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Weizman AV, Huang B, Targan S, Dubinsky M, Fleshner P, Kaur M, Ippoliti A, Panikkath D, Vasiliauskas E, Shih D, McGovern DPB, Melmed GY. Pyoderma Gangrenosum among Patients with Inflammatory Bowel Disease: A Descriptive Cohort Study. J Cutan Med Surg 2015; 19:125-31. [PMID: 25775631 DOI: 10.2310/7750.2014.14053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a severe extraintestinal manifestation of inflammatory bowel disease (IBD). OBJECTIVE To better characterize PG features and management among an IBD cohort. METHODS Subjects with PG were identified using a large database at a tertiary center. Patient demographics and clinical characteristics were summarized using descriptive statistics. RESULTS Eighty patients with an episode(s) of PG were identified, yielding an overall prevalence of 1.9%. Overall, 93% of patients with PG had some degree of colonic inflammation. Thirty-one (39%) patients required hospitalization for PG. Underlying bowel disease was active at the time of PG episode(s) in 52 (65%) patients. The PG location was variable, with the lower extremity being the most common. Most patients (71.3%) required multiple therapies to achieve PG healing. CONCLUSIONS We describe one of the largest case series of PG among patients with IBD. The variety of treatment strategies used highlights the lack of clear guidelines in managing this complex group of patients.
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Affiliation(s)
- Adam V Weizman
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - Brian Huang
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - Stephan Targan
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - Marla Dubinsky
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - Phillip Fleshner
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - Manreet Kaur
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - Andrew Ippoliti
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - Deepa Panikkath
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - Eric Vasiliauskas
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - David Shih
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - Dermot P B McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
| | - Gil Y Melmed
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CAWomen's College Hospital, Division of Gastroenterology, University of Toronto, Toronto, ONDepartment of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CAMedical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, CA
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Hazlewood GS, Rezaie A, Borman M, Panaccione R, Ghosh S, Seow CH, Kuenzig E, Tomlinson G, Siegel CA, Melmed GY, Kaplan GG. Comparative effectiveness of immunosuppressants and biologics for inducing and maintaining remission in Crohn's disease: a network meta-analysis. Gastroenterology 2015; 148:344-54.e5; quiz e14-5. [PMID: 25448924 DOI: 10.1053/j.gastro.2014.10.011] [Citation(s) in RCA: 185] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 09/28/2014] [Accepted: 10/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS There is controversy regarding the best treatment for patients with Crohn's disease because of the lack of direct comparative trials. We compared therapies for induction and maintenance of remission in patients with Crohn's disease, based on direct and indirect evidence. METHODS We performed systematic reviews of MEDLINE, EMBASE, and Cochrane Central databases, through June 2014. We identified randomized controlled trials (N = 39) comparing methotrexate, azathioprine/6-mercaptopurine, infliximab, adalimumab, certolizumab, vedolizumab, or combined therapies with placebo or an active agent for induction and maintenance of remission in adult patients with Crohn's disease. Pairwise treatment effects were estimated through a Bayesian random-effects network meta-analysis and reported as odds ratios (OR) with a 95% credible interval (CrI). RESULTS Infliximab, the combination of infliximab and azathioprine (infliximab + azathioprine), adalimumab, and vedolizumab were superior to placebo for induction of remission. In pair-wise comparisons of anti-tumor necrosis factor agents, infliximab + azathioprine (OR, 3.1; 95% CrI, 1.4-7.7) and adalimumab (OR, 2.1; 95% CrI, 1.0-4.6) were superior to certolizumab for induction of remission. All treatments were superior to placebo for maintaining remission, except for the combination of infliximab and methotrexate. Adalimumab, infliximab, and infliximab + azathioprine were superior to azathioprine/6-mercaptopurine: adalimumab (OR, 2.9; 95% CrI, 1.6-5.1), infliximab (OR, 1.6; 95% CrI, 1.0-2.5), infliximab + azathioprine (OR, 3.0; 95% CrI, 1.7-5.5) for maintenance of remission. Adalimumab and infliximab + azathioprine were superior to certolizumab: adalimumab (OR, 2.5; 95% CrI, 1.4-4.6) and infliximab + azathioprine (OR, 2.6; 95% CrI, 1.3-6.0). Adalimumab was superior to vedolizumab (OR, 2.4; 95% CrI, 1.2-4.6). CONCLUSIONS Based on a network meta-analysis, adalimumab and infliximab + azathioprine are the most effective therapies for induction and maintenance of remission of Crohn's disease.
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Affiliation(s)
- Glen S Hazlewood
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ali Rezaie
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Meredith Borman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Subrata Ghosh
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Departmet of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ellen Kuenzig
- Departmet of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - George Tomlinson
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Corey A Siegel
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Gil Y Melmed
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Departmet of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
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103
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Nagaraja V, Hays RD, Khanna PP, Spiegel BMR, Chang L, Melmed GY, Bolus R, Khanna D. Construct validity of the Patient-Reported Outcomes Measurement Information System gastrointestinal symptom scales in systemic sclerosis. Arthritis Care Res (Hoboken) 2014; 66:1725-30. [PMID: 24692332 DOI: 10.1002/acr.22337] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 03/25/2014] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Gastrointestinal (GI) involvement is common in patients with systemic sclerosis (SSc; scleroderma). The Patient-Reported Outcomes Measurement Information System (PROMIS) GI symptom item bank captures upper and lower GI symptoms (reflux, disrupted swallowing, nausea/vomiting, belly pain, gas/bloating/flatulence, diarrhea, constipation, and fecal incontinence). The objective of this study was to evaluate the construct validity of the PROMIS GI bank in SSc. METHODS A total of 167 patients with SSc were administered the PROMIS GI bank and the University of California, Los Angeles, Scleroderma Clinical Trials Consortium Gastrointestinal Scale (GIT 2.0) instrument. GIT 2.0 is a multi-item instrument that measures SSc-associated GI symptoms. Product-moment correlations and a multitrait-multimethod analysis of the PROMIS GI scales with the GIT 2.0 symptom scales were used to evaluate convergent and discriminant validity. RESULTS Patients with SSc GI involvement had PROMIS GI scale scores 0.2-0.7 SD worse than the US general population. Correlations among scales measuring the same domains for the PROMIS GI and GIT 2.0 measures were large, ranging from 0.61 to 0.87 (average r = 0.77). The average correlation between different symptom scales was 0.22, supporting discriminant validity. CONCLUSION This study provides support for the construct validity of the PROMIS GI scales in SSc. Future research is needed to assess the responsiveness to change of these scales in patients with SSc.
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Spiegel BM, Hays RD, Bolus R, Melmed GY, Chang L, Whitman C, Khanna PP, Paz SH, Hays T, Reise S, Khanna D. Development of the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) gastrointestinal symptom scales. Am J Gastroenterol 2014; 109:1804-14. [PMID: 25199473 PMCID: PMC4285435 DOI: 10.1038/ajg.2014.237] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 06/24/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS(®)) is a standardized set of patient-reported outcomes (PROs) that cover physical, mental, and social health. The aim of this study was to develop the NIH PROMIS gastrointestinal (GI) symptom measures. METHODS We first conducted a systematic literature review to develop a broad conceptual model of GI symptoms. We complemented the review with 12 focus groups including 102 GI patients. We developed PROMIS items based on the literature and input from the focus groups followed by cognitive debriefing in 28 patients. We administered the items to diverse GI patients (irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), systemic sclerosis (SSc), and other common GI disorders) and a census-based US general population (GP) control sample. We created scales based on confirmatory factor analyses and item response theory modeling, and evaluated the scales for reliability and validity. RESULTS A total of 102 items were developed and administered to 865 patients with GI conditions and 1,177 GP participants. Factor analyses provided support for eight scales: gastroesophageal reflux (13 items), disrupted swallowing (7 items), diarrhea (5 items), bowel incontinence/soilage (4 items), nausea and vomiting (4 items), constipation (9 items), belly pain (6 items), and gas/bloat/flatulence (12 items). The scales correlated significantly with both generic and disease-targeted legacy instruments, and demonstrate evidence of reliability. CONCLUSIONS Using the NIH PROMIS framework, we developed eight GI symptom scales that can now be used for clinical care and research across the full range of GI disorders.
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Affiliation(s)
- Brennan M.R. Spiegel
- Department of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA,Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California, USA,Department of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Ron D. Hays
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Roger Bolus
- Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California, USA
| | - Gil Y. Melmed
- Department of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lin Chang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA,Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Cynthia Whitman
- Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California, USA
| | - Puja P. Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sylvia H. Paz
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Tonya Hays
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Steve Reise
- Department of Psychology, UCLA, Los Angeles, California, USA
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
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105
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Cohen E, Bolus R, Khanna D, Hays RD, Chang L, Melmed GY, Khanna P, Spiegel B. GERD symptoms in the general population: prevalence and severity versus care-seeking patients. Dig Dis Sci 2014; 59:2488-96. [PMID: 24811245 PMCID: PMC4275099 DOI: 10.1007/s10620-014-3181-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 04/20/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prior estimates suggest that up to 40% of the US general population (GP) report symptoms of gastroesophageal reflux disease (GERD). However, symptoms in the GP versus patients seeking care for gastrointestinal (GI) complaints have not been compared. We estimated the prevalence and severity of GERD symptoms in the GP versus GI patients, and identified predictors of GERD severity. We hypothesized that similar to functional GI disorders, psychosocial factors would predict symptom severity in GERD as much, or perhaps more, than care-seeking behavior alone. METHODS We compared the prevalence of heartburn and regurgitation between a sample from the US GP and patients seeking GI specialty care. We compared GERD severity between groups using the NIH PROMIS(®) GERD scale. We then performed multivariable regression to identify predictors of GERD severity. RESULTS There was no difference in the prevalence of heartburn between the GP and patient groups (59 vs. 59%), but regurgitation was more common in patients versus GP (46 vs. 39%; p = 0.004). In multivariable regression, having high visceral anxiety (p < 0.001) and being divorced or separated (p = 0.006) were associated with higher GERD severity. CONCLUSIONS More than half of a GP sample reports heartburn-higher than previous series and no different from GI patients. Although regurgitation was more prevalent in patients versus the GP, there was no difference in GERD severity between groups after adjusting for other factors; care seeking in GERD appears related to factors beyond symptoms, including visceral anxiety.
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Affiliation(s)
- Erica Cohen
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Bldg 115, Room 215, Los Angeles, CA 90073, USA; Department of Gastroenterology, Cedars-Sinai Medical Center, West Hollywood, CA, USA
| | - Roger Bolus
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; UCLA/VA Center for Outcomes Research and Education, Los Angeles, CA, USA
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Ron D. Hays
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Health Services, UCLA School of Public Health, Los Angeles, CA, USA
| | - Lin Chang
- Center for Neurobiology of Stress, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gil Y. Melmed
- Department of Gastroenterology, Cedars-Sinai Medical Center, West Hollywood, CA, USA
| | - Puja Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Brennan Spiegel
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Bldg 115, Room 215, Los Angeles, CA 90073, USA; Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; UCLA/VA Center for Outcomes Research and Education, Los Angeles, CA, USA
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106
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Weizman AV, Huang B, Targan S, Dubinsky M, Fleshner P, Kaur M, Ippoliti A, Panikkath D, Vasiliauskas E, Shih D, McGovern DP, Melmed GY. Pyoderma Gangrenosum among Patients with Inflammatory Bowel Disease: A Descriptive Cohort Study. J Cutan Med Surg 2014; 18:361. [PMID: 25277124 PMCID: PMC5089702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a severe extraintestinal manifestation of inflammatory bowel disease (IBD). OBJECTIVE To better characterize PG features and management among an IBD cohort. METHODS Subjects with PG were identified using a large database at a tertiary center. Patient demographics and clinical characteristics were summarized using descriptive statistics. RESULTS Eighty patients with an episode(s) of PG were identified, yielding an overall prevalence of 1.9%. Overall, 93% of patients with PG had some degree of colonic inflammation. Thirty-one (39%) patients required hospitalization for PG. Underlying bowel disease was active at the time of PG episode(s) in 52 (65%) patients. The PG location was variable, with the lower extremity being the most common. Most patients (71.3%) required multiple therapies to achieve PG healing. CONCLUSIONS We describe one of the largest case series of PG among patients with IBD. The variety of treatment strategies used highlights the lack of clear guidelines in managing this complex group of patients.
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Affiliation(s)
- Adam V. Weizman
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Women’s College Hospital, Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Brian Huang
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stephan Targan
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Marla Dubinsky
- Department of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Manreet Kaur
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew Ippoliti
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Deepa Panikkath
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric Vasiliauskas
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David Shih
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dermot P.B. McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Medical Genetics Research Institute, Cedars-Sinai Medical AU2 Center, Los Angeles, California
| | - Gil Y. Melmed
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
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107
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Spiegel BMR, Reid MW, Bolus R, Whitman CB, Talley J, Dea S, Shahedi K, Karsan H, Teal C, Melmed GY, Cohen E, Fuller G, Yen L, Hodgkins P, Erder MH. Development and validation of a disease-targeted quality of life instrument for chronic diverticular disease: the DV-QOL. Qual Life Res 2014; 24:163-79. [DOI: 10.1007/s11136-014-0753-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2014] [Indexed: 12/17/2022]
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Abstract
Vaccines play a key role in the prevention of illness in the elderly, are cost effective, and generally safe. Hepatitis C, cirrhosis, autoimmune hepatitis, and inflammatory bowel disease are more prevalent than ever among older adults. Along with an age-related decline in immune system function (immunosenescence), these diseases make elderly individuals more susceptible to infections and more likely to experience a poor outcome relative to their younger counterparts. Vaccinations also appear to be less effective in the elderly, warranting research into different vaccination strategies such as booster vaccines, higher doses of vaccine, and measurement of antibody titers to guide vaccination.
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Affiliation(s)
- Henry A Horton
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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109
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Bradford K, Melmed GY, Fleshner P, Silverman N, Dubinsky MC. Significant variation in recommendation of care for women of reproductive age with ulcerative colitis postileal pouch-anal anastomosis. Dig Dis Sci 2014; 59:1115-20. [PMID: 24549832 DOI: 10.1007/s10620-014-3043-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 01/16/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND AIM Ileal pouch-anal anastomosis (IPAA) is the preferred surgical option for treatment refractory ulcerative colitis. Infertility risk post IPAA and sphincter injury concerns with vaginal delivery has led to a lack of consensus regarding timing and recommended mode of delivery (MOD) post-IPAA. To better understand these issues, we surveyed gastroenterologists (GI), colorectal surgeons (CRS), and obstetricians (OB) to assess practice variation in recommendations for delivery post IPAA. METHODS Clinical vignettes were developed to assess knowledge, attitudes, and beliefs surrounding (1) the impact of IPAA on fertility, (2) IPAA timing around pregnancy, (3) recommended MOD after IPAA and (4) which specialist should advise on MOD. These were emailed to providers using specialty society address lists. Univariate analyses tested differences among groups. RESULTS A total of 244 GI, 158 CRS and 39 OBs responded to the survey. The majority of GI (67%) and CRS (60%) quoted fertility reduction of >20% post-IPAA versus 11% OB (p < 0.001). More GI than CRS (67 vs. 45%) recommended delaying IPAA until after pregnancy (p < 0.001), and this was more commonly suggested by CRS in practice <10 years (p = 0.01) and <45 years old (p = 0.003). Vaginal delivery was recommended post-IPAA in 43, 20 and 57% for GI, CRS and OB, respectively (p < 0.001). Only 28% CRS versus 59% OB thought OB should primarily advise on MOD (p < 0.001). CONCLUSIONS There is significant intra- and inter-group variation in management of women post-IPAA. There is need for consensus among subspecialists involved in managing women with this complex condition.
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Affiliation(s)
- Kara Bradford
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA
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110
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Vu MP, Melmed GY, Targan SR. Weeding out the facts: the reality about cannabis and Crohn's disease. Clin Gastroenterol Hepatol 2014; 12:898-9. [PMID: 24269921 DOI: 10.1016/j.cgh.2013.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 11/14/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Michelle P Vu
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California; Department of Digestive Diseases, University of California Los Angeles, Los Angeles, California
| | - Gil Y Melmed
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stephan R Targan
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
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111
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Weizman A, Huang B, Berel D, Targan SR, Dubinsky M, Fleshner P, Ippoliti A, Kaur M, Panikkath D, Brant S, Oikonomou I, Duerr R, Rioux J, Silverberg M, Rotter JI, Vasiliauskas E, Haritunians T, Shih D, Li D, Melmed GY, McGovern DP. Clinical, serologic, and genetic factors associated with pyoderma gangrenosum and erythema nodosum in inflammatory bowel disease patients. Inflamm Bowel Dis 2014; 20:525-33. [PMID: 24487271 PMCID: PMC4046633 DOI: 10.1097/01.mib.0000442011.60285.68] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) and erythema nodosum (EN) are the most common cutaneous manifestations of inflammatory bowel disease (IBD) but little is known regarding their etiopathogenesis. METHODS We performed a case-control study comparing characteristics between IBD patients with a documented episode of PG (PG+) and/or EN (EN+) with those without PG (PG-) and EN (EN-). Data on clinical features were obtained by chart review. IBD-related serology was determined using enzyme-linked immunosorbent assay and genome-wide data generated using Illumina technology. Standard statistical tests for association were used. RESULTS We identified a total of 92 cases of PG and 103 cases of EN with genetic and clinical characteristics, of which 64 PG and 55 EN cases were available for serological analyses. Fewer male subjects were identified in the PG(+) (odds ratio 0.6, P = 0.009) and EN(+) groups (odds ratio 0.31, P = 0 < 0.0001). Colonic disease, previous IBD-related surgery, and noncutaneous extra-intestinal manifestations were more common among both PG(+) and EN(+) patients compared with controls. PG(+) was associated with anti-nuclear cytoplasmic antibody seropositivity (P = 0.03) and higher anti-nuclear cytoplasmic antibody level (P = 0.02) in Crohn's disease. Genetic associations with PG included known IBD loci (IL8RA [P = 0.00003] and PRDM1 [0.03]) as well as with USP15 (4.8 × 10) and TIMP3 (5.6 ×10). Genetic associations with EN included known IBD susceptibility genes (PTGER4 [P = 8.8 × 10], ITGAL [0.03]) as well as SOCS5 (9.64 × 10), CD207 (3.14 × 10), ITGB3 (7.56 × 10), and rs6828740 (4q26) (P < 5.0 × 10). Multivariable models using clinical, serologic, and genetic parameters predicted PG (area under the curve = 0.8) and EN (area under the curve = 0.97). CONCLUSION Cutaneous manifestations in IBD are associated with distinctive genetic characteristics and with the similar clinical characteristics, including the development of other extra-intestinal manifestations suggesting shared and distinct etiologies.
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Affiliation(s)
- Adam Weizman
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Brian Huang
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dror Berel
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stephan R. Targan
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Marla Dubinsky
- Departments of Pediatrics, Pediatric Inflammatory Bowel Disease Center, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Phillip Fleshner
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Andrew Ippoliti
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Manreet Kaur
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deepa Panikkath
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Steve Brant
- Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, School of Medicine, and Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ioannis Oikonomou
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rick Duerr
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John Rioux
- Universite de Montreal and the Montreal Heart Institute, Research Center, Montreal, Quebec, Canada
| | - Mark Silverberg
- Mount Sinai Inflammatory Bowel Disease Center, University of Toronto, Toronto, Ontario, Canada
| | - Jerome I Rotter
- Institute for Translational Genomics and Population Sciences, Los Angeles BioMedical Research Institute and Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Eric Vasiliauskas
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Talin Haritunians
- Medical Genetics Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David Shih
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dalin Li
- Medical Genetics Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gil Y. Melmed
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dermot P.B. McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA,Medical Genetics Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Siegel CA, Allen JI, Melmed GY. Translating improved quality of care into an improved quality of life for patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2013; 11:908-12. [PMID: 23747710 DOI: 10.1016/j.cgh.2013.05.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 05/15/2013] [Accepted: 05/16/2013] [Indexed: 02/07/2023]
Abstract
The term quality of care has been interpreted in different ways in medicine. Skeptics of the quality movement insist that checkboxes and government and payer oversight will not lead to better patient outcomes. Supporters refer to areas in medicine in which quality improvement efforts have led to improved survival, such as in cystic fibrosis and cardiovascular disease. For quality improvement to be effective, the process demands rigorous documentation, analysis, feedback, and behavioral change. This requires valid metrics and mechanisms to provide dynamic point-of-care (or close to point of care) feedback in a manner that drives improvement. For inflammatory bowel disease, work has been performed in Europe and the United States to develop a framework for how practitioners can improve quality of care. Improve Care Now has created a sophisticated quality improvement program for pediatric patients with inflammatory bowel disease. The American Gastroenterology Association has worked within the National Quality Strategy framework to develop quality measures for patients with inflammatory bowel disease that have been incorporated into Federal programs that are moving Medicare reimbursement from a volume-based to a value-based structure. The Crohn's and Colitis Foundation of America is initiating a quality intervention program that can be implemented in community and academic practices to stimulate continual improvement processes for patients with inflammatory bowel disease. All of this work is intended to make quality improvement programs both feasible and useful, with the ultimate goal of improving quality of life for our patients.
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Affiliation(s)
- Corey A Siegel
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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113
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Surti B, Spiegel B, Ippoliti A, Vasiliauskas E, Simpson P, Shih D, Targan S, McGovern D, Melmed GY. Assessing health status in inflammatory bowel disease using a novel single-item numeric rating scale. Dig Dis Sci 2013; 58:1313-21. [PMID: 23250673 PMCID: PMC4161217 DOI: 10.1007/s10620-012-2500-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Accepted: 11/20/2012] [Indexed: 01/22/2023]
Abstract
BACKGROUND Current instruments used to measure disease activity and health-related quality of life in patients with Crohn's disease (CD) and ulcerative colitis (UC) are often cumbersome, time-consuming, and expensive; although used in clinical trials, they are not convenient for clinical practice. A numeric rating scale (NRS) is a quick, inexpensive, and convenient patient-reported outcome that can capture the patient's overall perception of health. AIMS The aim of this study was to assess the validity, reliability, and responsiveness of an NRS and evaluate its use in clinical practice in patients with CD and UC. METHODS We prospectively evaluated patient-reported NRS scores and measured correlations between NRS and a range of severity measures, including physician-reported NRS, Crohn's disease activity index (CDAI), Harvey-Bradshaw index (HBI), inflammatory bowel disease questionnaire (IBDQ), and C-reactive protein (CRP) in patients with CD. Subsequently, we evaluated the correlation between the NRS and standard measures of health status (HBI or simple colitis clinical activity index [SCCAI]) and laboratory tests (sedimentation rate [ESR], CRP, and fecal calprotectin) in patients with CD and UC. RESULTS The patient-reported NRS showed excellent correlation with CDAI (R (2) = 0.59, p < 0.0001), IBDQ (R (2) = 0.66, p < 0.0001), and HBI (R (2) = 0.32, p < 0.0001) in patients with CD. The NRS showed poor, but statistically significant correlation with SCCAI (R (2) = 0.25, p < 0.0001) in patients with UC. The NRS did not correlate with CRP, ESR, or calprotectin. The NRS was reliable and responsive to change. CONCLUSIONS The NRS is a valid, reliable, and responsive measure that may be useful to evaluate patients with CD and possibly UC.
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Affiliation(s)
- Bijal Surti
- lnflammatory Bowel Disease Center, Cedars-Sinai Medical Center,Division of Digestive Diseases, David Geffen School of Medicine at UCLA
| | - Brennan Spiegel
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA,Department of Gastroenterology, VA Greater Los Angeles Healthcare System,Center for Outcomes Research Digestive Disease Research Center, Veteran Affairs Greater Los Angeles Healthcare System
| | - Andrew Ippoliti
- lnflammatory Bowel Disease Center, Cedars-Sinai Medical Center
| | | | - Peter Simpson
- lnflammatory Bowel Disease Center, Cedars-Sinai Medical Center
| | - David Shih
- lnflammatory Bowel Disease Center, Cedars-Sinai Medical Center
| | - Stephan Targan
- lnflammatory Bowel Disease Center, Cedars-Sinai Medical Center
| | - Dermot McGovern
- lnflammatory Bowel Disease Center, Cedars-Sinai Medical Center
| | - Gil Y. Melmed
- lnflammatory Bowel Disease Center, Cedars-Sinai Medical Center,Department of Gastroenterology, VA Greater Los Angeles Healthcare System
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Melmed GY, Siegel CA. Quality improvement in inflammatory bowel disease. Gastroenterol Hepatol (N Y) 2013; 9:286-92. [PMID: 23943663 PMCID: PMC3740804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Chronic illnesses such as inflammatory bowel disease (IBD) present a unique opportunity to define and improve the quality of care. Processes of care can be complex, and outcomes of care may vary across different healthcare delivery settings. Patients with IBD are managed over long periods of time and often by the same physician within a single care delivery system. Both patients with Crohn's disease and ulcerative colitis have variable courses of disease progression that require changes in therapy over time. These factors necessitate multiple areas of potential assessment and improvement of processes and outcomes of care. A current initiative is the development of quality measures. The American Gastroenterological Association has developed accountability measures for the Physician Quality Reporting System, and the Crohn's and Colitis Foundation of America has developed a set of top 10 recommended processes and outcomes of measurement for high-quality care of patients with IBD. In addition, the pediatric ImproveCareNow collaborative network has collected improvement data from dozens of pediatric centers over the past 5 years and has demonstrated improvement in overall disease activity in their cohort through iterative quality improvement processes. Future directions for quality indicators for adults with IBD will involve implementation of quality-measure reporting, both for purposes of reimbursement as well as improvement of care. These strategies will need to be closely monitored to evaluate the effect of improvement programs on outcomes.
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Affiliation(s)
- Gil Y Melmed
- Dr. Melmed is a Clinical Assistant Professor of Medicine in the Division of Gastroenterology in the Department of Medicine at Cedars-Sinai Medical Center in Los Angeles, California. Dr. Siegel is an Associate Professor of Medicine in the Section of Gastroenterology and Hepatology in the Department of Medicine at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire
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Cheifetz AS, Melmed GY, Spiegel B, Talley J, Devlin SM, Raffals L, Irving PM, Jones J, Kaplan GG, Kozuch P, Sparrow M, Velayos F, Baidoo L, Bressler B, Siegel CA. Setting priorities for comparative effectiveness research in inflammatory bowel disease: results of an international provider survey, expert RAND panel, and patient focus groups. Inflamm Bowel Dis 2012; 18:2294-300. [PMID: 22337359 DOI: 10.1002/ibd.22920] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 01/24/2012] [Indexed: 12/09/2022]
Abstract
BACKGROUND Comparative effectiveness research (CER) is an emerging field that compares the relative effectiveness of alternative strategies to prevent, diagnose, or treat patients who are typical of day-to-day practice. We developed a priority list of CER topics for inflammatory bowel disease (IBD). METHODS Following the Institute of Medicine's approach, we developed and administered a survey to gastroenterologists asking for important CER topics in IBD. Two patient focus groups were convened to solicit additional CER studies. CER topics were presented to the expert panel using the RAND/UCLA methodology. Following initial ratings, the panel met to discuss and re-rate priorities. The top 10 CER topics were identified using a point-allocation system. RESULTS Responses were collated into 234 CER topics across 21 categories, of which 87 were prioritized for discussion and re-rated. Disagreement regarding priorities was observed in 5 of 87 studies. We utilized a point-allocation system to prioritize the top-10 CER topics. These related to comparing the effectiveness of: biomarkers in IBD; withdrawal of anti-tumor necrosis factor (TNF) or immunomodulators for Crohn's disease in remission; mucosal healing as an endpoint of treatment; infliximab levels versus standard infliximab dosing; anti-TNF monotherapy versus combination therapy in patients failing thiopurines; safety of long-term treatment options; anti-TNF versus thiopurines for prevention of postoperative recurrence; and treatment options for steroid-refractory UC. CONCLUSIONS We systematically developed a list of high-priority IBD topics for CER based on a survey of gastroenterologists, expert review, and patient input. This list may guide IBD research toward the most important CER studies.
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Affiliation(s)
- A S Cheifetz
- Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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116
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Zaghiyan KN, Murrell Z, Melmed GY, Fleshner PR. High-dose perioperative corticosteroids in steroid-treated patients undergoing major colorectal surgery: necessary or overkill? Am J Surg 2012; 204:481-6. [DOI: 10.1016/j.amjsurg.2011.09.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 09/21/2011] [Accepted: 09/21/2011] [Indexed: 10/28/2022]
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Basseri RJ, Basseri B, Vassilaki ME, Melmed GY, Ippoliti A, Vasiliauskas EA, Fleshner PR, Lechago J, Hu B, Berel D, Targan SR, Papadakis KA. Colorectal cancer screening and surveillance in Crohn's colitis. J Crohns Colitis 2012; 6:824-9. [PMID: 22398087 DOI: 10.1016/j.crohns.2012.01.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Revised: 12/23/2011] [Accepted: 01/04/2012] [Indexed: 02/07/2023]
Abstract
AIMS To assess colonoscopic screening and surveillance for detecting neoplasia in patients with long-standing colonic Crohn's disease (CD). PATIENTS AND METHODS Colonoscopy and biopsy records from patients with colonic CD were evaluated at the Cedars-Sinai Inflammatory Bowel Disease Center during a 17-year period (1992-2009). RESULTS Overall, 904 screening and surveillance examinations were performed on 411 patients with Crohn's colitis (mean 2.2 examinations per patient). The screening and surveillance examinations detected neoplasia in 5.6% of the patient population; 2.7% had low-grade dysplasia (LGD) (n=11), 0.7% had high-grade dysplasia (HGD) (n=3), and 2.2% had carcinoma (anal carcinoma n=3; rectal carcinoma n=6). Mean age of CD diagnosis was 25.6±0.8 years in those with normal examinations, compared to 17.7±2.7 years (p<0.001) in those with HGD, 36.85±1.43 in those with LGD (p=0.021) and 28.32±3.24 years in those with any dysplasia/cancer (p=0.034). Disease duration in patients with normal examinations was 19.1±0.5 years, compared to 36.8±4.4 years (p<0.001) in HGD, 16.88±2.59 in those with LGD (p=0.253) and 30.68±4.03 years in those with any dysplasia/cancer (p=0.152). The mean interval between examinations was higher in HGD (31.5±9.4 months) compared to those with normal colonoscopies (12.92±1.250 months; p=0.002). CONCLUSIONS We detected cancer or dysplasia in 5.6% of patients with long-standing Crohn's colitis enrolled in a screening and surveillance program. Younger age at diagnosis of CD, longer disease course, and greater interval between exams were risk factors for the development of dysplasia.
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Affiliation(s)
- Robert J Basseri
- Department of Medicine and Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Dezfoli S, Melmed GY. Vaccination issues in patients with inflammatory bowel disease receiving immunosuppression. Gastroenterol Hepatol (N Y) 2012; 8:504-512. [PMID: 23293563 PMCID: PMC3533208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Treatment regimens for Crohn's disease and ulcerative colitis increase susceptibility to infections, many of which can be prevented by vaccinations. Increased awareness concerning vaccine-preventable diseases has led to several studies investigating the immunologic responses to vaccines in immunosuppressed patients with inflammatory bowel disease. This review provides an overview of the evidence-based rationale for currently accepted recommendations regarding the use of both inactivated and live vaccines in this unique population.
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Affiliation(s)
- Seper Dezfoli
- Dr. Dezfoli is a PGY-3 Resident in Internal Medicine at Cedars-Sinai Medical Center in Los Angeles, California. Dr. Melmed is the Director of Clinical Trials at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center and an Assistant Clinical Professor of Medicine at the David Geffen School of Medicine at the University of California, Los Angeles, both in Los Angeles, California
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119
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Horton HA, Melmed GY. Clostridium difficile in Inflammatory Bowel Disease. Seminars in Colon and Rectal Surgery 2012. [DOI: 10.1053/j.scrs.2012.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Huang B, Melmed GY, Shih DQ. Facial ulceration in a patient with Crohn's disease. Gastroenterology 2012; 142:1071, 1258. [PMID: 22440954 DOI: 10.1053/j.gastro.2011.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 09/04/2011] [Accepted: 09/16/2011] [Indexed: 12/30/2022]
Affiliation(s)
- Brian Huang
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Ollington KF, Brelian D, Morgan J, Le Q, Fleshner P, Melmed GY. Comparison of adenoma detection rates between gastroenterologists and colorectal surgeons. Am Surg 2012; 78:269-270. [PMID: 22369845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Kevin F Ollington
- Cedars-Sinai Medical Center, Department of Internal Medicine, Los Angeles, CA 90048, USA
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Ollington KF, Brelian D, Morgan J, Le Q, Fleshner P, Melmed GY. Comparison of Adenoma Detection Rates between Gastroenterologists and Colorectal Surgeons. Am Surg 2012. [DOI: 10.1177/000313481207800254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Kevin F. Ollington
- Cedars-Sinai Medical Center Department of Internal Medicine Los Angeles, California
| | - Daniel Brelian
- Cedars-Sinai Medical Center Department of Internal Medicine Los Angeles, California
| | - Janet Morgan
- Specialty Surgical Center Beverly Hills, California
| | - Quy Le
- Cedars-Sinai Medical Center Division of Colorectal Surgery Los Angeles, California
| | - Phillip Fleshner
- Cedars-Sinai Medical Center Division of Colorectal Surgery Los Angeles, California
| | - Gil Y. Melmed
- Cedars-Sinai Medical Center Division of Gastroenterology Los Angeles, California
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123
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Melmed GY. Immunizations and IBD: whose responsibility is it? If I'm the prescribing doctor, shouldn't it be mine? Inflamm Bowel Dis 2012; 18:41-2. [PMID: 21351213 DOI: 10.1002/ibd.21666] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2010] [Accepted: 01/06/2011] [Indexed: 12/09/2022]
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Agarwal N, Ollington K, Kaneshiro M, Frenck R, Melmed GY. Are immunosuppressive medications associated with decreased responses to routine immunizations? A systematic review. Vaccine 2011; 30:1413-24. [PMID: 22197580 DOI: 10.1016/j.vaccine.2011.11.109] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 11/26/2011] [Accepted: 11/29/2011] [Indexed: 01/02/2023]
Abstract
BACKGROUND Long-term immunosuppressive medications are being used more commonly for a variety of medical conditions, including immune-mediated diseases and organ transplantation. While these medications are often necessary, they are associated with an increased risk of serious infections. Vaccination may be a way to prevent a variety of infections but vaccine responses among patients receiving immunosuppressive therapies have been variable. PURPOSE To systematically review the literature describing immune responses among patients on immunosuppressive therapies to vaccinations including influenza, pneumococcal, meningococcal, hepatitis A and B, tetanus toxoid, pertussis, varicella, and zoster. DATA SOURCES English language citations in the MEDLINE and EMBASE databases from 1985 to 2010. STUDY SELECTION Two reviewers independently screened titles and abstracts to identify prospective, controlled studies reporting pre- and post-vaccination titers of recommended vaccines in patients receiving long-term immunosuppressive therapies for full-text review. DATA EXTRACTION Three reviewers independently assessed study characteristics including treatment regimens and pre- and post-vaccination titers. DATA SYNTHESIS Of the 972 identified titles, fifteen met inclusion criteria. Ten studies assessed the effects of immunosuppressive medications on responses to influenza vaccine, four studies investigated responses following pneumococcal vaccination, and one study assessed both influenza and pneumococcal vaccination. Five of the studies that evaluated influenza vaccination showed partially diminished responses among individuals receiving immunosuppressive therapies, while one of the pneumococcal vaccine studies showed significantly decreased responses following vaccination. Patients treated with more than one immunosuppressive medication were the least likely to respond to vaccination. LIMITATIONS The heterogeneity of reported outcomes limits generalizeability. CONCLUSIONS Immunosuppressive therapy, particularly combination regimens, may blunt response to influenza and pneumococcal vaccinations. To ensure the best chance of response, immunizations should be administered prior to initiation of immunosuppressive medications whenever possible.
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Affiliation(s)
- Nikhil Agarwal
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Abstract
The arrival of anti-tumor necrosis factor (TNF) agents has led to a dramatic improvement in the care of patients with Crohn's disease. Since these medications do not work in everyone, and are associated with rare, but serious side effects, we want to selectively treat patients who have the highest chance of responding. A number of variables have been studied to determine their association with response to anti-TNF agents. Clinical parameters include patient characteristics, smoking status and disease phenotype, and biologic markers include C-reactive protein, serum TNF levels and immune responses to microbial antigens. More recently, research has focused on genetics to identify polymorphisms associated with treatment response. Results from individual studies of these factors have not yet allowed for solid clinical applicability. However, further work in this area along with multivariate clinical prediction modeling may soon allow us to deliver 'personalized medicine' by predicting individualized treatment response in patients with Crohn's disease.
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Affiliation(s)
- Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Haritunians T, Jones MR, McGovern DP, Shih DQ, Barrett RJ, Derkowski C, Dubinsky MC, Dutridge D, Fleshner PR, Ippoliti A, King L, Leshinsky-Silver E, Levine A, Melmed GY, Mengesha E, Vasilauskas EA, Ziaee S, Rotter JI, Targan SR, Taylor KD. Variants in ZNF365 isoform D are associated with Crohn's disease. Gut 2011; 60:1060-7. [PMID: 21257989 PMCID: PMC3250380 DOI: 10.1136/gut.2010.227256] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Genome-wide association studies have identified multiple Crohn's disease (CD) susceptibility loci, including association with non-coding intergenic single-nucleotide polymorphisms (SNPs) at 10q21. DESIGN To fine-map the 10q21 locus, the authors genotyped 86 SNPs in 1632 CD cases and 961 controls and performed single-marker and conditional analyses using logistic regression. RESULTS Association with CD risk spanning 11 SNPs (p<0.001) was observed. The most significant association observed was at the non-synonymous SNP, rs7076156 (Ala62Thr), in ZNF365. The alanine allele was over-represented in CD (p=5.23×10⁻⁷; OR=1.39 (95% CI 1.22 to 1.58)); allele frequency of 76% in CD and 69.7% in controls). Conditional analysis on rs7076156 nullified all other significant associations, suggesting that this is the causative variant at this locus. Four isoforms of ZNF365 have previously been identified, and rs7076156 is located in an exon unique to ZNF365 isoform D. The authors demonstrated, using reverse transcription-PCR, expression of ZNF365D in intestinal resections from both CD subjects and controls. Markedly reduced mean expression levels of ZNF365D were identified in Epstein-Barr virus-transformed lymphoblastoid cell lines from CD subjects homozygous for the risk allele (Ala). A whole-genome microarray expression study further suggested that the Ala62Thr change in ZNF365 isoform D is related to differential expression of the genes ARL4A, MKKS, RRAGD, SUMF2, TDR1 and ZNF148 in CD. CONCLUSIONS Collectively, these data support the hypothesis that the non-synonymous Ala62Thr SNP, rs7076156, underlies the association between 10q21 and CD risk and suggest that this SNP acts by altering expression of genes under the control of ZNF365 isoform D.
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Affiliation(s)
- Talin Haritunians
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
| | - Michelle R. Jones
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA,Graduate Program in Biomedical Science and Translational Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Dermot P.B. McGovern
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA,Graduate Program in Biomedical Science and Translational Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA,Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - David Q. Shih
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Robert J. Barrett
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Carrie Derkowski
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Marla C. Dubinsky
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA,Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Debra Dutridge
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Phillip R. Fleshner
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Andrew Ippoliti
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Lily King
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | | | - Arie Levine
- Pediatric Gastroenterology Unit, Wolfson Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Gil Y. Melmed
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Emebet Mengesha
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Eric A. Vasilauskas
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Shabnam Ziaee
- Graduate Program in Biomedical Science and Translational Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA,Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Jerome I. Rotter
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Stephan R. Targan
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Kent D. Taylor
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
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Haritunians T, Taylor KD, Targan SR, Dubinsky M, Ippoliti A, Kwon S, Guo X, Melmed GY, Berel D, Mengesha E, Psaty BM, Glazer NL, Vasiliauskas EA, Rotter JI, Fleshner PR, McGovern DPB. Genetic predictors of medically refractory ulcerative colitis. Inflamm Bowel Dis 2010; 16:1830-40. [PMID: 20848476 PMCID: PMC2959149 DOI: 10.1002/ibd.21293] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute severe ulcerative colitis (UC) remains a significant clinical challenge and the ability to predict, at an early stage, those individuals at risk of colectomy for medically refractory UC (MR-UC) would be a major clinical advance. The aim of this study was to use a genome-wide association study (GWAS) in a well-characterized cohort of UC patients to identify genetic variation that contributes to MR-UC. METHODS A GWAS comparing 324 MR-UC patients with 537 non-MR-UC patients was analyzed using logistic regression and Cox proportional hazards methods. In addition, the MR-UC patients were compared with 2601 healthy controls. RESULTS MR-UC was associated with more extensive disease (P = 2.7 × 10(-6)) and a positive family history of UC (P = 0.004). A risk score based on the combination of 46 single nucleotide polymorphisms (SNPs) associated with MR-UC explained 48% of the variance for colectomy risk in our cohort. Risk scores divided into quarters showed the risk of colectomy to be 0%, 17%, 74%, and 100% in the four groups. Comparison of the MR-UC subjects with healthy controls confirmed the contribution of the major histocompatibility complex to severe UC (peak association: rs17207986, P = 1.4 × 10(-16)) and provided genome-wide suggestive association at the TNFSF15 (TL1A) locus (peak association: rs11554257, P = 1.4 × 10(-6)). CONCLUSIONS A SNP-based risk scoring system, identified here by GWAS analyses, may provide a useful adjunct to clinical parameters for predicting the natural history of UC. Furthermore, discovery of genetic processes underlying disease severity may help to identify pathways for novel therapeutic intervention in severe UC.
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Affiliation(s)
- Talin Haritunians
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Melmed GY, Spiegel BM, Bressler B, Cheifetz AS, Devlin SM, Harrell LE, Irving PM, Jones J, Kaplan GG, Kozuch PL, Velayos FS, Baidoo L, Sparrow MP, Siegel CA. The appropriateness of concomitant immunomodulators with anti-tumor necrosis factor agents for Crohn's disease: one size does not fit all. Clin Gastroenterol Hepatol 2010; 8:655-9. [PMID: 20451665 DOI: 10.1016/j.cgh.2010.04.023] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Revised: 04/13/2010] [Accepted: 04/16/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is no consensus on the appropriateness of concomitant immunomodulators with anti-tumor necrosis factor (TNF) therapy for Crohn's disease. Some patients benefit from concomitant immunomodulators, but concerns related to infections and lymphoma risk have dampened enthusiasm for this approach. We applied the RAND/University of California Los Angeles Appropriateness Method toward establishing appropriateness of concomitant immunomodulators and anti-TNF therapies for Crohn's disease. METHODS A literature review was conducted regarding efficacy and safety of concomitant immunomodulators in the setting of anti-TNF therapy for Crohn's disease and presented to the Building Research in Inflammatory Bowel Disease Globally group, a globally diverse panel of 13 gastroenterologists clinically experienced in inflammatory bowel disease. A total of 134 scenarios were constructed using several clinical variables. Panelists used a modified Delphi method to rate the appropriateness of concomitant immunomodulators, and met to discuss and re-rate appropriateness. Disagreement was assessed using a validated index. RESULTS Concomitant immunomodulators were generally rated appropriate for 63 scenarios, uncertain for 60 scenarios, and inappropriate for 11 scenarios. In general, concomitant immunomodulators were appropriate for those with extensive disease, shorter duration of disease, perianal involvement, prior surgery, females, and older patients (>26 y). Concomitant immunomodulators were generally rated inappropriate for young males, and in some scenarios involving uncomplicated disease. Smoking and the particular anti-TNF medication did not influence ratings. Disagreement was observed in 6 of 134 scenarios. CONCLUSIONS The appropriateness of concomitant immunomodulators with anti-TNF therapy for Crohn's disease was determined through a modified Delphi panel approach based on expert interpretation of the available literature. Clinicians should consider multiple factors when considering concomitant immunomodulators with anti-TNF treatment.
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Affiliation(s)
- Gil Y Melmed
- Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
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White E, Melmed GY, Vasiliauskas EA, Dubinsky M, Berel D, Targan SR, Fleshner PR. A prospective analysis of clinical variables, serologic factors, and outcome of ileal pouch-anal anastomosis in patients with backwash ileitis. Dis Colon Rectum 2010; 53:987-94. [PMID: 20551749 PMCID: PMC5002988 DOI: 10.1007/dcr.0b013e3181dcb3f2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE The outcome of ileal pouch-anal anastomosis in patients with backwash ileitis is controversial. We prospectively compared the outcomes of ileal pouch-anal anastomosis in colitis patients with backwash ileitis and colitis patients without backwash ileitis. METHODS Consecutive colitis patients undergoing ileal pouch-anal anastomosis were reviewed. All patients were classified after surgery as being either backwash ileitis-positive or backwash ileitis-negative. Serum drawn preoperatively was assayed, using enzyme-linked immunosorbent assay, for anti-Saccharomyces cerevisiae, anti-outer membrane of porin C, anti-CBir1, anti-I2, and perinuclear anti-neutrophil cytoplasmic antibody. Outcomes included acute pouchitis (antibiotic responsive), chronic pouchitis (antibiotic dependent or refractory), or de novo Crohn's disease (small inflammation above the pouch inlet or pouch fistula). RESULTS Out of 334 patients, 39 (12%) were backwash ileitis-positive. Compared with backwash ileitis-negative patients, backwash ileitis-positive patients had a higher incidence of pancolitis (100% vs 74%; P = .0001), primary sclerosing cholangitis (15% vs 2%; P = .001) and high-level (>100 enzyme-linked immunosorbent assay units/ml) perinuclear anti-neutrophil cytoplasmic antibody expression (29% vs 9%; P = .001). After a median follow-up of 26 months, 53 patients (16%) developed acute pouchitis, 37 (11%) developed chronic pouchitis, and 40 (12%) developed de novo Crohn's disease. There was no significant difference between the backwash ileitis-positive and backwash ileitis-negative patient groups in the incidence of acute pouchitis, chronic pouchitis, or de novo Crohn's disease. CONCLUSION There was a significantly higher incidence of pancolitis, primary sclerosing cholangitis, and high-level perinuclear anti-neutrophil cytoplasmic antibody expression in backwash ileitis-positive patients than in backwash ileitis-negative patients. The incidence of acute pouchitis, chronic pouchitis, and de novo Crohn's disease after ileal pouch-anal anastomosis does not differ significantly between backwash ileitis-positive and backwash ileitis-negative patients.
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Affiliation(s)
- Evan White
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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McGovern DPB, Gardet A, Törkvist L, Goyette P, Essers J, Taylor KD, Neale BM, Ong RTH, Lagacé C, Li C, Green T, Stevens CR, Beauchamp C, Fleshner PR, Carlson M, D'Amato M, Halfvarson J, Hibberd ML, Lördal M, Padyukov L, Andriulli A, Colombo E, Latiano A, Palmieri O, Bernard EJ, Deslandres C, Hommes DW, de Jong DJ, Stokkers PC, Weersma RK, Sharma Y, Silverberg MS, Cho JH, Wu J, Roeder K, Brant SR, Schumm LP, Duerr RH, Dubinsky MC, Glazer NL, Haritunians T, Ippoliti A, Melmed GY, Siscovick DS, Vasiliauskas EA, Targan SR, Annese V, Wijmenga C, Pettersson S, Rotter JI, Xavier RJ, Daly MJ, Rioux JD, Seielstad M. Genome-wide association identifies multiple ulcerative colitis susceptibility loci. Nat Genet 2010; 42:332-7. [PMID: 20228799 DOI: 10.1038/ng.549] [Citation(s) in RCA: 493] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Accepted: 01/26/2010] [Indexed: 02/07/2023]
Abstract
Ulcerative colitis is a chronic, relapsing inflammatory condition of the gastrointestinal tract with a complex genetic and environmental etiology. In an effort to identify genetic variation underlying ulcerative colitis risk, we present two distinct genome-wide association studies of ulcerative colitis and their joint analysis with a previously published scan, comprising, in aggregate, 2,693 individuals with ulcerative colitis and 6,791 control subjects. Fifty-nine SNPs from 14 independent loci attained an association significance of P < 10(-5). Seven of these loci exceeded genome-wide significance (P < 5 x 10(-8)). After testing an independent cohort of 2,009 cases of ulcerative colitis and 1,580 controls, we identified 13 loci that were significantly associated with ulcerative colitis (P < 5 x 10(-8)), including the immunoglobulin receptor gene FCGR2A, 5p15, 2p16 and ORMDL3 (orosomucoid1-like 3). We confirmed association with 14 previously identified ulcerative colitis susceptibility loci, and an analysis of acknowledged Crohn's disease loci showed that roughly half of the known Crohn's disease associations are shared with ulcerative colitis. These data implicate approximately 30 loci in ulcerative colitis, thereby providing insight into disease pathogenesis.
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Affiliation(s)
- Dermot P B McGovern
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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Abstract
The treatment of patients with IBD has evolved towards biologic therapy, which seeks to target specific immune and biochemical abnormalities at the molecular and cellular level. Multiple genes have been associated with susceptibility to IBD, and many of these can be linked to alterations in immune pathways. These immune pathways provide avenues for understanding the pathogenesis of IBD and suggest future drug targets, such as the IL-12-IL-23 pathway. In addition, failed therapeutic drug trials can provide valuable information about pitfalls in study design, drug delivery and disease activity assessment. Future biologic drug development will benefit from the early identification of subsets of patients who are most likely to respond to therapy by use of biological markers of genetic susceptibility or immunologic susceptibility.
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Affiliation(s)
- Gil Y Melmed
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, 8635 West 3rd Street, 960-W Los Angeles, CA 90048, USA.
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Pimentel M, Hwang L, Melmed GY, Low K, Vasiliauskas E, Ippoliti A, Yang J, Lezcano S, Conklin JL, Sahakian A. New clinical method for distinguishing D-IBS from other gastrointestinal conditions causing diarrhea: the LA/IBS diagnostic strategy. Dig Dis Sci 2010; 55:145-9. [PMID: 19169820 DOI: 10.1007/s10620-008-0694-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 12/29/2008] [Indexed: 01/14/2023]
Abstract
Modern methods of diagnosing diarrhea-predominant irritable bowel syndrome (D-IBS) require a "diagnosis of exclusion" approach. In this study we aim to test the diagnostic ability of using the fluctuation of frequency and consistency of bowel patterns in IBS to discriminate it from other causes of diarrhea. Eligible subjects were asked to complete a questionnaire on the changes in form and frequency of bowel habits by time. The primary endpoint was to evaluate the diagnostic effectiveness of having irregularly irregular bowel function and form as more characteristic of IBS versus non-IBS causes. Patients were prospectively recruited from a tertiary care GI clinic. Subjects had to have diarrhea as their primary complaint. In the case of IBS, D-IBS subjects were recruited. Subjects with celiac disease, Crohn's and ulcerative colitis were recruited for comparison and were categorically called "non-IBS." Non-IBS subjects could not have a recent history of blood in stool or a history of bowel surgery, fistulae or narcotic use. Sixty-two IBS and 37 non-IBS subjects were recruited. Among the 62 IBS subjects, 49 (79%) stated that their bowel habits varied in form and frequency on a daily basis compared to 35% in non-IBS subjects (OR = 8.9, CI = 3.5-22.5, P < 0.00001). When subjects were compared by the number of different stool forms they had witnessed in the prior week, IBS subjects noted 3.58 +/- 0.19 types and non-IBS reported 2.35 +/- 0.16 (P < 0.00001). Using > or = 3 stool forms per week as a method of discriminating IBS from non-IBS, 50 out of 62 subjects with IBS (81%) reported this greater number of forms compared to 15 out of 37 (41%) non-IBS subjects (sensitivity = 0.81; specificity = 0.60). The use of this simple tool that identifies an irregularly irregular bowel form and function is successful in separating D-IBS from non-IBS subjects.
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Affiliation(s)
- Mark Pimentel
- GI Motility Program, Cedars-Sinai Medical Center, 8730 Alden Drive, Suite 225E, Los Angeles, CA 90048, USA.
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Melmed GY, Kar S, Geft I, Lo SK. A new method for endoscopic closure of gastrocolonic fistula: novel application of a cardiac septal defect closure device (with video). Gastrointest Endosc 2009; 70:542-5. [PMID: 19699982 DOI: 10.1016/j.gie.2009.03.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 03/11/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastrocolonic fistula after percutaneous endoscopic gastrostomy PEG tube placement is an uncommon but serious complication. These fistulous tracts are often fibrotic and frequently require surgical intervention. OBJECTIVE To describe a novel endoscopic treatment for gastrocolonic fistula. DESIGN Case report. SETTING Inpatient hospital setting. PATIENT An 82-year-old woman was seen 1 year after PEG placement with feculent vomiting; imaging studies showed a gastrocolonic fistula. Cardiopulmonary comorbidities posed an unacceptable surgical risk. Endoscopic attempts at fistula closure with hemoclip placement and biodegradable plug were unsuccessful. Total parenteral nutrition resulted in multiple metabolic and infectious complications. INTERVENTION Gastrocolonic fistula closure was performed twice by using cardiac septal defect closure devices. The first closure was achieved by using the Amplatzer double-disk nitinol wire mesh atrial septal defect closure device, which was deployed under endoscopic and fluoroscopic guidance across the fistula tract. The proximal disk was then injected with cyanoacrylate glue to create a watertight seal. The second closure, performed 4 months later after collapse of the initial device, was performed by using the CardioSEAL septal repair implant. This was secured in place with hemoclips and similarly injected with cyanoacrylate glue to create a watertight seal. MAIN OUTCOME MEASUREMENTS Fistula closure, as determined by contrast gastrogram through a PEG tube and gastrograffin enema. RESULTS Successful fistula closure was achieved for 4 months after initial device placement. After the second device was placed, the patient remained clinically well until her demise 18 months later from unrelated causes. LIMITATIONS These procedures were performed on only one subject. CONCLUSIONS Successful endoscopic closure of gastrocolonic fistula can be achieved, even with long-standing, fibrotic fistulous tracts by using a novel endoscopic approach.
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Affiliation(s)
- Gil Y Melmed
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, David Geffen School of Medicine, University of California, Los Angeles, California 90048, USA.
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Abstract
The treatment of Crohn's disease and ulcerative colitis frequently includes potent immunomodulator and biologic therapy to reduce intestinal inflammation, heal fistulae, limit complications, and improve quality of life. These medications may increase susceptibility to and severity of infections, many of which are preventable by preemptive immunizations. Conversely, live-virus vaccines are generally contraindicated in patients receiving immunosuppressive regimens due to risks of vaccine-associated infection. While most patients on immunosuppressive therapies develop immune responses after vaccinations, these may be impaired relative to their nonimmunosuppressed counterparts. This review discusses the rationale for currently recommended vaccinations, as well as issues pertaining to vaccine safety and immunogenicity in immunosuppressed patients with inflammatory bowel disease and their household contacts.
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Affiliation(s)
- Gil Y Melmed
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Murrell ZA, Melmed GY, Ippoliti A, Vasiliauskas EA, Dubinsky M, Targan SR, Fleshner PR. A prospective evaluation of the long-term outcome of ileal pouch-anal anastomosis in patients with inflammatory bowel disease-unclassified and indeterminate colitis. Dis Colon Rectum 2009; 52:872-8. [PMID: 19502850 DOI: 10.1007/dcr.0b013e31819f5d4c] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The long-term outcome of ileal pouch-anal anastomosis in patients with indeterminate colitis is controversial. The aim of this study was to prospectively evaluate the long-term outcome of ileal pouch-anal anastomosis in a closely monitored cohort of patients with ulcerative colitis or indeterminate colitis. METHODS Prospectively generated clinical profiles on consecutive patients with ulcerative colitis or indeterminate colitis undergoing ileal pouch-anal anastomosis with close postoperative follow-up by one surgeon were reviewed. All patients were classified before surgery as either ulcerative colitis or inflammatory bowel disease-unclassified, and after surgery as either ulcerative colitis or indeterminate colitis. Long-term outcomes included acute pouchitis (antibiotic responsive), chronic pouchitis (antibiotic dependent or refractory), or de novo Crohn's disease (small inflammation above the pouch inlet or pouch fistula). RESULTS The study cohort of 334 patients were classified before surgery as ulcerative colitis in 237 (71 percent) and inflammatory bowel disease-unclassified in 97 (29 percent). After surgery, patients were classified as ulcerative colitis in 236 (71 percent) and indeterminate colitis in 98 (29 percent). After a median follow-up after stoma closure of 26 months, 53 patients (16 percent) developed acute pouchitis, 37 patients (11 percent) developed chronic pouchitis, and 40 patients (12 percent) developed de novo Crohn's disease. There was no significant difference in the incidence of acute pouchitis, chronic pouchitis, or de novo Crohn's disease between the ulcerative colitis, inflammatory bowel disease-unclassified, and indeterminate colitis patient groups. CONCLUSION The incidence of acute pouchitis, chronic pouchitis, and de novo Crohn's disease after ileal pouch-anal anastomosis do not differ significantly between patients with ulcerative colitis, inflammatory bowel disease-unclassified, or indeterminate colitis. Patients with inflammatory bowel disease-unclassified and indeterminate colitis can undergo ileal pouch-anal anastomosis and expect a long-term outcome equivalent to patients with ulcerative colitis.
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Affiliation(s)
- Zuri A Murrell
- Department of Surgery, Division of Colon and Rectal Surgery, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Affiliation(s)
- Gil Y Melmed
- David Geffen UCLA School of Medicine, Cedars-Sinai Medical Center, USA
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Melmed GY. Vaccinations and the Utilization of Immunosuppressive IBD Therapy. Gastroenterol Hepatol (N Y) 2008; 4:859-861. [PMID: 21904475 PMCID: PMC3093688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Gil Y Melmed
- Clinical Assistant Professor of Medicine Department of Gastroenterology Cedars-Sinai Medical Center David Geffen UCLA School of Medicine
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Sparrow MP, Irving PM, Baidoo L, Bressler B, Cheifetz AS, Devlin SM, Harrell LE, Jones J, Kozuch PL, Melmed GY, Velayos FS, Siegel CA. Current Controversies in Crohn's Disease: A Roundtable Discussion of the BRIDGe Group. Gastroenterol Hepatol (N Y) 2008; 4:713-20. [PMID: 21960891 PMCID: PMC3104182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In March 2008, a roundtable discussion was convened by the inflammatory bowel disease (IBD) specialist panel the BRIDGe (Building Resources and Research in IBD Globally) group, which consists of junior faculty gastroenterologists who have undergone advanced fellowship training at IBD referral centers in the United States, Canada, the United Kingdom, and Australia. An agenda was formulated to discuss three current controversies in Crohn's disease management: the role of 5-aminosalicylates, the use of biologic combination therapy versus monotherapy, and the use of step-up therapy versus top-down therapy for Crohn's disease. The aim of the meeting was three-fold: to review the data pertaining to each topic; to collect opinions from the participants as to their analysis of the literature and their current practice; and, where possible, to formulate recommendations of current best practice given the available evidence. This manuscript summarizes the discussions on these three areas of controversy in the current management of Crohn's disease.
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Affiliation(s)
| | - Peter M. Irving
- Southend University Hospital NHS Foundation Trust, United Kingdom
| | | | | | | | | | | | | | | | - Gil Y. Melmed
- Cedars-Sinai Medical Center, Los Angeles, California
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Melmed GY, Fleshner PR, Papadakis KA. Proximal small intestinal CD detected by CE. Gastrointest Endosc 2008; 68:202-3; author reply 203-4. [PMID: 18577488 DOI: 10.1016/j.gie.2007.12.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2007] [Accepted: 12/26/2007] [Indexed: 02/08/2023]
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Melmed GY, Devlin SM, Vlotides G, Dhall D, Ross S, Yu R, Melmed S. Anti-aging therapy with human growth hormone associated with metastatic colon cancer in a patient with Crohn's colitis. Clin Gastroenterol Hepatol 2008; 6:360-3. [PMID: 18255351 PMCID: PMC2696478 DOI: 10.1016/j.cgh.2007.12.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The nonapproved use of human growth hormone (HGH) for anti-aging has been increasing. Theoretical concerns for neoplastic potentiation by HGH have been raised, but not proven clinically. METHODS We report the case of a 68-year-old man with colonic Crohn's disease who was found to have aggressive metastatic colon cancer. The patient had been receiving HGH therapy for anti-aging purposes for 7 years before presentation. Normal and malignant colonic tissue was examined for qualitative and quantitative molecular profiles of growth hormone (GH) and its signaling molecules, using immunohistochemistry and RNA extraction with polymerase chain reaction amplification. RESULTS Immunoreactivity was more robust in tumor tissue than in normal colon for insulin-like growth factor-1 receptor (IGF-1R) but not for IGF, GH, or GH receptor. RNA extraction with quantitative polymerase chain reaction showed that IGF-1R and vascular endothelial growth factor expression, but not IGF-1, GH receptor, or suppressor of cytokine signaling-2, were higher in tumor than in normal colonic tissue. CONCLUSIONS Colorectal cancer development concurrent with administration of HGH for anti-aging purposes occurred in an individual already at increased risk for colon cancer. This underscores the need for further investigation of the proneoplastic potential of GH supplementation for anti-aging.
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Affiliation(s)
| | | | | | - Deepti Dhall
- Departments of Medicine and Anatomic Pathology, Cedars-Sinai Medical Center, David Geffen School of Medicine, University of California, Los Angeles, CA
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Melmed GY, Fleshner PR, Bardakcioglu O, Ippoliti A, Vasiliauskas EA, Papadakis KA, Dubinsky M, Landers C, Rotter JI, Targan SR. Family history and serology predict Crohn's disease after ileal pouch-anal anastomosis for ulcerative colitis. Dis Colon Rectum 2008; 51:100-8. [PMID: 18085333 PMCID: PMC2442922 DOI: 10.1007/s10350-007-9158-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 09/27/2007] [Accepted: 10/17/2007] [Indexed: 12/13/2022]
Abstract
PURPOSE Approximately 5 to 10 percent of patients undergoing ileal pouch-anal anastomosis with a diagnosis of ulcerative colitis are subsequently diagnosed with Crohn's disease. Preoperative predictors for Crohn's disease post-ileal pouch-anal anastomosis have not been prospectively defined. METHODS A total of 238 consecutive patients with ulcerative colitis or indeterminate colitis undergoing ileal pouch-anal anastomosis were prospectively enrolled into a longitudinal database. Clinical factors were assessed perioperatively. Serum drawn preoperatively was assayed for anti-Saccharomyces cerevisiae, antiouter membrane porin-C, anti-CBir1, and perinuclear antineutrophil cytoplasmic antibody using enzyme-linked immunosorbent assay. Crohn's disease was defined by small bowel inflammation proximal to the ileal pouch or a perianal fistula identified at least three months after ileostomy closure. Predictors were assessed in a multivariate Cox proportional hazards model to predict the rate of Crohn's disease after ileostomy closure. RESULTS Sixteen patients (7 percent) were diagnosed with Crohn's disease; median time to Crohn's disease was 19 (range, 1-41) months. Significant factors for postoperative Crohn's disease after ileal pouch-anal anastomosis included family history of Crohn's disease (hazard ratio, 8.4; 95 percent confidence interval, 2.96-24.1; P < 0.0001) and anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity (hazard ratio, 3.14; 95 percent confidence interval, 1.1-9.81; P = 0.04). Crohn's disease developed in only 8 of 198 patients (4 percent) without these predictors vs. 8 of 40 patients (20 percent) in those with at least one of these factors (P = 0.002). The cumulative risk of Crohn's disease among patients with two risk factors (67 percent) was higher than in patients with either risk factor (18 percent) or neither risk factor (4 percent, P < 0.001). CONCLUSIONS Patients with ulcerative colitis and indeterminate colitis with a family history of Crohn's disease or preoperative anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity are more likely to be diagnosed with Crohn's disease after ileal pouch-anal anastomosis.
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Affiliation(s)
- Gil Y Melmed
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Melmed GY, Elashoff R, Chen GC, Nastaskin I, Papadakis KA, Vasiliauskas EA, Liu W, Landers C, Ippoliti AF, Targan SR. Predicting a change in diagnosis from ulcerative colitis to Crohn's disease: a nested, case-control study. Clin Gastroenterol Hepatol 2007; 5:602-8; quiz 525. [PMID: 17478347 DOI: 10.1016/j.cgh.2007.02.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Some patients diagnosed with UC undergo a change in diagnosis to CD. Identification of predictors of a diagnostic change could potentially impact the management of patients with colonic inflammation. Our aim was to characterize clinical and serologic predictors of a change in diagnosis from UC to CD. METHODS A nested, case-controlled study was performed to compare individuals with a change in diagnosis from UC to CD (cases) with age-matched UC and CD controls; primary analysis compared cases with UC controls. Subjects underwent chart review for clinical "red flags" identified by gastroenterologists with expertise in IBD. Serum collected at the time of database enrollment was tested for antibodies to oligomannan (anti-Saccharomyces cerevisiae), Pseudomonas fluorescens-related protein, Escherichia coli outer membrane porin C, CBir1 flagellin, and perinuclear antineutrophil cytoplasmic antibodies. RESULTS Twenty-one cases, 52 UC controls, and 56 CD controls were assessed. Three red flags, but no serologic markers, differed between cases and UC controls. At initial colonoscopy, cases were more likely to have extensive colonic involvement than UC controls (P = .008). Multivariate regression identified non-bloody diarrhea at initial presentation (P = .01) and weight loss >10% at presentation (P = .007) as independent predictors of diagnostic change. Serologic markers did not add to the contribution of these 2 clinical factors in predicting a change in diagnosis from UC to CD. Diagnostic change was evident in 6 of 6 (100%) patients with both predictors, compared with 8 of 50 (16%) with neither of these factors (P < .0001). CONCLUSIONS Patients with a diagnosis of UC with initial non-bloody diarrhea or weight loss have an increased likelihood of subsequent change in diagnosis to CD and might thus warrant further diagnostic work-up.
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Affiliation(s)
- Gil Y Melmed
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, David Geffen School of Medicine, University of California Los Angeles, California, USA
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Dubois RW, Aguilar D, Fass R, Orr WC, Elfant AB, Dean BB, Harper AS, Yu HT, Melmed GY, Lynn R, Singh A, Tedeschi M. Consequences of frequent nocturnal gastro-oesophageal reflux disease among employed adults: symptom severity, quality of life and work productivity. Aliment Pharmacol Ther 2007; 25:487-500. [PMID: 17270005 DOI: 10.1111/j.1365-2036.2006.03189.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Effects of frequent nocturnal symptoms of gastro-oesophageal reflux disease (GERD-FNS) on health-related quality of life (HRQOL) and work productivity are not well documented. AIM To assess symptom severity, production loss, and HRQOL among employed adults with and without GERD-FNS. METHODS Using several validated outcome measures in a web survey design, GERD was pre-specified as GERD Symptom and Medication Questionnaire score >9, and > or =1 episode of heartburn or acid regurgitation during the preceding week. GERD-FNS patients were those reporting > or =2 symptom-nights during the previous week; their outcomes were compared with those of patients having minimal or no nocturnal symptoms (GERD-NNS) and vs. non-GERD controls. RESULTS Data were collected from 1002 GERD patients (476 GERD-FNS, 526 GERD-NNS) and 513 controls. Severe symptoms were more common, sleep abnormalities were more frequent (P < 0.0001) and SF-36 scores lower (P < 0.05, all scores) among GERD-FNS patients vs. GERD-NNS patients. GERD-related work loss was greater among those with GERD-FNS vs. GERD-NNS (P < 0.0001). Work loss and functional limitations were more pronounced when comparing GERD-FNS cases vs. non-GERD controls. CONCLUSION Employed adults with frequent nocturnal GERD report more severe symptoms, and are associated with impaired sleep, HRQOL and work productivity compared with controls and patients with minimal or no nocturnal symptoms.
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Affiliation(s)
- R W Dubois
- Cerner LifeSciences, Los Angeles, CA, USA
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Devlin SM, Yang H, Ippoliti A, Taylor KD, Landers CJ, Su X, Abreu MT, Papadakis KA, Vasiliauskas EA, Melmed GY, Fleshner PR, Mei L, Rotter JI, Targan SR. NOD2 variants and antibody response to microbial antigens in Crohn's disease patients and their unaffected relatives. Gastroenterology 2007; 132:576-86. [PMID: 17258734 DOI: 10.1053/j.gastro.2006.11.013] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Accepted: 10/26/2006] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The Cdcs1 locus of the C3Bir mouse confers severe colitis associated with a decrease in innate immune function and an increase in adaptive T-cell responses to commensal bacterial products. The aim of our study was to determine if defects in innate immunity are similarly associated with increased adaptive immune responses to microbial antigens in Crohn's disease patients. METHODS Sera from 732 patients, 220 unaffected relatives, and 200 healthy controls were tested for antibodies to oligomannan, the Pseudomonas fluorescens-related protein, Escherichia coli outer membrane porin C, CBir1 flagellin, and DNA from the same subjects was tested for 3 Crohn's disease-associated variants of the NOD2 gene, and 5 toll-like receptor (TLR) 2, 2 TLR4, and 2 TLR9 variants. The magnitude of responses to microbial antigens was examined according to variant status. RESULTS NOD2 variant carriage increased in frequency with increasing number of positive antibodies and increasing cumulative quantitative response as measured by quartile sum (P for trend, .0008 and .0003, respectively). Mean antibody and quartile sums were higher for patients carrying any NOD2 variant versus those carrying none (2.24 vs 1.92 and 10.60 vs 9.72; P = .0008 and P = 0.0003, respectively). The mean quartile sum was higher for unaffected relatives carrying any NOD2 variant versus those carrying none (10.67 vs 9.75, respectively; P = .02). No association was found between any TLR variant and the magnitude of response. CONCLUSIONS Patients with Crohn's disease and unaffected relatives carrying variants of the NOD2 gene have increased adaptive immune responses to microbial antigens.
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Affiliation(s)
- Shane M Devlin
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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Melmed GY, Ippoliti AF, Papadakis KA, Tran TT, Birt JL, Lee SK, Frenck RW, Targan SR, Vasiliauskas EA. Patients with inflammatory bowel disease are at risk for vaccine-preventable illnesses. Am J Gastroenterol 2006; 101:1834-40. [PMID: 16817843 DOI: 10.1111/j.1572-0241.2006.00646.x] [Citation(s) in RCA: 234] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with chronic, immune-mediated conditions such as inflammatory bowel disease (IBD) are often treated with long-term immunosuppressive therapies, potentially increasing their risk of developing an infection. Empiric data suggest that vaccines are underutilized in immunocompromised patients, despite published guidelines recommending their use. We aimed to assess exposure risk and immunization status among patients receiving care in an IBD specialty clinic. METHODS Patients completed a self-administered, pretested, structured questionnaire during a routine visit for the management of IBD. Survey questions related to medical and immunization histories, and exposures to known risk factors for influenza, pneumococcus, viral hepatitis, and varicella. Additionally, in a subgroup of patients who agreed to donate a sample of blood, immune status to hepatitis A (HAV), hepatitis B (HBV), and varicella was determined. RESULTS Two hundred four patients were asked to participate in the study; 169 completed surveys and comprised the study population. Mean age was 35 yr (range 13-75 yr). One hundred forty-six respondents (86%) reported current or prior use of immunosuppressive medications. Only 45% of respondents recalled tetanus immunization within the past 10 yr, 41 (28%) reported regularly receiving flu shots, and 13 (9%) reported having received pneumococcal vaccine. The most common reasons for nonimmunization with influenza included lack of awareness (49%) and concern for side effects (18%). Responses indicated that 75 (44%) patients were at risk for HBV but only 47 (28%) had been vaccinated against the infection; of patients with previous HBV vaccination, only three of nine (33%) had measurable antibodies against hepatitis B surface antigen. CONCLUSIONS Immunization against selected vaccine-preventable illnesses was uncommon in patients with IBD, despite the presence of significant risk factors. Efforts to improve immunization status among patients with IBD and other chronic, immune-mediated conditions are needed.
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Affiliation(s)
- Gil Y Melmed
- Department of Medicine, Division of Gastroenterology, Cedars-Sinai Medical Center Los Angeles, California 90048, USA
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Abstract
Few advances in the history of gastroenterology have made as dramatic an impact on the diagnosis of gastrointestinal disease as the development and rapid clinical implementation of wireless capsule endoscopy. Less than 4 years after the landmark publication, capsule endoscopy is widely considered an essential component of the diagnostic workup of obscure gastrointestinal bleeding, and its role is expanding in the diagnosis of small bowel diseases such as Crohn's disease. This review appraises the available literature and highlights practical aspects of capsule endoscopy of interest to the clinician. We discuss safety concerns, optimal preparation for the procedure, diagnostic utility as compared to conventional methods, indications for capsule endoscopy, and outcomes.
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Affiliation(s)
- Gil Y Melmed
- Divison of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Abstract
Several important advances have been made over the past few years that have expanded our knowledge of the immunology of the gut and its complex interactions with commensal organisms. Critical developments in our understanding of the pathogenesis of inflammatory bowel diseases include the discovery of Toll-like receptors and the identification of not one but two susceptibility genes for Crohn's disease. We have furthered our understanding significantly concerning the role of dendritic cells in the development of gut inflammation. In addition, a novel hypothesis suggesting a protective role for helminthic infections is gaining experimental evidence and direct clinical applicability. In this review we summarize these key developments in the pathophysiology of inflammatory bowel disease and attempt to ascribe clinical relevance where applicable.
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Affiliation(s)
- Gil Y Melmed
- Department of Medicine, Division of Gastroenterology, Inflammatory Bowel Disease Center, Mount Sinai School of Medicine, 1190 Fifth Avenue, New York, NY 10029, USA
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