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Salimi-Jazi F, Rafeeqi T, Cunningham A, Park KT, Goyal A, Rosen MJ, Bruzoni M. Total colectomy in severe Crohn's colitis in children: Is permanent ileostomy necessary? Journal of Pediatric Surgery Open 2023; 3:100043. [DOI: 10.1016/j.yjpso.2023.100043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Kappelman MD, Wohl DA, Herfarth HH, Firestine AM, Adler J, Ammoury RF, Aronow JE, Bass DM, Bass JA, Benkov K, Berenblum Tobi C, Boccieri ME, Boyle BM, Brinkman WB, Cabera JM, Chun K, Colletti RB, Dodds CM, Dorsey JM, Ebach DR, Entrena E, Forrest CB, Galanko JA, Grunow JE, Gulati AS, Ivanova A, Jester TW, Kaplan JL, Kugathasan S, Kusek ME, Leibowitz IH, Linville TM, Lipstein EA, Margolis PA, Minar P, Molle Rios Z, Moses J, Olano KK, Osaba L, Palomo PJ, Pappa H, Park KT, Pashankar DS, Pitch L, Robinson M, Samson CM, Sandberg KC, Schuchard JR, Seid M, Shelly KA, Steiner SJ, Strople JA, Sullivan JS, Tung J, Wali P, Zikry M, Weinberger M, Saeed SA, Bousvaros A. Comparative Effectiveness of Anti-TNF in Combination with Low Dose Methotrexate vs Anti-TNF Monotherapy in Pediatric Crohn's Disease: a Pragmatic Randomized Trial. Gastroenterology 2023:S0016-5085(23)00538-3. [PMID: 37004887 DOI: 10.1053/j.gastro.2023.03.224] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [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: 02/16/2023] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND AND AIMS Tumor Necrosis Factor inhibitors (TNFi), including infliximab and adalimumab, are a mainstay of pediatric Crohn's disease (PCD) therapy; however, non-response and loss of response is common. As combination therapy with methotrexate may improve response, we performed a multi-center, randomized, double-blind, placebo-controlled pragmatic trial to compare TNFi with oral methotrexate to TNFi monotherapy. METHODS PCD patients initiating infliximab or adalimumab were randomized in 1:1 allocation to methotrexate or placebo and followed for 12-36 months. The primary outcome was a composite indicator of treatment failure. Secondary outcomes included anti-drug antibodies (ADA) and patient reported outcomes (PROs) of pain interference and fatigue. Adverse events (AEs) and Serious AEs (SAEs) were collected. RESULTS Of 297 participants (mean age 13.9 years, 35% female), 156 were assigned to methotrexate (110 infliximab initiators and 46 adalimumab initiators) and 141 to placebo (102 infliximab initiators and 39 adalimumab initiators). In the overall population, time to treatment failure did not differ by study arm (HR 0.69, 95% CI 0.45-1.05). Among infliximab initiators, there were no differences between combination and monotherapy (HR 0.93, 95% CI 0.55-1.56). Among adalimumab initiators, combination therapy was associated with longer time to treatment failure (HR 0.40, 95% CI 0.19-0.81). A trend towards lower ADA development in the combination therapy arm was not significant. [(infliximab OR 0.72 (0.49-1.07); adalimumab OR 0.71 (0.24-2.07)]. No differences in PROs were observed. Combination therapy resulted in more AEs but fewer SAEs. CONCLUSIONS Among adalimumab but not infliximab initiators, PCD patients treated with methotrexate combination therapy experienced a 2-fold reduction in treatment failure with a tolerable safety profile.
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Affiliation(s)
- Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David A Wohl
- Institute of Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC
| | - Ann M Firestine
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jeremy Adler
- Susan B. Meister Child Health Evaluation and Research Center and Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, MI
| | - Rana F Ammoury
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, VA
| | | | - Dorsey M Bass
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Julie A Bass
- Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, MO, Division of Gastroenterology, Children's Mercy Kansas City, Kansas City, MO
| | - Keith Benkov
- Division of Pediatric Gastroenterology, Icahn School of Medicine at Mt Sinai, New York City, NY
| | | | - Margie E Boccieri
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Brendan M Boyle
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - William B Brinkman
- Department of Pediatrics, University of Cincinnati College of Medicine; Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jose M Cabera
- Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Kelly Chun
- Esoterix Specialty Laboratory, Labcorp, Calabasas, CA
| | - Richard B Colletti
- Division of Gastroenterology, Department of Pediatrics, University of Vermont, Burlington, VT
| | - Cassandra M Dodds
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jill M Dorsey
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nemours Children's Health, Jacksonville, FL
| | - Dawn R Ebach
- Division of Pediatric Gastroenterology, Hepatology, Pancreatology, and Nutrition, University of Iowa, Iowa City, IA
| | - Edurne Entrena
- Progenika Biopharma, a Grifols Company, Derio, Bizkaia Spain
| | | | - Joseph A Galanko
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - John E Grunow
- University of Oklahoma Children's Physicians, Pediatric Gastroenterology, Oklahoma City, OK
| | - Ajay S Gulati
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Traci W Jester
- Department of Pediatrics, Division of Gastroenterology, University of Alabama at Birmingham, AL
| | - Jess L Kaplan
- Division of Pediatric Gastroenterology, Mass General for Children and Harvard Medical School, Boston, MA
| | | | - Mark E Kusek
- Division of Gastroenterology, University of Nebraska Medical Center, Omaha, NE
| | - Ian H Leibowitz
- Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, Department of Pediatrics, George Washington University, Washington, DC
| | - Tiffany M Linville
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Levine Children's Hospital, Charlotte, NC
| | - Ellen A Lipstein
- Department of Pediatrics, University of Cincinnati College of Medicine, James M. Anderson Center for Health Systems Excellence, and Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Peter A Margolis
- Department of Pediatrics, University of Cincinnati College of Medicine, James M. Anderson Center for Health Systems Excellence, and Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Phillip Minar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Zarela Molle Rios
- Division of Pediatric Gastroenterology, Nemours Children's Hospital, Wilmington, DE
| | - Jonathan Moses
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, UH Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Kelly K Olano
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lourdes Osaba
- Progenika Biopharma, a Grifols Company, Derio, Bizkaia Spain
| | - Pablo J Palomo
- Division of Pediatric Gastroenterology, Nemours Children's Hospital, Orlando, FL
| | - Helen Pappa
- Division of Pediatric Gastroenterology, Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, Saint Louis, MO
| | - K T Park
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Dinesh S Pashankar
- Section of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, CT
| | | | - Michelle Robinson
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Charles M Samson
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kelly C Sandberg
- Department of Gastroenterology, Dayton Children's Hospital, Boonshoft School of Medicine, Wright State University, Dayton, OH
| | - Julia R Schuchard
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Michael Seid
- Department of Pediatrics, University of Cincinnati College of Medicine; Division Pulmonary Medicine and the James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kimberly A Shelly
- Division of Pediatric Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Steven J Steiner
- Division of Pediatric Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Jennifer A Strople
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Jillian S Sullivan
- The University of Vermont Children's Hospital and Department of Pediatrics, Larner College of Medicine, The University of Vermont, Burlington, VT
| | - Jeanne Tung
- University of Oklahoma Children's Physicians, Pediatric Gastroenterology, Oklahoma City, OK
| | - Prateek Wali
- Division of Gastroenterology, Hepatology, and Nutrition, State University of New York Upstate Medical University, Syracuse, NY
| | - Michael Zikry
- Esoterix Specialty Laboratory, Labcorp, Calabasas, CA
| | - Morris Weinberger
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Shehzad A Saeed
- Boonshoft School of Medicine, Wright State University, Associate Chief Medical Officer, Physician Lead, Patient and Family Experience, Dayton Children's Hospital, Dayton OH
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
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Levitte S, Yarani R, Ganguly A, Martin L, Gubatan J, Nadel HR, Franc B, Gugig R, Syed A, Goyal A, Park KT, Thakor AS. Case Series of Precision Delivery of Methylprednisolone in Pediatric Inflammatory Bowel Disease: Feasibility, Clinical Outcomes, and Identification of a Vasculitic Transcriptional Program. J Clin Med 2023; 12:jcm12062386. [PMID: 36983386 PMCID: PMC10053508 DOI: 10.3390/jcm12062386] [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: 01/24/2023] [Revised: 03/05/2023] [Accepted: 03/18/2023] [Indexed: 03/30/2023] Open
Abstract
Systemic steroid exposure, while useful for the treatment of acute flares in inflammatory bowel disease (IBD), is associated with an array of side effects that are particularly significant in children. Technical advancements have enabled locoregional intraarterial steroid delivery directly into specific segments of the gastrointestinal tract, thereby maximizing tissue concentration while limiting systemic exposure. We investigated the feasibility of intraarterial steroid administration into the bowel in a cohort of nine pediatric patients who had IBD. This treatment approach provided symptom relief in all patients, with sustained relief (>2 weeks) in seven out of nine; no serious adverse effects occurred in any patient. In addition, we identified patterns of vascular morphologic changes indicative of a vasculopathy within the mesenteric circulation of inflamed segments of the bowel in pediatric patients with Crohn's disease, which correlated with disease activity. An analysis of publicly available transcriptomic studies identified vasculitis-associated molecular pathways activated in the endothelial cells of patients with active Crohn's disease, suggesting a possible shared transcriptional program between vasculitis and IBD. Intraarterial corticosteroid treatment is safe and has the potential to be widely accepted as a locoregional approach for therapy delivery directly into the bowel; however, this approach still warrants further consideration as a short-term "bridge" between therapy transitions for symptomatic IBD patients with refractory disease, as part of a broader steroid-minimizing treatment strategy.
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Affiliation(s)
- Steven Levitte
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Reza Yarani
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Abantika Ganguly
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Lynne Martin
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - John Gubatan
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA 94304, USA
| | - Helen R Nadel
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - Benjamin Franc
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Ali Syed
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - Alka Goyal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - K T Park
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Avnesh S Thakor
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
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Burisch J, Zhao M, Odes S, De Cruz P, Vermeire S, Bernstein CN, Kaplan GG, Duricova D, Greenberg D, Melberg HO, Watanabe M, Ahn HS, Targownik L, Pittet VEH, Annese V, Park KT, Katsanos KH, Høivik ML, Krznaric Z, Chaparro M, Loftus EV, Lakatos PL, Gisbert JP, Bemelman W, Moum B, Gearry RB, Kappelman MD, Hart A, Pierik MJ, Andrews JM, Ng SC, D'Inca R, Munkholm P. The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2023; 8:458-492. [PMID: 36871566 DOI: 10.1016/s2468-1253(23)00003-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/06/2023]
Abstract
The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.
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Affiliation(s)
- Johan Burisch
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark.
| | - Mirabella Zhao
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Selwyn Odes
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, Austin Academic Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - Severine Vermeire
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium; Faculty of Medicine, KU Leuven University, Leuven, Belgium
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada; Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Gilaad G Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Dana Duricova
- IBD Clinical and Research Centre for IBD, ISCARE, Prague, Czech Republic; Department of Pharmacology, Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans O Melberg
- Department of Community Medicine, University of Tromsø-The Arctic University of Norway, Tromsø, Norway; Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Mamoru Watanabe
- Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, South Korea
| | - Laura Targownik
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Valérie E H Pittet
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Vito Annese
- Division of Gastroenterology, Department of Internal Medicine, Fakeeh University Hospital, Dubai, United Arab Emirates
| | - K T Park
- Stanford Health Care, Packard Health Alliance, Alameda, CA, USA; Genentech (Roche Group), South San Francisco, CA, USA
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Marte L Høivik
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Zagreb, Zagreb, Croatia
| | - María Chaparro
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Montreal, QC, Canada; Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Javier P Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Bjorn Moum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics and Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ailsa Hart
- IBD Unit, St Mark's Hospital, Middlesex, UK
| | - Marieke J Pierik
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Siew C Ng
- Department of Medicine and Therapeutics, Li Ka Shing Institute of Health Sciences, State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Renata D'Inca
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Pia Munkholm
- Department of Gastroenterology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
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Kim D, Choi H, Ko DG, Park KT. The association between cardiovascular risk factors and coronary CT angiography findings for predicting obstructive coronary artery disease in Korean patients with stable chest pain. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1187] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background/Introduction
The 2019 European Society of Cardiology (ESC) guidelines currently recommend the use of coronary computed tomography angiography (CCTA) as the initial test for diagnosing coronary artery disease (CAD) in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone.
Purpose
The purpose of this study is to identify the prevalence of obstructive CAD in patients with stable chest pain, and the correlation between several clinical cardiovascular disease (CVD) risk factors and CCTA findings presented by Coronary Artery Disease Reporting and Data System (CAD-RADS).
Methods
The present study is a single-center retrospective cross-sectional study. A total of 1,892 patients with stable chest pain who underwent CCTA were enrolled in this study. Diamond-Forrester classification, Framingham risk score (FRS), atherosclerotic CVD (ASCVD) 10-year risk score, coronary artery calcium score (CACS) and CAD-RADS category were obtained from every patient.
Results
Among 1,892 patients (mean age, 60.5±8.6 years; men, 59.3%), 356 (18.8%) had obstructive CAD according to CCTA. Patients with high and intermediate ASCVD 10-year risk score had 2.59 times (aOR 2.59, 95% CI; 1.58 to 4.23) and 1.66 times (aOR 1.66, 95% CI; 1.04 to 2.65) higher odds of having obstructive CAD than patients with low ASCVD 10-year risk score, respectively (adjusted for Diamond-Forrester classification and CACS group). Higher ASCVD risk scores were significantly associated with higher CAD-RADS category (p<0.001), and patients with CAD-RADS category 3 had ASCVD 10-year risk score of 20.1±12.7. CACS showed the highest discrimination in presence of obstructive CAD, followed by ASCVD 10-year risk score, FRS, and Diamond-Forrester classification (AUC: 0.821 [95% CI; 0.797–0.845]; 0.711 [95% CI; 0.683–0.740]; 0.675 [95% CI; 0.646–0.704]; 0.600 [95% CI; 0.569–0.632], respectively).
Conclusion
This is the first study of CCTA findings in stable chest pain patients in Korea. The prevalence of obstructive CAD in patients with stable chest pain was 18.8%. Higher ASCVD score is significantly associated with presence of obstructive CAD and higher CAD-RADS category. As coronary stenosis of 50%-69% had a mean ASCVD score of 20.1, we should consider CCTA for identifying obstructive CAD in patients with ASCVD score over 20 with stable chest pain.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- D Kim
- Hallym University , Chuncheon , Korea (Republic of)
| | - H Choi
- Chuncheon Sacred Heart Hospital , Chuncheon , Korea (Republic of)
| | - D G Ko
- Hallym University , Chuncheon , Korea (Republic of)
| | - K T Park
- Chuncheon Sacred Heart Hospital , Chuncheon , Korea (Republic of)
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Zhang W, Scalori A, Fuh F, McBride J, She G, Kierkus J, Korczowksi B, Li R, Abouhossein M, Kadva A, Park KT, Tang MT. Pharmacokinetics, Pharmacodynamics, and Safety of Etrolizumab in Children With Moderately to Severely Active Ulcerative Colitis or Crohn's Disease: Results from a Phase 1 Randomized Trial. Inflamm Bowel Dis 2022; 28:1348-1356. [PMID: 34849918 PMCID: PMC9434437 DOI: 10.1093/ibd/izab275] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Etrolizumab, a humanized anti-β7 antibody, has not been studied in children. Here, we evaluate the pharmacokinetics, pharmacodynamics, and safety of etrolizumab in children with inflammatory bowel disease. METHODS Patients age 4 to 17 years with moderately to severely active ulcerative colitis or Crohn's disease were randomized 1:1 to receive 1.5mg/kg of etrolizumab subcutaneously every 4 weeks (q4w) or 3.0mg/kg every 8 weeks (q8w) for 16 weeks in this open-label phase 1 trial. Pharmacokinetics, pharmacodynamics, safety, and efficacy were assessed. RESULTS Of the 24 patients treated, 21 completed the study. In the groups of 1.5mg/kg q4w and 3.0mg/kg q8w, respectively, mean (SD) maximum concentration (Cmax) was 9.8 (4.86) µg/mL and 18.1 (6.25) µg/mL; and mean (SD) area under the curve within a dosing interval (AUCtau) was 167 (86.9) and 521 (306) μg·day/mL after the last dose. The Cmax increased dose proportionally. The AUC over an 8-week period was slightly higher in the 3.0mg/kg q8w dose group. Median half-life was similar for both dosing regimens. Median numbers of free β7high gut-homing T and B cell subsets declined below 10% of baseline, confirming β7 target engagement and complete/near-complete receptor occupancy. Adverse events were consistent with the safety profile in adults. Approximately 60% of patients achieved a clinical response. CONCLUSIONS Etrolizumab showed a dose-proportional increase in Cmax and a slightly greater than dose-proportional increase in AUCtau. Both regimens achieved complete/near-complete β7 receptor occupancy, with a similar relationship to concentration as adults. Etrolizumab was well tolerated and demonstrated clinical activity in children.
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Affiliation(s)
| | - Astrid Scalori
- Roche Products Limited, Welwyn Garden City, United Kingdom
| | | | | | - Gaohong She
- Genentech, Inc., South San Francisco, CA, USA
| | | | | | - Regan Li
- Roche Products Limited, Welwyn Garden City, United Kingdom
| | | | | | - K T Park
- Genentech, Inc., South San Francisco, CA, USA
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Zhang W, Scalori A, Fuh F, McBride J, She G, Kierkus J, Korczowski B, Li R, Abouhossein M, Kadva A, Park KT, Tang MT. Correction to: Pharmacokinetics, Pharmacodynamics, and Safety of Etrolizumab in Children With Moderately to Severely Active Ulcerative Colitis or Crohn's Disease: Results from a Phase 1 Randomized Trial. Inflamm Bowel Dis 2022; 28:e143. [PMID: 35366308 PMCID: PMC9527608 DOI: 10.1093/ibd/izac066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Wenhui Zhang
- Address correspondence to: Wenhui Zhang, PhD, Genentech, Inc., 1 DNA Way, South San Francisco, CA, 94080, USA ()
| | | | | | | | - Gaohong She
- Genentech, Inc., South San Francisco, CA, USA
| | | | | | - Regan Li
- Roche Products Limited, Welwyn Garden City, United Kingdom
| | | | | | - K T Park
- Genentech, Inc., South San Francisco, CA, USA
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Saiki JP, Andreasson JO, Grimes KV, Frumkin LR, Sanjines E, Davidson MG, Park KT, Limketkai B. Treatment-refractory ulcerative colitis responsive to indigo naturalis. BMJ Open Gastroenterol 2022; 8:bmjgast-2021-000813. [PMID: 34969665 PMCID: PMC8718466 DOI: 10.1136/bmjgast-2021-000813] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 11/10/2021] [Accepted: 12/10/2021] [Indexed: 02/06/2023] Open
Abstract
Background Indigo naturalis (IN) is an herbal medicine that has been used for ulcerative colitis with an unclear mechanism of action. Indigo and indirubin, its main constituents, are ligands of the aryl hydrocarbon receptor (AhR). We assessed the safety, efficacy, and colon AhR activity of IN given orally to patients with treatment-refractory ulcerative colitis. The role of AhR in IN benefit was further evaluated with an AhR antagonist in a murine colitis model. Methods This open-label, dose-escalation study sequentially treated 11 patients with ulcerative colitis with either IN 500 mg/day or 1.5 g/day for 8 weeks, followed by a 4-week non-treatment period. The primary efficacy endpoint was clinical response at week 8, assessed by total Mayo score. Secondary endpoints included clinical remission, Ulcerative Colitis Endoscopic Index of Severity, quality of life, and colon AhR activity measured by cytochrome P450 1A1 (CYP1A1) RNA expression. Results Ten of 11 (91%) patients, including 8/9 (89%) with moderate-to-severe disease, achieved a clinical response. Among these 10 patients, all had failed treatment with 5-aminosalicylic acid, 8 patients with a tumour necrosis factor (TNF)-alpha inhibitor, and 6 patients with TNF-alpha inhibitor and vedolizumab. Five patients were corticosteroid dependent. Clinical response was observed in all five patients who had been recommended for colectomy. Three patients achieved clinical remission. All patients experienced improved endoscopic severity and quality of life. Four weeks after treatment completion, six patients had worsened partial Mayo scores. Four patients progressed to colectomy after study completion. Colon CYP1A1 RNA expression increased 12 557-fold at week 8 among six patients evaluated. No patient discontinued IN due to an adverse event. Concomitant administration of 3-methoxy-4-nitroflavone, an AhR antagonist, in a murine colitis model abrogated the benefit of IN. Conclusion IN is a potentially effective therapy for patients with treatment-refractory ulcerative colitis. This benefit is likely through AhR activation. Trial registration number NCT02442960.
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Affiliation(s)
- Julie P Saiki
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, California, USA
| | - Johan Ol Andreasson
- Department of Genetics, Department of Biochemistry, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin V Grimes
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, California, USA
| | - Lyn R Frumkin
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, California, USA
| | - Elvi Sanjines
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | | | - K T Park
- Division of Pediatric Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
| | - Berkeley Limketkai
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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9
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Chang HP, Shakhnovich V, Frymoyer A, Funk RS, Becker ML, Park KT, Shah DK. A population physiologically-based pharmacokinetic model to characterize antibody disposition in pediatrics and evaluation of the model using infliximab. Br J Clin Pharmacol 2022; 88:290-302. [PMID: 34189743 PMCID: PMC8714867 DOI: 10.1111/bcp.14963] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/13/2021] [Accepted: 05/23/2021] [Indexed: 01/03/2023] Open
Abstract
AIMS In order to better predict the pharmacokinetics (PK) of antibodies in children, and to facilitate dose optimization of antibodies in paediatric patients, there is a need to develop systems PK models that integrate ontogeny-related changes in human physiological parameters. METHODS A population-based physiological-based PK (PBPK) model to characterize antibody PK in paediatrics has been developed, by incorporating age-related changes in body weight, organ weight, organ blood flow rate and interstitial volumes in a previously published platform model. The model was further used to perform Monte Carlo simulations to investigate clearance vs. age and dose-exposure relationships for infliximab. RESULTS By estimating only one parameter and associated interindividual variability, the model was able to characterize clinical PK of infliximab from two paediatric cohorts (n = 141, 4-19 years) reasonably well. Model simulations demonstrated that only 50% of children reached desired trough concentrations when receiving FDA-labelled dosing regimen for infliximab, suggesting that higher doses and/or more frequent dosing are needed to achieve target trough concentrations of this antibody. CONCLUSION The paediatric PBPK model presented here can serve as a framework to characterize the PK of antibodies in paediatric patients. The model can also be applied to other protein therapeutics to advance precision medicine paradigm and optimize antibody dosing regimens in children.
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Affiliation(s)
- Hsuan Ping Chang
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, The State University of New York at Buffalo, Buffalo, NY, United States
| | - Valentina Shakhnovich
- Children's Mercy Kansas City, Kansas City, MO, United States
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Ryan Sol Funk
- Department of Pharmacy Practice, University of Kansas School of Pharmacy, Kansas City, KS, United States
| | - Mara L. Becker
- Department of Pediatrics, Division of Rheumatology, Duke University, Durham, NC, United States
- Duke Clinical Research Institute, Durham, NC, United States
| | - K. T. Park
- Genentech, Inc., South San Francisco, CA, USA
| | - Dhaval K. Shah
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, The State University of New York at Buffalo, Buffalo, NY, United States
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10
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Dehghan M, Wong G, Neuberger E, Kin C, Rieder F, Park KT. Worse outcomes and higher costs of care in fibrostenotic Crohn's disease: a real-world propensity-matched analysis in the USA. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000781. [PMID: 34930755 PMCID: PMC8689124 DOI: 10.1136/bmjgast-2021-000781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/31/2021] [Accepted: 11/16/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with Crohn's disease (CD) may develop fibrostenotic strictures. No currently available therapies prevent or treat fibrostenotic CD (FCD), making this a critical unmet need. AIM To compare health outcomes and resource utilisation between CD patients with and without fibrostenotic disease. METHODS Patients aged ≥18 years with FCD and non-FCD between 30 October 2015 and 30 September 2018 were identified in the Truven MarketScan Commercial Claims and Encounters Database. We conducted 1:3 nearest neighbour propensity score matching on age, sex, malnutrition, payer type, anti-tumour necrosis factor use, and Charlson Comorbidity Index score. Primary outcomes up to 1 year from the index claim were ≥1 hospitalisation, ≥1 procedure, ≥1 surgery, and steroid dependency (>100 day supply). Associations between FCD diagnosis and outcomes were estimated with a multivariable logistic regression model. This study was exempt from institutional review board approval. RESULTS Propensity score matching yielded 11 022 patients. Compared with non-FCD, patients with FCD had increased likelihood of hospitalisations (17.1% vs 52.4%; p<0.001), endoscopic procedures (4.4% vs 8.6%; p<0.001), IBD-related surgeries (4.7% vs 9.1%; p<0.001), steroid dependency (10.0% vs 15.7%; p<0.001), and greater mean annual costs per patient ($47 575 vs $77 609; p<0.001). FCD was a significant risk factor for ≥1 hospitalisation (adjusted OR (aOR), 6.1), ≥1 procedure (aOR, 2.1), ≥1 surgery (aOR, 2.0), and steroid dependency (aOR, 1.7). CONCLUSIONS FCD was associated with higher risk for hospitalisation, procedures, abdominal surgery, and steroid dependency. Patients with FCD had a greater mean annual cost per patient. FCD represents an ongoing unmet medical need.
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Affiliation(s)
| | - Gabriel Wong
- Genentech Inc, South San Francisco, California, USA
| | | | - Cindy Kin
- Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Florian Rieder
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - K T Park
- Genentech Inc, South San Francisco, California, USA
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11
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Rubin DT, Peyrin-Biroulet L, Reinisch W, Tole S, Sullivan L, Park KT, Regueiro M. Inflammatory Bowel Disease Patients' Perspectives of Clinical Trials: A Global Quantitative and Qualitative Analysis. Crohns Colitis 360 2021; 3:otab079. [PMID: 36777264 PMCID: PMC9802428 DOI: 10.1093/crocol/otab079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/09/2021] [Indexed: 12/13/2022] Open
Abstract
Background Despite recent progress, inflammatory bowel disease (IBD) therapies with pronounced long-term efficacy and improved safety are needed. IBD clinical trials face challenges with patient recruitment because of study designs, competitive or overlapping trials, and limited numbers of eligible patients. We aimed to better understand patients' awareness of, attitudes toward, and experience with IBD clinical trials. Methods This multinational, cross-sectional cohort study of adults with IBD recruited online consisted of 2 components: a quantitative 15-minute online survey completed by all participants and a qualitative 30-minute telephone interview completed by a subset of patients from the United States. Results Quantitative survey respondents (N = 226) included patients with ulcerative colitis (52%) and Crohn's disease (48%) from the United States (n = 100, 21 of whom were interviewed), Brazil (n = 26), Canada (n = 25), France (n = 25), Germany (n = 25), and Spain (n = 25); 96% of respondents reported at least a basic understanding of clinical trials. Patients rated conversations with health care providers most helpful for researching trials, but during interviews patients discussed their desire for increased patient-physician communication about trials. Major barriers to participation included invasive screening/monitoring (35% of quantitative responses) and concern over receiving placebo (35%) or suboptimal treatment (33%). Most respondents (68%) reported that clinical trial participants are "guinea pigs" for an experimental treatment. Conclusions Opportunities to improve participation in IBD trials include improved communication with health care providers, further patient education, and alternative trial designs. Ultimately, a better understanding of the patient perspective will be important for more informed patients and more successful recruitment and enrollment.
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Affiliation(s)
- David T Rubin
- Department of Medicine and Biological Sciences, University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA,Address correspondence to: David T. Rubin, MD, University of Chicago Medicine, 5841 S. Maryland Ave. MC 4076, Chicago, IL, 60637, USA ()
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, Vandoeuvre-Les-Nancy, France,Department of Gastroenterology, Inserm U1256, Lorraine University, Vandoeuvre-Les-Nancy, France
| | - Walter Reinisch
- Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Swati Tole
- Clinical Science, Genentech, Inc., South San Francisco, California, USA
| | - Laura Sullivan
- Clinical Science, Genentech, Inc., South San Francisco, California, USA
| | - K T Park
- Clinical Science, Genentech, Inc., South San Francisco, California, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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12
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Casavant E, Park KT, Elias JE. Proteomic Discovery of Stool Protein Biomarkers for Distinguishing Pediatric Inflammatory Bowel Disease Flares. Clin Gastroenterol Hepatol 2020; 18:2618-2619.e1. [PMID: 31499250 DOI: 10.1016/j.cgh.2019.08.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/05/2019] [Accepted: 08/25/2019] [Indexed: 02/07/2023]
Abstract
Fecal calprotectin, the heterodimer of S100A8/S100A9, makes up ∼60% of neutrophil cytoplasmic protein content and is a canonical clinical biomarker of gut inflammation.1,2 Fecal calprotectin is commonly used to diagnose inflammatory bowel disease (IBD) and has an average sensitivity of 93% and specificity of 96%.1 For diagnosing pediatric IBD, calprotectin fecal tests have similar sensitivity (92%) but substantially less specificity (76%).1 Low specificity, especially in pediatric patients, means a high likelihood of false negative diagnoses, suggesting that a substantial number of active IBD cases remain undiagnosed and untreated. To improve on calprotectin as an effective IBD monitoring tool in pediatric populations, specificity must be increased. To develop an assay with higher specificity in pediatric patients, we identified a panel of multiple proteins that are present in both IBD flare and remission but have distinct abundance ranges between each condition. From a pilot cohort of 10 pediatric patients in states of either active disease or remission, we discovered and relatively quantified hundreds of stool proteins. Of these, our mass spectrometry-based study prioritized at least 5 that have potential to augment negative predictive power of mucosal-level inflammation alongside fecal biomarkers such as calprotectin.
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Affiliation(s)
- Ellen Casavant
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, California
| | - K T Park
- Stanford Inflammatory Bowel Disease Center, Department of Pediatrics, Stanford, California; GastroImmunology, Genentech, South San Francisco, California
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13
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Park KT, Ehrlich OG, Allen JI, Meadows P, Szigethy EM, Henrichsen K, Kim SC, Lawton RC, Murphy SM, Regueiro M, Rubin DT, Engel-Nitz NM, Heller CA. Corrigendum to The Cost of Inflammatory Bowel Disease: An Initiative From the Crohn's & Colitis Foundation. Inflamm Bowel Dis 2020; 26:1118. [PMID: 32374862 PMCID: PMC7301401 DOI: 10.1093/ibd/izaa081] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Maller J, Fox E, Park KT, Paul SS, Baszis K, Borocco C, Prahalad S, Quartier P, Reinhardt A, Schonenberg-Meinema D, Shipman-Duensing L, Terreri MT, Simard J, Lavi I, Chalom E, Hsu J, Zisman D, Mellins ED. Inflammatory Bowel Disease in Children With Systemic Juvenile Idiopathic Arthritis. J Rheumatol 2020; 48:567-574. [PMID: 32541073 DOI: 10.3899/jrheum.200230] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The incidence of inflammatory bowel disease (IBD) in juvenile idiopathic arthritis (JIA) is higher than in the general pediatric population. However, reports of IBD in the systemic JIA (sJIA) subtype are limited. We sought to characterize sJIA patients diagnosed with IBD and to identify potential contributing risk factors. METHODS Using an internationally distributed survey, we identified 16 patients with sJIA who were subsequently diagnosed with IBD (sJIA-IBD cohort). Five hundred twenty-two sJIA patients without IBD were identified from the CARRA Legacy Registry and served as the sJIA-only cohort for comparison. Differences in demographic, clinical characteristics, and therapy were assessed using chi-square test, Fisher exact test, t-test, and univariate and multivariate logistic regression, as appropriate. RESULTS Of the patients with sJIA-IBD, 75% had a persistent sJIA course and 25% had a history of macrophage activation syndrome. sJIA-IBD subjects were older at sJIA diagnosis, more often non-White, had a higher rate of IBD family history, and were more frequently treated with etanercept or canakinumab compared to sJIA-only subjects. Sixty-nine percent of sJIA-IBD patients successfully discontinued sJIA medications following IBD diagnosis, and sJIA symptoms resolved in 9 of 12 patients treated with tumor necrosis factor-α (TNF-α) inhibitors. CONCLUSION IBD in the setting of sJIA is a rare occurrence. The favorable response of sJIA symptoms to therapeutic TNF-α inhibition suggests that the sJIA-IBD cohort may represent a mechanistically distinct sJIA subgroup. Our study highlights the importance of maintaining a high level of suspicion for IBD when gastrointestinal involvement occurs in patients with sJIA and the likely broad benefit of TNF-α inhibition in those cases.
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Affiliation(s)
- Justine Maller
- J. Maller, MD, PhD, Department of Pediatrics, Division of Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Emily Fox
- E. Fox, MD, Department of Pediatrics, Division of Rheumatology, Stanford University School of Medicine, Stanford, California, and Department of Pediatrics, Division of Rheumatology, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - K T Park
- K.T. Park, MD, Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
| | - Sarah Sertial Paul
- S. Sertial Paul, DO, Department of Pediatrics, Goryeb Children's Hospital, Morristown, New Jersey, USA
| | - Kevin Baszis
- K. Baszis, MD, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charlotte Borocco
- C. Borocco, MD, Paris University, Imagine Institute and Pediatric Hematology-Immunology and Rheumatology Unit, Necker Hospital, AP-HP, Paris, France
| | - Sampath Prahalad
- S. Prahalad, MD, Department of Pediatrics and Department of Genetics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Pierre Quartier
- P. Quartier, MD, Paris University, Imagine Institute, RAISE Reference Centre and Pediatric Hematology-Immunology and Rheumatology Unit, Necker Hospital, AP-HP, Paris, France
| | - Adam Reinhardt
- A. Reinhardt, MD, Department of Pediatrics, Boys Town National Research Hospital, Omaha, Nebraska, USA
| | - Dieneke Schonenberg-Meinema
- D. Schonenberg-Meinema, MD, Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Amsterdam Universitair Medische Centra, Amsterdam, the Netherlands
| | - Lauren Shipman-Duensing
- L. Shipman-Duensing, MD, Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maria Teresa Terreri
- M.T. Terreri, MD, Department of Pediatrics, Pediatric Rheumatology Unit, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Julia Simard
- J. Simard, ScD, Department of Health Research & Policy, Division of Epidemiology, and Department of Medicine, Division of Immunology & Rheumatology, Stanford University, Stanford, California, USA
| | - Idit Lavi
- I. Lavi, MA, Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Elizabeth Chalom
- E. Chalom, MD, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Joyce Hsu
- J. Hsu, MD, Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Devy Zisman
- D. Zisman, MD, Carmel Medical Center, Rheumatology Unit, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Elizabeth D Mellins
- E.D. Mellins, MD, Department of Pediatrics, Division of Human Gene Therapy, Program in Immunology, Stanford University School of Medicine, Stanford, California, USA.
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Sharp D, Ringer S, Park KT, Tole S, Rubin DT, Regueiro M. Listening to the Patient: Improving the Design and Conduct of Clinical Trials in Inflammatory Bowel Diseases. Crohns Colitis 360 2020; 2:otaa011. [PMID: 36777962 PMCID: PMC9802181 DOI: 10.1093/crocol/otaa011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Lay Summary
There is an urgent need for new treatments for inflammatory bowel diseases, but it’s hard to enroll the large number of patients needed for clinical trials. Making trials more patient-friendly by giving patients a voice would help solve this problem.
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Affiliation(s)
- Dan Sharp
- IBD patient advocate, DanSharpIBD.org
| | - Sara Ringer
- IBD patient advocate, InflamedAndUntamed.org
| | - K T Park
- Genentech, Inc, South San Francisco, California, USA
| | - Swati Tole
- Genentech, Inc, South San Francisco, California, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Address correspondence to: Miguel Regueiro, MD, Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 ()
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16
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Park KT, Ehrlich OG, Allen JI, Meadows P, Szigethy EM, Henrichsen K, Kim SC, Lawton RC, Murphy SM, Regueiro M, Rubin DT, Engel-Nitz NM, Heller CA. The Cost of Inflammatory Bowel Disease: An Initiative From the Crohn's & Colitis Foundation. Inflamm Bowel Dis 2020; 26:1-10. [PMID: 31112238 PMCID: PMC7534391 DOI: 10.1093/ibd/izz104] [Citation(s) in RCA: 232] [Impact Index Per Article: 58.0] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Crohn's & Colitis Foundation's Cost of Inflammatory Bowel Disease (IBD) Care Initiative seeks to quantify the wide-ranging health care costs affecting patients living with IBD. We aimed to (1) describe the annualized direct and indirect costs of care for patients with Crohn's disease (CD) or ulcerative colitis (UC), (2) determine the longitudinal drivers of these costs, and (3) characterize the cost of care for newly diagnosed patients. METHODS We analyzed the Optum Research Database from the years 2007 to 2016, representing commercially insured and Medicare Advantage-insured patients in the United States. Inclusion for the study was limited to those who had continuous enrollment with medical and pharmacy benefit coverage for at least 24 months (12 months before through 12 months after the index date of diagnosis). The value of patient time spent on health care was calculated as number of workplace hours lost due to health care encounters multiplied by the patients' estimated average wage derived from the Bureau of Labor Statistics. Comparisons between IBD patients and non-IBD patients were analyzed based on demographics, health plan type, and length of follow-up. We used generalized linear models to estimate the association between total annual costs and various patient variables. RESULTS There were 52,782 IBD patients (29,062 UC; 23,720 CD) included in the analysis (54.1% females). On a per-annual basis, patients with IBD incurred a greater than 3-fold higher direct cost of care compared with non-IBD controls ($22,987 vs $6956 per-member per-year paid claims) and more than twice the out-of-pocket costs ($2213 vs $979 per-year reported costs), with all-cause IBD costs rising after 2013. Patients with IBD also experienced significantly higher costs associated with time spent on health care as compared with controls. The burden of costs was most notable in the first year after initial IBD diagnosis (mean = $26,555). The study identified several key drivers of cost for IBD patients: treatment with specific therapeutics (biologics, opioids, or steroids); ED use; and health care services associated with relapsing disease, anemia, or mental health comorbidity. CONCLUSION The costs of care for IBD have increased in the last 5 years and are driven by specific therapeutics and disease features. In addition, compared with non-IBD controls, IBD patients are increasingly incurring higher costs associated with health care utilization, out-of-pocket expenditures, and workplace productivity losses. There is a pressing need for cost-effective strategies to address these burdens on patients and families affected by IBD.
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Affiliation(s)
- K T Park
- Stanford University School of Medicine & Stanford Health Care, Palo Alto, CA, USA
| | | | - John I Allen
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Perry Meadows
- Medical Director, Government Programs, Geisinger Health Plan, Danville, PA, USA
| | - Eva M Szigethy
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kim Henrichsen
- Medical Management, Centene Corporation, St. Louis, MO, USA
| | - Sandra C Kim
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Rachel C Lawton
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital and Medical Center, Cincinnati, OH, USA
| | - Sean M Murphy
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
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Kim M, Kim HL, Park KT, Lim WH, Seo JB, Kim SH, Kim MA, Zo JH. P1348 Impact of left ventricular ejection fraction and aortic valve sclerosis on cardiovascular outcome in patients with acute ischemic stroke. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.784] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Introduction
Previous studies have focused on only 1 or 2 echocardiographic parameters as prognostic marker in patients with acute ischemic stroke (AIS).
Purpose
Various echocardiographic parameters in the same patient were systemically evaluated for their prognostic significance in AIS.
Methods
A total of 900 patients with AIS who underwent transthoracic echocardiography (TTE) (72.6 ± 12.0 years and 60% male) were retrospectively reviewed. Composite events including all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, and coronary revascularization were assessed during clinical follow-up.
Results
During a median follow-up of 3.3 years (interquartile range, 0.6-5.1 years), there were 151 (16.8%) composite events. Univariable analyses showed that low left ventricular ejection fraction (LVEF) (< 60%), increased peak tricuspid regurgitation (TR) velocity (> 2.8 m/s) and aortic valve (AV) sclerosis were associated with composite events (P < 0.05 for each). In the multivariable analyses after controlling for potential confounders, LVEF < 60% (hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.30-2.77; P = 0.001) and AV sclerosis (HR, 1.56; 95% CI, 1.10-2.21; P = 0.013) were independent prognostic factors associated with composite events. Multivariable analysis showed that HR for composite events gradually increased according to LVEF and AV sclerosis: HR was 2.8-fold higher in the highest-risk group than in the lowest group (P = 0.001).
Conclusions
In patients with AIS, LVEF < 60% and the presence of AV sclerosis predicts the future vascular events. Patients with AIS exhibiting reduced LVEF and AV sclerosis may benefit from aggressive secondary prevention
Abstract P1348 Figure. COX plot for composite event
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Affiliation(s)
- M Kim
- Boramae Hospital, Seoul, Korea (Republic of)
| | - H L Kim
- Boramae Hospital, Seoul, Korea (Republic of)
| | - K T Park
- Boramae Hospital, Seoul, Korea (Republic of)
| | - W H Lim
- Boramae Hospital, Seoul, Korea (Republic of)
| | - J B Seo
- Boramae Hospital, Seoul, Korea (Republic of)
| | - S H Kim
- Boramae Hospital, Seoul, Korea (Republic of)
| | - M A Kim
- Boramae Hospital, Seoul, Korea (Republic of)
| | - J H Zo
- Boramae Hospital, Seoul, Korea (Republic of)
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18
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Keyashian K, Dehghan M, Sceats L, Kin C, Limketkai BN, Park KT. Comparative Incidence of Inflammatory Bowel Disease in Different Age Groups in the United States. Inflamm Bowel Dis 2019; 25:1983-1989. [PMID: 31095681 PMCID: PMC7534454 DOI: 10.1093/ibd/izz092] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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: 02/21/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data on the incidence of inflammatory bowel disease (IBD) by age group are available in countries outside of the United States or localized populations within the United States. We aimed to estimate the incidence rates (IRs) of IBD by age group using a US multiregional data set. METHODS We used the Optum Research Database to identify incident IBD patients with a disease-free interval of 1.5 years between 2005 and 2015. Overall and age-specific IRs were calculated for 4 different age groups: pediatric (0-17 years), young adult (18-25 years), adult (26-59 years), elderly (>60 years). Time trends of incidence were evaluated in each age group. Perianal phenotype (in Crohn's disease [CD]) was also compared. RESULTS The mean IR for the cohort (n = 60,247) from 2005 to 2015 was 37.5/100,000. The IR was highest in adult and elderly cohorts (36.4 and 36.7/100,000 respectively). In the adult and elderly groups, the IR for UC was higher than that for CD, whereas the opposite was true in the pediatric and young adult groups. The IR increased over the 10-year study period for all age groups (time trends P < 0.001). The elderly group had less perianal disease than the adult group (20.8 vs 22.3%, respectively; P < 0.05). CONCLUSIONS In one of the most comprehensive evaluations of the incidence of IBD in the United States, we found an incidence rate similar to those of other national populations. We also confirmed differences of specific IBD phenotypes based on age groups, with lower rates of perianal disease in the elderly.
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Affiliation(s)
- Kian Keyashian
- Division of Gastroenterology, Department of Medicine, Stanford, California, USA
- Address correspondence to: Kian Keyashian, MD, Stanford Health Care, 430 Broadway, Pavilion C—3rd Floor, Redwood City, CA 94063 ()
| | - Melody Dehghan
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California, USA
| | - Lindsay Sceats
- Department of Surgery & Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, Stanford, California, USA
| | - Cindy Kin
- Department of Surgery & Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, Stanford, California, USA
| | | | - K T Park
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California, USA
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19
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Lai C, Sceats LA, Qiu W, Park KT, Morris AM, Kin C. Patient decision-making in severe inflammatory bowel disease: the need for improved communication of treatment options and preferences. Colorectal Dis 2019; 21:1406-1414. [PMID: 31295766 DOI: 10.1111/codi.14759] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/27/2019] [Indexed: 01/09/2023]
Abstract
AIM Patients with inflammatory bowel disease and their physicians must navigate ever-increasing options for treatment. The aim of this study was to elucidate the key drivers of treatment decision-making in inflammatory bowel disease. METHODS We conducted qualitative semi-structured in-person interviews of 20 adult patients undergoing treatment for inflammatory bowel disease at an academic medical centre who either recently initiated biologic therapy or underwent an operation or surgical evaluation. Interviews were audio-recorded, transcribed verbatim, iteratively coded, and discussed to consensus by five researchers. We used thematic analysis to explore factors influencing decision-making. RESULTS Four major themes emerged as key drivers of treatment decision-making: perceived clinical state and disease severity, the patient-physician relationship, knowledge, attitudes and beliefs about treatment options, and social isolation and stigma. Patients described experiencing a clinical turning point as the impetus for proceeding with a previously undesired treatment such as infusion medication or surgery. Patients reported delays in care or diagnosis, inadequate communication with their physicians, and lack of control over their disease management. Patients often stated that they considered surgery to be the treatment of last resort, which further compounded the complexity of making treatment decisions. CONCLUSION Patients described multiple barriers to making informed and collaborative decisions about treatment, especially when considering surgical options. Our study reveals a need for more comprehensive communication between the patient and their physician about the range of medical and surgical treatment options. We recommend a patient-centred approach toward the decision-making process that accounts for patient decision-making preferences, causes of social stress, and clinical status.
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Affiliation(s)
- C Lai
- Stanford University School of Medicine, Stanford, California, USA
| | - L A Sceats
- Department of Surgery, S-SPIRE Center, Stanford University School of Medicine, Stanford, California, USA
| | - W Qiu
- Stanford University School of Medicine, Stanford, California, USA
| | - K T Park
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - A M Morris
- Department of Surgery, S-SPIRE Center, Stanford University School of Medicine, Stanford, California, USA
| | - C Kin
- Department of Surgery, S-SPIRE Center, Stanford University School of Medicine, Stanford, California, USA
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20
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Berinstein JA, Steiner CA, Bousvaros A, Tiongco FP, Greenberg E, Hardi R, Lembo AJ, Friedenberg K, Sedghi S, Fint A, Florez DA, Kumar A, Arsenescu R, Park KT, Kupchak P, Grob A, Leavitt J, Higgins PDR. The Clinical Accuracy of the BÜHLMANN fCAL ELISA in the Differentiation of Inflammatory Bowel Disease From Irritable Bowel Syndrome: A Multicenter Prospective Case–Control Study. Crohn's & Colitis 360 2019. [DOI: 10.1093/crocol/otz037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Abstract
Background
Fecal calprotectin (fCAL) is a noninvasive biomarker used to differentiate between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS).
Methods
A multicenter prospective case–control study evaluating the BÜHLMANN fCAL enzyme-linked immunosorbent assay (ELISA) was conducted in 478 subjects. Sensitivity, specificity, predictive values, and area under the receiver operator characteristic (AuROC) curve are reported and compared to another device.
Results
In differentiating IBD from IBS, the BÜHLMANN fCAL ELISA is very sensitive (93.3%) at a cutoff <80 μg/g and balanced sensitivity (84.4%) and specificity (85.4%) at a cutoff >160 μg/g (AuROC 0.933).
Conclusions
The BÜHLMANN fCAL ELISA demonstrates excellent discriminating between IBD and IBS.
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Affiliation(s)
- Jeffrey A Berinstein
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Calen A Steiner
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Felix P Tiongco
- Clinical Research Division, Gastroenterology Associates of Tidewater, Chesapeake, VA
| | - Eugene Greenberg
- Clinical Research Division, Greenberg Digestive Health Institute/Carle Foundation, Urbana, IL
| | - Robert Hardi
- George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Anthony J Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | | | - Razvan Arsenescu
- Atlantic Inflammatory Bowel Disease Center of Excellence, Atlantic Digestive Health Institute, Morristown, NJ
| | - K T Park
- Division of Gastroenterology, Hepatology, and Nutrition, Stanford University School of Medicine, Palo Alto, CA
| | | | | | | | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
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21
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Pratt J, Jeffers D, King EC, Kappelman MD, Collins J, Margolis P, Baron H, Bass JA, Bassett MD, Beasley GL, Benkov KJ, Bornstein JA, Cabrera JM, Crandall W, Dancel LD, Garin-Laflam MP, Grunow JE, Hirsch BZ, Hoffenberg E, Israel E, Jester TW, Kiparissi F, Lakhole A, Lapsia SP, Minar P, Navarro FA, Neef H, Park KT, Pashankar DS, Patel AS, Pineiro VM, Samson CM, Sandberg KC, Steiner SJ, Strople JA, Sudel B, Sullivan JS, Suskind DL, Uppal V, Wali PD. Implementing a Novel Quality Improvement-Based Approach to Data Quality Monitoring and Enhancement in a Multipurpose Clinical Registry. EGEMS (Wash DC) 2019; 7:51. [PMID: 31646151 PMCID: PMC6777196 DOI: 10.5334/egems.262] [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] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 09/10/2019] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To implement a quality improvement based system to measure and improve data quality in an observational clinical registry to support a Learning Healthcare System. DATA SOURCE ImproveCareNow Network registry, which as of September 2019 contained data from 314,250 visits of 43,305 pediatric Inflammatory Bowel Disease (IBD) patients at 109 participating care centers. STUDY DESIGN The impact of data quality improvement support to care centers was evaluated using statistical process control methodology. Data quality measures were defined, performance feedback of those measures using statistical process control charts was implemented, and reports that identified data items not following data quality checks were developed to enable centers to monitor and improve the quality of their data. PRINCIPAL FINDINGS There was a pattern of improvement across measures of data quality. The proportion of visits with complete critical data increased from 72 percent to 82 percent. The percent of registered patients improved from 59 percent to 83 percent. Of three additional measures of data consistency and timeliness, one improved performance from 42 percent to 63 percent. Performance declined on one measure due to changes in network documentation practices and maturation. There was variation among care centers in data quality. CONCLUSIONS A quality improvement based approach to data quality monitoring and improvement is feasible and effective.
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Affiliation(s)
| | | | - Eileen C. King
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, US
| | | | | | - Peter Margolis
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, US
| | - Howard Baron
- Pediatric Gastroenterology & Nutrition Associates, US
| | | | | | - Genie L. Beasley
- UF Health Pediatric Gastroenterology, Hepatology and Nutrition, US
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Phillip Minar
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, US
| | | | - Haley Neef
- University of Michigan – C.S. Mott Children’s Hospital, US
| | | | | | | | | | | | | | | | | | | | | | | | - Vikas Uppal
- Nemours Children’s Health System – Wilmington, US
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22
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Schroeder AR, Newman TB, Park KT. Dangers of Opioid Prescribing for Young Adults After Dental Procedures-Reply. JAMA Intern Med 2019; 179:998. [PMID: 31107504 DOI: 10.1001/jamainternmed.2019.0213] [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] [Indexed: 11/14/2022]
Affiliation(s)
- Alan R Schroeder
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Division of Critical Care, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Thomas B Newman
- Department of Epidemiology and Biostatistics, University of California, San Francisco.,Department of Pediatrics, University of California, San Francisco
| | - K T Park
- Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Genentech, South San Francisco, California
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23
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Park KT. P273The Association between Coronary Artery Disease by Coronary CT Angiography and ASCVD Score with Stable Chest Pain. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez148.004] [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] [Indexed: 11/14/2022] Open
Affiliation(s)
- K T Park
- Myongji Hospital, Jecheon Si, Korea (Republic of)
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24
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Damman J, Arias P, Kerner J, Zhang KY, Dehghan M, Krishnan G, Nespor C, Bensen R, Park KT. Procalcitonin as a Predictive Marker for Bacteremia in Children With a Central Line and Fever. Hosp Pediatr 2019; 9:434-439. [PMID: 31097470 PMCID: PMC6537123 DOI: 10.1542/hpeds.2018-0123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/24/2022]
Abstract
OBJECTIVES Unnecessary use of antibiotics is an increasing problem. In this study, we sought to determine the diagnostic accuracy of procalcitonin in predicting bacteremia in children with a central line and fever, and we sought to determine optimal cutoff values to maximize sensitivity and specificity. This is the largest study to date in which procalcitonin is examined as a predictive marker of bacteremia in pediatric patients with a central line and fever. METHODS We conducted a retrospective cohort study of children aged 0 to 23 years with a central line and fever of 38°C who had procalcitonin and blood cultures drawn before initiation of antibiotics and had no other identified bacterial infection. Patients were also prospectively monitored via a custom-built electronic medical record dashboard for eligibility. RESULTS There were 523 patients and >2500 procalcitonin values reviewed for eligibility. Of these, 169 (47%) patients and 335 blood cultures with procalcitonin were included. There were 94 (28%) positive bacterial blood cultures and 241 (72%) negative bacterial blood cultures. In bacteremic cultures, the mean procalcitonin level was 9.96 ± 15.96 ng/mL, and the median procalcitonin level was 4.85 ng/mL (interquartile range 18.5). In nonbacteremic cultures, the mean procalcitonin level was 1.23 ± 10.37 ng/mL, and the median procalcitonin level was 0.3 ng/mL (interquartile range 0.7). A receiver operating characteristic analysis indicated a procalcitonin level of ≥0.6 ng/mL as the best cutoff point that produced a sensitivity of 85.6% and a specificity of 65.7% (area under the curve 0.85). CONCLUSIONS Procalcitonin is a sensitive biomarker in predicting bacteremia in children with a central line and fever.
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Affiliation(s)
- Jennifer Damman
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; and
| | - Patricio Arias
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; and
| | - John Kerner
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; and
| | - Ke-You Zhang
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; and
| | - Melody Dehghan
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; and
| | | | - Colleen Nespor
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; and
| | - Rachel Bensen
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; and
| | - K T Park
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; and
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25
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Affiliation(s)
- Amir Jazayeri
- Division of Gastroenterology (Pediatrics), Columbia University Medical Center, New York, New York
| | - K T Park
- Division of Gastroenterology (Pediatrics), Stanford University School of Medicine, Palo Alto, California.
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26
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Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT. Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Intern Med 2019; 179:145-152. [PMID: 30508022 PMCID: PMC6439650 DOI: 10.1001/jamainternmed.2018.5419] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Through prescription writing, dental clinicians are a potential source of initial opioid exposure and subsequent abuse for adolescents and young adults. OBJECTIVE To examine the association between index dental opioid prescriptions from dental clinicians for opioid-naive adolescents and young adults in 2015 and new persistent use and subsequent diagnoses of abuse in this population. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined outpatient opioid prescriptions for patients aged 16 to 25 years in the Optum Research Database in 2015. Prescriptions were linked by National Provider Identifier number to a clinician category. EXPOSURES Individuals were included in the index dental opioid (opioid-exposed) cohort if they filled an opioid prescription from a dental clinician in 2015, had continuous health plan coverage and no record of opioid prescriptions for 12 months before receiving the prescription, and had 12 months of health plan coverage after receiving the prescription. Two age- and sex-matched opioid-nonexposed control individuals were selected for each opioid-exposed individual and were assigned a corresponding phantom prescription date. MAIN OUTCOMES AND MEASURES Receipt of an opioid prescription within 90 to 365 days, a health care encounter diagnosis associated with opioid abuse within 365 days, and all-cause mortality within 365 days of the index opioid or phantom prescription date. RESULTS Among 754 002 individuals with continuous enrollment in 2015, 97 462 patients (12.9%) received 1 or more opioid prescriptions, of whom 29 791 (30.6%) received prescriptions supplied by a dental clinician. The opioid-exposed cohort included 14 888 participants (7882 women [52.9%], 11 273 white [75.7%], with mean [SD] age, 21.8 [2.4] years), and the randomly selected opioid-nonexposed cohort included 29 776 participants (15 764 women [52.9%], 20 078 [67.4%] white, with mean [SD] age, 21.8 [2.4] years). Among the 14 888 individuals in the index dental opioid cohort, 1021 (6.9%) received another opioid prescription 90 to 365 days later compared with 30 of 29 776 (0.1%) opioid-nonexposed controls (adjusted absolute risk difference, 6.8%; 95% CI, 6.3%-7.2%), and 866 opioid-exposed individuals (5.8%) experienced 1 or more subsequent health care encounters with an opioid abuse-related diagnosis compared with 115 opioid-nonexposed controls (0.4%) (adjusted absolute risk difference, 5.3%; 95% CI, 5.0%-5.7%). There was only 1 death in each cohort. CONCLUSIONS AND RELEVANCE The findings suggest that a substantial proportion of adolescents and young adults are exposed to opioids through dental clinicians. Use of these prescriptions may be associated with an increased risk of subsequent opioid use and abuse.
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Affiliation(s)
- Alan R Schroeder
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Division of Critical Care, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Melody Dehghan
- Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Thomas B Newman
- Department of Epidemiology and Biostatistics, University of California, San Francisco.,Department of Pediatrics, University of California, San Francisco
| | - Jason P Bentley
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - K T Park
- Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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27
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Wong JJ, Sceats L, Dehghan M, Wren AA, Sellers ZM, Limketkai BN, Bensen R, Kin C, Park KT. Depression and Health Care Use in Patients With Inflammatory Bowel Disease. J Crohns Colitis 2019; 13:19-26. [PMID: 30256923 DOI: 10.1093/ecco-jcc/jjy145] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Depression frequently co-occurs in patients with inflammatory bowel disease [IBD] and is a driver in health care costs and use. AIM This study examined the associations between depression and total health care costs, emergency department [ED] visits, computed tomography [CT] during ED/inpatient visits, and IBD-related surgery among IBD patients. METHODS Our sample included 331772 IBD patients from a national administrative claims database [Truven Health MarketScan® Database]. Gamma and Poisson regression analyses assessed differences related to depression, controlling for key variables. RESULTS Approximately 16% of the IBD cohort was classified as having depression. Depression was associated with a $17,706 (95% confidence interval [CI] [$16,892, 18,521]) increase in mean annual IBD-related health care costs and an increased incidence of ED visits (adjusted incidence rate ratio [aIRR] of 1.5; 95% CI [1.5, 1.6]). Among patients who had one or more ED/inpatient visits, depression was associated with an increased probability of receiving repeated CT [one to four scans, adjusted odds ratio [aOR] of 1.6; 95% CI [1.5, 1.7]; five or more scans, aOR of 4.6; 95% CI [2.9, 7.3]) and increased odds of undergoing an IBD-related surgery (aOR of 1.2; 95% CI [1.1, 1.2]). Secondary analysis with a paediatric subsample revealed that approximately 12% of this cohort was classified as having depression, and depression was associated with increased costs and incidence rates of ED visits and CT, but not of IBD-related surgery. CONCLUSIONS Quantifiable differences in health care costs and patterns of use exist among patients with IBD and depression. Integration of mental health services within IBD care may improve overall health outcomes and costs of care.
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Affiliation(s)
- Jessie J Wong
- Pediatric Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lindsay Sceats
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Melody Dehghan
- Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Anava A Wren
- Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Zachary M Sellers
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Berkeley N Limketkai
- Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Rachel Bensen
- Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Cindy Kin
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - K T Park
- Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Palo Alto, CA, USA
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28
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Lai C, Sceats LA, Qiu W, Park KT, Morris AM, Kin CJ. Should Surgery Feel Like the Last Resort? Drivers of Decision Making in Inflammatory Bowel Disease. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Wren AA, Bensen R, Sceats L, Dehghan M, Yu H, Wong JJ, MacIsaac D, Sellers ZM, Kin C, Park KT. Starting Young: Trends in Opioid Therapy Among US Adolescents and Young Adults With Inflammatory Bowel Disease in the Truven MarketScan Database Between 2007 and 2015. Inflamm Bowel Dis 2018; 24:2093-2103. [PMID: 29986015 PMCID: PMC6692855 DOI: 10.1093/ibd/izy222] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 01/07/2018] [Indexed: 12/22/2022]
Abstract
Background Opioids are commonly prescribed for relief in inflammatory bowel disease (IBD). Emerging evidence suggests that adolescents and young adults are a vulnerable population at particular risk of becoming chronic opioid users and experiencing adverse effects. Objectives This study evaluates trends in the prevalence and persistence of chronic opioid therapy in adolescents and young adults with IBD in the United States. Method A longitudinal retrospective cohort analysis was conducted with the Truven MarketScan Database from 2007 to 2015. Study subjects were 15-29 years old with ≥2 IBD diagnoses (Crohn's: 555/K50; ulcerative colitis: 556/K51). Opioid therapy was identified with prescription claims within the Truven therapeutic class 60: opioid agonists. Persistence of opioid use was evaluated by survival analysis for patients who remained in the database for at least 3 years following index chronic opioid therapy use. Results In a cohort containing 93,668 patients, 18.2% received chronic opioid therapy. The annual prevalence of chronic opioid therapy increased from 9.3% in 2007 to 10.8% in 2015 (P < 0.01), peaking at 12.2% in 2011. Opioid prescriptions per patient per year were stable (approximately 5). Post hoc Poisson regression analyses demonstrated that the number of opioid pills dispensed per year increased with age and was higher among males. Among the 2503 patients receiving chronic opioid therapy and followed longitudinally, 30.5% were maintained on chronic opioid therapy for 2 years, and 5.3% for all 4 years. Conclusion Sustained chronic opioid use in adolescents and young adults with IBD is increasingly common, underscoring the need for screening and intervention for this vulnerable population.
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Affiliation(s)
- Anava A Wren
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California
| | - Rachel Bensen
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California
| | - Lindsay Sceats
- Division of Colorectal Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Melody Dehghan
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California
| | - Helen Yu
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California
| | - Jessie J Wong
- Center for Primary Care and Outcomes Research, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Donna MacIsaac
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California
- Division of Colorectal Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Zachary M Sellers
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California
| | - Cindy Kin
- Division of Colorectal Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - K T Park
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California
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30
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Abstract
As clinicians have begun to provide targeted pharmacotherapy for children with inflammatory bowel disease (IBD), several ethical challenges have arisen. In this paper, we review 3 challenges related to applying a precision health approach to pediatric IBD populations: selection of a disease monitoring method, pharmacotherapy optimization, and economic considerations in clinical decision making.
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Affiliation(s)
- Anava A Wren
- An instructor in the Department of Pediatrics, Division of Gastroenterology, at Stanford University School of Medicine in Palo Alto, California, and a clinical psychologist at Stanford Children's Inflammatory Bowel Disease (IBD) Center, where she provides support to pediatric patients and families from diagnosis of IBD through their transition to adult care
| | - K T Park
- An associate professor in the Department of Pediatrics, Division of Gastroenterology, at Stanford University School of Medicine in Stanford, California, and the codirector of Stanford Children's Inflammatory Bowel Disease (IBD) Center
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Park KT, Sceats L, Dehghan M, Trickey AW, Wren A, Wong JJ, Bensen R, Limketkai BN, Keyashian K, Kin C. Risk of post-operative surgical site infections after vedolizumab vs anti-tumour necrosis factor therapy: a propensity score matching analysis in inflammatory bowel disease. Aliment Pharmacol Ther 2018; 48:340-346. [PMID: 29876995 PMCID: PMC6043399 DOI: 10.1111/apt.14842] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 03/20/2018] [Revised: 04/27/2018] [Accepted: 05/20/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Perioperative vedolizumab (VDZ) and anti-tumour necrosis factor (TNFi) therapies are implicated in causing post-operative complications in inflammatory bowel disease (IBD). AIM To compare the risk of surgical site infections (SSIs) between VDZ- and TNFi-treated IBD patients in propensity-matched cohorts. METHODS The Optum Research Database was used to identify IBD patients who received VDZ or TNFi within 30 days prior to abdominal surgery between January 2015 and December 2016. The date of IBD-related abdominal surgery was defined as the index date. SSIs were determined by ICD-9/10 and CPT codes related to superficial wound infections or deep organ space infections after surgery. Propensity score 1:1 matching established comparable cohorts based on VDZ or TNFi exposure before surgery based on evidence-based risk modifiers. RESULTS The propensity-matched sample included 186 patients who received pre-operative biologic therapy (VDZ, n = 94; TNFi, n = 92). VDZ and TNFi cohorts were similar based on age, gender, IBD type, concomitant immunomodulator exposure, chronic opioid or corticosteroid therapy, Charlson Comorbidity Index and malnutrition. VDZ patients were more likely to undergo an open bowel resection with ostomy. After propensity score matching, there was no significant difference in post-operative SSIs (TNFi 12.0% vs VDZ 14.9%, P = 0.56). Multivariable analysis indicated that malnutrition was the sole risk factor for developing SSI (OR 3.1, 95% CI 1.11-8.71) regardless of the type of biologic exposure. CONCLUSION In the largest, risk-adjusted cohort analysis to date, perioperative exposure to VDZ therapy was not associated with a significantly higher risk of developing an SSI compared to TNFi therapy.
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Affiliation(s)
- KT Park
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine
| | - Lindsay Sceats
- Division of Colorectal Surgery, Department of Surgery & Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine
| | - Melody Dehghan
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine
| | - Amber W. Trickey
- Division of Colorectal Surgery, Department of Surgery & Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine
| | - Anava Wren
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine
| | - Jessie J. Wong
- Health Services Research & Development, VA Palo Alto Health Care System, Palo Alto, CA
| | - Rachel Bensen
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine
| | - Berkeley N. Limketkai
- Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine
| | - Kian Keyashian
- Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine
| | - Cindy Kin
- Division of Colorectal Surgery, Department of Surgery & Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine
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Sellers ZM, MacIsaac D, Yu H, Dehghan M, Zhang KY, Bensen R, Wong JJ, Kin C, Park KT. Nationwide Trends in Acute and Chronic Pancreatitis Among Privately Insured Children and Non-Elderly Adults in the United States, 2007-2014. Gastroenterology 2018; 155:469-478.e1. [PMID: 29660323 PMCID: PMC6067969 DOI: 10.1053/j.gastro.2018.04.013] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [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: 11/13/2017] [Revised: 03/07/2018] [Accepted: 04/06/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Epidemiologic analyses of acute pancreatitis (AP) and chronic pancreatitis (CP) provide insight into causes and strategies for prevention and affect allocation of resources to its study and treatment. We sought to determine current and accurate incidences of AP and CP, along with the prevalence of CP, in children and adults in the United States. METHODS We collected data from the Truven MarketScan Research Databases of commercial inpatient and outpatient insurance claims in the United States from 2007 through 2014 (patients 0-64 years old). We calculated the incidences of AP and CP and prevalence of CP based on International Classification of Diseases, 9th Revision diagnosis codes. Children were defined as 18 years or younger and adults as 19 to 64 years old. RESULTS The incidence of pediatric AP was stable from 2007 through 2014, remaining at 12.3/100,000 persons in 2014. Meanwhile, the incidence for adult AP decreased from 123.7/100,000 persons in 2007 to 111.2/100,000 persons in 2014. The incidence of CP decreased over time in children (2.2/100,000 persons in 2007 to 1.9/100,000 persons in 2014) and adults (31.7/100,000 persons in 2007 to 24.7/100,000 persons in 2014). The prevalences of pediatric and adult CP were 5.8/100,000 persons and 91.9/100,000 persons, respectively, in 2014. Incidences of AP and CP increased with age. We found little change in incidence during the first decade of life but linear increases starting in the second decade. CONCLUSIONS We performed a comprehensive epidemiologic analysis of privately insured, non-elderly adults and children with AP and CP in the United States. Changes in gallstone formation, smoking, and alcohol consumption, along with advances in pancreatitis management, may be responsible for the stabilization and even decrease in the incidences of AP and CP.
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Affiliation(s)
- Zachary M Sellers
- Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, California.
| | - Donna MacIsaac
- Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, California; Surgery, Stanford University, Palo Alto, California
| | - Helen Yu
- Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, California
| | - Melody Dehghan
- Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, California
| | - Ke-You Zhang
- Pediatrics, Stanford University, Palo Alto, California
| | - Rachel Bensen
- Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, California
| | - Jessie J Wong
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California; Center for Primary Care and Outcomes Research, Stanford University, Palo Alto, California
| | - Cindy Kin
- Surgery, Stanford University, Palo Alto, California
| | - K T Park
- Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, California
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Picoraro JA, Lee D, Heller CA, Weaver A, Hyams JS, Conklin LS, Otley A, Ziring D, Kugathasan S, Rosh JR, Mulberg A, Denson LA, Kappelman MD, Grossman AB, Bousvaros A, Park KT. Pediatric Inflammatory Bowel Disease Clinical Innovations Meeting of the Crohn's & Colitis Foundation: Charting the Future of Pediatric IBD. Inflamm Bowel Dis 2018; 25:27-32. [PMID: 29931102 PMCID: PMC8133504 DOI: 10.1093/ibd/izy205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Indexed: 12/30/2022]
Abstract
The Crohn's & Colitis Foundation has facilitated transformational research in pediatric inflammatory bowel disease (IBD), through the RISK and PROTECT studies, that has laid the groundwork for a comprehensive understanding of molecular mechanisms of disease and predictors of therapeutic response in children. Despite these advances, children have lacked timely and informed access to the latest therapeutic advancements in IBD. The Crohn's & Colitis Foundation convened a Pediatric Resource Organization for Kids with Inflammatory Intestinal Diseases (PRO-KIIDS) Clinical Innovations Meeting at the inaugural Crohn's and Colitis Congress in January 2018 to devise how to advance the care of children with IBD. The working group selected 2 priorities: (1) accelerating therapies to children with IBD and (2) stimulating investigator-initiated research while fostering sustainable collaboration; and proposed 2 actions: (a) the convening of a task force to specifically address how to accelerate pharmacotherapies to children with IBD and (b) the funding of a multicenter clinical and translational research study that incorporates the building of critical research infrastructure.10.1093/ibd/izy205_video1izy205.video15799266615001.
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Affiliation(s)
- Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Medical Center, New York, New York
| | - Dale Lee
- Division of Pediatric Gastroenterology and Hepatology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington
| | | | | | - Jeffrey S Hyams
- Division of Gastroenterology, Hepatology, and Nutrition, Connecticut Children’s Medical Center, Hartford, Connecticut
| | - Laurie S Conklin
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s National Medical Center, Washington, DC,ReveraGen Biopharma, LLC, Rockville, Maryland
| | - Anthony Otley
- Division of Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - David Ziring
- Pediatric Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Subra Kugathasan
- Division of Pediatric Gastroenterology, Emory University School of Medicine, Atlanta, Georgia
| | - Joel R Rosh
- Pediatric Gastroenterology, Clinical Development and Research Affairs, Goryeb Children’s Hospital/Atlantic Health, Morristown, New Jersey
| | | | - Lee A Denson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Andrew B Grossman
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts,Address correspondence to: Athos Bousvaros, MD, MPH, Inflammatory Bowel Disease Center, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 ()
| | - K T Park
- Division of Gastroenterology, Hepatology and Nutrition, Stanford University School of Medicine, Palo Alto, California
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Suh JH, Degagné É, Gleghorn EE, Setty M, Rodriguez A, Park KT, Verstraete SG, Heyman MB, Patel AS, Irek M, Gildengorin GL, Hubbard NE, Borowsky AD, Saba JD. Sphingosine-1-Phosphate Signaling and Metabolism Gene Signature in Pediatric Inflammatory Bowel Disease: A Matched-case Control Pilot Study. Inflamm Bowel Dis 2018; 24:1321-1334. [PMID: 29788359 PMCID: PMC5986285 DOI: 10.1093/ibd/izy007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Indexed: 12/12/2022]
Abstract
GOAL The aim of this study was to investigate gene expression levels of proteins involved in sphingosine-1-phosphate (S1P) metabolism and signaling in a pediatric inflammatory bowel disease (IBD) patient population. BACKGROUND IBD is a debilitating disease affecting 0.4% of the US population. The incidence of IBD in childhood is rising. Identifying effective targeted therapies that can be used safely in young patients and developing tools for selecting specific candidates for targeted therapies are important goals. Clinical IBD trials now underway target S1PR1, a receptor for the pro-inflammatory sphingolipid S1P. However, circulating and tissue sphingolipid levels and S1P-related gene expression have not been characterized in pediatric IBD. METHODS Pediatric IBD patients and controls were recruited in a four-site study. Patients received a clinical score using PUCAI or PCDAI evaluation. Colon biopsies were collected during endoscopy. Gene expression was measured by qRT-PCR. Plasma and gut tissue sphingolipids were measured by LC-MS/MS. RESULTS Genes of S1P synthesis (SPHK1, SPHK2), degradation (SGPL1), and signaling (S1PR1, S1PR2, and S1PR4) were significantly upregulated in colon biopsies of IBD patients with moderate/severe symptoms compared with controls or patients in remission. Tissue ceramide, dihydroceramide, and ceramide-1-phosphate (C1P) levels were significantly elevated in IBD patients compared with controls. CONCLUSIONS A signature of elevated S1P-related gene expression in colon tissues of pediatric IBD patients correlates with active disease and normalizes in remission. Biopsied gut tissue from symptomatic IBD patients contains high levels of pro-apoptotic and pro-inflammatory sphingolipids. A combined analysis of gut tissue sphingolipid profiles with this S1P-related gene signature may be useful for monitoring response to conventional therapy.
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Affiliation(s)
- Jung H Suh
- UCSF Benioff Children’s Hospital Oakland, Oakland, Califorina, USA
| | - Émilie Degagné
- UCSF Benioff Children’s Hospital Oakland, Oakland, Califorina, USA
| | | | - Mala Setty
- UCSF Benioff Children’s Hospital Oakland, Oakland, Califorina, USA
| | - Alexis Rodriguez
- Lucile Packard Children’s Hospital Stanford, Division of Gastroenterology, Palo Alto, Califorina, USA
| | - K T Park
- Lucile Packard Children’s Hospital Stanford, Division of Gastroenterology, Palo Alto, Califorina, USA
| | - Sofia G Verstraete
- Department of Pediatrics, University of California, San Francisco, and UCSF Benioff Children’s Hospital San Francisco, San Francisco, California, USA
| | - Melvin B Heyman
- Department of Pediatrics, University of California, San Francisco, and UCSF Benioff Children’s Hospital San Francisco, San Francisco, California, USA
| | - Ashish S Patel
- Division of Pediatric Gastroenterology, Children’s Medical Center of Dallas, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Melissa Irek
- Division of Pediatric Gastroenterology, Children’s Medical Center of Dallas, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | | | - Neil E Hubbard
- Department of Pathology, University of California at Davis School of Medicine, Sacramento, California, USA
| | - Alexander D Borowsky
- Department of Pathology, University of California at Davis School of Medicine, Sacramento, California, USA
| | - Julie D Saba
- UCSF Benioff Children’s Hospital Oakland, Oakland, Califorina, USA,Address correspondence to: Julie D. Saba MD, PhD, Children’s Hospital Oakland Research Institute, 5700 Martin Luther King Jr. Way, Oakland, CA 94609. E-mail:
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Nakayuenyongsuk W, Christofferson M, Stevenson DK, Sylvester K, Lee HC, Park KT. Point-of-Care Fecal Calprotectin Monitoring in Preterm Infants at Risk for Necrotizing Enterocolitis. J Pediatr 2018. [PMID: 29519542 DOI: 10.1016/j.jpeds.2017.12.069] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To establish baseline trends in fecal calprotectin, a protein excreted into the stool when there is neutrophilic inflammation in the bowel, in infants at risk for necrotizing enterocolitis (NEC). STUDY DESIGN We performed a prospective observational cohort study in infants with a birth weight of <1500 g without existing bowel disease at a level IV neonatal intensive care unit from October 2015 to September 2016. Stools were collected once daily for 30 days or until 32 weeks postmenstrual age and processed using the Fecal Calprotectin High Range Quantitative Quantum Blue assay. RESULTS In 64 preterm infants, during the first week after birth, 62% of infants had an initial stool sample with high baseline calprotectin levels (≥200 µg/g). In assessment of maternal and neonatal risk factors, maternal etiology for preterm birth (ie, eclamplsia or preeclampsia) was the only significant factor associated with high baseline calprotectin level. Two patients in the cohort developed NEC. Calprotectin levels for the entire cohort fluctuated during the observed period but generally increased in the third and fourth weeks after birth. CONCLUSIONS At-risk infants had highly variable fecal calprotectin levels, with maternal causes for preterm birth associated with higher baseline levels. More longitudinal data in infants with NEC are necessary to determine whether acute rises in fecal calprotectin levels prior to clinical diagnosis can be confirmed as a diagnostic or prognostic biomarker.
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Affiliation(s)
- Warapan Nakayuenyongsuk
- Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, CA
| | - Megan Christofferson
- Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, CA
| | - David K Stevenson
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Karl Sylvester
- Departement of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Henry C Lee
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - K T Park
- Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, CA.
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Abstract
Background Severe colitis flare from ulcerative colitis (UC) or Crohn’s disease (CD) may be refractory to corticosteroids and antitumour necrosis factor (TNF) agents resulting in high colectomy rates. We aimed to describe the utility of tacrolimus to prevent colectomy during second-line vedolizumab initiation after corticosteroid and anti-TNF treatment failure in paediatric severe colitis. Methods A retrospective cohort analysis was performed between 1 October 2014 and 31 October 2016 at a single tertiary care centre. Inclusion criteria were patients with severe colitis who received tacrolimus before or during vedolizumab induction and previous exposure to anti-TNF therapy with or without corticosteroids. The initiation of tacrolimus was clinician dependent based on an institutional protocol. Results Twelve patients (10 UC, two CD; median age 16 years; three female) received at least one dose of vedolizumab 10 mg/kg (max of 300 mg) due to anti-TNF therapy failure and persistent flare not responsive to corticosteroids. Of the 12 patients, eight (67%) and four (33%) had failed one or two anti-TNF agents, respectively. Tacrolimus was initiated for acute disease severity during hospitalisation (58%) or ongoing flare during outpatient care (42%). 9 (75%) of 12 patients avoided colectomy or inflammatory bowel disease-related surgery at 24 weeks and eight (68%) continued on vedolizumab maintenance with no adverse events out to 80 weeks. Conclusion We report real-world data on the outcome of tacrolimus around vedolizumab initiation in paediatric UC or CD after corticosteroid and anti-TNF therapy treatment failure. Our pilot experience indicates a potential benefit of concomitant tacrolimus when initiating vedolizumab therapy.
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Affiliation(s)
- Blaise Hamel
- Department of Pharmacy, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - May Wu
- Department of Pharmacy, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Elizabeth O Hamel
- Department of Biology, Stanford University, Stanford, California, USA
| | - Dorsey M Bass
- Department of Pediatrics, Stanford Children's Inflammatory Bowel Disease Center, Division of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
| | - K T Park
- Department of Pediatrics, Stanford Children's Inflammatory Bowel Disease Center, Division of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
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Piester T, Frymoyer A, Christofferson M, Yu H, Bass D, Park KT. A Mobile Infliximab Dosing Calculator for Therapy Optimization in Inflammatory Bowel Disease. Inflamm Bowel Dis 2018; 24:227-234. [PMID: 29361094 PMCID: PMC6048868 DOI: 10.1093/ibd/izx037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 06/15/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Inadequate infliximab (IFX) drug exposure remains a clinical challenge and leads to high loss of response rates and therapy failure in inflammatory bowel disease (IBD). We aimed to determine the feasibility and pilot effectiveness of a novel, web-based, mobile IFX dosing calculator (mIDC) for therapy optimization. METHODS We developed an mIDC leveraging the known clinical variables of C-reative protein (CRP), albumin, patient's weight, disease activity indices, calprotectin, drug trough levels, and antibodies to IFX that significantly affect pharmacokinetics and/or outcomes. A prospective observational cohort study in pediatric and young adult IBD patients receiving maintenance IFX was performed. System-wide practice adoption of mIDC was achieved through a quality improvement (QI) initiative within a hospital-based infusion unit. RESULTS Forty-nine patients (median age: 16.0 years; 55% female; 65% Crohn's disease) were followed over 9 months. mIDC recommendations for dose optimization were followed by the treating physicians in 198 (89%) out of 222 infusions. Twenty-eight (13%) of 222 mIDC recommendations were to escalate IFX dosing; 15 (54%) of 28 escalation recommendations were declined, and these patients were more likely to already be receiving IFX dose intensification compared with those in whom escalation recommendations were followed (P < 0.05). From mIDC initiation to end of follow-up, mean albumin levels remained unchanged at 3.8 g/dL. Median CRP remained unchanged at 2 g/L. Median calprotectin levels showed a downward trend from 30 to 27 μg/g (n = 9, P < 0.05). The percentage of patients undergoing therapeutic drug monitoring in clinical care increased from 34% to 86% with the QI initiative. The target median IFX trough goal of >5 μg/mL was achieved with 81% probability throughout the QI initiative, an increase of 12% compared with pre-QI values. CONCLUSIONS The use of a novel mIDC is feasible and potentially effective, facilitating both standardization and individualization of therapy in clinical care. mIDC appears to be a practical IFX dosing tool for point-of-care use, leveraging individual pharmacokinetic considerations.
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Affiliation(s)
- Travis Piester
- Stanford Children’s Inflammatory Bowel Disease Center, Division of
Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - Adam Frymoyer
- Division of Neonatal and Developmental Medicine, Department of Pediatrics,
Stanford University School of Medicine, Stanford, California
| | - Megan Christofferson
- Stanford Children’s Inflammatory Bowel Disease Center, Division of
Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - Helen Yu
- Stanford Children’s Inflammatory Bowel Disease Center, Division of
Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - Dorsey Bass
- Stanford Children’s Inflammatory Bowel Disease Center, Division of
Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - K T Park
- Stanford Children’s Inflammatory Bowel Disease Center, Division of
Gastroenterology, Stanford University School of Medicine, Stanford, California,Address correspondence to: K. T. Park, MD, MS, Pediatric Gastroenterology,
Hepatology, and Nutrition, 750 Welch Road, Ste 116, Palo Alto, CA 94304 ()
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Yu H, MacIsaac D, Wong JJ, Sellers ZM, Wren AA, Bensen R, Kin C, Park KT. Market share and costs of biologic therapies for inflammatory bowel disease in the USA. Aliment Pharmacol Ther 2018; 47:364-370. [PMID: 29164650 PMCID: PMC5760274 DOI: 10.1111/apt.14430] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [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: 09/07/2017] [Revised: 10/06/2017] [Accepted: 10/31/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Real-world data quantifying the costs of increasing use of biologics in inflammatory bowel disease (IBD) are unknown. AIM To determine the outpatient IBD drug utilization trends, relative market share, and costs in the USA during a 9-year period. METHODS The Truven MarketScan® Database was analysed for patients with Crohn's disease (CD) and ulcerative colitis (UC) during 2007-2015. National drug codes were used to identify prescription drugs; Healthcare Common Procedure Coding System J-codes were used to capture biologic out-patient infusions. Proportion of drug usage, relative market share and per-member per-year (PMPY) costs were analysed for biologics, immunomodulators, 5-ASAs and corticosteroids. RESULTS In 415 405 patients (188 842 CD; 195 183 UC; 31 380 indeterminate colitis; 54.67% female), utilization trends show a consistent rise in the market share of biologics during the 9-year study period. The proportion of patients using biologics increased from 21.8% to 43.8% for CD and 5.1%-16.2% for UC. This contrasts a small decrease in immunomodulator and 5-ASA use for CD and relative constancy of other classes including corticosteroids-only use as primary IBD medication from 2007 to 2015. The average biologic-taking patient accounted for $25 275 PMPY in 2007 and $36 051 PMPY in 2015. The average paediatric biologic-taking patient accounted for $23 616 PMPY in 2007 and $41 109 PMPY in 2015. In all patients, the share of costs for biologics increased from 72.9% in 2007 to 85.7% in 2015 (81.7% in 2007 to 94.9% in 2015 in paediatrics). CONCLUSION The vast majority of costs allocated to out-patient IBD medications in the USA is attributed to increasing use of biologic therapies despite the relative minority of biologic-taking patients.
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Affiliation(s)
- Helen Yu
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Donna MacIsaac
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA,Division of Colorectal Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jessie J. Wong
- Center for Health Policy, Department of Medicine, Palo Alto Veterans Affairs, Stanford University School of Medicine, Stanford, CA, USA
| | - Zachary M. Sellers
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Anava A. Wren
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Rachel Bensen
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Cindy Kin
- Division of Colorectal Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - KT Park
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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Iturralde E, Adams RN, Barley RC, Bensen R, Christofferson M, Hanes SJ, Maahs DM, Milla C, Naranjo D, Shah AC, Tanenbaum ML, Veeravalli S, Park KT, Hood KK. Implementation of Depression Screening and Global Health Assessment in Pediatric Subspecialty Clinics. J Adolesc Health 2017; 61:591-598. [PMID: 28830798 PMCID: PMC7162556 DOI: 10.1016/j.jadohealth.2017.05.030] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [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: 02/04/2017] [Revised: 05/10/2017] [Accepted: 05/24/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE Adolescents with chronic illness face greater risk of psychosocial difficulties, complicating disease management. Despite increased calls to screen for patient-reported outcomes, clinical implementation has lagged. Using quality improvement methods, this study aimed to investigate the feasibility of standardized screening for depression and assessment of global health and to determine recommended behavioral health follow-up, across three pediatric subspecialty clinics. METHODS A total of 109 patients aged 12-22 years (median = 16.6) who were attending outpatient visits for treatment of diabetes (80% type 1), inflammatory bowel disease, or cystic fibrosis completed the 9-item Patient Health Questionnaire (PHQ-9) depression and Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health measures on electronic tablets. Patients screening positive on the PHQ-9 received same-day behavioral health assessment and regular phone check-ins to facilitate necessary follow-up care. RESULTS Overall, 89% of 122 identified patients completed screening during a 6-month window. Patients completed measures in a timely manner (within 3 minutes) without disruption to clinic flow, and they rated the process as easy, comfortable, and valuable. Depression scores varied across disease type. Patients rated lower global health relative to a previously assessed validation cohort. Depression and global health related significantly to certain medical outcomes. Fifteen percent of patients screened positive on the PHQ-9, of whom 50% confirmed attending behavioral health appointments within 6 months of screening. CONCLUSIONS A standardized depression and global health assessment protocol implemented across pediatric subspecialties was feasible and effective. Universal behavioral health screening for adolescents and young adults living with chronic disease is necessary to meet programmatic needs in pediatric subspecialty clinics.
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Affiliation(s)
- Esti Iturralde
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Rebecca N Adams
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Regan C Barley
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Rachel Bensen
- Division of Gastroenterology, Department of Pediatrics, Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Stanford, California
| | - Megan Christofferson
- Division of Gastroenterology, Department of Pediatrics, Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Stanford, California
| | - Sarah J Hanes
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David M Maahs
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Carlos Milla
- Division of Pulmonary Medicine, Stanford Children's CysticFibrosis Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Diana Naranjo
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Avni C Shah
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Molly L Tanenbaum
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sruthi Veeravalli
- Division of Pulmonary Medicine, Stanford Children's CysticFibrosis Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - K T Park
- Division of Gastroenterology, Department of Pediatrics, Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Stanford, California
| | - Korey K Hood
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California.
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Abstract
In this report, we describe incremental changes, during a 2-year period at a single center with the administration of maintenance infliximab infusions. Given practice-driven changes consisting of 1-hour infusions and omission of premedications, we aimed to investigate if these changes contributed to severe infusion reactions. We reviewed approximately 900 infliximab infusions in a pediatric ambulatory infusion center from January 1, 2014, to December 31, 2015, for severe adverse reactions requiring either rescue epinephrine or a code blue or "rapid response" activation. In 2015, these practice changes resulted in a 51% decrease in total infusion hours (1281 to 630 infusion hours), despite a 9% increase in total number of infusions. No increase in severe adverse events associated with either rapid 1-hour infusion or omission of premedications. Our findings highlight a quality-improvement opportunity to standardize infliximab infusions to streamline care in an ambulatory setting.
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Affiliation(s)
- Stephanie Q Hutsell
- *Department of Pharmacy, Lucile Packard Children's Hospital, Stanford †Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
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Nakayuenyongsuk W, Christofferson M, Nguyen K, Burgis J, Park KT. Diet to the Rescue: Cessation of Pharmacotherapy After Initiation of Exclusive Enteral Nutrition (EEN) Followed by Strict and Liberalized Specific Carbohydrate Diet (SCD) in Crohn's Disease. Dig Dis Sci 2017; 62:2686-2689. [PMID: 28084605 DOI: 10.1007/s10620-016-4446-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Warapan Nakayuenyongsuk
- Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Stanford, CA, USA.
| | - Megan Christofferson
- Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Kaylie Nguyen
- Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer Burgis
- Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Stanford, CA, USA
| | - K T Park
- Stanford Children's Inflammatory Bowel Disease Center, Stanford University School of Medicine, Stanford, CA, USA
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Abstract
The advent of biosimilars in inflammatory bowel disease (IBD) represents an opportunity for cost-savings and increased patient access to effective disease-modifying therapies. While preliminary data in adult IBD and rheumatology patients suggest comparable effectiveness and pharmacokinetics between original biologics and biosimilars, long-term immunogenicity data are unknown. Without this data, conclusions about interchangeability should not be made for pediatric patients with IBD. Children affected by IBD, in particular, are a vulnerable group if automatic substitution and non-medical switching are allowed based on limited data in adult patients. Robust, long term immunogenicity data of biosimilars are needed in pediatric cohorts before policies allow interchangeability in children.
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Affiliation(s)
- Dimple Patel
- Saint Louis University School of Medicine, Saint Louis, MO
| | - KT Park
- Department of Pediatrics, Division of Gastroenterology, Stanford University Medical Center, Palo Alto, CA
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Haas K, Martin A, Park KT. Text Message Intervention (TEACH) Improves Quality of Life and Patient Activation in Celiac Disease: A Randomized Clinical Trial. J Pediatr 2017; 185:62-67.e2. [PMID: 28343658 PMCID: PMC5637528 DOI: 10.1016/j.jpeds.2017.02.062] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [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: 11/14/2016] [Revised: 01/20/2017] [Accepted: 02/23/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the impact of the Text Message Educational Automated Compliance Help (TEACH) text message intervention as a pragmatic approach for patient engagement among adolescents with celiac disease (CD) as measured by gluten-free diet (GFD) adherence, patient activation, and quality of life (QOL). STUDY DESIGN Randomized controlled trial with patient recruitment at a pediatric, university-based hospital and through social media; 61 participants ages 12-24 years with CD diagnosed at least 1 year were enrolled. The TEACH intervention cohort received 45 unique text messages over a 3-month study period while the control group received standard of care treatment. Primary outcome measures included objective markers of GFD adherence included serum tissue transglutaminase IgA and deamidated gliadin peptide IgA levels. Secondary patient-reported outcomes collected via online survey included the Celiac Dietary Adherence Test, National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Global Short Form measure of QOL, Celiac Symptom Index, and Patient Activation Measure. All measures were assessed at enrollment and after the 3-month study period. Statistical analysis performed using the 2-tailed paired Student t test. RESULTS Among the TEACH intervention group, there was significant improvement comparing enrollment scores with 3-month follow-up scores in patient activation (Patient Activation Measure score 63.1 vs 72.5, P?=?.01) and QOL (NIH PROMIS Global Mental Health 50.8 vs 53.3, P?=?.01 and NIH PROMIS Global Physical Health 50.8 vs 57.7, P?=?.03). There was no statistically significant difference in patient-reported or objectively measured GFD adherence. CONCLUSIONS TEACH is an effective intervention among patients with CD to improve patient activation and QOL, even among a cohort with GFD adherence at baseline. TRIAL REGISTRATION ClinicalTrials.gov: NCT02458898.
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Affiliation(s)
- Kelly Haas
- Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Stanford University, Palo Alto, CA.
| | - Andrew Martin
- Center for Clinical Informatics, Stanford University School of Medicine, Stanford University, Palo Alto, CA
| | - KT Park
- Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Stanford University, Palo Alto, CA
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Rodriguez A, Yokomizo L, Christofferson M, Barnes D, Khavari N, Park KT. Correlation of rapid point-of-care vs send-out fecal calprotectin monitoring in pediatric inflammatory bowel disease. World J Gastrointest Pharmacol Ther 2017; 8:127-130. [PMID: 28533922 PMCID: PMC5421111 DOI: 10.4292/wjgpt.v8.i2.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/25/2016] [Accepted: 01/18/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the correlation between the send-out enzyme-linked immuno sorbent assay (ELISA) and the point-of-care (POC) calprotectin test in pediatric inflammatory bowel disease (IBD) patients.
METHODS We prospectively collected stool samples in pediatric IBD patients for concomitant send-out ELISA analysis and POC calprotectin testing using the Quantum Blue® (QB) Extended immunoassay. Continuous results between 17 to 1000 μg/g were considered for comparison. Agreement between the two tests was measured by a Bland-Altman plot and statistical significance was determined using Pitman’s test.
RESULTS Forty-nine stool samples were collected from 31 pediatric IBD patients. The overall means for the rapid and ELISA tests were 580.5 and 522.87 μg/g respectively. Among the 49 samples, 18 (37.5%) had POC calprotectin levels of ≤ 250 μg/g and 31 (62.5%) had levels > 250 μg/g. Calprotectin levels ≤ 250 μg/g show good correlation between the two assays. Less correlation was observed at quantitatively higher calprotectin levels.
CONCLUSION In pediatric IBD patients, there is better correlation of between ELISA and POC calprotectin measurements at clinically meaningful, low-range levels. Future adoption of POC calprotectin testing in the United States may have utility for guiding clinical decision making in real time.
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Affiliation(s)
| | - K T Park
- Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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46
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Park KT, Cox K. Optimizing health outcomes in young children waiting for liver transplantation requires more than bridging geographical distances. Pediatr Transplant 2017; 21. [PMID: 28191753 DOI: 10.1111/petr.12836] [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] [Indexed: 11/29/2022]
Affiliation(s)
- K T Park
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Kenneth Cox
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
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Abstract
PURPOSE OF REVIEW Tremendous acceleration has been made in understanding the gut microbiota in the past decade and, with it, further understanding of the pathologic role of dysbiosis and the use of fecal microbiota transplantation (FMT) as therapy. FMT has been studied in many disease states including the most common indication of Clostridium difficile infection (CDI), though many questions regarding stool donor selection remain. RECENT FINDINGS Though traditionally, one donor has provided stool for one patient, research is underway to explore many donor selection considerations from the use of pooled donor stool to selection of a high diversity donor. It is well-known that dietary intake shapes the gut microbiota and the potential implications of this on FMT donor selection are being explored. Though further high-quality research is needed, optimizing the fecal microbiota inoculum holds great promise.
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Affiliation(s)
- Danielle Barnes
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Naval Medical Center San Diego, San Diego, CA, USA.
| | - K T Park
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Stanford Children's Health, Palo Alto, CA, USA
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Abstract
BACKGROUND The relationship between limited English proficiency (LEP) and worse pediatric health outcomes is well documented. OBJECTIVES To determine the relationship between LEP status and pediatric hospital readmissions. METHODS We performed a retrospective cohort analysis of children ≤ 18 years old admitted to a tertiary children's hospital from 2008 to 2014. The main exposure was LEP status. Independent variables included sex, age, race/ethnicity, insurance, median household income, surgical/medical status, severity of illness (SOI), the presence of a complex chronic condition, and length of stay. Primary outcome measures were 7- and 30-day readmission. RESULTS From 67 473 encounters, 7- and 30-day readmission rates were 3.9% and 8.2%, respectively. LEP patients were more likely to be younger, poorer, and Hispanic; have lower SOI; and government-subsidized insurance. Adjusted odds for 7- or 30-day readmission for LEP versus English-proficient (EP) patients were 1.00 (P = .99) and 0.97 (P = .60), respectively. Hispanic ethnicity (adjusted odds ratio [aOR]: 1.26 [P = .002] and 1.14 [P = .02]), greater SOI (aOR: 1.04 [P < .001] and 1.05 [P < .001]), and the presence of a complex chronic condition (aOR: 2.31 [P < .001] and 3.03 [P < .001]) were associated with increased odds of 7- and 30-day readmission, respectively. White LEP patients had increased odds of 7- and 30-day readmission compared with white EP patients (aOR: 1.46 [P = .006] and 1.32 [P = .007]) and the poorest LEP patients had increased odds of 7- and 30-day readmission compared with the poorest EP patients (aOR: 1.77 [P = .04] and 2.00 [P < .001]). CONCLUSIONS This is the first large study evaluating the relationship between LEP and pediatric hospital readmission. There was no increased risk of readmission in LEP patients compared with EP patients.
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Affiliation(s)
- Mindy Ju
- Divisions of Pediatric Critical Care Medicine and
| | - Nathan Luna
- Divisions of Pediatric Critical Care Medicine and
| | - K T Park
- Pediatric Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Festa N, Park KT, Schwenk H. Anchoring Bias as a Limiting Factor in High-Value Care: A Case of Fever of Unknown Origin in a Hospitalized Child. Hosp Pediatr 2016; 6:699-701. [PMID: 27789539 DOI: 10.1542/hpeds.2016-0027] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Natalia Festa
- Stanford University School of Medicine, Stanford, California; and
| | - K T Park
- Stanford University School of Medicine, Stanford, California; and
- Lucile Packard Children's Hospital, Palo Alto, California
| | - Hayden Schwenk
- Stanford University School of Medicine, Stanford, California; and
- Lucile Packard Children's Hospital, Palo Alto, California
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50
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Butte MJ, Park KT, Lewis DB. Treatment of CGD-associated Colitis with the IL-23 Blocker Ustekinumab. J Clin Immunol 2016; 36:619-20. [PMID: 27465505 DOI: 10.1007/s10875-016-0318-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/13/2016] [Indexed: 01/22/2023]
Affiliation(s)
- Manish J Butte
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University, 300 Pasteur Drive, Grant Building Room H307A, Stanford, CA, 94305, USA.
| | - K T Park
- Division of Gastroenterology, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - David B Lewis
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University, 300 Pasteur Drive, Grant Building Room H307A, Stanford, CA, 94305, USA
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