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Saito K, Gabbeta A, Mulvihill E, Al-Jaberi L, Beukelman T, Lewis JD, Rose CD, Strom BL, Horton DB. Validation of new medication use algorithms as proxies for worsening disease activity in patients with juvenile idiopathic arthritis. Pharmacoepidemiol Drug Saf 2024; 33:e5803. [PMID: 38685851 DOI: 10.1002/pds.5803] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 04/04/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE To facilitate claims-based research on populations with juvenile idiopathic arthritis (JIA), we sought to validate an algorithm of new medication use as a proxy for worsening JIA disease activity. METHODS Using electronic health record data from three pediatric centers, we defined new JIA medication use as (re)initiation of disease-modifying antirheumatic drugs or glucocorticoids (oral or intra-articular). Data were collected from 201 randomly selected subjects with (101) or without (100) new medication use. We assessed the positive predictive value (PPV) and negative predictive value (NPV) based on a reference standard of documented worsening of JIA disease activity. The algorithm was refined to optimize test characteristics. RESULTS Overall, the medication-based algorithm had suboptimal performance in representing worsening JIA disease activity (PPV 69.3%, NPV 77.1%). However, algorithm performance improved for definitions specifying longer times after JIA diagnosis (≥1-year post-diagnosis: PPV 82.9%, NPV 80.0%) or after initiation of prior JIA treatment (≥1-year post-treatment: PPV 89.7%, NPV 80.0%). CONCLUSION An algorithm for new JIA medication use appears to be a reasonable proxy for worsening JIA disease activity, particularly when specifying new use ≥1 year since initiating a prior JIA medication. This algorithm will be valuable for conducting research on JIA populations within administrative claims databases.
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Affiliation(s)
- Kyoko Saito
- Brown University, Providence, Rhode Island, USA
| | - Avinash Gabbeta
- St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| | | | - Lina Al-Jaberi
- Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Timothy Beukelman
- Childhood Arthritis & Rheumatology Research Alliance, Washington, DC, USA
| | - James D Lewis
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carlos D Rose
- Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Brian L Strom
- Rutgers Biomedical and Health Sciences, Newark, New Jersey, USA
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
| | - Daniel B Horton
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, USA
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Vajravelu RK, Byerly AR, Feldman R, Rothenberger SD, Schoen RE, Gellad WF, Lewis JD. Active surveillance pharmacovigilance for Clostridioides difficile infection and gastrointestinal bleeding: an analytic framework based on case-control studies. EBioMedicine 2024; 103:105130. [PMID: 38653188 PMCID: PMC11041851 DOI: 10.1016/j.ebiom.2024.105130] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Active surveillance pharmacovigilance is an emerging approach to identify medications with unanticipated effects. We previously developed a framework called pharmacopeia-wide association studies (PharmWAS) that limits false positive medication associations through high-dimensional confounding adjustment and set enrichment. We aimed to assess the transportability and generalizability of the PharmWAS framework by using medical claims data to reproduce known medication associations with Clostridioides difficile infection (CDI) or gastrointestinal bleeding (GIB). METHODS We conducted case-control studies using Optum's de-identified Clinformatics Data Mart Database of individuals enrolled in large commercial and Medicare Advantage health plans in the United States. Individuals with CDI (from 2010 to 2015) or GIB (from 2010 to 2021) were matched to controls by age and sex. We identified all medications utilized prior to diagnosis and analysed the association of each with CDI or GIB using conditional logistic regression adjusted for risk factors for the outcome and a high-dimensional propensity score. FINDINGS For the CDI study, we identified 55,137 cases, 220,543 controls, and 290 medications to analyse. Antibiotics with Gram-negative spectrum, including ciprofloxacin (aOR 2.83), ceftriaxone (aOR 2.65), and levofloxacin (aOR 1.60), were strongly associated. For the GIB study, we identified 450,315 cases, 1,801,260 controls, and 354 medications to analyse. Antiplatelets, anticoagulants, and non-steroidal anti-inflammatory drugs, including ticagrelor (aOR 2.81), naproxen (aOR 1.87), and rivaroxaban (aOR 1.31), were strongly associated. INTERPRETATION These studies demonstrate the generalizability and transportability of the PharmWAS pharmacovigilance framework. With additional validation, PharmWAS could complement traditional passive surveillance systems to identify medications that unexpectedly provoke or prevent high-impact conditions. FUNDING U.S. National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Ravy K Vajravelu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Amy R Byerly
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert Feldman
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Scott D Rothenberger
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert E Schoen
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Siddique SM, Hettinger G, Dash A, Neuman M, Mitra N, Lewis JD. The Role of Hospital Characteristics in Clinical and Quality Outcomes for Gastrointestinal Bleeding in a National Cohort. Am J Gastroenterol 2024:00000434-990000000-01064. [PMID: 38477470 DOI: 10.14309/ajg.0000000000002755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/07/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes. METHODS This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality. RESULTS Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services. DISCUSSION Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.
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Affiliation(s)
- Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gary Hettinger
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anwesh Dash
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark Neuman
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nandita Mitra
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James D Lewis
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Sehgal P, Su S, Zech J, Nobel Y, Luk L, Economou I, Shen B, Lewis JD, Freedberg DE. Visceral Adiposity Independently Predicts Time to Flare in Inflammatory Bowel Disease but Body Mass Index Does Not. Inflamm Bowel Dis 2024; 30:594-601. [PMID: 37307420 PMCID: PMC10988099 DOI: 10.1093/ibd/izad111] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Obesity is associated with progression of inflammatory bowel disease (IBD). Visceral adiposity may be a more meaningful measure of obesity compared with traditional measures such as body mass index (BMI). This study compared visceral adiposity vs BMI as predictors of time to IBD flare among patients with Crohn's disease and ulcerative colitis. METHODS This was a retrospective cohort study. IBD patients were included if they had a colonoscopy and computed tomography (CT) scan within a 30-day window of an IBD flare. They were followed for 6 months or until their next flare. The primary exposure was the ratio of visceral adipose tissue to subcutaneous adipose tissue (VAT:SAT) obtained from CT imaging. BMI was calculated at the time of index CT scan. RESULTS A total of 100 Crohn's disease and 100 ulcerative colitis patients were included. The median age was 43 (interquartile range, 31-58) years, 39% had disease duration of 10 years or more, and 14% had severe disease activity on endoscopic examination. Overall, 23% of the cohort flared with median time to flare 90 (interquartile range, 67-117) days. Higher VAT:SAT was associated with shorter time to IBD flare (hazard ratio of 4.8 for VAT:SAT ≥1.0 vs VAT:SAT ratio <1.0), whereas higher BMI was not associated with shorter time to flare (hazard ratio of 0.73 for BMI ≥25 kg/m2 vs BMI <25 kg/m2). The relationship between increased VAT:SAT and shorter time to flare appeared stronger for Crohn's than for ulcerative colitis. CONCLUSIONS Visceral adiposity was associated with decreased time to IBD flare, but BMI was not. Future studies could test whether interventions that decrease visceral adiposity will improve IBD disease activity.
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Affiliation(s)
- Priya Sehgal
- Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Steven Su
- Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - John Zech
- Department of Radiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Yael Nobel
- Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Lyndon Luk
- Department of Radiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Ioannis Economou
- Division of Colorectal Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Bo Shen
- Division of Colorectal Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
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Adimadhyam S, Lewis JD, Simon AL, Wolfe AE, Smith S, Hou L, Moyneur É, Reynolds JS, Toh S, Dobes A, Parlett L, Haynes K, Burris J, Dorand JE, Long MD, Kappelman MD. Real-world Evidence Comparing Tofacitinib and Vedolizumab in Anti-TNF-experienced Patients With Ulcerative Colitis. Inflamm Bowel Dis 2024; 30:554-562. [PMID: 37358904 DOI: 10.1093/ibd/izad115] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Antitumor necrosis factor (anti-TNF) inhibitors are first-line treatment among patients with ulcerative colitis (UC). With time, patients tend to lose response or become intolerant, necessitating switching to small cell biologics such as tofacitinib or vedolizumab. In this real-world study of a large, geographically diverse US population of TNF-experienced patients with UC, we evaluated the effectiveness and safety of newly initiating treatment with tofacitinib vs vedolizumab. METHODS We conducted a cohort study using secondary data from a large US insurer (Anthem, Inc.). Our cohort included patients with UC newly initiating treatment with tofacitinib or vedolizumab. Patients were required to have evidence of treatment with anti-TNF inhibitors in the 6 months prior to cohort entry. The primary outcome was treatment persistence >52 weeks. Additionally, we evaluated the following secondary outcomes as additional measures of effectiveness and safety: (1) all-cause hospitalization; (2) total abdominal colectomy; (3) hospitalization for infection; (4) hospitalization for malignancy; (5) hospitalization for cardiac events; and (6) hospitalization for thromboembolic events. We used fine stratification by propensity scores to control for confounding by demographics, clinical factors, and treatment history at baseline. RESULTS Our primary cohort included 168 new users of tofacitinib and 568 new users of vedolizumab. Tofacitinib was associated with lower treatment persistence (adjusted risked ratio, 0.77; 95% CI, 0.60 -0.99). Differences in secondary measures of effectiveness or safety between tofacitinib initiators vs vedolizumab initiators were not statistically significant (all-cause hospitalization, adjusted hazard ratio, 1.23; 95% CI, 0.83-1.84; total abdominal colectomy, adjusted HR, 1.79; 95% CI, 0.93-3.44;and hospitalization for any infection, adjusted HR, 1.94; 95% CI, 0.83-4.52). DISCUSSION Ulcerative colitis patients with prior anti-TNF experience initiating tofacitinib demonstrated lower treatment persistence compared with those initiating vedolizumab. This finding is in contrast to other recent studies suggesting superior effectiveness of tofacitinib. Ultimately, head-to-head randomized, controlled trials that focus on directly measured end points may be needed to best inform clinical practice.
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Affiliation(s)
- Sruthi Adimadhyam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew L Simon
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Audrey E Wolfe
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Samantha Smith
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Laura Hou
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | | | - Juliane S Reynolds
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Angela Dobes
- Crohn's and Colitis Foundation, New York City, New York, USA
| | | | | | | | | | - Millie D Long
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Dawwas GK, Cuker A, Schaubel DE, Lewis JD. Effectiveness and safety of prophylactic anticoagulation among hospitalized patients with inflammatory bowel disease. Blood Adv 2024; 8:1272-1280. [PMID: 38163322 PMCID: PMC10918481 DOI: 10.1182/bloodadvances.2023011756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT Hospitalized patients with inflammatory bowel disease (IBD) are at increased risk of venous thromboembolism (VTE). We aimed to evaluate the effectiveness and safety of prophylactic anticoagulation compared with no anticoagulation in hospitalized patients with IBD. We conducted a retrospective cohort study using a hospital-based database. We included patients with IBD who had a length of hospital stay ≥2 days between 1 January 2016 and 31 December 2019. We excluded patients who had other indications for anticoagulation, users of direct oral anticoagulants, warfarin, therapeutic-intensity heparin, and patients admitted for surgery. We defined exposure to prophylactic anticoagulation using charge codes. The primary effectiveness outcome was VTE. The primary safety outcome was bleeding. We used propensity score matching to reduce potential differences between users and nonusers of anticoagulants and Cox proportional-hazards regression to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). The analysis included 56 194 matched patients with IBD (users of anticoagulants, n = 28 097; nonusers, n = 28 097). In the matched sample, prophylactic use of anticoagulants (vs no use) was associated with a lower rate of VTE (HR, 0.62; 95% CI, 0.41-0.94) and with no difference in the rate of bleeding (HR, 1.05; 95% CI, 0.87-1.26). In this study of hospitalized patients with IBD, prophylactic use of heparin was associated with a lower rate of VTE without increasing bleeding risk compared with no anticoagulation. Our results suggest potential benefits of prophylactic anticoagulation to reduce the burden of VTE in hospitalized patients with IBD.
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Affiliation(s)
- Ghadeer K. Dawwas
- Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam Cuker
- Departments of Medicine and Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Douglas E. Schaubel
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James D. Lewis
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Tse CS, Hunt MG, Brown LA, Lewis JD. Inflammatory Bowel Diseases-related Disability: Risk Factors, Outcomes, and Interventions. Inflamm Bowel Dis 2024; 30:501-507. [PMID: 37603844 DOI: 10.1093/ibd/izad182] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Indexed: 08/23/2023]
Abstract
The diagnosis of inflammatory bowel disease (IBD) is a life-changing moment for most adults. Biomedical advances over the past 2 decades have resulted in unprecedented growth of therapeutic options for IBD. However, due to the incurable nature of IBD, medical and surgical intervention alone may not be adequate to completely normalize health status and prevent long-term disability. In the biopsychosocial model of health and disease, a person's health and function result from complex physical, psychosocial, and environmental interactions. Adapting the World Health Organization definition, IBD-related disability encompasses limitations in educational and employment opportunities, exclusions in economic and social activities, and impairments in physical and psychosocial function. Although the concept of IBD-related disability is a long-term treatment end point in the updated Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II) treatment guideline, it has received limited attention in the literature. This review article explores an etiological framework of the physical and psychosocial aspects that contribute to IBD-related disability. We also explore the impact of IBD-related disability on the direct and indirect costs of IBD. Lastly, we present the available evidence for interventions with the potential to improve function and reduce IBD-related disability.
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Affiliation(s)
- Chung Sang Tse
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa G Hunt
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lily A Brown
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Hashash JG, Elkins J, Lewis JD, Binion DG. AGA Clinical Practice Update on Diet and Nutritional Therapies in Patients With Inflammatory Bowel Disease: Expert Review. Gastroenterology 2024; 166:521-532. [PMID: 38276922 DOI: 10.1053/j.gastro.2023.11.303] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/19/2023] [Accepted: 11/05/2023] [Indexed: 01/27/2024]
Abstract
DESCRIPTION Diet plays a critical role in human health, but especially for patients with inflammatory bowel disease (IBD). Guidance about diet for patients with IBD are often controversial and a source of uncertainty for many physicians and patients. The role of diet has been investigated as a risk factor for IBD etiopathogenesis and as a therapy for active disease. Dietary restrictions, along with the clinical complications of IBD, can result in malnutrition, an underrecognized condition among this patient population. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice statements, primarily to clinical gastroenterologists, covering the topics of diet and nutritional therapies in the management of IBD, while emphasizing identification and treatment of malnutrition in these patients. We provide guidance for tailored dietary approaches during IBD remission, active disease, and intestinal failure. A healthy Mediterranean diet will benefit patients with IBD, but may require accommodations for food texture in the setting of intestinal strictures or obstructions. New data in Crohn's disease supports the use of enteral liquid nutrition to help induce remission and correct malnutrition in patients heading for surgery. Parenteral nutrition plays a critical role in patients with IBD facing acute and/or chronic intestinal failure. Registered dietitians are an essential part of the interdisciplinary team approach for optimal nutrition assessment and management in the patient population with IBD. METHODS This expert review was commissioned and approved by the AGA Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. The best practice advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the role of diet and nutritional therapies in patients with IBD. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Unless there is a contraindication, all patients with IBD should be advised to follow a Mediterranean diet rich in a variety of fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins and low in ultraprocessed foods, added sugar, and salt for their overall health and general well-being. No diet has consistently been found to decrease the rate of flares in adults with IBD. A diet low in red and processed meat may reduce ulcerative colitis flares, but has not been found to reduce relapse in Crohn's disease. BEST PRACTICE ADVICE 2: Patients with IBD who have symptomatic intestinal strictures may not tolerate fibrous, plant-based foods (ie, raw fruits and vegetables) due to their texture. An emphasis on careful chewing and cooking and processing of fruits and vegetables to a soft, less fibrinous consistency may help patients with IBD who have concomitant intestinal strictures incorporate a wider variety of plant-based foods and fiber in their diets. BEST PRACTICE ADVICE 3: Exclusive enteral nutrition using liquid nutrition formulations is an effective therapy for induction of clinical remission and endoscopic response in Crohn's disease, with stronger evidence in children than adults. Exclusive enteral nutrition may be considered as a steroid-sparing bridge therapy for patients with Crohn's disease. BEST PRACTICE ADVICE 4: Crohn's disease exclusion diet, a type of partial enteral nutrition therapy, may be an effective therapy for induction of clinical remission and endoscopic response in mild to moderate Crohn's disease of relatively short duration. BEST PRACTICE ADVICE 5: Exclusive enteral nutrition may be an effective therapy in malnourished patients before undergoing elective surgery for Crohn's disease to optimize nutritional status and reduce postoperative complications. BEST PRACTICE ADVICE 6: In patients with IBD who have an intra-abdominal abscess and/or phlegmonous inflammation that limits ability to achieve optimal nutrition via the digestive tract, short-term parenteral nutrition may be used to provide bowel rest in the preoperative phase to decrease infection and inflammation as a bridge to definitive surgical management and to optimize surgical outcomes. BEST PRACTICE ADVICE 7: We suggest the use of parenteral nutrition for high-output gastrointestinal fistula, prolonged ileus, short bowel syndrome, and for patients with IBD with severe malnutrition when oral and enteral nutrition has been trialed and failed or when enteral access is not feasible or contraindicated. BEST PRACTICE ADVICE 8: In patients with IBD and short bowel syndrome, long-term parenteral nutrition should be transitioned to customized hydration management (ie, intravenous electrolyte support and/or oral rehydration solutions) and oral intake whenever possible to decrease the risk of developing long-term complications. Treatment with glucagon-like peptide-2 agonists can facilitate this transition. BEST PRACTICE ADVICE 9: All patients with IBD warrant regular screening for malnutrition by their provider by means of assessing signs and symptoms, including unintended weight loss, edema and fluid retention, and fat and muscle mass loss. When observed, more complete evaluation for malnutrition by a registered dietitian is indicated. Serum proteins are no longer recommended for the identification and diagnosis of malnutrition due to their lack of specificity for nutritional status and high sensitivity to inflammation. BEST PRACTICE ADVICE 10: All patients with IBD should be monitored for vitamin D and iron deficiency. Patients with extensive ileal disease or prior ileal surgery (resection or ileal pouch) should be monitored for vitamin B12 deficiency. BEST PRACTICE ADVICE 11: All outpatients and inpatients with complicated IBD warrant co-management with a registered dietitian, especially those who have malnutrition, short bowel syndrome, enterocutaneous fistula, and/or are requiring more complex nutrition therapies (eg, parenteral nutrition, enteral nutrition, or exclusive enteral nutrition), or those on a Crohn's disease exclusion diet. We suggest that all newly diagnosed patients with IBD have access to a registered dietitian. BEST PRACTICE ADVICE 12: Breastfeeding is associated with a lower risk for diagnosis of IBD during childhood. A healthy, balanced, Mediterranean diet rich in a variety of fruits and vegetables and decreased intake of ultraprocessed foods have been associated with a lower risk of developing IBD.
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Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida.
| | - Jaclyn Elkins
- Department of Nutrition, Mayo Clinic, Jacksonville, Florida
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David G Binion
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
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Lapp SL, Bewtra M, Lewis JD. Yield of Serial Testing for Tuberculosis Exposure in Patients With Inflammatory Bowel Diseases: One Test is Not Enough. Clin Gastroenterol Hepatol 2024; 22:420-422.e2. [PMID: 37331412 PMCID: PMC10725512 DOI: 10.1016/j.cgh.2023.06.003] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/19/2023] [Accepted: 06/02/2023] [Indexed: 06/20/2023]
Affiliation(s)
- Sean L Lapp
- Messiah University, New Holland, Pennsylvania
| | - Meenakshi Bewtra
- Division of Gastroenterology and Hepatology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania..
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10
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Krasnovsky L, Weber AT, Gershuni V, Pettke E, Lewis JD. Preoperative Exclusive Enteral Nutrition Is Associated With Reduced Skin and Soft Tissue and Intra-abdominal Infections in Patients With Crohn's Disease Undergoing Intestinal Surgery: Results from a Meta-Analysis. Inflamm Bowel Dis 2024:izad304. [PMID: 38262631 DOI: 10.1093/ibd/izad304] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Malnutrition is an independent risk factor for adverse postoperative outcomes and is common among patients with Crohn's disease (CD). The objective of this meta-analysis was to precisely quantify the association of preoperative exclusive enteral nutrition (EEN) and total parenteral nutrition (TPN) with surgical outcomes in patients undergoing intestinal surgery for CD. METHODS PubMed, Embase, and Scopus were queried for comparative studies evaluating the impact of preoperative nutritional support on postoperative outcomes in patients undergoing surgery for CD. Random effects modeling was used to compute pooled estimates of risk difference. Heterogeneity was assessed using I2. RESULTS Fourteen studies, all nonrandomized cohort studies, met inclusion criteria for studying EEN. After pooling data from 14 studies (874 EEN treated and 1044 control patients), the relative risk of intra-abdominal septic complications was decreased 2.1-fold in patients receiving preoperative EEN (relative risk 0.47, 95% confidence interval [CI], 0.35-0.63, I2 = 0.0%). After pooling data from 9 studies (638 EEN treated and 819 control patients), the risk of skin and soft tissue infection was decreased 1.6-fold (relative risk 0.63; 95% CI, 0.42-0.94, I2 = 42.7%). No significant differences were identified in duration of surgery, length of bowel resected, or operative blood loss. Among the 9 studies investigating TPN, no significant differences were identified in infectious outcomes. CONCLUSIONS Preoperative nutritional optimization with EEN was associated with reduced risk of infectious complications in CD patients undergoing intestinal surgery. Preoperative nutritional support with EEN should be considered for optimizing outcomes in CD patients requiring bowel resection surgery.
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Affiliation(s)
- Lev Krasnovsky
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew T Weber
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria Gershuni
- Division of Gastrointestinal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Erica Pettke
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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11
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Compher CW, Quinn R, Haslam R, Bader E, Weaver J, Dudek S, Ritchie MD, Lewis JD, Wu GD. Penn Healthy Diet survey: pilot validation and scoring. Br J Nutr 2024; 131:156-162. [PMID: 37519237 DOI: 10.1017/s0007114523001642] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Though diet quality is widely recognised as linked to risk of chronic disease, health systems have been challenged to find a user-friendly, efficient way to obtain information about diet. The Penn Healthy Diet (PHD) survey was designed to fill this void. The purposes of this pilot project were to assess the patient experience with the PHD, to validate the accuracy of the PHD against related items in a diet recall and to explore scoring algorithms with relationship to the Healthy Eating Index (HEI)-2015 computed from the recall data. A convenience sample of participants in the Penn Health BioBank was surveyed with the PHD, the Automated Self-Administered 24-hour recall (ASA24) and experience questions. Kappa scores and Spearman correlations were used to compare related questions in the PHD to the ASA24. Numerical scoring, regression tree and weighted regressions were computed for scoring. Participants assessed the PHD as easy to use and were willing to repeat the survey at least annually. The three scoring algorithms were strongly associated with HEI-2015 scores using National Health and Nutrition Examination Survey 2017-2018 data from which the PHD was developed and moderately associated with the pilot replication data. The PHD is acceptable to participants and at least moderately correlated with the HEI-2015. Further validation in a larger sample will enable the selection of the strongest scoring approach.
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Affiliation(s)
- Charlene W Compher
- University of Pennsylvania School of Nursing, Department of Biobehavioral Health Science, Philadelphia, PA, USA
| | - Ryan Quinn
- University of Pennsylvania School of Nursing, Department of Biostatistics, Philadelphia, PA, USA
| | - Richard Haslam
- University of Dublin, School of Medicine, Dublin, Republic of Ireland
| | | | - Joellen Weaver
- University of Pennsylvania Health System, Penn Medicine Biobank, Philadelphia, PA, USA
| | - Scott Dudek
- Department of Genetics and Institute for Biomedical Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marylyn D Ritchie
- Department of Genetics and Institute for Biomedical Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - James D Lewis
- University of Pennsylvania Perelman School of Medicine, Division of Gastroenterology and Hepatology, Philadelphia, PA, USA
| | - Gary D Wu
- University of Pennsylvania Perelman School of Medicine, Division of Gastroenterology and Hepatology, Philadelphia, PA, USA
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12
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Lewis JD. Recent Research on Dietary Therapy for Patients With Crohn's Disease. Gastroenterol Hepatol (N Y) 2024; 20:50-53. [PMID: 38405048 PMCID: PMC10885419] [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: 02/27/2024]
Affiliation(s)
- James D Lewis
- Professor of Medicine and Epidemiology Division of Gastroenterology and Hepatology, Department of Medicine Center for Clinical Epidemiology and Biostatistics Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
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13
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Dawwas GK, Weiss A, Constant BD, Parlett LE, Haynes K, Yang JY, Brensinger C, Wu Q, Pate V, Jonsson Funk M, Schaubel DE, Hurtado-Lorenzo A, David Kappelman M, Lewis JD. Development and Validation of Claims-Based Definitions to Identify Incident and Prevalent Inflammatory Bowel Disease in Administrative Healthcare Databases. Inflamm Bowel Dis 2023; 29:1993-1996. [PMID: 37043675 PMCID: PMC10697409 DOI: 10.1093/ibd/izad053] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Indexed: 04/14/2023]
Abstract
BACKGROUND To facilitate inflammatory bowel disease (IBD) research in the United States, we developed and validated claims-based definitions to identify incident and prevalent IBD diagnoses using administrative healthcare claims data among multiple payers. METHODS We used data from Medicare, Medicaid, and the HealthCore Integrated Research Database (Anthem commercial and Medicare Advantage claims). The gold standard for validation was review of medical records. We evaluated 1 incidence and 4 prevalence algorithms based on a combination of International Classification of Diseases codes, National Drug Codes, and Current Procedural Terminology codes. The claims-based incident diagnosis date needed to be within ±90 days of that recorded in the medical record to be valid. RESULTS We reviewed 111 charts of patients with a potentially incident diagnosis. The positive predictive value (PPV) of the claims algorithm was 91% (95% confidence interval [CI], 81%-97%). We reviewed 332 charts to validate prevalent case definition algorithms. The PPV was 94% (95% CI, 86%-98%) for ≥2 IBD diagnoses and presence of prescriptions for IBD medications, 92% (95% CI, 85%-97%) for ≥2 diagnoses without any medications, 78% (95% CI, 67%-87%) for a single diagnosis and presence of an IBD medication, and 35% (95% CI, 25%-46%) for 1 physician diagnosis and no IBD medications. CONCLUSIONS Through a combination of diagnosis, procedural, and medication codes in insurance claims data, we were able to identify incident and prevalent IBD cases with high accuracy. These algorithms can be useful for the ascertainment of IBD cases in future studies.
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Affiliation(s)
- Ghadeer K Dawwas
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexandra Weiss
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Brad D Constant
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Kevin Haynes
- Janssen Research and Development, LLC, Titusville, NJ, USA
| | - Jeff Yufeng Yang
- Center for Pharmacoepidemiology, Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Colleen Brensinger
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Qufei Wu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Virginia Pate
- Center for Pharmacoepidemiology, Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michele Jonsson Funk
- Center for Pharmacoepidemiology, Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Michael David Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James D Lewis
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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14
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Dubinsky MC, Delbecque L, Hunter T, Harding G, Stassek L, Moses RE, Lewis JD. Validation of the bowel urgency numeric rating scale in patients with Crohn's disease: results from a mixed methods study. Qual Life Res 2023; 32:3403-3415. [PMID: 37540296 PMCID: PMC10624712 DOI: 10.1007/s11136-023-03494-y] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE Bowel urgency (BU) is an important symptom of Crohn's disease (CD), however there is no patient-reported outcome (PRO) scale validated in this population to assess BU severity. Here we evaluated the content validity and psychometric properties of the Urgency Numeric Rating Scale (NRS). METHOD Qualitative interviews were conducted with moderate-to-severe CD participants to confirm importance and relevance of BU in this population, cognitively debrief the Urgency NRS, and explore score interpretation and CD remission. A quantitative web survey study was conducted to explore the measurement properties of the urgency NRS. RESULTS Qualitative Interview: 34 of 35 participants reported BU. It was most bothersome for 44%, 47% reported it daily, 18% with every bowel movement. BU had a severe impact on daily activities, causing many participants to stay home more than preferred. Patients confirmed the relevance, appropriateness, comprehensibility of the item, recall period, response options, and instructions of the Urgency NRS. Small reductions on the Urgency NRS score reflected meaningful improvements. Quantitative survey: The study sample comprised 76 participants (65.8% female). Mean Urgency NRS score was 4.7 (SD 2.26; N = 76) at Week 1, with no floor/ceiling effect. Test-retest reliability was acceptable. Construct and known-groups validity against selected PROs were overall strong and within ranges hypothesized a priori. CONCLUSION The Urgency NRS is a valid and reliable instrument to assess BU severity in CD.
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Affiliation(s)
- Marla C Dubinsky
- Pediatric GI and Nutrition, Icahn School of Medicine- Mount Sinai Hospital, New York City, NY, USA
| | - Laure Delbecque
- Eli Lilly and Company, 893 Delaware St, Indianapolis, IN, 46225, USA
| | - Theresa Hunter
- Eli Lilly and Company, 893 Delaware St, Indianapolis, IN, 46225, USA.
| | | | | | - Richard E Moses
- Eli Lilly and Company, 893 Delaware St, Indianapolis, IN, 46225, USA
| | - James D Lewis
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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15
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Daniel N, Wu GD, Walters W, Compher C, Ni J, Delaroque C, Albenberg L, Ley RE, Patterson AD, Lewis JD, Gewirtz AT, Chassaing B. Human Intestinal Microbiome Determines Individualized Inflammatory Response to Dietary Emulsifier Carboxymethylcellulose Consumption. Cell Mol Gastroenterol Hepatol 2023; 17:315-318. [PMID: 37931789 PMCID: PMC10829520 DOI: 10.1016/j.jcmgh.2023.11.001] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Noëmie Daniel
- INSERM U1016, Team "Mucosal Microbiota in Chronic Inflammatory Diseases", CNRS UMR 8104, Université de Paris, Paris, France
| | - Gary D Wu
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Walters
- Department of Microbiome Science, Max Planck Institute for Developmental Biology, Tübingen, Germany
| | - Charlene Compher
- Biobehavioral Health Sciences Department, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Josephine Ni
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Clara Delaroque
- INSERM U1016, Team "Mucosal Microbiota in Chronic Inflammatory Diseases", CNRS UMR 8104, Université de Paris, Paris, France
| | - Lindsey Albenberg
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ruth E Ley
- Department of Microbiome Science, Max Planck Institute for Developmental Biology, Tübingen, Germany
| | - Andrew D Patterson
- Center for Molecular Toxicology and Carcinogenesis, Department of Veterinary and Biomedical Sciences, Pennsylvania State University, State College, Pennsylvania
| | - James D Lewis
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew T Gewirtz
- Institute for Biomedical Sciences, Center for Inflammation, Immunity and Infection, Digestive Disease Research Group, Georgia State University, Atlanta, Georgia
| | - Benoit Chassaing
- INSERM U1016, Team "Mucosal Microbiota in Chronic Inflammatory Diseases", CNRS UMR 8104, Université de Paris, Paris, France.
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16
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Lewis JD, Parlett LE, Jonsson Funk ML, Brensinger C, Pate V, Wu Q, Dawwas GK, Weiss A, Constant BD, McCauley M, Haynes K, Yang JY, Schaubel DE, Hurtado-Lorenzo A, Kappelman MD. Incidence, Prevalence, and Racial and Ethnic Distribution of Inflammatory Bowel Disease in the United States. Gastroenterology 2023; 165:1197-1205.e2. [PMID: 37481117 PMCID: PMC10592313 DOI: 10.1053/j.gastro.2023.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [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: 02/09/2023] [Revised: 06/30/2023] [Accepted: 07/07/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND & AIMS We sought to estimate the incidence, prevalence, and racial-ethnic distribution of physician-diagnosed inflammatory bowel disease (IBD) in the United States. METHODS The study used 4 administrative claims data sets: a 20% random sample of national fee-for-service Medicare data (2007 to 2017); Medicaid data from Florida, New York, Pennsylvania, Ohio, and California (1999 to 2012); and commercial health insurance data from Anthem beneficiaries (2006 to 2018) and Optum's deidentified Clinformatics Data Mart (2000 to 2017). We used validated combinations of medical diagnoses, diagnostic procedures, and prescription medications to identify incident and prevalent diagnoses. We computed pooled age-, sex-, and race/ethnicity-specific insurance-weighted estimates and pooled estimates standardized to 2018 United States Census estimates with 95% confidence intervals (CIs). RESULTS The age- and sex-standardized incidence of IBD per 100,000 person-years was 10.9 (95% CI, 10.6-11.2). The incidence of IBD peaked in the third decade of life, decreased to a relatively stable level across the fourth to eighth decades, and declined further. The age-, sex- and insurance-standardized prevalence of IBD was 721 per 100,000 population (95% CI, 717-726). Extrapolated to the 2020 United States Census, an estimated 2.39 million Americans are diagnosed with IBD. The prevalence of IBD per 100,000 population was 812 (95% CI, 802-823) in White, 504 (95% CI, 482-526) in Black, 403 (95% CI, 373-433) in Asian, and 458 (95% CI, 440-476) in Hispanic Americans. CONCLUSIONS IBD is diagnosed in >0.7% of Americans. The incidence peaks in early adulthood and then plateaus at a lower rate. The disease is less commonly diagnosed in Black, Asian, and Hispanic Americans.
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Affiliation(s)
- James D Lewis
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | | | - Michele L Jonsson Funk
- Center for Pharmacoepidemiology, Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Colleen Brensinger
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Virginia Pate
- Center for Pharmacoepidemiology, Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Qufei Wu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ghadeer K Dawwas
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexandra Weiss
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brad D Constant
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maureen McCauley
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Haynes
- Janssen Research and Development, LLC, Titusville, New Jersey
| | - Jeff Yufeng Yang
- Center for Pharmacoepidemiology, Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Michael David Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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17
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Iacovou M, Lewis JD. Commentary: When applying dietary therapies for gastrointestinal conditions, family values, culture, and social challenges matter. Nutr Rev 2023; 81:1490-1494. [PMID: 36809548 DOI: 10.1093/nutrit/nuad014] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Some gastrointestinal conditions now have diet as a cornerstone to therapy. Three examples include the low-fermentable, oligosaccharide, disaccharide, monosaccharide, and polyol diet for irritable bowel syndrome, a gluten-free diet for celiac disease, and a hypoallergenic diet for eosinophilic esophagitis. All have been shown to be effective in Western or highly industrialized countries. However, these gastrointestinal conditions occur worldwide. Less is known regarding the effectiveness of dietary therapies in cultures and regions of dense religious and traditional practices where food is a central focus. This includes South Asia, the Mediterranean region, Africa, the Middle East, South America, and within Indigenous communities. Hence, there is a need to reproduce dietary intervention studies within cultures of dense traditional dietary practices to understand the applicability and acceptability of dietary therapy to establish generalizability. Furthermore, there is a need for nutrition experts to have a deep understanding of various cultural cuisines, practices, values, and customs. To achieve this, increasing the diversity of students in the sciences and having a diverse workforce of nutrition experts and health professionals that reflects the patient population will allow for more personalized care. In addition, there are social challenges, including a lack of medical insurance coverage, the cost of dietary interventions, and inconsistent nutrition messaging. Although there are many cultural considerations and social challenges to implementing effective dietary interventions around the world, these barriers are addressable through research methodologies that address culture and society challenges, and enhanced training of dietitians.
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Affiliation(s)
- Marina Iacovou
- is with the Centre of Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, and the Department of Molecular and Translational Science, Monash University, Clayton, Victoria, Australia
| | - James D Lewis
- is with the Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
As medical management of inflammatory bowel disease makes great advances, most patients with inflammatory bowel disease will have long life expectancies without need for total colectomy. With prolonged disease duration, however, there is increased risk of dysplasia leading to colorectal cancer. Multiple consensus and guideline documents have been published over the last decade with recommendations to optimize early detection and management of dysplastic lesions. Endoscopic technology has improved tremendously, even over the past few years. Previously invisible dysplasia has become visible in most cases with advanced imaging technologies that now allow for much clearer and more detailed mucosal inspection. New tools to facilitate endoscopic resection of visible lesions have also enabled patients to avoid colectomy, with resulting need to continue colon surveillance. There are limited or conflicting data leading to inconsistent recommendations regarding the need for random biopsies, the preferred endoscopic imaging technique, and surveillance intervals after resection of dysplasia. Similarly, there remains significant variability in the application of guidelines into daily practice and availability of and training with advanced imaging technologies. Here, we present a narrative review of which patients are at highest risk for dysplasia, the current guidelines on surveillance colonoscopy, factors affecting optimal mucosal visualization, enhanced imaging techniques, standardized reporting terminologies for surveillance colonoscopy, endoscopic management of dysplasia, indications for colectomy, and briefly on future potential technologies to assist in dysplasia detection.
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Affiliation(s)
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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19
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Yang JY, Lund JL, Funk MJ, Hudgens MG, Lewis JD, Kappelman MD. Utilization of Treat-to-Target Monitoring Colonoscopy After Treatment Initiation in the US-Based Study of a Prospective Adult Research Cohort With Inflammatory Bowel Disease. Am J Gastroenterol 2023; 118:1638-1647. [PMID: 37053548 DOI: 10.14309/ajg.0000000000002294] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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] [Received: 11/02/2022] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Endoscopic healing has been associated with improved long-term clinical outcomes in inflammatory bowel disease (IBD) and is a recommended target for treatment. Evidence is limited regarding real-world uptake and patterns of treat-to-target monitoring to assess endoscopic healing after treatment initiation. We aimed to estimate the proportion of patients in the Study of a Prospective Adult Research Cohort with IBD (SPARC IBD) who received colonoscopy in the 3-15 months after starting a new IBD treatment. METHODS We identified SPARC IBD patients who initiated a new biologic (infliximab, adalimumab, certolizumab pegol, golimumab, vedolizumab, and ustekinumab) or tofacitinib. We estimated the proportion of patients who received colonoscopies in the 3-15 months after IBD treatment initiation and described use by patient subgroups. RESULTS Among 1,708 eligible initiations from 2017 to 2022, the most common medications were ustekinumab (32%), infliximab (22%), vedolizumab (20%), and adalimumab (16%). The median patient age was 38 years, with 66% Crohn's disease; 55% were female, and 12% were non-White. In the 3-15 months after medication initiation, 49.3% (95% confidence interval 46.2%-52.5%) of initiations were followed by a colonoscopy. Colonoscopy use was similar between ulcerative colitis and Crohn's disease, but was higher among male patients, those older than 40 years, and those who received colonoscopy within 3 months of initiation. Colonoscopy use varied between study sites, from 26.6% (15.0%-38.3%) to 63.2% (54.5%-72.0%). DISCUSSION Approximately half of SPARC IBD patients received colonoscopy in the 3-15 months after initiation to a new IBD treatment, suggesting a low uptake of treat-to-target colonoscopy for the assessment of mucosal healing in real-world clinical practice. The variation in colonoscopy use between study sites suggests a lack of consensus and a need for more robust evidence around whether or not the practice of routine monitoring colonoscopy is associated with improved patient outcomes.
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Affiliation(s)
- Jeff Y Yang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael G Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - James D Lewis
- Division of Gastroenterology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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Long MD, Parlett L, Lewis JD, Haynes K, Adimadhyam S, Hou L, Wolfe A, Toh S, Burris J, Dorand J, Kappelman MD. Corticosteroids but not Anti-TNF Are Associated With Increased COVID-19 Complications in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2023:izad176. [PMID: 37611117 DOI: 10.1093/ibd/izad176] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 08/25/2023]
Abstract
BACKGROUND AND AIMS Immunosuppressed individuals are at higher risk for COVID-19 complications, yet data in patients with inflammatory bowel disease (IBD) are limited. We evaluated the risk of COVID-19- severe sequelae by medication utilization in a large cohort of patients with IBD. METHODS We conducted a retrospective cohort study utilizing insurance claims data between August 31, 2019, and August 31, 2021.We included IBD patients identified by diagnosis and treatment codes. Use of IBD medications was defined in the 90 days prior to cohort entry. Study outcomes included COVID-19 hospitalization, mechanical ventilation, and inpatient death. Patients were followed until the outcome of interest, outpatient death, disenrollment, or end of study period. Due to the aggregate nature of available data, we were unable to perform multivariate analyses. RESULTS We included 102 986 patients (48 728 CD, 47 592 UC) with a mean age of 53 years; 55% were female. Overall, 412 (0.4%) patients were hospitalized with COVID-19. The incidence of hospitalization was higher in those on corticosteroids (0.6% vs 0.3%; P < .0001; 13.6 per 1000 person-years; 95% confidence interval [CI], 10.8-16.9) and lower in those receiving anti-tumor necrosis factor α therapy (0.2% vs 0.5%; P < .0001; 3.9 per 1000 person-years; 95% CI, 2.7-5.4). Older age was associated with increased hospitalization with COVID-19. Overall, 71 (0.07%) patients required mechanical ventilation and 52 (0.05%) died at the hospital with COVID-19. The proportion requiring mechanical ventilation (1.9% vs 0.05%; P < .0001; 3.9 per 1000 person-years; 95% CI, 2.5-5.9) was higher among users of corticosteroids. CONCLUSIONS Among patients with IBD, those on corticosteroids had more hospitalizations and mechanical ventilation with COVID-19. Anti-tumor necrosis factor α therapy was associated with a decreased risk of hospitalization. These findings reinforce previous guidance to taper and/or discontinue corticosteroids in IBD.
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Affiliation(s)
- Millie D Long
- Department of Medicine and Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - James D Lewis
- Department of Medicine, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Sruthi Adimadhyam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Laura Hou
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Audrey Wolfe
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | | | | | - Michael D Kappelman
- Department of Medicine and Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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21
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Lewis JD. Model-based prediction of otoacoustic emission level, noise level, and signal-to-noise ratio during time-synchronous averaging. J Acoust Soc Am 2023; 154:709-720. [PMID: 37550237 DOI: 10.1121/10.0020568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/20/2023] [Indexed: 08/09/2023]
Abstract
Although averaging is effective in reducing noise, its efficiency rapidly decreases beyond several hundred averages. Depending on environmental and patient noise levels, several hundred averages may be insufficient for informed clinical decision making. The predictable nature of the otoacoustic emission (OAE) and noise during time-synchronous averaging implicates the use of predictive modeling as an alternative to increased averaging when noise is high. Click-evoked OAEs were measured in 98, normal-hearing subjects. Average OAE and noise levels were calculated for subsets of the total number of averages and then fit using variants of a power function. The accuracy of the models was quantified as the difference between the measured value and model output. Models were used to predict the OAE signal-to-noise ratio (SNR) for a criterion noise level. Based on predictions, the OAE was categorized as present or absent. Model-based decisions were compared to decisions from direct measurements. Model accuracy improved as the number of averages (and SNR in the case of OAEs) from which the model was derived increased. Model-based classifications permitted correct categorization of the OAE status from fewer averages than measurement-based classifications. Furthermore, model-based predictions resulted in fewer false positives (i.e., absent OAE despite normal hearing).
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Affiliation(s)
- James D Lewis
- Department of Audiology and Speech Pathology, University of Tennessee Health Science Center, Knoxville, Tennessee 37996, USA
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22
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Kappelman MD, Long MD, Zhang X, Lin FC, Weisbein L, Chen W, Burris J, Dorand JE, Parlett LE, Fehlmann T, Brensinger CM, Haynes K, Nair V, Kaul AF, Dobes A, Lewis JD. Comparing Patient-Reported Outcomes Among Anti-TNF Experienced Patients With Ulcerative Colitis Initiating Vedolizumab Versus Tofacitinib. Crohns Colitis 360 2023; 5:otad031. [PMID: 37350775 PMCID: PMC10284045 DOI: 10.1093/crocol/otad031] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Indexed: 06/24/2023] Open
Abstract
Background Primary and secondary nonresponse to anti-tumor necrosis factor (TNF) therapy is common in patients with ulcerative colitis (UC), yet limited research has compared the effectiveness of subsequent biological therapy. Objective We sought to compare the effectiveness of vedolizumab and tofacitinib in anti-TNF experienced patients with UC, focusing on patient-prioritized patient-reported outcomes (PROs). Methods We conducted a prospective cohort study nested within the Crohn's & Colitis Foundation's IBD Partners and SPARC IBD initiatives. We identified anti-TNF experienced patients with UC initiating vedolizumab or tofacitinib and analyzed PROs reported approximately 6 months later (minimum 4 months, maximum 10 months). Co-primary outcomes were Patient Reported Outcome Measurement Information System (PROMIS) domains of Fatigue and Pain Interference. Secondary outcomes included PRO2, treatment persistence, and need for colectomy. Results We compared 72 vedolizumab initiators and 33 tofacitinib initiators. At follow-up, Pain Interference (P = .04), but not Fatigue (P = .53) was lower among tofacitinib initiators. A trend toward higher Social Role Satisfaction was not significant. The remainder of secondary outcomes (PRO2, treatment persistence, colectomy) did not differ between treatment groups. Conclusions Among anti-TNF experienced patients with UC, Pain Interference 4-10 months after treatment initiation was lower among tofacitinib users as compared with vedolizumab users. Many, but not all, secondary endpoints and subanalyses also favored tofacitinib. Future studies with larger sample sizes are needed to further evaluate these findings.
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Affiliation(s)
- Michael D Kappelman
- Address correspondence to: Michael D. Kappelman, MD, MPH, University of North Carolina at Chapel Hill, Campus Box 7229, Bioinformatics Building, 130 Mason Farm Rd., Chapel Hill, NC 27599-7555, USA ()
| | - Millie D Long
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Xian Zhang
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Feng-Chang Lin
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura Weisbein
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Wenli Chen
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | | | - Tara Fehlmann
- Crohn’s & Colitis Foundation, New York, New York, USA
| | - Colleen M Brensinger
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin Haynes
- Janssen Research & Development, Titusville, New Jersey, USA
| | | | - Alan F Kaul
- Medical Outcomes Management and the Practice Research Network (PRACnet), Sharon, Massachusetts, USA
| | - Angela Dobes
- Crohn’s & Colitis Foundation, New York, New York, USA
| | - James D Lewis
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Abstract
OBJECTIVES The objective of the study was to quantify inter-subject variability in the dependence of the medial-olivocochlear reflex (MOCR) on noise bandwidth. Of specific interest was whether inter-subject variability in MOCR dependence on bandwidth explained variability in the MOCR response elicited by wideband noise. DESIGN Thirty-two young adults with normal hearing participated in the study. Click-evoked otoacoustic emissions were measured in the ipsilateral ear with and without noise presented in the contralateral ear. Presentation of contralateral noise served to activate the MOCR. The MOCR was activated using five different noise stimuli with bandwidths ranging from 1- to 5-octaves wide (center frequency of 2 kHz; bandwidth incremented in 1-octave steps). Noise spectral levels (19.6 dB SPL/Hz) were held constant across all bandwidths. MOCR metrics included the normalized-percent change in the otoacoustic emission (OAE), the MOCR-induced OAE magnitude shift, and the MOCR-induced OAE phase shift. Linear mixed-effect models were fit to model the dependence of MOCR-induced OAE magnitude and phase changes on noise bandwidth. The use of a mixed-effect modeling approach allowed for the estimation of subject-specific model parameters that capture on- and off-frequency contributions to the MOCR effects. Regression analysis was performed to evaluate the predictive capacity of subject-specific model parameters on the MOCR response elicited by wideband noise. RESULTS All OAE-based MOCR metrics increased as the noise bandwidth increased from 1- to 5-octaves wide. The dependence of MOCR-induced OAE magnitude and phase shifts on activator bandwidth was well approximated using a linear model with intercept and slope terms. On average, MOCR-induced magnitude and phase shifts increased at a rate of 0.3 dB/octave and 0.01 cycles/octave, respectively, as bandwidth extended beyond the predicted region of OAE generation. A statistically significant random effect of subject was found for both the intercept and slope parameter of each model. Subject-specific slope estimates were statistically significant predictors of a repeated measure of the wideband MOCR response. A higher slope was predictive of larger wideband MOCR effects. CONCLUSIONS MOCR-induced changes to the OAE are greatest when the MOCR is elicited using wideband noise. Variability in the process of spectral integration within the MOCR pathway appears to explain, in part, inter-subject variability in OAE-based estimates of the MOCR response elicited by wideband noise.
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Affiliation(s)
- Donguk Lee
- Department of Audiology and Speech Pathology, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
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24
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Kappelman MD, Lewis JD, Zhang X, Lin FC, Weisbein L, Chen W, Burris J, Dorand JE, Parlett LE, Haynes K, Nair V, Kaul AF, Dobes A, Long MD. Comparing Patient-Reported Outcomes Among Anti-TNF-Experienced Patients with Crohn's Disease Initiating Vedolizumab Versus Ustekinumab. Dig Dis Sci 2023:10.1007/s10620-023-07942-0. [PMID: 37115362 DOI: 10.1007/s10620-023-07942-0] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/30/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Primary and secondary non-response to anti-tumor necrosis factor (TNF) therapy is common in patients with Crohn's disease (CD), yet limited research has compared the effectiveness of subsequent biological therapy. OBJECTIVE We sought to compare the effectiveness of vedolizumab and ustekinumab in anti-TNF-experienced patients with CD, focusing on patient-prioritized patient-reported outcomes (PROs). METHODS We conducted a prospective, internet-based cohort study nested within IBD Partners. We identified anti-TNF-experienced patients initiating with CD vedolizumab or ustekinumab and analyzed PROs reported approximately 6 months later (minimum 4 months, maximum 10 months). Co-primary outcomes were Patient-Reported Outcome Measurement Information System (PROMIS) domains of Fatigue and Pain Interference. Secondary outcomes included patient-reported short Crohn's disease activity index (sCDAI), treatment persistence, and corticosteroid use. Inverse probability of treatment weighting (IPTW) was used to control for a number of potential confounders and incorporated into linear and logistic regression models for continuous and categorical outcomes, respectively. RESULTS Overall, 141 vedolizumab and 219 ustekinumab initiators were included in our analysis. After adjustment, we found no differences between treatment groups in our primary outcomes of Pain Interference or Fatigue or the secondary outcome of sCDAI. However, vedolizumab was associated with lower treatment persistence (OR 0.4, 95% CI 0.2-0.6) and higher corticosteroid use at follow-up assessment (OR 1.7, 95% CI 1.1-2.6). DISCUSSION Among anti-TNF experienced patients with CD, Pain Interference or Fatigue was not significantly different 4-10 months after starting ustekinumab or vedolizumab. However, reduced steroid use and increased persistence suggest superiority of ustekinumab for non-PRO outcomes.
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Affiliation(s)
- Michael D Kappelman
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA.
| | - J D Lewis
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - X Zhang
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA
| | - F C Lin
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA
| | - L Weisbein
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA
| | - W Chen
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA
| | - J Burris
- Yale School of Medicine, New Haven, CT, USA
| | - J E Dorand
- Crohn's & Colitis Foundation, New York, NY, USA
| | | | | | - V Nair
- Medical Outcomes Management and the Practice Research Network (PRACNET), Sharon, MA, USA
| | - A F Kaul
- Medical Outcomes Management and the Practice Research Network (PRACNET), Sharon, MA, USA
| | - A Dobes
- Crohn's & Colitis Foundation, New York, NY, USA
| | - M D Long
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA
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25
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Lewis JD, Goettl-Meyer M, Lee D. Medial Olivocochlear Reflex Strength in Ears With Low-to-Moderate Annual Noise Exposure. J Speech Lang Hear Res 2023; 66:1428-1443. [PMID: 36940474 DOI: 10.1044/2022_jslhr-22-00433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE Studies in lower mammals demonstrate enhancement of the medial olivocochlear reflex (MOCR) following noise exposure. A similar effect may occur in humans, and there is some evidence of an individual's acoustic history affecting the MOCR. The current work evaluates the relationship between an individual's annual noise exposure history and their MOCR strength. Given the potential role of the MOCR as a biological hearing protector, it is important to identify factors associated with MOCR strength. METHOD Data were collected from 98 normal-hearing young adults. Annual noise exposure history was estimated using the Noise Exposure Questionnaire. MOCR strength was assayed using click-evoked otoacoustic emissions (CEOAEs) measured with and without noise presented to the contralateral ear. MOCR metrics included the MOCR-induced otoacoustic emission (OAE) magnitude shift and phase shift. A CEOAE signal-to-noise ratio (SNR) of at least 12 dB was required for estimation of the MOCR metrics. Linear regression was applied to evaluate the relationship between MOCR metrics and annual noise exposure. RESULTS Annual noise exposure was not a statistically significant predictor of the MOCR-induced CEOAE magnitude shift. However, annual noise exposure was a statistically significant predictor of the MOCR-induced CEOAE phase shift-the MOCR-induced phase shift decreased with increasing noise exposure. Additionally, annual noise exposure was a statistically significant predictor of OAE level. CONCLUSIONS Findings contrast with recent work that suggests MOCR strength increases with annual noise exposure. Compared with previous work, data for this study were collected using more stringent SNR criteria, which is expected to increase the precision of the MOCR metrics. Additionally, data were collected for a larger subject population with a wider range of noise exposures. Whether findings generalize to other exposure durations and levels is unknown and requires future study.
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Affiliation(s)
- James D Lewis
- Department of Audiology and Speech Pathology, The University of Tennessee Health Science Center, Knoxville
| | - Morgaine Goettl-Meyer
- Department of Physiology and Biophysics, University of Colorado Anschutz Medical Campus, Aurora
| | - Donguk Lee
- Department of Audiology and Speech Pathology, The University of Tennessee Health Science Center, Knoxville
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26
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Kralicek SE, Jenkins C, Allegretti JR, Lewis JD, Osman M, Hecht GA. Transmission of the potential pathogen atypical enteropathogenic E. coli by fecal microbiota transplant. Gastroenterology 2023:S0016-5085(23)00536-X. [PMID: 36990294 DOI: 10.1053/j.gastro.2023.03.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/20/2022] [Revised: 03/03/2023] [Accepted: 03/14/2023] [Indexed: 03/31/2023]
Affiliation(s)
- Sarah E Kralicek
- Department of Biochemistry and Molecular Biology, Loyola University Chicago, Maywood, Illinois
| | - Celeste Jenkins
- Research Assistant II, Department of Medicine, Division of Gastroenterology, Loyola University Medical Center
| | - Jessica R Allegretti
- Assistant Professor of Medicine, Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - James D Lewis
- Professor of Medicine and Epidemiology, Department of Medicine, Division of Gastroenterology and Hepatology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Majdi Osman
- Chief Medical Officer, OpenBiome, Cambridge, Massachusetts
| | - Gail A Hecht
- Professor, Department of Medicine, Division of Gastroenterology, Loyola University Medical Center; Department of Microbiology and Immunology, Loyola University Chicago, Maywood, Illinois
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27
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Mahmud N, Panchal S, Abu-Gazala S, Serper M, Lewis JD, Kaplan DE. Association Between Bariatric Surgery and Alcohol Use-Related Hospitalization and All-Cause Mortality in a Veterans Affairs Cohort. JAMA Surg 2023; 158:162-171. [PMID: 36515960 PMCID: PMC9856780 DOI: 10.1001/jamasurg.2022.6410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Bariatric surgery procedures, in particular Roux-en-Y gastric bypass (RYGB), have been associated with subsequent alcohol-related complications. However, previous studies lack data to account for changes in body mass index (BMI) or alcohol use over time, which are key potential confounders. Objective To evaluate the association between RYGB, sleeve gastrectomy, or gastric banding on subsequent alcohol use disorder (AUD)-related hospitalization and all-cause mortality as compared with referral to a weight management program alone. Design, Setting, and Participants This cohort study included 127 Veterans Health Administration health centers in the US. Patients who underwent RYGB, sleeve gastrectomy, or gastric banding or who were referred to MOVE!, a weight management program, and had a BMI (calculated as weight in kilograms divided by height in meters squared) of 30 or greater between January 1, 2008, and December 31, 2021, were included in the study. Exposures RYGB, sleeve gastrectomy, or gastric banding or referral to the MOVE! program. Main Outcomes and Measures The primary outcome was time to AUD-related hospitalization from the time of bariatric surgery or MOVE! referral. The secondary outcome was time to all-cause mortality. Separate propensity scores were created for each pairwise comparison (RYGB vs MOVE! program, RYGB vs sleeve gastrectomy, sleeve gastrectomy vs MOVE!). Sequential Cox regression approaches were used for each pairwise comparison to estimate the relative hazard of the primary outcome in unadjusted, inverse probability treatment weighting (IPTW)-adjusted (generated from the pairwise logistic regression models), and IPTW-adjusted approaches with additional adjustment for time-updating BMI and categorical Alcohol Use Disorders Identification Test-Concise scores. Results A total of 1854 patients received RYGB (median [IQR] age, 53 [45-60] years; 1294 men [69.8%]), 4211 received sleeve gastrectomy (median [IQR] age, 52 [44-59] years; 2817 men [66.9%]), 265 received gastric banding (median [IQR] age, 55 [46-61] years; 199 men [75.1%]), and 1364 were referred to MOVE! (median [IQR] age, 59 [49-66] years; 1175 men [86.1%]). In IPTW Cox regression analyses accounting for time-updating alcohol use and BMI, RYGB was associated with an increased hazard of AUD-related hospitalization vs MOVE! (hazard ratio [HR], 1.70; 95% CI, 1.20-2.41; P = .003) and vs sleeve gastrectomy (HR, 1.98; 95% CI, 1.55-2.53; P < .001). There was no significant difference between sleeve gastrectomy and MOVE! (HR, 0.76; 95% CI, 0.56-1.03; P = .08). While RYGB was associated with a reduced mortality risk vs MOVE! (HR, 0.63; 95% CI, 0.49-0.81; P < .001), this association was mitigated by increasing alcohol use over time. Conclusions and Relevance This cohort study found that RYGB was associated with an increased risk of AUD-related hospitalizations vs both sleeve gastrectomy and the MOVE! program. The mortality benefit associated with RYGB was diminished by increased alcohol use, highlighting the importance of careful patient selection and alcohol-related counseling for patients undergoing this procedure.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Medicine, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania,Leonard David Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sarjukumar Panchal
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Samir Abu-Gazala
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Medicine, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania,Leonard David Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - James D. Lewis
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Leonard David Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Medicine, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Bittermann T, Lewis JD, Levy C, Goldberg DS. Sociodemographic and geographic differences in the US epidemiology of autoimmune hepatitis with and without cirrhosis. Hepatology 2023; 77:367-378. [PMID: 35810446 PMCID: PMC9829924 DOI: 10.1002/hep.32653] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 03/14/2022] [Revised: 05/17/2022] [Accepted: 07/04/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIMS Data on the epidemiology of autoimmune hepatitis (AIH) in the United States are limited. This study investigated the sociodemographic and geographic factors associated with AIH incidence and prevalence with and without cirrhosis. APPROACH AND RESULTS In a retrospective cohort of adults in the Optum Clinformatics Data Mart (2009-2018), we identified AIH cases using a validated claims-based algorithm. Incidence and prevalence were compared between sociodemographic subgroups. Logistic regression evaluated the association of US Census Division with AIH incidence and the factors associated with incident AIH with cirrhosis. From 2009 to 2018, the age- and sex-standardized prevalence of AIH in the Optum cohort was 26.6 per 100,000 persons with an incidence of 4.0 per 100,000 person-years. AIH incidence increased earlier among Hispanics (age 50-59 years) and later among Asians (≥80 years). Adjusted AIH incidence was higher in the Mountain Division (odds ratio [OR] 1.17) and lower in the Pacific (OR 0.68), Middle Atlantic (OR 0.81), and West North Central Divisions (OR 0.86 vs. East North Central; p < 0.001). Male sex (OR 1.31, p = 0.003), Black race (OR 1.32, p = 0.022), and Hispanic ethnicity (OR 1.37 vs. non-Hispanic White, p = 0.009) were associated with incident AIH with cirrhosis. Incident AIH with cirrhosis was greater in the West South Central Division (OR 1.30 vs. South Atlantic; p = 0.008). CONCLUSIONS AIH epidemiology differs according to sociodemographic and geographic factors in the United States. Studies are needed to determine the genetic, epigenetic, and environmental factors underlying the heterogeneity in AIH risk and outcomes.
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Affiliation(s)
- Therese Bittermann
- Division of Gastroenterology & Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics and Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James D. Lewis
- Division of Gastroenterology & Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics and Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cynthia Levy
- Division of Digestive Health and Liver Disease, University of Miami Miller School of Medicine, Miami, FL
| | - David S. Goldberg
- Division of Digestive Health and Liver Disease, University of Miami Miller School of Medicine, Miami, FL
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29
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Lewis JD. Statistical Power for Clinical Trials of Proactive Therapeutic Drug Monitoring. Gastroenterology 2023; 164:165-166. [PMID: 35863526 DOI: 10.1053/j.gastro.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/10/2022] [Accepted: 07/13/2022] [Indexed: 02/03/2023]
Affiliation(s)
- James D Lewis
- Penn Presbyterian Medical Center, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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30
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Dubinsky MC, Newton L, Delbecque L, Hunter T, Guobyte A, Naegeli AN, McFadden S, Donaldson J, Symonds T, Lewis JD. Exploring Disease Remission and Bowel Urgency Severity Among Adults with Moderate to Severe Ulcerative Colitis: A Qualitative Study. Patient Relat Outcome Meas 2022; 13:287-300. [PMID: 36582542 PMCID: PMC9793422 DOI: 10.2147/prom.s378759] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose Achieving and maintaining symptom control is a key treatment goal in ulcerative colitis (UC). Bowel urgency is an important symptom of UC, thus measurement of urgency is critical. This research explored the patient experience of UC and "remission" in UC, with a focus on urgency, and cognitively debriefed the Urgency Numeric Rating Scale (NRS), including score interpretation and examination of meaningful improvement. Patients and Methods Semi-structured hybrid concept elicitation and cognitive debriefing interviews with adults with moderately-severely active UC were conducted to explore experiences of UC and urgency, as well as examine meaningful improvement and score interpretation of the Urgency NRS. Purposive sampling was used to identify 20 eligible adult participants with UC. Concept elicitation data were analyzed using thematic analysis, and a deductive approach was used to analyze cognitive debriefing data. Thematic analysis was also applied to meaningful change-related data. Results Twenty participants were interviewed (average age = 42.6 years old, 50% male); 14 with moderately active (70.0%) and 6 with severely active UC (30.0%). Disease remission was not consistently defined by participants and description varied in terms of definition (absence vs not complete absence of symptoms), duration (months vs days) and key symptoms to consider. Urgency was a prominent symptom for all participants, with 8 (40.0%) identifying it as the most bothersome aspect of UC. No issues were identified with the Urgency NRS. Participants were able to define different levels of urgency severity, describe how they relate to daily life impacts, and score them differently on the Urgency NRS. Participants were also able to reflect urgency improvement on the NRS and discuss how small changes in numeric ratings of urgency can reflect meaningful change in the symptom burden of their UC. Conclusion The Urgency NRS is a content valid and interpretable measure to assess bowel urgency severity.
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Affiliation(s)
| | | | - Laure Delbecque
- Eli Lilly and Company, Brussels, Belgium,Correspondence: Laure Delbecque, Principal Research Scientist, Eli Lilly and Company, Brussels, Belgium, Tel +32 (0)499 72 31 37, Email
| | | | | | | | | | | | | | - James D Lewis
- Perelman School of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
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Kim HS, Hernaez R, Sansgiry S, Waljee AK, Scott FI, Lewis JD, El-Serag HB, Hou JK. Comparative Effectiveness of Surveillance Colonoscopy Intervals on Colorectal Cancer Outcomes in a National Cohort of Patients with Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2022; 20:2848-2857.e2. [PMID: 35240331 PMCID: PMC9489337 DOI: 10.1016/j.cgh.2022.02.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 08/18/2021] [Revised: 01/20/2022] [Accepted: 02/17/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Surveillance colonoscopy is recommended to reduce colorectal cancer (CRC)-related morbidity and mortality in patients with inflammatory bowel disease (IBD). The comparative effectiveness of varying colonoscopy intervals on CRC outcomes among patients with IBD is unknown. METHODS We performed a retrospective cohort study of patients with confirmed CRC within a cohort of 77,824 patients with IBD during 2000 to 2015 in the National Veterans Health Administration. We examined the association between colonoscopy surveillance intervals on CRC stage, treatment, or all-cause and cancer-specific mortality. The interval of colonoscopy prior to CRC diagnosis was categorized as those performed within <1 year, 1 to 3 years, 3 to 5 years, or none within 5 years. RESULTS Among 566 patients with CRC-IBD, most (69.4%) did not have colonoscopy within 5 years prior to CRC diagnosis, whereas 9.7% had colonoscopy within 1 year prior to diagnosis, 17.7% within 1 to 3 years, and 3.1% between 3 and 5 years. Compared with no surveillance, colonoscopy within 1 year (adjusted odds ratio, 0.40; 95% confidence interval [CI], 0.20-0.82), and 1 to 3 years (adjusted odds ratio, 0.56; 95% CI, 0.32-0.98) were less likely to be diagnosed at late stage. Regardless of IBD type and duration, colonoscopy within 1 year was associated with a lower all-cause mortality (adjusted hazard ratio, 0.56; 95% CI, 0.36-0.88). CONCLUSIONS In a national cohort of patients with CRC-IBD, colonoscopy within 3 years prior to CRC diagnosis was associated with early tumor stage at diagnosis, and colonoscopy within 1 year was associated with a reduced all-cause mortality compared with no colonoscopy. Our findings support colonoscopy intervals of 1 to 3 years in patients with IBD to reduce late-stage CRC and all-cause mortality.
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Affiliation(s)
- Hyun-Seok Kim
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Shubhada Sansgiry
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Section of Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Akbar K Waljee
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan; Health Services Research and Development Center of Clinical Management Research, Veterans Administration Ann Arbor, Ann Arbor, Michigan
| | - Frank I Scott
- Division of Gastroenterology, University of Colorado, Aurora, Colorado
| | - James D Lewis
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Jason K Hou
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
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Delaroque C, Wu GD, Compher C, Ni J, Albenberg L, Liu Q, Tian Y, Patterson AD, Lewis JD, Gewirtz AT, Chassaing B. Diet standardization reduces intra-individual microbiome variation. Gut Microbes 2022; 14:2149047. [PMID: 36426908 PMCID: PMC9704386 DOI: 10.1080/19490976.2022.2149047] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The human gut microbiota is highly heterogenous between individuals and also exhibits considerable day-to-day variation within individuals. We hypothesized that diet contributed to such inter- and/or intra-individual variance. Hence, we investigated the extent to which diet normalization impacted microbiota heterogeneity. We leveraged the control arm of our recently reported controlled-feeding study in which nine healthy individuals consumed a standardized additive-free diet for 10 days. Diet normalization did not impact inter-individual differences but reduced the extent of intra-individual day-to-day variation in fecal microbiota composition. Such decreased heterogeneity reflected individual-specific enrichment and depletion of an array of taxa microbiota members and was paralleled by a trend toward reduced intra-individual variance in fecal LPS and flagellin, which, collectively, reflect microbiota's pro-inflammatory potential. Yet, the microbiota of some subjects did not change significantly over the course of the study, suggesting heterogeneity in microbiota resilience to dietary stress or that baseline diets of some subjects were perhaps similar to our study's standardized diet. Collectively, our results indicate that short-term diet heterogeneity contributes to day-to-day intra-individual microbiota composition variance.
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Affiliation(s)
- Clara Delaroque
- INSERM U1016, Team “Mucosal Microbiota in Chronic Inflammatory Diseases”, CNRS UMR 8104, Université Paris Cité, Paris, France
| | - Gary D. Wu
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charlene Compher
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Josephine Ni
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lindsey Albenberg
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Qing Liu
- Center for Molecular Toxicology and Carcinogenesis, Department of Veterinary and Biomedical Sciences, Pennsylvania State University, Philadelphia, Pennsylvania, USA
| | - Yuan Tian
- Center for Molecular Toxicology and Carcinogenesis, Department of Veterinary and Biomedical Sciences, Pennsylvania State University, Philadelphia, Pennsylvania, USA
| | - Andrew D. Patterson
- Center for Molecular Toxicology and Carcinogenesis, Department of Veterinary and Biomedical Sciences, Pennsylvania State University, Philadelphia, Pennsylvania, USA
| | - James D. Lewis
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew T. Gewirtz
- Institute for Biomedical Sciences, Center for Inflammation, Immunity and Infection, Digestive Disease Research Group, Georgia State University, Atlanta, Georgia, USA
| | - Benoit Chassaing
- INSERM U1016, Team “Mucosal Microbiota in Chronic Inflammatory Diseases”, CNRS UMR 8104, Université Paris Cité, Paris, France,CONTACT Benoit Chassaing INSERM U1016, Team “Mucosal, Microbiota in Chronic Inflammatory Diseases”, CNRS UMR 8104, Université Paris Cité, Paris, France
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Compher CW, Quinn R, Burke F, Piccinin D, Sartor L, Lewis JD, Wu GD. Development of the Penn Healthy Diet screener with reference to adult dietary intake data from the National Health and Nutrition Examination Survey. Nutr J 2022; 21:70. [PMID: 36384552 PMCID: PMC9670424 DOI: 10.1186/s12937-022-00821-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is a need for a feasible, user-friendly tool that can be employed to assess the overall quality of the diet in U.S. CLINICAL SETTINGS Our objectives were to develop the Penn Healthy Diet (PHD) screener, evaluate screener item correlations with Healthy Eating Index (HEI)-2015 components, and develop a simple scoring algorithm. METHODS National Health and Nutrition Examination Survey (NHANES) 2017-18 dietary recall data in adults were used to define food examples in screener food groups based on components of the HEI-2015, Diet Approach to Stop Hypertension, and Alternative Mediterranean diet approaches. Instrument Content Validity Index (I-CVI) was used to evaluate the clarity and relevance of the screener. Patient acceptability was evaluated by completion time and response rates. NHANES 2017-18 food recall data were used to simulate responses to the screener items, which were evaluated for association with HEI-2015 components. A scoring algorithm was developed based on screener items moderately or strongly associated with HEI-2015 components. Reproducibility was tested using NHANES 2015-16 data. RESULTS The screener had strong clarity (I-CVI = 0.971) and relevance for nutrition counseling (I-CVI = 0.971). Median (IQR) completion time was 4 (3-5) minutes on paper and 4 (4-8) minutes online, and 73% of patients invited online completed the survey. Based on simulated NHANES participant screener responses, 15 of the 29 screener items were moderately or strongly associated with HEI-2015 components, forming the basis of the scoring algorithm with a range of 0-63 points, where higher score indicates a healthier diet. The median (IQR) screener and HEI-2015 scores were 14.96 (11.99-18.36) and 48.96 (39.51-59.48), respectively. The simulated PHD score was highly correlated with the HEI-2015 score (Spearman rho 0.75) in NHANES 2017-18 and confirmed in NHANES 2015-16 data (Spearman rho 0.75). CONCLUSIONS The Penn Healthy Diet screener may be a useful tool for assessing diet quality due to its acceptable content validity, ease of administration, and ability to distinguish between servings of key food groups associated with a healthy versus unhealthy diet according to the HEI-2015. Additional research is needed to further establish the instrument's validity, and to refine a scoring algorithm.
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Affiliation(s)
- Charlene W. Compher
- grid.25879.310000 0004 1936 8972University of Pennsylvania School of Nursing, Philadelphia, PA USA
| | - Ryan Quinn
- grid.25879.310000 0004 1936 8972University of Pennsylvania School of Nursing, Philadelphia, PA USA
| | - Frances Burke
- grid.25879.310000 0004 1936 8972Department of Cardiology, Perelman University of Pennsylvania School of Medicine, Philadelphia, PA USA
| | - Doris Piccinin
- grid.25879.310000 0004 1936 8972Abramson Cancer Center, Perelman University of Pennsylvania School of Medicine, Philadelphia, PA USA
| | - Linda Sartor
- grid.25879.310000 0004 1936 8972Bariatric Surgery Program, Perelman University of Pennsylvania School of Medicine, Philadelphia, PA USA
| | - James D. Lewis
- grid.25879.310000 0004 1936 8972Department of Gastroenterology, Perelman University of Pennsylvania School of Medicine, Philadelphia, PA USA
| | - Gary D. Wu
- grid.25879.310000 0004 1936 8972Department of Gastroenterology, Perelman University of Pennsylvania School of Medicine, Philadelphia, PA USA
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Dubinsky MC, Shan M, Delbecque L, Lissoos T, Hunter T, Harding G, Stassek L, Andrae D, Lewis JD. Psychometric evaluation of the Urgency NRS as a new patient-reported outcome measure for patients with ulcerative colitis. J Patient Rep Outcomes 2022; 6:114. [PMID: 36334163 PMCID: PMC9637076 DOI: 10.1186/s41687-022-00522-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background The Urgency Numeric Rating Scale (NRS) was developed as a content-valid single-item patient-reported outcome measure to assess severity of bowel urgency. Here, we evaluated the psychometric properties of the Urgency NRS. Methods Data were from a multicenter, randomized, placebo-controlled phase 3 trial in adults with moderately to severely active ulcerative colitis (NCT03518086). Patients completed the Urgency NRS using a daily electronic diary, from which weekly average Urgency NRS scores were calculated. Test–retest reliability, known-groups validity, construct validity, responsiveness, and score interpretation were assessed using the modified Mayo score, Inflammatory Bowel Disease Questionnaire (IBDQ), Patient Global Rating of Severity (PGRS), Patient Global Rating of Change (PGRC), and Geboes score. Results The study sample comprised 1,162 participants (40.2% female). Mean Urgency NRS score was higher (worse) at baseline than at week 12 (6.2 vs. 3.7). Test–retest reliability was strong, with intra-class correlation coefficients of 0.76–0.89. Baseline least-square mean Urgency NRS score was higher for participants with a PGRS score greater than the median (worse symptoms) than for those with a PGRS score less than or equal to the median (7.5 vs. 5.4; p < 0.0001), indicating good known-groups validity. Urgency NRS score was moderately correlated with IBDQ total and domain scores, PGRS, PGRC, and modified Mayo stool frequency, establishing its convergent validity. Correlations were weak for Geboes score and weak to moderate for modified Mayo endoscopic subscore and modified Mayo rectal bleeding, indicating that the Urgency NRS also had discriminant validity. Patients achieving clinical remission, clinical response, IBDQ remission, and PGRS score improvement showed significantly greater improvement on the Urgency NRS (p < 0.0001 for all), demonstrating responsiveness to change. A ≥ 3-point improvement in Urgency NRS score represented a meaningful improvement in bowel urgency and an Urgency NRS score of ≤ 1 point represented a bowel urgency remission threshold that was closely associated with clinical, endoscopic, and histologic remission. Conclusions The Urgency NRS is a valid and reliable patient-reported outcome measure that is suitable for evaluating treatment benefits in clinical trials in patients with moderately to severely active ulcerative colitis. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00522-2.
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Kaplan GG, Underwood FE, Coward S, Agrawal M, Ungaro RC, Brenner EJ, Gearry RB, Kissous-Hunt M, Lewis JD, Ng SC, Rahier JF, Reinisch W, Steinwurz F, Zhang X, Kappelman MD, Colombel JF. The Multiple Waves of COVID-19 in Patients With Inflammatory Bowel Disease: A Temporal Trend Analysis. Inflamm Bowel Dis 2022; 28:1687-1695. [PMID: 35032167 PMCID: PMC8807298 DOI: 10.1093/ibd/izab339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cases of coronavirus disease 2019 (COVID-19) have emerged in discrete waves. We explored temporal trends in the reporting of COVID-19 in inflammatory bowel disease (IBD) patients. METHODS The Surveillance Epidemiology of Coronavirus Under Research Exclusion for Inflammatory Bowel Disease (SECURE-IBD) is an international registry of IBD patients diagnosed with COVID-19. The average percent changes (APCs) were calculated in weekly reported cases of COVID-19 during the periods of March 22 to September 12, September 13 to December 12, 2020, and December 13 to July 31, 2021. RESULTS Across 73 countries, 6404 cases of COVID-19 were reported in IBD patients. COVID-19 reporting decreased globally by 4.2% per week (95% CI, -5.3% to -3.0%) from March 22 to September 12, 2020, then climbed by 10.2% per week (95% CI, 8.1%-12.3%) from September 13 to December 12, 2020, and then declined by 6.3% per week (95% CI, -7.8% to -4.7%). In the fall of 2020, weekly reporting climbed in North America (APC, 11.3%; 95% CI, 8.8-13.8) and Europe (APC, 17.7%; 95% CI, 12.1%-23.5%), whereas reporting was stable in Asia (APC, -8.1%; 95% CI, -15.6-0.1). From December 13, 2020, to July 31, 2021, reporting of COVID-19 in those with IBD declined in North America (APC, -8.5%; 95% CI, -10.2 to -6.7) and Europe (APC, -5.4%; 95% CI, -7.2 to -3.6) and was stable in Latin America (APC, -1.5%; 95% CI, -3.5% to 0.6%). CONCLUSIONS Temporal trends in reporting of COVID-19 in those with IBD are consistent with the epidemiological patterns COVID-19 globally.
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Affiliation(s)
- Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Fox E Underwood
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Stephanie Coward
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Manasi Agrawal
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ryan C Ungaro
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erica J Brenner
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Richard B, Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Michele Kissous-Hunt
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- New York Gastroenterology Associates, New York, New York, USA
| | - James D Lewis
- Department of Epidemiology and Biostatistics, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong SAR, The People’s Republic of China
| | - Jean-Francois Rahier
- Department of Gastroenterology, Université Catholique de Louvain, Yvoir, Belgium
| | - Walter Reinisch
- Department Internal Medicine III, Division Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
| | - Flavio Steinwurz
- Department of Gastroenterology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Xian Zhang
- Department of Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jean-Frederic Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Dawwas GK, Cuker A, Barnes GD, Lewis JD, Hennessy S. Apixaban Versus Rivaroxaban in Patients With Atrial Fibrillation and Valvular Heart Disease : A Population-Based Study. Ann Intern Med 2022; 175:1506-1514. [PMID: 36252244 PMCID: PMC10878325 DOI: 10.7326/m22-0318] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/22/2022] Open
Abstract
BACKGROUND Although apixaban and rivaroxaban are commonly used in patients with atrial fibrillation (AF) and valvular heart disease (VHD), there is limited evidence comparing the 2 drugs in these patients. OBJECTIVE To emulate a target trial of effectiveness and safety of apixaban and rivaroxaban in patients with AF and VHD. DESIGN New-user, active comparator, cohort study design. SETTING Commercial health insurance database from 1 January 2013 to 31 December 2020. PATIENTS New users of apixaban or rivaroxaban who had a diagnosis of AF and VHD before initiation of anticoagulant therapy. MEASUREMENTS The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of gastrointestinal or intracranial bleeding. Cox proportional hazards regression with a robust variance estimator was used to estimate hazard ratios (HRs) and 95% CIs. RESULTS When compared with rivaroxaban in a propensity score-matched cohort of 19 894 patients (9947 receiving each drug), apixaban was associated with a lower rate of ischemic stroke or systemic embolism (HR, 0.57 [95% CI, 0.40 to 0.80]) and bleeding (HR, 0.51 [CI, 0.41 to 0.62]). The absolute reduction in the probability of stroke or systemic embolism with apixaban compared with rivaroxaban was 0.0026 within 6 months and 0.011 within 1 year of treatment initiation. The absolute reduction in the probability of bleeding events with apixaban compared with rivaroxaban was 0.012 within 6 months and 0.019 within 1 year of treatment initiation. LIMITATION Short follow-up time and inability to ascertain some types of VHD. CONCLUSION In this study of patients with AF and VHD, patients receiving apixaban had a lower risk for ischemic stroke or systemic embolism and for bleeding when compared with those receiving rivaroxaban. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Ghadeer K Dawwas
- Center for Real-world Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D.)
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.C.)
| | - Geoffrey D Barnes
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan (G.D.B.)
| | - James D Lewis
- Center for Real-world Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, and Division of Gastroenterology and Hepatology, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (J.D.L.)
| | - Sean Hennessy
- Center for Real-world Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, and Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (S.H.)
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Bittermann T, Lewis JD, Goldberg DS. Recipient and Center Factors Associated With Immunosuppression Practice Beyond the First Year After Liver Transplantation and Impact on Outcomes. Transplantation 2022; 106:2182-2192. [PMID: 35706103 PMCID: PMC9613480 DOI: 10.1097/tp.0000000000004209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Immunosuppression is a critical aspect of post-transplant management, yet practices at intermediate and late time points after liver transplantation (LT) are poorly characterized. METHODS A retrospective cohort of 11 326 adult first LT alone recipients between 2007 and 2016 was identified by linking United Network for Organ Sharing transplant data to Medicare administrative claims. The immunosuppression regimen was obtained from Medicare billing claims. Factors associated with calcineurin inhibitor (CNI) monotherapy at 1-, 3-, and 5-y post-LT were investigated using mixed-effects logistic regression. Center practice heterogeneity was evaluated. The association of immunosuppression regimen (time-updating) with patient and graft survival was studied. RESULTS CNI monotherapy was used in 51.9% at 1-y post-LT and 68.6% at 5-y post-LT. Center-specific rates ranged from 20.0%-79.9% to 15.4%-95.2%, respectively. CNI monotherapy at 1- and 3-y post-LT was less likely among Black recipients ( P = 0.027 and P = 0.015 versus White, respectively). CNI plus antimetabolite was associated with improved adjusted patient (hazard ratio, 0.59; P < 0.001) and graft (hazard ratio, 0.62; P < 0.001) survival versus CNI monotherapy. The benefit of CNI plus antimetabolite on patient and graft survival increased with older age. CONCLUSIONS In this first longitudinal analysis of LT immunosuppression practices among Medicare beneficiaries, a CNI plus antimetabolite approach led to improved outcomes. Significant center heterogeneity in practice was observed.
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Affiliation(s)
- Therese Bittermann
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
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Sieber A, Aberra FN, Bonhomme B, McKeever L, Lewis JD. Influence of Corticosteroid Use on Short- and Long-Term Outcomes of Biologic Therapy for Inflammatory Bowel Diseases. Dig Dis Sci 2022; 67:5168-5176. [PMID: 35094254 DOI: 10.1007/s10620-021-07361-z] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 12/06/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Corticosteroids (CS) are widely used to treat Crohn's disease (CD) and ulcerative colitis (UC), but are not recommended as maintenance therapy. Biologic drugs are widely used as an alternative to or in conjunction with CS to induce and maintain remission. This meta-analysis tested the hypothesis that CS use is associated with differential response to biologics. METHODS We identified published placebo-controlled clinical trials of biologic drugs approved for the treatment of CD or UC. Pooled estimates of the risk difference (RD) and 95% confidence intervals were derived from random effects models for induction of response and remission and maintenance of remission comparing biologic with CS versus biologic alone. Heterogeneity of response was estimated using I2. RESULTS Fifteen studies met the inclusion criteria. Pooled estimates of the RD and I2 comparing biologic plus CS versus biologic alone were as follows: induction of UC response 0.15 (0.05, 0.25), I2 = 57.29% and CD response 0.02 (- 0.03, 0.06), I2 = 0.01%; induction of UC remission 0.03 (- 0.01, 0.08), I2 = 0.00% and CD remission 0.08(0.02, 0.14), I2 = 7.81%; and maintenance of UC remission - 0.06 (- 0.13, 0.01), I2 = 0.00% and CD remission - 0.06 (- 0.14, 0.03), I2 = 11.24%. Patients in the placebo arm of CD trials who were receiving CS were less likely to achieve remission during the induction phase (pooled RD - 0.05 (- 0.09, - 0.00), I2 = 0.00%). CONCLUSIONS In this meta-analysis of placebo-controlled trials, CS use was associated with higher biologic response rates for UC and remission rates for CD during the induction phase, but were not associated with improved maintenance of remission.
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Affiliation(s)
- Alexis Sieber
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Faten N Aberra
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Brittaney Bonhomme
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Liam McKeever
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - James D Lewis
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, PA, Philadelphia, USA. .,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Siddique SM, Mehta SJ, Parsikia A, Neuman MD, Lewis JD. Hospital Performance for Gastrointestinal Bleeding Mortality, Length of Stay, and Complication Rates in the USA. Dig Dis Sci 2022; 67:4678-4686. [PMID: 35031875 PMCID: PMC10045790 DOI: 10.1007/s10620-021-07345-z] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 11/22/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hospitals are held accountable for quality metrics, through public reporting programs and by payers. However, little is known about hospital performance in GIB nationally. METHODS A retrospective longitudinal analysis utilizing Vizient's database was performed to identify GIB hospitalizations across 349 hospitals from 2016 to 2018. The primary outcome was risk-adjusted mortality; secondary outcomes included risk-adjusted length of stay and complication rate. Trends in performance were characterized using quintiles, with analysis of concordance within hospitals and across hospitals over time. Pearson's correlation coefficients were performed to assess the relationship among metrics. RESULTS 28.1% of hospitals had a steadily improving risk-adjusted mortality index from 2016 to 2018, while 15.5% were steadily worsening in mortality. For LOS, 25.2% of hospitals were improving, while 22.4% deteriorated. For complication rate, 22.9% of hospitals steadily improved, while 19.2% of hospitals deteriorated. Although many hospitals improved substantially in one outcome, they did not necessarily improve in all outcomes. Of the 98 hospitals that steadily improved in mortality from 2016 to 2018, only 8 out of 98 steadily improved in all three outcomes (8.3%). Across all 3 years, mortality was weakly correlated with LOS (r = 0.22, p < 0.001), but not with the rate of complications (r = 0.08, p = 0.12). CONCLUSION Hospital performance metrics for GIB, such as mortality, length of stay, and complication rate, are weakly correlated and thus likely measure different aspects of care. While many hospitals improved over time, few hospitals improved in all three metrics. Additionally, many hospitals are deteriorating over time, and further research is needed to determine which care processes are associated with better outcomes.
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Affiliation(s)
- Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania, 3400 Civic Center Blvd, 7th floor Gastroenterology, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA.
| | - Shivan J Mehta
- Division of Gastroenterology, University of Pennsylvania, 3400 Civic Center Blvd, 7th floor Gastroenterology, Philadelphia, PA, 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
| | - Afshin Parsikia
- Division of Gastroenterology, University of Pennsylvania, 3400 Civic Center Blvd, 7th floor Gastroenterology, Philadelphia, PA, 19104, USA
| | - Mark D Neuman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, USA
| | - James D Lewis
- Division of Gastroenterology, University of Pennsylvania, 3400 Civic Center Blvd, 7th floor Gastroenterology, Philadelphia, PA, 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, USA
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Verburgt CM, Dunn KA, Ghiboub M, Lewis JD, Wine E, Sigall Boneh R, Gerasimidis K, Shamir R, Penny S, Pinto DM, Cohen A, Bjorndahl P, Svolos V, Bielawski JP, Benninga MA, de Jonge WJ, Van Limbergen JE. Successful Dietary Therapy in Paediatric Crohn's Disease is Associated with Shifts in Bacterial Dysbiosis and Inflammatory Metabotype Towards Healthy Controls. J Crohns Colitis 2022; 17:61-72. [PMID: 36106847 PMCID: PMC9880954 DOI: 10.1093/ecco-jcc/jjac105] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 06/02/2022] [Accepted: 07/28/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS Nutritional therapy with the Crohn's Disease Exclusion Diet + Partial Enteral Nutrition [CDED+PEN] or Exclusive Enteral Nutrition [EEN] induces remission and reduces inflammation in mild-to-moderate paediatric Crohn's disease [CD]. We aimed to assess if reaching remission with nutritional therapy is mediated by correcting compositional or functional dysbiosis. METHODS We assessed metagenome sequences, short chain fatty acids [SCFA] and bile acids [BA] in 54 paediatric CD patients reaching remission after nutritional therapy [with CDED + PEN or EEN] [NCT01728870], compared to 26 paediatric healthy controls. RESULTS Successful dietary therapy decreased the relative abundance of Proteobacteria and increased Firmicutes towards healthy controls. CD patients possessed a mixture of two metabotypes [M1 and M2], whereas all healthy controls had metabotype M1. M1 was characterised by high Bacteroidetes and Firmicutes, low Proteobacteria, and higher SCFA synthesis pathways, and M2 was associated with high Proteobacteria and genes involved in SCFA degradation. M1 contribution increased during diet: 48%, 63%, up to 74% [Weeks 0, 6, 12, respectively.]. By Week 12, genera from Proteobacteria reached relative abundance levels of healthy controls with the exception of E. coli. Despite an increase in SCFA synthesis pathways, remission was not associated with increased SCFAs. Primary BA decreased with EEN but not with CDED+PEN, and secondary BA did not change during diet. CONCLUSION Successful dietary therapy induced correction of both compositional and functional dysbiosis. However, 12 weeks of diet was not enough to achieve complete correction of dysbiosis. Our data suggests that composition and metabotype are important and change quickly during the early clinical response to dietary intervention. Correction of dysbiosis may therefore be an important future treatment goal for CD.
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Affiliation(s)
| | | | - Mohammed Ghiboub
- Department of Paediatric Gastroenterology and Nutrition, Amsterdam University Medical Centers, University of Amsterdam, Emma Children’s Hospital, Amsterdam, The Netherlands,Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - James D Lewis
- Centre for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eytan Wine
- Division of Paediatric Gastroenterology, Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
| | - Rotem Sigall Boneh
- Wolfson Medical Centre, Holon, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Konstantinos Gerasimidis
- Department of Human Nutrition, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Medical Centre, Petach-Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Susanne Penny
- Human Health Therapeutics, National Research Council, Halifax, NS, Canada
| | - Devanand M Pinto
- Human Health Therapeutics, National Research Council, Halifax, NS, Canada
| | - Alejandro Cohen
- Proteomics and Mass Spectrometry Core Facility, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Paul Bjorndahl
- Department of Mathematics & Statistics, Dalhousie University, Halifax, NS, Canada
| | - Vaios Svolos
- Department of Human Nutrition, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Joseph P Bielawski
- Centre for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Mathematics & Statistics, Dalhousie University, Halifax, NS, Canada
| | - Marc A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Amsterdam University Medical Centers, University of Amsterdam, Emma Children’s Hospital, Amsterdam, The Netherlands
| | - Wouter J de Jonge
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands,Department of Mathematics & Statistics, Dalhousie University, Halifax, NS, Canada,Department of Surgery, University of Bonn, Bonn, Germany
| | - Johan E Van Limbergen
- Corresponding author: Dr Johan Van Limbergen, MD, PhD, Department of Paediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. Tel.: +31-20 566 3053;
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Mahmud N, Goldberg DS, Abu-Gazala S, Lewis JD, Kaplan DE. Modeling Optimal Clinical Thresholds for Elective Abdominal Hernia Repair in Patients With Cirrhosis. JAMA Netw Open 2022; 5:e2231601. [PMID: 36098965 PMCID: PMC9471978 DOI: 10.1001/jamanetworkopen.2022.31601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Patients with cirrhosis have increased risk of postoperative mortality. Several models have been developed to estimate this risk; however, current risk estimation scores cannot compare surgical risk with the risk of not operating. OBJECTIVE To identify clinical optimal thresholds to favor operative or nonoperative management for a common cirrhosis surgical scenario, the symptomatic abdominal hernia. DESIGN, SETTING, AND PARTICIPANTS This was a Markov cohort decision analytical modeling study evaluating elective surgery vs nonoperative management for a symptomatic abdominal hernia in a patient with cirrhosis. Transition probabilities and utilities were derived from the literature and from data using an established cirrhosis cohort in the Veterans Health Administration. Participants included patients who were referred to a surgery clinic for a symptomatic abdominal hernia. Data were obtained from patients diagnosed with cirrhosis between January 1, 2008 and December 31, 2018. Data were analyzed from January 1 to May 1, 2022. MAIN OUTCOMES AND MEASURES Expected quality-adjusted life-years (QALYs) were estimated for each pathway and iterated over baseline model for end-stage liver disease-sodium (MELD-Na) scores ranging from 6 to 25. Markov models were cycled over a 5-year time horizon. RESULTS A total 2740 patients with cirrhosis (median [IQR] age, 62 [56-66] years; 2699 [98.5%] men) were referred to a surgery clinic for a symptomatic abdominal hernia; 1752 patients (63.9%) did not receive surgery. The median (IQR) follow-up was 42.1 (25.3-70.0) months. Using this cohort to estimate the mortality risk of operative and nonoperative pathways, an initial MELD-Na threshold of 21.3 points, below which surgery was associated with maximized QALYs was identified. Nonoperative management was associated with increased QALYs above this MELD-Na threshold. Although more patients experienced death with a surgical treatment decision across all initial MELD-Na values, this was counterbalanced by increased time spent in a resolved hernia state associated with increased utility. Model results were sensitive to the probability of hernia recurrence and hernia incarceration and utility decrement in the symptomatic hernia state. CONCLUSIONS AND RELEVANCE This decision analytical model study found that elective surgical treatment for a symptomatic abdominal hernia was favored even in the setting of relatively high MELD-Na scores. Patient symptoms, hernia-specific characteristics, and surgeon and center expertise may potentially impact the optimal strategy, emphasizing the importance of shared decision-making.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Samir Abu-Gazala
- Division of Transplant Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - James D. Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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42
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Chassaing B, Gewirtz AT, Lewis JD. Reply. Gastroenterology 2022; 163:781-782. [PMID: 35595123 DOI: 10.1053/j.gastro.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/10/2022] [Accepted: 05/13/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Benoit Chassaing
- INSERM U1016, Team "Mucosal microbiota in chronic inflammatory diseases", Université de Paris, Paris, France
| | - Andrew T Gewirtz
- Institute for Biomedical Sciences, Center for Inflammation Immunity and Infection, Digestive Disease Research Group, Georgia State University, Atlanta, Georgia
| | - James D Lewis
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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43
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Sazonovs A, Stevens CR, Venkataraman GR, Yuan K, Avila B, Abreu MT, Ahmad T, Allez M, Ananthakrishnan AN, Atzmon G, Baras A, Barrett JC, Barzilai N, Beaugerie L, Beecham A, Bernstein CN, Bitton A, Bokemeyer B, Chan A, Chung D, Cleynen I, Cosnes J, Cutler DJ, Daly A, Damas OM, Datta LW, Dawany N, Devoto M, Dodge S, Ellinghaus E, Fachal L, Farkkila M, Faubion W, Ferreira M, Franchimont D, Gabriel SB, Ge T, Georges M, Gettler K, Giri M, Glaser B, Goerg S, Goyette P, Graham D, Hämäläinen E, Haritunians T, Heap GA, Hiltunen M, Hoeppner M, Horowitz JE, Irving P, Iyer V, Jalas C, Kelsen J, Khalili H, Kirschner BS, Kontula K, Koskela JT, Kugathasan S, Kupcinskas J, Lamb CA, Laudes M, Lévesque C, Levine AP, Lewis JD, Liefferinckx C, Loescher BS, Louis E, Mansfield J, May S, McCauley JL, Mengesha E, Mni M, Moayyedi P, Moran CJ, Newberry RD, O'Charoen S, Okou DT, Oldenburg B, Ostrer H, Palotie A, Paquette J, Pekow J, Peter I, Pierik MJ, Ponsioen CY, Pontikos N, Prescott N, Pulver AE, Rahmouni S, Rice DL, Saavalainen P, Sands B, Sartor RB, Schiff ER, Schreiber S, Schumm LP, Segal AW, Seksik P, Shawky R, Sheikh SZ, Silverberg MS, Simmons A, Skeiceviciene J, Sokol H, Solomonson M, Somineni H, Sun D, Targan S, Turner D, Uhlig HH, van der Meulen AE, Vermeire S, Verstockt S, Voskuil MD, Winter HS, Young J, Duerr RH, Franke A, Brant SR, Cho J, Weersma RK, Parkes M, Xavier RJ, Rivas MA, Rioux JD, McGovern DPB, Huang H, Anderson CA, Daly MJ. Large-scale sequencing identifies multiple genes and rare variants associated with Crohn's disease susceptibility. Nat Genet 2022; 54:1275-1283. [PMID: 36038634 PMCID: PMC9700438 DOI: 10.1038/s41588-022-01156-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/12/2022] [Indexed: 01/18/2023]
Abstract
Genome-wide association studies (GWASs) have identified hundreds of loci associated with Crohn's disease (CD). However, as with all complex diseases, robust identification of the genes dysregulated by noncoding variants typically driving GWAS discoveries has been challenging. Here, to complement GWASs and better define actionable biological targets, we analyzed sequence data from more than 30,000 patients with CD and 80,000 population controls. We directly implicate ten genes in general onset CD for the first time to our knowledge via association to coding variation, four of which lie within established CD GWAS loci. In nine instances, a single coding variant is significantly associated, and in the tenth, ATG4C, we see additionally a significantly increased burden of very rare coding variants in CD cases. In addition to reiterating the central role of innate and adaptive immune cells as well as autophagy in CD pathogenesis, these newly associated genes highlight the emerging role of mesenchymal cells in the development and maintenance of intestinal inflammation.
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Affiliation(s)
- Aleksejs Sazonovs
- Genomics of Inflammation and Immunity Group, Human Genetics Programme, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | - Christine R Stevens
- Program in Medical and Population Genetics, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Stanley Center for Psychiatric Research, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Analytic and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Kai Yuan
- Stanley Center for Psychiatric Research, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Analytic and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Brandon Avila
- Program in Medical and Population Genetics, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Maria T Abreu
- Crohn's and Colitis Center, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | | | - Matthieu Allez
- Hopital Saint-Louis, APHP, Universite de Paris, INSERM U1160, Paris, France
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Crohn's and Colitis Center, Massachusetts General Hospital, Boston, MA, USA
| | - Gil Atzmon
- Department for Human Biology, University of Haifa, Haifa, Israel
- Departments of Medicine and Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aris Baras
- Regeneron Genetics Center, Tarrytown, NY, USA
| | - Jeffrey C Barrett
- Human Genetics Programme, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | - Nir Barzilai
- Departments of Medicine and Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
- The Institute for Aging Research, The Nathan Shock Center of Excellence in the Basic Biology of Aging and the Paul F. Glenn Center for the Biology of Human Aging Research at Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, USA
| | - Laurent Beaugerie
- Gastroenterology Department, Sorbonne Universite, Saint Antoine Hospital, Paris, France
| | - Ashley Beecham
- John P. Hussman Institute for Human Genomics, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
- The Dr. John T. Macdonald Foundation Department of Human Genetics, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | | | - Alain Bitton
- McGill University and McGill University Health Centre, Montreal, Quebec, Canada
| | - Bernd Bokemeyer
- Department of Internal Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Andrew Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Womens Hospital, Boston, MA, USA
| | | | | | - Jacques Cosnes
- Professeur Chef de Service chez APHP and Universite Paris-6, Paris, France
| | - David J Cutler
- Department of Human Genetics, Emory University, Atlanta, GA, USA
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Allan Daly
- Human Genetics Informatics, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | | | - Lisa W Datta
- Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Noor Dawany
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Marcella Devoto
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
- University of Rome Sapienza, Rome, Italy
- IRGB - CNR, Cagliari, Italy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Sheila Dodge
- Genomics Platform, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Eva Ellinghaus
- Christian-Albrechts-University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Laura Fachal
- Genomics of Inflammation and Immunity Group, Human Genetics Programme, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | | | | | | | | | - Stacey B Gabriel
- Genomics Platform, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Tian Ge
- Stanley Center for Psychiatric Research, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Center for Precision Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | | | - Kyle Gettler
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mamta Giri
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Benjamin Glaser
- Department of Endocrinology and Metabolism, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Philippe Goyette
- Research Center Montreal Heart Institute, Montreal, Quebec, Canada
| | - Daniel Graham
- Infectious Disease and Microbiome Program, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, MA, USA
- Department of Molecular Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Eija Hämäläinen
- Institute for Molecular Medicine Finland, FIMM, HiLIFE, University of Helsinki, Helsinki, Finland
| | - Talin Haritunians
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | | | - Mikko Hiltunen
- Institute of Biomedicine, University of Eastern Finland, Kuopio, Finland
| | - Marc Hoeppner
- Christian-Albrechts-University of Kiel, Kiel, Germany
| | | | - Peter Irving
- Department of Gastroenterology, Guys and Saint Thomas Hospital, London, UK
- School of Immunology and Microbial Sciences, Kings College London, London, UK
| | - Vivek Iyer
- Human Genetics Informatics, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | - Chaim Jalas
- Director of Genetic Resources and Services, Center for Rare Jewish Genetic Disorders, Bonei Olam, Brooklyn, NY, USA
| | - Judith Kelsen
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Hamed Khalili
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara S Kirschner
- Department of Gastroenterology, University of Chicago Medicine, Chicago, IL, USA
| | - Kimmo Kontula
- Department of Medicine, Helsinki University Hospital, and Research Program for Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
| | - Jukka T Koskela
- Institute for Molecular Medicine Finland, FIMM, HiLIFE, University of Helsinki, Helsinki, Finland
| | - Subra Kugathasan
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Juozas Kupcinskas
- Department of Gastroenterology and Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Christopher A Lamb
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Chloé Lévesque
- Research Center Montreal Heart Institute, Montreal, Quebec, Canada
| | | | - James D Lewis
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Crohn's and Colitis Foundation, New York, NY, USA
| | | | - Britt-Sabina Loescher
- Christian-Albrechts-University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - John Mansfield
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sandra May
- Christian-Albrechts-University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Jacob L McCauley
- John P. Hussman Institute for Human Genomics, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
- The Dr. John T. Macdonald Foundation Department of Human Genetics, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Emebet Mengesha
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Myriam Mni
- University of Liège, ULG, Liège, Belgium
| | | | | | | | | | - David T Okou
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
- Institut National de Sante Publique (INSP), Abidjan, Côte d'Ivoire
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Harry Ostrer
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aarno Palotie
- Program in Medical and Population Genetics, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Stanley Center for Psychiatric Research, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Analytic and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Institute for Molecular Medicine Finland, FIMM, HiLIFE, University of Helsinki, Helsinki, Finland
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jean Paquette
- Research Center Montreal Heart Institute, Montreal, Quebec, Canada
| | - Joel Pekow
- Department of Gastroenterology, University of Chicago Medicine, Chicago, IL, USA
| | - Inga Peter
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marieke J Pierik
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | | | - Natalie Prescott
- Department of Medical and Molecular Genetics, Kings College London, London, UK
| | - Ann E Pulver
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Daniel L Rice
- Genomics of Inflammation and Immunity Group, Human Genetics Programme, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | - Päivi Saavalainen
- Research Programs Unit, Immunobiology, University of Helsinki, Helsinki, Finland
| | - Bruce Sands
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - R Balfour Sartor
- Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Stefan Schreiber
- Christian-Albrechts-University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - L Philip Schumm
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | | | - Philippe Seksik
- Gastroenterology Department, Sorbonne Universite, Saint Antoine Hospital, Paris, France
| | - Rasha Shawky
- IBD BioResource, NIHR BioResource, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Shehzad Z Sheikh
- Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Alison Simmons
- MRC Human Immunology Unit, NIHR Biomedical Research Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Jurgita Skeiceviciene
- Department of Gastroenterology and Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Harry Sokol
- Gastroenterology Department, Sorbonne Universite, Saint Antoine Hospital, Paris, France
| | - Matthew Solomonson
- Program in Medical and Population Genetics, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Hari Somineni
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Dylan Sun
- Regeneron Genetics Center, Tarrytown, NY, USA
| | - Stephan Targan
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Dan Turner
- Shaare Zedek Medical Center, Jerusalem, Israel
| | - Holm H Uhlig
- Translational Gastroenterology Unit and Biomedical Research Centre, Nuffield Department of Clinical Medicine, Experimental Medicine Division, University of Oxford, Oxford, UK
- Department of Pediatrics, John Radcliffe Hospital, Oxford, UK
| | - Andrea E van der Meulen
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Séverine Vermeire
- University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Sare Verstockt
- Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Michiel D Voskuil
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | - Andre Franke
- Christian-Albrechts-University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Steven R Brant
- Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Crohn's Colitis Center of New Jersey, Department of Medicine, Rutgers Robert Wood Johnson Medical School and Department of Genetics and the Human Genetics Institute of New Jersey, Rutgers University, New Brunswick and Piscataway, NJ, USA
| | - Judy Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Miles Parkes
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ramnik J Xavier
- Infectious Disease and Microbiome Program, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, MA, USA
- Department of Molecular Biology, Massachusetts General Hospital, Boston, MA, USA
- Kurt Isselbacher Professor of Medicine at Harvard Medical School, Cambridge, MA, USA
- Core Institute Member, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Klarman Cell Observatory, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Immunology Program, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Microbiome Informatics and Therapeutics at MIT, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Manuel A Rivas
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - John D Rioux
- Research Center Montreal Heart Institute, Montreal, Quebec, Canada
- Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Dermot P B McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Hailiang Huang
- Stanley Center for Psychiatric Research, The Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Analytic and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Carl A Anderson
- Genomics of Inflammation and Immunity Group, Human Genetics Programme, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK.
| | - Mark J Daly
- Program in Medical and Population Genetics, The Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Stanley Center for Psychiatric Research, The Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Analytic and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Institute for Molecular Medicine Finland, FIMM, HiLIFE, University of Helsinki, Helsinki, Finland.
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Uhl S, Siddique SM, Bloschichak A, McKeever W, D'Anci K, Leas B, Mull NK, Compher C, Lewis JD, Wu GD, Tsou AY. Interventions for malnutrition in hospitalized adults: A systematic review and meta-analysis. J Hosp Med 2022; 17:556-564. [PMID: 35729866 DOI: 10.1002/jhm.12891] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Received: 02/25/2022] [Revised: 04/22/2022] [Accepted: 04/29/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Malnutrition is associated with poor outcomes in hospitalized adults. We aimed to assess the effectiveness of hospital-initiated interventions for patients with malnutrition. METHODS Data sources included MEDLINE, Embase, Cochrane Library from January 1, 2000 to June 3, 2021. We included randomized controlled trials (RCTs) assessing interventions for hospitalized adults diagnosed or identified as at-risk for malnutrition using malnutrition screening and diagnostic assessment tools. Individual reviewers extracted study data and performed quality checks for accuracy. Meta-analysis was conducted using a random-effects model with variance correction. We assessed the overall strength of evidence at the outcome level. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. RESULTS We found 11 RCTs that assessed two types of interventions: specialized nutrition care (8 RCTs) and increased protein provision (3 RCTs). The pooled findings of 11 RCTs found moderate strength of evidence that specialized nutrition care and increased protein provision reduced mortality by 21% (relative risk [RR]: 0.79, 95% confidence interval [CI]: 0.63-0.98; absolute risk reduction [ARR]: -0.02, 95% CI: -0.03 to -0.00). Pooled estimates indicated a nonsignificant decrease of 0.18 days in the length of stay (9 RCTs) and a 10% reduction in readmissions (7 RCTs). No eligible RCTs assessed parenteral or enteral nutrition. CONCLUSION Certain malnutrition-focused hospital-initiated interventions (e.g., specialized nutrition care and increased protein provision) reduce mortality and may improve the quality of life among patients at risk for or diagnosed with malnutrition. Future trials are needed to assess the effectiveness of parenteral and enteral nutrition.
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Affiliation(s)
- Stacey Uhl
- ECRI Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania, USA
| | - Shazia M Siddique
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aaron Bloschichak
- ECRI Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania, USA
| | - William McKeever
- Center for Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kristen D'Anci
- ECRI Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania, USA
| | - Brian Leas
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Nikhil K Mull
- Division of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Charlene Compher
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - James D Lewis
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gary D Wu
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Amy Y Tsou
- ECRI Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania, USA
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Sands BE, Irving PM, Hoops T, Izanec JL, Gao LL, Gasink C, Greenspan A, Allez M, Danese S, Hanauer SB, Jairath V, Kuehbacher T, Lewis JD, Loftus EV, Mihaly E, Panaccione R, Scherl E, Shchukina OB, Sandborn WJ. Ustekinumab versus adalimumab for induction and maintenance therapy in biologic-naive patients with moderately to severely active Crohn's disease: a multicentre, randomised, double-blind, parallel-group, phase 3b trial. Lancet 2022; 399:2200-2211. [PMID: 35691323 DOI: 10.1016/s0140-6736(22)00688-2] [Citation(s) in RCA: 86] [Impact Index Per Article: 43.0] [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] [Received: 11/03/2021] [Revised: 03/31/2022] [Accepted: 04/05/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Active-comparator trials are important to inform patient and physician choice. We aimed to evaluate the efficacy and safety of monotherapy with either ustekinumab or adalimumab in biologic-naive patients with moderately to severely active Crohn's disease. METHODS We conducted a randomised, double-blind, parallel-group, active-comparator, phase 3b trial (SEAVUE) at 121 hospitals or private practices in 18 countries. We included biologic-naive patients aged 18 years or older with moderately to severely active Crohn's disease and a Crohn's Disease Activity Index (CDAI) score of 220-450, who had not responded to or were intolerant to conventional therapy (or were corticosteroid dependent) and had at least one ulcer of any size at baseline endoscopic evaluation. Eligible patients were randomly assigned (1:1; via an interactive web response system) to receive ustekinumab (approximately 6 mg/kg intravenously on day 0, then 90 mg subcutaneously once every 8 weeks) or adalimumab (160 mg on day 0, 80 mg at 2 weeks, then 40 mg once every 2 weeks, subcutaneously) through week 56. Study treatments were administered as monotherapy and without dose modifications. Patients, investigators, and study site personnel were masked to treatment group assignment. The primary endpoint was the proportion of patients who were in clinical remission (CDAI score <150) at week 52 in the intention-to-treat population (ie, all patients who were randomly assigned to a treatment group). This trial is registered with ClinicalTrials.gov, NCT03464136, and EudraCT, 2017-004209-41. FINDINGS Between June 28, 2018, and Dec 12, 2019, 633 patients were assessed for eligibility and 386 were enrolled and randomly assigned to receive ustekinumab (n=191) or adalimumab (n=195). 29 (15%) of 191 patients in the ustekinumab group and 46 (24%) of 195 in the adalimumab group discontinued study treatment before week 52. There was no significant difference between the ustekinumab and adalimumab groups in the occurrence of the primary endpoint; at week 52, 124 (65%) of 191 patients in the ustekinumab group versus 119 (61%) of 195 in the adalimumab group were in clinical remission (between-group difference 4%, 95% CI -6 to 14; p=0·42). Safety for both groups was consistent with previous reports. Serious infections were reported in four (2%) of 191 patients in the ustekinumab group and five (3%) of 195 in the adalimumab group. No deaths occurred through week 52 of the study. INTERPRETATION Both ustekinumab and adalimumab monotherapies were highly effective in this population of biologic-naive patients, with no difference in the primary outcome between the drugs. FUNDING Janssen Scientific Affairs.
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Affiliation(s)
- Bruce E Sands
- Dr Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Timothy Hoops
- Immunology Global Medical Affairs, Janssen Pharmaceutical Companies of Johnson & Johnson, Horsham, PA, USA
| | | | | | | | | | - Matthieu Allez
- Gastroenterology Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), INSERM U1160, Université de Paris, Paris, France
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Università Vita-Salute San Raffaele, Milan, Italy
| | - Stephen B Hanauer
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, University Hospital, London, ON, Canada; Division of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Tanja Kuehbacher
- Department of Internal Medicine, Gastroenterology, Diabetology, Hemato-Oncology, and Palliative Medicine, Medius Clinic Nuertingen, Nürtingen, Germany
| | - James D Lewis
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Emese Mihaly
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Remo Panaccione
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Ellen Scherl
- Weill Department of Medicine, New York Presbyterian Hospital Weill Cornell Medicine, New York, NY, USA
| | - Oksana B Shchukina
- Division The City Center for IBD Diagnosis and Treatment, Saint Petersburg State Budgetary Health Institution, City Clinical Hospital 31, Saint Petersburg, Russia
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
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Dubinsky MC, Panaccione R, Lewis JD, Sands BE, Hibi T, Lee SD, Naegeli AN, Shan M, Green LA, Morris N, Arora V, Bleakman AP, Belin R, Travis S. Impact of Bowel Urgency on Quality of Life and Clinical Outcomes in Patients With Ulcerative Colitis. Crohns Colitis 360 2022; 4:otac016. [PMID: 36777426 PMCID: PMC9802402 DOI: 10.1093/crocol/otac016] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Indexed: 11/14/2022] Open
Abstract
Background Bowel urgency is commonly experienced by patients with ulcerative colitis (UC) and is associated with reduced health-related quality of life (QoL). Mirikizumab, a humanized monoclonal antibody directed against the p19 subunit of IL-23, significantly reduced bowel urgency in a double-blind, randomized, placebo-controlled Phase 2 clinical trial in patients with moderate-to-severe UC (NCT02589665). Methods All patients (N = 249) reported symptoms including absence or presence of bowel urgency. Absence of urgency was defined as no urgency for the 3 consecutive days prior to each scheduled visit. Missing urgency data were imputed as present. After 12 weeks of induction treatment, patients who achieved clinical response continued maintenance mirikizumab treatment through Week 52. We assessed the relationship of urgency with QoL, clinical outcomes, and inflammatory biomarkers at Weeks 12 and 52. Results Patients with absence of urgency demonstrated significantly greater improvement in Inflammatory Bowel Disease Questionnaire (IBDQ) scores even after adjusting for rectal bleeding (RB) and stool frequency (SF), significantly higher rates of all clinical outcomes at Weeks 12 and 52, and a greater decrease in inflammatory biomarkers C-reactive protein and fecal calprotectin compared to those with presence of urgency. Absence of urgency at Week 12 was associated with improved IBDQ scores at Week 52, while Week 12 RB or SF status was not. Conclusions Absence of urgency is strongly associated with improvement in QoL as well as clinical measures of UC disease activity. These findings suggest urgency may be a useful surrogate marker of disease activity and an important treatment target for UC.
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Affiliation(s)
- Marla C Dubinsky
- Address correspondence to: Marla C. Dubinsky, MD, Icahn School of Medicine at Mount Sinai, One Gustav Levy Place, Box 1134, New York, NY 10029, USA ()
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - James D Lewis
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Toshifumi Hibi
- Department of Gastroenterology, Kitasato Institute Hospital Center for Advanced IBD Research and Treatment, Minato-ku, Tokyo, Japan
| | - Scott D Lee
- Division of Gastroenterology, University of Washington Medical Center, Seattle, Washington, USA
| | | | | | | | | | - Vipin Arora
- Eli Lilly and Company, Indianapolis, IndianaUSA
| | | | - Ruth Belin
- Eli Lilly and Company, Indianapolis, IndianaUSA
| | - Simon Travis
- Nuffield Department of Medicine, Oxford University Hospital, Oxford, UK
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Vajravelu RK, Shapiro JM, Ni J, Thanawala SU, Lewis JD, El-Serag HB. Risk for Post-Colonoscopy Irritable Bowel Syndrome in Patients With and Without Antibiotic Exposure: A Retrospective Cohort Study. Clin Gastroenterol Hepatol 2022; 20:e1305-e1322. [PMID: 34481956 PMCID: PMC8891390 DOI: 10.1016/j.cgh.2021.08.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 05/19/2021] [Revised: 08/23/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Laboratory studies have demonstrated that antibiotic use in conjunction with bowel purgatives causes alterations to the gut microbiota. Because gut microbiota changes may be a trigger for the development of irritable bowel syndrome (IBS), we sought to assess whether individuals who undergo bowel cleansing for colonoscopy and have concurrent antibiotic exposure develop IBS at higher rates than individuals who undergo colonoscopy without antibiotic exposure. METHODS We used data from Optum's de-identified Clinformatics Data Mart Database in the United States to study a cohort of 50- to 55-year-olds who underwent screening colonoscopy. Individuals exposed to antibiotics within 14 days of colonoscopy were propensity-score matched to individuals who were not exposed to antibiotics around colonoscopy. The primary outcome was a new IBS diagnosis, and the composite outcome was a new claim for IBS, IBS medications, or IBS symptoms. The association of antibiotic exposure and the outcomes was calculated using Cox proportional hazards regression. RESULTS There were 408,714 individuals who met criteria for the screening colonoscopy cohort. Of these, 24,617 (6.0%) were exposed to antibiotics around the time of colonoscopy, and they were propensity-score matched to 24,617 individuals not exposed to antibiotics. There was no statistically significant association between antibiotic use and IBS (hazard ratio, 1.11; 95% confidence interval, 0.89-1.39), but there was a weak association between antibiotic use and the composite outcome (hazard ratio, 1.12; 95% confidence interval, 1.02-1.24; number needed to harm, 94). CONCLUSIONS Individuals concurrently exposed to antibiotics and bowel purgative had slightly higher rates of surrogate IBS outcomes compared with matched controls who did not receive antibiotics concurrently with bowel purgative.
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Affiliation(s)
- Ravy K. Vajravelu
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Center for Health Equity Research Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jordan M. Shapiro
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Josephine Ni
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shivani U. Thanawala
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James D. Lewis
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hashem B. El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States,U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service at the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX
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48
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Segura A, Dalal RS, Golla M, Gerson JN, Mahmud N, Lewis JD, Vajravelu RK. Endoscopy Is Not Associated with Infectious Adverse Events After Hematopoietic Cell Transplantation: A Retrospective Cohort Study. Dig Dis Sci 2022; 67:2310-2319. [PMID: 34050445 PMCID: PMC8820278 DOI: 10.1007/s10620-021-07062-7] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/13/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Patients with recent hematopoietic cell transplantation (HCT) are considered high risk for gastrointestinal endoscopy due to the potential for procedural bacterial translocation. Prior studies investigating these risks do not account for the higher baseline rate of infectious complications among those who are immunocompromised. We performed a retrospective cohort study of patients with recent HCT who underwent endoscopy and their matched controls who did not undergo endoscopy. METHODS We identified patients who underwent HCT followed by upper and/or lower endoscopy at the University of Pennsylvania from 2000 to 2018. Individuals were matched 1:1 by age, sex, and type of HCT to controls who underwent HCT without subsequent endoscopy. Infectious adverse events were assessed by Sepsis-3 and Sepsis-2 criteria. Factors associated with infectious adverse events after endoscopy/index date were assessed using multivariable conditional logistic regression. RESULTS We identified 149 patients who underwent HCT and endoscopy and 149 matched controls who underwent HCT without endoscopy. Sepsis-3 infectious adverse events occurred in 3.4% of patients in each group. Sepsis-2 infectious adverse events occurred in 20.1% of patients who underwent endoscopy compared to 19.5% of controls. There was no association between endoscopy and Sepsis-2 infectious adverse events in the multivariable regression analysis (adjusted odds ratio 1.65, 95% CI 0.51-5.26). CONCLUSIONS When compared to controls with similar immune statuses, patients who underwent endoscopy after HCT did not have a higher risk of infectious adverse events. These results may inform clinical decision making regarding the risks and benefits of endoscopic management after HCT.
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Affiliation(s)
- Abraham Segura
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Rahul S. Dalal
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Meghana Golla
- Department of Medicine, Vanderbilt University, 719 Thompson Lane, Suite 20400, Nashville, TN 37204, USA
| | - James N. Gerson
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Perelman Center 12th Floor, Philadelphia, PA 19104, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Perelman Center 7th Floor, Philadelphia, PA 19104, USA
| | - James D. Lewis
- Division of Gastroenterology and Hepatology and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Perelman Center 7th Floor, Philadelphia, PA 19104, USA
| | - Ravy K. Vajravelu
- Division of Gastroenterology and Hepatology and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Perelman Center 7th Floor, Philadelphia, PA 19104, USA
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49
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Kutos S, Barnes EM, Bhutada A, Lewis JD. Preferential associations of soil fungal taxa under mixed compositions of eastern American tree species. FEMS Microbiol Ecol 2022; 98:6581587. [PMID: 35521705 DOI: 10.1093/femsec/fiac056] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/12/2022] [Accepted: 05/04/2022] [Indexed: 11/14/2022] Open
Abstract
Soil fungi are vital to forest ecosystem function, in part through their role mediating tree responses to environmental factors, as well as directly through effects on resource cycling. While the distribution of soil fungi can vary with abiotic factors, plant species identity is also known to affect community composition. However, the particular influence that a plant will have on its soil microbiota remains difficult to predict. Here, we paired amplicon sequencing and enzymatic assays to assess soil fungal composition and function under three tree species, Quercus rubra, Betula nigra, and Acer rubrum, planted individually and in all combinations in a greenhouse. We observed that fungal communities differed between each of the individual planted trees, suggesting at least some fungal taxa may associate preferentially with these tree species. Additionally, fungal community composition under mixed-tree plantings broadly differed from the individual planted trees, suggesting mixing of these distinct soil fungal communities. The data also suggest that there were larger enzymatic activities in the individual plantings as compared to all mixed-tree plantings which may be due to variations in fungal community composition. This study provides further evidence of the importance of tree identity on soil microbiota and functional changes to forest soils.
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Affiliation(s)
- Steve Kutos
- Department of Biological Sciences, Fordham University, Bronx, NY 10458, USA.,Louis Calder Center - Biological Field Station, Fordham University, Armonk, NY 10504, USA
| | - Elle M Barnes
- Department of Biological Sciences, Fordham University, Bronx, NY 10458, USA.,Louis Calder Center - Biological Field Station, Fordham University, Armonk, NY 10504, USA
| | - Arnav Bhutada
- Department of Biological Sciences, Fordham University, Bronx, NY 10458, USA
| | - J D Lewis
- Department of Biological Sciences, Fordham University, Bronx, NY 10458, USA.,Louis Calder Center - Biological Field Station, Fordham University, Armonk, NY 10504, USA
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50
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Mahmud N, Fricker Z, Lewis JD, Taddei TH, Goldberg DS, Kaplan DE. Risk Prediction Models for Postoperative Decompensation and Infection in Patients With Cirrhosis: A Veterans Affairs Cohort Study. Clin Gastroenterol Hepatol 2022; 20:e1121-e1134. [PMID: 34246794 PMCID: PMC8741885 DOI: 10.1016/j.cgh.2021.06.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 05/14/2021] [Revised: 06/08/2021] [Accepted: 06/18/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis have an increased risk of postoperative mortality for a range of surgeries; however, they are also at risk of postoperative complications such as infection and cirrhosis decompensation. To date, there are no prediction scores that specifically risk stratify patients for these morbidities. METHODS This was a retrospective study using data of patients with cirrhosis who underwent diverse surgeries in the Veterans Health Administration. Validated algorithms and/or manual adjudication were used to ascertain postoperative decompensation and postoperative infection through 90 days. Multivariable logistic regression was used to evaluate prediction models in derivation and validation sets using variables from the recently-published Veterans Outcomes and Costs Associated with Liver Disease (VOCAL)-Penn cirrhosis surgical risk scores for postoperative mortality. Models were compared with the Mayo risk score, Model for End-stage Liver Disease (MELD)-sodium, and Child-Turcotte-Pugh (CTP) scores. RESULTS A total 4712 surgeries were included; patients were predominantly male (97.2 %), white (63.3 %), and with alcohol-related liver disease (35.3 %). Through 90 postoperative days, 8.7 % of patients experienced interval decompensation, and 4.5 % infection. Novel VOCAL-Penn prediction models for decompensation demonstrated good discrimination for interval decompensation (C-statistic 0.762 vs 0.663 Mayo vs 0.603 MELD-sodium vs 0.560 CTP; P < .001); however, discrimination was only fair for postoperative infection (C-statistic 0.666 vs 0.592 Mayo [P = .13] vs 0.502 MELD-sodium [P < .001] vs 0.503 CTP [P < .001]). The model for interval decompensation had excellent calibration in both derivation and validation sets. CONCLUSION We report the derivation and internal validation of a novel, parsimonious prediction model for postoperative decompensation in patients with cirrhosis. This score demonstrated superior discrimination and calibration as compared with existing clinical standards, and will be available at www.vocalpennscore.com.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tamar H Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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