Similar geographic variations of mortality and hospitalization associated with IBD and Clostridium difficile colitis

Similar geographic distribution of mortality from multiple sclerosis, Hodgkin lymphoma, and inflammatory bowel disease in the United States

BACKGROUND

Previous epidemiologic studies have suggested a linkage between the occurrence of multiple sclerosis (MS), Hodgkin lymphoma (HL), Crohn's disease (CD), and ulcerative colitis (UC). It was hypothesized that the 4 diagnoses would be characterized by similar geographic distributions within the United States.

AIMS

To compare the US geographic distributions of these 4 diagnoses in a cross-sectional study.

METHODS

Using the US vital statistics, state-specific death rates and age-specific proportional mortality ratios (PMR) were calculated for each diagnosis. Similarities in the geographic distributions of the 4 diagnoses were tested by linear and Poisson regression analyses. The PMR values from different states were correlated among pairs of consecutive age-groups.

RESULTS

The 6 linear correlation coefficients (r) among the geographic distributions of the 4 diseases were as follows: HL vs. MS (r = 0.28), HL vs. CD (r = 0.74), HL vs. UC (r = 0.64); MS vs. CD (r = 0.18), MS vs. UC (r = 0.66); CD vs. UC (r = 0.58). Using Poisson regression, the geographic distributions of MS, HL, CD, and UC were all found to be significantly correlated with each other. In MS, significant correlations between the PMR values of each two consecutive age-groups started with the age-group 25-44 years. In HL, such significant correlations started at age 10-14, in CD at age 20-24, and in UC at age 20-24 years.

CONCLUSIONS

Within the United States, mortality from MS, HL, CD, and UC are characterized by similar geographic distributions. The environmental influences responsible for these resembling geographic distributions start exerting their influence during early lifetime.

Similar geographic distributions of death rates from inflammatory bowel disease and Hodgkin lymphoma or multiple sclerosis

BACKGROUND

A previous comparative analysis of the time trends of Hodgkin lymphoma (HL), multiple sclerosis (MS), Crohn's disease (CD), and ulcerative colitis (UC) suggested that the occurrence of all four diseases was precipitated by exposure to similar environmental risk factors during early lifetime. In the present cross-sectional study, it was hypothesized that besides their resembling temporal variations the four diseases would also show similar geographic distributions.

METHODS

Using the vital statistics of 21 countries from 1951 to 2020, overall and age-specific death rates from the four diseases were calculated for each individual country. The death rates of different countries were compared using linear regression analysis.

RESULTS

The data revealed strikingly similar geographic distributions of all four diseases. Their occurrence was common in Europe and relatively uncommon in countries outside Europe. Further stratification by consecutive age groups showed that for each disease analyzed separately, there were significant correlations amongst each two sequential age groups. In HL and UC, the inter-age correlations started at age 5 years or less. In MS and CD, the inter-age correlations only started at age 15 years.

CONCLUSIONS

The similarities in the geographic distributions of death rates from HL, MS, CD, and UC suggest that these four diseases share a set of one or more common environmental risk factors. The data also support the contention that the exposure to such shared risk factors starts during an early period of lifetime.

Similar Time Trends of Hodgkin Lymphoma, Multiple Sclerosis, and Inflammatory Bowel Disease

BACKGROUND

The Epstein-Barr virus (EBV) plays a role in the causation of Hodgkin lymphoma (HL) and multiple sclerosis (MS). A previous study showed that the time trends of mortality from Crohn's disease (CD) and MS shared striking similarities. It was hypothesized that such similarities would also involve the time trends of ulcerative colitis and HL.

AIMS

To compare the time trends of CD and UC with those of HL and MS in 6 different countries.

METHODS

Using the vital statistics of England, Canada, Netherlands, Scotland, Switzerland, and United States from 1951 to 2020, the time trends of mortality from these 4 diseases were compared. The time-dependent changes of death rates were subjected to a birth-cohort analysis.

RESULTS

Similar trends were observed in all 6 countries. UC mortality rose among generations born during the nineteenth century and decreased among all generations born subsequently during the twentieth century. CD mortality was similarly characterized by a birth-cohort pattern with a rise and fall that were shifted by 20-30 years towards more recent generations when compared to UC. The birth-cohort pattern of UC was matched by a similar pattern of HL, whereas the birth-cohort pattern of CD was matched by a similar pattern of MS.

CONCLUSIONS

The similarities in the ubiquitous birth-cohort patterns of UC, CD, HL, and MS suggest that these 4 diseases share a common environmental risk factor. Such risk factor may be linked to EBV or its acquisition during an early period of a patient's lifetime.

Obesity Is Associated with Increased Risk of Colectomy in Inflammatory Bowel Disease Patients Hospitalized with Clostridium difficile Infection

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.

The incidence and outcomes from Clostridium difficile infection in hospitalized adults with inflammatory bowel disease

OBJECTIVES

Clostridium difficile infection (CDI) may worsen outcomes in patients with inflammatory bowel disease (IBD), but large database-driven studies have conflicting results. The study objective is to analyze clinical features and outcomes in patients with CDI and IBD using the National Hospital Discharge Survey (NHDS) database from 2005 to 2009.

MATERIALS AND METHODS

NHDS collects the clinical information on patients dismissed from non-Federal short-stay United States hospitals. CDI and IBD patients were identified using ICD-9 codes. Demographics, diagnoses, procedures, length of stay (LOS) and dismissal information were abstracted.

RESULTS

Of an estimated 162 million hospitalizations; 5.62 × 10⁵ were for IBD (0.35%); 53.2% were female. CDI developed in 3.7% of hospitalized IBD patients as compared to 0.78% of all adults (OR, 3.9; 95% CI, 3.3-4.6; p < .0001). African-Americans with IBD had a higher likelihood of CDI compared to Caucasians with IBD (OR, 1.67; 95% CI, 1.59-1.75; p < .0001). After adjusting for age, sex and comorbidities, IBD patients with CDI had a longer LOS (mean difference 1 day, p < .0001), higher all-cause, in-hospital mortality (adjusted OR, 4.5; 95% CI, 4.2-4.9; p < .0001), and a higher risk of dismissal to a care facility (adjusted OR, 2.3; 95% CI, 2.2-2.4; p < .0001).

CONCLUSIONS

CDI in IBD patients prolonged hospitalization and increased in-hospital mortality and likelihood of dismissal to a care-facility as compared to IBD patients without CDI. CDI was more common among African-American IBD patients compared to IBD patients of other races.

Hospitalizations for Crohn's Disease - United States, 2003-2013

In 2009, an estimated 565,000 Americans had Crohn's disease (1), an inflammatory bowel disorder that can affect any part of the gastrointestinal tract. Symptoms include persistent diarrhea, abdominal cramps and pain, constipation leading to bowel obstruction, and rectal bleeding.* Symptoms sometimes intensify in severity and require hospitalization and surgeries of the small intestine, colon, or rectum (2). Hospital discharge data from the National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) were used to estimate U.S. hospitalizations^† for Crohn's disease as both the first-listed and any-listed^§ discharge diagnosis and common surgical procedures during hospitalizations with Crohn's disease as first-listed diagnosis from 2003 to 2013, the most recent decade of data. Despite new therapies that were expected to improve remission and reduce hospitalizations, estimated numbers (and age-adjusted rates per 100,000 U.S. population) of hospitalizations for Crohn's disease as the first-listed diagnosis did not change significantly from 2003 to 2013. The proportion of these hospitalizations during which small bowel resection was performed decreased from 4.9% in 2003 to 3.9% in 2013 (p<0.05); however, colorectal resection and fistula repair rates remained stable. Hospital stays for any-listed Crohn's disease increased from >120,000 (44.2 per 100,000) in 2003 to >196,000 (59.7 per 100,000) in 2013 (p<0.05). Patient education initiatives should focus on increasing awareness of exacerbating factors and medication compliance to prevent hospitalizations.

Clostridium difficile Infection and Risk of Colectomy in Patients with Inflammatory Bowel Disease: A Bias-adjusted Meta-analysis

BACKGROUND

Clostridium difficile infection (CDI) is a common complication of inflammatory bowel diseases (IBDs) and is associated with worse outcome. Variable rates of colectomy have been reported among IBD complicated by CDI. We conducted a systematic review and meta-analysis of studies to assess the association between CDI and colectomy among patients with IBD.

METHODS

The literature was systematically searched using PubMed from inception through April 2016. Studies were limited to cohort, case-control, and cross-sectional studies reporting colectomy risk stratified by CDI in patients with IBD. We estimated summary ORs and 95% CIs using the quality-effects model. Study quality was assessed using an adaptation of the Newcastle-Ottawa scale.

RESULTS

Six studies were included in the meta-analysis, comprising 8 data sets. Results from meta-analysis showed that CDI was a significant risk factor for colectomy among patients with IBD, mainly patients with ulcerative colitis, almost doubling the odds (OR 1.90; 95% CI, 1.23-2.93). There was significant heterogeneity across studies (Q = 22.02, P < 0.001; I = 68%). Funnel plots were grossly asymmetrical. Results of sensitivity analysis restricting studies to those reporting ulcerative colitis only and studies using laboratory tests to confirm CDI were consistent with the result from the main analysis.

CONCLUSIONS

CDI is a significant risk factor for colectomy in patients with IBD. Further research is needed to investigate the attributable risks of surgery due to CDI among patients with Crohn's disease.

Mortality Trends in Crohn's Disease and Ulcerative Colitis: A Population-based Study in Québec, Canada

BACKGROUND

Mortality rates greater than in the general population have been reported in the population with Crohn's disease (CD), but reports for ulcerative colitis (UC) are conflicting. Trends with time were rarely described. We aimed to assess whether CD and UC mortality in Québec differs from that in the general population and to describe the trends over a 10-year observation period.

METHODS

This is a population-based cohort study using the Québec administrative health databases and death certificates registry. All-cause and cause-specific standardized mortality ratios (SMRs) were computed for 1999 to 2008. A time trend analysis was used to assess changes in the SMR with the calendar year.

RESULTS

All-cause mortality was significantly increased in CD and UC compared to the general population: SMR: CD 1.45 (95% confidence interval: 1.34-1.58), UC 1.21 (95% confidence interval: 1.12-1.32). In CD, mortality from digestive conditions, all neoplasms, digestive neoplasms, and colorectal, lymphatic, and lung cancer was significantly higher than in the general population. In UC, mortality from digestive, respiratory, and infectious conditions was also significantly increased. In both CD and UC, there was a decrease with time in all-cause SMRs and in digestive conditions, digestive neoplasms, colorectal cancer, and infectious diseases. SMRs for lung cancer and respiratory conditions increased over time in CD.

CONCLUSIONS

All-cause mortality was significantly higher in CD and UC populations than in the general population. However, a decreasing trend with time was observed in all-cause and some cause-specific SMRs. In CD, SMRs for lung cancer and respiratory conditions increased during the observation period.

The role of geographical ecological studies in identifying diseases linked to UVB exposure and/or vitamin D

Using a variety of approaches, researchers have studied the health effects of solar ultraviolet (UV) radiation exposure and vitamin D. This review compares the contributions from geographical ecological studies with those of observational studies and clinical trials. Health outcomes discussed were based on the author's knowledge and include anaphylaxis/food allergy, atopic dermatitis and eczema, attention deficit hyperactivity disorder, autism, back pain, cancer, dental caries, diabetes mellitus type 1, hypertension, inflammatory bowel disease, lupus, mononucleosis, multiple sclerosis, Parkinson disease, pneumonia, rheumatoid arthritis, and sepsis. Important interactions have taken place between study types; sometimes ecological studies were the first to report an inverse correlation between solar UVB doses and health outcomes such as for cancer, leading to both observational studies and clinical trials. In other cases, ecological studies added to the knowledge base. Many ecological studies include other important risk-modifying factors, thereby minimizing the chance of reporting the wrong link. Laboratory studies of mechanisms generally support the role of vitamin D in the outcomes discussed. Indications exist that for some outcomes, UVB effects may be independent of vitamin D. This paper discusses the concept of the ecological fallacy, noting that it applies to all epidemiological studies.

Vitamin D deficiency in patients with intestinal malabsorption syndromes--think in and outside the gut

There is a very high prevalence of vitamin D deficiency, which is defined by a serum level of 25-hydroxyvitamin D [25(OH)D] of lower than 20 ng/mL, in all populations of the world. Unfortunately, the prevalence of vitamin D deficiency in patients with intestinal malabsorption syndromes, including cystic fibrosis (CF), celiac disease (CD), short bowel syndrome and inflammatory bowel disease (IBD), is higher than that in the general population, indicating the presence of disease-specific causative factors. In this review, we aimed to present clinical findings to highlight the roles of insufficient exposure to sunlight and inflammation in the development of vitamin D deficiency in patients with intestinal malabsorption syndromes. Furthermore, we aimed to present experimental evidence that supported a role of vitamin D deficiency in the pathogenesis of IBD. Finally, we reviewed clinical intervention strategies aiming to normalize vitamin D status in and even to improve the conditions of patients and to discuss certain issues that needed to be addressed in future research.

The impact of Clostridum difficile on surgical rate among ulcerative colitis patients: A systemic review and meta-analysis

There is growing recognition of the impact of Clostridum difficile infection (CDI) on patients with inflammatory bowel disease. Clostridium difficile infection causes greater morbidity and mortality. This study aimed to evaluate the impact of C. difficile on surgical risk among ulcerative colitis (UC) patients. We searched the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, ACP Journal Club, DARE, CMR, and HTA. Studies were included if fulfilled the following criteria: (1) Cohort or case-control studies, which involved a comparison group that lacked CDI, (2) Patients were given a primary diagnosis of UC, (3) Comorbidity of CDI was evaluated by enzyme immunoassay of stool for C. difficile toxin A and B or C. difficile stool culture, (4) Studies evaluated surgical rate, and (5) Studies reported an estimate of odds ratio, accompanied by a corresponding measure of uncertainty. Five studies with 2380 patients fulfilled the inclusion criteria. Overall, meta-analysis showed that UC with CDI patients had a significant higher surgical rate than patients with UC alone. (OR=1.76, 95% CI=1.36-2.28). C. difficile infection increased the surgical rate in UC patients. However, results should be interpreted with caution, given the limitations of this stud.

Inflammatory bowel disease

Scandinavian researchers have contributed to the present understanding of inflammatory bowel disease (IBD). Important epidemiological data and family risk factors have been reported from all the Nordic countries, original twin studies mainly from Denmark and Sweden, and relationships to cancer and surgery mostly from Sweden. In collaboration with the industry, development of medical compounds was for a long time in the front line of international research, and the Scandinavian countries participated in the clinical breakthrough of biologic treatment. At present, many Nordic centers are working in the forefront of IBD research. An increasing number of young investigators have entered the scene along with the extended distribution of University clinics and research laboratories in these countries. This presentation of IBD gives a brief overview in the fields of clinical epidemiology and molecular biology. Many areas are covered by International collaborations with partners from Nordic centers. IBD was a topic focused by the founders of Scandinavian Journal of Gastroenterology. After 50 years one may state that the journal's history reflects important pieces of scientific knowledge within these diseases. The early scope of Johannes Myren for IBD was shown through his work in the original World Association of Gastroenterology (OMG), and after 50 years we can clearly support the view that global perspectives in IBD are increasingly important.

The prevalence of Clostridium difficile infection in pediatric and adult patients with inflammatory bowel disease

OBJECTIVES

Adults with inflammatory bowel disease (IBD) have a high prevalence of Clostridium difficile infection (CDI). CDI in children with IBD may differ from adults. We aim to compare the prevalence of CDI in hospitalized pediatric and adult IBD patients and patients without IBD.

METHODS

The rates of CDI per 1,000 IBD and non-IBD hospitalizations between 1993 and 2012 were examined using the Maryland Health Services Cost Review Commission database. Age, sex and calendar year adjusted incidence rate ratios comparing CDI in pediatrics and adults by type of IBD and with patients without IBD were calculated. p values for trend identifying changes in rates over time were calculated.

RESULTS

Among children, the rate of CDI was over 12 times greater in IBD than non-IBD hospitalizations (p < 0.0001) and among adults, the rate of CDI was four times greater in IBD than non-IBD hospitalizations (p < 0.0001). In adults, CDI was significantly higher in ulcerative colitis (UC) than Crohn's disease (60.4 per 1,000 vs. 19.8 per 1,000, p < 0.0001) but in children there was no difference in CDI in UC compared with Crohn's disease (32 per 1,000 vs. 27 per 1,000, p = 0.45). The prevalence of CDI increased in pediatric and adult IBD patients, and patients without IBD, between 1993 and 2012 (p for trend <0.0001).

CONCLUSIONS

CDI was more common in adult patients with UC, and no difference was found between CDI and IBD type in pediatrics. There may be different risk factors for CDI during hospitalization between adults and children with IBD.

Seasonality and pediatric inflammatory bowel disease

OBJECTIVES

Seasonal and geographic variations of inflammatory bowel disease (IBD) exacerbations have been described in adults, with inconsistent findings. We sought to determine whether disease activity in pediatric-onset IBD is associated with a seasonal pattern.

METHODS

We examined children with Crohn disease (CD) and ulcerative colitis (UC) using data from the ImproveCareNow Collaborative between December 2008 and November 2010. We compared the proportion of patients in continuous remission for all recorded visits in each season. We also compared the distribution of all recorded visits with a physician global assessment (PGA) of remission or active disease across seasons.

RESULTS

A total of 1325 patients with CD (6102 visits) and 587 patients with UC (2394 visits) were included. The proportion of patients with UC in continuous remission during each season was highest in the summer (67%) and lowest in the winter (55%) (P=0.01). A similar pattern was found for CD but was not significant. Similarly, the proportion of visits in remission was highest in the summer and lowest in the winter for both UC (29%, 21%; P<0.001) and CD (28%, 23%; P<0.001); however, the distribution of visits with active disease was not significantly different across seasons.

CONCLUSIONS

The higher proportion of patients with UC in continuous remission in the summer may be related to the higher proportion of remission visits in the summer, because the proportion of visits with active disease was similar across seasons. These findings do not support any strong associations between season of the year and disease activity in pediatric IBD.

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.

Systematic review: Clostridium difficile and inflammatory bowel disease

BACKGROUND

There is increasing concern about the apparently rising incidence and worsening outcome of Clostridium difficile infection (CDI) associated with inflammatory bowel disease (IBD). We have systematically reviewed the literature to evaluate the incidence, risk factors, endoscopic features, treatment and outcome of CDI complicating IBD.

AIM

To systematically review: clostridium difficile & inflammatory bowel disease.

METHODS

Structured searches of Pubmed up to September 2010 for original, cross-sectional, cohort and case-controlled studies were undertaken.

RESULTS

Of 407 studies, 42 met the inclusion criteria: their heterogeneity precluded formal meta-analysis. CDI is commoner in active IBD, particularly ulcerative colitis, than in controls. Certainty about a temporal trend to its increasing incidence in IBD is compromised by possible detection bias and miscoding. Risk factors include immunosuppressants and antibiotics, the latter less commonly than in controls. Endoscopy rarely shows pseudomembranes and is unhelpful for diagnosing CDI in IBD. There are no controlled therapeutic trials of CDI in IBD. In large studies, outcome of CDI in hospitalised IBD patients appears worse than in controls.

CONCLUSIONS

The complication of IBD by Clostridium difficile infection has received increasing attention in the past decade, but whether its incidence is really increasing or its outcome worsening remains unproven. Therapeutic trials of Clostridium difficile infection in IBD are lacking and are needed urgently.