Transition Readiness in Youth with Inflammatory Bowel Disease.

OBJECTIVES: To examine readiness of adolescents and young adults (AYAs) with inflammatory bowel disease (IBD) to transition to adult care. STUDY DESIGN: A cross-sectional multicenter study evaluating transition readiness in individuals with IBD 16-19 years old prospectively recruited from 8 Canadian IBD centers using the validated ON Taking Responsibility for Adolescent to Adult Care (ON TRAC) questionnaire. Secondary aims included (1) screening for depression and anxiety using the 8-item Personal Health Questionnaire Depression Scale and The Screen for Child Anxiety Related Emotional Disorders questionnaires, respectively; (2) evaluating the association between depression and anxiety with readiness and disease activity; and (3) subjectively evaluating AYA readiness based on physician and parent assessments. RESULTS: In total, 186 participants (139 adolescent, 47 young adult) were enrolled, mean age 17.4 years (SD, 0.87). ON TRAC scores determined that 26.6% of AYAs at pediatric and 40.4% at adult centers reached the threshold of readiness. On multivariable linear regression analysis age was positively (P = .001) and disease remission negatively (P = .03) associated with ON TRAC scores. No statistically significant differences were determined across centers. A significant percentage of AYAs reported moderate-to-severe depression (21.7%) and generalized anxiety (36%); however, neither were significantly associated with ON TRAC scores. Notably, physician and parental assessment of AYA readiness correlated poorly with ON TRAC scores (⍴ = 0.11, ⍴ = 0.24, respectively). CONCLUSIONS: Assessment of transition readiness in AYAs with IBD highlighted that a large proportion do not have adequate knowledge or behavior skills needed for transition to adult care. This study infers that readiness assessment tools are essential during transition to identify deficits in knowledge and behavior skills that could be specifically targeted by the youth, caregivers, and multidisciplinary team.

Increased Incidence of Inflammatory Bowel Disease After Hirschsprung Disease: A Population-based Cohort Study.

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.

Trends and Predictors of Clostridium difficile Infection among Children: A Canadian Population-Based Study.

OBJECTIVE: To assess time trends in Clostridium difficile infection (CDI) rates, and predictors of CDIs, including recurrent CDIs, in children. STUDY DESIGN: Data were extracted from Manitoba Health Provider Claims, and other population registry datasets from 2005 to 2015. CDI was identified from the Manitoba Health Public Health Branch Epidemiology and Surveillance population-based laboratory-confirmed CDI dataset. Children aged 2-17 years with CDI were matched by age, sex, area of residence, and duration of residence in Manitoba with children without CDI. The rates and time trends of CDIs using previously recommended definitions were determined. Predictors of CDI subtypes were determined using multivariable logistic regression models. Cox regression analysis was used to assess for the potential predictors of recurrent CDI. RESULTS: Children with and without CDI were followed for 828 and 2753 persons-years, respectively. The overall CDI rate during the study period was 7.8 per 100 000 person-years. There was no significant change in CDI rates over the observation period. Comorbid conditions, more prevalent among children with CDI than matched controls, included Hirschsprung disease (P < .001) and inflammatory bowel disease (P < .0001). Recurrent CDIs (>2 occurrences) were responsible for 10% of CDI episodes (range, 2-6 infections). Predictors of recurrence included malignancy (hazard ratio, 3.0, 95% CI, 1.1-8.8), diabetes (hazard ratio, 4.8; 95% CI, 1.1-21.4), and neurodegenerative diseases (hazard ratio, 8.4; 95% CI, 1.9-37.5). CONCLUSIONS: The incidence of CDI is stable among children in Manitoba. Children with Hirschsprung disease and inflammatory bowel disease are more susceptible to CDI, and those with malignancy, diabetes. and neurodegenerative disorders are more likely to develop recurrent CDI.

Combination of corticosteroids and 5-aminosalicylates or corticosteroids alone for patients with moderate-severe active ulcerative colitis: A global survey of physicians' practice.

AIM: To examine treatment decisions of gastroenterologists regarding the choice of prescribing 5-aminosalycilates (5ASA) with corticosteroids (CS) versus corticosteroids alone for patients with active ulcerative colitis (UC). METHODS: A cross-sectional questionnaire exploring physicians' attitude toward 5ASA + CS combination therapy vs CS alone was developed and validated. The questionnaire was distributed to gastroenterology experts in twelve countries in five continents. Respondents' agreement with stated treatment choices were assessed by standardized Likert scale. Background professional characteristics of respondents were analyzed for correlation with responses. RESULTS: Six hundred and sixty-four questionnaires were distributed and 349 received (52.6% response rate). Of 340 eligible respondents, 221 (65%) would continue 5ASA in a patient hospitalized for intravenous CS treatment due to a moderate-severe UC flare, while 108 (32%) would stop the 5ASA (P < 0.001), and 11 (3%) are undecided. Similarly, 62% would continue 5ASA in an out-patient starting oral CS. However, only 140/340 (41%) would proactively start 5ASA in a hospitalized patient not receiving 5ASA before admission. Most (94%) physicians consider the safety profile of 5ASA as very good. Only 52% consider them inexpensive, 35% perceive them to be expensive and 12% are undecided. On multi-variable analysis, less years of practice and perception of a plausible additive mechanistic effect of 5ASA + CS were positively associated with the decision to continue 5ASA with CS. CONCLUSION: Despite the absence of data supporting its benefit, most gastroenterologists endorse combination of 5ASA + CS for patients with active moderate-to-severe UC. Randomized controlled trials are needed to assess if 5ASA confer any benefit for these patients.

Academic Performance among Children with Inflammatory Bowel Disease: A Population-Based Study.

OBJECTIVES: To determine grade 12 academic performance for children with inflammatory bowel disease (IBD). STUDY DESIGN: Children diagnosed with IBD at age<17 years identified from the population-based University of Manitoba IBD Epidemiology Database were matched by age-, sex-, and area of residence to 10 randomly selected controls. Grade 12 educational outcomes (scores on the provincial grade 12 language arts and mathematics standards tests, and enrollment-in-grade-12-by- age-17) were determined by linkage to the province wide Manitoba Education Database. Linear and logistic regression analysis were used to compare the educational outcomes, adjusting for socioeconomic status and comorbidities and evaluate predictors of educational outcomes among children with IBD. RESULTS: Grade 12 educational outcomes among 337 children with IBD were compared with 3093 without IBD. There were no significant differences among the 2 groups in the standardized scores (language arts: P=.31; mathematics: P=.48) or enrollment-in-grade-12-by- age-17 (P=.25). Lower socioeconomic status and diagnosis with mental health problems 6 months prior to and 6 months post-IBD diagnosis were independent predictors of worse educational outcomes. There was no significant effect of age of diagnosis of IBD, type of IBD (ulcerative colitis vs Crohn's disease), use of corticosteroids or immunomodulator agents, hospitalizations, or surgery for IBD. CONCLUSIONS: Children with IBD on average achieve similar levels of academic achievement in grade 12 as those without IBD. This study underscores the educational impact of mental health conditions at IBD diagnosis among children.

Association between early childhood otitis media and pediatric inflammatory bowel disease: an exploratory population-based analysis.

OBJECTIVE: To determine whether a diagnosis of otitis media in the first 5 years of childhood is associated with the development of pediatric inflammatory bowel disease (IBD). STUDY DESIGN: This was a nested case-control analysis of a population-based IBD database in Manitoba, Canada. A total of 294 children with IBD diagnosed between 1989 and 2008 were matched to 2377 controls, based on age, sex, and geographic region. The diagnosis of ottis media was based on physician claims. IBD status was determined based on a validated administrative database definition. Multivariate conditional logistic regression models were used to model the association between otitis media and IBD, adjusted for annual physician visits. RESULTS: Approximately 5% of the IBD cases and 12% of the controls did not have an otitis media diagnosis before that IBD case date. By age 5 years, 89% of the IBD cases had at least one diagnosis of otitis media, compared with 82% of the controls. In multivariate analyses, compared with cases and controls without an otitis media diagnosis, individuals with an otitis media diagnosis by age 5 years were 2.8-fold more likely to be an IBD case (95% CI, 1.5-5.2; P = .001). This association was detected in stratified models examining Crohn's disease and ulcerative colitis separately. CONCLUSION: Compared with controls, subjects diagnosed with IBD were more likely to have had at least one early childhood episode of otitis media before their diagnosis. We suspect that otitis media serves as a proxy measure of antibiotic use.