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García MJ, Riestra S, Amiot A, Julsgaard M, García de la Filia I, Calafat M, Aguas M, de la Peña L, Roig C, Caballol B, Casanova MJ, Farkas K, Boysen T, Bujanda L, Cuarán C, Dobru D, Fousekis F, Gargallo-Puyuelo CJ, Savarino E, Calvet X, Huguet JM, Kupcinskas L, López-Cardona J, Raine T, van Oostrom J, Gisbert JP, Chaparro M. Effectiveness and safety of a third-line rescue treatment for acute severe ulcerative colitis refractory to infliximab or ciclosporin (REASUC study). Aliment Pharmacol Ther 2024; 59:1248-1259. [PMID: 38445785 DOI: 10.1111/apt.17938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/03/2024] [Accepted: 02/24/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND The advent of new therapeutic agents and the improvement of supporting care might change the management of acute severe ulcerative colitis (ASUC) and avoid colectomy. AIMS To evaluate the colectomy-free survival and safety of a third-line treatment in patients with ASUC refractory to intravenous steroids and who failed either infliximab or ciclosporin. METHODS Multicentre retrospective cohort study of patients with ASUC refractory to intravenous steroids who had failed infliximab or ciclosporin and received a third-line treatment during the same hospitalisation. Patients who stopped second-line treatment due to disease activity or adverse events (AEs) were eligible. We assessed short-term colectomy-free survival by logistic regression analysis. Kaplan-Meier curves and Cox regression models were used for long-term assessment. RESULTS Among 78 patients, 32 received infliximab and 46 ciclosporin as second-line rescue treatment. Third-line treatment was infliximab in 45 (58%), ciclosporin in 17 (22%), tofacitinib in 13 (17%) and ustekinumab in 3 (3.8%). Colectomy was performed in 29 patients (37%) during follow-up (median 21 weeks). Of the 78 patients, 32 and 18 were in clinical remission at, respectively, 12 and 52 weeks. At the last visit, 25 patients were still on third-line rescue treatment, while 12 had stopped it due to clinical remission. AEs were reported in 26 (33%) patients. Two patients died (2.6%), including one following colectomy. CONCLUSION Third-line rescue treatment avoided colectomy in over half of the patients with ASUC and may be considered a therapeutic strategy.
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Affiliation(s)
- María José García
- Gastroenterology and Hepatology Department, Hospital Universitario Marqués de Valdecilla, Grupo de Investigación Clínica y Traslacional en Enfermedades Digestivas, Instituto de Investigación Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain
| | - Sabino Riestra
- Gastroenterology Department, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Aurelien Amiot
- Department of Gastroenterology, CHU Bicêtre, Universite Paris Saclay, Paris, France
| | - Mette Julsgaard
- Department of Gastroenterology and Hepatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease [PREDICT], Aalborg University, Copenhagen, Denmark
| | | | - Margalida Calafat
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Mariam Aguas
- Gastroenterology Department, La Fe University and Polytechnic Hospital, Health Research Institute La Fe, Valencia, Spain
| | - Luisa de la Peña
- Gastroenterology Department, Bellvitge University Hospital, Barcelona, Spain
| | - Cristina Roig
- Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Berta Caballol
- Gastroenterology Department, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - María José Casanova
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Klaudia Farkas
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - Trine Boysen
- 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
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Luis Bujanda
- Department of Gastroenterology, Biodonostia Health Research Institute, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Universidad del País Vasco (UPV/EHU), San Sebastián, Spain
| | - Camila Cuarán
- Gastroenterology Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Daniela Dobru
- Gastroenterology Department, University of Medicine and Pharmacy, Science and Tehnology "G E Palade" Tg.Mures, Târgu-Mureș, Romania
| | - Fotios Fousekis
- Department of Gastroenterology, University Hospital of Ioannina, Ioannina, Greece
| | - Carla Jerusalén Gargallo-Puyuelo
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Gastroenterology Unit, Azienda Ospedale Università di Padova (AOUP), University of Padua, Padua, Italy
| | - Xavier Calvet
- Gastroenterology Department, Servei d'Aparell Digestiu, Parc Taulí, Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí, Departamento de Medicina, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Sabadell, Spain
| | - José María Huguet
- Digestive Diseases Department, General University Hospital of Valencia, Valencia, Spain
| | - Limas Kupcinskas
- Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joep van Oostrom
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Javier P Gisbert
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - María Chaparro
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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Barber GE, Zhuo J, Okafor PN, Streett S. Gastroenterology Clinic Follow-Up Reduces Gastroenterology-Specific Readmissions Among Patients With Severe Ulcerative Colitis. Inflamm Bowel Dis 2023:izad207. [PMID: 37738588 DOI: 10.1093/ibd/izad207] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND AIMS Readmission within 30 days occurs in up to 18% of admitted patients with ulcerative colitis (UC). The importance of postdischarge follow-up with a gastroenterologist as well as the optimal follow-up interval is unknown. METHODS We conducted a retrospective cohort study of patients with UC who were admitted to Stanford University Hospital between 2010 and 2020. We included adult patients with UC who were admitted for a UC flare. Patients with a colectomy during hospitalization or with Clostridium difficile infection at the index hospitalization were excluded. The primary outcome was time to readmission for a gastroenterology (GI) indication, and the primary predictor (time dependent) was follow-up with a GI provider. Patients were followed for 180 days after discharge. Data were analyzed using a Cox proportional hazards model. RESULTS Of the 223 patients hospitalized with UC during the study period, 25% (n = 57) were readmitted within 180 days, with 13.9% occurring within 30 days. Early follow-up (within 7 days) was observed in 29% (n = 65) of patients, while 30-day follow-up was seen in 68.7% (n = 153), and follow-up within 180 days was seen in 198 (89%) patients. In the adjusted Cox proportional hazards model, GI follow-up was associated with fewer readmissions (hazard ratio, 0.42; 95% confidence interval, 0.22-0.81; P = .009). Early follow-up was strongly associated with a reduced risk of readmission (hazard ratio, 0.24; 95% 95% confidence interval, 0.09-0.69; P = .008). Follow-up in 7 days was associated with fewer readmissions (P < .0001). CONCLUSIONS Outpatient GI follow-up after UC hospitalization reduces readmissions, with the greatest reduction occurring among patients followed up within 1 week of discharge.
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Affiliation(s)
- Grant E Barber
- Department of Gastroenterology and Hepatology, Stanford University, Redwood City, CA, USA
| | - Justin Zhuo
- Department of Gastroenterology and Hepatology, Rutgers University, Newark, NJ, USA
| | - Philip N Okafor
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Sarah Streett
- Department of Gastroenterology and Hepatology, Stanford University, Redwood City, CA, USA
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Inflammatory bowel disease and COVID-19 outcomes: a meta-analysis. Sci Rep 2022; 12:21333. [PMID: 36494448 PMCID: PMC9734125 DOI: 10.1038/s41598-022-25429-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Abstract
There is conflicting evidence concerning the effect of inflammatory bowel disease (IBD) on COVID-19 incidence and outcome. Hence, we aimed to evaluate the published evidence through a systematic review process and perform a meta-analysis to assess the association between IBD and COVID-19. A compressive literature search was performed in PubMed/Medline, Scopus, Embase, and Cochrane Library from inception to July 2021. A snowball search in Google, Google Scholar, Research Gate, and MedRxiv; and bibliographic research were also performed to identify any other relevant articles. Quantitative observational studies such as cohort, cross-sectional, and case-control studies that assessed the incidence, risk, and outcomes of COVID-19 among the adult IBD patients published in the English language, were considered for this review. The incidence and risk of COVID-19, COVID-19 hospitalization, the severity of COVID-19, and mortality were considered as the outcomes of interest. The Joanna Briggs Institute critical appraisal checklist was used for quality assessment. A subgroup and sensitivity analysis were performed to explore the heterogeneity and robustness of the results, respectively. A total of 86 studies out of 2828 non-duplicate records were considered for this meta-analysis. The studies were single or multicentric internationally from settings such as IBD centres, medical colleges, hospitals, or from the general public. Most of the studies were observed to be of good quality with an acceptable risk of bias. The pooled prevalence of COVID-19, COVID-19 hospitalization, severe COVID-19, and mortality in the IBD population were 6.10%, 10.63%, 40.43%, and 1.94%, respectively. IBD was not significantly (p > 0.05) associated with the risk of COVID-19, COVID-19 hospitalization, severe COVID-19, and mortality. In contrast, ulcerative colitis was significantly associated with a higher risk of COVID-19 (OR 1.37; p = 0.01), COVID-19 hospitalization (OR 1.28; p < 0.00001), and severe COVID-19 (OR 2.45; p < 0.0007). Crohn's disease was significantly associated with a lesser risk of severe COVID-19 (OR 0.48; p = 0.02). Type of IBD was a potential factor that might have contributed to the higher level of heterogeneity. There was a significant association between ulcerative colitis and increased risk of COVID-19, COVID-19 hospitalization, and severe COVID-19 infection. This association was not observed in patients with Crohns' disease or in those diagnosed non-specifically as IBD.
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Chen L, Liu D, Mao M, Liu W, Wang Y, Liang Y, Cao W, Zhong X. Betaine ameliorates acute sever ulcerative colitis by inhibiting oxidative stress induced inflammatory pyroptosis. Mol Nutr Food Res 2022; 66:e2200341. [PMID: 36069237 DOI: 10.1002/mnfr.202200341] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/13/2022] [Indexed: 11/10/2022]
Abstract
SCOPE Betaine rich in beet is used as an important source of human nutrition. Here we aimed to explore whether betaine supplementation can protect against acute sever ulcerative colitis (ASUC) and the underlying mechanism METHODS AND RESULTS: : ASUC model was induced by dextran sulfate sodium (DSS), and effects of betaine as a methyl donor on ASUC were evaluated. Betaine mitigated the changes, e.g., elevated DAI, weight lose, spleen enlargement, colon shortening and disordered colonic mucosa. We then verified the protective effects of betaine on colonic barrier integrity in ASUC through examining tight junction proteins by western blot and immunofluorescence. Spectrophotometry method and western blot confirmed that betaine can decrease levels of oxidative markers (MDA, MPO, NOS and COX2), and promote expressions of antioxidant proteins (GSH, NRF2, CAT and SOD1). Further, betaine prevented colonic inflammatory pyroptosis by blocking expressions of NLRP3 inflammasome complex (NLRP3, ASC and cleaved-caspase 1), N terminal-GSDMD, and release of relevant inflammatory factors. CONCLUSION Betaine inhibits colonic oxidative stress induced inflammatory pyroptosis to alleviate ASUC, which shows therapeutic potential against colitis and other acute inflammatory disorder. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ling Chen
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Dandan Liu
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Mingli Mao
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Wenjia Liu
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Yajuan Wang
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Yue Liang
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Wenyu Cao
- Clinical Anatomy & Reproductive Medicine Application Institute, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Xiaolin Zhong
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
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Dulai PS, Rai V, Raffals LE, Lukin D, Hudesman D, Kochhar GS, Damas OM, Sauk JS, Levy AN, Sofia MA, Tuskey A, Deepak P, Yarur AJ, Afzali A, Ananthakrishnan AN, Cross RK, Hanauer SB, Siegel CA. Recommendations on the Appropriate Management of Steroids and Discharge Planning During and After Hospital Admission for Moderate-Severe Ulcerative Colitis: Results of a RAND Appropriateness Panel. Am J Gastroenterol 2022; 117:1288-1295. [PMID: 35416799 PMCID: PMC9437635 DOI: 10.14309/ajg.0000000000001775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/04/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Limited guidance exists for the postdischarge care of patients with ulcerative colitis hospitalized for moderate-severe flares. METHODS RAND methodology was used to establish appropriateness of inpatient and postdischarge steroid dosing, discharge criteria, follow-up, and postdischarge biologic or small molecule initiation. A literature review informed on the panel's voting, which occurred anonymously during 2 rounds before and after a moderated virtual session. RESULTS Methylprednisolone 40-60 mg intravenous every 24 hours or hydrocortisone 100 mg intravenous 3 times daily is appropriate for inpatient management, with methylprednisolone 40 mg being appropriate if intolerant of higher doses. It is appropriate to discharge patients once rectal bleeding has resolved (Mayo subscore 0-1) and/or stool frequency has returned to baseline frequency and form (Mayo subscore 0-1). It is appropriate to discharge patients on 40 mg of prednisone after observing patients for 24 hours in hospital to ensure stability before discharge. For patients being discharged on steroids without in-hospital biologic or small molecule therapy initiation, it is appropriate to start antitumor necrosis factor (TNF) therapy after discharge for anti-TNF-naive patients. For anti-TNF-exposed patients, it is appropriate to start vedolizumab or ustekinumab for all patients and tofacitinib for those with a low risk of adverse events. It is appropriate to follow up patients clinically within 2 weeks and with lower endoscopy within 4-6 months after discharge. DISCUSSION We provide recommendations on the inpatient and postdischarge management of patients with ulcerative colitis hospitalized for moderate-severe flares.
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Affiliation(s)
- Parambir S Dulai
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Victoria Rai
- Department of Cellular and Molecular Physiology, Yale University, New Haven, Connecticut, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dana Lukin
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - David Hudesman
- Division of Gastroenterology and Hepatology, New York University, New York, New York, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology and Hepatology, Alleghany Health, Pittsburgh, Pennsylvania, USA
| | - Oriana M Damas
- Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jenny S Sauk
- Division of Gastroenterology and Hepatology, University of California Los Angeles, Los Angeles, California, USA
| | - Alexander N Levy
- Division of Gastroenterology and Hepatology, Tufts Medical Center, Boston, Massachusetts, USA
| | - M Anthony Sofia
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Anne Tuskey
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Parakkal Deepak
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Andres J Yarur
- Division of Gastroenterology and Hepatology, Wisconsin University, Milwaukee, Wisconsin, USA
| | - Anita Afzali
- Division of Gastroenterology and Hepatology, Ohio State University, Columbus, Ohio, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Stephen B Hanauer
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Hone Lopez S, Jalving M, Fehrmann RS, Nagengast WB, de Vries EG, de Haan JJ. The gut wall’s potential as a partner for precision oncology in immune checkpoint treatment. Cancer Treat Rev 2022; 107:102406. [DOI: 10.1016/j.ctrv.2022.102406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/29/2022] [Accepted: 05/01/2022] [Indexed: 11/02/2022]
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Caplan A, McConnell R, Velayos F, Mahadevan U, Lewin S. Delayed Initiation of Rescue Therapy Associated with Increased Length of Stay in Acute Severe Ulcerative Colitis. Dig Dis Sci 2022; 67:5455-5461. [PMID: 35389167 PMCID: PMC9652198 DOI: 10.1007/s10620-022-07490-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/16/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reducing hospitalization length of stay (LOS) for acute severe ulcerative colitis (ASUC) will reduce healthcare costs, mitigate hospitalization-associated risks (e.g., venous thromboembolism), and improve quality of life. METHODS A chart review was performed of all adult ASUC-related hospitalizations at University of California, San Francisco, from July 1, 2014, to December 31, 2017. Univariate and multivariate analyses were performed to identify factors associated with LOS < 7 days versus ≥ 7 days. A subgroup analysis was performed excluding patients who underwent colectomy during hospitalization. RESULTS A total of 95 ASUC-related hospitalizations were identified. The initial univariable analysis identified the following factors associated with LOS ≥ 7 days (P < 0.05): higher maximum heart rate in the first 24 h, higher C-reactive protein, being biologic therapy naïve, and a later hospital day of biologic therapy initiation. On mixed model multivariable analysis, later hospital day of biologic initiation was associated with increased LOS ≥ 7 days (OR 3.1 95% CI 1.2-7.56, p = 0.012). CONCLUSIONS We identified multiple predictors for longer hospital LOS, including factors related to disease severity (non-modifiable) and treatment (potentially modifiable). Importantly, this study identified biologic naïve treatment status and delayed inpatient biologic therapy initiation as predictors of longer LOS (≥ 7 days) in patients who did not ultimately require colectomy during their hospital stay. Potentially modifiable strategies to reduce LOS may include early communication and patient education about biologic therapy in both the inpatient and outpatient setting.
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Affiliation(s)
- Alyssa Caplan
- Division of Gastroenterology, University of California, 513 Parnassus Avenue S-357, San Francisco, CA 94143 USA
| | | | | | - Uma Mahadevan
- Division of Gastroenterology, University of California, 513 Parnassus Avenue S-357, San Francisco, CA 94143 USA
| | - Sara Lewin
- Division of Gastroenterology, University of California, 513 Parnassus Avenue S-357, San Francisco, CA 94143 USA
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8
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Racial differences in the outcomes of IBD hospitalizations: a national population-based study. Int J Colorectal Dis 2022; 37:221-229. [PMID: 34694440 DOI: 10.1007/s00384-021-04052-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE There are scarce data describing the outcomes of hospitalized patients admitted with inflammatory bowel disease (IBD) stratified by race. In this retrospective cohort study, we evaluated the difference in outcomes between adult white and black patients hospitalized with a principal diagnosis of inflammatory bowel disease. METHODS Data were obtained from the 2016 and 2017 National Inpatient Sample (NIS) database. Our primary outcome was inpatient mortality while the secondary outcomes were hospital length of stay (LOS), total hospital charges (THC), red blood cell (RBC) transfusion, diagnosis of bowel perforation, and severe sepsis with septic shock. We conducted the analysis using STATA software. We used propensity-matched multivariate regression analysis to adjust for potential confounders. RESULTS Among 71 million hospital hospitalizations, we found 177,574 hospitalizations with a principal diagnosis of IBD, with 24,635 (13.9%) for black patients, 124,899 (70.3%) for white patients, and 28,040 (15.8%) were for others. There was no significant difference in inpatient mortality for black vs white patients. Among secondary outcomes, white compared to black patients had increased odds of having a diagnosis of bowel perforation when admitted with a diagnosis of IBD while there was no difference in the odds of developing septic shock. White patients admitted with a diagnosis of UC were also found to have increased total LOS and THC. CONCLUSION White patients hospitalized with a principal diagnosis of IBD had no difference in inpatient mortality or septic shock but had worse outcomes such as increased odds of bowel perforation compared to black patients.
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Weissman S, Sharma, S, Fung BM, Aziz M, Sciarra M, Swaminath A, Feuerstein JD. Increased Mortality and Healthcare Costs Upon Hospital Readmissions of Ulcerative Colitis Flares: A Large Population-Based Cohort Study. CROHN'S & COLITIS 360 2021; 3:otab029. [PMID: 36776672 PMCID: PMC9802231 DOI: 10.1093/crocol/otab029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Indexed: 12/15/2022] Open
Abstract
Background Ulcerative colitis (UC) flares often result in prolonged hospitalization and considerable mortality. Nevertheless, large-scale analyses evaluating the frequency and characteristics of hospital readmissions for UC remain limited. We aimed to examine these clinical outcomes in a nationwide cohort of patients hospitalized with UC. Methods We queried the 2017 Nationwide Readmission Database using ICD-10-CM codes to identify all adult patients admitted for UC. Outcomes including mortality, readmission rates, predictors of readmission and mortality, and healthcare usage were assessed. Multivariate analysis was used to adjust for potential confounders. Results From the 31,063 patients hospitalized for UC, 17.38% were readmitted within 30 days and 28.51% in 90 days. UC accounted for 28.17% and 29.82% of readmissions at 30 and 90 days, respectively. Compared to index admission, 30- and 90-day readmissions were characterized by significantly higher mortality (0.42% vs 1.99% and 1.65%, respectively), longer hospital stays (5.05 vs 6.62 and 6.04 days, respectively), and increased hospital cost ($49,999 vs $62,288 and $59,698, respectively) (all P < 0.01). Numerous factors, including chronic steroid use [hazard ratio (HR) 1.35] and opioid use (HR 1.6, were independently associated with increased 30-day readmission (P < 0.01). Numerous factors, including anxiety (HR 1.21) and venous thromboembolism (HR 5.39), were independently associated with increased 30-day mortality (P < 0.01). Conclusions In a large cohort of patients hospitalized for UC, we found that readmission is associated with higher mortality and more lengthy/costly admissions. Additionally, we found independent associations for readmission and mortality that may help identify patients who can benefit from close postdischarge follow-up.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, New Jersey, USA,Address correspondence to: Simcha Weissman, DO, Department of Medicine, Hackensack Meridian Health Palisades Medical Center, 7600 River Road, North Bergen, NJ 07047, USA ()
| | - Sachit Sharma,
- Department of Medicine, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Brian M Fung
- Division of Gastroenterology and Hepatology, University of Arizona College of Medicine—Phoenix, Phoenix, Arizona, USA
| | - Muhammad Aziz
- Division of Gastroenterology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Michael Sciarra
- Department of Gastroenterology and Hepatology, Hackensack Meridian Health Palisades Medical Center, North Bergen, New Jersey, USA
| | - Arun Swaminath
- Division of Gastroenterology, Inflammatory Bowel Disease Program, Lenox Hill Hospital, New York, New York, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Barberio B, Black CJ, Savarino EV, Ford AC. Ciclosporin or Infliximab as Rescue Therapy in Acute Glucorticosteroid-Refractory Ulcerative Colitis: Systematic Review and Network Meta-Analysis. J Crohns Colitis 2021; 15:733-741. [PMID: 33175102 DOI: 10.1093/ecco-jcc/jjaa226] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite randomized controlled trials [RCTs] and trial-based meta-analyses, the optimal rescue therapy for patients with acute glucorticosteroid-refractory ulcerative colitis [UC], to avoid colectomy and improve long-term outcomes, remains unclear. We conducted a network meta-analysis examining this issue. METHODS We searched MEDLINE, EMBASE, EMBASE Classic and the Cochrane central register up to June 2020. We included RCTs comparing ciclosporin and infliximab, either with each other or with placebo, in patients with glucorticosteroid-refractory UC. RESULTS We identified seven RCTs containing 534 patients [415 in head-to-head trials of ciclosporin vs infliximab]. Risk of colectomy at ≤ 1 month was reduced significantly with both treatments, compared with placebo (relative risk [RR] of colectomy with infliximab vs placebo = 0.37; 95% confidence interval [CI] 0.21-0.65, RR with ciclosporin vs placebo = 0.40; 95% CI 0.21-0.77). In terms of colectomy between > 1 month and < 1 year, both drugs ranked equally [P-score 0.75]. Neither treatment was more effective than placebo in reducing the risk of colectomy at ≥ 1 year. Both ciclosporin and infliximab were significantly more efficacious than placebo in achieving a response. Neither treatment was more effective than placebo in inducing remission, nor more likely to cause serious adverse events than placebo. CONCLUSIONS Both ciclosporin and infliximab were superior to placebo in terms of response to therapy and avoiding colectomy up to 1 year, with no significant differences in efficacy or safety between the two. Ciclosporin remains a valid option to treat refractory UC patients, especially those who do not respond to previous treatment with infliximab, or as a bridge to other biological therapies.
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Affiliation(s)
- Brigida Barberio
- Department of Surgery, Oncology and Gastroenterology (DISCOG), Gastroenterology Unit, University of Padova-Azienda Ospedaliera di Padova, Padova, Italy
| | - Christopher J Black
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology (DISCOG), Gastroenterology Unit, University of Padova-Azienda Ospedaliera di Padova, Padova, Italy
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
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11
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Feuerstein J. Hospital Management of Acute Severe Ulcerative Colitis. Gastroenterol Hepatol (N Y) 2021; 17:128-131. [PMID: 34035772 PMCID: PMC8132715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Joseph Feuerstein
- Associate Clinical Chief, Gastroenterology Center for Inflammatory Bowel Disease Associate Professor of Medicine, Harvard Medical School Beth Israel Deaconess Medical Center Boston, Massachusetts
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12
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Lewin S, Velayos FS. Day-by-Day Management of the Inpatient With Moderate to Severe Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2020; 16:449-457. [PMID: 34035752 PMCID: PMC8132655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Hospitalization for inflammatory bowel disease is common and requires coordination of care. The goals of hospitalization are to markedly improve symptoms, transition management to an outpatient regimen, and prevent complications. Initially, providers should determine the phenotype and severity of disease flare and provide optimal medical salvage therapy for induction of disease remission. In addition, complications of Crohn's disease and ulcerative colitis should be addressed with testing for Clostridioides difficile and cytomegalovirus infections and pharmacologic venous thromboembolism prophylaxis, and early enteral feeding should be encouraged to optimize nutritional status. A standardized daily assessment to determine response to treatment should be performed. Objective measures of response to disease treatment that are measured within 3 to 4 days of hospitalization can predict which patients will benefit from either second-line rescue therapy or surgical intervention. These same measures can be used to determine readiness for hospital discharge. Safe discharge can be optimized with thorough patient education and a comprehensive outpatient follow-up plan.
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Affiliation(s)
- Sara Lewin
- Division of Gastroenterology; University of California, San Francisco; San Francisco, California
| | - Fernando S. Velayos
- Department of Gastroenterology and Hepatology, Kaiser Permanente Medical Group, San Francisco, California
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13
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2020; 63:1028-1052. [PMID: 32692069 DOI: 10.1097/dcr.0000000000001716] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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14
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Kotwani P, Terdiman J, Lewin S. Tofacitinib for Rescue Therapy in Acute Severe Ulcerative Colitis: A Real-world Experience. J Crohns Colitis 2020; 14:1026-1028. [PMID: 32020189 DOI: 10.1093/ecco-jcc/jjaa018] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute severe ulcerative colitis is a high stakes event with significant numbers still requiring emergent colectomy, representing a need to establish alternative medical management options. We report a case series of tofacitinib as rescue therapy in biologic-experienced patients with acute severe ulcerative colitis. METHODS Four patients were identified over a 1-year period at our institution who initiated tofacitinib for acute severe ulcerative colitis. All four had previously failed at least two biologics, including infliximab, and were failing high-dose oral prednisone therapy before admission. All patients had Mayo disease activity index of at least 10 at admission. After no significant improvement despite receiving a minimum of 3 days of intravenous methylprednisolone and based on elevated Ho and Travis indices at Day 3, patients were offered rescue tofacitinib for induction of remission, or colectomy. Standard induction of tofacitinib was used [10 mg twice daily], and one patient was escalated to 15 mg twice daily after inadequate response. RESULTS All patients experienced improvement in objective symptoms and laboratory markers, and were discharged without colectomy on tofacitinib as maintenance therapy and prednisone taper; 30-day and 90-day colectomy rates on tofacitinib maintenance therapy were zero and 90-day readmission rate was also zero. Two of four patients achieved steroid-free remission on maintenance tofacitinib monotherapy based on clinical symptoms and follow-up endoscopy. No major adverse reaction was reported during induction or maintenance therapy. CONCLUSIONS Tofacitinib may be an acceptable rescue agent in biologic-experienced patients with acute severe ulcerative colitis. Tofacitinib may also be safely continued as maintenance therapy once remission has been achieved.
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Affiliation(s)
- Prashant Kotwani
- University of California San Francisco, Department of Medicine, Division of Gastroenterology, San Francisco, CA, USA
| | - Jonathan Terdiman
- University of California San Francisco, Department of Medicine, Division of Gastroenterology, San Francisco, CA, USA
| | - Sara Lewin
- University of California San Francisco, Department of Medicine, Division of Gastroenterology, San Francisco, CA, USA
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15
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Grossberg LB, Pellish RS, Cheifetz AS, Feuerstein JD. Review of Societal Recommendations Regarding Management of Patients With Inflammatory Bowel Disease During the SARS-CoV-2 Pandemic. Inflamm Bowel Dis 2020; 27:940-946. [PMID: 32619010 PMCID: PMC7337829 DOI: 10.1093/ibd/izaa174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Laurie B Grossberg
- Lahey Hospital and Medical Center, Tufts Medical School, Burlington, Massachusetts
- Address correspondence to: Laurie B. Grossberg, MD, 41 Mall Road, Burlington, MA, 01805 ()
| | - Randall S Pellish
- Lahey Hospital and Medical Center, Tufts Medical School, Burlington, Massachusetts
| | - Adam S Cheifetz
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Joseph D Feuerstein
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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16
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The management of the hospitalized ulcerative colitis patient: the medical-surgical conundrum. Curr Opin Gastroenterol 2020; 36:265-276. [PMID: 32487850 DOI: 10.1097/mog.0000000000000637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW In this review article, we address emerging evidence for the medical and surgical treatment of the hospitalized patient with ulcerative colitis. RECENT FINDINGS Ulcerative colitis is a chronic inflammatory disease involving the colon and rectum. About one-fifth of patients will be hospitalized from ulcerative colitis, and about 20-30%, experiencing an acute flare will undergo colectomy. Because of the significant clinical consequences, patients hospitalized need prompt evaluation for potential complications, stratification of disease severity, and a multidisciplinary team approach to therapy, which involves both the gastroenterologist and surgeon. Although corticosteroids remain first-line therapy, second-line medical rescue options, primarily infliximab or cyclosporine, are considered within 3-5 days of presentation. In conjunction, an early surgical consultation to present the possibility of a staged proctocolectomy as one of the therapeutic options is equally important. SUMMARY A coordinated multidisciplinary, individualized approach to treatment, involving the patient preferences throughout the process, is optimal in providing patient-centered effective care.
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Bouguen G, Huguet A, Amiot A, Viennot S, Cholet F, Nachury M, Flamant M, Reimund JM, Desfourneaux V, Boureille A, Siproudhis L. Efficacy and Safety of Tumor Necrosis Factor Antagonists in Treatment of Internal Fistulizing Crohn's Disease. Clin Gastroenterol Hepatol 2020; 18:628-636. [PMID: 31128337 DOI: 10.1016/j.cgh.2019.05.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/01/2019] [Accepted: 05/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Few data are available on the effects of tumor necrosis factor (TNF) antagonist therapy for patients with internal fistulizing Crohn's disease (CD) and there is debate regarding the risk of abscess. We aimed to assess the long-term efficacy and safety of anti-TNF therapy for patients with internal fistulas. METHODS We performed a retrospective study of data collected from the Groupe d'Etude Thérapeutique des Affections Inflammatoires Digestives trial, from January 1, 2000, through December 31, 2017. Our final analysis included 156 patients who began treatment with an anti-TNF agent for CD with internal fistula (83 men; median disease duration, 4.9 y). The primary end point was the onset of a major abdominal surgery. Secondary analysis included disappearance of the fistula tract during follow-up evaluation and safety. The Kaplan-Meier method was used for statistical analysis. RESULTS After a median follow-up period of 3.5 years, 68 patients (43.6%) underwent a major abdominal surgery. The cumulative probabilities for being surgery-free were 83%, 64%, and 51% at 1, 3, and 5 years, respectively. A concentration of C-reactive protein >18 mg/L, an albumin concentration <36 g/L, the presence of an abscess at the fistula diagnosis, and the presence of a stricture were associated independently with the need for surgery. The cumulative probabilities of fistula healing, based on imaging analyses, were 15.4%, 32.3%, and 43.9% at 1, 3, and 5 years, respectively. Thirty-two patients (20.5%) developed an intestinal abscess and 4 patients died from malignancies (3 intestinal adenocarcinomas). One patient died from septic shock 3 months after initiation of anti-TNF therapy. CONCLUSIONS In a retrospective analysis of data from a large clinical trial, we found that anti-TNF therapy delays or prevents surgery for almost half of patients with CD and luminal fistulas. However, anti-TNF therapy might increase the risk for sepsis-related death or gastrointestinal malignancies.
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Affiliation(s)
- Guillaume Bouguen
- Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris Rennes, University Rennes, Rennes, France; INSERM, CIC1414, Institut Nutrition Metabolisms and Cancer, Rennes, France.
| | - Audrey Huguet
- Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris Rennes, University Rennes, Rennes, France
| | - Aurélien Amiot
- Department of Gastroenterology, Henri Mondor Hospital, APHP, EC2M3-EA 7375, Université Paris-Est Créteil (UPEC) Val de Marne University, Creteil, France
| | - Stéphanie Viennot
- Hépato-Gastro-Entérologie et Nutrition, Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris de Caen, Caen, France
| | - Franck Cholet
- Centre Hospitalier Universitaire Brest, Service d'Hépato-gastro-entérologie, Brest, France
| | - Maria Nachury
- Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris Lille, University of Lille 2, Inserm Unit 995, Lille, France
| | - Mathurin Flamant
- Clinique Jules Verne, Institut des Maladies de l'Appareil Digestif, Hotel Dieu, Nantes, France
| | - Jean-Marie Reimund
- Hôpitaux Universitaires de Strasbourg (Hôpital de Hautepierre), INSERM U1113 Interface de Recherche Fondamentale et Appliquée en Cancérologie, Université de Strasbourg, Strasbourg, France
| | - Véronique Desfourneaux
- Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris Rennes, University Rennes, Rennes, France
| | - Arnaud Boureille
- Inserm, U1235, University Nantes, Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris de Nantes, Institut des Maladies de l'Appareil Digestif, Hotel Dieu, Nantes, France
| | - Laurent Siproudhis
- Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris Rennes, University Rennes, Rennes, France; INSERM, CIC1414, Institut Nutrition Metabolisms and Cancer, Rennes, France
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18
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Persaud A, Patel P, Motlaghzadeh Y, Ahlawat S. The weekend effect does not influence management of inflammatory bowel disease. JGH Open 2020; 4:44-48. [PMID: 32055696 PMCID: PMC7008161 DOI: 10.1002/jgh3.12205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/11/2019] [Accepted: 05/04/2019] [Indexed: 11/12/2022]
Abstract
Background The weekend effect describes worsened outcomes due to perceived inefficiency occurring over the weekend. This effect has not been studied in inflammatory bowel disease (IBD) despite increasing prevalence in the community. Therefore, our aim is to assess differences in the outcomes of weekend versus weekday management of IBD exacerbations. Methods The National Inpatient Sample database comprises approximately 20% of admissions to nonfederal hospitals in the United States. Complications requiring hospitalization (“flares”) were the criteria upon which patient selection was based. A total of 193, 848 flares were identified from 2008 to 2014 using the International Classification of Diseases 9th edition codes. Differences in time to first procedure, length of stay (LOS), and cost were evaluated for patients with flares between weekend and weekday admissions. Results The time to first procedure was 3.33 days on weekends versus 3.19 days on weekdays (P < 0.001). The mean LOS was shorter when admissions occurred on weekends versus weekdays (8.01 days vs 8.22 days, P < 0.001). Finally, the cost of hospitalization was higher for weekday admissions versus weekend admissions ($18 072 vs $17 495, P < 0.001). Conclusion Our results showed a similar LOS and cost associated with the management of exacerbations on the weekend compared to weekdays. While many high‐risk conditions exhibit increased mortality and prolonged hospital course over the weekend, this phenomenon does not appear to affect IBD. These findings indicate efficient patient care on the weekend and can be utilized for logistical purposes such as resource allocation and procedure scheduling in the endoscopy suite.
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Affiliation(s)
- Alana Persaud
- Division of MedicineRutgers New Jersey Medical School Newark New Jersey USA
| | - Pavan Patel
- Division of Gastroenterology and HepatologyRutgers New Jersey Medical School Newark New Jersey USA
| | | | - Sushil Ahlawat
- Division of Gastroenterology and HepatologyRutgers New Jersey Medical School Newark New Jersey USA
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19
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Lewin SM, McConnell RA, Patel R, Sharpton SR, Velayos F, Mahadevan U. Improving the Quality of Inpatient Ulcerative Colitis Management: Promoting Evidence-Based Practice and Reducing Care Variation With an Inpatient Protocol. Inflamm Bowel Dis 2019; 25:1822-1827. [PMID: 30980712 DOI: 10.1093/ibd/izz066] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hospitalization for ulcerative colitis is a high-risk period associated with increased risk of Clostridium difficile infection, thromboembolism, and opiate use. The study aim was to develop and implement a quality-improvement intervention for inpatient ulcerative colitis management that standardizes gastroenterology consultant recommendations and improves delivery of evidence-based care. METHODS All adult patients hospitalized for ulcerative colitis between July 1, 2014, and December 31, 2017, who received intravenous corticosteroids were included. On July 1, 2016, the UCSF Inpatient Ulcerative Colitis Protocol was implemented, featuring standardized core recommendations and a daily checklist for gastroenterology consultant notes, a bundled IBD electronic order set, and an opiate awareness campaign. The composite primary outcome was adherence to all 3 evidence-based care metrics: C. difficile testing performed, pharmacologic venous thromboembolism (VTE) prophylaxis ordered, and opiates avoided. RESULTS Ninety-three ulcerative colitis hospitalizations occurred, including 36 preintervention and 57 postintervention. Age, gender, disease duration, disease extent, and medication use were similar preintervention and postintervention. C. difficile testing was performed in 100% of hospitalizations. Venous thromboembolism prophylaxis was ordered on 84% of hospital days before intervention compared with 100% after intervention (P ≤ 0.001). Opiates were administered in 67% of preintervention hospitalizations, compared with 53% of postintervention hospitalizations (P = 0.18). The median daily dose of oral morphine equivalents decreased from 12.1 mg before intervention to 0.5 mg after intervention (P = 0.02). The composite outcome of adherence to all 3 metrics was higher after intervention (25% vs. 47%, P = 0.03). CONCLUSIONS Evidence-based inpatient ulcerative colitis management may be optimized with standardized algorithms that reinforce core principles, reduce care variation, and do not require IBD specialists to implement.
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Affiliation(s)
- Sara M Lewin
- Division of Gastroenterology, University of California, San Francisco, California, USA
| | | | - Roshan Patel
- Kaiser Permanente Medical Group, Walnut Creek, California, USA
| | - Suzanne R Sharpton
- Division of Gastroenterology, University of California, San Francisco, California, USA
| | | | - Uma Mahadevan
- Division of Gastroenterology, University of California, San Francisco, California, USA
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20
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Tsiaoussis GI, Assimakopoulos SF, Thomopoulos KC. The Writing Is on the Wall: The Utility of Mural Stratification for Risk Stratification of Hospitalized Patients with Severe Ulcerative Colitis. Dig Dis Sci 2019; 64:2072-2074. [PMID: 31093813 DOI: 10.1007/s10620-019-05672-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Georgios I Tsiaoussis
- Department of Gastroenterology, General Hospital of Karditsa, CP 43100, Karditsa, Greece.
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Abstract
Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disorder of the colon that causes continuous mucosal inflammation extending from the rectum to the more proximal colon, with variable extents. UC is characterized by a relapsing and remitting course. UC was first described by Samuel Wilks in 1859 and it is more common than Crohn's disease worldwide. The overall incidence and prevalence of UC is reported to be 1.2-20.3 and 7.6-245 cases per 100,000 persons/year respectively. UC has a bimodal age distribution with an incidence peak in the 2nd or 3rd decades and followed by second peak between 50 and 80 years of age. The key risk factors for UC include genetics, environmental factors, autoimmunity and gut microbiota. The classic presentation of UC include bloody diarrhea with or without mucus, rectal urgency, tenesmus, and variable degrees of abdominal pain that is often relieved by defecation. UC is diagnosed based on the combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses. In addition to confirming the diagnosis of UC, it is also important to define the extent and severity of inflammation, which aids in the selection of appropriate treatment and for predicting the patient's prognosis. Ileocolonoscopy with biopsy is the only way to make a definitive diagnosis of UC. A pathognomonic finding of UC is the presence of continuous colonic inflammation characterized by erythema, loss of normal vascular pattern, granularity, erosions, friability, bleeding, and ulcerations, with distinct demarcation between inflamed and non-inflamed bowel. Histopathology is the definitive tool in diagnosing UC, assessing the disease severity and identifying intraepithelial neoplasia (dysplasia) or cancer. The classical histological changes in UC include decreased crypt density, crypt architectural distortion, irregular mucosal surface and heavy diffuse transmucosal inflammation, in the absence of genuine granulomas. Abdominal computed tomographic (CT) scanning is the preferred initial radiographic imaging study in UC patients with acute abdominal symptoms. The hallmark CT finding of UC is mural thickening with a mean wall thickness of 8 mm, as opposed to a 2-3 mm mean wall thickness of the normal colon. The Mayo scoring system is a commonly used index to assess disease severity and monitor patients during therapy. The goals of treatment in UC are three fold-improve quality of life, achieve steroid free remission and minimize the risk of cancer. The choice of treatment depends on disease extent, severity and the course of the disease. For proctitis, topical 5-aminosalicylic acid (5-ASA) drugs are used as the first line agents. UC patients with more extensive or severe disease should be treated with a combination of oral and topical 5-ASA drugs +/- corticosteroids to induce remission. Patients with severe UC need to be hospitalized for treatment. The options in these patients include intravenous steroids and if refractory, calcineurin inhibitors (cyclosporine, tacrolimus) or tumor necrosis factor-α antibodies (infliximab) are utilized. Once remission is induced, patients are then continued on appropriate medications to maintain remission. Indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding.
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Nalagatla N, Falloon K, Tran G, Borren NZ, Avalos D, Luther J, Colizzo F, Garber J, Khalili H, Melia J, Bohm M, Ananthakrishnan AN. Effect of Accelerated Infliximab Induction on Short- and Long-term Outcomes of Acute Severe Ulcerative Colitis: A Retrospective Multicenter Study and Meta-analysis. Clin Gastroenterol Hepatol 2019; 17:502-509.e1. [PMID: 29944926 PMCID: PMC6309670 DOI: 10.1016/j.cgh.2018.06.031] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/12/2018] [Accepted: 06/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS In patients with acute severe ulcerative colitis (ASUC), standard infliximab induction therapy has modest efficacy. There are limited data on the short-term or long-term efficacy of accelerated infliximab induction therapy for these patients. METHODS In a retrospective study, we collected data from 213 patients with steroid refractory ASUC who received infliximab rescue therapy at 3 centers, from 2005 through 2017. Patients were classified that received standard therapy (5mg/kg infliximab at weeks 0, 2, and 6) or accelerated therapy (>5mg/kg infliximab at shorter intervals). The primary outcome was colectomy in-hospital and at 3, 6, 12, and 24 months. Multivariable regression models were adjusted for relevant confounders. We also performed a meta-analysis of published effects of standard vs accelerated infliximab treatment of ASUC. RESULTS In the retrospective analysis, 81 patients received accelerated infliximab therapy and 132 received standard infliximab therapy. There were no differences in characteristics between the groups, including levels of C-reactive protein or albumin. Similar proportions of patients in each group underwent in-hospital colectomy (9% receiving accelerated therapy vs 8% receiving standard therapy; adjusted odds ratio, 1.35; 95% CI, 0.38-4.82). There was no significant difference between groups in proportions that underwent colectomy at 3, 6, 12, or 24 months (P > .20 for all comparisons). Among those in the accelerated group, an initial dose of 10 mg/kg was associated with a lower rate of colectomy compared to patients who initially received 5 mg/kg followed by subsequent doses of 5mg/kg or higher. Our systematic review identified 7 studies (181 patients receiving accelerated infliximab and 436 receiving standard infliximab) and found no significant differences in short- or long-term outcomes. CONCLUSION In a retrospective study and meta-analysis, we found no association between accelerated infliximab induction therapy and lower rates of colectomy in patients with ASUC, compared to standard induction therapy. However, confounding by disease severity cannot be excluded. Randomized trials are warranted to compare these treatment strategies.
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Affiliation(s)
- Niharika Nalagatla
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Katherine Falloon
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Gloria Tran
- Division of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, Indiana
| | - Nienke Z Borren
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Danny Avalos
- Division of Gastroenterology, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Jay Luther
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Francis Colizzo
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - John Garber
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Joanna Melia
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Matthew Bohm
- Division of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, Indiana
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Maaser C, Sturm A, Vavricka SR, Kucharzik T, Fiorino G, Annese V, Calabrese E, Baumgart DC, Bettenworth D, Borralho Nunes P, Burisch J, Castiglione F, Eliakim R, Ellul P, González-Lama Y, Gordon H, Halligan S, Katsanos K, Kopylov U, Kotze PG, Krustinš E, Laghi A, Limdi JK, Rieder F, Rimola J, Taylor SA, Tolan D, van Rheenen P, Verstockt B, Stoker J. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis 2019; 13:144-164. [PMID: 30137275 DOI: 10.1093/ecco-jcc/jjy113] [Citation(s) in RCA: 857] [Impact Index Per Article: 171.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Andreas Sturm
- Department of Gastroenterology, DRK Kliniken Berlin I Westend, Berlin, Germany
| | | | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Gionata Fiorino
- Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic & American Hospital, Dubai, UAE
| | - Emma Calabrese
- Department of Systems Medicine, University of Rome, Tor Vergata, Italy
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Paula Borralho Nunes
- Department of Anatomic Pathology, Hospital Cuf Descobertas; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital; Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Pierre Ellul
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Yago González-Lama
- Department of Gastroenterology, University Hospital Puerta De Hierro, Majadahonda [Madrid], Spain
| | - Hannah Gordon
- Department of Gastroenterology, Royal London Hospital, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná [PUCPR], Curitiba, Brazil
| | - Eduards Krustinš
- Department of of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrea Laghi
- Department of Clinical and Surgical Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester; Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Clinical Radiology, St James's University Hospital, Leeds, UK
| | - Patrick van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, Groningen, The Netherlands
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven and CHROMETA - Translational Research in Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center [AMC], University of Amsterdam, Amsterdam, The Netherlands
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Micic D, Hirsch A, Setia N, Rubin DT. Enteric infections complicating ulcerative colitis. Intest Res 2018; 16:489-493. [PMID: 30090049 PMCID: PMC6077301 DOI: 10.5217/ir.2018.16.3.489] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 04/30/2018] [Accepted: 05/10/2018] [Indexed: 12/18/2022] Open
Abstract
Enteric infections have previously been postulated to play a role in the pathogenesis of inflammatory bowel disease (IBD), however, little evidence exists in the etiologic role of specific enteric infections in the development of IBD. When encountered in the setting of IBD, enteric infections pose a clinical challenge in management given the competing treatment strategies for infectious conditions and autoimmune disorders. Here we present the case of a young male with enteric infections complicating a new diagnosis of IBD. Our patient's initial clinical presentation included diagnoses of Klebsiella oxytoca isolation and Clostridium difficile infection. Directed therapies to include withdrawal of antibiotics and fecal microbiota transplantation were performed without resolution of clinical symptoms. Given persistence of symptoms and active colitis, the patient was diagnosed with ulcerative colitis (UC), requiring treatments directed at severe UC to include cyclosporine therapy. The finding of multiple enteric infections in a newly presenting patient with IBD is an unexpected finding that has treatment implications.
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Affiliation(s)
- Dejan Micic
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Ayal Hirsch
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Namrata Setia
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - David T Rubin
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago, Chicago, IL, USA
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25
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Abstract
PURPOSE OF REVIEW We discuss the newest evidence-based data on management of ulcerative colitis (UC). We emphasize risk-stratification, optimizing medical therapies, and surgical outcomes of UC. RECENT FINDINGS Recent medical advances include introduction of novel agents for UC. Vedolizumab, an anti-adhesion molecule, has demonstrated efficacy in moderate to severe UC. Tofacitinib, a small molecule, has also demonstrated efficacy. Data on optimization of infliximab show the superiority of combination therapy with azathioprine over monotherapy with infliximab or azathioprine alone. Data on anti-tumor necrosis factor-alpha (anti-TNF) therapeutic drug monitoring also hold promise, as do preliminary data on the dose escalation of infliximab in severe hospitalized UC. Surgical outcome data are reassuring, with new fertility data showing the effectiveness of in vitro fertilization. UC management is multi-disciplinary and changing. While novel therapies hold promise, better optimization of our current arsenal will also improve outcomes.
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Affiliation(s)
- Rohini Vanga
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, CB #7080, Chapel Hill, NC, 27599-7080, USA.,Center for Gastrointestinal Biology and Disease, Chapel Hill, NC, USA
| | - Millie D Long
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, CB #7080, Chapel Hill, NC, 27599-7080, USA. .,Center for Gastrointestinal Biology and Disease, Chapel Hill, NC, USA.
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26
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Risk factors for organ space infection after ileal pouch anal anastomosis for chronic ulcerative colitis: An ACS NSQIP analysis. Am J Surg 2018. [PMID: 29534812 DOI: 10.1016/j.amjsurg.2018.02.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Organ space infection (OSI) after ileal pouch anal anastomosis (IPAA) is a devastating complication. The aim of this was study was to determine separately risk factors for OSI after total proctocolectomy (TPC) with IPAA and completion proctectomy (CP) with IPAA. METHODS 4049 patients with a diagnosis of chronic ulcerative colitis undergoing TPC with IPAA or CP with IPAA between 2005 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Primary outcome was an OSI within 30 days of surgery. Multivariable analyses were conducted for the development of OSI after each operation. RESULTS For TPC with IPAA, urgent surgery (OR: 2.0, p < 0.01) and obesity (OR: 1.6, p < 0.01) were independent risk factors for OSI. Operation length of 275 + minutes (versus <170 min; OR: 2.2, p = 0.02) was predictive of OSI after CP with IPAA. CONCLUSION Risk factors for OSI differed between the operations. This highlights the importance of the consideration of the physiologic status of the patient when deciding to perform TPC with IPAA or subtotal colectomy with ileostomy initially.
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27
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Kelso M, Weideman RA, Cipher DJ, Feagins LA. Factors Associated With Length of Stay in Veterans With Inflammatory Bowel Disease Hospitalized for an Acute Flare. Inflamm Bowel Dis 2017; 24:5-11. [PMID: 29272483 DOI: 10.1093/ibd/izx020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reducing hospital costs and risk of complications by shortening length of stay has become paramount. The aim of our study was to identify predictors and potentially modifiable factors that influence length of stay among veterans with inflammatory bowel disease admitted for an acute flare. METHODS Retrospective review of patients admitted to the Dallas VA with an acute flare of their inflammatory bowel disease between 2000 and 2015. Patients with a length of stay of ≤4 days were compared with those whose length of stay >4 days. RESULTS A total of 180 admissions involving 113 patients (59 with ulcerative colitis and 54 with Crohn's disease) were identified meeting inclusion criteria. The mean length of stay was 5.3 ± 6.8 days, and the median length of stay was 3.0 days. On multiple logistic regression analysis, initiation of a biologic, having undergone 2 or more imaging modalities, and treatment with intravenous steroids were significant predictors of longer lengths of stay, even after controlling for age and comorbid diseases. CONCLUSIONS We identified several predictors for longer hospital length of stay, most related to disease severity but several of which may be modifiable to reduce hospital stays, including most importantly consideration of earlier prebiologic testing. Future studies are needed to evaluate the impact of interventions targeting modifiable predictors of length of stay on health care utilization and patient outcomes.
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Affiliation(s)
- Michael Kelso
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas.,Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Daisha J Cipher
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas
| | - Linda A Feagins
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas.,Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Baidoo L. Management of Hospitalized Patients With Ulcerative Colitis. Gastroenterol Hepatol (N Y) 2017; 13:180-183. [PMID: 28539846 PMCID: PMC5439138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Leonard Baidoo
- Associate Professor of Medicine Director, Inflammatory Bowel Disease Center Division of Gastroenterology and Hepatology Northwestern University Feinberg School of Medicine Chicago, Illinois
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29
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Panes J, Jairath V, Levesque BG. Advances in Use of Endoscopy, Radiology, and Biomarkers to Monitor Inflammatory Bowel Diseases. Gastroenterology 2017; 152:362-373.e3. [PMID: 27751880 DOI: 10.1053/j.gastro.2016.10.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/07/2016] [Accepted: 10/11/2016] [Indexed: 02/07/2023]
Abstract
Crohn's disease and ulcerative colitis are heterogeneous inflammatory bowel diseases, and therapeutic requirements vary among patients. We have a limited capacity to predict disease progression for individual patients, therefore it is important that they are evaluated for the presence of active disease when symptoms are mild or even absent, when patients are more likely to respond to new treatment interventions. It then is important to monitor responses to treatment, to quickly identify those therapies that are ineffective, modify or change therapy, and avoid disease complications. Studies are underway to assess the effects of different monitoring strategies. Because of the heavy burden of severe inflammatory bowel disease on patients' health and quality of life, and the association between intestinal healing and disease progression in high-risk patients, a treat-to-target strategy (based on tissue healing) is likely to be optimal.
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Affiliation(s)
- Julian Panes
- Department of Gastroenterology Hospital Clinic of Barcelona, Institud d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
| | - Vipul Jairath
- Department of Medicine, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
| | - Barrett G Levesque
- Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
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30
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Feagan BG, Rubin DT, Danese S, Vermeire S, Abhyankar B, Sankoh S, James A, Smyth M. Efficacy of Vedolizumab Induction and Maintenance Therapy in Patients With Ulcerative Colitis, Regardless of Prior Exposure to Tumor Necrosis Factor Antagonists. Clin Gastroenterol Hepatol 2017; 15:229-239.e5. [PMID: 27639327 DOI: 10.1016/j.cgh.2016.08.044] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/05/2016] [Accepted: 08/16/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The efficacy and safety of vedolizumab, a humanized immunoglobulin G1 monoclonal antibody against the integrin α4β7, were demonstrated in multicenter, phase 3, randomized, placebo-controlled trials in patients with moderately to severely active ulcerative colitis (UC) or Crohn's disease. We analyzed data from 1 of these trials to determine the effects of vedolizumab therapy in patients with UC, based on past exposure to anti-tumor necrosis factor-α (TNF) antagonists. METHODS We performed a post hoc analysis of data from the GEMINI 1 study, collected from 464 patients who received vedolizumab or placebo but had not received a previous TNF antagonist (naive to TNF antagonists) and 367 patients with an inadequate response, loss of response, or intolerance to TNF antagonists (failure of TNF antagonists). Predefined outcomes of GEMINI 1 were evaluated in these subpopulations. RESULTS At Week 6, there were greater absolute differences in efficacy between vedolizumab and placebo in patients naive to TNF antagonists than patients with failure of TNF antagonists, although the risk ratios (RRs) for efficacy were similar for each group. Week 6 rates of response to vedolizumab and placebo were 53.1% and 26.3%, respectively, among patients naive to TNF antagonists (absolute difference, 26.4%; 95% confidence interval [CI], 12.4-40.4; RR, 2.0; 95% CI, 1.3-3.0); these rates were 39.0% and 20.6%, respectively, in patients with failure of TNF antagonists (absolute difference, 18.1%; 95% CI, 2.8-33.5; RR, 1.9; 95% CI, 1.1-3.2). During maintenance therapy, the absolute differences were similar but the RR for efficacy was higher for patients with failure of TNF antagonists than for patients naive to TNF antagonists, for most outcomes. Week 52 rates of remission with vedolizumab and placebo were 46.9% and 19.0%, respectively, in patients naive to TNF antagonists (absolute difference, 28.0%; 95% CI, 14.9-41.1; RR, 2.5; 95% CI, 1.5-4.0) and 36.1% and 5.3%, respectively, in patients with failure of TNF antagonists (absolute difference, 29.5%; 95% CI, 12.8-46.1; RR, 6.6; 95% CI, 1.7-26.5). No differences in adverse events were observed among groups. CONCLUSIONS Vedolizumab demonstrated significantly greater efficacy as induction and maintenance therapy for UC than placebo in patients naive to TNF antagonists and patients with TNF antagonist failure. There were numerically greater treatment differences at Week 6 among patients receiving vedolizumab who were naive to TNF antagonists than patients with TNF antagonist failure. ClinicalTrials.gov no: NCT00783718.
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Affiliation(s)
- Brian G Feagan
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois
| | | | | | | | - Serap Sankoh
- Takeda Pharmaceuticals International Co, Cambridge, Massachusetts
| | - Alexandra James
- Takeda Development Centre Europe Ltd, London, United Kingdom
| | - Michael Smyth
- Takeda Development Centre Europe Ltd, London, United Kingdom
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31
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Law CCY, Sasidharan S, Rodrigues R, Nguyen DD, Sauk J, Garber J, Giallourakis C, Xavier R, Khalili H, Yajnik V, Ananthakrishnan AN. Impact of Specialized Inpatient IBD Care on Outcomes of IBD Hospitalizations: A Cohort Study. Inflamm Bowel Dis 2016; 22:2149-57. [PMID: 27482978 PMCID: PMC4992425 DOI: 10.1097/mib.0000000000000870] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The management of inflammatory bowel diseases (IBDs; Crohn's disease, ulcerative colitis) is increasingly complex. Specialized care has been associated with improved ambulatory IBD outcomes. AIMS To examine if the implementation of specialized inpatient IBD care modified short-term and long-term clinical outcomes in IBD-related hospitalizations. METHODS This retrospective cohort study included IBD patients hospitalized between July 2013 and April 2015 at a single tertiary referral center where a specialized inpatient IBD care model was implemented in July 2014. In-hospital medical and surgical outcomes as well as postdischarge outcomes at 30 and 90 days were analyzed along with measures of quality of in-hospital care. Effect of specialist IBD care was examined on multivariate analysis. RESULTS A total of 408 IBD-related admissions were included. With implementation of specialized IBD inpatient care, we observed increased frequency of use of high-dose biologic therapy for induction (26% versus 9%, odds ratio 5.50, 95% confidence interval 1.30-23.17) and higher proportion of patients in remission at 90 days after discharge (multivariate odds ratio 1.60, 95% confidence interval 0.99-2.69). Although there was no difference in surgery by 90 days, among those who underwent surgery, early surgery defined as in-hospital or within 30 days of discharge, was more common in the study period (71%) compared with the control period (46%, multivariate odds ratio 2.73, 95% confidence interval 1.22-6.12). There was no difference in length of stay between the 2 years. CONCLUSIONS Implementation of specialized inpatient IBD care beneficially impacted remission and facilitated early surgical treatment.
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Affiliation(s)
- Cindy CY Law
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Deanna D Nguyen
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jenny Sauk
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - John Garber
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Cosmas Giallourakis
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ramnik Xavier
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Vijay Yajnik
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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32
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Arsoniadis EG, Melton GB. Leveraging the electronic health record for research and quality improvement: Current strengths and future challenges. SEMINARS IN COLON AND RECTAL SURGERY 2016. [DOI: 10.1053/j.scrs.2016.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Romano C, Syed S, Valenti S, Kugathasan S. Management of Acute Severe Colitis in Children With Ulcerative Colitis in the Biologics Era. Pediatrics 2016; 137:peds.2015-1184. [PMID: 27244779 DOI: 10.1542/peds.2015-1184] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Approximately one-third of children with ulcerative colitis will experience at least 1 attack of acute severe colitis (ASC) before 15 years of age. Severe disease can be defined in children when Pediatric Ulcerative Colitis Activity Index is >65 and/or ≥6 bloody stools per day, and/or 1 of the following: tachycardia, fever, anemia, and elevated erythrocyte sedimentation rate with or without systemic toxicity. Our aim was to provide practical suggestions on the management of ASC in children. The goal of medical therapy is to avoid colectomy while preventing complications of disease, side effects of medications, and mortality. METHODS A systematic search was carried out through Medline via PubMed to identify all articles published in English to date, based on the following keywords "ulcerative colitis," "pediatric ulcerative colitis," "biological therapy," and "acute severe colitis." Multidisciplinary clinical evaluation is recommended to identify early nonresponders to conventional treatment with intravenous corticosteroids, and to start, if indicated, second-line therapy or "rescue therapy," such as calcineurin inhibitors (cyclosporine, tacrolimus) and anti-tumor necrosis factor molecules (infliximab). RESULTS Pediatric Ulcerative Colitis Activity Index is a valid predictive tool that can guide clinicians in evaluating response to therapy. Surgery should be considered in the case of complications or rapid clinical deterioration during medical treatment. CONCLUSIONS Several pitfalls may be present in the management of ASC, and a correct clinical and therapeutic approach is recommended to reduce surgical risk.
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Affiliation(s)
- Claudio Romano
- Inflammatory Bowel Disease Unit, Pediatric Department, University of Messina, Messina, Italy; and
| | - Sana Syed
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Simona Valenti
- Inflammatory Bowel Disease Unit, Pediatric Department, University of Messina, Messina, Italy; and
| | - Subra Kugathasan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
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Opportunities for Improvement in the Care of Patients Hospitalized for Inflammatory Bowel Disease-Related Colitis. Dig Dis Sci 2016; 61:1003-12. [PMID: 26860508 PMCID: PMC5716623 DOI: 10.1007/s10620-016-4046-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 01/18/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Algorithms for the diagnosis, management, and follow-up have been proposed for patients hospitalized for inflammatory bowel disease (IBD) colitis flare. The degree to which providers adhere to these algorithms is unknown. This study evaluated the quality of care in IBD patients hospitalized for disease-associated exacerbations and factors correlated with higher degrees of care. METHODS Retrospective chart review of 34 patients during 60 admissions to the medicine service for IBD colitis exacerbation between 2005 and 2012 at the Veterans Affairs San Diego Medical Center. Examined factors included laboratory testing, timing of consultation and intravenous steroids, abdominal imaging, endoscopic examination, venous thromboembolism (VTE) prophylaxis, narcotic use, Clostridium difficile and cytomegalovirus testing, symptomatology at discharge, timing of follow-up, and rates of readmission and mortality. RESULTS Quality of care varied among the factors studied, ranging from 30.5 % for pharmacologic VTE prophylaxis to 84.7 % for gastroenterology consultation within 24 h. Of 60 admissions, 22 % were not tested for C. difficile. Fifteen percent of patients were discharged before meeting commonly used discharge criteria. Eighty percent were seen in clinic at any time post-discharge; 6.7 % were readmitted; 10 % were lost to follow-up; 1.7 % opted for outside follow-up; and 1.7 % expired. CONCLUSIONS The quality of care for patients admitted with IBD colitis flares is variable. These data outline opportunities for improvement, particularly in regard to pain management, VTE prophylaxis, and follow-up. Further studies are needed to test intervention strategies for practice improvement.
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Annese V, Duricova D, Gower-Rousseau C, Jess T, Langholz E. Impact of New Treatments on Hospitalisation, Surgery, Infection, and Mortality in IBD: a Focus Paper by the Epidemiology Committee of ECCO. J Crohns Colitis 2016; 10:216-25. [PMID: 26520163 DOI: 10.1093/ecco-jcc/jjv190] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 10/08/2015] [Indexed: 02/08/2023]
Abstract
The medical management of inflammatory bowel disease has changed considerably over time with wider use of immunosuppressant therapy and the introduction of biological therapy. To what extent this change of medical paradigms has influenced and modified the disease course is incompletely known. To address this issue, an extensive review of the literature has been carried out on time trends of hospitalization, surgery, infections, cancer, and mortality rates in inflammatory bowel disease [IBD] patients. Preference was given to population-based studies but, when data from these sources were limited, large cohort studies and randomised controlled trials were also considered. In general, data on hospitalisation rates are strikingly heterogeneous and conflicting. In contrast, the consistent drop in surgery/colectomy rates suggests that the growing use of immunosuppressants and biological agents has had a positive impact on the course of IBD. Most clinical trial data indicate that the risk of serious infections is not increased in patients treated with anti-tumour necrosis factor alpha [TNFα] agents, but a different picture emerges from cohort studies. The use of thiopurines increases the risk for non-melanoma skin cancers and to a lesser extent for lymphoma and cervical cancer [absolute risk: low], whereas no clear increase in the cancer risk has been reported for anti-TNF agents. Finally, the majority of studies reported in the literature do not reveal any increase in mortality with immunosuppressant therapy or biologicals/anti-TNF agents.
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Affiliation(s)
- Vito Annese
- Emergency Department, Gastroenterology Unit, AOU Careggi, Florence, Italy
| | - Dana Duricova
- Clinical and Research Centre for Inflammatory Bowel Disease, ISCARE a.s. and Charles University in Prague, Prague, Czech Republic
| | - Corinne Gower-Rousseau
- Epidemiology Unit, Lille University and Hospital, Université Lille Nord de France, Lille, France
| | - Tine Jess
- Department of Epidemiology Research, Statens Serum Institut, National Center for Health Data and Disease Control, Copenhagen, Denmark
| | - Ebbe Langholz
- Department of Medicine, Gentofte Hospital, Hellerup, Denmark
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36
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Seah D, De Cruz P. Review article: the practical management of acute severe ulcerative colitis. Aliment Pharmacol Ther 2016; 43:482-513. [PMID: 26725569 DOI: 10.1111/apt.13491] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 09/10/2015] [Accepted: 11/11/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a life-threatening condition for which optimal management strategies remain ill-defined. AIM To review the evidence regarding the natural history, diagnosis, monitoring and treatment of ASUC to inform an evidence-based approach to management. METHODS Relevant articles addressing the management of ASUC were identified from a search of MEDLINE, the Cochrane Library and conference proceedings. RESULTS Of ASUC, 31-35% is steroid-refractory. Infliximab and ciclosporin salvage therapies have improved patient outcomes in randomised controlled trials. Short-term response rates (within 3 months) have ranged from 40% - 54% for ciclosporin and 46-83% for infliximab. Long-term clinical response rates (≥1 year) have ranged from 42%-50% for ciclosporin and 50-65% for infliximab. Short-term and long-term colectomy rates have been respectively: 26-47% and 36-58% for ciclosporin, and 0-50% and 35-50% for infliximab. Mortality rates for ciclosporin and infliximab-treated patients have been: 0-5% and 0-2%, respectively. At present, management challenges include the selection, timing and assessment of response to salvage therapy, utilisation of therapeutic drug monitoring and long-term maintenance of remission. CONCLUSIONS Optimal management of acute severe ulcerative colitis should be guided by risk stratification using predictive indices of corticosteroid response. Timely commencement and assessment of response to salvage therapy is critical to reducing morbidity and mortality. Emerging pharmacokinetic models and therapeutic drug monitoring may assist clinical decision-making and facilitate a shift towards individualised acute severe ulcerative colitis therapies.
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Affiliation(s)
- D Seah
- Department of Medicine, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia
| | - P De Cruz
- Department of Medicine, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital, Melbourne, Vic., Australia
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37
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Gupta V, Rodrigues R, Nguyen D, Sauk J, Khalili H, Yajnik V, Ananthakrishnan AN. Adjuvant use of antibiotics with corticosteroids in inflammatory bowel disease exacerbations requiring hospitalisation: a retrospective cohort study and meta-analysis. Aliment Pharmacol Ther 2016; 43:52-60. [PMID: 26541937 PMCID: PMC4673010 DOI: 10.1111/apt.13454] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/25/2015] [Accepted: 10/12/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients hospitalised with an exacerbation of inflammatory bowel disease (IBD) often receive antibiotics in addition to intravenous steroids. However, their efficacy in this setting is unclear. AIM To ascertain if the addition of antibiotics to intravenous steroids modifies short and long-term clinical outcomes. METHODS Our study included IBD patients hospitalised between 2009 and 2014 who received intravenous (IV) steroids with or without adjuvant antibiotics. Outcomes of interest included length of stay (LOS), need for medical and surgical rescue therapy during the hospitalisation, and at 90 and 365 days. A meta-analysis of previously published randomised trials was additionally performed. RESULTS A total of 354 patients were included [145 ulcerative colitis (UC); 209 Crohn's disease (CD)]. In CD, combination of IV steroids and antibiotics did not change need for in-hospital medical rescue therapy, surgery or hospitalisations at 1 year but was associated with greater LOS (6.1 vs. 4.6 days, P = 0.02). In UC, patients receiving antibiotics were less likely to require in-hospital medical rescue therapy [odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19-0.93] but experienced no statistically significant differences in LOS, in-hospital surgery, re-hospitalisations or surgery by 1 year. A meta-analysis of three relevant randomised trials demonstrated no difference in clinical improvement with antibiotics over placebo (OR: 1.08, 95% CI: 0.50-2.32). CONCLUSIONS The addition of antibiotics to intravenous steroids for treatment of IBD exacerbations was associated with a reduced need for in-hospital medical rescue therapy in ulcerative colitis without significant long-term benefit, and did not affect short- or long-term outcomes in Crohn's disease.
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Affiliation(s)
- Vikas Gupta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Deanna Nguyen
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Jenny Sauk
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Vijay Yajnik
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
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38
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Fornaro R, Caratto M, Barbruni G, Fornaro F, Salerno A, Giovinazzo D, Sticchi C, Caratto E. Surgical and medical treatment in patients with acute severe ulcerative colitis. J Dig Dis 2015; 16:558-67. [PMID: 26315728 DOI: 10.1111/1751-2980.12278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 07/05/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis (UC) is a chronic inflammatory disease of the mucosa of the colorectum. The treatment of UC depends on the severity of symptoms and the extent of the disease. Acute severe colitis (ASC) occurs in 12-25% of patients with UC. Patients with ASC must be managed by a multidisciplinary team. Medically or surgically aggressive treatment is carried out with the final aim of reducing mortality. Intravenous administration of corticosteroids is the mainstay of the therapy. Medical rescue therapy based on cyclosporine or infliximab should be considered if there is no response to corticosteroids for 3 days. If there has been no response to medical rescue therapy after 4-7 days, the patient must undergo colectomy in emergency surgery. Prolonged observation is counterproductive, as over time it increases the risk of toxic megacolon and perforation, with a very high mortality rate. The best potential treatment is subtotal colectomy with ileostomy and preservation of the rectum. Emergency surgery in UC should not be seen as a last chance, but can be considered as a life-saving procedure. Colectomies in emergency setting are characterized by high morbidity rates but the mortality is low.
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Affiliation(s)
- Rosario Fornaro
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Michela Caratto
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Ginevra Barbruni
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Francesco Fornaro
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Alexander Salerno
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Davide Giovinazzo
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | | | - Elisa Caratto
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
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Zhang Y, Jin Y, Lin Y, Lin LJ, Cao Y, Wang DX, Zheng CQ. Adipose-Derived Mesenchymal Stem Cells Ameliorate Ulcerative Colitis Through miR-1236 Negatively Regulating the Expression of Retinoid-Related Orphan Receptor Gamma. DNA Cell Biol 2015; 34:618-25. [PMID: 26237452 DOI: 10.1089/dna.2015.2961] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ying Zhang
- Second Department of Gastroenterology, The Shengjing Affiliated Hospital, China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Yu Jin
- Second Department of Gastroenterology, The Shengjing Affiliated Hospital, China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Yan Lin
- Second Department of Gastroenterology, The Shengjing Affiliated Hospital, China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Lian-jie Lin
- Second Department of Gastroenterology, The Shengjing Affiliated Hospital, China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Yong Cao
- Second Department of Gastroenterology, The Shengjing Affiliated Hospital, China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Dong-xu Wang
- Second Department of Gastroenterology, The Shengjing Affiliated Hospital, China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Chang-qing Zheng
- Second Department of Gastroenterology, The Shengjing Affiliated Hospital, China Medical University, Shenyang, Liaoning, People's Republic of China
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40
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Reply to Use of CT Scan in Ulcerative Colitis Patients Presenting to the Emergency Department. Inflamm Bowel Dis 2015. [PMID: 26197384 DOI: 10.1097/mib.0000000000000513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Abstract
BACKGROUND Computed tomography (CT) is used in the emergency department (ED) for triage of patients with gastrointestinal complaints. Patients with inflammatory bowel disease undergo radiologic studies for gastrointestinal symptoms and are at risk for excessive ionizing radiation exposure; however, the utility of CT in the ED in patients with ulcerative colitis (UC) is not clear. In this study, we assess the frequency and risk factors for clinically significant CT findings in patients with UC in the ED. METHODS We retrospectively reviewed 163 consecutive cases of patients with UC who presented to a tertiary care ED and underwent abdominopelvic CT between June 2008 and December 2011. Using logistic regression, we identified predictors of significant CT findings and derived a model to predict CT scans without clinically significant findings. RESULTS Of note, 63.2% (103/163) of CT scans had no clinically significant findings. Less than 2% of scans revealed complications related to UC. Predictors of CT scans without clinically significant findings included rectal bleeding or diarrhea (P < 0.001), use of 5-aminosalicylate (P = 0.011), or immunomodulator (P = 0.032). Alternatively, predictors of clinically significant CT findings included nausea and vomiting (P < 0.001), history of colectomy (P < 0.001), history of abdominal or pelvic surgery (P < 0.001), surgery within 1 month (P < 0.001), age (P = 0.004), elevated white blood cell count (P = 0.003), and no UC medications (P = 0.001). CONCLUSIONS Most patients with UC who presented to the ED and underwent CT had no clinically significant findings. We devised a model to predict lack of clinically significant CT findings, which may assist in reducing cost and radiation exposure in patients with UC.
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Aceituno M, Montserrat A, Zabana Y, Yamile Z, Esteve M, Maria E. [Treatment of severe ulcerative colitis flares]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:471-9. [PMID: 25015428 DOI: 10.1016/j.gastrohep.2014.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 05/09/2014] [Accepted: 05/16/2014] [Indexed: 10/25/2022]
Abstract
The treatment of severe ulcerative colitis remains a challenge for gastroenterologists. A not inconsiderable number of patients will experience severe flares throughout their lives and will require hospitalization. Mortality in severe ulcerative colitis is still high and consequently treatment must be aggressive, avoiding delays in rescue therapies or even surgery. The aim of this review was to describe the medical treatment of severe ulcerative colitis, highlighting recent therapeutic advances.
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Affiliation(s)
| | - Aceituno Montserrat
- Servicio de Aparato Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España.
| | | | - Zabana Yamile
- Servicio de Aparato Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | | | - Esteve Maria
- Servicio de Aparato Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
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Olaisen M, Rydning A, Martinsen TC, Nordrum IS, Mjønes P, Fossmark R. Cytomegalovirus infection and postoperative complications in patients with ulcerative colitis undergoing colectomy. Scand J Gastroenterol 2014; 49:845-52. [PMID: 24947587 DOI: 10.3109/00365521.2014.929172] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ulcerative colitis (UC) can be complicated by reactivation of cytomegalovirus (CMV). CMV reactivation may change the course of UC and may require antiviral treatment. Some risk factors of CMV reactivation have previously been identified, whereas the association between CMV reactivation and postoperative complications has not been examined systematically. METHODS Patients with UC operated with colectomy due to active UC were studied (n = 77). Patient and disease characteristics, as well as postoperative complications were recorded and CMV was detected by immunohistochemical examination of multiple sections from the colectomy specimen. RESULTS CMV was found in nine (11.7%) colectomy specimens. CMV-positive patients received significantly higher doses of corticosteroids at colectomy than CMV-negative patients (61.1 ± 23 vs 32.5 ± 32 mg/day, p = 0.01). CMV-positive patients were also older, had a higher risk of severe complications, higher American Society of Anesthesiologists (ASA) score, longer preoperative stay, and a higher rate of acute surgery. Complications occurred in 30 (39%) patients after surgery, 8(10.4%) of whom were serious. Two CMV-positive patients (2.6%) died in-hospital after the colectomy. High ASA score was associated with the occurrence of serious complications. CONCLUSION A relatively small proportion of patients with UC operated by colectomy were CMV positive. CMV positivity was associated with old age, high dose of corticosteroids at operation, high ASA score, acute surgery, and severe postoperative complications. Patients with such characteristics may be at risk of CMV infection and may require special management.
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Affiliation(s)
- Maya Olaisen
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU) , Trondheim , Norway
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Abstract
Ulcerative colitis (UC) is an idiopathic, inflammatory gastrointestinal disease of the colon. As a chronic condition, UC follows a relapsing and remitting course with medical maintenance during periods of quiescent disease and appropriate escalation of therapy during times of flare. Initial treatment strategies must not only take into account current clinical presentation (with specific regard for extent and severity of disease activity) but must also take into consideration treatment options for the long-term. The following review offers an approach to new-onset UC with a focus on early treatment strategies. An introduction to the disease entity is provided along with an approach to initial diagnosis. Stratification of patients based on clinical parameters, disease extent, and severity of illness is paramount to determining course of therapy. Frequent assessments are required to determine clinical response, and treatment intensification may be warranted if expected improvement goals are not appropriately reached. Mild-to- moderate UC can be managed with aminosalicylates, mesalamine, and topical corticosteroids with oral corticosteroids reserved for unresponsive cases. Moderate-to-severe UC generally requires oral or intravenous corticosteroids in the short-term with consideration of long-term management options such as biologic agents (as initial therapy or in transition from steroids) or thiopurines (as bridging therapy). Patients with severe or fulminant UC who are recalcitrant to medical therapy or who develop disease complications (such as toxic megacolon) should be considered for colectomy. Early surgical referral in severe or refractory UC is crucial, and colectomy may be a life-saving procedure. The authors provide a comprehensive evidence-based approach to current treatment options for new-onset UC with discussion of long-term therapeutic efficacy and safety, patient-centered perspectives including quality of life and medication compliance, and future directions in related inflammatory bowel disease care.
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Affiliation(s)
- Renée Marchioni Beery
- Division of Gastroenterology and Hepatology, University of Connecticut Health Center, Farmington, CT, USA
| | - Sunanda Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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A review of mortality and surgery in ulcerative colitis: milestones of the seriousness of the disease. Inflamm Bowel Dis 2013; 19:2001-10. [PMID: 23624887 DOI: 10.1097/mib.0b013e318281f3bb] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Standardized mortality rates in ulcerative colitis (UC) are no different than that in the general population. Patients who are older and have more comorbidities have increased mortality. Emergent colectomy still carries 30-day mortality rates of approximately 5%. In more recent studies, UC surgery rates at 10 years from diagnosis are nearly 3% in Hungary, <10% in referral center studies from Asia, approximately 10% in Norway, the European Cohort Study of Inflammatory Bowel Diseases and Manitoba, Canada, and nearly 17% in Olmsted County, Minnesota. These rates are for the most part lower than reported colectomy rates from studies completed before 1990. Short-term colectomy rates in severe hospitalized UC have remained stable at 27% for several years. Generally, children seem to have higher rates of extensive colitis at diagnosis than adults. There also seems to be higher rates of colectomy in children than in adults (i.e., at least 20% at 10 years), and perhaps, this reflects a higher rate of extensive disease. Acute severe colitis in patients with UC still represents a condition with a high early colectomy rate and a measurable mortality rate.
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