemiology and trends of infections after TJA. QUESTIONS/PURPOSES We therefore determined (1) trends of postoperative pneumonia, urinary tract infection (UTI), surgical site infection (SSI), sepsis, and severe sepsis after TJA; (2) risk factors of these infections; (3) effect of these infections on length of stay (LOS) and hospital charges; and (4) the infection-related mortality rate and its predictors. METHODS The International Classification of Diseases, 9th Revision codes were used to identify patients who underwent TJA and were diagnosed with aforementioned infections during hospitalization in the Nationwide Inpatient Sample database from 2002 to 2010. Multivariate analysis was performed to identify risk factors of these infections. RESULTS Rates of pneumonia, UTI, SSI, sepsis, and severe sepsis were 0.74%, 3.26%, 0.31%, 0.25%, and 0.15%, respectively. Number of comorbidities and type of TJA were independent predictors of infection. Mortality decreased during the study period (odds ratio, 0.87; 95% confidence interval, 0.86-0.89). The median LOS was 3 days without complications but increased in the presence of SSI (median, 7 days), sepsis (median, 12 days), and severe sepsis (median, 15 days). Occurrence of pneumonia, sepsis, and severe sepsis increased risk of mortality 5.2, 8.5, and 66.2 times, respectively. CONCLUSIONS Rates of UTI, pneumonia, and SSI but not sepsis and severe sepsis are apparently decreasing. The likelihood of infection is increasing with number of comorbidities and revision surgeries. Rate of sepsis-related mortality is also decreasing. LEVEL OF EVIDENCE Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Ha CY, Katz S. Clinical outcomes and management of inflammatory bowel disease in the older patient. Curr Gastroenterol Rep 2013; 15:310. [PMID: 23307425 DOI: 10.1007/s11894-012-0310-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The management of inflammatory bowel disease in the older patient extends beyond the gastrointestinal tract. Pre-existing comorbidities, polypharmacy, functional status and physical reserve can impact disease course, response to therapy and quality of life. Current therapeutic endpoints may not be as immediately applicable to the older IBD patient at higher risk for adverse outcomes. This review focuses on the latest studies addressing the natural history, clinical course and therapeutic outcomes among the older IBD cohort.
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Affiliation(s)
- Christina Y Ha
- Meyerhoff Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, 1830 East Monument Street, Suite 430, Baltimore, MD, 21287, USA.
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Jan S, Slap G, Dai D, Rubin DM. Variation in surgical outcomes for adolescents and young adults with inflammatory bowel disease. Pediatrics 2013; 131 Suppl 1:S81-9. [PMID: 23457154 DOI: 10.1542/peds.2012-1427j] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To examine whether hospital type (children's hospital or generalist hospital) and surgeon specialty are associated with variations in surgical outcomes for hospitalized adolescents and young adults with inflammatory bowel disease (IBD) requiring surgery. METHODS The 2007-2009 Perspective Data Warehouse was used to identify a retrospective cohort study of all inpatients 16 to 25 years old who received surgery for IBD. Multivariate regression, clustered at the hospital level, examined the association of hospital type and surgical specialty with surgical complications and 30-day readmissions. RESULTS Surgery was performed in 917 hospitalizations of 598 patients across 20 children's hospitals and 198 general hospitals by 566 general surgeons, 46 pediatric surgeons, and 305 colorectal surgeons. After adjustment, children's hospitals had higher predicted probabilities of surgical complication (predicted probability [PP]: 35% [95% confidence interval (CI): 28-42]) compared with general hospitals (PP: 26% [95% CI: 23-29]). Despite higher complications among children's hospitals, pediatric surgeons had lowest predicated probabilities of surgical complication or 30-day readmission (PP: 24% [95% CI: 10-39]) compared with general surgeons (PP: 39% [95% CI: 35-43]) and colorectal surgeons (PP: 35% [95% CI: 28-42]). CONCLUSIONS Disparate outcomes for adolescents and young adults receiving care in children's versus generalist hospitals and from different types of surgeons reveal the need to better understand how practice setting and surgical specialty may modify outcomes for a population that traverses a variety of health care settings.
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Affiliation(s)
- Sophia Jan
- Division of General Internal Medicine, Perelman School of Medicine of University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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