Inflammatory bowel disease and African Americans: a systematic review

A guide to developing population files for physiologically-based pharmacokinetic modeling in the Simcyp Simulator

The Simcyp Simulator is a software platform widely used in the pharmaceutical industry to conduct stochastic physiologically-based pharmacokinetic (PBPK) modeling. This approach has the advantage of combining routinely generated in vitro data on drugs and drug products with knowledge of biology and physiology parameters to predict a priori potential pharmacokinetic changes in absorption, distribution, metabolism, and excretion for populations of interest. Combining such information with pharmacodynamic knowledge of drugs enables planning for potential dosage adjustment when clinical studies are feasible. Although the conduct of dedicated clinical studies in some patient groups (e.g., with hepatic or renal diseases) is part of the regulatory path for drug development, clinical studies for all permutations of covariates potentially affecting pharmacokinetics are impossible to perform. The role of PBPK in filling the latter gap is becoming more appreciated. This tutorial describes the different input parameters required for the creation of a virtual population giving robust predictions of likely changes in pharmacokinetics. It also highlights the considerations needed to qualify the models for such contexts of use. Two case studies showing the step-by-step development and application of population files for obese or morbidly obese patients and individuals with Crohn's disease are provided as the backbone of our tutorial to give some hands-on and real-world examples.

Altered Bioavailability and Pharmacokinetics in Crohn's Disease: Capturing Systems Parameters for PBPK to Assist with Predicting the Fate of Orally Administered Drugs

Backgrond and Objective

Crohn’s disease (CD) is a chronic inflammatory bowel disease that affects a wide age range. Hence, CD patients receive a variety of drugs over their life beyond those used for CD itself. The changes to the integrity of the intestine and its drug metabolising enzymes and transporters (DMETs) can alter the oral bioavailability of drugs. However, there are other changes in systems parameters determining the fate of drugs in CD, and understanding these is essential for dose adjustment in patients with CD.

Methods

The current analysis gathered all the available clinical data on the kinetics of drugs in CD (by March 2021), focusing on orally administered small molecule drugs. A meta-analysis of the systems parameters affecting oral drug pharmacokinetics was conducted. The systems information gathered on intestine, liver and blood proteins and other physiological parameters was incorporated into a physiologically based pharmacokinetic (PBPK) platform to create a virtual population of CD patients, with a view for guiding dose adjustment in the absence of clinical data in CD.

Results

There were no uniform trends in the reported changes in reported oral bioavailability. The nature of the drug as well as the formulation affected the direction and magnitude of variation in kinetics in CD patients relative to healthy volunteers. Even for the same drug, the reported changes in exposure varied, possibly due to a lack of distinction between the activity states of CD. The highest alteration was seen with S-verapamil and midazolam, 8.7- and 5.3-fold greater exposure, respectively, in active CD patients relative to healthy volunteers. Only one report was available on liver DMETs in CD, and indicated reduced CYP3A4 activity. In a number of reports, mRNA expression of DMETs in the ileum and colon of CD patients was measured, focussing on P-glycoprotein (p-gp) transporter and CYP3A4 enzyme, and showed contradictory results. No data were available on protein expression in duodenum and jejunum despite their dominant role in oral drug absorption.

Conclusion

There are currently inadequate dedicated clinical or quantitative proteomic studies in CD to enable predictive PBPK models with high confidence and adequate verification. The PBPK models for CD with the available systems parameters were able to capture the major physiological influencers and the gaps to be filled by future research. Quantification of DMETs in the intestine and the liver in CD is warranted, alongside well-defined clinical drug disposition studies with a number of index drugs as biomarkers of changes in DMETs in these patients, to avoid large-scale dedicated studies for every drug to determine the effects of disease on the drug’s metabolism and disposition and the consequential safety and therapeutic concerns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40262-022-01169-4.

Racial and Ethnic Distribution of Inflammatory Bowel Disease in the United States

BACKGROUND

The current burden of Crohn's disease (CD) and ulcerative colitis (UC) in minority populations is largely unknown. We sought to evaluate the relative prevalence of CD and UC across racial and ethnic groups within the National Patient-Centered Clinical Research Network (PCORnet).

METHODS

We queried electronic health records from 337 centers from January 2013 to December 2018. We compared the relative prevalence of CD and UC across racial/ethnic groups to the general PCORnet populations using χ 2 and univariable logistic regression.

RESULTS

Among 39,864,077 patients, 114,168 had CD, and 98,225 had UC. Relative to the overall PCORnet population, Black adult patients were significantly less likely than White patients to have a diagnosis of CD (odds ratio [OR], 0.53; 95% CI, 0.52-0.54) or UC (OR, 0.41; 95% CI, 0.40-0.43). Pediatric Black patients were also less likely to have a diagnosis of CD (OR, 0.41; 95% CI, 0.39-0.43) or UC (OR, 0.38; 95% CI, 0.35-0.41). Adult Hispanic patients were less likely to have a diagnosis of CD (OR, 0.33; 95% CI, 0.32-0.34) or UC (OR, 0.45; 95% CI, 0.44-0.46) compared with non-Hispanic patients. Similarly, pediatric Hispanic patients were less likely to have a diagnosis of CD (OR, 0.34; 95% CI, 0.32-0.36) or UC (OR, 0.50; 95% CI, 0.47-0.53).

CONCLUSIONS

Despite the increasing racial and ethnic diversity in the United States, these data suggest that CD and UC are modestly less prevalent among patients of non-White races and Hispanic ethnicity.

The interplay of pineal hormones and socioeconomic status leading to colorectal cancer disparity

Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Despite increased screening options and state-of-art treatments offered in clinics, racial differences remain in CRC. African Americans (AAs) are disproportionately affected by the disease; the incidence and mortality are higher in AAs than Caucasian Americans (CAs). At the time of diagnosis, AAs more often present with advanced stages and aggressive CRCs, primarily accounting for the racial differences in therapeutic outcomes and mortality. The early incidence of CRC in AAs could be attributed to race-specific gene polymorphisms and lifestyle choices associated with socioeconomic status (SES). Altered melatonin-serotonin signaling, besides the established CRC risk factors (age, diet, obesity, alcoholism, and tobacco use), steered by SES, glucocorticoid, and Vitamin D status in AAs could also account for the early incidence in this racial group. This review focuses on how the lifestyle factors, diet, allelic variants, and altered expression of specific genes could lead to atypical serotonin and melatonin signaling by modulating the synthesis, secretion, and signaling of these pineal hormones in AAs and predisposing them to develop more aggressive CRC earlier than CAs. Crosstalk between gut microbiota and pineal hormones and its impact on CRC pathobiology is addressed from a race-specific perspective. Lastly, the status of melatonin-focused CRC treatments, the need to better understand the perturbed melatonin signaling, and the potential of pineal hormone-directed therapeutic interventions to reduce CRC-associated disparity are discussed.

Racial differences in the outcomes of IBD hospitalizations: a national population-based study

PURPOSE

There are  scarce data describing the outcomes of hospitalized patients admitted with inflammatory bowel disease (IBD) stratified by race. In this retrospective cohort study, we evaluated the difference in outcomes between adult white and black patients hospitalized with a principal diagnosis of inflammatory bowel disease.

METHODS

Data were obtained from the 2016 and 2017 National Inpatient Sample (NIS) database. Our primary outcome was inpatient mortality while the secondary outcomes were hospital length of stay (LOS), total hospital charges (THC), red blood cell (RBC) transfusion, diagnosis of bowel perforation, and severe sepsis with septic shock. We conducted the analysis using STATA software. We used propensity-matched multivariate regression analysis to adjust for potential confounders.

RESULTS

Among 71 million hospital hospitalizations, we found 177,574 hospitalizations with a principal diagnosis of IBD, with 24,635 (13.9%) for black patients, 124,899 (70.3%) for white patients, and 28,040 (15.8%) were for others. There was no significant difference in inpatient mortality for black vs white patients. Among secondary outcomes, white compared to black patients had increased odds of having a diagnosis of bowel perforation when admitted with a diagnosis of IBD while there was no difference in the odds of developing septic shock. White patients admitted with a diagnosis of UC were also found to have increased total LOS and THC.

CONCLUSION

White patients hospitalized with a principal diagnosis of IBD had no difference in inpatient mortality or septic shock but had worse outcomes such as increased odds of bowel perforation compared to black patients.

Epidemiology of Ocular Manifestations in Autoimmune Disease

The global prevalence of autoimmune diseases is increasing. As a result, ocular complications, ranging from minor symptoms to sight-threatening scenarios, associated with autoimmune diseases have also risen. These ocular manifestations can result from the disease itself or treatments used to combat the primary autoimmune disease. This review provides detailed insights into the epidemiological factors affecting the increasing prevalence of ocular complications associated with several autoimmune disorders.

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease

BACKGROUND

Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients.

METHODS

This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005-2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes.

RESULTS

Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1-1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1-2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4-1.9), and sepsis (OR: 1.7; 95% CI 1.4-2.02) compared to White patients.

CONCLUSIONS

Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.

Comparison of Disease Phenotypes and Clinical Characteristics Among South Asian and White Patients with Inflammatory Bowel Disease at a Tertiary Referral Center

BACKGROUND

The prevalence and clinical features of inflammatory bowel disease (IBD) vary among different racial and ethnic groups. The aim of this study was to compare the clinical and phenotypic features of Crohn's disease (CD) and ulcerative colitis (UC) in South Asian patients living in the United States with those of a white cohort.

METHODS

The demographic, clinical, and phenotypic characteristics of 73 South Asian patients (31 CD and 42 UC) who presented initially to our tertiary referral center from 2012 to 2016 and had subsequent follow-up were retrospectively compared with those of 408 consecutive white patients (245 CD and 163 UC).

RESULTS

South Asian IBD patients were significantly more likely to have UC (58.0% vs 40.0%; P = 0.005) than white patients. South Asians with CD were less likely to have a family history of IBD (9.7% vs 26.9%; P = 0.037) and required fewer CD-related surgeries (22.5% vs 46.1; P = 0.012). South Asians were also less likely to be active or former smokers in both the CD (P = 0.004) and UC (P = 0.020) groups. South Asians with UC had a higher incidence of Clostridium difficile infection compared with white patients (19.0% vs 8.6%; P = 0.050).

CONCLUSIONS

A cohort of South Asian patients with IBD were more likely to have UC and had differing family and tobacco risk factors, requirements for surgery, and Clostridium difficile infection rates as compared with white patients.

Low Health Literacy Exists in the Inflammatory Bowel Disease (IBD) Population and Is Disproportionately Prevalent in Older African Americans

BACKGROUND

Low health literacy is common in general populations, but its prevalence in the inflammatory bowel disease (IBD) population is unclear. The objective of this study was to assess the prevalence of low health literacy in a diverse IBD population and to identify risk factors for low health literacy.

METHODS

Adult patients with IBD at a single institution from November 2017 to May 2018 were assessed for health literacy using the Newest Vital Sign (NVS). Demographic and socioeconomic data were also collected. Primary outcome was the prevalence of low health literacy. Secondary outcomes were length-of-stay (LOS) and 30-day readmissions after surgical encounters. Bivariate comparisons and multivariable regression were used for analyses.

RESULTS

Of 175 IBD patients, 59% were women, 23% were African Americans, 91% had Crohn disease, and mean age was 46 years (SD = 16.7). The overall prevalence of low health literacy was 24%. Compared to white IBD patients, African Americans had significantly higher prevalence of low health literacy (47.5% vs 17.0%, P < 0.05). On multivariable analysis, low health literacy was associated with older age and African American race (P < 0.05). Of 83 IBD patients undergoing abdominal surgery, mean postoperative LOS was 5.5 days and readmission rate was 28.9%. There was no significant difference between LOS and readmissions rates by health literacy levels.

CONCLUSIONS

Low health literacy is present in IBD populations and more common among older African Americans. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities and to benefit those with low health literacy.

The Prevalence and Characterization of Axial Spondyloarthritis Among Veterans with Inflammatory Bowel Disease

Background

Axial spondyloarthritis (axSpA) includes ankylosing spondylitis and inflammatory spinal disease. We validated an algorithm to identify patients with axSpA and examine the prevalence of axSpA in inflammatory bowel disease (IBD) patients.

Methods

Diagnostic code algorithms to identify patients with axSpA were compared using a sample of randomly selected patients for chart review and used to estimate prevalence in a national cohort of IBD patients.

Results

Using the best performing algorithm for axSpA among IBD patients [&gt;3 codes and &gt;90 days between encounters (positive predictive value = 0.813, negative predictive value = 0.742)], 1545 cases of axSpA were identified among 77,824 IBD patients, a prevalence of 1.99%. Fifty-five percent of patients were diagnosed with IBD before axSpA, 24% were diagnosed concurrently, and 21% of patients were diagnosed with axSpA before IBD.

Characteristics of inflammatory bowel disease in patients of Roma/Gypsy ethnicity. A case-control study

BACKGROUND

Peculiarities of inflammatory bowel disease (IBD) have been explored in ethnic groups, such as Asians, Hispanics, and Afro-Americans, but not in other ethnic minorities, such as Roma/Gypsies.

METHODS

In a retrospective, hospital-based study, all adult Roma/Gypsy patients included in the IBD databases of seven Spanish centres were identified as cases. For each Roma/Gypsy patient, a Caucasian patient, matched for several demographic features, was searched as a control. Data on phenotypic features, therapeutic requirements, and familial aggregation were recorded.

RESULTS

Sixty-eight Roma/Gypsy patients were identified, 29 of them being women. The mean age at diagnosis of IBD was 24.9±9.5years, and the mean time elapsed since diagnosis was 96.6±72.2months. Roma/Gypsy IBD patients showed a significantly higher rate of familial aggregation (43%) than their Caucasian controls (9%) (p=0.00001). CD in Roma/Gypsies had more often a complicated pattern (mainly penetrating) while UC patients showed a marked trend to more often developing extraintestinal manifestations. In addition, Roma/Gypsy IBD patients had a somewhat greater need for immunosuppressants, biological agents or surgery.

CONCLUSIONS

These are the first data on IBD in Roma/Gypsy patients. Familial aggregation is the most prominent feature in these patients, suggesting a predominant role of genetics in its pathogenesis.

Crohn's disease in a developing African mission hospital: a case report

Background

A case is reported of innocuous intestinal obstruction requiring surgical intervention that was confirmed to be Crohn’s disease histopathologically in a resource-constrained rural mission hospital in Cameroon.

Case presentation

A 70-year man of Kumbo origin from Northwest region of Cameroon with a history of crampy right lower-quadrant abdominal pain, non-bloody, non-mucoid diarrhea alternating with constipation presented to my institution. Abdominal examination of the patient revealed an ill-defined mass in the right iliac fossa and visible peristalsis. An abdominal computed tomographic scan and barium enema study confirmed a complex ascending colonic and cecal tumor. The patient underwent exploratory laparotomy. The intraoperative finding was a huge complex inflammatory mass involving the cecum, terminal ileum, and sigmoid colon. He subsequently had sigmoidectomy with end–to-end sigmoidorectal anastomosis and a cecal resection, and the proximal ascending colon was exteriorized because end mucoid fistula and terminal ileostomy were performed. The histopathological diagnosis confirmed Crohn’s disease. The patient subsequently received five courses of adjuvant chemotherapy consisting of azathioprine, methotrexate, mesalamine, and methylprednisolone. He had complete disease remission and subsequently had closure of ileostomy with satisfactory postoperative status. The most recent follow-up abdominal computed tomographic scan and colonoscopy revealed disease-free status. The patient is also currently receiving a maintenance dose of rectal mesalamine and oral omeprazole treatment. He has been followed every 2 months in the surgical outpatient clinic over the last 16 months with satisfactory clinical outcome.

Conclusions

Crohn’s disease is uncommon in Africa, and this entity is encountered sparingly. The signs and symptoms of Crohn’s disease overlap with many other abdominal disorders, such as tuberculosis, ulcerative colitis, irritable bowel syndrome, and others. Several publications in the literature describe that it is difficult to make an accurate diagnosis of this disease, despite the fact that many diagnostic armamentaria are available to suggest its presence. Most of the patients with Crohn’s disease are treated conservatively, and a few may require surgical intervention, especially those presenting with complications such as intestinal obstruction, perforations, and abscess as well as fistula formations, as seen in this index patient. Crohn’s disease is considered by many to be a very rare disease in Africa. It is interesting to know that Crohn’s disease, which affects mainly young adults, may debut at any age. The rarity and clinical curiosity of this entity suggested reporting of my patient’s case. Evidence-based up-to-date information on Crohn’s disease is also documented.

Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients.

METHODS

A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes.

RESULTS

Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64).

CONCLUSIONS

Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.

Socioeconomic Status and Race are both Independently associated with Increased Hospitalization Rate among Crohn's Disease Patients

Racial disparities are observed clinically in Crohn’s Disease (CD) with research suggesting African Americans (AA) have worse outcomes than Caucasian Americans (CA). The aim of this study is to assess whether socioeconomic status (SES) rather than race is the major predictor of worse outcomes. We designed a retrospective cohort study of 944 CD patients seen at our center. Patients’ billing zip codes were collected and average income and percent of population living above or below poverty level (PL) for each zip code calculated. Patients were separated by quartiles using average state income level and federal PL. Demographics and hospitalization rates were collected. Poison regression models estimated incidence rate ratios (IRR) for CD-related hospitalizations. Incidence rate (IR) of hospitalization per 100-person years for the lowest income group was 118 (CI 91.4–152.3), highest income group was 29 (CI 21.7–38.9), Above PL was 26.9 (25.9–28.9), Below PL was 35.9 (33.1–38.9), CA was 25.3 (23.7–27), and AA was 51.4 (46.8–56.3). IRR for a CD-related hospitalization for lowest income group was 2.01 (CI 1.34–3.01), for Below PL was 1.26 (CI 1.12–1.42), and for AAs was 1.88 (CI 1.66–2.12). SES and race are both associated with hospitalization among CD patients and need further investigation.

Oral and upper gastrointestinal Crohn's disease

Crohn's disease is a heterogeneous, inflammatory condition that can affect any location of the gastrointestinal tract. Proximal gastrointestinal involvement occurs in 0.5-16% of patients, and it is usually diagnosed after recognition of intestinal disease. Symptoms are often mild and nonspecific; however, upper gastrointestinal disease predicts a more severe Crohn's phenotype with a greater frequency of complications such as obstruction and perforation. Gastroscopy and biopsy is the most sensitive diagnostic investigation. There is a paucity of data examining the treatment of this condition. Management principles are similar to those for intestinal disease, commencing with topical therapy where appropriate, progressing to systemic therapy such as glucocorticoids, 5-aminosalicylic acid, immunomodulators, and biologics. Acid suppression therapy has symptomatic but no anti-inflammatory benefit for gastroduodenal and esophageal involvement. Surgical intervention with bypass, strictureplasty, or less frequently, endoscopic balloon dilation may be required for complications or failed medical therapy.

IBD Serology and Disease Outcomes in African Americans With Crohn's Disease

BACKGROUNDS

Recent studies have identified the role of serologic markers in characterizing disease phenotype, location, complications, and severity among Northern Europeans (NE) with Crohn's disease (CD). However, very little is known about the role of serology in CD among African Americans (AA). Our study explored the relationship between serology and disease phenotype in AA with CD, while controlling for genetic ancestry.

METHODS

AAs with CD were enrolled as participants through multicenter collaborative efforts. Serological levels of IgA anti-Saccharomyces cervisiae antibody (ASCA), IgG ASCA, E. coli outermembrane porin C, anti-CBir1, and ANCA were measured using enzyme-linked immunosorbent assays. Genotyping was performed using Illumina immunochip technology; an admixture rate was calculated for each subject. Multiple imputation by chained equations was performed to account for data missing at random. Logistic regression was used to calculate adjusted odds ratio (OR) for associations between serological markers and both complicated disease and disease requiring surgery.

RESULTS

A total of 358 patients were included in the analysis. The majority of our patients had inflammatory, noncomplicated disease (58.4%), perianal disease (55.7%), and documented colonic inflammation (86.8%). On multivariable analysis, both IgG ASCA and OmpC were associated with complicated disease (OR, 2.67; 95% CI, 1.67-4.28; OR, 2.23; 95% CI, 1.41-3.53, respectively) and disease requiring surgery (OR, 2.51; 95% CI, 1.49-4.22; OR, 3.57; 95% CI, 2.12-6.00). NE admixture to the African genome did not have any associations or interactions in relation to clinical outcome.

CONCLUSIONS

Our study comprises the largest cohort of AAs with CD. The utility of serological markers for the prognosis of CD in NE applies equally to AA populations.

Rates of hospitalization among African American and Caucasian American patients with Crohn's disease seen at a tertiary care center

BACKGROUND

There is equivocal evidence regarding differences in the clinical course and outcomes of Crohn's disease (CD) among African Americans compared with Caucasian Americans. We sought to analyze whether African Americans with CD are more likely to be hospitalized for CD-related complications when compared with Caucasian Americans with CD.

METHODS

We conducted a retrospective cohort study including 909 African Americans and Caucasian Americans with CD who were seen at our tertiary care Inflammatory Bowel Disease (IBD) referral center between 2000 and 2013. We calculated the rate of hospitalization for CD-related complications among African Americans and Caucasian Americans separately. Zero-inflated Poisson regression models with robust variance estimates were used to estimate crude and multivariable adjusted rate ratios (RR) for CD-related hospitalizations. Multivariable adjusted models included adjustment for age, sex, duration of CD, smoking and CD therapy.

RESULTS

The cumulative rate of CD-related hospital admissions was higher among African American patients compared with Caucasian American patients (395.6/1000 person-years in African Americans vs. 230.4/1000 person-years in Caucasian Americans). Unadjusted and multivariable adjusted rate ratios for CD-related hospitalization comparing African Americans and Caucasian Americans were 1.59 (95% confidence interval [95%CI]: 1.10-2.29; P=0.01) and 1.44 (95%CI: 1.02-2.03; P=0.04), respectively.

CONCLUSIONS

African Americans with CD followed at a tertiary IBD-referral center had a higher rate for CD-related hospitalizations compared with Caucasian Americans. Future studies should examine whether socioeconomic status and biologic markers of disease status could explain the higher risk observed among African Americans.

Race/Ethnicity-Specific Disparities in the Severity of Disease at Presentation in Adults with Ulcerative Colitis: A Cross-Sectional Study

BACKGROUND

While ulcerative colitis (UC) is well studied in Caucasian populations, less data are available on UC patients of racial/ethnic minorities, including variations in disease severity at presentation.

AIM

To evaluate race/ethnicity-specific disparities in UC disease presentation among an ethnically diverse underserved population.

METHODS

We performed a cross-sectional study of all consecutive UC adults among a large ethnically diverse safety-net hospital from July 2014 to May 2016 to compare race/ethnicity-specific disparities in severity of disease at presentation. Severity was evaluated using the clinician-based simple clinical colitis activity index (SCCAI) and the Mayo score at time of presentation. Multivariate ordered logistic regression models were used to evaluate associations with SCCAI and Mayo scores.

RESULTS

Among 98 UC patients (56.1% male, mean age 40.1 (SD 14.2), 32.0% were African-American, 26.7% Hispanic, 16.0% Asian, and 20.0% Caucasian. Mean Mayo score was 6.6 and mean SCCAI score was 6.5. When stratified by race/ethnicity, SCCAI scores were significantly higher in non-Caucasians compared to Caucasians (7.0 vs 4.6, p = 0.03) and in Asians compared to Caucasians (8.0 vs 4.6, p = 0.02). There was a trend toward higher mean SCCAI in Hispanics compared to Caucasians (6.9 vs 4.6, p = 0.07). Mayo scores at presentation demonstrated similar trends. On multivariate logistic regression, Asians (OR 5.26, 95% CI 1.24-22.42) and Hispanics (OR 3.74; 95% CI 1.02-13.66) had more severe disease at presentation than Caucasians based on SCCAI.

CONCLUSIONS

Among a diverse underserved cohort of UC patients, racial/ethnic minority patients with UC, specifically Asians and Hispanics, had more severe disease at presentation compared to Caucasians. The differences may reflect disparities in timely access to specialty care and treatment and deserves greater attention and research.

Characterization and prevalence of spondyloarthritis and peripheral arthritis among patients with inflammatory bowel disease

Background

Joint complaints such as spondyloarthritis and peripheral arthritis are the most common extraintestinal manifestations in patients with inflammatory bowel disease (IBD); however, the evaluation of these symptoms are poorly described.

Objectives

To examine the clinical characteristics and prevalence of ankylosing spondylitis (AS) and other joint complaints among patients with IBD.

Methods

In a local cohort of patients diagnosed with IBD between 1996 and 2009, we performed a retrospective study at the Veterans Affairs Hospital. Patients with IBD were identified by International Classification of Diseases, Ninth Revision codes and confirmed by chart review. The occurrence of AS, peripheral arthritis, and other peripheral and axial joint symptoms were identified.

Results

We identified 626 patients with IBD between ages 18 and 90 (90% males), of whom 57% had ulcerative colitis (UC), 74% were Caucasians, and the mean age at diagnosis was 54 (±16) years. Among the study population, 108 patients (17%) had at least one type of joint pain. Among these 17% with joint pain, 12% had AS, 43% had peripheral arthritis, 32% had chronic back pain without AS, and 13% had other types of joint pain. The overall prevalence of peripheral arthritis among patients with IBD was three times higher than that of AS (7% vs 2.1%, respectively, OR 3.5; 95% confidence interval [CI] 1.9–6.5; p=0.001). There was no difference in the prevalence of AS or peripheral arthritis between patients with Crohn’s disease and UC. The initial diagnosis of AS occurred after the initial diagnosis of IBD in 80% of patients within a mean (SD) period of 5.6 (±6) years.

Conclusion

Spondyloarthritis among patients with IBD is usually diagnosed after the initial diagnosis of IBD. No difference in the prevalence of AS or peripheral arthritis was observed by IBD type, age, or race. Recognition and understanding of these results will have important implications for the management of IBD patients with spondyloarthritis.

Race Differences in Initial Presentation, Early Treatment, and 1-year Outcomes of Pediatric Crohn's Disease: Results from the ImproveCareNow Network

BACKGROUND

Racially disparate care has been shown to contribute to suboptimal health care outcomes for minorities. Using the ImproveCareNow network, we investigated differences in management and outcomes of pediatric patients with Crohn's disease at diagnosis and 1-year postdiagnosis.

METHODS

ImproveCareNow is a learning health network for pediatric inflammatory bowel disease. It contains prospective, longitudinal data from outpatient encounters. This retrospective study included all patients with Crohn's disease ≤21 years, September 2006 to October 2014, with the first recorded encounter ≤90 days from date of diagnosis and an encounter 1 year ±60 days. We examined the effect of race on remission rate and treatment at diagnosis and 1 year from diagnosis using t-tests, Wilcoxon rank-sum tests, χ statistic, and Fisher's exact tests, where appropriate, followed by univariate regression models.

RESULTS

Nine hundred seventy-six patients (Black = 118 (12%), White = 858 (88%), mean age = 13 years, 63% male) from 39 sites were included. Black children had a higher percentage of Medicaid insurance (44% versus 11%, P < 0.001). At diagnosis, Black children had more active disease according to physician global assessment (P = 0.027), but not by short Pediatric Crohn's Disease Activity Index (P = 0.67). Race differences in treatment were not identified. Black children had lower hematocrit (34.8 versus 36.7, P < 0.001) and albumin levels (3.6 versus 3.9, P = 0.001). At 1 year, Black children had more active disease according to physician global assessment (P = 0.016), but not by short Pediatric Crohn's Disease Activity Index (P = 0.06).

CONCLUSIONS

Black children with Crohn's disease may have more severe disease than White children based on physician global assessment. Neither disease phenotype differences at diagnosis nor treatment differences at 1-year follow-up were identified.

African Americans and Short-Term Outcomes after Surgery for Crohn's Disease: An ACS-NSQIP Analysis

BACKGROUND

Previous reports on racial disparities in the treatment of Crohn's disease [CD] in African American [AA] patients have shown differences in both medical and surgical treatments in this population. No study thus far has examined the effect of AA race on outcomes after surgery for CD.

METHODS

Utilizing the National Surgical Quality Improvement Program [NSQIP] Participant User File [PUF] for the years 2005-2013, we examined the effect of AA race on postoperative complications in patients with CD undergoing intestinal surgery.

RESULTS

AA patients had a significantly higher rate of complications overall compared to non-AA patients [23.5% vs 18.9%, p = 0.002]. Postoperative sepsis [10.9% vs 6.6%, p < 0.001] and surgical site infection [17.6% vs 14.8%, p = 0.037] were most significant. After adjustment for age, sex, preoperative disease severity and lifestyle factors [smoking], race remained a statistically significant factor in postoperative complication rate. Only after additional adjustment was made for comorbidities and American Society of Anesthesiologists class did race lose significance within our model.

CONCLUSION

African Americans experience a greater amount of postoperative complications following surgery for Crohn's disease. Preoperative disease management, addressing smoking status and control of comorbid disease are important factors in addressing the racial disparities in the surgical treatment of Crohn's disease.

Differences in the socio-economic distribution of inflammatory bowel disease and microscopic colitis

AIM

Inflammatory bowel disease (IBD) and microscopic colitis are characterized by different geographical distributions across the USA. In this cross-sectional study we utilized demographic and socio-economic information associated with individual ZIP codes to further delineate the epidemiological characteristics of the two diseases.

METHOD

A total of 813 057 patients who underwent colonoscopy between 2008 and 2014 were extracted from an electronic database of histopathology reports. The prevalence of patients with IBD or microscopic colitis was expressed as percentage of the population associated with specific demographic (age, sex, ethnicity) and socio-economic characteristics (population size, housing value, annual income, tertiary education).

RESULTS

Both diseases were more common among subjects from ZIP codes with predominantly White residents and less common among subjects from ZIP codes with predominantly non-White residents such as Black, Hispanic and Asian. These ethnic variations were more pronounced in microscopic colitis than IBD. Markers of affluence, such as average residential house value and annual income, were positively associated with IBD and negatively with microscopic colitis. The prevalence of both diseases was positively correlated with tertiary education.

CONCLUSION

The occurrence of both IBD and microscopic colitis is influenced by environmental risk factors. The differences in the demographic, ethnic and socio-economic distributions of the two diseases suggest that different sets of risk factors affect the two diseases and that their aetiology is unrelated.

The genetic architecture of inflammatory bowel disease: past, present and future

PURPOSE OF REVIEW

Genome-wide association studies (GWAS) have helped to understand the genetic basis and pathogenesis of inflammatory bowel disease (IBD). However, understanding the functional and clinical consequences of the associated alleles has not followed the same pace. In this review, we discuss how studying the genetic predisposition to IBD has increased our understanding about IBD pathogenesis and how epigenetics is becoming more and more important. We describe the potential clinical applications of genetics, and provide important challenges in the field and the future steps to be taken.

RECENT FINDINGS

GWAS and meta-analyses have identified 163 loci associated with IBD, and have implicated key pathways in IBD pathogenesis. Only few of the association signals correspond to nonsynonymous coding variation with a clear effect on protein function. The majority of signals involve noncoding genetic variation, of which a large part is related to gene expression changes. More recently, expression and epigenetic studies in IBD are increasingly being reported, and have shown that many effects seem to be highly cell-type specific.Predictive genetic testing will not be for the immediate future for the majority of IBD patients. However, for the subset of patients with very-early onset IBD, several causal mutations have been found. Predictive genetic panels for these adolescents presenting with a very severe disease course, and/or families with high penetrance of disease will be of benefit.

SUMMARY

Genetic, transcriptomic and epigenetic studies have offered exciting clues about IBD pathogenesis but are unlikely to provide all answers. To fully grasp the function of disease-associated genetic variants, identifying causal genes and translating this knowledge into predictive biomarkers and new treatments, we should now integrate all these disciplines.

The Demographic and Clinical Characteristics of Ulcerative Colitis in a Northeast Brazilian Population

INTRODUCTION

The purpose of this study was to describe the clinical and demographic characteristics of UC in Bahia, a Brazilian state, and to identify the variables associated with extensive colitis, steroid therapy, immunosuppression, and colectomy.

METHODS

In this cross-sectional study UC patients were interviewed, and additional information was collected from the medical records. Descriptive statistics and multivariate Poisson regression analysis were used.

RESULTS

This study included 267 individuals, the mean age of whom was 39.4 years at diagnosis. There was a predominance of females and left-side colitis. Extensive colitis was positively associated with male gender, diarrhea, weight loss, and a younger age at diagnosis. In contrast, active smoking and a family history of IBD were negatively associated with extensive colitis. Positive associations were observed between steroid therapy and diarrhea, weight loss, urban patients, extraintestinal manifestations (EIMs), and hospitalization. Younger age and weight loss at diagnosis, a family history of IBD, extensive colitis, EIMs, hospitalization, and steroid therapy were all positively associated with immunosuppression. In contrast, Caucasian individuals, smokers, patients with rectal bleeding, and rural patients areas were all observed to have a decreased likelihood of immunosuppression.

CONCLUSIONS

Our results corroborate the association between higher prevalence of extensive colitis and younger age at diagnosis. An association between steroid therapy and clinical presentation at diagnosis was observed. The observation that white individuals and rural patients use less immunosuppressive drugs highlights the need to study the influence of environmental and genetic factors on the behavior of UC in this population.

Inflammatory Bowel Disease: Historical Perspective, Epidemiology, and Risk Factors

Inflammatory bowel disease (IBD) describes a group of closely related yet heterogeneous predominantly intestinal disease processes that are a result of an uncontrolled immune mediated inflammatory response. It is estimated that approximately one and a half million persons in North America have IBD. Pathogenesis of IBD involves an uncontrolled immune mediated inflammatory response in genetically predisposed individuals to a still unknown environmental trigger that interacts with the intestinal flora. There continues to be an enormous amount of information emanating from epidemiological studies providing expanded insight into the occurrence, distribution, determinants, and mechanisms of inflammatory bowel disease.

Hispanics and inflammatory bowel disease

BACKGROUND

Historically, inflammatory bowel disease (IBD) was considered a disease, which predominately affects whites. As such, the majority of research in IBD has been conducted in this population. However, more research on this suggests that IBD affects other ethnic groups. Rapidly shifting demographics in the United States necessitates a better understanding of how IBD may affect Hispanics. We reviewed the current literature on IBD in Hispanics.

METHODS

A PubMed search was conducted using keywords inflammatory bowel disease, Ulcerative Colitis, Crohn's disease, Hispanics, Latinos, ethnicity, to identify existing literature with a focus on adult populations. Non-English language articles were excluded.

RESULTS

The existing data and literature on Hispanic patients with IBD remains sparse. Limited studies on prevalence suggest IBD may be more common in Hispanics in the United States compared with those in Latin America. Conflicting data exist as to whether Hispanics patients with IBD are more likely to have ulcerative colitis compared with Crohn's disease. One study explored difference in IBD between foreign-born and U.S.-born Hispanics and found that ulcerative colitis was more common only in foreign-born Hispanics, whereas within 1 generation, U.S.-born Hispanics resemble their non-Hispanic white counterparts about development of Crohn's disease. Such a rapid change in the proportion of ulcerative colitis and Crohn's disease points strongly to environmental factors driving the change in proportion of disease subtypes. Additionally, a trend towards less use of biologic and immunomodulators in Hispanics was noted in several studies.

CONCLUSIONS

Additional research is needed to better understand how diversity within the Hispanic population (U.S.-born and foreign-born) may be driving difference in disease manifestations. More investigations should focus on determining the cause of a potential disparity in the use of biologic and immunomodulators in Hispanics.

Epidemiology and risk factors for IBD

IBD, comprising Crohn's disease and ulcerative colitis, is a chronic immunologically mediated disease at the intersection of complex interactions between genetics, environment and gut microbiota. Established high-prevalence populations of IBD in North America and Europe experienced the steepest increase in incidence towards the second half of the twentieth century. Furthermore, populations previously considered 'low risk' (such as in Japan and India) are witnessing an increase in incidence. Potentially relevant environmental influences span the spectrum of life from mode of childbirth and early-life exposures (including breastfeeding and antibiotic exposure in infancy) to exposures later on in adulthood (including smoking, major life stressors, diet and lifestyle). Data support an association between smoking and Crohn's disease whereas smoking cessation, but not current smoking, is associated with an increased risk of ulcerative colitis. Dietary fibre (particularly fruits and vegetables), saturated fats, depression and impaired sleep, and low vitamin D levels have all been associated with incident IBD. Interventional studies assessing the effects of modifying these risk factors on natural history and patient outcomes are an important unmet need. In this Review, the changing epidemiology of IBD, mechanisms behind various environmental associations and interventional studies to modify risk factors and disease course are discussed.

Race and fistulizing perianal Crohn's disease

BACKGROUND

There is increasing recognition of Crohn's disease (CD) in non-white populations. However, reports of racial disparities in the phenotype of CD are still inconsistent.

AIM

: The aim of this study was to test the hypothesis that African American (AA) patients have higher incidence of severe fistulizing perianal Crohn's disease (FPD) compared with white patients.

METHODS

Cross-sectional analysis of 333 adult CD patients treated at The Mount Sinai Hospital with infliximab between May 2011 and December 2011 was conducted. Self-reported race/ethnicity was recorded and proportions of each group with FPD were compared across the population.

RESULTS

Among all 333 evaluable CD patients on infliximab, 73.6% were white, 11.4% AA, 13.2% Hispanic, and 1.8% Asian. Of these 333 patients, 88 had FPD: only 48 of these (54.5%) were white, whereas fully 18 (20.5%) were AA, 20 (22.7%) were Hispanic, and 2 (2.3%) were Asian. Thus, patients receiving infliximab for FPD were significantly more likely to be AA or Hispanic than white (AA vs. whites: risk ratio=2.63; 95% confidence interval, 1.74-3.96; P=<0.0001; Hispanics vs. whites: risk ratio=2.32; 95% confidence interval, 1.54-3.50; P=0.0001). There was no statistically significant difference between AA and Hispanics.

CONCLUSION

CD patients at our medical center with FPD requiring infliximab therapy were significantly more likely to be AA or Hispanic.

Racial differences in disease activity and quality of life in patients with Crohn's disease

BACKGROUND

The existing literature on racial differences in Crohn's disease (CD) activity and quality of life (QOL) is limited and extrapolated from surrogate measures.

AIM

The aim of our study was to compare objective markers of disease activity and QOL over time by race.

STUDY

A clinical data repository of inflammatory bowel disease (IBD) patients at University of Maryland, Baltimore IBD Program, was used. CD patients from 2004 to 2009 were included if they had greater than or equal to two clinic visits with disease activity and QOL scores during the study period. Differences in disease activity and QOL were compared by race over time.

RESULTS

A total of 296 patients with CD met inclusion criteria; of these, 19% (56/296) were African Americans (AA) and 81% (240/296) were Caucasian. Baseline disease activity and QOL scores did not differ by race (p > 0.05). Caucasians had a steady decline in disease activity and increase in QOL. AA experienced a similar pattern of change in disease activity and QOL scores over time; however, the declines were not statistically significant between groups. At each time point post-baseline, disease activity and QOL scores were similar between races.

CONCLUSION

We found that Caucasian and AA patients with CD had similar disease activity and QOL scores at initial presentation and over time. Thus, AA do not represent a more severe subgroup of CD patients to treat. These findings have important implications for clinicians that care for patients with CD.

Clinical presentation and disease course of inflammatory bowel disease differs by race in a large tertiary care hospital

BACKGROUND

While the incidence of inflammatory bowel disease (IBD) among African-Americans (AAs) is increasing, there is limited understanding of phenotypic differences and outcomes by race.

AIM

To describe disease characteristics of AA patients compared to Caucasian (Ca) patients in a tertiary care population.

METHODS

We performed a cross-sectional review of the IBD registry at the University of Chicago from January 2008 to January 2013. Data regarding race, phenotype, disease onset, disease duration, medical therapy, and surgical treatment were abstracted from the database, then compared via Pearson's chi-square analysis, Kruskal-Wallis analysis, and logistic regression with a significance level of p < 0.05.

RESULTS

A total of 1,235 patients with Crohn's disease (CD) and 541 patients with ulcerative colitis (UC) included 108 AA CD patients and 28 AA UC patients. AA CD patients had an increased rate of IBD-related arthralgias (36.5 vs. 23.9 %, p < 0.01) and surgery (p < 0.01), less ileal involvement (57.8 vs. 71.0 %, p < 0.01), and no differences for other extraintestinal manifestations or disease locations compared to Ca CD patients. AA UC patients were older at diagnosis, had an increased rate of arthralgias (28.6 vs. 14.6 %, p = 0.047) and ankylosing spondylitis/sacroiliitis (7.1 vs. 1.6 %, p = 0.035), with no differences for disease extent or rate of IBD-related surgeries compared to Ca UC patients. There were no differences in medication usage by race for CD and UC patients.

CONCLUSION

We identified significant differences in disease characteristics and extraintestinal manifestations between AA and Ca IBD patients in a large tertiary care population. These results have implications for future genotype-phenotype studies.

A comparison of abdominal surgical outcomes between African-American and Caucasian Crohn's patients

BACKGROUND AND OBJECTIVE

Whether race affects the natural history of Crohn's disease is a matter of debate. The aim of the current study was to evaluate the differences in surgical outcomes between African-American (AA) and Caucasian (C) Crohn's patients undergoing surgery at a tertiary care referral center.

METHODS

With Institutional Review Board approval, the medical records of our institution were queried to identify consecutive AA and C patients who underwent surgery for Crohn's disease from December 1, 2009 to December 15, 2011. A retrospective chart review was performed using electronic medical records.

RESULTS

A total of 77 patients were included in this study, including 32 AA (41 %) and 45 C (59 %). No significant differences were seen with respect to age, gender, type of insurance, preoperative exposure to immunosuppressives, body mass index, or smoking history between the two populations (p > 0.05). There was a trend toward lower albumin in AAs (p = 0.09). AA and C patients who underwent their first Crohn's disease (CD)-related surgery had similar lag periods between diagnosis and surgery. No significant differences were seen in location of disease, indication for operation, and need for open laparotomy over laparoscopy. No significant differences were seen in need for a repeat operation within 90 days of the original surgery or major postoperative complications. There was a trend toward higher rate of minor complications in the AA group (p = 0.07).

CONCLUSION

No significant differences were noted in the current study in several preoperative variables and surgical outcomes between AA and C.

Ubiquitous occurrence of birth-cohort patterns in inflammatory bowel disease

BACKGROUND AND AIMS

The aim of the present study was to demonstrate the ubiquitous occurrence of the birth-cohort phenomenon of inflammatory bowel disease among US whites and nonwhites, as well as males and females.

METHODS

Mortality from Crohn's disease and ulcerative colitis in the USA between 1950 and 2010 were analyzed to discern underlying birth-cohort patterns affecting both their time trends. Age-standardized cohort mortality ratio was used as a summary statistic to represent the overall mortality associated with consecutive birth-cohorts.

RESULTS

The cohort-age contours of Crohn's disease aligned to form one hyperbola with an initial rise between 1865 and 1935 and a subsequent decline. This pattern was confirmed by the time trends of the corresponding standardized cohort mortality ratio values. In ulcerative colitis, the individual cohort-age contours also aligned into one hyperbola that appeared shifted towards earlier generations by about 30 years when compared with Crohn's disease. Similar trends were observed in men and women or whites and nonwhites analyzed separately.

CONCLUSION

The birth-cohort patterns indicate that exposure to two separate risk factors must have occurred in both diseases during an early period of life. In the USA, these exposures have changed over historical times similarly in both sexes and different ethnic groups.

An exploration of family problem-solving and affective involvement as moderators between disease severity and depressive symptoms in adolescents with inflammatory bowel disease

Little is known about how family functioning relates to psychosocial functioning of youth with inflammatory bowel disease (IBD). The study aim was to examine family problem solving and affective involvement as moderators between adolescent disease severity and depressive symptoms. Participants were 122 adolescents with IBD and their parents. Measures included self-reported and parent-reported adolescent depressive symptoms, parent-reported family functioning, and physician-completed measures of disease severity. Disease severity was a significant predictor of adolescent-reported depressive symptoms, but not parent-reported adolescent depressive symptoms. Family affective involvement significantly predicted parent-reported adolescent depressive symptoms, while family problem-solving significantly predicted adolescent self-report of depressive symptoms. Neither affective involvement nor problem-solving served as moderators. Family affective involvement may play an important role in adolescent emotional functioning but may not moderate the effect of disease severity on depressive symptoms. Research should continue to examine effects of family functioning on youth emotional functioning and include a sample with a wider range of disease severity to determine if interventions aimed to enhance family functioning are warranted.

Racial/Ethnic and regional differences in the prevalence of inflammatory bowel disease in the United States

BACKGROUND

The magnitude of racial/ethnic and regional differences in the prevalence of inflammatory bowel disease (IBD) in the United States remains largely unknown.

AIMS

To estimate differences in the prevalence of IBD by race/ethnicity and region.

METHODS

The Medical Expenditure Panel Survey, a nationally representative survey of US households and medical conditions, was used. A multivariate logistic model was used in statistical analysis.

RESULTS

Among 202,468 individuals surveyed during 1996-2007, 316 were diagnosed with IBD (26 Blacks, 21 Hispanics, and 5 Asians). The prevalence of IBD was higher in Whites [Crohn's disease: 154; ulcerative colitis (UC): 89] than Blacks (Crohn's disease: 68; UC: 25), Hispanics (Crohn's disease: 15; UC: 35), and Asians (Crohn's: 45; UC: 40) (all p < 0.05, except for UC in Asians). The differences in Crohn's disease between Whites and minorities and the difference in UC between Whites and Blacks remained significant in multivariate analysis. In multivariate analysis, there was no regional difference in the prevalence of Crohn's disease, but the prevalence of UC was higher in the Northeast than the South (p < 0.05).

CONCLUSIONS

There were significant racial/ethnic differences in the prevalence of IBD in the USA. The underlying etiology of these differences warrants additional research.

Racial and ethnic differences in health care utilization and outcomes among ulcerative colitis patients in an integrated health-care organization

BACKGROUND

Current knowledge of racial disparities in healthcare utilization and disease outcomes for ulcerative colitis (UC) is limited. We sought to investigate these differences among Caucasian, African American, Asian, and Hispanic patients with ulcerative colitis in Kaiser Permanente, a large integrated health-care system in Northern California.

METHODS

This retrospective cohort study used computerized clinical data from 5,196 Caucasians, 387 African-Americans, 550 Asians, and 801 Hispanics with prevalent UC identified between 1996 and 2007. Healthcare utilization and outcomes were compared at one and five-year follow-up by use of multivariate logistic regression analysis.

RESULTS

Compared with whites, the male-to-female ratio differed for African-Americans (0.68 vs. 0.91, p < 0.01) and Asians (1.3 vs. 0.91, p < 0.01). Asians had fewer co-morbid conditions (p < 0.01) than whites, whereas more African-Americans had hypertension and asthma (p < 0.01). Use of immunomodulators did not differ significantly among race and/or ethnic groups. Among Asians, 5-ASA use was highest (p < 0.05) and the incidence of surgery was lowest (p < 0.01). Prolonged steroid exposure was more common among Hispanics (p < 0.05 at 1-year) who also had more UC-related surgery (p < 0.01 at 5-year) and hospitalization (<0.05 at 5-year), although these differences were not significant in multivariate analysis.

CONCLUSIONS

In this population of UC patients with good access to care, overall health-care utilization patterns and clinical outcomes were similar across races and ethnicity. Asians may have milder disease than other races whereas Hispanics had a trend toward more aggressive disease, although the differences we observed were modest. These differences may be related to biological factors or different treatment preferences.

Crohn's disease in Caucasians and African Americans, as defined by clinical predictors and single nucleotide polymorphisms

OBJECTIVES

To compare three aspects of Crohn's disease (CD) between African Americans and Caucasians: (1) demographic data and environmental factors affecting CD susceptibility, (2) disease presentation and clinical course, and (3) genetic susceptibility via the use of single nucleotide polymorphism (SNP) data for inflammatory bowel disease (IBD) susceptibility loci.

METHODS

Clinical data and peripheral blood were obtained from 1032 patients (554 CD patients and 478 controls) derived from a clinically well-defined university-based medical and surgical digestive disease practice and included those who were diagnosed with IBD. Genomic DNA was extracted and polymerase chain reaction (PCR) amplification and genotyping were performed for 11 SNPs, including the NOD2, IL-23r, OCTN 1, and the IGR gene variants.

RESULTS

A total of 554 patients with CD were included in this study: 53 African Americans (10%), 485 Caucasians (87%), and 15 of other races (3%). The strongest demographic predictor of CD in African American patients was a family history of IBD. Ileocolic disease (L3) was the most common site involved in both African Americans and Caucasians, while the penetrating phenotype (B3) was the most common CD disease behavior in both races. Genotype association analysis showed a significant association between 2 IL23r gene SNPs and CD susceptibility in African Americans (p = .016 and .028, respectively).

CONCLUSION

We believe this study is the first to report on genotype-phenotype associations in African American CD patients and compare findings to Caucasian CD patients within the same geographic area. We found no association between NOD2 gene SNPs and CD susceptibility in African Americans patients (p > .05).

The effect of bifid triple viable on immune function of patients with ulcerative colitis

Objective. To study effect and its mechanism of Bifid Triple Viable for initially treating ulcerative colitis with 5-aminosalicylic acid. Methods. 82 patients, who were firstly diagnosed as ulcerative colitis, were randomized into experiment group (41 cases, treated with Bifid Triple Viable and Etiasa) and control group (41 cases, treated with Etiasa). The clinic symptom score, colon mucosa inflammation score, and some immune indices were detected and compared between two groups before and two months after treatment. Results. Two months after treatment, the clinical symptom score, colon mucosa inflammation score, and IL-1β expression in colon mucosa decreased significantly (P < 0.01), and IL-10 and IgA expressions in colon mucosa increased significantly (P < 0.01). Those differences were more marked in experiment group than control group (P < 0.05). However, peripheral blood T cell subgroup, immunoglobulins, and complements had no significant difference between two groups two months after treatment, but the ratio of peripheral blood CD4+ T cell to CD8+ T cell in experiment group increased more than that in control group (P < 0.05). Conclusion. Bifid Triple Viable contributed to Etiasa to treat ulcerative colitis in inducing remission period, which was perhaps related to affecting the patient's immune function.

Risk of colorectal cancer among Caucasian and African American veterans with ulcerative colitis

BACKGROUND

African Americans are at an increased risk of developing sporadic colorectal cancer (CRC) compared to Caucasians. Ulcerative colitis (UC) is a risk factor for developing CRC; however, risk differences for CRC between African Americans and Caucasians with UC are unknown.

METHODS

We performed a cohort study of patients with a diagnosis of UC during fiscal years 1998 to 2009 using the national Veterans Affairs administrative datasets. Cumulative CRC incidence rates and incidence rate ratios were calculated and Cox proportional hazards models were used to examine the association between race and the CRC risk.

RESULTS

The cohort comprised of 20,949 patients with UC. A total of 168 incident cases of CRC were identified during 112,243 patient-years (PY) of follow-up; overall CRC incidence rate was 163/100,000 PY (95% confidence interval [CI] 139-187/100,000 PY). The CRC incidence rates were 158/100,000 PY (95% CI 134-181/100,000 PY) and 180/100,000 PY (95% CI 155-205/100,000 PY) in Caucasians and African Americans, respectively, with an incidence rate ratio of 1.17 (95% CI 0.69-1.97). The 3, 5, and 10-year cumulative incidence rates for CRC were 0.36%, 0.76%, 1.79% for African Americans and 0.41%, 0.76%, 1.43% for Caucasians. African Americans were not at an increased risk for CRC (adjusted hazard ratio: 1.10, 95% CI 0.65-1.87) compared to Caucasians.

CONCLUSIONS

In a national cohort of UC patients the risk of developing CRC in African Americans was no higher than in Caucasians. The reasons for lack of racial differences compared to sporadic CRC are not clear; access to care, genetic factors, and molecular pathways require further study.

Comparison of the natural history of ulcerative colitis in African Americans and non-Hispanic Caucasians: a historical cohort study

BACKGROUND

There has been an increase in the number of studies on the interaction of African American race and the natural history of inflammatory bowel disease (IBD). However, the results from these studies have been conflicting. We aimed to characterize the natural history of ulcerative colitis (UC) in a cohort of African American patients compared with Caucasian controls.

METHODS

We performed a retrospective chart review of patients with UC who were seen in our IBD Center from 2000 to 2010. In all, 102 African American patients and 209 Caucasian patients were included. We assessed clinical variables related to the natural history of UC as well as outcome variables that reflected disease severity.

RESULTS

African American patients had a shorter median duration (8.0, interquartile range [IQR] = 4.0, 14.0) of UC than Caucasians (10.0, IQR = 6.0, 18.0) (P = 0.006). African American disease patients had more distal disease than controls. African Americans were significantly less likely to use corticosteroids (74.2% vs. 88.8%, P = 0.002), or use immunomodulators (25.8% vs. 69.7%, P < 0.001) than Caucasians. Adjusted multivariate analysis showed that ethnicity was not a risk factor for colectomy (hazard ratio [HR] = 1.6; 95% confidence interval [CI]: 0.78, 3.3).

CONCLUSIONS

There appear to be differences in the natural history of UC in our African American patients when compared with Caucasian controls, while ethnicity was not shown to be a risk factor for colectomy.

Clinical predictors of inflammatory bowel disease in a genetically well-defined Caucasian population

Background

Crohn's disease (CD) and ulcerative colitis (UC), the two main types of inflammatory bowel disease (IBD), are multifactorial conditions of unknown etiology. The objective of this study is to examine the combined gene-environment interactions influencing IBD susceptibility in a well-defined Caucasian cohort in rural mid-America.

Methods

Patients were diagnosed to have CD or UC using conventional radiologic, endoscopic, and/or histopathologic findings. Histological diagnosis was made by a single specialist gastrointestinal pathologist with a particular interest in IBD. Information regarding cigarette smoke exposure was obtained by administration of the Behavioral Risk Factor Surveillance System Survey (BRFSS) to all patients. Genomic DNA was extracted from peripheral blood leukocytes, and polymerase chain reaction (PCR) amplification and genotyping were performed for 11 Single Nucleotide Polymorphisms (SNP) in NOD2, IL23r, OCTN1 genes along with IGR.

Results

Our cohort consists of 1196 patients: 435 controls, 485 CD patients, and 276 UC patients. Only patients with genotype data for at least 7 of 11 SNPs were included in our data analysis. The control groups for all 11 SNPs were in Hardy-Weinberg Equilibrium. In genotype-association SNP analysis, all NOD2 SNPs (rs5743293, rs2066844, rs2066845) and the IL23r SNP (rs11465804) showed a significant association to IBD (p < 0.03). A multiple gene-interaction analysis showed an association between NOD2 and IL23r with UC (p = 0.04). There were no associations between any OCTN1 and IGR SNPs and IBD in this cohort. A multivariable logistic regression analysis showed that female gender, "current" or "former" smoking status, family history of IBD, and NOD2 SNP minor alleles were associated with CD.

Conclusion

IBD remains to be challenging to properly diagnose, characterize, and treat. Our study proposes a combined genetic, phenotypic, and environmental approach in an attempt to better understand IBD. Previously demonstrated associations between OCTN1 and IGR and IBD were not confirmed.

Inflammatory Bowel Disease in Hispanics: The University of Puerto Rico IBD Registry

A registry of patients with inflammatory bowel diseases, ulcerative colitis (UC) and Crohn's disease (CD), was created at the University of Puerto Rico in 1995. Subjects with a documented diagnosis of IBD by clinical, radiologic, endoscopic, and/or pathologic criteria were recruited from the IBD clinics, support groups, and community practices, and demographic and medical data was collected. All entries from 1995 to 2009 were analyzed for demographics, family history, disease extent, extraintestinal manifestations, surgery, and smoking history. Results were described using summary statistics. 635 Hispanics living in Puerto Rico, 299 with UC and 336 with CD, were included. Mean ages were 40.3 for UC and 30.9 for CD. Over half (56%) of UC and 41% of CD were females. Family history was present in 19.3% of UC and 17.5% of CD. Surgery for IBD had been performed in 31.9% of UC and 51.2% of the CD patients. Over one-fourth of the patients reported extraintestinal manifestations, most frequently arthropathies. Our findings contribute to the limited epidemiologic and clinical data on Hispanics with IBD.

Diagnostic medical radiation in pediatric patients with inflammatory bowel disease

OBJECTIVES

Certain diagnostic radiology procedures may expose patients with inflammatory bowel disease (IBD) to radiation and increase the risk for cancer. In the present study, we quantify the acute and cumulative effective dose of diagnostic radiation received by a cohort of pediatric patients with IBD.

PATIENTS AND METHODS

Patients with IBD were identified from the medical records of a pediatric tertiary care center. The number and type of radiology procedures for each patient were determined from medical record review. Cumulative effective radiation dose was calculated using radiation effective dose estimates.

RESULTS

One hundred five patients with IBD underwent radiation-associated abdominopelvic diagnostic radiology procedures with an average cumulative radiation exposure dose of 15 (18) [mean (SD)] mSv. Forty-two percent of the patients were exposed to acute radiation doses ≥10 mSv, and 6 patients (6%) were exposed to levels of cumulative radiation exposure ≥50 mSv, which has been associated with an increased risk of cancer development. Patients with Crohn disease, an increased number of hospital admissions, and a history of surgery were more likely to have been exposed to higher levels of cumulative radiation than their clinical counterparts.

CONCLUSIONS

A majority of patients with IBD are exposed to radiation from typical diagnostic radiology procedures. Radiation-sparing procedures should be strongly considered in certain pediatric patients with IBD to reduce their risk for cancer given an already present increased lifetime malignancy potential.

Assessment of heterogeneity between European Populations: a Baltic and Danish replication case-control study of SNPs from a recent European ulcerative colitis genome wide association study

BACKGROUND

Differences in the genetic architecture of inflammatory bowel disease between different European countries and ethnicities have previously been reported. In the present study, we wanted to assess the role of 11 newly identified UC risk variants, derived from a recent European UC genome wide association study (GWAS) (Franke et al., 2010), for 1) association with UC in the Nordic countries, 2) for population heterogeneity between the Nordic countries and the rest of Europe, and, 3) eventually, to drive some of the previous findings towards overall genome-wide significance.

METHODS

Eleven SNPs were replicated in a Danish sample consisting of 560 UC patients and 796 controls and nine missing SNPs of the German GWAS study were successfully genotyped in the Baltic sample comprising 441 UC cases and 1156 controls. The independent replication data was then jointly analysed with the original data and systematic comparisons of the findings between ethnicities were made. Pearson's χ2, Breslow-Day (BD) and Cochran-Mantel-Haenszel (CMH) tests were used for association analyses and heterogeneity testing.

RESULTS

The rs5771069 (IL17REL) SNP was not associated with UC in the Danish panel. The rs5771069 (IL17REL) SNP was significantly associated with UC in the combined Baltic, Danish and Norwegian UC study sample driven by the Norwegian panel (OR = 0.89, 95% CI: 0.79-0.98, P = 0.02). No association was found between rs7809799 (SMURF1/KPNA7) and UC (OR = 1.20, 95% CI: 0.95-1.52, P = 0.10) or between UC and all other remaining SNPs. We had 94% chance of detecting an association for rs7809799 (SMURF1/KPNA7) in the combined replication sample, whereas the power were 55% or lower for the remaining SNPs.Statistically significant PBD was found for OR heterogeneity between the combined Baltic, Danish, and Norwegian panel versus the combined German, British, Belgian, and Greek panel (rs7520292 (P = 0.001), rs12518307 (P = 0.007), and rs2395609 (TCP11) (P = 0.01), respectively).No SNP reached genome-wide significance in the combined analyses of all the panels.

CONCLUSIONS

This replication study supports an important role for the studied rs5771069 (IL17REL) SNP, but not for rs7809799 (SMURF1/KPNA7), in UC etiology in the Danish, Baltic, and Norwegian populations. Significant genetic heterogeneity was suggested for rs7520292, rs12518307, and rs2395609 (TCP11) in UC etiology between the Nordic and the other European populations.

Distinguishing orofacial granulomatosis from crohn's disease: two separate disease entities?

BACKGROUND

Orofacial granulomatosis (OFG) is a rare chronic inflammatory disease of unknown etiology sharing histological features with Crohn's disease (CD). This study aimed to 1) define the clinical presentation of OFG, 2) establish differentiating features for those with CD, 3) examine if onset of OFG is predictive of CD, and 4) establish differentiating features for children.

METHODS

Data were extracted from medical notes (n = 207) for demographics, clinical features, blood parameters, diagnosis of CD, and treatment's for patients with OFG.

RESULTS

Ninety-seven patients (47%) were female. The lips (184/203; 91%) and buccal mucosa (151/203; 74%) were mainly affected. Forty-six (22%) had intestinal CD. Ulcers (24/46; 46% versus 29/159; 15%, P = <0.001) were more common in patients with CD as was a raised C-reactive protein (24/33; 73% versus 60/122; 49%, P = 0.016) and abnormal full blood count (19/41; 46% versus 35/150; 23%). The buccal-sulcus (12/44; 27% versus 20/158; 13%, P = 0.019) was more often affected in those with CD. Half the patients with CD were diagnosed prior to onset of OFG. The remainder were diagnosed after. The incidence of CD is similar for children (16/69; 23%) and adults (29/132; 22%), although oral onset in childhood is more likely to occur prior to diagnosis of CD.

CONCLUSIONS

OFG mainly presents in young adults with lip and buccal involvement. Abnormalities in inflammatory markers, hematology and oral features of ulceration, and buccal-sulcal involvement are factors more commonly associated with CD. Initial presentation of OFG does not necessarily predict development of CD, although this is more likely in childhood.

Epidemiologic characteristics of patients with inflammatory bowel disease undergoing colonoscopy

BACKGROUND

The aim was too describe the demographic characteristics of patients with inflammatory bowel disease (IBD) undergoing colonoscopy.

METHODS

The Clinical Outcomes Research Initiative (CORI) maintains a database of endoscopic procedures in diverse clinical practices distributed throughout the US. The data from 2000-2007 were used to analyze the demographic characteristics of patients with Crohn's disease (CD) and ulcerative colitis (UC).

RESULTS

During the period 2000-2007, 4631 patients with CD and 6619 patients with UC were compared to a control population of 826,207 patients without IBD. CD and UC patients were significantly (P < 0.0001) younger than controls: 41.7 ± 18.4, 47.3 ± 17.4, 59.2 ± 14.0 years, respectively. CD and UC were less common among nonwhite than white endoscopy patients: odds ratio (OR) = 0.64 (0.58-0.70) for CD and OR = 0.71 (0.66-0.77) for UC. Endoscopy for IBD was only slightly less common among female than male CD patients (0.94, 0.89-1.00), but significantly less common among female than male UC patients (0.72, 0.68-0.75). Compared with community/private practices, relatively more endoscopies were performed among IBD patients in academic institutions: OR = 1.68 (1.56-1.81) for CD and OR = 1.27 (1.19-1.36) for UC. The race-, sex-, and age-adjusted rates of CD and UC were both significantly higher in the northern than southern regions of the US, with a significant correlation of r = 0.89, degrees of freedom = 4, P = 0.017 between the geographic distributions of the two diagnoses.

CONCLUSIONS

The endoscopy patterns of IBD patients may be influenced in part by the epidemiology of these two diagnoses, as well as by underlying trends in the utilization of colonoscopy.

Epidemiology of inflammatory bowel disease among an indigent multi-ethnic population in the United States

BACKGROUND

Environmental factors, including socioeconomic status, may affect inflammatory bowel disease (IBD). There is a paucity of data on the epidemiology of IBD among patients of low socioeconomic status.

AIM

To examine the epidemiologic features of IBD among African-American, Hispanic, and Caucasian patients from a county hospital, where the majority of the patients are socioeconomically disadvantaged.

METHODS

A retrospective study was conducted on a cohort of patients diagnosed with IBD based on clinical, radiologic, endoscopic, and histological data. We reviewed charts of adults aged 20-70 years diagnosed with IBD between 2000 and 2006. Demographic data, disease subtype, and phenotypic features of IBD were recorded based on the Montreal Classification. The data were analyzed using the chi-square, Fisher exact, Wilcoxon rank-sum, and Student's t-tests.

RESULTS

The study cohort included 273 patients, with 54% female, 30% Caucasian, 44% African-American, and 26% Hispanic. Over half (54%) of the patients had Crohn's disease (CD), and 46% had ulcerative colitis (UC). The mean age at diagnosis was 40 ± 14 years with no significant difference between CD and UC (age 43 ± 13 versus 44.5 ± 14, respectively; P = 0.5). Females were diagnosed at a significantly later age than males (46 ± 13 years versus 40 ± 13, respectively; P = 0.001). This trend remained significant for females with CD and UC, and across each racial/ethnic group. Hispanic patients were diagnosed with UC more often than Caucasian patients (64% versus 34%; odds ratio [OR] 3.5; 95% confidence interval [CI]: 1.8-6.5, P = 0.0003) or African-Americans (64% versus 43%; OR 2.3; 95% CI: 1.3-4.3, P = 0.005). Among the 147 patients with CD, 54% had fistulizing and/or stricturing disease. The prevalence of fistulizing, stricturing, and inflammatory CD was similar across all age, gender, and racial/ethnic groups.

CONCLUSIONS

Within an indigent population, UC was diagnosed more often in Hispanics than CD. Females were diagnosed at a significantly older age than males across all racial/ethnic groups. There was no difference in the CD phenotypes between the three ethnic groups. Understanding the epidemiology of IBD will require examination of the interactions between gender, race/ethnicity, and environmental factors.

African-American inflammatory bowel disease in a Southern U.S. health center

Background

Inflammatory Bowel Diseases (IBD) remain significant health problems in the US and worldwide. IBD is most often associated with eastern European ancestry, and is less frequently reported in other populations of African origin e.g. African Americans ('AAs'). Whether AAs represent an important population with IBD in the US remains unclear since few studies have investigated IBD in communities with a majority representation of AA patients. The Louisiana State University Health Sciences Center in Shreveport (LSUHSC-S) is a tertiary care medical center, with a patient base composed of 58% AA and 39% Caucasian (W), ideal for evaluating racial (AA vs. W) as well and gender (M vs. F) influences on IBD.

Methods

In this retrospective study, we evaluated 951 visits to LSUHSC-S for IBD (between 2000 to 2008) using non-identified patient information based on ICD-9 medical record coding (Crohn's disease 'CD'-555.0- 555.9 and ulcerative colitis 'UC'-556.0-556.9).

Results

Overall, there were more cases of CD seen than UC. UC and CD affected similar ratios of AA and Caucasian males (M) and females (F) with a rank order of WF > WM > AAF > AAM. Interestingly, in CD, we found that annual visits per person was the highest in AA M (10.7 ± 1.7); significantly higher (* -p < 0.05) than in WM (6.3 ± 1.0). Further, in CD, the female to male (F: M) ratio in AA was significantly higher (*- p < 0.05) (1.9 ± 0.2) than in Caucasians (F:M = 1.3 ± 0.1) suggesting a female dominance in AACD; no differences were seen in UC F: M ratios.

Conclusion

Although Caucasians still represent the greatest fraction of IBD (~64%), AAs with IBD made up >1/3 (36.4%) of annual IBD cases from 2000-2008 at LSUHSC-S. Further studies on genetic and environments risks for IBD risk in AAs are needed to understand differences in presentation and progression in AAs and other 'non-traditional' populations.