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Zisman-Ilani Y, Thompson KD, Siegel LS, Mackenzie T, Crate DJ, Korzenik JR, Melmed GY, Kozuch P, Sands BE, Rubin DT, Regueiro MD, Cross R, Wolf DC, Hanson JS, Schwartz RM, Vrabie R, Kreines MD, Scherer T, Dubinsky MC, Siegel CA. Crohn's disease shared decision making intervention leads to more patients choosing combination therapy: a cluster randomised controlled trial. Aliment Pharmacol Ther 2023; 57:205-214. [PMID: 36377259 PMCID: PMC9790033 DOI: 10.1111/apt.17286] [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] [Received: 06/07/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Crohn's disease requires effective patient-clinician communication for successful illness and medication management. Shared decision making (SDM) has been suggested to improve communication around early intensive therapy. However, effective evidence-based SDM interventions for Crohn's disease are lacking, and the impact of SDM on Crohn's disease decision making and choice of therapy is unclear. AIM To test the impact of SDM on choice of therapy, quality of the decision and provider trust compared to standard Crohn's disease care. METHODS We conducted a multi-site cluster randomised controlled trial in 14 diverse gastroenterology practices in the US. RESULTS A total of 158 adult patients with Crohn's disease within 15 years of their diagnosis, with no prior Crohn's disease complications, and who were candidates to receive immunomodulators or biologics, participated in the study. Among these, 99 received the intervention and 59 received standard care. Demographics were similar between groups, although there were more women assigned to standard care, and a slightly shorter disease duration among those in the intervention group. Participants in the intervention group more frequently chose combination therapy (25% versus 5% control, p < 0.001), had a significantly lower decisional conflict (p < 0.05) and had greater trust in their provider (p < 0.05). CONCLUSIONS With rapidly expanding medication choices for Crohn's disease and slow uptake of early intensive therapy, SDM can personalise treatment strategies and has the potential to move the field of Crohn's disease management forward with an ultimate goal of consistently treating this disease early and intensively in appropriate patients. TRIAL REGISTRATION Evaluating a Shared Decision Making Program for Crohn's Disease, ClinicalTrials.gov Identifier NCT02084290 https://clinicaltrials.gov/ct2/show/NCT02084290.
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Affiliation(s)
- Yaara Zisman-Ilani
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, Pennsylvania, USA,Department of Clinical, Educational and Health Psychology, Division of Psychology and Language Sciences, University College London, London, UK
| | - Kimberly D. Thompson
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | - Todd Mackenzie
- Geisel School of Medicine at Dartmouth, Biomedical Data Science, Hanover, New Hampshire, USA
| | - Damara J. Crate
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Joshua R. Korzenik
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Gil Y. Melmed
- Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Patricia Kozuch
- Inflammatory Bowel Disease Program, Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Bruce E. Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - David T. Rubin
- Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, Illinois, USA
| | | | - Raymond Cross
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - John S. Hanson
- Atrium Health Gastroenterology and Hepatology, Charlotte, North Carolina, USA
| | | | - Raluca Vrabie
- Gastroenterology Division, New York University, New York City, New York, USA
| | | | | | - Marla C. Dubinsky
- Department of Pediatrics, Susan and Leonard Feinstein IBD Center, Icahn School of Medicine Mount Sinai, New York City, New York, USA
| | - Corey A. Siegel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Abstract
Intussusception is defined as telescoping of the proximal bowel (intussusceptum) into the lumen of the distal bowel, otherwise called the intussuscipiens. While it is one of the most common causes of intestinal obstruction in children between the ages of 3 months and 6 years, intussusception accounts for about 1% of such cases in adults. Intussusception is idiopathic in 8–20% of patients and most commonly occurs in the small intestines in adults. We describe the unique case of a colo-colonic intussusception in a 54-year-old female patient 1 week after a colonoscopy for suspected inflammatory bowel disease. The discussion focuses on the presentation and management options of intussusception.
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Affiliation(s)
- Harry He
- Department of Medicine, NYU Winthrop University Hospital, Mineola, New York, USA
| | | | - Matthew DeMaria
- Department of Medicine, NYU Winthrop University Hospital, Mineola, New York, USA
| | - Mohammad Ali
- Gastroenterology and Hepatology, Guthrie Cortland Medical Center, Cortland, New York, USA
| | - Raluca Vrabie
- Department of Gastroenterology, NYU Winthrop University Hospital, Mineola, New York, USA
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Patel KS, Benshar O, Vrabie R, Patel A, Adler M, Hines G. A major pain in the … Back and epigastrium: an unusual case of spontaneous celiac artery dissection. J Community Hosp Intern Med Perspect 2014; 4:23840. [PMID: 25432642 PMCID: PMC4246143 DOI: 10.3402/jchimp.v4.23840] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 08/13/2014] [Accepted: 09/11/2014] [Indexed: 11/14/2022] Open
Abstract
A 60-year-old woman with mitral valve prolapse, chronic low back pain, and a 30-pack year smoking history presented for a second admission of poorly controlled mid-back pain 10 days after her first admission. She had concomitant epigastric pain, sharp/burning in quality, radiating to the right side and to the mid-back, not associated with food nor improving with pain medications. She denied nausea, vomiting, diarrhea, constipation, dark stools, or blood per rectum. Our purpose was to determine the cause of the patient's epigastric pain. Physical examination revealed epigastric and mid-back tenderness on palpation. Labs were normal except for a hemoglobin drop from 14 to 12.1 g/dL over 2 days. Abdominal ultrasound and subsequent esophagogastroduodenoscopy were normal. Contrast-enhanced abdominal computed tomographic (CT) scan revealed the development of a spontaneous celiac artery dissection as the cause of the epigastric pain. The patient was observed without stenting and subsequent CT angiography 4 days later did not reveal worsening of the dissection. She was discharged on aspirin and clopidogrel with outpatient follow-up. Thus far, less than 100 cases of isolated spontaneous celiac artery dissections have been reported. The advent of CT scans and magnetic resonance imaging has increasingly enabled its detection. Risk factors may include hypertension, arteriosclerosis, smoking, and cystic medial necrosis. There is a 5:1 male to female ratio with an average presenting age of 55. Management of dissections may include surgical repair, endovascular stenting, and selective embolization. Limited dissections can be managed conservatively with anti-platelet and/or anticoagulation agents and strict blood pressure control, as done in our patient.
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Affiliation(s)
- Kumkum Sarkar Patel
- Department of Internal Medicine, Winthrop-University Hospital, Mineola, NY, USA;
| | - Orel Benshar
- School of Medicine, St. George's University, Great Neck, NY, USA
| | - Raluca Vrabie
- Division of Gastroenterology, Winthrop-University Hospital, Mineola, NY, USA
| | - Anik Patel
- Division of Gastroenterology, Winthrop-University Hospital, Mineola, NY, USA
| | - Marc Adler
- Department of Internal Medicine, Winthrop-University Hospital, Mineola, NY, USA
| | - George Hines
- Department of Vascular Surgery, Winthrop-University Hospital, Mineola, NY, USA
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Vrabie R, Kane S. Noninvasive Markers of Disease Activity in Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2014; 10:576-584. [PMID: 27551251 PMCID: PMC4991533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
It is often difficult to assess disease activity in inflammatory bowel disease (IBD). Noninvasive biomarkers are a means of quantifying often nebulous symptoms without subjecting patients to endoscopy or radiation. This paper highlights markers present in feces, serum, or urine that have all been compared with the gold standard, histologic analysis of endoscopically collected specimens. Two categories of markers are featured: well-researched markers of mucosal inflammation with high sensitivity and specificity (calprotectin, lactoferrin, and S100A12) and novel promising markers, some of which are already clinically employed for reasons unrelated to IBD (interleukin [IL]-17, IL-33/ST2, adenosine deaminase, polymorphonuclear elastase, matrix metalloproteinase-9, neopterin, serum M30, and fecal immunohistochemistry). The data pertaining to the more-established markers are intended to highlight recent clinical applications for these markers (ie, assessing disease outside of the colon or in the pediatric population as well as being a cost-saving alternative to colonoscopy to screen for IBD). As there is no evidence to date that a specific marker will accurately be able to represent the entire IBD patient population, it is likely that a combination of the existing markers will be most clinically relevant to the practicing gastroenterologist attempting to evaluate disease severity in a specific patient. Familiarity with the most promising emerging markers will allow a better understanding of new studies and their impact on patient care.
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Affiliation(s)
- Raluca Vrabie
- Dr Vrabie is an assistant professor of clinical medicine at Stony Brook School of Medicine in Stony Brook, New York and the director of the Center of Inflammatory Bowel Disease at Winthrop University Hospital in Mineola, New York. Dr Kane is a professor of medicine at the Mayo Clinic in Rochester, Minnesota
| | - Sunanda Kane
- Dr Vrabie is an assistant professor of clinical medicine at Stony Brook School of Medicine in Stony Brook, New York and the director of the Center of Inflammatory Bowel Disease at Winthrop University Hospital in Mineola, New York. Dr Kane is a professor of medicine at the Mayo Clinic in Rochester, Minnesota
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Abstract
Stricture formation is a common complication of Crohn’s disease, occurring in approximately one third of all patients with this condition. While the traditional management of such strictures has been largely surgical, there have been case series going back three decades highlighting the potential role of endoscopic balloon dilation in this clinical setting. This review article summarizes the stricture pathogenesis, focusing on known clinical and genetic risk factors. It then highlights the endoscopic balloon dilation research to date, with particular emphasis on three large recent case series. It concludes by describing the literature consensus regarding specific methodology and presenting avenues for future investigations.
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Affiliation(s)
- Raluca Vrabie
- Raluca Vrabie, Gerald L Irwin, David Friedel, Winthrop University Hospital, 259 First Street, Mineola, NY 11501, United States
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Radbill BD, Gupta R, Ramirez MCM, DiFeo A, Martignetti JA, Alvarez CE, Friedman SL, Narla G, Vrabie R, Bowles R, Saiman Y, Bansal MB. Loss of matrix metalloproteinase-2 amplifies murine toxin-induced liver fibrosis by upregulating collagen I expression. Dig Dis Sci 2011; 56:406-16. [PMID: 20563750 PMCID: PMC2964408 DOI: 10.1007/s10620-010-1296-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 05/27/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Matrix metalloproteinase-2 (MMP-2), a type IV collagenase secreted by activated hepatic stellate cells (HSCs), is upregulated in chronic liver disease and is considered a profibrotic mediator due to its proliferative effect on cultured HSCs and ability to degrade normal liver matrix. Although associative studies and cell culture findings suggest that MMP-2 promotes hepatic fibrogenesis, no in vivo model has definitively established a pathologic role for MMP-2 in the development and progression of liver fibrosis. We therefore examined the impact of MMP-2 deficiency on liver fibrosis development during chronic CCl(4) liver injury and explored the effect of MMP-2 deficiency and overexpression on collagen I expression. METHODS Following chronic CCl(4) administration, liver fibrosis was analyzed using Sirius Red staining with quantitative morphometry and real-time polymerase chain reaction (PCR) in MMP-2-/- mice and age-matched MMP-2+/+ controls. These studies were complemented by analyses of cultured human stellate cells. RESULTS MMP-2-/- mice demonstrated an almost twofold increase in fibrosis which was not secondary to significant differences in hepatocellular injury, HSC activation or type I collagenase activity; however, type I collagen messenger RNA (mRNA) expression was increased threefold in the MMP-2-/- group by real-time PCR. Furthermore, targeted reduction of MMP-2 in cultured HSCs using RNA interference significantly increased collagen I mRNA and protein, while overexpression of MMP-2 resulted in decreased collagen I mRNA. CONCLUSIONS These findings suggest that increased MMP-2 during the progression of liver fibrosis may be an important mechanism for inhibiting type I collagen synthesis by activated HSCs, thereby providing a protective rather than pathologic role.
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Affiliation(s)
- Brian D. Radbill
- Division of Nephrology, Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA
| | - Ritu Gupta
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine, 1425 Madison Avenue, Room 11-70, Box 1123, New York, NY 10029, USA
| | - Maria Celeste M. Ramirez
- Departments of Medicine and Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY, USA
| | - Analisa DiFeo
- Departments of Medicine and Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY, USA
| | - John A. Martignetti
- Departments of Medicine and Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY, USA
| | - Carlos E. Alvarez
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine, 1425 Madison Avenue, Room 11-70, Box 1123, New York, NY 10029, USA
| | - Scott L. Friedman
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine, 1425 Madison Avenue, Room 11-70, Box 1123, New York, NY 10029, USA
| | - Goutham Narla
- Departments of Medicine and Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY, USA
| | - Raluca Vrabie
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine, 1425 Madison Avenue, Room 11-70, Box 1123, New York, NY 10029, USA
| | - Robert Bowles
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine, 1425 Madison Avenue, Room 11-70, Box 1123, New York, NY 10029, USA
| | - Yedidya Saiman
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine, 1425 Madison Avenue, Room 11-70, Box 1123, New York, NY 10029, USA
| | - Meena B. Bansal
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine, 1425 Madison Avenue, Room 11-70, Box 1123, New York, NY 10029, USA
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Vrabie R, Aberra FN. Prescribing an antibiotic? Do not forget the probiotic. Gastroenterology 2009; 137:1846-7. [PMID: 19789082 DOI: 10.1053/j.gastro.2009.09.035] [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: 12/02/2022]
Affiliation(s)
- Raluca Vrabie
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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