Geographical patterns of the standing and active human gut microbiome in health and IBD

OBJECTIVE

A global increase of IBD has been reported, especially in countries that previously had low incidence rates. Also, the knowledge of the human gut microbiome is steadily increasing, however, limited information regarding its variation on a global scale is available. In the light of the microbial involvement in IBDs, we aimed to (1) identify shared and distinct IBD-associated mucosal microbiota patterns from different geographical regions including Europe (Germany, Lithuania) and South Asia (India) and (2) determine whether profiling based on 16S rRNA transcripts provides additional resolution, both of which may hold important clinical relevance.

DESIGN

In this study, we analyse a set of 89 mucosal biopsies sampled from individuals of German, Lithuanian and Indian origins, using bacterial community profiling of a roughly equal number of healthy controls, patients with Crohn's disease and UC from each location, and analyse 16S rDNA and rRNA as proxies for standing and active microbial community structure, respectively.

RESULTS

We find pronounced population-specific as well as general disease patterns in the major phyla and patterns of diversity, which differ between the standing and active communities. The geographical origin of samples dominates the patterns of β diversity with locally restricted disease clusters and more pronounced effects in the active microbial communities. However, two genera belonging to the Clostridium leptum subgroup, Faecalibacteria and Papillibacter, display consistent patterns with respect to disease status and may thus serve as reliable 'microbiomarkers'.

CONCLUSIONS

These analyses reveal important interactions of patients' geographical origin and disease in the interpretation of disease-associated changes in microbial communities and highlight the added value of analysing communities on both the 16S rRNA gene (DNA) and transcript (RNA) level.

Advances in nutritional therapy in inflammatory bowel diseases: Review

Inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn's disease are chronic, life-long, and relapsing diseases of the gastrointestinal tract. Currently, there are no complete cure possibilities, but combined pharmacological and nutritional therapy may induce remission of the disease. Malnutrition and specific nutritional deficiencies are frequent among IBD patients, so the majority of them need nutritional treatment, which not only improves the state of nutrition of the patients but has strong anti-inflammatory activity as well. Moreover, some nutrients, from early stages of life are suspected as triggering factors in the etiopathogenesis of IBD. Both parenteral and enteral nutrition is used in IBD therapy, but their practical utility in different populations and in different countries is not clearly established, and there are sometimes conflicting theories concerning the role of nutrition in IBD. This review presents the actual data from research studies on the influence of nutrition on the etiopathogenesis of IBD and the latest findings regarding its mechanisms of action. The use of both parenteral and enteral nutrition as therapeutic methods in induction and maintenance therapy in IBD treatment is also extensively discussed. Comparison of the latest research data, scientific theories concerning the role of nutrition in IBD, and different opinions about them are also presented and discussed. Additionally, some potential future perspectives for nutritional therapy are highlighted.

Systematic review with meta-analysis: the incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies

BACKGROUND

The recognition of eosinophilic oesophagitis (EoE) has risen sharply, but its current epidemiology is still under debate.

AIM

To estimate accurately the prevalence and incidence rates of EoE, by a systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE and SCOPUS databases were searched for population-based studies on the epidemiology of EoE. Pooled incidence and prevalence rates, male:female and children:adult ratios, and geographical and temporal variations were calculated with random-effects models.

RESULTS

The search yielded 1334 references; the final quantitative summary included 13 population-based studies from North America, Europe and Australia, with the results showing high heterogeneity. The pooled EoE incidence rate was 3.7/100 000 persons/year [95% confidence interval (CI): 1.7-6.5] and was higher for adults (7; 95% CI: 1-18.3) than for children (5.1; 95% CI: 1.5-10.9). The pooled prevalence of EoE was 22.7 cases/100 000 inhabitants (95% CI: 12.4-36), rising to 28.1 (95% CI: 13-49) when studies with a lower risk of bias were considered; prevalence was higher in adults than in children (43.4; 95% CI: 22.5-71.2 vs. 29.5; 95% CI: 17.5-44.7, respectively), and in American compared to European studies. A steady rise in EoE incidence and prevalence rates was observed upon comparison of studies conducted before and after 2008. No significant publication bias was found.

CONCLUSIONS

Eosinophilic oesophagitis is an increasingly common diagnosis in North America and Europe. The population-based incidence and prevalence of eosinophilic oesophagitis vary widely across individual studies, probably due to variations in diagnosis and risk of bias of research. More prospective, large-scale, multicenter studies are needed to evaluate reported data.

Early Course of Inflammatory Bowel Disease in a Population-Based Inception Cohort Study From 8 Countries in Asia and Australia

BACKGROUND & AIMS

The incidence of inflammatory bowel disease (IBD) is increasing in Asia, but little is known about disease progression in this region. The Asia-Pacific Crohn's and Colitis Epidemiology Study was initiated in 2011, enrolling subjects from 8 countries in Asia (China, Hong Kong, Indonesia, Sri Lanka, Macau, Malaysia, Singapore, and Thailand) and Australia. We present data from this ongoing study.

METHODS

We collected data on 413 patients diagnosed with IBD (222 with ulcerative colitis [UC], 181 with Crohn's disease [CD], 10 with IBD unclassified; median age, 37 y) from 2011 through 2013. We analyzed the disease course and severity and mortality. Risks for medical and surgical therapies were assessed using Kaplan-Meier analysis.

RESULTS

The cumulative probability that CD would change from inflammatory to stricturing or penetrating disease was 19.6%. The cumulative probabilities for use of immunosuppressants or anti-tumor necrosis factor agents were 58.9% and 12.0% for patients with CD, and 12.7% and 0.9% for patients with UC, respectively. Perianal CD was associated with an increased risk of anti-tumor necrosis factor therapy within 1 year of its diagnosis (hazard ratio, 2.97; 95% confidence interval, 1.09-8.09). The cumulative probabilities for surgery 1 year after diagnosis were 9.1% for patients with CD and 0.9% for patients with UC. Patients with CD and penetrating disease had a 7-fold increase for risk of surgery, compared with patients with inflammatory disease (hazard ratio, 7.67; 95% confidence interval, 3.93-14.96). The overall mortality for patients with IBD was 0.7%.

CONCLUSIONS

In a prospective population-based study, we found that the early course of disease in patients with IBD in Asia was comparable with that of the West. Patients with CD frequently progress to complicated disease and have accelerated use of immunosuppressants. Few patients with early stage UC undergo surgery in Asia. Increasing our understanding of IBD progression in different populations can help optimize therapy and improve outcomes.

Colectomy Rates for Ulcerative Colitis Differ between Ethnic Groups: Results from a 15-Year Nationwide Cohort Study

Introduction. Previous epidemiological studies suggest a higher rate of pancolonic disease in South Asians (SA) compared with White Europeans (WE). The aim of the study was to compare colectomy rates for ulcerative colitis (UC) in SA to those of WE. Methods. Patients with UC were identified from a national administrative dataset (Hospital Episode Statistics, HES) between 1997 and 2012 according to ICD-10 diagnosis code K51 for UC. The colectomy rate for each ethnic group was calculated as the proportion of patients who underwent colectomy from the total UC cases for that group. Results. Of 212,430 UC cases, 73,318 (35.3%) were coded for ethnicity. There was no significant difference in the colectomy rate between SA and WE (6.93% versus 6.90%). Indians had a significantly higher colectomy rate than WE (9.8% versus 6.9%, p < 0.001). Indian patients were 21% more likely to require colectomy for UC compared with WE group (OR: 1.21, 95% CI: 1.04-1.42, and p = 0.001). Conclusions. Given the limitations in coding, the colectomy rate in this cohort was higher in Indians compared to WE. A prospectively recruited ethnic cohort study will decipher whether this reflects a more aggressive phenotype or is due to other confounding factors.

A Retrospective Evaluation of the Utility of Capsule Endoscopy and Double-Balloon Endoscopy in Crohn's Disease

Background. Although the usefulness of capsule endoscopy (CE) and double-balloon endoscopy (DBE) for the evaluation of Crohn's disease (CD) is established, their capabilities in the differential diagnosis of small bowel stenosis have not been sufficiently addressed. The present study therefore aimed to retrospectively determine the types of patients for whom CE and DBE would confer the most benefit. Patients and Methods. We retrospectively reviewed data from 185 patients with established CD. A change of treatment based on CE or DBE results or successful DBE balloon dilation was defined as clinically useful indication. We then analyzed the factors significantly related to useful and poor indications. Results. CE results were assessed as useful indications in 28 (45%) of 62 patients. Multivariate analysis demonstrated that positive CRP and low IOIBD score are factors significantly related to a useful indication. DBE results were recognized as useful indications in 118 (77%) of 153 patients. Multivariate analysis indicated small bowel stenosis and abdominal pain as factors significantly associated with useful indications. All patients with a poor indication on CE had small bowel stenosis. Conclusions. CE was most useful for patients in clinical remission with positive CRP and without stenosis, whereas DBE was useful for patients with symptoms of stenosis.

Characteristics of Pediatric Crohn's Disease in Saudi Children: A Multicenter National Study

Background and Aims. Crohn's disease (CD) is an evolving disease in KSA. Little is known about its characteristics in the Saudi population. The aims of this study were to describe the characteristics of Saudi children with CD and to determine whether the characteristics of CD in KSA are different from those seen in Western countries. Methods. In this study, children younger than eighteen years of age diagnosed with CD between January 2003 and December 2012 were included. Results. Of 330 patients identified, 186 (56.4%) were males. The median age at diagnosis was 15.8 years. A positive family history for IBD in first-degree relatives occurred in 13.6% of patients. The most common symptoms were abdominal pain (84.2%), weight loss (75.2%), and diarrhea (71.8%). The main disease location was ileocolonic (42.1%) and the main disease behavior was nonstricturing and nonpenetrating (63.6%). Perianal involvement was seen in 60 (18.2%) patients. Laboratory findings revealed anemia in 57.9% of patients, low albumin in 34.5%, and high CRP in 39.4%. Conclusions. Saudi children with CD have lower frequency of first-degree relatives with IBD, lower prevalence of early onset disease, longer diagnostic delay, higher prevalence of growth failure, and greater frequency of stricturing and penetrating disease behavior compared to Western patients.

Ultrasound elastography: liver

Ultrasound elastography, also termed sonoelastography, is being used increasingly in clinical practice to aid the diagnosis and management of diffuse liver disease. Elastography has been shown to be capable of differentiating advanced and early-stage liver fibrosis, and consequently a major application in clinical liver care includes progression to cirrhosis risk stratification through (1) assessment of liver fibrosis stage in HCV and HBV patients, (2) distinguishing non-alcoholic steatohepatitis from simple steatosis in non-alcoholic fatty liver disease patients, and (3) prognostic evaluation of liver disease is autoimmune liver disease. In addition, elastographic characterization of focal liver lesions and evaluation of clinically significant portal hypertension have the potential to be clinically useful and are areas of active clinical research.

The global burden of IBD: from 2015 to 2025

Over 1 million residents in the USA and 2.5 million in Europe are estimated to have IBD, with substantial costs for health care. These estimates do not factor in the 'real' price of IBD, which can impede career aspirations, instil social stigma and impair quality of life in patients. The majority of patients are diagnosed early in life and the incidence continues to rise; therefore, the effect of IBD on health-care systems will rise exponentially. Moreover, IBD has emerged in newly industrialized countries in Asia, South America and Middle East and has evolved into a global disease with rising prevalence in every continent. Understanding the worldwide epidemiological patterns of IBD will prepare us to manage the burden of IBD over time. The goal of this article is to establish the current epidemiology of IBD in the Western world, contrast it with the increase in IBD in newly industrialized countries and forecast the global effects of IBD in 2025.

Cost-effectiveness of non-invasive methods for assessment and monitoring of liver fibrosis and cirrhosis in patients with chronic liver disease: systematic review and economic evaluation

BACKGROUND

Liver biopsy is the reference standard for diagnosing the extent of fibrosis in chronic liver disease; however, it is invasive, with the potential for serious complications. Alternatives to biopsy include non-invasive liver tests (NILTs); however, the cost-effectiveness of these needs to be established.

OBJECTIVE

To assess the diagnostic accuracy and cost-effectiveness of NILTs in patients with chronic liver disease.

DATA SOURCES

We searched various databases from 1998 to April 2012, recent conference proceedings and reference lists.

METHODS

We included studies that assessed the diagnostic accuracy of NILTs using liver biopsy as the reference standard. Diagnostic studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-analysis was conducted using the bivariate random-effects model with correlation between sensitivity and specificity (whenever possible). Decision models were used to evaluate the cost-effectiveness of the NILTs. Expected costs were estimated using a NHS perspective and health outcomes were measured as quality-adjusted life-years (QALYs). Markov models were developed to estimate long-term costs and QALYs following testing, and antiviral treatment where indicated, for chronic hepatitis B (HBV) and chronic hepatitis C (HCV). NILTs were compared with each other, sequential testing strategies, biopsy and strategies including no testing. For alcoholic liver disease (ALD), we assessed the cost-effectiveness of NILTs in the context of potentially increasing abstinence from alcohol. Owing to a lack of data and treatments specifically for fibrosis in patients with non-alcoholic fatty liver disease (NAFLD), the analysis was limited to an incremental cost per correct diagnosis. An analysis of NILTs to identify patients with cirrhosis for increased monitoring was also conducted.

RESULTS

Given a cost-effectiveness threshold of £20,000 per QALY, treating everyone with HCV without prior testing was cost-effective with an incremental cost-effectiveness ratio (ICER) of £9204. This was robust in most sensitivity analyses but sensitive to the extent of treatment benefit for patients with mild fibrosis. For HBV [hepatitis B e antigen (HBeAg)-negative)] this strategy had an ICER of £28,137, which was cost-effective only if the upper bound of the standard UK cost-effectiveness threshold range (£30,000) is acceptable. For HBeAg-positive disease, two NILTs applied sequentially (hyaluronic acid and magnetic resonance elastography) were cost-effective at a £20,000 threshold (ICER: £19,612); however, the results were highly uncertain, with several test strategies having similar expected outcomes and costs. For patients with ALD, liver biopsy was the cost-effective strategy, with an ICER of £822.

LIMITATIONS

A substantial number of tests had only one study from which diagnostic accuracy was derived; therefore, there is a high risk of bias. Most NILTs did not have validated cut-offs for diagnosis of specific fibrosis stages. The findings of the ALD model were dependent on assuptions about abstinence rates assumptions and the modelling approach for NAFLD was hindered by the lack of evidence on clinically effective treatments.

CONCLUSIONS

Treating everyone without NILTs is cost-effective for patients with HCV, but only for HBeAg-negative if the higher cost-effectiveness threshold is appropriate. For HBeAg-positive, two NILTs applied sequentially were cost-effective but highly uncertain. Further evidence for treatment effectiveness is required for ALD and NAFLD.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001561.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Is gallstone disease associated with inflammatory bowel diseases? A meta-analysis

OBJECTIVE

To investigate the association between inflammatory bowel disease (IBD) and gallstone disease (GD) by performing a meta-analysis.

METHODS

PubMed, Medline, Embase, Web of Science and the Cochrane Library were searched for relevant articles published between January 1980 and February 2015. All statistical analyses were performed using STATA 12.0. A fixed-effects model was adopted; heterogeneity was evaluated by χ(2) test and I(2) statistic; publication bias was assessed by Begg's and Egger's tests.

RESULTS

Five studies qualified for inclusion in the meta-analysis. Patients with IBD had a significantly higher prevalence of GD than those in the control group [odds ratio (OR) 1.72, 95% confidence interval (CI) 1.40-2.12, P < 0.0001]. Subgroup analyses showed a significantly higher prevalence of GD in patients with Crohn's disease (CD) (OR 2.05, 95% CI 1.61-2.63, P < 0.0001). However, no significant difference in the prevalence of GD was observed between patients with ulcerative colitis (UC) and controls (OR 1.12, 95% CI 0.75-1.68, P = 0.585). Studies from Italy, Sweden and the UK revealed a higher prevalence of GD in patients with IBD. No heterogeneity (I(2) = 25.2%, P = 0.228) or publication bias was observed in our meta-analysis (Begg's test, P = 0.711; Egger's test, P = 0.805).

CONCLUSIONS

Our meta-analysis suggests there is a trend towards higher prevalence of GD in IBD patients, and especially in patients with CD. More rigorous, large-scale multi-center studies are required to investigate the association between GD and IBD.

Health Care Cost Analysis in a Population-based Inception Cohort of Inflammatory Bowel Disease Patients in the First Year of Diagnosis

BACKGROUND

There are limited prospective population-based data on the health care cost of IBD in the post-biologicals era. A prospective registry that included all incident cases of inflammatory bowel disease [IBD] was established to study disease progress and health cost.

AIM

To prospectively assess health care costs in the first year of diagnosis among a well-characterised cohort of newly diagnosed IBD patients.

METHOD

Incident cases of IBD were prospectively identified in 2007-2008 and 2010-2013 from multiple health care providers, and enrolled into the population-based registry. Health care resource utilisation for each patient was collected through active surveillance of case notes and investigations including specialist visits, diagnostic tests, medications, medical hospitalisation, and surgery.

RESULTS

Off 276 incident cases of IBD, 252 [91%] were recruited to the registry, and health care cost was calculated for 242 (146 Crohn's disease [CD] and 96 ulcerative colitis [UC] patients). The median cost in CD was higher at A$5905 per patient (interquartile range [IQR]: A$1571-$91,324) than in UC at A$4752 [IQR: A$1488-A$58,072]. In CD, outpatient resources made up 55% of all cost, with medications accounting for 32% of total cost [15% aminosalicylates, 15% biological therapy], followed by surgery [31%], and diagnostic testing [21%]. In UC, medications accounted for 39% of total cost [of which 37% was due to 5-aminosalicylates, and diagnostics 29%; outpatient cost contributed 71% to total cost.

CONCLUSION

In the first year of diagnosis, outpatient resources account for the majority of cost in both CD and UC. Medications are the main cost driver in IBD.

Reciprocal interaction of diet and microbiome in inflammatory bowel diseases

PURPOSE OF REVIEW

Diet is an emerging but poorly defined disease modulator in inflammatory bowel diseases (IBDs). Dietary factors exert direct effects on epithelial and immune cells and indirectly modulate immune homeostasis by shaping the intestinal microbiota.

RECENT FINDINGS

The increase in IBD prevalence in industrialized countries is associated with lifestyle changes including diets rich in energy, saturated fats, meat and sugar. Despite the fact that the intestinal ecosystem shows high stability and resilience to short-term perturbations, long-term dietary habits have profound effects on composition and function eventually leading to dysbiosis, that is changes in microbial composition associated with deleterious effects to the host. High-throughput sequencing data generated deeper insights of the intestinal ecosystems related to health and disease. However, the available cohort-studies establish associative relationships between microbiota changes and disease, rather than causality. New mouse models of intestinal inflammation and the possibility to transfer disease-associated microbial consortia state an essential tool to unravel the potential of diet-induced microbial shifts.

SUMMARY

This review will discuss new insights of how nutrition or single dietary factors shape the intestinal ecosystem. Furthermore, we want to provide perspectives for clinical translation of this knowledge to treat or prevent IBD.

Current stage in inflammatory bowel disease: What is next?

In recent years, the incidence of inflammatory bowel disease (IBD) has been on the rise, extending to countries where it was infrequent in the past. As a result, the gap between high and low incidence countries is decreasing. The disease, therefore, has an important economic impact on the healthcare system. Advances in recent years in pharmacogenetics and clinical pharmacology have allowed for the development of treatment strategies adjusted to the patient profile. Concurrently, new drugs aimed at inflammatory targets have been developed that may expand future treatment options. This review examines advances in the optimization of existing drug treatments and the development of novel treatment options for IBD.

Oxidative Stress and DNA Damage: Implications in Inflammatory Bowel Disease

This review will focus on published human studies on oxidative stress and DNA damage in inflammatory bowel disease (IBD), both ulcerative colitis and Crohn's disease, assessing their role in the pathophysiology of these diseases. Search was performed over PubMed and ScienceDirect databases to identify relevant bibliography, using keywords including "oxidative stress," "DNA damage," "IBD," and "oxidative DNA damage." Whether as cause or effect, mechanisms underlying oxidative stress have the potential to condition the course of various pathologies, particularly those driven by inflammatory scenarios. IBDs are chronic inflammatory relapsing conditions. Oxidative stress has been associated with some of the characteristic clinical features exhibited in IBD, namely tissue injury and fibrosis, and also to the ulcerative colitis-associated colorectal cancer. The possible influence of oxidative stress over therapeutic behavior and response, as well as their contribution to the oxidative burden and consequences, is also addressed. Due to the high prevalence and incidence of IBD worldwide, and also to its associated morbidity, complications, and disease and treatment costs, it is of paramount importance to better understand the pathophysiology of these diseases.

High School Diet and Risk of Crohn's Disease and Ulcerative Colitis

BACKGROUND

Diet may play an important role in the pathogenesis of Crohn's disease (CD) and ulcerative colitis (UC); yet, there are few prospective studies of dietary factors. None have examined the association between adolescent diet and risk of inflammatory bowel diseases (CD and UC).

METHODS

This study included women enrolled in Nurses' Health Study II who completed a validated high school dietary questionnaire in 1998. We examined the effect of dietary patterns (prudent or Western diet) and individual components of each patterns. We documented incident cases of CD and UC through 2011 based on physician review of medical records and used Cox proportional hazards models adjusting for confounders to estimate hazard ratios and confidence intervals for CD and UC.

RESULTS

Over 763,229 person-years of follow-up, we identified 70 incident cases of CD and 103 cases of UC. Compared with women in the lowest quartile of a prudent diet score (characterized by greater intake of fruits, vegetables, and fish), women in the highest quartile had a 53% lower risk of CD (hazard ratio, 0.47; 95% confidence interval, 0.23-0.98; P trend = 0.04). Specifically, greater intake of fish (P trend = 0.01) and fiber (P trend = 0.06) were associated with lower risk of CD. In contrast, Western diet score was not associated with risk of CD. Neither dietary patterns nor individual food or nutrient groups was associated with UC.

CONCLUSIONS

Adolescent diet is associated with risk of CD, but not UC, offering insights into disease pathogenesis.

Inflammatory Bowel Disease: Historical Perspective, Epidemiology, and Risk Factors

Inflammatory bowel disease (IBD) describes a group of closely related yet heterogeneous predominantly intestinal disease processes that are a result of an uncontrolled immune mediated inflammatory response. It is estimated that approximately one and a half million persons in North America have IBD. Pathogenesis of IBD involves an uncontrolled immune mediated inflammatory response in genetically predisposed individuals to a still unknown environmental trigger that interacts with the intestinal flora. There continues to be an enormous amount of information emanating from epidemiological studies providing expanded insight into the occurrence, distribution, determinants, and mechanisms of inflammatory bowel disease.

Treatment Steps, Surgery, and Hospitalization Rates During the First Year of Follow-up in Patients with Inflammatory Bowel Diseases from the 2011 ECCO-Epicom Inception Cohort

BACKGROUND AND AIMS

The ECCO-EpiCom study investigates the differences in the incidence and therapeutic management of inflammatory bowel diseases [IBD] between Eastern and Western Europe. The aim of this study was to analyse the differences in the disease phenotype, medical therapy, surgery, and hospitalization rates in the ECCO-EpiCom 2011 inception cohort during the first year after diagnosis.

METHODS

Nine Western, five Eastern European centres and one Australian centre with 258 Crohn's disease [CD], 380 ulcerative colitis [UC] and 71 IBD unclassified [IBDU] patients [female/male: 326/383; mean age at diagnosis: 40.9 years, SD: 17.3 years] participated. Patients' data were registered and entered in the web-based ECCO-EpiCom database [www.epicom-ecco.eu].

RESULTS

In CD, 36 [19%] Western Europe/Australian and 6 [9%] Eastern European patients received biological therapy [p = 0.04], but the immunosuppressive [IS] use was equal and high in these regions [Eastern Europe vs Western Europe/Australia: 53% vs 45%; p = 0.27]. Surgery was performed in 17 [24%] CD patients in Eastern Europe and 13 [7%] in Western Europe/Australia [p < 0.001, pLogRank = 0.001]. Of CD patients from Eastern Europe, 24 [34%] were hospitalized, and 39 [21%] from Western Europe/Australia, [p = 0.02, pLogRank = 0.01]. In UC, exposure to biologicals and colectomy rates were low and hospitalization rates did not differ between these regions during the 1-year follow-up period [16% vs 16%; p = 0.93].

CONCLUSIONS

During the first year after diagnosis, surgery and hospitalization rates were significantly higher in CD patients in Eastern Europe compared with Western Europe/Australia, whereas significantly more CD patients were treated with biologicals in the Western Europe/Australian centres.

Prospective population-based cohort of inflammatory bowel disease in the biologics era: Disease course and predictors of severity

BACKGROUND AND AIM

We have previously found high incidence of inflammatory bowel disease (IBD) in Australia. A population-based registry was established to assess disease severity, frequency of complications, and prognostic factors.

METHODS

Incident cases were prospectively identified over 4 years. Early disease severity was assessed according to need for hospitalization and resective surgery and medication use.

RESULTS

We report on the early outcomes (median 18 months, range 12-60 months) for 252 patients comprising 146 with Crohn's disease (CD), 96 with ulcerative colitis (UC), and 10 IBD undifferentiated. Eighty-seven percent of CD patients had inflammatory disease at diagnosis, and this reduced to 73% at 5 years (n = 38). Immunomodulators were prescribed in 57% of CD patients and 19% with UC. A third of all CD patients were hospitalized, the majority (77%) in the first 12 months. Risk factors for hospitalization included penetrating, perianal, and ileocolonic disease (P < 0.05). Twenty-four percent of UC patients were hospitalized, most within the first 12 months. Intestinal resection rates were 13% at 1 year in CD and 26% at 5 years. Risk factors include penetrating and stricturing disease (P < 0.001) and ileal involvement (P < 0.05). Colectomy rates in UC were 2% and 13% at 1 and 5 years. High C-reactive protein (CRP) at diagnosis was associated with colectomy.

CONCLUSIONS

A high rate of inflammatory disease, frequent immunomodulator use in CD, and a low rate of surgery in both CD and UC were identified. In CD, ileal involvement and complex disease behavior are associated with a more severe disease course, while in UC a high CRP predicted this outcome.

Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE): Determining Therapeutic Goals for Treat-to-Target

OBJECTIVES

The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) program was initiated by the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD). It examined potential treatment targets for inflammatory bowel disease (IBD) to be used for a "treat-to-target" clinical management strategy using an evidence-based expert consensus process.

METHODS

A Steering Committee of 28 IBD specialists developed recommendations based on a systematic literature review and expert opinion. Consensus was gained if ≥75% of participants scored the recommendation as 7-10 on a 10-point rating scale (where 10=agree completely).

RESULTS

The group agreed upon 12 recommendations for ulcerative colitis (UC) and Crohn's disease (CD). The agreed target for UC was clinical/patient-reported outcome (PRO) remission (defined as resolution of rectal bleeding and diarrhea/altered bowel habit) and endoscopic remission (defined as a Mayo endoscopic subscore of 0-1). Histological remission was considered as an adjunctive goal. Clinical/PRO remission was also agreed upon as a target for CD and defined as resolution of abdominal pain and diarrhea/altered bowel habit; and endoscopic remission, defined as resolution of ulceration at ileocolonoscopy, or resolution of findings of inflammation on cross-sectional imaging in patients who cannot be adequately assessed with ileocolonoscopy. Biomarker remission (normal C-reactive protein (CRP) and calprotectin) was considered as an adjunctive target.

CONCLUSIONS

Evidence- and consensus-based recommendations for selecting the goals for treat-to-target strategies in patients with IBD are made available. Prospective studies are needed to determine how these targets will change disease course and patients' quality of life.

Consumption of dental treatment in patients with inflammatory bowel disease, a register study

Objective

The aim of this study was to compare the consumption of dental treatment among patients with Crohn´s disease (CD) or ulcerative colitis (UC) compared to age and gender matched control groups.

Design

The study group comprised 2085 patients with CD and 3161 with UC from the Uppsala-Örebro region and from the Stockholm region. The patients in the cohort were diagnosed between 1960 and 1989. Patients up to 70 years of age were included in the study. The two patients groups were compared to age- and gender-matched, randomly selected control groups from the same geographic area comprising a corresponding number of participants.

Results

CD patients had significantly higher total number of procedures registered (p < 0.000). The difference was most pronounced for removable dentures (+65%), fillings in front teeth (+52%) and endodontic treatment (+46%) when Crohn’s patients were compared to controls (p<0.001). The corresponding figures for UC patients were also a significantly higher total number of procedures (p < 0.005), more clinical examinations (p<0.000), fillings in canines and incisors (p < 0.001) and fillings in bicuspids and molars (p < 0.000).

Conclusion

This study demonstrate that CD and UC individuals use more dental treatment compared to an age-gender matched control group, and more caries-related treatments. The difference was most pronounced for restorative treatment in patients with Crohn’s.

Ulcerative colitis outpatient management: development and evaluation of tools to support primary care practitioners

BACKGROUND

Current models of care for ulcerative colitis (UC) across healthcare systems are inconsistent with a paucity of existing guidelines or supportive tools for outpatient management.

AIMS

This study aimed to produce and evaluate evidence-based outpatient management tools for UC to guide primary care practitioners and patients in clinical decision-making.

METHODS

Three tools were developed after identifying current gaps in the provision of healthcare services for patients with UC at a Clinical Insights Meeting in 2013. Draft designs were further refined through consultation and consolidation of feedback by the steering committee. Final drafts were developed following feasibility testing in three key stakeholder groups (gastroenterologists, general practitioners and patients) by questionnaire. The tools were officially launched into mainstream use in Australia in 2014.

RESULTS

Three quarters of all respondents liked the layout and content of each tool. Minimal safety concerns were aired and those, along with pieces of information that were felt to be omitted, that were reviewed by the steering committee and incorporated into the final documents. The majority (over 80%) of respondents felt that the tools would be useful and would improve outpatient management of UC.

CONCLUSION

Evidence-based outpatient clinical management tools for UC can be developed. The concept and end-product have been well received by all stakeholder groups. These tools should support non-specialist clinicians to optimise UC management and empower patients by facilitating them to safely self-manage and identify when medical support is needed.

Medical Therapy of Active Ulcerative Colitis

Background

Medical therapy of mild and moderate ulcerative colitis (UC) of any extent is evidence-based and standardized by national and international guidelines. However, patients with steroid-refractory UC still represent a challenge.

Methods

A literature search using PubMed (search terms: ulcerative colitis, therapy, new, 1-2008-2015) resulted in 821 publications. For the current article, 88 citations were extracted including 36 randomized controlled studies, 18 reviews, and 8 meta-analyses.

Results

In steroid-refractory UC, early intensive therapy using anti-tumor necrosis factor (TNF) antibodies or the calcineurin inhibitors cyclosporine and tacrolimus is indicated in any case to prevent progression to a toxic megacolon and/or to avoid proctocolectomy. In patients with chronic disease activity, treatment with anti-TNF antibodies has a higher level of evidence than azathioprine therapy and should therefore be preferred. However, there is a subgroup of UC patients who may achieve prolonged steroid-free remission on azathioprine monotherapy. The importance of vedolizumab, a newly registered inhibiting antibody against integrin, has not yet been fully clarified since direct comparison studies are lacking, in particular in relation to anti-TNF antibodies.

Conclusion

There is a great need for additional innovative therapies, especially in cases of primary non-response or secondary loss of response to anti-TNF antibodies. New small molecules (Janus kinase inhibitors) are promising with an acceptable safety profile and efficacy in UC. Further, strategies that target the intestinal microbiome are currently considered for patients with active or relapsing UC, and may in the future open up new therapeutic options.

Emerging treatments in Neurogastroenterology: Perspectives of guanylyl cyclase C agonists use in functional gastrointestinal disorders and inflammatory bowel diseases

BACKGROUND

Functional gastrointestinal disorders (FGID) and inflammatory bowel diseases (IBD) are the most frequent pathologic conditions affecting the gastrointestinal (GI) tract and both significantly reduce patients' quality of life. Recent studies suggest that guanylyl cyclase C (GC-C) expressed in the GI tract constitutes a novel pharmacological target in the treatment of FGID and IBD. Endogenous GC-C agonists - guanylin peptides: guanylin and uroguanylin, by the regulation of water and electrolyte transport, are involved in the maintenance of homeostasis in the intestines and integrity of the intestinal mucosa. Linaclotide, a synthetic agonist of GC-C was approved by Food and Drug Administration and European Medicines Agency as a therapeutic in constipation-predominant irritable bowel syndrome (IBS-C) and chronic idiopathic constipation (CIC). Lately, several preclinical and clinical trials focused on assessment of therapeutic properties of synthetic agonists of uroguanylin, plecanatide, and SP-333. Plecanatide is currently tested as a potential therapeutic in diseases related to constipation and SP-333 is a promising drug in ulcerative colitis treatment.

PURPOSE

Here, we discuss the most recent findings and future trends on the development of GC-C agonists and their use in clinical trials.

The epidemiology of inflammatory bowel disease

BACKGROUND AND AIMS

The inflammatory bowel diseases (IBD), Crohn's disease (CD) and ulcerative colitis (UC), are chronic relapsing disorders of unknown aetiology. The aim of this review is to present the latest epidemiology data on occurrence, disease course, risk for surgery, as well as mortality and cancer risks.

MATERIAL AND METHODS

Gold standard epidemiology data on the disease course and prognosis of patients with inflammatory bowel disease (IBD) are based on unselected population-based cohort studies.

RESULTS

The incidence of ulcerative colitis (UC) and Crohn's disease (CD) has increased overall in Europe from 6.0 per 100,000 person-years in UC and 1.0 per 100,000 person-years in CD in 1962 to 9.8 per 100,000 person-years and 6.3 per 100,000 person-years in 2010, respectively. The highest incidence of IBD is found on the Faroe Islands. Overall, surgery rates have been declining over the last decades, partly due to aggressive medical therapy. Among IBD patients, mortality risk is increased by up to 50% in CD when compared to the background population, but this is not the case for UC. In CD, 25 - 50% deaths are disease-specific deaths, e.g. malnutrition, postoperative complications and intestinal cancer. In UC, disease-specific causes of deaths include colorectal cancer (CRC), and surgical and postoperative complications. The risk of CRC and small bowel cancer is increased two- to eightfold among IBD patients. Various subgroups carry increased risk of malignancy, e.g. those with persistent inflammation, long-standing disease, extensive disease, young age at diagnosis, family history of CRC and co-existing primary sclerosing cholangitis. The risk of extra-intestinal cancers, including lymphoproliferative disorders (LD) and intra- and extrahepatic cholangio carcinoma, is significantly higher among IBD patients.

CONCLUSION

In recent years, self-management and patient empowerment, combined with evolving eHealth solutions, has utilized epidemiological knowledge on disease patterns and has been improving compliance and the timing of adjusting therapies, thus optimizing efficacy by individualizing medication in the community setting.

Costs of ulcerative colitis from a societal perspective in a regional health care area in Spain: A database study

OBJECTIVES

To estimate the management of UC associated costs from the societal perspective in Spain.

METHODS

Observational, longitudinal study with retrospective data collection based on reviews of outpatient health records. Socio-demographic, clinical and sick leave information was gathered. Patients diagnosed of UC between 2002 and 2012, older than 18 years, followed-up by a minimum of 12 months post diagnosis, with at least two clinical and use of resources data recorded, were included.

RESULTS

285 UC patients [51.2% men; 44.5 (SD: 15.6) years old; 88.4% without family history of UC; 39.3% proctitis; 5.6 (2.5) years disease follow-up] participated. More than half (65.6%) were active workers, 75.9% were on sick leave for reasons different from UC [mean 0.66 (0.70) times per year] during (mean) 28.43 (34.45) days. Only 64 patients were on UC-related sick-leaves, lasting (mean) 26.17 (37.43) days. Absenteeism due to medical visits caused loss of 29.55 (21.38) working hours per year. Mean direct and indirect annual cost per UC patient were €1754.10 (95%CI: 1473.37-2034.83) and €399.32 (282.31-422.69), respectively. Absenteeism was estimated at €88.21(32.72-50.06) per patient per year, in which sick-leaves were the main component of indirect costs (88.2%). Age, UC family history, diarrhea at diagnosis, blood and blood-forming organs diseases and psychological disorders were the main predictors of indirect costs.

CONCLUSIONS

UC is a costly disease for the society and the Spanish National Healthcare System. Indirect costs imply a major burden by affecting the most productive years of patients. Further research is needed considering all components of productivity loss, including presenteeism-associated costs.

Environmental risk factors in inflammatory bowel disease: a population-based case-control study in Asia-Pacific

OBJECTIVE

The rising incidence of inflammatory bowel disease in Asia supports the importance of environmental risk factors in disease aetiology. This prospective population-based case-control study in Asia-Pacific examined risk factors prior to patients developing IBD.

DESIGN

442 incident cases (186 Crohn's disease (CD); 256 UC; 374 Asians) diagnosed between 2011 and 2013 from eight countries in Asia and Australia and 940 controls (frequency-matched by sex, age and geographical location; 789 Asians) completed an environmental factor questionnaire at diagnosis. Unconditional logistic regression models were used to estimate adjusted ORs (aOR) and 95% CIs.

RESULTS

In multivariate model, being breast fed >12 months (aOR 0.10; 95% CI 0.04 to 0.30), antibiotic use (aOR 0.19; 0.07 to 0.52), having dogs (aOR 0.54; 0.35 to 0.83), daily tea consumption (aOR 0.62; 0.43 to 0.91) and daily physical activity (aOR 0.58; 0.35 to 0.96) decreased the odds for CD in Asians. In UC, being breast fed >12 months (aOR 0.16; 0.08 to 0.31), antibiotic use (aOR 0.48; 0.27 to 0.87), daily tea (aOR 0.63; 0.46 to 0.86) or coffee consumption (aOR 0.51; 0.36 to 0.72), presence of hot water tap (aOR 0.65; 0.46 to 0.91) and flush toilet in childhood (aOR 0.71; 0.51 to 0.98) were protective for UC development whereas ex-smoking (aOR 2.02; 1.22 to 3.35) increased the risk of UC.

CONCLUSIONS

This first population-based study of IBD risk factors in Asia-Pacific supports the importance of childhood immunological, hygiene and dietary factors in the development of IBD, suggesting that markers of altered intestinal microbiota may modulate risk of IBD later in life.

Beliefs and behaviour about smoking among inflammatory bowel disease patients

BACKGROUND AND AIMS

We investigated the beliefs and behaviours about tobacco among inflammatory bowel disease (IBD) patients.

MATERIALS AND METHODS

A questionnaire of 18 items was developed and administered to all consecutive patients followed for IBD at Nancy University Hospital from October 2012 to March 2013.

RESULTS

Two hundred and thirty-one patients participated in the survey [Crohn's disease (CD)=171, ulcerative colitis (UC)=60]. Among IBD patients who were smokers at diagnosis, 10.5% of CD patients versus 14.3% of UC patients believed that tobacco could have triggered their IBD; about half the CD smokers at diagnosis were not aware that smoking might promote their disease. Three quarters of smokers after diagnosis knew that tobacco was not beneficial for their CD, whereas all UC were aware that smoking had a beneficial effect on their disease course. About half of the CD patients had stopped smoking during a flare-up. Four former smokers with UC (21.1%) resumed smoking during a relapse. Nearly 90% of IBD current smokers wished to quit smoking. About half the IBD patients were aware of the relation between smoking and IBD, and the Internet was a source for 24.3% of these patients.

CONCLUSION

The majority of IBD patients are unaware of the effects of tobacco on their disease. Better information through a therapeutic education programme should be systematically recommended in IBD.

Biosimilars in inflammatory bowel disease: ready for prime time?

PURPOSE OF REVIEW

The goal is to review the most recent literature about biosimilars in inflammatory bowel disease (IBD), with emphasis on controversial regulatory issues.

RECENT FINDINGS

Although biosimilars have been in use in Europe since 2005, the recent approval of CT-P13 (Remsima, Inflectra), a biosimilar of the reference infliximab (Remicade), by the European Medicines Agency (EMA) and several regulatory agencies has become a widely discussed topic in IBD, rheumatology, and other areas. Biologics are the main drivers of cost in current IBD units, and biosimilars can reduce prices thus increasing the availability of this type of treatment. The guidelines for evaluation of biosimilars are considerably different from those of the reference biologics, regulatory agencies relying on detailed in-vitro studies for defining 'high similarity', and requiring many fewer clinical data. 'High similarity' is considered sufficient for clinical trials, as the new molecule is demonstrated so structurally similar to the reference one that no significant difference in efficacy or safety is expected. Two trials in ankylosing spondylitis and rheumatoid arthritis gave no evidence of real difference and provided the required pharmacokinetic and PD data. The main controversy remains in the 'extrapolation' of indications, accepted by EMA but not by Health Canada. Position statements from several scientific societies and some expert's reviews have expressed concerns to the concept of extrapolation without direct IBD clinical evidence, whereas EMA experts have published detailed reviews supporting extrapolation.

SUMMARY

Biosimilars in IBD are here to stay. New data are awaited to settle the controversy of extrapolation, but only the complex behavior of markets will show whether biosimilars fuel competition and extend access to biologics with significant cuts in drug costs.

Diagnostic accuracy of three different MRI protocols in patients with inflammatory bowel disease

BACKGROUND

Magnetic resonance imaging (MRI) is used for workup and control of inflammatory bowel disease (IBD); however, disagreement remains as to how the MRI should be performed.

PURPOSE

To compare prospectively the diagnostic accuracy of MRI with neither oral nor intravenous contrast medium (plain MRI), magnetic resonance follow-through (MRFT) and MR enteroclysis (MRE) using MRE as the reference standard in patients with inflammatory bowel disease.

MATERIAL AND METHODS

Plain MRI and MRE were carried out in addition to MRFT. All patients underwent both plain MR and MRFT on the same day and MRE within seven days. For the evaluation, the bowel was divided into nine segments. One radiologist, blinded to clinical findings, evaluated bowel wall thickness, diffusion weighted imaging (DWI), mural hyperenhancement, and other inflammatory changes in each bowel segment.

RESULTS

Twenty patients (6 men, 14 women; median age, 43.5 years; age range, 26-76 years) underwent all three examinations; 10 with Crohn's disease (CD), three with ulcerative colitis (UC), and seven with IBD unclassified (IBD-U). Sensitivity, specificity, and accuracy were in the range of 0-75%, 81-96%, and 75-95% for wall thickening, and 0-37%, 59-89%, and 50-86% for DWI in plain MRI, respectively. Sensitivity, specificity, and accuracy were in the range of 0-50%, 96-100%, and 90-100% for wall thickening, 0-50%, 84-97%, and 82-95% for DWI, and 0-71%, 94-100%, and 85-100% for mural hyperenhancement in MRFT, respectively.

CONCLUSION

The use of oral and intravenous contrast agent improves detection of bowel lesions resulting in MRFT remaining the superior choice over plain MRI for diagnostic workup in patients with IBD.

Prevalence and predictors of hospitalization in Crohn’s disease in a prospective population-based inception cohort from 2000-2012

AIM: To analyze the prevalence, length and predictors of hospitalization in the biological era in the population-based inception cohort from Veszprem province.

METHODS: Data of 331 incident Crohn’s disease (CD) patients diagnosed between January 1, 2000 and December 31, 2010 were analyzed (median age at diagnosis: 28; IQR: 21-40 years). Both in- and outpatient records were collected and comprehensively reviewed.

RESULTS: Probabilities of first CD-related hospitalization and re-hospitalization were 32.3%, 45.5%, 53.7% and 13.6%, 23.9%, 29.8%, respectively after one, three and five years of follow-up in Kaplan-Meier analysis. First-year hospitalizations were related to diagnostic procedures (37%), surgery or disease activity (27% and 21%). Non-inflammatory disease behavior at diagnosis (HR = 1.32, P = 0.001) and perianal disease (HR = 1.47, P = 0.04) were associated with time to first CD-related hospitalization, while disease behavior change (HR = 2.38, P = 0.002) and need for steroids (HR = 3.14, P = 0.003) were associated with time to first re-hospitalization in multivariate analyses. Early CD-related hospitalization (within the year of diagnosis) was independently associated with need for immunosuppressives (OR = 2.08, P = 0.001) and need for surgeries (OR = 7.25, P < 0.001) during the disease course.

CONCLUSION: Hospitalization and re-hospitalization rates are still high in this cohort, especially during the first-year after the diagnosis. Non-inflammatory disease behavior at diagnosis was identified as the pivotal predictive factor of both hospitalization and re-hospitalization.

Does the consumption of fruits and vegetables differ between Eastern and Western European populations? Systematic review of cross-national studies

BACKGROUND

Difference in fruit and vegetable consumption has been suggested as a possible reason for the large gap in cardiovascular disease (CVD) mortality rates between Eastern and Western European populations. However, individual-level dietary data which allow direct comparison across the two regions are rare. In this systematic review we aimed to answer the question whether cross-national studies with comparable individual-level dietary data reveal any systematic differences in fruit and vegetable consumption between populations in Central and Eastern Europe (CEE) and the Former Soviet Union (FSU) compared to Western Europe (WE).

METHODS

Studies were identified by electronic search of MEDLINE, EMBASE and Web of Science databases from inception to September 2014, and hand search. Studies which reported data on fruit, vegetable consumption or carotene and vitamin C intake or tissue concentrations of adult participants from both CEE/FSU and WE countries were considered for inclusion. Quality of the included studies was assessed by a modified STROBE statement. Power calculation was performed to determine the statistical significance of the comparison results.

RESULTS

Twenty-two studies fulfilled the inclusion criteria. Fruit consumption was found to be consistently lower in CEE/FSU participants compared to Western Europeans. Results on vegetable intake were less unambiguous. Antioxidant studies indicated lower concentration of beta-carotene in CEE/FSU subjects, but the results for vitamin C were not consistent.

CONCLUSION

This systematic review suggests that populations in CEE and FSU consume less fruit than Western Europeans. The difference in the consumption of fruit may contribute to the CVD gap between the two regions.

Inflammatory Bowel Disease Cohort Studies in Korea: Present and Future

Inflammatory bowel disease (IBD) is defined as a chronic and relapsing inflammatory disorder of the intestine. Intestinal inflammation in IBD has been proposed to be attributable to the interplay between microbial, genetic, environmental, and immunological factors. The incidence and prevalence rates of IBD are rapidly increasing apparently in other parts of the world, with dramatic increases especially in East Asia. Generally, cohort studies are useful for estimating the incidence, prevalence, natural course, prognosis, and risk factors of diseases. In particular, cohort studies performed in Western countries have well described the prevalence, risk factors, and natural course of IBD and investigated its genetic pathophysiology. However, the outcomes of IBD cohort studies performed in Korea are not as persuasive as those of Western studies because of the relatively low prevalence of IBD and short follow-up periods of the cohorts in Korea. Despite this critical limitation, members of the Korean Association for the Study of Intestinal Diseases have demonstrated outstanding results. Some unique features of IBD patients in Korea are well demonstrated, such as thiopurine-induced leukopenia or risks of opportunistic tuberculosis infection in patients receiving tumor necrosis factor-α inhibitors. In this review, the present authors summarized the key points of the results of the cohort studies performed in Korea and explored future perspectives.

Direct and indirect healthcare resource utilization and costs associated with ulcerative colitis in a privately-insured employed population in the US

OBJECTIVE

To assess direct and indirect healthcare resource utilization and costs of privately insured US employees with ulcerative colitis (UC) from a societal perspective.

RESEARCH DESIGN AND METHODS

Employees aged 18-64 with ≥ 2 UC diagnoses and no more than one diagnosis of Crohn's disease (CD) were identified from a large, de-identified, private insurance US claims database from January 1, 2005 through March 31, 2013. Patients with UC were matched 1:1 to non-IBD controls based on demographics and index date (a randomly selected UC diagnosis). All patients were required to have continuous eligibility for ≥ 1 year before (baseline period) and after (study period) the index date. Descriptive analyses compared baseline characteristics and study period outcomes. Multivariate cost analysis adjusted for baseline comorbidities. Sub-group analyses compared patients with moderate-to-severe UC with matched controls.

MAIN OUTCOME MEASURES

Costs (2013 US dollars) were measured from a societal perspective, which included direct (patient and payer costs) and indirect (lost wages because of time away from work) costs.

RESULTS

Patients with UC (n = 4314; mean age = 45.1 years, 63.6% male) had significantly higher baseline comorbidity rates compared with controls. In the study period, significantly more patients with UC (p < 0.0001) had higher hospitalization rates (16.9% vs 6.2%), emergency department visits (31.1% vs 22.0%), prescription drug use (95.3% vs 72.0%), and work loss (100% vs 81.4%). Patients with UC also had significantly higher adjusted total direct ($15,548 vs $4812) and indirect costs ($4125 vs $1961). Patients with moderate-to-severe UC (n = 1728) had significantly (p < 0.0001) higher hospitalization rates (26.5% vs 6.2%) and adjusted total direct ($23,085 vs $4932) and indirect costs ($5666 vs $1960).

CONCLUSIONS

Patients with UC had higher resource utilization and direct and indirect costs compared with matched controls. The excess burden was greatest in patients with moderate-to-severe UC.

The risk of colorectal cancer is related to frequent hospitalization of IBD in an Asian population: results from a nationwide study

BACKGROUND

The occurrence of inflammatory bowel disease (IBD) is higher in Western countries and is increasing worldwide. The incidence of IBDs is about nearly 20-fold in Western countries than Asia and has risen in Taiwan over the past few decades. Epidemiological studies have demonstrated an increased risk of colorectal cancer (CRC) in patients with IBD. The prevalence of IBD as well as IBD-associated CRC is changing and the risk of CRC in patients with IBD appears to be greater in Western countries, but CRC risk in IBD patients is less well understood in low endemic areas, such as Asia.

METHODS

This population-based cohort study collected data from the Taiwan Health Insurance Research Database (from January 1998 to December 2011). In total, 10 650 patients with confirmed diagnosis of IBD served as the IBD cohort and 42 600 non-IBD subjects were enrolled. Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) were used to assess the risk of CRC.

RESULTS

The incidence of CRC was slightly lower in the IBD cohort compared with that in the non-IBD cohort (0.94 vs. 1.13 per 1000 person-years), with an adjusted HR of 0.99 (95% CI: 0.71-1.37). More than four hospitalizations were associated with a significantly higher risk of CRC in IBD patients in the Cox model (adjusted HR = 3.48, 95% CI: 1.59-7.63).

CONCLUSIONS

The risk for CRC was not increased among IBD patients overall, but appeared to be increased with cumulative frequency of hospitalizations for IBD.

Inflammatory bowel disease associates with proinflammatory potential of the immunoglobulin G glycome

BACKGROUND

Glycobiology is an underexplored research area in inflammatory bowel disease (IBD), and glycans are relevant to many etiological mechanisms described in IBD. Alterations in N-glycans attached to the immunoglobulin G (IgG) Fc fragment can affect molecular structure and immunological function. Recent genome-wide association studies reveal pleiotropy between IBD and IgG glycosylation. This study aims to explore IgG glycan changes in ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

IgG glycome composition in patients with UC (n = 507), CD (n = 287), and controls (n = 320) was analyzed by ultra performance liquid chromatography.

RESULTS

Statistically significant differences in IgG glycome composition between patients with UC or CD, compared with controls, were observed. Both UC and CD were associated with significantly decreased IgG galactosylation (digalactosylation, UC: odds ratio [OR] = 0.71; 95% confidence interval [CI], 0.5-0.9; P = 0.01; CD: OR = 0.41; CI, 0.3-0.6; P = 1.4 × 10) and significant decrease in the proportion of sialylated structures in CD (OR = 0.46, CI, 0.3-0.6, P = 8.4 × 10). Logistic regression models incorporating measured IgG glycan traits were able to distinguish UC and CD from controls (UC: P = 2.13 × 10 and CD: P = 2.20 × 10), with receiver-operator characteristic curves demonstrating better performance of the CD model (area under curve [AUC] = 0.77) over the UC model (AUC = 0.72) (P = 0.026). The ratio of the presence to absence of bisecting GlcNAc in monogalactosylated structures was increased in patients with UC undergoing colectomy compared with no colectomy (FDR-adjusted, P = 0.05).

CONCLUSIONS

The observed differences indicate significantly increased inflammatory potential of IgG in IBD. Changes in IgG glycosylation may contribute to IBD pathogenesis and could alter monoclonal antibody therapeutic efficacy. IgG glycan profiles have translational potential as IBD biomarkers.

The use of prognostic factors in inflammatory bowel diseases

The disease spectrum and natural course of Crohn's disease and ulcerative colitis are highly variable. The majority of Crohn's disease patients will require surgery at a certain stage in their disease compared to only a fraction of the ulcerative colitis patients. Similarly, some patients are destined to experience an indolent disease course while others will require early intensive therapy. Ideally, these subtypes of patients should be identified as early as possible with the help of reliable prognostic factors in order to guide personalized therapeutic decisions. In this review, the authors focused on the most relevant reports on the use of different prognostic factors to predict disease course, postoperative recurrence and response to therapy in patients with inflammatory bowel disease. The last 15 years have seen a wealth of novel genetic and serological markers of disease severity. Nevertheless, none of these markers have proven to be superior to careful clinical phenotyping and endoscopic features early in the disease course. Future attempts should apply an integrated approach that unites clinical, serological and (epi)genetic information with environmental influences, with a clear focus on the microbiome to ultimately identify molecular-based and clinically relevant subgroups.

Extraintestinal Helminth Infection Limits Pathology and Proinflammatory Cytokine Expression during DSS-Induced Ulcerative Colitis: A Role for Alternatively Activated Macrophages and Prostaglandins

Chronic inflammation of the intestinal mucosa is characteristic of inflammatory bowel diseases such as ulcerative colitis and Crohn's disease. Helminth parasites have developed immunomodulatory strategies that may impact the outcome of several inflammatory diseases. Therefore, we investigated whether Taenia crassiceps infection is able to decrease the inflammatory effects of dextran sulfate sodium- (DSS-) induced ulcerative colitis in BALB/c and C57BL/6 mice. Preinfection significantly reduced the manifestations of DSS-induced colitis, as weight loss and shortened colon length, and decreased the disease activity index independently of the genetic background of the mice. Taenia infection decreased systemic levels of proinflammatory cytokines while increasing levels of IL-4 and IL-10, and the inflammatory infiltrate into the colon was also markedly reduced. RT-PCR assays from colon showed that T. crassiceps-infected mice displayed increased expression of Arginase-1 but decreased expression of iNOS compared to DSS-treated uninfected mice. The percentages of T regulatory cells were not increased. The adoptive transfer of alternatively activated macrophages (AAMФs) from infected mice into mice with DSS-induced colitis reduced the severity of colon inflammation. Administration of indomethacin abrogated the anticolitic effect of Taenia. Thus, T. crassiceps infection limits the pathology of ulcerative colitis by suppressing inflammatory responses mechanistically associated with AAMФs and prostaglandins.

Tools for primary care management of inflammatory bowel disease: Do they exist?

Healthcare systems throughout the world continue to face emerging challenges associated with chronic disease management. Due to the likely increase in chronic conditions in the future it is now vital that cooperation and support between specialists, generalists and primary health care physicians is conducted. Inflammatory bowel disease (IBD) is one such chronic disease. Despite specialist care being essential, much IBD care could and probably should be delivered in primary care with continued collaboration between all stakeholders. Whilst most primary care physicians only have few patients currently affected by IBD in their caseload, the proportion of patients with IBD-related healthcare issues cared for in the primary care setting appears to be widespread. Data suggests however, that primary care physician’s IBD knowledge and comfort in management is suboptimal. Current treatment guidelines for IBD are helpful but they are not designed for the primary care setting. Few non-expert IBD management tools or guidelines exist compared with those used for other chronic diseases such as asthma and scant data have been published regarding the usefulness of such tools including IBD action plans and associated supportive literature. The purpose of this review is to investigate what non-specialist tools, action plans or guidelines for IBD are published in readily searchable medical literature and compare these to those which exist for other chronic conditions.

Incidence and phenotype at diagnosis of inflammatory bowel disease. Results in Spain of the EpiCom study

INTRODUCTION

Incidence of inflammatory bowel disease (IBD) is increasing progressively. Few recent epidemiological prospective studies are available in Spain. The Epicom study, a population-based inception cohort of unselected IBD patients developed within the European Crohn's and Colitis Organization, was started in 2010. Vigo is the only Spanish area participating.

OBJECTIVE

To describe the incidence of IBD in the Vigo area and the phenotypical characteristics at diagnosis and to compare them with previous data available in Spain.

MATERIAL AND METHODS

Epidemiological, descriptive, prospective, and population-based study. All incident cases of IBD during 2010 and living in the Vigo area at diagnosis were included. The Copenhagen Diagnostic criteria were used to define cases. Background population at the start of the study was 579,632 inhabitants. Data were prospectively entered in the EpiCom database.

RESULTS

A total of 106 patients were included (57.5% men, median age 39.5 years). Of them 53 were diagnosed of as Crohn's disease (CD), 47 ulcerative colitis (UC) and six IBD unclassified (IBDU). The incidence rate per 100,000 per year for patients aged 15 years or older was 21.4 (10.8 for CD, 9.4 for UC, 1.2 IBDU). Including pediatric population incidence rates were 18.3 (10.3 CD, 8.7 UC, 1.2 IBDU). Median time since onset of symptoms until diagnosis was 2 months.

CONCLUSIONS

The incidence rate of IBD in Vigo is the highest compared to former Spanish cohorts, especially in CD patients. Median time since onset of symptoms until diagnosis is relatively short.

Protective effects of Semen Crotonis Pulveratum on trinitrobenzene sulphonic acid-induced colitis in rats and H₂O₂-induced intestinal cell apoptosis in vitro

Ulcerative colitis (UC) is a chronic inflammatory bowel disease. Semen Crotonis Pulveratum (SCP) has been used as a traditional medicine for the treatment of UC. However, its molecular mechanisms of action have not yet been elucidated. In the present study, we aimed to investigate the preliminary mechanisms of the role of SCP on trinitrobenzene sulphonic acid (TNBS)-induced UC in rats and hydrogen peroxide (H2O2)-induced intestinal cell apoptosis in vitro. Wistar rats (n=9 per group) were randomly divided into 4 groups: the normal control group, the UC group, the UC + SCP group and the UC + sulfasalazine group as a positive control. The proportion of CD4+CD25+ T cells and CD4+CD25+Foxp3+ Tregs, and the expression levels of interleukin (IL)-6 and IL-10 in the peripheral blood, as well as the expression levels of cyclooxygenase-2 (COX-2) and intercellular adhesion molecule-1 (ICAM-1) in the colon tissues were determined by flow cytometry, ELISA and immunohistochemical staining, respectively. Rat intestinal epithelial (IEC-6) cell apoptosis induced by H2O2 was determined by TUNEL assay, flow cytometry using Annexin V/propidium iodide (PI) staining and western blot analysis of caspase-3 activation, respectively. Significantly higher proportions of circulating CD4+CD25+ T cells and CD4+CD25+Foxp3+ Tregs were present in the UC + SCP group compared with the UC group. A significantly decreased expression of IL-6 and an increased expression of IL-10 were also observed in the UC + SCP group compared with UC group. SCP significantly reduced the UC-induced increase in the expression of COX-2 and ICAM-1 in the colon tissues. SCP inhibited cell apoptosis and caspase-3 activation induced by H2O2 in the ICE-6 cells. Our data thus indicate that SCP inhibits inflammation in UC by increasing the proportion of circulating Tregs, altering cytokine production and decreasing COX-2 and ICAM-1 expression. In addition it protects against H2O2-induced intestinal cell apoptosis in vitro.

Clinical aspects of indirect immunofluorescence for autoimmune diseases

Because the most common term used in conversations considering autoimmunity is autoantibodies, it is well-expected that the indirect immunofluorescence assay, which detects antibodies directed against various antigens, is one of our most impressive techniques for investigating autoimmune diseases (AIDs). Roughly speaking, the current literature corroborates that this immunopathologic investigation means that autoantibodies detection makes a considerable contribution to both diagnostic and prognostic aspects of AIDs in the clinical setting. However, it varies between different AIDs, autoantibodies, ethnicities or detection methodologies. Directly focusing on the indirect immunofluorescence assay, we present evidence to support this multidimensional variation regarding the subject via reviewing briefly the best-investigated autoantibodies in the well-documented AIDs, including vasculitis, inflammatory bowel disease, scleroderma, autoimmune hepatitis, primary biliary cirrhosis, systemic lupus erythematosus and Sjögren's syndrome.

Inflammatory bowel disease among Bedouin Arabs in southern Israel: urbanization and increasing prevalence rates

BACKGROUND AND AIM

Inflammatory bowel disease (IBD) has been associated with genetic and environmental factors, including urban living. IBD was rare in the Israeli Bedouin community 30 years ago. Over recent decades, a large proportion of this community has undergone a transition from a nomadic to a western lifestyle. Our aim was to carry out an updated evaluation of the clinical and epidemiological features of IBD in the Bedouin sector of southern Israel.

METHODS

All Bedouin patients with a known diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were included in the retrospective study.

RESULTS

The cohort included 31 CD patients and 31 UC patients. The mean age of the patients at diagnosis was 29±10.9 and 35±17.5 years for CD and UC, respectively. The prevalence rate for CD was 15.5/100,000 and the incidence rate was 0.8-3.55/100,000. Fourteen of the CD patients (45%) had ileal disease and 64.5% had inflammatory disease behavior according to the Montreal classification. Eleven of the CD patients (35%) were treated with anti-TNF-α and 26% had undergone surgery. Over the previous decade, the prevalence of UC was 14/100,000 and the incidence was 0.5-2.39/100,000. Eighteen UC patients (58%) had left-sided colitis. Three (9.7%) had undergone total colectomy for severe disease.

CONCLUSION

We found an increased prevalence of IBD in the Bedouin population, associated with their change in lifestyle over previous decades. However, the prevalence is still markedly lower than that in other population groups. A high percentage of patients were treated with anti-TNF-α and/or surgery.

Funding a smoking cessation program for Crohn's disease: an economic evaluation

OBJECTIVES

Patients with Crohn's disease (CD) who smoke are at a higher risk of flaring and requiring surgery. Cost-effectiveness studies of funding smoking cessation programs are lacking. Thus, we performed a cost-utility analysis of funding smoking cessation programs for CD.

METHODS

A cost-utility analysis was performed comparing five smoking cessation strategies: No Program, Counseling, Nicotine Replacement Therapy (NRT), NRT+Counseling, and Varenicline. The time horizon for the Markov model was 5 years. The health states included medical remission (azathioprine or antitumor necrosis factor (anti-TNF), dose escalation of an anti-TNF, second anti-TNF, surgery, and death. Probabilities were taken from peer-reviewed literature, and costs (CAN$) for surgery, medications, and smoking cessation programs were estimated locally. The primary outcome was the cost per quality-adjusted life year (QALY) gained associated with each smoking cessation strategy. Threshold, three-way sensitivity, probabilistic sensitivity analysis (PSA), and budget impact analysis (BIA) were carried out.

RESULTS

All strategies dominated No Program. Strategies from most to least cost effective were as follows: Varenicline (cost: $55,614, QALY: 3.70), NRT+Counseling (cost: $58,878, QALY: 3.69), NRT (cost: $59,540, QALY: 3.69), Counseling (cost: $61,029, QALY: 3.68), and No Program (cost: $63,601, QALY: 3.67). Three-way sensitivity analysis demonstrated that No Program was only more cost effective when every strategy's cost exceeded approximately 10 times their estimated costs. The PSA showed that No Program was the most cost-effective <1% of the time. The BIA showed that any strategy saved the health-care system money over No Program.

CONCLUSIONS

Health-care systems should consider funding smoking cessation programs for CD, as they improve health outcomes and reduce costs.

The th17/treg immune balance in ulcerative colitis patients with two different chinese syndromes: dampness-heat in large intestine and spleen and kidney yang deficiency syndrome

Objective. To investigate the Th17/Treg immune balance in the ulcerative colitis (UC) patients with two Chinese syndrome: dampness-heat in large intestine (DHLI) and spleen and kidney Yang deficiency (SKYD). Methods. Ninety UC patients (45 were diagnosed with DHLI and 45 with SKYD syndrome) and 23 healthy people were recruited. The serumIL-17 and TGF-β1 levels of these participants were measured with ELISA; the expression of IL-17 and TGF-β 1 in colonic mucosa tissue was determined with immunohistochemistry and the percentage of Th17 and Treg in peripheral blood with flow cytometry. Results. The levels of IL-17 and Th17 were significantly higher in both DHLI and SKYD groups than in healthy control group and higher in DHLI than in SKYD group (P < 0.05). The levels of TGF-β1 and Treg were significantly lower in the two UC patients groups than in healthy control group; and lower in SKYD group than in DHLI group (P < 0.05). Conclusions. UC with DHLI syndrome could be characterized by the elevation of Th17 and IL-17 levels, which indicated an accentuation of inflammatory reaction; UC with SKYD syndrome could be characterized by the reduction of serum Treg and TGF-β1 levels, which represented a depression of immune tolerance.

Higher levels of knowledge reduce health care costs in patients with inflammatory bowel disease

BACKGROUND

The potentially high costs of care associated with inflammatory bowel disease are recognized. A knowledge-based self-management approach seems to reduce health care costs, improve disease control, and reduce indirect costs. The aim of this study was to determine whether there is a significant association between patient knowledge and health care costs.

METHODS

Patients diagnosed with inflammatory bowel disease, Crohn's disease (CD), ulcerative colitis, or indeterminate colitis, in 2010 to 2011 were included. Direct costs were investigated for each patient, including costs of blood tests, procedures, medications, hospitalization, and visits. Specific prices were reported according to the hospital billing database for 2010. For medical and surgical hospital admissions, DRG 19 prices were reported. A validated questionnaire (CCKNOW) was used to assess disease-related knowledge.

RESULTS

Ninety-one patients (38 men), mean age 47 years (range, 33-63 yr) were studied (14 indeterminate colitis, 33 CD, and 44 ulcerative colitis). Median cost for patients is higher in CD (&OV0556;4099.02). The mean overall CCKNOW score was 8.00 (8.50 for indeterminate colitis, 7.50 for CD, and 7.50 for ulcerative colitis). An increase of 5 points on the CCKNOW corresponds to a cost decrease of &OV0556;1099.53 in the first year of disease.

CONCLUSIONS

Higher levels of knowledge were shown to be associated with significantly lower health care costs. The data suggest that better information could lead to better choices and improved outcomes; thus, patient information and education is a key priority for managing patients with inflammatory bowel disease, perhaps planning structured and formal patient education programs in the future.