Prognostic factors and long-term clinical outcomes for surgical patients with intestinal Behcet's disease

Outcome measures used in clinical trials for Behçet syndrome: a systematic review

Behçet syndrome (BS) is a multisystem vasculitis that is most active during young adulthood, causing serious disability and significant impairment in quality of life. Differences in the disease course, severity, and organ involvement between patients, depending on the age at presentation and sex, makes it impossible to determine a single management strategy. The diversity and variability in the outcome measures used in clinical trials in BS makes it difficult to compare the results or inform physicians about the best management strategy for individual patients. There is a large unmet need to determine or develop validated outcome measures for use in clinical trials in BS that are acceptable to researchers and regulatory agencies. We conducted a systematic review to describe the outcomes and outcome measures that have been used in clinical trials in BS. This review revealed the diversity and variability in the outcomes and outcome measures and the lack of standard definitions for most outcomes and rarity of validated outcome tools for disease assessment in BS. This systematic literature review will identify domains and candidate instruments for use in a Delphi exercise, the next step in the development of a core set of outcome measures that are properly validated and widely accepted by the collaboration of researchers from many different regions of the world and from different specialties, including rheumatology, ophthalmology, dermatology, gastroenterology, and neurology.

Radiation exposure from abdominal imaging studies in patients with intestinal Behçet disease

Background/Aims

Recently, several studies have revealed that diagnostic imaging can result in exposure to harmful levels of ionizing radiation in inflammatory bowel disease patients. However, the extent of radiation exposure in intestinal Behcet disease (BD) patients has not been documented. The aim of this study was to estimate the radiation exposure from abdominal imaging studies in intestinal BD patients.

Methods

Patients with a diagnosis of intestinal BD established between January 1990 and March 2012 were investigated at a single tertiary academic medical center. The cumulative effective dose (CED) was calculated retrospectively from standard tables and by counting the number of abdominal imaging studies performed. High exposure was defined as CED >50 mSv.

Results

In total, 270 patients were included in the study. The mean CED was 41.3 mSv, and 28.1% of patients were exposed to high levels of radiation. Computed tomography (CT) accounted for 81.7% of the total effective dose. In multivariate analyses, predictors of high radiation exposure were azathioprine/6-mercaptopurine use, surgery, and hospitalization.

Conclusions

Approximately a quarter of intestinal BD patients were exposed to harmful levels of diagnostic radiation, mainly from CT examination. Clinicians should reduce the number of unnecessary CT examinations and consider low-dose CT profiles or alternative modalities such as magnetic resonance enterography.

Outcome predictors for intestinal Behçet's disease

Behçet's disease (BD) is a multisystem inflammatory disorder that presents as recurrent oral and genital ulcers in conjunction with other dermatological and ocular manifestations. The prevalence of BD is higher in Middle and East Asia than in Western countries. Intestinal BD is a specific subtype of BD, characterized by intestinal ulcers and associated gastrointestinal symptoms. Similar to inflammatory bowel disease, intestinal BD exhibits a fluctuating disease course with repeated episodes of relapse and remission that necessitate adequate maintenance therapy after achievement of clinical remission. Medical treatment of intestinal BD is largely empirical since well-controlled studies have been difficult to perform due to the heterogeneity and rarity of the disease. To date, 5-aminosalicylic acid, systemic corticosteroids, and immunosuppressants have been used anecdotally to treat intestinal BD. The clinical course of intestinal BD shows considerable variability, and the exact point at which more potent agents such as immunosuppressants should be used has not yet been elucidated. Given the difficulty in predicting which patients will experience complicated disease courses and the fact that these drugs are related with certain risk resulting from immunosuppression, proper identification of prognostic factors in intestinal BD may allow physicians to implement tailored medical therapy and individualized patient monitoring based on risk stratification. In this review, the impact of baseline characteristics on the long-term course of intestinal BD, prognostic factors during various medical therapies, and outcome predictors related to surgery will be discussed.

Clinical course of intestinal Behcet's disease during the first five years

BACKGROUND

Little is known about the clinical course of patients with intestinal Behcet's disease (BD). We aimed to evaluate the clinical course of intestinal BD during the first 5 years after diagnosis, and to identify factors that could predict the 5-year clinical course.

METHODS

We reviewed the medical records of 130 intestinal BD patients who were regularly followed-up for at least 5 years at a single tertiary academic medical center between March 1986 and September 2011.

RESULTS

Of the five different clinical course patterns that we observed, persistent remission or mild clinical activity was the most frequent course (56.2 %). The majority of patients (74.6 %) had remission or mild clinical activity at 5 years, and only the minority (16.2 %) had multiple relapses or chronic symptoms. The clinical course of the first year after diagnosis of intestinal BD influenced the clinical course of the following years. Patients in the severe clinical course group were younger, and had a higher ESR, CRP level, and disease activity index for intestinal Behcet's disease (DAIBD), and lower albumin level at diagnosis than patients in the mild clinical course group. Initial presentation with a high DAIBD was independently associated with a severe clinical course.

CONCLUSIONS

The clinical course of intestinal BD during the first 5 years was variable. A substantial proportion of patients went into remission or had a mild clinical activity, while some patients had a severe, debilitating clinical course as time progressed. High disease activity at diagnosis was a negative prognostic predictor.

Long-term clinical outcomes of Crohn's disease and intestinal Behcet's disease

BACKGROUND

Crohn's disease (CD) and intestinal Behcet's disease (BD) are transmural inflammatory diseases with fluctuating courses characterized by repeated episodes of relapse and remission that often require operation or reoperation. However, no study has directly compared the long-term prognoses of these two diseases.

METHODS

We reviewed the medical records of 332 patients with CD and 276 patients with intestinal BD who were regularly followed up at a single tertiary academic medical center in Korea between March 1986 and July 2010. The clinical outcomes after diagnosis and surgery were analyzed using the Kaplan-Meier method and log-rank test.

RESULTS

There were no significant differences in the cumulative probabilities of surgery (29.4% and 36.0% vs. 31.6% and 44.4% at 5 and 10 years, respectively: P = 0.287) or admission (66.1% and 73.8% vs. 59.0% and 69.2%, P = 0.259) between CD and intestinal BD. Furthermore, no differences were observed between the two diseases for the cumulative probabilities of postoperative clinical recurrence (P = 0.724) and reoperation (P = 0.770). However, the cumulative probabilities of corticosteroid use (63.8% and 76.6% vs. 42.6% and 59.4% at 5 and 10 years, respectively: P < 0.001) and immunosuppressant use (49.1% and 65.5% vs. 27.1% and 37.7%, P < 0.001) were significantly higher in CD patients than in intestinal BD patients.

CONCLUSIONS

There were no significant differences in the long-term clinical outcomes and postoperative prognoses between CD and intestinal BD, although CD patients required corticosteroid or immunosuppressant therapy more often than intestinal BD patients.

Correlations between endoscopic and clinical disease activity indices in intestinal Behcet's disease

AIM: To develop a novel endoscopic severity model of intestinal Behcet's disease (BD) and to evaluate its feasibility by comparing it with the actual disease activity index for intestinal Behcet's disease (DAIBD).

METHODS: We reviewed the medical records of 167 intestinal BD patients between March 1986 and April 2011. We also investigated the endoscopic parameters including ulcer locations, distribution, number, depth, shape, size and margin to identify independent factors associated with DAIBD. An endoscopic severity model was developed using significant colonoscopic variables identified by multivariate regression analysis and its correlation with the DAIBD was evaluated. To determine factors related to the discrepancy between endoscopic severity and clinical activity, clinical characteristics and laboratory markers of the patients were analyzed.

RESULTS: A multivariate regression analysis revealed that the number of intestinal ulcers (≥ 2, P = 0.031) and volcanoshaped ulcers (P = 0.001) were predictive factors for the DAIBD. An endoscopic severity model (Y) was developed based on selected endoscopic variables as follows: Y = 47.44 + 9.04 × non-Ileocecal area + 11.85 ×≥ 2 of intestinal ulcers + 5.03 × shallow ulcers + 12.76 × deep ulcers + 4.47 × geographic-shaped ulcers + 26.93 × volcano-shaped ulcers + 8.65 ×≥ 20 mm of intestinal ulcers. However, endoscopic parameters used in the multivariate analysis explained only 18.9% of the DAIBD variance. Patients with severe DAIBD scores but with moderately predicted disease activity by the endoscopic severity model had more symptoms of irritable bowel syndrome (21.4% vs 4.9%, P = 0.026) and a lower rate of corticosteroid use (50.0% vs 75.6%, P = 0.016) than those with severe DAIBD scores and accurately predicted disease by the model.

CONCLUSION: Our study showed that the number of intestinal ulcers and volcano-shaped ulcers were predictive factors for severe DAIBD scores. However, the correlation between endoscopic severity and DAIBD (r = 0.434) was weak.

Long-term clinical outcomes and factors predictive of relapse after 5-aminosalicylate or sulfasalazine therapy in patients with intestinal Behcet disease

BACKGROUND

Currently, 5-aminosalicylic acid (5-ASA)/sulfasalazine is used to empirically treat patients with intestinal Behcet disease (BD) without clear clinical evidence. In this study, we investigated long-term clinical outcomes and predictors of clinical relapse in patients with intestinal BD receiving 5-ASA/sulfasalazine maintenance therapy.

METHODS

We reviewed the medical records of all the patients with intestinal BD, who received 5-ASA/sulfasalazine therapy in a single tertiary academic medical center between March 1986 and January 2011. The cumulative probabilities of clinical relapse after remission were calculated using the Kaplan-Meier method. Predictors of clinical relapse were identified by univariate analysis using the log-rank test and by multivariate analysis using Cox proportional hazards regression models.

RESULTS

Among the 143 patients enrolled, 46 (32.2%) had a clinical relapse while they were being treated with 5-ASA/sulfasalazine therapy. The cumulative relapse rates at 1, 3, 5, and 10 years after remission were 8.1%, 22.6%, 31.2%, and 46.7%, respectively. By multivariate analysis, a younger age (<35 y) at the time of diagnosis, higher C-reactive protein level (≥1.5 mg/dL), and a higher disease activity index for intestinal Behcet disease score (≥60) at the time of 5-ASA/sulfasalazine initiation were independent predictors of relapse in patients with intestinal BD receiving 5-ASA/sulfasalazine maintenance therapy.

CONCLUSIONS

This study has shown that 5-ASA/sulfasalazine therapy has a positive effect in maintaining remission in patients with intestinal BD. However, a younger age (<35 y), higher C-reactive protein level (≥1.5 mg/dL), and a higher disease activity index for intestinal Behcet disease score (≥60) were associated with a poor response to 5-ASA/sulfasalazine therapy, making careful observation and intensive treatment necessary in these risk groups.

Early versus late surgery in patients with intestinal Behçet disease

BACKGROUND

To date, no studies have been conducted to evaluate the potential benefits of early surgery in patients with intestinal Behçet disease.

OBJECTIVE

We investigated the long-term clinical outcomes in patients with intestinal Behçet disease first diagnosed at surgery ("early surgery") compared with those requiring surgical resection during the course of the disease ("late surgery").

DESIGN

This is a retrospective cohort study.

SETTINGS

This study was conducted at a single tertiary academic medical center.

PATIENTS

We reviewed the medical records of 272 consecutive patients with intestinal Behçet disease between March 1986 and August 2010.

MAIN OUTCOME MEASURES

The cumulative probabilities of clinical recurrence and reoperation after operation were the main outcomes measures.

RESULTS

Forty of 272 patients were first diagnosed with intestinal Behçet disease at surgery (early surgery); the remaining 232 were diagnosed clinically, with 62 undergoing surgery during their follow-up after clinical diagnosis (late surgery). The cumulative probabilities of postoperative clinical recurrence and reoperation were significantly lower in the early-surgery group than in the late-surgery group (p = 0.045 and p = 0.003). In multivariate analysis, early surgery was the only independent factor significantly associated with a reduced probability of reoperation (HR 0.26; 95% CI 0.10-0.71; p = 0.008). However, when we analyzed only the patients who underwent surgery because of chronic symptoms, early surgery was not associated with lower cumulative clinical recurrence and reoperation rates (p = 0.896 and p = 0.492).

LIMITATIONS

We analyzed the clinical characteristics retrospectively, and the number of patients was insufficient to reach a decisive conclusion.

CONCLUSIONS

: According to the current study, the patients with intestinal Behçet disease undergoing early surgery showed better prognoses in comparison with those undergoing late surgery. Early surgery may represent a valid approach in the initial management of the patients with intestinal Behçet disease, at least in the subset of the patients with acute symptoms.

A case of intestinal Behçet's disease treated with infliximab monotherapy who successfully maintained clinical remission and complete mucosal healing for six years

Behçet's disease is a chronic relapsing disease with multiple organ system involvement, including the gastrointestinal tract, which is known as intestinal Behçet's disease. Intestinal Behçet's disease is often resistant to empirical treatments such as 5-aminosalicylic acid, immunomodulators and steroids and often causes a perforation, requiring surgical resection. Therefore, intestinal lesions are considered to be a poor prognostic factor in Behçet's disease. Recently, several reports have demonstrated the efficacy of anti-TNFα monoclonal antibodies, such as infliximab, against intestinal Behçet's disease, however, it remains unknown whether anti-TNFα therapy can improve the prognosis of patients with intestinal Behçet's disease. We herein report the case of an adult female patient with intestinal Behçet's disease who responded well to the induction therapy with infliximab, and has been maintained in remission by scheduled administration of infliximab. Her C-reactive protein level has been sustained at a negative level, and endoscopic findings revealed complete mucosal healing. Therefore, infliximab may have the potential to induce "sustained deep remission" in patients with intestinal Behçet's disease.