RESUMEN
BACKGROUND: As an important quality measure, the rates of recommended immunizations among immunocompromised inflammatory bowel disease (IBD) patients in community practice have not been well studied. AIMS: This study sought to investigate the rates and predictors of recommended immunizations and screening tests among IBD patients receiving anti-tumor necrosis factor (TNF) therapy in a large integrated healthcare organization. METHODS: We conducted a retrospective cohort study of 1401 IBD patients on anti-TNF therapy between 2010 and 2013 within the Kaiser Permanente Northern California healthcare system. The rates of vaccinations and screening tests were quantified, and the associated predictors were investigated. RESULTS: Vaccination rates for influenza and pneumococcus were 43.5 and 24.1%, respectively. The majority of patients (73.7%) received hepatitis B screening and/or vaccine. Patients receiving infliximab had higher rates of pneumococcal vaccine (P = 0.002), hepatitis B screening (P < 0.001), and tuberculin skin test (P < 0.001) compared with patients receiving adalimumab. Older patient age (≥50 years) was associated with higher likelihood of having HBsAg test (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-2.0, P = 0.002), influenza vaccine (OR 2.6 [2.1-3.4], P < 0.001), and pneumococcal vaccine (OR 4.0 [3.0-5.3], P < 0.001). In contrast, older providers (≥50 years) were associated with significantly lower likelihood of their patients' having hepatitis A and B screening tests, and pneumococcal vaccination. CONCLUSIONS: The rates of immunizations for IBD patients receiving anti-TNF treatment were lower than recommended. Structured reminders for vaccinations and education for both patients and providers (older physicians in particular) may prove beneficial in improving immunization rates among immunocompromised IBD patients.
Asunto(s)
Adalimumab/uso terapéutico , Colitis Ulcerosa/tratamiento farmacológico , Enfermedad de Crohn/tratamiento farmacológico , Infliximab/uso terapéutico , Vacunación , Adolescente , Adulto , Anciano , Antiinflamatorios/uso terapéutico , Estudios de Cohortes , Fármacos Gastrointestinales/uso terapéutico , Humanos , Persona de Mediana Edad , Oportunidad Relativa , Estudios Retrospectivos , Vacunas/administración & dosificación , Adulto JovenRESUMEN
Objectives. To assess the relationship between infections and the risk of pediatric-onset inflammatory bowel disease (IBD). Methods. We conducted a nested case-control study of 501 incident cases aged ≤17 years and 9,442 controls who were members of Kaiser Permanente Northern California for at least one consecutive year between 1996 and 2006. IBD was confirmed and the incidence date was adjudicated by pediatric gastroenterologists. Hospitalized infections were identified from the principal diagnosis code of electronic inpatient records. Medications to treat infections were identified during the hospitalization. Conditional logistic regression was used to assess the associations between hospitalized infections, medications, and Crohn's disease and ulcerative colitis. Results. In the year prior to diagnosis, both hospitalized infection of any system (OR 6.3; 95% CI 1.6-23.9) and hospitalized intestinal infection (OR 19.4; 95% CI 2.6-143.2) were associated with CD. Hospitalized infections of any system were inversely associated with UC after excluding the year prior to diagnosis (OR 0.4; 95% CI 0.2-0.9). No UC case had a hospitalized gastrointestinal infection prior to diagnosis. Conclusion. Infections appear to play opposite roles prior to the diagnosis of CD and UC. Infections may be associated with an increased risk of CD and a decreased risk of UC.
RESUMEN
BACKGROUND: Current knowledge of racial disparities in healthcare utilization and disease outcomes for ulcerative colitis (UC) is limited. We sought to investigate these differences among Caucasian, African American, Asian, and Hispanic patients with ulcerative colitis in Kaiser Permanente, a large integrated health-care system in Northern California. METHODS: This retrospective cohort study used computerized clinical data from 5,196 Caucasians, 387 African-Americans, 550 Asians, and 801 Hispanics with prevalent UC identified between 1996 and 2007. Healthcare utilization and outcomes were compared at one and five-year follow-up by use of multivariate logistic regression analysis. RESULTS: Compared with whites, the male-to-female ratio differed for African-Americans (0.68 vs. 0.91, p < 0.01) and Asians (1.3 vs. 0.91, p < 0.01). Asians had fewer co-morbid conditions (p < 0.01) than whites, whereas more African-Americans had hypertension and asthma (p < 0.01). Use of immunomodulators did not differ significantly among race and/or ethnic groups. Among Asians, 5-ASA use was highest (p < 0.05) and the incidence of surgery was lowest (p < 0.01). Prolonged steroid exposure was more common among Hispanics (p < 0.05 at 1-year) who also had more UC-related surgery (p < 0.01 at 5-year) and hospitalization (<0.05 at 5-year), although these differences were not significant in multivariate analysis. CONCLUSIONS: In this population of UC patients with good access to care, overall health-care utilization patterns and clinical outcomes were similar across races and ethnicity. Asians may have milder disease than other races whereas Hispanics had a trend toward more aggressive disease, although the differences we observed were modest. These differences may be related to biological factors or different treatment preferences.
Asunto(s)
Asiático , Negro o Afroamericano , Colitis Ulcerosa/terapia , Prestación Integrada de Atención de Salud/estadística & datos numéricos , Conocimientos, Actitudes y Práctica en Salud/etnología , Sistemas Prepagos de Salud/estadística & datos numéricos , Recursos en Salud/estadística & datos numéricos , Hispánicos o Latinos , Población Blanca , Adolescente , Adulto , Negro o Afroamericano/estadística & datos numéricos , Asiático/estadística & datos numéricos , California/epidemiología , Niño , Preescolar , Colitis Ulcerosa/diagnóstico , Colitis Ulcerosa/etnología , Prestación Integrada de Atención de Salud/tendencias , Femenino , Sistemas Prepagos de Salud/tendencias , Recursos en Salud/tendencias , Disparidades en el Estado de Salud , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Sistema de Registros , Estudios Retrospectivos , Factores de Tiempo , Población Blanca/estadística & datos numéricos , Adulto JovenRESUMEN
BACKGROUND: The incidence of pediatric ulcerative colitis (UC), a chronic autoinflammatory disease of the colon, is on the rise. Although an increased infiltration of B cells from the peripheral blood into the colon occurs in UC, B-cell trafficking is understudied. We hypothesized that the frequency of circulating plasmablasts (PBs) and their trafficking receptor (TR) expression may be indicative of the location and degree of pathology in pediatric UC. METHODS: We conducted multicolor flow cytometry analyses of circulating IgA(+/-) PBs and IgA(+) memory B cells (MBCs) in pediatric UC patients with remission, mild, moderate, and severe state of disease (n = 12), and healthy pediatric (n = 2) and adult donors (n = 11). RESULTS: Compared to healthy donors the average frequency of PBs among total peripheral blood lymphocytes is increased 30-fold during severe UC activity, and positively correlates with Pediatric Ulcerative Colitis Activity Index score, C-reactive protein level, and erythrocyte sedimentation rate. A greater percent of PBs in severe patients express the gut-homing receptors α4ß7 and CCR10, and the inflammatory homing molecule P-selectin ligand (P-sel lig). The percent of IgA(+) MBCs expressing α4ß7, however, is reduced. Furthermore, expression of the small intestine TR CCR9 is decreased on α4ß7(high) PBs, and on α4ß7(high) /CCR10(high) PBs and MBCs in these patients, consistent with preferential cell targeting to the colon. CONCLUSIONS: Peripheral blood PBs with a colon-homing phenotype (α4ß7/CCR10/P-sel lig) are elevated in children with severe UC. Screening this B-cell subset may provide a complementary approach in monitoring disease activity or therapeutic efficacy in pediatric UC.
Asunto(s)
Colitis Ulcerosa/metabolismo , Células Plasmáticas/fisiología , Receptores Mensajeros de Linfocitos/metabolismo , Adolescente , Adulto , Subgrupos de Linfocitos B/fisiología , Proteína C-Reactiva/análisis , Estudios de Casos y Controles , Niño , Colitis Ulcerosa/inmunología , Femenino , Citometría de Flujo , Humanos , Recuento de Linfocitos , Masculino , Persona de Mediana Edad , Receptores Mensajeros de Linfocitos/fisiología , Índice de Severidad de la Enfermedad , Adulto JovenRESUMEN
BACKGROUND: The majority of studies that report early life risk factors for pediatric-onset inflammatory bowel disease (IBD) do not account for potential confounding, which can lead to spurious associations and incorrect inferences. AIMS: To assess the relationship between prenatal and perinatal characteristics and the risk of pediatric-onset IBD accounting for potential confounding. METHODS: We conducted a nested case-control study of 189 cases aged ≤18 years and 3,080 age- and membership-matched controls born at a Kaiser Permanente Northern California facility between 1984 and 2006. The cases were diagnosed with IBD between 1996 and 2006 and diagnosis was confirmed by chart review. We obtained prenatal and perinatal characteristics from the electronic clinical records of the mother and child. Conditional logistic regression was used to assess the associations between these factors and risk of incident IBD, Crohn's disease, and ulcerative colitis. RESULTS: In analyses accounting for confounding, maternal IBD (odds ratio [OR] 5.1, 95 % confidence interval [CI] 2.0-12.9) and white race (OR 2.3, 95 % CI 1.6-3.2) were the only factors statistically associated with pediatric-onset IBD. Maternal respiratory infection during pregnancy (OR 2.0, 95 % CI 1.0-4.0), age < 20 years (OR 2.0, 95 % CI 0.8-4.7) and gestational hypertension (OR 1.7, 95 % CI 1.0-2.7) were associated with pediatric-onset IBD, but did not achieve statistical significance. CONCLUSIONS: Maternal history of IBD and race were the only characteristics of those that we examined that were associated with the development of pediatric IBD in this well-documented population of cases and matched controls.
Asunto(s)
Enfermedades Inflamatorias del Intestino/epidemiología , Complicaciones del Embarazo/epidemiología , Efectos Tardíos de la Exposición Prenatal/epidemiología , Adolescente , Adulto , California/epidemiología , Estudios de Casos y Controles , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Embarazo , Estudios Retrospectivos , Población Blanca , Adulto JovenRESUMEN
BACKGROUND: Hepatosplenic T-cell lymphoma (HSTCL), a rare and rapidly progressive subtype of peripheral T-cell lymphoma, has been reported following TNF-α-blocker therapy. To better understand this relationship, we conducted an epidemiologic study in the Kaiser Permanente membership. METHODS: The retrospective cohort study was conducted among Northern California members of all ages. The Kaiser Permanente Cancer Registry, supplemented with review of medical charts and pathology slides, was used to identify and confirm cases of HSTCL. Medical histories were obtained, and we computed the standardized incidence rate for the 7-year period 2000-2006, when immunohistochemical staining was fully established throughout the health plan for diagnosing lymphoma. RESULTS: Six cases were diagnosed during 2000-2006, for an annual age-standardized incidence rate of 0.3 (95%CI, 0.11-0.65) per million person-years. One case had a prior diagnosis of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS); another had a prior diagnosis of Crohn's disease treated with steroids, thiopurine and infliximab. CONCLUSION: Prior cases of HIV/AIDS-linked HSTCL are uncommon in the existing literature. Multiple case reports of HSTCL in the setting of Crohn's disease treated with anti-TNF plus thiopurine have been published, but HSTCL is rare, making epidemiologic assessments difficult.
Asunto(s)
Neoplasias Hepáticas/epidemiología , Linfoma de Células T Periférico/epidemiología , Neoplasias del Bazo/epidemiología , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Adulto , Anciano , California/epidemiología , Estudios de Cohortes , Enfermedad de Crohn/tratamiento farmacológico , Enfermedad de Crohn/epidemiología , Femenino , Infecciones por VIH/epidemiología , Humanos , Incidencia , Neoplasias Hepáticas/etiología , Neoplasias Hepáticas/patología , Linfoma de Células T Periférico/etiología , Linfoma de Células T Periférico/patología , Masculino , Programas Controlados de Atención en Salud/estadística & datos numéricos , Persona de Mediana Edad , Estudios Retrospectivos , Neoplasias del Bazo/etiología , Neoplasias del Bazo/patología , Adulto JovenRESUMEN
BACKGROUND & AIMS: The absence of grade A supporting evidence for surveillance colonoscopy in patients with ulcerative colitis (UC) has led to controversy regarding its benefit, yet it is routinely recommended in practice guidelines. Limited data are available on rates of colonoscopy surveillance and factors associated with surveillance. METHODS: A retrospective study of UC patients receiving care between 2006 and 2007 with ≥ 8 years history of UC was conducted. Primary outcome was the proportion of patients who underwent surveillance during this 2-year study period. Sociodemographic and disease factors were identified a priori from variables recorded electronically in the medical record; multivariable associations with surveillance were estimated using logistic regression. RESULTS: Of 771 patients with ≥ 8 years history of UC, 24.6% of patients underwent at least 1 surveillance colonoscopy within the 2-year study period, with a maximum of 38.5% observed among patients with primary sclerosing cholangitis. In a multivariable analysis, gender, age, race, and education were not associated with surveillance. Factors associated with increasing surveillance included lack of significant comorbidity (Charlson-Deyo index 0 vs 1+: odds ratio [OR], 1.7; 95% confidence interval: 1.1-2.5), > 3 inflammatory bowel disease-related outpatient visits (OR, 2.0; 95% CI: 1.4-3.0), and use of mesalamine (OR, 2.8; 95% CI: 1.7-4.4). CONCLUSIONS: Utilization of surveillance colonoscopy in a 2-year period was low, even among high-risk patients. Although specific factors recorded in computerized data were identified to be associated with surveillance, a greater understanding of how patients and physicians decide on surveillance is needed.
Asunto(s)
Colitis Ulcerosa/epidemiología , Neoplasias Colorrectales/epidemiología , Prestación Integrada de Atención de Salud/métodos , Tamizaje Masivo/métodos , California/epidemiología , Colitis Ulcerosa/complicaciones , Colitis Ulcerosa/diagnóstico , Colonoscopía/métodos , Neoplasias Colorrectales/complicaciones , Neoplasias Colorrectales/diagnóstico , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Pronóstico , Estudios RetrospectivosRESUMEN
OBJECTIVE: To examine the incidence and prevalence of pediatric inflammatory bowel disease (IBD) during 1996-2006 in a community-based health-care delivery system. STUDY DESIGN: Members of Kaiser Permanente Northern California aged 0 to 17 years with IBD were identified by use of computerized medical information with confirmation obtained through review of the medical record. RESULTS: The average annual incidence of IBD per 100000 was 2.7 (95% confidence interval [CI], 2.3-3.1) for Crohn's disease (CD) and 3.2 (CI, 2.8-3.6) for ulcerative colitis (UC). During the 11-year study period, the annual incidence per 100000 increased from 2.2 to 4.3 for CD (P = .09) and from 1.8 to 4.9 for UC (P < .001). The ratio of incident CD cases to incident UC cases was 0.9 in non-Hispanic whites, 1.6 in African Americans (P = .12), 0.3 in Hispanics (P < .001) and 0.4 in Asians (P = .04). The average length of enrollment during the 11-year study period exceeded 8 years. The point prevalence on December 31, 2006, per 100000 was 12.0 for CD (CI, 9.6-14.4) and 19.5 (CI, 16.5-22.6) for UC. CONCLUSIONS: In this population the incidence of UC increased significantly by 2.7-fold and CD increased 2.0-fold without reaching statistical significance. Hispanic and Asian children had development of UC more often than CD, suggesting possible etiologic differences across racial and ethnic groups.
Asunto(s)
Colitis Ulcerosa/diagnóstico , Colitis Ulcerosa/epidemiología , Enfermedad de Crohn/diagnóstico , Enfermedad de Crohn/epidemiología , Adolescente , California , Niño , Preescolar , Servicios de Salud Comunitaria/estadística & datos numéricos , Etnicidad , Gastroenterología/métodos , Humanos , Incidencia , Lactante , Recién Nacido , Enfermedades Inflamatorias del Intestino/diagnóstico , Enfermedades Inflamatorias del Intestino/epidemiología , Pediatría/métodos , PrevalenciaRESUMEN
BACKGROUND: The development of disease complications is poorly characterized in pediatric patients with Crohn's disease (CD). METHODS: We retrospectively determined the cumulative incidence of stricturing and penetrating complications of CD prior to first surgery utilizing data from 989 consecutively enrolled CD patients (age 0-17 years at diagnosis) collected between January 2000 and November 2003 and stored in the Pediatric IBD Consortium Registry. RESULTS: Mean age at diagnosis was 11.5 +/- 3.8 (standard deviation) years. Median follow-up time was 2.8 years. Prior to first surgery, the cumulative incidence of stricturing or penetrating complications was 27% at 5 years and 38% at 10 years from the diagnosis of inflammatory bowel disease. The cumulative incidence of complicated disease was lowest in isolated colonic disease (P = 0.009). Penetrating complications that followed stricturing complications prior to first surgery occurred within 2 years of stricturing complications (cumulative incidence was 13% at 2 years from diagnosis of stricturing disease). Stricturing complications that followed penetrating complications prior to first surgery occurred within 8 years of penetrating complications (cumulative incidence was 26% at 8 years from diagnosis of penetrating complications). CONCLUSIONS: Strictures, abscesses, and fistulas are common in pediatric CD. Earlier aggressive management may be indicated. Prospective study is required to identify genetic and serologic markers that predict a patient's risk for the development of complicated disease and to determine optimal treatment regimens.
Asunto(s)
Colitis Ulcerosa/complicaciones , Enfermedad de Crohn/complicaciones , Mucosa Intestinal/patología , Complicaciones Posoperatorias , Adolescente , Niño , Preescolar , Colitis Ulcerosa/diagnóstico , Colitis Ulcerosa/cirugía , Constricción Patológica , Enfermedad de Crohn/diagnóstico , Enfermedad de Crohn/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Lactante , Fístula Intestinal/etiología , Obstrucción Intestinal , Masculino , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
BACKGROUND & AIMS: Thiopurines (azathioprine and 6-mercaptopurine) can induce life-threatening myelosuppression. This study determined the frequency, timing, and outcomes of mild and severe myelosuppression after initiation of thiopurine therapy. METHODS: This retrospective cohort study included patients with inflammatory bowel disease who were new users of thiopurines; those tested for thiopurine methyltransferase levels before therapy were excluded. Patients were followed from their first thiopurine prescription until the earliest of severe leukopenia (white blood cell count, <1.0 x 10(9)/L), severe thrombocytopenia (platelet level, <20 x 10(9)/L), the end of therapy, the first gap in therapy, disenrollment, or December 31, 2006. RESULTS: Among 1997 new users, the incidence of severe leukopenia per 100 person-months was 0.16 (95% confidence interval [CI], 0.03-0.29; n = 6) in weeks 0 to 8, 0.00 in weeks 9 to 24, and 0.01 (95% CI, 0-0.03; n = 3) after week 26 of therapy. The incidence of severe neutropenia and severe thrombocytopenia per 100 person-months during the first 8 weeks of therapy was 0.51 (95% CI, 0.31-0.80; n = 19) and 0.08 (95% CI, 0.02-0.23; n = 3), respectively. During the first 8 weeks, the median duration from a normal white blood cell count to severe leukopenia was 13 days (range, 8-26 d) and to severe neutropenia was 14 days (range, 7-23 d). CONCLUSIONS: The high incidence of severe myelosuppression justifies frequent monitoring during the first 8 weeks of therapy. Subsequently, the rate of severe myelosuppression and the proportion of patients who progress from mild to severe myelosuppression decrease, justifying less-frequent monitoring.
Asunto(s)
Antimetabolitos/uso terapéutico , Azatioprina/uso terapéutico , Médula Ósea/efectos de los fármacos , Enfermedades Inflamatorias del Intestino/tratamiento farmacológico , Leucopenia/inducido químicamente , Mercaptopurina/uso terapéutico , Trombocitopenia/inducido químicamente , Adulto , Anciano , Antimetabolitos/efectos adversos , Estudios de Cohortes , Monitoreo de Drogas/métodos , Femenino , Humanos , Estudios Longitudinales , Masculino , Mercaptopurina/efectos adversos , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND & AIMS: The management of inflammatory bowel disease (IBD) has become increasingly complicated, and it is unknown whether poor outcomes (prolonged steroid use, hospitalizations, and surgery) have declined in the general population. METHODS: This multilevel study used computerized clinical data. The study comprised 2892 adults with Crohn's disease (CD) and 5895 with ulcerative colitis (UC) who received care at 16 medical centers within an integrated care organization in Northern California between 1998 and 2005. RESULTS: Time trends included (1) a shift in gastroenterology-related visits from the gastroenterology division to primary care; (2) increased use of IBD-related drugs, except for a 7% decline in use of 5-aminosalicylate in CD and no change in steroid use for CD; (3) for the prevalence of prolonged steroid exposure (120 days of continuous use), a 36% decline for CD with a 27% increase for UC; (4) declines in the hospitalization rates of 33% for CD and 29% for UC; and (5) for the surgery rate, no significant change for CD with a 50% decline for UC. CONCLUSIONS: Declines in prolonged steroid exposure and the hospitalization rate for CD and in the hospitalization and surgery rate for UC are encouraging; however, the increase in prolonged steroid exposure for UC merits concern and further investigation. The variability in care patterns observed in this study suggests lack of standardization of care and the opportunity to identify targets for quality improvement. These findings should stimulate research to quantify the effect of current trends in IBD management.
Asunto(s)
Colitis Ulcerosa/mortalidad , Colitis Ulcerosa/terapia , Enfermedad de Crohn/mortalidad , Enfermedad de Crohn/terapia , Adolescente , Corticoesteroides/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , California , Colitis Ulcerosa/diagnóstico , Terapia Combinada , Intervalos de Confianza , Enfermedad de Crohn/diagnóstico , Estudios Transversales , Prestación Integrada de Atención de Salud/tendencias , Procedimientos Quirúrgicos del Sistema Digestivo/tendencias , Femenino , Estudios de Seguimiento , Humanos , Inmunosupresores/uso terapéutico , Enfermedades Inflamatorias del Intestino/diagnóstico , Enfermedades Inflamatorias del Intestino/mortalidad , Enfermedades Inflamatorias del Intestino/terapia , Clasificación Internacional de Enfermedades , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Probabilidad , Sistema de Registros , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Extraintestinal manifestations (EIMs) in pediatric patients with inflammatory bowel disease (IBD) are poorly characterized. We examined the prevalence of EIMs at diagnosis, subsequent incidence, and risk factors for EIMs. METHODS: Data for 1649 patients from the PediIBD Consortium Registry, diagnosed with IBD before 18 years of age (1007 [61%] with Crohn's disease, 471 [29%] with ulcerative colitis, and 171 [10%] with indeterminate colitis), were analyzed using logistic regression, Kaplan-Meier, log rank tests, and Cox models. RESULTS: EIMs were reported prior to IBD diagnosis in 97 of 1649 patients (6%). Older children at diagnosis had higher rates compared with younger children, and arthritis (26%) and aphthous stomatitis (21%) were most common. Among the 1552 patients without EIM at diagnosis, 290 developed at least 1 EIM. Kaplan-Meier estimates of cumulative incidence were 9% at 1 year, 19% at 5 years, and 29% at 15 years after diagnosis. Incidence did not differ by IBD type (P = 0.20), age at diagnosis (P = 0.22), or race/ethnicity (P = 0.24). Arthritis (17%) and osteopenia/osteoporosis (15%) were the most common EIMs after IBD diagnosis. CONCLUSIONS: In our large cohort of pediatric IBD patients, 6% had at least 1 EIM before diagnosis of IBD. At least 1 EIM will develop in 29% within 15 years of diagnosis. The incidence of EIMs both before and after diagnosis of IBD differs by type of EIM and may be slightly higher in girls, but is independent of the type of IBD, age at diagnosis, and race/ethnicity.
Asunto(s)
Artritis/etiología , Colitis Ulcerosa/complicaciones , Enfermedad de Crohn/complicaciones , Estomatitis Aftosa/etiología , Adolescente , Artritis/patología , Niño , Preescolar , Estudios de Cohortes , Colitis Ulcerosa/diagnóstico , Enfermedad de Crohn/diagnóstico , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Estudios Prospectivos , Estudios Retrospectivos , Estomatitis Aftosa/patologíaRESUMEN
BACKGROUND: The relationship between the age at diagnosis and disease course is poorly defined in children with Crohn's disease (CD). We examined the presentation and course of disease in patients 0-5 compared to 6-17 yr of age at diagnosis. METHODS: We analyzed uniform data from 989 consecutive CD patients collected between January 2000 and November 2003, and stored in the Pediatric IBD Consortium Registry. The statistical tests account for the length of follow-up of each patient. RESULTS: In total, 98 patients (9.9%) were of 0-5 yr of age at diagnosis. The mean follow-up time was 5.6 +/- 5.0 yr in the younger group and 3.3 +/- 2.8 yr in the older group (P < 0.001). Race/ethnicity differed by the age group (P= 0.015); a larger proportion of the younger group was Asian/Pacific Islander or Hispanic, and a larger proportion of the older group was African American. The initial classification as ulcerative colitis or indeterminate colitis was more common among the 0-5 yr of age group (P < 0.001). The 6-17 yr of age patients presented with more abdominal pain (P < 0.001), weight loss (P= 0.001), or fever (P= 0.07), while the 0-5 yr of age patients presented with more rectal bleeding (P= 0.008). The 6-17 yr of age patients were more likely to be treated with antibiotics (P < 0.001), 6-mercaptopurine/azathioprine (P < 0.001), infliximab (P= 0.001), or corticosteroids (P= 0.0006). The 6-17 yr of age patients had a higher cumulative incidence of treatment with 5-aminosalicylates (P= 0.009) or methotrexate (P= 0.04). The risk for developing an abscess (P= 0.001), a fistula (P= 0.02), a stricture (P= 0.05), or a perianal fissure (P= 0.06) was greater in the 6-17 yr of age patients. CONCLUSIONS: The 6-17 yr of age patients with CD appear to have a more complicated disease course compared to 0-5 yr of age children. The 0-5 yr of age group may represent a unique disease phenotype and benefit from different approaches to management. Long-term prospective studies are required to validate these findings.
Asunto(s)
Enfermedad de Crohn/epidemiología , Adolescente , Edad de Inicio , Niño , Preescolar , Estudios de Cohortes , Enfermedad de Crohn/complicaciones , Enfermedad de Crohn/diagnóstico , Progresión de la Enfermedad , Femenino , Humanos , Lactante , Masculino , Sistema de Registros , Factores de Riesgo , Índice de Severidad de la Enfermedad , Estados UnidosRESUMEN
BACKGROUND: Information on infliximab use in a community setting is important to understand patterns of medication use and to anticipate and plan for costs associated with the drug. We sought to understand predictors of initiation and discontinuation of infliximab in the community-based setting of Kaiser Permanente, Northern California, which provides integrated care to its members. METHODS: The cohort study was set during 1998-2006. Predictors of initiation were assessed among 494 Crohn's disease (CD) patients who initiated infliximab and 2470 CD patients who did not initiate infliximab (controls). Data were obtained through linkage of computerized clinical information and were analyzed using logistic regression and Cox survival analysis. RESULTS: Infliximab infusions have increased rapidly since 2001, with no evidence of leveling off. Initiators were appreciably younger than controls (P < 0.001), but were similar to controls with respect to sex and race/ethnicity. The presence of at least 1 comorbidity was related to a modest increase in the risk of initiating (compared with none: 1 comorbidity, odds ratio [OR] = 1.52 with 95% confidence interval [CI] 1.16-2.00; 2 comorbidities, OR = 1.38 with CI 0.89-2.13). By 3 years after initiating, only 20% of patients remained on infliximab. CONCLUSIONS: In a community-based setting infliximab use has steadily increased. Age and comorbidity are associated with initiation, but sex and race/ethnicity are not. More information is needed to determine why, in this community-based setting, a large number of patients on infliximab discontinued their treatment.(Inflamm Bowel Dis 2008).
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Enfermedad de Crohn/tratamiento farmacológico , Fármacos Gastrointestinales/uso terapéutico , Adolescente , Adulto , California/epidemiología , Niño , Preescolar , Estudios de Cohortes , Enfermedad de Crohn/diagnóstico , Enfermedad de Crohn/epidemiología , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Lactante , Recién Nacido , Infliximab , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Resultado del TratamientoRESUMEN
OBJECTIVE: The objective of this study was to determine gender differences in pediatric patients with Crohn disease. METHODS: We conducted a retrospective cohort study of 989 consecutive pediatric patients (566 boys, 423 girls) who had Crohn disease (aged 0 to 17 years at diagnosis) by using the Pediatric IBD Consortium Registry. Uniform data were analyzed to compare the presentation and course of disease according to gender. RESULTS: Median follow-up time was 2.8 years. Mean +/- SD age at diagnosis of inflammatory bowel disease (11.5 +/- 3.8 years) did not differ by gender. Compared with boys, girls had a higher prevalence of mouth sores at symptom onset and a higher prevalence of hypoalbuminemia at the time of diagnosis. Location of disease did not differ by gender. A higher proportion of girls had abnormal anti-outer membrane porin of Escherichia coli levels compared with boys. Girls were at increased risk for erythema nodosum/pyoderma gangrenosum and decreased risk for growth failure compared with boys. CONCLUSIONS: Girls appear to have an overall more severe course of disease; however, boys are at increased risk for developing growth failure. Disease course and the impact of disease severity on growth according to gender in pediatric Crohn disease require prospective study.
Asunto(s)
Enfermedad de Crohn/diagnóstico , Adolescente , Niño , Preescolar , Estudios de Cohortes , Enfermedad de Crohn/complicaciones , Enfermedad de Crohn/terapia , Femenino , Humanos , Lactante , Masculino , Estudios Retrospectivos , Caracteres SexualesRESUMEN
BACKGROUND & AIMS: The cumulative incidence of surgery ranges from 40%-70% at 10 years from the time of diagnosis of Crohn's disease in adults. We retrospectively determined the cumulative incidence of and risk factors for surgery (intestinal resection) in pediatric patients with Crohn's disease. METHODS: Uniform data from 989 consecutive Crohn's disease patients (age 0-17 years at diagnosis), collected from 6 different pediatric centers between January 2000 and November 2003 and stored in the Pediatric IBD Consortium Registry, were analyzed. RESULTS: Median follow-up time was 2.8 years (range, 1 day to 16.7 years). One hundred twenty-eight patients underwent surgery. Kaplan-Meier survival estimates of the cumulative incidence of surgery were 17% at 5 years and 28% at 10 years from the diagnosis of inflammatory bowel disease. Univariate Cox proportional hazards models showed leukocytosis (2.85 [hazard ratio]; P = .02), hypoalbuminemia (3.41; P = .05), and anti-Saccharomyces cerevisiae antibody (ASCA) positivity (3.43; P = .05) were associated with increased risk for surgery. Multivariate Cox models showed female gender (1.49; P = .03), initial diagnosis of ulcerative colitis (3.63; P < .0001), poor growth at presentation (2.16; P = .007), and abscess (1.90; P = .009), fistula (2.30; P = .0005), or stricture (3.41; P < .0001) development were associated with increased risk for surgery. Age 3-5 years (0.26; P = .01) or 6-12 years (0.62; P = .01) at diagnosis, fever at presentation (0.50; P = .03), and treatment with infliximab (0.36; P = .0005) or 5-aminosalicylic acid (0.44; P < .0001) were associated with decreased risk for surgery. CONCLUSIONS: Risk stratification during the course of Crohn's disease in pediatric patients will help to guide therapy that may improve the natural history of disease and decrease the need for surgery.
Asunto(s)
Enfermedad de Crohn/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo , Adolescente , Negro o Afroamericano , Niño , Preescolar , Estudios de Cohortes , Enfermedad de Crohn/complicaciones , Enfermedad de Crohn/etnología , Enfermedad de Crohn/fisiopatología , Procedimientos Quirúrgicos del Sistema Digestivo/estadística & datos numéricos , Femenino , Fármacos Gastrointestinales/uso terapéutico , Granuloma/complicaciones , Hispánicos o Latinos , Humanos , Lactante , Enfermedades Intestinales/complicaciones , Masculino , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Población BlancaRESUMEN
The ultimate goal in antibiotic treatment of acute otitis media (AOM) is eradication of the pathogens from the middle ear fluid (MEF). To test the ability of an antibiotic to achieve this goal, the best available method is to obtain MEF by aspiration before initiating antibiotics and to repeat this procedure during treatment, a method which was termed the 'in vivo sensitivity test'. This advantageous method is difficult to perform and thus only a few groups were able to conduct such large-scale studies. The available information is discussed in the present manuscript, as well as some preliminary results suggesting that oral beta-lactam antibiotics may not be the ideal drugs to date, due to the emergence of resistant pneumococci.