Vaccination Against Measles, Mumps, Rubella and Incident Inflammatory Bowel Disease in a National Cohort of Privately Insured Children

BACKGROUND

Infection is believed to be a potential trigger for inflammatory bowel disease (IBD). Whether vaccination against childhood infections including measles, mumps, and rubella may reduce risk of IBD is uncertain.

METHODS

We conducted a retrospective cohort study using de-identified claims data from a national private payer (Optum Clinformatics Data Mart). Eligible infants were born between 2001 and 2018 and were continuously enrolled with medical and pharmacy coverage from birth for at least 2 years (n = 1 365 447). Measles, mumps, and rubella vaccination or MMR is administered beginning at 12 months of age. Cox proportional hazard regression models were used to compare time with incident disease in children by category of vaccination, after adjustment for sex, birth year, region of country, history of allergy to vaccines, and seizure history.

RESULTS

The incidence of early pediatric IBD increased between 2001 and 2018. Ten percent (n = 141 230) of infants did not receive MMR, and 90% (n = 1 224 125) received at least 1 dose of MMR. There were 334 cases of IBD, 219 cases of Crohn's disease, and 164 cases of ulcerative colitis. Children who had received at least 1 dose of MMR had lower risk for IBD than children who did not (hazard ratio, 0.71; 95% confidence interval, 0.59-0.85). These associations did not change after further adjustment for childhood comorbid conditions, preterm birth, or older siblings affected with IBD. Similar associations were observed for MMR with Crohn's disease and ulcerative colitis, although these did not reach statistical significance.

CONCLUSION

MMR is associated with decreased risk for childhood IBD.

Trends of 5-Aminosalicylate Medication Use in Patients With Crohn Disease

BACKGROUND

5-aminosalicylate (5-ASA) medications have a long history of use for the treatment of inflammatory bowel disease and continue to be widely prescribed today. The effectiveness of 5-ASAs in ulcerative colitis is clear; however, studies have shown little benefit for induction or maintenance treatment of Crohn disease (CD). We aimed to quantify usage and examine trends in 5-ASA prescription rates in patients with CD.

METHODS

Using a retrospective design, we queried a national database of commercially insured patients (Truven-Health databases) between 2009 and 2014 to identify patients with CD aged 18 to 65 years. Prescription rates for 5-ASA medications including sulfasalazine, mesalamine, olsalazine, and balsalazide were calculated for each calendar year. Regression models were used to examine year-to-year trends in prescription rates and identify patient factors associated with 5-ASA use.

RESULTS

We identified 132,804 patients with CD, of whom 37.3% (n = 49,529) received a 5-ASA prescription during the study period. From 2009 to 2014, the overall prescription rates of 5-ASAs declined from 42.9% to 30.0% (P < 0.001). Patient factors independently associated with 5-ASA use included younger age, male sex, multimorbidity, and a health maintenance organization insurance plan, while controlling for the region of residence.

CONCLUSIONS

About 1 in 3 privately insured patients with CD received 5-ASA prescriptions despite their questionable effectiveness; however, in an encouraging trend, prescription rates significantly decreased from 2009 to 2014. This high prescription rate may reflect a gap in providers' knowledge regarding the available evidence-an opportunity for cost savings with improved health care delivery.

Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm

Background and study aims Colonic polyps > 1 cm in size are commonly managed using hot polypectomy techniques. The most frequent adverse events (delayed bleeding, post-polypectomy syndrome, and perforation) are related to electrocautery-induced injury. We hypothesized that cold resection of large polyps may have similar efficacy and improved safety compared to hot polypectomy. Our aims were to evaluate efficacy and safety of piecemeal cold snare resection of colonic polyps > 1 cm. Patients and methods Patients undergoing lift and piecemeal cold snare polypectomy of non-pedunculated colon polyps > 1 cm from October 2013 to September 2015 were identified retrospectively. Efficacy was defined by the absence of residual adenomatous tissue at endoscopic follow-up. Adverse events (AEs), including post-procedural bleeding, bowel perforation, or post-procedural pain requiring hospitalization were assessed by chart review and telephone follow-up.  Results Seventy-three patients underwent piecemeal cold snare polypectomy for 94 colon polyps > 1 cm with 56 of 73 patients completing follow-up on 72 polyps. Residual or recurrent adenoma was found in 7 cases (9.7 %). Median polyp size was significantly greater in those with residual/recurrent adenoma (37.1 vs. 19.1 mm, P < .0001). There were no AEs among all 73 patients enrolled. Conclusions Piecemeal cold snare resection of colon polyps > 1 cm is feasible, safe and efficacious when compared to published hot polypectomy data. Additional observational and randomized comparative effectiveness studies are necessary to demonstrate comparable adenoma eradication and improved safety advantage over existing hot snare polypectomy techniques.

Corticosteroid Use and Complications in a US Inflammatory Bowel Disease Cohort

Background and Aims

Corticosteroids are effective for the short-term treatment of inflammatory bowel disease (IBD). Long-term use, however, is associated with significant adverse effects. To define the: (1) frequency and duration of corticosteroid use, (2) frequency of escalation to corticosteroid-sparing therapy, (3) rate of complications related to corticosteroid use, (4) rate of appropriate bone density measurements (dual energy X-ray absorptiometry [DEXA] scans), and (5) factors associated with escalation and DEXA scans.

Methods

Retrospective review of Veterans Health Administration (VHA) data from 2002–2010.

Results

Of the 30,456 Veterans with IBD, 32% required at least one course of corticosteroids during the study time period, and 17% of the steroid users had a prolonged course. Among these patients, only 26.2% underwent escalation of therapy. Patients visiting a gastroenterology (GI) physician were significantly more likely to receive corticosteroid-sparing medications. Factors associated with corticosteroid-sparing medications included younger age (OR = 0.96 per year,95%CI:0.95, 0.97), male gender (OR = 2.00,95%CI:1.16,3.46), GI visit during the corticosteroid evaluation period (OR = 8.01,95%CI:5.85,10.95) and the use of continuous corticosteroids vs. intermittent corticosteroids (OR = 2.28,95%CI:1.33,3.90). Rates of complications per 1000 person-years after IBD diagnosis were higher among corticosteroid users (venous thromboembolism [VTE] 9.0%; fragility fracture 2.6%; Infections 54.3) than non-corticosteroid users (VTE 4.9%; fragility fracture 1.9%; Infections 26.9). DEXA scan utilization rates among corticosteroid users were only 7.8%.

Conclusions

Prolonged corticosteroid therapy for the treatment of IBD is common and is associated with significant harm to patients. Patients with prolonged use of corticosteroids for IBD should be referred to gastroenterology early and universal efforts to improve the delivery of high quality care should be undertaken.

Intragenic suppressors of an OmpF assembly mutant and assessment of the roles of various OmpF residues in assembly through informational suppressors

We employed two separate genetic approaches to examine the roles of various OmpF residues in assembly. In one approach, intragenic suppressors of a temperature-sensitive OmpF assembly mutant carrying a W214E substitution were sought at 42 degrees C, or at 37 degrees C in a genetic background lacking the periplasmic folding factor SurA. In the majority of cases (58 out of 61 revertants), the suppressors mapped either at the original site (position 214) or two residues downstream from it. In the remaining three revertants that were obtained in a surA background, an alteration of N230Y was located 16 residues away from the original site. The N230Y suppressor also corrected OmpF315 assembly at 42 degrees C in a surA(+) background, indicating that the two different physiological environments imposed similar assembly constraints. The specificity of N230Y was tested against five different residues at position 214 of mature OmpF. Clear specificity was displayed, with maximum suppression observed for the original substitution at position 214 (E214) against which the N230Y suppressor was isolated, and no negative effect on OmpF assembly was noted when the wild-type W214 residue was present. The mechanism of suppression may involve compensation for a specific conformational defect. The second approach involved the application of informational suppressors (Su-tRNA) in combination with ompF amber mutations to generate variant OmpF proteins. In this approach we targeted the Y40, Q66, W214, and Y231 residues of mature OmpF and replaced them with S, Q, L, and Y through the action of Su-tRNAs. Thus, a total of 16 variant OmpF proteins were generated, of which three were identical to the parental protein, and two variants carrying W214Q and Y231Q substitutions were similar to assembly-defective proteins isolated previously (R. Misra, J. Bacteriol. 175:5049-5056, 1993). The results obtained from these analyses provided useful information regarding the compatibility of various alterations in OmpF assembly.