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1.
Am J Gastroenterol ; 2024 May 08.
Artículo en Inglés | MEDLINE | ID: mdl-38717045

RESUMEN

INTRODUCTION: Hepatitis B virus (HBV) vaccination is recommended in patients with inflammatory bowel disease (IBD). Although the 2-dose Heplisav-B vaccine has proven effective, more than 20% of patients with IBD do not seroconvert. We prospectively evaluated the effectiveness of a third Heplisav-B dose in patients with IBD lacking HBV immunity despite 2-dose vaccination. METHODS: Adults with IBD who had received 2-dose Heplisav-B vaccination between 2018 and 2023 were identified. Seroconversion was defined as hepatitis B surface antibody (HBsAb) ≥ 10 IU/L measured at ≥4 weeks after vaccination. Patients who did not seroconvert were prospectively offered a third Heplisav-B dose, followed by repeat HBsAb measurement. Demographic, clinical, medication, and vaccination data were compared between those who did and did not seroconvert. RESULTS: Of 192 patients identified, 71.9% (138/192) seroconverted after 2-dose Heplisav-B vaccination. The 54 patients (28.1%) who did not seroconvert were more likely to be male, have diabetes, chronic kidney disease, or elevated Charlson Comorbidity Index. Of the 54 patients, 30 (55.6%) elected to receive a third Heplisav-B dose, with 56.7% (17/30) achieving seroconversion (median HBsAb titer 376 IU/L, IQR 47-1,000 IU/L) despite a median intervaccination time of 416 days (IQR 90.8-667.8). No differences were noted between patients who did vs did not seroconvert after third-dose vaccination. DISCUSSION: In patients with IBD lacking HBV immunity despite 2-dose Heplisav-B vaccination, administration of a third dose resulted in a 56.7% seroconversion rate. Our results suggest that administration of an additional Heplisav-B dose may be an effective strategy in patients lacking immunity despite primary 2-dose vaccination.

2.
BMC Gastroenterol ; 24(1): 225, 2024 Jul 15.
Artículo en Inglés | MEDLINE | ID: mdl-39009983

RESUMEN

BACKGROUND/OBJECTIVES: The Oakland score was developed to predict safe discharge in patients who present to the emergency department with lower gastrointestinal bleeding (LGIB). In this study, we retrospectively evaluated if this score can be implemented to assess safe discharge (score ≤ 10) at WellStar Atlanta Medical Center (WAMC). METHODS: A retrospective cohort study of 108 patients admitted at WAMC from January 1, 2020 to December 30, 2021 was performed. Patients with LGIB based on the ICD-10 codes were included. Oakland score was calculated using 7 variables (age, sex, previous LGIB, digital rectal exam, pulse, systolic blood pressure (SBP) and hemoglobin (Hgb)) for all patients at admission and discharge from the hospital. The total score ranges from 0 to 35 and a score of ≤ 10 is a cut-off that has been shown to predict safe discharge. Hgb and SBP are the main contributors to the score, where lower values correspond to a higher Oakland score. Descriptive and multivariate analysis was performed using SPSS 23 software. RESULTS: A total of 108 patients met the inclusion criteria, 53 (49.1%) were female with racial distribution was as follows: 89 (82.4%) African Americans, 17 (15.7%) Caucasian, and 2 (1.9%) others. Colonoscopy was performed in 69.4% patients; and 61.1% patients required blood transfusion during hospitalization. Mean SBP records at admission and discharge were 129.0 (95% CI, 124.0-134.1) and 130.7 (95% CI,125.7-135.8), respectively. The majority (59.2%) of patients had baseline anemia and the mean Hgb values were 11.0 (95% CI, 10.5-11.5) g/dL at baseline prior to hospitalization, 8.8 (95% CI, 8.2-9.5) g/dL on arrival and 9.4 (95% CI, 9.0-9.7) g/dL at discharge from hospital. On admission, 100/108 (92.6%) of patients had an Oakland score of > 10 of which almost all patients (104/108 (96.2%)) continued to have persistent elevation of Oakland Score greater than 10 at discharge. Even though, the mean Oakland score improved from 21.7 (95% CI, 20.4-23.1) of the day of arrival to 20.3 (95% CI, 19.4-21.2) at discharge, only 4/108 (3.7%) of patients had an Oakland score of ≤ 10 at discharge. Despite this, only 9/108 (8.33%) required readmission for LGIB during a 1-year follow-up. We found that history of admission for previous LGIB was associated with readmission with adjusted odds ratio 4.42 (95% CI, 1.010-19.348, p = 0.048). CONCLUSIONS: In this study, nearly all patients who had Oakland score of > 10 at admission continued to have a score above 10 at discharge. If the Oakland Score was used as the sole criteria for discharge most patients would not have met discharge criteria. Interestingly, most of these patients did not require readmission despite an elevated Oakland score at time of discharge, indicating the Oakland score did not really predict safe discharge. A potential confounder was the Oakland score did not consider baseline anemia during calculation. A prospective study to evaluate a modified Oakland score that considers baseline anemia could add value in this patient population.


Asunto(s)
Hemorragia Gastrointestinal , Alta del Paciente , Humanos , Femenino , Masculino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiología , Estudios Retrospectivos , Persona de Mediana Edad , Anciano , Alta del Paciente/estadística & datos numéricos , Hemoglobinas/análisis , Servicio de Urgencia en Hospital/estadística & datos numéricos , Enfermedad Aguda , Adulto , Medición de Riesgo , Presión Sanguínea , Hospitalización/estadística & datos numéricos
3.
Am J Gastroenterol ; 118(7): 1282-1284, 2023 07 01.
Artículo en Inglés | MEDLINE | ID: mdl-36940436

RESUMEN

INTRODUCTION: Use of the electronic health record (EHR) has become increasingly widespread. Higher EHR burden is associated with burnout, but this has not been specifically investigated among gastroenterology (GI) providers. METHODS: We retrospectively collected measures of EHR use for outpatient GI providers during a 6-month period. We compared metrics across provider sex, subspecialty, and training (physicians vs nonphysician providers [NPPs]). RESULTS: Data collected represented more than 16,000 appointments from 41 providers across the Division of Gastroenterology and Hepatology. Inflammatory bowel disease (IBD) and hepatology specialists spent more time per appointment in the EHR, clinical review, and outside regular hours compared with other subspecialists. NPPs spent more EHR time than physicians. DISCUSSION: IBD and hepatology specialists and NPPs may have disproportionally high EHR burden. More work is needed to understand differences in provider workload to combat burnout.


Asunto(s)
Gastroenterología , Enfermedades Inflamatorias del Intestino , Humanos , Registros Electrónicos de Salud , Estudios Retrospectivos , Enfermedades Inflamatorias del Intestino/terapia
4.
Dig Dis Sci ; 68(2): 423-433, 2023 02.
Artículo en Inglés | MEDLINE | ID: mdl-36565367

RESUMEN

BACKGROUND/OBJECTIVES: Data regarding incidence, health-care burden, and predictors for readmission in patients with acute alcoholic pancreatitis (AAP) is scarce. We aim to identify incidence, health-care burden, and predictors of readmission over an 11-month period. METHODS: Retrospective cohort study using the 2016 National Readmission Database of adult patients admitted with a principal diagnosis of AAP in January and 11-month readmission follow up for all-cause readmission. Incidence of all-cause readmission, mortality rate, morbidity, length of stay (LOS), total hospitalization charges and costs were evaluated. Independent risk factors for all-cause readmission were identified using a Cox multivariate logistic regression analysis. RESULTS: A total of 6633 patients were included in the study. The mean age was 45.7 years and 28.9% of patients were female. 73.1% of patients had a modified BISAP score of 0. The 11-month readmission rate was 43.1%. The main cause of readmission was another episode of AAP. The mortality rate of readmission was 0.5% and the mortality rate during the index admission (IA) was 1.1% (P = 0.03). The mean LOS, total hospitalization charges and costs for readmission were 4.5 days, $34,307 and $8958, respectively. Independent predictors of readmission were Charlson Comorbidity Index score of ≥ 3, associated chronic alcoholic pancreatitis, and chronic pancreatitis (CP) from other causes. CONCLUSION: Among patients admitted with AAP, the 11-month readmission rate was 43.1%. Over one-third of readmissions were due to another episode of AAP. Readmission associated with significant resource utilization. Special attention should be placed in patients with underlying CP due to the increased risk of readmission.


Asunto(s)
Pancreatitis Alcohólica , Readmisión del Paciente , Adulto , Humanos , Femenino , Persona de Mediana Edad , Masculino , Estudios Retrospectivos , Incidencia , Factores de Riesgo
5.
Clin Gastroenterol Hepatol ; 19(10): 2112-2120.e1, 2021 10.
Artículo en Inglés | MEDLINE | ID: mdl-34048936

RESUMEN

BACKGROUND & AIMS: Despite rescue therapy, more than 30% of patients with acute severe ulcerative colitis (ASUC) require colectomy. Tofacitinib is a rapidly acting Janus kinase inhibitor with proven efficacy in ulcerative colitis. Tofacitinib may provide additional means for preventing colectomy in patients with ASUC. METHODS: A retrospective case-control study was performed evaluating the efficacy of tofacitinib induction in biologic-experienced patients admitted with ASUC requiring intravenous corticosteroids. Tofacitinib patients were matched 1:3 to controls according to gender and date of admission. Using Cox regression adjusted for disease severity, we estimated the 90-day risk of colectomy. Rates of complications and steroid dependence were examined as secondary outcomes. RESULTS: Forty patients who received tofacitinib were matched 1:3 to controls (n = 113). Tofacitinib was protective against colectomy at 90 days compared with matched controls (hazard ratio [HR], 0.28, 95% confidence interval [CI], 0.10-0.81; P = .018). When stratifying according to treatment dose, 10 mg three times daily (HR, 0.11; 95% CI, 0.02-0.56; P = .008) was protective, whereas 10 mg twice daily was not significantly protective (HR, 0.66; 95% CI, 0.21-2.09; P = .5). Rate of complications and steroid dependence were similar between tofacitinib and controls. CONCLUSIONS: Tofacitinib with concomitant intravenous corticosteroids may be an effective induction strategy in biologic-experienced patients hospitalized with ASUC. Prospective trials are needed to identify the safety, optimal dose, frequency, and duration of tofacitinib for ASUC.


Asunto(s)
Productos Biológicos , Colitis Ulcerosa , Estudios de Casos y Controles , Colectomía , Colitis Ulcerosa/tratamiento farmacológico , Colitis Ulcerosa/cirugía , Humanos , Piperidinas , Estudios Prospectivos , Pirimidinas , Estudios Retrospectivos
6.
Clin Gastroenterol Hepatol ; 17(5): 988-990.e1, 2019 04.
Artículo en Inglés | MEDLINE | ID: mdl-30458248

RESUMEN

As many as 25% of patients diagnosed with ulcerative colitis are hospitalized with an episode of acute severe ulcerative colitis (ASUC).1 The standard of care for patients hospitalized with ASUC relies on rapid induction with intravenous (IV) corticosteroids. Up to 30% of patients do not respond to corticosteroids alone.2 Rescue therapy with infliximab or cyclosporine has been shown to reduce rates of colectomy to 20% by 90 days.3,4 This still represents a significant rate of treatment failure, which leads to an unplanned and irreversible surgery. In recent years, increasing numbers of patients admitted with ASUC have already failed infliximab therapy, highlighting the need for additional treatment options for these patients. Tofacitinib is a rapidly acting, oral, small-molecule Janus kinase inhibitor that was recently approved by the Food and Drug Administration for treatment of ulcerative colitis.5 We present the first reported use of off-label, high-intensity tofacitinib in 4 patients admitted to our institution with ASUC predicted to fail medical management.


Asunto(s)
Colitis Ulcerosa/tratamiento farmacológico , Factores Inmunológicos/administración & dosificación , Quimioterapia de Inducción/métodos , Piperidinas/administración & dosificación , Inhibidores de Proteínas Quinasas/administración & dosificación , Pirimidinas/administración & dosificación , Pirroles/administración & dosificación , Adulto , Animales , Femenino , Hospitales , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Adulto Joven
8.
ACG Case Rep J ; 11(6): e01368, 2024 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-38883582

RESUMEN

Treatment options for patients with inflammatory bowel disease are constantly evolving; however, medication-refractory disease remains an issue. Pediatric case series show the potential benefit of sirolimus therapy in refractory Crohn's disease (CD); however, limited data exist in adult patients. As such, we retrospectively identified and report clinical outcomes for 4 patients prescribed sirolimus for treatment of refractory CD. Despite a median sirolimus therapy duration of 524 days and some therapeutic benefits, all patients discontinued therapy due to adverse effects. Our findings suggest that while sirolimus may have clinical utility, its role may be limited by treatment-derived adverse effects.

9.
Crohns Colitis 360 ; 6(1): otae007, 2024 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-38352117

RESUMEN

Introduction: Crohn's disease (CD) with short bowel syndrome (SBS) can present as chronic intestinal failure (CIF) often requiring nutritional support. Teduglutide is a treatment option for these patients. We investigated clinical outcomes of CD-CIF patients with SBS treated with teduglutide. Methods: Adults with CD-CIF and SBS who received teduglutide were identified at a tertiary care academic center between 2012 and 2023. Data was collected retrospectively. Primary outcome measured was reduction in parenteral support (PS) by ≥20% volume, with PS defined as utilization of parenteral nutrition (PN) or intravenous fluids (IVF). Several secondary outcomes included immunosuppressive medication changes, subjective symptom improvement, and stool output. Results: We identified 32 patients with CD-CIF and SBS receiving teduglutide. Comparing clinical outcomes before and after teduglutide, 26 of 32 patients achieved the primary outcome of ≥20% PS reduction. A decrease was seen in patients requiring PN + IVF, with corresponding increases in patients requiring PN only and IVF only. Among all 3 groups, a total of 23 patients received PN prior to teduglutide, which decreased to 14 following teduglutide. Weekly PN volume reduced from 7.00 to 3.55 L and weekly frequency decreased from 7.00 to 3.00 instances (P < .01). Reductions in weekly volume and frequency were observed among all patients receiving IVF support (25 vs 15). Secondary outcomes showed improvement in patient reported subjective symptoms (84.4%), stool output (90.6%), patients meeting criteria for diarrhea/high ostomy output (27 vs 14), and use of unique antidiarrheal medications (3.0 vs 2.0). Conclusions: This retrospective case series demonstrated improved clinical outcomes in patients with CD-CIF and SBS treated with teduglutide resulting in decreased PS requirements, antidiarrheal medications requirement, and stool output without significant effects on immunosuppressive therapy.

10.
Inflamm Bowel Dis ; 2024 Jul 12.
Artículo en Inglés | MEDLINE | ID: mdl-39001616

RESUMEN

BACKGROUND: Metformin exerts anti-inflammatory properties through a positive effect on oxidative stress, gut barrier integrity, and the gut microbiota. Our aim was to evaluate the influence of metformin on inflammatory bowel disease (IBD) outcomes in patients with type 2 diabetes mellitus (T2DM). METHODS: We conducted a retrospective cohort study using the TriNetX database in patients with IBD and T2DM who initiated metformin vs oral hypoglycemics or insulin (control cohort) between August 31, 2002, and August 31, 2022. One-to-one propensity score matching was performed. Primary outcomes were need for intravenous (IV) steroid use or IBD-related surgery within 1, 2, and 3 years after metformin initiation. RESULTS: Our cohorts included 1323 patients with ulcerative colitis (UC) (mean age 58.7 ±â€…12.2 years, 50.1% female, 77.3% White) and 1278 patients with Crohn's disease (CD) (mean age 56.3 ±â€…12.6 years, 58.2% female, 76.5% White). At 1 year, patients with UC and CD were less likely to require IV steroids (UC: adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.34-0.59; P < .01; CD: aOR, 0.67; 95% CI, 0.53-0.85; P < .01). The decreased need for IV steroids persisted in all metformin groups at 2 and 3 years. Patients with CD were at a lower risk for IBD-related surgery at year 1 (aOR, 0.5; 95% CI, 0.31-0.81; P < .01), and this finding persisted at 3 years (aOR, 0.62; 95% CI, 0.43-0.89; P < .01). Metformin did not affect risk for surgery in patients with UC. CONCLUSIONS: Patients with IBD and T2DM on metformin had a decreased likelihood of worse IBD outcomes.


Our study shows that metformin is associated with decreased risk of corticosteroids in patients with ulcerative colitis and Crohn's disease and decreased risk of surgery in patients with Crohn's disease.

11.
Clin Gastroenterol Hepatol ; 11(12): 1601-8.e1-4, 2013 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-23872237

RESUMEN

BACKGROUND & AIMS: An association between inflammatory activity and colorectal neoplasia (CRN) has been documented in patients with ulcerative colitis (UC). However, previous studies did not address the duration of inflammation or the effects of therapy on risk for CRN. We investigated the effects of inflammation, therapies, and characteristics of patients with UC on their risk for CRN. METHODS: We collected data from 141 patients with UC without CRN (controls) and 59 matched patients with UC who developed CRN (cases), comparing disease extent and duration and patients' ages. We used a new 6-point histologic inflammatory activity (HIA) scale to score biopsy fragments (n = 4449). Information on medications, smoking status, primary sclerosing cholangitis, and family history of CRN were collected from the University of Chicago Inflammatory Bowel Disease Endoscopy Database. Relationships between HIA, clinical features, and CRN were assessed by conditional logistic regression. RESULTS: Cases and controls were similar in numbers of procedures and biopsies, exposure to steroids or mesalamine, smoking status, and family history of CRN. They differed in proportion of men vs women, exposure to immune modulators, and primary sclerosing cholangitis prevalence. In univariate analysis, HIA was positively associated with CRN (odds ratio [OR], 2.56 per unit increase; P = .001), whereas immune modulators (including azathioprine, 6-mercaptopurine, and methotrexate) reduced the risk for CRN (OR, 0.35; P < .01). HIA was also associated with CRN in multivariate analysis (OR, 3.68; P = .001). CONCLUSIONS: In a case-control study, we associated increased inflammation with CRN in patients with UC. Use of immune modulators reduced the risk for CRN, indicating that these drugs have chemoprotective effects. On the basis of these data, we propose new stratified surveillance and treatment strategies to prevent and detect CRN in patients with UC.


Asunto(s)
Colitis Ulcerosa/complicaciones , Colitis Ulcerosa/patología , Neoplasias del Colon/epidemiología , Adulto , Estudios de Casos y Controles , Femenino , Histocitoquímica , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo
12.
Inflamm Bowel Dis ; 29(5): 744-751, 2023 05 02.
Artículo en Inglés | MEDLINE | ID: mdl-35792493

RESUMEN

BACKGROUND: Tofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of ulcerative colitis (UC). Patients with inflammatory bowel disease are susceptible to Clostridium difficile infection (CDI). Here, we evaluate CDI in the tofacitinib UC clinical program. METHODS: Events from 4 randomized, placebo-controlled studies (phase [P] 2 or P3 induction [NCT00787202; NCT01465763; NCT01458951], P3 maintenance [NCT01458574]) and an open-label, long-term extension (OLE) study (NCT01470612), were analyzed as 3 cohorts: Induction (P2/P3 induction), Maintenance (P3 maintenance), and Overall (patients receiving tofacitinib 5 or 10 mg twice daily [BID] in P2, P3, and OLE studies; including final data from the OLE study, as of August 24, 2020). Proportions and incidence rates (unique patients with events per 100 patient-years of exposure) of CDI were evaluated. RESULTS: The overall cohort comprised 1157 patients who received ≥1 dose of tofacitinib 5 or 10 mg BID, with a total of 2814.4 patient-years of tofacitinib exposure and up to 7.8 years of treatment. A total of 82.6% of patients received predominantly tofacitinib 10 mg BID. In the induction, maintenance, and overall cohorts, 3 (2 tofacitinib treated, 1 placebo treated), 3 (all placebo treated), and 9 patients had CDI, respectively; the overall cohort incidence rate was 0.31 (95% confidence interval, 0.14-0.59). CDI were all mild-moderate in severity and resolved with treatment in 8 patients. Six of 9 patients continued tofacitinib treatment without interruption. Two patients had events reported as serious due to hospitalization. Two patients were receiving corticosteroids when the CDI occurred. CONCLUSION: CDIs among patients with UC receiving tofacitinib were infrequent, cases were mild-moderate in severity, and most resolved with treatment.


The incidence of Clostridium difficile infection in the tofacitinib ulcerative colitis clinical program was evaluated. C. difficile infection among patients with ulcerative colitis receiving tofacitinib were infrequent; cases were mild­moderate in severity, and most resolved with treatment.


Asunto(s)
Infecciones por Clostridium , Colitis Ulcerosa , Inhibidores de las Cinasas Janus , Humanos , Infecciones por Clostridium/tratamiento farmacológico , Colitis Ulcerosa/tratamiento farmacológico , Inhibidores de las Cinasas Janus/uso terapéutico , Pirimidinas/uso terapéutico , Resultado del Tratamiento
13.
Inflamm Bowel Dis ; 29(1): 51-61, 2023 01 05.
Artículo en Inglés | MEDLINE | ID: mdl-35380664

RESUMEN

BACKGROUND: Tofacitinib is an oral, small molecule JAK inhibitor for the treatment of ulcerative colitis (UC). These post hoc analyses assessed associations between C-reactive protein (CRP), partial Mayo score (PMS), and efficacy outcomes during tofacitinib induction in UC. METHODS: Patients received tofacitinib 10 mg twice daily (BID) in an 8-week, phase 2 induction study and 2 identical, 8-week, phase 3 induction studies (OCTAVE Induction 1&2); induction nonresponders (IndNR) received an additional 8 weeks of tofacitinib 10 mg BID in an open-label, long-term extension study. Associations between CRP and PMS, and efficacy outcomes (clinical response, clinical remission, endoscopic improvement, and endoscopic remission) were analyzed using univariate and multivariable logistic regression and receiver operating characteristic curves. RESULTS: Changes from baseline in the logarithm of CRP ([log]CRP) and PMS at week 4 were associated with clinical response at week 8 (univariate: per unit, odds ratio [OR], 0.55 [95% confidence interval (CI), 0.48-0.62]; and 0.42 [0.37-0.47], respectively). Among IndNR, change from baseline in PMS at week 8 was associated with clinical response at week 16 (univariate: per unit, OR, 0.59; 95% CI, 0.46-0.75). C-reactive protein at week 4 (area under the curve [AUC] > 0.6) and PMS at weeks 2 and 4 (AUC, > 0.7) generally exhibited predictive value for week 8 efficacy outcomes. CONCLUSIONS: Patients who achieved clinical response at week 8 had larger decreases in CRP and PMS at week 4 than patients who did not. IndNR who achieved clinical response at week 16 with extended tofacitinib induction had a larger decrease in PMS at week 8 vs those who did not. ClinicalTrials.gov:NCT00787202;NCT01465763;NCT01458951;NCT01470612.


Early decreases in partial Mayo score and C-reactive protein were found to be associated with achieving efficacy outcomes following tofacitinib 10 mg twice daily induction therapy in the ulcerative colitis clinical program.


Asunto(s)
Colitis Ulcerosa , Inhibidores de las Cinasas Janus , Humanos , Proteína C-Reactiva , Quimioterapia de Inducción , Colitis Ulcerosa/tratamiento farmacológico , Inhibidores de las Cinasas Janus/uso terapéutico , Inducción de Remisión , Resultado del Tratamiento
14.
Inflamm Bowel Dis ; 29(8): 1177-1190, 2023 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-36271884

RESUMEN

BACKGROUND: Recommendations regarding signs and symptoms that should prompt referral of patients with inflammatory bowel disease (IBD) to an IBD specialist for a consultation could serve to improve the quality of care for these patients. Our aim was to develop a consult care pathway consisting of clinical features related to IBD that should prompt appropriate consultation. METHODS: A scoping literature review was performed to identify clinical features that should prompt consultation with an IBD specialist. A panel of 11 experts was convened over 4 meetings to develop a consult care pathway using the RAND/UCLA Appropriateness Method. Items identified via scoping review were ranked and were divided into major and minor criteria. Additionally, a literature and panel review was conducted assessing potential barriers and facilitators to implementing the consult care pathway. RESULTS: Of 43 features assessed, 13 were included in the care pathway as major criteria and 15 were included as minor criteria. Experts agreed that stratification into major criteria and minor criteria was appropriate and that 1 major or 2 or more minor criteria should be required to consider consultation. The greatest barrier to implementation was considered to be organizational resource allocation, while endorsements by national gastroenterology and general medicine societies were considered to be the strongest facilitator. CONCLUSIONS: This novel referral care pathway identifies key criteria that could be used to triage patients with IBD who would benefit from IBD specialist consultation. Future research will be required to validate these findings and assess the impact of implementing this pathway in routine IBD-related care.


This study aimed to develop a care pathway consisting of clinical features that should prompt inflammatory bowel disease expert consultation. A scoping literature review was performed to identify attributes, and an expert panel finalized the structure and components of the pathway.


Asunto(s)
Gastroenterología , Enfermedades Inflamatorias del Intestino , Humanos , Enfermedades Inflamatorias del Intestino/diagnóstico , Enfermedades Inflamatorias del Intestino/terapia , Derivación y Consulta
15.
ACG Case Rep J ; 9(10): e00867, 2022 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-36212237

RESUMEN

Ustekinumab is a common biologic therapy for the treatment of inflammatory bowel disease. Posterior reversible encephalopathy syndrome (PRES) is an uncommon condition consisting of a constellation of neurologic findings and characteristic findings on imaging. The association between ustekinumab and PRES is not well defined. We present a case of PRES in a patient with Crohn's disease on ustekinumab and a brief review of the literature. Clinicians should be aware of this rare complication with high morbidity in patients with inflammatory bowel disease on ustekinumab and be able to recognize clinical symptoms.

16.
Cureus ; 14(9): e29298, 2022 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-36277552

RESUMEN

Cronkhite-Canada syndrome (CCS) is a rare cause of chronic diarrhea and malabsorption where patients develop multiple polyps throughout the gastrointestinal (GI) tract, accompanied by ectodermal changes. Due to its rarity, early detection and diagnosis are challenging for physicians, inevitably leading to high mortality. CCS patients have a higher prevalence of GI cancer compared to the general population. Therefore, a follow-up endoscopy is necessary. We report a new case of CCS in an 85-year-old male who presented with chronic watery diarrhea, weight loss, and skin changes including alopecia, nail dystrophy, and hyperpigmentation. Laboratory results showed anemia and hypoalbuminemia. He underwent an endoscopy that found diffuse edematous polyposis in the stomach, duodenum, terminal ileum, and large intestine. The biopsy result confirmed the diagnosis of CCS. The patient received supportive treatment with total parenteral nutrition with improvement in his symptoms. He was placed on corticosteroid taper and azathioprine upon discharge. At the one-year follow-up, he was found in endoscopic remission.

17.
Cureus ; 14(4): e23834, 2022 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-35530927

RESUMEN

A 23-year-old male presented to the hospital with altered mental status (AMS) and hypoglycemia requiring admission to the ICU. He had improvement in AMS after administration of dextrose 50% and naloxone and endorsed the use of alcohol, cocaine, and marijuana that morning. It was confirmed with a positive urine toxicology screen for cocaine and tetrahydrocannabinol (THC). During this hospital admission, his physical examination was notable for paraplegia with no motor abilities from the T6 dermatome and below. Sensation was intact throughout all dermatomes but he was found to have urinary retention. Workup included an abnormal MRI showing T2 signal spanning from T2-T8, raising a high suspicion of a probable acute ischemic spinal cord infarction. Several hours after admission, the patient began to exhibit the first signs of abnormal bowel function and experienced one episode of hematemesis, prolonging his ICU stay.

18.
Acad Med ; 96(1): 113-117, 2021 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-33394663

RESUMEN

PURPOSE: Teaching by way of asking questions is a time-honored practice that has taken on the negative connotation of "pimping" among medical students and has made some faculty hesitant to ask students questions during clerkship rotations. Yet, quantitative studies exploring student perspectives on this practice are limited. This study aimed to solicit student and faculty views and investigate faculty perceptions of students' preferences. METHOD: Students who completed their internal medicine clerkship during the 2017-2018 academic year (n = 165) and were from the 2020 graduating class and their supervising faculty (n = 144) at the University of Michigan Medical School were asked to complete a Likert response survey in April 2019. The survey solicited perspectives on questions probing medical knowledge posed to students by faculty. Surveys were constructed using an iterative process, and data were analyzed using t tests and linear regressions. RESULTS: A total of 140 (85%) students and 112 (78%) faculty participated. Of those, 125 (89%) students and 109 (97%) faculty agreed that probing questions are valuable for student education, but only 73 (65%) faculty perceived that students agreed with this statement (P < .001). In addition, 115 (82%) students preferred to be asked too many questions than none at all. Fifty-five (39%) students agreed that they feel humiliated when they answer a question incorrectly. However, only 7 (5%) students agreed that faculty ask questions to humiliate them, and only 20 (14%) preferred that faculty stop asking questions if they answer a question incorrectly. CONCLUSIONS: Students valued probing questions more than faculty perceived, which argues against a withdrawal from the Socratic teaching method in the clinical arena. The students' experience of humiliation when answering incorrectly requires further study and perhaps can be tempered by more explicit framing of the role of the questioning process.


Asunto(s)
Educación de Pregrado en Medicina/organización & administración , Docentes/psicología , Internado y Residencia/organización & administración , Filosofía Médica , Aprendizaje Basado en Problemas/organización & administración , Estudiantes de Medicina/psicología , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Adulto Joven
19.
Crohns Colitis 360 ; 2(2): otaa022, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-36798650

RESUMEN

Background: Ustekinumab is approved for Crohn's disease and Ulcerative colitis with acute infusion reactions reported at a rate of 0.9%-4.5%. Methods: A retrospective chart review was conducted on inflammatory bowel disease (IBD) patients experiencing an acute infusion reaction to ustekinumab at 2 large institutions. Results: Acute ustekinumab infusion reactions occurred in 16 patients with Crohn's disease (CD) and Ulcerative colitis (UC), at a rate of 0.8%-3%. Patients were all naïve to ustekinumab, receiving their initial IV induction. Ninety-three percent subsequently tolerated the injection without issues. Conclusions: In this large, real-world study of acute infusion reactions to ustekinumab, the rate was similar to that seen in clinical trials-0.8%-3%.

20.
Inflamm Bowel Dis ; 26(9): 1291-1305, 2020 08 20.
Artículo en Inglés | MEDLINE | ID: mdl-32820340

RESUMEN

BACKGROUND: The level of inflammatory bowel disease (IBD) training in general gastroenterology fellowship is often insufficient to prepare trainees to deliver advanced IBD care in practice. Advanced IBD fellowships have been developed to fill this training gap, but there is no established curriculum, and significant variability exists across programs. Entrustable professional activities (EPAs) are practical and realistic objectives that define essential tasks of a specialty that physicians should master to be competent during independent practice. The American College of Gastroenterology (ACG) and Crohn's & Colitis Foundation (Foundation) established a task force to develop and appraise EPAs for advanced IBD fellowship. METHODS: Entrustable professional activities were developed using a multistep approach in a similar manner to other specialties. Initial EPAs identified via focus groups were evaluated, critiqued, and changed using an iterative model of feedback. The final EPAs were selected after the task force conducted a 3-phase modified Delphi method consisting of 2 sequential rounds of web-based voting and an in-person consensus meeting. RESULTS: Ten EPAs for advanced IBD fellowship were established including detailed descriptions with the associated knowledge, skills, and attitudes for each that can serve as curricular milestones. CONCLUSION: Ten EPAs describing the core work of an advanced IBD fellowship-trained physician have been established by a multisociety task force. Creating EPAs for an advanced curriculum comes with unique challenges, particularly the need to prevent duplication of prior training competencies while demonstrating the potential for unique milestones.


Asunto(s)
Educación de Postgrado en Medicina/métodos , Becas , Gastroenterología/educación , Enfermedades Inflamatorias del Intestino , Competencia Clínica , Humanos , Estados Unidos
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