Short Pediatric Crohn's Disease Research Articles

Subjective and objective sleep quality assessment in adolescent patients with inflammatory bowel disease

ObjectivesThere is a link between inflammatory bowel disease (IBD) and poor sleep quality that is presumed to be multifactorial. The purpose of this study was to identify factors that impact sleep quality in this group including clinical disease activity, depression, anxiety, quality of life, and disordered social media use through questionnaires. MethodsThis prospective study analyzed sleep quality in adolescent patients ages 13 to 18 with a diagnosis of IBD using objective data from wrist actigraphy and subjective report from the Pittsburgh Sleep Quality Index (PSQI). Additional screeners including the Short Pediatric Crohn's Disease Activity Index or Pediatric Ulcerative Colitis Activity Index, Pediatric Quality of Life Inventory Gastrointestinal Symptoms Module, Generalized Anxiety Disorder 7-item screener, Patient Health Questionnaire depression screener, and Social Media Disorder scale were also collected. ResultsTwenty-three subjects enrolled and 16 completed questionnaires. 62.5 % of participants were in clinical remission and the remaining 37.5 % had mild to severe clinical IBD activity. Poor subjective sleep quality was associated with a shorter duration of sleep time and an increased clinical disease activity score. Patients in clinical remission slept for a longer duration than those with mild IBD activity. ConclusionsThis study did not identify a significant relationship between sleep quality and psychosocial factors in the adolescent population with IBD, though their influence cannot be discounted. There was a connection between the presence of disease activity and shorter sleep duration. Similarly, PSQI scores correlated with sleep time but not sleep quality.

Interpreting Patient-Reported Outcome Scores: Pediatric Inflammatory Bowel Disease as a Use Case.

To demonstrate how to interpret Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric patient-reported outcome measure (PROM) scores for patients with pediatric inflammatory bowel disease (IBD). Using data from a prospective cohort study of patients ages 8 to 23 years with IBD (n=1049), we established disease-specific percentiles and computed the minimal clinically important difference (MCID) change score for 6 pediatric PROMs. We applied these results, general population percentiles, and the reliable change index to interpret PROM scores in a clinical trial sample of patients ages 8 to 20 years with IBD (n=294) in which PROMIS PROMs were obtained at baseline and 3 months later. Application of general population percentiles showed that the clinical trial sample at baseline had moderately worse self-reported health than the general population (22% of patients at or above the 95th percentile on Fatigue; 21% on Pain Interference). IBD-specific percentiles showed that the sample was somewhat worse than the reference IBD sample (8% of patients at or above the 95th percentile on Fatigue; 11% on Pain Interference). Application of the MCID threshold indicated that among the subgroup of patients that improved by 15 or more on the short Pediatric Crohn's Disease Activity Index (n=38), 45% also improved on IBD Symptoms, 47% for Fatigue, and 65% for Pain Interference. This study established IBD-specific percentiles for 6 pediatric PROMIS measures and demonstrated the application of percentiles and other methods for interpreting PROM scores.

Defining the ultrasound longitudinal natural history of newly diagnosed pediatric small bowel Crohn disease treated with infliximab and infliximab-azathioprine combination therapy.

Little is known about changes in the imaging appearances of the bowel and mesentery over time in either pediatric or adult patients with newly diagnosed small bowel Crohn disease treated with anti-tumor necrosis factor-alpha (anti-TNF-α) therapy. To define how bowel ultrasound findings change over time and correlate with laboratory inflammatory markers in children who have been newly diagnosed with pediatric small bowel Crohn disease and treated with infliximab. We included 28 pediatric patients treated with infliximab for newly diagnosed ileal Crohn disease who underwent bowel sonography prior to medical therapy and at approximately 2weeks, 1month, 3months and 6months after treatment initiation; these patients also had laboratory testing at baseline, 1month and 6months. We used linear mixed models to compare mean results between visits and evaluate whether ultrasound measurements changed over time. We used Spearman rank correlation to assess bivariate relationships. Mean subject age was 15.3±2.2years; 11 subjects were girls (39%). We observed decreases in mean length of disease involvement (12.0±5.4 vs. 9.1±5.3cm, P=0.02), maximum bowel wall thickness (5.6±1.8 vs. 4.7±1.7mm, P=0.02), bowel wall color Doppler signal (1.7±0.9 vs. 1.2±0.8, P=0.002) and mesenteric color Doppler signal (1.1±0.9 vs. 0.6±0.6, P=0.005) at approximately 2weeks following the initiation of infliximab compared to baseline. All laboratory inflammatory markers decreased at 1month (P-values<0.0001). There was strong correlation between bowel wall color Doppler signal and fecal calprotectin (ρ=0.710; P<0.0001). Linear mixed models confirmed that maximum bowel wall thickness (P=0.04), length of disease involvement (P=0.0002) and bowel wall color Doppler signal (P<0.0001) change over time in response to infliximab, when adjusted for age, sex, azathioprine therapy, scanning radiologist and baseline short pediatric Crohn's disease activity index score. The ultrasound appearance of the bowel changes as early as 2weeks after the initiation of infliximab therapy. There is strong correlation between bowel wall color Doppler signal and fecal calprotectin.

Incidence of Bowel Surgery and Associated Risk Factors in Pediatric-Onset Crohn's Disease.

Data describing the incidence and the risk factors for surgical interventions in pediatric Crohn's disease (CD) is inconsistent. Our aim was to describe the rates of intestinal surgery and to identify associated risk factors in a large cohort of children with CD. Medical charts of 482 children with CD from the Schneider Pediatric Inflammatory Bowel Disease cohort who were diagnosed between 1981 and 2013 were carefully reviewed retrospectively. Of 482 patients, 143 (29.7%) underwent intestinal surgery with a median follow-up time of 8.6 years (range, 1-30.5). Kaplan-Meier survival estimates of the cumulative probability of CD-related intestinal surgery were 14.2% at 5 years and 24.5% at 10 years from diagnosis. Of these, 14% needed more than one operation. Multivariate Cox models showed that isolated ileal disease (hazard ratio [HR] 2.39, P = 0.008), complicated behavior (penetrating or stricturing) (HR 2.44, P < 0.001) and higher severity indices, at diagnosis, including Harvey-Bradshaw (HR 1.06, P = 0.009) and short Pediatric Crohn's Disease Activity Index (HR 1.02, P = 0.001) were associated with increased risk for intestinal surgery. Age, gender, family history of CD, early introduction of immunomodulators, treatment with anti-tumor necrosis factor α, or diagnosis before the year 2000 did not affect the risk of bowel surgery. Ileal location, complicated behavior, and higher disease activity indices at diagnosis are independent risk factors for bowel surgery, whereas anti-tumor necrosis factor α treatment and diagnosis during the "biological era" are not associated with diminished long-term surgical risk.

P-207 Racial Differences in Initial Presentation, Early Treatment, and 1-Year Outcomes of Pediatric Crohnʼs Disease

Racially disparate care has been shown to contribute to suboptimal healthcare outcomes for minorities in some settings. Using data from the ImproveCareNow (ICN) network, we sought to investigate differences in the medical management and outcomes of pediatric patients with Crohn's disease (CD) at time of diagnosis and 1-year post-diagnosis. ICN is a learning health network for children with inflammatory bowel disease. It contains data collected prospectively and longitudinally during outpatient encounters. Inclusion criteria: all CD patients ≤21 years of age with a visit between September 2006 and October 2014, with the first recorded encounter ≤90 days from the date of CD diagnosis and an encounter 1-year post diagnosis (within 60 days). Analyses were conducted at 2 time periods: baseline (diagnosis) and the 1-year encounter. Analyses included summary statistics, nonparametric Kruskal-Wallis test, Χ2, and Fisher's exact tests as appropriate. Baseline: 976 patients (Black = 118 [12%], White = 858 [88%], mean age = 13 years, 63% male) from 39 sites were included. Black children had a higher percentage of Medicaid insurance (44% versus 11%, P < 0.001). There were no race differences in gender, age at diagnosis, BMI, disease behavior or disease location. Black children had more active disease according to Physician Global Assessment (PGA) at diagnosis (remission 29% versus 35%, mild 37% versus43%, moderate/severe 34% versus 22%; P = 0.027), though there was no difference according to the short Pediatric Crohn's Disease Activity Index (sPCDAI) (P = 0.67). Black children had a lower hematocrit (34.8 versus 36.7, P < 0.001) and albumin level (3.6 versus 3.9, P = 0.001). There were no differences in initial treatment (Black versus White: anti-TNFα 12% versus 11%, P = 0.94; thiopurines 32% versus 34%, P = 0.75); corticosteroids 58% versus 61%, P = 0.71). Black children had more psychosocial concerns noted at diagnosis (30% versus 12%, P = 0.021). At 1 year following diagnosis, Black children had more active disease according to PGA (remission 63% versus 75%, mild 26% versus 29%, moderate/severe 11% versus 6%; P = 0.016); however, there was no difference in disease activity based on the sPCDAI (P = 0.060). Black children had a lower hematocrit (36.6 versus 37.9, P = 0.004), lower albumin level (3.9 versus 4.2, P <0.001), and higher erythrocyte sedimentation rate (20.0 versus 15.2, P = 0.03). There were no differences in treatment (Black versus White: anti-TNFα 35% versus 33%, P = 0.69; thiopurines 47% versus 44%, P = 0.52); corticosteroids 7% versus 10%, P = 0.32). In this cohort, minor differences were identified between Black and White children at baseline and 1-year, with Black children having slightly worse disease activity by some measures. Specifically, statistical differences were identified with respect to hematocrit, albumin, and erythrocyte sedimentation rate (at 1-year), although these differences may not have been clinically meaningful. Remission rates were lower in Black children according to PGA, although not according to C-reactive protein and sPCDAI, suggesting that either Black children were perceived to be more ill despite similar disease activity, or that Black children actually were more ill, but this was not adequately reflected by the sPCDAI. Racial differences in treatment were not identified.

P-218 Using Quality Improvement to Increase Utilization of Enteral Therapy in Pediatric Crohn Disease

Enteral nutrition therapy (EN) is safe and effective for induction of remission in Crohn's disease (CD) but is underutilized in the United States due to multiple perceived barriers. We implemented a protocol to initiate and overcome barriers related to EN. We hypothesized that implementing this protocol using a quality improvement-based approach would increase utilization of EN and induce remission of CD. In July 2013, we developed and implemented an algorithm for administration of EN. Tools were developed for providers to effectively discuss EN with patients and families, initiate the correct amount of formula, record use, and document medical necessity. Dietitians provided follow –up and providers assessed response. For induction of remission, children were given polymeric formula meeting 90% to 100% of their caloric requirements over a 12-week period. To assess improvement in utilization, we compared the average number of patients per month who were prescribed EN before and after implementing the protocol. Clinical outcomes were assessed for children ≤21 years with active CD and no history of prior intestinal resection that completed a minimum of 8 of the 12 weeks of EN between July 2013 and May 2015. The short pediatric Crohn's disease activity index (sPCDAI), body mass index (BMI), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin, and hemoglobin were compared before and after induction with EN. Between July 2013 and May 2015, 65 patients with CD started EN; 5 were excluded because of inactive disease and three were lost to follow up. Of the 57 remaining patients (mean age 12.7 ± 2.9 years, 49% female, 86% white), 40 (70%) had ileocolonic disease and eleven (19%) had perianal phenotype. EN was started within four weeks of diagnosis for 42 (74%) patients. Average calories were 1798 (±348) or 90.2% of estimated caloric requirements. The average number of patients starting EN increased from 0.6 patients per month before to 3.4 after implementing the protocol (560% increase). Of the 57 patients who started EN, 24 (44%) both completed at least 8 weeks of treatment and achieved remission. Of the 29 who completed at least 8 weeks of EN and had follow up data, 24 (83%) achieved remission. In these patients, there was a significant reduction of sPCDAI (33 ± 15.7 to 9.5 ± 11.6, P < 0.0001) and ESR (27 ± 17 to 17 ± 10, P < 0.001) and an increase in albumin (4 ± 0.5 to 4.2 ± 0.4, P < 0.05). Changes in BMI, CRP, and hemoglobin were not statistically significant. Twenty-five children (44%) were unable to complete induction and finished an average of 4.3 weeks (±2). Twelve patients (48%) cited inability to drink the formula, 14 (56%) had inadequate response, and 4 (16%) stopped because of a complication of CD. Adverse events were reported in 25 patients (44%) including nausea, vomiting, diarrhea, and bloating. Systematic implementation of tools designed to increase utilization of EN is effective in overcoming perceived barriers and increasing the acceptance of primary enteral therapy. Remission was successfully achieved in children who completed induction therapy with EN.

Improved Outcomes With Quality Improvement Interventions in Pediatric Inflammatory Bowel Disease

Variations in chronic illness care are common in our health care system and may lead to suboptimal outcomes. Specifically, inconsistent use and suboptimal medication dosing have been demonstrated in the care of patients with inflammatory bowel disease (IBD). Quality improvement (QI) efforts have improved outcomes in conditions such as asthma and diabetes mellitus, but have not been well studied in IBD. We hypothesized that QI efforts would lead to improved outcomes in our pediatric IBD population. A QI team was formed within our IBD center in 2005. By 2007, we began prospectively capturing physician global assessment (PGA) and patient-reported global assessment. Significant QI interventions included creating evidence-based medication guidelines, joining a national QI collaborative, initiation of preclinic planning, and monitoring serum 25-hydroxyvitamin D. From 2007 to 2010, 505 patients have been followed at our IBD center. During this time, the frequency of patients in clinical remission increased from 59% to 76% (P < 0.05), the frequency of patients who report that their global assessment is >7 increased from 69% to 80% (P < 0.05), and the frequency of patients with a Short Pediatric Crohn's Disease Activity Index (sPCDAI) <15 increased from 60% to 77% (P < 0.05). The frequency of repeat steroid use decreased from 17% to 10% (P < 0.05). We observed an association between the use of a vitamin D supplement (P = 0.02), serum 25-hydroxyvitamin D (P < 0.05), and quiescent disease activity. Our results show that significant improvements in patient outcomes are associated with QI efforts that do not rely on new medication or therapies.