Faculty Bibliography

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.

INTRODUCTION/BACKGROUND:We investigated the impact of racial/ethnic disparities in therapy initiation on colorectal cancer (CRC) mortality using Surveillance, Epidemiology, and End Results Program (SEER) database. METHODS:Adults aged 18-84 years with CRC were identified. Cox models for 60-month all-cause and cancer-specific mortality were adjusted for demographics, stage, tumor site, income, and rural-urban residence. RESULTS:Therapy initiation was slower for Hispanics (HR 0.85) and non-Hispanic Black (NHB) patients (HR 0.80) compared with non-Hispanic Whites (p < 0.001). Each additional month of delay was associated with a 3% increase in cancer mortality (p < 0.001). Findings were consistent across diagnosis eras, with no significant race-by-era interaction, and adjustment for socioeconomic and geographic factors resulted in minimal attenuation of racial disparities. CONCLUSION/CONCLUSIONS:Treatment delays independently contribute to all-cause and cancer-specific mortality, disproportionately affecting NHB and lower-SES patients.

OBJECTIVE:Gastrointestinal (GI) symptoms such as constipation are prevalent autonomic symptoms seen in prodromal and end-stage Parkinson's disease (PD). The aim of this systematic review and meta-analysis is to assess the association of GI symptoms and constipation alone with progression and severity of PD-associated cognitive impairment. METHODS:). RESULTS:Eleven prospective, nine cross-sectional, three retrospective, three case-control, and one randomized controlled studies were included, totaling 7042 PD patients. The presence of GI symptoms like constipation was significantly associated with PD dementia (RR 1.37; 95% CI 1.09, 1.71; p = 0.005). However, over 5 years, GI symptoms were not found to be associated with an increased prevalence of PD dementia. In subgroup analysis of three prospective studies, constipation was associated with worsened PD cognitive impairment over 5 years (decreased MOCA score by 1.259 points; 95% CI -2.059, -0.459; p = 0.002). CONCLUSIONS:GI symptoms, and constipation specifically, were commonly reported among patients with PD dementia. In a subgroup analysis of prospective studies, worsening constipation seemed to correlate with greater cognitive impairment over 5 years. Although this meta-analysis did not establish causation, these findings highlight the potential importance of monitoring constipation in PD individuals as ongoing research about the role of the gut-brain axis continues.

PURPOSE/OBJECTIVE:Studies show women are underrepresented in gastroenterology (GI). Understanding representation is crucial to improving representation. This study describes the geographic distribution of women in academic GI in the United States (US). METHODS:We conducted a cross-sectional study of 224 US GI fellowship programs in 2023 by review of program websites and direct inquiry. Gender distribution of trainees and faculty across US regions was evaluated. Program characteristics were examined in univariate analyses. Logistic regression models assessed factors associated with women in leadership, adjusting for program type and region. RESULTS:Women comprised 39.3% of 1,801 fellows and 30.2% of 3,899 GI faculty. Percentage of women fellows was highest in the West (50%), Northeast (38%), South (33%), and Midwest (33%), (p = 0.014). Median percentage of senior women faculty was highest in the Northeast (27%) (p = 0.009). Programs with women GI division chiefs had more women GI fellowship program directors (60% vs 40%, p = 0.001) and higher median percentage of women faculty (33% vs 26%, p = 0.016). The presence of a woman GI division chief was independently associated with having a woman GI fellowship program director (p = 0.008) and increased percentage of women faculty (p < 0.001). CONCLUSION/CONCLUSIONS:Gender representation varied regionally, with some institutions lacking women faculty or trainees. Women in leadership are associated with greater faculty gender diversity, potentially impacting trainee recruitment, faculty retention, and patient care. The association between women GI division chiefs and increased women faculty and program directors highlights how leadership gender diversity may support recruitment and retention of women in academic GI.

BACKGROUND:An association between higher adenoma detection rate (ADR) at index screening colonoscopy and lower risk of metachronous advanced neoplasia (AN, defined as colorectal cancer (CRC) or advanced adenoma (AA)) has been reported. However, the relationship between ADR at both index and surveillance colonoscopy and subsequent AN is unknown. We examined the association between ADR and withdrawal time (WT) at index and surveillance colonoscopy and risk of metachronous AN at surveillance colonoscopy. METHODS:We used GIQuIC, a repository of colonoscopies across the US. Each patient has a unique ID at a participating site. Endoscopist NPI are associated with each exam. We included patients with two colonoscopies at least 3 years apart (index and surveillance) between 2011 and 2022 and calculated the ADR and average WT for the endoscopist performing the index and surveillance colonoscopies respectively. We built a multivariable logistic regression model with metachronous AN as the outcome and ADR and WT as independent variables, controlling for patient age, sex and race. RESULTS:We included 768,274 patients and 3,425 endoscopists. Mean patient age was 61 years and 48% were male; 66% were White and 3% were Hispanic. Indication for index colonoscopy were screening (43.4%), surveillance (39.0%) and diagnostic (17.6%). ADR quartiles were ≤29.7%, >29.7%-37.2%, >37.2%-45.0% and >45%. WT quartiles were ≤7.1 min, >7.1 -8.2 min, >8.2-9.7min, >9.7min. Advanced neoplasia detection was lowest when low ADR endoscopists performed both index and surveillance exams (5.4%, Table 1) and high ADR index exams were followed by low ADR surveillance exams (4.0%). Compared to low ADR endoscopists for both index and surveillance exams, advanced was significantly higher when both exams performed by a high ADR endoscopist (AA 7.4%; OR for AN 1.10(1.05-1.16)) or low ADR index exams were followed by high ADR surveillance exams (AA 13.3%; OR for AN 1.448 (1.37-1.51)). Compared to short WT endoscopists for both exams (AA 7.2%; CRC 0.3%), advanced neoplasia detection was higher when both exams were performed by a long WT endoscopist or short WT index exams were followed by long WT surveillance exams (AA 7.0% p=.53 and 9.9%, P<0.001) but similar CRC detection of 0.2% and 0.2% (p 0.14). Other factors associated with finding of metachronous advanced neoplasia were older age (>=76 years vs 45-55 years OR 1.64; 95% CI 1.48, 1.82), male sex (Male vs female OR 1.15; 95% CI 1.10-1.19), White race compared to non-white (OR1.10; 95% CI 1.06, 1.14), 7-10 years between exams compared to 3-5 years between exams (OR 1.24; 95% CI 1.11, 1.37), indication of surveillance vs. screening for the index exam (OR 1.1.7; 95% CI 1.13, 1.22), advanced adenoma or sessile serrated lesion finding on the index exam (OR 2.08; 95% CI 1.97, 21.9 and OR 1.23; 95% CI 1.16, 1.30 respectively). CONCLUSION/CONCLUSIONS:Our findings show endoscopist ADR and WT for both index and surveillance colonoscopy are associated with risk of metachronous neoplasia, including CRC. Future studies on metachronous neoplasia should include both sets of quality indicators.

BACKGROUND AND AIMS/OBJECTIVE:Colorectal cancer screening reduces mortality, yet uptake remains suboptimal. Various interventions aim to improve screening rates, but their comparative effectiveness is unclear. We aim to evaluate the effectiveness of colorectal cancer screening uptake interventions using a systematic review and network meta-analysis. METHODS:We analyzed data from 76 randomized clinical trials across eight intervention strategies: patient navigation, mailed FIT outreach, educational multimedia, reminder-only, choice-based outreach, colonoscopy outreach, multistep, and usual care. Network meta-analysis compared interventions using risk ratios (RRs) and 95% confidence intervals (CIs). P-scores and rankograms assessed intervention rankings. Risk of bias was assessed, and certainty of evidence was graded using the GRADE framework. RESULTS:Patient navigation (RR 1.58, 95% CI 1.23-2.02; P-score 0.81) and mailed FIT outreach (RR 1.36, 95% CI 1.07-1.74; P-score 0.79) were the most effective strategies, significantly outperforming usual care. Educational multimedia (RR 1.27, 95% CI 0.91-1.78) and reminder-only interventions (RR 1.24, 95% CI 0.98-1.57) showed modest effects. Choice-based outreach and colonoscopy outreach were not significantly more effective than usual care. Mailed FIT outreach was superior to colonoscopy outreach (RR 1.35, 95% CI 1.11-1.63), and patient navigation outperformed reminder-only interventions (RR 1.48, 95% CI 1.14-1.94). In low baseline uptake settings (<30%), mailed FIT outreach was most effective (RR 3.12, 95% CI 1.70-5.71), while educational multimedia performed best in higher uptake populations (≥30%) and in recent studies (2021-2024). Majority of studies were at low risk of bias while the certainty of evidence mostly ranged from moderate to low. CONCLUSION/CONCLUSIONS:Patient navigation and mailed FIT outreach are the most effective strategies for increasing colorectal cancer screening uptake, particularly in low baseline uptake populations. Educational multimedia shows promise in recent years and high baseline uptake settings, offering a scalable alternative.

BACKGROUND AND AIMS/OBJECTIVE:Growing evidence suggests that the gut microbiome plays a role in carcinogenesis for early-onset colorectal cancer (EOCRC). The novel Ring Finger Protein 213 (RNF213) gene has broad antimicrobial properties. Our study aimed to compare RNF213 mutation rates in EOCRC and late-onset colorectal cancer using data from the cBioPortal for Cancer Genomics. METHODS:All participants from the cBioPortal with CRC samples that profiled the RNF213 gene were included. Multivariable logistic regression was used to assess the association between EOCRC and primary tumor RNF213 mutation. Cox proportional hazards models were used to evaluate the influence of RNF213 mutation on all-cause mortality risk. All tests were two-sided. RESULTS:OR 1.61, 95% CI 0.72, 3.22). There was no significant difference in all-cause mortality risk by RNF213 mutation status. CONCLUSIONS:Primary tumor mutations in exon 29 of the RNF213 gene are associated with significantly increased odds of EOCRC diagnosis in a multicohort sample of participants with CRC. Future studies of germline and precancerous RNF213 mutations are needed to elucidate its possible role in EOCRC tumorigenesis.