I am a gastroenterologist who strives to provide high-quality and exceptional medical care to every patient, every day. My patients always come first, so I focus on listening to them at every clinic visit. This enables me to provide care that respects their wishes and yields the best outcomes. My clinical practice involves seeing patients with general gastroenterological conditions. In addition, I care for patients with celiac disease, hereditary colon cancer and polyposis syndromes.
Clinical Assistant Professor, Medicine - Gastroenterology & Hepatology
Clinical Assistant Professor, Stanford Healthcare (2016 - Present)
Honors & Awards
Best Original Research Project, Internal Medicine Residency Program Boston University Medical Center (6/2013)
Boards, Advisory Committees, Professional Organizations
Chair, American College of Gastroenterology, Diversity, Equity and Inclusion - ACG Ed Universe Health Equity Subcommittee (2020 - Present)
Member, American College of Gastroenterology, Diversity, Equity and Inclusion Committee (2015 - Present)
Member, American College of Gastroenterology (2013 - Present)
Member, American Society for Gastrointestinal Endoscopy (2013 - Present)
Member, American Gastroenterological Association (2013 - Present)
Board Certification: American Board of Internal Medicine, Gastroenterology (2016)
Board Certification: American Board of Internal Medicine, Internal Medicine (2013)
Residency: BOSTON MEDICAL CENTER (2013) MA
Medical Education: College of Medicine University of Ibadan (2005) Nigeria
Fellowship, Mayo Clinic, Rochester, MN, Gastroenterology (2016)
Board Certification, American Board of Internal Medicine, Internal Medicine (2013)
Residency, Boston University, Boston, MA, Internal Medicine (2013)
C.P.H., National Board of Public Health Examiners, Public Health (2008)
M.P.H., Harvard University, Boston, MA, Health Policy and Management (2008)
M.D., University of Ibadan, Medicine (2005)
Current Research and Scholarly Interests
I am a health services researcher who studies variations in access to health care resources, including under- and overutilization of available resources to see how these inequalities impact outcomes. I utilize large database methodologies to identify novel disparities with the goal of finding solutions that will improve health equity for all.
The Impact of Night-time Emergency Department Presentation on Upper Gastrointestinal Hemorrhage Outcomes.
Journal of clinical gastroenterology
The aim was to investigate the impact of night-time emergency department (ED) presentation on outcomes of patients admitted for acute upper gastrointestinal hemorrhage (UGIH).The relationship between time of ED presentation and outcomes of gastrointestinal hemorrhage is unclear.Using the 2016 and 2017 Florida State Inpatient Databases which provide times of ED arrival, we identified and categorized adults hospitalized for UGIH to daytime (07:00 to 18:59 h) and night-time (19:00 to 06:59 h) based on the time of ED presentation. We matched both groups with propensity scores, and assessed their clinical outcomes including all-cause in-hospital mortality, in-hospital endoscopy utilization, length of stay (LOS), total hospitalization costs, and 30-day all-cause readmission rates.Of the identified 38,114 patients with UGIH, 89.4% (n=34,068) had acute nonvariceal hemorrhage (ANVH), while 10.6% (n=4046) had acute variceal hemorrhage (AVH). Compared with daytime patients, ANVH patients admitted at night-time had higher odds of in-hospital mortality (odds ratio: 1.32; 95% confidence interval: 1.06-1.60), lower odds of in-patient endoscopy (odds ratio: 0.83; 95% confidence interval: 0.77-0.90), higher total hospital costs ($9911 vs. $9545, P<0.016), but similar LOS and readmission rates. Night-time AVH patients had a shorter LOS (5.4 vs. 5.8 d, P=0.045) but similar mortality rates, endoscopic utilization, total hospitalization costs, and readmission rates as daytime patients.Patients arriving in the ED at night-time with ANVH had worse outcomes (mortality, hospitalization costs, and endoscopy utilization) compared with daytime patients. However, those with AVH had comparable outcomes irrespective of ED arrival time.
View details for DOI 10.1097/MCG.0000000000001596
View details for PubMedID 34319947
The fragility of randomized placebo-controlled trials for irritable bowel syndrome.
Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society
2021; 33 (8): e14166
The fragility index (FI) represents the number of participants whose status in a trial would have to change from a non-event (not experiencing the primary endpoint) to an event (experiencing the primary endpoint) in order to turn a statistically significant result into a non-significant result. We sought to evaluate the fragility indices of irritable bowel syndrome [IBS-mixed (IBS-M), IBS-constipation (IBS-C), & IBS-diarrhea (IBS-D)] trials.Irritable bowel syndrome trials published in high-impact journals were identified from Medline. Trials had to be in adults, randomized, parallel-armed, with at least one statistically significant binary outcome, and an achieved primary endpoint of therapeutic efficacy. FI and correlation coefficients were calculated, and regression modeling used to identify predictors of a high FI.Twelve trials were analyzed with a median FI of 6 (range: 0-38). Median sample size in all trials was 366 (range: 44-856). Trial publication year (p = 0.71), journal impact factor (p = 0.52), duration of study (p = 0.12), and number need to treat [NNT] (p = 0.29) were not predictive of a high FI. While a lower p-value correlated with a higher FI (p = 0.039), no correlation was noted between FI and impact factor (R = -0.20, p = 0.52), trial publication year (R = 0.12, p = 0.71), duration of trial (R = -0.46, p = 0.13), NNT (R = -0.34, p = 0.29), and sample size (R = 0.23, p = 0.5). The highest FI was in a Ramosetron trial (FI = 30) for IBS-D.A median of six participants is needed to nullify results in the included IBS trials suggesting how easily statistical significance based on a threshold p-value may be overturned.
View details for DOI 10.1111/nmo.14166
View details for PubMedID 34399023
Outcomes Following Inter-Hospital Transfer in Patients Admitted With Inflammatory Bowel Disease in the United States
LIPPINCOTT WILLIAMS & WILKINS. 2020: S368–S369
View details for Web of Science ID 000607196702035
Time Trends and Outcomes of Inter-Hospital Transfer in Patients With Upper Gastrointestinal Bleeding: A Nationwide Analysis
LIPPINCOTT WILLIAMS & WILKINS. 2020: S311–S312
View details for Web of Science ID 000607196701275
Marijuana, Ondansetron, and Promethazine Are Perceived as Most Effective Treatments for Gastrointestinal Nausea.
Digestive diseases and sciences
BACKGROUND: Many anti-nausea treatments are available for chronic gastrointestinal syndromes, but data on efficacy and comparative effectiveness are sparse.AIMS: To conduct a sectional survey study of patients with chronic nausea to assess comparative effectiveness of commonly used anti-nausea treatments.METHODS: Outpatients at a single center presenting for gastroenterology evaluation were asked to rate anti-nausea efficacy on a scale of 0 (no efficacy) to 5 (very effective) of 29 commonly used anti-nausea treatments and provide other information about their symptoms. Additional information was collected from the patients' chart. The primary outcome was to determine which treatments were better or worse than average using a t test. The secondary outcome was to assess differential response by individual patient characteristics using multiple linear regression.RESULTS: One hundred and fifty-three patients completed the survey. The mean efficacy score of all anti-nausea treatments evaluated was 1.73. After adjustment, three treatments had scores statically higher than the mean, including marijuana (2.75, p<0.0001), ondansetron (2.64, p<0.0001), and promethazine (2.46, p<0.0001). Several treatments, including many neuromodulators, complementary and alternative treatments, erythromycin, and diphenhydramine had scores statistically below average. Patients with more severe nausea responded better to marijuana (p=0.036) and diphenhydramine (p<0.001) and less so to metoclopramide (p=0.020). There was otherwise no significant differential response by age, gender, nausea localization, underlying gastrointestinal cause of nausea, and GCSI.CONCLUSIONS: When treating nausea in patients with chronic gastrointestinal syndromes, clinicians may consider trying higher performing treatments first, and forgoing lower performing treatments. Further prospective research is needed, particularly with respect to highly effective treatments.
View details for DOI 10.1007/s10620-020-06195-5
View details for PubMedID 32185665
Cytomegalovirus infection is associated with worse outcomes in inflammatory bowel disease hospitalizations nationwide.
International journal of colorectal disease
BACKGROUND: Cytomegalovirus (CMV) infection may complicate ulcerative colitis (UC) or Crohn's disease (CD) hospitalizations. Studies examining this relationship are often single-center examining short time periods.AIMS: To quantify the prevalence of CMV and its impact on outcomes among UC and CD hospitalizations over time using nationwide administrative databases.METHODS: The National Inpatient Sample and Nationwide Readmissions Database were analyzed to calculate CMV prevalence per 1000 UC and CD hospitalizations between 1998 and 2014. Univariable and multivariable logistic and linear regression were used to assess CMV's association with outcomes. Separate analyses examined effects from the introduction of anti-TNF therapy in UC in 2005, CD anatomic extent, and Clostridioides difficile infection.RESULTS: Among UC, from 1998 to 2014, the prevalence of CMV infection rose from 1.4 to 6.3 per 1000 UC hospitalizations (p<0.001), although this increase was not statistically significant for the years 2006 to 2014 (p=0.07). Among CD, prevalence rose from 0.3 to 1.8 per 1000 CD hospitalizations (p<0.001) from 1998 to 2014. CMV was independently associated with increased inpatient mortality (UC: odds ratio (OR) 2.3, 95% confidence interval (CI) 1.2-4.5; CD: OR 4.6, CI 1.5-13.7), colectomy in UC (OR 2.5, CI 1.9-3.3), and higher length of stay and costs.CONCLUSION: CMV infection's prevalence among UC and CD hospitalizations is rising over time, but may have slowed after 2005 in UC. CMV is independently associated with increased inpatient mortality, length of stay, and hospital charges in UC and CD and with colectomy in UC.
View details for DOI 10.1007/s00384-020-03536-8
View details for PubMedID 32124046
- The Fragility of Randomized Placebo-Controlled Trials for Irritable Bowel Syndrome Management LIPPINCOTT WILLIAMS & WILKINS. 2019: S287
- Trends and Per-Patient Expenditures Associated With Proton Pump Inhibitor Use Among the Elderly in the United States: A 10-Year Analysis of the Medical Expenditure Panel Survey LIPPINCOTT WILLIAMS & WILKINS. 2019: S210
- Same- vs Different-Hospital Readmissions in Patients With Cirrhosis After Hospital Discharge AMERICAN JOURNAL OF GASTROENTEROLOGY 2019; 114 (3): 464–71
Same- vs Different-Hospital Readmissions in Patients With Cirrhosis After Hospital Discharge.
The American journal of gastroenterology
INTRODUCTION: There is a lack of data on the impact of readmission to the same vs a different hospital following an index hospital discharge in cirrhosis patients.METHODS: We sought to describe rates and predictors of different-hospital readmissions (DHRs) among patients with cirrhosis and also determine the impact on cirrhosis outcomes including all-cause inpatient mortality and hospital costs. Using the national readmissions database, we identified cirrhosis hospitalizations in 2013. Regression analysis was used to determine the predictors of DHRs. A time-to-event analysis was performed to assess the impact on subsequent readmissions and all-cause inpatient mortality.RESULTS: In 2013, there were 109,039 cirrhosis readmissions with 67% of these being same-hospital readmissions and 33% being DHRs (P < 0.001). Two percent of readmitted patients were treated at ≥4 different hospitals. The 30-day readmission rate was 29.1%. Predictors of DHR included Medicaid payer (adjusted odds ratio [OR] 1.07, 95% confidence interval [95% CI] 1.01-1.14), age (OR 0.98, 95% CI 0.978-0.982), elective admission (OR 1.09, 95% CI 1.01-1.17), hepatic encephalopathy (OR 1.20, 95% CI 1.16-1.25), hepatorenal syndrome (OR 1.09, 95% CI 1.03-1.16), and low socioeconomic status (OR 1.15, 95% CI 1.06-1.25). No difference was observed in 30-day readmission risk following a DHR (adjusted hazard ratio 1.044, 95% CI 0.975-1.118). In addition, there was no increased risk of inpatient death observed during a DHR within 30 days (adjusted hazard ratio 1.08, 95% CI 0.94-1.23). However, patients with DHR had significantly higher hospital costs and length of stay.CONCLUSIONS: Majority of cirrhosis readmissions are same-hospital readmissions. Different-hospital readmissions do not increase the risk of 30-day readmissions and inpatient mortality but are associated with higher hospital costs.
View details for PubMedID 30676364
- Response to Rosenblatt et al. The American journal of gastroenterology 2019
Prevalence and Outcomes of Chronic Hepatitis B and C in Hospitalized Patients With Inflammatory Bowel Disease
NATURE PUBLISHING GROUP. 2018: S1557–S1558
View details for Web of Science ID 000464611005356
Visual Processing Impairments Detected by Oculometric Assessment Provide Evidence of Obesity-Related Neurological Dysfunction
NATURE PUBLISHING GROUP. 2018: S586–S587
View details for Web of Science ID 000464611002157
Endoscopic ultrasound for rectal cancer staging: A population-based study of utilization, impact on treatment patterns, and survival.
Journal of gastroenterology and hepatology
BACKGROUND AND AIM: Optimal rectal cancer (RC) outcomes depend on accurate locoregional staging. The study sought to describe the impact of endoscopic ultrasound (EUS) on RC treatment patterns and survival.METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare database, the study identified patients with RC between 2005 and 2007. The study excluded patients with stage IV disease, those not enrolled in Medicare parts A and B, those enrolled in managed care, and those staged with pelvic magnetic resonance imaging (because of low numbers). The study then compared outcomes between patients who received EUS and computed tomography of the abdomen and pelvis (CTAP) to those staged with CTAP alone after propensity score matching.RESULTS: Between 2005 and 2007, we identified 3,408 nonmetastatic RC patients. Compared with patients staged with CTAP alone, those who received EUS and CTAP were younger (median age: 75 vs 76years, P<0.0001), more likely men (57.6% vs 48.7%, P<0.0001), with a lower Charlson comorbidity index (P<0.0001). Predictors of EUS included socioeconomic status (highest vs lowest) (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.4-2.5), care by a gastroenterologist (OR 1.713, 95% CI 1.38-2.13), and care in a teaching hospital (OR 1.68, 95% CI 1.35-2.08). Receipt of neoadjuvant chemoradiation was higher in EUS-staged patients (50.3% vs 16.0%, P<0.0001). EUS-staged patients had longer overall survival compared with those staged with CTAP alone (60 vs 57months), but this was not statistically significant (P=0.24).CONCLUSION: Endoscopic ultrasound in RC staging is associated with higher utilization of neoadjuvant chemoradiation without a significant difference in overall survival.
View details for PubMedID 29372573
Rising Incidence of Intestinal Infections in Inflammatory Bowel Disease: A Nationwide Analysis.
Inflammatory bowel diseases
Intestinal infections are common in patients with inflammatory bowel disease (IBD) and may mimic IBD flares. In this study, we estimate the changing incidence of intestinal infections among IBD hospitalizations and assess the impact of intestinal infections on key hospitalization metrics.The National Inpatient Sample (NIS) was analyzed for hospitalizations from IBD between 1998 and 2014. Intestinal infections were identified using ICD-9-CM codes, and incidence for each infection was calculated for Crohn's disease (CD) and ulcerative colitis (UC). Linear and logistic regression analyses were used to assess the effects of intestinal infections on hospitalization duration, charges, and mortality.There were 4,030,620 hospitalizations for IBD between 1998 and 2014. The annual incidence of intestinal infections rose from 26.2 to 70.6 infections per 1000 IBD hospitalizations (Ptrend < 0.01). A main driver of this rising incidence was Clostridium difficile infections, which increased from 7.8 to 32.1 per 1000 CD hospitalizations and from 23.0 to 84.7 per 1000 UC hospitalizations (Ptrend < 0.01). The incidence of other intestinal infections increased from 10.2 to 15.3 per 1000 CD hospitalizations and 16.5 to 25.3 per 1000 UC hospitalizations. Intestinal infections and particularly C. difficile infections were associated with longer hospitalizations, greater hospital charges, and greater all-cause mortality.The incidence of intestinal infections among hospitalized IBD patients has increased over the past 15 years, primarily driven by C. difficile infections. Intestinal infections are associated with length of stay, hospital charges, and all-cause mortality. More aggressive measures for prevention of C. difficile infections are needed. 10.1093/ibd/izy086_video1izy086.video15779257979001.
View details for PubMedID 29722832
Secondary analysis of large databases for hepatology research.
Journal of hepatology
2016; 64 (4): 946-956
Secondary analysis of large datasets involves the utilization of existing data that has typically been collected for other purposes to advance scientific knowledge. This is an established methodology applied in health services research with the unique advantage of efficiently identifying relationships between predictor and outcome variables but which has been underutilized for hepatology research. Our review of 1431 abstracts published in the 2013 European Association for the Study of Liver (EASL) abstract book showed that less than 0.5% of published abstracts utilized secondary analysis of large database methodologies. This review paper describes existing large datasets that can be exploited for secondary analyses in liver disease research. It also suggests potential questions that could be addressed using these data warehouses and highlights the strengths and limitations of each dataset as described by authors that have previously used them. The overall goal is to bring these datasets to the attention of readers and ultimately encourage the consideration of secondary analysis of large database methodologies for the advancement of hepatology.
View details for DOI 10.1016/j.jhep.2015.12.019
View details for PubMedID 26739689
- Inflammation of the Jejunum Caused by Myeloid Sarcoma. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 2016; 14 (8): A23–4
Socioeconomic Inequalities in the Utilization of Colorectal Stents for the Treatment of Malignant Bowel Obstruction.
Digestive diseases and sciences
2016; 61 (6): 1669–76
Colorectal stents are increasingly employed as a bridge to surgery or for palliative relief of malignant large bowel obstruction.To explore determinants of inpatient colorectal stent utilization (CRSU).An analysis of the 2012 National Inpatient Sample was performed. International Classification of Diseases, 9th revision, codes were used to identify discharges associated with CRSU and patient/hospital factors for inclusion in a logistic regression model.We identified 217,055 inpatient colonoscopies, approximating 1.1 million inpatient colonoscopies nationwide. Colorectal stents were placed in 1.4 % of all procedures. Across all racial groups, Medicare was the most common payer. Patients with commercial insurance had lower CRSU compared with Medicare patients [adjusted odds ratio (OR) 0.83, 95 % confidence interval (CI) 0.75-0.92]. No gender disparities were identified (OR 0.96, 95 % CI 0.89-1.03). In addition, no racial differences in CRSU existed between Caucasians versus African-Americans (OR 0.94, 95 % CI 0.83-1.06) and Caucasians versus Hispanics (OR 0.96, 95 % CI 0.83-1.1). Compared with patients living in less affluent neighborhoods, those residing in more affluent areas had higher CRSU (OR 1.65, 95 % CI 1.46-1.86). This displayed a linear relationship with the odds of CRSU increasing as household income increased. Less affluent patients also had the highest total charges and longest wait time to CRSU. CRSU was highest among patients treated in larger medical centers (OR 1.7, 95 % CI 1.51-1.93) and teaching hospitals (OR 3.9, 95 % CI 3.2-4.8).Individuals from less affluent neighborhoods have lower colorectal stent utilization. This disparity is independent of race and likely related to poorer access to healthcare resources.
View details for DOI 10.1007/s10620-015-4019-8
View details for PubMedID 26738737
African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients.
The American journal of gastroenterology
2016; 111 (5): 649–57
We sought to characterize the relationship between hospital inpatient racial diversity and outcomes for African-American patients including rates of major complications or mortality during hospitalization for five common gastrointestinal diagnoses.Using the 2012 National Inpatient Sample database, hospital inpatient racial diversity was defined as the percentage of African-American patients discharged from each hospital. Logistic regression was used to predict major complication rates or death, long length of stay, and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of African Americans with patient race.There were 848,395 discharges across 3,392 hospitals. The patient population was on average 27% minority (s.d.±21%) with African Americans accounting for 14% of all patients. Overall, African-American patients had higher rates of major complications or death relative to white patients (adjusted odds ratio (aOR) 1.19; 95% confidence interval (CI) 1.16-1.23). However, when treated in hospitals with higher patient racial diversity, African-American patients experienced significantly lower rates of major complications or mortality (aOR 0.80; 95% CI 0.74-0.86).African Americans have better outcomes for five common gastrointestinal diagnoses when treated in hospitals with higher inpatient racial diversity. This has major ramifications on total hospital charges.
View details for DOI 10.1038/ajg.2016.64
View details for PubMedID 27002802
Cost-effectiveness of Prophylaxis Against Pneumocystis jiroveci Pneumonia in Patients with Crohn's Disease
DIGESTIVE DISEASES AND SCIENCES
2015; 60 (12): 3743-3755
Emerging evidence suggests that Pneumocystis jiroveci pneumonia is occurring more frequently in Crohn's disease patients on immunosuppressive medications, especially corticosteroids. Considering its excess mortality and the efficacy of chemoprophylaxis in reducing P. jiroveci pneumonia in acquired immunodeficiency syndrome, there is debate without consensus on the need for chemoprophylaxis in Crohn's disease patients on corticosteroids.We sought to address this debate using insights from simulation modeling.We used a Markov microsimulation model to simulate the natural history of Crohn's disease in 1 million virtual patients receiving appropriate care and who faced P. jiroveci pneumonia risks that varied with corticosteroid use. We examined several chemoprophylaxis strategies and compared their population-level economic and clinical impact using various indices including costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios. We also performed several nested probabilistic sensitivity analyses to estimate the health and economic impact of chemoprophylaxis in patients on triple immunosuppressive therapy.At the current PJP incidence, no PJP chemoprophylaxis was the preferred strategy from a population perspective. Considered chemoprophylactic strategies led to higher average costs and fewer P. jiroveci pneumonia cases. However, they also led to lower average quality-adjusted life expectancy and were thus dominated. Nevertheless, these alternative strategies became preferred with progressively higher risks of P. jiroveci pneumonia. Our results also suggest that PJP chemoprophylaxis may be cost-effective in patients on triple immunosuppressive therapy.Our findings support a case-by-case consideration of P. jiroveci pneumonia chemoprophylaxis in Crohn's disease patients receiving corticosteroids.
View details for DOI 10.1007/s10620-015-3796-4
View details for Web of Science ID 000364563600033
View details for PubMedID 26177704
The Value of Vedolizumab as Rescue Therapy in Moderate-Severe Crohn's Disease Patients with Adalimumab Non-response in the USA
JOURNAL OF CROHNS & COLITIS
2015; 9 (8): 669-675
In May 2014, vedolizumab was approved by the Food and Drug Administration for the treatment of moderate-to-severe Crohn's disease. In clinical practice it is typically used in patients who are primary or secondary non-responders to adalimumab [Humira]. We aim to estimate the incremental benefits and costs of using vedolizumab as rescue therapy for adalimumab non-responders.A Markov model was used to simulate the clinical course of Crohn's disease in a hypothetical cohort of 10,000 patients over a 12-month period. The treatment strategies evaluated were adalimumab only [with and without dose intensification] and adalimumab and vedolizumab [with and without adalimumab dose intensification]. The base case strategy was adalimumab only with 25% of non-responders undergoing dose intensification. Our primary outcomes were changes in costs and quality of life measures over the analytical horizon.In a 1-year period, initiating vedolizumab as rescue therapy in adalimumab non-responders reduces the average total cost per patient by 10%, and increases the average amount of time spent in remission or mild disease by up to 2 months.Treating on-label adalimumab non-responders with vedolizumab can, in the short term, significantly improves the quality of life of Crohn's disease patients that do not respond to adalimumab.
View details for DOI 10.1093/ecco-jcc/jjv090
View details for Web of Science ID 000359316900011
View details for PubMedID 25987351
Effect of vagotomy during Roux-en-Y gastric bypass surgery on weight loss outcomes
OBESITY RESEARCH & CLINICAL PRACTICE
2015; 9 (3): 274-280
During Roux-en-Y gastric bypasses (RYGB), some surgeons elect to perform a vagotomy to reduce symptoms of gastro-oesophageal reflux (GER). Routine vagotomy during RYGB may independently affect weight loss and metabolic outcomes following bariatric surgery. We aimed to determine whether vagotomy augments percent excess weight loss in obese patients after RYGB.We examined the effect of vagotomy in 1278 patients undergoing RYGB at our institution from 2003 to 2009. Weight and percent excess weight loss (%EWL) were modelled at three months and annually up to five years using a longitudinal linear mixed model controlling for differences in age, gender, initial body mass index (BMI), ideal body weight, and presence of vagotomy.Vagotomy was performed on 40.3% of our cohort. Vagotomy patients had significantly lower initial BMI (46.4±6.2 vs. 48.3±7.7kg/m(2), p<0.001), but there were no other significant differences at baseline. The strongest predictor of %EWL over time was initial BMI, with lower BMI patients exhibiting greater %EWL (p<0.001). Age and gender effects were also significant, with younger patients (p<0.04) and males (p<0.002) attaining greater %EWL. Vagotomy had no effect on %EWL in either simple or multiple regression models.Our series suggest that vagotomy does not augment %EWL when performed with RYGB.
View details for DOI 10.1016/j.orcp.2014.09.005
View details for Web of Science ID 000356059400010
View details for PubMedID 25458372
Determinants of Palliative Care Utilization Among Patients Hospitalized With Metastatic Gastrointestinal Malignancies.
The American journal of hospice & palliative care
Gastrointestinal tract cancers account for a significant proportion of the national cancer burden.We sought to explore patient- and hospital-level determinants of palliative care utilization among patients hospitalized with metastatic gastrointestinal tract cancers using a national database.An analysis of the 2012 National Inpatient Sample was performed. International Classification of Diseases, Ninth Revision codes were used to identify hospital discharges associated with metastatic digestive tract cancers and patient/hospital covariates for inclusion in a logistic regression model. Total charges and length of stay were analyzed in a linear regression model.Compared to males, females were more likely to receive inpatient palliative care (adjusted odds ratio [OR] 1.12, P = .002). No difference was seen between white and Asian patients (adjusted OR 1.2, P = .11) or Native Americans patients (adjusted OR 1.4, P = .22). However, relative to white patients, African Americans (adjusted OR 1.13, P = .02) and Hispanics (adjusted OR 1.25, P = .001) had significantly higher odds of inpatient palliative care. Medicare patients were least likely to receive palliative care compared to those with Medicaid or commercial payers. Length of stay during these hospitalizations was longer in African Americans (P = .0001), Asians (P = .0001), and Native Americans (P = .03) compared to white patients. No difference was seen when total charges were compared between white and African American patients (P = .08). Conversely, total charges were higher in Hispanics (P = .005) and Asians (P = .001) relative to white patients.Gender and racial differences exist in utilization of inpatient palliative care among patients hospitalized with metastatic gastrointestinal tract cancers.
View details for DOI 10.1177/1049909115624373
View details for PubMedID 26718956
Cost-effectiveness of Nonmelanoma Skin Cancer Screening in Crohn's Disease Patients
INFLAMMATORY BOWEL DISEASES
2013; 19 (13): 2787-2795
Several studies have demonstrated an increased risk of nonmelanoma skin cancer (NMSC) in patients with inflammatory bowel disease, with the greatest risk in patients with Crohn's disease (CD). We investigated the cost-effectiveness of NMSC screening in patients with CD.A mathematical model was used to compare lifetime costs, life expectancies, and benefits of NMSC screening in a hypothetical cohort of 100,000 patients with CD. Strategies studied include: (1) Treat NMSC cases as they present and follow affected patients annually; (2) Screen patients with CD annually once they turn 50 years old, treat NMSC cases as they present and follow affected patients annually; (3) Screen patients with CD annually once they start receiving thiopurines, treat NMSC cases as they present and follow affected patients annually; (4) Screen patients with CD annually when they turn 50 years old or start receiving thiopurines, treat NMSC cases as they present, and follow affected patients annually; (5) Screen all patients with CD annually. These strategies were then studied on a biennial basis, accounting for 10 competing strategies.Screening all patients with CD annually proved the most cost-effective strategy with an average lifetime cost of more than $333,000, a quality-adjusted life expectancy of about 26 QALYs (95% confidence interval: 22-29), ICER of $3263/QALY, and led to early detection of about 94% of incident NMSC cases. The next best strategy was screening all CD patients biennially with an average lifetime cost of more than $328,000 with 24.5 QALYs (95% confidence interval: 21-25). Only 47% of new NMSC cases were detected early with this strategy.At a willingness-to-pay threshold of $50,000, screening all patients with CD annually for NMSC proved the most cost-effective strategy.
View details for DOI 10.1097/01.MIB.0000435850.17263.13
View details for Web of Science ID 000329360500009
View details for PubMedID 24193153
Pneumocystis Jiroveci Pneumonia in Inflammatory Bowel Disease: When Should Prophylaxis be Considered?
INFLAMMATORY BOWEL DISEASES
2013; 19 (8): 1764-1771
The incidence of inflammatory bowel disease (IBD) has increased over the past several decades with a corresponding increase in the number of patients on combination immunosuppressive therapy including corticosteroids, anti-metabolites and biologic agents. The exact incidence of pneumocystis jiroveci pneumonia (PJP) in IBD patients is unknown but there has been an increase in the number of reports of PJP in IBD patients on combination immunosuppressive therapy.We evaluated the published literature describing PJP infections in IBD patients, as well as other non-HIV cohorts and identified risk factors for PJP infection in this group of patients. Prophylaxis and treatment regimens were reviewed.Corticosteroid therapy, lymphopenia (total lymphocyte count < 600 cells/mm), and age greater than 55 years appear to be risk factors for developing pneumocystis jiroveci pneumonia. In addition, PJP mortality is greater in the non-HIV cohort in contrast to the HIV population. No evidence-based guidelines for primary PJP prophylaxis exist to direct practice for gastroenterology providers.Better surveillance and reporting of opportunistic infections including PJP are needed to elucidate risk factors for acquisition of infection. Gastroenterology providers should continue to evaluate the need for PJP prophylaxis on a case-by-case basis to recognize patients who may benefit from primary PJP prophylaxis. In particular, older patients on corticosteroids, multiple immunosuppressive agents, and patients with lymphopenia should be considered for prophylaxis.
View details for DOI 10.1097/MIB.0b013e318281f562
View details for Web of Science ID 000329363800024
View details for PubMedID 23615530
Increased Risk of Pneumocystis Jiroveci Pneumonia Among Patients with Inflammatory Bowel Disease
INFLAMMATORY BOWEL DISEASES
2013; 19 (5): 1018-1024
Patients with inflammatory bowel disease (IBD) may be at increased risk for pneumocystis jiroveci pneumonia (PCP). Our aims were (1) to determine the incidence and relative risk of PCP in IBD and (2) to describe medication exposures in patients with IBD with PCP.We performed a retrospective cohort study and a case series using administrative data from IMS Health Inc, LifeLink Health Plan Claims Database. In the cohort, patients with IBD were matched to 4 individuals with no IBD claims. PCP risk was evaluated by incidence rate ratio and adjusted Cox proportional hazards modeling. The demographics and medication histories of the 38 cases of PCP in patients with IBD were extracted.The cohort included 50,932 patients with Crohn's disease, 56,403 patients with ulcerative colitis, and 1269 patients with unspecified IBD; matched to 434,416 individuals without IBD. The crude incidence of PCP was higher in the IBD cohort (10.6/100,000) than in the non-IBD cohort (3.0/100,000). In the adjusted analyses, PCP risk was higher in the IBD versus non-IBD cohort (hazard ratio, 2.96; 95% confidence interval, 1.75-4.29), with the greatest risk in Crohn's disease compared with non-IBD (hazard ratio, 4.01; 95% confidence interval, 1.88-8.56). In the IBD case series of PCP cases (n = 38), the median age was 49 (interquartile range, 43-57). A total of 20 individuals (53%) were on corticosteroids alone or in combination with other immunosuppression.Although the overall incidence of PCP is low, patients with IBD are at increased risk. Patients with IBD with PCP are predominantly on corticosteroids alone or in combination before PCP diagnosis.
View details for DOI 10.1097/MIB.0b013e3182802a9b
View details for Web of Science ID 000336084200028
View details for PubMedID 23478805
Pneumocystis Jiroveci Pneumonia in Patients with Inflammatory Bowel Disease: A Survey of Prophylaxis Patterns Among Gastroenterology Providers
INFLAMMATORY BOWEL DISEASES
2013; 19 (4): 812-817
The use of combination immunosuppressive agents is associated with reports of pneumocystis jiroveci pneumonia (PJP). The aim of this study was to determine practice patterns among gastroenterology providers for PJP prophylaxis in patients with inflammatory bowel disease (IBD) on immunosuppressive therapy.An internet-based survey of 14 questions was sent through e-mail to a random sampling of 4000 gastroenterologists, nurse practitioners, and physician assistants between November 2011 and February 2012. Three reminder e-mails were sent to providers who had not completed the survey.The invitation e-mail that contained the link to the survey was clicked by 504 providers and the completed surveys were returned by 123 of them (78% physicians, 11% nurse practitioners, 11% physician assistants). The response rate was 24.4%. Seventy-nine percent of the respondents had managed >25 patients with IBD in the past year, with as much as one-third of all respondents managing >100 patients. Eight percent of the respondents reported patients who had developed PJP on immunosuppressive therapy, 11% reported initiating PJP prophylaxis, mostly for patients on triple immunosuppressive therapy. Prescription of PJP prophylaxis was not significantly associated with the number of years in practice or the number of IBD patients treated. However, providers with patients that had developed PJP were 7.4 times more likely to prescribe prophylaxis (P = 0.01). In addition, providers in academic centers were 4 times more likely to initiate PJP prophylaxis than those in nonacademic centers (P = 0.03). The most common reasons for not prescribing PJP prophylaxis included the absence of guidelines on the benefits of prophylaxis, lack of personal experience with PJP, and the lack of knowledge on the need for prophylaxis in patients with IBD on combination immunosuppressive therapy.The lack of guidelines seems to influence the decision on not to prescribe PJP prophylaxis in patients with IBD. Additional studies are needed to determine PJP risk factors and risks and benefits of prophylaxis.
View details for DOI 10.1097/MIB.0b013e31828029f4
View details for Web of Science ID 000316451600027
View details for PubMedID 23435401
- Duodenal obstruction due to erosion and migration of an adjustable gastric band: a novel endoscopic approach to management SURGERY FOR OBESITY AND RELATED DISEASES 2010; 6 (2): 206-208