RESUMEN
OBJECTIVE: To evaluate a novel telehealth inpatient pediatric gastroenterology (GI) consult service at a regional children's hospital in regard to acceptance, utility, quality, sustainability, and provider resiliency. STUDY DESIGN: Patients requiring GI care at a regional children's hospital between July 2020 and June 2021 were treated by an in-person or telehealth physician with physician assistant support, randomly assigned based on a weekly preset staffing schedule. A retrospective, multidomain program evaluation was performed based on the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) and STEM (SPROUT Telehealth Evaluation and Management) frameworks, using statistical analysis to compare the patient cohorts and anonymous surveys to assess provider perceptions. RESULTS: In total, 1051 patient-days of GI care were provided for 348 patients, 17% by telehealth and 83% in-person. There were no significant differences in diagnosis, transfer, or readmission rates between the cohorts. No transfers occurred for reasons other than need to access specialized services not available at the regional hospital. Daily consult workload was slightly greater for telehealth physicians. Primary and consult team providers accepted the practice. The model continued beyond the first year. In total, 75% of local GI physicians reported greater Brief Resilience Scores in the context of shifting 20% of their inpatient call weeks to another campus's physicians. CONCLUSION: Episodic pediatric GI consult service coverage via telehealth at a regional hospital was well accepted, useful, and sustainable, with improved physician resilience and no adverse outcomes seen. Telehealth holds promise for leveraging pediatric subspecialty physicians across hospitals, allowing complex patients to be admitted closer to home while reducing inpatient coverage requirements for smaller physician groups.
Asunto(s)
Gastroenterología , Telemedicina , Humanos , Niño , Estudios Retrospectivos , Hospitalización , HospitalesRESUMEN
OBJECTIVES: Celiac disease (CeD) autoimmunity and coexisting inflammatory bowel disease (IBD) present a diagnostic dilemma. Our aims were to describe the phenotype of children with IBD and CeD seropositivity and evaluate provider confidence for diagnosing CeD in this population. METHODS: We performed a single-center retrospective cohort study of subjects ≤18 years old with IBD and CeD seropositivity between 2006 and 2020. Subjects were considered to have IBD-CeD if they met CeD diagnosis by serology and histology per North American Society For Pediatric Gastroenterology, Hepatology and Nutrition guidelines and if providers suspected CeD as evaluated by a survey. The IBD-only cohort included seropositive participants that did not meet criteria for CeD. Demographic, histologic, gross endoscopic, and laboratory features were compared using Fisher exact test. RESULTS: Of 475 children with IBD, 8 had concomitant CeD, 5 had tissue transglutaminase (tTG) immunoglobulin A (IgA) > 10x upper limit of normal (ULN, P = 0.006), and 8 had villous atrophy (VA, P = 0.003) when compared with 17 seropositive participants with IBD-only. No children with IBD-CeD had esophageal eosinophilia, duodenal cryptitis, duodenal ulceration, or fecal calprotectin >250 µg/g. Factors that contributed to provider uncertainty for diagnosing CeD in IBD included the absence of VA and intraepithelial lymphocytes, the presence of neutrophilic and eosinophilic duodenitis, diffuse ulceration, elevated inflammatory markers, and immunosuppression therapy. CONCLUSIONS: Diagnosing CeD in children with IBD continues to be challenging. Although high titers of tTG IgA and VA increased provider confidence for diagnosing CeD in IBD, development of evidence-based guidelines are needed. They should better assess the importance of features atypical of concomitant CeD that contribute to uncertainty.
Asunto(s)
Enfermedad Celíaca , Enfermedades Inflamatorias del Intestino , Humanos , Enfermedad Celíaca/complicaciones , Enfermedad Celíaca/diagnóstico , Estudios Retrospectivos , Duodeno/patología , Enfermedades Inflamatorias del Intestino/complicaciones , Enfermedades Inflamatorias del Intestino/patología , Autoanticuerpos , Inmunoglobulina A , TransglutaminasasRESUMEN
OBJECTIVE: To evaluate marijuana use by adolescents and young adults with inflammatory bowel disease (IBD). STUDY DESIGN: This descriptive cross-sectional study of patients seen between December 2015 through June 2017 at Children's Hospital Colorado for IBD enrolled patients 13-23 years of age, independent of marijuana use status. Information obtained consisted of chart review, electronic and interview self-report, and serum cannabinoid levels. Marijuana ever-users were compared with never-users for clinical characteristics and perceptions of risk with use; users provided information on routes, patterns, motivations, and perceived benefits and problems with use. RESULTS: Of 99 participants, ever-use was endorsed by 32% (32 of 99) and daily or almost daily use by 9% (9 of 99). Older age was the only characteristic related to endorsing marijuana use. Twenty-nine ever-users completed all questionnaires. After adjusting for age, users were 10.7 times more likely to perceive low risk of harm with regular use (P < .001). At least 1 medical reason for use was endorsed by 57% (17 of 30), most commonly for relief of physical pain (53%, 16 of 30) (2 did not complete all questionnaires). Problems from use were identified by 37% (11 of 30), most commonly craving/strong urge to use. Most common route of use was smoking (83%) followed by edibles (50%), dabbing (40%), and vaping (30%). CONCLUSIONS: Marijuana use by adolescents and young adults with IBD is common and perceived as beneficial. Guidelines for screening, testing, and counseling of marijuana use should be developed for patients with IBD.
Asunto(s)
Enfermedades Inflamatorias del Intestino/tratamiento farmacológico , Fumar Marihuana , Uso de la Marihuana/epidemiología , Motivación/fisiología , Adolescente , Colorado/epidemiología , Estudios Transversales , Femenino , Humanos , Incidencia , Masculino , Autoinforme , Encuestas y Cuestionarios , Adulto JovenAsunto(s)
Enfermedad de Crohn/diagnóstico , Trasplante de Corazón/efectos adversos , Inmunosupresores/efectos adversos , Adolescente , Colonoscopía , Enfermedad de Crohn/tratamiento farmacológico , Enfermedad de Crohn/etiología , Fármacos Gastrointestinales/uso terapéutico , Humanos , Infliximab/uso terapéutico , MasculinoRESUMEN
The trend toward decriminalization of cannabis (marijuana) continues sweeping across the United States. Colorado has been a leader of legalization of medical and recreational cannabis use. The growing public interest in the medicinal properties of cannabis and its use by patients with a variety of illnesses including inflammatory bowel disease (IBD) makes it important for pediatric gastroenterologists to understand this movement and its potential effect on patients. This article describes the path to legalization and "medicalization" of cannabis in Colorado and the public perception of safety despite the known adverse health effects of use. We delineate the mammalian endocannabinoid system and our experience of caring for children and adolescents with IBD in an environment of increasing awareness and acceptance of its use. We then summarize the rationale for considering that cannabis may have beneficial and harmful effects for patients with IBD. Finally, we highlight the challenges federal laws impose on conducting research on cannabis in IBD. The intent of this article is to inform health care providers about the issues around cannabis use and research in adolescents and young adults with IBD.
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Antiinflamatorios/uso terapéutico , Colitis Ulcerosa/tratamiento farmacológico , Enfermedad de Crohn/tratamiento farmacológico , Conocimientos, Actitudes y Práctica en Salud , Uso de la Marihuana , Marihuana Medicinal/uso terapéutico , Adolescente , Antiinflamatorios/efectos adversos , Niño , Colitis Ulcerosa/psicología , Colorado , Enfermedad de Crohn/psicología , Humanos , Legislación de Medicamentos , Uso de la Marihuana/efectos adversos , Uso de la Marihuana/epidemiología , Uso de la Marihuana/legislación & jurisprudencia , Uso de la Marihuana/psicología , Marihuana Medicinal/efectos adversos , SeguridadAsunto(s)
Aneurisma Infectado/complicaciones , Coartación Aórtica/complicaciones , Enfermedades de la Aorta/complicaciones , Fístula Arterio-Arterial/complicaciones , Fístula Esofágica/complicaciones , Hematemesis/etiología , Adolescente , Aneurisma Infectado/microbiología , Coartación Aórtica/microbiología , Enfermedades de la Aorta/microbiología , Fístula Arterio-Arterial/microbiología , Fístula Esofágica/microbiología , Hematemesis/microbiología , Humanos , Masculino , Infecciones Neumocócicas/complicaciones , Infecciones Neumocócicas/microbiología , Streptococcus pneumoniaeRESUMEN
OBJECTIVE: To determine the benefits of screening for celiac autoimmunity via immunoglobulin A transglutaminase autoantibodies (TG) in children with type 1 diabetes (T1D). STUDY DESIGN: We followed up 79 screening-identified TG+ and 56 matched TG- children with T1D for 2 years to evaluate growth, bone mineral density, nutritional status, and diabetes control. TG+ subjects self-selected to gluten-free or gluten-containing diet. RESULTS: Of the initial cohort, 80% were available for reexamination after 2 years. TG+ subjects had consistently lower weight z-scores and higher urine N-telopeptides than TG- subjects, but similar measures of bone density and diabetes outcomes. TG+ children who remained on a gluten-containing diet had lower insulin-like growth factor binding protein 3 z-scores compared with TG+ subjects who reported following a gluten-free diet. Children who continued with high TG index throughout the study had lower bone mineral density z-scores, ferritin, and vitamin D 25OH levels, compared with the TG- group. CONCLUSIONS: No significant adverse outcomes were identified in children with T1D with screening-identified TG+ who delay therapy with a gluten-free diet for 2 years. Children with persistently high levels of TG may be at greater risk. The optimal timing of screening and treatment for celiac disease in children with T1D requires further investigation.
Asunto(s)
Autoinmunidad/inmunología , Enfermedad Celíaca/epidemiología , Enfermedad Celíaca/inmunología , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 1/inmunología , Adolescente , Distribución por Edad , Biopsia con Aguja , Estudios de Casos y Controles , Enfermedad Celíaca/dietoterapia , Enfermedad Celíaca/patología , Niño , Diabetes Mellitus Tipo 1/diagnóstico , Dieta Sin Gluten , Femenino , Estudios de Seguimiento , Humanos , Inmunoglobulina A/análisis , Inmunoglobulina A/inmunología , Inmunohistoquímica , Incidencia , Masculino , Tamizaje Masivo/métodos , Valores de Referencia , Medición de Riesgo , Distribución por Sexo , Factores de Tiempo , Transglutaminasas/análisis , Transglutaminasas/inmunologíaRESUMEN
OBJECTIVE: Children with type 1 diabetes (T1DM) are at increased risk for celiac disease (CD); however, the benefits of screening for IgA tissue transglutaminase autoantibodies (TG), a marker for CD, are unclear. STUDY DESIGN: We compared 71 screening-identified TG+ with 63 matched TG- children with TIDM. Growth, bone density, and diabetes control measures were obtained. RESULTS: The group was 10 +/- 3 years of age, 46% male, with TIDM for 4 +/- 3 years. Z scores for weight (0.3 +/- 1 vs 0.7 +/- 0.8, P = .024), body mass index (BMI) (0.3 +/- 0.9 vs 0.8 +/- -0.8, P = .005), and midarm circumference (0.3 +/- 1.1 vs 0.6 +/- 0.9, P = .031) were lower in the TG+ group. Bone mineral density and diabetes control measures were similar. When limiting the analysis to the 35 TG+ subjects with biopsy changes of CD, the BMI Z score was lower than the control group (0.4 +/- 0.9 vs 0.7 +/- 0.7, P = .05). CONCLUSIONS: In children with TIDM, screening-identified evidence of CD is associated with altered body composition, but not bone mineral density or diabetes control. Further study is needed to determine the benefit of early diagnosis and treatment of CD in TIDM children.
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Autoanticuerpos/sangre , Enfermedad Celíaca/sangre , Enfermedad Celíaca/inmunología , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/complicaciones , Autoinmunidad , Enfermedad Celíaca/complicaciones , Enfermedad Celíaca/diagnóstico , Niño , Femenino , Humanos , Masculino , Transglutaminasas/inmunologíaRESUMEN
OBJECTIVES: To assess several transglutaminase autoantibody (TGAA) assays in their ability to distinguish celiac disease (CD) in screening-identified children with abnormal intestine biopsy specimens from those with normal biopsy specimens. STUDY DESIGN: Children at risk for CD (n = 54) composed of type 1 diabetics, first-degree relatives of type 1 diabetics or CD, and HLA-DQ2+ individuals followed from birth received intestine biopsy. Sera obtained at the time of biopsy were tested for TGAA, using the radioimmunoassay and 5 other commercially available enzyme-linked immunosorbent assays. RESULTS: False-positive rates ranged from 28% to 80%. The positive predictive value (PPV) of the tests ranged from 63% to 84% (lower than reported for symptomatic children). Setting a higher cutoff for each assay maximized PPV. CONCLUSIONS: There are significant quantitative differences among all TGAA assays that could affect interpretation of a positive test for CD. The overall false-positive rate for all assays was high in this population. Using the assay as a quantitative rather than qualitative tool by increasing the cutoff of positivity to indicate biopsy increases PPV. Multicenter workshops are needed to identify critical differences and to standardize TGAA assays among laboratories.
Asunto(s)
Autoanticuerpos/sangre , Enfermedad Celíaca/sangre , Enfermedad Celíaca/diagnóstico , Transglutaminasas/inmunología , Adolescente , Ensayo de Inmunoadsorción Enzimática , Humanos , Radioinmunoensayo , Sensibilidad y EspecificidadRESUMEN
OBJECTIVES: To estimate the frequency of celiac disease (CD) in children in the general population of Denver, Colorado. STUDY DESIGN: From 22,346 newborns characterized as expressing 0, 1, or 2 HLA-DR3(DQB1*0201) alleles, 987 were selected for a prospective stratified cohort study. Participants were followed for as long as 7 years with serial testing for serum IgA anti-transglutaminase antibodies and for evidence of CD (intestinal mucosal changes or persistent seropositivity). RESULTS: Of 40 children with at least one positive serologic test, 19 had evidence of CD (10 by biopsy, 9 by persistent seropositivity). Those expressing 0, 1, or 2 HLA-DR3 alleles had, respectively, 0.3% (95% CI, 0.0-2.7), 3.4% (3.0-11.7), and 3.2% (1.0-11.0) risk for evidence of CD by age 5 years. The adjusted risk estimate for evidence of CD by age 5 years for the Denver general population was 0.9% (0.4-2.0), or 1 in 104 (1:49-221). After adjusting for number of HLA-DR3 alleles expressed, risk was higher in females: RR=3.34 (1.00-10.9, P=.048). Evidence of CD was not observed before age 2.6 years. CONCLUSIONS: Celiac disease may affect 0.9% of Denver children by 5 years of age. Children positive for the HLA-DR3 allele and females appear to be at increased risk.