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Loeb L, Nasir A, Picco MF, Hashash JG, Kinnucan JA, Farraye FA. Prior Authorization of Biologics in the Management of Inflammatory Bowel Disease. Inflamm Bowel Dis 2023; 29:e37. [PMID: 37196096 DOI: 10.1093/ibd/izad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Lauren Loeb
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Ayan Nasir
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Michael F Picco
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Jana G Hashash
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Jami A Kinnucan
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Francis A Farraye
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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Bali AS, Hashash JG, Picco MF, Kinnucan JA, Farraye FA. Electronic Health Record Burden Amongst Gastroenterology Providers Associated with Sub-specialty and Training. Am J Gastroenterol 2023:00000434-990000000-00700. [PMID: 36940436 DOI: 10.14309/ajg.0000000000002254] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/22/2023] [Indexed: 03/22/2023]
Abstract
Introduction Use of the electronic health record (EHR) has become increasingly widespread. Higher EHR burden is associated with burnout, but this has not been specifically investigated among gastroenterology (GI) providers. Methods We retrospectively collected measures of EHR use for outpatient GI providers during a 6-month period. We compared metrics across provider sex, sub-specialty, and training (physicians vs non-physician providers [NPPs]). Results Data collected represented over 16,000 appointments from 41 providers across the Division of Gastroenterology and Hepatology. Inflammatory bowel disease (IBD) and hepatology specialists spent more time per appointment in the EHR, clinical review, and outside regular hours compared to other sub-specialists. NPPs spent more EHR time than physicians. Conclusion IBD and hepatology specialists and NPPs may have disproportionally high EHR burden. More work is needed to understand differences in provider workload to combat burnout.
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Affiliation(s)
- Aman S Bali
- Division of Gastroenterology and Hepatology, Mayo Clinic, FL
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Loftus EV, Baumgart DC, Gecse K, Kinnucan JA, Connelly SB, Salese L, Su C, Kwok KK, Woolcott JC, Armuzzi A. Clostridium difficile Infection in Patients with Ulcerative Colitis Treated with Tofacitinib in the Ulcerative Colitis Program. Inflamm Bowel Dis 2022; 29:744-751. [PMID: 35792493 PMCID: PMC10152280 DOI: 10.1093/ibd/izac139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Tofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of ulcerative colitis (UC). Patients with inflammatory bowel disease are susceptible to Clostridium difficile infection (CDI). Here, we evaluate CDI in the tofacitinib UC clinical program. METHODS Events from 4 randomized, placebo-controlled studies (phase [P] 2 or P3 induction [NCT00787202; NCT01465763; NCT01458951], P3 maintenance [NCT01458574]) and an open-label, long-term extension (OLE) study (NCT01470612), were analyzed as 3 cohorts: Induction (P2/P3 induction), Maintenance (P3 maintenance), and Overall (patients receiving tofacitinib 5 or 10 mg twice daily [BID] in P2, P3, and OLE studies; including final data from the OLE study, as of August 24, 2020). Proportions and incidence rates (unique patients with events per 100 patient-years of exposure) of CDI were evaluated. RESULTS The overall cohort comprised 1157 patients who received ≥1 dose of tofacitinib 5 or 10 mg BID, with a total of 2814.4 patient-years of tofacitinib exposure and up to 7.8 years of treatment. A total of 82.6% of patients received predominantly tofacitinib 10 mg BID. In the induction, maintenance, and overall cohorts, 3 (2 tofacitinib treated, 1 placebo treated), 3 (all placebo treated), and 9 patients had CDI, respectively; the overall cohort incidence rate was 0.31 (95% confidence interval, 0.14-0.59). CDI were all mild-moderate in severity and resolved with treatment in 8 patients. Six of 9 patients continued tofacitinib treatment without interruption. Two patients had events reported as serious due to hospitalization. Two patients were receiving corticosteroids when the CDI occurred. CONCLUSION CDIs among patients with UC receiving tofacitinib were infrequent, cases were mild-moderate in severity, and most resolved with treatment.
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Affiliation(s)
- Edward V Loftus
- Address correspondence to: Edward V. Loftus Jr, MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905-0001, USA ()
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Krisztina Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, The Netherlands
| | - Jami A Kinnucan
- Division of Gastroenterology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | | | | | | | - Alessandro Armuzzi
- IBD Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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Dubinsky MC, Magro F, Steinwurz F, Hudesman DP, Kinnucan JA, Ungaro RC, Neurath MF, Kulisek N, Paulissen J, Su C, Ponce de Leon D, Regueiro M. Association of C-reactive Protein and Partial Mayo Score With Response to Tofacitinib Induction Therapy: Results From the Ulcerative Colitis Clinical Program. Inflamm Bowel Dis 2022; 29:51-61. [PMID: 35380664 PMCID: PMC9825285 DOI: 10.1093/ibd/izac061] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Tofacitinib is an oral, small molecule JAK inhibitor for the treatment of ulcerative colitis (UC). These post hoc analyses assessed associations between C-reactive protein (CRP), partial Mayo score (PMS), and efficacy outcomes during tofacitinib induction in UC. METHODS Patients received tofacitinib 10 mg twice daily (BID) in an 8-week, phase 2 induction study and 2 identical, 8-week, phase 3 induction studies (OCTAVE Induction 1&2); induction nonresponders (IndNR) received an additional 8 weeks of tofacitinib 10 mg BID in an open-label, long-term extension study. Associations between CRP and PMS, and efficacy outcomes (clinical response, clinical remission, endoscopic improvement, and endoscopic remission) were analyzed using univariate and multivariable logistic regression and receiver operating characteristic curves. RESULTS Changes from baseline in the logarithm of CRP ([log]CRP) and PMS at week 4 were associated with clinical response at week 8 (univariate: per unit, odds ratio [OR], 0.55 [95% confidence interval (CI), 0.48-0.62]; and 0.42 [0.37-0.47], respectively). Among IndNR, change from baseline in PMS at week 8 was associated with clinical response at week 16 (univariate: per unit, OR, 0.59; 95% CI, 0.46-0.75). C-reactive protein at week 4 (area under the curve [AUC] > 0.6) and PMS at weeks 2 and 4 (AUC, > 0.7) generally exhibited predictive value for week 8 efficacy outcomes. CONCLUSIONS Patients who achieved clinical response at week 8 had larger decreases in CRP and PMS at week 4 than patients who did not. IndNR who achieved clinical response at week 16 with extended tofacitinib induction had a larger decrease in PMS at week 8 vs those who did not. ClinicalTrials.gov:NCT00787202;NCT01465763;NCT01458951;NCT01470612.
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Affiliation(s)
- Marla C Dubinsky
- Address correspondence to: Marla C. Dubinsky, Chief of Pediatric Gastroenterology and Nutrition, Co-Director, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA ()
| | - Fernando Magro
- University of Porto and Centro Hospitalar São João, Porto, Portugal
| | - Flavio Steinwurz
- Unit of Inflammatory Bowel Disease, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Jami A Kinnucan
- Mayo Clinic Division of Gastroenterology and Hepatology, Jacksonville, FL, USA
| | - Ryan C Ungaro
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Markus F Neurath
- Department of Medicine, University of Erlangen-Nürnberg, University Hospital, Erlangen, Germany
| | | | | | | | | | - Miguel Regueiro
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
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Abou-Hanna JJ, Owens ST, Kinnucan JA, Mian SI, Kolars JC. Resuscitating the Socratic Method: Student and Faculty Perspectives on Posing Probing Questions During Clinical Teaching. Acad Med 2021; 96:113-117. [PMID: 33394663 DOI: 10.1097/acm.0000000000003580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE Teaching by way of asking questions is a time-honored practice that has taken on the negative connotation of "pimping" among medical students and has made some faculty hesitant to ask students questions during clerkship rotations. Yet, quantitative studies exploring student perspectives on this practice are limited. This study aimed to solicit student and faculty views and investigate faculty perceptions of students' preferences. METHOD Students who completed their internal medicine clerkship during the 2017-2018 academic year (n = 165) and were from the 2020 graduating class and their supervising faculty (n = 144) at the University of Michigan Medical School were asked to complete a Likert response survey in April 2019. The survey solicited perspectives on questions probing medical knowledge posed to students by faculty. Surveys were constructed using an iterative process, and data were analyzed using t tests and linear regressions. RESULTS A total of 140 (85%) students and 112 (78%) faculty participated. Of those, 125 (89%) students and 109 (97%) faculty agreed that probing questions are valuable for student education, but only 73 (65%) faculty perceived that students agreed with this statement (P < .001). In addition, 115 (82%) students preferred to be asked too many questions than none at all. Fifty-five (39%) students agreed that they feel humiliated when they answer a question incorrectly. However, only 7 (5%) students agreed that faculty ask questions to humiliate them, and only 20 (14%) preferred that faculty stop asking questions if they answer a question incorrectly. CONCLUSIONS Students valued probing questions more than faculty perceived, which argues against a withdrawal from the Socratic teaching method in the clinical arena. The students' experience of humiliation when answering incorrectly requires further study and perhaps can be tempered by more explicit framing of the role of the questioning process.
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Affiliation(s)
- Jacob J Abou-Hanna
- J.J. Abou-Hanna was a fourth-year student, University of Michigan Medical School, Ann Arbor, Michigan, at the time of this work. He is currently a first-year resident, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - Sonal T Owens
- S.T. Owens is associate professor, Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jami A Kinnucan
- J.A. Kinnucan is assistant professor, Department of Internal Medicine, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Shahzad I Mian
- S.I. Mian is professor, Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Joseph C Kolars
- J.C. Kolars is senior associate dean for education and global initiatives, University of Michigan Medical School, Ann Arbor, Michigan
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Riehl ME, Kinnucan JA, Chey WD, Stidham RW. Nuances of the psychogastroenterology patient: A predictive model for gastrointestinal quality of life improvement. Neurogastroenterol Motil 2019; 31:e13663. [PMID: 31206935 DOI: 10.1111/nmo.13663] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/31/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastrointestinal conditions are multifactorial in nature, and certain patients can benefit greatly from brain-gut psychotherapies delivered by mental health professionals who specialize in psychogastroenterology. This study aimed to identify features associated with improvements in GI-specific quality of life scores following behavioral health interventions (BHI). The second aim was to create a psychogastroenterology referral care pathway incorporating identified characteristics for greatest benefit from GI-specific behavioral therapy. METHODS We performed a prospective observational study of 101 (63 women; median age, 45 years) gastroenterology patients referred for psychogastroenterology consultation at a single center. Patients attended an average of seven sessions with a single GI psychologist where evidence-based brain-gut psychotherapies were employed. GI-specific quality of life (IBS-QOL) and psychological distress (BSI-18) were assessed before and after BHI. Patients completed self-reported questionnaires. We performed a multivariable analysis to determine predictors associated with IBS-QOL score improvement. KEY RESULTS A total of 53 (52.5%) patients experienced improvement in IBS-QOL score. Patients with improved IBS-QOL scores had significantly higher baseline BSI general domain T-scores (61.9 vs. 56.9, P = 0.002). Female gender (odds ratio [OR], 3.2), pretreatment BSI somatization T-score ≥63 (OR, 3.7), and a diagnosis of depression (OR, 4.2) were associated with greater odds of IBS-QOL score improvement following BHI. CONCLUSIONS AND INFERENCES We identified factors associated with response to GI-specific BHI to aid in optimizing the utilization of psychogastroenterology services and provide referring providers with information to inform treatment recommendations. Female patients with disorders of gut-brain interaction (DGBIs), high somatization, and depression should be considered a priority for brain-gut psychotherapies.
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Affiliation(s)
- Megan E Riehl
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jami A Kinnucan
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - William D Chey
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan W Stidham
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
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Rubin DT, Huo D, Kinnucan JA, Sedrak MS, McCullom NE, Bunnag AP, Raun-Royer EP, Cohen RD, Hanauer SB, Hart J, Turner JR. Inflammation is an independent risk factor for colonic neoplasia in patients with ulcerative colitis: a case-control study. Clin Gastroenterol Hepatol 2013; 11:1601-8.e1-4. [PMID: 23872237 PMCID: PMC3840031 DOI: 10.1016/j.cgh.2013.06.023] [Citation(s) in RCA: 209] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 06/15/2013] [Accepted: 06/18/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS An association between inflammatory activity and colorectal neoplasia (CRN) has been documented in patients with ulcerative colitis (UC). However, previous studies did not address the duration of inflammation or the effects of therapy on risk for CRN. We investigated the effects of inflammation, therapies, and characteristics of patients with UC on their risk for CRN. METHODS We collected data from 141 patients with UC without CRN (controls) and 59 matched patients with UC who developed CRN (cases), comparing disease extent and duration and patients' ages. We used a new 6-point histologic inflammatory activity (HIA) scale to score biopsy fragments (n = 4449). Information on medications, smoking status, primary sclerosing cholangitis, and family history of CRN were collected from the University of Chicago Inflammatory Bowel Disease Endoscopy Database. Relationships between HIA, clinical features, and CRN were assessed by conditional logistic regression. RESULTS Cases and controls were similar in numbers of procedures and biopsies, exposure to steroids or mesalamine, smoking status, and family history of CRN. They differed in proportion of men vs women, exposure to immune modulators, and primary sclerosing cholangitis prevalence. In univariate analysis, HIA was positively associated with CRN (odds ratio [OR], 2.56 per unit increase; P = .001), whereas immune modulators (including azathioprine, 6-mercaptopurine, and methotrexate) reduced the risk for CRN (OR, 0.35; P < .01). HIA was also associated with CRN in multivariate analysis (OR, 3.68; P = .001). CONCLUSIONS In a case-control study, we associated increased inflammation with CRN in patients with UC. Use of immune modulators reduced the risk for CRN, indicating that these drugs have chemoprotective effects. On the basis of these data, we propose new stratified surveillance and treatment strategies to prevent and detect CRN in patients with UC.
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Affiliation(s)
- David T. Rubin
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Dezheng Huo
- Department of Health Studies, University of Chicago Medical Center, Chicago, IL, USA
| | - Jami A. Kinnucan
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Mina S. Sedrak
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Nicole E. McCullom
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Alana P. Bunnag
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Elin P. Raun-Royer
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Russell D. Cohen
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Stephen B. Hanauer
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - John Hart
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
,Department of Pathology, University of Chicago Medical Center, Chicago, IL, USA
| | - Jerrold R. Turner
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
,Department of Pathology, University of Chicago Medical Center, Chicago, IL, USA
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Kinnucan JA, Rubin DT, Ali T. Sleep and inflammatory bowel disease: exploring the relationship between sleep disturbances and inflammation. Gastroenterol Hepatol (N Y) 2013; 9:718-727. [PMID: 24764789 PMCID: PMC3995194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Sleep disturbances are associated with a greater risk of serious adverse health events, economic consequences, and, most importantly, increased all-cause mortality. Several studies support the associations among sleep, immune function, and inflammation. The relationship between sleep disturbances and inflammatory conditions is complex and not completely understood. Sleep deprivation can lead to increased levels of inflammatory cytokines, including interleukin (IL)-1β IL-6, tumor necrosis factor-α and C-reactive protein, which can lead to further activation of the inflammatory cascade. The relevance of sleep in inflammatory bowel disease (IBD), a chronic immune-mediated inflammatory disease of the gastrointestinal tract, has recently received more attention. Several studies have shown that patients with both inactive and active IBD have self-reported sleep disturbances. Here, we present a concise review of sleep and its association with the immune system and the process of inflammation. We discuss the studies that have evaluated sleep in patients with IBD as well as possible treatment options for those patients with sleep disturbances. An algorithm for evaluating sleep disturbances in the IBD population is also proposed. Further research is still needed to better characterize sleep disturbances in the IBD population as well as to assess the effects of various therapeutic interventions to improve sleep quality. It is possible that the diagnosis and treatment of sleep disturbances in this population may provide an opportunity to alter disease outcomes.
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Affiliation(s)
- Jami A Kinnucan
- Dr Kinnucan is a gastroenterology fellow and Dr Rubin is a professor of medicine and codirector of the Inflammatory Bowel Disease Center at the University of Chicago School of Medicine in Chicago, Illinois. Dr Ali is an assistant professor of medicine and the director of the OU Physicians Inflammatory Bowel Disease Center at the University of Oklahoma Health Sciences Center in Oklahoma City, Oklahoma
| | - David T Rubin
- Dr Kinnucan is a gastroenterology fellow and Dr Rubin is a professor of medicine and codirector of the Inflammatory Bowel Disease Center at the University of Chicago School of Medicine in Chicago, Illinois. Dr Ali is an assistant professor of medicine and the director of the OU Physicians Inflammatory Bowel Disease Center at the University of Oklahoma Health Sciences Center in Oklahoma City, Oklahoma
| | - Tauseef Ali
- Dr Kinnucan is a gastroenterology fellow and Dr Rubin is a professor of medicine and codirector of the Inflammatory Bowel Disease Center at the University of Chicago School of Medicine in Chicago, Illinois. Dr Ali is an assistant professor of medicine and the director of the OU Physicians Inflammatory Bowel Disease Center at the University of Oklahoma Health Sciences Center in Oklahoma City, Oklahoma
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Kinnucan JA, Hanauer SB. Reassessing the risks and benefits of thiopurines in Crohn's disease. Clin Gastroenterol Hepatol 2013; 11:395-7. [PMID: 23333707 DOI: 10.1016/j.cgh.2012.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 12/12/2012] [Accepted: 12/13/2012] [Indexed: 02/07/2023]
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