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Valentine KD, Leavitt L, Sepucha KR, Atlas SJ, Simmons L, Siegel L, Richter JM, Han PKJ. Uncertainty tolerance among primary care physicians: Relationship to shared decision making-related perceptions, practices, and physician characteristics. Patient Educ Couns 2024; 123:108232. [PMID: 38458091 PMCID: PMC10997439 DOI: 10.1016/j.pec.2024.108232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Understand how physicians' uncertainty tolerance (UT) in clinical care relates to their personal characteristics, perceptions and practices regarding shared decision making (SDM). METHODS As part of a trial of SDM training about colorectal cancer screening, primary care physicians (n = 67) completed measures of their uncertainty tolerance in medical practice (Anxiety subscale of the Physician's Reactions to Uncertainty Scale, PRUS-A), and their SDM self-efficacy (confidence in SDM skills). Patients (N = 466) completed measures of SDM (SDM Process scale) after a clinical visit. Bivariate regression analyses and multilevel regression analyses examined relationships. RESULTS Higher UT was associated with greater physician age (p = .01) and years in practice (p = 0.015), but not sex or race. Higher UT was associated with greater SDM self-efficacy (p < 0.001), but not patient-reported SDM. CONCLUSION Greater age and practice experience predict greater physician UT, suggesting that UT might be improved through training, while UT is associated with greater confidence in SDM, suggesting that improving UT might improve SDM. However, UT was unassociated with patient-reported SDM, raising the need for further studies of these relationships. PRACTICE IMPLICATIONS Developing and implementing training interventions aimed at increasing physician UT may be a promising way to promote SDM in clinical care.
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Affiliation(s)
- K D Valentine
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lauren Leavitt
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Karen R Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Leigh Simmons
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lydia Siegel
- Harvard Medical School, Boston, MA, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - James M Richter
- Harvard Medical School, Boston, MA, USA; Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Paul K J Han
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA.
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Williams KM, Challa PK, Lopes EW, Burke KE, Ananthakrishnan AN, Richter JM, Chan AT, Khalili H. Periodontal disease is not associated with risk of inflammatory bowel disease: Results from two prospective cohort studies in the US. Aliment Pharmacol Ther 2023; 58:1052-1061. [PMID: 37781885 DOI: 10.1111/apt.17732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/19/2023] [Accepted: 09/15/2023] [Indexed: 10/03/2023]
Abstract
AIM To examine the relationship between periodontal disease and tooth loss and risk of inflammatory bowel disease (IBD). METHODS We conducted a prospective cohort study of 86,602 women from the Nurses' Health Study (1992-2016) and 50,349 men from the Health Professionals Follow-up Study (1986-2016) with available data on periodontal disease and tooth loss. Cases of IBD were initially reported by participants and then confirmed by medical record review. We used Cox proportional hazards modelling to estimate multivariable-adjusted hazard ratios (aHRs) and 95% CIs. RESULTS Through the end of follow-up, we documented 175 cases of Crohn's disease (CD) and 209 cases of ulcerative colitis (UC). After adjustment for potential risk factors, there was no association between periodontal disease and risk of CD (pooled aHR: 0.99, 95% CI: 0.65-1.52, p = 0.970) or UC (aHR: 0.99, 95% CI: 0.68-1.45, p = 0.971). Similarly, we did not observe an association between tooth loss and risk of CD (aHR: 0.72, 95% CI: 0.43-1.21, p = 0.218) or UC (aHR: 0.89, 95% CI: 0.58-1.36, p = 0.581) in the pooled analysis. The associations were not modified by sex, age, body mass index (BMI), smoking status or NSAID use (all pinteraction > 0.87). CONCLUSION In two large prospective cohort studies, we did not observe an association between periodontal disease and tooth loss and risk of CD or UC.
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Affiliation(s)
- Katherine M Williams
- Division of Gastroenterology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Prasanna K Challa
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily W Lopes
- Division of Gastroenterology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kristin E Burke
- Division of Gastroenterology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James M Richter
- Division of Gastroenterology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew T Chan
- Division of Gastroenterology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Channing Laboratory, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Hamed Khalili
- Division of Gastroenterology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
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Tracy MS, Challa PK, Canha L, Burke K, Ananthakrishnan AN, Lopes EW, Richter JM, Chan AT, Khalili H. Endogenous Levels of Circulating Androgens Are Not Associated with Risk of Microscopic Colitis. Dig Dis Sci 2023; 68:571-579. [PMID: 36040554 DOI: 10.1007/s10620-022-07678-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/18/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Microscopic colitis is a chronic inflammatory disease that most commonly affects post-menopausal women. Exogenous hormone use has recently been linked with increased risk of microscopic colitis. Yet, it is unclear whether levels of endogenous sex hormones are also associated with risk of microscopic colitis. AIM To evaluate the association between prediagnostic plasma androgens and subsequent risk of microscopic colitis. METHODS We conducted a case-control study nested within prospective cohort studies of the Nurses' Health Study (NHS) and NHSII. Cases of microscopic colitis were each matched to two controls according to age, cohort, menopause status, fasting status, and season of plasma collection. Prediagnosis plasma levels of androgens including dehydroepiandrosterone sulfate, testosterone, and sex hormone-binding globulin were measured. We examined the association of each analyte with risk of microscopic colitis using conditional logistic regression models. RESULTS Our study included 96 cases of microscopic colitis matched to 190 controls. Plasma levels of testosterone were not associated with risk of microscopic colitis (Ptrend = 0.70). Compared to participants in the lowest quartile of plasma testosterone levels, the aOR of microscopic colitis for women in the highest quartile was 0.88, 95% CI 0.45-1.71. Similarly, we did not observe an association between dehydroepiandrosterone sulfate and sex hormone-binding globulin and risk of microscopic colitis (all Ptrend > 0.52). CONCLUSION Among women, prediagnostic circulating levels of testosterone, dehydroepiandrosterone sulfate, and sex hormone-binding globulin are not associated with risk of microscopic colitis.
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Affiliation(s)
- Michaela S Tracy
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Prasanna K Challa
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Lauren Canha
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Kristin Burke
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
- Division of Gastroenterology, Digestive Healthcare Center - Crohn's and Colitis Center, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
| | - Ashwin N Ananthakrishnan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
- Division of Gastroenterology, Digestive Healthcare Center - Crohn's and Colitis Center, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
| | - Emily W Lopes
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
- Division of Gastroenterology, Digestive Healthcare Center - Crohn's and Colitis Center, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
| | - James M Richter
- Division of Gastroenterology, Digestive Healthcare Center - Crohn's and Colitis Center, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
- Division of Gastroenterology, Digestive Healthcare Center - Crohn's and Colitis Center, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA.
- Division of Gastroenterology, Digestive Healthcare Center - Crohn's and Colitis Center, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA.
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Lopes EW, Chan SSM, Song M, Ludvigsson JF, Håkansson N, Lochhead P, Clark A, Burke KE, Ananthakrishnan AN, Cross AJ, Palli D, Bergmann MM, Richter JM, Chan AT, Olén O, Wolk A, Khalili H. Lifestyle factors for the prevention of inflammatory bowel disease. Gut 2022; 72:gutjnl-2022-328174. [PMID: 36591609 PMCID: PMC10241983 DOI: 10.1136/gutjnl-2022-328174] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/05/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To estimate the proportion of cases of Crohn's disease (CD) and ulcerative colitis (UC) that could be prevented by modifiable lifestyle factors. DESIGN In a prospective cohort study of US adults from the Nurses' Health Study (NHS; n=72 290), NHSII (n=93 909) and Health Professionals Follow-up Study (HPFS; n=41 871), we created modifiable risk scores (MRS; 0-6) for CD and UC based on established lifestyle risk factors, and healthy lifestyle scores (HLS; 0-9) derived from American healthy lifestyle recommendations. We calculated the population attributable risk by comparing the incidence of CD and UC between low-risk (CD-MRS≤1, UC-MRS≤2, HLS≥7) and high-risk groups. We externally validated our findings in three European cohorts: the Swedish Mammography Cohort (n=37 275), Cohort of Swedish Men (n=40 810) and European Prospective Investigation into Cancer and Nutrition (n=404 144). RESULTS Over 5 117 021 person-years of follow-up (NHS, HPFS: 1986-2016; NHSII: 1991-2017), we documented 346 CD and 456 UC cases. Adherence to a low MRS could have prevented 42.9% (95% CI 12.2% to 66.1%) of CD and 44.4% (95% CI 9.0% to 69.8%) of UC cases. Similarly, adherence to a healthy lifestyle could have prevented 61.1% (95% CI 16.8% to 84.9%) of CD and 42.2% (95% CI 1.7% to 70.9%) of UC cases. In our validation cohorts, adherence to a low MRS and healthy lifestyle could have, respectively, prevented 43.9%-51.2% and 48.8%-60.4% of CD cases and 20.6%-27.8% and 46.8%-56.3% of UC cases. CONCLUSIONS Across six US and European cohorts, a substantial burden of inflammatory bowel diseases risk may be preventable through lifestyle modification.
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Affiliation(s)
- Emily W Lopes
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Simon S M Chan
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mingyang Song
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
- Department of Pediatrics, Orebro universitet, Orebro, Sweden
| | - Niclas Håkansson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Kristin E Burke
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amanda J Cross
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
- Cancer Screening & Prevention Research Group, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Domenico Palli
- Cancer Risk Factors and Life-Style Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network-ISPRO, Florence, Italy
| | - Manuela M Bergmann
- Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrucke, Nuthetal, Germany
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ola Olén
- Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska institutet, Stockholm, Sweden
- Pediatric Gastroenterology Unit, Sachs' Children's Hospital, Stockholm, Sweden
| | - Alicja Wolk
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Broad Institute, of MIT and Harvard, Cambridge, MA, USA
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Dailey J, Nguyen LH, Kohli A, Ha JB, Russell MB, Dhingra R, Kiernan MS, Thomas MF, Coglianese EC, Sterling MJ, Yacavone RF, Natov N, Richter JM. A Multicenter Study of Left Ventricular Assist Device-Related Gastrointestinal Bleeding. Clin Transl Gastroenterol 2022; 13:e00526. [PMID: 36007177 PMCID: PMC9624495 DOI: 10.14309/ctg.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Continuous left ventricular assist devices (LVADs) offer hemodynamic support in advanced and decompensated heart failure but are often complicated by gastrointestinal bleeding (GIB) in medically fragile patients. METHODS We performed a retrospective analysis of 475 consecutive patients who underwent LVAD implantation at the Massachusetts General Hospital and Tufts Medical Center from 2008 to 2019 and identified 128 patients with clinically significant GIB. Clinical characteristics of each bleeding event, including procedures and interventions, were recorded. We examined LVAD patients with overt and occult presentations to determine diagnostic endoscopic yield and analyzed predictors of recurrent GIB. RESULTS We identified 128 unique patients with LVAD implantation complicated by GIB. No significant difference was observed based on study center, underlying cardiomyopathy, race/ethnicity, serum indices, and medications used. Overt bleeders presented more commonly during LVAD implantation admission ( P = 0.001) than occult bleeders. Occult bleed presentations had only 1 lower and no middle GI bleed source identified, despite similar workups to overt bleeds. Destination therapy (e.g., among nontransplant candidates) LVAD implantation (odds ratio 2.38, 95% confidence interval 1.05-5.58) and a history of GIB (odds ratio 3.85, 95% confidence interval 1.29-12.7) were independently associated with an increased risk of recurrent GIB-related hospitalization. DISCUSSION Our findings confirm a high rate of GIB, especially in destination LVAD patients, and show a low diagnostic yield for colonoscopy and middle GI bleed assessments in LVAD patients with occult bleeds. Overt bleeding was more common and associated with vascular malformations. Although endoscopic interventions stopped active hemorrhage, GIB often recurred.
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Affiliation(s)
- Joseph Dailey
- Division of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
| | - Long H. Nguyen
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Clinical and Translational Epidemiology Unit, Boston, Massachusetts, USA
| | - Arushi Kohli
- Division of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
| | - Jasmine B. Ha
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael B. Russell
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Rohit Dhingra
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Michael S. Kiernan
- Department of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Molly F. Thomas
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erin C. Coglianese
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Transplant Center, Boston, Massachusetts, USA
| | - Mark J. Sterling
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Robert F. Yacavone
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Nikola Natov
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - James M. Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Lopes EW, Lochhead P, Burke KE, Richter JM, Ananthakrishnan AN, Chan AT, Khalili H. Risk Factors for Incident Inflammatory Bowel Disease According to Disease Phenotype. Clin Gastroenterol Hepatol 2022; 20:2347-2357.e14. [PMID: 35031525 PMCID: PMC9850926 DOI: 10.1016/j.cgh.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/22/2021] [Accepted: 01/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We examined whether relationships between known risk factors for Crohn's disease (CD) and ulcerative colitis (UC) differ according to disease phenotype, defined by Montreal classification, at the time of diagnosis. METHODS We performed a prospective cohort study of 208,070 adults from the Nurses' Health Study (NHS), NHSII, and Health Professionals Follow-Up Study (HPFS). Dietary, lifestyle, and medical data were obtained at baseline and every 2-4 years. We confirmed cases of inflammatory bowel disease (IBD) and their phenotypes via medical record review. We tested for heterogeneity across CD subtypes using the likelihood ratio test and for linear heterogeneity across UC subtypes using the meta-regression method. RESULTS We ascertained 346 cases of CD and 456 cases of UC over 5,117,021 person-years of follow-up (1986-2016 for NHS and HPFS; 1991-2017 for NHSII). Fiber intake was associated with decreased risk for ileocolonic but not ileal or colonic CD (Pheterogeneity = .04). Physical activity was associated with decreased risk of nonstricturing and nonpenetrating CD but not of penetrating CD (Pheterogeneity = .02). Higher body mass index and current smoking were associated with decreased risk of proctitis and left-sided UC but not of pan-UC (Plinear heterogeneity= .004 and .02, respectively). The associations between other risk factors examined and risk of CD and UC did not differ by disease phenotype (all Pheterogeneity > .06). CONCLUSIONS In 3 large prospective cohorts, we observed that dietary and lifestyle risk factors for IBD may differ according to disease phenotype. These findings highlight the need for disease stratification in future epidemiologic studies.
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Affiliation(s)
- Emily W Lopes
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kristin E Burke
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Broad Institute of MIT and Harvard, Cambridge, Massachusetts.
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Sepucha KR, Valentine KD, Atlas SJ, Chang Y, Fairfield KM, Ha J, Leavitt L, Lee V, Percac‐Lima S, Richter JM, Simmons L. Getting patients back for routine colorectal cancer screening: Randomized controlled trial of a shared decision-making intervention. Cancer Med 2022; 12:3555-3566. [PMID: 36052811 PMCID: PMC9939149 DOI: 10.1002/cam4.5172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/11/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
Thousands of colonoscopies were canceled during the initial surge of the COVID-19 pandemic. As facilities resumed services, some patients were hesitant to reschedule. The purpose of this study was to determine whether a decision aid plus telephone coaching would increase colorectal cancer (CRC) screening and improve patient reports of shared decision making (SDM). A randomized controlled trial assigned adults aged 45-75 without prior history of CRC who had a colonoscopy canceled from March to May 2020 to intervention (n = 400) or usual care control (n = 400) arms. The intervention arm received three-page decision aid and call from decision coach from September 2020 through November 2020. Screening rates were collected at 6 months. A subset (n = 250) in each arm was surveyed 8 weeks after randomization to assess SDM (scores range 0-4, higher scores indicating more SDM), decisional conflict, and screening preference. The sample was on average, 60 years old, 53% female, 74% White, non-Hispanic, and 11% Spanish speaking. More intervention arm patients were screened within 6 months (35% intervention vs 23% control, p < 0.001). The intervention respondents reported higher SDM scores (mean difference 0.7 [0.4, 0.9], p < 0.001) and less decisional conflict than controls (-21% [-35%, -7%], p = 0.003). The majority in both arms preferred screening versus delaying (68% intervention vs. 65% control, p = 0.75). An SDM approach that offered alternatives and incorporated patients' preferences resulted in higher screening rates. Patients who are overdue for CRC screening may benefit from proactive outreach with SDM support.
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Affiliation(s)
- Karen R. Sepucha
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Kathrene D. Valentine
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Steven J. Atlas
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Yuchiao Chang
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Jasmine Ha
- Massachusetts General HospitalBostonMassachusettsUSA
| | | | - Vivian Lee
- Massachusetts General HospitalBostonMassachusettsUSA
| | - Sanja Percac‐Lima
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - James M. Richter
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Leigh Simmons
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
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8
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Sun CL, Li DK, Zenteno AC, Bravard MA, Carolan P, Daily B, Elamin S, Ha J, Moore A, Safavi K, Yun BJ, Dunn P, Levi R, Richter JM. Low-Volume Bowel Preparation Is Associated With Reduced Time to Colonoscopy in Hospitalized Patients: A Propensity-Matched Analysis. Clin Transl Gastroenterol 2022; 13:e00482. [PMID: 35347098 PMCID: PMC10476773 DOI: 10.14309/ctg.0000000000000482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 02/09/2022] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION Delays in inpatient colonoscopy are commonly caused by inadequate bowel preparation and result in increased hospital length of stay (LOS) and healthcare costs. Low-volume bowel preparation (LV-BP; sodium sulfate, potassium sulfate, and magnesium sulfate ) has been shown to improve outpatient bowel preparation quality compared with standard high-volume bowel preparations (HV-BP; polyethylene glycol ). However, its efficacy in hospitalized patients has not been well-studied. We assessed the impact of LV-BP on time to colonoscopy, hospital LOS, and bowel preparation quality among inpatients. METHODS We performed a propensity score-matched analysis of adult inpatients undergoing colonoscopy who received either LV-BP or HV-BP before colonoscopy at a quaternary academic medical center. Multivariate regression models with feature selection were developed to assess the association between LV-BP and study outcomes. RESULTS Among 1,807 inpatients included in this study, 293 and 1,514 patients received LV-BP and HV-BP, respectively. Among the propensity score-matched population, LV-BP was associated with a shorter time to colonoscopy (β: -0.43 [95% confidence interval: -0.56 to -0.30]) while having similar odds of adequate preparation (odds ratio: 1.02 [95% confidence interval: 0.71-1.46]; P = 0.92). LV-BP was also significantly associated with decreased hospital LOS among older patients (age ≥ 75 years), patients with chronic kidney disease, and patients who were hospitalized with gastrointestinal bleeding. DISCUSSION LV-BP is associated with decreased time to colonoscopy in hospitalized patients. Older inpatients, inpatients with chronic kidney disease, and inpatients with gastrointestinal bleeding may particularly benefit from LV-BP. Prospective studies are needed to further establish the role of LV-BP for inpatient colonoscopies.
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Affiliation(s)
- Christopher L.F. Sun
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Healthcare Systems Engineering, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Darrick K. Li
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ana Cecilia Zenteno
- Healthcare Systems Engineering, Massachusetts General Hospital, Boston, Massachusetts, USA
- Perioperative Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marjory A. Bravard
- Harvard Medical School, Harvard, Boston, Massachusetts, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Carolan
- Harvard Medical School, Harvard, Boston, Massachusetts, USA
- Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bethany Daily
- Healthcare Systems Engineering, Massachusetts General Hospital, Boston, Massachusetts, USA
- Perioperative Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sami Elamin
- Harvard Medical School, Harvard, Boston, Massachusetts, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jasmine Ha
- Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amber Moore
- Harvard Medical School, Harvard, Boston, Massachusetts, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kyan Safavi
- Healthcare Systems Engineering, Massachusetts General Hospital, Boston, Massachusetts, USA
- Perioperative Services, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Harvard, Boston, Massachusetts, USA
| | - Brian J. Yun
- Harvard Medical School, Harvard, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Dunn
- Healthcare Systems Engineering, Massachusetts General Hospital, Boston, Massachusetts, USA
- Perioperative Services, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Harvard, Boston, Massachusetts, USA
| | - Retsef Levi
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - James M. Richter
- Harvard Medical School, Harvard, Boston, Massachusetts, USA
- Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
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9
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Valentine KD, Leavitt L, Atlas SJ, Chen E, Ha J, Percac-Lima S, Fairfield KM, Korsen N, Han PKJ, Richter JM, Simmons L, Sepucha KR. Cross-sectional Survey Examining Patient Attitudes and Preferences for Rescheduling Screening Colonoscopies Canceled due to the COVID-19 Pandemic. MDM Policy Pract 2022; 7:23814683221141377. [PMID: 36532296 PMCID: PMC9749064 DOI: 10.1177/23814683221141377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/21/2022] [Indexed: 10/06/2023] Open
Abstract
UNLABELLED Background. Early in the COVID-19 pandemic colonoscopies for colorectal cancer (CRC) screening were canceled. Patient perceptions of the benefits and risks of routine screening relative to health concerns associated with the COVID-19 pandemic were unknown. Purpose. Assess patient anxiety, worry, and interest in CRC screening during the COVID-19 pandemic. Methods. A random sample of 200 patients aged 45 to 75 y with colonoscopy cancellation due to COVID-19 in March to May 2020 were surveyed. Anxiety, COVID-19 and CRC risk perceptions, COVID-19 and CRC worry, likelihood of following through with colonoscopy in the next month, and interest in alternatives to colonoscopy were assessed. Subsequent screening was tracked for 12 mo. Results. Respondents (N = 127/200, 63.5%) were on average 60 y old, female (59%), college educated (62% college degree or more), and White (91%). A substantial portion of patients (46%) stated they may not follow through with a colonoscopy in the next month. There was greater interest in stool-based testing than in delaying screening (48% v. 26%). Women, older patients, and patients indicating tolerance of uncertainty due to complexity reported they were less likely to follow through with colonoscopy in the next month. Greater interest in stool-based testing was related to lower perceptions of CRC risk. Greater interest in delaying screening was related to less worry about CRC and less tolerance of risk. Over 12 mo, 60% of participants completed screening. Patients who stated they were more likely to screen in the next month were more likely to complete CRC screening (P = 0.01). Conclusions. Respondents who had a colonoscopy canceled during the COVID-19 pandemic varied in interest in rescheduling the procedure. A shared decision-making approach may help patients address varying concerns and select the best approach to screening for them. HIGHLIGHTS In the wake of the first wave of the COVID-19 pandemic, almost half of patients stated they were not likely to follow through with a colonoscopy in the short term, about half were interested in screening with a stool-based test, and only one-quarter were interested in delaying screening until next year.Patients who perceived themselves at higher risk of colorectal cancer were less interested in stool-based testing, and patients who were more worried about colorectal cancer were less interested in delaying screening.A shared decision-making approach may be necessary to tailor screening discussions for patients during subsequent waves of the pandemic, other occasions where resources are limited and patient preferences vary, or where patients hold conflicting views of screening.
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Affiliation(s)
- K. D. Valentine
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
| | | | - Steven J. Atlas
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
| | | | - Jasmine Ha
- Massachusetts General Hospital, Boston, MA, USA
| | - Sanja Percac-Lima
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
| | | | | | | | - James M. Richter
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
| | - Leigh Simmons
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
| | - Karen R. Sepucha
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
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10
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Lo CH, Khandpur N, Rossato SL, Lochhead P, Lopes EW, Burke KE, Richter JM, Song M, Korat AVA, Sun Q, Fung TT, Khalili H, Chan AT, Ananthakrishnan AN. Ultra-processed Foods and Risk of Crohn's Disease and Ulcerative Colitis: A Prospective Cohort Study. Clin Gastroenterol Hepatol 2022; 20:e1323-e1337. [PMID: 34461300 PMCID: PMC8882700 DOI: 10.1016/j.cgh.2021.08.031] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The rising incidence of inflammatory bowel disease in regions undergoing Westernization has coincided with the increase in ultra-processed food (UPF) consumption over the past few decades. We aimed to examine the association between consumption of UPFs and the risk of Crohn's disease (CD) and ulcerative colitis (UC). METHODS We performed a prospective cohort study of 3 nationwide cohorts of health professionals in the United States-the Nurses' Health Study (1986-2014), the Nurses' Health Study II (1991-2017), and the Health Professionals Follow-up Study (1986-2012). We employed Cox proportional hazards models with adjustment for confounders to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for CD and UC according to self-reported consumption of UPFs. RESULTS The study included 245,112 participants. Over 5,468,444 person-years of follow-up, we documented 369 incident cases of CD and 488 incident cases of UC. The median age at diagnosis was 56 years (range, 29-85 years). Compared with participants in the lowest quartile of simple updated UPF consumption, those in the highest quartile had a significantly increased risk of CD (HR, 1.70; 95% CI, 1.23-2.35; Ptrend = .0008). Among different UPF subgroups, ultra-processed breads and breakfast foods; frozen or shelf-stable ready-to-eat/heat meals; and sauces, cheeses, spreads, and gravies showed the strongest positive associations with CD risk (HR per 1 standard deviation increase in intake, 1.18 [95% CI, 1.07-1.29], 1.11 [95% CI, 1.01-1.22], and 1.14 [95% CI, 1.02-1.27], respectively). There was no consistent association between UPF intake and UC risk. CONCLUSIONS Higher UPF intake was associated with an increased risk of incident CD. Further studies are needed to identify specific contributory dietary components.
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Affiliation(s)
- Chun-Han Lo
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Neha Khandpur
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil,Center for Epidemiological Studies in Health and Nutrition, Faculty of Public Health, University of São Paulo, São Paulo, Brazil
| | - Sinara Laurini Rossato
- Graduation course in Public Health, Federal University of Uberlandia, Uberlandia, Minas Gerais, Brazil
| | - Paul Lochhead
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Emily W. Lopes
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin E. Burke
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - James M. Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mingyang Song
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Andres Victor Ardisson Korat
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Qi Sun
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Teresa T. Fung
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Department of Nutrition, Simmons University, Boston, Massachusetts, USA
| | - Hamed Khalili
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew T. Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA,Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ashwin N. Ananthakrishnan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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11
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Lochhead P, Khalili H, Ananthakrishnan AN, Burke KE, Richter JM, Sun Q, Grandjean P, Chan AT. Plasma concentrations of perfluoroalkyl substances and risk of inflammatory bowel diseases in women: A nested case control analysis in the Nurses' Health Study cohorts. Environ Res 2022; 207:112222. [PMID: 34662575 PMCID: PMC9960490 DOI: 10.1016/j.envres.2021.112222] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/08/2021] [Accepted: 10/13/2021] [Indexed: 05/03/2023]
Abstract
BACKGROUND Perfluoroalkyl substances (PFASs) are synthetic compounds used in a wide variety of industrial and consumer applications. An association between PFAS exposure and risk of ulcerative colitis (UC) has been reported in a highly exposed population. However, data are limited on risk of inflammatory bowel diseases (IBD) among individuals with background population levels of PFAS exposure. OBJECTIVES We set out to examine the association between plasma PFAS concentrations and risk of IBD among women in two population-based, prospective cohort studies in which pre-diagnostic blood specimens were available. METHODS We conducted a nested case-control study in the Nurses' Health Study and Nurses' Health Study II cohorts. We identified 73 participants with incident Crohn's disease (CD) and 80 participants with incident UC who had provided blood samples before diagnosis. Cases were matched 1:2 to IBD-free controls. Plasma concentrations of five major PFASs were measured by liquid chromatography and tandem mass spectrometry. We used conditional logistic models to estimated odds ratios for risk of IBD according to log10-transformed PFAS concentrations, adjusting for potential confounders. RESULTS In multivariable models, we observed inverse associations between plasma concentrations of three PFASs and risk of CD (all P ≤ 0.012 for a standard deviation increase in log10PFAS). The inverse association with CD was strongest for perfluorodecanoate, where, compared to the lowest tertile, the odds ratio (OR) for the highest tertile was 0.39 (95% confidence interval, 0.17-0.92). No associations were observed between PFAS concentrations and UC risk. DISCUSSION Our results do not support the hypothesis that elevated PFAS exposure is associated with higher risk of UC. Contrary to expectation, our data suggest that circulating concentrations of some PFASs may be inversely associated with CD development.
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Affiliation(s)
- Paul Lochhead
- Clinical and Translational Epidemiology Unit, Massachusetts Hospital and Harvard Medical School, Boston, MA, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hamed Khalili
- Clinical and Translational Epidemiology Unit, Massachusetts Hospital and Harvard Medical School, Boston, MA, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Clinical and Translational Epidemiology Unit, Massachusetts Hospital and Harvard Medical School, Boston, MA, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kristin E Burke
- Clinical and Translational Epidemiology Unit, Massachusetts Hospital and Harvard Medical School, Boston, MA, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - James M Richter
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Qi Sun
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Philippe Grandjean
- Institute of Public Health, University of Southern Denmark, Odense, Denmark; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts Hospital and Harvard Medical School, Boston, MA, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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12
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Pathipati MP, Silvernale CJ, Barshop KG, Ha JB, Richter JM, Staller KD. Rectal Evacuation Disorders are Associated With Poor Bowel Preparation in Patients With Chronic Constipation: Results From Two Centers. J Clin Gastroenterol 2022; 56:438-443. [PMID: 34334764 DOI: 10.1097/mcg.0000000000001593] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/15/2021] [Indexed: 12/10/2022]
Abstract
INTRODUCTION We evaluated factors that can predict the adequacy of bowel preparation in patients with chronic constipation undergoing colonoscopy. MATERIALS AND METHODS We identified patients with chronic constipation who underwent anorectal manometry and at least 1 colonoscopy at 2 tertiary referral centers from 2003 to 2019. We also identified a subgroup of patients who underwent colonic transit testing through radiopaque marker testing. We determined demographic, medical, and constipation-related factors associated with poor bowel preparation and their effect on standardized quality metrics using univariate and multivariate analyses. RESULTS We identified 274 patients with chronic constipation who underwent anorectal manometry testing. Both outlet dysfunction (prolonged balloon expulsion) and slow-transit constipation were associated with suboptimal bowel preparation. Outlet dysfunction was also associated with decreased cecal intubation rates, adenoma detection rates, and sessile serrated polyp detection rates. In multivariable analyses controlling for demographics and known factors associated with poor bowel preparation, outlet dysfunction was associated with an almost 3-fold odds of suboptimal bowel preparation [odds ratio (OR): 2.9; 95% confidence interval (CI): 1.6-5.1] and a 3-fold reduction in cecal intubation rates (OR: 0.3; 95% CI: 0.1-0.8). Among those with radiopaque marker colonic transit testing available, slow-transit constipation was associated with a >2-fold odds of suboptimal bowel preparation (OR: 2.2; 95% CI: 1.1-4.4). CONCLUSIONS Among a cohort of patients with chronic constipation undergoing colonoscopy, outlet dysfunction was associated with suboptimal bowel preparation and other quality metrics. Constipated patients with a rectal evacuation disorder may represent a subgroup of patients that could benefit from individualized strategies for better bowel preparation.
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Affiliation(s)
- Mythili P Pathipati
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
| | - Casey J Silvernale
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
| | - Kenneth G Barshop
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jasmine B Ha
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
| | - Kyle D Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
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13
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Zapata MC, Ha JB, Hernandez-Barco YG, Richter JM. Using A Customized SMS Program to Promote Colonoscopy Adherence and Support Bowel Cleanliness for Spanish-speaking Patients. J Health Care Poor Underserved 2022; 33:1069-1082. [DOI: 10.1353/hpu.2022.0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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14
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Affiliation(s)
- James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Darrick K Li
- Section of Digestive Diseases, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
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15
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Hua X, Lopes EW, Burke KE, Ananthakrishnan AN, Richter JM, Lo CH, Lochhead P, Chan AT, Khalili H. Smoking Behaviour Changes After Diagnosis of Inflammatory Bowel Disease and Risk of All-cause Mortality. J Crohns Colitis 2022; 16:1030-1038. [PMID: 35102373 PMCID: PMC9351977 DOI: 10.1093/ecco-jcc/jjac015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/30/2021] [Accepted: 01/25/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS We examined smoking behaviour changes after diagnoses of Crohn's disease [CD] and ulcerative colitis [UC] and evaluated their impact on mortality. METHODS Study population included incident CD or UC cases from three cohorts of the Nurses' Health Study [NHS], NHSII, and Health Professionals Follow-up Study. Smoking and other risk factors were prospectively assessed. Smoking behaviour changes were categorised as never, former [i.e., quit smoking before diagnosis], quitters [i.e., quit smoking after diagnosis], and current [i.e., continue smoking after diagnosis]. Follow-up for date and cause of death was completed through linkage to the National Death Index. Cox proportional hazard regression was used to estimate hazard ratios [HRs] and 95% confidence intervals [CIs]. RESULTS Among 909 eligible CD and UC cases, 45% were never smokers, 38% were past smokers, and 16% were active smokers at the time of diagnosis. Among active smokers, 70% of patients with CD and 44% of patients with UC continued to smoke after diagnosis. In patients with CD, compared with current smokers, the multivariable-adjusted HRs [95% CI] of death were 0.19 [0.10 to 0.38] for never smokers, 0.31 [0.16 to 0.57] for former smokers, and 0.41 [0.18 to 0.93] for quitters. Similarly for UC, compared with current smokers, we observed a reduced risk of mortality for never smokers [HR = 0.23, 95% CI 0.10 to 0.51], former smokers [HR = 0.23, 95% CI 0.11 to 0.48], and quitters [HR = 0.28, 95% CI 0.11 to 0.72]. CONCLUSIONS In three cohorts of health professionals, a substantial proportion of patients with new diagnosis of CD and UC and history of smoking continued to smoke after diagnosis. Smoking cessation around the time of diagnosis was associated with a significant reduction in mortality.
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Affiliation(s)
- Xinwei Hua
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Emily W Lopes
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kristin E Burke
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Chun-Han Lo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Corresponding author: Hamed Khalili, MD, MPH, Digestive Healthcare Center, Crohn’s and Colitis Center, Massachusetts General Hospital, 165 Cambridge Street, 9th Floor, Boston, MA 02114, USA. Tel.: 617 726 7933; fax: 617 726 3080;
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16
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Lopes EW, Lebwohl B, Burke KE, Ivey KL, Ananthakrishnan AN, Lochhead P, Richter JM, Ludvigsson JF, Willett WC, Chan AT, Khalili H. Dietary Gluten Intake Is Not Associated With Risk of Inflammatory Bowel Disease in US Adults Without Celiac Disease. Clin Gastroenterol Hepatol 2022; 20:303-313.e6. [PMID: 33775898 PMCID: PMC8586848 DOI: 10.1016/j.cgh.2021.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/15/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Diet is thought to play a role in the development of inflammatory bowel disease (IBD), though it is unknown whether gluten intake confers risk of IBD. The aim of this study was to determine the relationship between gluten intake and risk of incident Crohn's disease (CD) and ulcerative colitis (UC). METHODS We performed a prospective cohort study of 208,280 US participants from the Nurses' Health Study (1986-2016), Nurses' Health Study II (1991-2017), and the Health Professionals Follow-up Study (1986-2016) who did not have IBD at baseline or celiac disease, and who completed semiquantitative food frequency questionnaires. We used Cox proportional hazards modeling to estimate the risk of IBD according to quintiles of cumulative average energy-adjusted dietary gluten intake over the follow-up period. RESULTS We documented 337 CD cases and 447 UC cases over 5,115,265 person-years of follow-up evaluation. Dietary gluten intake was not associated with risk of IBD. Compared with participants in the lowest quintile of gluten intake, the adjusted hazard ratios and 95% CIs for participants in the highest quintile of gluten intake were 1.16 (95% CI, 0.82-1.64; Ptrend = .41) for CD and 1.04 (95% CI, 0.75-1.44; Ptrend = .64) for UC. Adjusting for primary sources of gluten intake did not materially change our estimates. CONCLUSIONS In 3 large adult US prospective cohorts, gluten intake was not associated with risk of CD or UC. Our findings are reassuring at a time when consumption of gluten has been increasingly perceived as a trigger for chronic gastrointestinal diseases.
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Affiliation(s)
- Emily W. Lopes
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kristin E. Burke
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA
| | - Kerry L. Ivey
- Department of Nutrition and Dietetics, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA,South Australian Health and Medical Research Institute, Infection and Immunity Theme, School of Medicine, Flinders University, Adelaide, SA, Australia
| | - Ashwin N. Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA,Clinical and Translation Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston MA
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA
| | - James M. Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Walter C Willett
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA,Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew T. Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA,Clinical and Translation Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston MA,Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Clinical and Translation Epidemiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts.
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17
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Casey K, Lopes EW, Niccum B, Burke K, Ananthakrishnan AN, Lochhead P, Richter JM, Chan AT, Khalili H. Alcohol consumption and risk of inflammatory bowel disease among three prospective US cohorts. Aliment Pharmacol Ther 2022; 55:225-233. [PMID: 34881819 DOI: 10.1111/apt.16731] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/15/2021] [Accepted: 11/28/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS There are limited data on alcohol dose and types and risk of Crohn's Disease (CD) and Ulcerative Colitis (UC). We therefore sought to comprehensively examine the association between alcohol consumption and risk of CD and UC. METHODS We conducted a prospective cohort study of 237,835 participants from the Nurses' Health Study, Nurses' Health Study II, and Health Professional Follow-Up Study. Alcohol consumption was obtained through questionnaires submitted every four years; additional covariates were obtained at two or four-year intervals. Cases were confirmed independently by two physicians through medical record review. We used Cox proportional hazards regression to estimate age and multivariable-adjusted hazards ratios and 95% confidence intervals. RESULTS Across 5,170,474 person-years of follow-up, 370 cases of CD and 486 cases of UC were documented. Increased consumption of alcohol intake was not associated with CD (Ptrend = 0.455) or UC (Ptrend = 0.745). Compared to non-users, the MV-adjusted HRs for 15.0 + g/day of alcohol intake group were 0.84 (95% CI 0.56, 1.24) for CD and 1.08 (95% CI 0.77, 1.51) for UC. In analyses of alcohol subtypes, we observed that only moderate consumption of beer (>1-4 servings/week) was marginally associated with reduced risk of CD, while consumption of >4 servings/week of liquor was associated with an increased risk of UC. CONCLUSION This prospective study did not identify a relationship between overall alcohol consumption and risk of CD or UC. Our suggestive associations between alcohol types and risk of CD and UC deserve additional investigation.
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Affiliation(s)
- Kevin Casey
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily W Lopes
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Blake Niccum
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kristin Burke
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ashwin N Ananthakrishnan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Lochhead
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hamed Khalili
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
BACKGROUND Patients with cirrhosis and ascites experience frequent hospital admissions, leading to poor quality of life and high healthcare costs. Monitoring weight is a component of ascites care and telemonitoring may improve outcomes and costs. Goals We aimed to evaluate the cost and outcomes of current care compared to a telemonitoring system for ascites. Study We developed a decision-analytic model that examined 100 simulated patients over a 6-month horizon. We compared usual care to a new telemonitoring program, which we estimate costs $50,000/6 months. RESULTS The cost of standard of care for 100 patients with cirrhotic ascites over a 6-month period is $167,500 more expensive than telemonitoring. By varying parameter probabilities by ± 10% and outcome costs by ± 20%, we found that standard of care remains more expensive than care with a telemonitoring intervention by $9400 to $340,200 per 6-month period. Standard of care leads to 9 more admissions (range 4 to 12) than a telemonitoring intervention, while telemonitoring leads to 9 more outpatient visits (range 6 to 9) and 28 additional outpatient large volume paracenteses (LVPs) (range 17 to 28). With more and less expensive telemonitoring interventions, standard of care remained more expensive. With 50% adherence to the intervention, standard of care was $89,848 more expensive. CONCLUSIONS In almost all probability and cost scenarios, a telemonitoring intervention is cost-saving for the management of cirrhotic ascites. Using hospital admissions as a surrogate for quality of care, patient outcomes are improved primarily though more proactive medical intervention and more LVPs.
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Affiliation(s)
- Patricia P. Bloom
- Gastrointestinal Unit, University of Michigan, Taubman Center, Floor 1, Reception G, 1500 E. Medical Center Dr., Ann Arbor, MI USA
| | - Martin Ventoso
- Department of Medicine, Harvard Medical School, Boston, USA
| | - Elliot Tapper
- Gastrointestinal Unit, University of Michigan, Taubman Center, Floor 1, Reception G, 1500 E. Medical Center Dr., Ann Arbor, MI USA
| | - Jasmine Ha
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA
| | - James M. Richter
- Department of Medicine, Harvard Medical School, Boston, USA ,Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA
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19
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Niccum B, Casey K, Burke K, Lopes EW, Lochhead P, Ananthakrishnan A, Richter JM, Ludvigsson JF, Chan AT, Khalili H. Alcohol Consumption is Associated With An Increased Risk of Microscopic Colitis: Results From 2 Prospective US Cohort Studies. Inflamm Bowel Dis 2021; 28:1151-1159. [PMID: 34473269 PMCID: PMC9340522 DOI: 10.1093/ibd/izab220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND No dietary factors have yet been shown to conclusively impact the incidence of microscopic colitis (MC). Here, we sought to examine the relationship between alcohol intake and the risk of MC. METHODS We conducted a prospective cohort study of 209,902 participants (age range, 28.5-66.7 years) enrolled in the Nurses' Health Study (NHS) and Nurses' Health Study II (NHSII). Validated data on alcohol consumption were collected at baseline in 1986 in the NHS and 1991 in the NHSII and updated every 4 years. Diagnoses of MC were confirmed via review of histopathology data. We used Cox proportional hazards modeling to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). RESULTS Through 2016 in the NHS and 2017 in the NHSII, we confirmed 352 incident cases of MC over 4,994,324 person-years. Higher alcohol consumption was associated with an increased risk of MC (Ptrend < .001). Compared to non-users, the aHRs of MC were 1.20 (95% CI, 0.86-1.67) for consumers of 0.1-4.9 g/day of alcohol, 1.90 (95% CI, 1.34-2.71) for consumers of 5-14.9 g/day, and 2.31 (95% CI, 1.54-3.46) for consumers of ≥15 g/day. The associations were consistent across the histologic subtypes of collagenous and lymphocytic colitis (Pheterogeneity = .523). When stratified by alcohol type, the risk according to every 2 servings/week appeared to be strongest with consumption of wine (aHR, 1.08; 95% CI, 1.04-1.12) as compared to beer (aHR, 1.01; 95% CI, 0.91-1.12) or liquor (aHR, 1.00; 95% CI, 0.92-1.09). CONCLUSIONS Alcohol consumption was associated with an increased risk of MC. Further studies are needed to determine the mechanism underlying these associations, as well as the impact of reducing alcohol intake in patients with MC.
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Affiliation(s)
- Blake Niccum
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin Casey
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kristin Burke
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Emily W Lopes
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Ashwin Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Pediatrics, Orebro University Hospital, Orebro, Sweden,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, UK,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Hamed Khalili
- Address correspondence to: Hamed Khalili, MD, MPH, Massachusetts General Hospital, Clinical Translational Epidemiology Unit, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA ()
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20
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Lo CH, Khalili H, Lochhead P, Song M, Lopes EW, Burke KE, Richter JM, Chan AT, Ananthakrishnan AN. Immune-mediated diseases and risk of Crohn's disease or ulcerative colitis: a prospective cohort study. Aliment Pharmacol Ther 2021; 53:598-607. [PMID: 33280139 PMCID: PMC8082435 DOI: 10.1111/apt.16210] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/01/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although immune-mediated diseases (IMDs) including inflammatory bowel diseases (IBDs) are known to cluster, to what extent this is due to common environmental influences is unknown. AIM To examine the incidence of IBD in individuals with another IMD. METHODS We used data from the prospective Nurses' Health Study II cohort (1995-2017) to examine the effect of diagnoses of several common IMDs on subsequent risk of Crohn's disease (CD) or ulcerative colitis (UC) using Cox proportional hazards models, adjusting for detailed diet and lifestyle confounders. RESULTS We documented 132 cases of CD and 186 cases of UC over 2 016 163 person-years of follow-up (median age at IBD diagnosis 50 years). Compared to participants with no history of IMD, the HRs of CD for those with 1 and ≥ 2 IMDs were 2.57 (95% CI 1.77-3.74) and 2.74 (95% CI 1.36 to 5.49), respectively (Ptrend < 0.0001). This association was only modestly attenuated by adjustment for environmental risk factors (HR 2.35 and 2.46, respectively). The risk of UC was not increased, with multivariable-adjusted HRs of 1.22 (95% CI 0.85-1.76) and 1.33 (95% CI 0.67-2.65) for those with 1 and ≥ 2 IMDs, respectively, compared to those with none (Ptrend 0.16) (Pheterogeneity comparing CD and UC 0.037). Asthma, atopic dermatitis, psoriasis and rosacea were individually associated with higher risk of CD (HR ranging from 2.15 to 3.39) but not UC. CONCLUSIONS Individuals with one or more IMDs are at an increased risk for CD but not UC.
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Affiliation(s)
- Chun-Han Lo
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA;,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mingyang Song
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA;,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Emily W Lopes
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin E Burke
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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21
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Percac-Lima S, Ashburner JM, Enogieru I, Ho JJ, Mitton J, Richter JM, He W, Whited EC, Atlas SJ. Timeliness of Surveillance Colonoscopy in Underserved Populations: Association with Patient Navigation for Initial Screening Colonoscopy. J Health Care Poor Underserved 2021; 32:712-723. [PMID: 34120972 DOI: 10.1353/hpu.2021.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Patient navigation (PN) improves initial colorectal cancer (CRC) screening in underserved populations. Whether the impact persists and improves the timeliness of follow-up screening colonoscopy (FSC) is not known. Patients receiving PN at initial colonoscopy between 2010-2011 with findings requiring FSC were matched to unnavigated patients requiring FSC. The primary outcome was proportion of patients with timely FSC, defined as colonoscopy within six months of recommendation. Of 216 patients in the study 103 (48%) completed FSC: 33 of 62 (53%) who received PN compared with 70 of 154 (45%) in the control group (p=.30). After adjusting for insurance, education, language and visits, navigated patients had higher odds (AOR=1.53, 95% CI 0.80-2.92) of timely FSC completion compared with unnavigated patients. Timely FSC completion in underserved patients is low. Patients navigated for initial colonoscopy or not had similar rates of FSC completion. Future studies should investigate navigation for FSC to improve equity in CRC.
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22
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Lo CH, Khalili H, Song M, Lochhead P, Burke KE, Richter JM, Giovannucci EL, Chan AT, Ananthakrishnan AN. Healthy Lifestyle Is Associated With Reduced Mortality in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2021; 19:87-95.e4. [PMID: 32142939 PMCID: PMC7483199 DOI: 10.1016/j.cgh.2020.02.047] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/13/2020] [Accepted: 02/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear whether a healthy lifestyle affects mortality of patients with inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC). METHODS We collected data form the Nurses' Health Study (1986-2014), Nurses' Health Study II (1991-2015), and Health Professionals Follow-up Study (1986-2014), which assess lifestyles with serial questionnaires. We estimated joint and individual associations between 5 healthy lifestyle factors after IBD diagnosis (never smoking, body mass index 18.5-24.9 kg/m2, vigorous physical activity in the highest 50% with non-zero value, alternate Mediterranean diet score ≥4, and light drinking [0.1-5.0 g/d]) and mortality using Cox proportional hazards models. RESULTS We documented 83 deaths in 363 patients with CD during 4741 person-years and 80 deaths in 465 patients with UC during 6061 person-years. The median age of IBD diagnosis was 55 y. Compared to patients with IBD with no healthy lifestyle factors, patients with IBD with 3-5 healthy lifestyle factors had a significant reduction in all-cause mortality (hazard ratio [HR], 0.29; 95% CI, 0.16-0.52; Ptrend < .0001). This reduction was significant in patients with CD (Ptrend = .003) as well as in patients with UC (Ptrend = .0003). Individual associations were more than 25 pack-years (HR, 1.92; 95% CI, 1.24-2.97; Ptrend < .0001), physical activity (HR according to quintiles, 0.55-0.31; Ptrend = .001), Mediterranean diet (HR, 0.69; 95% CI, 0.49-0.98), and alcohol consumption (HR0.1-5 g/d 0.61; 95% CI, 0.39-0.95 vs HR>15 g/d 1.84; 95% CI, 1.02-3.32). The findings did not change when we adjusted for family history of IBD, immunomodulator use, and IBD-related surgery. CONCLUSIONS In an analysis of data from 3 large cohort studies, we associated adherence to a healthy lifestyle with reduced mortality in patients with CD or UC.
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Affiliation(s)
- Chun-Han Lo
- Department of Epidemiology, Harvard T.H. Chan School of
Public Health, Boston, MA;,Division of Gastroenterology, Massachusetts General
Hospital and Harvard Medical School, Boston, MA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General
Hospital and Harvard Medical School, Boston, MA;,Clinical and Translational Epidemiology Unit, Massachusetts
General Hospital and Harvard Medical School, Boston, MA
| | - Mingyang Song
- Department of Epidemiology, Harvard T.H. Chan School of
Public Health, Boston, MA;,Division of Gastroenterology, Massachusetts General
Hospital and Harvard Medical School, Boston, MA;,Clinical and Translational Epidemiology Unit, Massachusetts
General Hospital and Harvard Medical School, Boston, MA;,Department of Nutrition, Harvard T.H. Chan School of Public
Health, Boston, MA
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General
Hospital and Harvard Medical School, Boston, MA;,Clinical and Translational Epidemiology Unit, Massachusetts
General Hospital and Harvard Medical School, Boston, MA
| | - Kristin E Burke
- Division of Gastroenterology, Massachusetts General
Hospital and Harvard Medical School, Boston, MA;,Clinical and Translational Epidemiology Unit, Massachusetts
General Hospital and Harvard Medical School, Boston, MA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General
Hospital and Harvard Medical School, Boston, MA
| | - Edward L Giovannucci
- Department of Epidemiology, Harvard T.H. Chan School of
Public Health, Boston, MA;,Department of Nutrition, Harvard T.H. Chan School of Public
Health, Boston, MA;,Channing Division of Network Medicine, Department of
Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston,
MA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General
Hospital and Harvard Medical School, Boston, MA;,Clinical and Translational Epidemiology Unit, Massachusetts
General Hospital and Harvard Medical School, Boston, MA;,Channing Division of Network Medicine, Department of
Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston,
MA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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23
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Drew DA, Schuck MM, Magicheva-Gupta MV, Stewart KO, Gilpin KK, Miller P, Parziale MP, Pond EN, Takacsi-Nagy O, Zerjav DC, Chin SM, Mackinnon Krems J, Meixell D, Joshi AD, Ma W, Colizzo FP, Carolan PJ, Nishioka NS, Staller K, Richter JM, Khalili H, Gala MK, Garber JJ, Chung DC, Yarze JC, Zukerberg L, Petrucci G, Rocca B, Patrono C, Milne GL, Wang M, Chan AT. Effect of Low-dose and Standard-dose Aspirin on PGE 2 Biosynthesis Among Individuals with Colorectal Adenomas: A Randomized Clinical Trial. Cancer Prev Res (Phila) 2020; 13:877-888. [PMID: 32718943 PMCID: PMC7541643 DOI: 10.1158/1940-6207.capr-20-0216] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/04/2020] [Accepted: 07/15/2020] [Indexed: 12/12/2022]
Abstract
Low-dose aspirin is recommended by the U.S. Preventive Services Task Force for primary prevention of colorectal cancer in certain individuals. However, broader implementation will require improved precision prevention approaches to identify those most likely to benefit. The major urinary metabolite of PGE2, 11α-hydroxy-9,15-dioxo-2,3,4,5-tetranor-prostane-1,20-dioic acid (PGE-M), is a biomarker for colorectal cancer risk, but it is unknown whether PGE-M is modifiable by aspirin in individuals at risk for colorectal cancer. Adults (N = 180) who recently underwent adenoma resection and did not regularly use aspirin or NSAIDs were recruited to a double-blind, placebo-controlled, randomized trial of aspirin at 81 or 325 mg/day for 8-12 weeks. The primary outcome was postintervention change in urinary PGE-M as measured by LC/MS. A total of 169 participants provided paired urine samples for analysis. Baseline PGE-M excretion was 15.9 ± 14.6 (mean ± S.D, ng/mg creatinine). Aspirin significantly reduced PGE-M excretion (-4.7 ± 14.8) compared with no decrease (0.8 ± 11.8) in the placebo group (P = 0.015; mean duration of treatment = 68.9 days). Aspirin significantly reduced PGE-M levels in participants receiving either 81 (-15%; P = 0.018) or 325 mg/day (-28%; P < 0.0001) compared with placebo. In 40% and 50% of the individuals randomized to 81 or 325 mg/day aspirin, respectively, PGE-M reduction reached a threshold expected to prevent recurrence in 10% of individuals. These results support that aspirin significantly reduces elevated levels of PGE-M in those at increased colorectal cancer risk to levels consistent with lower risk for recurrent neoplasia and underscore the potential utility of PGE-M as a precision chemoprevention biomarker. The ASPIRED trial is registered as NCT02394769.
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Affiliation(s)
- David A Drew
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Madeline M Schuck
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marina V Magicheva-Gupta
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kathleen O Stewart
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Katherine K Gilpin
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Patrick Miller
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Melanie P Parziale
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Emily N Pond
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Oliver Takacsi-Nagy
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Dylan C Zerjav
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Samantha M Chin
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer Mackinnon Krems
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Dana Meixell
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Amit D Joshi
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Wenjie Ma
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Francis P Colizzo
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Peter J Carolan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Norman S Nishioka
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kyle Staller
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - James M Richter
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hamed Khalili
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Manish K Gala
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - John J Garber
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel C Chung
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph C Yarze
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lawrence Zukerberg
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Giovanna Petrucci
- Institute of Pharmacology, Catholic University School of Medicine and IRCCS Fondzione Policlinico Gemielli, Rome, Italy
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine and IRCCS Fondzione Policlinico Gemielli, Rome, Italy
| | - Carlo Patrono
- Institute of Pharmacology, Catholic University School of Medicine and IRCCS Fondzione Policlinico Gemielli, Rome, Italy
| | - Ginger L Milne
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Molin Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew T Chan
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Bloom P, Wang T, Marx M, Tagerman M, Green B, Arvind A, Ha J, Bloom J, Richter JM. A Smartphone App to Manage Cirrhotic Ascites Among Outpatients: Feasibility Study. JMIR Med Inform 2020; 8:e17770. [PMID: 32876581 PMCID: PMC7495260 DOI: 10.2196/17770] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Ascites is a common, painful, and serious complication of cirrhosis. Body weight is a reliable proxy for ascites volume; therefore, daily weight monitoring is recommended to optimize ascites management. OBJECTIVE This study aims to evaluate the feasibility of a smartphone app in facilitating outpatient ascites management. METHODS In this feasibility study, patients with cirrhotic ascites requiring active management were identified in both inpatient and outpatient settings. Patients were provided with a Bluetooth-connected scale, which transmitted weight data to a smartphone app and then via the internet to an electronic medical record (EMR). Weights were monitored every weekday. In the event of a weight change of ≥5 lbs in 1 week, patients were called and administered a short symptom questionnaire, and providers received an email alert. The primary outcomes of this study were the percentage of enrolled days during which weight data were successfully transmitted to an EMR and the percentage of weight alerts that prompted responses by the provider. RESULTS In this study, 25 patients were enrolled: 12 (48%) were male, and the mean age was 58 (SD 13; range 35-81) years. A total of 18 (72%) inpatients were enrolled. Weight data were successfully transmitted to an EMR during 71.2% (697/979) of the study enrollment days, with technology issues reported on 16.5% (162/979) of the days. Of a total of 79 weight change alerts fired, 41 (52%) were triggered by weight loss and 38 (48%) were by weight gain. Providers responded in some fashion to 66 (84%) of the weight alerts and intervened in response to 45 (57%) of the alerts, for example, by contacting the patient, scheduling clinic or paracentesis appointments, modifying the diuretic dose, or requesting a laboratory workup. Providers responded equally to weight increase and decrease alerts (P=.87). The staff called patients a mean of 3.7 (SD 3.5) times per patient, and the number of phone calls correlated with technology issues (r=0.60; P=.002). A total of 60% (15/25) of the patients chose to extend their participation beyond 30 days. A total of 17 patient readmissions occurred during the study period, with only 4 (24%) related to ascites. CONCLUSIONS We demonstrated the feasibility of a smartphone app to facilitate the management of ascites and reported excellent rates of patient and provider engagement. This innovation could enable early therapeutic intervention, thereby decreasing the burden of morbidity and mortality among patients with cirrhosis.
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Affiliation(s)
- Patricia Bloom
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Thomas Wang
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Madeline Marx
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Michelle Tagerman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Bradley Green
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Ashwini Arvind
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Jasmine Ha
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Judith Bloom
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - James M Richter
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
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Lo CH, Lochhead P, Khalili H, Song M, Tabung FK, Burke KE, Richter JM, Giovannucci EL, Chan AT, Ananthakrishnan AN. Dietary Inflammatory Potential and Risk of Crohn's Disease and Ulcerative Colitis. Gastroenterology 2020; 159:873-883.e1. [PMID: 32389666 PMCID: PMC7502466 DOI: 10.1053/j.gastro.2020.05.011] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/29/2020] [Accepted: 05/01/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Inflammation is a potential mechanism through which diet modulates the onset of inflammatory bowel disease. We analyzed data from 3 large prospective cohorts to determine the effects of dietary inflammatory potential on the risk of developing Crohn's disease (CD) and ulcerative colitis (UC). METHODS We collected data from 166,903 women and 41,931 men in the Nurses' Health Study (1984-2014), Nurses' Health Study II (1991-2015), and Health Professionals Follow-up Study (1986-2012). Empirical dietary inflammatory pattern (EDIP) scores were calculated based on the weighted sums of 18 food groups obtained via food frequency questionnaires. Self-reported CD and UC were confirmed by medical record review. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS We documented 328 cases of CD and 428 cases of UC over 4,949,938 person-years of follow-up. The median age at IBD diagnosis was 55 years (range 29-85 years). Compared with participants in the lowest quartile of cumulative average EDIP score, those in the highest quartile (highest dietary inflammatory potential) had a 51% higher risk of CD (HR 1.51; 95% CI 1.10-2.07; Ptrend = .01). Compared with participants with persistently low EDIP scores (at 2 time points, separated by 8 years), those with a shift from a low to high inflammatory potential of diet or persistently consumed a proinflammatory diet had greater risk of CD (HR 2.05; 95% CI 1.10-3.79 and HR 1.77; 95% CI 1.10-2.84). In contrast, dietary inflammatory potential was not associated with the risk of developing UC (Ptrend = .62). CONCLUSIONS In an analysis of 3 large prospective cohorts, we found dietary patterns with high inflammatory potential to be associated with increased risk of CD but not UC.
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Affiliation(s)
- Chun-Han Lo
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA;,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mingyang Song
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA;,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Fred K Tabung
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA;,Department of Internal Medicine, Division of Medical Oncology, The Ohio State University College of Medicine and Comprehensive Cancer Center – James Cancer Hospital and Solove Research Institute, Columbus, Ohio, USA
| | - Kristin E Burke
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Edward L Giovannucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA;,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA;,Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Yan Y, Drew DA, Markowitz A, Lloyd-Price J, Abu-Ali G, Nguyen LH, Tran C, Chung DC, Gilpin KK, Meixell D, Parziale M, Schuck M, Patel Z, Richter JM, Kelsey PB, Garrett WS, Chan AT, Stadler ZK, Huttenhower C. Structure of the Mucosal and Stool Microbiome in Lynch Syndrome. Cell Host Microbe 2020; 27:585-600.e4. [PMID: 32240601 PMCID: PMC7453618 DOI: 10.1016/j.chom.2020.03.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 11/22/2019] [Accepted: 03/10/2020] [Indexed: 12/12/2022]
Abstract
The gut microbiota has been associated with colorectal cancer (CRC), but causal alterations preceding CRC have not been elucidated. To prospectively assess microbiome changes prior to colorectal neoplasia, we investigated samples from 100 Lynch syndrome patients using 16S rRNA gene sequencing of colon biopsies, coupled with metagenomic and metatranscriptomic sequencing of feces. Colectomy and CRC history represented the largest effects on microbiome profiles. A subset of Clostridiaceae were depleted in stool corresponding with baseline adenomas, while Desulfovibrio was enriched both in stool and in mucosal biopsies. A classifier leveraging stool metatranscriptomes resulted in modest power to predict interval development of preneoplastic colonic adenoma. Predictive transcripts corresponded with a shift in flagellin contributors and oxidative metabolic microenvironment, potentially factors in local CRC pathogenesis. This suggests that the effectiveness of prospective microbiome monitoring for adenomas may be limited but supports the potential causality of these consistent, early microbial changes in colonic neoplasia.
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Affiliation(s)
- Yan Yan
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - David A Drew
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Arnold Markowitz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jason Lloyd-Price
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Galeb Abu-Ali
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Long H Nguyen
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Christina Tran
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel C Chung
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Katherine K Gilpin
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Dana Meixell
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Melanie Parziale
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Madeline Schuck
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Zalak Patel
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter B Kelsey
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Wendy S Garrett
- Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Immunology & Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Curtis Huttenhower
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Immunology & Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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Bloom PP, Marx M, Wang TJ, Green B, Ha J, Bay C, Chung RT, Richter JM. Attitudes towards digital health tools for outpatient cirrhosis management in patients with decompensated cirrhosis. ACTA ACUST UNITED AC 2020. [DOI: 10.1136/bmjinnov-2019-000369] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BackgroundTechnology represents a promising tool to improve healthcare delivery for patients with cirrhosis. We sought to assess utilisation of technology and preferred features of a digital health management tool, in patients with an early readmission for decompensated cirrhosis.MethodsWe conducted a cross-sectional study of patients readmitted within 90 days for decompensated cirrhosis. A semistructured interview obtained quantitative and qualitative data through open-ended questions.ResultsOf the 50 participants, mean age was 57.6 years and mean (range) model for end stage liver disease was 22.7 (10–46). Thirty-eight (76%) patients own a Smartphone and 62% have regular access to a computer with internet. Thirty-nine (78%) patients would consider using a Smartphone application to manage their cirrhosis. Forty-six (92%) patients report having a principal caregiver, of which 80% own a Smartphone. Patients were interested in a Smartphone application that could communicate with their physician (85%), send medication notifications to the patient (65%) and caregiver (64%), transmit diagnostic results and appointment reminders (82%), educate about liver disease (79%), regularly transmit weight data to the doctor (85% with ascites) and play a game to detect cognitive decline (67% with encephalopathy). Common themes from qualitative data include a desire to learn about liver disease and communicate with providers via digital tools.ConclusionAmong patients with cirrhosis with an early readmission for decompensation, most have Smartphones and would be willing to use a Smartphone to manage their disease. Future digital health management tools should be tailored to the use patterns and preferences of the patients with cirrhosis and their caregivers.
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Burke KE, Nayor J, Campbell EJ, Ananthakrishnan AN, Khalili H, Richter JM. Interval Colorectal Cancer in Inflammatory Bowel Disease: The Role of Guideline Adherence. Dig Dis Sci 2020; 65:111-118. [PMID: 31367882 PMCID: PMC6946853 DOI: 10.1007/s10620-019-05754-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/19/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Factors associated with interval colorectal cancer (CRC) development in the inflammatory bowel disease (IBD) population remain unclear. AIMS Among a cohort of patients with interval CRC, we aimed to evaluate IBD characteristics, colonoscopy quality indicators, and surveillance guideline adherence. METHODS We performed a retrospective review of IBD- and non-IBD-associated interval CRCs diagnosed between January 2007 and December 2014 within a large US healthcare system. We evaluated risk factors for CRC among patients with IBD. We assessed adherence to surveillance guidelines according to the American Society for Gastrointestinal Endoscopy (IBD surveillance) and the US Multi-Society Task Force on Colorectal Cancer (polyp surveillance). We compared colonoscopy quality measures between patients with and without IBD. RESULTS Among 5345 cases of colonic adenocarcinoma, we detected 15 IBD-associated cases of interval CRC and 230 non-IBD-associated cases of interval CRC. Compared to patients without IBD, IBD patients were younger (54.5 vs. 70.4 years; p < 0.0001) and experienced a shorter interval between index colonoscopy and CRC diagnosis (20.7 vs. 35.1 months; p = 0.0009). Fifty three percent (8/15) of interval CRCs in IBD patients were detected within surveillance guidelines. All IBD patients with interval CRC detected after guideline surveillance interval had high-risk features, including active inflammation, previous low-grade or indefinite dysplasia, multiple pseudopolyps on index colonoscopy, or a first-degree relative with CRC. There were no differences in colonoscopy quality measures between patients with and without IBD. CONCLUSIONS This study stresses the importance of strict short-interval surveillance for IBD patients with high-risk features, including active inflammation on index colonoscopy.
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Affiliation(s)
- Kristin E Burke
- Division of Gastroenterology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Jennifer Nayor
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily J Campbell
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
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Liu PH, Burke KE, Ananthakrishnan AN, Lochhead P, Olen O, Ludvigsson JF, Richter JM, Chan AT, Khalili H. Obesity and Weight Gain Since Early Adulthood Are Associated With a Lower Risk of Microscopic Colitis. Clin Gastroenterol Hepatol 2019; 17:2523-2532.e1. [PMID: 30529732 PMCID: PMC6551326 DOI: 10.1016/j.cgh.2018.11.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/16/2018] [Accepted: 11/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Obesity promotes intestinal inflammation and might contribute to the pathogenesis of inflammatory bowel disease. We examined the association between obesity and risk of microscopic colitis in a prospective cohort study. METHODS We collected data from 192,101 women enrolled in the Nurses' Health Study (NHS) (from 1986 through 2014) or the NHSII (from 1991 through 2015). Anthropomorphic and lifestyle information were self-reported biennially. Obesity was defined using body mass index (BMI). Microscopic colitis was confirmed by review of medical records. We used Cox proportional hazard models to estimate adjusted hazard ratios (aHRs) and 95% CIs. RESULTS Among the participants in the NHS and NHSII, we confirmed 244 cases of microscopic colitis during 4,223,868 person-years of follow-up evaluation. Higher BMI was associated inversely with risk of microscopic colitis (Ptrend < .001). Compared with women with BMIs ranging from 18.5 to 20.9 kg/m2, the aHRs were 0.61 (95% CI, 0.41-0.91) for overweight women (BMI, 25-29.9 kg/m2) and 0.50 (95% CI, 0.32-0.79) for obese women (BMI ≥ 30 kg/m2). The aHR for each 5-kg/m2 increase in BMI was 0.79 (95% CI, 0.69-0.90). Weight gain since early adulthood (age, 18 y) also was associated inversely with risk of microscopic colitis (Ptrend = .001). The aHR for each 10-kg weight gain since early adulthood was 0.85 (95% CI, 0.77-0.94). The associations were not modified by age, cohort, physical activity, or smoking status (all Pinteraction ≥ .26). CONCLUSIONS Unlike many other immune- and metabolic-related disorders, obesity and weight gain since early adulthood were associated with a lower risk of microscopic colitis, based on an analysis of participants in the NHS and NHSII.
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Affiliation(s)
- Po-Hong Liu
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kristin E Burke
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ashwin N Ananthakrishnan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Paul Lochhead
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ola Olen
- Department of Medicine, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - James M Richter
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts; Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hamed Khalili
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Medicine, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.
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Abstract
Introduction: Many patients struggle with colonoscopy preparation, which is complex and can be an uncomfortable as well as a time-consuming process. The confusion and anxiety from the preprocedure process may lead patients to delay their colonoscopy or skip it altogether. Digital health technology that focuses on patient engagement can play an important role in promoting colorectal cancer screening. Methods: A digital preprocedure instruction program was implemented for outpatient colonoscopy by sending critical reminders and instructions to patients through a series of short message service messages and/or emails. Eligible patients included English speakers on GoLYTELY®/NuLYTELY® or MiraLAX® preparation regimens with a valid cellphone or email address in the electronic health record. We examined the impact of digital instructions on bowel preparation quality, no-show and same-day cancellations over a 3-month period between an intervention group of 756 patients and a control group of 2,103 patients. Patients who enrolled in the digital instructions also received a patient satisfaction survey. Results: Our controlled study demonstrated the effectiveness of digital instructions to reduce no-show and same-day cancellation rates for outpatient colonoscopy from 10.40% to 6.08% (p < 0.001). Bowel preparation quality was not significantly different between the two groups (p = 0.23). However, 90% of patients who enrolled in the program rated their satisfaction with the digital reminders very highly. Discussion: A digital preprocedure instruction program can have a positive impact on operational efficiency, quality of care, and patient satisfaction. This study shows how digital health tools can effectively engage patients scheduled for a colonoscopy, increase appointment adherence, and, therefore, lead to better cancer screening.
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Affiliation(s)
- James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jasmine B Ha
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Madeline Marx
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily J Campbell
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael C Pandolfi
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
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Liu PH, Lebwohl B, Burke KE, Ivey KL, Ananthakrishnan AN, Lochhead P, Olen O, Ludvigsson JF, Richter JM, Chan AT, Khalili H. Dietary Gluten Intake and Risk of Microscopic Colitis Among US Women without Celiac Disease: A Prospective Cohort Study. Am J Gastroenterol 2019; 114:127-134. [PMID: 30181535 PMCID: PMC6329641 DOI: 10.1038/s41395-018-0267-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Microscopic colitis is a common cause of chronic watery diarrhea among the elderly. Although the prevalence of celiac disease appears to be higher in patients with microscopic colitis, the relationship between dietary gluten intake and risk of microscopic colitis among individuals without celiac disease has not been explored. METHODS We conducted a prospective study of 160,744 US women without celiac disease enrolled in the Nurses' Health Study (NHS) and the NHSII. Dietary gluten intake was estimated using validated food frequency questionnaires every 4 years. Microscopic colitis was confirmed through medical records review. We used Cox proportional hazard modeling to estimate the multivariable-adjusted hazard ratio (HR) and 95% confidence interval (CI). RESULTS We documented 219 incident cases of microscopic colitis over more than 20 years of follow-up encompassing 3,716,718 person-years (crude incidence rate: 5.9/100,000 person-years) in NHS and NHSII. Dietary gluten intake was not associated with risk of microscopic colitis (Ptrend = 0.88). Compared to individuals in the lowest quintile of energy-adjusted gluten intake, the adjusted HR of microscopic colitis was 1.18 (95% CI: 0.77-1.78) for the middle quintile and 1.03 (95% CI: 0.67-1.58) for the highest quintile. Additional adjustment for primary dietary sources of gluten including refined and whole grains did not materially alter the effect estimates (All Ptrend ≥ 0.69). The null association did not differ according to lymphocytic or collagenous subtypes (Pheterogeneity = 0.72) and was not modified by age, smoking status, or body mass index (All Pinteraction ≥ 0.17). CONCLUSIONS Dietary gluten intake during adulthood was not associated with risk of microscopic colitis among women without celiac disease.
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Affiliation(s)
- Po-Hong Liu
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kristin E. Burke
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Kerry L. Ivey
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA,South Australian Health and Medical Research Institute, Infection and Immunity Theme, School of Medicine, Flinders University, Adelaide, Australia
| | - Ashwin N. Ananthakrishnan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Paul Lochhead
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Ola Olen
- Department of Medicine, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F. Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - James M. Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew T. Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA,Broad Institute of MIT and Harvard, Cambridge, MA, USA,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, MA, USA,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Department of Medicine, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
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Burke KE, Ananthakrishnan AN, Lochhead P, Liu SPH, Olen O, Ludvigsson JF, Richter JM, Tworoger SS, Chan AT, Khalili H. Identification of Menopausal and Reproductive Risk Factors for Microscopic Colitis-Results From the Nurses' Health Study. Gastroenterology 2018; 155:1764-1775.e2. [PMID: 30144433 PMCID: PMC6279488 DOI: 10.1053/j.gastro.2018.08.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 07/20/2018] [Accepted: 08/05/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND & AIMS Microscopic colitis is a chronic inflammatory disorder of the colon primarily affecting postmenopausal women. However, the relation between hormonal determinants, including reproductive and menopausal factors, and risk of microscopic colitis has yet to be characterized. METHODS We collected data from 227,766 women who participated in the Nurses' Health Study (NHS) and the NHSII without a baseline history of microscopic colitis. Reproductive and menopausal factors were assessed in 1988 in the NHS and 1989 in the NHSII and updated biennially. Cases of microscopic colitis were confirmed through review of pathology records. We used Cox proportional hazards modeling to estimate hazard ratios and 95% confidence intervals. RESULTS Through 2014 in the NHS and 2015 in the NHSII, we confirmed 275 incident cases of microscopic colitis over 5,147,282 person-years. Compared with never use, current use of menopausal hormone therapy was associated with increased risk of microscopic colitis (multivariable-adjusted hazard ratio 2.64; 95% confidence interval 1.78-3.90). The risk increased with longer duration of use (P for trend < .0001) and decreased after discontinuation (P for trend = .002). The association did not differ according to disease subtype (P for heterogeneity = .34). Similarly, ever use of oral contraceptives was associated with increased risk of microscopic colitis (multivariable-adjusted hazard ratio 1.57; 95% confidence interval 1.16-2.13). There were no associations between age at menarche, parity, age at first birth, age at menopause, or menopause type and incident microscopic colitis. CONCLUSIONS In 2 large prospective cohort studies, we observed an association between exogenous hormone use and incident microscopic colitis. Further studies are needed to determine the mechanisms underlying these associations.
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Affiliation(s)
- Kristin E. Burke
- Gastroenterology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Ashwin N. Ananthakrishnan
- Gastroenterology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Lochhead
- Gastroenterology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Stuart Po-Hong Liu
- Gastroenterology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Ola Olen
- Pediatric Gastroenterology and Nutrition Unit, Sachs’ Children’s Hospital, Stockholm, Sweden,Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F. Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - James M. Richter
- Gastroenterology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Shelley S Tworoger
- Moffit Cancer Center, Tampa, Florida,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Andrew T. Chan
- Gastroenterology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA,Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA,Broad Institute, Cambridge, Massachusetts, USA,Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Hamed Khalili
- Gastroenterology Unit, Massachusetts General Hospital, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Karolinska Clinical Epidemiology Unit, Karolinska Institutet, Solna, Sweden.
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Olson GS, Moore SW, Richter JM, Garber JJ, Bowman BA, Rawlings CA, Flagg M, Corleis B, Kwon DS. Increased frequency of systemic pro-inflammatory Vδ1 + γδ T cells in HIV elite controllers correlates with gut viral load. Sci Rep 2018; 8:16471. [PMID: 30405182 PMCID: PMC6220338 DOI: 10.1038/s41598-018-34576-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 10/17/2018] [Indexed: 12/11/2022] Open
Abstract
γδ T cells predominate in the intestinal mucosa and help maintain gut homeostasis and mucosal immunity. Although HIV infection significantly alters these cells, what drives these perturbations is unclear. Growing evidence suggests that impaired intestinal immune function in HIV leads to chronic immune activation and disease progression. This occurs even in HIV controllers - individuals with undetectable HIV viremia without antiretroviral therapy (ART). We show that Vδ1+ cells, a subset of γδ T cells described as being important in intestinal barrier function, increase in frequency in HIV-infected individuals, including HIV controllers. These cells resemble terminally differentiated effector memory cells, producing the pro-inflammatory cytokines IFNγ, TNFα, and MIP-1β upon stimulation. Importantly, pro-inflammatory Vδ1+ cell frequency correlates with levels of HIV RNA in intestinal tissue but not in plasma. This study supports a model in which local viral replication in the gut in HIV controllers disrupts the phenotype and function of Vδ1+ cells, a cell type involved in the maintenance of epithelial barrier integrity, and may thereby contribute to systemic immune activation and HIV disease progression.
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Affiliation(s)
- Gregory S Olson
- The Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Sarah W Moore
- The Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - John J Garber
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Brittany A Bowman
- The Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Crystal A Rawlings
- The Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Meaghan Flagg
- The Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Björn Corleis
- The Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Douglas S Kwon
- The Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, United States of America.
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Venkatesh RD, Campbell EJ, Thiim M, Rao SK, Ferris TG, Wasfy JH, Richter JM. e-Consults in gastroenterology: An opportunity for innovative care. J Telemed Telecare 2018; 25:499-505. [DOI: 10.1177/1357633x18781189] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background and aim Deploy and evaluate a gastroenterology (GI) electronic consultation (e-consult) program. E-consults are a promising approach to enhance provider communication, facilitate timely specialty advice and may replace some outpatient visits. Study As part of our health system’s efforts to provide more cost-effective care under risk-based contracts, we implemented an e-consult program where referring providers submit patient-specific clinical questions electronically via an electronic referral system. A GI consultant then reviews the patient’s record and provides a written recommendation back to the referring physician. For our program evaluation, we conducted chart reviews of each e-consult to understand how the program was being used and surveyed the participating providers and consultants. Results From September 2015 to March 2016, we received 144 e-consults, with most questions concerning GI symptoms or abnormal hepatology labs. Only 36% of e-consults recommended an in-person GI consult or procedure. In our survey of participating providers, referring providers strongly agreed that the GI e-consults promoted good patient care (88%) and were satisfied with the program (84%). The majority of GI consultants felt strongly that e-consults were useful for referring providers and their patients, but that current reimbursement and time allotted were not adequate. Conclusions We report on the implementation of a GI e-consult program within an ACO, showing that many clinical questions could be answered using this mechanism. E-consults in gastroenterology have the potential to reduce unnecessary visits and/or procedures for patients who can be managed by their primary provider, potentially increasing access for other patients.
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Affiliation(s)
- Rajitha D Venkatesh
- Duke Pediatric GI & Nutrition, Duke University Medical Center, Durham, NC, USA
| | - Emily J Campbell
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Thiim
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sandhya K Rao
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Timothy G Ferris
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jason H Wasfy
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Burke KE, Ananthakrishnan AN, Lochhead P, Olen O, Ludvigsson JF, Richter JM, Chan AT, Khalili H. Smoking is Associated with an Increased Risk of Microscopic Colitis: Results From Two Large Prospective Cohort Studies of US Women. J Crohns Colitis 2018; 12:559-567. [PMID: 29370359 PMCID: PMC6018687 DOI: 10.1093/ecco-jcc/jjy005] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 01/15/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Long-term data on the influence of smoking on risk of microscopic colitis are limited. We therefore sought to examine and characterize the association between smoking and risk of incident microscopic colitis in two large prospective cohorts of women. METHODS We conducted a prospective study of 231015 women enrolled in the Nurses' Health Study [NHS] and NHSII. Information regarding smoking, other lifestyle factors and medications were collected biennially from 1976 to 2012 in NHS and from 1989 to 2013 in NHSII. Incident cases of microscopic colitis were confirmed through physician medical record review. We used Cox proportional hazards modelling to examine the association between smoking and risk of microscopic colitis. RESULTS We documented 166 incident cases of microscopic colitis over 6122779 person-years of follow up. Compared to non-smokers, the multivariable-adjusted hazard ratio [HR] for microscopic colitis was 2.52 (95% confidence interval [CI] 1.59-4.00) amongst current smokers and 1.54 [95% CI 1.09-2.17] amongst past smokers. The risk increased with higher pack-years of smoking [p trend = 0.001] and diminished following smoking cessation [p trend = 0.017]. Current smoking appeared to be more strongly associated with risk of collagenous colitis [HR 3.68; 95% CI 1.94-6.97] than lymphocytic colitis [HR 1.71; 95% CI 0.83-3.53]. CONCLUSION In two large prospective cohort studies, we observed an association between current smoking and risk of microscopic colitis. Risk of microscopic colitis appeared to increase with higher pack-years and diminish following smoking cessation. Future studies focused on characterizing the biological mechanisms underlying these associations are warranted.
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Affiliation(s)
- Kristin E Burke
- Gastroenterology Unit, Massachusetts General Hospital, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Gastroenterology Unit, Massachusetts General Hospital, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Paul Lochhead
- Gastroenterology Unit, Massachusetts General Hospital, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Ola Olen
- Pediatric Gastroenterology and Nutrition Unit, Sachs’ Children’s Hospital, Stockholm, Sweden,Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - James M Richter
- Gastroenterology Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Andrew T Chan
- Gastroenterology Unit, Massachusetts General Hospital, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Gastroenterology Unit, Massachusetts General Hospital, Boston, MA, USA,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Karolinska Clinical Epidemiology Unit, Karolinska Institutet, Solna, Sweden,Corresponding author: Hamed Khalili, MD, Massachusetts General Hospital, Gastroenterology Unit, Crohn’s and Colitis Center, 165 Cambridge Street, 9th Floor, Boston, MA 02114, USA. Tel: 617-726-4951; fax: 978-882-6710;
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Argyropoulos SK, Mahmood SK, Campbell EJ, Richter JM. Improving the Quality of Inpatient Bowel Preparation for Colonoscopies. Dig Dis Sci 2018; 63:338-344. [PMID: 29302876 DOI: 10.1007/s10620-017-4896-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 12/18/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hospitalized patients completing bowel preparation for colonoscopy typically have preparations of poorer quality when compared to outpatient populations. AIMS Our study aimed to evaluate the effectiveness of a performance improvement program in improving colonoscopy preparation for an inpatient population. METHODS We identified a cohort of adult patients (n = 641) undergoing an inpatient colonoscopy during a 12-month period at an academic medical center and compared a multifactor intervention group to a historical baseline group. During this 12-month period, a performance improvement program including use of a dedicated gastrointestinal nurse facilitator, implementation of standardized order sets, and introduction of split bowel preparations in the inpatient setting was made available to the cohort group. RESULTS The primary outcome was quality of bowel preparation for colonoscopy as rated by endoscopists using the modified Aronchick scale. When comparing the baseline group to the intervention group, the rate of acceptable preparations, characterized as excellent, good, or adequate, increased from 69.9 to 78.9%, which was statistically significant (p < 0.001). CONCLUSIONS A comprehensive performance improvement program improved the quality of colonoscopy preparation among inpatients. The use of a dedicated gastrointestinal nurse facilitator, implementation of standardized order sets, and introduction of split bowel preparations are recommended in the inpatient setting for an effective bowel preparation.
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Affiliation(s)
- Sarah K Argyropoulos
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Bartlett 920, Boston, MA, 02114, USA
| | - S Kashif Mahmood
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Bartlett 920, Boston, MA, 02114, USA.,Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Emily J Campbell
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Bartlett 920, Boston, MA, 02114, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Bartlett 920, Boston, MA, 02114, USA.
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Wangda S, Richter JM, Kuenzang P, Wangchuk K, Choden T, Tenzin K, Malaty HM. Epidemiology of Helicobacter pylori infection in asymptomatic schoolchildren in Bhutan. Helicobacter 2017; 22. [PMID: 28940523 DOI: 10.1111/hel.12439] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM Bhutan is a small mountainous country between Tibet and India with relatively homogenous population. According to the World Health Organization, gastric cancer is the most frequent cause of cancer death in Bhutan. This study examined the prevalence of Helicobacter pylori among children in Bhutan with emphasis on water source and living conditions. METHODS A cross-sectional sero-epidemiologic study was conducted among schoolchildren who attended public schools in Thimphu, Bhutan. Between 2015 and 2016, blood samples from schoolchildren were collected after obtaining an informed consent from the school management and the children's parents. Demographic information, parents' education, family size living in the same household, and aspects of household environment including type of latrines, boiling drinking water were collected. All serum samples were tested for H. pylori immunoglobulin G (IgG) by commercial ELISA kits. RESULTS There were 327 children between 4 and 19 years of age participated, 44% boys, mean age = 13.6 ± 3 years. The overall prevalence of H. pylori was 66% with no difference between boys and girls (66 vs 64%, respectively), P = .42. H. pylori prevalence was 75% among both 4-7 and 15-19 years and not statically different from that of the 8-10 or 11-14 age groups (59% and 63%, respectively), P = .1. H. pylori prevalence was inversely correlated with the level of mother's education (70% vs 55%) for those without and with a college education, respectively (OR = 2.3; 95%CI = 0.9-1.7), P = .08. The total number of people living in the same household did not correlate with H. pylori sero-prevalence, but households had less than 3 children had lower prevalence than those with 3 or more children (62% vs 71%, respectively OR = 1.7, 95% CI = [1.0-2.6], P = .05). CONCLUSIONS H. pylori infection is prevalent among all age group children in Bhutan. The results suggest that transmission of H. pylori is related to personal care practices that directly correlate with the mothers' education and crowded living condition with children. Our results are important to developing prevention strategies for gastric cancer in Bhutan.
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Affiliation(s)
- Sonam Wangda
- Health care and Diagnostic Division, Department of Medical Services, Ministry of Health, Thimphu, Bhutan
| | - James M Richter
- Harvard Medical School, Gastroenterology Associates Massachusetts General Hospital, Boston, MA, USA
| | | | - Kinley Wangchuk
- Sherbutse College, Kanglung, Royal University, Thimphu, Bhutan
| | - Tashi Choden
- Sherbutse College, Kanglung, Royal University, Thimphu, Bhutan
| | - Karma Tenzin
- Microbiology unit, Department of Laboratory Medicine, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Hoda M Malaty
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Ananthakrishnan AN, Khalili H, Song M, Higuchi L, Lochhead P, Richter JM, Chan AT. Genetic Polymorphisms in Fatty Acid Metabolism Modify the Association Between Dietary n3: n6 Intake and Risk of Ulcerative Colitis: A Prospective Cohort Study. Inflamm Bowel Dis 2017; 23:1898-1904. [PMID: 28991856 PMCID: PMC5675119 DOI: 10.1097/mib.0000000000001236] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION High intake of dietary n-3 polyunsaturated fatty acids (PUFA) is associated with a decreased risk of ulcerative colitis (UC) and Crohn's disease (CD). However, results have been heterogeneous suggesting that genetic variations in PUFA metabolism may modify this risk. METHODS We conducted a case-control study nested within 2 prospective cohorts, the Nurses' Health Study (NHS) and NHS II. Among women providing blood (n = 62,437) or buccal cells (n = 59,543) for genotyping, we confirmed new diagnoses of CD or UC. Dietary intake was assessed 4 years before diagnosis. Confirmed cases were matched 1:2 to controls. Subjects were genotyped for single nucleotide polymorphisms at CYP4F3, FADS1, and FADS2 loci. Conditional logistic regression models examined the interaction between genotype, n3:n6 PUFA intake and risk of CD and UC. RESULTS Our study included 101 CD and 139 UC patients matched to 495 controls. On multivariable analysis, high intake of n3:n6 PUFA (above median) demonstrated a trend toward reduced risk of UC (Odds ratio [OR] 0.71, 95% confidence interval [CI], 0.47-1.09, P = 0.11). High n3:n6 PUFA intake was associated with a reduced risk of UC in individuals with the GG/AG genotype at a single nucleotide polymorphism in CYP4F3 (OR 0.57, 95% CI, 0.32-0.99) but not those with the AA genotype (OR 0.95, 95% CI, 0.47-1.93) (P-interaction = 0.049). No gene-diet interactions were noted for CD. CONCLUSIONS The association between dietary n3:n6 PUFA intake and risk of UC may be modified variants at CYP4F3. Further gene-environment studies of the association between diet and IBD risk are warranted.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA
| | - Mingyang Song
- Departments of Nutrition and Epidemiology, Harvard School of Public Health, Boston, MA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA
| | - Leslie Higuchi
- Division of Gastroenterology and Nutrition, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA
- Channing Division of Network Medicine, Department of Medicine, Brigham and women's Hospital, Boston, MA
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Seraj SM, Campbell EJ, Argyropoulos SK, Wegermann K, Chung RT, Richter JM. Hospital readmissions in decompensated cirrhotics: Factors pointing toward a prevention strategy. World J Gastroenterol 2017; 23:6868-6876. [PMID: 29085229 PMCID: PMC5645619 DOI: 10.3748/wjg.v23.i37.6868] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/24/2017] [Accepted: 03/31/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To reduce readmissions and improve patient outcomes in cirrhotic patients through better understanding of readmission predictors.
METHODS We performed a single-center retrospective study of patients admitted with decompensated cirrhosis from January 1, 2011 to December 31, 2013 (n = 222). Primary outcomes were time to first readmission and 30-d readmission rate due to complications of cirrhosis. Clinical and demographic data were collected to help describe predictors of readmission, along with care coordination measures such as post-discharge status and outpatient follow-up. Univariate and multivariate analyses were performed to describe variables associated with readmission.
RESULTS One hundred thirty-two patients (59.4%) were readmitted at least once during the study period. Median time to first and second readmissions were 54 and 93 d, respectively. Thirty and 90-d readmission rates were 20.7 and 30.1 percent, respectively. Predictors of 30-d readmission included education level, hepatic encephalopathy at index, ALT more than upper normal limit and Medicare coverage. There were no statistically significant differences in readmission rates when stratified by discharge disposition, outpatient follow-up provider or time to first outpatient visit.
CONCLUSION Readmissions are challenging aspect of care for cirrhotic patients and risk continues beyond 30 d. More initiatives are needed to develop enhanced, longitudinal post-discharge systems.
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Affiliation(s)
- Siamak M Seraj
- Massachusetts General Hospital, Division of Gastroenterology, Boston, MA 02114, United States
| | - Emily J Campbell
- Massachusetts General Hospital, Division of Gastroenterology, Boston, MA 02114, United States
| | - Sarah K Argyropoulos
- Massachusetts General Hospital, Division of Gastroenterology, Boston, MA 02114, United States
| | - Kara Wegermann
- Duke University Hospital, Department of Medicine, Durham, NC 27710, United States
| | - Raymond T Chung
- Massachusetts General Hospital, Division of Gastroenterology, Boston, MA 02114, United States
- Harvard Medical School, Boston, MA 02115, United States
| | - James M Richter
- Massachusetts General Hospital, Division of Gastroenterology, Boston, MA 02114, United States
- Harvard Medical School, Boston, MA 02115, United States
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40
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Campbell EJ, Richter JM. Performance Improvement: Quality Is in the Cards. Dig Dis Sci 2017; 62:821-822. [PMID: 28194665 DOI: 10.1007/s10620-017-4480-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Emily J Campbell
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA.
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Khalili H, Malik S, Ananthakrishnan AN, Garber JJ, Higuchi LM, Joshi A, Peloquin J, Richter JM, Stewart KO, Curhan GC, Awasthi A, Yajnik V, Chan AT. Identification and Characterization of a Novel Association between Dietary Potassium and Risk of Crohn's Disease and Ulcerative Colitis. Front Immunol 2016; 7:554. [PMID: 28003811 PMCID: PMC5141241 DOI: 10.3389/fimmu.2016.00554] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 11/18/2016] [Indexed: 12/19/2022] Open
Abstract
Background Recent animal studies have identified that dietary salt intake may modify the risk and progression of autoimmune disorders through modulation of the IL-23/TH17 pathway, which is critical in the pathogenesis of ulcerative colitis (UC) and Crohn’s disease (CD). Methods We conducted a prospective study of U.S. women enrolled in the Nurses’ Health Study (NHS) and NHSII who provided detailed and validated information on diet and lifestyle beginning in 1984 in NHS and 1991 in NHSII. We confirmed incident cases of UC and CD reported through 2010 in NHS and 2011 in NHSII. We used Cox proportional hazards models to calculate hazard ratios and 95% confidence intervals. In a case–control study nested within these cohorts, we evaluated the interaction between single nucleotide polymorphisms (SNPs) in genes involved in TH17 pathway and dietary potassium on risk of CD and UC. In a cohort of healthy volunteers, we also assessed the effect of supplemental potassium on development of naïve and memory T cells, differentiated with TGFβ1 or TH17 conditions. Results Among a total of 194,711 women over a follow-up of 3,220,247 person-years, we documented 273 cases of CD and 335 cases of UC. Dietary intake of potassium (Ptrend = 0.005) but not sodium (Ptrend = 0.44) was inversely associated with risk of CD. Although, both dietary potassium and sodium were not significantly associated with risk of UC, there was a suggestion of an inverse association with dietary potassium (Ptrend = 0.08). The association of potassium with risk of CD and UC appeared to be modified by loci involved in the TH17 pathway that have previously been associated with susceptibility to CD, particularly SNP rs7657746 (IL21) (Pinteraction = 0.004 and 0.01, respectively). In vitro, potassium enhanced the expression of Foxp3 in both naïve and memory CD4+ T cells via activating Smad2/3 and inhibiting Smad7 in TH17 cells. Conclusion Dietary potassium is inversely associated with risk of CD with both in vitro and gene–environment interaction data suggesting a potential role for potassium in regulating immune tolerance through its effect on Tregs and TH17 pathway.
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Affiliation(s)
- Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Sakshi Malik
- Translational Health Science and Technology Institute, NCR Biotech Science Cluster , Faridabad , India
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - John J Garber
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
| | - Leslie M Higuchi
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School , Boston, MA , USA
| | - Amit Joshi
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Joanna Peloquin
- Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine , Baltimore, MD , USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
| | - Kathleen O Stewart
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
| | - Gary C Curhan
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA , USA
| | - Amit Awasthi
- Translational Health Science and Technology Institute, NCR Biotech Science Cluster , Faridabad , India
| | - Vijay Yajnik
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA; Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Ananthakrishnan AN, Khalili H, Song M, Higuchi LM, Richter JM, Chan AT. Zinc intake and risk of Crohn’s disease and ulcerative colitis: a prospective cohort study. Int J Epidemiol 2016; 44:1995-2005. [PMID: 26546032 DOI: 10.1093/ije/dyv301] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diet plays a role in the pathogenesis of Crohn’s disease (CD) and ulcerative colitis (UC). Dietary zinc may influence risk of disease through effects on autophagy, innate and adaptive immune response and maintenance of the intestinal barrier. METHODS We analysed data from 170 776 women from the Nurses Health Study I and Nurses Health Study II, who were followed for 26 years. Zinc intake was assessed using semi-quantitative food frequency questionnaires administered every 4 years. Incident CD and UC were ascertained by medical record review. Cox proportional hazards models adjusting for potential confounders determined the independent association between zinc intake and incident disease. RESULTS Over 3 317 550 person-years (p-y) of follow-up, we identified 269 incident cases of CD and 338 incident cases of UC. Zinc intake ranged from 9 mg/day in the lowest quintile to 27 mg/day in the highest quintile. Compared with women with the lowest quintile of intake, the multivariate hazard ratios (HR) for CD were 0.92 [95% confidence interval (CI), 0.65 – 1.29) for women in the second quintile of intake, 0.60 (95% CI, 0.40 – 0.89) for the third quintile, 0.57 (95% CI, 0.38 – 0.86) for fourth quintile and 0.74 (95% CI, 0.50 – 1.10) for the highest quintile (Ptrend = 0.003). The association was stronger for dietary zinc (HR 0.63, 95% CI, 0.43 – 0.93, comparing extreme quintiles) than for zinc intake from supplements. Neither dietary nor supplemental zinc modified risk of UC. CONCLUSIONS In two large prospective cohorts of women, intake of zinc was inversely associated with risk of CD but not UC.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Lochhead P, Khalili H, Ananthakrishnan AN, Richter JM, Chan AT. Association Between Circulating Levels of C-Reactive Protein and Interleukin-6 and Risk of Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2016; 14:818-824.e6. [PMID: 26844874 PMCID: PMC4875875 DOI: 10.1016/j.cgh.2016.01.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/05/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is evidence that immune dysfunction precedes symptoms of inflammatory bowel disease (IBD) by several years. Characterization of preclinical systemic inflammation could contribute to the understanding of the biology of IBD and, ultimately, facilitate development of strategies for early disease detection and intervention. We evaluated associations between circulating levels of interleukin-6 (IL6) and high-sensitivity C-reactive protein (hsCRP) and diagnosis of incident Crohn's disease (CD) or ulcerative colitis (UC). METHODS We conducted a nested case-control study of participants enrolled in 2 population-based, nationwide, prospective cohort studies (the Nurses' Health Study and the Nurses' Health Study II). We analyzed blood specimens, collected before diagnosis, from 83 persons with CD, 90 persons with UC, and 344 matched individuals without IBD (control subjects). Plasma levels of hsCRP and IL6 were measured. We investigated associations between each inflammatory marker and IBD risk using multivariable logistic regression models to adjust for potential confounding exposures. RESULTS Compared with the lowest quintile of IL6 level, the highest quintile was associated with an odds ratio (OR) of 4.68 (95% confidence interval, 1.91-11.46) for CD (Ptrend < .001) and an OR of 3.43 (95% confidence interval, 1.44-8.15) for UC (Ptrend = .004). The highest quintile of hsCRP level, compared with the lowest quintile, was associated with an OR of 2.82 (95% confidence interval, 1.15-6.87) for CD (Ptrend = .019) and an OR of 1.79 (95% confidence interval, 0.80-3.99) for UC (Ptrend = .015). CONCLUSIONS Plasma levels of IL6 and hsCRP before diagnosis are associated with risk of incident CD and UC. Subclinical levels of systemic inflammation may be a feature of an early disease state that precedes the development of symptomatic IBD.
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Affiliation(s)
- Paul Lochhead
- Clinical and Translational Epidemiology Unit, Division of Medicine, Massachusetts General Hospital, Boston, MA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Hamed Khalili
- Clinical and Translational Epidemiology Unit, Division of Medicine, Massachusetts General Hospital, Boston, MA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ashwin N. Ananthakrishnan
- Clinical and Translational Epidemiology Unit, Division of Medicine, Massachusetts General Hospital, Boston, MA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - James M. Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Andrew T. Chan
- Clinical and Translational Epidemiology Unit, Division of Medicine, Massachusetts General Hospital, Boston, MA,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Richter JM, Oster G, Arshi NK. Oral 5-aminosalicylate, mesalamine suppository and mesalamine enema as initial therapy for ulcerative proctitis in clinical practice with quality of care implications. Can J Gastroenterol Hepatol 2015:17111. [PMID: 26469062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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Dendup T, Richter JM, Yamaoka Y, Wangchuk K, Malaty HM. Geographical distribution of the incidence of gastric cancer in Bhutan. World J Gastroenterol 2015; 21:10883-10889. [PMID: 26478679 PMCID: PMC4600589 DOI: 10.3748/wjg.v21.i38.10883] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 05/09/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To estimate the prevalence of gastric cancer (GC) in a cohort of patients diagnosed with GC and to compare it with patients diagnosed with all other types of gastro-intestinal (GI) cancer during the same period.
METHODS: Between 2008 and 2013, five-year period, the medical records of all GI cancer patients who underwent medical care and confirm diagnosis of cancer were reviewed at the National Referral Hospital, Thimphu which is the only hospital in the country where surgical and cancer diagnosis can be made. Demographic information, type of cancer, and the year of diagnosis were collected.
RESULTS: There were a total of 767 GI related cancer records reviewed during the study period of which 354 (46%) patients were diagnosed with GC. There were 413 patients with other GI cancer including; esophagus, colon, liver, rectum, pancreas, gall bladder, cholangio-carcinoma and other GI tract cancers. The GC incidence rate is approximately 0.9/10000 per year (367 cases/5 years per 800000 people). The geographic distribution of GC was the lowest in the south region of Bhutan 0.3/10000 per year compared to the central region 1.4/10000 per year, Eastern region 1.2/10000 per year, and the Western region 1.1/10000 per year. Moreover, GC in the South part was significantly lower than the other GI cancer in the same region (8% vs 15%; OR = 1.8, 95%CI: 1.3-3.1, P = 0.05). Among GC patients, 38% were under the age of 60 years, mean age at diagnosis was 62.3 (± 12.1) years with male-to-female ratio 1:0.5. The mean age among patients with all other type GI cancer was 60 years (± 13.2) and male-to-female ratio of 1:0.7. At time of diagnosis of GC, 342 (93%) were at stage 3 and 4 of and by the year 2013; 80 (23%) GC patients died compared to 31% death among patients with the all other GI cancer (P = 0.08).
CONCLUSION: The incidence rate of GC in Bhutan is twice as high in the United States but is likely an underestimate rate because of unreported and undiagnosed cases in the villages. The high incidence of GC in Bhutan could be attributed to the high prevalence of Helicobacter pylori infection that we previously reported. The lowest incidence of GC in Southern part of the country could be due to the difference in the ethnicity as most of its population is of Indian and Nepal origin. Our current study emphasizes on the importance for developing surveillance and prevention strategies for GC in Bhutan.
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Cai JX, Campbell EJ, Richter JM. Concordance of Outpatient Esophagogastroduodenoscopy of the Upper Gastrointestinal Tract With Evidence-Based Guidelines. JAMA Intern Med 2015; 175:1563-4. [PMID: 26192987 DOI: 10.1001/jamainternmed.2015.3533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jennifer X Cai
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily J Campbell
- Division of Gastroenterology, Massachusetts General Hospital, Boston
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Boston
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Abstract
BACKGROUND Obesity is associated with intestinal-specific inflammation. Nonetheless, a specific role of obesity in the etiology of inflammatory bowel disease is unclear. METHODS We conducted a prospective cohort study of U.S. women enrolled in 1989 in the Nurses' Health Study II. At baseline, we collected information on height, weight, waist and hip circumference, weight at age 18, and body shape at age 20. We used Cox proportional hazard models to calculate hazard ratios and 95% confidence intervals (CIs). RESULTS Among 111,498 women (median age, 35 yr), we documented 153 cases of Crohn's disease (CD) and 229 cases of ulcerative colitis (UC) more than 18 years of follow-up, encompassing 2,028,769 person-years. Compared with women with normal BMI, the multivariate-adjusted hazard ratios of CD were 2.33 (95% CI, 1.15-4.69) for obese women at age 18 and 1.58 (95% CI, 1.01-2.47) for obese women at baseline. Increasing weight gain between age 18 and baseline was associated with increased risk of CD (Ptrend = 0.04). Adolescent body habitus was also associated with risk of CD with a multivariate-adjusted hazard ratio of CD of 1.63 (95% CI, 1.07-2.50) for women with overweight/obese body shape compared with women with a thin/slender body shape. We did not observe a significant association between any of these anthropometric measures and risk of UC. CONCLUSIONS In a large prospective cohort of U.S. women, measures of adiposity were associated with an increased risk of CD but not UC. Additional studies are needed to elucidate the biological mechanisms by which excess adiposity may increase the risk of CD.
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Affiliation(s)
- Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA 02114
| | - Ashwin N. Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA 02114
| | - Gauree G. Konijeti
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA 02114
| | - Leslie M. Higuchi
- Division of Gastroenterology and Nutrition, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115
| | - Charles S. Fuchs
- Department of Adult Oncology, Dana-Farber Cancer Institute, Boston, MA 02115
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - James M. Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA 02114
| | - Andrew T. Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston MA 02114
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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Richter JM. Capsule commentary on Tang et al., Evaluation of a primary care-based post-discharge phone call program: keeping the primary care practice at the center of post-hospitalization care transition. J Gen Intern Med 2014; 29:1532. [PMID: 25183472 PMCID: PMC4238199 DOI: 10.1007/s11606-014-2957-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- James M Richter
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA,
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Guimaraes ES, Campbell EJ, Richter JM. The safety of nurse-administered procedural sedation compared to anesthesia care in a historical cohort of advanced endoscopy patients. Anesth Analg 2014; 119:349-356. [PMID: 24859079 DOI: 10.1213/ane.0000000000000258] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND In April 2010, in response to a change in Centers for Medicare and Medicaid Services regulation placing deep sedation under hospital anesthesia services, our institution began providing anesthesia care for all advanced endoscopic procedures. Because it remains unknown whether anesthesia care reduces sedation-related complications or improves quality of care versus nurse-administered sedation for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound patients, we retrospectively compared complications in a 5-year historical cohort before and after the policy change. METHODS We reviewed a historical cohort of 9598 consecutive endoscopic retrograde cholangiopancreatography and endoscopic ultrasound examinations for adult patients at a single institution during a 5-year period (October 2007-October 2012). We compared procedures performed before and after the policy change for the incidence of sedation, endoscopic, and total complications, and for major morbidity and mortality. RESULTS The incidence of reported sedation-related complications was 0.38% (17 of 4514) before the policy change and 0.08% (4 of 5084) after the policy change, which was statistically significant (P = 0.002, diff = 0.3, 95% confidence interval, 0.11%-0.53%). Endoscopic complications were not significantly different before versus after: 0.66% vs 0.87% (P = 0.293, diff = 0.2, 95% confidence interval, -0.16% to 0.56%). Total complications (1.11% vs 1.00%, P = 0.618) and major morbidity and mortality (0.27% vs 0.33%, P = 0.581) did not differ between the 2 time periods. CONCLUSIONS Anesthesia care for advanced endoscopy in a high-risk population significantly reduced sedation complications compared with nurse-administered sedation. Endoscopic complications were unchanged. The sedation risk reduction did not reduce major morbidity, mortality, or total complications.
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Affiliation(s)
- Emily S Guimaraes
- From the *Department of Anesthesia, Critical Care, and Pain Management, Massachusetts General Hospital; †Harvard Medical School; and ‡Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
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Richter JM, Pino MS, Austin TR, Campbell E, Szymonifka J, Russo AL, Hong TS, Borger D, Iafrate AJ, Chung DC. Genetic mechanisms in interval colon cancers. Dig Dis Sci 2014; 59:2255-63. [PMID: 24705641 DOI: 10.1007/s10620-014-3134-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 03/23/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM The factors underlying the development of interval colon cancers are not well defined and are likely heterogeneous. We sought to determine whether there are distinct molecular properties associated with interval colon cancers. METHODS Colon cancers diagnosed within 5 years of a complete and well-prepped colonoscopic examination were identified over a 7-year period at a single institution. The clinical and pathological features of the tumors were defined. Analysis of DNA mismatch repair (MMR) and genotyping of a panel of oncogenes associated with colon cancer were performed. RESULTS Forty-two interval colon cancers were diagnosed at an average age of 70 years. 69 % of tumors were located in the right colon. 41 % of tumors exhibited DNA microsatellite instability (MSI). Loss of staining of DNA MMR proteins by immunohistochemistry (IHC) was confirmed in 82 % of the MSI-positive tumors. Among tumors with abnormal MSI and IHC, 54 % exhibited somatic methylation of the MLH1 promoter, but the remaining 43 % exhibited molecular features indicative of underlying Lynch syndrome (LS). The frequency of somatic mutations in the KRAS, BRAF, NRAS, and PIK3CA oncogenes was similar between interval cancer cases and controls. CONCLUSIONS Interval colon cancers are not distinguished by the activation of the KRAS, NRAS, BRAF, or PIK3CA oncogenic pathways. However, MSI pathway defects are present in a significant proportion of interval colon cancers. Underlying LS may explain nearly half of these MSI-positive cases, and the remaining cases appear to represent sporadic serrated pathway tumors.
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Affiliation(s)
- James M Richter
- GRJ 704, Gastrointestinal Unit, Massachusetts General Hospital, 50 Blossom Street, Boston, MA, 02114, USA,
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