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Background: Patients with an ileal pouch-anal anastomosis (IPAA) can experience pouch inflammation postoperatively. The use of antitumor necrosis factor (anti-TNF) biologics may be associated with pouch inflammation, but limited data exist on the impact of multiple advanced therapies on development of subsequent pouch inflammation. The aim of this study was to assess for an association between preoperative use of multiple advanced therapies and risk of endoscopically detected inflammatory pouch diseases (EIPDs)., Methods: We performed a retrospective analysis of ulcerative colitis (UC) and indeterminate colitis (IBDU) patients who underwent an IPAA at a quaternary care center from January 2015 to December 2019. Patients were grouped based on number and type of preoperative drug exposures. The primary outcome was EIPD within 5 years of IPAA., Results: Two hundred ninety-eight patients were included in this analysis. Most of these patients had UC (95.0%) and demonstrated pancolonic disease distribution (86.1%). The majority of patients were male (57.4%) and underwent surgery for medically refractory disease (79.2%). The overall median age at surgery was 38.6 years. Preoperatively, 68 patients were biologic/small molecule-naïve, 125 received anti-TNF agents only, and 105 received non-anti-TNF agents only or multiple classes. Ninety-one patients developed EIPD. There was no significant association between type (P = .38) or number (P = .58) of exposures and EIPD, but older individuals had a lower risk of EIPD (P = .001; hazard ratio, 0.972; 95% confidence interval, 0.956-0.989)., Conclusion: Development of EIPD was not associated with number or type of preoperative advanced therapies., (© The Author(s) 2023. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: There are limited data on the postoperative outcomes in Crohn's disease patients exposed to preoperative ustekinumab or vedolizumab. We hypothesised that preoperative biologic use in Crohn's disease is not associated with postoperative complications after ileocolic resection., Methods: Crohn's disease patients who underwent ileocolic resection over 2009-2019 were identified at a large regional health system. Preoperative biologic use within 12 weeks of surgery was categorised as no biologic, anti-tumour necrosis factor, vedolizumab, or ustekinumab. The primary endpoint was 90-day intra-abdominal septic complication. Risk factors included preoperative medical therapies, demographics, disease characteristics, laboratory values, and surgical approach. Regression models assessed the association of biologic use with intra-abdominal septic complication., Results: A total of 815 Crohn's disease patients who underwent an ileocolic resection were included [62% no biologic, 31.4% anti-tumour necrosis factor, 3.9% vedolizumab, 2.6% ustekinumab]. Primary anastomosis was performed in 85.9% of patients [side-to-side 48.8%, end-to-side 26%, end-to-end 25%] in primarily a stapled [77.2%] manner. Minimally invasive approach was used in 41.4%. The 90-day postoperative intra-abdominal sepsis rate of 810 patients was 12%, abscess rate was 9.6%, and anastomotic leak rate was 3.2%. Multivariable regression modelling controlling for confounding variables demonstrated that preoperative biologic use with anti-tumour necrosis factor [p = 0.21], vedolizumab [p = 0.17], or ustekinumab [p = 0.52] was not significantly associated with intra-abdominal septic complication. Preoperative albumin < 3.5 g/dl was independently associated with intra-abdominal septic complication (odds ratio [OR] 1.76 [1.03, 3.01])., Conclusions: In Crohn's disease patients undergoing ileocolic resection, preoperative biologics are not associated with 90-day postoperative intra-abdominal septic complication. Preoperative biologic exposure should not delay necessary surgery., (© The Author(s) 2021. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The use of biological agents for the treatment of chronic inflammatory conditions such as inflammatory bowel diseases (IBD) has been on the rise.1,2 Current biological therapies include antitumor necrosis factor-α (anti-TNF-α), anti-interleukin-12/23, and anti-integrin agents. Before initiation of biological drugs, screening for Mycobacterium tuberculosis infection is required to avoid reactivation or worsening of disease after immunosuppression. It has been shown that anti-TNF-α treated patients have a 14-fold increased risk of tuberculosis (TB) infection/reactivation compared with healthy controls.3 The methods for screening for TB have evolved over time and vary from region to region., (© 2020 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Chronic idiopathic inflammatory bowel disease (IBD) is a significant risk factor for the development of intestinal adenocarcinoma. The underlying molecular alterations in IBD-associated intestinal adenocarcinoma remain largely unknown., Methods: We compared the clinicopathologic and molecular features of 35 patients with 47 IBD-associated intestinal adenocarcinomas with a consecutive series of 451 patients with sporadic colorectal carcinoma identified at our institution and published data on sporadic colorectal carcinoma., Results: c-MYC amplification was the most frequent molecular alteration identified in 33% of IBD-associated intestinal adenocarcinoma that is a significantly higher frequency than in sporadic colorectal carcinoma (8%) (P = 0.0001). Compared to sporadic colorectal carcinoma, IBD-associated intestinal adenocarcinomas more frequently demonstrated mucinous differentiation (60% vs 25%, P < 0.001) and signet ring cell differentiation (28% vs 4%, P < 0.001). Mucinous and signet ring cell differentiation were significantly associated with the presence of c-MYC amplification (both with P < 0.05). HER2 positivity (11%), KRAS exon 2 or 3 mutation (10%), and IDH1 mutation (7%) were less commonly observed in IBD-associated intestinal adenocarcinoma. There was an association between poor survival and HER2 status with 3 of 4 patients having HER2-positive adenocarcinoma dead of disease at last clinical follow-up; however, no statistically significant survival effect was identified for any of the molecular alterations identified., Conclusions: We demonstrate that IBD-associated intestinal adenocarcinomas have a high frequency of c-MYC amplification that is associated with mucinous and signet ring cell differentiation. Many of the identified molecular alterations have potential therapeutic relevance, including HER2 amplification, IDH1 mutation, and low frequency KRAS mutation.

Patients with inflammatory Bowel Disease (IBD) often require hospitalization and this experience is stressful. Health care providers frequently do not have adequate time to address the emotional impact of the hospitalization on the patient and family. Nonmedical support for inpatients was identified as an unmet need by a Crohn's disease patient's family. This led to the development of a volunteer peer specialist network, IBD Connect, where peer volunteers visit hospitalized patients with IBD to offer emotional support and educational materials. We aimed to determine the feasibility of incorporating IBD Connect into an inpatient IBD service, evaluate the impact of IBD Connect on patients' willingness to share their disease experience with family and friends, and improve stress. Since the inception of IBD Connect in 2012, peer volunteers have made 1469 total visits to 677 unique inpatients. Patient satisfaction of IBD Connect has been favorable with a significant decrease in stress related to the hospitalization. Similarly, there was significant increase in patients sharing their IBD diagnosis and experience with family and friends. Patients and their families are willing to share important information and ask questions to volunteers that may not have been discussed with their health care providers. In an era of patient-reported outcomes and patient-centered care, peer volunteers are an important component of chronic disease management and should be incorporated into IBD inpatient health care teams.

New models of health care have emerged over the past decade. Accountable care organizations and patient-centered medical homes are designed to improve the patient experience, enhance health care quality, and decrease cost. These models have been developed in the primary care domain and have yet to be tested in specialty care. Certain chronic diseases require principal care by a specialist or health care team. The specialty medical home would provide patient-centered care for specific populations of patients whose health care derives from a single chronic disease. This article defines the parameters for a specialty medical home and provides a specific payer-provider experience for the comprehensive care of an inflammatory bowel disease population.

Background: Antimicrobial treatment is known to cause short- and long-term changes in the composition of normal human microbiota. The relationship between antibiotic use and overall clinical behavior in inflammatory bowel disease (IBD) has not been explored. We aim to prospectively characterize patterns of antibiotic use and clinical IBD activity in a large IBD cohort., Methods: Prospective observational study from a longitudinal IBD natural history registry between 2009 and 2012. Antibiotic prescriptions were identified and categorized using electronic medical record data. Cumulative rates over the 4-year study period were compared. Demographic, clinical, laboratory, health care utilization, and treatment data of the patients with IBD were collected and analyzed. Quality of life was measured by Short IBD Questionnaire data. Primary outcomes were markers of disease activity including Short IBD Questionnaire scores, C-reactive protein levels, health care utilization, and medication use., Results: Seven hundred eighteen patients followed over 4 years were included (47.6% male; mean age, 46.7 ± 15.2 yr), 59.9% had Crohn's disease, whereas 38.6% had ulcerative colitis. Most patients (66.3%) were exposed to antibiotics during the study period. Antibiotic-exposed patients were more likely to have Crohn's disease (63% versus 53.7%; P = 0.05), require narcotics (43.7% versus 14.9%; P < 0.0001), receive antidepressants (43.1% versus 18.6%; P < 0.001), prednisone (52.7% versus 31%; P < 0.0001), or biological therapy (52% versus 36.5%; P < 0.0001). Antibiotic-exposed patients had a lower mean Short IBD Questionnaire (50.2 ± 11.5 versus 56.4 ± 9.5; P < 0.0001), higher rates of C-reactive protein elevation (49.2% versus 31.8%; P < 0.0001), and higher health care utilization compared with nonantibiotic-exposed patients., Conclusions: The majority of patients with IBD receive antibiotic treatment, and these individuals demonstrate a more severe clinical course.

Background: Managing patients with inflammatory bowel disease requires multidisciplinary coordination. Technological advances have enhanced access to care for patients and improved physician interactions. The primary aim of our project was to convene diverse institutions and specialties through a multisite virtual conferencing platform to discuss complex patient management., Methods: The case conference is designed to include multiple institutions to exchange ideas, review evidence-based data, and provide input on the management of patients with Crohn's disease and ulcerative colitis. Technology is supplied and coordinated by an information technology specialist and Chorus Call, Inc., an international teleconferencing service provider. The Inflammatory Bowel Disease Live Interinstitutional Interdisciplinary Videoconference Education (IBD LIVE) initiative is accredited by the University of Pittsburgh Medical Center (UPMC) Center for Continuing Education in the Health Sciences for 1 AMA PRA Category 1 Credit per weekly session., Results: IBD LIVE began in 2009 comprising only adult gastroenterology and pediatric gastroenterology from UPMC Presbyterian and Children's Hospitals. Participation steadily increased from 5 sites in 2010 to 11 sites in 2014. Maximum attendance for a single conference was 73 participants with a median of 48. The Continuing Medical Education scores (1 = worst to 5 = best) have a high median overall score (4.6, range 3.2-5.0) with positive responses with regard to the degree to which the conference changed practice., Conclusions: IBD LIVE has been successful and continues to grow. Implementation of the Crohn's and Colitis Foundation of America Virtual Preceptor Program using the IBD LIVE platform will provide expanded national physician access to this professional education activity.

Background: Chronic pain is common in patients with inflammatory bowel disease and often attributed to inflammation. However, many patients with inflammatory bowel disease without evidence of active disease continue to experience pain. This study was undertaken to determine the prevalence of pain in patients with ulcerative colitis (UC) and examine the role of inflammation and psychiatric comorbidities in patients with UC with pain., Methods: We performed a retrospective cross-sectional analysis of adult patients with UC seen at a tertiary referral inflammatory bowel disease center. Age, gender, disease duration and extent, abdominal pain rating, quality of life, physician global assessment, endoscopic and histological rating of disease severity, C reactive protein, and erythrocyte sedimentation rate were abstracted., Results: A total of 1268 patients were identified using billing codes for colitis. Five hundred and two patients (48.2% women) met all inclusion criteria. Two hundred and sixty-two individuals (52.2%) complained of abdominal pain, with 108 individuals (21.5%) describing more frequent pain ("some of the time or more"). Of those with quiescent disease (n = 326), 33 patients (10%) complained of more frequent pain. Physician global assessment, endoscopic and histological severity rating, erythrocyte sedimentation rate, and C reactive protein significantly correlated with pain ratings. The best predictors of pain were physician global assessment, C reactive protein and erythrocyte sedimentation rate, female gender, and coexisting mood disorders., Conclusions: Abdominal pain affects more than 50% of patients with UC. Although inflammation is important, the skewed gender distribution and correlation with mood disorders highlight parallels with functional bowel disorders and suggest a significant role for central mechanisms. Management strategies should thus go beyond a focus on inflammation and also include interventions that target psychological mechanisms of pain.

Background: Crohn's disease (CD) is a chronic inflammatory, relapsing, and progressive condition that leads to bowel damage and subsequent stricturing or penetrating complications. Tumor necrosis factor (TNF) α antagonists (e.g., infliximab) can achieve sustained remission in CD. However, a paradox exists as to whether use of these medications, which effectively treat psoriasis, also confer risk of developing psoriasiform lesions., Methods: Data from the Food and Drug Administration Adverse Event Reporting System (2004-2011) were analyzed. Adverse event reports for the TNF-α antagonists infliximab, adalimumab, and certolizumab were reviewed. Primary "control" drugs examined included the non-CD drugs propranolol and lithium because of their recognized association with risk of psoriasis and the nonbiological CD drug mesalamine. Proportional reporting ratios for psoriasis adverse events were calculated for TNF-α antagonists versus control drugs., Results: From more than 13 million reports in Adverse Event Reporting System, the biological group included 5432 reports with psoriasis listed (infliximab = 1789; adalimumab = 3475; and certolizumab = 168) compared with just 88 psoriasis reports for the control group (propranolol = 24; mesalamine = 24; and lithium = 40). Compared with control drugs, the psoriasis proportional reporting ratios for TNF-α antagonists were as follows: infliximab (6.61), adalimumab (12.13), and certolizumab (5.43) (P < 0.0001). The aggregate "class" proportional reporting ratio for all TNF-α antagonists versus control drugs was 9.24 (P < 0.0001). Similar results were observed when psoriasis reports were compared between TNF-α antagonists and other drugs used to treat CD, including azathioprine, 6-mercaptopurine, methotrexate, corticosteroids, ciprofloxacin, and the antimalarial drug, hydroxychloroquine., Conclusions: Data from the Food and Drug Administration Adverse Event Reporting System suggest that TNF-α antagonists used in the treatment of CD confer an increased risk of psoriasiform adverse events.