The Risk of Developing Disabling Crohn's Disease: Validation of a Clinical Prediction Rule to Improve Treatment Decision Making.

BACKGROUND: Crohn's disease (CD) is characterized by the development of complications over the course of the disease. It is crucial to identify predictive factors of disabling disease, in order to target patients for early intervention. We evaluated risk factors of disabling CD and developed a prognostic model. METHODS: In total, 511 CD patients were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to identify demographic, clinical, and biological risk factors. A predictive nomogram model was developed in a subgroup of patients with noncomplicated CD (inflammatory pattern and no perianal disease). RESULTS: The rate of disabling CD within 5 years after diagnosis was 74.6%. Disabling disease was associated with gender, location of disease, requirement of steroids for the first flare, and perianal lesions. In the subgroup of patients (310) with noncomplicated CD, the rate of disabling CD was 80%. In the multivariate analysis age at onset <40 years (OR = 3.46, 95% confidence interval [CI] = 1.52-7.90), extensive disease (L3/L4) (OR = 2.67, 95% CI = 1.18-6.06), smoking habit (OR = 2.09, 95% CI = 1.03-4.27), requirement of steroids at the first flare (OR = 2.20, 95% CI = 1.09-4.45), and albumin (OR = 0.59, 95% CI = 0.36-0.96) were associated with development of disabling disease. The developed predictive nomogram based on these factors presented good discrimination, with an area under the receiver operating characteristic curve of 0.723 (95% CI: 0.670-0.830). CONCLUSION: We identified predictive factors of disabling CD and developed an easy-to-use prognostic model that may be used in clinical practice to help identify patients at high risk and address treatment effectively.

Using Interpretable Machine Learning to Identify Baseline Predictive Factors of Remission and Drug Durability in Crohn's Disease Patients on Ustekinumab.

Ustekinumab has shown efficacy in Crohn's Disease (CD) patients. To identify patient profiles of those who benefit the most from this treatment would help to position this drug in the therapeutic paradigm of CD and generate hypotheses for future trials. The objective of this analysis was to determine whether baseline patient characteristics are predictive of remission and the drug durability of ustekinumab, and whether its positioning with respect to prior use of biologics has a significant effect after correcting for disease severity and phenotype at baseline using interpretable machine learning. Patients' data from SUSTAIN, a retrospective multicenter single-arm cohort study, were used. Disease phenotype, baseline laboratory data, and prior treatment characteristics were documented. Clinical remission was defined as the Harvey Bradshaw Index ≤ 4 and was tracked longitudinally. Drug durability was defined as the time until a patient discontinued treatment. A total of 439 participants from 60 centers were included and a total of 20 baseline covariates considered. Less exposure to previous biologics had a positive effect on remission, even after controlling for baseline disease severity using a non-linear, additive, multivariable model. Additionally, age, body mass index, and fecal calprotectin at baseline were found to be statistically significant as independent negative risk factors for both remission and drug survival, with further risk factors identified for remission.

Long-Term Real-World Effectiveness and Safety of Ustekinumab in Crohn's Disease Patients: The SUSTAIN Study.

BACKGROUND: Large real-world-evidence studies are required to confirm the durability of response, effectiveness, and safety of ustekinumab in Crohn's disease (CD) patients in real-world clinical practice. METHODS: A retrospective, multicentre study was conducted in Spain in patients with active CD who had received ≥1 intravenous dose of ustekinumab for ≥6 months. Primary outcome was ustekinumab retention rate; secondary outcomes were to identify predictive factors for drug retention, short-term remission (week 16), loss of response and predictive factors for short-term efficacy and loss of response, and ustekinumab safety. RESULTS: A total of 463 patients were included. Mean baseline Harvey-Bradshaw Index was 8.4. A total of 447 (96.5%) patients had received prior biologic therapy, 141 (30.5%) of whom had received ≥3 agents. In addition, 35.2% received concomitant immunosuppressants, and 47.1% had ≥1 abdominal surgery. At week 16, 56% had remission, 70% had response, and 26.1% required dose escalation or intensification; of these, 24.8% did not subsequently reduce dose. After a median follow-up of 15 months, 356 (77%) patients continued treatment. The incidence rate of ustekinumab discontinuation was 18% per patient-year of follow-up. Previous intestinal surgery and concomitant steroid treatment were associated with higher risk of ustekinumab discontinuation, while a maintenance schedule every 12 weeks had a lower risk; neither concomitant immunosuppressants nor the number of previous biologics were associated with ustekinumab discontinuation risk. Fifty adverse events were reported in 39 (8.4%) patients; 4 of them were severe (2 infections, 1 malignancy, and 1 fever). CONCLUSIONS: Ustekinumab is effective and safe as short- and long-term treatment in a refractory cohort of CD patients in real-world clinical practice.

This large retrospective study demonstrated the short- and long-term effectiveness and safety of ustekinumab in patients with Crohn's disease in real-world clinical practice, including those with refractory disease.

Acute gastric dilatation in a patient with anorexia nervosa.

A 43-year-old female with a history of anorexia nervosa presented to our hospital with diffuse abdominal pain and distension after a binge eating episode. Vital signs and routine laboratory test results were unremarkable, except for a slightly elevated white blood cell count (14.5 x 109/l). Abdominal radiography and computed tomography (CT) revealed a massively dilated stomach, with a craniocaudal measurement of 37 cm.

Tofacitinib in Ulcerative Colitis: Real-world Evidence From the ENEIDA Registry.

AIM: To evaluate the effectiveness and safety of tofacitinib in ulcerative colitis [UC] in real life. METHODS: Patients from the prospectively maintained ENEIDA registry and treated with tofacitinib due to active UC were included. Clinical activity and effectiveness were defined based on Partial Mayo Score [PMS]. Short-term response/remission was assessed at Weeks 4, 8, and 16. RESULTS: A total of 113 patients were included. They were exposed to tofacitinib for a median time of 44 weeks. Response and remission at Week 8 were 60% and 31%, respectively. In multivariate analysis, higher PMS at Week 4 (odds ratio [OR] = 0].2; 95% confidence interval [CI] = 0].1-0.4) was the only variable associated with lower likelihood of achieving remission at Week 8. Higher PMS at Week 4 [OR = 0.5; 95% CI = 0.3-0.7] and higher PMS at Week 8 [OR = 0.2; 95% CI = 0.1-0.5] were associated with lower probability of achieving remission at Week 16. A total of 45 patients [40%] discontinued tofacitinib over time. Higher PMS at Week 8 was the only factor associated with higher tofacitinib discontinuation [hazard ratio = 1.5; 95% CI = 1.3-1.6]. A total of 34 patients had remission at Week 8; of these, 65% had relapsed 52 weeks after achieving remission; the dose was increased to 10 mg/12 h in nine patients, and five of them reached remission again. Seventeen patients had adverse events. CONCLUSIONS: Tofacitinib is effective and safe in UC patients in real practice, even in a highly refractory cohort. A relevant proportion of patients discontinue the drug over time, mainly due to primary failure.

Abordaje terapéutico de adolescentes con graves problemas de conducta en un centro de menores. Evolución de un caso / Therapy for adolescents with severe conduct disorders in a young residential center. A case evolution

La prevalencia de problemas de conducta, violencia, consumo de tóxicos y trastornos mentales en la población de menores usuarios de recursos de Justicia Juvenil y/o protección es muy significativa. En el siguiente trabajo presentamos el caso de un joven adolescente en el que destacan una personalidad de tendencia borderline, con presencia de relaciones interpersonales inestables y conductas impulsivas y autopunitivas. Detallamos el itinerario educativo-terapéutico con él realizado y los cambios registrados en las distintas pruebas psicométricas (MACI- Inventario Clínico para Adolescentes de Millon) a las que se ha sometido al joven durante su paso por el centro de internamiento. La experiencia acumulada en el campo de la Justicia Juvenil nos permite describir un modelo de atención específica que integra profesionales de los ámbitos educativo, clínico y judicial, que parte con el objetivo prioritario de asegurar la atención óptima del menor. La intervención que se lleva a cabo en el Centro tiene como modelo terapéutico de referencia la Psicoterapia de Vinculación Emocional Validante (VEV). La VEV se enmarca dentro de los modelos integradores en psicoterapia y constituye una metodología especializada de intervención en dispositivos de justicia juvenil y protección de menores

The prevalence of behavioral problems, violence, drug consumption and mental disorders is significant in juvenile detention centers. In the following paper, we present the case of a young teenager, highlighting a borderline personality trend, with the presence of unstable interpersonal relationships and self-punitive and impulsive behavior.We outline the educational and therapeutic itinerary he underwent, and the changes registered in various psychometric tests carried out (MACI -Millon Adolescent Clinical Inventory) during his time at the detention center. The experience accumulated in the field of juvenile justice allows us to determine a specific model, involving educational, clinical, and legal professionals, commencing with the primary objective of ensuring the optimal care of the child. The intervention takes place in the Centre and has a therapeutic model of reference, Validation Emotional Bonding Psychotherapy (VSV). This is part of the integrative models in psychotherapy, a methodology specializing in intervention in juvenile justice and child protection

El encuadre en contextos de intervención convivencial de pretección de menores y justicia juvenil. Intervención psicoterapéutica en instituciones / The setting in context of convivential intervention for the protection of minors and juvenile justice. Psychotherapeutic intervention in institutions

La intervención psicoterapéutica y educativa en contextos de convivencia involuntaria, como pueden ser los centros de justicia juvenil y protección de menores, requiere de la adaptación a un nuevo entorno donde el encuadre, por un lado, va a favorecer una resonancia emocional mutua y bidireccional tanto en el menor como en el profesional que le acompaña y, por otro, va a determinar la relación terapéutica entre ambos participes, fundada sobre la contención y validación de esa resonancia que evoca el propio encuadre y sobre la que se basará la alianza terapéutica y el vínculo. Dado que va a ser a través de las experiencias que brinda la relación de convivencia, en las que van a poder reconocer aquellos ecos de experiencias pasadas, es precisamente en estos vínculos en los que se podrán sostener determinados cambios. Todo ello en el marco de un encuadre que defina la mutualidad de la experiencia relacional entre el menor y el profesional

Psychotherapeutic and educational intervention in situations of involuntary cohabitation, such as juvenile detention centers for young offenders and child protection requires the adaptation to a new environment. The framework for this, on the one hand, will encourage a mutual emotional resonance in both the child and the professional. On the other hand, it will establish the therapeutic relationship between them, based on containment and validation of this resonance. Thereafter, the therapeutic alliance and the link will be founded. Given that it will be through the experience that determines the relationship of coexistence, where they will be able to recognise echoes of past experiences, it is precisely these links that will sustain change. All this within a framework that defines the relational mutuality of experience between the child and the professional

Effects of annual influenza vaccination on winter mortality in elderly people with chronic heart disease.

AIMS: Although there is general agreement for the recommendation of the influenza vaccine to elderly and high-risk adults, the magnitude of clinical effectiveness and benefit from the annual vaccination is controversial. In this study, we have assessed the effects of annual influenza vaccination on winter mortality in older adults with chronic heart disease. METHODS AND RESULTS: Cohort study that included 1340 Spanish community-dwelling individuals 65 years or older who had chronic heart disease (congestive heart failure or coronary artery disease) followed from January 2002 to April 2005. Annual influenza vaccine status was a time-varying condition and primary outcome was all-cause death during the study period. Multivariable Cox proportional-hazard models adjusted by age, sex, and comorbidity were used to evaluate vaccine effectiveness. Influenza vaccination was associated with a significant reduction of 37% in the adjusted risk of winter mortality during the overall period 2002-2005. The attributable mortality risk reduction in vaccinated people was 8.2 deaths per 1000 person-winters. We estimated that one death was prevented for every 122 annual vaccinations (ranging between 49 in Winter 2005 and 455 in Winter 2003). CONCLUSION: Our results suggest a benefit from the influenza vaccination and support an annual vaccination strategy for elderly people with cardiac diseases.

Effect of influenza vaccine status on winter mortality in Spanish community-dwelling elderly people during 2002-2005 influenza periods.

This study assessed the relationship between the reception of conventional inactivated influenza vaccine and winter mortality in a prospective cohort that included 11,240 Spanish community-dwelling elderly individuals followed from January 2002 to April 2005. Annual influenza vaccine status was a time-varying condition and primary outcome was all-cause death during study period. Multivariable Cox proportional-hazard models adjusted by age, sex and co-morbidity were used to evaluate vaccine effectiveness. Influenza vaccination was associated with a significant reduction of 23% in winter mortality risk during overall influenza periods. The attributable mortality risk in non-vaccinated people was 24 deaths per 100,000 persons-week within influenza periods, the prevented fraction for the population was 14%, and one death was prevented for every 239 annual vaccinations (ranging from 144 in Winter 2005 to 1748 in Winter 2002).

Niveles de presión arterial en escolares de 6 a 14 años en la ciudad de Medellín

En una muestra aleatoria de 3050 escolares entre los 6 y 14 años, de colegios privados y oficiales de la ciudad de medellin, se obtuvo información sobre, edad, sexo, cifras de presión arterial, peso, talla para construir el índice de masa corporal (CBMI =logaritmo del peso en kilogramos, menos de 0.0008 por talla en centimetros). En los mayores de 12 años se midio maduración sexual y actividad física. Se calcularon en los escolares con peso normal, los valores de presión arterial sistólica y diastólica para los percentiles 50, 75, 90 y 99 por edad y sexo y se determinaron algunos de los factores de riesgo asociados estadisticamente con hipertensión esencial. Se presentan en cada edad y sexo, para los escolares de peso normal, los percentiles de presión arterial sitolica y diastolica y los valores de presión arterial, talla, peso, correspondientes al percentil 90. De los factores de riesgo estudiados la única asociación constante con la presión sistólica y diastólica fue el sobrepeso