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Minar PP, Colman RJ, Zhang N, Mizuno T, Vinks AA. Precise infliximab exposure and pharmacodynamic control to achieve deep remission in paediatric Crohn's disease (REMODEL-CD): study protocol for a multicentre, open-label, pragmatic clinical trial in the USA. BMJ Open 2024; 14:e077193. [PMID: 38531570 DOI: 10.1136/bmjopen-2023-077193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION The only biologic therapy currently approved to treat moderate to severe Crohn's disease in children (<18 years old) are those that antagonise tumour necrosis factor-alpha (anti-TNF). Therefore, it is critically important to develop novel strategies that maximise treatment effectiveness in this population. There is growing evidence that rates of sustained corticosteroid-free clinical remission, endoscopic healing and drug durability considerably improve when patients receive early anti-TNF dose optimisations guided by reactive or proactive therapeutic drug monitoring and pharmacodynamic monitoring. In response, our team has developed a personalised and scalable infliximab dosing intervention that starts with dose selection and continues throughout maintenance to optimise drug exposure. We hypothesise that a precision dosing strategy starting from induction and targeting dose-specific pharmacokinetic and pharmacodynamic endpoints throughout therapy will significantly improve outcomes compared with a conventional dosing strategy. METHODS AND ANALYSIS Conduct a clinical trial to assess rates of deep remission between Crohn's disease patients receiving infliximab with precision dosing (n=90) versus conventional care (n=90). Patients (age 6-22 years) will be recruited from 10 medical centres in the USA. Each centre has been selected to provide either precision dosing or conventional care dosing. Precision dosing includes the use of a clinical decision support tool (RoadMAB) from the start of infliximab to achieve specific (personalised) trough concentrations and specific pharmacodynamic targets (at doses 3, 4 and 6). Conventional care includes the use of a modified infliximab starting dose (5 or 7.5 mg/kg based on the pretreatment serum albumin) with a goal to achieve maintenance trough concentrations of 5-10 µg/mL. The primary endpoint is year 1 deep remission defined as a combination of clinical remission (paediatric Crohn's disease activity index<10 (child) or a Crohn's disease activity index<150 (adults)), off prednisone>8 weeks and endoscopic remission (simple endoscopic severity-Crohn's disease≤2). ETHICS AND DISSEMINATION ). The study protocol has been approved by the Cincinnati Children's Hospital Medical Centre Institutional Review Board. Study results will be disseminated in peer-reviewed journals and presented at scientific meetings. TRIAL REGISTRATION NUMBER NCT05660746.
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Affiliation(s)
- Phillip Paul Minar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Ruben J Colman
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Nanhua Zhang
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tomoyuki Mizuno
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Samalik JM, Goldberg CS, Modi ZJ, Fredericks EM, Gadepalli SK, Eder SJ, Adler J. Discrepancies in Race and Ethnicity in the Electronic Health Record Compared to Self-report. J Racial Ethn Health Disparities 2023; 10:2670-2675. [PMID: 36418736 DOI: 10.1007/s40615-022-01445-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/19/2022] [Accepted: 11/01/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Racial and ethnic disparities are commonplace in health care. Research often relies on sociodemographic information recorded in the electronic health record (EHR). Little evidence is available about the accuracy of EHR-recorded sociodemographic information, and none in pediatrics. Our objective was to determine the accuracy of EHR-recorded race and ethnicity compared to self-report. METHODS Patients/guardians enrolled in two prospective observational studies (10/2014-1/2019) provided self-reported sociodemographic information. Corresponding EHR information was abstracted. EHR information was compared to self-report, considered "gold standard." Agreement was evaluated with Cohen's kappa. RESULTS A total of 503 patients (42% female, median age 12.8 years) were identified. Self-reported race (N = 484) was 73% White, 16% Black or African American (AA), 4% Asian, 5% multiracial, and 2% other. Self-reported ethnicity (N = 410) was 9% Hispanic/Latino, and 88% non-Hispanic/Latino. Agreement between self-reported and EHR-recorded race was substantial (kappa = 0.77, 95% CI 0.72-0.83). Race was discordant among 10% (47/476). Hispanic/Latino ethnicity also had strong agreement (kappa = 0.77, 95% CI 0.65-0.89). Among those who self-reported Hispanic/Latino and reported race (N = 21), race was less accurately recorded in the EHR (kappa = 0.26, 95% CI 0-0.54). Race did not match among 43% with recorded race (9/21). Among self-reported racial and/or ethnic minorities, 13% (12/164) were misclassified in the EHR as non-Hispanic White. CONCLUSIONS We found race and ethnicity are often inaccurately recorded in the EHR for patients who self-identify as minorities, leading to under-representation of minorities in the EHR. Inaccurately recorded race and ethnicity has important implications for disparity research, and for informing health policy. Reliable processes are needed to incorporate self-reported race and ethnicity in the EHR at institutional and national levels.
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Affiliation(s)
- Joann M Samalik
- Division of Pediatric Gastroenterology, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Caren S Goldberg
- Division of Pediatric Cardiology, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Zubin J Modi
- Susan B. Meister Child Health Evaluation and Research Center, 2900 Plymouth Rd, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Pediatric Nephrology, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Emily M Fredericks
- Susan B. Meister Child Health Evaluation and Research Center, 2900 Plymouth Rd, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Pediatric Psychology, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Susan B. Meister Child Health Evaluation and Research Center, 2900 Plymouth Rd, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Pediatric Surgery, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sally J Eder
- Susan B. Meister Child Health Evaluation and Research Center, 2900 Plymouth Rd, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeremy Adler
- Division of Pediatric Gastroenterology, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Susan B. Meister Child Health Evaluation and Research Center, 2900 Plymouth Rd, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
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Erculiani M, Poluzzi F, Mottadelli G, Felici E, Ml N, Caraccia M, Grandi A, Casella S, Giacometti L, Montobbio G, Ceccherini I, Di Marco E, Bonaretti C, Biassoni R, Squillario M, Pietrantoni A, Villanacci V, Pini Prato A. A unicentric cross-sectional observational study on chronic intestinal inflammation in total colonic aganglionosis: beware of an underestimated condition. Orphanet J Rare Dis 2023; 18:339. [PMID: 37891621 PMCID: PMC10612252 DOI: 10.1186/s13023-023-02958-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/23/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Inflammatory Bowel Diseases (IBD) are known to occur in association with Hirschsprung disease (HSCR). Most of cases are represented by Crohn Disease (CD) occurring in patients with Total Colonic Aganglionosis (TCSA) with an estimated prevalence of around 2%. Based on these considerations and on a number of provisional data belonging to our Center for Digestive Diseases, we developed a unicentric cross-sectional observational study aimed at describing phenotype, genotype, pathology and metagenomics of all patients with TCSA and Crohn-like lesions. RESULTS Out of a series of 62 eligible TCSA patients, 48 fulfilled inclusion criteria and were enrolled in the study. Ten patients did not complete the study due to non-compliance or withdrawal of consent and were subsequently dropped out. A total of 38 patients completed the study. All patients were tested for chronic intestinal inflammation by a combination of fecal calprotectine (FC) or occult fecal blood (OFB) and underwent fecal metagenomics. Nineteen (50%) tested positive for FC, OFB, or both and subsequently underwent retrograde ileoscopy. Fourteen patients (36.8%) presented Crohn-like lesions, occurring after a median of 11.5 years after surgery (range 8 months - 21.5 years). No statistically significant differences regarding demographic, phenotype and genotype were observed comparing patients with and without lesions, except for need for blood transfusion that was more frequent in those with lesions. Faecal microbiome of patients with lesions (not that of caregivers) was less biodiverse and characterized by a reduction of Bacteroidetes, and an overabundance of Proteobacteria. FC tested negative in 3/14 patients with lesions (21%). CONCLUSIONS Our study demonstrated an impressive 10-folds higher incidence of chronic inflammation in TCSA. Up to 50% of patients may develop IBD-like lesions postoperatively. Nonetheless, we failed in identifying specific risk factors to be used to implement prevention strategies. Based on the results of our study, we suggest screening all TCSA patients with retrograde ileoscopy regardless of FC/OFB values. The frequency of endoscopic assessments and the role of FC/OFB screening in prompting endoscopy is yet to be determined.
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Affiliation(s)
- M Erculiani
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - F Poluzzi
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - G Mottadelli
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - E Felici
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Novi Ml
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - M Caraccia
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - A Grandi
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - S Casella
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - L Giacometti
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
- Division of Pathology, Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - G Montobbio
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - I Ceccherini
- UOSD Laboratory of Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - E Di Marco
- Central Laboratory, Giannina Gaslini Institute, Genoa, Italy
| | - C Bonaretti
- Molecular Diagnostic, Giannina Gaslini Institute, Genoa, Italy
| | - R Biassoni
- Molecular Diagnostic, Giannina Gaslini Institute, Genoa, Italy
| | - M Squillario
- IRCCS Ospedale Policlinico San Martino Genoa, Genoa, Italy
| | - A Pietrantoni
- Institute of Pathology, ASST-Spedali Civili, University of Brescia, Brescia, Italy
| | - V Villanacci
- Institute of Pathology, ASST-Spedali Civili, University of Brescia, Brescia, Italy
| | - A Pini Prato
- Umberto Bosio Center for Digestive Diseases, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.
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Liu R, Liu S, Yi L, Wang D, Zhou X, Zhiming W, Ren K, Ke J, Zhu W, Lu Y. Development and validation of multiparametric models based on computed tomography enterography to determine endoscopic activity and surgical risk in patients with Crohn's disease: A multi-center study. Heliyon 2023; 9:e19942. [PMID: 37810028 PMCID: PMC10559359 DOI: 10.1016/j.heliyon.2023.e19942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 08/24/2023] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Objective To develop novel multiparametric models based on computed tomography enterography (CTE) scores to identify endoscopic activity and surgical risk in patients with Crohn's disease (CD). Methods We analyzed 171 patients from 3 hospitals. Correlations between CTE outcomes and endoscopic scores were assessed using Spearman's rank correlation analysis. Predictive models for moderate to severe CD were developed, and receiver operating characteristic (ROC) curves were constructed to determine the area under the ROC curve (AUC). A combined nomogram based on CTE scores and clinical variables was also developed for predicting moderate to severe CD and surgery. Results CTE scores were significantly correlated with endoscopy scores at the segment level. The global CTE score was an independent predictor of severe (HR = 1.231, 95% CI: 1.048-1.446, p = 0.012) and moderate-to-severe Simplified Endoscopic Scores for Crohn's Disease (SES-CD) (HR = 1.202, 95% CI: 1.090-1.325, p < 0.001). The nomogram integrating CTE and clinical data predicted moderate to severe SES-CD and severe SES-CD scores in the validation cohort with AUCs of 0.837 and 0.807, respectively. The CTE score (HR = 1.18; 95% CI: 1.103-1.262; p = 0.001) and SES-CD score (HR = 3.125, 95% CI: 1.542-6.33; p = 0.001) were independent prognostic factors for surgery-free survival. A prognostic nomogram incorporating CTE scores, SES-CD and C-reactive protein (CRP) accurately predicted the risk of surgery in patients with CD. Conclusion The newly developed CTE score and multiparametric models displayed high accuracy in predicting moderate to severe CD and surgical risk for CD patients.
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Affiliation(s)
- Ruiqing Liu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Shunli Liu
- Department of Radiology, The Affiliated Hospital of Qingdao University Qingdao, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Li Yi
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Dongsheng Wang
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Xiaoming Zhou
- Department of Radiology, The Affiliated Hospital of Qingdao University Qingdao, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Wang Zhiming
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Keyu Ren
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510655, Guangdong, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Yun Lu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
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Huang JS, Smith N, Hamilton J, Young J, Choi L. Harnessing Electronic Medical Record Tools to Provide Proceduralist Feedback on Pediatric Endoscopy Quality Metrics. J Pediatr Gastroenterol Nutr 2023; 77:422-425. [PMID: 37364063 DOI: 10.1097/mpg.0000000000003872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
In 2022, the Pediatric Endoscopy Quality Improvement Network published quality metrics related to pediatric endoscopy. We utilized electronic medical record (EMR) tools to collect pediatric endoscopy quality metrics (PEQM) and to standardize proceduralist feedback. EMR tools were created to capture and display PEQM: (1) an endoscopy documentation template, (2) nursing documentation of events during endoscopy for timed calculations, and (3) a data dashboard. Dashboard metrics provided individualized PEQM feedback relative to group performance and ideals where available. Utilization of the endoscopy documentation tools and data dashboard was measured. Utility was assessed using a survey based on the Technology Adoption Model. Adoption of documentation tools has been nearly universal with positive survey outcomes. Robust dashboard visualization has been demonstrated. Use of EMR documentation tools standardized PEQM collection. Future capture and sharing of common PEQM data across institutions could help determine PEQM benchmarks.
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Affiliation(s)
- Jeannie S Huang
- From the Department of Pediatrics, University of California San Diego, La Jolla, CA
- the Department of Gastroenterology, Rady Children's Hospital, San Diego, CA
- the Department of Clinical Informatics, Rady Children's Hospital, San Diego, CA
| | - Nicole Smith
- the Department of Clinical Informatics, Rady Children's Hospital, San Diego, CA
| | - Jennine Hamilton
- the Department of Clinical Informatics, Rady Children's Hospital, San Diego, CA
| | - Jocelyn Young
- From the Department of Pediatrics, University of California San Diego, La Jolla, CA
- the Department of Gastroenterology, Rady Children's Hospital, San Diego, CA
| | - Lillian Choi
- From the Department of Pediatrics, University of California San Diego, La Jolla, CA
- the Department of Gastroenterology, Rady Children's Hospital, San Diego, CA
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Ashton JJ, Gurung A, Davis C, Seaby EG, Coelho T, Batra A, Afzal NA, Ennis S, Beattie RM. The Pediatric Crohn Disease Morbidity Index (PCD-MI): Development of a Tool to Assess Long-Term Disease Burden Using a Data-Driven Approach. J Pediatr Gastroenterol Nutr 2023; 77:70-78. [PMID: 37079872 PMCID: PMC10259218 DOI: 10.1097/mpg.0000000000003793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/05/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND/OBJECTIVE Heterogeneity and chronicity of Crohn disease (CD) make prediction of outcomes difficult. To date, no longitudinal measure can quantify burden over a patient's disease course, preventing assessment and integration into predictive modeling. Here, we aimed to demonstrate the feasibility of constructing a data driven, longitudinal disease burden score. METHODS Literature was reviewed for tools used in assessment of CD activity. Themes were identified to construct a pediatric CD morbidity index (PCD-MI). Scores were assigned to variables. Data were extracted automatically from the electronic patient records at Southampton Children's Hospital, diagnosed from 2012 to 2019 (inclusive). PCD-MI scores were calculated, adjusted for duration of follow up and assessed for variation (ANOVA) and distribution (Kolmogorov-Smirnov). RESULTS Nineteen clinical/biological features across five themes were included in the PCD-MI including blood/fecal/radiological/endoscopic results, medication usage, surgery, growth parameters, and extraintestinal manifestations. Maximal score was 100 after accounting for follow-up duration. PCD-MI was assessed in 66 patients, mean age 12.5 years. Following quality filtering, 9528 blood/fecal test results and 1309 growth measures were included. Mean PCD-MI score was 14.95 (range 2.2-32.5); data were normally distributed ( P = 0.2) with 25% of patients having a PCD-MI < 10. There was no difference in the mean PCD-MI when split by year of diagnosis, F -statistic 1.625, P = 0.147. CONCLUSIONS PCD-MI is a calculatable measure for a cohort of patients diagnosed over an 8-year period, integrating a wide-range of data with potential to determine high or low disease burden. Future iterations of the PCD-MI require refinement of included features, optimized scores, and validation on external cohorts.
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Affiliation(s)
- James J. Ashton
- From the Department of Human Genetics and Genomic Medicine, University of Southampton, Southampton, UK
- the Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
| | - Abhilasha Gurung
- the Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
| | - Cai Davis
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Eleanor G. Seaby
- From the Department of Human Genetics and Genomic Medicine, University of Southampton, Southampton, UK
| | - Tracy Coelho
- the Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
| | - Akshay Batra
- the Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
| | - Nadeem A. Afzal
- the Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
| | - Sarah Ennis
- From the Department of Human Genetics and Genomic Medicine, University of Southampton, Southampton, UK
| | - R. Mark Beattie
- the Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
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Zulqarnain F, Rhoads SF, Syed S. Machine and deep learning in inflammatory bowel disease. Curr Opin Gastroenterol 2023; 39:294-300. [PMID: 37144491 PMCID: PMC10256313 DOI: 10.1097/mog.0000000000000945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE OF REVIEW The Management of inflammatory bowel disease (IBD) has evolved with the introduction and widespread adoption of biologic agents; however, the advent of artificial intelligence technologies like machine learning and deep learning presents another watershed moment in IBD treatment. Interest in these methods in IBD research has increased over the past 10 years, and they offer a promising path to better clinical outcomes for IBD patients. RECENT FINDINGS Developing new tools to evaluate IBD and inform clinical management is challenging because of the expansive volume of data and requisite manual interpretation of data. Recently, machine and deep learning models have been used to streamline diagnosis and evaluation of IBD by automating review of data from several diagnostic modalities with high accuracy. These methods decrease the amount of time that clinicians spend manually reviewing data to formulate an assessment. SUMMARY Interest in machine and deep learning is increasing in medicine, and these methods are poised to revolutionize the way that we treat IBD. Here, we highlight the recent advances in using these technologies to evaluate IBD and discuss the ways that they can be leveraged to improve clinical outcomes.
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Affiliation(s)
- Fatima Zulqarnain
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Carman N, Picoraro JA. Advances in Endoscopy for Pediatric Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2023; 33:447-461. [PMID: 36948755 DOI: 10.1016/j.giec.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Endoscopic characterization of pediatric inflammatory bowel disease (IBD) has developed in accordance with advances in treatment and improved understanding of disease progression and complications. Reliable and consistent endoscopic reporting practices and tools continue to evolve. The roles of endoscopic ultrasonography, capsule endoscopy, and deep enteroscopy in the care of children and adolescents with IBD are beginning to be clarified. Opportunities for therapeutic intervention with endoscopy in pediatric IBD, including endoscopic balloon dilation and electroincision therapy, require further study. This review discusses the current utility of endoscopic assessment in Pediatric Inflammatory Bowel Disease, as well as emerging and evolving techniques to improve patient care.
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Affiliation(s)
- Nicholas Carman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, University of Ottawa, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Sickkids Inflammatory Bowel Disease Centre, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, 622 West 168th Street, PH17-105, New York, NY 10032, USA; NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY 10032, USA
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Meade S, Routledge E, Sharma E, Honap S, Zeki S, Ray S, Anderson SHC, Sanderson J, Mawdsley J, Irving PM, Samaan MA. How achievable are STRIDE-II treatment targets in real-world practice and do they predict long-term treatment outcomes? Frontline Gastroenterol 2022; 14:312-318. [PMID: 37409343 PMCID: PMC11138174 DOI: 10.1136/flgastro-2022-102309] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/26/2022] [Indexed: 12/13/2022] Open
Abstract
Objective The second iteration of the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II) initiative recommends use of the Simple Endoscopic Score for Crohn's disease (SES-CD) as a treatment target for patients with CD. We aimed to assess whether the STRIDE-II endoscopic endpoints are achievable and whether the degree of mucosal healing (MH) affects long-term outcomes. Design/method We performed a retrospective observational study between 2015 and 2022. Patients with CD who had baseline and follow-up SES-CD scores after biological therapy initiation were included. The primary outcome was treatment failure, defined as the need for: (1) change of biological therapy for active disease (2) corticosteroid use (3) CD-related hospitalisation or (4) surgery. We compared rates of treatment failure with the degree of MH achieved. Patients were followed up until treatment failure or study end (August 2022). Results 50 patients were included and followed up for median 39.9 (34.6-48.6) months. Baseline characteristics: 62% male, median age 36.4 (27.8-43.9) years, disease distribution (L1: 4, L2: 11, L3: 35, perianal: 18). The proportion of patients achieving STRIDE-II end-points were: SES-CD≤ 2-25 (50%) and >50% reduction in SES-CD-35 (70%). Failure to achieve SES-CD≤ 2 (HR 11.62; 95% CI 3.33 to 40.56, p=0.003) or >50% improvement in SES-CD (HR 30.30; 95% CI 6.93 to 132.40, p<0.0001) predicted treatment failure. Conclusion Use of SES-CD is feasible in real-world clinical practice. Achieving an SES-CD≤ 2 or a greater than 50% reduction, as set out by STRIDE-II, is associated with reduced rates of overall treatment failure including CD-related surgery.
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Affiliation(s)
- Susanna Meade
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Emma Routledge
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Esha Sharma
- Pharmacy Department, Guy's and Saint Thomas' Hospitals NHS Trust, London, UK
| | - Sailish Honap
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Sebastian Zeki
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Shuvra Ray
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Simon H C Anderson
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Jeremy Sanderson
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Joel Mawdsley
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Peter M Irving
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Mark A Samaan
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
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Adler J, Eder SJ, Gebremariam A, Moran CJ, Bass LM, Moses J, Lewis JD, Singer AAM, Morhardt TL, Picoraro JA, Cardenas V, Zacur GM, Colletti RB. Quantification of Mucosal Activity from Colonoscopy Reports via the Simplified Endoscopic Mucosal Assessment for Crohn's Disease. Inflamm Bowel Dis 2022; 28:1537-1542. [PMID: 34964861 DOI: 10.1093/ibd/izab315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Endoscopic mucosal healing is the gold standard for evaluating Crohn's disease (CD) treatment efficacy. Standard endoscopic indices are not routinely used in clinical practice, limiting the quality of retrospective research. A method for retrospectively quantifying mucosal activity from documentation is needed. We evaluated the simplified endoscopic mucosal assessment for CD (SEMA-CD) to determine if it can accurately quantify mucosal severity recorded in colonoscopy reports. METHODS Pediatric patients with CD underwent colonoscopy that was video recorded and evaluated via Simple Endoscopic Score for CD (SES-CD) and SEMA-CD by central readers. Corresponding colonoscopy reports were de-identified. Central readers blinded to clinical history and video scoring were randomly assigned colonoscopy reports with and without images. The SEMA-CD was scored for each report. Correlation with video SES-CD and SEMA-CD were assessed with Spearman rho, inter-rater, and intrarater reliability with kappa statistics. RESULTS Fifty-seven colonoscopy reports were read a total of 347 times. The simplified endoscopic mucosal assessment for CD without images correlated with both SES-CD and SEMA-CD from videos (rho = 0.82, P < .0001 for each). The addition of images provided similar correlation. Inter-rater and intrarater reliability were 0.93 and 0.92, respectively. CONCLUSIONS The SEMA-CD applied to retrospective evaluation of colonoscopy reports accurately and reproducibly correlates with SES-CD and SEMA-CD of colonoscopy videos. The SEMA-CD for evaluating colonoscopy reports will enable quantifying mucosal healing in retrospective research. Having objective outcome data will enable higher-quality research to be conducted across multicenter collaboratives and in clinical registries. External validation is needed.
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Affiliation(s)
- Jeremy Adler
- C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sally J Eder
- Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Lee M Bass
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jonathan Moses
- UH/Rainbow Babies & Children's Hospital, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cleveland, OH, USA
| | | | - Andrew A M Singer
- C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tina L Morhardt
- Children's Hospital at Dartmouth-Hitchcock, Lebanon, NH, USA
| | | | - Vanessa Cardenas
- Children's Hospital of Alabama, University of Alabama Birmingham, Birmingham, AL, USA
| | - George M Zacur
- C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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11
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Britto SL, Qian J, Ihekweazu FD, Kellermayer R. Racial and Ethnic Variation in Presentation, Diagnosis, Treatment, and Outcome of Pediatric Crohn Disease: A Single Center Study. J Pediatr Gastroenterol Nutr 2022; 75:313-319. [PMID: 35687587 DOI: 10.1097/mpg.0000000000003516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Disparities in health care for racial/ethnic minority children in the United States who are burdened by pediatric Crohn's disease (PCD) are not well understood. METHODS A retrospective review of the Texas Children's Hospital ImproveCareNow database from 2007 to 2015 was performed. CD patients with a minimum of 2-year follow-up were included if the onset of symptoms attributable to inflammatory bowel disease was clearly documented. We primarily aimed to identify race and ethnicity associations in diagnostic delay, presentation, treatment, and 2-year outcomes. We also examined early versus late diagnosis (ie, over 6 months from disease onset) associations with these variables unrelated to race/ethnicity. RESULTS One hundred and sixty-six PCD patients [57.8% non-Hispanic White (NH-White), 18.1% African American (AA), and 15.7% Hispanic] met selection criteria. Time to diagnosis was shorter in Hispanic patients ( P < 0.01) and they were older at diagnosis than NH-White patients ( P = 0.0164). AA patients (33%, P < 0.01) and Hispanic patients (35%, P < 0.05) had lower rates of granuloma detection than NH-White patients (63%). AA patients had lower rates of steroid-free remission (SFR) at 2 years than NH-White patients ( P < 0.05). Higher ESR and lower hemoglobin levels were associated with early diagnosis ( P < 0.01). Early diagnosis was associated with higher rates of surgery within 2 years of diagnosis ( P < 0.05). Diagnostic fecal calprotectin levels inversely associated with SFR at 2 years ( P < 0.05). Early use of biologics positively, and early use of corticosteroids negatively correlated with 2-year SFR ( P < 0.05). CONCLUSIONS Race and ethnicity may influence the diagnosis, treatment, and outcomes of PCD. This recognition presents a nidus toward establishing equity in PCD care.
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Affiliation(s)
- Savini Lanka Britto
- From the Section of Pediatric Gastroenterology, Texas Children's Hospital Baylor College of Medicine, Houston, TX
| | - Justin Qian
- From the Section of Pediatric Gastroenterology, Texas Children's Hospital Baylor College of Medicine, Houston, TX
| | - Faith Dorsey Ihekweazu
- From the Section of Pediatric Gastroenterology, Texas Children's Hospital Baylor College of Medicine, Houston, TX
| | - Richard Kellermayer
- From the Section of Pediatric Gastroenterology, Texas Children's Hospital Baylor College of Medicine, Houston, TX.,the USDA/ARS Children's Nutrition Research Center, Houston, TX
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12
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Adler J, Colletti RB, Noonan L, Berzin TM, Cheifetz AS, Conklin LS, Hoops TC, Huang CS, Lewis B, Mishkin DS, Hung Lo K, Xiao Y, Volger S. Validating the Simplified Endoscopic Mucosal Assessment for Crohn's Disease: A Novel Method for Assessing Disease Activity. Inflamm Bowel Dis 2022:6682834. [PMID: 36049024 DOI: 10.1093/ibd/izac183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND To demonstrate treatment efficacy in Crohn's disease (CD), regulatory authorities require that trials include an endoscopic remission/response end point; however, standardized endoscopic assessment of disease activity, such as the Simple Endoscopic Score for Crohn's Disease (SES-CD), is not typically recorded by clinicians in practice or outside of clinical trials. The novel Simplified Endoscopic Mucosal Assessment for Crohn's Disease (SEMA-CD) was developed to be easy to use in routine clinical practice and as a trial end point. We conducted a study to assess and validate the reliability and feasibility of SEMA-CD as a measure of endoscopic disease activity. METHODS Pre- and post-treatment ileocolonoscopy videos of pediatric (n = 36) and adult (n = 74) CD patients from 2 ustekinumab clinical trials were each scored with SEMA-CD by 2 to 3 professional central readers, blinded to clinical history and other video scorings; the correlation between SEMA-CD and SES-CD previously completed during the trials was assessed. Sensitivity to change, inter- and intrarater reliability, and comparative ease of scoring were also assessed. RESULTS The SEMA-CD strongly correlated with SES-CD (Spearman ρ = 0.89; 95% confidence interval, 0.86-0.92). Pre- to post-treatment changes in SEMA-CD vs in SES-CD were strongly correlated, and the correlation remained strong between the scores when compared by study population (pediatric, adult), disease severity, and video quality. Intra- and inter-rater reliability were good, and SEMA-CD was rated easier than SES-CD to score 63.0% of the time, although slightly more difficult than SES-CD to score <1.0% of the time. CONCLUSIONS The SEMA-CD is reliable, reproducible, sensitive to change, and easy to use in both pediatric and adult patients with CD.
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Affiliation(s)
- Jeremy Adler
- C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Lenore Noonan
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - Tyler M Berzin
- Beth Israel Deaconess Medical Center, Division of Gastroenterology, Harvard Medical School, Boston, MA, USA
| | - Adam S Cheifetz
- Beth Israel Deaconess Medical Center, Division of Gastroenterology, Harvard Medical School, Boston, MA, USA
| | | | - Timothy C Hoops
- Immunology Global Medical Affairs, Janssen Pharmaceutical Companies (a subsidiary of Johnson & Johnson), Horsham, PA, USA
| | - Christopher S Huang
- Boston Medical Center, Section of Gastroenterology, Boston University School of Medicine, Boston, MA, USA
| | - Blair Lewis
- Division of Gastroenterology, Mount Sinai Health System, New York, NY, USA
| | | | - Kim Hung Lo
- Janssen Research & Development, LLC, Spring House, PA, USA
| | | | - Sheri Volger
- Janssen Research & Development, LLC, Spring House, PA, USA
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