Faculty Bibliography

BACKGROUND & AIMS/OBJECTIVE:IL-17-mediated diseases have great global burden. Basic science research suggests that excessive sodium intake can trigger systemic IL-17-mediated inflammation, but population-based data on the association between sodium intake and IL-17-mediated diseases are limited. We aim to understand if increased estimated dietary sodium is associated with higher rates of IL-17-mediated disease. METHODS:We conducted a population-based cross-sectional study using UK Biobank data from 468,673 participants (aged 37-73 years) recruited between March 2006 and October 2010. The exposure, dietary sodium, was estimated using the International Study of Electrolyte Secretion and Blood Pressure equation. The main outcome, prevalence of any IL-17-mediated disease (psoriasis, psoriatic arthritis, ankylosing spondylitis, hidradenitis suppurativa, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis), was determined by diagnostic codes. RESULTS:After adjusting for age, sex, ethnicity, Townsend deprivation index, and education, a 1-gram higher estimated daily sodium intake was associated with higher odds of having an IL-17-mediated disease (adjusted odds ratio [aOR] 1.08, 95% confidence interval [CI] 1.06 to 1.10) as well as more IL-17-mediated diseases (adjusted rate ratio 1.08, 95% CI 1.06 to 1.10). Sub-analyses of individual diseases showed that higher estimated dietary sodium was associated with higher odds of psoriasis (aOR 1.17, 95% CI 1.13 to 1.22), psoriatic arthritis (aOR 1.22, 95% CI 1.13 to 1.32), hidradenitis suppurativa (aOR 2.07, 95% CI 1.73 to 2.47), and rheumatoid arthritis (aOR 1.19, 95% CI 1.14 to 1.24), and lower odds of having inflammatory bowel disease (aOR 0.84, 95% CI 0.80 to 0.88). There was no significant association with ankylosing spondylitis (aOR 1.00, 95% CI 0.93 to 1.08), systemic lupus erythematosus (aOR 0.93, 95% CI 0.69 to 1.26), or multiple sclerosis (aOR 0.95, 95% CI 0.81 to 1.12). CONCLUSION/CONCLUSIONS:In a large population-based cohort, higher estimated dietary sodium was associated with a small increase in the odds of IL-17-mediated disease, particularly those of the skin and joints. Future work should investigate whether a low-salt diet improves IL-17-mediated diseases.

UNLABELLED:Structured exercise (SE) and physical therapy (PT) are integral components of disease management. Older adults with inflammatory bowel disease (IBD) represent a growing proportion of patients, and are at disproportionate risk of functional decline due to the combined effects of aging, chronic inflammation, malnutrition, and inactivity. Despite the well-established benefits of SE and PT, most gastroenterologists report feeling inadequately equipped to counsel and refer patients with physical function limitations, and thus these therapies remain underutilized. The purpose of this review is to synthesize the existing evidence and provide practical, actionable guidance for gastroenterologists to incorporate SE and PT into IBD care. RECENT FINDINGS/UNASSIGNED:Initial studies suggest complementary SE and PT may significantly improve IBD-related musculoskeletal extraintestinal manifestations (EIMs), such as joint pain, fatigue, sarcopenia, frailty, and improve exercise confidence as compared with standard care alone. Additionally, multimodal prehabilitation strategies may significantly reduce severe postoperative complications and shorten hospital stays in older patients undergoing IBD-related surgery. SUMMARY/UNASSIGNED:SE and PT are low-cost, low-risk interventions with benefits spanning multiple domains of physical function and morbidity in older adults with IBD. This article highlights pertinent SE and PT literature in the aging IBD population, including underlying pathophysiology, interventions, and scope of practice. Gastroenterologists are provided evidence-based, condition-specific assessments and PT referral pathways that can be implemented in routine practice. Integrating this into the multidisciplinary IBD care team may improve patients' physical function and quality of life.

As the prevalence of inflammatory bowel disease (IBD) rises rapidly among older adults, gastroenterologists and other health care providers increasingly face challenges in managing age-related comorbidities, polypharmacy, and functional impairments such as frailty and sarcopenia. This narrative review proposes a dual approach to management by optimizing care for patients aged >60 years while promoting the healthy aging of those aged 40-60 years. For patients aged >60 years, we emphasize prescribing effective corticosteroid-sparing medications to control inflammation, conducting medication reconciliations to assess appropriateness and drug interactions, and evaluating baseline hepatic and renal function for necessary dose adjustments. For patients aged 40-60 years, we advise regular screening and nutritional counseling to delay the onset of age-related comorbidities and recommend targeting endoscopic remission to modify the disease course and reduce complications and disability later in life. Given that patients with IBD receiving long-term immunosuppression are at increased risk of infections, adherence to age-appropriate vaccination schedules is also recommended. A proactive and personalized approach to disease management has the potential to optimize quality of life for older adults with IBD.

PURPOSE/UNASSIGNED:Inflammatory bowel disease (IBD) consists of Crohn's disease (CD) and ulcerative colitis (UC) and is a spectrum autoimmune disease of the gastrointestinal tract. Large scale real-world evidence studies could provide valuable evidence about IBD for personalized healthcare recommendations. The Observational Medical Outcomes Partnership Common Data Model (OMOP CDM) standardizes electronic health record (EHR) data, allowing for research that incorporates multiple data sources. We are interested in whether OMOP CDM data on IBD are fit-for-use. METHODS/UNASSIGNED:We selected IBD diagnosis codes to define the phenotype. We used a data quality checklist to evaluate 5 domains: conformance, completeness, concordance, plausibility, and temporality. We also did sensitivity analyses for CD and UC that consisted of at least 2 diagnosis codes that were at least 30 days apart. RESULTS/UNASSIGNED:All of the phenotype-defining ICD source codes mapped to SNOMED. Many concept prevalences were low. A total of 78 (30.1%) out of 253 concept correlations were above our strength threshold (⍴ > 0.5). The age distribution of concepts and relative frequency of IBD medications were plausible. The median time between diagnosis and biopsy for the cohort was 4.43 [-0.05, 104.29] weeks. For the subgroup of participants who had sufficient data for the timeline analysis, IBD diagnosis concepts tended to occur first. In our sensitivity analyses, the completeness percentages of many variables in the UC and CD subgroups were similar to IBD, except for disease specific workup and treatment concepts. CONCLUSION/UNASSIGNED:We have shown a novel implementation of our data quality framework on IBD cohorts.

BACKGROUND:Chronic intestinal inflammation is a well-established driver of colorectal dysplasia in inflammatory bowel disease (IBD). However, the role of metabolic factors such as obesity remains poorly understood. We evaluated whether chronic obesity, measured using five-year longitudinal body mass index (BMI), is independently associated with colorectal dysplasia in patients with IBD. METHODS:using all outpatient measurements over a five-year period prior to the index colonoscopy. Multivariable conditional logistic regression was used to evaluate the association between obesity and dysplasia, adjusting for established dysplasia risk factors and surveillance-related variables. RESULTS:A total of 312 patients were included (156 dysplasia cases and 156 matched controls). Dysplasia cases had significantly longer IBD duration compared with controls (median 12.1 vs. 8.0 years, p < 0.01) and were more likely to have a history of prior colorectal dysplasia (16.0% vs. 3.8%, p < 0.01). In multivariable analysis, obesity was independently associated with colorectal dysplasia (adjusted odds ratio [aOR] 2.23, 95% CI 1.08-4.57). Longer disease duration (aOR 1.05 per year, 95% CI 1.02-1.08) and prior dysplasia (aOR 4.88, 95% CI 1.69-14.06) were also independently associated with dysplasia. In a secondary model adjusting for additional surveillance-related and structural colonic factors, obesity remained significantly associated with dysplasia (aOR 2.11, 95% CI 1.05-4.24). CONCLUSIONS:Obesity is independently associated with colorectal dysplasia in patients with IBD, suggesting that metabolic factors contribute to neoplastic risk beyond traditional inflammation-driven pathways. Incorporation of metabolic risk into dysplasia risk stratification may improve CRC prevention strategies in IBD.

GOAL/OBJECTIVE:To investigate the safety of corticosteroid escalation before antimicrobial treatment among inflammatory bowel disease (IBD) flares associated with an enteric infection. BACKGROUND:Corticosteroids are often necessary to treat individuals with IBD; however, there is concern that immunosuppression in the setting of a gastrointestinal infection may worsen outcomes. METHODS:We conducted a retrospective study of adults (18 y or older) hospitalized for an IBD flare (2015 to 2023) who received both systemic corticosteroids and antimicrobials for a gastrointestinal infection. The primary outcome was a composite of in-hospital death, IBD-related surgery, need for intensive care unit, toxic megacolon, or acute kidney injury, stratified by timing of corticosteroid escalation (before vs. after antimicrobial initiation). Outcomes at 90 days were also collected in a secondary analysis. RESULTS:Overall, 76 individuals were included; 48 (63.2%) had ulcerative colitis. The most common infection was Clostridioides difficile (n=50; 65.8%), and the majority of patients (n=51, 67.1%) received corticosteroid initiation (or escalation) before antimicrobials. There was no significant difference in the development of the primary (9.8% vs. 8.0%, P=1.00) or secondary (29.4% vs. 32.0%, P=0.82) outcome based on corticosteroid initiation before versus after antimicrobial initiation. Among patients with C. difficile, similar results were seen. CONCLUSIONS:Among patients hospitalized with an IBD flare complicated by enteric infection, initiation or escalation of corticosteroids before antimicrobial therapy did not increase the risk of in-hospital or 90-day adverse events. This study supports the notion that corticosteroids can be safely utilized while awaiting the results of the gastrointestinal infectious testing.

BACKGROUND:Individuals with inflammatory bowel disease (IBD) have an elevated risk of colorectal neoplasia (CRN), including colorectal dysplasia and cancer (CRC). Despite surveillance strategies to prevent CRC, the clinical course of dysplasia types remains poorly understood. METHODS:We conducted a nationwide cohort study using the Swedish Patient Register and the ESPRESSO histopathology cohort to identify patients diagnosed with IBD between 1969 and 2023. Patients were classified according to their first (baseline) incident episode of dysplasia (no dysplasia, ND; indefinite, IND; low-grade, LGD; high-grade, HGD). Our primary outcome was future advanced CRN (HGD or CRC) during follow-up. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CI) were estimated using Cox regression. RESULTS:We identified 54,534 patients with IBD, including 1,320 with a first (baseline) episode of dysplasia (264 IND, 1031 LGD, 25 HGD), and 53,214 with ND. Over a median follow-up of 13.3 years, 2.3% of ND patients had future advanced CRN compared to 5.3% of IND patients (aHR 1.85, 95% CI 1.09-3.15) and 8.3% of LGD patients (aHR 3.51, 95% CI 2.77-4.45). Of those with HGD, 40% developed CRC (aHR 47.88, 95% CI 25.53-89.80). Risk factors for future dysplasia included male sex, younger age at diagnosis, extensive colitis, primary sclerosing cholangitis, and histologic inflammation. CONCLUSION/CONCLUSIONS:Patients with IBD and dysplasia have a significantly increased risk of future dysplasia, particularly among patients with HGD. Personalized surveillance strategies based on risk factors are critical for preventing advanced CRN.

INTRODUCTION/BACKGROUND:Potassium competitive acid blockers (PCABs) are superior to proton pump inhibitors (PPIs) for healing of Los Angeles (LA) class C/D erosive esophagitis (EE) and are approved for non-erosive gastroesophageal reflux disease (GERD) given their efficacy measured by heartburn-free days. However, they are more expensive than PPIs. We estimated the cost-effectiveness of PCABs compared to PPIs for the management of GERD. METHODS:A decision tree was constructed for the base case of a patient with GERD. We tested scenarios in which NERD, LA A/B, or LA C/D esophagitis was present, comparing PCABs to PPIs as first-line therapy, including step up therapy and/or class switching if symptoms persisted. Using publicly available cost estimates, quality-adjusted life years (QALYs) were compared using a willingness-to-pay (WTP) threshold of $100,000/QALY from a societal perspective at 6 months. RESULTS:The cost of PCABs for GERD was $3,240 more than PPIs, with an ICER of $144,208/QALY. When evaluating GERD phenotypes separately, the ICER was consistently over our WTP threshold. One-way analyses showed the most influential parameters were PCAB cost and efficacy for heartburn-free days. Probabilistic sensitivity analysis favored PPIs 71.7% out of 100,000 iterations. Reducing one-week costs to below $91 would make PCABs a cost effective first-line strategy across all GERD phenotypes. DISCUSSION/CONCLUSIONS:Despite PCAB efficacy, PPIs are a cost-effective strategy for GERD treatment, and can be positioned ahead of PCAB escalation on this basis. Reducing PCAB costs or accepting a higher WTP threshold would influence this finding, though PCABs may be favored in some current situations as evidenced by probabilistic sensitivity results.

BACKGROUND:Cognitive impairment, a precursor to dementia, is an important geriatric syndrome. We aimed to describe cognitive function in adults ≥60 years with inflammatory bowel disease (IBD) and determine the relationship between cognitive function and IBD activity. METHODS:We recruited IBD patients ≥60 years from 6 American centers. We collected demographics, IBD history, administered IBD activity indices and the Montreal Cognitive Assessment (MoCA). Follow-up assessments were nested in routine clinical care within one year. The primary outcome was change in cognitive function testing at follow-up; secondary outcome was IBD activity at follow-up. We constructed multi-variate logistic regression models to assess for the outcomes. RESULTS:We recruited 356 patients with a median age of 70 years (range: 60-89 years), 51% female, 66% had at least a Bachelor's degree; median IBD duration was 18 years and 60% had Crohn's disease. At baseline, 42% screened positive for cognitive impairment. Deficits in delayed recall and visuospatial functioning were the most prevalent. At follow-up within a year, 31% demonstrated an improved MoCA score, while 19% had a worse MoCA score. Adjusting for age, race, education, depression, number of comorbidities, IBD type, IBD duration as well as cognitive function score at baseline, symptomatically active IBD at baseline was significantly associated with worsening cognitive testing at follow-up (aOR:3.01, 95%CI:1.20-7.50). We also found that deficits in delayed recall, a MoCA sub-domain, were significantly associated with symptomatically active IBD at follow-up (aOR:2.22, 95%CI:1.10-4.47). CONCLUSION/CONCLUSIONS:These data provide further impetus to effectively treat IBD in older adults and suggest that delayed recall could be a useful screening tool for older adults with IBD.