Fecal Microbiome Associated with Both Colon Adenomas and Lifetime Colorectal Cancer Risk.

BACKGROUND: Increasing data indicates the gut flora including bacteria and fungi combined with environmental factors are important in the pathogenesis of colorectal cancer (CRC). Understanding differences in the microbiome in patients with colon neoplasia will foster the development of biomarkers for early detection. AIMS: Determine the association of microbiome with presence of adenomas and predicted CRC risk. METHODS: In subjects referred for colonoscopy, the NCI CRC risk assessment tool was completed and stool for microbiome analysis as well as fecal immunochemical test (FIT) were collected. We calculated the microbiome alpha diversity using the Shannon index as well as individual bacterial and fungal species. RESULTS: Among 34 patients, we identified 10 with one or more adenomas. Only 2 patients were FIT positive. The median predicted lifetime CRC risk was 2.75% and the prevalence of adenoma was higher in the fourth quartile (P < 0.001). The measured alpha diversity was somewhat higher in patients with adenomas (P = 0.07). We identified 4 bacterial species with an increased relative abundance among patients with adenomas [P < 0.5]. Lifetime CRC risk was associated with 2 specific bacterial species, P. distasonis & E. hermannii [P = 0.05 & 0.09, respectively]. No associations were seen with fungal species and adenoma prevalence or lifetime CRC risk. CONCLUSIONS: In addition to a strong correlation of predicted CRC risk and adenoma prevalence, we also found important differences in specific bacterial species and both adenoma prevalence and CRC risk. Larger trials are needed to potentially implement further data in the clinical setting.

Patient Decisions Regarding Rescheduling Colonoscopies Postponed Due to the COVID-19 Pandemic.

BACKGROUND: Due to the COVID-19 pandemic, elective colonoscopies were postponed in Ohio from 3/17/2020 to 5/1/2020. When the ban was lifted, canceled patients determined whether to reschedule their colonoscopy in the midst of the ongoing pandemic. AIMS: We aim to determine whether demographic, colorectal cancer (CRC) risk, and COVID-19 morbidity and mortality risk factors are associated with rescheduling of colonoscopies canceled by the COVID-19 pandemic. METHODS: A medical record review of 420 participants ages 40-74 at a midwestern academic health system with elective colonoscopies canceled from 3/17/2020 to 5/1/2020 due to the COVID-19 pandemic was performed. RESULTS: More than half of participants (71.0%) rescheduled their colonoscopy within the next 8 months. Indication for colonoscopy being 'surveillance following adenoma', colonoscopy ordered by primary care provider rather than gastroenterologist, and dyslipidemia were independently associated with rescheduling colonoscopy. Higher body mass index, indication for colonoscopy being simply 'screening for CRC,' and stool testing were associated with not rescheduling. Diagnoses associated with colorectal cancer risk such as adenomas, personal or family history of colorectal cancer, and inflammatory bowel disease were not associated with rescheduling, nor were other comorbidities associated with increased COVID-19 severity. 4.5% (19/420) opted for stool fecal immunochemical test or Cologuard testing. CONCLUSIONS: Most patients rescheduled their colonoscopy despite the risk of virus exposure, suggesting that concern of missed colorectal cancer diagnosis outweighed coronavirus concerns. Patient trust in referring providers may be important for rescheduling, and colonoscopy indications were independently associated with rescheduling status.

Excess cancer prevalence in men with HIV: A nationwide analysis of Medicaid data.

BACKGROUND: Cancer is one of the most common comorbidities in men living with HIV (MLWH). However, little is known about the MLWH subgroups with the highest cancer burden to which cancer prevention efforts should be targeted. Because Medicaid is the most important source of insurance for MLWH, we evaluated the excess cancer prevalence in MLWH on Medicaid relative to their non-HIV counterparts. METHODS: In this cross-sectional study using 2012 Medicaid Analytic eXtract data nationwide, we flagged the presence of HIV, 13 types of cancer, symptomatic HIV, and viral coinfections using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. The study population included individuals administratively noted to be of male sex (men), aged 18 to 64 years, with (n = 82,495) or without (n = 7,302,523) HIV. We developed log-binomial models with cancer as the outcome stratified by symptomatic status, age, and race/ethnicity. RESULTS: Cancer prevalence was higher in MLWH than in men without HIV (adjusted prevalence ratio [APR], 1.84; 95% confidence interval [CI], 1.78-1.90) and was higher among those with symptomatic HIV (APR, 2.74; 95% CI, 2.52-2.97) than among those with asymptomatic HIV (APR, 1.73; 95% CI, 1.67-1.79). The highest APRs were observed for anal cancer in younger men, both in the symptomatic and asymptomatic groups: APR, 312.97; 95% CI, 210.27-465.84, and APR, 482.26; 95% CI, 390.67-595.32, respectively. In race/ethnicity strata, the highest APRs were among Hispanic men for anal cancer (APR, 198.53; 95% CI, 144.54-272.68) and for lymphoma (APR, 9.10; 95% CI, 7.80-10.63). CONCLUSIONS: Given the Medicaid program's role in insuring MLWH, the current findings highlight the importance of the program's efforts to promote healthy behaviors and vaccination against human papillomavirus in all children and adolescents and to provide individualized cancer screening for MLWH.

Rates of Intestinal Resection and Colectomy in Inflammatory Bowel Disease Patients After Initiation of Biologics: A Cohort Study.

BACKGROUND & AIMS: 50% to 80% Crohn's disease (CD) and 10% to 30% ulcerative colitis (UC) patients require surgery over their lifetime. Biologic therapies may alter this natural history, but data on the effect of biologics on surgery rates in this patient population are mixed. We sought to investigate the influence of biologics on surgery prevalence in CD and UC. METHODS: We used a commercial database (Explorys Inc, Cleveland, OH), which includes electronic health record data from 26 major integrated US healthcare systems. We identified all patients who were diagnosed with CD or UC that were treated with any biologics between 2015 and 2020. The primary outcome was to examine the association between biologics therapy and the prevalence of bowel resection. Also, we identified the factors associated with surgery in IBD patients on biologics. RESULTS: Of 32,904,480 patients in the database, we identified 140,540 patients with CD and 115,260 patients with UC, of whom 25,840 (18%) and 9,050 (7.8%) patients received biologics, respectively. The prevalence of intestinal resection was significantly lower in biologics-treated CD patients (9.3%) compared to those who did not receive biologics (12.1%) (p < .001). Similarly, biologic-treated UC patients were significantly less likely to undergo colectomy (7.3%) compared to UC patients who did not receive biologic therapy (11.0%) (p < .001). Tobacco use, Clostridium difficile infection, and perianal disease were associated with intestinal resection in CD. Colon neoplasm and Clostridium difficile infection were associated with colectomy in UC. CONCLUSIONS: In this study of a large healthcare administrative database, inflammatory bowel disease (IBD) patients treated with biologics were significantly less likely to undergo bowel resection when compared to those who never received biologics. This data suggests that biologics may impact surgical rates in IBD.

Post-Affordable Care Act Improvements in Cancer Stage Among Ohio Medicaid Beneficiaries Resulted From an Increase in Stable Coverage.

BACKGROUND: The mechanisms underlying improvements in early-stage cancer at diagnosis following Medicaid expansion remain unknown. We hypothesized that Medicaid expansion allowed for low-income adults to enroll in Medicaid before cancer diagnosis, thus increasing the number of stably-enrolled relative to those who enroll in Medicaid only after diagnosis (emergently-enrolled). METHODS: Using data from the 2011-2017 Ohio Cancer Incidence Surveillance System and Medicaid enrollment files, we identified individuals diagnosed with incident invasive breast (n=4850), cervical (n=1023), and colorectal (n=3363) cancer. We conducted causal mediation analysis to estimate the direct effect of pre- (vs. post-) expansion on being diagnosed with early-stage (-vs. regional-stage and distant-stage) disease, and indirect (mediation) effect through being in the stably- (vs. emergently-) enrolled group, controlling for individual-level and area-level characteristics. RESULTS: The percentage of stably-enrolled patients increased from 63.3% to 73.9% post-expansion, while that of the emergently-enrolled decreased from 36.7% to 26.1%. The percentage of patients with early-stage diagnosis remained 1.3-2.9 times higher among the stably-than the emergently-enrolled group, both pre-expansion and post-expansion. Results from the causal mediation analysis showed that there was an indirect effect of Medicaid expansion through being in the stably- (vs. emergently-) enrolled group [risk ratios with 95% confidence interval: 1.018 (1.010-1.027) for breast cancer, 1.115 (1.064-1.167) for cervical cancer, and 1.090 (1.062-1.118) for colorectal cancer. CONCLUSION: We provide the first evidence that post-expansion improvements in cancer stage were caused by an increased reliance on Medicaid as a source of stable insurance coverage.

Receipt of Serial Endoscopy Procedures Prior to Esophageal Adenocarcinoma Diagnosis Is Associated with Better Survival.

BACKGROUND: The poor prognosis of esophageal adenocarcinoma (EAC) has focused efforts on early detection by serial endoscopic surveillance of Barrett's esophagus (BE). Previously, we reported that receipt of endoscopy before EAC diagnosis was associated with improved survival. AIM: We aimed to refine our previous analysis, assessing surveillance as measured by performance of serial endoscopy before EAC diagnosis and evaluating its association with stage and survival. METHODS: A retrospective cohort study was performed using the Surveillance, Epidemiology and End Results-Medicare database. Patients aged ≥ 70 years with EAC diagnosed during 1998-2009 were identified. Diagnosis with BE and receipt of ≥ 2 upper endoscopic procedures within 5 years before cancer diagnosis were identified. We compared a reference group not receiving serial endoscopy to 3 patterns based on ≥ 2 endoscopy dates relative to a timepoint 2 years before cancer diagnosis: "remote," "recent," and "sustained." RESULTS: Among 5532 patients, 28% (n = 1,575) had localized stage. Thirteen percent (n = 703) received ≥ 2 endoscopic procedures before cancer diagnosis: 224, 298, and 181 in the "recent," "remote," and "sustained" groups. Serial endoscopy and prior BE were associated with localized stage ("sustained" group OR 2.95, 95% confidence interval [CI] 2.07, 4.19; prior BE OR 2.68, 95% CI 2.03, 3.56). Serial endoscopy was associated with improved survival even with adjustment for lead time bias ("sustained" group HR 0.45, 95% CI 0.37, 0.55) and length time bias. CONCLUSIONS: Sustained endoscopy was associated with earlier stage and improved survival. These results support the role of sustained surveillance in early detection of EAC.

Medicaid Expansion Associated With Reduction in Geospatial Breast Cancer Stage at Diagnosis Disparities.

CONTEXT: Prior studies demonstrate that Medicaid expansion has been associated with earlier-stage breast cancer diagnosis among women with low income, likely through increased access to cancer screening services. However, how this policy change has impacted geospatial disparities in breast cancer stage at diagnosis is unclear. OBJECTIVE: To examine whether there were reductions in geospatial disparities in advanced stage breast cancer at diagnosis in Ohio after Medicaid expansion. DESIGN: The study included 33 537 women aged 40 to 64 years diagnosed with invasive breast cancer from the Ohio Cancer Incidence Surveillance System between 2010 and 2017. The space-time scan statistic was used to detect clusters of advanced stage at diagnosis before and after Medicaid expansion. Block group variables from the Census were used to describe the contextual characteristics of detected clusters. RESULTS: The percentage of local stage diagnosis among women with breast cancer increased from 60.2% in the pre-expansion period (2010-2013) to 62.6% in the post-expansion period (2014-2017), while the uninsured rate among those women decreased from 13.7% to 7.5% during the same period. Two statistically significant ( P < .05) and 6 nonsignificant spatial clusters ( P > .05) of advanced stage breast cancer cases were found in the pre-expansion period, while none were found in the post-expansion period. These clusters were in the 4 largest metropolitan areas in Ohio, and individuals inside the clusters were more likely to be disadvantaged along numerous socioeconomic factors. CONCLUSIONS: Medicaid expansion has played an important role in reducing geospatial disparities in breast cancer stage at diagnosis, likely through the reduction of advanced stage disease among women living in socioeconomically disadvantaged communities.

Dietary inflammatory index and risk of colorectal adenoma: effect measure modification by race, nonsteroidal anti-inflammatory drugs, cigarette smoking and body mass index?

PURPOSE: To investigate if the association between dietary inflammatory potential and colorectal adenoma (CRA) is modified by race and factors known to modulate inflammation. METHODS: We examined effect measure modification of race, nonsteroidal anti-inflammatory drugs (NSAIDs), cigarette smoking and body mass index (BMI) on the diet-CRA association by employing energy-adjusted dietary inflammatory index (E-DII™) to characterize dietary inflammatory potential among 587 cases and 1,313 controls participating in a colonoscopy screening-based cross-sectional study of CRA. Participants completed a food frequency questionnaire from which E-DII score was derived. E-DII score was calculated from 34 food parameters (constituents), utilizing an energy-adjusted global comparative database to compute z scores from which centered proportions were summed to create the score. CRA cases were defined as individuals whose colonoscopy detected at least one pathologically confirmed adenomatous polyp. Unconditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: A pro-inflammatory diet was not statistically significantly associated with elevated CRA risk (OR 1.07; 95% CI 0.97-1.19; p value = 0.18) in the multivariate regression model. NSAIDs use (ORnever-users 1.19; 95% CI 1.03-1.38; ORever-users 0.96; 95% CI 0.83-1.12; Pinteraction = 0.04) and race (ORAfrican Americans 1.22; 95% CI 1.03-1.44; OREuropean Americans 0.99; 95% CI 0.86-1.14; Pinteraction = 0.14) appeared to modify the association, whereas cigarette smoking and BMI did not (Pinteraction = 0.40 and 0.78, respectively). CONCLUSION: NSAIDs use and race may modify the diet-CRA association. Further investigation in prospective cohort studies is warranted to confirm these findings.

Epidemiology of Diverticulitis and Prevalence of First-Ever Colorectal Cancer Postdiverticulitis in Adults in the United States: A Population-Based National Study.

BACKGROUND: The incidence of acute diverticulitis is increasing, and previous studies showed a wide range of prevalence of colorectal cancer after diverticulitis. There is a lack of high-quality evidence to support performing colonoscopy after diverticulitis. OBJECTIVE: We aimed to describe the incidence of first-ever diverticulitis and prevalence of first-ever colorectal cancer postdiverticulitis in the United States. DESIGN: This is a retrospective cohort study. SETTINGS: We queried a national database that contains data from 26 major integrated healthcare systems in the United States. PATIENTS: We identified an aggregated patient cohort aged ≥18 years with a diagnosis of first-ever diverticulitis from February 2015 to February 2020, followed by first-ever colorectal cancer diagnosis, at least 1 day after and within 1 year of diverticulitis. MAIN OUTCOME MEASURES: The incidence of first-ever diverticulitis was calculated. The prevalence and OR of first-ever colorectal cancer after diverticulitis were analyzed. RESULTS: Among 31,778,290 individuals, we found the incidence of first-ever acute diverticulitis to be 2.9%. The prevalence of colorectal cancer within 1 year of first-ever acute diverticulitis was 0.57%, whereas the prevalence of colorectal cancer without a history of diverticulitis was 0.31% (OR = 1.8 (95% CI, 1.76-1.86)). The majority (92.3%) of the postdiverticulitis colorectal cancer were diagnosed within the first 6 months. The risk of colorectal cancer postdiverticulitis was higher in women (OR = 1.9), African Americans (OR = 2.0), and adults aged 18 to 65 years (OR = 2.3). LIMITATIONS: We are unable to validate the diagnostic code because patient information in our database is deidentified. CONCLUSIONS: Individuals are twice as likely to be diagnosed with colorectal cancer within 1 year of their first episode of acute diverticulitis compared with individuals without diverticulitis. We advocate for colonoscopy after the first occurrence of acute diverticulitis to screen for colorectal cancer, particularly for patients without a recent colonoscopy. See Video Abstract at http://links.lww.com/DCR/B412.

ANTECEDENTES: La incidencia de diverticulitis aguda está aumentando y los estudios anteriores mostraron una amplia gama de prevalencia de cáncer colorrectal después de diverticulitis. Hay una falta de evidencia de alta calidad para apoyar la realización de una colonoscopia después de la diverticulitis. OBJETIVOS: Nuestro objetivo fue describir la incidencia de la primera diverticulitis y la prevalencia del cáncer colorrectal posterior a la primera diverticulitis en los Estados Unidos.DISEÑO:Este es un estudio de cohorte retrospectivo. AJUSTES: Consultamos una base de datos nacional que contiene datos de 26 sistemas de salud integrados importantes en los Estados Unidos. PACIENTES: Identificamos una cohorte agregada de pacientes mayores de 18 años con un diagnóstico de diverticulitis por primera vez entre febrero de 2015 y febrero de 2020, seguido de un diagnóstico de cáncer colorrectal por primera vez, al menos 1 día después y dentro de 1 año de diverticulitis. PRINCIPALES MEDIDAS DE RESULTADO: Se calculó la incidencia de la primer diverticulitis. Se analizaron la prevalencia y el odds ratio del primer CCR después de la diverticulitis. RESULTADOS: Entre 31,778,290 individuos, encontramos que la incidencia de la primera diverticulitis aguda fue del 2.9%. La prevalencia de cáncer colorrectal dentro de 1 año de la primera diverticulitis aguda fue del 0,57%, mientras que la prevalencia del cáncer colorrectal sin antecedentes de diverticulitis fue del 0,31% (OR 1,8; IC del 95%: 1,76-1,86). La mayoría (92,3%) de los pacientes con cáncer colorrectal posterior a diverticulitis se diagnosticaron dentro de los primeros 6 meses. El riesgo de CCR después de diverticulitis fue mayor en mujeres (OR 1,9), afroamericanos (OR 2,0) y adultos de 18 a 65 años (OR 2,3). LIMITACIONES: No podemos validar el código de diagnóstico debido a que la información del paciente en nuestra base de datos no está identificada. CONCLUSIONES: Las personas tienen el doble de probabilidades de ser diagnosticadas con cáncer colorrectal dentro del primer año de su primer episodio de diverticulitis aguda en comparación con las personas sin diverticulitis. Abogamos por la colonoscopia después de la primera aparición de diverticulitis aguda para detectar cáncer colorrectal, particularmente en pacientes sin una colonoscopia reciente.

Epidemiology of Autoimmune Hepatitis (AIH) in the United States Between 2014 and 2019: A Population-based National Study.

BACKGROUND AND AIMS: Autoimmune hepatitis (AIH) is a chronic, inflammatory disease of the liver with increasing prevalence. However, limited epidemiological data exist for the prevalence of AIH in the United States. We used a large database to describe the prevalence of AIH in the United States and the autoimmune diseases associated with it. APPROACH AND RESULTS: Data was collected from a commercial database (Explorys Inc., Cleveland, OH), an aggregate of Electronic Health Record data from 26 major integrated health care systems in the United States. We identified a cohort of patients with a diagnosis of AIH from April 2014 to April 2019 based on a Systemized Nomenclature of Medicine-Clinical Terms and calculated the prevalence of AIH. Of the 37,161,280 individuals active in the database from April 2014 to 2019, we identified 11,600 individuals with a diagnosis of AIH with an overall prevalence rate of 31.2/100,000. The prevalence of AIH was increased in females compared with males [odds ratio (OR)=3.21, P<0.0001], elderly (aged above 65 y) compared with adults (aged 18 to 65 y) and children (aged below 18 y) (OR=2.51, P<0.0001) and whites compared with African Americans, Asians, and Hispanics (OR=1.12, P<0.0001). Moreover, patients with AIH were more likely to have Sjögren syndrome, systemic lupus erythematosus, ulcerative colitis, celiac disease, rheumatoid arthritis, Crohn's disease, and autoimmune thyroiditis as compared with patients without AIH. CONCLUSIONS: We found that the estimated prevalence of AIH in the United States is 31.2/100,000, which is comparable to the reported prevalence of AIH in Europe. We confirmed that AIH has a strong association with other autoimmune diseases studied in the literature.

Colorectal Cancer, Age, and Obesity-Related Comorbidities: A Large Database Study.

BACKGROUND AND AIMS: The association between obesity and colorectal cancer (CRC) is well established in older individuals, but evidence is limited in the younger population. The study aims to analyze the relationship of obesity and its related comorbidities in early-onset CRC (E-CRC) and compare it to late-onset CRC (L-CRC). METHODS: A retrospective, cross-sectional study was performed on average-risk individuals ≥ 20 years who were active patients in the commercial database, IBM Watson Health Explorys in the last 5 years. Individuals with CRC were compared to those without CRC across different age groups (20-39, 40-49, and 50-74 years). Individuals with CRC diagnosed < 50 years (E-CRC) were compared to those with CRC between 50 and 74 years (L-CRC). Variables included sex, smoking, obese BMI, diabetes mellitus type 2 (DM2), hypertension (HTN), and hyperlipidemia (HLD). Since Explorys aggregates population-level, de-identified data, approval from institutional review board was not required. RESULTS: Among 37,483,140 individuals, 162,150 cases of sporadic CRC were identified. Compared to the general population, obesity and HLD were independent risk factors for CRC across all age groups; DM2, HTN, and smoking were independent risk factors for CRC in men of all age groups and women with L-CRC. Compared to L-CRC, individuals with E-CRC had lower percentages of obesity-related comorbidities. CONCLUSION: In E-CRC, obesity, DM2, HTN, HLD, and smoking are independent risk factors for CRC among men; obesity and HLD are independent risk factors for CRC in women. These subgroups may benefit from a personalized screening approach to detect early-onset CRC.

Disparities in Colorectal Cancer Screening Practices in a Midwest Urban Safety-Net Healthcare System.

AIMS: Although colorectal cancer screening (CRC) using stool-based test is well-studied, evidence on fecal immunochemical test (FIT) patterns in a safety-net healthcare system utilizing opportunistic screening is limited. We studied the FIT completion rates and adenoma detection rate (ADR) of positive FIT-colonoscopy (FIT-C) in an urban safety-net system. METHODS: We performed a retrospective cross-sectional chart review on individuals ≥ 50 years who underwent CRC screening using FIT or screening colonoscopy, 09/01/2017-08/30/2018. Demographic differences in FIT completion were studied; ADR of FIT-C was compared to that of screening colonoscopy. RESULTS: Among 13,427 individuals with FIT ordered, 7248 (54%) completed the stool test and 230 (48%) followed up a positive FIT with colonoscopy. Increasing age (OR 1.01, CI 1.01-1.02), non-Hispanic Blacks (OR 0.87, CI 0.80-0.95, p = 0.002), current smokers (OR 0.84, CI 0.77-0.92, p < 0.0001), those with Medicaid (OR 0.86, CI 0.77-0.96, p = 0.006), commercial insurance (OR 0.85, CI 0.78-0.94, p = 0.002), CCI score ≥ 3 (OR 0.82, CI 0.74-0.91, p < 0.0001), orders by family medicine providers (OR 0.87, CI 0.81-0.94, p < 0.0001) were associated with lower completion of stool test. Individuals from low median household income cities had lower follow-up of positive FIT, OR 0.43, CI 0.21-0.86, p = 0.017. ADR of FIT-C was higher than that of screening colonoscopy. CONCLUSION: Adherence to CRC screening is low in safety-net systems employing opportunistic screening. Understanding demographic differences may allow providers to formulate targeted strategies in high-risk vulnerable groups.

Identifying 'win-win-win' futures from inequitable value chain trade-offs: A system dynamics approach.

CONTEXT: There is growing recognition that food systems must adapt to become more sustainable and equitable. Consequently, in developing country contexts, there is increasing momentum away from traditional producer-facing value chain upgrades towards efforts to increase both the availability and affordability of nutritious foods at the consumer level. However, such goals must navigate the inherent complexities of agricultural value chains, which involve multiple interactions, feedbacks and unintended consequences, including important but often surprising trade-offs between producers and consumers. OBJECTIVE AND METHODS: Based around the 'Loop' horticultural aggregation scheme of Digital Green in Bihar, India, we develop a system dynamics modelling framework to survey the value chain trade-offs emerging from upgrades that aim to improve the availability of fruits and vegetables in small retail-oriented markets. We model the processes of horticultural production, aggregation, marketing, and retailing - searching for futures that are 'win-win-win' for: (i) the availability of fruits and vegetables in small retail markets, (ii) the profits of farmers participating in aggregation, and (iii) the sustainability of the initial scheme for Digital Green as an organisation. We simulate two internal upgrades to aggregation and two upgrades to the wider enabling environment through a series of 5000 Monte Carlo trajectories - designed to explore the plausible future dynamics of the three outcome dimensions relative to the baseline. RESULTS: We find that 'win-win-win' futures cannot be achieved by internal changes to the aggregation scheme alone, emerging under a narrow range of scenarios that boost supplies to the small retail market whilst simultaneously supporting the financial takeaways of farmers. In contrast, undesirable producer versus consumer trade-offs emerge as unintended consequences of scaling-up aggregation and the introduction of market-based cold storage. SIGNIFICANCE: This approach furthers ongoing efforts to capture complex value chain processes, outcomes and upgrades within system dynamics modelling frameworks, before scanning the horizon of plausible external scenarios, internal dynamics and unintended trade-offs to identify 'win-win-win' futures for all.

Real-World Practice Patterns in the Era of Rectal Indomethacin for Prophylaxis Against Post-ERCP Pancreatitis in a High-Risk Cohort.

INTRODUCTION: The benefit of indomethacin suppositories for prophylaxis against post-ERCP pancreatitis (PEP) in high-risk patients was established in a landmark trial published in 2012. The aims of this study were to measure the adoption of indomethacin prophylaxis in widespread clinical practice, evaluate concurrent trends in pancreatic duct (PD) stent utilization, and estimate the impact of these changes on PEP in a high-risk population. METHODS: Data were extracted from a commercial database (Explorys, IBM Watson Health, Somers, NY) that aggregates electronic health records from 26 US healthcare systems from 2009 to 2018. Using Systematized Nomenclature of Medicine Clinical Terms, we identified a cohort of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and were at high risk for PEP based on narrow criteria. PEP was defined as an emergency department or hospital admission 1-5 days after ERCP with an associated diagnosis of pancreatitis. RESULTS: Twenty six thousand eight hundred twenty ERCPs were performed on this high-risk cohort from 2009 to 2018. The overall PEP rate during the study period was 8.6%. There was no decrease in PEP rates from 2012 to 2018. Beginning in 2012, indomethacin usage increased linearly (P < 0.001), but remained below 50% in 2018. As indomethacin increased, utilization of PD stents declined abruptly from 2013 to 2014 (40.7%-8.5%) and trended to a nadir of 3.0%. DISCUSSION: Despite its low cost, widespread availability, and level I evidence of benefit in reducing the risk of PEP in high-risk patients, the adoption of rectal indomethacin during ERCP has been slow and the medication continues to be under-utilized. In parallel, the PD stent usage has declined dramatically. The lack of change in PEP rates during the study period could be attributable to the persistent low usage of rectal indomethacin or the decline in PD stent use. Further educational efforts and quality assurance measures are warranted to ensure that rectal indomethacin and PD stent placement are more appropriately used in clinical practice.

Epidemiology of Large Bowel Carcinoid Tumors in the USA: A Population-Based National Study.

BACKGROUND AND AIMS: Prior studies have shown that about 90% of all carcinoid tumors occur in the GI tract. However, epidemiological studies of these tumors have been limited by small sample size. Our aim was to obtain a more robust epidemiologic survey of large bowel carcinoids (LBC), using population-based data in order to more accurately identify risk factors for these tumors. METHODS: We used a commercial database (Explorys Inc, Cleveland, OH) which includes electronic health record data from 26 major integrated US healthcare systems. We identified all patients aged 18 and older who were diagnosed with LBC, excluding appendiceal carcinoids, between 1999 and 2018 based on Systematized Nomenclature Of Medicine-Clinical Terms (SNOMED-CT) and evaluated the prevalence of LBC. We also performed univariate analysis to describe age-, race-, and gender-based distributions and to identify potential risk factors. RESULTS: Of the 62,817,650 individuals in the database, 4530 were identified to have LBC with an overall prevalence of 7.21/100,000. Individuals with LBC were more likely to be elderly (age > 65) [OR 2.17, CI 2.05-2.31, p < 0.0001], smokers [OR 3.25; 95% CI 3.00-3.53, p < 0.0001], have a history of alcohol use [OR 3.75; 95% CI 3.52-3.99, p < 0.0001], diabetes mellitus (DM) [OR 4.42; 95% CI 4.14-4.72, p < 0.0001], obesity [OR 1.58; 95% CI 1.43-1.74, p < 0.0001], family history of cancer [OR 8.06; 95% CI 7.47-8.71, p < 0.0001], and personal history of ulcerative colitis [OR 6.93; 95% CI 5.55-8.64, p < 0.0001] or Crohn's disease [OR 6.45; 95% CI 5.24-7.95, p < 0.0001]. The prevalence of LBC was less among Caucasians compared to African-Americans [OR 0.57; 95% CI 0.53-0.61, p < 0.0001]. There was no statistically significant gender-based difference; men versus women [OR 1.02; 95% CI 0.96-1.08, p = 0.47]. The most common presenting symptoms included flushing, diarrhea, nausea, weight loss, and abdominal pain, while the most common GI associations included perforation, obstruction, hemorrhage, intussusception, and volvulus. CONCLUSION: This is the largest epidemiological study evaluating the prevalence of LBC. We estimated the prevalence rate of LBC to be 7.21/100,000. The presence of significant risk factors with the clinical picture suspicious for a LBC should warrant thorough evaluation as these tumors can lead to life-threatening complications. Further studies are needed to better understand the mechanism of association between these risk factors and LBC.

Development and validation of a model to predict outcomes of colon cancer surveillance.

PURPOSE: Clinical trials suggest that intensive surveillance of colon cancer (CC) survivors to detect recurrence increases curative-intent treatment, although any survival benefit of surveillance as currently practiced appears modest. Realizing the potential of surveillance will require tools for identifying patients likely to benefit and for optimizing testing regimens. We describe and validate a model for predicting outcomes for any schedule of surveillance in CC survivors with specified age and cancer stage. METHODS: A Markov process parameterized based on individual-level clinical trial data generates natural history events for simulated patients. A utilization submodel simulates surveillance and diagnostic testing. We validate the model against outcomes from the follow-up after colorectal surgery (FACS) trial. RESULTS: Prevalidation sensitivity analysis showed no parameter influencing curative-intent treatment by > 5.0% or overall five-year survival (OS5) by > 1.5%. In validation, the proportion of recurring subjects predicted to receive curative-intent treatment fell within FACS 95% CI for carcinoembryonic antigen (CEA)-intensive, computed tomography (CT)-intensive, and combined CEA+CT regimens, but not for a minimum surveillance regimen, where the model overestimated recurrence and curative treatment. The observed OS5 fell within 95% prediction intervals for all regimens. CONCLUSION: The model performed well in predicting curative surgery for three of four FACS arms. It performed well in predicting OS5 for all arms.

Epidemiology of Whipple's Disease in the USA Between 2012 and 2017: A Population-Based National Study.

OBJECTIVE: Prior studies on the epidemiology of Whipple's disease are limited by small sample size and case series design. We sought to characterize the epidemiology of Whipple's disease in the USA utilizing a large population-based database. METHODS: We queried a commercial database (Explorys Inc, Cleveland, OH), an aggregate of electronic health record data from 26 major integrated healthcare systems in the USA. We identified a cohort of patients with a diagnosis of Whipple's disease based on systemized nomenclature of medical terminology (SNOMED CT) codes. We calculated the overall and age-, race-, ethnicity, and gender-based prevalence of Whipple's disease and prevalence of associated diagnoses using univariate analysis. RESULTS: A total of 35,838,070 individuals were active in the database between November 2012 and November 2017. Of these, 350 individuals had a SNOMED CT diagnosis of Whipple's disease, with an overall prevalence of 9.8 cases per 1 million. There was no difference in prevalence based on sex. However, prevalence of Whipple's disease was higher in Caucasians, non-Hispanics, and individuals > 65 years old. Individuals with a diagnosis of Whipple's disease were more likely to have associated diagnoses/findings of arthritis, CNS disease, endocarditis, diabetes, malignancy, dementia, vitamin D deficiency, iron deficiency, chemotherapy, weight loss, abdominal pain, and lymphadenopathy. CONCLUSIONS: To our knowledge, this is the largest study to date examining the epidemiology of Whipple's disease. In this large population-based study, the overall prevalence of Whipple's disease in the USA is 9.8 cases per 1 million people. It affects men and women at similar rates and is more common in Caucasians, non-Hispanics, and people > 65 years old.

Epidemiology of Colorectal Cancer in Average Risk Adults 20-39 Years of Age: A Population-Based National Study.

BACKGROUND/AIMS: While overall rates of colorectal cancer (CRC) have declined in individuals aged above 50 years of age, this decline has not been seen in younger individuals who do not benefit from current screening guidelines. We sought to describe the prevalence of CRC in adults 20-39 years of age without family history of CRC or inflammatory bowel disease as early-onset CRC (EoCRC), evaluate associated signs and symptoms and medical comorbidities in EoCRC, and compare them with individuals aged 20-39 years without CRC (NoCRC). Our secondary aim was to compare EoCRC with individuals aged 40 years and above with CRC (LoCRC). METHODS: Utilizing a commercial database (Explorys Inc, Cleveland, OH), we identified a cohort of patients aged 20-39 years with first ever diagnosis of CRC between 2013 and 2018 based on the Systematized Nomenclature of Medicine-Clinical Terms. We calculated the overall prevalence rate of EoCRC, described age, race, and gender-based prevalence rates of EoCRC, and identified associated symptoms and medical comorbidities associated with EoCRC. RESULTS: The overall rate of EoCRC was 18.9/100,000. Compared to NoCRC, EoCRC patients were more likely to be Caucasian and female, with predominant symptoms of hematochezia, anemia, and decreased appetite. EoCRC group had higher prevalence rates of medical comorbidities such as diabetes, smoking, and obesity. Compared to LoCRC, EoCRC group presented more frequently with left-sided CRC and rectal cancers. CONCLUSION: This is one of the largest studies to date to describe the epidemiology of EoCRC in USA. We found EoCRC to occur predominantly in the Caucasian and female population. EoCRC presented more frequently with left-sided and rectal CRC. We also identified signs/symptoms as well as comorbidities associated with EoCRC. Patients with these features may benefit from earlier screening.

Performance of multitarget stool DNA testing in African American patients.

BACKGROUND: Multitarget stool DNA (mt-sDNA) is an approved method for colon cancer screening that is especially relevant for patients who cannot undergo colonoscopy. Although the test performance has been evaluated in a large clinical trial, it was limited to a predominantly white population. Given differences in the epidemiology and biology of colon cancer in African American individuals, the authors sought to compare the performance of mt-sDNA between racial groups. METHODS: The authors prospectively identified patients aged ≥40 years who were referred for colonoscopy at an academic medical center and 2 satellite facilities. Prior to the colonoscopy, the authors collected stool for mt-sDNA and fecal immunochemical testing (FIT). They compared the sensitivity, specificity, and receiver operating characteristic curve between African American and white patients for the detection of advanced lesions or any adenoma. RESULTS: A total of 760 patients were included, 34.9% of whom were African American. The prevalence of any adenoma (38.9% for African American patients and 33.9% for white patients) and that for advanced lesions (6.8% and 6.7%, respectively) were similar between groups. The overall sensitivities of mt-sDNA for the detection of advanced lesions and any adenoma were 43% and 19%, respectively, and the specificities were 91% and 93%, respectively. In general, mt-sDNA was more sensitive and less specific than FIT. When stratified by race, the sensitivity, specificity, and receiver operating characteristic curve area were similar between African American and white patients for both mt-sDNA and FIT. CONCLUSIONS: Test performance characteristics of mt-sDNA were comparable in African American and white patients. Given the lower uptake of colonoscopy in African American individuals, mt-sDNA may offer a promising screening alternative in this patient population.

Rates of Prevalent Colorectal Cancer Occurrence in Persons 75 Years of Age and Older: A Population-Based National Study.

BACKGROUND/AIMS: There is a lack of studies describing the epidemiology of colorectal cancer (CRC) in patients aged 75 years and older (elderly). Current guidelines recommend against routine screening colonoscopies in this population. We sought to describe the epidemiology of CRC in the elderly, utilizing a large, population-based database as this may impact screening guidelines in this population. METHODS: Utilizing a commercial database (Explorys Inc, Cleveland, OH), we identified a cohort of patients with a first-ever diagnosis of CRC between 2012 and 2017 based on the Systematized Nomenclature of Medicine-Clinical Terms. We calculated the rate of first-ever CRC occurrence in the elderly, described age, race, and gender-based rates of new CRC diagnoses, and identified associated conditions for new CRC in the elderly. RESULTS: The rate of first-ever CRC in the elderly (aged 75 and above) was 102.6/100,000 persons. The rate of new CRC was higher in males than females and in African Americans than Caucasians and Asians. There was a higher prevalence of right than left colon cancer. The rate of new CRC was higher in elderly with certain comorbidities. CONCLUSION: The rate of new CRC diagnosis in the elderly was substantially greater compared to the overall population. Screening would be justified especially if a patient's life expectancy warrants it particularly if the patient has specific associated conditions that increase the risk for CRC.