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Mårild K, Söderling J, Stephansson O, Axelrad J, Halfvarson J, Bröms G, Marsal J, Olén O, Ludvigsson JF. Histologic Remission in Inflammatory Bowel Disease and Female Fertility: A Nationwide Study. Gastroenterology 2024; 166:802-814.e18. [PMID: 38331202 DOI: 10.1053/j.gastro.2024.01.018] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 01/04/2024] [Accepted: 01/13/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND & AIMS Inflammatory bowel disease (IBD) is linked to reduced female fertility, but it is unclear how fertility rates vary by histologic disease activity. METHODS Nationwide IBD cohort of Swedish women aged 15 to 44 years. We examined fertility rates during periods with vs without histologic inflammation (n = 21,046; follow-up, 1990-2016) and during periods with vs without clinical activity (IBD-related hospitalization, surgery, or treatment escalation) (n = 24,995; follow-up, 2006-2020). Accounting for sociodemographics and comorbidities, we used Poisson regression to estimate adjusted fertility rate ratios (aFRRs) for live births conceived during 12-month periods of histologic inflammation (vs histologic remission) and 3-month periods of clinically active IBD (vs quiescent IBD). RESULTS During periods with vs without histologic inflammation, there were 6.35 (95% confidence interval [CI], 5.98-6.73) and 7.09 (95% CI, 6.48-7.70) live births conceived per 100 person-years of follow-up, respectively, or 1 fewer child per 14 women with 10 years of histologic inflammation (aFRR, 0.90; 95% CI, 0.81-1.00). In women with histologic inflammation, fertility was similarly reduced in ulcerative colitis (UC) (aFRR, 0.89 [95% CI, 0.78-1.02]) and Crohn's disease (CD) (aFRR, 0.86 [95% CI, 0.72-1.04]). Clinical IBD activity was associated with an aFRR of 0.76 (95% CI, 0.72-0.79) or 1 fewer child per 6 women with 10 years of clinical activity. Fertility was reduced in clinically active UC (aFRR, 0.75 [95% CI, 0.70-0.81]) and CD (aFRR, 0.76 [95% CI, 0.70-0.82]). Finally, among women with clinically quiescent IBD, histologic inflammation (vs histologic remission) was associated with reduced fertility (aFRR, 0.85 [95% CI, 0.73-0.98]). CONCLUSIONS An association between histologic and clinical activity and reduced female fertility in CD and UC was found. Notably, histologic inflammation was also linked to reduced fertility in women with clinically quiescent IBD.
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Affiliation(s)
- Karl Mårild
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden; Department of Pediatrics, Queen Silvia Children's Hospital, Gothenburg, Sweden.
| | - Jonas Söderling
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden; Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jordan Axelrad
- Inflammatory Bowel Disease Center at NYU Langone Health, Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Gabriella Bröms
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Gastroenterology, Danderyd Hospital, Stockholm, Sweden
| | - Jan Marsal
- Department of Gastroenterology, Skåne University Hospital, Lund, Sweden; Immunology Section, Lund University, Lund, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden; Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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Mårild K, Söderling J, Axelrad J, Halfvarson J, Forss A, Olén O, Ludvigsson JF. Histologic Activity in Inflammatory Bowel Disease and Risk of Serious Infections: A Nationwide Study. Clin Gastroenterol Hepatol 2024; 22:831-846. [PMID: 37913937 PMCID: PMC10960698 DOI: 10.1016/j.cgh.2023.10.013] [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: 05/12/2023] [Revised: 10/03/2023] [Accepted: 10/16/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND & AIMS Individuals with inflammatory bowel disease (IBD) are at increased risk of serious infections, but whether this risk varies by histologic disease activity is unclear. METHODS This was a national population-based study of 55,626 individuals diagnosed with IBD in 1990 to 2016 with longitudinal data on ileocolorectal biopsy specimens followed up through 2016. Serious infections were defined as having an inpatient infectious disease diagnosis in the Swedish National Patient Register. We used Cox regression to estimate hazard ratios (HRs) for serious infections in the 12 months after documentation of histologic inflammation (vs histologic remission), adjusting for social and demographic factors, chronic comorbidities, prior IBD-related surgery, and hospitalization. We also adjusted for IBD-related medications in sensitivity analyses. RESULTS With histologic inflammation vs remission, there was 4.62 (95% CI, 4.46-4.78) and 2.53 (95% CI, 2.36-2.70) serious infections per 100 person-years of follow-up, respectively (adjusted HR [aHR], 1.59; 95% CI, 1.48-1.72). Histologic inflammation (vs remission) was associated with an increased risk of serious infections in ulcerative colitis (aHR, 1.68; 95% CI, 1.51-1.87) and Crohn's disease (aHR, 1.59; 95% CI, 1.40-1.80). The aHRs of sepsis and opportunistic infections were 1.66 (95% CI, 1.28-2.15) and 1.71 (95% CI, 1.22-2.41), respectively. Overall, results were consistent across age groups, sex, and education level, and remained largely unchanged after adjustment for IBD-related medications (aHR, 1.47; 95% CI, 1.34-1.61). CONCLUSIONS Histologic inflammation of IBD was an independent risk factor of serious infections, including sepsis, suggesting that achieving histologic remission may reduce infections in IBD. The study was approved by the Stockholm Ethics Review Board (approval numbers 2014/1287-31/4, 2018/972-32, and 2021-06209-01).
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Affiliation(s)
- Karl Mårild
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden; Department of Pediatrics, Queen Silvia Children's Hospital, Gothenburg, Sweden.
| | - Jonas Söderling
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden; Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jordan Axelrad
- Inflammatory Bowel Disease Center at New York University Langone Health, Division of Gastroenterology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Forss
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Gastroenterology Unit, Department of Gastroenterology, Dermatovenereology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Pediatric Gastroenterology Unit, Sach's Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden; Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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Allegretti JR, Axelrad J, Dalal RS, Kelly CR, Grinspan A, Fischer M. Outcomes after Fecal Microbiota Transplantation in combination with Bezlotoxumab for Inflammatory Bowel Disease and Recurrent C . difficile Infection. Am J Gastroenterol 2024:00000434-990000000-01081. [PMID: 38501667 DOI: 10.14309/ajg.0000000000002770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/06/2024] [Indexed: 03/20/2024]
Abstract
Fecal microbiota transplantation (FMT) prevents recurrent C. difficile infections (rCDI) in IBD. Patients. Bezlotoxumab is also indicated to prevent rCDI. We assess the impact of FMT in combination with bezlotoxumab in patients with IBD and rCDI. We conducted a multicenter randomized placebo-controlled trial. All received a single colonoscopic FMT. Patients were randomized 1:1 to receive bezlotoxumab or placebo. Sixty-one patients were enrolled (30 received treatment and 31 placebo. Overall, 5 participants (8%) experienced a CDI recurrence; 4 in the treatment arm, 1 in placebo (13% vs 3%, p=0.15). There was no clear benefit to the combination approach compared to FMT alone.
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Affiliation(s)
- Jessica R Allegretti
- . Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA
- . Harvard Medical School, Boston, MA
| | - Jordan Axelrad
- . Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY
| | - Rahul S Dalal
- . Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA
- . Harvard Medical School, Boston, MA
| | - Colleen R Kelly
- . Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA
- . Harvard Medical School, Boston, MA
| | - Ari Grinspan
- . The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Monika Fischer
- . Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN
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Eidelberg A, Axelrad J, Chedid V, Ballou S, Cheifetz A, Rabinowitz LG. Sexual Health in Sexual and Gender Minority Patients with Inflammatory Bowel Disease. Dig Dis Sci 2024; 69:743-748. [PMID: 38267727 DOI: 10.1007/s10620-023-08253-0] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/14/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND In recent years, legislation targeting the sexual and gender minority (SGM) community has been passed at an increasingly alarming rate, affecting access to safe and effective gender-affirming care and forcing many SGM patients, including those with inflammatory bowel disease (IBD), to withhold their identities and health concerns. Additionally, SGM patients with IBD may have unique health considerations that have not yet been well-studied OBJECTIVE: This article aims to explore the intersection of IBD and sexual health in patients who identify as SGM and to identify limitations for gastroenterologists in caring for SGM patients. The article also aims to provide suggestions for improvement in SGM-competent care within gastroenterology METHODS: A thorough literature review was conducted regarding sexual health and the SGM community with IBD. This included a review of surgical considerations in SGM patients, sexually transmitted infections (STIs) and prevention, and sexual dysfunction RESULTS: Overall, little is known about the impact of IBD on patients who identify as sexual and gender minorities. Surgery, medications, and STIs continue to be a concern in the SGM community with IBD and these areas represent opportunities to improve SGM-competent IBD care. Additionally, implementation of an SGM-focused curriculum is urgently needed in medical education to improve provider knowledge and care for this unique group of patients CONCLUSIONS: Patients with IBD who identify as SGM experience challenges that are not well described in prior literature. More research is needed and is actively being pursued to guide provider awareness and improve sexual health for this patient population.
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Affiliation(s)
- Andrew Eidelberg
- Department of Medicine and Division of Gastroenterology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Rabb 4, Boston, MA, 02215, USA.
| | | | | | - Sarah Ballou
- Department of Medicine and Division of Gastroenterology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Rabb 4, Boston, MA, 02215, USA
| | - Adam Cheifetz
- Department of Medicine and Division of Gastroenterology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Rabb 4, Boston, MA, 02215, USA
| | - Loren G Rabinowitz
- Department of Medicine and Division of Gastroenterology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Rabb 4, Boston, MA, 02215, USA
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Faye AS, Axelrad J, Sun J, Halfvarson J, Söderling J, Olén O, Ludvigsson JF. Atherosclerosis as a Risk Factor of Inflammatory Bowel Disease: A Population-Based Case-Control Study. Am J Gastroenterol 2024; 119:313-322. [PMID: 37721310 PMCID: PMC10872602 DOI: 10.14309/ajg.0000000000002502] [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: 06/06/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Data suggest atherosclerotic-related inflammation may play a role in the pathogenesis of inflammatory bowel disease (IBD), but large-scale studies are missing. METHODS In this nationwide case-control study, we used the Swedish Patient Register and the Epidemiology Strengthened by histoPathology Reports in Sweden cohort to identify adult cases of incident IBD between 2002 and 2021, with each case matched to up to 10 general population controls. We used conditional logistic regression to calculate odds ratios (OR) for exposure to an atherosclerotic-related condition (myocardial infarction, thromboembolic stroke, or atherosclerosis itself) before being diagnosed with IBD. RESULTS There were a total of 56,212 individuals with IBD and 531,014 controls. Of them, 2,334 (4.2%) cases and 18,222 (3.4%) controls had a prior diagnosis of an atherosclerotic-related condition, corresponding to an OR of 1.30 (95% confidence interval [CI] 1.24-1.37). Results were statistically significant for both Crohn's disease (OR 1.37, 95% CI 1.26-1.48) and ulcerative colitis (OR 1.27, 95% CI 1.20-1.35) and for individuals who developed IBD at 40-59 years of age and 60 years or older. In addition, associations persisted when adjusting for underlying comorbidities, including the presence of immune-mediated diseases and prior aspirin and/or statin use. The highest odds of an atherosclerotic-related condition were seen in the 6-12 months before IBD diagnosis, though odds were increased even ≥5 years before. A higher magnitude of odds was also observed when having 2 or more atherosclerotic-related conditions when compared with having only 1 condition. DISCUSSION A history of an atherosclerotic-related condition is associated with increased odds of developing IBD, particularly among older adults. Future studies should investigate whether drugs targeting atherosclerotic-related inflammation may prevent IBD in higher-risk individuals.
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Affiliation(s)
- Adam S. Faye
- Inflammatory Bowel Disease Center at NYU Langone Health, Division of Gastroenterology, Department of Medicine, NYU School of Medicine, New York, New York, USA
| | - Jordan Axelrad
- Inflammatory Bowel Disease Center at NYU Langone Health, Division of Gastroenterology, Department of Medicine, NYU School of Medicine, New York, New York, USA
| | - Jiangwei Sun
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jonas Söderling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Sachs’ Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F. Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
- Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, New York, USA
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Li T, Shah R, Click B, Cohen BL, Barnes E, Joseph A, Bachour S, Hu J, Contreras S, Li E, Axelrad J. American Gastroenterological Association-Proposed Fecal Calprotectin Cutoff of 50 ug/g is Associated With Endoscopic Recurrence in a Real-World Cohort of Patients With Crohn's Disease Post-ileocolic Resection. Crohns Colitis 360 2024; 6:otae016. [PMID: 38525200 PMCID: PMC10960600 DOI: 10.1093/crocol/otae016] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Indexed: 03/26/2024] Open
Abstract
Background Fecal calprotectin (FC) is a reliable predictor of active bowel inflammation in postoperative Crohn's disease (CD), but cutoffs vary between studies. Recent guidelines recommend a cutoff of <50 ug/g to avoid routine endoscopy in patients at low pretest probability for CD recurrence. We evaluated the performance of this threshold in a real-world CD cohort after ileocolic resection (ICR). Methods In this retrospective study, patients with CD post-ICR between 2009 to 2020 with FC > 60 days but < 1 year of surgery were included from a multicenter database. Established risk factors and/or biologic prophylaxis (biologic within 90 days of surgery) defined pretest probability. Those without postoperative colonoscopy were excluded. Rates of endoscopic recurrence, defined as Rutgeerts score ≥ i2b at any time after surgery, were compared between FC < 50 versus ≥ 50 ug/g. Student's t-test and Fisher's exact test were utilized for statistical analysis. All postoperative FCs were matched to closest colonoscopy within 1 year to calculate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results Thirty-seven patients categorized as either low-risk or high-risk and received biologic prophylaxis and had postoperative colonoscopy were included. Median time to first FC was 217 days (IQR 131-288). 15 (41%) patients had initial FC < 50 ug/g versus 22 (59%) ≥50 ug/g. Median time to first colonoscopy was 234 days (IQR 189-369). Compared to initial FC ≥ 50 ug/g, FC < 50ug/g experienced less endoscopic recurrence (0% vs. 36%, P = .005). Median time to first endoscopic recurrence in FC ≥ 50 ug/g was 145 days. There were 39 matched pairs of FC and colonoscopy. At an FC cutoff of 50 ug/g, calculated sensitivity was 90% and NPV was 93%, whereas specificity and PPV were 48% and 38%, respectively. Conclusions In this real-world cohort, FC < 50 ug/g is a useful cutoff to exclude endoscopic recurrence in a post-ICR CD population that is at low pretest probability of recurrence.
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Affiliation(s)
- Terry Li
- Department of Internal Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Ravi Shah
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Click
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Edward Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Abel Joseph
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Salam Bachour
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jessica Hu
- University of North Carolina School of Medicine, ChapelHill, NC, USA
| | - Susell Contreras
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Elizabeth Li
- NYU Grossman School of Medicine, NewYork, NY, USA
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, New York, NY, USA
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Bachour SP, Khan MZ, Shah RS, Joseph A, Syed H, Ali AH, Rieder F, Holubar SD, Barnes EL, Axelrad J, Regueiro M, Cohen BL, Click BH. Anastomotic Configuration and Temporary Diverting Ileostomy Do Not Increase Risk of Anastomotic Stricture in Postoperative Crohn's Disease. Am J Gastroenterol 2023; 118:2212-2219. [PMID: 37410924 PMCID: PMC10921865 DOI: 10.14309/ajg.0000000000002393] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 02/21/2023] [Accepted: 06/13/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Surgical management of Crohn's disease (CD) is common. Postoperative complications include anastomotic stricturing (AS). The natural history and risk factors for AS have not been elucidated. METHODS A retrospective cohort study of patients with CD who underwent ileocolonic resection (ICR) with ≥1 postoperative ileocolonoscopy between 2009 and 2020. Postoperative ileocolonoscopies with corresponding cross-sectional imaging were evaluated for evidence of AS without neoterminal ileal extension. Severity of AS and endoscopic intervention at time of detection were collected. Primary outcome was development of AS. Secondary outcome was time to AS detection. RESULTS A total of 602 adult patients with CD underwent ICR with postoperative ileocolonoscopy. Of these, 426 had primary anastomosis, and 136 had temporary diversion at time of ICR. Anastomotic configuration consisted of 308 side-to-side, 148 end-to-side, and 136 end-to-end. One hundred ten (18.3%) patients developed AS with median time of 3.2 years to AS detection. AS severity at time of detection was associated with need for repeat surgical resection for AS. On multivariable Cox proportional hazard regression, anastomotic configuration and temporary diversion were not associated with risk of or time to AS. Preoperative stricturing disease was associated with decreased time to AS (adjusted hazard ratio 1.8; P = 0.049). Endoscopic ileal recurrence before AS was not associated with subsequent AS detection. DISCUSSION AS is a relatively common postoperative CD complication. Patients with previous stricturing disease behavior are at increased risk of AS. Anastomotic configuration, temporary diversion, and ileal CD recurrence do not increase risk of AS. Early detection and intervention for AS may help prevent progression to repeat ICR.
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Affiliation(s)
- Salam P. Bachour
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Muhammad Z. Khan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ravi S. Shah
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Abel Joseph
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Hareem Syed
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Adel Hajj Ali
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH, USA
| | - Stefan D. Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Edward L. Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jordan Axelrad
- Department of Gastroenterology and Hepatology, New York University, New York, NY, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin L. Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin H. Click
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Bachour SP, Shah RS, Joseph A, Syed H, Ali AH, Rieder F, Barnes EL, Axelrad J, Holubar SD, Regueiro M, Cohen BL, Click BH. Change in Biologic Class Promotes Endoscopic Remission Following Endoscopic Postoperative Crohn's Disease Recurrence. J Clin Gastroenterol 2023:00004836-990000000-00238. [PMID: 38019054 DOI: 10.1097/mcg.0000000000001943] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/19/2023] [Indexed: 11/30/2023]
Abstract
GOALS Assess the outcomes of various therapeutic regimens to treat initial endoscopic postoperative recurrence despite biologic prophylaxis. BACKGROUND Postoperative biologic prophylaxis reduces postoperative Crohn's disease (CD) recurrence rates. Optimal treatment strategies for endoscopic recurrence have not been elucidated. STUDY Retrospective cohort study of adult CD patients who underwent ileocolonic resection between 2009 and 2020. Patients with endoscopic postoperative recurrence despite prophylactic biologic therapy and ≥1 subsequent colonoscopy were included. Treatment changes after recurrence were categorized as (1) therapy optimization or continuation or (2) new biologic class. The primary outcome was composite endoscopic or surgical recurrence at the time of or prior to subsequent follow-up colonoscopy. RESULTS Eighty-one CD patients with endoscopic recurrence (54.3% i2b, 22.2% i3, and 23.5% i4) despite biologic prophylaxis (86.4% anti-tumor necrosis factor, 8.6% vedolizumab, 4.9% ustekinumab) were included. Most patients received therapy optimization or continuation (76.3%, n=61) following recurrence compared to being started on a new biologic class. Sixty patients (N=48 therapy optimization; N=12 new biologic class) experienced composite recurrence (78.3% endoscopic, 21.7% surgical). On multivariable modeling, initiation of a new biologic class was associated with reduced risk for composite recurrence compared to therapy optimization or continuation (aOR: 0.26; P=0.04). Additionally, initiation of a new biologic class was associated with endoscopic improvement when adjusting for endoscopic severity at the time of recurrence (aOR: 3.4; P=0.05). On sensitivity analysis, a new biologic class was associated or trended with improved rates of endoscopic healing and composite recurrence when directly compared to therapy optimization or continuation. CONCLUSION In patients with CD who experience endoscopic recurrence despite biologic prophylaxis, changing the mechanism of biologic action may promote endoscopic improvement.
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Affiliation(s)
- Salam P Bachour
- Cleveland Clinic Lerner College of Medicine
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Ravi S Shah
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic
| | - Abel Joseph
- Department of Internal Medicine, Cleveland Clinic
| | - Hareem Syed
- Department of Internal Medicine, Cleveland Clinic
| | - Adel Hajj Ali
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic
- Department of Colorectal Surgery, Cleveland Clinic
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, NC
| | - Jordan Axelrad
- Department of Gastroenterology and Hepatology, New York University, New York, NY
| | - Stefan D Holubar
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic
| | - Benjamin H Click
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO
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Chang S, Hong S, Hudesman D, Remzi F, Sun K, Cao W, Kani HT, Axelrad J, Sarkar SA. Histologic Predictors of Clinical Outcomes and Healthcare Utilization in Patients With Ileal Pouch-Anal Anastomosis. Inflamm Bowel Dis 2023; 29:1769-1777. [PMID: 36702534 PMCID: PMC10628915 DOI: 10.1093/ibd/izac277] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 09/20/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The prognostic significance of histology in ileal pouch-anal anastomosis (IPAA) remains unclear. The aim of this study was to evaluate if histologic variables are predictive of IPAA clinical outcomes and healthcare utilization. METHODS This was a retrospective cohort study of patients with IPAA undergoing surveillance pouchoscopy at a tertiary care institution. Pouch body biopsies were reviewed by gastrointestinal pathologists, who were blinded to clinical outcomes, for histologic features of acute or chronic inflammation. Charts were reviewed for clinical outcomes including development of acute pouchitis, chronic pouchitis, biologic or small molecule initiation, hospitalizations, and surgery. Predictors of outcomes were analyzed using univariable and multivariable logistic and Cox regression. RESULTS A total of 167 patients undergoing surveillance pouchoscopy were included. Polymorphonuclear leukocytes (odds ratio [OR], 1.67), ulceration and erosion (OR, 2.44), chronic inflammation (OR, 1.97), and crypt distortion (OR, 1.89) were associated with future biologic or small molecule initiation for chronic pouchitis. Loss of goblet cells was associated with development of chronic pouchitis (OR, 4.65). Pyloric gland metaplasia was associated with hospitalizations (OR, 5.24). No histologic variables were predictive of development of acute pouchitis or surgery. In an exploratory subgroup analysis of new IPAA (<1 year), loss of goblet cells was associated with acute pouchitis (OR, 14.86) and chronic pouchitis (OR, 12.56). Pyloric gland metaplasia was again associated with hospitalizations (OR, 13.99). CONCLUSIONS Histologic findings may be predictive of IPAA outcomes. Pathologists should incorporate key histologic variables into pouchoscopy pathology reports. Clinicians may need to more closely monitor IPAA patients with significant histologic findings.
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Affiliation(s)
- Shannon Chang
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Simon Hong
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - David Hudesman
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Feza Remzi
- Department of Colorectal Surgery, New York University Langone Health, New York, NY, USA
| | - Katherine Sun
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
| | - Wenqing Cao
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
| | - H Tarik Kani
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Jordan Axelrad
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Suparna A Sarkar
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
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Zhang B, Upadhyay R, Hao Y, Samanovic MI, Herati RS, Blair JD, Axelrad J, Mulligan MJ, Littman DR, Satija R. Multimodal single-cell datasets characterize antigen-specific CD8 + T cells across SARS-CoV-2 vaccination and infection. Nat Immunol 2023; 24:1725-1734. [PMID: 37735591 PMCID: PMC10522491 DOI: 10.1038/s41590-023-01608-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 01/24/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
The immune response to SARS-CoV-2 antigen after infection or vaccination is defined by the durable production of antibodies and T cells. Population-based monitoring typically focuses on antibody titer, but there is a need for improved characterization and quantification of T cell responses. Here, we used multimodal sequencing technologies to perform a longitudinal analysis of circulating human leukocytes collected before and after immunization with the mRNA vaccine BNT162b2. Our data indicated distinct subpopulations of CD8+ T cells, which reliably appeared 28 days after prime vaccination. Using a suite of cross-modality integration tools, we defined their transcriptome, accessible chromatin landscape and immunophenotype, and we identified unique biomarkers within each modality. We further showed that this vaccine-induced population was SARS-CoV-2 antigen-specific and capable of rapid clonal expansion. Moreover, we identified these CD8+ T cell populations in scRNA-seq datasets from COVID-19 patients and found that their relative frequency and differentiation outcomes were predictive of subsequent clinical outcomes.
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Affiliation(s)
- Bingjie Zhang
- New York Genome Center, New York, NY, USA
- Center for Genomics and Systems Biology, New York University, New York, NY, USA
- Department of Cell Biology, New York University Grossman School of Medicine, New York, NY, USA
| | - Rabi Upadhyay
- Department of Cell Biology, New York University Grossman School of Medicine, New York, NY, USA
- Perlmutter Cancer Center, New York University Langone Health, New York, NY, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Yuhan Hao
- New York Genome Center, New York, NY, USA
- Center for Genomics and Systems Biology, New York University, New York, NY, USA
| | - Marie I Samanovic
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- New York University Langone Vaccine Center, New York, NY, USA
| | - Ramin S Herati
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- New York University Langone Vaccine Center, New York, NY, USA
| | - John D Blair
- New York Genome Center, New York, NY, USA
- Center for Genomics and Systems Biology, New York University, New York, NY, USA
| | - Jordan Axelrad
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Mark J Mulligan
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- New York University Langone Vaccine Center, New York, NY, USA
| | - Dan R Littman
- Department of Cell Biology, New York University Grossman School of Medicine, New York, NY, USA.
- Perlmutter Cancer Center, New York University Langone Health, New York, NY, USA.
- Howard Hughes Medical Institute, New York, NY, USA.
| | - Rahul Satija
- New York Genome Center, New York, NY, USA.
- Center for Genomics and Systems Biology, New York University, New York, NY, USA.
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11
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George LA, Feldman HT, Alizadeh M, Abutaleb A, Zullow S, Hine A, Stashek K, Sarkar S, Sun K, Hudesman D, Axelrad J, Cross RK. Histologic Inflammation can Predict Future Clinical Relapse in Ulcerative Colitis Patients in Endoscopic Remission. Crohns Colitis 360 2023; 5:otad059. [PMID: 37886705 PMCID: PMC10599395 DOI: 10.1093/crocol/otad059] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Indexed: 10/28/2023] Open
Abstract
Background In ulcerative colitis (UC), endoscopic improvement, defined as a Mayo Endoscopic Score (MES) of 0 or 1, is a target of treatment. The aim of our study was to evaluate the risk of clinical relapse between patients with an MES of 0 or 1 and determine if histologic activity using the Robarts Histopathologic Index (RHI) was predictive of clinical relapse. Methods UC patients with an MES score of 0 or 1, no prior colectomy, and at least 1 year of outpatient follow-up after colonoscopy were included. Demographic, clinical characteristics, and clinical relapse were retrospectively collected. Biopsy specimens were read by a gastrointestinal pathologist. Primary outcome was defined as a composite of relapse requiring change in medical therapy, new steroid use, UC-related hospitalization, and/or colectomy. Results Four hundred and forty-five UC patients were identified. Ninety-five percent of patients with MES 0 were in histologic remission by the RHI whereas only 35% of patients with MES 1 were in histologic remission. Twenty-six percent of patients experienced a clinical relapse; patients with MES 1 or RHI > 3 were significantly more likely to relapse (P < .01) compared to patients with MES 0 or RHI ≤ 3. When patients were stratified into 4 groups (MES 0, RHI ≤ 3; MES 0, RHI > 3; MES 1, RHI ≤ 3; MES 1, RHI > 3) and adjusted for age and sex, RHI > 3 was predictive of relapse (P = .008). Conclusions UC patients with endoscopic improvement have a high rate of clinical relapse over time. Histologic activity is a predictor of clinical relapse.
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Affiliation(s)
- Lauren A George
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Harris T Feldman
- Department of Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Madeline Alizadeh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ameer Abutaleb
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samantha Zullow
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ashley Hine
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Kristen Stashek
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Suparna Sarkar
- Department of Pathology, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Katherine Sun
- Department of Pathology, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - David Hudesman
- Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Center at NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Jordan Axelrad
- Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Center at NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Young S, Lee B, Smukalla S, Axelrad J, Chang S. Anorectal Manometry in Patients With Fecal Incontinence After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Cohort Study. Crohns Colitis 360 2023; 5:otad063. [PMID: 38077748 PMCID: PMC10708921 DOI: 10.1093/crocol/otad063] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Indexed: 02/12/2024] Open
Abstract
Background Fecal incontinence commonly occurs in patients with ulcerative colitis and ileal pouch-anal anastomosis. There is a paucity of manometric data in pouch patients. We aimed to better define manometric parameters in pouch patients with fecal incontinence. Methods We compared clinical and manometric variables in ulcerative colitis patients with pouch and fecal incontinence to ulcerative colitis patients with pouch without fecal incontinence and to non-ulcerative colitis patients with fecal incontinence. Manometric data for the 3 cohorts were compared to established normative data. An independent-samples t-test was performed for continuous variables, and chi-square test was used for categorical variables. Logistic regression was performed to identify predictors of incontinence in pouch patients (P < .05). Results Among 26 pouch patients with fecal incontinence (73% female), 26 pouch patients without fecal incontinence (35% female), and 84 patients with fecal incontinence without ulcerative colitis (68% female), there were no differences in anorectal pressures between patients with fecal incontinence. Lower pressures were observed in pouch patients with fecal incontinence compared to those without fecal incontinence. Resting pressure was similar between pouch patients with fecal incontinence and healthy controls (60.9 ± 36.1 mmHg vs. 66.9 ± 3.2 mmHg, P = .40). Female sex (P = .019) and defecatory disorders (P = .033) each independently predicted fecal incontinence in pouch patients. Conclusions Pouch patients with fecal incontinence have lower anorectal pressures compared to pouch patients without incontinence, though have similar pressures to non-ulcerative colitis patients with fecal incontinence. Pouch patients with fecal incontinence have similar resting pressures as healthy controls. Distinct manometric normative values for pouch patients are needed.
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Affiliation(s)
- Sigrid Young
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Briton Lee
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Scott Smukalla
- Division of Gastroenterology, NYU Langone Health, New York, NY, USA
| | - Jordan Axelrad
- Division of Gastroenterology, Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Shannon Chang
- Division of Gastroenterology, Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
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13
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Jang KK, Heaney T, London M, Ding Y, Putzel G, Yeung F, Ercelen D, Chen YH, Axelrad J, Gurunathan S, Zhou C, Podkowik M, Arguelles N, Srivastava A, Shopsin B, Torres VJ, Keestra-Gounder AM, Pironti A, Griffin ME, Hang HC, Cadwell K. Antimicrobial overproduction sustains intestinal inflammation by inhibiting Enterococcus colonization. Cell Host Microbe 2023; 31:1450-1468.e8. [PMID: 37652008 PMCID: PMC10502928 DOI: 10.1016/j.chom.2023.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 02/10/2023] [Revised: 07/02/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
Loss of antimicrobial proteins such as REG3 family members compromises the integrity of the intestinal barrier. Here, we demonstrate that overproduction of REG3 proteins can also be detrimental by reducing a protective species in the microbiota. Patients with inflammatory bowel disease (IBD) experiencing flares displayed heightened levels of secreted REG3 proteins that mediated depletion of Enterococcus faecium (Efm) from the gut microbiota. Efm inoculation of mice ameliorated intestinal inflammation through activation of the innate immune receptor NOD2, which was associated with the bacterial DL-endopeptidase SagA that generates NOD2-stimulating muropeptides. NOD2 activation in myeloid cells induced interleukin-1β (IL-1β) secretion to increase the proportion of IL-22-producing CD4+ T helper cells and innate lymphoid cells that promote tissue repair. Finally, Efm was unable to protect mice carrying a NOD2 gene variant commonly found in IBD patients. Our findings demonstrate that inflammation self-perpetuates by causing aberrant antimicrobial activity that disrupts symbiotic relationships with gut microbes.
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Affiliation(s)
- Kyung Ku Jang
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Thomas Heaney
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Mariya London
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Yi Ding
- Department of Laboratory Medicine, Geisinger Health, Danville, PA 17822, USA
| | - Gregory Putzel
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA; Antimicrobial-Resistant Pathogens Program, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Frank Yeung
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Defne Ercelen
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Ying-Han Chen
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Sakteesh Gurunathan
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Chaoting Zhou
- Cell and Molecular Biology Graduate Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Magdalena Podkowik
- Antimicrobial-Resistant Pathogens Program, New York University Grossman School of Medicine, New York, NY 10016, USA; Division of Infectious Diseases and Immunology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Natalia Arguelles
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA; Antimicrobial-Resistant Pathogens Program, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Anusha Srivastava
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA; Antimicrobial-Resistant Pathogens Program, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Bo Shopsin
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA; Antimicrobial-Resistant Pathogens Program, New York University Grossman School of Medicine, New York, NY 10016, USA; Division of Infectious Diseases and Immunology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Victor J Torres
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA; Antimicrobial-Resistant Pathogens Program, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - A Marijke Keestra-Gounder
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Alejandro Pironti
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA; Antimicrobial-Resistant Pathogens Program, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Matthew E Griffin
- Department of Immunology and Microbiology, Scripps Research, 10550 North Torrey Pines Road, La Jolla, CA 92037, USA
| | - Howard C Hang
- Department of Immunology and Microbiology, Scripps Research, 10550 North Torrey Pines Road, La Jolla, CA 92037, USA; Department of Chemistry, Scripps Research, 10550 North Torrey Pines Road, La Jolla, CA 92037, USA
| | - Ken Cadwell
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA.
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14
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Li T, Click B, Bachour S, Sachs M, Barnes EL, Cohen BL, Contreras S, Axelrad J. Suboptimal Guideline Adherence and Biomarker Underutilization in Monitoring of Post-operative Crohn's Disease. Dig Dis Sci 2023; 68:3596-3604. [PMID: 37548896 DOI: 10.1007/s10620-023-08044-7] [Citation(s) in RCA: 2] [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: 03/17/2023] [Accepted: 07/13/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Crohn's disease recurrence after ileocecal resection is common. Guidelines suggest colonoscopy within 6-12 months of surgery to assess for post-operative recurrence, but use of adjunctive monitoring is not protocolized. We aimed to describe the state of monitoring in post-operative Crohn's. METHODS We conducted a retrospective study of patients with Crohn's after ileocolic resection with ≥ 1-year follow-up. Patients were stratified into high and low risk based on guidelines. Post-operative biomarker (C-reactive protein, fecal calprotectin), cross-sectional imaging, and colonoscopy use were assessed. Biomarker, radiographic, and endoscopic post-operative recurrence were defined as elevated CRP/calprotectin, active inflammation on imaging, and Rutgeerts ≥ i2b, respectively. Data were stratified by surgery year to assess changes in practice patterns over time. P-values were calculated using Wilcoxon test and Fisher exact test. RESULTS Of 901 patients, 53% were female and 78% high risk. Median follow-up time was 60 m for LR and 50 m for high risk. Postoperatively, 18% low and 38% high risk had CRPs, 5% low and 10% high risk had calprotectins, and half of low and high risk had cross-sectional imaging. 29% low and 38% high risk had colonoscopy by 1 year. Compared to pre-2015, time to first radiography (584 days vs. 398 days) and colonoscopy (421 days vs. 296 days) were significantly shorter for high-risk post-2015 (P < 0.001). Probability of colonoscopy within 1 year increased over time (0.48, 2011 vs. 0.92, 2019). CONCLUSION Post-operative colonoscopy completion by 1 year is low. The use of CRP and imaging are common, whereas calprotectin is infrequently utilized. Practice patterns are shifting toward earlier monitoring.
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Affiliation(s)
- Terry Li
- Department of Internal Medicine, NYU Grossman School of Medicine, New York University Langone Health, 550 First Avenue, New York, NY, USA.
| | - Benjamin Click
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Salam Bachour
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Sachs
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Susell Contreras
- Inflammatory Bowel Disease Center, New York University Langone Health, New York, NY, USA
| | - Jordan Axelrad
- Inflammatory Bowel Disease Center, New York University Langone Health, New York, NY, USA
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Kassim G, Yzet C, Nair N, Debebe A, Rendon A, Colombel JF, Traboulsi C, Rubin DT, Maroli A, Coppola E, Carvello MM, Ben David N, De Lucia F, Sacchi M, Danese S, Spinelli A, Hirdes MMC, Ten Hove J, Oldenburg B, Cholapranee A, Riter M, Lukin D, Scherl E, Eren E, Sultan KS, Axelrad J, Sachar DB. Long-Term Outcomes of the Excluded Rectum in Crohn's Disease: A Multicenter International Study. Inflamm Bowel Dis 2023; 29:417-422. [PMID: 35522225 DOI: 10.1093/ibd/izac099] [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: 12/16/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Many patients with Crohn's disease (CD) require fecal diversion. To understand the long-term outcomes, we performed a multicenter review of the experience with retained excluded rectums. METHODS We reviewed the medical records of all CD patients between 1990 and 2014 who had undergone diversionary surgery with retention of the excluded rectum for at least 6 months and who had at least 2 years of postoperative follow-up. RESULTS From all the CD patients in the institutions' databases, there were 197 who met all our inclusion criteria. A total of 92 (46.7%) of 197 patients ultimately underwent subsequent proctectomy, while 105 (53.3%) still had retained rectums at time of last follow-up. Among these 105 patients with retained rectums, 50 (47.6%) underwent reanastomosis, while the other 55 (52.4%) retained excluded rectums. Of these 55 patients whose rectums remained excluded, 20 (36.4%) were symptom-free, but the other 35 (63.6%) were symptomatic. Among the 50 patients who had been reconnected, 28 (56%) were symptom-free, while 22(44%) were symptomatic. From our entire cohort of 197 cases, 149 (75.6%) either ultimately lost their rectums or remained symptomatic with retained rectums, while only 28 (14.2%) of 197, and only 4 (5.9%) of 66 with initial perianal disease, were able to achieve reanastomosis without further problems. Four patients developed anorectal dysplasia or cancer. CONCLUSIONS In this multicenter cohort of patients with CD who had fecal diversion, fewer than 15%, and only 6% with perianal disease, achieved reanastomosis without experiencing disease persistence.
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Affiliation(s)
- Gassan Kassim
- Division of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Clara Yzet
- Division of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nilendra Nair
- Division of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anketse Debebe
- Division of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexa Rendon
- Division of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frédéric Colombel
- Division of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cindy Traboulsi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Annalisa Maroli
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Elisabetta Coppola
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Michele M Carvello
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Nadat Ben David
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Francesca De Lucia
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Matteo Sacchi
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Silvio Danese
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Meike M C Hirdes
- Division of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joren Ten Hove
- Division of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bas Oldenburg
- Division of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Aurada Cholapranee
- Division of Gastroenterology and Hepatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Maxine Riter
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, NY, USA
| | - Dana Lukin
- Jill Roberts Center for IBD, Weill Cornell Medicine, NY, USA
| | - Ellen Scherl
- Jill Roberts Center for IBD, Weill Cornell Medicine, NY, USA
| | - Esen Eren
- Inflammatory Bowel Disease Center at NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Keith S Sultan
- Division of Gastroenterology and Hepatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jordan Axelrad
- Inflammatory Bowel Disease Center at NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - David B Sachar
- Division of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Jang KK, Heaney T, London M, Ding Y, Yeung F, Ercelen D, Chen YH, Axelrad J, Gurunathan S, Marijke Keestra-Gounder A, Griffin ME, Hang HC, Cadwell K. Antimicrobial overproduction sustains intestinal inflammation by inhibiting Enterococcus colonization. bioRxiv 2023:2023.01.29.526128. [PMID: 36778381 PMCID: PMC9915521 DOI: 10.1101/2023.01.29.526128] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Loss of antimicrobial proteins such as REG3 family members compromises the integrity of the intestinal barrier. Here, we demonstrate that overproduction of REG3 proteins can also be detrimental by reducing a protective species in the microbiota. Patients with inflammatory bowel disease (IBD) experiencing flares displayed heightened levels of secreted REG3 proteins that mediated depletion of Enterococcus faecium ( Efm ) from the gut microbiota. Efm inoculation of mice ameliorated intestinal inflammation through activation of the innate immune receptor NOD2, which was associated with the bacterial DL-endopeptidase SagA. Microbiota sensing by NOD2 in myeloid cells mediated IL-1β secretion and increased the proportion of IL-22-producing CD4 + T helper cells and innate lymphoid cells. Finally, Efm was unable to protect mice carrying a NOD2 gene variant commonly found in IBD patients. Our findings demonstrate that inflammation self-perpetuates by causing aberrant antimicrobial activity that disrupts symbiotic relationships with gut microbes.
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Zhang B, Upadhyay R, Hao Y, Samanovic MI, Herati RS, Blair J, Axelrad J, Mulligan MJ, Littman DR, Satija R. Multimodal characterization of antigen-specific CD8 + T cells across SARS-CoV-2 vaccination and infection. bioRxiv 2023:2023.01.24.525203. [PMID: 36747786 PMCID: PMC9900816 DOI: 10.1101/2023.01.24.525203] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The human immune response to SARS-CoV-2 antigen after infection or vaccination is defined by the durable production of antibodies and T cells. Population-based monitoring typically focuses on antibody titer, but there is a need for improved characterization and quantification of T cell responses. Here, we utilize multimodal sequencing technologies to perform a longitudinal analysis of circulating human leukocytes collected before and after BNT162b2 immunization. Our data reveal distinct subpopulations of CD8 + T cells which reliably appear 28 days after prime vaccination (7 days post boost). Using a suite of cross-modality integration tools, we define their transcriptome, accessible chromatin landscape, and immunophenotype, and identify unique biomarkers within each modality. By leveraging DNA-oligo-tagged peptide-MHC multimers and T cell receptor sequencing, we demonstrate that this vaccine-induced population is SARS-CoV-2 antigen-specific and capable of rapid clonal expansion. Moreover, we also identify these CD8 + populations in scRNA-seq datasets from COVID-19 patients and find that their relative frequency and differentiation outcomes are predictive of subsequent clinical outcomes. Our work contributes to our understanding of T cell immunity, and highlights the potential for integrative and multimodal analysis to characterize rare cell populations.
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Affiliation(s)
- Bingjie Zhang
- New York Genome Center, New York, NY, USA
- Center for Genomics and Systems Biology, New York University, New York, NY, USA
- Department of Cell Biology and Regenerative Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Rabi Upadhyay
- Department of Cell Biology and Regenerative Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Perlmutter Cancer Center, New York University Langone Health, New York, NY, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Yuhan Hao
- New York Genome Center, New York, NY, USA
- Center for Genomics and Systems Biology, New York University, New York, NY, USA
| | - Marie I. Samanovic
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- New York University Langone Vaccine Center, New York, NY, USA
| | - Ramin S. Herati
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- New York University Langone Vaccine Center, New York, NY, USA
| | - John Blair
- New York Genome Center, New York, NY, USA
- Center for Genomics and Systems Biology, New York University, New York, NY, USA
| | - Jordan Axelrad
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Mark J. Mulligan
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
- New York University Langone Vaccine Center, New York, NY, USA
| | - Dan R. Littman
- Department of Cell Biology and Regenerative Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Perlmutter Cancer Center, New York University Langone Health, New York, NY, USA
- Howard Hughes Medical Institute, New York, NY, USA
| | - Rahul Satija
- New York Genome Center, New York, NY, USA
- Center for Genomics and Systems Biology, New York University, New York, NY, USA
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18
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Mårild K, Söderling J, Stephansson O, Axelrad J, Halfvarson J, Bröms G, Marsal J, Olén O, Ludvigsson JF. Histological remission in inflammatory bowel disease and risk of adverse pregnancy outcomes: A nationwide study. EClinicalMedicine 2022; 53:101722. [PMID: 36467453 PMCID: PMC9716329 DOI: 10.1016/j.eclinm.2022.101722] [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: 08/21/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) has been linked to adverse pregnancy outcomes, but it is unclear how risks vary by histological activity. METHODS We performed a nationwide study of Swedish women diagnosed with IBD 1990-2016 and a pre-pregnancy (<12 months) colorectal biopsy with vs. without histological inflammation (1223 and 630 births, respectively). We also examined pregnancy outcomes in 2007-2016 of women with vs. without clinically active IBD (i.e., IBD-related hospitalization, surgery, or medication escalation) <12 months before pregnancy (2110 and 4993 births, respectively). Accounting for smoking, socio-demographics, and comorbidities, generalized linear models estimated adjusted risk ratios (aRRs) for preterm birth (<37 gestational weeks) and small-for-gestational age (SGA, <10th percentile weight for age). FINDINGS Of infants to women with vs. without histological inflammation, 9.6% (n = 117) and 6.5% (n = 41) were preterm, respectively (aRR = 1.46; 95%CI = 1.03-2.06). Histological inflammation was associated with preterm birth in ulcerative colitis (UC) (aRR = 1.64; 95%CI = 1.07-2.52), especially extensive colitis (aRR = 2.37; 95%CI = 1.12-5.02), but not in Crohn's disease (aRR = 0.99; 95%CI = 0.55-1.78). Of infants to women with vs. without histological inflammation, 116 (9.6%) and 56 (8.9%), respectively, were SGA (aRR = 1.09; 95%CI = 0.81-1.47). Clinically active disease before pregnancy was linked to preterm birth (aRR = 1.42; 95%CI = 1.20-1.69), but not to SGA birth (aRR = 1.13; 95%CI = 0.96-1.32). Finally, of infants to women without clinical activity, histological inflammation was not significantly associated with preterm birth (aRR = 1.20; 95%CI = 0.68-2.13). INTERPRETATION Histological and clinical activity in IBD, especially in UC, were risk factors for preterm birth. Further research is needed to determine the importance of pre-pregnancy histological activity in women without clinically-defined disease activity. FUNDING The Swedish Society of Medicine.
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Affiliation(s)
- Karl Mårild
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Paediatrics, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Jonas Söderling
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jordan Axelrad
- Inflammatory Bowel Disease Centre at NYU Langone Health, Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Gabriella Bröms
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Danderyd hospital, Stockholm, Sweden
| | - Jan Marsal
- Department of Gastroenterology, Skåne University Hospital, Lund, Sweden
- Immunology Section, Lund University, Lund, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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19
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Bachour SP, Shah RS, Lyu R, Nakamura T, Shen M, Li T, Dane B, Barnes EL, Rieder F, Cohen B, Qazi T, Lashner B, Achkar JP, Philpott J, Holubar SD, Lightner AL, Regueiro M, Axelrad J, Baker ME, Click B. Test Characteristics of Cross-sectional Imaging and Concordance With Endoscopy in Postoperative Crohn's Disease. Clin Gastroenterol Hepatol 2022; 20:2327-2336.e4. [PMID: 34968729 PMCID: PMC9234099 DOI: 10.1016/j.cgh.2021.12.033] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Postoperative Crohn's disease (CD) surveillance relies on endoscopic monitoring. The role of cross-sectional imaging is less clear. We evaluated the concordance of cross-sectional enterography with endoscopic recurrence and the predictive ability of radiography for future CD postoperative recurrence. METHODS We performed a multi-institution retrospective cohort study of postoperative adult patients with CD who underwent ileocolonoscopy and cross-sectional enterography within 90 days of each other following ileocecal resection. Imaging studies were interpreted by blinded, expert CD radiologists. Patients were categorized by presence of endoscopic postoperative recurrence (E+) (modified Rutgeerts' score ≥i2b) or radiographic disease activity (R+) and grouped by concordance status. RESULTS A total of 216 patients with CD with paired ileocolonoscopy and imaging were included. A majority (54.2%) exhibited concordance (34.7% E+/R+; 19.4% E-/R-) between studies. The plurality (41.7%; n = 90) were E-/R+ discordant. Imaging was highly sensitive (89.3%), with low specificity (31.8%), in detecting endoscopic postoperative recurrence. Intestinal wall thickening, luminal narrowing, mural hyper-enhancement, and length of disease on imaging were associated with endoscopic recurrence (all P < .01). Radiographic disease severity was associated with increasing Rutgeerts' score (P < .001). E-/R+ patients experienced more rapid subsequent endoscopic recurrence (hazard ratio, 4.16; P = .033) and increased rates of subsequent endoscopic (43.8% vs 22.7%) and surgical recurrence (20% vs 9.5%) than E-/R- patients (median follow-up, 4.5 years). CONCLUSIONS Cross-sectional imaging is highly sensitive, but poorly specific, in detecting endoscopic disease activity and postoperative recurrence. Advanced radiographic disease correlates with endoscopic severity. Patients with radiographic activity in the absence of endoscopic recurrence may be at increased risk for future recurrence, and closer monitoring should be considered.
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Affiliation(s)
- Salam P Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Ravi S Shah
- Cleveland Clinic Department of Internal Medicine, Cleveland, Ohio
| | - Ruishen Lyu
- Cleveland Clinic Department of Quantitative Health Sciences, Cleveland, Ohio
| | - Takahiro Nakamura
- New York University Department of Internal Medicine, New York, New York
| | - Michael Shen
- New York University Department of Internal Medicine, New York, New York
| | - Terry Li
- New York University Department of Internal Medicine, New York, New York
| | - Bari Dane
- New York University Department of Radiology, New York, New York
| | - Edward L Barnes
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina
| | - Florian Rieder
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Benjamin Cohen
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Taha Qazi
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Bret Lashner
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Jean Paul Achkar
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Jessica Philpott
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Stefan D Holubar
- Cleveland Clinic Department of Colorectal Surgery, Cleveland, Ohio
| | - Amy L Lightner
- Cleveland Clinic Department of Colorectal Surgery, Cleveland, Ohio
| | - Miguel Regueiro
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Jordan Axelrad
- New York University Department of Gastroenterology and Hepatology, New York, New York
| | - Mark E Baker
- Cleveland Clinic Imaging Institute, Cleveland, Ohio
| | - Benjamin Click
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio.
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20
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Bachour SP, Shah RS, Rieder F, Qazi T, Achkar JP, Philpott J, Lashner B, Holubar SD, Lightner AL, Barnes EL, Axelrad J, Regueiro M, Click B, Cohen BL. Intra-abdominal septic complications after ileocolic resection increases risk for endoscopic and surgical postoperative Crohn's disease recurrence. J Crohns Colitis 2022; 16:1696-1705. [PMID: 35705188 PMCID: PMC9924045 DOI: 10.1093/ecco-jcc/jjac078] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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] [Indexed: 12/27/2022]
Abstract
BACKGROUND Postoperative recurrence [POR] of Crohn's disease following ileocolonic resection is common. The impact of immediate postoperative intra-abdominal septic complications [IASC] on endoscopic and surgical recurrence has not been elucidated. AIMS To evaluate if IASC is associated with an increased risk for endoscopic and surgical POR. METHODS This was a retrospective study of adult Crohn's disease patients undergoing ileocolonic resection with primary anastomosis between 2009 and 2020. IASC was defined as anastomotic leak or intra-abdominal abscess within 90 days of the date of surgery. Multivariable logistic and Cox proportional hazard modelling were performed to assess the impact of IASC on endoscopic POR [modified Rutgeerts' score ≥ i2b] at index postoperative ileocolonoscopy and long-term surgical recurrence. RESULTS In 535 Crohn's disease patients [median age 35 years, 22.1% active smokers, 35.7% one or more prior resection] had an ileocolonic resection with primary anastomosis. A minority of patients [N = 47; 8.8%] developed postoperative IASC. In total, 422 [78.9%] patients had one or more postoperative ileocolonoscopies, of whom 163 [38.6%] developed endoscopic POR. After adjusting for other risk factors for postoperative recurrence, postoperative IASC was associated with significantly greater odds (adjusted odds ratio [aOR]: 2.45 [1.23-4.97]; p = 0.01) and decreased time (adjusted hazards ratio [aHR]: 1.60 [1.04-2.45]; p = 0.03] to endoscopic POR. Furthermore, IASC was associated with increased risk (aOR: 2.3 [1.04-4.87] p = 0.03) and decreased survival-free time [aHR: 2.53 [1.31-4.87]; p = 0.006] for surgical recurrence. CONCLUSION IASC is associated with an increased risk for endoscopic and surgical POR of Crohn's disease. Preoperative optimization to prevent IASC, in addition to postoperative biological prophylaxis, may help reduce the risk for endoscopic and surgical POR.
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Affiliation(s)
- Salam P Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Ravi S Shah
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Florian Rieder
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH, USA
| | - Taha Qazi
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Jean Paul Achkar
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Jessica Philpott
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Bret Lashner
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Stefan D Holubar
- Cleveland Clinic Department of Colorectal Surgery, Cleveland, OH, USA
| | - Amy L Lightner
- Cleveland Clinic Department of Colorectal Surgery, Cleveland, OH, USA
| | - Edward L Barnes
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Jordan Axelrad
- New York University Department of Gastroenterology and Hepatology, New York, NY, USA
| | - Miguel Regueiro
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Benjamin Click
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Benjamin L Cohen
- Correspondence: Benjamin L. Cohen, MD, MAS, Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, 9500 Euclid Ave., A30, Cleveland, OH, 44195, USA.
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21
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Bachour SP, Shah RS, Lyu R, Rieder F, Qazi T, Lashner B, Achkar JP, Philpott J, Barnes EL, Axelrad J, Holubar SD, Lightner AL, Regueiro M, Cohen BL, Click BH. Mild neoterminal ileal post-operative recurrence of Crohn's disease conveys higher risk for severe endoscopic disease progression than isolated anastomotic lesions. Aliment Pharmacol Ther 2022; 55:1139-1150. [PMID: 35285534 PMCID: PMC9677520 DOI: 10.1111/apt.16804] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 12/06/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 12/15/2022]
Abstract
There are conflicting data assessing the impact of isolated post-operative anastomotic inflammation on future disease progression. The aim of this study was to determine the relative risk of severe disease progression in post-operative Crohn's disease (CD) patients with isolated anastomotic disease. METHODS Retrospective cohort study of adult CD patients undergoing ileocolonic resection between 2009 and 2020. Patients with a post-operative ileocolonoscopy ≤18 months from surgery and ≥1 subsequent ileocolonoscopy were included. Disease activity was assessed using the modified Rutgeerts' score (RS). Primary outcome was severe endoscopic progression, defined as i3 or i4 disease, on immediate subsequent ileocolonoscopy and during entire post-operative follow-up. Secondary outcome was surgical recurrence. RESULTS One hundred and ninety-nine CD patients had an ileocolonoscopy ≤18 months from surgery, index RS of i0-i2b and ≥1 subsequent ileocolonoscopy. At index ileocolonoscopy, 34.7% had i0 disease, 16.1% i1, 24.6% i2a and 24.6% i2b. On multivariable logistic regression, i2b disease was associated with severe endoscopic progression compared to i0 or i1 (aOR 5.53; P < 0.001) and i2a disease patients (aOR 2.63; P = 0.03). However, i2a disease did not confer increased risk compared to i0 or i1 disease (P = 0.09). Furthermore, i2b patients experienced severe endoscopic progression significantly earlier than i0 or i1 disease (aHR 4.68; P < 0.001), whereas i2a disease did not differ from i0 or i1 disease (P = 0.25). Surgical recurrence was not associated with index RS i0-i2b (P = 0.86). CONCLUSION Post-operative ileal disease recurrence, not isolated anastomotic inflammation, confers increased risk for severe endoscopic disease progression. Location of CD recurrence may impact optimal management strategies.
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Affiliation(s)
- Salam P. Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Ravi S. Shah
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Ruishen Lyu
- Cleveland Clinic Department of Quantitative Health Sciences
| | - Florian Rieder
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition,Department of Inflammation and Immunity, Lerner Research Institute
| | - Taha Qazi
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Bret Lashner
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Jean Paul Achkar
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Jessica Philpott
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Edward L. Barnes
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology
| | - Jordan Axelrad
- New York University Department of Gastroenterology and Hepatology
| | | | | | - Miguel Regueiro
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Benjamin L. Cohen
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Benjamin H. Click
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
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22
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Jang KK, Kaczmarek ME, Dallari S, Chen YH, Tada T, Axelrad J, Landau NR, Stapleford KA, Cadwell K. Variable susceptibility of intestinal organoid-derived monolayers to SARS-CoV-2 infection. PLoS Biol 2022; 20:e3001592. [PMID: 35358182 PMCID: PMC9004766 DOI: 10.1371/journal.pbio.3001592] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 04/12/2022] [Accepted: 03/04/2022] [Indexed: 01/08/2023] Open
Abstract
Gastrointestinal effects associated with Coronavirus Disease 2019 (COVID-19) are highly variable for reasons that are not understood. In this study, we used intestinal organoid-derived cultures differentiated from primary human specimens as a model to examine interindividual variability. Infection of intestinal organoids derived from different donors with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) resulted in orders of magnitude differences in virus replication in small intestinal and colonic organoid-derived monolayers. Susceptibility to infection correlated with angiotensin I converting enzyme 2 (ACE2) expression level and was independent of donor demographic or clinical features. ACE2 transcript levels in cell culture matched the amount of ACE2 in primary tissue, indicating that this feature of the intestinal epithelium is retained in the organoids. Longitudinal transcriptomics of organoid-derived monolayers identified a delayed yet robust interferon signature, the magnitude of which corresponded to the degree of SARS-CoV-2 infection. Interestingly, virus with the Omicron variant spike (S) protein infected the organoids with the highest infectivity, suggesting increased tropism of the virus for intestinal tissue. These results suggest that heterogeneity in SARS-CoV-2 replication in intestinal tissues results from differences in ACE2 levels, which may underlie variable patient outcomes.
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Affiliation(s)
- Kyung Ku Jang
- Kimmel Center for Biology and Medicine at the Skirball Institute, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Maria E. Kaczmarek
- Department of Microbiology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Simone Dallari
- Kimmel Center for Biology and Medicine at the Skirball Institute, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Ying-Han Chen
- Kimmel Center for Biology and Medicine at the Skirball Institute, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Takuya Tada
- Department of Microbiology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Nathaniel R. Landau
- Department of Microbiology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Kenneth A. Stapleford
- Department of Microbiology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Ken Cadwell
- Kimmel Center for Biology and Medicine at the Skirball Institute, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Microbiology, New York University Grossman School of Medicine, New York, New York, United States of America
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, United States of America
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23
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Lin X, Gaudino SJ, Jang KK, Bahadur T, Singh A, Banerjee A, Beaupre M, Chu T, Wong HT, Kim CK, Kempen C, Axelrad J, Huang H, Khalid S, Shah V, Eskiocak O, Parks OB, Berisha A, McAleer JP, Good M, Hoshino M, Blumberg R, Bialkowska AB, Gaffen SL, Kolls JK, Yang VW, Beyaz S, Cadwell K, Kumar P. IL-17RA-signaling in Lgr5 + intestinal stem cells induces expression of transcription factor ATOH1 to promote secretory cell lineage commitment. Immunity 2022; 55:237-253.e8. [PMID: 35081371 PMCID: PMC8895883 DOI: 10.1016/j.immuni.2021.12.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [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: 12/11/2020] [Revised: 07/06/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022]
Abstract
The Th17 cell-lineage-defining cytokine IL-17A contributes to host defense and inflammatory disease by coordinating multicellular immune responses. The IL-17 receptor (IL-17RA) is expressed by diverse intestinal cell types, and therapies targeting IL-17A induce adverse intestinal events, suggesting additional tissue-specific functions. Here, we used multiple conditional deletion models to identify a role for IL-17A in secretory epithelial cell differentiation in the gut. Paneth, tuft, goblet, and enteroendocrine cell numbers were dependent on IL-17A-mediated induction of the transcription factor ATOH1 in Lgr5+ intestinal epithelial stem cells. Although dispensable at steady state, IL-17RA signaling in ATOH1+ cells was required to regenerate secretory cells following injury. Finally, IL-17A stimulation of human-derived intestinal organoids that were locked into a cystic immature state induced ATOH1 expression and rescued secretory cell differentiation. Our data suggest that the cross talk between immune cells and stem cells regulates secretory cell lineage commitment and the integrity of the mucosa.
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Affiliation(s)
- Xun Lin
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Stephen J Gaudino
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Kyung Ku Jang
- Kimmel Center for Biology and Medicine at the Skirball Institute, New York University Grossman School of Medicine, New York, NY, USA
| | - Tej Bahadur
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Ankita Singh
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Anirban Banerjee
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Michael Beaupre
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Timothy Chu
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Hoi Tong Wong
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Chang-Kyung Kim
- Department of Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Cody Kempen
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Huakang Huang
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Saba Khalid
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Vyom Shah
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Onur Eskiocak
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Olivia B Parks
- University of Pittsburgh School of Medicine, Medical Scientist Training Program, Pittsburgh, PA 15213, USA
| | - Artan Berisha
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Jeremy P McAleer
- Department of Pharmaceutical Science, Marshall University School of Pharmacy, Huntington, WV 25701, USA
| | - Misty Good
- Washington University School of Medicine, Department of Pediatrics, Division of Newborn Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA
| | - Miko Hoshino
- Department of Biochemistry and Cellular Biology, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo 187-8502, Japan
| | - Richard Blumberg
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Agnieszka B Bialkowska
- Department of Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Sarah L Gaffen
- Division of Rheumatology and Clinical Immunology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Jay K Kolls
- Center for Translational Research in Infection and Inflammation, Tulane School of Medicine, New Orleans, LA 70112, USA
| | - Vincent W Yang
- Department of Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Semir Beyaz
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Ken Cadwell
- Kimmel Center for Biology and Medicine at the Skirball Institute, New York University Grossman School of Medicine, New York, NY, USA; Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA.
| | - Pawan Kumar
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA.
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Malick A, Wang Y, Axelrad J, Salmasian H, Freedberg D. Obesity is not associated with adverse outcomes among hospitalized patients with Clostridioides difficile infection. Gut Pathog 2022; 14:7. [PMID: 35093158 PMCID: PMC8799984 DOI: 10.1186/s13099-022-00479-z] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/06/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Obesity is associated with increased risk for death in most infections but has not been studied as a risk factor for mortality in Clostridioides difficile infection (CDI). This study tested obesity as a risk factor for death in patients hospitalized with CDI. This was a three-center retrospective study that included hospitalized adults with CDI at Columbia University Irving Medical Center, Brigham and Women’s Hospital, and NYU Langone from 2010 to 2018. Multivariate logistic regression was used to assess the relationship between obesity, measured by body mass index, and death from any cause within 30 days after the index CDI test.
Results
Data for 3851 patients were analyzed, including 373 (9.7%) who died within 30 days following a diagnosis of CDI. After adjusting for other factors, BMI was not associated with increased risk for death in any BMI category [adjusted OR (aOR) 0.96, 95% CI 0.69 to 1.34 for BMI > 30 vs BMI 20–30; aOR 1.02, 95% CI 0.53 to 1.87 for BMI > 40 vs BMI 20–30]. After stratifying into three groups by age, there were trends towards increased mortality with obesity in the middle-aged (56–75 vs ≤ 55 years old) yet decreased mortality with obesity in the old (> 75 vs ≤ 55) (p = NS for all). Advanced age and low albumin were the factors most strongly associated with death.
Conclusions
We found no association between obesity and death among patients with CDI, in contrast to most other infections. Obesity is not likely to be useful for risk-stratifying hospitalized patients with CDI.
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Varma S, Faye AS, Kannan A, Lawlor G, Verma A, Axelrad J, Freedberg DE. Patients with More Severe IBD Get Clostridioides difficile Rather than Clostridioides difficile Increasing the Severity of IBD. Dig Dis Sci 2021; 66:3113-3123. [PMID: 32729015 DOI: 10.1007/s10620-020-06504-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/18/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) patients who have Clostridioides difficile infection (CDI) have worse outcomes. AIMS We aimed to determine whether such outcomes are the result of CDI or whether CDI occurs in patients who have more severe IBD. METHODS This was a retrospective study of patients hospitalized for ≥ 2 IBD flares from 2010 to 2019. The primary outcome was time to IBD flare between hospitalizations. First, time to flare was compared between patients who were hospitalized for a flare complicated by CDI and subsequently for a CDI-negative flare (cohort A, denoted +/-) versus patients who were hospitalized for two CDI-negative flares (cohort B, -/-). Second, time between flares was compared within the subset of cohort A patients who had three flares (cohort C, -/+/-) before and after CDI. RESULTS Time between flares was a median of 4 months (IQR 1-9) among 51 cohort A patients versus 12 months (IQR 6-38) among 51 cohort B patients (log-rank P < 0.01). In contrast, the median time between flares was similar within cohort C before and after CDI (log-rank P = 0.54). At time of the second IBD flare, patients in cohort A (+/-) were more likely to have moderate or severe disease compared to patients in cohort B (-/-). CONCLUSIONS Patients with prior CDI had shorter time to subsequent IBD flare relative to their CDI-negative counterparts. This is not likely due to CDI itself because there was no difference in time between flares before versus after acquiring CDI. Rather, patients who acquire CDI may have more severe IBD.
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Affiliation(s)
- Sanskriti Varma
- Department of Medicine, New York Presbyterian Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA.
| | - Adam S Faye
- Division of Digestive and Liver Diseases, Department of Medicine, College of Physicians and Surgeons, Columbia University, 622 West 168th Street, New York, NY, 10032, USA
| | - Adithya Kannan
- Vagelos College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY, 10032, USA
| | - Garrett Lawlor
- Division of Digestive and Liver Diseases, Department of Medicine, College of Physicians and Surgeons, Columbia University, 622 West 168th Street, New York, NY, 10032, USA
| | - Abhishek Verma
- Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, NYU School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, College of Physicians and Surgeons, Columbia University, 622 West 168th Street, New York, NY, 10032, USA
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26
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Venzon M, Bernard-Raichon L, Klein J, Axelrad J, Hussey G, Sullivan A, Casanovas-Massana A, Noval M, Valero-Jimenez A, Gago J, Wilder E, Team YIR, Iwasaki A, Thorpe L, Littman D, Dittmann M, Stapleford K, Shopsin B, Torres V, Ko A, Cadwell K, Schluter J. Gut microbiome dysbiosis during COVID-19 is associated with increased risk for bacteremia and microbial translocation. Res Sq 2021. [PMID: 34341786 PMCID: PMC8328072 DOI: 10.21203/rs.3.rs-726620/v1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The microbial populations in the gut microbiome have recently been associated with COVID-19 disease severity. However, a causal impact of the gut microbiome on COVID-19 patient health has not been established. Here we provide evidence that gut microbiome dysbiosis is associated with translocation of bacteria into the blood during COVID-19, causing life-threatening secondary infections. Antibiotics and other treatments during COVID-19 can potentially confound microbiome associations. We therefore first demonstrate that the gut microbiome is directly affected by SARS-CoV-2 infection in a dose-dependent manner in a mouse model, causally linking viral infection and gut microbiome dysbiosis. Comparison with stool samples collected from 101 COVID-19 patients at two different clinical sites also revealed substantial gut microbiome dysbiosis, paralleling our observations in the animal model. Specifically, we observed blooms of opportunistic pathogenic bacterial genera known to include antimicrobial-resistant species in hospitalized COVID-19 patients. Analysis of blood culture results testing for secondary microbial bloodstream infections with paired microbiome data obtained from these patients suggest that bacteria translocate from the gut into the systemic circulation of COVID-19 patients. These results are consistent with a direct role for gut microbiome dysbiosis in enabling dangerous secondary infections during COVID-19.
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27
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Levine I, Malik F, Castillo G, Jaros B, Alaia E, Ream J, Scher JU, Hudesman D, Axelrad J. Prevalence, Predictors, and Disease Activity of Sacroiliitis Among Patients with Crohn's Disease. Inflamm Bowel Dis 2021; 27:809-815. [PMID: 32793977 DOI: 10.1093/ibd/izaa198] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sacroiliitis is an inflammatory arthritis of the sacroiliac joints and is associated with inflammatory bowel disease (IBD). Yet, sacroiliitis often goes undiagnosed in IBD, and the clinical association between IBD disease activity and sacroiliitis is not well established. Patients with Crohn's disease (CD) often receive magnetic resonance enterography (MRE) to assess disease activity, affording clinicians the opportunity to evaluate for the presence of sacroiliitis. We aimed to identify the prevalence and disease characteristics associated with sacroiliitis in CD patients undergoing MRE. METHODS All CD patients undergoing MRE for any indication between 2014 and 2018 at an IBD referral center were identified. The MREs were reviewed for the presence of sacroiliitis based on bone marrow edema (BME) and structural lesions. We analyzed demographics, IBD characteristics, clinical and endoscopic disease activity, and management between CD patients with and without sacroiliitis. RESULTS Two hundred fifty-eight patients with CD underwent MRE during the study period. Overall, 17% of patients had MR evidence of sacroiliitis, of whom 73% demonstrated bone marrow edema. Female gender, back pain, and later age of CD diagnosis were associated with sacroiliitis (P = 0.05, P < 0.001, P = 0.04, respectively). Disease location and CD therapy were not associated with sacroiliitis on MRE. Clinical, endoscopic, and radiographic disease activity were not associated with sacroiliitis on MRE. CONCLUSION Sacroiliitis is a common comorbid condition in CD. With limited clinical clues and disease characteristics to suggest sacroiliitis, physicians may utilize MRE to identify sacroiliitis, especially in CD patients with back pain.
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Affiliation(s)
- Irving Levine
- NYU School of Medicine, Department of Medicine, New York, NY, USA
| | - Fardina Malik
- NYU Langone Health, Department of Medicine, Division of Rheumatology, New York, NY, USA
| | - Gabriel Castillo
- NYU School of Medicine, Department of Medicine, New York, NY, USA
| | - Brian Jaros
- NYU School of Medicine, Department of Medicine, New York, NY, USA
| | - Erin Alaia
- NYU Langone Health, Department of Radiology, New York, NY, USA
| | - Justin Ream
- NYU Langone Health, Department of Radiology, New York, NY, USA
| | - Jose U Scher
- NYU Langone Health, Department of Medicine, Division of Rheumatology, New York, NY, USA
| | - David Hudesman
- NYU Langone Health, Department of Medicine, Division of Gastroenterology, New York, NY, USA
| | - Jordan Axelrad
- NYU Langone Health, Department of Medicine, Division of Gastroenterology, New York, NY, USA
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28
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Devlin JC, Axelrad J, Hine AM, Chang S, Sarkar S, Lin JD, Ruggles KV, Hudesman D, Cadwell K, Loke P. Single-Cell Transcriptional Survey of Ileal-Anal Pouch Immune Cells From Ulcerative Colitis Patients. Gastroenterology 2021; 160:1679-1693. [PMID: 33359089 PMCID: PMC8327835 DOI: 10.1053/j.gastro.2020.12.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [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: 09/08/2020] [Revised: 12/04/2020] [Accepted: 12/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Restorative proctocolectomy with ileal pouch-anal anastomosis is a surgical procedure in patients with ulcerative colitis refractory to medical therapies. Pouchitis, the most common complication, is inflammation of the pouch of unknown etiology. To define how the intestinal immune system is distinctly organized during pouchitis, we analyzed tissues from patients with and without pouchitis and from patients with ulcerative colitis using single-cell RNA sequencing (scRNA-seq). METHODS We examined pouch lamina propria CD45+ hematopoietic cells from intestinal tissues of ulcerative colitis patients with (n = 15) and without an ileal pouch-anal anastomosis (n = 11). Further in silico meta-analysis was performed to generate transcriptional interaction networks and identify biomarkers for patients with inflamed pouches. RESULTS In addition to tissue-specific signatures, we identified a population of IL1B/LYZ+ myeloid cells and FOXP3/BATF+ T cells that distinguish inflamed tissues, which we further validated in other scRNA-seq datasets from patients with inflammatory bowel disease (IBD). Cell-type-specific transcriptional markers obtained from scRNA-seq was used to infer representation from bulk RNA sequencing datasets, which further implicated myeloid cells expressing IL1B and S100A8/A9 calprotectin as interacting with stromal cells, and Bacteroidales and Clostridiales bacterial taxa. We found that nonresponsiveness to anti-integrin biologic therapies in patients with ulcerative colitis was associated with the signature of IL1B+/LYZ+ myeloid cells in a subset of patients. CONCLUSIONS Features of intestinal inflammation during pouchitis and ulcerative colitis are similar, which may have clinical implications for the management of pouchitis. scRNA-seq enables meta-analysis of multiple studies, which may facilitate the identification of biomarkers to personalize therapy for patients with IBD. The processed single cell count tables are provided in Gene Expression Omnibus; GSE162335. Raw sequence data are not public and are protected by controlled-access for patient privacy.
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Affiliation(s)
- Joseph C. Devlin
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA,Sackler Institute of Graduate Biomedical Sciences, New York University Grossman School of Medicine, New York, NY 10016, USA,Institute of Systems Genetics, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Ashley M. Hine
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA,Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Shannon Chang
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Suparna Sarkar
- Department of Pathology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Jian-Da Lin
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA,Skirball Institute of Biomedical Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Kelly V. Ruggles
- Division of Translational Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA,Institute of Systems Genetics, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - David Hudesman
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Ken Cadwell
- Department of Microbiology; Division of Gastroenterology and Hepatology, Department of Medicine; Skirball Institute of Biomedical Medicine.
| | - P’ng Loke
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA,Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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29
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Ludvigsson JF, Axelrad J, Halfvarson J, Khalili H, Larsson E, Lochhead P, Roelstraete B, Simon TG, Söderling J, Olén O. Inflammatory bowel disease and risk of severe COVID-19: A nationwide population-based cohort study in Sweden. United European Gastroenterol J 2021; 9:177-192. [PMID: 33704918 PMCID: PMC8014882 DOI: 10.1002/ueg2.12049] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There are concerns that individuals with chronic immune-mediated diseases are at increased risk of COVID-19 and related severe adverse outcome, including intensive care admission or death. We aimed to explore the absolute and relative risk of severe COVID-19 in inflammatory bowel disease (IBD). METHODS This population-based cohort study used nationwide registers in Sweden, with 67,292 individuals with a diagnosis of IBD 1969-2017 (Crohn's disease, n = 21,599; ulcerative colitis: n = 43,622; IBD-unclassified: n = 2071) and alive on 1 February 2020. Patients with IBD were matched to up to five controls from the general population (n = 297,910). Cox regression estimated hazard ratios (HRs) for (i) hospital admission with laboratory-confirmed COVID-19 as the primary diagnosis, and (ii) severe COVID-19 (composite outcome consisting of (a) COVID-19 intensive care admission, or (b) death from COVID-19 or (c) death within 30 days of COVID-19 hospital admission), were calculated. Analyses were conditioned on age, sex, calendar period, and county and adjusted for other comorbidities. RESULTS Between 1 February and 31 July 2020, 179 (0.27%) IBD patients and 500 (0.17%) general population controls were admitted to hospital with COVID-19 (adjusted HR [aHR] = 1.43; 95% CI = 1.19-1.72). The corresponding numbers for severe COVID-19 was 65 (0.10%) and 183 (0.06%; aHR = 1.11; 95% CI = 0.81-1.52). Adjusted HRs were similar in Crohn's disease and ulcerative colitis. In a propensity score-matched model taking comorbidity into account until 2016, the increased risk for COVID-19 hospital admission remained (aHR = 1.32; 1.12-1.56), but there was no increased risk of severe COVID-19 (aHR = 1.12; 0.85-1.47). CONCLUSIONS While individuals with IBD were more likely to be admitted to hospital for COVID-19 than the general population, the risk of severe COVID-19 was not higher.
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Affiliation(s)
- Jonas F. Ludvigsson
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
- Department of PaediatricsÖrebro University HospitalÖrebroSweden
- Division of Epidemiology and Public HealthSchool of MedicineUniversity of NottinghamNottinghamUK
- Department of MedicineCeliac Disease CenterColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Jordan Axelrad
- Division of GastroenterologyDepartment of MedicineNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Jonas Halfvarson
- Department of GastroenterologyFaculty of Medicine and HealthÖrebro UniversityÖrebroSweden
| | - Hamed Khalili
- Clinical and Translational Epidemiology Unit and Division of GastroenterologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Emma Larsson
- Department of Physiology and PharmacologyKarolinska InstitutetStockholmSweden
- Perioperative Medicine and Intensive CareKarolinska University HospitalStockholmSweden
| | - Paul Lochhead
- Clinical and Translational Epidemiology Unit and Division of GastroenterologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Bjorn Roelstraete
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Tracey G. Simon
- Clinical and Translational Epidemiology Unit and Division of GastroenterologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Jonas Söderling
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Ola Olén
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden
- Sachs' Children and Youth HospitalStockholm South General HospitalStockholmSweden
- Department of Clinical Science and Education SödersjukhusetKarolinska InstitutetStockholmSweden
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30
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Kani HT, Ramai D, Caniglia E, Hudesman D, Axelrad J, Nicholson J, Hong S, Chang S. Systematic review with meta-analysis: a history of smoking is not associated with a higher risk of pouchitis. Aliment Pharmacol Ther 2020; 52:1117-1124. [PMID: 32780484 DOI: 10.1111/apt.15997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 05/09/2020] [Revised: 05/22/2020] [Accepted: 07/05/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ileal pouch-anal anastomosis is a common surgical procedure in patients with an initial diagnosis of ulcerative colitis or indeterminate colitis. Tobacco smoking has been associated with protection from onset of ulcerative colitis. Smoking has been reported to be both a protective factor and a risk factor for the development of pouchitis. AIM To examine the influence of smoking on the risk of pouchitis. METHODS We identified 15 studies evaluating smoking as a risk factor for developing pouchitis in ulcerative colitis or indeterminate colitis patients with a history of ileal pouch-anal anastomosis in a systematic search performed from inception through May 4, 2020. A meta-analysis was then performed using a random-effects model to generate risk ratios (RR) and 95% confidence intervals (CI). RESULTS A history of smoking compared with never smoking was not associated with an increased risk of developing pouchitis (RR = 0.94, 95% CI 0.76-1.18, I2 = 73.7%). There was also no significant risk of pouchitis when comparing current smokers vs nonsmokers (RR = 0.93, 95% CI 0.70-1.24, I2 = 78.5%) and former smokers vs nonsmokers (RR = 0.96, 95% CI 0.74-1.23, I2 = 78.5%). CONCLUSIONS Smoking, past or present, is not associated with an increased risk for the development of pouchitis in patients with ulcerative colitis or indeterminate colitis.
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Affiliation(s)
- H Tarik Kani
- Division of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey.,Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Daryl Ramai
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Ellen Caniglia
- Department of Population Health, New York University Langone Health, New York, NY, USA
| | - David Hudesman
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Jordan Axelrad
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Joseph Nicholson
- NYU Health Sciences Library, New York University Langone Health, New York, NY, USA
| | - Simon Hong
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
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31
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Haberman R, Axelrad J, Chen A, Castillo R, Yan D, Izmirly P, Neimann A, Adhikari S, Hudesman D, Scher JU. Covid-19 in Immune-Mediated Inflammatory Diseases - Case Series from New York. N Engl J Med 2020; 383:85-88. [PMID: 32348641 PMCID: PMC7204427 DOI: 10.1056/nejmc2009567] [Citation(s) in RCA: 331] [Impact Index Per Article: 82.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | | | - Alan Chen
- New York University Grossman School of Medicine, New York, NY
| | | | - Di Yan
- New York University Langone Health, New York, NY
| | | | | | | | | | - Jose U Scher
- New York University Langone Health, New York, NY
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32
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Mahmoud R, Shah SC, Torres J, Castaneda D, Glass J, Elman J, Kumar A, Axelrad J, Harpaz N, Ullman T, Colombel JF, Oldenburg B, Itzkowitz SH. Association Between Indefinite Dysplasia and Advanced Neoplasia in Patients With Inflammatory Bowel Diseases Undergoing Surveillance. Clin Gastroenterol Hepatol 2020; 18:1518-1527.e3. [PMID: 31446183 PMCID: PMC7354098 DOI: 10.1016/j.cgh.2019.08.032] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 07/29/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Little is known about the clinical significance of indefinite dysplasia (IND) in patients with inflammatory bowel diseases (IBD) undergoing colonoscopic surveillance for colorectal neoplasia. METHODS We conducted a retrospective cohort analysis of 492 patients with colonic IBD for 8 or more years or concomitant primary sclerosing cholangitis, with no history of advanced colorectal neoplasia (high-grade dysplasia or colorectal cancer) or colectomy, undergoing colorectal neoplasia surveillance at a tertiary IBD referral center from 2001 through 2017. Subjects received consistent histopathologic grading of dysplasia. We collected data on time to development of (advanced) colorectal neoplasia or colectomy using Kaplan Meier methods. We identified factors independently associated with (advanced) colorectal neoplasia with multivariable Cox regression analysis. RESULTS After 2149 person-years of follow-up, 53 patients (10.8%) received a diagnosis of IND without prior or synchronous low-grade dysplasia (LGD). Compared to patients without dysplasia, patients with IND had a significantly higher risk of advanced colorectal neoplasia (adjusted hazard ratio, 6.85; 95% CI, 1.78-26.4) and colorectal neoplasia (adjusted hazard ratio, 3.25; 95% CI, 1.50-7.05), but not colectomy (P = .78). Compared to IND, LGD was associated with a significantly higher risk of advanced colorectal neoplasia (P = .05). Following a diagnosis of no dysplasia, IND only, or LGD, the incidence rates of advanced colorectal neoplasia were 0.4% per patient-year, 3.1% per patient-year, and 8.4% per patient-year, respectively. CONCLUSIONS In a retrospective analysis of patients with IBD undergoing colorectal neoplasia surveillance with consistent histopathologic grading of dysplasia, IND was independently associated with a significant increase in risk of advanced colorectal neoplasia. These findings require validation and if confirmed, a reappraisal of the colorectal neoplasia surveillance guidelines.
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Affiliation(s)
- Remi Mahmoud
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Shailja C. Shah
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joana Torres
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Daniel Castaneda
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jason Glass
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Internal Medicine, Division of Digestive and Liver Sciences, University of Texas Southwestern, Dallas, TX, USA
| | - Jordan Elman
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Akash Kumar
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jordan Axelrad
- Inflammatory Bowel Disease Center, NYU Langone Health, Division of Gastroenterology NYU School of Medicine, New York, NY, USA
| | - Noam Harpaz
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas Ullman
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Montefiore Hospital, New York, NY, USA
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H. Itzkowitz
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Rosen MH, Axelrad J, Hudesman D, Rubin DT, Chang S. Management of Acute Severe Ulcerative Colitis in a Pregnant Woman With COVID-19 Infection: A Case Report and Review of the Literature. Inflamm Bowel Dis 2020; 26:971-973. [PMID: 32393973 PMCID: PMC7239163 DOI: 10.1093/ibd/izaa109] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 12/13/2022]
Abstract
First detected in Wuhan, China, the novel 2019 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an enveloped RNA beta-coronavirus responsible for an unprecedented, worldwide pandemic caused by COVID-19. Optimal management of immunosuppression in inflammatory bowel disease (IBD) patients with COVID-19 infection currently is based on expert opinion, given the novelty of the infection and the corresponding lack of high-level evidence in patients with immune-mediated conditions. There are limited data regarding IBD patients with COVID-19 and no data regarding early pregnancy in the era of COVID-19. This article describes a patient with acute severe ulcerative colitis (UC) during her first trimester of pregnancy who also has COVID-19. The case presentation is followed by a review of the literature to date on COVID-19 in regard to inflammatory bowel disease and pregnancy, respectively.
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Affiliation(s)
- Melissa H Rosen
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, NY,Address correspondence to: Melissa H. Rosen, MD, NYU Langone Health Joan H. Tisch Center for Women’s Health, 207 East 84th Street, New York, NY 10028, USA. E-mail:
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, NY
| | - David Hudesman
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, NY
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL
| | - Shannon Chang
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, NY
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Abstract
PURPOSE OF REVIEW Both the chronic inflammation in inflammatory bowel disease (IBD), and its treatment, can increase the risk of malignancy. There is also an increasing number of patients with current and prior cancer who require IBD treatment. Thus, there is a complex interplay between immunosuppressive treatment and monitoring for new and recurrent cancer. RECENT FINDINGS Vedolizumab and ustekinumab have not been shown to increase the risk of malignancy. Transplant data shows a potential risk with tofacitinib although rheumatoid arthritis data does not. IBD patients have been shown to tolerate chemotherapy, specifically with cytotoxic compared with hormonal chemotherapy. Patients with prior cancer are at increased risk of new or recurrent cancers; however, immunosuppression appears to be safe. Emerging treatments for IBD have demonstrated acceptable safety profiles for malignancy risk, and immunosuppression appears to be safe for use in patients with current and prior malignancy. More data is still needed to assess long-term risk of malignancy in these patients, especially with newer treatments.
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Affiliation(s)
- Jessica Kimmel
- Division of Gastroenterology, Department of Medicine, New York University School of Medicine, New York, NY, USA.
| | - Jordan Axelrad
- Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Center at New York University Langone Health, New York University School of Medicine, New York, NY, USA
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35
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Axelrad J, Faye A, Pinsino A, Cagliostro B, Thanataveerat A, Effner L, Pineda F, Garan A, Takayama H, Takeda K, Naka Y, Colombo P, Gonda T, Yuzefpolskaya M. Prospective Validation of the First Endoscopic Management Algorithm for Gastrointestinal Bleeding in Patients with Left Ventricular Assist Devices. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.318] [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: 10/27/2022] Open
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36
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Ten Hove JR, Shah SC, Shaffer SR, Bernstein CN, Castaneda D, Palmela C, Mooiweer E, Elman J, Kumar A, Glass J, Axelrad J, Ullman TA, Colombel JF, Torres J, van Bodegraven AA, Hoentjen F, Jansen JM, de Jong ME, Mahmmod N, van der Meulen-de Jong AE, Ponsioen CY, van der Woude CJ, Itzkowitz SH, Oldenburg B. Consecutive negative findings on colonoscopy during surveillance predict a low risk of advanced neoplasia in patients with inflammatory bowel disease with long-standing colitis: results of a 15-year multicentre, multinational cohort study. Gut 2019; 68:615-622. [PMID: 29720408 DOI: 10.1136/gutjnl-2017-315440] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 10/10/2017] [Revised: 01/31/2018] [Accepted: 03/01/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Surveillance colonoscopy is thought to prevent colorectal cancer (CRC) in patients with long-standing colonic IBD, but data regarding the frequency of surveillance and the findings thereof are lacking. Our aim was to determine whether consecutive negative surveillance colonoscopies adequately predict low neoplastic risk. DESIGN A multicentre, multinational database of patients with long-standing IBD colitis without high-risk features and undergoing regular CRC surveillance was constructed. A 'negative' surveillance colonoscopy was predefined as a technically adequate procedure having no postinflammatory polyps, no strictures, no endoscopic disease activity and no evidence of neoplasia; a 'positive' colonoscopy was a technically adequate procedure that included at least one of these criteria. The primary endpoint was advanced colorectal neoplasia (aCRN), defined as high-grade dysplasia or CRC. RESULTS Of 775 patients with long-standing IBD colitis, 44% (n=340) had >1 negative colonoscopy. Patients with consecutive negative surveillance colonoscopies were compared with those who had at least one positive colonoscopy. Both groups had similar demographics, disease-related characteristics, number of surveillance colonoscopies and time intervals between colonoscopies. No aCRN occurred in those with consecutive negative surveillance, compared with an incidence rate of 0.29 to 0.76/100 patient-years (P=0.02) in those having >1 positive colonoscopy on follow-up of 6.1 (P25-P75: 4.6-8.2) years after the index procedure. CONCLUSION Within this large surveillance cohort of patients with colonic IBD and no additional high-risk features, having two consecutive negative colonoscopies predicted a very low risk of aCRN occurrence on follow-up. Our findings suggest that longer surveillance intervals in this selected population may be safe.
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Affiliation(s)
- Joren R Ten Hove
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Shailja C Shah
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Seth R Shaffer
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Daniel Castaneda
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Carolina Palmela
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Erik Mooiweer
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jordan Elman
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Akash Kumar
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jason Glass
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jordan Axelrad
- Division of Gastroenterology, Columbia University, New York, USA
| | - Thomas A Ullman
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Joana Torres
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
- Surgical Department, Gastroenterology Division, Hospital Beatriz Angelo, Loures, Lisboa, Portugal
| | - Adriaan A van Bodegraven
- Department of Gastroenterology and Hepatology, Vrije Universiteit Medical Center Amsterdam, Amsterdam, The Netherlands
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
| | - Frank Hoentjen
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen M Jansen
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis Amsterdam, Amsterdam, The Netherlands
| | - Michiel E de Jong
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nofel Mahmmod
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Andrea E van der Meulen-de Jong
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Cyriel Y Ponsioen
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, Netherlands
| | - Christine J van der Woude
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Steven H Itzkowitz
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
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Mahmoud R, Shah SC, ten Hove JR, Torres J, Mooiweer E, Castaneda D, Glass J, Elman J, Kumar A, Axelrad J, Ullman T, Colombel JF, Oldenburg B, Itzkowitz SH. No Association Between Pseudopolyps and Colorectal Neoplasia in Patients With Inflammatory Bowel Diseases. Gastroenterology 2019; 156:1333-1344.e3. [PMID: 30529584 PMCID: PMC7354096 DOI: 10.1053/j.gastro.2018.11.067] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 11/21/2018] [Accepted: 11/29/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel diseases who have postinflammatory polyps (PIPs) have an increased risk of colorectal neoplasia (CRN). European guidelines propose that patients with PIPs receive more frequent surveillance colonoscopies, despite limited evidence of this increased risk. We aimed to define the risk of CRN and colectomy in patients with inflammatory bowel diseases and PIPs. METHODS We conducted a multicenter retrospective cohort study of patients with inflammatory bowel diseases who underwent colonoscopic surveillance for CRN, from January 1997 through January 2017, at 5 academic hospitals and 2 large nonacademic hospitals in New York or the Netherlands. Eligible patients had confirmed colonic disease with duration of at least 8 years (or any duration, if they also had primary sclerosing cholangitis) and no history of advanced CRN (high-grade dysplasia or colorectal cancer) or colectomy. The primary outcome was occurrence of advanced CRN according to PIP status; secondary outcomes were occurrence of CRN (inclusive of low-grade dysplasia) and colectomy. RESULTS Of 1582 eligible patients, 462 (29.2%) had PIPs. PIPs were associated with more severe inflammation (adjusted odds ratio 1.32; 95% confidence interval [CI] 1.13-1.55), greater disease extent (adjusted odds ratio 1.92; 95% CI 1.34-2.74), and lower likelihood of primary sclerosing cholangitis (adjusted odds ratio 0.38; 95% CI 0.26-0.55). During a median follow-up period of 4.8 years, the time until development of advanced CRN did not differ significantly between patients with and those without PIPs. PIPs did not independently increase the risk of advanced CRN (adjusted hazard ratio 1.17; 95% CI 0.59-2.31). The colectomy rate was significantly higher in patients with PIPs (P = .01). CONCLUSIONS In a retrospective analysis of data from 2 large independent surveillance cohorts, PIPs were associated with greater severity and extent of colon inflammation and higher rates of colectomy, but were not associated with development of any degree of CRN. Therefore, intervals for surveillance should not be shortened based solely on the presence of PIPs.
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Affiliation(s)
- Remi Mahmoud
- Department of Gastroenterology and Hepatology, University
Medical Center Utrecht, Utrecht, The Netherlands.,Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shailja C. Shah
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Hepatology and Nutrition,
Department of Medicine, Vanderbilt University Medical Center, Nashville, TN,
USA
| | - Joren R. ten Hove
- Department of Gastroenterology and Hepatology, University
Medical Center Utrecht, Utrecht, The Netherlands
| | - Joana Torres
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Surgical Department,
Hospital Beatriz Ângelo, Loures, Portugal
| | - Erik Mooiweer
- Department of Gastroenterology and Hepatology, University
Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniel Castaneda
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jason Glass
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jordan Elman
- Department of Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Akash Kumar
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jordan Axelrad
- Division of Digestive and Liver Diseases, Department of
Medicine, Columbia University Medical Center, New York, NY, USA
| | - Thomas Ullman
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University
Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H. Itzkowitz
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Agrawal M, Cohen-Mekelburg S, Kayal M, Axelrad J, Galati J, Tricomi B, Kamal K, Faye AS, Abrudescu P, Scherl E, Lawlor G, Sultan K, Lukin D, Colombel JF, Ungaro RC. Disability in inflammatory bowel disease patients is associated with race, ethnicity and socio-economic factors. Aliment Pharmacol Ther 2019; 49:564-571. [PMID: 30663075 DOI: 10.1111/apt.15107] [Citation(s) in RCA: 7] [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: 09/24/2018] [Revised: 10/22/2018] [Accepted: 11/30/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Race, ethnicity and socio-economic status impact clinical outcomes in inflammatory bowel disease (IBD) patients. However, their impact on disability has not been studied. AIM To determine the association between race, ethnicity and socio-economic factors with disability in IBD, using the validated IBD disability index (IBD-DI). METHODS Ambulatory IBD patients were enrolled at five academic centres participating in the New York Crohn's and Colitis Organization. We assessed the IBD-DI, and collected clinical and socio-economic data. Factors associated with moderate-to-severe disability (IBD-DI score > 35) on univariable analysis were tested in multivariable models with adjusted odds ratios (aOR) and 95% confidence intervals (CI) reported. RESULTS In this study, 323 patients (57.3% CD, 51.4% female) were enrolled; 17.7% were Hispanic, 17% were non-Hispanic black, 56.0% were non-Hispanic Caucasian and 9.3% belonged to non-Hispanic non-black minority races. However, 39.0% of patients were publicly insured and 38.4% of patients had low annual household income (<$50 000). 100 (31.0%) patients reported moderate-to-severe disability. On multivariable analysis, Hispanic ethnicity (aOR 2.7, 95% CI 1.3-5.6), non-Hispanic non-black minority race (aOR 3.5, 95% CI 1.3-8.9), public payer (aOR 2.1, 95% CI 1.1-4.0) and low annual household income (aOR 3.0, 95% CI 1.7-5.4) were associated with moderate-to-severe disability controlling for disease characteristics. CONCLUSIONS IBD patients who are minorities, have public insurance, or low household income, are 2-3 times more likely to report moderate-to-severe disability independent of disease characteristics in the United States. Future studies are needed to study their complex relationship and to mitigate disability.
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Affiliation(s)
- Manasi Agrawal
- Division of Gastroenterology, Montefiore Medical Center, Bronx, New York.,Division of Gastroenterology, Lenox Hill Hospital, New York, New York
| | | | - Maia Kayal
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, Columbia University Medical Center, New York, New York.,Division of Gastroenterology and Hepatology, New York University Langone Medical Center, New York, New York
| | - Jonathan Galati
- Division of Gastroenterology and Hepatology, Weil Cornell Medical Center, New York, New York
| | - Brad Tricomi
- Albert Einstein College of Medicine, Bronx, New York
| | - Kanika Kamal
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Adam S Faye
- Division of Gastroenterology and Hepatology, Columbia University Medical Center, New York, New York
| | - Paul Abrudescu
- Division of Gastroenterology and Hepatology, Northwell University, Long Island, New York
| | - Ellen Scherl
- Division of Gastroenterology and Hepatology, Weil Cornell Medical Center, New York, New York
| | - Garrett Lawlor
- Division of Gastroenterology and Hepatology, Columbia University Medical Center, New York, New York
| | - Keith Sultan
- Division of Gastroenterology and Hepatology, Northwell University, Long Island, New York
| | - Dana Lukin
- Division of Gastroenterology, Montefiore Medical Center, Bronx, New York.,Division of Gastroenterology and Hepatology, Weil Cornell Medical Center, New York, New York
| | | | - Ryan C Ungaro
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
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Nobel YR, Axelrad J, Lewis SK, Whittier S, Lawlor G, Lichtiger S, Green PHR, Lebwohl B. Stool PCR for Gastrointestinal Pathogens in Patients With and Without Immune-Mediated Intestinal Diseases. Dig Dis Sci 2018; 63:996-1002. [PMID: 29411208 DOI: 10.1007/s10620-018-4959-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/30/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with celiac disease and inflammatory bowel disease, two immune-mediated luminal conditions, have higher rates of certain infections than healthy counterparts. The prevalence of many gastrointestinal infections in these patients, however, is unknown. AIMS Using a novel clinical stool pathogen PCR test, we investigated the hypothesis that patients with celiac disease/inflammatory bowel disease had different distributions of diarrheal pathogens than other patients. METHODS We performed a retrospective cohort study of outpatients who underwent stool pathogen testing with the FilmArray Gastrointestinal PCR Panel (BioFire Diagnostics, Salt Lake City, UT) at our institution from January 1 to December 31, 2015. Rates of pathogens were measured in patients with or without celiac disease/inflammatory bowel disease. RESULTS Of 955 patients, 337 had positive test for any pathogen, with 465 bacterial, parasitic, or viral pathogens identified. One hundred and twenty-seven patients (13.3%) had celiac disease or inflammatory bowel disease, of which 29/127 (22.8%) had a positive test, compared to 308/828 other patients (37.2%) (p = 0.002). Patients with celiac disease/inflammatory bowel disease had significantly fewer viruses (1.6 vs. 8.1% of patients; p = 0.008) and parasites (0 vs. 3.3%; p = 0.039), with nonsignificant trend toward fewer bacteria (21.3 vs. 29.2%; p = 0.063). Escherichia coli species were most common in both populations. CONCLUSIONS Stool PCR identified numerous pathogens in patients with or without celiac disease/inflammatory bowel disease. Patients with celiac disease/inflammatory bowel disease were significantly less likely to have any pathogen identified, and had significantly fewer viruses and parasites. In this population, knowledge of common pathogens can guide diagnostic evaluation and offer opportunities for treatment.
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Affiliation(s)
- Yael R Nobel
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Jordan Axelrad
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Suzanne K Lewis
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Susan Whittier
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Garrett Lawlor
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Simon Lichtiger
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Peter H R Green
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, 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.
- The Celiac Disease Center at Columbia University, 180 Fort Washington Avenue, Suite 936, New York, NY, 10032, USA.
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Ungaro R, Fausel R, Chang HL, Chang S, Chen LA, Nakad A, El Nawar A, Prytz Berset I, Axelrad J, Lawlor G, Atreja A, Roque Ramos L, Torres J, Colombel JF. Bariatric surgery is associated with increased risk of new-onset inflammatory bowel disease: case series and national database study. Aliment Pharmacol Ther 2018; 47:1126-1134. [PMID: 29512187 DOI: 10.1111/apt.14569] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 08/14/2017] [Revised: 08/25/2017] [Accepted: 01/19/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Case series suggest a possible association between bariatric surgery and incident IBD. AIM The aim of this study was to evaluate the association between bariatric surgery and new-onset IBD. METHODS We first conducted a multi-institutional case series of patients with a history of IBD and bariatric surgery. We next conducted a matched case-control study using medical and pharmacy claims from 2008 to 2012 in a US national database from Source Healthcare Analytics LLC. Bariatric surgery was defined by ICD-9 or CPT code. Bariatric surgery was evaluated as recent (code in database timeframe), past (past history V code) or no history. Conditional logistic regression was used to estimate odds ratios (OR) and 95% CI for new-onset IBD, CD and UC. RESULTS A total of 15 cases of IBD (10 CD, 4 UC, 1 IBD, type unclassified) with a prior history of bariatric surgery were identified. Most cases were women, had Roux-en-Y surgery years prior to diagnosis and few IBD-related complications. A total of 8980 cases and 43 059 controls were included in our database analysis. Adjusting for confounders, a past history of bariatric surgery was associated with an increased risk of new-onset IBD (OR 1.93, 95% CI 1.34-2.79). However, patients who had recent bariatric surgery did not appear to be at shorter term risk of IBD (OR 0.94, 95% CI 0.58-1.52). CONCLUSION New-onset IBD was significantly associated with a past history of bariatric surgery. This potential association needs to be confirmed in future prospective studies.
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Affiliation(s)
- R Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - R Fausel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,The Oregon Clinic, Portland, OR, USA
| | - H L Chang
- Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - S Chang
- New York University School of Medicine, New York, NY, USA
| | - L A Chen
- New York University School of Medicine, New York, NY, USA
| | - A Nakad
- CHwapi Notre Dame, Tournai, Belgium
| | | | | | - J Axelrad
- Columbia University Medical Center/NY-Presbyterian Hospital, New York, NY, USA
| | - G Lawlor
- Columbia University Medical Center/NY-Presbyterian Hospital, New York, NY, USA
| | - A Atreja
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - J Torres
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Hospital Beatriz Ângelo, Loures, Portugal
| | - J-F Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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41
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Affiliation(s)
- Jordan Axelrad
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Mark Lebwohl
- Department of Dermatology, the Icahn School of Medicine at Mount Sinai, New York, New York
| | - Oscar Lebwohl
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York
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42
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Axelrad J, Kriplani A, Ozbek U, Harpaz N, Colombel JF, Itzkowitz S, Holcombe RF, Ang C. Chemotherapy Tolerance and Oncologic Outcomes in Patients With Colorectal Cancer With and Without Inflammatory Bowel Disease. Clin Colorectal Cancer 2016; 16:e205-e210. [PMID: 27742264 DOI: 10.1016/j.clcc.2016.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/08/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD), comprising Crohn disease and ulcerative colitis, is a risk factor for colorectal cancer (CRC). Chemotherapy toxicity may exacerbate IBD symptoms and vice versa, but data are limited. We evaluated chemotherapy tolerance and oncologic outcomes in patients with CRC with and without IBD. PATIENTS AND METHODS Medical records of patients with CRC with and without IBD treated between 2008 and 2013 were reviewed. Where possible, patients were matched by age, sex, stage, and diagnosis year. Chemotherapy tolerance and survival outcomes were compared between patients with IBD and without IBD. RESULTS A total of 158 subjects with CRC were included: 80 patients had IBD and 78 matched control patients did not have IBD. Between cases and controls, there were no significant differences in demographic data, stage of CRC, and cancer treatments, with equivalent numbers of patients receiving surgery, radiation, and chemotherapy. Patients with IBD experienced more CRC treatment alterations than those without IBD (74% vs. 44%, P = .03), largely due to a higher frequency of treatment delays among patients with IBD. Differences in stage-specific 5-year overall survival (OS) and recurrence-free survival (RFS) in patients with and without IBD were not significant, except for stage IV patients with IBD who had significantly shorter OS than those without IBD. Patients with histologically active IBD did not require more chemotherapy alterations than patients with inactive IBD. CONCLUSION In this series, patients with CRC with IBD experienced more treatment alterations (mostly delays) than those without IBD. Patients with stage IV CRC with IBD had shorter survival than patients without IBD.
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Affiliation(s)
- Jordan Axelrad
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY.
| | - Anuja Kriplani
- Division of Hematology and Oncology, Department of Medicine, the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Umut Ozbek
- Population Health Science and Policy, the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Noam Harpaz
- Division of Hematology and Oncology, Department of Medicine, the Icahn School of Medicine at Mount Sinai, New York, NY; Department of Pathology, the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Department of Medicine, the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Itzkowitz
- Division of Gastroenterology, Department of Medicine, the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Randall F Holcombe
- Division of Hematology and Oncology, Department of Medicine, the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Celina Ang
- Division of Hematology and Oncology, Department of Medicine, the Icahn School of Medicine at Mount Sinai, New York, NY
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Ang C, Ozbek U, Kriplani A, Axelrad J, Harpaz N, Colombel JF, Itzkowitz SH, Holcombe RF. Chemotherapy tolerance and oncologic outcomes in colorectal cancer (CRC) patients with and without inflammatory bowel disease (IBD). J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e15162] [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] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Celina Ang
- Mt Sinai Medcl Ctr Tisch Cancer Inst, New York, NY
| | - Umut Ozbek
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Noam Harpaz
- Mount Sinai School of Medicine, New York, NY
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Axelrad J, Bernheim O, Colombel JF, Malerba S, Ananthakrishnan A, Yajnik V, Hoffman G, Agrawal M, Lukin D, Desai A, McEachern E, Bosworth B, Scherl E, Reyes A, Zaidi H, Mudireddy P, DiCaprio D, Sultan K, Korelitz B, Wang E, Williams R, Chen L, Katz S, Itzkowitz S. Risk of New or Recurrent Cancer in Patients With Inflammatory Bowel Disease and Previous Cancer Exposed to Immunosuppressive and Anti-Tumor Necrosis Factor Agents. Clin Gastroenterol Hepatol 2016; 14:58-64. [PMID: 26247164 DOI: 10.1016/j.cgh.2015.07.037] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [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: 03/16/2015] [Revised: 07/22/2015] [Accepted: 07/24/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Our understanding of malignancy associated with immunosuppression in patients with inflammatory bowel disease (IBD) comes from studies of individuals with no history of cancer. We investigated whether patients with IBD and a history of cancer who were subsequently immunosuppressed have an increased risk of developing incident cancer. METHODS We performed a retrospective analysis of data from 333 patients with IBD treated at 8 academic medical centers who developed cancer and subsequently received treatment with anti-tumor necrosis factor (TNF), anti-TNF with an antimetabolite (thiopurines, methotrexate), antimetabolites, or no subsequent exposure to immunosuppressive agents (controls). We collected data on their primary outcomes of incident cancers (new or recurrent). Hazard ratios (HRs) were calculated by using Cox proportional hazards and Kaplan-Meier survival curves; study groups were compared by using the log-rank test. RESULTS During the follow-up period, 90 patients (27%) developed an incident cancer. Patient characteristics between groups differed, but matching was not possible because of the relatively small sample sizes. There was no difference in time to incident cancer (P = .14) or type of incident cancer (P = .61) among the 4 groups. After adjusting for recurrence risk for type of prior cancer, there was no difference in risk of incident cancer (HR for anti-TNF, 0.32; 95% confidence interval [CI], 0.09-1.09; HR for anti-TNF with an antimetabolite, 0.64; 95% CI, 0.26-1.59; HR for an antimetabolite, 1.08; 95% CI, 0.54-2.15) or time to subsequent cancer between study arms (P = .22). CONCLUSION On the basis of a retrospective study, in patients with IBD and a history of cancer, exposure to an anti-TNF agent or an antimetabolite after cancer was not associated with an increased risk of incident cancer, compared with patients who did not receive immunosuppression. Larger, matched, prospective studies are needed to confirm these findings.
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Affiliation(s)
- Jordan Axelrad
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, New York
| | - Oren Bernheim
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stefano Malerba
- Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ashwin Ananthakrishnan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | - Vijay Yajnik
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | - Gila Hoffman
- Albert Einstein College of Medicine, New York, New York
| | - Manasi Agrawal
- Department of Medicine, Montefiore Medical Center, New York, New York
| | - Dana Lukin
- Division of Gastroenterology and Liver Diseases, Department of Medicine, Montefiore Medical Center, New York, New York
| | - Amit Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, New York
| | | | - Brian Bosworth
- Division of Gastroenterology and Hepatology, Department of Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Ellen Scherl
- Division of Gastroenterology and Hepatology, Department of Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Andre Reyes
- Department of Medicine, North Shore-Long Island Jewish University Hospital, Manhasset, New York
| | - Hina Zaidi
- Division of Gastroenterology, Department of Medicine, North Shore-Long Island Jewish North Shore University Hospital, Manhasset, New York
| | - Prashant Mudireddy
- Division of Gastroenterology, Department of Medicine, North Shore-Long Island Jewish Lenox Hill Hospital, New York, New York
| | - David DiCaprio
- Department of Medicine, North Shore- Long Island Jewish Lenox Hill Hospital, New York, New York
| | - Keith Sultan
- Division of Gastroenterology, Department of Medicine, North Shore-Long Island Jewish North Shore University Hospital, Manhasset, New York
| | - Burton Korelitz
- Division of Gastroenterology, Department of Medicine, North Shore-Long Island Jewish Lenox Hill Hospital, New York, New York
| | - Erwin Wang
- Department of Medicine, NYU Langone Medical Center, New York, New York
| | - Renee Williams
- Division of Gastroenterology, Department of Medicine, NYU Langone Medical Center, New York, New York
| | - LeaAnn Chen
- Division of Gastroenterology, Department of Medicine, NYU Langone Medical Center, New York, New York
| | - Seymour Katz
- Division of Gastroenterology, Department of Medicine, NYU Langone Medical Center, New York, New York
| | - Steven Itzkowitz
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
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Abstract
Immunomodulators and biologic agents are effective in treating inflammatory bowel diseases (IBDs), and recent evidence supports their introduction earlier in the disease course. An important concern to both patients and physicians considering immunosuppression (IS) for the treatment of IBD is the potential associated cancer risk. Several important clinical questions deserve attention with respect to IBD therapy and cancer. First, does medical therapy for IBD predispose to developing cancer? Second, in an IBD patient with a history of cancer, does IBD therapy impact cancer recurrence? Third, once cancer develops in an IBD patient, is the cancer outcome different? Finally, in an IBD patient with current cancer, does the cancer therapy affect IBD outcomes? In a recent multicentric study, patients were identified based on a diagnosis of IBD and cancer with subsequent exposure to anti-tumor necrosis factor α (anti-TNFα arm), thiopurines or methotrexate (antimetabolite arm) or without subsequent IS exposure (control arm). Two hundred and fifty-five patients met the inclusion criteria. Prior cancers included 121 solid, 62 gastrointestinal, 55 dermatologic and 17 hematologic malignancies. During the follow-up period, 75 (29.4%) patients developed incident cancer: 36 (14.1%) a new cancer, 33 (12.9%) a recurrent cancer and 6 (2.4%) a new and recurrent cancer. Incident cancer rate per 100 person-years for patients exposed to anti-TNFα, anti-metabolites and controls was 2.6 with 795 person-years of follow-up, 14.8 with 122 person-years of follow-up and 8.52 with 422 person-years of follow-up, respectively. In this series of IBD patients with a history of cancer, exposure to IS following a cancer diagnosis was not associated with an increased risk of incident cancer compared to patients who did not receive these agents. Prospective data are needed to confirm these findings.
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Axelrad J, Itzkowitz S, Colombel J, Harpaz N, Holcombe R, Ozbek U, Ang C. 2114 Chemotherapy tolerance and oncologic outcomes in patients with inflammatory bowel disease and gastrointestinal malignancy: The Mount Sinai Hospital experience. Eur J Cancer 2015. [DOI: 10.1016/s0959-8049(16)31036-x] [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: 12/01/2022]
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Abstract
Misfolded prion protein (PrP) is generally accepted as causing transmissible spongiform encephalopathies (TSEs) by aligning alongside normal host prion protein and inducing it to change to the misfolded configuration. This paper disputes this theory, and proposes that, rather than causing TSEs, misfolded PrP is the result of an autoimmune response to the host PrP, a component both of nerve cells and of lymphocytes. Autoimmunity is initiated by detachment of the phosphotidylinositol glycolipid anchor as a result of exposure to organophosphate pesticides. Once PrP is detached, antibodies are mobilized against it. In some individuals, point mutations, like the codon 129 met-val substitution, have evolved as a self-defence mechanism, causing a change in PrP to the misfolded, protease-resistant form seen in TSEs. Increased PrP production, both in response to nerve damage, and as a component of lymphocytes stimulated to proliferate in response to PrP, produces a positive feedback mechanism, resulting in symptoms of brain destruction.
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Parker S, Muensterberger W, Axelrad J. The Psychoanalytic Study of Society. Volume II. Anthropologica 1963. [DOI: 10.2307/25604591] [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: 11/10/2022] Open
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