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ABSTRACT: : Early life factors have been postulated to play a role in development of immune tolerance and intestinal microbiome, which in turn may influence the risk of inflammatory bowel disease.
: We conducted a prospective cohort study of 60,186 U.S. women enrolled since 1976 in the Nurses Health Study (NHS) I and 86,495 women enrolled since 1989 in the NHS II with no history of ulcerative colitis (UC) or Crohn's disease (CD). Information about breastfeeding, birth weight, and preterm birth were collected in 1992 in NHS I and 1991 in NHS II. Diagnoses of CD and UC were confirmed through review of medical records. We used Cox proportional hazards models to calculate hazard ratios and 95% confidence intervals.
: Among 146,681 women over 3,373,726 person-years of follow-up, we documented 248 cases of CD and 304 cases of UC through 2007 in NHS II and 2008 in NHS I. The median age of diagnosis was 51 for CD and 49 for UC. Compared with women who were not breastfed, women who were breastfed had multivariate-adjusted hazard ratios of 0.99 (95% confidence interval, 0.76-1.30) for CD and 1.03 (95% confidence interval, 0.81-1.32) for UC. Similarly, low or high birth weight and preterm birth were not significantly associated with risk of UC or CD.
: In 2 large prospective cohorts of U.S. women, we did not observe a significant association between early life factors including having been breastfed, birth weight, preterm birth, and risk of adult-onset UC and CD.
Inflammatory Bowel Diseases 03/2013; 19(3):542-7. · 4.86 Impact Factor
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ABSTRACT: BACKGROUND & AIMS: Depression and psychosocial stress are believed to contribute to the pathogenesis of Crohn's disease (CD) and ulcerative colitis (UC). Although many mechanisms have been proposed to link these disorders, few prospective studies have examined the relationship between depressed mood and incidence of CD or UC. METHODS: We analyzed data from 152,461 women (age 29-72 years) enrolled since 1992-1993 in the Nurses' Health Study cohorts I and II. Self-reported depressive symptoms were assessed by using the Mental Health Index (MHI)-5, a validated 5-item subscale of the 36-item Short-Form health survey, which is designed to estimate psychological distress on the basis of scores that range from 0-100. Self-reported CD and UC were confirmed through blinded record review by 2 gastroenterologists. Cox proportional hazards models were used to associate recent (within 4 years) and baseline MHI-5 scores with risk for CD or UC, adjusting for other risk factors. RESULTS: During 1,787,070 person-years of follow-up, we documented 170 cases of CD and 203 cases of UC. Compared with women with recent MHI-5 scores of 86-100, women with recent depressive symptoms (MHI-5 scores < 52) had an increased risk of CD (multivariate-adjusted hazard ratio [HR], 2.39; 95% confidence interval [CI], 1.40-3.98; P trend = .001). Baseline depressive symptoms, assessed from the baseline MHI-5 score, were also associated with CD, although with a lower HR (1.62; 95% CI, 0.94-2.77). Recent (HR, 1.14; 95% CI, 0.68-1.92) and baseline depressive symptoms were not associated with increased risk of UC (HR, 1.07; 95% CI, 0.63-1.83). CONCLUSIONS: On the basis of data from the Nurses' Health Study, depressive symptoms increase the risk for CD, but not UC, among women. Psychological factors might therefore contribute to development of CD. Further studies are needed to determine the mechanisms of this association.
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 08/2012; · 5.64 Impact Factor
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ABSTRACT: Estrogen has been proposed to modulate gut inflammation through an effect on estrogen receptors found on gastrointestinal epithelial and immune cells. The role of postmenopausal hormone therapy on risk of Crohn's disease (CD) and ulcerative colitis (UC) is unclear.
We conducted a prospective cohort study of 108,844 postmenopausal US women (median age, 54 years) enrolled in 1976 in the Nurses' Health Study without a prior history of CD or UC. Every 2 years, we have updated information on menopause status, postmenopausal hormone use, and other risk factors. Self-reported diagnoses of CD and UC were confirmed through medical record review by 2 gastroenterologists who were blinded to exposure information. We used Cox proportional hazards models to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs).
Through 2008, with more than 1.8 million person-years of follow-up, we documented 138 incident cases of CD and 138 cases of UC. Compared with women who never used hormones, the multivariate-adjusted HR for UC was 1.71 (95% CI, 1.07-2.74) among women who currently used hormones and 1.65 (95% CI, 1.03-2.66) among past users. The risk of UC appeared to increase with longer duration of hormone use (P(trend) = .04) and decreased with time since discontinuation. There was no difference in risk according to the type of hormone therapy used (estrogen vs estrogen plus progestin). In contrast, we did not observe an association between current use of hormones and risk of CD (multivariate-adjusted HR, 1.19; 95% CI, 0.78-1.82). The effect of hormones on risk of UC and CD was not modified by age, body mass index, or smoking.
In a large prospective cohort of women, postmenopausal hormone therapy was associated with an increased risk of UC but not CD. These findings indicate that pathways related to estrogens might mediate the pathogenesis of UC.
Gastroenterology 07/2012; 143(5):1199-206. · 11.68 Impact Factor
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ABSTRACT: Long-term data on the influence of cigarette smoking, especially cessation, on the risk of Crohn's disease (CD) and ulcerative colitis (UC) are limited.
We conducted a prospective study of 229,111 women in the Nurses' Health Study (NHS) and Nurses' Health Study II (NHS II). Biennially, we collected updated data on cigarette smoking, other risk factors, and diagnoses of CD or UC confirmed by medical record review.
Over 32 years in NHS and 18 years in NHS II, we documented 336 incident cases of CD and 400 incident cases of UC. Compared with never smokers, the multivariate hazard ratio (HR) of CD was 1.90 (95% confidence interval (CI), 1.42-2.53) among current smokers and 1.35 (95% CI, 1.05-1.73) among former smokers. Increasing pack-years was associated with increasing risk of CD (Ptrend< 0.0001), whereas smoking cessation was associated with an attenuation of risk. By contrast, the multivariate HR of UC was 0.86 (95% CI, 0.61-1.20) among current smokers and 1.56 (95% CI, 1.26-1.93) among former smokers. The risk of UC was significantly increased within 2-5 years of smoking cessation (HR, 3.06; 95% CI, 2.00-4.67) and remained persistently elevated over 20 years.
Current smoking is associated with an increased risk of CD, but not UC. By contrast, former smoking is associated with an increased risk of UC, with risk persisting over two decades after cessation.
The American Journal of Gastroenterology 07/2012; 107(9):1399-406. · 7.28 Impact Factor
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ABSTRACT: BACKGROUND: Oral contraceptive use has been associated with risk of Crohn's disease (CD) and ulcerative colitis (UC). OBJECTIVE: To determine whether this association is confounded or modified by other important lifestyle and reproductive factors. DESIGN: A prospective cohort study was carried out of 117 375 US women enrolled since 1976 in the Nurses Health Study I (NHS I) and 115 077 women enrolled since 1989 in the Nurses' Health Study II (NHS II) with no prior history of UC or CD. These women had provided information every 2 years, on age at menarche, oral contraceptive use, parity, menopause status and other risk factors. Diagnoses of CD and UC were confirmed by review of medical records. Cox proportional hazards models were used to calculate HRs and 95% CIs. RESULTS: Among 232 452 women with over 5 030 196 person-years of follow-up, 315 cases of CD and 392 cases of UC were recorded through 2007 in NHS II and 2008 in NHS I. Compared with never users of oral contraceptives, the multivariate-adjusted HRs for CD were 2.82 (95% CI 1.65 to 4.82) among current users and 1.39 (95% CI 1.05 to 1.85) among past users. The association between oral contraceptives and UC differed according to smoking history (p(heterogeneity)=0.04). Age at menarche, age at first birth and parity were not associated with risk of UC or CD. CONCLUSION: In two large prospective cohorts of US women, oral contraceptive use was associated with risk of CD. The association between oral contraceptive use and UC was limited to women with a history of smoking.
Gut 05/2012; · 10.11 Impact Factor
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ABSTRACT: Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) are anti-inflammatory but have been linked in some studies to Crohn disease (CD) and ulcerative colitis (UC).
To assess the association between aspirin and NSAID use and incident CD and UC.
Prospective cohort study.
Nurses' Health Study I.
76,795 U.S. women who provided biennially updated data about aspirin and NSAID use.
Incident CD and UC between 1990 and 2008 (outcome) and NSAID and aspirin use (exposure).
123 incident cases of CD and 117 cases of UC occurred over 18 years and 1,295,317 person-years of follow-up. Compared with nonusers, women who used NSAIDs at least 15 days per month seemed to have increased risk for both CD (absolute difference in age-adjusted incidence, 6 cases per 100,000 person-years [95% CI, 0 to 13]; multivariate hazard ratio, 1.59 [CI, 0.99 to 2.56]) and UC (absolute difference, 7 cases per 100,000 person-years [CI, 1 to 12]; multivariate hazard ratio, 1.87 [CI, 1.16 to 2.99]). Less frequent NSAID use was not clearly associated with risk for CD or UC, and there was no clear association between aspirin use and disease.
Cohort participants were exclusively women, most of whom were white. Aspirin and NSAID use were self-reported.
Frequent use of NSAIDs but not aspirin seemed to be associated with increased absolute incidence of CD and UC. The findings have more mechanistic than clinical implications, because the absolute incidence of CD or UC associated with NSAIDs was low and the increase in risk for CD or UC associated with NSAIDs is unlikely to alter the balance of more common and clinically significant risks and benefits associated with these agents.
American Gastroenterological Association, IBD Working Group, Broad Medical Research Program, and National Institutes of Health.
Annals of internal medicine 03/2012; 156(5):350-9. · 16.73 Impact Factor
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ABSTRACT: OBJECTIVE: Geographical variation in the incidence of Crohn's disease (CD) and ulcerative colitis (UC) according to the latitude of residence has been reported in Europe. However, there are no comparable data in the USA. The incidence of CD and UC in relation to latitude was assessed in a geographically diverse population of women enrolled in two large prospective studies in the USA. DESIGN: A prospective study was undertaken of women enrolled in the Nurses' Health Study I (NHS) in 1976 and in the NHS II in 1989. Information on state of residence at the time of birth, at age 15 years and age 30 years was collected in 1992 in NHS I and in 1993 in NHS II. Reported diagnoses of incident CD or UC to the end of 2003 were confirmed by medical record review. Cox proportional hazards models were used to calculate HRs and 95% CIs for risk of CD and UC. RESULTS: In both cohorts, among 175 912 women reporting their residence in 1992, 257 cases of CD and 313 cases of UC were documented over 3 428 376 person-years of follow-up. The incidence of CD and UC increased significantly with increasing latitude (p(trend)<0.01), with residence at age 30 years more strongly associated with risk. Compared with women residing in northern latitudes at age 30, the multivariate-adjusted HR for women residing in southern latitudes was 0.48 (95% CI 0.30 to 0.77) for CD and 0.62 (95% CI 0.42 to 0.90) for UC. The effect of latitude of residence on risk of CD and UC did not vary according to smoking history (p(interaction)=0.26 for CD and 0.99 for UC). CONCLUSION: In a population of US women, increasing latitude of residence was associated with a higher incidence of CD and UC.
Gut 01/2012; · 10.11 Impact Factor
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ABSTRACT: Vitamin D influences innate immunity, which is believed to be involved in the pathogenesis of Crohn's disease (CD) and ulcerative colitis (UC). However, data examining vitamin D status in relation to risk of CD and UC are lacking.
We conducted a prospective cohort study of 72,719 women (age, 40-73 y) enrolled in the Nurses' Health Study. In 1986, women completed an assessment of diet and lifestyle, from which a 25-hydroxy vitamin D [25(OH)D] prediction score was developed and validated against directly measured levels of plasma 25(OH)D. Through 2008, we confirmed reported diagnoses of incident CD or UC through medical record review. We used Cox proportional hazards modeling to examine the hazard ratio (HR) for incident CD or UC after adjusting for potential confounders.
During 1,492,811 person-years of follow-up evaluation, we documented 122 incident cases of CD and 123 cases of UC. The median predicted 25(OH)D level was 22.3 ng/mL in the lowest and 32.2 ng/mL in the highest quartiles. Compared with the lowest quartile, the multivariate-adjusted HR associated with the highest quartile of vitamin D was 0.54 (95% confidence interval [CI], 0.30-.99) for CD (P(trend) = .02) and 0.65 (95% CI, 0.34-1.25) for UC (P(trend) = .17). Compared with women with a predicted 25(OH)D level less than 20 ng/mL, the multivariate-adjusted HR was 0.38 (95% CI, 0.15-0.97) for CD and 0.57 (95% CI, 0.19-1.70) for UC for women with a predicted 25(OH)D level greater than 30 ng/mL. There was a significant inverse association between dietary and supplemental vitamin D and UC, and a nonsignificant reduction in CD risk.
Higher predicted plasma levels of 25(OH)D significantly reduce the risk for incident CD and nonsignificantly reduce the risk for UC in women.
Gastroenterology 12/2011; 142(3):482-9. · 11.68 Impact Factor
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ABSTRACT: Regular screening of cirrhotic patients for hepatocellular carcinoma (HCC) has been suboptimal, but there is little data regarding specific risk factors for reduced screening.
From 1996 to 2010, patients with cirrhosis were retrospectively identified from outpatient gastroenterology and primary care practices. Data was obtained from the diagnosis of cirrhosis until the time of elevated alpha-fetoprotein (AFP) or lesion suspicious for HCC, death, liver transplantation, or end of the data collection period. Recommended screening was defined as abdominal imaging (ultrasound, contrast-enhanced CT, or MRI) with or without serum alpha-fetoprotein (AFP) at least once every 12 months based on professional guidelines.
One hundred fifty-six patients with cirrhosis were identified. The etiologies of cirrhosis were viral hepatitis (n = 65), alcohol (n = 40), non-alcoholic steatohepatitis (NASH) (n = 27), and non-viral, non-alcoholic, non-NASH cirrhosis (n = 24). Of the 156 patients, 51% received recommended screening for HCC. Patients with NASH cirrhosis received recommended screening significantly less (p = 0.016) than cirrhotics with viral hepatitis, alcoholic cirrhosis, or non-viral, non-alcoholic, non-NASH cirrhosis and were less likely to receive gastroenterology referral (p < 0.001). Additionally, 20 patients were diagnosed with cirrhosis incidentally during a surgical procedure. These patients were significantly less likely to receive recommended HCC screening than those diagnosed non-surgically (10.0 vs. 56.6%; p < 0.001). Screening was significantly more likely to occur in patients seen regularly by a gastrointestinal subspecialist (66.7 vs. 22.8%; p < 0.001).
Patients with NASH cirrhosis and incidentally discovered cirrhosis have low rates of HCC screening and are referred less often to gastroenterologists. These data suggest a need for increased education about NASH cirrhosis and better systems of communication among general practitioners, surgeons, and gastroenterologists.
Digestive Diseases and Sciences 07/2011; 56(11):3316-22. · 2.12 Impact Factor
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ABSTRACT: Colonoscopy is a screening modality for the early detection of colonic polyps and cancers but is underutilized, particularly among minorities.
To identify potential barriers to screening colonoscopy among low income Latino and white non-Latino patients in an urban community health center. DESIGN, PARTICIPANTS, AND APPROACH: We conducted semistructured interviews with a convenience sample of patients 53 to 70 years old, eligible for colorectal cancer screening that spoke English or Spanish. Open-ended questions explored knowledge, beliefs, and experience with or reasons for not having screening colonoscopy. We performed content analysis of transcripts using established qualitative techniques.
Of 40 participants recruited, 57% were women, 55% Latino, 20% had private health insurance, and 40% had a prior colonoscopy. Participants described a wide range of barriers categorized into 5 major themes: (1) System barriers including scheduling, financial, transportation, and language difficulties; (2) Fear of pain or complications of colonoscopy and fear of diagnosis (cancer); (3) Lack of desire or motivation, including "laziness" and "procrastination"; (4) Dissuasion by others influencing participants' decision regarding colonoscopy; and (5) Lack of provider recommendation including not hearing about colonoscopy or not understanding the preparation instructions.
Understanding of the range of barriers to colorectal cancer screening can help develop multimodal interventions to increase colonoscopy rates for all patients including low-income Latinos. Interventions including systems improvements and navigator programs could address barriers by assisting patients with scheduling, insurance issues, and transportation and providing interpretation, education, emotional support, and motivational interviewing.
Journal of General Internal Medicine 07/2008; 23(6):834-40. · 2.83 Impact Factor
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Journal of the American College of Radiology: JACR 03/2007; 4(2):133-6.
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ABSTRACT: The adoption of electronic health records (EHRs) is now a national priority, but evidence shows that the level of typical adoption is low. We describe the goal of "high-level adoption" of an EHR system defined as a community of clinicians using an EHR system to share patient information, and create a summary of a patient's health, through the timely documentation of care, as well as through effective communication among caregivers, with a focus on patient safety and efficient use of resources. There are 10 key principles to achieving high level-adoption. These are: (1) shared medication lists; (2) shared patient problem lists; (3) established guidelines for communication about patient information among clinicians; (4) use of standard terminology; (5) preventive services; (6) integration of external data; (7) computerized provider order entry; (8) regional health information exchange; (9) adoption of clinical decision support; and (10) reuse of data for public health and research.
The Journal of medical practice management: MPM 27(1):50-6.
