Escalation Of Medical Therapy Research Articles

Systematic review and meta-analysis: Impact of depression on prognosis in inflammatory bowel disease.

Depression is highly prevalent in patients with inflammatory bowel disease (IBD), which may affect the prognosis of IBD. This aimed to investigate the impact of depression on prognosis in IBD. A systematic literature search was performed in four databases (Medline, Embase, Web of Science, and PsycINFO) up to December 31, 2023. Studies were included if they investigated the impact of depression on prognosis in IBD. The primary outcome was flare in IBD, and secondary outcomes were hospitalization, readmission, emergency visits, surgery, and escalation of medical therapy. Relative risks (RRs) were utilized to estimate the risk in each of the above prognostic indicators. Fourteen cohort and 10 case-control studies matched our entry criteria, comprising 630 408 patients with IBD. Twenty-two of included studies were considered to have a low risk of bias. Depression was found to significantly increase the risk of flare (RR=1.37, 95% CI 1.16-1.63), hospitalization (RR=1.11, 95% CI 1.00-1.23), readmission (RR=1.32, 95% CI 1.04-1.67), emergency visits (RR=1.33, 95% CI 1.12-1.59), surgery (1.38, 95% CI 1.08-1.76), and escalation of medical therapy (RR=1.38, 95% CI 1.13-1.69) in IBD. Of note, patients with depression in ulcerative colitis had significant differences in readmission (RR=1.38, 95% CI 1.19-1.60) and escalation of medical therapy (RR=1.78, 95% CI 1.55-2.04). Additionally, the association was observed in patients with Crohn's disease in terms of flare (RR=1.47, 95% CI 1.08-2.01) and hospitalization (RR=1.20, 95% CI 1.03-1.40). Current evidence suggested that depression could significantly increase the risk of poor prognosis worsening in patients with IBD. However, the association varied in IBD subtypes.

P948 Hand Grip Strength is a useful objective measure associated with fatigue and impaired quality of life in patients with inflammatory bowel disease

Abstract Background Hand grip strength (HGS) is a recognised tool for diagnosis / screening of muscle impairment and sarcopenia, however it remains underutilised in IBD cohorts. The aim of the study was to measure the prevalence of muscle impairment by HGS and association with quality of life in a cohort of UC patients in disease remission. Methods Potential subjects were prospectively identified for selection from the Gastroenterology Department in St. Vincent’s University Hospital Outpatient Department. All patients had a confirmed diagnosis of UC for >3 month with stable, quiescent disease (no escalation of medical therapy in the previous 3 months with a documented Faecal Calprotectin (FCP) <100 μg/g). Along with anthropometry data, HGS measurements were performed using the Jamar®Plus+Dynamometer. Quality of life scores were measured using 36-item Short Form Survey (SF-36), Short Inflammatory Bowel Disease Questionnaire (SIBDQ), and Short Health Scale questionnaires were measured. Linear regression was used to calculate standardised β-coefficients for correlation analysis. Non-parametric data was analysed using algorithms including Kruskal-Wallis and Wilcoxon rank-sum test. Results 60% (n=18) of subjects had a HGS outside the lower limit of the 95% confidence interval of age and sex matched normative values, indicative of impaired grip strength. This was significantly more prevalent in subjects with normal BMI than BMI>30 (p=0.035). Prevalence of fatigue was 43.3% according to SIBDQ question 2a and ’Energy/Fatigue’ scores of SF-36 were significantly lower compared to normal Irish population data (51.0 v 64.8, p = 0.0002). Composite scores of fatigue in both SIBDQ (question 2a) and SF-36 were compared, resulting in a standardized β-coefficient of 0.52 of statistical significance (p value = 0.003).Significant correlation was demonstrated between predicted HGS and ’Energy/Fatigue’ SF-36 scores (standardised β-coefficient = 0.4, p value = 0.027). Conclusion HGS is a convenient means of measuring muscle function in an IBD population and correlates significantly with ’Energy/fatigue’ SF-36 scores. These results suggest sarcopenia as a potentially important contributor to fatigue in patients with IBD and suggest HGS is an objective, easily applied objective measure which merits validation as an outcome measure for intervention studies to improve fatigue in patients with IBD.

Re-intervention rates and symptom-free survival at 1year after endoscopic versus surgical management of strictures in Crohn's disease: A propensity matched analysis of a prospective inflammatory bowel disease cohort.

Resection for Crohn's disease (CD) related strictures is definitive but carries risk of morbidity, recurrence, and short bowel syndrome. On the contrary, the durability of endotherapy (ET) for CD-related strictures is questionable. Prospective comparative studies are limited. We aimed to prospectively compare the outcomes of ET in CD strictures with a case-matched surgical therapy (ST) cohort. Patients undergoing ET or resection for primary CD strictures (symptomatic, non-traversable, <5cm length, n≤3) between January 2021 and March 2022 in a high-volume tertiary center were compared with regard to recurrent symptoms, escalation of therapy, re-intervention, and re-operation based on propensity matched analysis. Fifty-nine patients [49% ET, 57.6% male, median (years): 34 (15-74)] had ≥12months of follow up. Before propensity matching, cumulative re-intervention rate was significantly higher with ET [34.5% (10/29) vs 3.3% (1/30) ST, P=0.002]. Recurrent symptoms (34.5% vs 26.7%, P=0.42), escalation of medical therapy (27.5% vs 23.3%, P=0.64), and re-operation (7.4% vs 3.1%, P=0.55) were comparable. In propensity matched analysis adjusted for demographics, disease, and stricture characteristics [n=42, 21 each, 62% male, median (years): 32 (15-60)], cumulative probability of re-intervention rates was higher in ET (28.6% vs 4.8%, P=0.042). The cumulative probability of recurrent symptoms (ET: 33.3% vs surgery 33.3%, P=0.93), therapy escalation (ET: 23.8% vs surgery 28.6%, P=0.75), and re-operation (ET: 9.5% vs surgery 4.8%, P=0.57) was similar. ET for CD strictures require higher re-interventions compared with resection although re-operation could be avoided in the majority with comparable symptom free survival at 1year.

Abstract #1402734: Next Generation Sequencing Testing for Genetic Causes of Refractory Hypertriglyceridemia in an Outpatient Endocrine Clinic: A Case Series

Endocrinologists often diagnose and treat patients with Hypertriglyceridemia (HTG), but genetic causes like Familial Chylomicronemia Syndrome (FCS) and Multifactorial Chylomicronemia Syndrome (MCS) can be missed in everyday practice. These are caused by mutations in the Lipoprotein Lipase (LPL) gene or genes required for the LPL activity and present with treatment-refractory elevated fasting Triglycerides (TRGs) and recurrent episodes of abdominal pain and/or acute pancreatitis (AP). By testing patients with refractory HTG for genetic variations linked to these syndromes we aimed to offer timely diagnosis and create more personalized treatment plans. Here, we strive to raise awareness over the importance of genetic testing in preventing HTG-related complications. Using Next Generation Sequencing we tested 7 patients presenting in an outpatient endocrine clinic with fasting TRGs above 500 mg/dl for mutations of 7 genes linked to HTG. None of the patients responded to treatment with at least 3 lipid-lowering drug classes and all reported recurrent abdominal pain, while 3 had history of at least 1 episode of AP. Genetic variants of MCS or FCS were found in 5 patients. Three patients had genotypes consistent with MCS, one being heterozygous for a risk mutation (C.-3A >G) of the Apolipoprotein A-V (APOA5) gene, and 2 heterozygous for a likely pathogenic allele (c.888delA and c.823C >T) of the same gene. Two patients had genotypes consistent with FCS, one compound heterozygous for 2 risk mutations of the APOA5 gene, and the other homozygous for a pathogenic variant (c.111delC) of the same gene. Interestingly, all the discovered mutations affected the APOA5 gene, responsible for enhancing the LPL activity, and none the LPL gene, the most common gene linked to FCS. Regarding treatment, strict low-fat diet lowered TRGs more than escalation of medical therapy in 4 patients. In outpatient endocrine clinics, patients with HTG often have a complicated comorbidity profile, which may lead providers to underestimate the potential genetic cause of HTG. A definitive diagnosis could relieve patients from the psychological burden of uncertainty. The diagnosis of genetic HTG makes a personalized treatment plan focusing on strict low-fat diet imperative in preventing complications. This can also help avoid unnecessary polypharmacy. Moreover, the need for more effective medications for FCS and MCS becomes clear. With new genetic treatments under development, the APOA5 gene could be a potential target. Hence, testing for genetic HTG can qualify patients to participate in relevant clinical trials and can direct the treatment towards these medications once they become available.

Is early bowel resection better than medical therapy for ileocolonic Crohn's disease? A systematic review and meta-analysis.

There is emerging evidence supporting early bowel resection (EBR) for ileocaecal Crohn's disease (CD) as an alternative to conventional escalation of medical therapy (MT). Here, we present a systematic review and meta-analysis of studies comparing the outcomes of EBR with those of MT in ileocolonic CD, with a focus on ileocaecal disease. The MEDLINE, Embase, CINAHL and Cochrane Central Register of Controlled Trials databases were searched for studies reporting the outcomes of EBR versus MT for ileocolonic CD. The Cochrane tools for assessment of risk of bias were used to assess the methodological quality of studies. Nine records (from 8 studies, with a total of 1867 patients) were included in the analysis. Six studies were observational and two were randomised controlled trials. There was a reduced need for drug therapy in the EBR arm. The rate of intestinal resection at 5 years was 7.8% in the EBR arm and 25.4% in the MT group with a pooled OR of 0.32 (95% CI 0.19, 0.54; p< 0.0001). The EBR group had a longer resection-free survival (HR 0.56, 95% CI 0.38, 0.83; p= 0.004). These outcomes were consistent in a subgroup analysis of patients with ileocaecal disease. Morbidity and quality of life scores were similar across the two groups. EBR is associated with a more stable remission compared to initial MT for ileocolonic Crohn's disease. There is enough evidence to support EBR as an alternative to escalation of MT in selected patients with limited ileocaecal disease.

P205 Impact of histologic disease activity on long-term outcomes in patients with ileal pouch-anal anastomosis for ulcerative colitis

Abstract Background Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can incur in several complications like pouchitis leading to the need of immunosuppressive therapy, hospitalization and pouch failure. Unlike non-operated UC patients, therapeutic goals are an unmet need in UC-IPAA patients and the impact of the histologic activity on the development of complications is unknown. The aim of the study was to assess the association between histology and the risk of long-term negative outcomes in UC subjects with IPAA. Methods This is a single-center, retrospective study which included UC adult patients with IPAA undergoing at least one pouchscopy with biopsies in the pouch body after ileostomy closure. Pouch biopsies were blindly reviewed by a gastrointestinal pathologist with expertise in IBD. Histologic disease remission was defined as a Pouchitis Disease Activity Index (PDAI) histology subscore £ 1. Negative outcomes were: IPAA related complications (acute or chronic pouchitis, hospitalization, pouch failure) and escalation of medical therapy (start of immunosuppressive or biologics). Both descriptive and inferential statistical analyses carried out Results A total of 66 patients were included (male n=37; 56,1%) of whom 40,9% (n=27) had histological activity at the baseline pouchscopy. The characteristics of the study population are represented in table 1. The median time of follow up was 38,5 months (range 12-151). During the study period, 27 patients (40,9%) developed acute pouchitis and 10 patients (15,2%) chronic pouchitis. Thirty-nine subjects (59,1%) required antibiotic therapy while 8 subjects required systemic steroids (12,1%). Furthermore, 15 patients (22,7%) started immunomodulatory therapy with either azathioprine or biologic agents. Six patients (9,1%) needed pouch-related hospitalization and 1 patients (1,5%) experienced pouch failure. Chronic pouchitis and the need of immunosuppressive/biology therapy was observed more frequently in patients with pouch histologic activity (29,6% vs. 5,1%, and 40,7% vs. 10,3%, respectively) (P&amp;lt;0.05). After adjusting for risk factors for pouchitis, the presence of histologic activity remained an independent risk factor for developing acute pouchitis (OR 4.10, 95% CI 1.39-12.04; P= 0.010), chronic pouchitis (OR 8.51, 95% CI 1.51-47.80, P=0.015) and the need for immunosuppressive or biologic therapy (OR 6.98, 95% CI 1.69-28.80; P=0.007). Conclusion Histologic activity was associated with an increased risk of developing both acute and chronic pouchitis and with the need for immunosuppressive/biologic therapy. Future research will clarify whether histologic remission might be considered as a therapeutic target for UC-IPAA patients developing pouchitis.

Association of Circulating Fibrocytes With Fibrostenotic Small Bowel Crohn's Disease.

Fibrocytes are hematopoietic cells with features of mesenchymal cells found in the circulation and inflammatory sites implicated in promoting fibrosis in many fibroinflammatory diseases. However, their role(s) in the development of intestinal fibrosis is poorly understood. Here, we investigated a potential role of fibrocytes in the development of fibrosis in Crohn's disease (CD) and sought factors that may impact their development and function. Plasma and mononuclear cells were collected from patients with and without fibrostenotic CD. Fibrocytes defined as CD11b+, CD34+, and Collagen 1+ were correlated with clinical assessments of fibrosis, including evaluation using intestinal ultrasound. We measured the levels of relevant circulating molecules via Luminex and studied the effect of patient plasma proteins on fibrocyte differentiation. Fibrocyte numbers were increased in CD patients with stricturing Crohn's disease compared with patients with an inflammatory phenotype (P = .0013), with strong correlation between fibrocyte numbers and acoustic radiation force impulse (ARFI), a measure of bowel elasticity on intestinal ultrasound (R = .8383, P = .0127). Fibrostenotic plasma was a more potent inducer of fibrocyte differentiation in both primary human monocytes and cell line and contained increased levels of cytokines implicated in fibrocyte differentiation compared with plasma from inflammatory patients. Interestingly, increased fibrocyte numbers at time of ultrasound were associated with escalation of medical therapy and endoscopic/surgical management of small bowel strictures at 30 months follow-up. Circulating fibrocytes strongly correlate with fibrostenotic disease in CD, and they may serve as predictors for escalation of medical +/- surgical therapy.

Longitudinal follow-up study: effect of psychological co-morbidity on the prognosis of inflammatory bowel disease.

Psychological co-morbidity is more common in patients with inflammatory bowel disease (IBD), compared with the general population, but little is known about the cumulative effect of increasing psychological burden on disease behaviour. To examine the effect of psychological co-morbidity on inflammatory bowel disease in a longitudinal follow-up study. We collected complete demographic, symptom and psychological co-morbidity data (anxiety, depression and somatisation scores) at baseline from adults with IBD in biochemical remission (faecal calprotectin <250µg/g). Objective markers of disease activity, including glucocorticosteroid prescription or flare of disease activity, escalation of therapy, hospitalisation or intestinal resection, were reviewed ≥2years of follow-up. We performed multivariate Cox regression, controlling for patient characteristics and follow-up duration, to examine cumulative effect of psychological co-morbidities on subsequent IBD behaviour. Among 218 participants, 48 (22.0%) had one, 13 (6.0%) two and nine (4.1%) three psychological co-morbidities at baseline. Following multivariate Cox regression analysis, glucocorticosteroid prescription or flare, and escalation of medical therapy were significantly higher among those with two (hazard ratio [HR]=3.18; 95% confidence interval [CI] 1.44-7.02, and HR=2.48; 95% CI 1.03-5.93, respectively) or three (HR=3.53; 95% CI 1.26-9.92, and HR=8.19; 95% CI 2.88-23.23, respectively) psychological co-morbidities. Occurrence of at least one endpoint of interest was significantly higher with increasing psychological co-morbidity (HR=1.74; 95% CI 1.07-2.82 for one, HR=2.47; 95% CI 1.12-5.46 for two and HR=4.93; 95% CI 1.84-13.17 for three psychological co-morbidities). Individuals with IBD in biochemical remission experienced a worse disease course with increasing psychological co-morbidity at baseline.

Patient characteristics of suspected mast‐cell activation syndrome with sinonasal obstruction: a single institution experience

Mast-cell activation syndrome (MCAS) is increasingly recognized. Sinonasal obstruction is common among these patients. There is a paucity of literature describing the characteristics of MCAS and treatment outcomes. Retrospective review of 192 patients with nasal congestion July 2017 to May 2019 among 3 providers (1 allergist, 2 rhinologists) was conducted. Suspected MCAS criteria were as follows: (1) at least 2 recurrent severe symptoms in addition to nasal congestion: flushing, pruritus, urticaria, angioedema, wheezing, throat swelling, headache, hypotension, diarrhea; (2) clinical response to medications that target mast cell mediators. Quality of life (QOL) outcomes were quantified using the 22-item Sino-Nasal Outcome Test (SNOT-22). Thirty-two patients with nasal congestion were suspected of MCAS. The median age was 47 years; 24 of 32 were female; 13 of 32 had prior history of sinonasal surgery and 11 of 32 allergen immunotherapy. Out of 32, 19 had history of asthma, 10 drug allergy, 11 food allergy, and 10 anaphylaxis. The median number of medications targeting mast cell activation was 4 (range, 2-7). Eleven patients were offered surgery by a rhinologist after adequate medical management. Three of 32 patients showed elevation of serum tryptase. Fourteen completed pretreatment and posttreatment SNOT-22 (4/14 surgery, 10/14 medical management). Pretreatment score was 59.8 ± 6.2 (mean ± standard error [SEM]) and posttreatment score was 42.8 ± 6.7; the difference was statistically and clinically significant (p = 0.0015). Both groups showed a mean 17-point reduction. A multidisciplinary approach to the treatment of sinonasal symptoms using both escalation of medical therapy and surgical approaches may improve QOL of patients with suspected MCAS. Consensus criteria for MCAS, which includes elevation in tryptase over baseline during an episode, may exclude the full spectrum of individuals with MCAS from potentially beneficial treatment.

P456 Longer-term outcomes in acute severe colitis

Abstract Background Acute severe ulcerative colitis (ASUC) is a medical emergency. Rescue medical therapy is increasingly used in steroid-refractory patients but has historically been considered to delay rather than prevent colectomy. We have previously described short-term outcomes from our unit of cases of ASUC, as defined by Truelove and Witt’s criteria, over a 1 year period (July 2016 to June 2017). Data on longer-term outcomes is now available. Methods Electronic patient records (EPRs) of cases included in the original study were reviewed. Outcomes including readmission rates, need for colectomy, steroid use, medical escalation and rates of biochemical remission (as defined by faecal Calprotectin (FC) &amp;lt;250μg/l) were recorded. Results In total, 58 cases (51 patients) were included in original cohort. 19 failed initial medical therapy with steroids with 10 successfully treated using rescue medical therapy thus avoiding colectomy. Only 1/10 required subsequent colectomy during our median follow-up period of 32 months. 29/51 (56.9%) patients settled with steroids alone. 3 died of unrelated causes so were excluded from further analysis. Further oral steroids were prescribed in 53.8% (14/26). 6 patients were already receiving an immunomodulator (azathioprine or mercaptopurine) prior to initial presentation. 75% of the remainder (15/20) were discharged on aminosalicylates as their only maintenance therapy but the majority (60%, 9/15) subsequently required medical escalation with only 30% (6/20) continuing aminosalicylate monotherapy. 1 colectomy also occurred in this group. 17 readmissions occurred in 12 patients with the majority (52.9%, 9/17) within 1 year. At the end of follow-up two out of three patients (66.7%, 12/18) were considered to be in biochemical remission (FC &amp;lt;250 μg/l). Conclusion Rescue medical therapy for ASUC provides sustained benefit with the vast majority avoiding delayed colectomy. Patients admitted with ASUC have significant readmission rates, particularly within 1 year with frequent need for further steroids and/or escalation of medical therapy. Long-term remission rates are high but aminosalicylate monotherapy is rarely adequate to achieve this. All patients with an adequate response to treatment for ASUC should be considered for initiation of immunomodulator and/or biologic Rx prior to discharge. ASUC patients should be considered for more intensive follow-up and early, aggressive medical escalation. An enhanced inpatient liaison service and early review clinic is planned to support this.

P417 Do ACE inhibitors and angiotensin II receptor blockers improve disease outcomes in inflammatory bowel disease?

Abstract Background The renin-angiotensin system (RAS) has an established role in the pathogenesis of fibrosis and inflammation in renal and cardiovascular disease. High concentrations of angiotensin-converting enzyme (ACE) and renin are found in the small and large bowel. This is elevated further within inflamed colonic tissue of inflammatory bowel disease (IBD) patients, compared with controls. (1) ACE inhibitor (ACEi) or angiotensin II receptor blocker (ARB) therapy may inhibit the effects of RAS in IBD. We aimed to examine the relationship between ACEi/ARB use and longitudinal disease activity outcomes in patients with IBD. Methods In a well-characterised cohort of IBD patients, followed up for a minimum of 2 years, baseline demographics and longitudinal disease activity were compared between patients using ACEi/ARB and those not. We reviewed case notes for flare or glucocorticosteroid use, escalation of medical therapy, hospitalisation, and intestinal resection. In univariate analyses, the χ² test was used to compare categorical variables and independent samples t-test for continuous data. A P value of &amp;lt;0.05 was considered statistically significant. Multivariate Cox regression analyses were expressed as hazard ratios (HR) with 95% confidence intervals (CI). Results In total, 764 patients with IBD (UC = 321, CD = 443) were included. There was no significant difference in baseline demographics (sex, ethnicity, and smoking) between those with ACEi/ARB use or non-use. Mean age was higher in those taking ACEi/ARBs (60 ± 13 vs. 41 ± 16). Univariate analyses showed a trend towards improved outcomes in those using ACEi/ARB, which was significant for intestinal resection (Table 1). Following multivariate Cox regression analysis, a continued trend of improved outcomes with ACEi/ARB use was observed (Graphs 2 and 3). Conclusion These data show a trend towards improved longitudinal disease activity outcomes in IBD patients using ACEi/ARBs. The study may be underpowered to detect a significant difference in these comparisons. Future studies performed in larger cohorts, with longer follow-up may yield significant results. Reference

Safety of Recombinant Zoster Vaccine in Patients with Inflammatory Bowel Disease.

Patients with inflammatory bowel disease (IBD) are at increased risk of developing herpes zoster. In October 2017, the FDA approved a two-dose adjuvanted, recombinant herpes zoster vaccine (RZV). There is a theoretical concern that vaccine adjuvants may cause flares in patients with immune-mediated diseases. We aimed to assess the rates of IBD flare and adverse reactions after administration of RZV in a cohort of patients with IBD. We conducted a prospective observational study of patients with IBD who received RZV between February 2018 and July 2019 at a tertiary IBD referral center. IBD activity scores were collected from patients during office visit or phone call after vaccination. The primary outcome was rate of IBD flare, defined as an increase in IBD activity, resulting in escalation of medical therapy, following vaccination. The secondary outcomes were rates of local and systemic adverse reactions after vaccination. We identified 67 patients (28 with ulcerative colitis and 39 with Crohn's disease) who received at least one dose of RZV. The two-dose vaccine series was completed by 55 patients (82%). Median duration of follow-up after vaccination was 207days. One case of IBD flare was identified. No cases of herpes zoster were identified. Local and systemic adverse reactions were reported in 74.6% and 56.7% of patients, respectively. In this cohort of 67 patients, a low rate of IBD flare (1.5%) was observed after RZV administration. Rates of local and systemic adverse reactions were comparable to those seen in the RZV clinical trials.

719 Utilization Analysis of a Treat to Target Approach for Inflammatory Bowel Disease: A Multi-Center Health Care System Review

INTRODUCTION: A treat-to-target (TT) strategy, setting mucosal healing (MH) in inflammatory bowel diseases (IBD) as the desired treatment endpoint, is currently favored by experts. Advocates of this approach recommend the intensification of medical therapy to reach the goal of MH, even in patients who are in steroid free clinical remission. The utilization and practice of the TT strategy is unknown. METHODS: A retrospective chart review was performed for all IBD patients in the Northwell Health system to identify those in clinical remission who underwent colonoscopy between 01/01/2016 and 12/31/2018. Clinical remission at the time of colonoscopy was defined by a stable, steroid free IBD drug regimen and no IBD related surgery or hospitalization for 6 months prior. Patients in clinical remission but without MH reported on colonoscopy were defined as TT candidates. Demographic and treatment data were extracted from the medical record. We examined the frequency and type of TT utilization, defined as escalation of medical therapy within 1 month of the index colonoscopy. Analysis of variables associated with TT utilization was performed using the chi-square test. RESULTS: 960 patients had a colonoscopy by 34 different gastroenterologists during the study period. 382 patients met criteria for clinical remission, 248 of whom had gross disease activity classifying them as TT candidates, Table 1. None of the 134 patients with MH had a change in their medication regimen within 1 month of colonoscopy. Among TT candidates 42 (16.93%) had utilization of TT during the 1 month follow-up. Patients utilizing TT were more likely to have no baseline medication use, 39.5% vs. 20.87 (P = 0.0102). There was decreased utilization of TT among those patients already using immunologic and/or biologic therapies, 21.42% vs. 38.88% (P = 0.03), Table 2. Patients utilizing vs. not utilizing TT where similar by age, gender, IBD type, and CD surgical history. For patients utilizing TT, strategies included initiation or modification of biologic therapy more commonly among CD vs. UC/indeterminate colitis patients, 64.29% vs. 10.71% (P = 0.0005). TT utilizing 5-ASA was more common for UC/indeterminate colitis vs. CD, 82.14% vs. 35.71% (P = 0.003), Table 3. CONCLUSION: We have demonstrated a low rate of TT utilization in our study population. When used, a TT strategy favoring biologic therapy was more common in CD. Further validation of TT, along with physician and patient education, will likely be needed if TT is to become widely adopted.

Electrocardiographic characteristics, antiarrhythmic utilization, and outcomes in patients with left ventricular assist devices

Background&#x0D; Left ventricular assist devices (LVAD) are an increasingly used therapy for patients with advanced heart failure. Arrhythmias are common complications following LVAD implantation requiring admission, initiation, and escalation of medical therapy. Despite their frequent use in the treatment of arrhythmias, little has been reported regarding electrocardiographic changes, antiarrhythmic utilization, and outcomes post-LVAD.&#x0D; Methods&#x0D; A total of 309 patients who received a LVAD underwent retrospective chart review pre- and post-LVAD. Kaplan-Meier curves were calculated and compared using the log-rank test. Cox regression model was used for univariate analysis and those with a p&#x0D; Results&#x0D; There was a significant reduction in both the QRS interval (p=0.0001) and QTc interval (p=0.0074) following LVAD implantation. Ventricular tachycardia is common following LVAD implant at 31.1%. Amiodarone use was frequent prior to LVAD (52.1%) and on discharge (68.6%). Amiodarone use (p=0.019, HR 1.7, 95% CI 1.1-2.6), age at implant (p&#x0D; Conclusion&#x0D; Amiodarone is a commonly used antiarrhythmic in advanced heart failure and its use prior to LVAD implantation may increase the risk of long-term mortality. Amiodarone's efficacy needs to be weighed against its long-term side effects and implant on clinical outcomes

Longitudinal impact of IBS-type symptoms on disease activity, healthcare utilization, psychological health, and quality of life in inflammatory bowel disease.

The impact of irritable bowel syndrome (IBS)-type symptoms on the natural history of inflammatory bowel disease (IBD) is uncertain. We aimed to address this in a longitudinal study of secondary care patients. Longitudinal disease activity was defined by disease flare, escalation of medical therapy, hospitalization, or intestinal resection. The number of investigations performed and clinics attended determined healthcare utilization. Psychological well-being and quality of life were assessed using validated questionnaires. These outcomes were compared over a minimum period of 2 years between patients reporting IBS-type symptoms and patients with quiescent disease, occult inflammation, and active disease at baseline. In 360 IBD patients, there were no differences in longitudinal disease activity between patients with IBS-type symptoms and patients with quiescent disease or occult inflammation. Disease flare and escalation of medical therapy was more common in patients with active disease than in patients with IBS-type symptoms (hazard ratio (HR) = 3.16; 95% confidence interval (CI) 1.93-5.19 and HR = 3.24; 95% CI 1.98-5.31, respectively). A greater number of investigations were performed in patients with IBS-type symptoms than quiescent disease (P = 0.008), but not compared with patients with occult inflammation or active disease. Anxiety, depression, and somatization scores at follow up were higher, and quality-of-life scores lower, in patients with IBS-type symptoms when compared with patients with quiescent disease, but were similar to patients with active disease. IBS-type symptoms in IBD were associated with increased healthcare utilization, psychological comorbidity, reduced quality of life, but not adverse disease activity outcomes during extended follow-up.

Factors affecting clinical decision-making in inflammatory bowel disease and the role of point-of-care calprotectin.

Objectives:Patient-reported symptoms correlate poorly with mucosal inflammation. Clinical decision-making may, therefore, not be based on objective evidence of disease activity. We conducted a study to determine factors associated with clinical decision-making in a secondary care inflammatory bowel disease (IBD) population, using a cross-sectional design.Methods:Decisions to request investigations or escalate medical therapy were recorded from outpatient clinic encounters in a cohort of 276 patients with ulcerative colitis (UC) or Crohn’s disease (CD). Disease activity was assessed using clinical indices, self-reported flare or faecal calprotectin ≥ 250 µg/g. Demographic, disease-related and psychological factors were assessed using validated questionnaires. Logistic regression was performed to determine the association between clinical decision-making and symptoms, mucosal inflammation and psychological comorbidity.Results:Self-reported flare was associated with requesting investigations in CD [odds ratio (OR) 5.57; 95% confidence interval (CI) 1.84–17.0] and UC (OR 10.8; 95% CI 1.8–64.3), but mucosal inflammation was not (OR 1.62; 95% CI 0.49–5.39; and OR 0.21; 95% CI 0.21–1.05, respectively). Self-reported flare (OR 7.96; 95% CI 1.84–34.4), but not mucosal inflammation (OR 1.67; 95% CI 0.46–6.13) in CD, and clinical disease activity (OR 10.36; 95% CI 2.47–43.5) and mucosal inflammation (OR 4.26; 95% CI 1.28–14.2) in UC were associated with escalation of medical therapy. Almost 60% of patients referred for investigation had no evidence of mucosal inflammation.Conclusions:Apart from escalation of medical therapy in UC, clinical decision-making was not associated with mucosal inflammation in IBD. The use of point-of-care calprotectin testing may aid clinical decision-making, improve resource allocation and reduce costs in IBD.

32 Does faecal calprotectin measurement have an impact on patient management

Background Faecal calprotectin (FC) is recommended to support the differential diagnosis of IBD or IBS in adults with recent onset lower gastrointestinal symptoms. FC can assess IBD activity in those with known disease, as a rising level is an early marker of potential relapse. There is presently no formal funding for FC within Northern Ireland. Aim To assess if FC measurement directs an immediate modification in patient management within two out-patient groups: 1) new patients with differential diagnosis of IBS or IBD; 2) review patients with known IBD. Method A random selection of FC results from secondary care patients over 12 months were analysed. Patient outcomes following the FC result stratified patients into one of four groups: Discharged, colonoscopy performed, clinic review or escalation of medical therapy. Results Group 1 (n=28): 8 positive FC, all proceeding to endoscopy. In the 14 negative FC, 12 patients were discharged, 2 had clinic review. For indeterminate result: one patient with 2 indeterminate results underwent colonoscopy; 4 had clinic review; 1 was discharged. Group 2 (n=28): of the 20 positive results, 11/20 (55%) had medical management escalated, 5/20 (25%) underwent colonoscopy and 20% had clinic review. In the negative and indeterminate results: 7/8 had clinic review. Conclusions For patients with suspected IBS, a negative FC avoided unnecessary colonoscopy. In patients with known IBD, a raised FC led to an escalation in therapy in the majority of patients to minimise the risk of relapse and potential hospital admission. This study supports the need for a Northern Ireland FC service.

Development and validation of a risk model for in-hospital worsening heart failure from the Acute Decompensated Heart Failure National Registry (ADHERE)

A subset of patients hospitalized with acute heart failure experiences in-hospital worsening heart failure, defined as persistent or worsening signs or symptoms requiring an escalation of therapy. We analyzed data from the Acute Decompensated Heart Failure National Registry (ADHERE) linked to Medicare claims to develop and validate a risk model for in-hospital worsening heart failure. Our definition of in-hospital worsening heart failure included events such as escalation of medical therapy (eg, inotropic medications) >12hours after admission. We considered candidate risk prediction variables routinely assessed at admission, including age, medical history, biomarkers, and renal function. We used logistic regression with robust standard errors to generate a risk model in a 66% random derivation sample; we validated the model in the remaining 34%. We evaluated the calibration and discrimination of the model in both samples. We evaluated 23,696 patients hospitalized with acute heart failure. Baseline characteristics were well matched in the derivation and validation samples, and the occurrence of in-hospital worsening heart failure was similar in both samples (15.4% and 15.6%, respectively). In the multivariable model, the strongest predictors of in-hospital worsening heart failure were increased troponin and creatinine. The model was well calibrated and had good discrimination in the derivation sample (c statistic, 0.74) and validation sample (c statistic, 0.72). The ADHERE worsening heart failure risk model is a clinical tool with good discrimination for use in patients hospitalized with acute heart failure to identify those at increased risk for in-hospital worsening heart failure. This tool may be useful to target treatment strategies for patients at high risk for in-hospital worsening heart failure.

Endoscopic Dilatation of Crohn's Anastomotic Strictures is Effective in the Long Term, and Escalation of Medical Therapy Improves Outcomes in the Biologic Era.

To investigate the long-term efficacy of endoscopic dilatation of Crohn's anastomotic strictures and to identify risk and protective factors associated with the need for repeat dilatation or surgery. A total of 54 patients who had endoscopic balloon dilatations for anastomotic Crohn's strictures between 2004 and 2009, with follow-up until June 2014, were identified from a single tertiary center. The primary end points were repeat dilatation or surgical resection, and the impact of radiology, medical therapy, and endoscopic data on these outcomes was analysed with Cox proportional hazards analysis. A total of 151 dilatations were performed on patients with a median age of 52 years [interquartile range (IQR), 46-62 years]. The median duration from the first to the second dilatation was 6 years (IQR, 5-7 years). The median disease duration was 28 years (IQR, 19-32 years). At endoscopy, disease activity was reported in 50/54 (92%) cases, with a median Rutgeerts grading of i2 (range, i0-i4). A median of two (IQR 1-9) dilatations was required, with a time to repeat dilatation of 23 months (IQR 7.2-56.9). Escalation of medical therapy was adopted in 22/54 patients (41% of the study population). On multivariate analysis, only combination therapy (anti-TNFα and immunomodulator) was significantly associated with the (decreased) need for repeated dilatation [hazard ratio (HR) 0.23; 95% CI, 0.07-0.67; p = 0.01]. Anastomotic resections were performed in 10 (18%) patients, with a Rutgeerts score of i4 at initial endoscopic balloon dilatation being associated with this outcome (HR 4.55; 95% CI 1.08-19.29; p = 0.04) on multivariate analysis. Endoscopic balloon dilatation of Crohn's anastomotic strictures is safe and effective in the long term. We demonstrate that active disease predicts for future surgery, while escalation of medical therapy may decrease the need for repeat dilatation.

OP025. Escalation of medical therapy decreases need for repeat dilatation in Crohn’s anastomatic strictures

OP025. Escalation of medical therapy decreases need for repeat dilatation in Crohn’s anastomatic strictures