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Kuenzig ME, Bitton A, Carroll MW, Otley AR, Singh H, Kaplan GG, Stukel TA, Mack DR, Jacobson K, Griffiths AM, El-Matary W, Targownik LE, Nguyen GC, Jones JL, Murthy SK, Bernstein CN, Lix LM, Peña-Sánchez JN, Dummer TJB, Spruin S, Fung SG, Nugent Z, Coward S, Cui Y, Coulombe J, Filliter C, Benchimol EI. Health Services Utilization and Specialist Care in Pediatric Inflammatory Bowel Disease: A Multiprovince Population-Based Cohort Study. Inflamm Bowel Dis 2024; 30:2356-2369. [PMID: 38366807 PMCID: PMC11630251 DOI: 10.1093/ibd/izae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Patterns of health services utilization among children with inflammatory bowel disease (IBD) are important to understand as the number of children with IBD continues to increase. We compared health services utilization and surgery among children diagnosed <10 years of age (Paris classification: A1a) and between 10 and <16 years of age (A1b). METHODS Incident cases of IBD diagnosed <16 years of age were identified using validated algorithms from deterministically linked health administrative data in 5 Canadian provinces (Alberta, Manitoba, Nova Scotia, Ontario, Quebec) to conduct a retrospective cohort study. We compared the frequency of IBD-specific outpatient visits, emergency department visits, and hospitalizations across age groups (A1a vs A1b [reference]) using negative binomial regression. The risk of surgery was compared across age groups using Cox proportional hazards models. Models were adjusted for sex, rural/urban residence location, and mean neighborhood income quintile. Province-specific estimates were pooled using random-effects meta-analysis. RESULTS Among the 1165 (65.7% Crohn's) children with IBD included in our study, there were no age differences in the frequency of hospitalizations (rate ratio [RR], 0.88; 95% confidence interval [CI], 0.74-1.06) or outpatient visits (RR, 0.95; 95% CI, 0.78-1.16). A1a children had fewer emergency department visits (RR, 0.70; 95% CI, 0.50-0.97) and were less likely to require a Crohn's-related surgery (hazard ratio, 0.49; 95% CI, 0.26-0.92). The risk of colectomy was similar among children with ulcerative colitis in both age groups (hazard ratio, 0.71; 95% CI, 0.49-1.01). CONCLUSIONS Patterns of health services utilization are generally similar when comparing children diagnosed across age groups.
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Affiliation(s)
- M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alain Bitton
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Anthony R Otley
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Harminder Singh
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Research Institute at CancerCare Manitoba, Winnipeg, MB, Canada
| | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Therese A Stukel
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - David R Mack
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, ON, Canada
- CHEO Research Institute, Ottawa, ON, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Kevan Jacobson
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Wael El-Matary
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Laura E Targownik
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Geoffrey C Nguyen
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sanjay K Murthy
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Gastroenterology, Ottawa Hospital IBD Centre, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Juan Nicolás Peña-Sánchez
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Trevor J B Dummer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Sarah Spruin
- ICES, Toronto, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Stephen G Fung
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, ON, Canada
- CHEO Research Institute, Ottawa, ON, Canada
| | - Zoann Nugent
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Stephanie Coward
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Yunsong Cui
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Janie Coulombe
- Department of Mathematics and Statistics, Université de Montréal, Montréal, QC, Canada
| | - Christopher Filliter
- Lady Davis Institute of Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
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Vuijk SA, Camman AE, de Ridder L. Considerations in Paediatric and Adolescent Inflammatory Bowel Disease. J Crohns Colitis 2024; 18:ii31-ii45. [PMID: 39475081 PMCID: PMC11523044 DOI: 10.1093/ecco-jcc/jjae087] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/03/2024] [Accepted: 06/11/2024] [Indexed: 11/02/2024]
Abstract
The incidence of inflammatory bowel disease [IBD] is rising most rapidly among children and adolescents. Paediatric-onset IBD is associated with a more extensive and severe disease course compared to adult-onset IBD. At a young age, screening for underlying genetic and immunological disorders is important and may impact treatment management. Early and effective treatment is crucial to reach disease remission and prevent complications of ongoing active disease. In children with Crohn's disease, exclusive enteral nutrition is an effective induction therapy. Other promising dietary therapies, such as the Crohn's disease exclusion diet, are emerging. Within paediatric IBD, anti-tumour necrosis factor therapy is the only approved biological thus far and additional treatment options are crucially needed. Other biological therapies, such as vedolizumab and ustekinumab, are currently prescribed off-label in this population. A specific challenge in paediatric IBD is the unacceptable and major delay in approval of drugs for children with IBD. A guided transfer period of paediatric patients to adult care is associated with improved disease outcomes and is required. Major knowledge gaps and challenges within paediatric IBD include the aetiology, diagnostics, and monitoring of disease, tailoring of treatment, and both understanding and coping with the physical and psychological consequences of living with IBD. Challenges and research gaps in paediatrics should be addressed without any delay in comparison with the adult field, in order to ensure a high quality of care for all patients with IBD, irrespective of the age of onset.
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Affiliation(s)
- Stephanie A Vuijk
- Department of Paediatric Gastroenterology, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Anouk E Camman
- Department of Paediatric Gastroenterology, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
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Lee JJY, Bernatsky S, Benchimol EI, Kuenzig ME, Kwong JC, Li Q, Widdifield J. COVID-19 vaccination safety and associated health care utilization among adults with inflammatory bowel disease - a population-based self-controlled case series analysis. BMC Gastroenterol 2024; 24:189. [PMID: 38816836 PMCID: PMC11137996 DOI: 10.1186/s12876-024-03273-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 05/22/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND AND AIMS There is an incomplete understanding of the full safety profiles of repeated COVID-19 vaccinations in patients with inflammatory bowel disease (IBD). Among individuals with IBD, we assessed whether COVID-19 vaccines were associated with serious adverse events of special interest (AESI) and health care utilization [all-cause hospitalizations, Emergency Department (ED) visits, gastroenterology visits, IBD-related visits]. METHODS Using comprehensive administrative health data from Ontario, Canada, adults with IBD who received at least one COVID-19 vaccine from December 2020-January 2022 were included. Self-controlled case series analyses were conducted to evaluate the relative incidence rates of AESI and health care utilization outcomes across post-vaccination risk and control periods. RESULTS Among 88,407 IBD patients, 99.7% received mRNA vaccines and 75.9% received ≥ 3 doses. Relative to control periods, we did not detect an increase in AESI. IBD patients had fewer all-cause hospitalizations during post-vaccination risk periods. Patients experienced more all-cause ED visits after dose 2 [Relative Incidence (RI):1.08(95%CI:1.04-1.12)] but fewer visits after doses 3 [RI:0.85 (95%CI:0.81-0.90)] and 4 [RI:0.73 (95%CI:0.57-0.92)]. There was no increase in gastroenterologist visits or IBD-related health care utilization post-vaccination. There were fewer IBD-related hospitalizations after dose 1 [RI:0.84 (95%CI:0.72-0.98)] and 3 [RI:0.63 (95%CI:0.52-0.76)], fewer IBD-related ED visits after dose 3 [RI:0.81 (95%CI:0.71-0.91)] and 4 [RI:0.55 (95%CI:0.32-0.96)], and fewer outpatient visits after dose 2 [RI:0.91 (95%CI:0.90-0.93)] and 3 [RI:0.87 (95%CI:0.86-0.89)]. CONCLUSION This population-based study did not detect increased AESI, all-cause or IBD-related health care utilization following COVID-19 vaccination, suggesting a lack of association between vaccination and increased disease activity.
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Affiliation(s)
- Jennifer J Y Lee
- ICES Central, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
| | - Sasha Bernatsky
- Division of Rheumatology and Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Eric I Benchimol
- ICES Central, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jeffrey C Kwong
- ICES Central, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Qing Li
- ICES Central, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Jessica Widdifield
- ICES Central, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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4
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Tandon P, Huang VW, Feig DS, Saskin R, Maxwell C, Gao Y, Fell DB, Seow CH, Snelgrove JW, Nguyen GC. Differences in Healthcare Utilization in Women with and without Inflammatory Bowel Diseases During Preconception, Pregnancy and Postpartum: A Population-Based Cohort Study. J Crohns Colitis 2023; 17:1587-1595. [PMID: 37186150 DOI: 10.1093/ecco-jcc/jjad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Indexed: 05/17/2023]
Abstract
BACKGROUND AND AIMS Compared to those without inflammatory bowel disease [IBD], women with IBD may have increased healthcare utilization during pregnancy and postpartum, though this remains to be confirmed. We aimed to characterize this healthcare use between these groups. METHODS Administrative databases were accessed to identify women [aged 18-55 years] with and without IBD who had a live, singleton pregnancy between 2003 and 2018. Differences in emergency department [ED] visits, hospitalizations and prenatal care during 12 months preconception, pregnancy and 12 months postpartum were characterized. Multivariable negative binomial regression was performed to report incidence rate ratios [IRRs] with 95% confidence intervals [95% CIs]. Covariates included maternal age at conception, location of residence, socioeconomic status and maternal comorbidity. RESULTS In total, 6163 women with IBD [9158 pregnancies] and 1091 013 women without IBD [1729 411 pregnancies] were included. Women with IBD were more likely to visit the ED [IRR 1.13, 95% CI 1.08-1.18] and be hospitalized [IRR 1.11, 95% CI 1.01-1.21] during pregnancy, and visit the ED [IRR 1.21, 95% CI 1.15-1.27] and be hospitalized [IRR 1.18, 95% CI 1.05-1.32] during postpartum. On unadjusted analysis, women with IBD were more likely to be hospitalized for venous thromboembolic events. There was no difference in healthcare use in preconception. Finally, women with IBD also had a greater number of prenatal visits during pregnancy and were more likely to receive a first-trimester prenatal visit. CONCLUSION Women with IBD have increased healthcare utilization during pregnancy and postpartum. Efforts should be made to increase ambulatory care access during this period, which in turn may reduce this health-services utilization.
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Affiliation(s)
- Parul Tandon
- Mount Sinai Centre for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Vivian W Huang
- Mount Sinai Centre for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Denice S Feig
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Refik Saskin
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Maxwell
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | | | - Deshayne B Fell
- ICES, Toronto, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - John W Snelgrove
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Geoffrey C Nguyen
- Mount Sinai Centre for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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5
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Yoo EJ, Cho SH, Park SJ, Kim TI, Kim WH, Cheon JH. Characteristics and Treatment Outcomes of Transition among Patients with Inflammatory Bowel Disease. Yonsei Med J 2023; 64:541-548. [PMID: 37634630 PMCID: PMC10462809 DOI: 10.3349/ymj.2022.0588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/07/2023] [Accepted: 06/25/2023] [Indexed: 08/29/2023] Open
Abstract
PURPOSE This study aimed to assess disease characteristics and outcomes of transition in patient care among adolescent patients with inflammatory bowel disease (IBD). MATERIALS AND METHODS Data from patients younger than 18 years who were diagnosed with IBD (Crohn's disease, ulcerative colitis, or intestinal Behçet's disease) were investigated. We categorized the patients into two groups: transition IBD group (Group A, diagnosed in pediatric care followed by transfer to/attendance in adult IBD care) and non-transition group (Group B, diagnosed and followed up in pediatric care or adult IBD care without transfer). RESULTS Data from a total of 242 patients [Group A (n=29, 12.0%), Group B (n=213, 88.0%)] were analyzed. A significantly higher number of patients was diagnosed at an earlier age in Group A than in Group B (p<0.001). Group A patients had more severe disease in terms of number of disease flare ups (p=0.011) and frequency of bowel-related complications (p<0.001). Multiple linear regression analysis showed that Group B patients had more medical non-compliance than Group A patients (β=2.31, p=0.018). After transition, IBD-related admission frequency, emergency admission frequency, disease flare frequency, and medical non-compliance were significantly improved. CONCLUSION The transition IBD group had more severe disease. Medical non-compliance was lower in the transition IBD group. Clinical outcomes improved after transition.
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Affiliation(s)
| | - Sang-Hoon Cho
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.
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Khan R, Kuenzig ME, Benchimol EI. Epidemiology of Pediatric Inflammatory Bowel Disease. Gastroenterol Clin North Am 2023; 52:483-496. [PMID: 37543395 DOI: 10.1016/j.gtc.2023.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
Inflammatory bowel disease (IBD), including subtypes Crohn disease and ulcerative colitis is a chronic inflammatory disorder most often diagnosed in young adulthood. The incidence and prevalence of pediatric-onset IBD is increasing globally. IBD is likely caused by an interplay of multiple environmental factors resulting in a dysregulated mucosal response to the commensal intestinal microbiota in genetically predisposed individuals. This article provides an overview of pediatric IBD epidemiology and environmental risk factors associated with its development, such as the Hygiene Hypothesis, air pollution, greenspace and blue space, neonatal factors, antibiotics, and diet.
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Affiliation(s)
- Rabia Khan
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), 555 University Avenue, Toronto, ON M5G 1X8, Canada; Child Health Evaluative Sciences, SickKids Research Institute
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), 555 University Avenue, Toronto, ON M5G 1X8, Canada; Child Health Evaluative Sciences, SickKids Research Institute; ICES, Toronto, Canada; Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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Gould MJ, Marcon MA, Nguyen GC, Benchimol EI, Moineddin R, Swayze S, Kopp A, Ratcliffe EM, Merritt N, Davidson J, Langer JC, Mistry N, Lorenzo AJ, Temple M, Walsh CM. Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study. Neurogastroenterol Motil 2023; 35:e14495. [PMID: 36377812 DOI: 10.1111/nmo.14495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 10/24/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization. METHODS We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori. KEY RESULTS One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications. CONCLUSIONS AND INFERENCES Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.
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Affiliation(s)
- Michelle J Gould
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Margaret A Marcon
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology, Mount Sinai Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Eric I Benchimol
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Division of Biostatistics, University of Toronto, Toronto, Canada
| | | | | | - Elyanne M Ratcliffe
- Division of Pediatric Gastroenterology and Nutrition, McMaster Children's Hospital, Hamilton, Canada.,Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Neil Merritt
- Division of Pediatric Surgery, London Health Sciences Center, London, Canada
| | - Jacob Davidson
- Division of Pediatric Surgery, London Health Sciences Center, London, Canada
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Niraj Mistry
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Canada
| | - Armando J Lorenzo
- Department of Surgery, University of Toronto, Toronto, Canada.,Division of Urology, Hospital for Sick Children, Toronto, Canada
| | - Michael Temple
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,SickKids Research and Learning Institutes, Toronto, Canada
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8
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Rintala RJ, Pakarinen MP. Inflammatory Bowel Disease. PEDIATRIC SURGERY 2023:1031-1050. [DOI: 10.1007/978-3-030-81488-5_76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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9
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Kuenzig ME, Fung SG, Marderfeld L, Mak JWY, Kaplan GG, Ng SC, Wilson DC, Cameron F, Henderson P, Kotze PG, Bhatti J, Fang V, Gerber S, Guay E, Kotteduwa Jayawarden S, Kadota L, Maldonado D F, Osei JA, Sandarage R, Stanton A, Wan M, Benchimol EI. Twenty-first Century Trends in the Global Epidemiology of Pediatric-Onset Inflammatory Bowel Disease: Systematic Review. Gastroenterology 2022; 162:1147-1159.e4. [PMID: 34995526 DOI: 10.1053/j.gastro.2021.12.282] [Citation(s) in RCA: 318] [Impact Index Per Article: 106.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/30/2021] [Accepted: 12/31/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The incidence of inflammatory bowel disease (IBD) is increasing internationally, particularly in nations with historically low rates. Previous reports of the epidemiology of pediatric-onset IBD identified a paucity of data. We systematically reviewed the global trends in incidence and prevalence of IBD diagnosed in individuals <21 years old over the first 2 decades of the 21st century. METHODS We systematically reviewed studies indexed in MEDLINE, EMBASE, Airiti Library, and SciELO from January 2010 to February 2020 to identify population-based studies reporting the incidence and/or prevalence of IBD, Crohn's disease, ulcerative colitis, and/or IBD-unclassified. Data from studies published before 2000 were derived from a previously published systematic review. We described the geographic distribution and trends in children of all ages and limiting to very early onset (VEO) IBD. RESULTS A total of 131 studies from 48 countries were included. The incidence and prevalence of pediatric-onset IBD is highest in Northern Europe and North America and lowest in Southern Europe, Asia, and the Middle East. Among studies evaluating trends over time, most (31 of 37, 84%) studies reported significant increases in incidence and all (7 of 7) reported significant increases in prevalence. Data on the incidence and prevalence of VEO-IBD are limited to countries with historically high rates of IBD. Time trends in the incidence of VEO-IBD were visually heterogeneous. CONCLUSIONS Rates of pediatric-onset IBD continue to rise around the world and data are emerging from regions where it was not previously reported; however, there remains a paucity of data on VEO-IBD and on pediatric IBD from developing and recently developed countries.
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Affiliation(s)
- M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada; CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada; CHEO Research Institute, Ottawa, Ontario, Canada
| | - Stephen G Fung
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada; CHEO Research Institute, Ottawa, Ontario, Canada
| | - Luba Marderfeld
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada; CHEO Research Institute, Ottawa, Ontario, Canada
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, Institute of Digestive Disease, LKS Institute of Health Science, State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, LKS Institute of Health Science, State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - David C Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children and Young People, Edinburgh, United Kingdom; Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Fiona Cameron
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children and Young People, Edinburgh, United Kingdom; Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Paulo G Kotze
- IBD Outpatients Clinic, Colorectal Surgery Unit, Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | - Jasmine Bhatti
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Vixey Fang
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Samantha Gerber
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Evelyne Guay
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Leo Kadota
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Fernando Maldonado D
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; Research Department, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Jessica Amankwah Osei
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ryan Sandarage
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amanda Stanton
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Melissa Wan
- Public Health and Preventive Medicine Residency Program, Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada; CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada; CHEO Research Institute, Ottawa, Ontario, Canada; Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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10
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Tsai L, Ma C, Dulai PS, Prokop LJ, Eisenstein S, Ramamoorthy SL, Feagan BG, Jairath V, Sandborn WJ, Singh S. Contemporary Risk of Surgery in Patients With Ulcerative Colitis and Crohn's Disease: A Meta-Analysis of Population-Based Cohorts. Clin Gastroenterol Hepatol 2021; 19:2031-2045.e11. [PMID: 33127595 PMCID: PMC8934200 DOI: 10.1016/j.cgh.2020.10.039] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We conducted a systematic review with meta-analysis to estimate rates and trends of colectomy in patients with ulcerative colitis (UC), and of primary and re-resection in patients with Crohn's disease (CD), focusing on contemporary risks. METHODS Through a systematic review until September 3, 2019, we identified population-based cohort studies that reported patient-level cumulative risk of surgery in patients with UC and CD. We evaluated overall and contemporary risk (after 2000) of surgery and analyzed time trends through mixed-effects meta-regression. RESULTS In patients with UC (26 studies), the overall 1-, 5-, and 10-year risks of colectomy was 4.0% (95% CI, 3.3-5.0), 8.8% (95% CI, 7.7-10.0), and 13.3% (95% CI, 11.3-15.5), respectively, with a decrease in risk over time (P < .001). Corresponding contemporary risks were 2.8% (95% CI, 2.0-3.9), 7.0% (95% CI, 5.7-8.6), and 9.6% (95% CI, 6.3-14.2), respectively. In patients with CD (22 studies), the overall 1-, 5-, and 10-year risk of surgery was 18.7% (95% CI, 15.0-23.0), 28.0% (95% CI, 24.0-32.4), and 39.5% (95% CI, 33.3-46.2), respectively, with a decrease in risk over time (P < .001). Corresponding contemporary risks were 12.3% (95% CI, 10.8-14.0), 18.0% (95% CI, 15.4-21.0), and 26.2% (95% CI, 23.4-29.4), respectively. In a meta-analysis of 8 studies in patients with CD with prior resection, the cumulative risk of a second resection at 5 and 10 years after the first resection was 17.7% (95% CI, 13.5-22.9) and 31.3% (95% CI, 24.1-39.6), respectively. CONCLUSIONS Patient-level risks of surgery have decreased significantly over time, with a 5-year cumulative risk of surgery of 7.0% in UC and 18.0% in CD in contemporary cohorts. This decrease may be related to early detection and/or better treatment.
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Affiliation(s)
- Lester Tsai
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Christopher Ma
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Parambir S Dulai
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Larry J Prokop
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Samuel Eisenstein
- Division of Colorectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Sonia L Ramamoorthy
- Division of Colorectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Brian G Feagan
- Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada
| | - Vipul Jairath
- Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California.
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11
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Benchimol EI, Tse F, Carroll MW, deBruyn JC, McNeil SA, Pham-Huy A, Seow CH, Barrett LL, Bessissow T, Carman N, Melmed GY, Vanderkooi OG, Marshall JK, Jones JL. Canadian Association of Gastroenterology Clinical Practice Guideline for Immunizations in Patients With Inflammatory Bowel Disease (IBD)-Part 1: Live Vaccines. J Can Assoc Gastroenterol 2021; 4:e59-e71. [PMID: 34476338 PMCID: PMC8407487 DOI: 10.1093/jcag/gwab015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/16/2020] [Indexed: 12/16/2022] Open
Abstract
Background & Aims Patients with inflammatory bowel disease (IBD) may be at increased risk of
some vaccine-preventable diseases. The effectiveness and safety of
vaccinations may be altered by immunosuppressive therapies or IBD itself.
These recommendations, developed by the Canadian Association of
Gastroenterology and endorsed by the American Gastroenterological
Association, aim to provide guidance on immunizations in patients with
inflammatory bowel disease. This publication focused on live vaccines. Methods Systematic reviews evaluating the efficacy, effectiveness, and safety of
vaccines in patients with IBD, other immune-mediated inflammatory diseases,
and the general population were performed. Critical outcomes included
mortality, vaccine-preventable diseases, and serious adverse events.
Immunogenicity was considered a surrogate outcome for vaccine efficacy.
Certainty of evidence and strength of recommendations were rated according
to the GRADE (Grading of Recommendation Assessment, Development, and
Evaluation) approach. Key questions were developed through an iterative
process and voted on by a multidisciplinary panel. Recommendations were
formulated using the Evidence-to-Decision framework. Strong recommendation
means that most patients should receive the recommended course of action,
whereas a conditional recommendation means that different choices will be
appropriate for different patients. Results Three good practice statements included reviewing a patient’s
vaccination status at diagnosis and at regular intervals, giving appropriate
vaccinations as soon as possible, and not delaying urgently needed
immunosuppressive therapy to provide vaccinations. There are 4
recommendations on the use of live vaccines. Measles, mumps, rubella vaccine
is recommended for both adult and pediatric patients with IBD not on
immunosuppressive therapy, but not for those using immunosuppressive
medications (conditional). Varicella vaccine is recommended for pediatric
patients with IBD not on immunosuppressive therapy, but not for those using
immunosuppressive medications (conditional). For adults, recommendations are
conditionally in favor of varicella vaccine for those not on
immunosuppressive therapy, and against for those on therapy. No
recommendation was made regarding the use of live vaccines in infants born
to mothers using biologics because the desirable and undesirable effects
were closely balanced and the evidence was insufficient. Conclusions Maintaining appropriate vaccination status in patients with IBD is critical
to optimize patient outcomes. In general, live vaccines are recommended in
patients not on immunosuppressive therapy, but not for those using
immunosuppressive medications. Additional studies are needed to evaluate the
safety and efficacy of live vaccines in patients on immunosuppressive
therapy.
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Affiliation(s)
- Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, and CHEO Research Institute, Ottawa, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada, SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, ICES, Toronto, Ontario, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer C deBruyn
- Section of Pediatric Gastroenterology, Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shelly A McNeil
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
| | - Cynthia H Seow
- Division of Gastroenterology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Lisa L Barrett
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Talat Bessissow
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nicholas Carman
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gil Y Melmed
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Otto G Vanderkooi
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California.,Section of Infectious Diseases, Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine and Community Health Sciences, University of Calgary, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer L Jones
- Department of Medicine and Community Health and Epidemiology, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
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12
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Benchimol EI, Tse F, Carroll MW, deBruyn JC, McNeil SA, Pham-Huy A, Seow CH, Barrett LL, Bessissow T, Carman N, Melmed GY, Vanderkooi OG, Marshall JK, Jones JL. Canadian Association of Gastroenterology Clinical Practice Guideline for Immunizations in Patients With Inflammatory Bowel Disease (IBD)-Part 1: Live Vaccines. Gastroenterology 2021; 161:669-680.e0. [PMID: 33617891 DOI: 10.1053/j.gastro.2020.12.079] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) may be at increased risk of some vaccine-preventable diseases. The effectiveness and safety of vaccinations may be altered by immunosuppressive therapies or IBD itself. These recommendations developed by the Canadian Association of Gastroenterology and endorsed by the American Gastroenterological Association, aim to provide guidance on immunizations in adult and pediatric patients with IBD. This publication focused on live vaccines. METHODS Systematic reviews evaluating the efficacy, effectiveness, and safety of vaccines in patients with IBD, other immune-mediated inflammatory diseases, and the general population were performed. Critical outcomes included mortality, vaccine-preventable diseases, and serious adverse events. Immunogenicity was considered a surrogate outcome for vaccine efficacy. Certainty of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. Key questions were developed through an iterative process and voted on by a multidisciplinary panel. Recommendations were formulated using the Evidence-to-Decision framework. Strong recommendation means that most patients should receive the recommended course of action, whereas a conditional recommendation means that different choices will be appropriate for different patients. RESULTS Three good practice statements included reviewing a patient's vaccination status at diagnosis and at regular intervals, giving appropriate vaccinations as soon as possible, and not delaying urgently needed immunosuppressive therapy to provide vaccinations. There are 4 recommendations on the use of live vaccines. Measles, mumps, rubella vaccine is recommended for both adult and pediatric patients with IBD not on immunosuppressive therapy, but not for those using immunosuppressive medications (conditional). Varicella vaccine is recommended for pediatric patients with IBD not on immunosuppressive therapy, but not for those using immunosuppressive medications (conditional). For adults, recommendations are conditionally in favor of varicella vaccine for those not on immunosuppressive therapy, and against for those on therapy. No recommendation was made regarding the use of live vaccines in infants born to mothers using biologics because the desirable and undesirable effects were closely balanced and the evidence was insufficient. CONCLUSIONS Maintaining appropriate vaccination status in patients with IBD is critical to optimize patient outcomes. In general, live vaccines are recommended in patients not on immunosuppressive therapy, but not for those using immunosuppressive medications. Additional studies are needed to evaluate the safety and efficacy of live vaccines in patients on immunosuppressive therapy.
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Affiliation(s)
- Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada, CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, and CHEO Research Institute, Ottawa, Ontario, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada, SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, ICES, Toronto, Ontario, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer C deBruyn
- Section of Pediatric Gastroenterology, Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shelly A McNeil
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
| | - Cynthia H Seow
- Division of Gastroenterology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Lisa L Barrett
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Talat Bessissow
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nicholas Carman
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada, CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gil Y Melmed
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Otto G Vanderkooi
- Section of Infectious Diseases, Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine and Community Health Sciences, University of Calgary, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer L Jones
- Department of Medicine and Community Health and Epidemiology, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
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Bernstein CN, Kuenzig ME, Coward S, Nugent Z, Nasr A, El-Matary W, Singh H, Kaplan GG, Benchimol EI. Increased Incidence of Inflammatory Bowel Disease After Hirschsprung Disease: A Population-based Cohort Study. J Pediatr 2021; 233:98-104.e2. [PMID: 33545193 DOI: 10.1016/j.jpeds.2021.01.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/08/2021] [Accepted: 01/26/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the frequency with which inflammatory bowel disease (IBD) is diagnosed in persons with Hirschsprung disease in population-based datasets from 3 Canadian provinces. STUDY DESIGN In study I, Ontario data were used to assess the incidence of IBD in a birth cohort of children with Hirschsprung disease relative to children without Hirschsprung disease. In study II, a case-control design was used in Alberta and Manitoba to determine the frequency of previously diagnosed Hirschsprung disease in persons with IBD, compared with the frequency of Hirschsprung disease in matched controls. Validated algorithms for Hirschsprung disease and IBD were applied to each provincial health registry. RESULTS In study I, of the 716 children diagnosed with Hirschsprung disease in Ontario since 1991, 18 (2.5%) ultimately developed IBD (168.8 per 100 000 person-years), compared with 7109 of 3 377 394 children without Hirschsprung disease (0.2%, 14.2 per 100 000 person-years). The percentage of males with post-Hirschsprung disease IBD was 77.8%. The incidence rate ratio was 11.9 (95% CI, 7.5-18.8). In study II, the OR of having had Hirschsprung disease before a diagnosis of IBD compared with controls was 74.9 (95% CI, 17.1-328.7) in Alberta and 23.8 (95% CI, 4.6-123) in Manitoba. Crohn's disease was more common after Hirschsprung disease than ulcerative colitis. CONCLUSIONS IBD can emerge in more than 2% of patients with Hirschsprung disease and, like Hirschsprung disease itself, is more common in males. IBD is much more common after a diagnosis of Hirschsprung disease than in the general population.
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Affiliation(s)
- Charles N Bernstein
- University of Manitoba IBD Clinical and Research Center, Winnipeg, Manitoba, Canada; Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - M Ellen Kuenzig
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Center, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ontario, Canada; CHEO Research Institute, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada
| | - Stephanie Coward
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Zoann Nugent
- University of Manitoba IBD Clinical and Research Center, Winnipeg, Manitoba, Canada; Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Ahmed Nasr
- Department of Pediatric Surgery, Children's Hospital of Eastern Ontario and Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Wael El-Matary
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; Manitoba and Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- University of Manitoba IBD Clinical and Research Center, Winnipeg, Manitoba, Canada; Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Gilaad G Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Eric I Benchimol
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Center, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ontario, Canada; CHEO Research Institute, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada; Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Kuenzig ME, Manuel DG, Donelle J, Benchimol EI. Life expectancy and health-adjusted life expectancy in people with inflammatory bowel disease. CMAJ 2021; 192:E1394-E1402. [PMID: 33168761 DOI: 10.1503/cmaj.190976] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) may be life-threatening and often reduces quality of life. We determined trends in life expectancy and health-adjusted life expectancy in people with and without IBD. METHODS We conducted a retrospective cohort study of population-level health administrative, demographic and health survey data available from databases in Ontario. We matched people with a diagnosis of IBD to those without a diagnosis of IBD. We used period life tables that were generated using age- and sex-specific 5-year mortality rates to calculate life expectancy (for 1996, 2000, 2008 and 2011). We incorporated the Health Utility Index (National Population Health Study; Canadian Community Health Survey) to estimate health-adjusted life expectancy (for 1996, 2000 and 2008). RESULTS Life expectancy in patients with IBD increased between 1996 and 2011 (females: from 75.5 to 78.4 yr, difference: 2.9 yr [95% confidence interval (CI) 1.3 to 4.5]; males: from 72.2 to 75.5 yr, difference: 3.2 yr [95% CI 2.1 to 4.4]). Between 1996 and 2008, health-adjusted life expectancy decreased among males by 3.9 years (95% CI 1.2 to 6.6). There was no statistically significant change in health-adjusted life expectancy among females with IBD (difference: 2.0 yr, 95% CI -1.6 to 5.7). Life expectancy and health-adjusted life expectancy were lower in people with IBD compared with those without IBD. Differences in life expectancy in people with and without IBD ranged from 6.6 to 8.1 years in females and 5.0 to 6.1 years in males, depending on the year. Differences in health-adjusted life expectancy for people with and without IBD ranged from 9.5 to 13.5 years in females and 2.6 to 6.7 years in males. INTERPRETATION Whilst life expectancy has increased among people with IBD, a gap in life expectancy between those with and without IBD remains, and the effect of pain on daily functioning contributes substantially to reduced health-adjusted life expectancy, suggesting that improved pain mitigation strategies should be implemented.
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Affiliation(s)
- M Ellen Kuenzig
- Division of Gastroenterology, Hepatology and Nutrition (Benchimol), The Hospital for Sick Children, Toronto, Ont.; Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition (Kuenzig, Benchimol: during the conduct of the study), CHEO and CHEO Research Institute; ICES uOttawa (Kuenzig, Manuel, Donelle, Benchimol); Ottawa Hospital Research Institute (Manuel, Donelle); School of Epidemiology and Public Health (Manuel, Benchimol), University of Ottawa; Department of Pediatrics (Benchimol), University of Ottawa, Ottawa, Ont
| | - Douglas G Manuel
- Division of Gastroenterology, Hepatology and Nutrition (Benchimol), The Hospital for Sick Children, Toronto, Ont.; Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition (Kuenzig, Benchimol: during the conduct of the study), CHEO and CHEO Research Institute; ICES uOttawa (Kuenzig, Manuel, Donelle, Benchimol); Ottawa Hospital Research Institute (Manuel, Donelle); School of Epidemiology and Public Health (Manuel, Benchimol), University of Ottawa; Department of Pediatrics (Benchimol), University of Ottawa, Ottawa, Ont
| | - Jessy Donelle
- Division of Gastroenterology, Hepatology and Nutrition (Benchimol), The Hospital for Sick Children, Toronto, Ont.; Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition (Kuenzig, Benchimol: during the conduct of the study), CHEO and CHEO Research Institute; ICES uOttawa (Kuenzig, Manuel, Donelle, Benchimol); Ottawa Hospital Research Institute (Manuel, Donelle); School of Epidemiology and Public Health (Manuel, Benchimol), University of Ottawa; Department of Pediatrics (Benchimol), University of Ottawa, Ottawa, Ont
| | - Eric I Benchimol
- Division of Gastroenterology, Hepatology and Nutrition (Benchimol), The Hospital for Sick Children, Toronto, Ont.; Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition (Kuenzig, Benchimol: during the conduct of the study), CHEO and CHEO Research Institute; ICES uOttawa (Kuenzig, Manuel, Donelle, Benchimol); Ottawa Hospital Research Institute (Manuel, Donelle); School of Epidemiology and Public Health (Manuel, Benchimol), University of Ottawa; Department of Pediatrics (Benchimol), University of Ottawa, Ottawa, Ont.
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15
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Dheri AK, Kuenzig ME, Mack DR, Murthy SK, Kaplan GG, Donelle J, Smith G, Benchimol EI. Shifting Health Care Use from Hospitalisations and Surgeries to Outpatient Visits in Children with Inflammatory Bowel Disease: A Population-based Cohort Study from Ontario, Canada. J Crohns Colitis 2021; 15:1991-2000. [PMID: 34019625 PMCID: PMC8684492 DOI: 10.1093/ecco-jcc/jjab095] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Modern, specialised care for children with inflammatory bowel disease [IBD] may have resulted in changes in health services use. We report trends over time in health services utilisation and surgery for children with IBD and children without IBD. METHODS Children aged <18 years, diagnosed with IBD between 1994 and 2013 [n = 5518] and followed until 2015 in Ontario, Canada, were identified from health administrative data and matched to children without IBD on age, sex, rural/urban household, and income [n = 26,677]. We report the annual percentage change [APC] with 95% confidence intervals [CI] in the rate of outpatient visits, emergency department [ED] visits, and hospitalisations, using negative binomial regression for events within 5 years from the diagnosis/index date. We used Cox proportional hazards regression models to report APC in hazards of intestinal resection [Crohn's disease; CD] and colectomy [ulcerative colitis; UC]. RESULTS IBD-specific hospitalisation rates decreased by 2.5% [95% CI 1.8-3.2%] annually, and all-cause hospitalisation rates in children without IBD decreased by 4.3% [95% CI 3.5-5.1%] annually. Intestinal resection risk in CD decreased by 6.0% [95% CI 4.6-7.3%] annually and colectomy risk in UC decreased by 3.0% [95% CI 0.7-5.2%] annually. In contrast, IBD-specific outpatient visit rates increased after 2005 by 4.0% [95% CI 3.1-4.9%] annually. Similar trends in outpatient visits were not observed in children without IBD. CONCLUSIONS Hospitalisations and surgeries decreased over time while outpatient visits increased after 2005. Decreasing hospitalisations were mirrored in children without IBD, likely resulting from a combination of changes in disease management and health system factors.
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Affiliation(s)
- Aman K Dheri
- Children’s Hospital of Eastern Ontario [CHEO] Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, ON, Canada,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON,Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, ON,Canada,Child Health Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON,Canada
| | - David R Mack
- Children’s Hospital of Eastern Ontario [CHEO] Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, ON, Canada,CHEO Research Institute, Ottawa, ON,Canada,Department of Pediatrics, University of Ottawa, Ottawa, ON,Canada
| | - Sanjay K Murthy
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON,Canada,ICES, Toronto, ON,Canada,Department of Medicine, University of Ottawa, Ottawa, ON,Canada
| | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB,Canada
| | | | | | - Eric I Benchimol
- Children’s Hospital of Eastern Ontario [CHEO] Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, ON, Canada,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON,Canada,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, ON,Canada,Child Health Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON,Canada,CHEO Research Institute, Ottawa, ON,Canada,Department of Pediatrics, University of Ottawa, Ottawa, ON,Canada,ICES, Toronto, ON,Canada,Department of Paediatrics and Institute of Health Policy, Management andEvaluation,Corresponding author: Eric Benchimol, Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. Tel.: [416]813–1500; fax: [416]813–4972;
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16
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Aloi M, Bramuzzo M, Norsa L, Arrigo S, Distante M, Miele E, Romano C, Giobbi C, Panceri R, Cucchiara S, Alvisi P. Disease Activity Patterns in the First 5 Years After Diagnosis in Children With Ulcerative Colitis: A Population-Based Study. J Crohns Colitis 2021; 15:367-374. [PMID: 33022055 DOI: 10.1093/ecco-jcc/jjaa203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to define clusters of activity in a population-based cohort during the first 5 years after diagnosis in children with ulcerative colitis [UC] and to identify early prognostic risk factors. METHODS All UC patients from the SIGENP IBD registry with a complete follow-up of at least 5 years were included. Active disease was defined every 6 months in the presence of at least one of the following: clinical activity [Paediatric Ulcerative Colitis Activity Index ≥ 35]; endoscopic activity [Mayo score ≥ 1]; faecal calprotectin > 250 µg/g; hospitalization; surgery; or treatment escalation. Formula-based clusters were generated based on four published questionnaire-based activity patterns in adults, plus one additional cluster. RESULTS In total, 226 patients were identified. Forty-two [19%] had moderate-severe chronically active disease, 31 [14%] chronic-intermittent, 75 [33%] quiescent, 54 [24%] active disease in the first 2 years after the diagnosis, then sustained remission, and 24 [11%] a remission in the first 2 years then an active disease. Mild disease onset along with a lower clinical severity not requiring the use of corticosteroids at 6 months were related to a quiescent disease course at the next follow-up (logistic model area under the curve 0.86 [95% confidence interval 0.78-0.94]; positive predictive value 67%; negative predictive value 70%). Eight per cent of patients needed surgery, none in the quiescent group [p = 0.04]. CONCLUSIONS More than one-third of children with UC present with a chronically active or intermittent course during the first 5 years of follow-up. A significant group of patients has active disease in the first 2 years and then sustained remission. Interestingly, after initial treatment, one-third of patients have well-controlled disease throughout.
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Affiliation(s)
- M Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - M Bramuzzo
- Institute for Maternal and Child Health IRCCS 'Burlo Garofalo', Trieste, Italy
| | - L Norsa
- Pediatric Hepatology Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - S Arrigo
- Pediatric Gastroenterology Unit, Institute 'Giannina Gaslini', Genoa, Italy
| | - M Distante
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - E Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II', Naples, Italy
| | - C Romano
- Pediatric Gastroenterology and Endoscopy, University of Messina, Messina, Italy
| | - C Giobbi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - R Panceri
- Department of Pediatrics, University of Milano-Bicocca Fond., MBBM/Hosp., San Gerardo Monza, Italy
| | - S Cucchiara
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - P Alvisi
- Pediatric Department, Maggiore Hospital, Bologna, Italy
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17
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Rintala RJ, Pakarinen MP, Koivusalo A. Ulcerative Colitis. PEDIATRIC SURGERY 2021:261-275. [DOI: 10.1007/978-3-662-43559-5_106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Abstract
INTRODUCTION In a population-based inflammatory bowel disease (IBD) cohort, we aimed to determine whether having lower socioeconomic status (LSS) impacted on outcomes. METHODS We identified all 9,298 Manitoba residents with IBD from April 1, 1995, to March 31, 2018 by applying a validated case definition to the Manitoba Health administrative database. We could identify all outpatient physician visits, hospitalizations, surgeries, intensive care unit admissions, and prescription medications. Their data were linked with 2 Manitoba databases, one identifying all persons who received Employment and Income Assistance and another identifying all persons with Child and Family Services contact. Area-level socioeconomic status was defined by a factor score incorporating average household income, single parent households, unemployment rate, and high school education rate. LSS was identified by any of ever being registered for Employment and Income Assistance or with Child and Family Services or being in the lowest area-level socioeconomic status quintile. RESULTS Comparing persons with LSS vs those without any markers of LSS, there were increased rates of annual outpatient physician visits (relative risk [RR] = 1.10, 95% confidence interval [CI] = 1.06-1.13), hospitalizations (RR = 1.38, 95% CI = 1.31-1.44), intensive care unit admission (RR = 1.94, 95% CI = 1.65-2.27), use of corticosteroids >2,000 mg/yr (RR = 1.12, 95% CI = 1.03-1.21), and death (hazard ratio 1.53, 95% CI = 1.36-1.73). Narcotics (RR = 2.17, 95% CI = 2.01-2.34) and psychotropic medication use (RR = 1.98, 95% CI = 1.84-2.13) were increased. The impact of LSS was greater for those with Crohn's disease than for those with ulcerative colitis. DISCUSSION LSS was associated with worse outcomes in persons with IBD. Social determinants of health at time of diagnosis should be highly considered and addressed.
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19
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Jenkinson PW, Plevris N, Siakavellas S, Lyons M, Arnott ID, Wilson D, Watson AJM, Jones GR, Lees CW. Temporal Trends in Surgical Resection Rates and Biologic Prescribing in Crohn's Disease: A Population-based Cohort Study. J Crohns Colitis 2020; 14:1241-1247. [PMID: 32840295 DOI: 10.1093/ecco-jcc/jjaa044] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The use of biologic therapy for Crohn's disease [CD] continues to evolve, however, the effect of this on the requirement for surgery remains unclear. We assessed changes in biologic prescription and surgery over time in a population-based cohort. METHODS We performed a retrospective cohort study of all 1753 patients diagnosed with CD in Lothian, Scotland, between January 1, 2000 and December 31, 2017, reviewing the electronic health record of each patient to identify all CD-related surgery and biologic prescription. Cumulative probability and hazard ratios for surgery and biologic prescription from diagnosis were calculated and compared using the log-rank test and Cox regression analysis stratified by year of diagnosis into cohorts. RESULTS The 5-year cumulative risk of surgery was 20.4% in cohort 1 [2000-2004],18.3% in cohort 2 [2005-2008], 14.7% in cohort 3 [2009-2013], and 13.0% in cohort 4 [2014-2017] p <0.001. The 5-year cumulative risk of biologic prescription was 5.7% in cohort 1, 12.2% in cohort 2, 22.0% in cohort 3, and 44.9% in cohort 4 p <0.001. CONCLUSIONS The increased and earlier use of biologic therapy in CD patients corresponded with a decreasing requirement for surgery over time within our cohort. This could mean that adopting a top-down or accelerated step-up treatment strategy may be effective at reducing the requirement for surgery in newly diagnosed CD.
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Affiliation(s)
- P W Jenkinson
- Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK.,Department of Surgery, Raigmore Hospital, Inverness, UK
| | - N Plevris
- Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
| | - S Siakavellas
- Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
| | - M Lyons
- School of Medicine, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - I D Arnott
- Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
| | - D Wilson
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Edinburgh, UK
| | - A J M Watson
- Department of Surgery, Raigmore Hospital, Inverness, UK
| | - G-R Jones
- Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
| | - C W Lees
- Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
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20
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Davies M, Dodd S, Coultate M, Ross A, Pears G, Gnaneswaran B, Tzivinikos C, Konidari A, Cheng J, Auth MK, Cameron F, Tamhne S, Renji E, Nair M, Baillie C, Collins P, Smith PJ, Subramanian S. From Paris to Montreal: disease regression is common during long term follow-up of paediatric Crohn's disease. Scand J Gastroenterol 2020; 55:148-153. [PMID: 31928099 DOI: 10.1080/00365521.2019.1710765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction: Paediatric Crohn's disease (PCD) often presents with extensive and a frequent pan-enteric phenotype at onset. However, its long term evolution into adulthood, especially since the widespread use of biological agents, is not well characterised. We conducted a single centre cohort study of all PCD patients transitioned to adult care to assess the long term disease evolution in the era of biologic therapy.Methods: We conducted a retrospective observational, study of all PCD patients who were subsequently transferred to the care of an adult gastroenterology unit and had a minimum follow up of 2 years. We examined the case notes for evolution of disease location and behaviour. Disease location and behaviour was characterised using Paris classification at diagnosis and Montreal classification at last follow-up. In addition, we examined variables associated with complicated disease behaviour and the need for CD related intestinal resection.Results: In total, 132 patients were included with a median age at diagnosis of 13 (IQR 11-14) and a median follow up of 11 years (range 4-14). At diagnosis, 23 (17.4%), 39 (29.6%) and 70 (53%) patients had ileal, colonic and ileocolonic disease respectively. In addition, 31 (23.5%) patients had L4a or L4b disease at diagnosis (proximal or distal to the ligament of treitz respectively) and 13 patients (9.8%) had both whilst 27 (20.4%) patients had perianal disease. At diagnosis, 27 (20.4%) patients had complicated disease behaviour but 83 (62.9)% of patients had an extensive 'pan-enteric' phenotype. Of these patients only 55 (66.3%) retained the pan-enteric phenotype at last follow-up (p = .0002). Disease extension was noted in 25 (18.9%) of patients and regression was noted in 47 (35.6%) of patients, whereas upper GI disease was noted in significantly fewer patients at last follow-up (21, 15.9%) (p = .0001). More patients had complicated disease behaviour (46 patients, 34.9%, p = .0018) at last follow-up. There was a high exposure to both thiopurines 121 (91.7%) and biologics 84 (63.6%). The cumulative probability (95% CI) of surgery was 0.05 (0.02, 0.11) at 1 year, 0.17 (0.11, 0.24) at 3 years and 0.22 (0.15, 0.30) at 5 years. Neither disease location nor behaviour were associated with the need for intestinal resectional surgery.Conclusions: Over the course of an extended follow-up period, there appeared to be changes in both disease location and behaviour in PCD. Interestingly, a significant proportion of patients had disease involution which may be related to a high rate of exposure to thiopurines and biologics. We were unable to identify any variables associated with complicated disease course or the need for intestinal surgery.
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Affiliation(s)
- Mike Davies
- Department of Gastroenterology, Royal Liverpool, and Broadgreen University Hospital NHS Trust, Liverpool, UK
| | - Susanna Dodd
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Morwenna Coultate
- Department of Gastroenterology, Royal Liverpool, and Broadgreen University Hospital NHS Trust, Liverpool, UK
| | - Andrew Ross
- Department of Gastroenterology, Royal Liverpool, and Broadgreen University Hospital NHS Trust, Liverpool, UK
| | - George Pears
- Department of Gastroenterology, Royal Liverpool, and Broadgreen University Hospital NHS Trust, Liverpool, UK
| | - Bruno Gnaneswaran
- Department of Gastroenterology, Royal Liverpool, and Broadgreen University Hospital NHS Trust, Liverpool, UK
| | - Christos Tzivinikos
- Pediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Anastasia Konidari
- Pediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jeng Cheng
- Pediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Marcus Kh Auth
- Pediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Cellular and Molecular Physiology, University of Liverpool, Liverpool, UK
| | - Fiona Cameron
- Pediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Sarang Tamhne
- Pediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Elizabeth Renji
- Pediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Manjula Nair
- Pediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Colin Baillie
- Department of Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Paul Collins
- Department of Gastroenterology, Royal Liverpool, and Broadgreen University Hospital NHS Trust, Liverpool, UK
| | - Philip J Smith
- Department of Gastroenterology, Royal Liverpool, and Broadgreen University Hospital NHS Trust, Liverpool, UK
| | - Sreedhar Subramanian
- Department of Gastroenterology, Royal Liverpool, and Broadgreen University Hospital NHS Trust, Liverpool, UK.,Department of Cellular and Molecular Physiology, University of Liverpool, Liverpool, UK
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21
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Kuenzig ME, Stukel TA, Kaplan GG, Murthy SK, Nguyen GC, Talarico R, Benchimol EI. Variation in care of patients with elderly-onset inflammatory bowel disease in Ontario, Canada: A population-based cohort study. J Can Assoc Gastroenterol 2020; 4:e16-e30. [PMID: 33855268 PMCID: PMC8023856 DOI: 10.1093/jcag/gwz048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/21/2019] [Indexed: 11/18/2022] Open
Abstract
Background Variation in health care, when not based on patient preference, may result in
poorer care. We determined whether variation in health services utilization,
gastroenterologist care and outcomes existed among patients with
elderly-onset inflammatory bowel disease (IBD). Methods Patients with IBD (diagnosed ≥65 years) were identified from
population-based health administrative data from Ontario, Canada (1999 to
2014). We assessed variation across multispecialty physician networks in
gastroenterologist care and outcomes using multilevel logistic regression.
Median odds ratios (MOR) described variation. We evaluated the association
between gastroenterologist supply, specialist care and outcomes. Results In 4806 patients, there was significant variation in having ever seen a
gastroenterologist (MOR 3.35, P < 0.0001), having a
gastroenterologist as the primary IBD care provider (MOR 4.16,
P < 0.0001), 5-year colectomy risk in ulcerative
colitis (MOR 1.38, P = 0.01), immunomodulator use (MOR
1.47, P = 0.001), and corticosteroid use (MOR 1.26,
P = 0.006). No variation in emergency department
visits, hospitalizations or intestinal resection (Crohn’s) was noted.
Patients in networks with fewer gastroenterologists were less likely to see
a gastroenterologist (odds ratio [OR] 0.29, 95% confidence interval [CI]
0.15 to 0.56), have a gastroenterologist as their primary care provider (OR
0.27, 95% CI 0.12 to 0.59), be hospitalized within 5 years (OR 0.82, 95% CI
0.69 to 0.98), and be prescribed biologics within 1 year (OR 0.50, 95% CI
0.28 to 0.89). Conclusions Utilization of gastroenterology care in patients with elderly-onset IBD
varies greatly. Patients treated by gastroenterologists and in networks with
more gastroenterologists have better outcomes. There is a need to ensure all
individuals with IBD have equal access to and utilization of specialist care
to ensure the best possible outcomes.
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Affiliation(s)
- M Ellen Kuenzig
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada.,CHEO Research Institute, Ottawa, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Therese A Stukel
- ICES, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gilaad G Kaplan
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanjay K Murthy
- The Ottawa Hospital IBD Centre, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey C Nguyen
- ICES, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Eric I Benchimol
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada.,CHEO Research Institute, Ottawa, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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22
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Abstract
The incidence of paediatric Crohn's disease (CD) and ulcerative colitis (UC) is increasing. Surgical intervention is required during childhood in approximately 25% of children diagnosed with CD, and for 10% of those diagnosed with UC. Although there is evidence that the rate of surgical intervention undertaken in children is decreasing since the introduction of biologic therapy, this may only represent a delay rather than true reversal of the risk of surgery. Surgery for CD is not curative and limited resection is the key principle thus preserving bowel length. For UC, subtotal colectomy is relatively curative; ileo-anal pouch anastomosis can be performed to restore bowel continuity.
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Affiliation(s)
- Arun Kelay
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
| | - Lucinda Tullie
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
| | - Michael Stanton
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
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23
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Lund K, Larsen MD, Knudsen T, Kjeldsen J, Nielsen RG, Nørgård BM. The impact of anti-TNFα therapy on colectomy rates and corticosteroid treatment among 3001 paediatric and adolescent patients with ulcerative colitis-a nationwide study from 1995 to 2015. Aliment Pharmacol Ther 2019; 50:1077-1085. [PMID: 31579961 DOI: 10.1111/apt.15510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/07/2019] [Accepted: 08/29/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The long-term effects of anti-TNFα therapy in ulcerative colitis are debatable. AIM To examine whether anti-TNFα therapy changed the colectomy proportion and reduced the use of corticosteroids. METHODS A nationwide cohort study among patients (age 0-20) diagnosed with ulcerative colitis through 1995-2015 from Danish health registries. We calculated the cumulative 5-year risk of colectomy after diagnosis and used a Cox regression model for comparison between a historical pre-anti-TNFα cohort 1 (1995-2003) and a cohort 2 for the era of anti-TNFα (2004-2015). Based on anti-TNFα users, defined as patients who had at least four anti-TNFα treatments within 4 months, we examined the subsequent need for corticosteroids. RESULTS We identified 3001 patients from 1995 to 2015. The 5-year cumulative proportion of colectomy in cohort 2 was 9.7% (95% confidence interval [CI] 8.4-11.1) and 12.3% (95% CI 10.4-14.6) in cohort 1. The adjusted 5-year hazard ratio (HR) was 0.76 (95% CI 0.60-0.96) for colectomy in cohort 2 compared to cohort 1. A total of 334 patients received anti-TNFα treatments, and 16.8% (56/334) were prescribed corticosteroids in the subsequent 3-month period. Corticosteroid treatment declined with follow-up after 6 and 12 months, 5.4% and 1.2%, respectively. CONCLUSION In patient's ≤20 years, the HR for colectomy within a period of 5 years from the time of diagnosis was reduced in the era of anti-TNFα compared to a historical cohort. In patients treated with anti-TNFα, prescriptions of corticosteroids were virtually ceased after 12 months.
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Affiliation(s)
- Ken Lund
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark.,Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael Due Larsen
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark.,Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Torben Knudsen
- Department of Medicine, Hospital of Southwest Jutland, Esbjerg, Denmark.,Institute for Regional Health Science, Center Southwest Jutland, University of Southern Denmark, Esbjerg, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastroenterology S, Odense University Hospital, Odense, Denmark.,Research Unit of Medical Gastroenterology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rasmus Gaardskjaer Nielsen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Research Unit of Pediatric, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark.,Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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24
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Trends in hospital length of stay and 30-day morbidity in pediatric patients undergoing laparoscopic ileocecal resection, 2012-2016. J Pediatr Surg 2019; 54:1340-1345. [PMID: 30638662 DOI: 10.1016/j.jpedsurg.2018.10.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 09/11/2018] [Accepted: 10/28/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE To examine postoperative length of stay (LOS), hospital readmission, and 30-day complications in pediatric patients undergoing laparoscopic ileocecal resection in a contemporary cohort. METHODS Retrospective review of the American College of Surgeons National Surgery Quality Improvement Project, Pediatric (NSQIP-P) 2012-2016 participant user files for patients <19 years old who underwent laparoscopic ileocecal resection. Mean postoperative LOS, hospital readmission and both wound-specific and composite complications were calculated and compared by year of operation. RESULTS 348 patients were identified (range, 46-96 per year); 55.2-69.8% of these were admitted the day of operation, with a nonsignificant increase in frequency over the study period. Postoperative LOS ranged from 5.4 ± 2.9 days to 7.3 ± 9.1 days (p = 0.24). In subset analysis of only those patients admitted on the day of operation, postoperative LOS remained relatively long, ranging from 5.0 ± 3.0 days to 5.7 ± 4.0 days (p = 0.89). 30-day hospital readmission proportions rose insignificantly, from 6.9% in 2012 to 15.5% in 2016 (p = 0.41). Wound complication rates (including superficial, deep, and deep organ space infections, as well as wound dehiscence) ranged from 0.0% to 8.6%, but did not vary in a statistically significant manner. Nonwound complication rates were vanishingly small. CONCLUSIONS Postoperative LOS in pediatric patients undergoing laparoscopic ileocecal resection in a select group of patients cared for in hospitals participating in NSQIP-P has not decreased in the past 5 years despite emerging evidence of the safety and relevance of enhanced recovery after surgery programs. Opportunities for shortening LOS without compromising patient safety may still exist. LEVEL-OF-EVIDENCE III Retrospective comparative study.
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deBruyn JCC, Soon IS, Fonseca K, Feng S, Purtzki M, Goedhart C, Kuhn S, Vanderkooi OG, Wrobel I. Serologic Status of Routine Childhood Vaccines, Cytomegalovirus, and Epstein-Barr Virus in Children With Inflammatory Bowel Disease. Inflamm Bowel Dis 2019; 25:1218-1226. [PMID: 30551205 DOI: 10.1093/ibd/izy366] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Data on the serologic status of childhood vaccines, cytomegalovirus (CMV) and Epstein-Barr virus (EBV), are limited in inflammatory bowel disease (IBD). Therefore, we evaluated vaccine coverage and seroprotection, along with CMV and EBV seropositivity, in pediatric IBD. METHODS In a cross-sectional study, demographic data, IBD history, vaccine records, and serum for antibodies against measles, mumps, rubella, diphtheria, tetanus, varicella, hepatitis B (HBV), CMV, and EBV were collected from children with IBD. We evaluated potential factors associated with serologic status. RESULTS Of 156 subjects, vaccine coverage was up to date for age in 93.5% for measles, mumps, rubella, 95.6% for diphtheria, tetanus, pertussis, polio, hemophilus influenza B, 75.8% for HBV, and 93.5% for varicella, including past infection and vaccination. Seroprotection was present in 65.8% for measles, 60.5% for mumps, 79.1% for rubella, 79.5% for diphtheria, 80.8% for tetanus, 70.5% for varicella, and 62.8% for HBV of subjects. Older age at diagnosis was associated with seroprotection among subjects with complete HBV (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.03-1.39) and rubella series (OR, 1.18; 95% CI, 1.02-1.37). Older age at serum collection was associated with seroprotection among subjects with prior varicella vaccination or infection (OR, 1.69; 95% CI, 1.33-2.15). Only 25.2% and 37.8% demonstrated seropositivity to CMV and EBV, respectively. Among subjects on immunosuppressive medications, 75.3% and 62.4% were seronegative for CMV and EBV, respectively. CONCLUSIONS Children with IBD have low serologic protection to childhood vaccines in spite of high vaccine coverage and universal vaccinations. Children with IBD, including a large proportion on immunosuppressive medications, have low seropositivity to CMV and EBV.
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Affiliation(s)
- Jennifer C C deBruyn
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ing Shian Soon
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Fonseca
- Virology, Provincial Laboratory for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Sharon Feng
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Melanie Purtzki
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Caitlin Goedhart
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Susan Kuhn
- Section of Infectious Diseases, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Otto G Vanderkooi
- Section of Infectious Diseases, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.,Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Iwona Wrobel
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
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Long-term outcome of pediatric-onset Crohn's disease: A population-based cohort study. Dig Liver Dis 2019; 51:496-502. [PMID: 30611597 DOI: 10.1016/j.dld.2018.11.033] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/23/2018] [Accepted: 11/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pediatric-onset Crohn's disease (CD) may represent a more severe form of disease. The aim of this study was to describe long-term outcome and identify associated risk factors of complicated behavior in a large population-based pediatric-onset CD cohort. PATIENTS AND METHODS Cases included all patients recorded in the EPIMAD registry diagnosed with definite or probable CD between January 1988 and December 2004, under the age of 17 years at the time of diagnosis, with at least two years of follow-up. RESULTS Five hundred and thirty-five patients were included. Median follow-up was 11.1 years [IQR, 7.3-15.0]. At the end of follow-up, 8% (n = 44) of patients had pure ileal disease (L1), 8% (n = 44) had pure colonic disease (L2), and 83% (n = 439) had ileocolonic disease (L3). L4 disease and perianal disease were observed in 42% (n = 227) and 16% (n = 85) of patients, respectively. At the end of follow-up, 58% (n = 308) of patients presented complicated disease behavior (B2, 39% and B3, 19%), and 42% (n = 163) of patients with inflammatory behavior at diagnosis had evolved to complicated behavior. During follow-up, 86% of patients (n = 466) received at least one course of corticosteroids, 67% (n = 357) of patients had been exposed to immunosuppressants and 35% (n = 187) of patients received at least one anti-TNF agent. Forty-three percent (n = 230) of patients underwent at least one intestinal resection. The overall mortality rate was 0.93% and the SMR was 1.6 [0.5-3.8] (p = 0.20). Five cancers were reported with a crude cancer incidence rate of 1.1% and an SIR of 3.3 [1.2-7.0] (p = 0.01). In a multivariate Cox model, ileal (HR, 1.87 [1.09-3.21], p = 0.022) or ileocolonic (HR, 1.54 [1.01-2.34], p = 0.042) and perianal lesions at diagnosis (HR, 1.81 [1.13- 2.89], p = 0.013) were significantly associated with complicated behavior. CONCLUSION About 80% of patients with pediatric-onset CD presented extensive ileocolonic disease during follow-up. The majority of patients evolved to complicated behavior. Surgery, cancer and mortality were observed in 43%, 0.9% and 0.9% of patients, respectively.
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Otto C, Tárnok A, Erős A, Szakács Z, Vincze Á, Farkas N, Sarlós P. Planned Transition of Adolescent Patients with Inflammatory Bowel Disease Results in Higher Remission Rates. J Pediatr Nurs 2019; 45:62-66. [PMID: 30745207 DOI: 10.1016/j.pedn.2019.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/09/2019] [Accepted: 02/01/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the effect of our current transition process on clinical outcomes in adolescent patients with inflammatory bowel diseases (IBD). DESIGN AND METHODS Two groups of patients with IBD diagnosed in pediatric care were compared retrospectively: Group A patients did not attend the transition process, while Group B patients entered the planned transition service. Outcomes at 1-year after transfer to adult care were evaluated. RESULTS Forty-five patients with IBD diagnosed under the age of 18 years were identified of whom 35 had Crohn's disease and 10 had ulcerative colitis. Twenty-four patients were in Group A (without transition), and 21 patients in Group B (with at least one planned transition visit). Mean age at diagnosis was 15.1 ± 2.2 and 13.7 ± 3.0 years (p = 0.086), respectively. There were no significant differences in disease duration before transfer, Montreal classification at diagnosis, body mass index, anti-TNF therapy usage, and disease status at transfer between the two groups. A significantly higher number of Group B patients were in remission at 12 months after transfer when compared to patients in Group A (11 vs. 18, respectively, p = 0.037). There was a significant difference between groups regarding the number of scheduled visits within the examined period (9 vs. 16, p = 0.011, respectively). CONCLUSIONS Planned transition visits resulted in higher disease remission rate at 1-year follow-up after transfer from pediatric to adult health care system in adolescent patients with IBD. PRACTICE IMPLICATION Well-established transition programs in IBD are needed.
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Affiliation(s)
- Caroline Otto
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - András Tárnok
- Department of Pediatrics, Medical School, University of Pécs, Pécs, Hungary
| | - Adrienn Erős
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Patricia Sarlós
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.
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Chaparro M, Garre A, Ricart E, Iglesias-Flores E, Taxonera C, Domènech E, Gisbert JP. Differences between childhood- and adulthood-onset inflammatory bowel disease: the CAROUSEL study from GETECCU. Aliment Pharmacol Ther 2019; 49:419-428. [PMID: 30637837 DOI: 10.1111/apt.15114] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/20/2018] [Accepted: 12/06/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cohort studies comparing the characteristics of childhood-onset and adulthood-onset inflammatory bowel disease (IBD) in the biologics era are scarce. AIM To compare disease characteristics, the use of immunomodulators and biologic agents and the need for surgery between childhood- and adulthood-onset IBD. METHODS Inflammatory bowel disease patients from the ENEIDA registry diagnosed between 2007 and 2017 were included. The childhood-onset cohort comprised patients diagnosed at ≤16 years of age and the adulthood-onset cohort those diagnosed at >16 years. The cumulative incidences of immunosuppressive therapy, biologic therapy and surgery were estimated using Kaplan-Meier curves, compared by the log-rank test. Cox regression analysis was performed to identify potential predictive factors of treatment with immunosuppressants, biologic agents or surgery. RESULTS The adulthood-onset cohort comprised 21 200 patients out of 20 354 (96%) and the childhood-onset cohort 846 (4%). Median follow-up was 54 months in the childhood-onset cohort and 38 months in the adulthood-onset cohort (P < 0.01). Proportions of Crohn's disease, ileocolonic involvement and inflammatory behaviour at diagnosis were higher in the childhood-onset cohort. In the multivariate analysis, after adjusting for sex, type of IBD, extraintestinal manifestations, family history and smoking habit, childhood-onset IBD was associated with higher risk of immunomodulator use (hazard ratio [HR] = 1.2, 95% confidence interval [95% CI] = 1.1-1.2) and higher probability of receiving biologic treatment (HR = 1.2, 95% CI = 1.1-1.3). However, childhood-onset IBD was not associated with higher risk of surgery (HR = 0.9, 95% CI = 0.8-1.2). CONCLUSIONS Childhood-onset IBD has differential characteristics and higher risk of treatment with immunomodulators and biologic agents, compared with adulthood-onset IBD. Nevertheless, paediatric IBD is not associated with higher risk of surgery.
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Affiliation(s)
- María Chaparro
- Gastroenterology Unit, Instituto de Investigación Sanitaria Princesa (IIS-IP) and CIBERehd, Hospital Universitario de La Princesa, Madrid, Spain
| | - Ana Garre
- Gastroenterology Unit, Instituto de Investigación Sanitaria Princesa (IIS-IP) and CIBERehd, Hospital Universitario de La Princesa, Madrid, Spain
| | - Elena Ricart
- Gastroenterology Unit and CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Carlos Taxonera
- Gastroenterology Unit, Hospital Clínico San Carlos, Madrid, Spain
| | - Eugeni Domènech
- Gastroenterology Unit and CIBERehd, Hospital Universitario Germans Trias i Pujol, Badalona, Spain
| | - Javier P Gisbert
- Gastroenterology Unit, Instituto de Investigación Sanitaria Princesa (IIS-IP) and CIBERehd, Hospital Universitario de La Princesa, Madrid, Spain
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Health Services Use during Transition from Pediatric to Adult Care for Inflammatory Bowel Disease: A Population-Based Study Using Health Administrative Data. J Pediatr 2018; 203:280-287.e4. [PMID: 30266506 DOI: 10.1016/j.jpeds.2018.08.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 07/02/2018] [Accepted: 08/09/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To evaluate the impact of the transfer from pediatric to adult care on health services use for adolescents with inflammatory bowel disease (IBD). STUDY DESIGN A population-based retrospective cohort study identified all children diagnosed with IBD from 1994 to 2008 and treated by pediatric gastroenterologists in Ontario, Canada, using health administrative data. Self-controlled case series analyses compared health service use in the 2 years before and 2 years after transfer with adult gastroenterologists, with a 6-month washout period at transfer. Outcomes evaluated included IBD-specific and IBD-related hospitalizations, emergency department use, outpatient visits, and laboratory use. The relative incidence (RI) in the post-transfer period was compared with pretransfer periods using Poisson regression analysis controlling for transfer starting age. Analyses were stratified by IBD type: Crohn's disease (CD) and ulcerative colitis (UC). RESULTS There were 536 patients included in the study (388 CD, 148 UC). Emergency department use rate was higher after transfer for both CD (RI, 2.12; 95% CI, 1.53-2.93) and UC (RI, 2.34; 95% CI, 1.09-5.03), as were outpatient visits (CD: RI, 1.56; 95% CI, 1.42-1.72; UC: RI, 1.48; 95% CI, 1.24-1.76), and laboratory investigations (CD: RI, 1.43; 95% CI, 1.26-1.63; UC: 1.38; 95% CI, 1.13-1.68). There was no change in the hospitalization rate (CD: RI, 0.70; 95% CI, 0.42-1.18; UC: RI, 2.41; 95% CI, 0.62-9.40). CONCLUSIONS Health services use in Canada increases after transfer from pediatric to adult care for outpatient visits, emergency department use, and laboratory tests, but not hospitalizations. This study has implications for the planning and budgeting of care for adolescents transitioning to adult care.
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Benchimol EI, Kuenzig ME, Bernstein CN, Nguyen GC, Guttmann A, Jones JL, Potter BK, Targownik LE, Catley CA, Nugent ZJ, Tanyingoh D, Mojaverian N, Underwood FE, Siddiq S, Otley AR, Bitton A, Carroll MW, deBruyn JC, Dummer TJ, El-Matary W, Griffiths AM, Jacobson K, Leddin D, Lix LM, Mack DR, Murthy SK, Peña-Sánchez JN, Singh H, Kaplan GG. Rural and urban disparities in the care of Canadian patients with inflammatory bowel disease: a population-based study. Clin Epidemiol 2018; 10:1613-1626. [PMID: 30519110 PMCID: PMC6233859 DOI: 10.2147/clep.s178056] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Canada's large geographic area and low population density pose challenges in access to specialized health care for remote and rural residents. We compared health services use, surgical rate, and specialist gastroenterologist care in rural and urban inflammatory bowel disease (IBD) patients in Canada. METHODS We used validated algorithms that were applied to population-based health administrative data to identify all people living with the following three Canadian provinces: Alberta, Manitoba, and Ontario (ON). We compared rural residents with urban residents for time to diagnosis, hospitalizations, outpatient visits, emergency department (ED) use, surgical rate, and gastroenterologist care. Multivariable regression compared the outcomes in rural/urban patients, controlling for confounders. Provincial results were meta-analyzed using random-effects models to produce overall estimates. RESULTS A total of 36,656 urban and 5,223 rural residents with incident IBD were included. Outpatient physician visit rate was similar in rural and urban patients. IBD-specific and IBD-related hospitalization rates were higher in rural patients (incidence rate ratio [IRR] 1.17, 95% CI 1.02-1.34, and IRR 1.27, 95% CI 1.04-1.56, respectively). The rate of ED visits in ON were similarly elevated for rural patients (IRR 1.53, 95% CI 1.42-1.65, and IRR 1.33, 95% CI 1.25-1.40). There were no differences in surgical rates or prediagnosis lag time between rural and urban patients. Rural patients had fewer IBD-specific gastroenterologist visits (IRR 0.79, 95% CI 0.73-0.84) and a smaller proportion of their IBD-specific care was provided by gastroenterologists (28.3% vs 55.2%, P<0.0001). This was less pronounced in children <10 years at diagnosis (59.3% vs 65.0%, P<0.0001), and the gap was widest in patients >65 years (33.0% vs 59.2%, P<0.0001). CONCLUSION There were lower rates of gastroenterologist physician visits, more hospitalizations, and greater rates of ED visits in rural IBD patients. These disparities in health services use result in costlier care for rural patients. Innovative methods of delivering gastroenterology care to rural IBD patients (such as telehealth, online support, and remote clinics) should be explored, especially for communities lacking easy access to gastroenterologists.
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Affiliation(s)
- Eric I Benchimol
- Children's Hospital of Eastern Ontario IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada,
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada,
- Department of Pediatrics, University of Ottawa, Ottawa, Canada,
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada,
- ICES, Toronto, Canada,
| | - M Ellen Kuenzig
- Children's Hospital of Eastern Ontario IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada,
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada,
- ICES, Toronto, Canada,
| | - Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Geoffrey C Nguyen
- ICES, Toronto, Canada,
- Department of Medicine, Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Canada
| | - Astrid Guttmann
- ICES, Toronto, Canada,
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | | | - Beth K Potter
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada,
| | - Laura E Targownik
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Zoann J Nugent
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Canada
- CancerCare Manitoba, Winnipeg, Canada
| | - Divine Tanyingoh
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Fox E Underwood
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shabnaz Siddiq
- Children's Hospital of Eastern Ontario IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada,
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada,
| | - Anthony R Otley
- Department of Pediatrics, Dalhousie University, Halifax, Canada
| | - Alain Bitton
- Division of Gastroenterology, McGill University Health Centre, Montreal, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Jennifer C deBruyn
- Division of Gastroenterology, Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Trevor Jb Dummer
- School of Population and Public Health, University of British Columbia, British Columbia, Canada
| | - Wael El-Matary
- Department of Pediatrics, University of Manitoba, Winnipeg, Canada
| | - Anne M Griffiths
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Kevan Jacobson
- Department of Pediatrics, The University of British Columbia, British Columbia, Canada
- Child and Family Research Institute, The University of British Columbia, British Columbia, Canada
| | - Desmond Leddin
- Department of Medicine, Dalhousie University, Halifax, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - David R Mack
- Children's Hospital of Eastern Ontario IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada,
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada,
- Department of Pediatrics, University of Ottawa, Ottawa, Canada,
| | - Sanjay K Murthy
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada,
- The Ottawa Hospital IBD Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Harminder Singh
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Kuenzig ME, Benchimol EI, Lee L, Targownik LE, Singh H, Kaplan GG, Bernstein CN, Bitton A, Nguyen GC, Lee K, Cooke-Lauder J, Murthy SK. The Impact of Inflammatory Bowel Disease in Canada 2018: Direct Costs and Health Services Utilization. J Can Assoc Gastroenterol 2018; 2:S17-S33. [PMID: 31294382 PMCID: PMC6512251 DOI: 10.1093/jcag/gwy055] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/26/2018] [Indexed: 12/12/2022] Open
Abstract
Direct health care costs of illness reflect the costs of medically necessary services and treatments paid for by public and private payers, including hospital-based care, outpatient physician consultations, prescription medications, diagnostic testing, complex continuing care, and home care. The costs of caring for persons with inflammatory bowel disease (IBD) have been rising well above inflation over the past fifteen years in Canada, largely due to the introduction and penetration of expensive biologic therapies. Changing paradigms of care toward frequent patient monitoring and achievement of stricter endpoints for disease control have also increased health services utilization and costs among IBD patients. While the frequency and costs of surgeries and hospitalizations have declined slightly in parallel with increased biologic use (due to better overall disease control), the direct medical costs of care for IBD patients are largely dominated by prescription drug costs. Introduction and penetration of biosimilar agents (at a markedly lower price point than the originator drugs) and increasing gastroenterologist involvement in the care of IBD patients may help to balance rising health care costs while improving health outcomes and quality of life for IBD patients. Ultimately, however, the predicted rise in the prevalence of IBD over the next decade, combined with increasing use of expensive biologic therapies, will likely dictate a continued rise in the direct costs of IBD patient care in Canada for years to come. In 2018, direct health care costs of IBD are estimated to be at least $1 billion Canadian dollars (CAD) and possibly higher than $2 billion CAD. Highlights 1. In Canada, the direct cost of caring for people living with IBD is estimated in 2018 to be close to $1.28 billion (roughly $4731 per person with IBD).2. The costs of caring for people living with IBD are dominated by prescription drugs, followed by hospitalization costs. There has been a shift away from hospitalizations and toward pharmaceuticals as the predominant driver of direct health care costs in IBD patients, due to the introduction and widespread use of expensive biologic therapies.3. The rates of hospitalizations and major abdominal surgeries have been declining in IBD patients in Canada over the past two decades, possibly due to penetration of biologic therapies and advances in patient management paradigms.4. Inflammatory bowel disease patients cared for by gastroenterologists have better outcomes, including lower risks of surgery and hospitalization. Canadians who live in rural and underserviced areas are less likely to receive gastroenterologist care, potentially due to care preferences or poorer access, which may result in poorer long-term outcomes.5. Introduction of biosimilar agents at a lower price point than originator biologic therapies, increased gastroenterologist care of IBD patients, and improvements in IBD care paradigms may balance overall treatment costs while improving health outcomes and quality of life for IBD patients. However, in the long-term, direct costs of care may continue to increase, dictated by a rising IBD prevalence and increasing use of biologic therapies. Key Summary Points 1. The costs of health care for patients with IBD are more than double those without IBD.2. Prescription drug use accounts for 42% of total direct costs in IBD patients, and costs to treat IBD continue to rise due to increased use of existing biologic therapies and the introduction of several new biologic therapies in recent years.3. In Manitoba, the mean health care utilization and medication costs for persons with IBD in the year before beginning anti-TNF therapy was $10,206 and increased to $44,786 in the first year of therapy.4. Biosimilar agents to anti-TNF drugs are now entering the Canadian marketplace and may result in cost savings in patients using biologic agents to treat their IBD.5. Timely gastroenterologist care has been associated with reduced risks of requiring surgery and emergency care among ambulatory IBD patients and a reduced risk of death among hospitalized patients with ulcerative colitis.6. Inflammatory bowel disease care provided by gastroenterologists has increased over the past two decades. Even then, the average time from symptom onset to IBD diagnosis exceeds six months, and only one-third of IBD patients receive continuing care with a gastroenterologist during the first five years following diagnosis.7. Senior (age ≥65), rural-dwelling, and non-immigrant IBD patients have less frequent gastroenterologist care than other groups.8. About one in five adults with Crohn's disease and one in eight adults with ulcerative colitis are hospitalized in Ontario every year. Hospitalizations are most common during the first year following IBD diagnosis. Children with IBD (age <18) have the highest rates of hospitalizations and hospital re-admissions.9. In Canada, 16% of patients hospitalized for Crohn's disease undergo an intestinal resection, and 11% of patients hospitalized for ulcerative colitis undergo a colectomy during their initial hospitalization. Rates of intestinal resection and colectomy are declining in Canada in persons with Crohn's disease and ulcerative colitis, respectively.10. In Ontario, one-third of adult-onset Crohn's disease patients undergo intestinal resection within ten years of diagnosis. Among Canadian children with Crohn's disease, approximately one in fifteen children will require intestinal surgery within the first year of diagnosis, and up to one-third will require surgery within ten years of diagnosis.11. In Ontario, the ten-year colectomy risk following ulcerative colitis diagnosis is 13.3% among young persons and adults and 18.5% among individuals with senior-onset ulcerative colitis. In children with ulcerative colitis, the risk of colectomy is 4.8% to 6% in the first year following diagnosis and increases to 15% to 17% by ten years. Gaps in Knowledge and Future Directions 1. Forecasting models are necessary to predict the rising costs attributable to biologics associated with increasing prevalence of IBD, more frequent use of these medications, and the introduction of newer agents.2. Research into ways to minimize the escalating costs associated with increasing use of biologic therapies to treat IBD (and other chronic diseases) is necessary to ensure sustainability of our publicly funded health care system. Biosimilars offer an opportunity to drive down the cost of biologic therapies, and future research should assess the uptake of biosimilars as new biosimilars are introduced into the marketplace.3. Cost-utility models and budget impact analyses that integrate changes in direct costs (i.e., reduced hospitalizations and increased pharmaceutical costs) with indirect cost savings from improved quality of life are necessary to inform policy decisions.4. Research into ways to reduce IBD hospitalizations further through targeted outpatient interventions is equally important for health system sustainability and to improve patient quality of life.5. Research into reasons for reduced gastroenterologist care among rural and underserviced IBD residents would allow targeted interventions to improve specialist care and thereby improve patient health outcomes and quality of life.
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Affiliation(s)
- M Ellen Kuenzig
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario IBD Centre, Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Eric I Benchimol
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario IBD Centre, Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Lawrence Lee
- McGill University Health Centre (MUHC) IBD Centre, McGill University, Montreal, Quebec, Canada
| | - Laura E Targownik
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gilaad G Kaplan
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Charles N Bernstein
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,McGill University Health Centre (MUHC) IBD Centre, McGill University, Montreal, Quebec, Canada
| | - Geoffrey C Nguyen
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Mount Sinai Hospital Centre for IBD, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kate Lee
- Crohn's and Colitis Canada, Toronto, Ontario, Canada
| | | | - Sanjay K Murthy
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Carroll MW, Kuenzig ME, Mack DR, Otley AR, Griffiths AM, Kaplan GG, Bernstein CN, Bitton A, Murthy SK, Nguyen GC, Lee K, Cooke-Lauder J, Benchimol EI. The Impact of Inflammatory Bowel Disease in Canada 2018: Children and Adolescents with IBD. J Can Assoc Gastroenterol 2018; 2:S49-S67. [PMID: 31294385 PMCID: PMC6512244 DOI: 10.1093/jcag/gwy056] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/30/2018] [Indexed: 12/15/2022] Open
Abstract
Canada has among the highest rates of childhood-onset IBD in the world. Over 7000 children and youth under 18 years old are living with IBD in Canada, and 600 to 650 children under 16 years old are diagnosed annually. While the peak age of onset of IBD is highest in the second and third decades of life, over the past two decades incidence has risen most rapidly in children under 5 years old. The treatment of children with IBD presents important challenges including therapeutic choices, risk of adverse events to medications, psychosocial impact on the child and family, increased cost of health care and the implications of the transition from pediatric to adult care. Despite the unique circumstances faced by children and their families, there is a lack of research to help understand the causes of the rising incidence and the best therapies for children with IBD. Scientific evidence—and specifically clinical trials of pharmaceuticals—are too often extrapolated from adult research. Health care providers must strive to understand the unique impact of childhood-onset IBD on patients and families, while researchers must expand work to address the important needs of this growing patient population. Highlights Key Summary Points Gaps in Knowledge and Future Research Directions
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Affiliation(s)
- Matthew W Carroll
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - M Ellen Kuenzig
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,Children's Hospital of Eastern Ontario IBD Centre, Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - David R Mack
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,Children's Hospital of Eastern Ontario IBD Centre, Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Anthony R Otley
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,Division of Gastroenterology and Nutrition, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anne M Griffiths
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,SickKids IBD Centre, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Gilaad G Kaplan
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta Canada
| | - Charles N Bernstein
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,McGill IBD Centre of Excellence, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sanjay K Murthy
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,Ottawa Hospital Research Institute, Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey C Nguyen
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,Mount Sinai Hospital Centre for IBD, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kate Lee
- Crohn's and Colitis Canada, Toronto, Ontario, Canada
| | | | - Eric I Benchimol
- Canadian Gastro-Intestinal Epidemiology Consortium Ottawa, Canada.,Children's Hospital of Eastern Ontario IBD Centre, Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, de Carpi JM, Bronsky J, Veres G, Aloi M, Strisciuglio C, Braegger CP, Assa A, Romano C, Hussey S, Stanton M, Pakarinen M, de Ridder L, Katsanos K, Croft N, Navas-López V, Wilson DC, Lawrence S, Russell RK. Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:257-291. [PMID: 30044357 DOI: 10.1097/mpg.0000000000002035] [Citation(s) in RCA: 316] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with ∼20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points. METHODS These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate. RESULTS These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines. CONCLUSIONS These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modern management strategies while maintaining vigilance around appropriate outcomes and safety issues.
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Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | | | - Anne M Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Gabor Veres
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli," Napoli, Italy
| | | | - Amit Assa
- Schneider Children's Hospital, Petach Tikva, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Claudio Romano
- Pediatric Department, University of Messina, Messina, Italy
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland
| | | | - Mikko Pakarinen
- Helsinki University Children's Hospital, Department of Pediatric Surgery, Helsinki, Finland
| | - Lissy de Ridder
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Nick Croft
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Victor Navas-López
- Pediatric Gastroenterology and Nutrition Unit. Hospital Materno, IBIMA, Málaga, Spain
| | - David C Wilson
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Sally Lawrence
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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Rates and trends for inpatient surgeries in pediatric Crohn's disease in the United States from 2003 to 2012. J Pediatr Surg 2018; 53:1334-1338. [PMID: 29289343 DOI: 10.1016/j.jpedsurg.2017.11.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 11/15/2017] [Accepted: 11/26/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Pediatric Crohn's disease (CD) is increasing in incidence globally. Trends in specific types of inpatient pediatric CD-related surgical procedures have not been widely reported. METHODS Patients ≤20 years of age with CD were identified in the Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Bowel resection, stoma creation, and perianal or percutaneous drainage procedures were identified using ICD-9 procedure codes, and trends were identified. Logistic regression was used to identify factors associated with surgical intervention and trends. RESULTS Rates of overall bowel resection (including ileocolic resection, other small bowel resection, or other colon resection) did not change significantly over time. However, the odds of having a laparoscopic colon resection increased by 41% annually (p<0.001). Rates of subsequent ileostomy formation increased (odds ratio 1.09, p<0.001). Older age, male sex, fewer comorbidities, and treatment in large urban teaching hospitals were also associated with higher odds of undergoing bowel resection. CONCLUSIONS This study noted a stable rate of all types of bowel resections and increase in post resection ileostomy formation in US pediatric inpatients with CD from 2003-2012. Other rates of many CD-related procedures have remained stable. Further studies correlating the effects of biologic agents on surgical rates are warranted. TYPE OF STUDY Treatment Study LEVEL OF EVIDENCE: Level III.
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Nordenvall C, Rosvall O, Bottai M, Everhov ÅH, Malmborg P, Smedby KE, Ekbom A, Askling J, Ludvigsson JF, Myrelid P, Olén O. Surgical Treatment in Childhood-onset Inflammatory Bowel Disease-A Nationwide Register-based Study of 4695 Incident Patients in Sweden 2002-2014. J Crohns Colitis 2018; 12:157-166. [PMID: 29029152 DOI: 10.1093/ecco-jcc/jjx132] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/19/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS The incidence of childhood-onset [< 18 years] inflammatory bowel disease [IBD] is increasing worldwide, and some studies suggest that it represents a more severe disease phenotype. Few nationwide, population-based studies have evaluated the surgical burden in patients with childhood-onset IBD, and whether the improved medical treatment has influenced the need for gastrointestinal surgery. The aim was to examine whether the surgical treatment at any age of patients with childhood-onset IBD has changed over time. METHODS In a nationwide cohort study we identified 4695 children [< 18 years] diagnosed with incident IBD in 2002-2014 through the Swedish Patient Register [ulcerative colitis: n = 2295; Crohn's disease: n = 2174; inflammatory bowel disease-unclassified: n = 226]. Abdominal [intestinal resections and colectomies] and perianal surgeries were identified through the Swedish Patient Register. The cumulative incidences of surgeries were calculated using the Kaplan-Meier method. RESULTS In the cohort, 44% were females and 56% males. The median age at inflammatory bowel disease diagnosis was 15 years and the maximum age at end of follow-up was 31 years. The 3-year cumulative incidence of intestinal surgery was 5% in patients with ulcerative colitis and 7% in patients with Crohn's disease, and lower in children aged < 6 years at inflammatory bowel disease diagnosis [3%] than in those aged 15-17 years at diagnosis [7%]. Calendar period of inflammatory bowel disease diagnosis was not associated with risk of surgery. CONCLUSION Over the past 13 years, the risk of surgery in childhood-onset inflammatory bowel disease has remained unchanged.
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Affiliation(s)
- Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Center for Digestive Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Oda Rosvall
- Department of Clinical and Experimental Medicine, Linköping University, and Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Matteo Bottai
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Åsa H Everhov
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Petter Malmborg
- Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Karin E Smedby
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ekbom
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, and Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Ola Olén
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
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Nasiri S, Kuenzig ME, Benchimol EI. Long-term outcomes of pediatric inflammatory bowel disease. Semin Pediatr Surg 2017; 26:398-404. [PMID: 29126510 DOI: 10.1053/j.sempedsurg.2017.10.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The incidence and prevalence of childhood-onset inflammatory bowel diseases (IBD), including subtypes Crohn's disease and ulcerative colitis, have risen dramatically in recent years, and have emerged globally as important pediatric chronic diseases. Therefore, health care providers are more frequently encountering very young children with IBD, a chronic and incurable condition requiring life-long therapy. These children are living long lives with IBD and therefore knowledge of long-term outcomes is increasingly important to better counsel families and determine the best course of treatment. This review summarizes the current knowledge and literature surrounding long-term outcomes of pediatric IBD, with emphasis on the following areas: need for surgery due to complicated disease behavior, risk of disease remission and recurrence, mental health and psychosocial well-being, educational outcomes, linear growth impairment, cancer risk, and mortality. In addition, we review recent research about predicting negative long-term outcomes in children with IBD.
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Affiliation(s)
- Soheila Nasiri
- Division of Gastroenterology, Hepatology and Nutrition, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Canada K1H 8L1
| | - Mary Ellen Kuenzig
- Division of Gastroenterology, Hepatology and Nutrition, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Canada K1H 8L1; Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Canada; Institute for Clinical Evaluative Sciences, Ottawa, Canada
| | - Eric I Benchimol
- Division of Gastroenterology, Hepatology and Nutrition, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Canada K1H 8L1; Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Canada; Institute for Clinical Evaluative Sciences, Ottawa, Canada; Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
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Coughlan A, Wylde R, Lafferty L, Quinn S, Broderick A, Bourke B, Hussey S. A rising incidence and poorer male outcomes characterise early onset paediatric inflammatory bowel disease. Aliment Pharmacol Ther 2017; 45:1534-1541. [PMID: 28449214 DOI: 10.1111/apt.14070] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/11/2016] [Accepted: 03/10/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The incidence of paediatric inflammatory bowel disease diagnosed before age 10 years is reportedly increasing, but national data are limited. AIM To characterise the epidemiology, phenotype and clinical outcomes of children diagnosed with inflammatory bowel disease before age 10 years, and compare with data from children diagnosed aged 10-16 years. METHODS A review of all Irish cases of early onset inflammatory bowel disease (diagnosis <10 years, EO-IBD) presenting between January 2000 and December 2014 was undertaken and compared to a cohort of later onset paediatric inflammatory bowel disease patients (diagnosis between 10 and 16 years, LO-IBD). Diagnostic investigations, phenotype, treatments, and long-term clinical and surgical outcomes were analysed. RESULTS One hundred and ninety children (99 male) with EO-IBD were identified; 92 (48%) CD, 77 (41%) UC and 21 (11%) IBDU. The incidence of EO-IBD increased by 0.6 per 100 000 per year (0.8-3.2 per 100 000 per year), with a significant increase in UC by 0.06 per 100 000 per year (P=.02). Males with CD had more upper GI disease (L4a; 48% vs 21%; P=.007), more extensive disease distribution (L3±L4; 31% vs 11%; P=.05) and more severe disease activity at presentation (52% vs 31%; P=.05) than females. Fewer patients with early onset than later onset Crohn's disease had ileocolonic disease (L3; 10% vs 20%; P<.001). More relapses were observed in the first year post-diagnosis in early onset than later onset IBD (1.02 vs 0.5 mean relapses; P<.001). CONCLUSIONS EO-IBD is increasing in incidence. Males have more extensive and severe disease phenotypes, and younger patients have higher relapse rates than older children. Further research to explain these findings is warranted.
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Affiliation(s)
- A Coughlan
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,National Children's Research Centre, OLCHC, Crumlin, Dublin, Ireland
| | - R Wylde
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,Leiden University Medical Centre, Leiden, The Netherlands
| | - L Lafferty
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland
| | - S Quinn
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland
| | - A Broderick
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,Academic Centre for Paediatric Research, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - B Bourke
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,National Children's Research Centre, OLCHC, Crumlin, Dublin, Ireland.,Academic Centre for Paediatric Research, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - S Hussey
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,National Children's Research Centre, OLCHC, Crumlin, Dublin, Ireland.,Academic Centre for Paediatric Research, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons of Ireland, Dublin, Ireland
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- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,National Children's Research Centre, OLCHC, Crumlin, Dublin, Ireland
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Amil-Dias J, Kolacek S, Turner D, Pærregaard A, Rintala R, Afzal NA, Karolewska-Bochenek K, Bronsky J, Chong S, Fell J, Hojsak I, Hugot JP, Koletzko S, Kumar D, Lazowska-Przeorek I, Lillehei C, Lionetti P, Martin-de-Carpi J, Pakarinen M, Ruemmele FM, Shaoul R, Spray C, Staiano A, Sugarman I, Wilson DC, Winter H, Kolho KL. Surgical Management of Crohn Disease in Children: Guidelines From the Paediatric IBD Porto Group of ESPGHAN. J Pediatr Gastroenterol Nutr 2017; 64:818-835. [PMID: 28267075 DOI: 10.1097/mpg.0000000000001562] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.
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Affiliation(s)
- Jorge Amil-Dias
- *Department of Pediatrics, Centro Hospitalar, S. João, Porto, Portugal †Children's Hospital Zagreb, Faculty of Medicine, Zagreb, Croatia ‡The Juliet Keidan Institute of Pediatric Gastroenterology & Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel §Department of Pediatrics, Hvidovre University Hospital, Hvidovre, Denmark ||Pediatric Surgery, Children's Hospital, University of Helsinki, Helsinki, Finland ¶Department of Pediatric Gastroenterology, University Hospital Southampton, Southampton, UK #Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland **Department of Pediatrics, University Hospital Motol, Prague, Czech Republic ††Queen Mary's Hospital for Children, Epsom and St Helier NHS Trust, Surrey ‡‡Chelsea and Westminster Hospital, London, UK §§Paris-Diderot Sorbonne-Paris-Cité University and Robert Debré Hospital, Paris, France ||||Pediatric Gastroenterology and Hepatology, Dr. von Hauner Children's Hospital, Ludwig Maximilians-University, Munich, Germany ¶¶St George's, University of London, London, UK ##Boston Children's Hospital and Harvard Medical School, Boston, MA ***Department NEUROFARBA, University of Florence - Meyer Hospital, Florence, Italy †††Unit for the Comprehensive Care of Pediatric Inflammatory Bowel Disease, Hospital Sant Joan de Déu, Barcelona, Spain ‡‡‡Department of Pediatric Gastroenterology, Necker Enfants Malades University Hospital, Sorbonne Paris Cité University, Paris Descartes University, Institut IMAGINE - INSERM U1163, Paris, France §§§Pediatric Gastroenterology Institute, Ruth Children's Hospital, Rambam Medical Center, Haifa, Israel ||||||Department of Pediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, UK ¶¶¶Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II," Naples, Italy ###Department of Pediatric Surgery, Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK ****Child Life and Health, University of Edinburgh, Scotland, UK ††††MassGeneral Hospital for Children, Harvard Medical School, Boston, MA ‡‡‡‡Children's Hospital, University of Helsinki, Helsinki, Finland
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Duricova D, Fumery M, Annese V, Lakatos PL, Peyrin-Biroulet L, Gower-Rousseau C. The natural history of Crohn's disease in children: a review of population-based studies. Eur J Gastroenterol Hepatol 2017; 29:125-134. [PMID: 27748673 DOI: 10.1097/meg.0000000000000761] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The incidence of Crohn's disease (CD) has been reported to increase. The aim of this review is to perform a comprehensive literature search of population-based studies focused on the natural history of paediatric-onset CD. A literature search of English and non-English language publications listed in the electronic database of MEDLINE (source PUBMED) and EMBASE from 1935 to 2016 was performed. Population-based studies or national cohorts reporting data on the short-term or long-term disease course of paediatric CD were included. Forty-nine paediatric and 15 nonpaediatric studies on CD have been identified. Up to one-third of children with inflammatory behaviour developed bowel complications more than 5 years after diagnosis. From 48 to 88% of children have experienced at least one corticosteroid course irrespective of the period of diagnosis and up to one-third became steroid dependent. Immunosuppressive preparations were used earlier and more frequently in newer than older cohorts (68 vs. 32% at 5 years) and more than one-third of children have received biological treatment early in the disease course. A decline in the surgery rate might be observed in more recent compared with older unselected populations. The relative risk of cancer in childhood-onset CD as well as the risk of death seem to have increased. Childhood-onset CD seems to be an aggressive phenotype of the disease. Compared with older cohorts, a trend towards decreasing surgical rate can be observed in newer cohorts paralleled by an increase in immunomodulator use and biologicals. Nevertheless, the causative role has yet to be investigated.
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Affiliation(s)
- Dana Duricova
- aIBD Clinical and Research Centre, ISCARE bInstitute of Pharmacology, First Faculty of Medicine, Charles University, Prague, Czech Republic cEPICOM, European Crohn & Colitis Organisation dGastroenterology Unit, EPIMAD Registry, Amiens University Hospital, University of Picardie Jules Verne, Amiens eGastroenterology Unit, Inserm U954, Nancy University and Hospital, Nancy fPublic Health, Epidemiology and Economic Health, EPIMAD Registry, Maison Régionale de la Recherche Clinique, Centre Hospitalier Universitaire Régional gLille Inflammation Research International Center LIRIC - UMR 995 Inserm/Université Lille 2/CHRU de Lille; Equipe IBD and Environmental factors: Epidemiology and Functional Analyses, Lille University, Lille, France hDepartment of Emergency, Unit of Gastroenterology, AOU Careggi, Florence, Italy iFirst Department of Medicine, Semmelweis University, Budapest, Hungary
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Health Services Utilization, Specialist Care, and Time to Diagnosis with Inflammatory Bowel Disease in Immigrants to Ontario, Canada: A Population-Based Cohort Study. Inflamm Bowel Dis 2016; 22:2482-90. [PMID: 27556836 DOI: 10.1097/mib.0000000000000905] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Canada has amongst the highest incidence of inflammatory bowel disease (IBD) in the world, and the highest proportion of immigrants among G8 nations. We determined differences in prediagnosis delay, specialist care, health services use, and risk of surgery in immigrants with IBD. METHODS All incident cases of IBD in children (1994-2009) and adults (1999-2009) were identified from population-based health administrative data in Ontario, Canada. Linked immigration data identified those who arrived to Ontario after 1985. We compared time to diagnosis, postdiagnosis health services use (IBD specific and related), physician specialist care in immigrants and nonimmigrants, and risk of surgery between immigrants and nonimmigrants. RESULTS Thousand two hundred two immigrants were compared with 22,990 nonimmigrants. Immigrants had similar time to diagnosis as nonimmigrants for Crohn's (hazard ratio [HR] 1.002; 95% confidence intervals [CIs] 0.89-1.12) and ulcerative colitis (HR 1.073; 95% CI 0.95-1.21). For outpatient visits, immigrants with IBD were seen by gastroenterologists more often than nonimmigrants. Immigrants had greater IBD-specific outpatient health services use after diagnosis (odds ratio 1.24; 95% CI 1.15-1.33), emergency department visits (odds ratio 1.57, 95% CI 1.30-1.91), and hospitalizations (odds ratio 1.19; 95% CI 1.02-1.40). In immigrants, there was lower risk of surgery for Crohn's (HR 0.66, 95% CI 0.43-0.99) and ulcerative colitis (HR 0.52, 95% CI 0.31-0.87). CONCLUSIONS Immigrants to Canada had greater outpatient and specialty care and lower risk of surgery, with no delay in diagnosis, indicating appropriate use of the health system.
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Larsen MD, Qvist N, Nielsen J, Kjeldsen J, Nielsen RG, Nørgård BM. Use of Anti-TNFα Agents and Time to First-time Surgery in Paediatric Patients with Ulcerative Colitis and Crohn's Disease. J Crohns Colitis 2016; 10:650-656. [PMID: 26802081 DOI: 10.1093/ecco-jcc/jjw017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 12/18/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS It is debated whether the need for surgery has changed following introduction of anti-TNFα agents in the treatment of paediatric ulcerative colitis [UC] and Crohn's disease [CD]. We aimed to describe the implementation of anti-TNFα agents in paediatric patients, and the need of first-time surgery before and after introduction of anti-TNFα agents. METHODS In the Danish National Patient Registry, we identified incident paediatric patients diagnosed from 1998. We calculated the proportion of patients receiving anti-TNFα agents within 5 years from diagnosis, and the cumulative 5 year proportion of surgery, according to calendar periods of diagnosis. RESULTS At the end of our study period [2007 and 2008], 29-41% of CD children were treated with anti-TNFα agents within 5 years, and for UC children 17-19%. In 1278 CD patients, the 5 year cumulative proportions of surgery were 14.6-15.6% for children diagnosed in 1998-2008 and 9.7% (95% confidence interval [CI]: 6.7-13.7) for those diagnosed in 2009-2013. In 1468 UC patients, the cumulative proportion of surgery suggested a decline in patients diagnosed after mid 2005, and the hazard ratio of surgery was 0.64 [95% CI: 0.47-0.86] after the introduction of anti-TNFα agents compared with before. For UC patients diagnosed in 2009-2013, the 5 year cumulative proportion of surgery was 7.6% [95% CI: 5.2-11.2]. CONCLUSIONS This nationwide study showed an extensive use of anti-TNFα agents at the end of our study period. For UC children, our data suggest a decline in the proportion of surgery in the period of increasing use of anti-TNFα agents.
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Affiliation(s)
- Michael Due Larsen
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, DenmarkC
| | - Niels Qvist
- Department of Surgical Gastroenterology A, Odense University Hospital, and Research Unit of Surgery, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jan Nielsen
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, DenmarkC
| | - Jens Kjeldsen
- Department of Medical Gastroenterology S, Odense University Hospital, and Research Unit of Medical Gastroenterology, Institute of Clinical Research, University of Southern Denmark, Odense Denmark
| | - Rasmus Gaardskær Nielsen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, and Paediatric Research Unit, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, DenmarkC
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Fumery M, Duricova D, Gower-Rousseau C, Annese V, Peyrin-Biroulet L, Lakatos PL. Review article: the natural history of paediatric-onset ulcerative colitis in population-based studies. Aliment Pharmacol Ther 2016; 43:346-355. [PMID: 26582737 DOI: 10.1111/apt.13478] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 08/18/2015] [Accepted: 10/27/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND A better knowledge of the natural history of disabling chronic diseases is essential to improve patient management, evaluate the impact of treatment strategies and provide predictors for disabling disease and comprehensive information for patients. AIM To summarise our current knowledge issued from population-based studies of the natural history of ulcerative colitis (UC) in children. METHODS We searched MEDLINE (source PubMed) and international conference abstracts, and included all population-based studies that evaluated long-term outcome of paediatric-onset (<17 years at diagnosis) UC. RESULTS A total of 26 population-based studies were considered in this review from the total of 61 articles or abstracts screened. Most patients presented disease extension and about two-thirds of patients had pancolitis at the end of follow-up. One-half of patients experienced extra-intestinal manifestations and primary sclerosing cholangitis was observed in 5-10% of patients. Overall, patients did not appear to have any significant growth retardation or delayed puberty. About two-thirds of patients required corticosteroid therapy and up to 25% were steroid dependent. An increased use of thiopurines was observed and the most recent data indicate that up to one-half of patients were exposed to thiopurines and 10-30% were exposed to anti-tumour necrosis factor. One-half of patients required hospitalisations and 20% of patients required colectomy after a follow-up of 10 years. CONCLUSIONS Paediatric-onset UC is characterised by a high rate of disease extension. About 20% of patients had been operated at 10-year follow-up. New population-based studies are needed to evaluate the impact of new treatment strategies comprising immunosuppressants and biologics.
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Affiliation(s)
- M Fumery
- Gastroenterology Unit, Epimad Registry, Amiens University Hospital, Université de Picardie Jules Verne, Amiens, France
| | - D Duricova
- Department of Gastroenterology, Univerzity Karlovy, Prague, Czech Republic
- EPICOM, European Crohn & Colitis Organization, Vienna, Austria
| | - C Gower-Rousseau
- EPICOM, European Crohn & Colitis Organization, Vienna, Austria
- Public Health, Epidemiology and Economic Health, Epimad Registry, Maison Régionale de la Recherche Clinique, Centre Hospitalier Universitaire Régional, 59037, Lille Cedex, France
- Lille Inflammation Research International Center LIRIC - UMR 995 Inserm/Université Lille 2/CHRU de Lille, Equipe IBD and Environmental Factors: Epidemiology and Functional Analyses, Lille University, Lille, France
| | - V Annese
- EPICOM, European Crohn & Colitis Organization, Vienna, Austria
- Division of Gastroenterology, AOU Careggi Hospital, Florence, Italy
| | - L Peyrin-Biroulet
- Gastroenterology, Inserm U954, University Hospital of Nancy-Brabois, Université Henri Poincaré, Vandoeuvre-lès-Nancy, France
| | - P L Lakatos
- EPICOM, European Crohn & Colitis Organization, Vienna, Austria
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
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The Challenges of Living with Inflammatory Bowel Disease: Summary of a Summit on Patient and Healthcare Provider Perspectives. Can J Gastroenterol Hepatol 2016; 2016:9430942. [PMID: 27446878 PMCID: PMC4904659 DOI: 10.1155/2016/9430942] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 09/27/2015] [Indexed: 12/31/2022] Open
Abstract
Canada has one of the highest rates of inflammatory bowel disease (IBD) and the disease represents a significant health, social, and economic burden. There is currently no cure for IBD, although earlier diagnosis and new therapies have improved the overall health outcomes and quality of life for patients. Crohn's and Colitis Canada is Canada's only national, volunteer-based charity dedicated to finding cures for IBD and improving the lives of those affected, through research, education, patient programs, advocacy, and increased awareness. On April 30, 2015, Crohn's and Colitis Canada hosted the "Patient and Healthcare Professional Summit on the Burden of Disease in IBD" to obtain a deeper understanding of the unmet needs of IBD patients and their caregivers. Through personal vignettes, patients articulated a pressing need to increase understanding of the challenges faced by people suffering from IBD among both health care professionals and the general public, develop best practices for navigating life transitions and addressing the unique challenges faced by children with IBD, and provide equitable access to appropriate, effective, and affordable treatments. The recommendations that emerged from the summit will inform about efforts to increase public awareness, inform about advocacy strategies, and contribute to the development of research priorities.
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Cole R, Ashok D, Razack A, Azaz A, Sebastian S. Evaluation of Outcomes in Adolescent Inflammatory Bowel Disease Patients Following Transfer From Pediatric to Adult Health Care Services: Case for Transition. J Adolesc Health 2015; 57:212-217. [PMID: 26206442 DOI: 10.1016/j.jadohealth.2015.04.012] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 04/02/2015] [Accepted: 04/03/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE We aimed to evaluate the impact of a transition service on clinical and developmental outcomes in adolescent Inflammatory Bowel Disease (IBD) patients on transfer to adult health care services. METHODS We reviewed the records of IBD patients diagnosed in pediatric care following their transfer/attendance to the adult IBD service. The data on patients who attended the transition service were compared with those who did not pass through the transition service. RESULTS Seventy-two patients were included in the study 41M and 31F. Forty-four patients went through the transition system (Group A), and 28 had no formalized transition arrangement before transfer (Group B). A significantly higher number of Group B patients needed surgery within 2 years of transfer when compared with patients in Group A (46% vs. 25%, p = .01). Sixty-one percent of patients in Group B needed at least one admission within 2 years of transfer when compared with 29% of Group A patients (p = .002). Nonattendance at clinics was higher in Group B patients with 78% having at least one nonattendance, whereas 29% of Group A failed to attend at least one appointment (p = .001). In addition, drug compliance rates were higher in the transition group when compared with Group B (89% and 46%, respectively; p = .002). A higher proportion of transitioned patients achieved their estimated maximum growth potential when completing adolescence. There was a trend toward higher dependence on opiates and smoking in Group B patients. CONCLUSIONS In adolescent IBD patients, transition care is associated with better disease specific and developmental outcomes. Prospective studies of different models of transition care in IBD are needed.
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Affiliation(s)
- Rebecca Cole
- Hull & York Medical School, Hull, United Kingdom
| | - Dhandapani Ashok
- Department of Paediatric Gastroenterology, Hull & East Yorkshire NHS Trust, Hull, United Kingdom
| | - Abdul Razack
- Department of Radiology, Hull & East Yorkshire NHS Trust, Hull, United Kingdom
| | - Amer Azaz
- Department of Paediatric Gastroenterology, Hull & East Yorkshire NHS Trust, Hull, United Kingdom
| | - Shaji Sebastian
- Inflammatory Bowel Disease Unit, Hull & East Yorkshire NHS Trust, Hull, United Kingdom.
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Mattioli G, Barabino A, Aloi M, Arrigo S, Caldaro T, Carlucci M, Cucchiara S, De Angelis P, Di Leo G, Illiceto MT, Impellizzeri P, Leonelli L, Lisi G, Lombardi G, Martelossi S, Martinelli M, Miele E, Randazzo A, Romano C, Romeo C, Romeo E, Selvaggi F, Valenti S, Dall'Oglio L. Paediatric ulcerative colitis surgery: Italian survey. J Crohns Colitis 2015; 9:558-64. [PMID: 25895877 DOI: 10.1093/ecco-jcc/jjv065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 04/13/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Recent epidemiological studies showed an increase in ulcerative colitis among children, especially in its aggressive form, requiring surgical treatment. Although medical therapeutic strategies are standardized, there is still no consensus regarding indications, timing and kind of surgery. This study aimed to define the surgical management of paediatric ulcerative colitis and describe attitudes to it among paediatric surgeons. METHODS This was a retrospective cohort study. All national gastroenterology units were invited to participate. From January 2009 to December 2013, data on paediatric patients diagnosed with ulcerative colitis that required surgery were collected. RESULTS Seven units participated in the study. Seventy-one colectomies were performed (77.3% laparoscopically). Main surgical indications were a severe ulcerative colitis attack (33.8%) and no response to medical therapies (56.3%). A three-stage strategy was chosen in 71% of cases. Straight anastomosis was performed in 14% and J-pouch anastomosis in 86% of cases. A reconstructive laparoscopic approach was used in 58% of patients. Ileo-anal anastomosis was performed by the Knight-Griffen technique in 85.4% and by the pull-through technique in 9.1% of patients. Complications after colectomy, after reconstruction and after stoma closure were reported in 12.7, 19.3 and 35% of cases, respectively. CONCLUSIONS This study shows that there is general consensus regarding indications for surgery. The ideal surgical technique remains under debate. Laparoscopy is a procedure widely adopted for colectomy but its use in reconstructive surgery remains limited. Longer follow-up must be planned to define the quality of life of these patients.
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Affiliation(s)
- G Mattioli
- DINOGMI, University of Genova, Genova, Italy Pediatric Surgery Unit, G. Gaslini Children's Hospital-IRCCS, Genova, Italy
| | - A Barabino
- Pediatric Gastroenterology Unit, G. Gaslini Children's Hospital-IRCCS, Genova, Italy
| | - M Aloi
- Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - S Arrigo
- Pediatric Gastroenterology Unit, G. Gaslini Children's Hospital-IRCCS, Genova, Italy
| | - T Caldaro
- Surgery and Digestive Endoscopy Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - M Carlucci
- DINOGMI, University of Genova, Genova, Italy Pediatric Surgery Unit, G. Gaslini Children's Hospital-IRCCS, Genova, Italy
| | - S Cucchiara
- Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - P De Angelis
- Surgery and Digestive Endoscopy Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - G Di Leo
- Gastroenterology Unit, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - M T Illiceto
- Department of Pediatrics, Unit of Pediatric Gastroenterology and Digestive Endoscopy - Ospedale Civile Spirito Santo, Pescara, Italy
| | - P Impellizzeri
- Pediatric Surgery Unit, Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Messina, Italy
| | - L Leonelli
- DINOGMI, University of Genova, Genova, Italy Pediatric Surgery Unit, G. Gaslini Children's Hospital-IRCCS, Genova, Italy
| | - G Lisi
- Pediatric Surgery Unit, 'G. d'Annunzio' University of Chieti, Chieti Italy
| | - G Lombardi
- Department of Pediatrics, Unit of Pediatric Gastroenterology and Digestive Endoscopy - Ospedale Civile Spirito Santo, Pescara, Italy
| | - S Martelossi
- Gastroenterology Unit, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - M Martinelli
- Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II', Naples, Italy
| | - E Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II', Naples, Italy
| | - A Randazzo
- IBD Unit Pediatric Department,University of Messina, Messina, Italy
| | - C Romano
- IBD Unit Pediatric Department,University of Messina, Messina, Italy
| | - C Romeo
- Pediatric Surgery Unit, Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Messina, Italy
| | - E Romeo
- Surgery and Digestive Endoscopy Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - F Selvaggi
- Unit of General Surgery, University of Naples 'Fedrico II', Naples, Italy
| | - S Valenti
- IBD Unit Pediatric Department,University of Messina, Messina, Italy
| | - L Dall'Oglio
- Surgery and Digestive Endoscopy Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Singh H, Nugent Z, Targownik LE, El-Matary W, Brownell M, Bernstein CN. Health Care Use by a Population-Based Cohort of Children With Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2015; 13:1302-1309.e3. [PMID: 25638585 DOI: 10.1016/j.cgh.2015.01.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 11/18/2014] [Accepted: 01/09/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There have been few population-based studies of health care used by children with inflammatory bowel disease (IBD). METHODS We identified all children with IBD in the population-based University of Manitoba IBD Epidemiology Database; 651 children with IBD were matched for age, sex, and area of residence with 5950 children without IBD (controls), and followed up for a total of 6419 and 53,875 person-years, respectively. We extracted and analyzed data on IBD type (Crohn's disease vs ulcerative colitis), diagnosis before or after 2002 (era of diagnosis), age, sex, ambulatory care visits and hospitalizations before and after diagnosis, comorbidities, exposure to IBD drugs, and surgeries. RESULTS Children with IBD were more likely to have visits for gastrointestinal symptoms in each of the 4 years before IBD diagnosis than controls, with no significant effect of era of diagnosis. Children with IBD had more physician encounters for psychosocial diagnoses in the 6 months before or after the IBD diagnosis, as well as in the second year after IBD diagnosis, than controls; 56% of children with IBD were exposed to corticosteroids within the year after their diagnosis, with no decrease over eras of follow-up evaluation. Among children diagnosed from 2002 through 2010, the 8-year actuarial rate of colectomy for those with ulcerative colitis was 8%, and the rate of resective surgery for Crohn's disease was 10%; both of these values were lower than for children diagnosed from 1987 through 2001. CONCLUSIONS In a population-based study from Canada, children with IBD were more likely to have visits for gastrointestinal symptoms in each of the 4 years before IBD diagnosis than children without IBD, indicating a potential delay in diagnosis of this disease. Rates of surgery are decreasing among children with IBD.
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Affiliation(s)
- Harminder Singh
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Zoann Nugent
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; CancerCare Manitoba, Department of Epidemiology and Cancer Registry, Winnipeg, Manitoba, Canada
| | - Laura E Targownik
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Wael El-Matary
- Department of Paediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marni Brownell
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Takeuchi M, Tomomasa T, Yasunaga H, Horiguchi H, Fushimi K. Descriptive epidemiology of children hospitalized for inflammatory bowel disease in Japan: Inpatient database analysis. Pediatr Int 2015; 57:443-8. [PMID: 25442802 DOI: 10.1111/ped.12547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 10/09/2014] [Accepted: 11/14/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) - Crohn's disease (CD) and ulcerative colitis (UC) - are chronic inflammatory disorders of the intestine. Patients with IBD are at risk of hospitalization for disease exacerbation or IBD-associated complications. In the pediatric population, however, there are limited data on IBD hospitalizations. We therefore investigated the descriptive epidemiology of hospitalizations relevant to pediatric IBD. METHODS The national inpatient claims database in Japan was searched for children (≤ 18 years old) with a diagnosis of IBD. The study period was 2007-2010. Data on demographic characteristics and descriptive statistics of the hospital course were extracted and analyzed. RESULTS A total of 3559 admissions of 2175 patients met the definition of pediatric IBD: there were 1999 admissions for CD and 1560 admissions for UC. Internists were responsible for patient care in 56.6% of admissions, followed by pediatricians (27.5%). Of 3559 admissions, unscheduled hospitalizations accounted for 79.7%, and 7.6% of hospitalizations were attributable to complications of IBD, including intestinal, extraintestinal and other manifestations. The median age at first admission was 16 years (IQR, 13-17 years), in both the CD and UC groups. Compared with UC patients, CD patients had a higher number of hospitalizations (P < 0.001), but hospital stay was shorter (median: 6 vs 16 days, P < 0.001). There were seven fatal cases of IBD, accounting for 0.32% in the present series, and sepsis was the cause in five. CONCLUSIONS This study provides a description of pediatric inpatients with IBD and their hospital course in Japan.
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Affiliation(s)
- Masato Takeuchi
- Department of Pediatrics, University of Tokyo Hospital, Tokyo, Japan.,Department of Pediatrics, Kikkoman General Hospital, Chiba, Japan
| | | | - Hideo Yasunaga
- Department of Health Economics and Epidemiology Research, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Hiromasa Horiguchi
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, Tokyo, Japan
| | - Kiyohide Fushimi
- Health Policy and Informatics Section, Department of Health Policy, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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Duricova D, Burisch J, Jess T, Gower-Rousseau C, Lakatos PL. Age-related differences in presentation and course of inflammatory bowel disease: an update on the population-based literature. J Crohns Colitis 2014; 8:1351-1361. [PMID: 24951261 DOI: 10.1016/j.crohns.2014.05.006] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 05/08/2014] [Accepted: 05/25/2014] [Indexed: 02/08/2023]
Abstract
Current data indicate a change in the epidemiology of inflammatory bowel diseases. The disease has become more widespread and the rise in the incidence has been reported in all age groups including early childhood and according to recent data also the elderly population. Some earlier studies have suggested that the phenotype and natural history of the disease may be different according to age of onset. Recently the importance of age at onset was reported in two population-based studies from France and Hungary including both paediatric and adult onset inception cohorts. Early onset disease was associated with more frequent disease extension in both Crohn's disease and ulcerative colitis and in most but not all studies with higher frequency of complicated disease behaviour. This is also accompanied by striking differences in the medical management with earlier and more prevalent (2-3-fold) use of immunosuppressives and to some extent biologicals in patients with early compared to elderly-onset disease, especially in Crohn's disease. However, the results of population-based studies on impact of age on surgery rates in Crohn´s disease as well as ulcerative colitis are conflicting. Furthermore, published data indicate that relative but not absolute risk of developing cancer and mortality is higher in patients with an early onset disease. Critical reviews that focus on the importance of age at onset in inflammatory bowel disease are rare. Therefore, the aim of this review is to describe the differences in epidemiology, clinical characteristics, and natural history of paediatric and elderly-onset inflammatory bowel disease based on studies performed in general population.
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Affiliation(s)
- Dana Duricova
- Clinical and Research Center for Inflammatory Bowel Disease, ISCARE a.s. and Charles University in Prague, Czech Republic
| | - Johan Burisch
- Digestive Disease Centre, Medical Section, Herlev University Hospital, Copenhagen, Denmark
| | - Tine Jess
- Department of Epidemiology Research, Statens Serum Institut, National Center for Health Data and Disease Control, Copenhagen, Denmark
| | - Corinne Gower-Rousseau
- Epidemiogy Unit, Lille University and Hospital, Université Lille Nord de France, France.
| | - Peter L Lakatos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
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Kulungowski AM, Acker SN, Hoffenberg EJ, Neigut D, Partrick DA. Initial operative treatment of isolated ileal Crohn's disease in adolescents. Am J Surg 2014; 210:141-5. [PMID: 25457242 DOI: 10.1016/j.amjsurg.2014.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 06/20/2014] [Accepted: 07/16/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We hypothesize that in children with Crohn's disease (CD) isolated to a single site, resection leads to clinical improvement, decreased medication requirements, and improved growth. METHODS A retrospective review was conducted of children with CD isolated to the terminal ileum undergoing operative intervention at Children's Hospital Colorado between 2002 and 2013. RESULTS Twenty-six patients underwent ileocecetomy (mean age at diagnosis 14.1 ± 2.6 years; mean age at resection 15.7 ± 2.5 years; median follow-up 2 ± 1.5 years). Twenty-two (84.6%) patients reported clinical improvement and 17 (65.4%) were able to decrease the number or dosage of medications. Average weight increased from the 29th to the 45th percentile (P = .09) at 1 year and to the 56th percentile (P = .02) at 3 years post resection. Average body mass index increased from the 30th to the 48th and 49th percentile at 1 and 3 years (P < .05 for both), respectively. Height increased from the 39th percentile at the time of resection to the 51st percentile at 3 years (P = nonsignificant). CONCLUSION Surgical resection of an isolated ileal segment in adolescents with CD allows for catch-up growth and reduction in medication requirements.
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Affiliation(s)
- Ann M Kulungowski
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA.
| | - Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - Edward J Hoffenberg
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - Deborah Neigut
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA
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Benchimol EI, Mack DR, Nguyen GC, Snapper SB, Li W, Mojaverian N, Quach P, Muise AM. Incidence, outcomes, and health services burden of very early onset inflammatory bowel disease. Gastroenterology 2014; 147:803-813.e7; quiz e14-5. [PMID: 24951840 DOI: 10.1053/j.gastro.2014.06.023] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 05/20/2014] [Accepted: 06/09/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The Paris pediatric modification of the Montreal classification defines very early onset inflammatory bowel disease (VEO-IBD) as a form of IBD distinct from that of older children. We compared the incidence and outcomes of VEO-IBD with those of IBD in older children. METHODS We performed a population-based retrospective cohort study of all children diagnosed with IBD in Ontario, Canada, from 1994 through 2009. Trends in standardized incidence were calculated using Poisson regression. We compared outpatient and emergency department visits, hospitalizations, and surgeries among children diagnosed with IBD when they were younger than age 6, ages 6-9.9, and older than age 10 years. Multivariable models were adjusted for income and stratified by sex. RESULTS The incidence of IBD increased from 9.4 per 100,000 children (95% confidence interval [CI], 8.2-10.8/100,000 children) in 1994 to 13.2 per 100,000 children (95% CI, 11.9-14.6/100,000 children) in 2009 (P < .0001). The incidence increased by 7.4% per year among children younger than 6 years old and 6-9.9 years old, and by 2.2% per year among children ≥10 years old. IBD-related outpatient visits were less frequent among children <6 years old than ≥10 years old (odds ratio for female patients, 0.67; 95% CI, 0.58-0.78; odds ratio for male patients, 0.86; 95% CI, 0.75-0.98). Hazard ratios [HRs] for hospitalization were lower for children <6 years old (female HR, 0.70; 95% CI, 0.56-0.87; male HR, 1.12; 95% CI, 0.94-1.33) than for older children. HRs for surgery among children <6 years old with Crohn's disease were 0.35 for female patients (95% CI, 0.16-0.78) and 0.59 for male patients (95% CI, 0.34-0.99). HRs for children <6 years old with ulcerative colitis were 0.88 for female patients (95% CI, 0.47-1.63) and 0.42 for male patients (95% CI, 0.21-0.85). There was no difference in hospitalization or surgery rates among children 6-9.9 years old vs those ≥10 years old. CONCLUSIONS Based on a retrospective cohort study, the incidence of VEO-IBD increased from 1994 through 2009. Children diagnosed with IBD before they were 6 years old used fewer health services and had lower rates of surgery than children diagnosed when they were 10 years or older.
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Affiliation(s)
- Eric I Benchimol
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Canada; Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada.
| | - David R Mack
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Geoffrey C Nguyen
- Institute for Clinical Evaluative Sciences, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Mount Sinai Centre for Inflammatory Bowel Disease, Toronto, Canada
| | - Scott B Snapper
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Boston, Boston, Massachusetts; Department of Medicine, Harvard University, Boston, Massachusetts
| | - Wenbin Li
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | | | - Pauline Quach
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Aleixo M Muise
- Department of Paediatrics, University of Toronto, Toronto, Canada; SickKids Inflammatory Bowel Disease Center, Division of Gastroenterology Hepatology and Nutrition, Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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