1
|
Greywoode R, Nahvi S, Ullman T, Keefer L. Feasibility and Acceptability of Digital Behavioral Interventions Among Black and Hispanic Patients With Inflammatory Bowel Disease: A Randomized Pilot Study. Inflamm Bowel Dis 2024:izae034. [PMID: 38427713 DOI: 10.1093/ibd/izae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Indexed: 03/03/2024]
Abstract
Lay Summary
The use of digital behavioral interventions was tested among patients with inflammatory bowel disease with a predominately low-income, Black/Hispanic background who had elevated symptoms of anxiety/depression. Both mood-tracking and cognitive behavioral self-management applications were feasible and acceptable to use, with opportunities for improvement identified.
Collapse
Affiliation(s)
- Ruby Greywoode
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Shadi Nahvi
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Thomas Ullman
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Laurie Keefer
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
2
|
Dubinsky MC, Armuzzi A, Gecse KB, Ullman T, Bushmakin AG, DiBonaventura M, Cappelleri JC, Connelly SB, Woolcott JC, Salese L. Improvements in disease activity partially mediate the effect of tofacitinib treatment on generic and disease-specific health-related quality of life in patients with ulcerative colitis: data from the OCTAVE program. Dig Dis 2023:000528788. [PMID: 36603566 PMCID: PMC10389790 DOI: 10.1159/000528788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 11/14/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients with ulcerative colitis (UC) often report impaired health-related quality of life (HRQoL). Tofacitinib is an oral small molecule Janus kinase inhibitor for the treatment of UC. In addition to previous demonstrations of improved clinical measures (e.g., Mayo score), tofacitinib has been shown to improve HRQoL in patients with UC. This analysis explored the interrelationships among tofacitinib treatment, HRQoL, and disease activity (measured using Mayo subscores) using mediation modeling. METHODS Data were collected from two 8-week induction studies (OCTAVE Induction 1 and 2) in patients with moderate to severe UC treated with tofacitinib or placebo. Two mediation models were specified. First, Mayo subscores were mediators between the binary treatment variable (tofacitinib vs placebo) and the eight Short Form-36 Health Survey (SF 36) domain scores as outcomes. Second, the four Inflammatory Bowel Disease Questionnaire (IBDQ) domain scores served as outcomes. Both models used data collected at Week 8. RESULTS Overall, 1073 and 1079 patients were included in the SF-36- and IBDQ-based models, respectively. For all SF-36 domains, improvements in Mayo subscores were estimated to explain 65.6% (bodily pain) to 92.9% (mental health) of the total treatment effect on SF-36 domain scores (all p<0.05). For all IBDQ domains, improvements in Mayo subscores explained 71.6% (systemic symptoms) to 84.7% (emotional function) of the total treatment effect (all p<0.05). CONCLUSION Mayo scores and Mayo subscores are significant but incomplete contributors to tofacitinib's effect on HRQoL in patients with moderate to severe UC. CLINICALTRIALS gov: NCT01465763; NCT01458951.
Collapse
|
3
|
Greywoode R, Ullman T, Keefer L. National Prevalence of Psychological Distress and Use of Mental Health Care in Inflammatory Bowel Disease. Inflamm Bowel Dis 2023; 29:70-75. [PMID: 35325138 PMCID: PMC9825280 DOI: 10.1093/ibd/izac050] [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: 11/11/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Individuals with inflammatory bowel disease (IBD) have elevated symptoms of anxiety and depression. The burden of such symptoms, accompanied by functional impairment in IBD, is not well documented, nor is utilization of mental health care in this population. METHODS Adults ≥18 years were identified in the cross-sectional 2015-2016 National Health Interview Survey. Responses from the Kessler Index were used to estimate the national prevalence of psychological distress with impairment and mental health-care use in IBD. Factors associated with psychological distress with impairment in IBD were analyzed using logistic regression. RESULTS The prevalence of psychological distress with impairment was significantly higher in IBD than non-IBD adults (7.69% vs. 3.50%, respectively; P < .01). Among those with IBD and psychological distress with impairment, only a third (36.29%) had seen or talked to a mental health provider in the preceding 12 months. About half of these found the cost of mental health care unaffordable. On multivariable analysis, factors associated with psychological distress in IBD included increasing emergency room visits and trouble finding a health provider. CONCLUSIONS A significant number of adults with IBD in the United States have psychological distress accompanied by functional impairment. However, mental health care is underutilized in this population. Many of these individuals find the cost of mental health care unaffordable, struggle to find a health provider, and experience repeated emergency room visits. Ongoing efforts to improve mental health care in IBD should address issues of access and cost. Additionally, these efforts should seek to understand other barriers to mental health-care use.
Collapse
Affiliation(s)
- Ruby Greywoode
- Assistant Professor of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Thomas Ullman
- Professor of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Laurie Keefer
- Professor of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
4
|
Hong SJ, Bhattacharya S, Aboubakr A, Nadkarni D, Lech D, Ungaro RC, Agrawal M, Hirten RP, Greywoode R, Mone A, Chang S, Hudesman DP, Ullman T, Sultan K, Lukin DJ, Colombel JF, Axelrad JE. COVID-19 is not associated with worse long-term inflammatory bowel disease outcomes: a multicenter case-control study. Therap Adv Gastroenterol 2022; 15:17562848221132363. [PMID: 36348637 PMCID: PMC9637830 DOI: 10.1177/17562848221132363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is not associated with worse coronavirus disease 2019 (COVID-19) outcomes. However, data are lacking regarding the long-term impact of severe acute respiratory syndrome coronavirus 2 infection on the disease course of IBD. OBJECTIVES We aimed to investigate the effect of COVID-19 on long-term outcomes of IBD. DESIGN We performed a multicenter case-control study of patients with IBD and COVID-19 between February 2020 and December 2020. METHODS Cases and controls were individuals with IBD with presence or absence, respectively, of COVID-19-related symptoms and confirmatory testing. The primary composite outcome was IBD-related hospitalization or surgery. RESULTS We identified 251 cases [ulcerative colitis (n = 111, 45%), Crohn's disease (n = 139, 55%)] and 251 controls, with a median follow-up of 394 days. The primary composite outcome of IBD-related hospitalization or surgery occurred in 29 (12%) cases versus 38 (15%) controls (p = 0.24) and on multivariate Cox regression, COVID-19 was not associated with increased risk of adverse IBD outcomes [adjusted hazard ratio (aHR): 0.84, 95% confidence interval [CI]: 0.44-1.42]. When stratified by infection severity, severe COVID-19 was associated with a numerically increased risk of adverse IBD outcomes (aHR: 2.43, 95% CI: 1.00-5.86), whereas mild-to-moderate COVID-19 was not (aHR: 0.68, 95% CI: 0.38-1.23). CONCLUSION In this case-control study, COVID-19 did not have a long-term impact on the disease course of IBD. However, severe COVID-19 was numerically associated with worse IBD outcomes, underscoring the continued importance of risk mitigation and prevention strategies for patients with IBD during the ongoing COVID-19 pandemic.
Collapse
Affiliation(s)
| | - Sumona Bhattacharya
- Inflammatory Bowel Disease Center, Division of
Gastroenterology, NYU Langone Health, New York, NY, USA
| | - Aiya Aboubakr
- Jill Roberts Center for Inflammatory Bowel
Disease, Division of Gastroenterology and Hepatology, Department of
Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Devika Nadkarni
- The Dr. Henry D. Janowitz Division of
Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
| | - Diana Lech
- Division of Gastroenterology, Northwell Health,
North Shore University Hospital and Long Island Jewish Medical Center, Great
Neck, NY, USA
| | - Ryan C. Ungaro
- The Dr. Henry D. Janowitz Division of
Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
| | - Manasi Agrawal
- The Dr. Henry D. Janowitz Division of
Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
| | - Robert P. Hirten
- The Dr. Henry D. Janowitz Division of
Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
| | - Ruby Greywoode
- Division of Gastroenterology, Montefiore
Medical Center, Bronx, NY, USA
| | - Anjali Mone
- Division of Gastroenterology, Northwell
Health, North Shore University Hospital and Long Island Jewish Medical
Center, Great Neck, NY, USA
| | - Shannon Chang
- Inflammatory Bowel Disease Center, Division of
Gastroenterology, NYU Langone Health, New York, NY, USA
| | - David P. Hudesman
- Inflammatory Bowel Disease Center, Division of
Gastroenterology, NYU Langone Health, New York, NY, USA
| | - Thomas Ullman
- Division of Gastroenterology, Montefiore
Medical Center, Bronx, NY, USA
| | - Keith Sultan
- Division of Gastroenterology, Northwell
Health, North Shore University Hospital and Long Island Jewish Medical
Center, Great Neck, NY, USA
| | - Dana J. Lukin
- Jill Roberts Center for Inflammatory Bowel
Disease, Division of Gastroenterology and Hepatology, Department of
Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of
Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
| | - Jordan E. Axelrad
- Inflammatory Bowel Disease Center, Division of
Gastroenterology, NYU Langone Health, New York, NY, USA
| |
Collapse
|
5
|
Mahmoud R, Shah SC, Torres J, Castaneda D, Glass J, Elman J, Kumar A, Axelrad J, Harpaz N, Ullman T, Colombel JF, Oldenburg B, Itzkowitz SH. Association Between Indefinite Dysplasia and Advanced Neoplasia in Patients With Inflammatory Bowel Diseases Undergoing Surveillance. Clin Gastroenterol Hepatol 2020; 18:1518-1527.e3. [PMID: 31446183 PMCID: PMC7354098 DOI: 10.1016/j.cgh.2019.08.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 07/29/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Little is known about the clinical significance of indefinite dysplasia (IND) in patients with inflammatory bowel diseases (IBD) undergoing colonoscopic surveillance for colorectal neoplasia. METHODS We conducted a retrospective cohort analysis of 492 patients with colonic IBD for 8 or more years or concomitant primary sclerosing cholangitis, with no history of advanced colorectal neoplasia (high-grade dysplasia or colorectal cancer) or colectomy, undergoing colorectal neoplasia surveillance at a tertiary IBD referral center from 2001 through 2017. Subjects received consistent histopathologic grading of dysplasia. We collected data on time to development of (advanced) colorectal neoplasia or colectomy using Kaplan Meier methods. We identified factors independently associated with (advanced) colorectal neoplasia with multivariable Cox regression analysis. RESULTS After 2149 person-years of follow-up, 53 patients (10.8%) received a diagnosis of IND without prior or synchronous low-grade dysplasia (LGD). Compared to patients without dysplasia, patients with IND had a significantly higher risk of advanced colorectal neoplasia (adjusted hazard ratio, 6.85; 95% CI, 1.78-26.4) and colorectal neoplasia (adjusted hazard ratio, 3.25; 95% CI, 1.50-7.05), but not colectomy (P = .78). Compared to IND, LGD was associated with a significantly higher risk of advanced colorectal neoplasia (P = .05). Following a diagnosis of no dysplasia, IND only, or LGD, the incidence rates of advanced colorectal neoplasia were 0.4% per patient-year, 3.1% per patient-year, and 8.4% per patient-year, respectively. CONCLUSIONS In a retrospective analysis of patients with IBD undergoing colorectal neoplasia surveillance with consistent histopathologic grading of dysplasia, IND was independently associated with a significant increase in risk of advanced colorectal neoplasia. These findings require validation and if confirmed, a reappraisal of the colorectal neoplasia surveillance guidelines.
Collapse
Affiliation(s)
- Remi Mahmoud
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Shailja C. Shah
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joana Torres
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Daniel Castaneda
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jason Glass
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Internal Medicine, Division of Digestive and Liver Sciences, University of Texas Southwestern, Dallas, TX, USA
| | - Jordan Elman
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Akash Kumar
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jordan Axelrad
- Inflammatory Bowel Disease Center, NYU Langone Health, Division of Gastroenterology NYU School of Medicine, New York, NY, USA
| | - Noam Harpaz
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas Ullman
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Montefiore Hospital, New York, NY, USA
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H. Itzkowitz
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
6
|
Ungaro RC, Limketkai BN, Jensen CB, Yzet C, Allin KH, Agrawal M, Ullman T, Burisch J, Jess T, Colombel JF. Stopping Mesalamine Therapy in Patients With Crohn's Disease Starting Biologic Therapy Does Not Increase Risk of Adverse Outcomes. Clin Gastroenterol Hepatol 2020; 18:1152-1160.e1. [PMID: 31419574 PMCID: PMC7015801 DOI: 10.1016/j.cgh.2019.08.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/01/2019] [Accepted: 08/02/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Little is known about the effects of discontinuing mesalamine therapy for patients with Crohn's disease (CD) who initiate therapy with an anti-tumor necrosis factor (anti-TNF) agent. We analyzed data from 2 national population cohorts to compare outcomes of patients with CD already on mesalamine therapy who started treatment with an anti-TNF agent and then either stopped or continued mesalamine. METHODS The primary outcome was any adverse clinical event, defined as a composite of new corticosteroid use or CD-related hospitalization or surgery. We collected data from the Truven MarketScan (IBM, Armonk, NY) health claims database in the United States and the Danish health registers. Our analysis included patients with CD who started anti-TNF therapy after at least 90 days of oral mesalamine therapy. Patients were classified as stopping mesalamine if therapy was discontinued within 90 days of starting anti-TNF. We performed multivariable Cox regression models controlling for demographics, clinical factors, and health care utilization. Adjusted hazard ratios with 95% CIs were calculated, comparing stopping mesalamine with continuing mesalamine. RESULTS A total of 3178 patients with CD were included in our final analysis (2960 in the United States and 218 in Denmark). Stopping mesalamine after initiating anti-TNF therapy was not associated with an increased risk of adverse clinical events in the US cohort (adjusted hazard ratio, 0.89; 95% CI, 0.77-1.03; P = .13) or in the Danish cohort (adjusted hazard ratio, 1.13; 95% CI, 0.68-1.87; P = .63). Similar results were obtained from sensitivity analyses of concomitant immunomodulator use and duration of mesalamine treatment before initiation of anti-TNF therapy. CONCLUSIONS In a retrospective analysis of 2 national databases, we found that stopping mesalamine therapy for patients with CD who were starting anti-TNF therapy did not increase their risk of adverse clinical events. These results should be validated in a prospective study.
Collapse
Affiliation(s)
- Ryan C. Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Berkeley N. Limketkai
- Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Camilla Bjørn Jensen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
| | - Clara Yzet
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kristine H Allin
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
| | - Manasi Agrawal
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Thomas Ullman
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Johan Burisch
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
| | - Tine Jess
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
7
|
Papamichael K, Cheifetz AS, Melmed GY, Irving PM, Casteele NV, Kozuch PL, Raffals LE, Baidoo L, Bressler B, Devlin SM, Jones J, Kaplan GG, Sparrow MP, Velayos FS, Ullman T, Siegel CA. Appropriate Therapeutic Drug Monitoring of Biologic Agents for Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2019; 17:1655-1668.e3. [PMID: 30928454 PMCID: PMC6661210 DOI: 10.1016/j.cgh.2019.03.037] [Citation(s) in RCA: 192] [Impact Index Per Article: 38.4] [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: 10/23/2018] [Revised: 02/24/2019] [Accepted: 03/24/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Therapeutic drug monitoring (TDM) is widely available for biologic therapies in patients with inflammatory bowel disease (IBD). We reviewed current data and provided expert opinion regarding the clinical utility of TDM for biologic therapies in IBD. METHODS We used a modified Delphi method to establish consensus. A comprehensive literature review was performed regarding the use of TDM of biologic therapy in IBD and presented to international IBD specialists. Subsequently, 28 statements on the application of TDM in clinical practice were rated on a scale of 1 to 10 (1 = strongly disagree and 10 = strongly agree) by each of the panellists. Statements were accepted if 80% or more of the participants agreed with a score ≥7. The remaining statements were discussed and revised based on the available evidence followed by a second round of voting. RESULTS The panel agreed on 24 (86%) statements. For anti-tumor necrosis factor (anti-TNF) therapies, proactive TDM was found to be appropriate after induction and at least once during maintenance therapy, but this was not the case for the other biologics. Reactive TDM was appropriate for all agents both for primary non-response and secondary loss of response. The panellists also agreed on several statements regarding TDM and appropriate drug and anti-drug antibody (ADA) concentration thresholds for biologics in specific clinical scenarios. CONCLUSION Consensus was achieved towards the utility of TDM of biologics in IBD, particularly anti-TNF therapies. More data are needed especially on non-anti-TNF biologics to further define optimal drug concentration and ADA thresholds as these can vary depending on the therapeutic outcomes assessed.
Collapse
Affiliation(s)
| | | | - Gil Y. Melmed
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | | | | | | | | | | | | | | | | | | | - Thomas Ullman
- Montefiore Medical Center/Albert Einstein College Medicine, Bronx, NY
| | | |
Collapse
|
8
|
Ungaro RC, Limketkai BN, Jensen CB, Allin KH, Agrawal M, Ullman T, Colombel JF, Jess T. Stopping 5-aminosalicylates in patients with ulcerative colitis starting biologic therapy does not increase the risk of adverse clinical outcomes: analysis of two nationwide population-based cohorts. Gut 2019; 68:977-984. [PMID: 30420398 PMCID: PMC7057119 DOI: 10.1136/gutjnl-2018-317021] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/04/2018] [Accepted: 10/06/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The benefit of continuing 5-aminosalicylate (5-ASA) in patients with ulcerative colitis (UC) who initiate anti-tumour necrosis factor-alpha (anti-TNF) biologics is unknown. We aimed to compare clinical outcomes in patients with UC already on 5-ASA who started anti-TNF and then either stopped or continued 5-ASA. DESIGN Our primary outcome was any adverse clinical event defined as a composite of new corticosteroid use, UC-related hospitalisation or surgery. We used two national databases: the United States (US) Truven MarketScan health claims database and the Danish health registers. Patients with UC who started anti-TNF after having been on oral 5-ASA for at least 90 days were included. Patients were classified as stopping 5-ASA if therapy was discontinued within 90 days of starting anti-TNF. We performed multivariable Cox regression models controlling for demographics, clinical factors and healthcare utilisation. Adjusted HRs (aHR) with 95% CI are reported comparing stopping 5-ASA with continuing 5-ASA. RESULTS A total of 3589 patients with UC were included (2890 US and 699 Denmark). Stopping 5-ASA after initiating anti-TNF was not associated with an increased risk of adverse clinical events in the U.S. cohort (aHR 1.04; 95% CI 0.90 to 1.21, p=0.57) nor in the Danish cohort (aHR 1.09; 95% CI 0.80 to 1.49, p=0.60). Results were similar in sensitivity analyses investigating concomitant immunomodulator use and duration of 5-ASA treatment before initiating anti-TNF. CONCLUSION In two national databases, stopping 5-ASA in patients with UC starting anti-TNF therapy did not increase the risk of adverse clinical events. These results should be validated in a prospective clinical trial.
Collapse
Affiliation(s)
- Ryan C Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Berkeley N Limketkai
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Camilla Bjørn Jensen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
| | - Kristine Højgaard Allin
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
| | - Manasi Agrawal
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Thomas Ullman
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Tine Jess
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
| |
Collapse
|
9
|
Mahmoud R, Shah SC, ten Hove JR, Torres J, Mooiweer E, Castaneda D, Glass J, Elman J, Kumar A, Axelrad J, Ullman T, Colombel JF, Oldenburg B, Itzkowitz SH. No Association Between Pseudopolyps and Colorectal Neoplasia in Patients With Inflammatory Bowel Diseases. Gastroenterology 2019; 156:1333-1344.e3. [PMID: 30529584 PMCID: PMC7354096 DOI: 10.1053/j.gastro.2018.11.067] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 11/21/2018] [Accepted: 11/29/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel diseases who have postinflammatory polyps (PIPs) have an increased risk of colorectal neoplasia (CRN). European guidelines propose that patients with PIPs receive more frequent surveillance colonoscopies, despite limited evidence of this increased risk. We aimed to define the risk of CRN and colectomy in patients with inflammatory bowel diseases and PIPs. METHODS We conducted a multicenter retrospective cohort study of patients with inflammatory bowel diseases who underwent colonoscopic surveillance for CRN, from January 1997 through January 2017, at 5 academic hospitals and 2 large nonacademic hospitals in New York or the Netherlands. Eligible patients had confirmed colonic disease with duration of at least 8 years (or any duration, if they also had primary sclerosing cholangitis) and no history of advanced CRN (high-grade dysplasia or colorectal cancer) or colectomy. The primary outcome was occurrence of advanced CRN according to PIP status; secondary outcomes were occurrence of CRN (inclusive of low-grade dysplasia) and colectomy. RESULTS Of 1582 eligible patients, 462 (29.2%) had PIPs. PIPs were associated with more severe inflammation (adjusted odds ratio 1.32; 95% confidence interval [CI] 1.13-1.55), greater disease extent (adjusted odds ratio 1.92; 95% CI 1.34-2.74), and lower likelihood of primary sclerosing cholangitis (adjusted odds ratio 0.38; 95% CI 0.26-0.55). During a median follow-up period of 4.8 years, the time until development of advanced CRN did not differ significantly between patients with and those without PIPs. PIPs did not independently increase the risk of advanced CRN (adjusted hazard ratio 1.17; 95% CI 0.59-2.31). The colectomy rate was significantly higher in patients with PIPs (P = .01). CONCLUSIONS In a retrospective analysis of data from 2 large independent surveillance cohorts, PIPs were associated with greater severity and extent of colon inflammation and higher rates of colectomy, but were not associated with development of any degree of CRN. Therefore, intervals for surveillance should not be shortened based solely on the presence of PIPs.
Collapse
Affiliation(s)
- Remi Mahmoud
- Department of Gastroenterology and Hepatology, University
Medical Center Utrecht, Utrecht, The Netherlands.,Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shailja C. Shah
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Hepatology and Nutrition,
Department of Medicine, Vanderbilt University Medical Center, Nashville, TN,
USA
| | - Joren R. ten Hove
- Department of Gastroenterology and Hepatology, University
Medical Center Utrecht, Utrecht, The Netherlands
| | - Joana Torres
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Surgical Department,
Hospital Beatriz Ângelo, Loures, Portugal
| | - Erik Mooiweer
- Department of Gastroenterology and Hepatology, University
Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniel Castaneda
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jason Glass
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jordan Elman
- Department of Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Akash Kumar
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jordan Axelrad
- Division of Digestive and Liver Diseases, Department of
Medicine, Columbia University Medical Center, New York, NY, USA
| | - Thomas Ullman
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University
Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H. Itzkowitz
- Division of Gastroenterology, Department of Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | |
Collapse
|
10
|
Contijoch EJ, Britton GJ, Yang C, Mogno I, Li Z, Ng R, Llewellyn SR, Hira S, Johnson C, Rabinowitz KM, Barkan R, Dotan I, Hirten RP, Fu SC, Luo Y, Yang N, Luong T, Labrias PR, Lira S, Peter I, Grinspan A, Clemente JC, Kosoy R, Kim-Schulze S, Qin X, Castillo A, Hurley A, Atreja A, Rogers J, Fasihuddin F, Saliaj M, Nolan A, Reyes-Mercedes P, Rodriguez C, Aly S, Santa-Cruz K, Peters L, Suárez-Fariñas M, Huang R, Hao K, Zhu J, Zhang B, Losic B, Irizar H, Song WM, Di Narzo A, Wang W, Cohen BL, DiMaio C, Greenwald D, Itzkowitz S, Lucas A, Marion J, Maser E, Ungaro R, Naymagon S, Novak J, Shah B, Ullman T, Rubin P, George J, Legnani P, Telesco SE, Friedman JR, Brodmerkel C, Plevy S, Cho JH, Colombel JF, Schadt EE, Argmann C, Dubinsky M, Kasarskis A, Sands B, Faith JJ. Gut microbiota density influences host physiology and is shaped by host and microbial factors. eLife 2019; 8:e40553. [PMID: 30666957 PMCID: PMC6342524 DOI: 10.7554/elife.40553] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 01/04/2019] [Indexed: 12/14/2022] Open
Abstract
To identify factors that regulate gut microbiota density and the impact of varied microbiota density on health, we assayed this fundamental ecosystem property in fecal samples across mammals, human disease, and therapeutic interventions. Physiologic features of the host (carrying capacity) and the fitness of the gut microbiota shape microbiota density. Therapeutic manipulation of microbiota density in mice altered host metabolic and immune homeostasis. In humans, gut microbiota density was reduced in Crohn's disease, ulcerative colitis, and ileal pouch-anal anastomosis. The gut microbiota in recurrent Clostridium difficile infection had lower density and reduced fitness that were restored by fecal microbiota transplantation. Understanding the interplay between microbiota and disease in terms of microbiota density, host carrying capacity, and microbiota fitness provide new insights into microbiome structure and microbiome targeted therapeutics. Editorial note This article has been through an editorial process in which the authors decide how to respond to the issues raised during peer review. The Reviewing Editor's assessment is that all the issues have been addressed (see decision letter).
Collapse
|
11
|
Côté-Daigneault J, Peerani F, Katsanos K, Ullman T, Marion J, Legnani P, Cohen B, Colombel JF. Agreement Between Crohn's Disease Endoscopic Severity Scores Derived from Live, Video-recorded, and Central Readings. Inflamm Bowel Dis 2018; 24:e6-e7. [PMID: 29688478 DOI: 10.1093/ibd/izy138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Justin Côté-Daigneault
- Division of Gastroenterology, Department of Medicine, CHUM, University of Montreal, Quebec, Canada
| | - Farhad Peerani
- Division of Gastroenterology, Department of Medicine, University of Alberta, Alberta, Canada
| | - Konstantinos Katsanos
- Division of Gastroenterology, Department of Internal Medicine, University of Ioannina School of Medical Sciences, Ioannina, Greece
| | - Thomas Ullman
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - James Marion
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Peter Legnani
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Benjamin Cohen
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Jean-Frédéric Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York
| |
Collapse
|
12
|
Tang MS, Bowcutt R, Leung JM, Wolff MJ, Gundra UM, Hudesman D, Malter LB, Poles MA, Chen LA, Pei Z, Neto AG, Abidi WM, Ullman T, Mayer L, Bonneau RA, Cho I, Loke P. Integrated Analysis of Biopsies from Inflammatory Bowel Disease Patients Identifies SAA1 as a Link Between Mucosal Microbes with TH17 and TH22 Cells. Inflamm Bowel Dis 2017; 23:1544-1554. [PMID: 28806280 PMCID: PMC5613756 DOI: 10.1097/mib.0000000000001208] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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] [Indexed: 01/01/2023]
Abstract
BACKGROUND Inflammatory bowel diseases (IBD) are believed to be driven by dysregulated interactions between the host and the gut microbiota. Our goal is to characterize and infer relationships between mucosal T cells, the host tissue environment, and microbial communities in patients with IBD who will serve as basis for mechanistic studies on human IBD. METHODS We characterized mucosal CD4 T cells using flow cytometry, along with matching mucosal global gene expression and microbial communities data from 35 pinch biopsy samples from patients with IBD. We analyzed these data sets using an integrated framework to identify predictors of inflammatory states and then reproduced some of the putative relationships formed among these predictors by analyzing data from the pediatric RISK cohort. RESULTS We identified 26 predictors from our combined data set that were effective in distinguishing between regions of the intestine undergoing active inflammation and regions that were normal. Network analysis on these 26 predictors revealed SAA1 as the most connected node linking the abundance of the genus Bacteroides with the production of IL17 and IL22 by CD4 T cells. These SAA1-linked microbial and transcriptome interactions were further reproduced with data from the pediatric IBD RISK cohort. CONCLUSIONS This study identifies expression of SAA1 as an important link between mucosal T cells, microbial communities, and their tissue environment in patients with IBD. A combination of T cell effector function data, gene expression and microbial profiling can distinguish between intestinal inflammatory states in IBD regardless of disease types.
Collapse
Affiliation(s)
- Mei San Tang
- Department of Microbiology, New York University School of Medicine, New York, NY, 10016, United States
| | - Rowann Bowcutt
- Department of Microbiology, New York University School of Medicine, New York, NY, 10016, United States
| | - Jacqueline M. Leung
- Department of Microbiology, New York University School of Medicine, New York, NY, 10016, United States
| | - Martin J. Wolff
- Department of Medicine, Division of Gastroenterology, New York University School of Medicine, New York, NY, United States
| | - Uma Mahesh Gundra
- Department of Microbiology, New York University School of Medicine, New York, NY, 10016, United States
| | - David Hudesman
- Department of Medicine, Division of Gastroenterology, New York University School of Medicine, New York, NY, United States
| | - Lisa B Malter
- Department of Medicine, Division of Gastroenterology, New York University School of Medicine, New York, NY, United States
| | - Michael A. Poles
- Department of Medicine, Division of Gastroenterology, New York University School of Medicine, New York, NY, United States
- Department of Veterans Affairs New York Harbor Healthcare System, New York, NY, United States
| | - Lea Ann Chen
- Department of Medicine, Division of Gastroenterology, New York University School of Medicine, New York, NY, United States
| | - Zhiheng Pei
- Department of Veterans Affairs New York Harbor Healthcare System, New York, NY, United States
- Department of Pathology, New York University School of Medicine, New York, NY, 10016, United States
| | - Antonio Galvao Neto
- Department of Pathology, New York University School of Medicine, New York, NY, 10016, United States
| | - Wasif M. Abidi
- Department of Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, NY, United States
| | - Thomas Ullman
- Department of Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, NY, United States
| | - Lloyd Mayer
- Immunology Institute, Mount Sinai School of Medicine, New York, New York 10029, USA
| | - Richard A. Bonneau
- Department of Biology, Center for Genomics and Systems Biology, New York University, New York, NY 10003, USA
- Simons Center for Data Analysis, Simons Foundation, New York, NY 10011, USA
| | - Ilseung Cho
- Department of Medicine, Division of Gastroenterology, New York University School of Medicine, New York, NY, United States
| | - P’ng Loke
- Department of Microbiology, New York University School of Medicine, New York, NY, 10016, United States
- Department of Medicine, Division of Gastroenterology, New York University School of Medicine, New York, NY, United States
| |
Collapse
|
13
|
Sandborn WJ, Colombel JF, Ghosh S, Sands BE, Dryden G, Hébuterne X, Leong RW, Bressler B, Ullman T, Lakatos PL, Reinisch W, Xu LA, Luo A. Eldelumab [Anti-IP-10] Induction Therapy for Ulcerative Colitis: A Randomised, Placebo-Controlled, Phase 2b Study. J Crohns Colitis 2016; 10:418-28. [PMID: 26721935 PMCID: PMC4946756 DOI: 10.1093/ecco-jcc/jjv224] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/30/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Interferon-γ-inducible protein-10 [IP-10] mediates immune cell trafficking from the circulation to the inflamed colon and decreases gut epithelial cell survival. IP-10 expression is increased in patients with ulcerative colitis [UC]. We report efficacy and safety results from a dose-ranging induction study of eldelumab, a fully human monoclonal antibody to IP-10, in moderately to severely active UC. METHODS A total of 252 adults with UC [Mayo score ≥ 6 and endoscopic subscore ≥ 2] were randomised 1:1:1 to placebo or eldelumab 15 or 25 mg/kg administered intravenously on Days 1 and 8 and every other week thereafter. The primary endpoint was clinical remission [Mayo score ≤ 2; no individual subscale score > 1] at Week 11. Key secondary endpoints included Mayo score clinical response and mucosal healing at Week 11. RESULTS Neither eldelumab 15 or 25 mg/kg resulted in significant increases vs placebo in the proportion of patients achieving Week 11 clinical remission. Remission and response rates were 17.6% and 47.1% with eldelumab 25mg/kg, 13.1% and 44.0% with eldelumab 15mg/kg, and 9.6% and 31.3% with placebo. Clinical remission and response rates were higher in anti-tumour necrosis factor [TNF]-naïve patients treated with eldelumab compared with placebo. Eldelumab treatment was well tolerated and no immunogenicity was observed. CONCLUSIONS The primary endpoint was not achieved with induction treatment with eldelumab 15 or 25 mg/kg in patients with UC. Trends towards clinical remission and response were observed in the overall population and were more pronounced in anti-TNF naïve patients. Eldelumab safety signals were consistent with those reported previously [ClinicalTrials.gov number, NCT01294410].
Collapse
Affiliation(s)
- William J. Sandborn
- Inflammatory Bowel Disease Center, University of California San Diego, La Jolla, CA, USA
| | - Jean-Frédéric Colombel
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Subrata Ghosh
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bruce E. Sands
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gerald Dryden
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
| | - Xavier Hébuterne
- Faculté de Médecine, Université de Nice-Sophia Antipolis, Hôpital de l’Archet, Nice, France
| | - Rupert W. Leong
- Concord Hospital, Gastroenterology and Liver Services, University of New South Wales, Sydney, Australia
| | - Brian Bressler
- Division of Gastroenterology, St Paul’s Hospital, Vancouver, BC, Canada
| | - Thomas Ullman
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter L. Lakatos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Walter Reinisch
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria, and McMaster University, Department of Internal Medicine, Hamilton, ON, Canada
| | - Li-An Xu
- Bristol-Myers Squibb, Lawrenceville, NJ, USA
| | - Allison Luo
- Formerly of Bristol-Myers Squibb, Lawrenceville, NJ, USA
| |
Collapse
|
14
|
Colombel JF, Ordás I, Ullman T, Rutgeerts P, Chai A, O'Byrne S, Lu TT, Panés J. Agreement Between Rectosigmoidoscopy and Colonoscopy Analyses of Disease Activity and Healing in Patients With Ulcerative Colitis. Gastroenterology 2016; 150:389-95.e3. [PMID: 26526713 DOI: 10.1053/j.gastro.2015.10.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 10/08/2015] [Accepted: 10/19/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Endoscopy limited to the rectosigmoid colon is the standard technique used to measure endoscopic healing in ulcerative colitis (UC) clinical trials. We evaluated whether rectosigmoidoscopy adequately measures UC activity in the more proximal colon. METHODS We analyzed data from a phase 2, placebo-controlled study that evaluated the efficacy and safety of etrolizumab in patients with moderate to severely active UC who had not responded to standard therapy. Central readers determined Mayo Clinic endoscopic subscores (MCSe) and ulcerative colitis endoscopic index of severity (UCEIS) scores from the rectosigmoid and proximal colon in videos of 331 examinations performed at baseline, week 6, and week 10. Rates of endoscopic healing (MCSe ≤ 1, MCSe = 0) and scores from rectosigmoidoscopy and colonoscopy analyses were compared among 239 examinations with endoscopic assessment proximal to the rectosigmoid colon. RESULTS There was a high degree of correlation between findings from rectosigmoidoscopy vs colonoscopy in assessment of disease activity based on MCSe of 2 or higher (r = 0.84) or MCSe of 1 or higher (r = 0.96), or the UCEIS score (r = 0.92). In 230 of 239 videos, findings from rectosigmoidoscopy agreed with those from colonoscopy in the detection of active disease (MCSe ≥ 2; n = 205) or healing (MCSe ≤ 1; n = 25). In 9 videos (2 taken at baseline, 7 taken after treatment), colonoscopy found proximal disease activity not detected by rectosigmoidoscopy. Post-treatment discordance was more frequent in the placebo group, affecting assessment of efficacy at week 10. When endoscopic healing was defined as MCSe of 0, there were discordant findings from only 1 video. CONCLUSIONS There is a high degree of correlation in assessments of UC activity made by rectosigmoidoscopy vs colonoscopy. For detection of endoscopic healing (MCSe ≤ 1), colonoscopy found persistent proximal lesions in the placebo group, which affected efficacy analyses. When endoscopic healing was defined as MCSe of 0, the concordance between rectosigmoidoscopy and colonoscopy was nearly perfect.
Collapse
Affiliation(s)
- Jean-Frédéric Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Ingrid Ordás
- Hospital Clínic de Barcelona, Institut D'Investigacions Biomédiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Thomas Ullman
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Paul Rutgeerts
- Department of Gastroenterology, University Hospital Leuven, Leuven, Belgium
| | - Akiko Chai
- Genentech Research and Early Development, South San Francisco, California
| | - Sharon O'Byrne
- Genentech Research and Early Development, South San Francisco, California
| | - Timothy T Lu
- Genentech Research and Early Development, South San Francisco, California
| | - Julián Panés
- Hospital Clínic de Barcelona, Institut D'Investigacions Biomédiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| |
Collapse
|
15
|
Laine L, Kaltenbach T, Barkun A, McQuaid KR, Subramanian V, Soetikno R, Farraye FA, Feagan B, Ioannidis J, Kiesslich R, Krier M, Matsumoto T, McCabe RP, Mönkemüller K, Odze R, Picco M, Rubin DT, Rubin M, Rubio CA, Rutter MD, Sanchez-Yague A, Sanduleanu S, Shergill A, Ullman T, Velayos F, Yakich D, Yang YX. SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. Gastroenterology 2015; 148:639-651.e28. [PMID: 25702852 DOI: 10.1053/j.gastro.2015.01.031] [Citation(s) in RCA: 330] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 12/09/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Tonya Kaltenbach
- Veterans Affairs Palo Alto Healthcare System and Stanford University School of Medicine (affiliate), Palo Alto, California
| | - Alan Barkun
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
| | - Kenneth R McQuaid
- University of California at San Francisco, Veterans Affairs Medical Center, San Francisco, California
| | | | - Roy Soetikno
- Veterans Affairs Palo Alto Healthcare System and Stanford University School of Medicine (affiliate), Palo Alto, California
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Atreja A, Khan S, Rogers JD, Otobo E, Patel NP, Ullman T, Colombel JF, Moore S, Sands BE. Impact of the Mobile HealthPROMISE Platform on the Quality of Care and Quality of Life in Patients With Inflammatory Bowel Disease: Study Protocol of a Pragmatic Randomized Controlled Trial. JMIR Res Protoc 2015; 4:e23. [PMID: 25693610 PMCID: PMC4376196 DOI: 10.2196/resprot.4042] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 12/23/2014] [Indexed: 12/30/2022] Open
Abstract
Background Inflammatory bowel disease (IBD) is a chronic condition of the bowel that affects over 1 million people in the United States. The recurring nature of disease makes IBD patients ideal candidates for patient-engaged care that is centered on enhanced self-management and improved doctor-patient communication. In IBD, optimal approaches to management vary for patients with different phenotypes and extent of disease and past surgical history. Hence, a single quality metric cannot define a heterogeneous disease such as IBD, unlike hypertension and diabetes. A more comprehensive assessment may be provided by complementing traditional quality metrics with measures of the patient’s quality of life (QOL) through an application like HealthPROMISE. Objective The objective of this pragmatic randomized controlled trial is to determine the impact of the HealthPROMISE app in improving outcomes (quality of care [QOC], QOL, patient adherence, disease control, and resource utilization) as compared to a patient education app. Our hypothesis is that a patient-centric self-monitoring and collaborative decision support platform will lead to sustainable improvement in overall QOL for IBD patients. Methods Participants will be recruited during face-to-face visits and randomized to either an interventional (ie, HealthPROMISE) or control (ie, education app). Patients in the HealthPROMISE arm will be able to update their information and receive disease summary, quality metrics, and a graph showing the trend of QOL (SIBDQ) scores and resource utilization over time. Providers will use the data for collaborative decision making and quality improvement interventions at the point of care. Patients in the control arm will enter data at baseline, during office visits, and at the end of the study but will not receive any decision support (trend of QOL, alert, or dashboard views). Results Enrollment in the trial will be starting in first quarter of 2015. It is intended that up to 300 patients with IBD will be recruited into the study (with 1:1 allocation ratio). The primary endpoint is number of quality indicators met in HealthPROMISE versus control arm. Secondary endpoints include decrease in number of emergency visits due to IBD, decrease in number of hospitalization due to IBD, change in generic QOL score from baseline, proportion of patients in each group who meet all eligible outpatient quality metrics, and proportion of patients in disease control in each group. In addition, we plan to conduct protocol analysis of intervention patients with adequate HealthPROMISE utilization (more than 6 log-ins with data entry from week 0 through week 52) achieving above mentioned primary and secondary endpoints. Conclusions HealthPROMISE is a unique cloud-based patient-reported outcome (PRO) and decision support tool that empowers both patients and providers. Patients track their QOL and symptoms, and providers can use the visual data in real time (integrated with electronic health records [EHRs]) to provide better care to their entire patient population. Using pragmatic trial design, we hope to show that IBD patients who participate in their own care and share in decision making have appreciably improved outcomes when compared to patients who do not. Trial Registration ClinicalTrials.gov NCT02322307; https://clinicaltrials.gov/ct2/show/NCT02322307 (Archived by WebCite at http://www.webcitation.org/6W8PoYThr).
Collapse
Affiliation(s)
- Ashish Atreja
- Sinai AppLab, Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Ullman T. Surveillance of Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2014; 10:827-829. [PMID: 27524951 PMCID: PMC4980817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Thomas Ullman
- Chief Medical Officer, Mount Sinai Doctors Faculty Practice Associate Dean for Clinical Excellence Associate Professor of Medicine Icahn School of Medicine at Mount Sinai New York, New York
| |
Collapse
|
18
|
Leung JM, Davenport M, Wolff MJ, Wiens KE, Abidi WM, Poles MA, Cho I, Ullman T, Mayer L, Loke P. IL-22-producing CD4+ cells are depleted in actively inflamed colitis tissue. Mucosal Immunol 2014; 7:124-33. [PMID: 23695510 PMCID: PMC3870042 DOI: 10.1038/mi.2013.31] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 04/12/2013] [Indexed: 02/04/2023]
Abstract
T helper type (Th17) cytokines such as interleukin (IL)-17A and IL-22 are important in maintaining mucosal barrier function and may be important in the pathogenesis of inflammatory bowel diseases (IBDs). Here, we analyzed cells from the colon of IBD patients and show that Crohn's disease (CD) patients had significantly elevated numbers of IL-17+, CD4+ cells compared with healthy controls and ulcerative colitis (UC) patients, but these numbers did not vary based on the inflammatory status of the mucosa. By contrast, UC patients had significantly reduced numbers of IL-22+ cells in actively inflamed tissues compared with both normal tissue and healthy controls. There was a selective increase in mono-IL-17-producing cells from the mucosa of UC patients with active inflammation together with increased expression of transforming growth factor (TGF)-β and c-Maf. Increasing concentrations of TGF-β in lamina propria mononuclear cell cultures significantly depleted Th22 cells, whereas anti-TGF-β antibodies increased IL-22 production. When mucosal microbiota was examined, depletion of Th22 cells in actively inflamed tissue was associated with reduced populations of Clostridiales and increased populations of Proteobacteria. These results suggest that increased TGF-β during active inflammation in UC may lead to the loss of Th22 cells in the human intestinal mucosa.
Collapse
Affiliation(s)
- JM Leung
- Division of Parasitology, Department of Microbiology, New York University School of Medicine, New York, New York, USA
| | - M Davenport
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - MJ Wolff
- Department of Medicine, New York University School of Medicine, New York, New York, USA
- VA New York Harbor Healthcare System, New York, New York, USA
| | - KE Wiens
- Division of Parasitology, Department of Microbiology, New York University School of Medicine, New York, New York, USA
| | - WM Abidi
- Department of Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York, USA
| | - MA Poles
- Department of Medicine, New York University School of Medicine, New York, New York, USA
- VA New York Harbor Healthcare System, New York, New York, USA
| | - I Cho
- Department of Medicine, New York University School of Medicine, New York, New York, USA
- VA New York Harbor Healthcare System, New York, New York, USA
| | - T Ullman
- Department of Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York, USA
| | - L Mayer
- Immunology Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - P Loke
- Division of Parasitology, Department of Microbiology, New York University School of Medicine, New York, New York, USA
| |
Collapse
|
19
|
Mahadevan U, Wolf DC, Dubinsky M, Cortot A, Lee SD, Siegel CA, Ullman T, Glover S, Valentine JF, Rubin DT, Miller J, Abreu MT. Placental transfer of anti-tumor necrosis factor agents in pregnant patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2013; 11. [PMID: 23200982 PMCID: PMC3913646 DOI: 10.1016/j.cgh.2012.11.011] [Citation(s) in RCA: 321] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Some women with inflammatory bowel disease require therapy with tumor necrosis factor (TNF) antagonists during pregnancy. It is not clear whether these drugs are transferred to the fetus via the placenta and then cleared, or whether structurally different TNF antagonists have different rates of transfer. METHODS We studied 31 pregnant women with inflammatory bowel disease receiving infliximab (IFX, n = 11), adalimumab (ADA, n = 10), or certolizumab (CZP, n = 10). Serum concentrations of the drugs were measured at birth in the mother, infant, and in cord blood, and then monthly in the infant until the drugs were undetectable. Drug concentrations in the cord and the infant at birth were compared with those of the mother. RESULTS Concentrations of IFX and ADA, but not CZP, were higher in infants at birth and their cords than in their mothers. The levels of CZP in infants and their cords were less than 2 μg/mL. The median level of IFX in the cord was 160% that of the mother, the median level of ADA in the cord was 153% that of the mother, and the median level of CZP in the cord was 3.9% that of the mother. IFX and ADA could be detected in the infants for as long as 6 months. No congenital anomalies or serious complications were reported. CONCLUSIONS The TNF antagonists IFX and ADA are transferred across the placenta and can be detected in infants at birth; the drugs were detected in infants up to 6 months after birth. CZP has the lowest level of placental transfer, based on levels measured in cords and infants at birth, of the drugs tested.
Collapse
Affiliation(s)
- Uma Mahadevan
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California 94115, USA.
| | | | - Marla Dubinsky
- Dept of Pediatrics Cedars Sinai Medical Center, Los Angeles, CA
| | - Antoine Cortot
- Hepato-Gastroenterolgie Cite Hospitaliere, Lille, France
| | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Goldstone R, Itzkowitz S, Harpaz N, Ullman T. Dysplasia is more common in the distal than proximal colon in ulcerative colitis surveillance. Inflamm Bowel Dis 2012; 18:832-7. [PMID: 21739534 DOI: 10.1002/ibd.21809] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [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: 01/17/2011] [Accepted: 05/16/2011] [Indexed: 01/02/2023]
Abstract
BACKGROUND In patients with long-standing ulcerative colitis (UC), current dysplasia surveillance guidelines recommend four-quadrant biopsies every 10 cm throughout the colon. However, this may be inefficient if neoplastic lesions are localized in particular segments of the colorectum. The aim was to determine whether a difference exists in the anatomic distribution of dysplasia discovered in UC patients undergoing colonoscopic surveillance. METHODS From an institutional database of over 700 patients with UC who underwent two or more surveillance colonoscopies between 1994-2006, we identified all patients with flat (endoscopically invisible) low-grade dysplasia (fLGD) or advanced neoplasia (colorectal cancer [CRC] or high-grade dysplasia [HGD]). Pathology reports were reviewed regarding the anatomic location of all dysplastic lesions. Fisher's exact test was used to compare the frequencies of neoplasia among the different colonic segments. RESULTS We identified 103 patients who progressed to any neoplasia (fLGD, HGD, or CRC). These patients underwent a total of 396 colonoscopies. The mean age at first surveillance colonoscopy was 48.6 years, with a mean UC disease duration of 18.2 years; 100% had extensive disease. Fifty-five patients developed advanced neoplasia. The rectosigmoid was found to have a significantly greater number of biopsies positive for advanced neoplasia and for any neoplasia compared to all other colonic segments (P < 0.0007); 71.2% of all advanced neoplasia was in the rectosigmoid. CONCLUSIONS The majority of dysplastic lesions identified in a surveillance program was detected in the rectosigmoid. Endoscopists should consider taking a greater percentage of biopsies in these segments as opposed to more proximal areas.
Collapse
Affiliation(s)
- Robert Goldstone
- Department of Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York 10029, USA
| | | | | | | |
Collapse
|
21
|
Kenny EE, Pe'er I, Karban A, Ozelius L, Mitchell AA, Ng SM, Erazo M, Ostrer H, Abraham C, Abreu MT, Atzmon G, Barzilai N, Brant SR, Bressman S, Burns ER, Chowers Y, Clark LN, Darvasi A, Doheny D, Duerr RH, Eliakim R, Giladi N, Gregersen PK, Hakonarson H, Jones MR, Marder K, McGovern DPB, Mulle J, Orr-Urtreger A, Proctor DD, Pulver A, Rotter JI, Silverberg MS, Ullman T, Warren ST, Waterman M, Zhang W, Bergman A, Mayer L, Katz S, Desnick RJ, Cho JH, Peter I. A genome-wide scan of Ashkenazi Jewish Crohn's disease suggests novel susceptibility loci. PLoS Genet 2012; 8:e1002559. [PMID: 22412388 PMCID: PMC3297573 DOI: 10.1371/journal.pgen.1002559] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 01/12/2012] [Indexed: 12/19/2022] Open
Abstract
Crohn's disease (CD) is a complex disorder resulting from the interaction of intestinal microbiota with the host immune system in genetically susceptible individuals. The largest meta-analysis of genome-wide association to date identified 71 CD-susceptibility loci in individuals of European ancestry. An important epidemiological feature of CD is that it is 2-4 times more prevalent among individuals of Ashkenazi Jewish (AJ) descent compared to non-Jewish Europeans (NJ). To explore genetic variation associated with CD in AJs, we conducted a genome-wide association study (GWAS) by combining raw genotype data across 10 AJ cohorts consisting of 907 cases and 2,345 controls in the discovery stage, followed up by a replication study in 971 cases and 2,124 controls. We confirmed genome-wide significant associations of 9 known CD loci in AJs and replicated 3 additional loci with strong signal (p<5×10⁻⁶). Novel signals detected among AJs were mapped to chromosomes 5q21.1 (rs7705924, combined p = 2×10⁻⁸; combined odds ratio OR = 1.48), 2p15 (rs6545946, p = 7×10⁻⁹; OR = 1.16), 8q21.11 (rs12677663, p = 2×10⁻⁸; OR = 1.15), 10q26.3 (rs10734105, p = 3×10⁻⁸; OR = 1.27), and 11q12.1 (rs11229030, p = 8×10⁻⁹; OR = 1.15), implicating biologically plausible candidate genes, including RPL7, CPAMD8, PRG2, and PRG3. In all, the 16 replicated and newly discovered loci, in addition to the three coding NOD2 variants, accounted for 11.2% of the total genetic variance for CD risk in the AJ population. This study demonstrates the complementary value of genetic studies in the Ashkenazim.
Collapse
Affiliation(s)
- Eimear E. Kenny
- Department of Computer Sciences, Columbia University, New York, New York, United States of America
| | - Itsik Pe'er
- Department of Computer Sciences, Columbia University, New York, New York, United States of America
| | - Amir Karban
- Department of Gastroenterology, Rambam Health Care Campus, B. Rappaport Institute for Research in the Medical Sciences, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Laurie Ozelius
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Adele A. Mitchell
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Sok Meng Ng
- Department of Medicine, Section of Digestive Diseases, Yale University, New Haven, Connecticut, United States of America
| | - Monica Erazo
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Harry Ostrer
- Department of Pathology, Albert Einstein College of Medicine, New York, New York, United States of America
| | - Clara Abraham
- Department of Medicine, Section of Digestive Diseases, Yale University, New Haven, Connecticut, United States of America
| | - Maria T. Abreu
- Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Gil Atzmon
- Genetic Core for Longevity, Institute for Aging Research and the Diabetes Research Center, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Nir Barzilai
- Genetic Core for Longevity, Institute for Aging Research and the Diabetes Research Center, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Steven R. Brant
- Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Susan Bressman
- Mirken Department of Neurology, Beth Israel Medical Center, New York, New York, United States of America
- The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Edward R. Burns
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, B. Rappaport Institute for Research in the Medical Sciences, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Lorraine N. Clark
- Department of Pathology and Cell Biology, Columbia University, New York, New York, United States of America
| | - Ariel Darvasi
- The Institute of Life Sciences, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dana Doheny
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Richard H. Duerr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Rami Eliakim
- Department of Gastroenterology and Hepatology, Sheba Medical Center, Raman Gan, Israel
| | - Nir Giladi
- Department of Neurology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Peter K. Gregersen
- Robert S. Boas Center for Genomics and Human Genetics, Feinstein Institute for Medical Research, North Shore LIJ Health System, Manhasset, New York, United States of America
| | - Hakon Hakonarson
- Center for Applied Genomics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Michelle R. Jones
- Division of Endocrinology, Diabetes, and Metabolism, Graduate Program in Biomedical Sciences and Translational Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Karen Marder
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
- Taub Institute for Research on Alzheimer's Disease and the Aging Brain, College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - Dermot P. B. McGovern
- Department of Translational Medicine, Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Jennifer Mulle
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Avi Orr-Urtreger
- Genetic Institute, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Deborah D. Proctor
- Department of Medicine, Section of Digestive Diseases, Yale University, New Haven, Connecticut, United States of America
| | - Ann Pulver
- Epidemiology-Genetics Program in Schizophrenia, Bipolar Disorders, and Related Disorders, Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Jerome I. Rotter
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | | | - Thomas Ullman
- Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Stephen T. Warren
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Departments of Biochemistry and Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Matti Waterman
- Department of Gastroenterology, Rambam Health Care Campus, B. Rappaport Institute for Research in the Medical Sciences, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Wei Zhang
- Department of Medicine, Section of Digestive Diseases, Yale University, New Haven, Connecticut, United States of America
| | - Aviv Bergman
- Department of Systems and Computational Biology, Albert Einstein College of Medicine, New York, New York, United States of America
| | - Lloyd Mayer
- Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Seymour Katz
- Albert Einstein College of Medicine, North Shore University Hospital-Long Island Jewish Hospital Systems, St. Francis Hospital, Great Neck, New York, United States of America
| | - Robert J. Desnick
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Judy H. Cho
- Department of Medicine, Section of Digestive Diseases, Yale University, New Haven, Connecticut, United States of America
- * E-mail: (JH Cho) (JC); (I Peter) (IP)
| | - Inga Peter
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, United States of America
- * E-mail: (JH Cho) (JC); (I Peter) (IP)
| |
Collapse
|
22
|
Dotan I, Werner L, Vigodman S, Agarwal S, Pfeffer J, Horowitz N, Malter L, Abreu M, Ullman T, Guzner-Gur H, Halpern Z, Mayer L. Normal response to vaccines in inflammatory bowel disease patients treated with thiopurines. Inflamm Bowel Dis 2012; 18:261-8. [PMID: 21438101 PMCID: PMC3919517 DOI: 10.1002/ibd.21688] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 01/20/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Thiopurines are considered immunosuppressive agents and may be associated with an increased risk for infections. However, few inflammatory bowel disease (IBD) patients are appropriately vaccinated, and data on their ability to mount an immune response are vague. We evaluated the effects of the thiopurines, azathioprine (AZA) and 6-mercaptopurine (6-MP), on cellular and humoral immune responses in IBD patients. METHODS A prospective clinical investigation was conducted on IBD patients referred for thiopurine treatment. Immune competence was evaluated by assessing lymphocyte counts and phenotype, response to mitogen and antigen stimulation, immunoglobulin levels, and response to pneumococcal and tetanus vaccines (before treatment, week 0), and to Haemophilus influenza type b vaccine (at week 24). RESULTS Thirty-one Crohn's disease and 12 ulcerative colitis patients who completed at least 24 weeks of therapy were included. The posttherapy average 6-MP dose was 1.05 ± 0.30 mg/kg, and white blood cell counts had decreased significantly from baseline values (P < 0.002). The posttreatment response to mitogens and antigens and the immunoglobulin levels were unchanged. Responses to vaccines were normal both in thiopurine-naïve and thiopurine-treated patients, suggesting that these patients were immunologically intact while on thiopurine therapy and capable of generating normal immune responses in vivo. CONCLUSIONS There is no evidence for any intrinsic systemic immunodeficiency in IBD patients. Thiopurines at the doses used for treating IBD showed no significant suppressive effect on the systemic cellular and humoral immune responses evaluated. Thiopurine-treated IBD patients can be safely and efficiently vaccinated.
Collapse
Affiliation(s)
- Iris Dotan
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv Israel,Mucosal Immunology Laboratory, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv Israel
| | - Lael Werner
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv Israel,Mucosal Immunology Laboratory, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv Israel
| | - Sharon Vigodman
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv Israel,Mucosal Immunology Laboratory, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv Israel
| | - Shradha Agarwal
- Immunobiology Center, Mount Sinai Medical Center, New York, NY, USA
| | - Jorge Pfeffer
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv Israel
| | - Noya Horowitz
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv Israel
| | - Lisa Malter
- Division of Gastroenterology, Mount Sinai Medical Center, New York, NY, USA
| | - Maria Abreu
- Division of Gastroenterology, Mount Sinai Medical Center, New York, NY, USA
| | - Thomas Ullman
- Division of Gastroenterology, Mount Sinai Medical Center, New York, NY, USA
| | - Hanan Guzner-Gur
- Mucosal Immunology Laboratory, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv Israel
| | - Zamir Halpern
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv Israel
| | - Lloyd Mayer
- Immunobiology Center, Mount Sinai Medical Center, New York, NY, USA,Division of Gastroenterology, Mount Sinai Medical Center, New York, NY, USA
| |
Collapse
|
23
|
Dotan I, Werner L, Vigodman S, Agarwal S, Pfeffer J, Horowitz N, Malter L, Abreu M, Ullman T, Guzner-Gur H, Halpern Z, Mayer L. Normal response to vaccines in inflammatory bowel disease patients treated with thiopurines. Inflamm Bowel Dis 2012. [PMID: 21438101 DOI: 10.1002/ibd.21688)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Thiopurines are considered immunosuppressive agents and may be associated with an increased risk for infections. However, few inflammatory bowel disease (IBD) patients are appropriately vaccinated, and data on their ability to mount an immune response are vague. We evaluated the effects of the thiopurines, azathioprine (AZA) and 6-mercaptopurine (6-MP), on cellular and humoral immune responses in IBD patients. METHODS A prospective clinical investigation was conducted on IBD patients referred for thiopurine treatment. Immune competence was evaluated by assessing lymphocyte counts and phenotype, response to mitogen and antigen stimulation, immunoglobulin levels, and response to pneumococcal and tetanus vaccines (before treatment, week 0), and to Haemophilus influenza type b vaccine (at week 24). RESULTS Thirty-one Crohn's disease and 12 ulcerative colitis patients who completed at least 24 weeks of therapy were included. The posttherapy average 6-MP dose was 1.05 ± 0.30 mg/kg, and white blood cell counts had decreased significantly from baseline values (P < 0.002). The posttreatment response to mitogens and antigens and the immunoglobulin levels were unchanged. Responses to vaccines were normal both in thiopurine-naïve and thiopurine-treated patients, suggesting that these patients were immunologically intact while on thiopurine therapy and capable of generating normal immune responses in vivo. CONCLUSIONS There is no evidence for any intrinsic systemic immunodeficiency in IBD patients. Thiopurines at the doses used for treating IBD showed no significant suppressive effect on the systemic cellular and humoral immune responses evaluated. Thiopurine-treated IBD patients can be safely and efficiently vaccinated.
Collapse
Affiliation(s)
- Iris Dotan
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, affiliated to tSackler Faculty of Medicine, Tel Aviv Israel.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Goldstone R, Itzkowitz S, Harpaz N, Ullman T. Progression of low-grade dysplasia in ulcerative colitis: effect of colonic location. Gastrointest Endosc 2011; 74:1087-93. [PMID: 21907984 DOI: 10.1016/j.gie.2011.06.028] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [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: 03/15/2011] [Accepted: 06/15/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Emerging evidence suggests that the biology of sporadic colorectal neoplasia may differ between the proximal and distal colon. Whether such a difference exists in colitis-associated colorectal neoplasia is unknown. OBJECTIVE To compare the rate of progression to advanced neoplasia (AN) between proximal and distal dysplasia in patients with ulcerative colitis (UC). DESIGN Retrospective cohort study. SETTING Tertiary medical center. PATIENTS From an institutional database of more than 700 patients with UC who underwent 2 or more surveillance colonoscopies between 1994 and 2006, we identified patients with extensive UC and low-grade dysplasia (LGD). Neoplasia proximal to the splenic flexure was considered proximal. MAIN OUTCOME MEASUREMENT Progression to AN, defined as high-grade dysplasia (HGD) or colorectal cancer (CRC). RESULTS Among 121 patients with LGD, all 7 who progressed to CRC and 6 of 8 who progressed to HGD had distal LGD initially. Subjects with distal LGD had a significantly shorter time to progression than those with proximal LGD (P = .019); 5-year AN-free survivals for distal and proximal LGD were 75 ± 7% and 95 ± 3%, respectively (hazard ratio [HR] 5.0; 95% CI, 1.1-22.0). Additionally, flat LGD was significantly more likely to progress than raised LGD on univariate testing (HR 3.6; 95% CI, 1.3-10.1). Neither morphology nor sidedness remained significant in multivariable testing, although there was little change in the HRs (HR 2.4; 95% CI, 0.8-7.1 for morphology; HR 3.5; 95% CI, 0.7-16.8 for sidedness) in proportional hazards modeling. LIMITATIONS Nonrandomized, retrospective trial and low incidence of AN. CONCLUSIONS In patients with long-standing, extensive UC, distal LGD is more common and progresses more rapidly to AN than proximal LGD.
Collapse
Affiliation(s)
- Robert Goldstone
- The Dr. Henry D. Janowitz Division of Gastroenterology, The Mount Sinai School of Medicine, New York, New York 10029, USA
| | | | | | | |
Collapse
|
25
|
Peter I, Mitchell AA, Ozelius L, Erazo M, Hu J, Doheny D, Abreu MT, Present DH, Ullman T, Benkov K, Korelitz BI, Mayer L, Desnick RJ. Evaluation of 22 genetic variants with Crohn's disease risk in the Ashkenazi Jewish population: a case-control study. BMC Med Genet 2011; 12:63. [PMID: 21548950 PMCID: PMC3212904 DOI: 10.1186/1471-2350-12-63] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 05/06/2011] [Indexed: 01/08/2023]
Abstract
Background Crohn's disease (CD) has the highest prevalence among individuals of Ashkenazi Jewish (AJ) descent compared to non-Jewish Caucasian populations (NJ). We evaluated a set of well-established CD-susceptibility variants to determine if they can explain the increased CD risk in the AJ population. Methods We recruited 369 AJ CD patients and 503 AJ controls, genotyped 22 single nucleotide polymorphisms (SNPs) at or near 10 CD-associated genes, NOD2, IL23R, IRGM, ATG16L1, PTGER4, NKX2-3, IL12B, PTPN2, TNFSF15 and STAT3, and assessed their association with CD status. We generated genetic scores based on the risk allele count alone and the risk allele count weighed by the effect size, and evaluated their predictive value. Results Three NOD2 SNPs, two IL23R SNPs, and one SNP each at IRGM and PTGER4 were independently associated with CD risk. Carriage of 7 or more copies of these risk alleles or the weighted genetic risk score of 7 or greater correctly classified 92% (allelic count score) and 83% (weighted score) of the controls; however, only 29% and 47% of the cases were identified as having the disease, respectively. This cutoff was associated with a >4-fold increased disease risk (p < 10e-16). Conclusions CD-associated genetic risks were similar to those reported in NJ population and are unlikely to explain the excess prevalence of the disease in AJ individuals. These results support the existence of novel, yet unidentified, genetic variants unique to this population. Understanding of ethnic and racial differences in disease susceptibility may help unravel the pathogenesis of CD leading to new personalized diagnostic and therapeutic approaches.
Collapse
Affiliation(s)
- Inga Peter
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY 10029 USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
Advances in the treatment of inflammatory bowel disease (IBD) are published routinely in medical journals. Some treatments are sufficiently helpful that their conclusions are incorporated into clinical guidelines. However, such publications and proclamations may go unheeded among practitioners. Underuse, overuse, and misuse of clinical therapeutics, diagnostics, and routine medical processes are sufficiently prevalent among IBD practitioners that movements are afoot to determine the best methods for achieving a minimal uniformity of effective care. Such explorations are part of an effort to improve the quality of care. In this article, we review the background that has led to a push toward quality improvements in medicine in general, in gastroenterology in general, and within IBD specifically.
Collapse
Affiliation(s)
- Brijen Shah
- Mount Sinai School of Medicine, New York, NY 10029, USA
| | | | | |
Collapse
|
27
|
Park SY, Yoon SJ, Hakomori SI, Kim JM, Kim JY, Bernert B, Ullman T, Itzkowitz SH, Kim JH. Dimeric Le(a) (Le(a)-on-Le(a)) status of beta-haptoglobin in sera of colon cancer, chronic inflammatory disease and normal subjects. Int J Oncol 2010; 36:1291-7. [PMID: 20372805 DOI: 10.3892/ijo_00000614] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The glycosyl epitope dimeric Lea (Lea-on-Lea), defined by mouse monoclonal antibody NCC-ST-421, was identified previously as tumor-associated antigen, expressed highly in various human cancer tissues and cell lines derived therefrom, but with minimal expression in various normal tissues. In the present study, we observed clearly higher expression of this epitope, defined by ST421, in beta-haptoglobin (beta-Hap) from sera of patients with colorectal cancer, compared to normal, healthy subjects or patients with chronic inflammatory processes (Crohn's disease, ulcerative colitis). We focused, therefore, on biochemical characterization of glycosyl epitope status expressed in beta-Hap. We concluded that the dimeric Lea epitope is carried by O-linked but not by N-linked structure, based on the following observations: i) Treatment of beta-Hap with alpha-L-fucosidase reduced its reactivity with ST421, but did not affect its reactivity with anti-Hap antibody. In contrast, treatment of purified beta-Hap with PNGase F, which releases N-linked glycans, had no effect on reactivity with ST421, but changed molecular mass from 40 kDa to 30 kDa. ii) Strong reactivity of Colo205 supernatant with ST421 was reduced clearly by pre-incubation of cells with benzyl-alpha-GalNAc.
Collapse
Affiliation(s)
- Seung-Yeol Park
- Department of Biological Sciences, Korea Advanced Institute of Science and Technology, Daejeon 305-701, Republic of Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Lazarev M, Ullman T, Schraut WH, Kip KE, Saul M, Regueiro M. Small bowel resection rates in Crohn's disease and the indication for surgery over time: experience from a large tertiary care center. Inflamm Bowel Dis 2010; 16:830-5. [PMID: 19798731 DOI: 10.1002/ibd.21118] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Our primary aim was to determine if the rate of small bowel resection (SBR) has declined over time among Crohn's disease (CD) patients seen at a single academic institution. A secondary aim was to establish whether the indication for surgery has changed. METHODS Patients with a primary or secondary ICD-9 code for CD (555.0-555.9) who underwent SBR at the University of Pittsburgh were included. Patients were divided into 4 separate time periods based on when they had surgery: 1995-1998 (Period 1), 1999-2001 (Period 2), 2002-2004 (Period 3), and 2005-2007 (Period 4). Medical records were reviewed for the 6 months preceding surgery. Use of 5-ASAs, immunomodulators (IMs), tumor necrosis factor (TNF) antagonists, and corticosteroids were noted. Disease behavior was defined as nonstricturing, nonpenetrating (B1), stricturing (B2), and penetrating (B3). Proportions of patients undergoing SBR were calculated according to calendar cohort and these rates were examined for time trends. RESULTS In all, 227 unique patients were analyzed for a total of 236 surgeries. The rates of 5-ASA, IM, and corticosteroid use were similar across the 4 time periods. By contrast, TNF antagonist usage progressively increased over time (0%, 18%, 34%, 35%; P = 0.0002). The annual rate of SBR per period did not change (1.6%, 1.9%, 1.6%, 1.9%; P = 0.93). Similarly, the disease behavior did not change over time. CONCLUSIONS While the frequency of TNF antagonist use in CD at the University of Pittsburgh has increased over time, the rate of SBR and indication for surgery has remained unchanged. These findings may be explained by long-standing, complicated disease refractory to medical therapy.
Collapse
Affiliation(s)
- Mark Lazarev
- Department of Medicine, Division of Gastroenterology, The Harvey M and Lyn P Meyerhoff Inflammatory Bowel Disease Center, Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
| | | | | | | | | | | |
Collapse
|
29
|
Park SY, Yoon SJ, Jeong YT, Kim JM, Kim JY, Bernert B, Ullman T, Itzkowitz SH, Kim JH, Hakomori SI. N-glycosylation status of beta-haptoglobin in sera of patients with colon cancer, chronic inflammatory diseases and normal subjects. Int J Cancer 2009; 126:142-55. [PMID: 19551866 DOI: 10.1002/ijc.24685] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
N-glycosylation status of purified beta-haptoglobin from sera of 17 patients, and from sera of 14 healthy volunteer subjects, was compared by blotting with various lectins and antibodies. Patients in this study were diagnosed as having colon cancer through histological examination of each tumor tissue by biopsy. Blotting index of serum beta-haptoglobin with Aleuria aurantia lectin (AAL) was clearly higher for cancer patients than for healthy subjects. No such distinction was observed for blotting with three other lectins and two monoclonal antibodies. To determine tumor-associated reactivity of AAL binding as compared to inflammatory processes in colonic tissues, beta-haptoglobin separated from sera of 5 patients with Crohn's disease (CD), and 4 patients with ulcerative colitis (UC), was studied. All these cases, except one case of UC, showed AAL index lower than that in cancer cases, similarly to healthy subjects. The higher AAL binding of beta-haptoglobin in colon cancer patients than in healthy subjects appeared to be due to alpha-L-fucosyl residue, since it was eliminated by bovine kidney alpha-fucosidase treatment. N-linked glycans of serum haptoglobin from colon cancer patients vs. healthy subjects were released by N-glycanase, fluorescence-labeled, and subjected to normal-phase high performance liquid chromatography (NP-HPLC). Glycan structures were determined based on glucose unit (GU) values and their changes upon sequential treatment with various exoglycosidases. Glycosyl sequences and their branching status of glycans from 14 cases of serum beta-haptoglobin were characterized. The identified glycans were sialylated or nonsialylated, bi-antennary or tri-antennary structures, with or without terminal fucosylation.
Collapse
Affiliation(s)
- Seung-Yeol Park
- Department of Biological Sciences, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Sachar DB, Lemmer E, Ibrahim C, Edden Y, Ullman T, Ciardulo J, Roth E, Greenstein AJ, Bauer JJ. Recurrence patterns after first resection for stricturing or penetrating Crohn's disease. Inflamm Bowel Dis 2009; 15:1071-5. [PMID: 19229992 DOI: 10.1002/ibd.20872] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Crohn's disease (CD) usually recurs after resection, but the factors associated with this risk remain obscure. We set out to determine the role of stricturing (Montreal Classification B2) versus penetrating (Classification B3) disease behavior in predicting early (<3 years) versus late (>or=3 years) postoperative recurrence. METHODS We identified a cohort of 34 patients seen at The Mount Sinai Hospital who had undergone a first ileocolic resection prior to December 31, 2004, who had been clinically thought to have had stricturing (B2) disease, and for whom we could verify 1) the operative and surgical pathology findings; and 2) the time of onset of symptoms attributable to recurrent CD by endoscopy, radiology, or surgery. Cases were reclassified as either "stricturing" (B2) or "penetrating" (B3) on the basis of operative and surgical pathology reports. Recurrences were classified as either "early" (<3 years) or "late" (>or=3 years) depending on the first appearance of postoperative symptoms that were verified endoscopically and histologically, radiologically, or surgically as being attributable to anastomotic recurrence of the CD. RESULTS Among these 34 patients clinically thought to have had B2 disease, 12 had B2 disease confirmed upon review of surgical and pathology reports and none of them had recurrence within 3 years. Among the 22 patients reclassified as B3 disease, 12 (55%) had early recurrence. This difference was significant at the 0.002 level by the Fisher Exact Test. CONCLUSIONS There is a strong proclivity for early postoperative recurrence of penetrating CD compared to stricturing disease, which may not be evident by behavioral classification on clinical grounds alone. Patients with confirmed uncomplicated stricturing obstruction at their first resection seem unlikely to experience a clinical recurrence within the next 3 years.
Collapse
Affiliation(s)
- David B Sachar
- Department of Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York 10029-6574, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Abstract
To minimize the possibility of developing lethal colorectal cancer (CRC) in ulcerative colitis (UC) and Crohn's colitis, patients are usually enrolled in a program of dysplasia surveillance. The success of a surveillance program depends on the identification of patients with dysplasia and timely referral for colectomy. While a number of issues might stand in the way of a surveillance system achieving its maximal effect (less than ideal agreement in the interpretation of biopsy specimens, sampling error by endoscopists, delays in referral to surgery, and patient drop-out among others), circumstantial evidence supports the concept that colonoscopic dysplasia surveillance is an effective means of reducing CRC mortality and morbidity while minimizing the application of colectomy for cancer prevention. This review critically appraises key issues in the diagnosis and management of dysplasia in UC and Crohn's disease as well as adjunct efforts to prevent CRC in inflammatory bowel disease.
Collapse
Affiliation(s)
- Thomas Ullman
- Mount Sinai School of Medicine, New York, New York, USA
| | | | | |
Collapse
|
32
|
Swaminath A, Ullman T, Rosen M, Mayer L, Lichtiger S, Abreu MT. Early clinical experience with adalimumab in treatment of inflammatory bowel disease with infliximab-treated and naïve patients. Aliment Pharmacol Ther 2009; 29:273-8. [PMID: 19006540 DOI: 10.1111/j.1365-2036.2008.03878.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Adalimumab, at an induction dose of 160/80 mg followed by 40 mg every other week is approved for treatment of refractory Crohn's disease (CD) and for patients with loss of response to infliximab. AIM To evaluate the indications for adalimumab, the proportion of inflammatory bowel disease patients who require dose escalation and to identify whether this strategy is effective in inducing or maintaining remission. METHODS Patients prescribed adalimumab for CD were identified and included for analysis, if they had follow-up of at least 6 weeks. Adalimumab dose was escalated if patients had return of symptoms prior to next dose. Clinical judgment was used to determine severity of disease. A second GI physician confirmed disease severity as determined by the first physician. RESULTS A total of 48 out of 60 patients met inclusion criteria. Adalimumab was used to treat CD in 47/48 (98%) and ulcerative colitis in one (2%). Most patients had moderate 30/48 (63%) or severe 17/48 (35%) disease. Prior infliximab exposure was present in 42/48 (88%). Adalimumab dose escalation occurred in 14/48 (29%) within an average time of 2.2 months (s.d. 1.5 months). A majority of patients who required dose escalation, nine of 14 (64%) did not improve clinically. Steroids could be discontinued in three of 16 (18.8%). Clinical improvement was noted in 21/48 (43.8%) and one of 48 (2%) patients achieved clinical remission. Adverse drug reactions necessitated drug discontinuation in four of 48 (8%) of patients. CONCLUSIONS This retrospective review from a single academic medical centre suggests that a minority of patients, who cannot be maintained on 40 mg every other week, of adalimumab benefit from an increased dose. This suggests the need for a treatment with an alternative mode of action in anti-TNF failures.
Collapse
Affiliation(s)
- A Swaminath
- Division of Digestive and Liver Diseases, Columbia University Presbyterian Hospital, New York, NY 10032, USA.
| | | | | | | | | | | |
Collapse
|
33
|
|
34
|
Ullman T, Croog V, Harpaz N, Hossain S, Kornbluth A, Bodian C, Itzkowitz S. Progression to colorectal neoplasia in ulcerative colitis: effect of mesalamine. Clin Gastroenterol Hepatol 2008; 6:1225-30; quiz 1177. [PMID: 18848502 DOI: 10.1016/j.cgh.2008.05.020] [Citation(s) in RCA: 64] [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: 12/07/2007] [Revised: 05/13/2008] [Accepted: 05/26/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Some studies have suggested that mesalamine can prevent the development of colorectal cancer in patients with ulcerative colitis (UC). The aim of this study was to compare rates of progression with advanced neoplasia in patient cohorts with UC taking low and high doses of mesalamine and to determine where in the process of neoplastic progression mesalamine might act. METHODS Three cohorts of UC patients were identified from an institutional database: 311 patients with no dysplasia (NoD), 56 with indefinite dysplasia (IND), and 26 with flat low-grade dysplasia (fLGD). The impact of mesalamine exposure on the subsequent development of advanced neoplasia (high-grade dysplasia or colorectal cancer) was assessed using life-table methods. RESULTS Seventeen of 311 patients with NoD progressed to advanced neoplasia (5-year rate, 1.1%). This rate was lower than the 5-year rate for the IND (9%; P = .02 vs NoD) and fLGD (45%; P < .001 vs NoD and P = .001 vs IND) cohorts. Among the NoD cohort, the hazard ratio for mesalamine users versus nonusers was 0.70 (95% confidence interval, 0.20-2.44), and for each 1 g/d increase in dose, the hazard ratio was 0.92 (95% confidence interval, 0.58-1.47). For patients with IND, no patients on greater than 2 g/d progressed versus 13.8% on low-dose mesalamine (P = .11). For fLGD, 62.5% on high dose progressed, versus 27.8% on low dose (P = .054). CONCLUSIONS In long-standing UC, patients with fLGD have a higher rate of progression to advanced neoplasia than those with NoD or IND. However, at none of these stages of disease did mesalamine use show definitive chemopreventive activity.
Collapse
Affiliation(s)
- Thomas Ullman
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA.
| | | | | | | | | | | | | |
Collapse
|
35
|
Maser EA, Deconda D, Lichtiger S, Ullman T, Present DH, Kornbluth A. Cyclosporine and infliximab as rescue therapy for each other in patients with steroid-refractory ulcerative colitis. Clin Gastroenterol Hepatol 2008; 6:1112-6. [PMID: 18928936 DOI: 10.1016/j.cgh.2008.04.035] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Revised: 03/21/2008] [Accepted: 04/17/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In patients with severe corticosteroid-refractory ulcerative colitis, cyclosporine or infliximab may be added in an effort to induce remission. If the patient then fails either of these drugs, it is unknown whether success can be achieved by using the other agent. The aim of this study was to assess outcomes of using cyclosporine after failure of infliximab, and vice versa. METHODS We retrospectively reviewed the charts of 19 patients with corticosteroid-refractory ulcerative colitis who received either infliximab after failed cyclosporine or cyclosporine after failed infliximab. Acute salvage therapy was defined as having received the alternate drug within 4 weeks of discontinuing the first agent. RESULTS Ten patients received infliximab after failing cyclosporine; 9 patients received cyclosporine after failing infliximab. Four patients (40%) in the infliximab-salvage group achieved remission, as did 3 (33%) in the cyclosporine-salvage group. Remission lasted a mean of 10.4 months (range, 4.4-17.03 mo) and 28.5 months (range, 5.0-41.5 mo), respectively. Severe adverse events included one patient who developed sepsis and died after receiving infliximab salvage. One patient who received cyclosporine salvage developed herpetic esophagitis, and another patient who received cyclosporine salvage developed pancreatitis and bacteremia. CONCLUSIONS In patients with severe corticosteroid-refractory ulcerative colitis who fail treatment with either cyclosporine or infliximab, remission rates using acute salvage therapy by crossing over to the other drug occur in approximately one third of patients and have limited duration. Serious adverse events occurred in 16%, including 1 death, suggesting that the risks of acute salvage therapy may outweigh the benefits.
Collapse
Affiliation(s)
- Elana A Maser
- The IBD Center, Division of Gastroenterology, Mount Sinai Medical Center, New York, New York 10029, USA.
| | | | | | | | | | | |
Collapse
|
36
|
|
37
|
Gupta RB, Harpaz N, Itzkowitz S, Hossain S, Matula S, Kornbluth A, Bodian C, Ullman T. Histologic inflammation is a risk factor for progression to colorectal neoplasia in ulcerative colitis: a cohort study. Gastroenterology 2007; 133:1099-105; quiz 1340-1. [PMID: 17919486 PMCID: PMC2175077 DOI: 10.1053/j.gastro.2007.08.001] [Citation(s) in RCA: 529] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 06/14/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although inflammation is presumed to contribute to colonic neoplasia in ulcerative colitis (UC), few studies have directly examined this relationship. Our aim was to determine whether severity of microscopic inflammation over time is an independent risk factor for neoplastic progression in UC. METHODS A cohort of patients with UC undergoing regular endoscopic surveillance for dysplasia was studied. Degree of inflammation at each biopsy site had been graded as part of routine clinical care using a highly reproducible histologic activity index. Progression to neoplasia was analyzed in proportional hazards models with inflammation summarized in 3 different ways and each included as a time-changing covariate: (1) mean inflammatory score (IS-mean), (2) binary inflammatory score (IS-bin), and (3) maximum inflammatory score (IS-max). Potential confounders were analyzed in univariate testing and, when significant, in a multivariable model. RESULTS Of 418 patients who met inclusion criteria, 15 progressed to advanced neoplasia (high-grade dysplasia or colorectal cancer), and 65 progressed to any neoplasia (low-grade dysplasia, high-grade dysplasia, or colorectal cancer). Univariate analysis demonstrated significant relationships between histologic inflammation over time and progression to advanced neoplasia (hazard ration (HR), 3.0; 95% CI: 1.4-6.3 for IS-mean; HR, 3.4; 95% CI: 1.1-10.4 for IS-bin; and HR, 2.2; 95% CI: 1.2-4.2 for IS-max). This association was maintained in multivariable proportional hazards analysis. CONCLUSIONS The severity of microscopic inflammation over time is an independent risk factor for developing advanced colorectal neoplasia among patients with long-standing UC.
Collapse
|
38
|
Brown SJ, Ullman T, Sachar DB. Filtering out the phagocytes in inflammatory bowel disease. J Clin Gastroenterol 2005; 39:845-6. [PMID: 16208106 DOI: 10.1097/01.mcg.0000180807.58737.e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
|
39
|
Matula S, Croog V, Itzkowitz S, Harpaz N, Bodian C, Hossain S, Ullman T. Chemoprevention of colorectal neoplasia in ulcerative colitis: the effect of 6-mercaptopurine. Clin Gastroenterol Hepatol 2005; 3:1015-21. [PMID: 16234048 DOI: 10.1016/s1542-3565(05)00738-x] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Evidence suggests that mesalamine-based anti-inflammatory medicines may prevent colorectal cancer (CRC) in ulcerative colitis (UC). If mesalamine exerts its chemopreventive effect by its anti-inflammatory activity, then other medications that reduce colitis activity also should possess chemopreventive properties. Our aim was to determine the effect of the immunomodulators 6-mercaptopurine (6MP) and azathioprine (AZA) in preventing the development of dysplasia or CRC in UC. METHODS Patients with UC who underwent a surveillance colonoscopy in 1996-1997 were identified from a gastrointestinal pathology database. A proportional hazards analysis assessing 6MP/AZA use as a time-changing covariate was performed to evaluate the effect of 6MP/AZA on: (1) progression to any neoplasia (low-grade dysplasia, high-grade dysplasia, or CRC), and (2) progression to advanced neoplasia (high-grade dysplasia or CRC). RESULTS A total of 315 subjects met inclusion criteria and were followed for an average of 8 years from their first surveillance examination. There were no significant differences in rates of progression to advanced neoplasia or to any neoplasia between 6MP/AZA users and never-users by log-rank testing. The proportional hazards analysis resulted in hazard ratios of 1.06 (95% confidence interval, .59-1.93) and 1.30 (95% confidence interval, .45-3.75) when considering the effect of exposure to 6MP/AZA on progression to any or to advanced neoplasia, respectively. The results were unaffected by known potential confounders. CONCLUSIONS In UC patients with no initial history of dysplasia, 6MP/AZA use appears to have little or no effect on the rate of neoplastic transformation in the colon. Importantly, the use of 6MP/AZA did not increase malignant transformation in UC.
Collapse
Affiliation(s)
- Sierra Matula
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA
| | | | | | | | | | | | | |
Collapse
|
40
|
Matula S, Croog V, Itzkowitz S, Harpaz N, Bodian C, Hossain S, Ullman T. Chemoprevention of colorectal neoplasia in ulcerative colitis: the effect of 6-mercaptopurine. Clin Gastroenterol Hepatol 2005. [PMID: 16234048 DOI: 10.1016/s1542-3565(05) 00738-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Evidence suggests that mesalamine-based anti-inflammatory medicines may prevent colorectal cancer (CRC) in ulcerative colitis (UC). If mesalamine exerts its chemopreventive effect by its anti-inflammatory activity, then other medications that reduce colitis activity also should possess chemopreventive properties. Our aim was to determine the effect of the immunomodulators 6-mercaptopurine (6MP) and azathioprine (AZA) in preventing the development of dysplasia or CRC in UC. METHODS Patients with UC who underwent a surveillance colonoscopy in 1996-1997 were identified from a gastrointestinal pathology database. A proportional hazards analysis assessing 6MP/AZA use as a time-changing covariate was performed to evaluate the effect of 6MP/AZA on: (1) progression to any neoplasia (low-grade dysplasia, high-grade dysplasia, or CRC), and (2) progression to advanced neoplasia (high-grade dysplasia or CRC). RESULTS A total of 315 subjects met inclusion criteria and were followed for an average of 8 years from their first surveillance examination. There were no significant differences in rates of progression to advanced neoplasia or to any neoplasia between 6MP/AZA users and never-users by log-rank testing. The proportional hazards analysis resulted in hazard ratios of 1.06 (95% confidence interval, .59-1.93) and 1.30 (95% confidence interval, .45-3.75) when considering the effect of exposure to 6MP/AZA on progression to any or to advanced neoplasia, respectively. The results were unaffected by known potential confounders. CONCLUSIONS In UC patients with no initial history of dysplasia, 6MP/AZA use appears to have little or no effect on the rate of neoplastic transformation in the colon. Importantly, the use of 6MP/AZA did not increase malignant transformation in UC.
Collapse
Affiliation(s)
- Sierra Matula
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA
| | | | | | | | | | | | | |
Collapse
|
41
|
Banikazemi M, Ullman T, Desnick RJ. Gastrointestinal manifestations of Fabry disease: clinical response to enzyme replacement therapy. Mol Genet Metab 2005; 85:255-9. [PMID: 15939645 DOI: 10.1016/j.ymgme.2005.04.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2005] [Revised: 04/18/2005] [Accepted: 04/22/2005] [Indexed: 11/16/2022]
Abstract
Gastrointestinal symptoms are often an early and prominent manifestation of Fabry disease, an X-linked inborn error of metabolism caused by the deficient activity of the lysosomal enzyme, alpha-galactosidase A. This enzyme deficiency results in the progressive accumulation of globotriaosylceramide and other glycosphingolipids in tissue lysosomes throughout the body. In classically affected patients, glycosphingolipid accumulation in the vascular endothelium eventually culminates in life-threatening renal, cardiac, and cerebrovascular disease. In addition, over 50% of patients experience post-prandial abdominal pain and diarrhea that interferes with the ability to work and quality of life. Here, we describe four males aged 17-40 years with classic Fabry disease and severe gastrointestinal symptoms who participated in clinical trials of enzyme replacement therapy with agalsidase beta (Fabrazyme, 1 mg/kg every 2 weeks). Before therapy, the three adult patients experienced post-prandial abdominal pain, bloating, and severe diarrhea with 7-10 bowel movements per day every day and the 17-year-old had weekly episodes of diarrhea with six bowel movements per day. Other symptoms included vomiting, food intolerance, and poor weight gain. All patients took medications for these symptoms (diphenoxylate-atropine [Lomotil], ranitidine hydrochloride [Zantac], or sulfasalazine). After 6-7 months of agalsidase beta therapy, all patients reported "no or only occasional" abdominal pain or diarrhea, had discontinued their gastrointestinal medications, and had gained 3-8 kg. These marked improvements in gastrointestinal symptoms have persisted for over 3 years of treatment. In such patients, enzyme replacement at 1 mg/kg effects an early and significant clinical improvement in the gastrointestinal manifestations of Fabry disease.
Collapse
Affiliation(s)
- Maryam Banikazemi
- Department of Human Genetics, Mount Sinai School of Medicine of New York University, New York, NY 1029, USA
| | | | | |
Collapse
|
42
|
|
43
|
Robert ME, Skacel M, Ullman T, Bernstein CN, Easley K, Goldblum JR. Patterns of colonic involvement at initial presentation in ulcerative colitis: a retrospective study of 46 newly diagnosed cases. Am J Clin Pathol 2004; 122:94-9. [PMID: 15272536 DOI: 10.1309/xlxk-j84c-3jcw-3rch] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
Studies have shown that rectal sparing and patchiness develop in treated and longstanding ulcerative colitis (UC), making the distinction from Crohn colitis increasingly difficult after treatment is initiated. However, no histologic studies of the incidence of rectal sparing in adults at UC onset have been performed. Colectomy specimens from 46 patients with classic UC histologic features and no Crohn disease features were identified. Biopsy specimens obtained before medical therapy were retrieved and examined blindly by 2 pathologists, along with appropriate control samples. Slides were scored for chronicity (crypt branching, subcryptal plasma cells, lamina propria plasma cells) and activity (cryptitis, crypt abscesses, epithelial injury). In 28 cases, only rectal biopsy specimens were taken; for 16, rectal and at least 1 proximal biopsy specimen were taken. All cases showed rectal involvement; none had rectal sparing at initial biopsy. Of 16 cases with rectal and more proximal biopsy specimens, 5 (31%) showed relative rectal sparing (lower scores in rectum than in more proximal sites). In 16 cases with rectal and more proximal biopsy specimens, chronicity and activity scores were higher in the rectum than in more proximal sites (P = .01; chronicity and activity). The mean overall chronicity score decreased in a linear manner from rectum to cecum. The rectum is involved and shows evidence of chronicity and activity at disease onset in UC, using colectomy as the gold standard for diagnosis. Because rectal sparing at UC onset has been reported, a prospective study using uniform biopsy protocols is needed to establish the true incidence of rectal sparing at presentation.
Collapse
Affiliation(s)
- Marie E Robert
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06520-8023, USA
| | | | | | | | | | | |
Collapse
|
44
|
Robert ME, Skacel M, Ullman T, Bernstein CN, Easley K, Goldblum JR. Patterns of Colonic Involvement at Initial Presentation in Ulcerative Colitis. Am J Clin Pathol 2004. [DOI: 10.1309/xlxkj84c3jcw3rch] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
45
|
|
46
|
Abstract
BACKGROUND & AIMS Long-standing ulcerative colitis has long been recognized as a risk factor for colorectal cancer, but there is still no universal consensus on the optimal management of ulcerative colitis patients with low-grade dysplasia in flat mucosa. Some authorities favor prompt colectomy, whereas others recommend continued surveillance. The purpose of our study was to determine the frequency with which flat low-grade dysplasia in ulcerative colitis progresses to advanced neoplasia (high-grade dysplasia or colorectal cancer) and whether specific variables could predict such progression. METHODS We reviewed the medical histories, colonoscopic findings, and surgical and pathology reports of 46 patients with ulcerative colitis diagnosed with flat low-grade dysplasia on a surveillance colonoscopy. The rates of neoplastic progression, as well as the frequency of advanced neoplasia, were tabulated. We correlated progression with several clinical and colonoscopic variables: the number of biopsy samples positive for flat low-grade dysplasia, the duration and anatomic extent of disease, patient age, and medication use. RESULTS Among these 46 patients, there were 7 cases of colorectal cancer, 5 of which were stage II or higher. Unexpected advanced neoplasia occurred in 4 of 17 (23.5%) patients who underwent colectomy for flat low-grade dysplasia. On an actuarial basis, the rate of neoplastic progression was 53% at 5 years. No clinical features predicted progression to advanced neoplasia. Cancers, including 2 at advanced stages, developed despite frequent follow-up surveillance examinations. CONCLUSIONS A finding of flat low-grade dysplasia during ulcerative colitis surveillance is a strong predictor of progression to advanced neoplasia. Early colectomy should be recommended for such patients.
Collapse
Affiliation(s)
- Thomas Ullman
- Department of Medicine, The Dr. Henry D. Janowitz Division of Gastroenterology, Box 1069, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA.
| | | | | | | | | |
Collapse
|
47
|
Ullman T, Korzenik JR. Yogurt as oral bacteriotherapy for diarrhea: back to the future? Indian Pediatr 1998; 35:503-6. [PMID: 10216643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
|
48
|
Affiliation(s)
- T Ullman
- Cornell University Medical College, Burke Rehabilitation Hospital, White Plains, NY 10605, USA
| | | |
Collapse
|
49
|
Abstract
This paper describes a new canine segmental spinal fusion model for the comparison of bone-grafting materials. The test sites in the model are three separate posterior interfacet-interlaminar fusion sites in the lumbar spine (L1-2, L3-4, and L5-6). The outcome was assessed by scoring of the fusion sites for union and by mechanical testing of fused segments. The results from two experiments are presented. Autogenous cancellous bone was the most effective material tested and had a statistically superior score for union compared with all other materials (p = 0.01). The results with an osteoconductive matrix of collagen and ceramic alone were no better than those with the controls (no graft). However, addition of an extract of matrix-derived proteins (15-30 kDa) to the collagen-ceramic carrier appeared to improve the score for union. The inclusion of nonresorbed ceramic granules had no evident effect on the mechanical properties of fusions, with a comparable score for union. This model appears to be a sensitive and efficient method for the comparison of graft materials. Advantages over previously described models are discussed.
Collapse
Affiliation(s)
- G F Muschler
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, OH 44195
| | | | | | | | | | | | | |
Collapse
|