Examining the impact of postoperative opioid use on length of hospital stay following radical cystectomy.

INTRODUCTION: Radical cystectomy (RC) is associated with high rates of morbidity, prolonged hospital stay, and increased opioid use for postoperative pain management; however, the relationship between postoperative opioid use and length of stay (LOS ) remains uncharacterized. This study serves to investigate the association between postoperative opioid use and length of hospital stay after RC. The relationship between patient and surgical factors on LOS was also characterized. METHODS: We retrospectively reviewed all patients between 2009 and 2019 who underwent RC at our institution. Patient and perioperative variables were analyzed to determine the relationship between postoperative opioid use and LOS using multivariable linear regression analysis. RESULTS: We identified 240 patients for study inclusion with a median age of 70.0 years. Median LOS was 10.0 days, with median daily mg morphine equivalent use of 57.5 for patients. Daily mg morphine equivalent use was significantly associated with an increased LOS, as were previous pelvic radiation, postoperative ileus, and higher Clavien-Dindo grade complication during admission (all p<0.05). Median LOS increased by one day for each increase of 13.2 daily mg morphine equivalents received. CONCLUSIONS: Increased daily opioid use was associated with increased length of hospital stay after RC. Non-opioid-based pain management approaches may be effective in reducing LOS after RC.

Major morbidity and mortality associated with delays to emergent surgery in children: a risk-adjusted analysis.

BACKGROUND: Delay of emergency surgery contributes to morbidity and mortality, and physiologic status affects outcomes of patients requiring emergent surgery. Our purpose was to determine whether delays to emergent surgery in children were associated with increased major morbidity or mortality in a risk-adjusted population. METHODS: We performed a retrospective review of class 1 (≤ 60 min to operating room) surgical procedures from July 11, 2011, to July 30, 2016, at BC Children's Hospital, Vancouver. Data sources included the operating room database, patient charts, American Society of Anesthesiologists classification, Neonatal Acute Physiology (SNAP II) and Pediatric Risk of Mortality (PRISM III) scores, time from booking to operating room and outcome. Patients were classified as being at low or high risk for death. We defined major morbidity as unintended loss of an organ, limb or function related to surgery, and delay to surgery as more than 60 minutes from booking to in room. We used the χ2 test for univariate analysis and logistic regression for multivariate analysis. RESULTS: There were 384 cases (367 patients), 223 high-risk and 161 low-risk. The median age was 4 years (range 0 d-18 yr). Overall, 184 cases (47.9%) were delayed. Major morbidity occurred in 94 cases (24.5%), and 28 patients (7.6%) (all in the high-risk group) died. The mean time to the operating room was 1.46 hours for patients with major morbidity/mortality and 1.17 hours for those without. After adjustment for risk level, multivariate analysis showed delay to surgery to be associated with 85% increased odds of morbidity and/or mortality (adjusted odds ratio 1.85, 95% confidence interval 1.20-2.94) compared to no delay. CONCLUSION: Delay to emergent surgery was associated with a significant increase in major morbidity and/or mortality. Children who require emergency surgery need their care prioritized by not only operating room teams but also hospitals and government; otherwise, they will continue to experience unintended consequences.

Peripheral Blood Monocytosis Is Associated With Long-Term Disease Severity in Pediatric-Onset Inflammatory Bowel Disease.

OBJECTIVES: Peripheral blood monocytosis (PBM) is a marker of increased disease severity in adults with inflammatory bowel diseases (IBDs). We sought to determine whether PBM serves as a prognostic biomarker in patients with pediatric-onset IBD for a more aggressive long-term disease course when followed into adulthood. METHODS: Patients with pediatric-onset inflammatory bowel disease were identified within an adult tertiary care center, within a consented, prospectively collected natural history disease registry, to compare clinical outcomes between patients with and without PBM from the years 2009 to 2019. Patients demonstrating elevation in PBM at any time defined membership and long-term clinical trajectories were compared with pediatric-onset patients without PBM. RESULTS: A total of 581 patients with IBD, diagnosed by 18 years of age, were identified for inclusion, of which 440 patients were diagnosed with Crohn disease and 141 with ulcerative colitis. Monocytosis was detected by complete blood cell counts in 40.1% of patients. PBM was associated with steroid and biologic exposure, number of IBD-related surgeries, and increased health care utilization. Multivariate logistic regression analyses, accounting for elevation of inflammatory markers and other values associated with acute disease activity as well as steroid use, showed persistently increased odds of biologic exposure, emergency department visits, and hospitalizations, but not surgeries, after detection of monocytosis. CONCLUSIONS: Within patients with pediatric-onset IBD, the sub-cohort with PBM had associated worse clinical outcomes and other markers of increased disease severity.

Biosimilars for Pediatric Patients With Inflammatory Bowel Disease: Pediatric Gastroenterology Clinical Practice Survey.

BACKGROUND: Biosimilars are biological agents that have been demonstrated to have similar safety and efficacy profiles as the originator. The objective of this study was to evaluate the perspectives of pediatric gastroenterologists in the United States (U.S.) toward biosimilar use and to explore factors that impact their comfort level with prescribing infliximab biosimilars. METHODS: A cross-sectional survey was developed and distributed to pediatric gastroenterology physicians from the U.S. via a listserv (Pediatric gastroenterology Bulletin Board). Respondent's demographics were recorded. Using a 6-point Likert scale, the survey assessed the respondent's perceptions toward biosimilars and initiating switches from the originator to biosimilar agent along with factors impacting provider's comfort level. Fischer exact tests were used to detect statistically significant differences in responses for hypotheses of interest. RESULTS: One hundred thirty-nine pediatric gastroenterologists completed the online survey (response rate 5.4%). Eighty-seven percent of respondents reported being comfortable prescribing infliximab biosimilars to anti-tumor necrosis factor naive patients, and 69% reported being comfortable doing a one-time switch if the patient was in clinical remission. Factors that negatively impacted a respondent's comfort level included respondents not practicing at an ImproveCareNow (ICN) center and managing less than 50 patients with inflammatory bowel diseases (IBD). CONCLUSIONS: Nearly 90% of pediatric gastroenterologists felt comfortable prescribing an infliximab biosimilar, and 70% felt comfortable with a one-time switch to the biosimilar if the patient was in clinical remission. Involvement in ICN a learning health system and caring for higher numbers of patients with IBD was associated with increased provider comfort with biosimilar use.

Ultrasound Correlates Highly With Cross Sectional Imaging for Small Renal Masses in a Contemporary Cohort.

OBJECTIVE: To determine the correlation between ultrasound (US), cross-sectional imaging, and pathological renal mass sizes. METHODS: Between January 2011 and January 2021, a cohort of patients from 14 academic institutions who had an US and cross-sectional imaging within 8 weeks of each other and within 6 months of surgery were identified. A second cohort of patients with small renal masses (≤4 cm) who had US and cross-sectional imaging within 8 weeks of each other were also examined, regardless of their treatment modality. Correlation coefficients, Bland-Altman plots, and sensitivity tables were generated. RESULTS: A total of 1464 patients were included in the surgical cohort and 1582 patients (1921 imaging pairs) were included in the small renal mass (SRM) cohort. Pearson correlation coefficients between computed tomography (CT)/magnetic resonance imaging (MRI) and pathologic size was 0.93 (P <.0001) and between US and pathological size was 0.90 (P <.0001). The correlation between US and CT/MRI was 0.93 (P <.0001). Bland-Altman plots demonstrated a greater agreement for smaller renal masses. For the SRM cohort when comparing US to CT/MRI, 1441 (75%) SRM measurements were within 0.5 cm and only 149 (7.8%) were greater than 1 cm in difference. Subgroup analysis demonstrated that correlation between US and CT/MRI for SRMs were higher in patients with lower body mass index. CONCLUSION: There is a strong correlation between US and cross-sectional imaging in 75% of patients at baseline imaging. Our study provides support for utilization of US for active surveillance.

Geospatial Analysis of Food Deserts and Their Impact on Health Outcomes in Children with Cystic Fibrosis.

Food insecurity (FI) is defined as "the limited or uncertain access to adequate food." One root cause of FI is living in a food desert. FI rates among people with cystic fibrosis (CF) are higher than the general United States (US) population. There is limited data on the association between food deserts and CF health outcomes. We conducted a retrospective review of people with CF under 18 years of age at a single pediatric CF center from January to December 2019 using demographic information and CF health parameters. Using a Geographic Information System, we conducted a spatial overlay analysis at the census tract level using the 2015 Food Access Research Atlas to assess the association between food deserts and CF health outcomes. We used multivariate logistic regression analysis and adjusted for clinical covariates and demographic covariates, using the Child Opportunity Index (COI) to calculate odds ratios (OR) with confidence intervals (CI) for each health outcome. People with CF living in food deserts and the surrounding regions had lower body mass index/weight-for-length (OR 3.18, 95% CI: 1.01, 9.40, p ≤ 0.05 (food desert); OR 4.41, 95% CI: 1.60, 12.14, p ≤ 0.05 (600 ft buffer zone); OR 2.83, 95% CI: 1.18, 6.76, p ≤ 0.05 (1200 ft buffer zone)). Food deserts and their surrounding regions impact pediatric CF outcomes independent of COI. Providers should routinely screen for FI and proximity to food deserts. Interventions are essential to increase access to healthy and affordable food.

Association of Baseline Luminal Narrowing With Ileal Microbial Shifts and Gene Expression Programs and Subsequent Transmural Healing in Pediatric Crohn Disease.

BACKGROUND: Transmural healing (TH) is associated with better long-term outcomes in Crohn disease (CD), whereas pretreatment ileal gene signatures encoding myeloid inflammatory responses and extracellular matrix production are associated with stricturing. We aimed to develop a predictive model for ileal TH and to identify ileal genes and microbes associated with baseline luminal narrowing (LN), a precursor to strictures. MATERIALS AND METHODS: Baseline small bowel imaging obtained in the RISK pediatric CD cohort study was graded for LN. Ileal gene expression was determined by RNASeq, and the ileal microbial community composition was characterized using 16S rRNA amplicon sequencing. Clinical, demographic, radiologic, and genomic variables were tested for association with baseline LN and future TH. RESULTS: After controlling for ileal location, baseline ileal LN (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.8), increasing serum albumin (OR, 4; 95% CI, 1.3-12.3), and anti-Saccharomyces cerevisiae antibodies IgG serology (OR, 0.97; 95% CI, 0.95-1) were associated with subsequent TH. A multivariable regression model including these factors had excellent discriminant power for TH (area under the curve, 0.86; positive predictive value, 80%; negative predictive value, 87%). Patients with baseline LN exhibited increased Enterobacteriaceae and inflammatory and extracellular matrix gene signatures, coupled with reduced levels of butyrate-producing commensals and a respiratory electron transport gene signature. Taxa including Lachnospiraceae and the genus Roseburia were associated with increased respiratory and decreased inflammatory gene signatures, and Aggregatibacter and Blautia bacteria were associated with reduced extracellular matrix gene expression. CONCLUSIONS: Pediatric patients with CD with LN at diagnosis are less likely to achieve TH. The association between specific microbiota, wound healing gene programs, and LN may suggest future therapeutic targets.

P046 Tofacitinib Induced Resolution of Severe Colitis and Reactive Atypia in an Adolescent Patient With IBD.

CASE: Tofacitinib is an anti-JAK/STAT small molecule approved for treatment of adults (but not children and adolescents) with moderate to severe ulcerative colitis. Data is limited in children and teens although two major centers have shown efficacy as both mono- and dual - combination therapy using tofacitinib in pediatric patients refractory to anti-TNF agents. We present a 16-year-old female diagnosed with inflammatory ileocolonic Crohn's disease without upper gastrointestinal involvement after presenting with several months of abdominal pain, diarrhea, and unintentional weight loss. Laboratory evaluation was notable for normal inflammatory markers, albumin and complete blood count and an elevated stool lactoferrin. Initial endoscopic evaluation revealed moderate to severe pancolitis and patchy ileitis; biopsies noted mild chronic active ileitis and moderate to severe chronic active pancolitis without dysplastic or atypical changes. She was started on infliximab for induction and maintenance therapy and dosage was increased due to suboptimal levels and marginal symptomatic improvement. However, despite increased dosing plus a course of budesonide (Uceris), she had minimal improvement in her symptoms and ongoing elevation of her lactoferrin. Given an equivocal result on a Clostridium difficile testing (GDH antigen positive only), she was started on oral vancomycin which resulted in mild improvement, but not resolution, of diarrhea and abdominal pain. This was continued after completion of a 14-day course (and subsequent negative testing) due to increased stool frequency with discontinuation of the medication and improvement with reinitiating it. She had severe pancolitis (Mayo 2 - 3) but normal TI on repeat colonoscopy 5 months after diagnosis. Biopsies (reviewed by a panel of adult GI pathologists) were notable for reactive atypia with features concerning for early dysplasia in the ascending and descending colon. Due to disease severity and rapid progression plus histologic changes concerning for possible dysplasia despite optimized therapy with infliximab and repeat negative C. difficile testing, she was started on tofacitinib 10 mg twice daily along with oral vancomycin. She had complete resolution of diarrhea, abdominal pain, and early satiety within a week; repeat fecal lactoferrin was negative (<30). She underwent repeat colonoscopy with chromoendoscopy 5 months after initiation of tofacitinib which revealed mild acute ileitis but no active colonic inflammation, atypia or dysplasia. This is the first report to our knowledge that an adolescent patient with colonic predominant Crohn's disease has complete resolution of atypia and possible early dysplasia with tofacitinib therapy.

Mucosal Inflammatory and Wound Healing Gene Programs Reveal Targets for Stricturing Behavior in Pediatric Crohn's Disease.

BACKGROUND AND AIMS: Ileal strictures are the major indication for resective surgery in Crohn's disease (CD). We aimed to define ileal gene programs present at diagnosis linked with future stricturing behavior during five year follow-up, and to identify potential small molecules to reverse these gene signatures. METHODS: Antimicrobial serologies and pre-treatment ileal gene expression were assessed in a representative subset of 249 CD patients within the RISK multicenter pediatric CD inception cohort study, including 113 that are unique to this report. These data were used to define genes associated with stricturing behavior and for model testing to predict stricturing behavior. A bioinformatics approach to define small molecules which may reverse the stricturing gene signature was applied. RESULTS: 19 of the 249 patients developed isolated B2 stricturing behavior during follow-up, while 218 remained B1 inflammatory. Using deeper RNA sequencing than in our prior report, we have now defined an inflammatory gene signature including an oncostatin M co-expression signature, tightly associated with extra-cellular matrix (ECM) gene expression in those who developed stricturing complications. We further computationally prioritize small molecules targeting macrophage and fibroblast activation and angiogenesis which may reverse the stricturing gene signature. A model containing ASCA and CBir1 serologies and a refined eight ECM gene set was significantly associated with stricturing development by year five after diagnosis (AUC (95th CI) = 0.82 (0.7-0.94)). CONCLUSION: An ileal gene program for macrophage and fibroblast activation is linked to stricturing complications in treatment naïve pediatric CD, and may inform novel small molecule therapeutic approaches.

Gaps Exist in the Comprehensive Care of Children with Inflammatory Bowel Diseases.

OBJECTIVES: To describe patterns of primary and specialty care delivery in pediatric patients with inflammatory bowel diseases (IBD), delineate which members of the healthcare team provided services, and identify gaps in care. STUDY DESIGN: Cross-sectional survey of parents of children (2-17 years) with IBD and adolescents with IBD (13-17 years) at a free-standing, quaternary children's hospital regarding healthcare receipt. RESULTS: There were 161 parents and 84 adolescents who responded to the survey (75% and 60% response, respectively). The mean patient age was 14 ± 3 years, 51% were male, 80% had Crohn's disease, 16% ulcerative colitis, and 4% IBD-unspecified. Most parents were white (94%), living in a suburban setting (57%). Sixty-nine percent of households had ≥1 parent with a bachelor's degree or higher. Most had private insurance (43%) or private primary with public secondary insurance (34%). Most patients received annual check-ups (70%), vaccinations (78%), and care for minor illnesses (74%) from their primary care provider. Check-ups for gastrointestinal symptoms, IBD monitoring, and changes in type/dosing of IBD treatment were provided by their gastroenterology provider (77%, 93%, and 86% of patients, respectively). Discussions about family/peer relationships, school/extracurricular activities, and mood were not addressed in 30%-40% of participants. Adolescents frequently reported that no one had talked to them about substance use (40%), sexual health (50%), or body image (60%); 75% of adolescents and 76% of their parents reported that no one had discussed transitioning to an adult provider. CONCLUSIONS: There were gaps in the psychosocial care of pediatric patients with IBD. Coordinated, comprehensive care delivery models are needed.

Factors predicting early mortality after radical cystectomy for urothelial carcinoma in a contemporary cohort of patients.

INTRODUCTION: We aimed to identify preoperatively available patient variables associated with increased mortality within 30 and 90 days of radical cystectomy (RC) for localized urothelial carcinoma (UC), and to evaluate temporal trends in early mortality rates. METHODS: We reviewed the National Cancer Database to identify patients who underwent RC for UC between 2006 and 2013. Preoperatively available patient-specific demographics and mortality rates at 30 and 90 days postoperatively were analyzed. Univariable and multivariable logistic regression analyses were performed to examine factors associated with 30- and 90-day mortality. RESULTS: We identified 37 366 patients who underwent RC between 2006 and 2013. Overall mortality rates remained stable over time. From 2006-2013, 936 patients (2.5%) and 2554 patients (6.8%) died of any cause within 30 and 90 days post-RC, respectively. On multivariable analysis, increased age, higher clinical T and N stage, increased Charlson-Deyo comorbidity classification, African-American race, lower hospital volume, non-academic centers, lower patient income, and absence of insurance were each significantly associated with increased early mortality after RC (p<0.05). The protective effect of higher hospital volume was similar regardless of patient's age, clinical stage, or comorbidity status. CONCLUSIONS: Our study identified patient-specific variables that are significantly associated with increased early mortality after RC. These findings can be used in counselling to identify ideal candidates for RC to decrease patient harm. Furthermore, early mortality rates after RC have remained stable over time, indicating that ongoing quality improvement is essential to improve outcomes.

Patterns of Primary, Specialty, Urgent Care, and Emergency Department Care in Children With Inflammatory Bowel Diseases.

OBJECTIVES: Pediatric patients with inflammatory bowel diseases (IBD) require treatment, monitoring, and health maintenance services. We described patterns of primary, specialty, emergency department (ED) and urgent care delivery, and explored patient- and system-related variables that impact ED/urgent care utilization. METHODS: We conducted a cross sectional survey of parents of children with IBD at a large tertiary children's hospital. RESULTS: One hundred sixty-one parents completed the survey (75% response). Mean patient age 13.9 years (51% boys); 80% Crohn disease, 16% ulcerative colitis, 4% IBD-unspecified. Mean disease duration 4 years (standard deviation [SD] 2.7). Thirty percent had at least 1 other chronic disease, 31% had a history of IBD-related surgery. Parents were predominantly Caucasian (94%), well-educated (61% bachelor's degree/higher), part of a 2-parent household (79%) living in a suburban setting (57%). Seventy-seven percent of patients had private insurance. In the past year, most children had 1 to 2 IBD-related office visits (54%) with their gastroenterology (GI) doctor and no IBD-related hospitalizations (79%). Eighty-eight percent (N = 141) had a primary care provider (PCP), and most (70%) saw their PCP 1 to 2 times. Even so, 86% (N = 139) received medical care from places other than their PCP or GI doctor; 27% in the ED and 45% at urgent care. Children of parents with less than a bachelor's degree, families that lived further from their GI doctor, and children who saw their PCP more often were more likely to utilize ED/urgent care. CONCLUSIONS: ED/urgent care utilization in pediatric patients with IBD was greater than expected, potentially contributing to fragmented, costly care and worse outcomes.

Peripheral Blood Eosinophilia and Long-term Severity in Pediatric-Onset Inflammatory Bowel Disease.

BACKGROUND: Peripheral blood eosinophilia (PBE) is a biomarker of an aggressive multiyear natural history in adults with inflammatory bowel diseases (IBDs). Additionally, PBE at diagnosis is associated with higher disease activity in pediatric-onset IBD. We sought to determine if PBE can function as a biomarker of long-term disease severity in pediatric-onset IBD patients who are followed into adulthood. METHODS: We analyzed a consented, prospective, natural history IBD registry at an adult tertiary center from 2009 to 2018. Prevalence of PBE was evaluated in both pediatric- and adult-onset IBD patients. Demographics, clinical characteristics, and health care utilization data were compared in patients with and without PBE. RESULTS: Among 2800 adult IBD patients, 23.4% had pediatric-onset disease. PBE was found in 34% of the pediatric-onset patients compared with 26.8% of the adult-onset IBD patients (P < 0.001). In the pediatric-onset IBD cohort, PBE was associated with higher rates of allergies (P < 0.0001), but not of asthma, allergic rhinitis, or primary sclerosing cholangitis. In the adult IBD patients with pediatric-onset disease, PBE was associated with higher rates of C-reactive protein elevation (P < 0.0001), erythrocyte sedimentation rate elevation (P < 0.0001), higher health care utilization, and higher average health care charges per year (P < 0.00001). CONCLUSIONS: Peripheral blood eosinophilia was more prevalent in adult IBD patients with pediatric-onset compared with adult-onset disease. Among all IBD patients with long-term follow-up, PBE defined a subgroup with more severe illness. These data suggest that PBE may be a biomarker for a high-risk subgroup with high cost trajectory and long-term severity in pediatric-onset IBD that persists into adulthood.

Rare case of upper urinary tract squamous cell carcinoma presenting with significant paraneoplastic syndrome.

Squamous cell carcinoma of the upper urinary tract is a rare entity associated with rapidly progressive disease and poor outcomes. Here, we describe a case of a squamous cell carcinoma of the upper urinary tract associated with significant progression and paraneoplastic syndrome. Post-operatively, the patient had near complete resolution of her paraneoplastic syndromes with significant improvements in her functional status.

The Cost of Inflammatory Bowel Disease: An Initiative From the Crohn's & Colitis Foundation.

BACKGROUND: The Crohn's & Colitis Foundation's Cost of Inflammatory Bowel Disease (IBD) Care Initiative seeks to quantify the wide-ranging health care costs affecting patients living with IBD. We aimed to (1) describe the annualized direct and indirect costs of care for patients with Crohn's disease (CD) or ulcerative colitis (UC), (2) determine the longitudinal drivers of these costs, and (3) characterize the cost of care for newly diagnosed patients. METHODS: We analyzed the Optum Research Database from the years 2007 to 2016, representing commercially insured and Medicare Advantage-insured patients in the United States. Inclusion for the study was limited to those who had continuous enrollment with medical and pharmacy benefit coverage for at least 24 months (12 months before through 12 months after the index date of diagnosis). The value of patient time spent on health care was calculated as number of workplace hours lost due to health care encounters multiplied by the patients' estimated average wage derived from the Bureau of Labor Statistics. Comparisons between IBD patients and non-IBD patients were analyzed based on demographics, health plan type, and length of follow-up. We used generalized linear models to estimate the association between total annual costs and various patient variables. RESULTS: There were 52,782 IBD patients (29,062 UC; 23,720 CD) included in the analysis (54.1% females). On a per-annual basis, patients with IBD incurred a greater than 3-fold higher direct cost of care compared with non-IBD controls ($22,987 vs $6956 per-member per-year paid claims) and more than twice the out-of-pocket costs ($2213 vs $979 per-year reported costs), with all-cause IBD costs rising after 2013. Patients with IBD also experienced significantly higher costs associated with time spent on health care as compared with controls. The burden of costs was most notable in the first year after initial IBD diagnosis (mean = $26,555). The study identified several key drivers of cost for IBD patients: treatment with specific therapeutics (biologics, opioids, or steroids); ED use; and health care services associated with relapsing disease, anemia, or mental health comorbidity. CONCLUSION: The costs of care for IBD have increased in the last 5 years and are driven by specific therapeutics and disease features. In addition, compared with non-IBD controls, IBD patients are increasingly incurring higher costs associated with health care utilization, out-of-pocket expenditures, and workplace productivity losses. There is a pressing need for cost-effective strategies to address these burdens on patients and families affected by IBD.

Fecal microbiota and metabolites are distinct in a pilot study of pediatric Crohn's disease patients with higher levels of perceived stress.

Stress is associated with increased Crohn's Disease (CD) activity. This pilot study tested whether pediatric patients with CD reporting higher levels of perceived stress exhibited differences in the fecal microbiome and metabolome. The perceived stress scale (PSS) questionnaire was administered within 2 days of collecting a stool sample for microbiome (using 16S rRNA gene sequencing) and metabolome (using NMR metabolomics) analyses. Higher levels of perceived stress were correlated with increased disease activity on the short Pediatric Crohn's Disease Activity Index (sPCDAI). Patients with High PSS scores vs. Low PSS scores based on a median split had significantly lower relative abundances of Firmicutes and Anaerostipes, as well as higher relative abundances of Parabacteroides. Fecal alanine and nicotinate were also significantly different in patients with High vs. Low PSS Scores. This pilot study suggests that the fecal microbiome and metabolome differs in pediatric patients with CD and high perceived stress.

Shared Decision Making About Starting Anti-TNFs: A Pediatric Perspective.

Shared decision making (SDM) is central to patient-centered medicine and has the potential to improve outcomes for pediatric patients with inflammatory bowel diseases. We surveyed specialists about their use of SDM in the decision to start a tumor necrosis factor-α inhibitor in pediatric patients. Results were compared between those who reported using SDM and those who did not. Of 209 respondents, 157 (75%) reported using SDM. Physician/practice characteristics were similar between users and nonusers. There were no statistically significant differences between groups in the components deemed important to the decision-making process nor the number of barriers or facilitators to SDM. Exploratory analyses suggested that physicians using SDM were more accepting of adolescent involvement in the decision-making process. Our results question the effectiveness of using reported barriers and facilitators to guide interventions to improve use of SDM, and suggest further work is needed to understand the adolescent role in decision making.

Evaluation of Optimal Timing of Expert Feedback in a Simulated Flexible Ureteroscopy Course.

Introduction: Simulation-based training (SBT) has become an increasingly popular modality to train novice surgical residents in the face of rapidly increasing innovative surgical techniques across all surgical disciplines. Recent studies have already demonstrated SBT to be effective in helping overcome the learning curve associated with new surgical techniques, especially in junior residents and endoscopic procedures. In addition, it is known that trainees benefit significantly from expert feedback; however, there is a paucity of data looking into the optimal timing of this feedback during SBT. To address this knowledge deficit, an SBT curriculum was developed for junior urology residents to assess optimal timing of feedback during SBT for flexible ureteroscopy (fURS). Materials and Methods: The SBT course consisted of a pretraining assessment, three independent practice sessions, and a post-training assessment, with residents receiving expert feedback right after their pretraining assessment (early feedback [EF]) or after their final independent training session (late feedback [LF]). Results: Fifteen trainees with similar baseline fURS experience and precourse fURS task performance score participated in the study. There was a significant difference between the pre- and post-task completion times overall (15.2 minutes vs 9.1 minutes, p < 0.001), with no difference between the early or LF groups (p = 0.884). The mean performance scores improved for both groups (18.2 vs 24.2, p < 0.001) with the EF group having a more statistically significant improvement in performance scores than the LF group (p = 0.05), and most (73%) of residents preferred EF. Conclusions: This study demonstrates that an SBT curriculum for fURS is effective for technical skills development among junior trainees, and that EF resulted in marginally better overall scores and was preferred by residents.