Proactive therapeutic drug monitoring and vedolizumab dose optimization in children with inflammatory bowel disease

OBJECTIVES

Therapeutic drug monitoring (TDM) and dose optimization have been shown to improve clinical outcomes with antitumor necrosis factor and recent studies in adults suggest an exposure-response relationship with drug levels associated with improved clinical outcomes. However, these levels are not universally recognized as therapeutic targets for vedolizumab dosing. We aimed to assess the impact of a TDM quality improvement (QI) initiative on 52-week clinical outcomes and describe proactively obtained vedolizumab levels during the induction period in children with inflammatory bowel disease (IBD).

METHODS

A QI initiative to proactively obtain TDM levels at Week 6 was implemented in 2019. A retrospective review of pediatric patients with IBD treated with vedolizumab from 2018 to 2022 was performed. Baseline demographic data, medication dosing details, disease characteristics, lab results, and 12-month clinical outcomes were recorded. For this study, we defined therapeutic target levels (>20 μg/mL at Week 6 and >12 μg/mL during maintenance) based on existing data correlating these levels with improved clinical outcomes.

RESULTS

Fifty-nine patients (31 Crohn disease [CD], 28 ulcerative colitis [UC]/indeterminate colitis [IC]) were included in the study. In total, 68% (40/59) of patients had vedolizumab levels at Week 6 and 90% (53/59) had levels drawn at Week 6 or 14. Thirty-five percent of Week 6 trough levels were below our defined target of 20 μg/mL. Fifty-two of 59 patients had available data at 52 weeks. Over 80% (42/52) of patients remained on vedolizumab 52 weeks after initiation (CD 79% [23/29], UC/IC 83% [19/23]). Sixty-two percent (26/42) of patients that remained on vedolizumab at 52 weeks were treated with an intensified dosing interval of <8 weeks. Thirty-one of these 42 (74%) were in clinical remission (CR) rate at 52 weeks with 29/42 (69%) in corticosteroid-free remission. The CR rate for the entire cohort including those who discontinued therapy due to a lack of efficacy before 52 weeks was 60% (31/52).

CONCLUSION

Proactive TDM and early dose optimization with vedolizumab may improve drug durability and clinical outcomes in pediatric patients with IBD.

Single-Center Analysis of Essential Laboratory Testing in Patients with Newly Diagnosed Celiac Disease

OBJECTIVE

To analyze laboratory testing results from pediatric patients newly diagnosed with celiac disease to determine the usefulness of each test derived from recommended guidelines.

METHODS

Serological testing at the time of diagnosis from patients enrolled in our celiac disease registry from January 2018 through December 2021 was reviewed. The incidence of abnormal laboratory results, routinely obtained as per the recommendations of Snyder et al and our institution's Celiac Care Index, was assessed. Rates of abnormal laboratory values and estimated costs associated with these screening measures were analyzed.

RESULTS

Our data demonstrated abnormalities in all serological testing obtained at celiac diagnosis. Hemoglobin, alanine aminotransferase, ferritin, iron, and vitamin D screening were found to be abnormal with notable frequency. Only 7% of patients had an abnormal thyroid-stimulating hormone and <0.1% had an abnormal free T4. Nonresponse to hepatitis B vaccination was prominent, with 69% of patients considered nonimmune. Screening protocols as currently outlined in our Celiac Care Index resulted in an estimated cost of approximately $320 000 during our study.

CONCLUSIONS

Review of screening laboratory results at our center reveals that abnormal values for several recommended measures are uncommon. Thyroid screening was infrequently abnormal and the usefulness of screening for hepatitis B at diagnosis is uncertain. Similarly, our data suggest that iron deficiency screening may be condensed effectively into hemoglobin and ferritin testing, eliminating the need for initial iron studies. Decreasing baseline screening measures could safely decrease the burden of testing on patients and overall healthcare expenditures.

Sleep in German female youth national ice hockey athletes

Background

Adequate sleep is of great importance in recovering from and preparing for training and competition.

Objective

This study aimed to investigate subjective sleep quality and daytime sleepiness of the German women’s junior national ice hockey team before and after a training camp immediately preceding the World Championship Division IA tournament.

Materials and methods

Twenty athletes (16.40 ± 0.68 years) completed German paper–pencil versions of the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS) before the training camp (T1, day 1) and on the final day of the training camp (T2, day 7).

Results

Paired t-tests indicated a significant decrease in PSQI global scores from pre- to post-training camp assessments (t = 2.33, p = 0.031, df = 19), with a medium effect size (d = 0.52). Regarding ESS global scores, results of the paired t-test indicated no significant pre- to post-training camp differences (t = 0.67, p = 0.510, df = 19) and the effect size was trivial (d = 0.15). Mean scores were reduced for both PSQI (T1 = 5.90 ± 2.36, T2 = 4.65 ± 2.18) and ESS (T1 = 9.00 ± 3.58, T2 = 8.60 ± 4.04) after the training camp. When analyzed according to the position of the players, no statistically significant intergroup differences were found.

Conclusion

This study underlines the need for monitoring and screening youth athletes’ sleep before special sports events in order to identify a potential need for intervention as early as possible, to prevent serious consequences for athletes’ performance capability and well-being.

A Celiac Care Index Improves Care of Pediatric Patients Newly Diagnosed with Celiac Disease

OBJECTIVES

To describe quality improvement efforts to reduce variability in the care of children diagnosed with celiac disease through use of an institutional patient registry and a chronic care index.

STUDY DESIGN

An institutional patient registry tracked rates of follow-up visits and repeat serologic testing. A Celiac Care Index that included anthropometrics, biopsy expectations, dietician consultation, and baseline laboratory evaluation was developed to standardize evaluation at diagnosis. Provider education sessions communicated expectations for this standard of care and order sets within the electronic medical record simplified test collection. Data was recorded and reviewed weekly and structured communications with providers were provided biweekly.

RESULTS

Adherence with follow-up expectations (77%-89% P = .03) and repeat serologic testing (50%-90% P < .0001) significantly increased during the study period. Adherence with completion of the Celiac Care Index resulted in significant improvement in obtaining complete blood count (80%-98% P < .0001), iron (25%-78% P < .0001), ferritin (34%-80% P < .0001), alanine aminotransferase/aspartate aminotransferase (74%-96% P < .0001), thyroid-stimulating hormone (64%-90% P < .0001), vitamin D (36%-83% P < .0001), and hepatitis B immune status (30%-80% P < .0001). Iron deficiency demonstrated by low ferritin levels was common (41%) and a high rate of nonimmunity to hepatitis B (70%) was detected.

CONCLUSIONS

The Celiac Care Index improved adherence with published care recommendations and reduced variability in baseline evaluation at diagnosis. Laboratory test results indicate further studies are needed to evaluate these recommendations.

Variation of the temporal delay to threshold in nanosecond-tunable dye lasers

We present an experimental study, complemented by numerical simulations, of the delay from the peak of the pump pulse to threshold of the dye laser pulse as a function of the selected wavelength. Delay variations of up to 0.2 nsec/nm were observed in Rhodamine dyes pumped by a N(2) laser. We conclude that the variations are intrinsic to the gain-loss characteristics and that excited-state singlet absorption can play a significant role.